First-onset postpartum psychosis

Mrs. B, a 28-year-old woman with no prior psychiatric history, delivered a healthy daughter after a first, normal pregnancy. During the first two days postpartum, she was breastfeeding her daughter with notably reduced sleep. By the third day postpartum, she became convinced that her husband wanted to kill their newborn. After her mother suggested that she discontinue breastfeeding, she became extremely violent, kicking her mother in the abdomen. Over the next 4 days, the family continued to struggle as Mrs. B became progressively more impulsive, irritable, and disorganized. One week postpartum, she wa

Guidelines on treatment of perinatal depression with antidepressants: An international review

Objective: Several countries have developed Clinical Practice Guidelines regarding treatment of perinatal depressive symptoms and perinatal use of antidepressant. We aimed to compare guidelines to guide clinicians in best clinical practice. Methods: An extensive search in guideline databases, MEDLINE and PsycINFO was performed. When no guidelines were (publicly) available online, we contacted psychiatric-, obstetric-, perinatal- and mood disorder societies of all first world countries and the five largest second world countries. Only Clinical Practice Guidelines adhering to quality criteria of the Appraisal of Guidelines for Research and Evaluation instrument and including a systematic review of evidence were included. Data extraction focussed on recommendations regarding continuation or withdrawal of antidepressants and preferred treatment in newly depressed patients. Results: Our initial search resulted in 1094 articles. After first screening, 40 full-text articles were screened. Of these, 24 were excluded for not being an official Clinical Practice Guidelines. In total, 16 Clinical Practice Guidelines were included originating from 12 countries. Eight guidelines were perinatal specific and eight were general guidelines. Conclusion: During pregnancy, four guidelines advise to continue antidepressants, while there is a lack of evidence supporting this recommendation. Five guidelines do not specifically advise or discourage continuation. For new episodes, guidelines agree on psychotherapy (especially cognitive behavioural therapy) as initial treatment for mild to moderate depression and antidepressants for severe depression, with a preference for sertraline. Paroxetine is not preferred treatment for new episodes but switching antidepressants for ongoing treatment is discouraged (three guidelines). If mothers use antidepressants, observation of the neonate is generally recommended and breastfeeding encouraged

Prescription patterns of benzodiazepine and benzodiazepine-related drugs in the peripartum period: A population-based study

Using prescription drugs during pregnancy is challenging and approached with caution. In this study, we present population-based information on prescription patterns of benzodiazepines and benzodiazepine-related drugs in the peripartum period. A population-based study of 1,154,817 pregnancies between 1997 and 2015 in Denmark, of which 205,406 (17.8%) pregnancies in women with a psychiatric history. Prescription drugs starting with Anatomical Therapeutic Chemical codes N05BA, N05CD, and N05CF from 12 months before pregnancy to 12 months following pregnancy were identified. We used generalised estimating equations to estimate the adjusted 5 year risk difference in the proportion of women redeeming benzodiazepines from 1 year to 5 years after. Logistic regression was used to analyze the association between characteristics and discontinuation of benzodiazepines during pregnancy. The prevalence of benzodiazepine prescriptions was 1.9% before pregnancy, 0.6% during pregnancy, and 1.3% after pregnancy. In women with a psychiatric history, the prevalence was 5–6 times higher. A significant decrease in prescriptions to women with a psychiatric history was observed, which was less profound among women with no psychiatric history. Approximately 90% of women discontinue benzodiazepines during pregnancy, with a higher percentage of women discontinuing from 1997 to 2015. The observed decrease is likely explained by changing treatment guidelines

Mother-to-Infant Bonding in Women with Postpartum Psychosis and Severe Postpartum Depression: A Clinical Cohort Study

