ABSTRACT
La depresión es un problema importante de salud pública que afecta a una proporción significativa de adultos jóvenes, como los estudiantes universitarios. Para su estudio se ha propuesto un enfoque basado en procesos, que busca identificar variables psicológicas transdiagnósticas que puedan ser objeto de cambio en las intervenciones psicoterapéuticas. El propósito de este trabajo fue analizar la interrelación entre un conjunto de variables de proceso (fusión cognitiva, rumia y evitación experiencial), así como examinar la relación entre cada una de estas variables y la depresión en 368 estudiantes universitarios de entre 18 y 29 años (M = 21.35, DE = 2.36, 77.7 % mujeres). Se halló que la fusión cognitiva y la rumia conformaban una variable global denominada hiperreflexividad, mientras que la evitación experiencial constituía un constructo diferente. Al analizar un modelo de ecuaciones estructurales, se encontró que solo la hiperreflexividad predecía significativamente la depresión. Se discuten estos resultados y sus posibles implicaciones para la práctica clínica. Se recomienda seguir estudiando la hiperreflexividad como una variable supraordinada de relevancia para la psicopatologia.
Depression is a major public health problem that affects a significant proportion of young adults, such as college students. A process-based approach has been proposed for its study, which seeks to identify transdiagnostic psychological variables that can be the target of change in psychotherapeutic interventions. The purpose of this paper was to analyze the interrelation between a set of process variables (cognitive fusion, rumination, and experiential avoidance), as well as to examine the relationship between each of these variables and depression in 368 college students aged 18-29 years (M = 21.35, SD = 2.36, 77.7% female). Cognitive fusion and rumination were found to comprise an overarching variable termed hyperreflexivity, while experiential avoidance constituted a different construct. By analyzing a structural equation model, it was found that only hyperreflexivity predicted depression significantly. These findings and their possible implications for clinical practice are discussed. Further study of hyperreflexivity as a superordinate variable of relevance to psychopathology is recommended.
ABSTRACT
Abstract Introduction: The scientific community is taking an increasing interest in mindful ness due to its positive association with physical and psychological health indicators. However, there is still ongoing debate as to whether there could be other explanations for these effects. Aim: This study explores the relationships between dispositional mindfulness, cognitive fusion, effortful control and repetitive negative thinking (RNT). RNT was chosen as a potential me diating variable due to its presence in multiple psychological disorders. Method: A mediation analysis was performed using the bootstrap method with 5000 replications on data collected from a non-clinical sample of 415 young adults who completed a battery of online questionnai res. Results: Dispositional mindfulness is negatively associated with measures of RNT, effortful control and cognitive fusion. The analyses indicate that the effect that dispositional mindful ness has on cognitive fusion in young people can be partially mediated with medium effect size by RNT. Conclusion: RNT may play a central role as an underlying process in the link between mindfulness and different psychological aspects.
Resumen Introducción: Mindfulness ha ganado interés dentro de la comunidad científica dada su asociación con resultados positivos sobre indicadores de salud física y psicológica. Sin embargo, el debate sigue abierto sobre cuáles son los procesos que podrían mediar estas re laciones. Objetivo: Explorar en una muestra de 415 jóvenes, las relaciones entre mindfulness disposicional, fusión cognitiva, control del esfuerzo y pensamiento negativo repetitivo (PNR). El PNR se propone como potencial variable mediadora debido a que se es común en múltiples trastornos psicológicos. Método: Los análisis de mediación realizados a través de Bootstrap ping con 5000 replicaciones, indicaron que el efecto que genera el mindfulness disposicional sobre la fusión cognitiva puede estar mediado parcialmente por el PNR en personas jóvenes con un tamaño del efecto medio. Conclusiones: Mindfulness disposicional se relaciona de manera negativa con las medidas de PNR, control del esfuerzo y fusión cognitiva. Por tanto, el PNR podría desempeñar un papel importante como proceso subyacente entre mindfulness y diferentes aspectos psicológicos.
