Impact of colocated behavioral health on OB-GYN clinicians' rate of perinatal behavioral health diagnosis and psychotropic prescription.

OBJECTIVE: To examine the association of colocated behavioral health(BH) care with rates of OB-GYN clinician coding of BH diagnoses and BH medications. METHOD: Using 2 years of EMR data from perinatal individuals treated across 24 OB-GYN clinics, we tested the hypothesis that colocated BH care would increase rates of OB-GYN BH diagnoses and psychotropic prescription. RESULTS: Psychiatrist integration(0.1 FTE) was associated with 45.7% higher odds of OB-GYN coding for BH diagnoses and BH clinician integration was associated with 25% lower odds of OB-GYN BH diagnosis and 37.7% lower odds of BH medication prescription. Non-white patients had 28-74% and 43-76% lower odds of having a BH diagnosis and a BH medication ordered, respectively. The most common diagnoses were anxiety and depressive disorders(60%) and the most prescribed BH medications were SSRIs(86%). CONCLUSIONS: OB-GYN clinicians made fewer BH diagnoses and prescribed fewer psychotropics after 2.0 FTE BH clinician integration, a possible indication of external referrals for BH treatment. Non-white patients received BH diagnoses and medications less often than white patients. Future research in real world implementation of BH integration in OB-GYN clinics should examine fiscal strategies that support BH care manager-OB-GYN collaboration as well as methods to ensure equitable delivery of BH care.

Preconception interpersonal personality features predict postpartum maternal parenting behaviors.

Individual differences in personality traits affect the quality of social relationships. The parent-child relationship is among the most impactful social relationships in an individual's life, and positive parenting behaviors are known to support positive child development. The present study aimed to identify personality predictors-measured prior to conception at age 16-on later positive parenting behaviors. Young women (n = 207; 83.5% Black or multiracial; 86.9% receiving public assistance) who were followed since childhood as part of a prospective longitudinal study were observed interacting with their infants 4 months postpartum. We tested prospective associations between personality factors relevant to the quality and maintenance of social relationships-empathy, callousness, and rejection sensitivity-and coded dimensions of parenting behavior: maternal warmth, responsiveness, and mental state talk. We additionally examined potential moderating effects of infant affect on the relations between personality and parenting behavior. Results indicated that preconception empathy predicted later maternal warmth and responsivity, whereas preconception callousness was inversely associated with maternal warmth. The association between rejection sensitivity and maternal mental state talk was moderated by infant affect, consistent with a "goodness-of-fit" framework. The present study is the first to our knowledge to report associations between preconception personality and later parenting behaviors. The findings suggest that a woman's personality traits in adolescence, potentially years before she becomes a mother, can predict her behavior during interactions with her infant. Clinically, findings suggest the potential for interventions in adolescence to influence later parenting behavior and ultimately impact children's developmental outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Using natural language from a smartphone pregnancy app to identify maternal depression.

Depression is highly prevalent in pregnancy, yet it often goes undiagnosed and untreated. Language can be an indicator of psychological well-being. This longitudinal, observational cohort study of 1,274 pregnancies examined written language shared in a prenatal smartphone app. Natural language feature of text entered in the app (e.g. in a journaling feature) throughout the course of participants' pregnancies were used to model subsequent depression symptoms. Language features were predictive of incident depression symptoms in a 30-day window (AUROC = 0.72) and offer insights into topics most salient in the writing of individuals experiencing those symptoms. When natural language inputs were combined with self-reported current mood, a stronger predictive model was produced (AUROC = 0.84). Pregnancy apps are a promising way to illuminate experiences contributing to depression symptoms. Even sparse language and simple patient-reports collected directly from these tools may support earlier, more nuanced depression symptom identification.

A lifespan perspective on depression in the postpartum period in a racially and socioeconomically diverse sample of young mothers.

