Course of major depressive disorder after pregnancy and the postpartum period.

BACKGROUND: Maternal major depressive disorder (MDD) has an adverse effect on child development and increases risk for child psychopathology. It is paramount to understand the course of maternal depression during the childhood years particularly before, during, and after pregnancy. OBJECTIVE: To follow the course of MDD in women with prior histories of depression followed during an index pregnancy. METHODS: Subjects were women with histories of MDD who had participated in prior prospective, observational studies during pregnancy. In the follow-up, participants completed a structured interview that addressed (1) the course of MDD since their index pregnancy, (2) new psychiatric diagnoses, and (3) the course of MDD and treatment across subsequent pregnancies. RESULTS: Out of 129 eligible women, 48.8% participated (N = 63) with an average/mean time of 12.9 years (SD = 1.9, 8.8-16.7) elapsed since participation in the prior pregnancy studies. Although approximately one third reported sustained remission from MDD since the pregnancy during which they had been originally followed, of the remaining two thirds of women who reported subsequent depressive episodes, almost one fifth (∼12% of the total sample) endorsed depression more than 50% of the time following their index pregnancy. A total of 6.3% of the women with previous validated diagnoses of MDD reported new diagnoses of bipolar disorder. Women reported similar treatment choices regarding the use of antidepressants during pregnancies subsequent to the one followed in the previous study. CONCLUSION: Women with MDD experienced high rates of recurrent depression across the childbearing years. This represents a critical variable for clinical care and research.

Prospective Longitudinal Study of Predictors of Postpartum-Onset Depression in Women With a History of Major Depressive Disorder.

OBJECTIVE: Risk factors for postpartum depression in euthymic pregnant women with histories of major depressive disorder (MDD) were evaluated. METHODS: From April 2003 to March 2009, 343 pregnant women with a history of Structured Clinical Interview for DSM-IV (SCID)-diagnosed major depressive disorder were prospectively assessed from the third trimester into the postpartum period using the SCID mood module and 17-item Hamilton Depression Rating Scale (HDRS). Data from 300 subjects who completed at least 2 mood module assessments (1 within 60 days before and the other within 60 days after delivery) were analyzed for predictive associations between variables assessed in the third trimester and the development of a postpartum depression. RESULTS: The majority of women were euthymic in pregnancy by SCID criteria. Women with third trimester SCID-diagnosed depression (n = 45) versus euthymia (n = 255) had a significantly higher risk for having depression after delivery (24% vs 11%, P = .013). For pregnant euthymic women, third trimester total HDRS scores significantly predicted postpartum depression (P < .0001); specifically, scores on 3 HDRS items alone-work activities, early insomnia, and suicidality-significantly predicted postpartum depression. Antidepressant use in the third trimester in euthymic women did not confer protection against the onset of postpartum depression. CONCLUSIONS: Among women with a history of MDD who are euthymic in the third trimester, 3 HDRS items-work activities, early insomnia, and suicidality-may be useful as screening items for clinicians working with pregnant women with histories of MDD to identify a group at risk for developing postpartum depression. Additionally, in euthymic women with a history of MDD, antidepressant use in the third trimester may not reduce the risk of developing postpartum depression.

Male fertility: psychiatric considerations.

OBJECTIVE: To examine: 1) current knowledge on normal biologic variation of seminal parameters; 2) how stress and psychological factors affect sperm quality in fertile and infertile males; and 3) how mental illness and psychopharmacologic agents can affect male fertility. DESIGN: English-language Medline, Embase, and Psycinfo were searched for relevant publications (from 1970 to January 2011) for systematic review. SETTING: None. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Possible effects of stress, mood, and psychotropic medications on male factor fertility. RESULT(S): Male-factor infertility is influenced by myriad factors (obesity, tobacco, etc.). Stress alone may reduce testosterone levels and spermatogenesis. Infertility assessment and treatment can lead to distress and negatively affect sperm samples. Available research has failed to control for potentially confounding variables. CONCLUSION(S): Although some trends have been identified, larger-scale studies that adequately control all confounding variables are needed before conclusions can be made about the relationship between stress, psychotropic agents, and male infertility.

