Immune and neuroendocrine correlates of temperament in infancy.

There is now a clear focus on incorporating, and integrating, multiple levels of analysis in developmental science. The current study adds to research in this area by including markers of the immune and neuroendocrine systems in a longitudinal study of temperament in infants. Observational and parent-reported ratings of infant temperament, serum markers of the innate immune system, and cortisol reactivity from repeated salivary collections were examined in a sample of 123 infants who were assessed at 6 months and again when they were, on average, 17 months old. Blood from venipuncture was collected for analyses of nine select innate immune cytokines; salivary cortisol collected prior to and 15 min and 30 min following a physical exam including blood draw was used as an index of neuroendocrine functioning. Analyses indicated fairly minimal significant associations between biological markers and temperament at 6 months. However, by 17 months of age, we found reliable and nonoverlapping associations between observed fearful temperament and biological markers of the immune and neuroendocrine systems. The findings provide some of the earliest evidence of robust biological correlates of fear behavior with the immune system, and identify possible immune and neuroendocrine mechanisms for understanding the origins of behavioral development.

Collaborative Care: a Pilot Study of a Child Psychiatry Outpatient Consultation Model for Primary Care Providers.

A Child Psychiatry Consultation Model (CPCM) offering primary care providers (PCPs) expedited access to outpatient child psychiatric consultation regarding management in primary care would allow more children to access mental health services. Yet, little is known about outpatient CPCMs. This pilot study describes an outpatient CPCM for 22 PCPs in a large Northeast Florida county. PCPs referred 81 patients, of which 60 were appropriate for collaborative management and 49 were subsequently seen for outpatient psychiatric consultation. The most common psychiatric diagnoses following consultation were anxiety (57%), ADHD (53%), and depression (39%). Over half (57%) of the patients seen for consultation were discharged to their PCP with appropriate treatment recommendations, and only a small minority (10%) of patients required long-term care by a psychiatrist. This CPCM helped child psychiatrists collaborate with PCPs to deliver mental health services for youth. The CPCM should be considered for adaptation and dissemination.

The Effects of Trauma History and Prenatal Affective Symptoms on Obstetric Outcomes.

Prenatal maternal mood may inform the adverse obstetric outcomes seen in disadvantaged populations. The contribution of having a trauma history is not well studied. We examined the impact of trauma exposure and mood symptoms on obstetric outcomes in 358 women. Women with antecedent trauma were more likely to have a history of depression, odds ratio = 2.83, 95% confidence interval [1.81, 4.42], were younger at their first pregnancy, 18.86 years versus 20.10 years, and had a higher number of previous pregnancies, 2.01 versus 1.54, compared to those with no trauma exposure. Women with prenatal anxiety had significantly smaller babies than nonanxious women, 3,313.17 g, (SD = 441.58) versus 3,429.27 g, (SD = 437.82) Trauma history magnified the effects of maternal prenatal mood on birthweight; the moderating effect was limited to those who first experienced a trauma under 18 years of age. Childhood trauma exposure increased vulnerability for low birthweight delivery associated with prenatal mood disturbance. Screening pregnant women for trauma history and current mood symptoms is indicated.

Pregnancy-related anxiety: Evidence of distinct clinical significance from a prospective longitudinal study.

BACKGROUND: Pregnancy-related anxiety (PrA) has attracted considerable research attention, but questions remain about its distinctiveness from conventional constructs and measures. In a high psychosocial risk, ethnically diverse sample, we examine the degree to which PrA is distinct from continuous and diagnostic measures of anxiety and worry in terms of longitudinal course, associations with psychosocial and perinatal risk, and prediction of postnatal mood disturbance. METHODS: 345 women oversampled for prenatal anxiety and depression were selected from an urban obstetrics clinic serving a predominantly low-income, ethnically diverse population. PrA was assessed at 20 and 32 weeks gestation; anxiety and depression symptoms were assessed from questionnaire and from clinical interview at 20 and 32 weeks gestation and again at 2 and 6 months postnatally. Data relevant to psychosocial and obstetric risks were ascertained from interview, medical exam, and chart review. RESULTS: Two distinct factors of PrA were identified, indexing specific concerns about the child's health and about the birth; these two PrA factors showed distinct longitudinal patterns in the prenatal period, and modest associations with general measures of anxiety and depression from questionnaire and clinical interview. PrA was also distinguished from conventional symptom measures in its associated features and prediction of birth weight and postnatal mood. LIMITATIONS: The sample was at high psychosocial risk and ethnically diverse; findings may not generalize to other samples. CONCLUSIONS: PrA can be distinguished from general measures of anxiety in pregnancy in terms of longitudinal course, associated features, and prediction to postnatal mood disturbance, and may warrant specific clinical attention.