BACKGROUND: Consistent evidence from retrospective reports and case registry studies indicates that a history of depression is a major risk factor for depression in the peripartum period. However, longitudinal studies with racially and socioeconomically diverse samples of young mothers are lacking, and little is known about developmental patterns of depression across the lifespan that can inform preventive interventions. METHODS: Young primiparous mothers (n = 399, 13-25 years, 81% Black) were recruited from a population-based prospective study that began in childhood. Women reported on depression symptoms for at least 3 years prior to their pregnancy, during pregnancy, and at 4 months postpartum. Linear regression models were used to estimate change in pre-pregnancy depression severity and to evaluate associations between patterns of lifetime history and postpartum depression symptoms. RESULTS: Results revealed high levels of continuity in depression from pregnancy to postpartum, and across multiple years pre-pregnancy to postpartum. Overall, depression severity leading up to pregnancy decreased over time, but patterns of worsening or improving symptoms were not associated with depression severity in the postpartum period. Instead, area under the pre-pregnancy trajectory curve, representing cumulative lifetime depression burden, was uniquely associated with postpartum depression after adjusting for prenatal depression severity. CONCLUSIONS: Depression in the postpartum period should be considered within a lifespan perspective of risk that accumulates before conception. Clinical screening and early interventions are needed in adolescence and young adulthood to prevent the onset and persistence of depressive symptoms that could have long-term implications for peripartum health.

An intensive outpatient program for suicidal college students.

Objective: College counseling centers (CCCs) have limited capacity to accommodate high-risk students who need more intensive care than traditional outpatient treatment. We describe an Intensive Outpatient Program (IOP) to meet the specialized needs of suicidal undergraduates. Participants: Suicidal undergraduates aged 18-24. Methods: Fact-gathering meetings with local universities confirmed high need for prompt access to IOP care for students presenting in crisis at CCCs and emergency rooms, and post-inpatient discharge. We thus iteratively designed and implemented the College Option Services for Teens at Risk (COSTAR) IOP. Results: The 6-week program includes initial diagnostic evaluation and risk assessment followed by weekly skills groups, individual therapy, and medication management. Between September 2017 and January 2020, 148 students (M age = 19.7) attended an average of 5.7 COSTAR group sessions (SD = 4.7). Conclusions: A specialty IOP for suicidal college students holds promise in a stepped care approach for at-risk college students.

Reduced postpartum hippocampal volume is associated with positive mother-infant caregiving behavior.

BACKGROUND: Maternal caregiving is a complex set of behaviors that can be impacted by early life stress (ELS), yet human neurobiological mechanisms are not well understood. METHODS: Young mothers (n=137) were enrolled into a neuroimaging substudy of the longitudinal Pittsburgh Girls Study (PGS). Using data collected annually while subjects were ages 8-16, ELS was calculated as a composite score of poverty, trauma, and difficult life circumstances. At 4 months postpartum, mothers underwent neuroimaging and filmed mother-infant interaction. Maternal caregiving was coded along 6 dimensions yielding "positive" and "negative" components of caregiving. Participants' MPRAGE images were subjected to preprocessing and voxel-based morphometry (VBM) to quantify vmPFC, amygdala and hippocampus gray matter (GM) volume. We used hierarchical linear regression to investigate the relationship between GM volume and maternal caregiving, covarying for ELS as well as maternal age, weeks postpartum, race and postpartum depression score. RESULTS: Hippocampal GM volume was inversely associated with independent observations of positive maternal caregiving. Similar findings in the vmPFC did not remain significant after correction for multiple comparisons. ELS, particularly physical assault, was associated with reduced GM volumes but was unrelated to observed maternal caregiving. LIMITATIONS: Our single-timepoint MRI-based GM volume method was not able to demonstrate time-related intra-individual perinatal neuroplasticity, nor could it resolve neural subregions involved in caregiving-related plasticity. CONCLUSIONS: Our findings shed light on the putative plasticity of the human maternal extra-hypothalamic stress-circuitry underlying positive maternal caregiving behavior. Whether reduced hippocampal GM volume represents pruning or represents neural resilience in the face of ELS, remains to be studied.

Implementation of perinatal collaborative care: a health services approach to perinatal depression care.

