Implementing an inpatient postpartum depression screening, education, and referral program: a quality improvement initiative.

BACKGROUND: Perinatal mood and anxiety disorders are common and may interfere with pregnancy, delivery, and the postpartum period. Best practice includes symptom screening, patient education, and appropriate referrals; however, many hospitals struggle to identify and support perinatal mood and anxiety disorders patients. OBJECTIVE: Therefore, the Cedars-Sinai Postpartum Depression Screening, Education and Referral Program was initiated and evaluated. STUDY DESIGN: Using the Standards for QUality Improvement Reporting Excellence 2.0 guidelines, we reported outcomes (N=19,564 deliveries) from 4 interventions: (1) nurse-champion training; (2) use of the 9-item Patient Health Questionnaire-9 in the postpartum unit; (3) a series of brief in-service trainings; and (4) a 10-minute video training. We collected data including nurse feedback, screening rates, screen-positive rates, and social work consultation rates. RESULTS: The 4 interventions increased: (1) nurse-champion screening comfort and perinatal mood and anxiety disorder knowledge; (2) Patient Health Questionnaire-9 screening rates from 10% to 99% and screen-positive rates from 0.04% to 2.9%; and (3) rates of social work consultation from 1.7% to 8.4%. CONCLUSION: Quality improvement results from the first 3 years of the program suggest that 4 interventions improved screening rates, screen-positive rates, and social work consultation rates. Future work will focus on method of screening, patients at highest risk of perinatal mood and anxiety disorders, and ongoing nurse training.

Vitamin D deficiency and depressive symptoms in pregnancy are associated with adverse perinatal outcomes.

Prenatal vitamin D deficiency and prenatal depression are both separately associated with adverse perinatal outcomes; however, to our knowledge no studies have investigated the effects of having both risk factors. Our objective was to determine to what extent vitamin D deficiency predicts adverse perinatal outcomes and whether elevated depressive symptoms in pregnancy places women at additional increased risk. This study was a secondary data analysis of prospective data collected from a cohort of pregnant women (N = 101) in an obstetric clinic of a large medical center. Maternal vitamin D deficiency (serum 25(OH)D ≤ 20 ng/ml) and depressive symptoms (Edinburgh Postnatal Depression Scale, EPDS) were assessed in early pregnancy. A composite of four adverse perinatal outcomes (low birth weight, preterm birth, small-for-gestational age, and preeclampsia) were abstracted from medical charts. Nineteen of the 101 women had one or more adverse perinatal outcome and 84% with an adverse outcome (16/19) were not White. Both prenatal and time of delivery vitamin D deficiency were associated with developing an adverse outcome compared to those vitamin D sufficient (prenatal relative risk 3.43; 95% CI 1.60-7.34, p = 0.004; delivery time relative risk 5.14, 95% CI 2.68-9.86, p = 0.004). These both remained significant after adjusting for BMI. A higher rate of adverse outcome was found when women had both prenatal vitamin D deficiency and elevated depressive symptoms (EPDS ≥ 10). Sixty percent with both risk factors had an adverse perinatal outcome versus 17% with only one or neither risk factor (relative risk 3.60; 95% CI 1.55-8.38, p = 0.045), worthy of investigation with larger samples. Together, prenatal vitamin D deficiency and elevated depressive symptoms in pregnancy may increase risk for adverse perinatal outcomes, especially in racial minorities. Obstetric providers should consider routine prenatal depression screening. The impact of vitamin D supplementation to reduce risk for adverse perinatal outcomes should be studied in prospective trials. Our results suggest that supplementation early in pregnancy might be especially beneficial for depressed women.

It Is Time for Routine Screening for Perinatal Mood and Anxiety Disorders in Obstetrics and Gynecology Settings.