DSM-V: modifying the postpartum-onset specifier to include hypomania.

By failing to include it under the rubric of the postpartum-onset specifier, Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR has ignored the clinical reality that childbirth is a potent trigger of hypomania. Given the serious and occasionally tragic consequences of misdiagnosis of bipolar II depression as unipolar depression in the postpartum period, it is argued that DSM-V should consider modifying the postpartum-onset specifier to include episodes of hypomania.

Assessment and treatment of bipolar II postpartum depression: a review.

OBJECTIVE: This paper critically reviews the current literature on the detection, diagnosis, and treatment of bipolar II postpartum depression. METHOD: A Pub-Med search (1998-2009), using the search terms 'postpartum depression', 'postpartum depression AND screening/detection/diagnosis/treatment', 'bipolar I AND postpartum depression', 'bipolar II AND postpartum depression', 'postpartum hypomania', and 'postpartum hypomania AND screening', was carried out. The reference lists of articles identified were also searched to select other relevant publications. RESULTS: Brief hypomanic symptoms occur in the early puerperium in approximately 15% of women. Despite preliminary evidence that postpartum depression in some patients may be a manifestation of bipolar II disorder or bipolar disorder NOS, there are no screening instruments to differentiate unipolar from bipolar depression arising in pregnancy or the postpartum. Also lacking are evidence-based treatment options specifically targeted to treat bipolar II postpartum depression. CONCLUSIONS: Research into postpartum mood disorders has focused primarily on major depressive disorder, bipolar I disorder, and puerperal psychosis, and has largely ignored the study of bipolarity beyond bipolar I disorder. The clinical and research implications of the misdiagnosis of bipolar II depression as major depressive disorder in the postpartum period are discussed.

Bipolar II postpartum depression: Detection, diagnosis, and treatment.

Research on postpartum mood disorders has focused primarily on major depressive disorder, bipolar I disorder, and puerperal psychosis and has largely ignored or neglected bipolar II disorder. Hypomanic symptoms are common after delivery but frequently unrecognized. DSM-IV does not consider early postpartum hypomania as a significant diagnostic feature. Although postpartum hypomania may not cause marked impairment in social or occupational functioning, it is often associated with subsequent, often disabling depression. Preliminary evidence suggests that bipolar II depression arising in the postpartum period is often misdiagnosed as unipolar major depressive disorder. The consequences of the misdiagnosis can be particularly serious because of delayed initiation of appropriate treatment and the inappropriate prescription of antidepressants. Moreover, no pharmacological or psychotherapeutic studies of bipolar postpartum depression are available to guide clinical decision making. Also lacking are screening instruments designed specifically for use before or after delivery in women with suspected bipolar depression. It is recommended that the treatment of postpartum bipolar depression follow the same guidelines as the treatment of nonpuerperal bipolar II depression, using medications that are compatible with lactation.

Mood disorders in women: focus on reproductive psychiatry in the 21st century--Motherisk update 2008.

The burden of mental illness in general, and depression in particular, has long been underestimated. One in 6 persons in the United States will, at some point, suffer from major depression. Depression is second only to heart disease as a leading cause of medical disability in the U.S. Women are vulnerable to mood instability at times of life-cycle related hormonal challenge (e.g., including the premenstruum, pregnancy, post-miscarriage, postpartum and perimenopause). Neurobiological, genetic, and psychosocial substrates underlie the increased vulnerability for depression in women. The significant negative impact of maternal depression on maternal and child health and psychological well-being and other possible consequences of chronic depression will be reviewed. The enormous burden of female depression on women, their children and their families has been well-documented over the past two decades. What remains is the need for serious, rigorously conducted research into effective and safe treatments for depression in women, particularly at times of reproductive transition.

Effects of antenatal depression and antidepressant treatment on gestational age at birth and risk of preterm birth.