Mood disorders and parity - a clue to the aetiology of the postpartum trigger.

BACKGROUND: Episodes of postpartum psychosis have been associated with first pregnancies in women with bipolar I disorder. It is unclear, however, if the effect extends to episodes at other times in relation to childbirth and to women with other mood disorders such as major depression and bipolar II disorder. This primiparity effect, which is also seen in other pregnancy related conditions such as pre-eclampsia, is a potentially important clue to the aetiology of childbirth related mood episodes. METHODS: Participants were interviewed and case notes reviewed. Best-estimate diagnoses were made according to DSM-IV criteria. Data on the occurrence of episodes in pregnancy and the postpartum were available on 3345 full term deliveries from 1667 participants, 934 with bipolar I disorder (BD-I), 278 with bipolar II disorder (BD-II) and 455 with recurrent major depression (RMD). RESULTS: Onsets of psychosis/mania within 6 weeks of childbirth were overrepresented in primiparae (p=0.007) with BD-I. Although primiparity was not associated with perinatal bipolar depression, there was an association with the onset of depression within 6 weeks in women with RMD (p=0.035). Whilst women experiencing a postpartum episode were less likely to go on to have further children, this did not account for the association with primiparity. LIMITATIONS: Data were collected retrospectively. Information on pharmacological treatment was not available. CONCLUSIONS: Primiparity is associated not only with postpartum psychosis/mania in BD-I, but also with postpartum depression in RMD. Psychosocial factors and biological differences between first and subsequent pregnancies may play a role and are candidates for examination in further studies.

Diurnal cortisol patterns and psychiatric symptoms in pregnancy: short-term longitudinal study.

Alteration in the HPA axis is a robust biomarker of anxiety and depression in adults, but questions remain about this association in pregnancy. We examined the longitudinal links between diurnal cortisol and mood symptoms from self-report questionnaire and diagnostic interview in an ethnically diverse, psychosocially at-risk sample of 101 women at mid-pregnancy and early third trimester. There were modest but significant associations between depression and elevated cortisol, indexed by a decreased morning level and diminished diurnal decline; the effects were strongest for diagnostic data from clinical interview. These effects were independent of socio-demographic factors and sleep disturbance. Associations with anxiety and trauma were generally non-significant. These findings extend prior work by showing that significant mood symptoms in pregnancy are associated with altered diurnal cortisol in pregnancy, which may have implications for maternal and child health.

Depressive symptoms and proinflammatory cytokines across the perinatal period in African American women.

BACKGROUND: Comparatively few studies have examined the biological mechanisms that may underlie the reported racial disparities in antenatal and postpartum depression. OBJECTIVE: To examine the associations among race, depressive symptoms and the proinflammatory cytokines interleukin (IL)-6 and tumor necrosis factor (TNF)-α across the perinatal period in a diverse sample of healthy pregnant women at elevated psychosocial risk. METHODS: 171 subjects were enrolled. Women were interviewed and blood samples drawn at 18 and 32 weeks gestation and 6 weeks and 6 months postpartum. Depressive symptoms were measured using the Edinburgh Postnatal Depression Scale. Serum levels of IL-6 and TNF-α were assayed using high sensitivity enzyme-linked immunosorbent assay kits. RESULTS: Compared with non-African American (AA) women, AA women had significantly higher levels of IL-6 (est. diff = 0.521, p = 0.02, confidence interval (CI): 0.088-0.954) but not TNF-α across all time points (est. diff = -0.060, p = 0.80, CI: -0.517 to 0.397). IL-6 was not associated with depressive symptoms but differences in IL-6 were accounted for by greater Body Mass Index in AA women. CONCLUSIONS: Compared with non-AA women, AA women entered pregnancy with elevated inflammatory cytokine levels that persisted across the perinatal period. This group difference in inflammation did not suggest increased risk for depression, but suggests other implications for long-term health.

Reproductive outcomes and risk of subsequent illness in women diagnosed with postpartum psychosis.

