Predictors of infant foster care in cases of maternal psychiatric disorders.

PURPOSE: Our aim was to investigate the factors associated with mother-child separation at discharge, after joint hospitalization in psychiatric mother-baby units (MBUs) in France and Belgium. Because parents with postpartum psychiatric disorders are at risk of disturbed parent-infant interactions, their infants have an increased risk of an unstable early foundation. They may be particularly vulnerable to environmental stress and have a higher risk of developing some psychiatric disorders in adulthood. METHODS: This prospective longitudinal study of 1,018 women with postpartum psychiatric disorders, jointly admitted with their infant to 16 French and Belgian psychiatric mother-baby units (MBUs), used multifactorial logistic regression models to assess the risk factors for mother-child separation at discharge from MBUs. Those factors include some infant characteristics associated with personal vulnerability, parents' pathology and psychosocial context. RESULTS: Most children were discharged with their mothers, but 151 (15 %) were separated from their mothers at discharge. Risk factors independently associated with separation were: (1) neonatal or infant medical problems or complications; (2) maternal psychiatric disorder; (3) paternal psychiatric disorder; (4) maternal lack of good relationship with others; (5) mother receipt of disability benefits; (6) low social class. CONCLUSIONS: This study highlights the existence of factors other than maternal pathology that lead to decisions to separate mother and child for the child's protection in a population of mentally ill mothers jointly hospitalized with the baby in the postpartum period.

[Predominant polarity, mixed states and suicide]. / Polarité prédominante, mixité et suicide.

Bipolar disorders are linked to a high suicidal risk. Many risk factors are identified but it seems relevant to highlight the relationship between suicidal behavior and the different subtypes of bipolar disorder, or the different kinds of outcomes, or the clinical characteristics of a recurrence. A high frequency of depressive episodes in the story of the illness, like in predominant depressive polarity forms, or mixed features during symptomatic recurrences seem to be linked to a higher suicidal risk in the course of the disorder. Underlying mechanisms are yet to be identified. The investigation of these specifics lead into considering specific therapeutic actions based upon the clinical identification of mixed symptomatology during a recurrence for a tailored treatment or a thorough screening and assessment of depressive states during the course of the bipolar illness in order to try to prevent them.

Could maternal perinatal atypical antipsychotic treatments program later metabolic diseases in the offspring?

An association is established between schizophrenia and the development of metabolic alterations including cardiovascular diseases, type 2 diabetes and obesity. Perinatal insults, such as undernutrition, have been shown to increase the propensity to develop these pathologies, reinforcing the idea that schizophrenia may have a neurodevelopmental origin. Moreover, the use of second generation antipsychotics (SGAs) also known as "atypical" neuroleptics has also been demonstrated to exacerbate metabolic anomalies in patients with schizophrenia. SGAs are able to cross the placental barrier and have been detected in milk from women receiving atypical neuroleptics treatment during the perinatal period. To date, the consequences of such treatment have only been examined on the birth weight and the cognitive capacities of the child from women with schizophrenia, but no data is available concerning the putative long-term effects of SGAs on their body weight and metabolic parameters. We have recently reported that rat offspring from prenatally undernourished mothers exhibit a low birth weight associated with modified sensitivity to clozapine and aripiprazole in adulthood reinforcing the idea that some forms of schizophrenia may be acquired during early development. In view of these observations, the risks of perinatal exposure to SGAs must be weighed against the growing evidence that maternal psychiatric illness poses risks to the fetus/newborn as well as for long-term susceptibility to diseases. Thus, metabolic follow-up of children born from mothers treated by SGAs during the perinatal period will be clearly recommended, in particular if they exhibit alterations of their body weight during this early critical period.

Pain as a confounding factor in postnatal depression screening.