OBJECTIVE: The authors evaluated the effects of prenatal antidepressant exposure and maternal depression on infant gestational age at birth and risk of preterm birth. METHOD: Ninety women were followed in a prospective, naturalistic design through pregnancy with monthly assessments of symptoms of depression and anxiety using the Structured Clinical Interview for DSM-IV mood module for depression, the Hamilton Depression Rating Scale, the Beck Depression Inventory, and the Perceived Stress Scale. Participants included 49 women with major depressive disorder who were treated with antidepressants during pregnancy (group 1), 22 women with major depressive disorder who were either not treated with antidepressants or had limited exposure to them during pregnancy (group 2), and 19 healthy comparison subjects (group 3). The primary outcome variables were the infants' gestational age at birth, birth weight, 1- and 5-minute Apgar scores, and admission to the special care nursery. RESULTS: Groups 1, 2, and 3 differed significantly in gestational age at birth (38.5 weeks, 39.4 weeks, 39.7 weeks, respectively), rates of preterm birth (14.3%, 0%, 5.3%, respectively), and rates of admission to the special care nursery (21%, 9%, 0%, respectively). Birth weight and Apgar scores did not differ significantly between groups. Mild to moderate depression during pregnancy did not affect outcome measures. CONCLUSIONS: Prenatal antidepressant use was associated with lower gestational age at birth and an increased risk of preterm birth. Presence of depressive symptoms was not associated with this risk. These results suggest that medication status, rather than depression, is a predictor of gestational age at birth.

Ruminative worrying during pregnancy: a case series.

BACKGROUND: Most women worry to some extent during pregnancy about exposure to agents that might harm their babies. CASES: We describe three women who worried excessively throughout pregnancy about harming their babies because of exposure to agents including, but not limited to, psychotropic drugs. These women were extremely resistant to reassurances that their babies would not be adversely affected, and it is likely there are more women in the community who fit this profile. We have described a number of management strategies that we found effective in caring for these women during pregnancy. CONCLUSION: A collaborative effort between caregivers in psychiatry and obstetrics, as well as other health professionals, is required to provide management for these women during pregnancy.

Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment.

CONTEXT: Pregnancy has historically been described as a time of emotional well-being, providing "protection" against psychiatric disorder. However, systematic delineation of risk of relapse in women who maintain or discontinue pharmacological treatment during pregnancy is necessary. OBJECTIVE: To describe risk of relapse in pregnant women who discontinued antidepressant medication proximate to conception compared with those who maintained treatment with these medications. DESIGN, SETTING, AND PATIENTS: A prospective naturalistic investigation using longitudinal psychiatric assessments on a monthly basis across pregnancy; a survival analysis was conducted to determine time to relapse of depression during pregnancy. A total of 201 pregnant women were enrolled between March 1999 and April 2003 from 3 centers with specific expertise in the treatment of psychiatric illness during pregnancy. The cohort of women was recruited from (1) within the hospital clinics, (2) self-referral via advertisements and community outreach detailing the study, and (3) direct referrals from the community. Participants were considered eligible if they (1) had a history of major depression prior to pregnancy, (2) were less than 16 weeks' gestation, (3) were euthymic for at least 3 months prior to their last menstrual period, and (4) were currently or recently (<12 weeks prior to last menstrual period) receiving antidepressant treatment. Of the 201 participants, 13 miscarried, 5 electively terminated their pregnancy, 12 were lost to follow-up prior to completion of pregnancy, and 8 chose to discontinue participation in the study. MAIN OUTCOME MEASURE: Relapse of major depression defined as fulfilling Structured Clinical Interview for DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] Diagnosis (SCID) criteria. RESULTS: Among the 201 women in the sample, 86 (43%) experienced a relapse of major depression during pregnancy. Among the 82 women who maintained their medication throughout their pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication. Women who discontinued medication relapsed significantly more frequently over the course of their pregnancy compared with women who maintained their medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P<.001). CONCLUSIONS: Pregnancy is not "protective" with respect to risk of relapse of major depression. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation.

Duloxetine for the treatment of major depressive disorder in women ages 40 to 55 years.