ABSTRACT
Objective:This study aimed to compare the detection efficacy of transrectal ultrasound-guided transrectal cognitive fusion targeted+ systematic prostate biopsy and transperineal cognitive fusion targeted + systematic biopsy in patients with suspected prostate cancer (PCa). In addition, the relative clinical characteristics of PCa were evaluated.Methods:A total of 385 patients with suspected prostate cancer in the affiliated hospital of Qingdao University from May 2019 to November 2019 were retrospectively analyzed. All patients met the prostate biopsy criterion, who underwent transrectal(n=275)and transperineal(n=110)prostate biopsy respectively. There were no significant differences of mean age [(70.7±7.3)years vs.(69.2±8.4) years], PSA [(55.12±116.96)ng/ml vs. (63.41±315.34)ng/ml], prostate volume [(55.96±35.26)ml vs. (64.35±55.99)ml] between two groups. According to preoperative prostate magnetic resonance imaging combined with intraoperative ultrasound, 2-4 needles targeted puncture of suspected lesion were performed, followed by 12 needle systematic prostate biopsy. The detection rate of prostate cancer between two biopsy ways were compared. The related factors of PCa including age, prostate volume and PSA level were collected for univariable and multivariable logistic analysis. The cancer detection rate was compared and logistic regression was used to assess the impact of patient characteristics on PCa detection.Results:For all patients, the detection rate with cancer between transrectal group and transperineal group were 121/275(40.0%) and 67/110(60.9%), respectively. The transperineal group detected a higher rate of PCa ( P=0.003)and more clinically significant prostate cancers (csPCa) (54.6% vs.36.7%, P=0.001) than that of the transrectal group, there were significant differences between two groups ( P<0.05). Univariate and multivariate logistic regression analysis revealed that PSA( OR=1.025, P=0.001) and prostate volume( OR=0.984, P=0.001)were two independent factors for the detection rate of prostate cancer between two biopsy ways( P<0.05). The effect of age on the detection rate of PCa in the transperieal group was significantly lower than that of the transrectal group( OR=0.037, P=0.238 vs. OR=0.053, P=0.002). Conclusion:The transperieal biopsy could find more PCa than the transrectal biopsy. PSA level and prostate volume could affect the detection rate of cancer between two prostate biopsy ways.
ABSTRACT
Objective:To compare the differences of emotional conflict and cognitive fusion between depression patients with high and low suicidal ideation.Methods:Beck scale for suicide ideation-Chinese version(BSI-CV), Hamilton depression scale-17(HAMD-17), Beck depression inventory (BDI) and cognitive fusion questionnaire (CFQ) were used for evaluation.The 2×2×2 word-face Stroop task hybrid experimental design was used to compare the response time and accuracy of emotional face judgment in patients with depression with high suicidal ideation( n=22) and patients with depression with low suicidal ideation( n=22) using two-factor repeated measure ANOVA.BSI-CV scores of the two groups( n=44) were used as the dependent variable, and the reaction time of happy face, angry face, consistent face, inconsistent face, BDI score and CFQ score were used as independent variables to perform multiple linear stepwise regression analysis. Results:Both high and low suicidal ideation depression patients had emotional conflict effect in the word-face Stroop task, that was, compared with the face word inconsistent condition, the participants in the face word consistent condition had shorter response time ((707.19±128.79)ms vs (793.55±148.33)ms, F(1, 41)=11.38, P<0.01, ηp2 =0.217)and higher accuracy(95.85±4.50)%, (84.77±11.54)%, ( F(1, 41) =6.06, P<0.05, ηp2 =0.129). Under the condition of consistent face words, the response time of depression patients with high suicidal ideation was longer than that of depression patients with low suicidal ideation((803.69±91.35) ms, (610.69±78.13)ms, P<0.01). The main effect of facial expression type was not statistically significant between the two groups, that was, depression patients with high and low suicidal ideation did not show attentional bias to happy faces or angry faces( F(1, 41) =0.68, P=0.413, ηp2 =0.016). Regression analysis results showed depression score, cognitive fusion score, and reaction time of inconsistent face had positively predictive effects on BSI-CV score( β=0.40, 0.29, 0.29, all P<0.05). Conclusion:The cognitive fusion degree of the depression patients with high suicidal ideation is different from that of the depression patients with low suicidal ideation, but there is no difference in the emotion recognition. Reaction time of inconsistent face, cognitive fusion score and depression score have positively predictive effects on suicidal ideation.