BACKGROUND: Postnatal depression (PND) is one of the most serious complications following delivery in developed countries today. Thus, early screening strategies by first-line healthcare workers are of primary importance. Pain following childbirth has been proposed as a possible risk-marker for later depressive disorder. We tested this assumption and explored the possible link between pain and overestimation of PND risk in routine clinical screenings. METHODS: We assessed 320 women between the third and fifth day after delivery as well as at 8 weeks post-partum (PP). Midwives were asked to evaluate the risk of later PND upon discharge from the maternity unit; additionally, pain measurements were obtained using the Visual Analogic Scale (VAS) over the same time period. A stepwise logistic regression analysis was performed to identify the risk markers linked to a positive depressive disorder diagnosis (according to the MINI-DSM-IV) at 8 weeks PP. RESULTS AND DISCUSSION: Multivariate risk analysis showed no statistical link between physical pain shortly after childbirth and subsequent PND diagnosis at 8 weeks PP. However, VAS measurements for pain were significantly higher for women that the midwives estimated to be at risk for PND (|Z| = 2.78, p = 0.005), suggesting the routine clinical screening for PND is susceptible for false-positives. Psychiatrists should encourage midwives to have an empathetic approach, to increase the detection as well as treatment of mental and physical suffering in early postpartum. At the same time, adequate education programmes for early PND screening should be proposed to non-psychiatric staffs to demonstrate that women at risk of PND often show minimal physical symptoms.

Impact of midwives' training on postnatal depression screening in the first week post delivery: a quality improvement report.

BACKGROUND: postnatal depression (PND) is a major public health problem. The objective of this study was to improve early PND screening by midwives in a maternity unit. Professional screening techniques were evaluated and compared with reference screening techniques [Edinburgh Postnatal Depression Scale (EPDS), Mini International Neuropsychiatric Interview (MINI-DSM-IV)]. METHODS: the evaluation took place before and after the midwife training in order to determine the effectiveness of specific clinical recommendations for two successive 10-week inclusion periods (from November 2004 to September 2005). A short training course and posters were used to convey the recommendations, agreed by obstetricians, paediatricians and psychiatrists. RESULTS: a total of 463 postpartum women were included in the two phases of the study. Quantitative and qualitative PND screening by midwives improved significantly following training (Z=2.07, p=0.04; Z=2.62, p=0.008, respectively). Early detection of major depressive episodes increased by 37.7% (95% confidence interval 25.7-49.7) following training. A combination of midwives' perception of poor emotional well-being and the EPDS led to a significant improvement in early detection of PND (Q=8.00, p=0.04). DISCUSSION: targeted recommendations given to the midwives led to an improvement in the early detection of PND. Suitable programmes need to be offered to reduce the number of cases of PND. Perinatal psychiatrists should be seen to be meticulous and available for such prevention action.

Predictive validation study of the Edinburgh Postnatal Depression Scale in the first week after delivery and risk analysis for postnatal depression.

BACKGROUND: Postnatal depression is a major public health problem. The aim of this study is to validate the use of the Edinburgh Postnatal Depression Scale (EPDS) in the early postpartum, and to identify the markers for risk of postnatal depression. METHODS: 815 women filled out an EPDS and general information questionnaire between the third and the fifth day postpartum. The women with an EPDS score of >8 and a randomized control group from those with scores of <8 were contacted 8 weeks postpartum. 363 women therefore had a structured diagnostic interview by telephone at 8 weeks postpartum (MINI-DSM-IV), without knowledge of their EPDS scores, to screen for a major or minor depressive episode. RESULTS: The sensitivity of EPDS was measured as 0.82 [0.78-0.86], with a positivity threshold of 9.5/30. For an estimated prevalence for all depressive episodes of 16.1%, the positive predictive value of EPDS was measured as 42.8% [39.1-46.5%]. Multivariate risk analysis using logistical regression identified the following as risk markers for postnatal depression: previous history of depression (postnatal or other), unemployment, premature delivery or stopping breast-feeding in the first month for non-medical reasons. CONCLUSION: The use of EPDS between the third and fifth day postpartum is valid. An EPDS score of >10 should be completed by a clinical assessment and suitable management. The risk markers identified here are clinical indices that can be used for first-line early screening by non-psychiatric health workers.