AIM: Our objective was to integrate lessons learned from perinatal collaborative care programs across the United States, recognizing the diversity of practice settings and patient populations, to provide guidance on successful implementation. BACKGROUND: Collaborative care is a health services delivery system that integrates behavioral health care into primary care. While efficacious, effectiveness requires rigorous attention to implementation to ensure adherence to the core evidence base. METHODS: Implementation strategies are divided into three pragmatic stages: preparation, program launch, and program growth and sustainment; however, these steps are non-linear and dynamic. FINDINGS: The discussion that follows is not meant to be prescriptive; rather, all implementation tasks should be thoughtfully tailored to the unique needs and setting of the obstetric community and patient population. In particular, we are aware that implementation on the level described here assumes commitment of both effort and money on the part of clinicians, administrators, and the health system, and that such financial resources are not always available. We conclude with synthesis of a survey of existing collaborative care programs to identify implementation practices of existing programs.

Benzodiazepine withdrawal in pregnant women with opioid use disorders: An observational study of current clinical practices at a tertiary obstetrical hospital.

BACKGROUND: As more patients are admitted for medical complications related to opioid use disorders, physicians are called upon to manage withdrawal from co-occurring substance use disorders. We present an observational study of pregnant women with comorbid opioid and sedative-hypnotic use disorders hospitalized for benzodiazepine withdrawal. OBJECTIVES: Our primary aims were to assess current practices in withdrawal management in the perinatal period in patients admitted to an antepartum unit at a tertiary care setting with comorbid opioid and sedative-hypnotic use disorders; specifically, to identify patterns of withdrawal management, including the type of withdrawal protocol utilized, the total dosage of benzodiazepine used during that protocol, to assess patient variables associated with higher dosing, and to analyze neonatal outcomes. METHODS: A chart review of psychiatry consultations for benzodiazepine withdrawal in antepartum women was conducted for patients seen over a 3 year period with manual extraction of patient age, number of pregnancies, modality of benzodiazepine withdrawal management (symptom-triggered versus standing benzodiazepine taper), total amount of benzodiazepine used during the detoxification period, active methadone conversion versus stable methadone dose on admission, and average fetal heart tones during the withdrawal detoxification period. RESULTS: The majority of patients (83%) were undergoing methadone conversion or were stable on methadone maintenance. The mean cumulative benzodiazepine dose used was 8.3 ±â€¯10.5 mg in lorazepam equivalents. Women placed on a symptom-triggered protocol received lower mean benzodiazepine doses (2.4 ±â€¯6.9 mg) compared to those on a benzodiazepine taper in conjunction with a symptom-triggered protocol (17.9 ±â€¯20.6 mg; p < 0.001). Women who started methadone during admission tended to receive lower mean lorazepam doses (7.1 ±â€¯10.4) compared to women admitted on stable outpatient doses of methadone (11.5 ±â€¯10.6; p = 0.07). Using t-test and chi-square analyses on a subgroup of women (N = 50), no differences were found between women placed on a taper compared to a symptom-triggered scale alone in neonatal outcomes such as APGARS, NICU admissions, and preterm delivery with low rates of complications in both groups. CONCLUSIONS: A symptom-triggered benzodiazepine withdrawal protocol was associated with significantly lower total benzodiazepine use compared to standing taper regimens. Women started on methadone during admission tended to receive lower lorazepam doses compared to women admitted on stable doses of methadone. Preliminary maternal/neonatal outcomes were similar between symptom-triggered and taper groups.

Severity of anxiety moderates the association between neural circuits and maternal behaviors in the postpartum period.