ABSTRACT
A cognitive magnetic resonance imaging (MRI)-targeted prostate biopsy conducted by an experienced clinician enhances the detection rate of (high-grade) prostate cancer; however, this method is less successful in the hands of inexperienced surgeons. Therefore, an alternative method of conducting a cognitive MRI-targeted biopsy that can be successfully performed by the inexperienced clinicians should be developed. Ninety-six males suspected of prostate cancer were analyzed using systematic biopsy and cognitive MRI-targeted biopsy based on our novel three-dimensional matrix positioning method. Typically, the core principle of the latter procedure was to put the MRI and ultrasound images into the same virtual coordinate system. Afterward, the targeted biopsy was transformed to target a coordinate for the suspected lesion in the MRI. Subsequently, patients were assessed for the presence/absence of prostate cancer or high-grade prostate cancer. According to our results, the overall detection rate of prostate cancer was 70.8% (68/96), and the detection rate of high-grade prostate cancer was 56.3% (54/96). Specifically, the detection rate of prostate cancer by systematic biopsy was 54.2% (52/96) and that by targeted biopsy was 59.4% (57/96; P = 0.560). Clearly, the combined application of targeted biopsy could remarkably increase the detection rates of prostate cancer (P = 0.025) and high-grade prostate cancer (P = 0.009). Taken together, the findings of this study suggest that the combination of systematic biopsy with our three-dimensional matrix positioning-driven cognitive-targeted biopsy is superior to systematic biopsy in detecting prostate cancer and high-grade prostate cancer.
ABSTRACT
This study aims to compare the prostate cancer detection rate between magnetic resonance imaging (MRI)-transrectal ultrasound (TRUS) cognitive fusion targeted biopsy and systematic biopsy. A total of 614 patients who underwent transrectal prostate biopsy during 2016-2018 with multiparametric magnetic resonance imaging (mpMRI) were included. All patients with a PI-RADS V2 score ≥ 3 accepted both targeted biopsy and systematic biopsy, and those with a PI-RADS V2 score ≤ 2 only accepted systematic biopsy. Overall prostate cancer detection rate between the two biopsies was compared. MRI-TRUS cognitive fusion targeted biopsy identified 342 cases (75.7%) of prostate cancer while systematic biopsy identified 358 cases (79.2%). There was no significant difference in the detection rate between the two groups ( = 1.621, = 0.203). Targeted biopsy had significant fewer biopsy cores compared with systematic biopsy, reducing (9.3 ± 0.11) cores ( < 0.001) in average. Targeted biopsy had about 10.8% ( < 0.001) more tumor tissues in positive cores compared with systematic biopsy. The results show that both MRI-TRUS cognitive fusion targeted biopsy and systematic biopsy have good detection rate on prostate cancer. Cognitive targeted biopsy may reduce biopsy cores and provide more tumor tissues in positive cores.
Subject(s)
Humans , Male , Biopsy , Methods , Image-Guided Biopsy , Magnetic Resonance Imaging, Interventional , Prospective Studies , Prostatic Neoplasms , Diagnostic Imaging , Ultrasonography, InterventionalABSTRACT
Objective:To explore the difference of cognitive fusion and empirical avoidance level between depression patients and normal people and the relationship between cognitive fusion and empirical avoidance and depression level in all subjects.Methods:Totally 124 patients with depression were selected from outpatients and hospitalized depressive patients in a hospital, and 99 normal participants were recruited online at the same time.The second edition of the Action Questionnaire (AAQ-II), Cognitive Fusion Scale (CFQ), Depression Self-Assessment Scale (SDS) were used to investigate cognitive fusion, empirical avoidance and depression.Results:The average scores of CFQ, AAO-II and SDS were higher in patients with depression than in the normal group (Ps＜0.01).Cognitive fusion scores and empirical avoidance scores could positively predict depression scores (β=0.40, 0.25, Ps＜0.05).Conclusion:The cognitive fusion level and experiential avoidance level are higher in patients with depression than in normal people.Cognitive fusion and empirical avoidance are positively correlated with depression level.