IMPORTANCE: Women are 2 to 3 times more likely than men to experience depression in their lifetime, and the greatest risk occurs during the reproductive years. As an obstetrics and gynecology physician or provider, you will likely encounter women who are at risk of development or relapse of a mental disorder during this vulnerable time. OBJECTIVE: The aim of this review is to examine theory and research on mood and anxiety disorders during the perinatal period with an emphasis on screening recommendations. EVIDENCE ACQUISITION: A PubMed and PsycINFO search for English-language publications about perinatal mood and anxiety disorders and screening was performed and included studies on subtopics. RESULTS: The literature reviewed suggests that perinatal mood and anxiety symptoms are prevalent and have significant consequences, and best practices for early detection are through routine depression and anxiety screening in the obstetrics setting. This includes overcoming barriers to care and use of liaison services to potentially reduce risk. CONCLUSIONS AND RELEVANCE: High-quality prenatal care systems should develop the capacity for depression and anxiety risk assessment and treatment. Providers should routinely screen using validated screening tools, provide maternal mental health education, and be aware of the various medical, psychological, and complementary approaches for treating mood and anxiety disorders, to best guide and refer patients. The use of this practice will increase the quality of life in pregnant women with depression and anxiety and may help to reduce the likelihood of adverse birth outcomes, postpartum mental health problems, and adverse effects on offspring.

Adverse Perinatal Outcomes and Postpartum Multi-Systemic Dysregulation: Adding Vitamin D Deficiency to the Allostatic Load Index.

Background Allostatic load (AL) is an index of multi-system physiological "wear-and-tear," operationalizing emergent chronic disease risk and predicting morbidity and mortality. AL has been proposed as an organizing framework for studying pregnancy outcomes and additional AL biomarkers for the study of maternal health would be valuable. Objectives To test whether adverse perinatal outcomes are associated with postpartum AL and if including vitamin D deficiency (serum 25(OH)D < 20 ng/ml) as an additional marker of postpartum AL increases the association. Methods The Community Child Health Network is a community-based participatory research network that enrolled women at birth and followed them for 2 years measuring ten biomarkers (body mass index, waist: hip ratio, pulse, systolic and diastolic blood pressures, cortisol slope, c-reactive protein, hgbA1c, HDL, and total cholesterol) at 6 and 12 months postpartum. A composite of four adverse perinatal outcomes (low birth weight, preterm birth, preeclampsia, and gestational diabetes) was collected from medical charts in a sample of 164 women from one site and serum 25(OH)D status was measured 24-39 weeks postpartum in this cohort. Results Twenty-nine percent experienced one or more of the four adverse perinatal outcomes. Serum 25(OH)D was significantly inversely correlated with the AL index (Spearman's r = -0.247, p = 0.002). Logistic regression results adjusting for maternal age and race showed that adverse outcome was significantly associated with higher postpartum AL (OR 1.53 for a 1-unit increase in AL, 95% CI 1.24-1.89). Adding 25(OH)D deficiency as an 11th component to the AL index improved the model fit (Delta (-2LogL) = 3.955, p = 0.047), and improved the Akaike information criterion (180.32 vs. 184.27). Conclusion Women with adverse perinatal outcomes have higher postpartum AL and adding vitamin D deficiency to the AL index strengthens this association.

Lower prenatal vitamin D status and postpartum depressive symptomatology in African American women: Preliminary evidence for moderation by inflammatory cytokines.

Vitamin D deficiency and elevated pro-inflammatory cytokines have each been associated individually with postpartum depression (PPD). African American women are at increased risk for prenatal vitamin D deficiency, inflammation, and prenatal and postpartum depressive symptoms, but biological risk factors for PPD in this population have rarely been tested. This prospective study tested whether low prenatal vitamin D status (serum 25-hydroxyvitamin D, 25[OH]D) predicted PPD symptomatology in pregnant African American women and whether high levels of prenatal inflammatory cytokines interacted with low 25(OH)D in effects on PPD symptoms. Vitamin D status was measured in the first trimester in a sample of 91 African American pregnant women who had a second trimester blood sample assayed for inflammatory markers. Depressive symptoms were assessed at a postpartum visit. An inverse association between prenatal log 25(OH)D and PPD symptomatology approached significance (ß = -0.209, p = 0.058), and interleukin-6 and IL-6/IL-10 ratio significantly moderated the effect. Among women with higher levels of inflammatory markers, lower prenatal log 25(OH)D was associated with significantly higher PPD symptoms (p < 0.05). These preliminary results are intriguing because, if replicable, easy translational opportunities, such as increasing vitamin D status in pregnant women with elevated pro-inflammatory cytokines, may reduce PPD symptoms.