Neuroimaging research has suggested that activity in the amygdala, center of the socioemotional network, and functional connectivity between the amygdala and cortical regions are associated with caregiving behaviors in postpartum mothers. Anxiety is common in the early postpartum period, with severity ranging from healthy maternal preoccupation to clinical disorder. However, little is known about the influence of anxiety on the neural correlates of early caregiving. We examined these relationships in a community cohort of 75 postpartum women (ages 18-22; predominantly low-SES, minority race) who listened to infant cry sounds while undergoing an fMRI assessment. Maternal self-reported symptoms of anxiety were mostly within the subclinical range. Positive and negative caregiving behaviors during filmed face-to-face mother-infant interactions were coded by independent observers. The results from whole-brain analyses showed that anxiety severity moderated the brain-maternal behavior relationships. Specifically, our results showed that the higher a mother's anxiety, the stronger the association between positive caregiving (i.e., maternal warmth and involvement) and amygdala-right posterior superior temporal sulcus (amygdala-RpSTS) functional connectivity. These results remained significant when we controlled for symptoms of depression and contextual variables. These findings suggest that functional connectivity between the amygdala and a social perception region (RpSTS) plays a particularly important role for anxious mothers in facilitating their positive parenting. These findings extend our understanding of the specific neural circuits that support positive maternal caregiving in the context of maternal anxiety, and they may help inform the future design of personalized and effective interventions.

Postpartum depressive symptoms moderate the link between mothers' neural response to positive faces in reward and social regions and observed caregiving.

Postpartum depression may disrupt socio-affective neural circuitry and compromise provision of positive parenting. Although work has evaluated how parental response to negative stimuli is related to caregiving, research is needed to examine how depressive symptoms during the postpartum period may be related to neural response to positive stimuli, especially positive faces, given depression's association with biased processing of positive faces. The current study examined the association between neural response to adult happy faces and observations of maternal caregiving and the moderating role of postpartum depression, in a sample of 18- to 22-year old mothers (n = 70) assessed at 17 weeks (s.d. = 4.7 weeks) postpartum. Positive caregiving was associated with greater precuneus and occipital response to positive faces among mothers with lower depressive symptoms, but not for those with higher symptoms. For mothers with higher depressive symptoms, greater ventral and dorsal striatal response to positive faces was associated with more positive caregiving, whereas the opposite pattern emerged for mothers with lower symptoms. There was no association between negative caregiving and neural response to positive faces or negative faces. Processing of positive stimuli may be an important prognostic target in mothers with depressive symptoms, given its link with healthy caregiving behaviors.

Telephone-Based Depression Care Management for Postpartum Women: A Randomized Controlled Trial.

OBJECTIVE: With a period prevalence of 21.9% in the year after birth, depression is a common complication of childbearing. We assessed the impact of telephone-delivered depression care management (DCM) on symptom levels, health service utilization, and functional status 3, 6, and 12 months postpartum. METHODS: The randomized controlled trial was conducted at the University of Pittsburgh, Pittsburgh, Pennsylvania, from March 2006 through September 2010. Women (N = 628) who screened positive for depression (a score of 10 or greater on the Edinburgh Postnatal Depression Scale) 4 to 6 weeks postpartum were evaluated with the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen and enrolled in a randomized trial of DCM compared to enhanced usual care (EUC). Clinicians conducted telephone contacts to educate, assist with treatment decisions, monitor symptoms, facilitate access to services, and encourage links to community resources. Independent evaluators collected symptom scores, functional status, and health services use at 3, 6, and 12 months postpartum. Primary outcome was reduction of symptoms as measured by the Structured Interview Guide for the Hamilton Depression Rating Scale with Atypical Depression Supplement. RESULTS: Mean depressive symptom and function scores significantly improved (by greater than 50%) in both groups of women but did not differ by DCM versus EUC assignment. Health services use was similar in women randomly assigned to DCM compared to EUC. Women with childhood sexual abuse responded significantly more favorably to DCM on depression and functional measures (all P values < .02). CONCLUSIONS: Both DCM and EUC favorably impacted depression symptom levels and function. The subgroup of women with childhood sexual abuse benefited significantly more from DCM compared to the EUC condition. Regular telephone availability of a clinician is a resource that appears to be particularly therapeutic to women with childhood sexual abuse. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00282776.

Mood symptoms in pregnant and postpartum women with bipolar disorder: a naturalistic study.