ABSTRACT
Objective To compare the difference of cognitive fusion,empirical avoidance between patients with obsessive-compulsive disorder and healthy control group,and to explore the relationship between obsessive-compulsive score and cognitive fusion,empirical avoidance.Methods The cognitive fusion questionnaire(CFQ),acceptance and action questionnaire-2nd edition (AAQ-Ⅱ) and Yale-Brown scale for obsessive-compulsive symptoms (Y-BOCS) were used to investigate 100 subjects with obsessive-compulsive disorder (OCD) and 166 healthy controls.And the differences in cognitive fusion and empirical avoidance scores were compared between the two groups.The relationship of obsessive-compulsive symptoms and cognitive fusion,empirical avoidance was analyzed using multiple linear regression analysis.Results The scores of cognitive fusion ((49.89± 10.62) vs (33.88 ± 11.44),t =-11.345,P＜ 0.01) and empirical avoidance ((29.75±9.53) vs (21.59±7.03),t=-7.995,P＜0.01) in obsessive-compulsive disorder group were significantly higher than those in healthy control group.There were significant differences in cognitive fusion and empirical avoidance in age variables (F=8.63,P＜0.01).In AAQ-Ⅱ,item 2 (r=0.246,P＜ 0.05),item 6 (r=0.223,P＜0.05) and total score (r=0.240,P＜0.05) were positively correlated with the total score of Y-BOCS.Item 2 (r=0.311,P＜0.01),item 3 (r=0.286,P＜0.05),item 6 (r=0.248,P＜0.05) and total score (r=0.229,P＜0.05) were positively correlated with the scores of obsessive-thinking.In CFQ,item 2 (r=0.231,P＜0.0) 5),item 4 (r=0.242,P＜ 0.05),item 7 (r =0.308,P＜ 0.05),item 8 (r =0.277,P＜0.05) and item 9 (r=0.249,P＜0.05) were positively correlated with the total score of Y-BOCS.Item 8 (r=0.261,P＜0.05) was positively correlated with the scores of obsessive-thinking,item 7 (r=0.237,P＜0.05) and item 9 (r=0.238,P＜0.05) were positively correlated with scores of obsessive-compulsive behavior.When predicting total obsessive-compulsive scores,only CF item 7 of Q (B=1.827,P＜0.01),item 3 (B=0.956,P＜0.05),and item 6 of AAQ-Ⅱ (B=0.584,P＜0.05) entered the equation with a joint explanatory variation of 19％.When predicting the score of obsessive-thinking,only item 2 of AAQ-Ⅱ (B=0.446,P＜0.01) entered the equation,explaining the variance was 9.7％.In the prediction of obsessive-compulsive behavior,only item 9 (B=0.815,P＜0.05) of CFQ entered the equation,and the explanatory variation was 5.6％.Conclusion Cognitive fusion in the patients with obsessive-compulsive disorder and the high level of empirical avoidance may be an important factor for the maintenance of the symptoms.
ABSTRACT
Objective@#To compare the difference of cognitive fusion, empirical avoidance between patients with obsessive-compulsive disorder and healthy control group, and to explore the relationship between obsessive-compulsive score and cognitive fusion, empirical avoidance.@*Methods@#The cognitive fusion questionnaire(CFQ), acceptance and action questionnaire-2nd edition(AAQ-II) and Yale-Brown scale for obsessive-compulsive symptoms (Y-BOCS) were used to investigate 100 subjects with obsessive-compulsive disorder (OCD) and 166 healthy controls.And the differences in cognitive fusion and empirical avoidance scores were compared between the two groups.The relationship of obsessive-compulsive symptoms and cognitive fusion, empirical avoidance was analyzed using multiple linear regression analysis.@*Results@#The scores of cognitive fusion ((49.89±10.62) vs (33.88±11.44), t=-11.345, P<0.01)and empirical avoidance ((29.75±9.53) vs (21.59±7.03), t=-7.995, P<0.01) in obsessive-compulsive disorder group were significantly higher than those in healthy control group.There were significant differences in cognitive fusion and empirical avoidance in age variables (F=8.63, P<0.01). In AAQ-Ⅱ, item 2 (r=0.246, P<0.05), item 6 (r=0.223, P<0.05) and total score (r=0.240, P<0.05) were positively correlated with the total score of Y-BOCS.Item 2 (r=0.311, P<0.01), item 3 (r=0.286, P<0.05), item 6 (r=0.248, P<0.05) and total score (r=0.229, P<0.05) were positively correlated with the scores of obsessive-thinking.In CFQ, item 2 (r=0.231, P<0.0) 5), item 4 (r=0.242, P<0.05), item 7 (r=0.308, P<0.05), item 8 (r=0.277, P<0.05) and item 9 (r=0.249, P<0.05) were positively correlated with the total score of Y-BOCS.Item 8 (r=0.261, P<0.05) was positively correlated with the scores of obsessive-thinking, item 7 (r=0.237, P<0.05) and item 9 (r=0.238, P<0.05) were positively correlated with scores of obsessive-compulsive behavior.When predicting total obsessive-compulsive scores, only CF item 7 of Q (B=1.827, P<0.01), item 3 (B=0.956, P<0.05), and item 6 of AAQ-Ⅱ (B=0.584, P<0.05) entered the equation with a joint explanatory variation of 19%.When predicting the score of obsessive-thinking, only item 2 of AAQ-Ⅱ (B=0.446, P<0.01) entered the equation, explaining the variance was 9.7%.In the prediction of obsessive-compulsive behavior, only item 9 (B=0.815, P<0.05) of CFQ entered the equation, and the explanatory variation was 5.6%.@*Conclusion@#Cognitive fusion in the patients with obsessive-compulsive disorder and the high level of empirical avoidance may be an important factor for the maintenance of the symptoms.