OBJECTIVES: Women who experience postpartum psychosis (PP) seek guidance on further pregnancies and risk of illness; however, empirical data are limited. This study describes reproductive and mental health outcomes in women diagnosed with PP and examines clinical risk factors as predictors of further illness. METHODS: A retrospective cohort design was used; 116 women who experienced episodes of mania or depression with psychotic features within six weeks of childbirth were recruited. All subjects underwent clinical diagnostic interviews and medical case notes were reviewed. RESULTS: Only 33% of women had an antecedent history, of which 34% had bipolar disorder and 55% unipolar depression. Only 58% of those with PP in their first pregnancy had a subsequent pregnancy, and 18% of marriages ended following the PP episode. Clinical presentation at the time of initial episode did not influence the timing of the onset of symptoms, treatment, or recovery. Although 86% of patients received treatment within 30 days of onset, 26% of women reported ongoing symptoms at a year after delivery. The recurrence rate of PP was 54.4%; a longer duration of the index episode (p < 0.05) and longer latency between the index PP and next pregnancy predicted a subsequent PP. The rate of subsequent non-puerperal episodes was 69%, and all these episodes were bipolar. CONCLUSIONS: Postpartum psychosis is difficult to predict in women with no antecedent history and is associated with a high rate of subsequent puerperal and non-puerperal illness. Risk of further illness needs to be conveyed in order to allow fully informed decisions to be made regarding future pregnancies.

Support needs of mothers who experience postpartum psychosis and their partners.

OBJECTIVES: To explore the perceived support needs and preferences of women with postpartum psychosis and their partners. DESIGN: A multisite, exploratory, qualitative descriptive design was used. SETTING AND PARTICIPANTS: A purposive sample of nine mothers (Canada, n = 7, United States, n = 2) and eight fathers (Canada, n = 7, United States, n = 1) was obtained. METHODS: Data were collected through one-on-one, in-depth, semistructured interviews. Inductive thematic analysis was used to explore the qualitative transcripts. RESULTS: Couples who experienced postpartum psychosis looked to health professionals to provide reassurance and information on the illness, its management, and prognosis. The quality of support and interactions with staff varied, and participants reported difficulty identifying and obtaining professional support upon discharge. All participants felt that support groups for postpartum illnesses would help to normalize the experience and dissipate feelings of isolation. Participants reported that informal support networks provided practical help but were limited or hindered recovery and management due to lack of knowledge of the illness. Despite feeling overwhelmed and isolated, fathers were reluctant to identify their own support needs and struggled to ask for help from professionals and their informal support network. CONCLUSION: These findings suggest that clinical interventions are needed to address the support needs and aid in the recovery of families affected by postpartum psychosis.

Psychiatric symptoms and proinflammatory cytokines in pregnancy.

OBJECTIVE: Clinical studies suggest that psychiatric symptoms, particularly depression, anxiety, and trauma, may be associated with inflammation, as indexed by proinflammatory cytokines. Such a link may be especially significant in pregnancy and may shed additional light on the etiology of perinatal mood disorders. METHODS: We prospectively observed 145 women selected from a community obstetric clinic serving a primarily low-income, high-psychosocial risk population. Women without evidence of medical high-risk pregnancies were screened (including psychiatric and trauma histories) and then assessed in detail (e.g., mood symptoms) at approximately 18 and 32 weeks' gestation. Blood was drawn to measure key proinflammatory markers, interleukin 6 and tumor necrosis factor α (TNF-α). Data on pregnancy and obstetric outcome were derived from medical records. RESULTS: There was considerable stability of cytokine levels within individuals and a significant mean increase across pregnancy observed for interleukin 6 (p < .001) and TNF-α (p < .001). History of trauma was associated with significantly elevated TNF-α levels (F(1,135) = 4.43, p < .05), controlling for psychosocial and obstetric covariates. In contrast, elevated measures of depression and anxiety were unrelated to proinflammatory cytokines (p > .1). Exploratory analyses indicated that neither psychiatric symptoms nor proinflammatory cytokines predicted birth weight, gestational age, or obstetric complications. CONCLUSIONS: These findings suggest that antecedent trauma may be associated with persistently elevated TNF-α levels during pregnancy. The evidence that a generalized proinflammatory state was associated with symptoms of depression or anxiety in pregnant women was not found.

Previous prenatal loss as a predictor of perinatal depression and anxiety.