OBJECTIVE: We conducted a prospective naturalistic study of pregnant women with bipolar disorder (BD) to evaluate symptoms of BD across childbearing and assess whether pharmacotherapy reduced their severity. METHODS: Assessments were scheduled at 20, 30, and 36 weeks' gestation and 2, 12, 26, and 52 weeks postpartum. Symptoms were assessed using the Structured Interview Guide for the Hamilton Depression Rating Scale-Atypical Depression Supplement (SIGH-ADS) and Mania Rating Scale (MRS). RESULTS: Pregnant women (N=152) with BD were evaluated; 88 women (58%) were treated and 64 untreated (42%) with psychotropic drugs during pregnancy. Among the 88 women treated, 23 (26%) discontinued their medication in the first trimester and the remaining 65 (74%) were exposed throughout pregnancy or in the second and third trimesters. More than two-thirds (73%) of the women who remained in the study took psychotropic agents postpartum. The mean scores on the SIGH-ADS were in the mild range of depressive symptoms in both the psychotropic-treated and untreated groups in both pregnancy and postpartum. The majority of women had no or few symptoms of mania. Of the pregnant women treated with psychotropic agents, 66% received a guideline-concordant drug, and 34% received either antidepressant monotherapy (for BD I) or mono- or polypharmacy with a variety of other agents. CONCLUSIONS: This sample of perinatal women with BD was characterized by mild residual symptoms of depression independent of pharmacotherapy, which poses a risk for recurrence and impaired parenting. The treatment of childbearing women with BD deserves urgent clinical and research attention to improve psychiatric outcomes.

Predicting adolescent postpartum caregiving from trajectories of depression and anxiety prior to childbirth: a 5-year prospective study.

Symptoms of depression and anxiety in pregnancy have been linked to later impaired caregiving. However, mood symptoms are often elevated in pregnancy and may reflect motherhood-specific concerns. In contrast, little is known about the effects of prepregnancy depression and anxiety on postpartum caregiving. Understanding these developmental risk factors is especially important when childbearing also occurs during adolescence. The sample comprised 188 adolescent mothers (ages 12-19 years) who had participated in a longitudinal study since childhood. Mothers were observed in face-to-face interaction with the infant at 4 months postpartum, and caregiving behaviors (sensitivity, hostile-intrusive behavior, and mental state talk) were coded independently. Data on self-reported depression and anxiety gathered in the 5 years prior to childbirth were drawn from the large-scale longitudinal study. Parallel process latent growth curve models revealed unique effects of distal anxiety and slow decline in anxiety over time on lower levels of maternal mental state talk after accounting for the overlap with depression development. Depressive symptoms showed significant stability from distal measurement to the postpartum period, but only concurrent postpartum mood was associated with poorer quality of maternal speech. The results highlight specific targets for well-timed preventive interventions with vulnerable dyads.

The influence of motherhood on neural systems for reward processing in low income, minority, young women.

OBJECTIVE: Given the association between maternal caregiving behavior and heightened neural reward activity in experimental animal studies, the present study examined whether motherhood in humans positively modulates reward-processing neural circuits, even among mothers exposed to various life stressors and depression. METHODS: Subjects were 77 first-time mothers and 126 nulliparous young women from the Pittsburgh Girls Study, a longitudinal study beginning in childhood. Subjects underwent a monetary reward task during functional magnetic resonance imaging in addition to assessment of current depressive symptoms. Life stress was measured by averaging data collected between ages 8-15 years. Using a region-of-interest approach, we conducted hierarchical regression to examine the relationship of psychosocial factors (life stress and current depression) and motherhood with extracted ventral striatal (VST) response to reward anticipation. Whole-brain regression analyses were performed post-hoc to explore non-striatal regions associated with reward anticipation in mothers vs nulliparous women. RESULTS: Anticipation of monetary reward was associated with increased neural activity in expected regions including caudate, orbitofrontal, occipital, superior and middle frontal cortices. There was no main effect of motherhood nor motherhood-by-psychosocial factor interaction effect on VST response during reward anticipation. Depressive symptoms were associated with increased VST activity across the entire sample. In exploratory whole brain analysis, motherhood was associated with increased somatosensory cortex activity to reward (FWE cluster forming threshold p<0.001). CONCLUSIONS: These findings indicate that motherhood is not associated with reward anticipation-related VST activity nor does motherhood modulate the impact of depression or life stress on VST activity. Future studies are needed to evaluate whether earlier postpartum assessment of reward function, inclusion of mothers with more severe depressive symptoms, and use of reward tasks specific for social reward might reveal an impact of motherhood on reward system activity.