ABSTRACT
OBJECTIVE@#Image-guided targeted biopsy techniques have been proposed to address problems ofsystematic transrectal ultrasound guided prostate biopsies that lead to the suboptimal cancer detectionrate as well as inaccurate grading of the disease. This study aims to provide local data on the diagnosticaccuracy of multiparametric MRI (MP-MRI) and MP-MRI ultrasound cognitive fusion biopsy inidentifying areas of clinically significant malignancy of the prostate.@*MATERIALS AND METHODS@#This is a validity study involving patients who underwent MP-MRI and MP-MRI ultrasound cognitive fusion biopsy, who eventually underwent robot-assisted laparoscopic radicalprostatectomy (RALRP). Outcome measures included sensitivity, specificity, positive and negativepredictive values of MP-MRI and MP-MRI ultrasound cognitive fusion biopsy. Reference standardused was the final histopathologic report obtained after RALRP.@*RESULTS@#MP-MRI has a sensitivity of 35.5%, specificity of 95.2%, positive predictive value of 97.1%,and negative predictive value of 25%. MP-MRI ultrasound fusion biopsy had similar results, withsensitivity of 34.4%, specificity of 81.0%, positive predictive value of 88.9%, and negative predictivevalue of 21.8%.@*CONCLUSION@#The high specificity and positive predictive value of MP-MRI (95.2% and 97.1%respectively) indicates the necessity for a prostate biopsy and supports the utility of a targeted MP-MRI guided ultrasound cognitive fusion biopsy. However, the low sensitivity and negative predictivevalue (25% and 35% respectively) of 35.5% indicates that MP-MRI guidance does not limit thenumber of biopsy samples only to visible MP-MRI lesions, since negative areas on MP-MRI stillcontains tumors in 75% of cases.
ABSTRACT
Abstract The Cognitive Fusion Questionnaire (CFQ) is a recently published measure of cogni tive fusion - a key construct in the model of psychopathology of acceptance and commitment therapy (ACT). This study presents the psychometric properties and factor structure data of a Spanish translation of the CFQ in Colombia. Three samples with a total of 1,763 participants were analyzed. The Spanish CFQ showed psychometric properties very similar to the ones obtained in the original version. Internal consistency across the different samples was good (Cronbach's alpha between .89 and .93). The one-factor model found in the original scale showed a good fit to the data. Measurement invariance was also found across sample and gen-der. The mean score of the clinical sample on the CFQ was significantly higher than the scores of the nonclinical samples. CFQ scores were significantly related to experiential avoidance, emotional symptoms, mindfulness, and life satisfaction. The CFQ was sensitive to the effects of a 1-session ACT intervention. This Spanish version of the CFQ shows good psychometric properties in Colombia.