The efficacy of duloxetine in the treatment of major depressive disorder in women of approximately perimenopausal age (40-55 years; 62 placebo subjects and 55 subjects taking duloxetine, 60 mg/day) was compared with that observed in cohorts of younger (<40 years, 94 placebo subjects and 85 duloxetine subjects) and older (>55 years, 26 placebo subjects and 25 duloxetine subjects) women. Women (ages 40-55 years) receiving duloxetine demonstrated significantly greater improvement in total scores on the 17-item Hamilton Rating Scale for Depression compared with placebo at the study endpoint (week 9). Significant advantages for duloxetine over placebo were observed on 17-item Hamilton depression scale subscales (core, Maier, anxiety, retardation, and sleep), in addition to the Clinical Global Impression severity and Patient Global Impression of Improvement Scale, the Quality of Life in Depression Scale, and Visual Analog Scales assessing pain severity. The magnitude of duloxetine's treatment effect in women ages 40-55 years was similar to that observed in younger (age <40 years) and older (age >55 years) female patients. In the placebo treatment groups, however, mean changes differed substantially by age group with the smallest placebo responses observed in the 40-55 age group. Duloxetine (60 mg/day) was demonstrated to be an effective treatment for major depressive disorder in this cohort of women ages 40-55 years.

Plotting the course to remission: the search for better outcomes in the treatment of depression.

Depression includes a wide range of symptoms that can impair a person's psychosocial and physical functioning. This impairment can lead to decreased productivity, increased health care utilization, alcohol and substance abuse, and an increased risk of suicide. While the treatment of depression has significantly advanced over the past 30 years, there is still room for improvement. Full remission of depressive symptoms is often elusive, and many patients never achieve full relief from their depression despite being regarded as responders to antidepressant treatment. Current treatments for depression tend to focus on emotional symptoms, not the physical and anxious symptoms also associated with depression. However, the physical and anxious symptoms of depression can be serious and sometimes more prominent than the emotional symptoms of depression, especially among special populations such as women. New treatment strategies, such as dual-acting agents and the combination of pharmacotherapy and psychotherapy, target the emotional and anxious symptoms of depression as well as symptoms associated with pain. In order to increase response and remission, depression should be seen as an illness comprising not only emotional symptoms but physical and anxious symptoms as well.

Special considerations in treating bipolar disorder in women.

There are obvious gaps in research surrounding issues specific to women who suffer from bipolar disorder, including gender differences and their implications for management, the impact of the reproductive cycle, and evidence based treatment guidelines for pregnancy and the postpartum period. Gender differences have not been reported for the prevalence of bipolar disorder; however, women are more likely to experience rapid cycling, mixed mania, and antidepressant-induced manias. This may affect response to treatment, which has been found, in some cases, to differ in men and women. In addition, side effects in response to treatments may well differ in men and women, especially with regard to lithium and valproate prescription. The course of bipolar disorder in women may be influenced by the menstrual cycle, pregnancy, the postpartum period, and menopause, although many issues require further clarification. Treatment of bipolar disorder during pregnancy and the postmenopausal period requires careful consideration, as does treatment during the childbearing years, as some mood stabilizers influence the metabolism of oral contraceptives. This review article has attempted to evaluate existing literature regarding women with bipolar disorder in a comprehensive and critical way, and to consolidate into a single source the gender-specific aspects of the disorder that may have treatment implications for women.

Epidemiology of depression throughout the female life cycle.

Women are at an increased risk for first onset of major depression from early adolescence until their mid-50s and have a lifetime rate of major depression 1.7 to 2.7 times greater than that for men. There is accumulating evidence that certain reproductive-related hormonal changes place women at increased risk for depression. For example, puberty marks the beginning of increased risk for depression in women. Most women report physical or emotional symptoms premenstrually, with some severe enough to be diagnosed as premenstrual dysphoric disorder. While pregnancy does not increase the risk for depression, women with past histories of depression are at risk for recurrent episodes or relapse if antidepressant medications are discontinued. Hormonal changes during the postpartum period also increase the incidence of depression. Similarly, women transitioning through perimenopause, particularly those with past psychiatric histories, report depressive symptoms. Prophylaxis and treatment to minimize severity in cases of recurrence are discussed in the article, using reproductive transitional events as markers.