Mother-to-infant bonding is important for long-term child development. The aim of this study was to investigate bonding in women admitted to a Mother and Baby Unit with postpartum depression (PD, n = 64) and postpartum psychosis (PP, n = 91). Participants completed the Postpartum Bonding Questionnaire (PBQ), the Edinburgh Postnatal Depression Scale (EPDS) and the Young Mania Rating Scale (YMRS) weekly during admission. At admission, 57.1% of women with PD had impaired bonding, compared to only 17.6% of women with PP (p-value < 0.001). At discharge, only 18.2% of women with PD and 5.9% of women with PP still experienced impaired bonding (p-value = 0.02). There was a strong association between decrease of depressive and manic symptoms and improved bonding over an eight-week admission period. In a small group of women (5.7%) impaired bonding persisted despite being in remission of their psychiatric disorder. The results from our study show that impaired bonding is a more present and evidently severe problem in postpartum depression but not so much in postpartum psychosis. Treatment of depressive symptoms will improve bonding in almost all women, but clinicians should assess if impaired bonding is still present after remission because for a small group special care and treatment focused on bonding might be required

Inflammatory activation is associated with a reduced glucocorticoid receptor alpha/beta expression ratio in monocytes of inpatients with melancholic major depressive disorder

In this study, we used new technology to investigate whether a coherent pattern of enhanced expression of inflammatory and other immune activation genes in circulating monocytes is found in patients with major depression. Since a high inflammatory state of monocytes might be related to glucocorticoid resistance, we also included the genes for the two isoforms of the glucocorticoid receptor. For this study, we aimed at finding a similar coherent pattern of inflammatory and immune activation genes in monocytes of patients with MDD and recruited 47 medication-free melancholic MDD inpatients and 42 healthy controls. A quantitative-polymerase chain reaction (Q-PCR) monocyte gene expression analysis was performed using a panel of inflammatory-related genes previously identified as abnormally regulated in mood disorder patients. Selected serum cytokines/ chemokines were assessed using a cytometric bead array. Depressive symptoms were analysed using Hamilton depression scores (HAMD). Thirty-four of the 47 monocyte inflammatory-related genes were significantly upregulated and 2 were significantly downregulated as compared to controls, the latter including the gene for the active GRa in particular in those with a high HAMD score. The reduced GRa expression correlated strongly to the upregulation of the inflammatory genes in monocytes. Serum levels of IL6, IL8, CCL2 and VEGF were significantly increased in patients compared to controls. Our data show the deregulation of two interrelated homoeostatic systems, that is, the immune system and the glucocorticoid system, co-occurring in major depression

Mindfulness During Pregnancy and Parental Stress in Mothers Raising Toddlers

Objectives: Parental stress has been associated with adverse child outcomes and maternal functioning. Yet, maternal factors during pregnancy that can potentially protect against later parental stress, such as mindfulness, have not been studied. Therefore, we aimed to address the possible associations between prenatal mindfulness and levels of parental stress in mothers raising toddlers. Methods: Women in the current study (n = 165) were prospectively followed from pregnancy until 3 years after childbirth, as part of a longitudinal population based cohort (HAPPY study). At 22 weeks of pregnancy, women completed the Three Facet Mindfulness Questionnaire–Short Form (TFMQ-SF) to assess facets of mindfulness (acting with awareness, non-judging, and non-reacting). Women completed the Parenting Stress Questionnaire (PSQ) 3 years after childbirth, reporting on three components of parental stress: (1) parent-child relationship problems, (2) parenting problems, and (3) role restriction. Results: Results of multiple linear regression analyses showed that the acting with awareness facet of mindfulness during pregnancy was a significant predictor of fewer parent-child relationship problems and parenting problems, even when adjusted for prenatal and maternal distress and child behavior problems. Higher levels of non-reacting during pregnancy were also significantly associated with fewer parenting problems in mothers raising toddlers. Conclusions: The current study emphasizes that mindfulness during pregnancy may be a protective factor for later parental stress. More research is needed to confirm these findings and to evaluate the possible benefit of a mindfulness intervention training during pregnancy on parenting and child outcomes

Lithium Use during Pregnancy and the Risk of Miscarriage

Recent studies have provided new data on the teratogenicity of lithium. Less is known about the risk of miscarriage after lithium use during pregnancy. The aim of this study was to investigate the association between lithium use during pregnancy and miscarriage. Participants were women with bipolar I disorder and one or more pregnancies, of which information on medication use and pregnancy outcome was available (n = 443). The unadjusted odds ratios for miscarriage after lithium use during pregnancy was calculated. Multilevel logistic regression was used to calculate the odds ratio, adjusted for the age at conception and the clustering of pregnancies per woman. Miscarriages occurred in 20.8% of the lithium-exposed pregnancies (16/77), compared with 10.9% of the unexposed pregnancies (40/366) (OR = 2.14; 95% CI: 1.13–4.06). The adjusted odds ratio of miscarriage after lithium use during pregnancy was 2.94 (95% CI: 1.39–6.22). Lithium use during pregnancy may increase the risk of miscarriage