Right Frontoinsular Cortex and Subcortical Activity to Infant Cry Is Associated with Maternal Mental State Talk.

The study objective was to examine neural correlates of a specific component of human caregiving: maternal mental state talk, reflecting a mother's proclivity to attribute mental states and intentionality to her infant. Using a potent, ecologically relevant stimulus of infant cry during fMRI, we tested hypotheses that postpartum neural response to the cry of "own" versus a standard "other" infant in the right frontoinsular cortex (RFIC) and subcortical limbic network would be associated with independent observations of maternal mental state talk. The sample comprised 76 urban-living, low socioeconomic mothers (82% African American) and their 4-month-old infants. Before the fMRI scan, mothers were filmed in face-to-face interaction with their infant, and maternal behaviors were coded by trained researchers unaware of all other information about the participants. The results showed higher functional activity in the RFIC to own versus other infant cry at the group level. In addition, RFIC and bilateral subcortical neural activity (e.g., thalamus, amygdala, hippocampus, putamen) was associated positively with maternal mental state talk but not with more global aspects of observed caregiving. These findings held when accounting for perceptual and contextual covariates, such as maternal felt distress, urge to help, depression severity, and recognition of own infant cry. Our results highlight the need to focus on specific components of caregiving to advance understanding of the maternal brain. Future work will examine the predictive utility of this neural marker for mother-child function. SIGNIFICANCE STATEMENT: The current study advances extant literature examining the neural underpinning of early parenting behavior. The findings highlight the special functional importance of the right frontoinsular cortex-thalamic-limbic network in a mother's proclivity to engage in mental state talk with her preverbal infant, a circumscribed aspect of maternal caregiving purported to be a prerequisite of sensitive and responsive caregiving. These associations existed specifically for maternal mentalizing behavior and were not evident for more generic aspects of caregiving in this urban sample of 76 postpartum mothers. Finally, the findings were robust even when controlling for potential demographic, perceptual, and contextual confounds, supporting the notion that these regions constitute an innate, specialized maternal mentalizing network.

Transdermal Estradiol Treatment for Postpartum Depression: A Pilot, Randomized Trial.

Postpartum depression occurs in 14.5% of women in the first 3 months after birth. This study was an 8-week acute phase randomized trial with 3 cells (transdermal estradiol [E2], sertraline [SERT], and placebo [PL]) for the treatment of postpartum major depressive disorder. However, the study was stopped after batch analysis revealed that the E2 serum concentrations were lower than prestudy projections. This paper explores our experiences that will inform future investigations of therapeutic E2 use. Explanations for the low E2 concentrations were as follows: (1) study patch nonadhesion, which did not explain the low concentrations across the entire sample. (2) Ineffective transdermal patch preparations, although 2 different patch preparations were used and no significant main effect of patch type on E2 concentrations was found. (3) Obesity, at study entry, E2-treated women had body mass index of 32.9 (7.4) (mean [SD]). No pharmacokinetic data comparing E2 concentrations from transdermal patches in obese women versus normal weight controls are available. (4) Induction of cytochrome P450 (CYP450) 3A4 and other E2 elimination pathways in pregnancy. CYP4503A4 is induced in pregnancy and is a pathway for the metabolism of E2. Conversion to estrone and phase II metabolism via glucuronidation and sulfation, which also increase in pregnancy, are routes of E2 elimination. The time required for these pathways to normalize after delivery has not been elucidated. The observation that transdermal E2 doses greater than 100 µg/d did not increase serum concentrations was unexpected. Another hypothesis consistent with this observation is suppression of endogenous E2 secretion with increasing exogenous E2 dosing.