Prenatal depression and adverse birth outcomes: an updated systematic review.

Complications related to preterm birth (PTB) and low birth weight (LBW) are leading causes of infant morbidity and mortality. Prenatal depression is a hypothesized psychosocial risk factor for both birth outcomes. The purpose of this systematic review was to examine evidence published between 1977 and 2013 on prenatal depression and risks of these primary adverse birth outcomes. A systematic search of the PUBMED and PsycINFO databases was conducted to identify studies testing the associations between prenatal depressive symptoms, or diagnoses of depression, and risk of PTB or LBW. We systematically selected 50 published reports on PTB and length of gestation, and 33 reports on LBW and BW. Results were reviewed by two independent reviewers and we evaluated the quality of the evidence with an established systematic review method, the Newcastle Ottawa Scale. We then undertook a narrative synthesis of the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Less than a quarter of 50 published reports found that prenatal depression was significantly associated with PTB or gestational age. In contrast, slightly more than half of the 33 reports found that prenatal depression was associated with LBW or BW. When weighing methodological features, we determined that the effects of prenatal depression on LBW are more consistent than effects on length of gestation or PTB. Although the evidence may not be strong enough to support routine depression screening for risk of adverse outcomes, screening to enable detection and timely treatment to reduce risk of postpartum depression is warranted. Further rigorous research on prenatal depression and adverse birth outcomes is needed.

Diagnosing premenstrual dysphoric disorder: the reliability of a structured clinical interview.

Premenstrual dysphoric disorder (PMDD), a diagnosis included for further study in the DSM-IV-TR (American Psychiatric Association 2000), lacks a structured interview. The reliability of a Structured Clinical Interview for DSM-IV-TR-Defined PMDD (SCID-PMDD) was assessed with 96 participants who spanned the full range of premenstrual problems. All individual SCID-PMDD items had high inter-rater agreement, and the overall reliability of diagnosis was high (kappa = 0.96). The SCID-PMDD provides a structured, sensitive, and reliable measure of the symptoms and impairment criteria for PMDD.

Women and major depressive disorder: clinical perspectives on causal pathways.

BACKGROUND AND AIMS: Epidemiological data on the prevalence of mood disorders demonstrate that major depressive disorder (MDD) is approximately twice as common in women as in men and that its first onset peaks during the reproductive years. We aimed to review key social, psychological, and biological factors that seem strongly implicated in the etiology of major depression and to focus on sex-specific aspects of depression, such as the role of a woman's reproductive life cycle in depressive symptomatology. METHODS: A review of the literature, from 1965 to present, was conducted. RESULTS: An integrated etiological model best explains gender and sex differences in depression. Social, psychological, and biological variables must be simultaneously taken into account. These vulnerabilities include (but are not limited to) gender-specific roles in society, life stress such as trauma, a tendency toward ruminative coping strategies, and the effects of sex hormones and genetic factors. CONCLUSIONS: To effectively treat MDD in women and to prevent the recurrence of illness in vulnerable women, clinicians must understand the sex-specific aspects of mood disorders over the longitudinal course of women's reproductive lives. A biopsychosocial approach should, therefore, be the main focus of future research and practice, to eventually result in an integrated etiological model of depression in women. Based on the prevalence of MDD in women, timely screening, diagnosis, and intervention should be public health priorities.

Frontal EEG asymmetry and premenstrual dysphoric symptomatology.

Resting frontal electroencephalographic (EEG) asymmetry has been hypothesized to tap a diathesis toward depression or other emotion-related psychopathology. Frontal EEG asymmetry was assessed in college women who reported high (n = 12) or low (n = 11) levels of premenstrual negative affect. Participants were assessed during both the follicular and the late luteal phases of the menstrual cycle. Women reporting low premenstrual dysphoric symptomatology exhibited greater relative left frontal activity at rest than did women high in premenstrual dysphoric symptomatology, an effect that was not qualified by phase of cycle. Although women with extreme levels of symptomatology were assessed, the question of whether such symptoms qualified for premenstrual dysphoric disorder criteria was not assessed. These results are consistent with a diathesis-stress model for premenstrual dysphoric symptomatology.