Development of the Tilburg Pregnancy Distress Scale: the TPDS

Contains fulltext : 96807.pdf (publisher's version ) (Open Access)ABSTRACT: BACKGROUND: Pregnant women with high levels of stress, depression and/or anxiety are at increased risk for adverse perinatal outcomes and impaired neurologic and emotional development of the offspring. Pregnancy specific instruments to measure psychological functioning during gestation are scarce and do not define items based on in-depth interviews of pregnant and recently delivered women. The current study developed a pregnancy specific scale that measures psychological functioning using in-depth interviews. METHODS: Three focus groups were formed to discuss issues most relevant to pregnancy distress; 22 candidate items were derived for pilot testing (study I, n = 419) its psychometric properties by means of explorative factor analyses (EFA). This resulted in a 17-item TPDS which was further explored by confirmatory factor analyses (CFA) and concurrent and construct validity assessment (study II, n = 454). RESULTS: EFA in study I suggested a two component solution (negative affect (NA) and partner involvement (PI)). CFA in study II resulted in a higher order model of the NA subscale into three more subscales: NA regarding confinement, delivery and general health. TPDS, EPDS and GAD-7 were all significantly correlated. CONCLUSIONS: The TPDS constitutes a valid and user friendly instrument to assess pregnancy distress. In addition to its proven ability to pick up pregnancy specific negative affect it also includes an important sub-scale measuring perceived partner involvement

Obsessive-compulsive personality disorder symptoms as a risk factor for postpartum depressive symptoms

For women with obsessive-compulsive personality disorder (OCPD) trait symptoms, coping with childbearing and parenting could be associated with postpartum depressive symptoms. Therefore, the possible relationship between OCPD trait symptoms and trajectories of postpartum depressive symptoms was examined. A cohort of 1427 women was followed from late pregnancy until 12 months’ postpartum. Trajectories of postpartum depressive symptoms were determined using growth mixture modeling with five repeated assessments. Next, the relationship between OCPD trait symptoms and these trajectories was examined through multinomial regression. Three postpartum depressive symptom trajectories were identified: (1) low symptoms (92%), (2) increasing-decreasing symptoms (inverted u-shape) (5%), and (3) increasing symptoms (3%). OCPD trait symptoms were associated with a higher likelihood of the trajectories increasing-decreasing symptoms (OR 1.26; 95% CI 1.14–1.39) and increasing symptoms (OR 1.16; 95% CI 1.02–1.32), compared to reference trajectory (low symptoms), adjusted for age, educational level, unplanned pregnancy, previous depressive episode (s), and parity

Lithium induced hypercalcemia:an expert opinion and management algorithm

Background: Lithium is the gold standard prophylactic treatment for bipolar disorder. Most clinical practice guidelines recommend regular calcium assessments as part of monitoring lithium treatment, but easy-to-implement specific management strategies in the event of abnormal calcium levels are lacking. Methods: Based on a narrative review of the effects of lithium on calcium and parathyroid hormone (PTH) homeostasis and its clinical implications, experts developed a step-by-step algorithm to guide the initial management of emergent hypercalcemia during lithium treatment. Results: In the event of albumin-corrected plasma calcium levels above the upper limit, PTH and calcium levels should be measured after two weeks. Measurement of PTH and calcium levels should preferably be repeated after one month in case of normal or high PTH level, and after one week in case of low PTH level, independently of calcium levels. Calcium levels above 2.8 mmol/l may require a more acute approach. If PTH and calcium levels are normalized, repeated measurements are suggested after six months. In case of persistent PTH and calcium abnormalities, referral to an endocrinologist is suggested since further examination may be needed. Conclusions: Standardized consensus driven management may diminish the potential risk of clinicians avoiding the use of lithium because of uncertainties about managing side-effects and consequently hindering some patients from receiving an optimal treatment