Resumen El Cuestionario de Fusión Cognitiva (CFQ) es una medida de fusión cognitiva recientemente publicada; un constructo clave en el modelo de psicopatología de la terapia de aceptación y compromiso. El presente estudio muestra las propiedades psicométricas y estructura factorial de una traducción al español del CFQ en Colombia. Se analizaron tres muestras con Fusión cognitiva; Flexibilidad psicológica un total de 1763 participantes. La versión en español del CFQ mostró resultados muy similares a los obtenidos en la versión original. La consistencia interna a través de las distintas muestras fue buena (alfa de Cronbach entre .89 y .93). El modelo unifactorial encontrado en la escala original mostró un buen ajuste a los datos. Se encontró invarianza de la medida a través de muestras y sexo. La puntuación media de la muestra clínica en el CFQ fue significativamente mayor que las puntuaciones de las muestras no clínicas. Las puntuaciones en el CFQ estuvieron significativamente correlacionadas con evitación experiencial, síntomas emocionales, mindfulness y satisfacción vital. El CFQ fue sensible a los efectos de una intervención de terapia de aceptación y compromiso de una sesión. Esta versión en español del CFQ mostró buenas propiedades psicométricas en Colombia.
Subject(s)
Psychometrics , Surveys and Questionnaires , Mindfulness , Acceptance and Commitment TherapyABSTRACT
Objective To explore the relationship among experiential avoidance,cognitive fusion and type D personality in pregnant women.Methods 309 pregnant women were assessed with self-made general information questionnaire,acceptance and action questionnaire-2nd edition (AAQ-Ⅱ),cognitive fusion questionnaire(CFQ) and type D personality scale(DS14).Results Average score of AAQ-Ⅱ and CFQ of 309 pregnant women were (16.41±7.55) and (24.24± 10.90),respectively.According to the type D personality questionnaire scores,the subjects were divided into four groups.Average score of each group on AAQ-Ⅱ and CFQ was respectively (21.25 ± 8.18) and (31.12± 10.99) for type D personality group (Group 1),(19.80±6.14) and (27.67±9.76) for negative emotion group(Group 2),(15.12±6.40) and (22.16±9.56)for social inhibition group (group 3) and (14.02±6.61) and (21.18±10.03) for group without negative emotions and social inhibition (group 4).The differences between groups were statistically significant (F=19.44,17.372,all P＜0.01).Correlation analysis revealed that AAQ-Ⅱ and CFQ were positively related to NA and SI (r=0.484,0.251,0.477,0.302,P＜0.05).NA and SI all entered the AAQ-Ⅱ regression equation and CFQ regression equation respectively:Y1 =4.655+ 1.032X1 + 0.836X2,Y2 =8.013+ 1.233X1 + 0.745X2 (Y1 as AAQ-Ⅱ,Y2 as CFQ,X1 as NA,X2 as SI).Conclusion Pregnant women with type D personality have the worst psychological flexibility.The two demensions of type D personality are predictive to experiential avoidance and cognitive fusion.
ABSTRACT
Objective To explore the relationship between cognitive fusion and the state of anxiety and depression of perinatal women and to provide empirical evidences for acceptance and commitment therapy in mental treatment of anxiety and depression in perinatal women.Methods 309 perinatal women collected by cluster random sampling were assessed with self-made general information questionnaire,Self-Rating Anxiety Scale (SAS),Self-Rating Depression Scale (SDS) and Cognitive Fusion Questionnaire (CFQ) in predelivcry period and 3-7 days after childbirth respectively.Results (1) CFQ scores in the predelivery or postpartum anxiety group ((32.18±10.78),(31.54±10.30))were higher than that in the normal group((21.49±9.56),(20.84±9.82)),and the difference was statistically significant (t=-8.26,-8.22;all P=0.000);CFQ scores in the predelivery or postpartum depression group ((26.74 ±11.76),(26.84 ± 12.11)) were higher than that in the normal group((23.06± 10.33),(21.79±9.90)),and the difference was statistically significant(t=-2.76,-3.71;P=0.006,0.000).(2)It was found that the predelivery or postpartum CFQ scores were positively associated with the SAS scores of predelivery periods and postpartum periods respectively(r=0.51,0.45,0.50,0.55;P=0.000);the predelivery or postpartum CFQ scores were positively associated with the SDS scores of predelive1y periods and postpartum periods respectively (r =0.26,0.31,0.21,0.38;P =0.000).(3) Hierarchical multiple regression analyses were then conducted.The predelivery CFQ had a significant effect on postpartum SAS(△R 2=0.02,P=0.006)and postpartum SDS respectively(△R 2=0.02,P=0.006),and the regression equations were statistically significant.Conclusion A function to predict the occurrence of matemal postpartum anxiety and depression is obtained from the cognitive fusion which is attributed to the risk of maternal postpartum anxiety and depression.