BACKGROUND: Prenatal loss, the death of a fetus/child through miscarriage or stillbirth, is associated with significant depression and anxiety, particularly in a subsequent pregnancy. AIMS: This study examined the degree to which symptoms of depression and anxiety associated with a previous loss persisted following a subsequent successful pregnancy. METHOD: Data were derived from the Avon Longitudinal Study of Parents and Children cohort, a longitudinal cohort study in the west of England that has followed mothers from pregnancy into the postnatal period. A total of 13,133 mothers reported on the number and conditions of previous perinatal losses and provided self-report measures of depression and anxiety at 18 and 32 weeks' gestation and at 8 weeks and 8, 21 and 33 months postnatally. Controls for pregnancy outcome and obstetric and psychosocial factors were included. RESULTS: Generalised estimating equations indicated that the number of previous miscarriages/stillbirths significantly predicted symptoms of depression (ß = 0.18, s.e. = 0.07, P<0.01) and anxiety (ß = 0.14, s.e. = 0.05, P<0.01) in a subsequent pregnancy, independent of key psychosocial and obstetric factors. This association remained constant across the pre- and postnatal period, indicating that the impact of a previous prenatal loss did not diminish significantly following the birth of a healthy child. CONCLUSIONS: Depression and anxiety associated with a previous prenatal loss shows a persisting pattern that continues after the birth of a subsequent (healthy) child. Interventions targeting women with previous prenatal loss may improve the health outcomes of women and their children.

Interventions for the prevention and treatment of postpartum psychosis: a systematic review.

Postpartum psychosis is a serious disorder that can cause negative consequences for the mother, infant, and entire family. While reports of this condition date back for centuries, little is known about what interventions are most effective for this population. The purpose of this systematic review was to examine the research evidence on interventions for the prevention and treatment of postpartum psychosis. Studies were searched using CINAHL, EMBASE, MEDLINE, PsycINFO, and PubMed databases. All primary research studies published in English since 1970 that explored interventions for the prevention or treatment of postpartum psychosis were included. The search resulted in 26 studies on interventions for postpartum psychosis, with 10 focusing on prevention and 17 focusing on treatment. Studies on the prevention of postpartum psychosis have examined the effects of mood stabilizers, antipsychotics, and hormone therapy, while those examining treatment have included electroconvulsive therapy, mood stabilizers, antipsychotics, hormones, and the beta blocker propranolol. Only preliminary evidence suggests which interventions may be effective strategies to prevent (e.g., lithium) and treat (e.g., electroconvulsive therapy) postpartum psychosis. Due to methodological limitations in the studies reviewed, extensive evidence-based recommendations for the prevention and treatment of postpartum psychosis cannot be made. The known risk factors and negative consequences of postpartum psychosis point to the importance of preventative and acute treatment measures. Well-designed prospective studies are needed to determine the efficacy of prevention and treatment interventions for women who experience postpartum psychosis.

Differentiation and clinical implications of postpartum depression and postpartum psychosis.

Postpartum depression and postpartum psychosis are serious mood disorders encountered by nurses working in a variety of settings. Postpartum depression refers to a nonpsychotic depressive episode, while postpartum psychosis refers to a manic or affective psychotic episode linked temporally with childbirth. The nursing profession plays a crucial role in the early identification and treatment of these postpartum mood disorders. This article explains the classification, clinical presentation, epidemiology, management, and long-term outcomes of postpartum depression and postpartum psychosis.

Work characteristics and social phobia in a nationally representative employed sample.

OBJECTIVE: Social phobia is associated with long-term impairment and disability. Environmental and genetic influences may be important in etiology and persistence. This is the first study to examine the association of work characteristics with social phobia in a representative nationally employed population. METHOD: Self-reported work characteristics were linked to 12-month social phobia diagnosed by the World Mental Health Composite International Diagnostic Interview in 24 324 employed individuals from the Canadian Community Health Survey. RESULTS: High job strain (OR = 1.62, 95%CI, 1.06 to 2.49) and job insecurity (OR = 2.47, 95%CI, 1.73 to 3.51) were associated with an increased risk of 12-month social phobia, adjusting for sociodemographic variables, prevalent depression, and other work characteristics. CONCLUSIONS: Work characteristics are associated with social phobia. Characteristics such as job insecurity may be a consequence of illness in employed populations, while high job strain may increase the risk of symptoms. More investigation is needed of the relation between work and social phobia to understand how to reduce occupational disability.

Psychosocial and clinical correlates of suicidal acts: results from a national population survey.

BACKGROUND: Clinical samples have identified a number of psychosocial risk factors for suicidal acts but it is unclear if these findings relate to the general population. AIMS: To describe the prevalence of and psychosocial risk factors for suicidal acts in a general adult population. METHOD: Data were obtained from a Canadian epidemiological survey of 36,984 respondents aged 15 years and older (weighted sample n=23,662,430). RESULTS: Of these respondents, 0.6% (weighted n=130,143) endorsed a 12-month suicidal act. Female gender (OR=4.27, 95% CI 4.05-4.50), being separated (OR=37.88, 95% CI 33.92-42.31) or divorced (OR=7.79, 95% CI 7.22-8.41), being unemployed (OR=1.70, 95% CI 1.50-1.80), experiencing a chronic physical health condition (OR=1.70, 95% CI 1.67-1.86) and experiencing a major depressive episode in the same 12-month period as the act (OR=9.10, 95% CI 8.65-9.59) were significantly associated with a suicidal act. CONCLUSIONS: The psychosocial correlates of suicidal acts in this sample are consistent with those previously reported in clinical and general population samples. These findings reinforce the importance of the determination of suicide risk and its prevention not only of psychiatric illness but of physical and psychosocial factors as well.

The role of depression and chronic pain conditions in absenteeism: results from a national epidemiologic survey.

OBJECTIVE: This study examined whether depression is associated with absenteeism in a sample of individuals with chronic pain. METHODS: Data were obtained from the Canadian Community Health Survey Cycle 1.2. Key variables were chronic pain, defined as fibromyalgia, arthritis/rheumatism, back problems, and migraine headaches, absenteeism, and depression. The sample comprised 9,238,154 individuals who reported at least one chronic pain condition and were absent from their job in the previous week because of illness or disability. RESULTS: Nineteen percent of absent individuals met criteria for major depression versus 7.9% of non-absent individuals. The presence of major depression represented a three-fold risk of absenteeism. Other risk factors for absenteeism included younger age, higher income, and more education. CONCLUSIONS: Comorbid depression and chronic pain represents a significant source of disability in the workforce.

Major depressive episodes and work stress: results from a national population survey.

OBJECTIVES: We determined the proportion of workers meeting criteria for major depressive episodes in the past year and examined the association between psychosocial work-stress variables and these episodes. METHODS: Data were derived from the Canadian Community Health Survey 1.2, a population-based survey of 24324 employed, community-dwelling individuals conducted in 2002. We assessed depressive episodes using the Composite International Diagnostic Interview. RESULTS: Of the original sample, 4.6% (weighted n=745948) met criteria for major depressive episodes. High job strain was significantly associated with depression among men (odds ratio [OR]=2.38; 95% confidence interval [CI]=1.29, 4.37), and lack of social support at work was significantly associated with depression in both genders (men, OR=2.70; 95% CI=1.55, 4.71; women, OR=2.37; 95% CI=1.71, 3.29). Women with low levels of decision authority were more likely to have depression (OR=1.59; 95% CI=1.06, 2.39) than were women with high levels of authority. CONCLUSIONS: A significant proportion of the workforce experienced major depressive episodes in the year preceding our study. Gender differences appear to affect work-stress factors that increase risk for depression. Prevention strategies need to be developed with employers and employee organizations to address work organization and to increase social support.

Predictors of self-reported antidepressant adherence.

The authors' objectives of this research were: (1) to assess levels of selfreported antidepressant adherence and reasons for nonadherence and (2) to investigate determinants of nonadherence. A group of general hospital and community psychiatry practice mood disorder outpatients (n=80) took a self-report questionnaire that assessed beliefs about antidepressants, self-efficacy, and reasons for nonadherence. High levels of adherence were reported: 58 patients (73%) indicated they took their medication as directed more than 80% of the time. Practical issues (e.g., simply forgetting or a change in routine) were the most frequently identified reasons for nonadherence. Patients were more likely to report nonadherence if they experienced a sexual side effect, had lower self-efficacy, were female, and had not completed post-secondary education. Clinicians should be cognizant of this complexity and address not only issues related to medication efficacy and tolerability, but also social mediators and health beliefs when prescribing antidepressants.