Aims, measures, study sites and participant samples of the Transcultural Study of Postnatal Depression.

BACKGROUND: Although postnatal depression is a common condition, with adverse effects on the child, mother and partner, there has been no research to date linking analyses of its origins and consequences with studies of service provision in different national health and social systems. AIMS: The Transcultural Study of Postnatal Depression (TCS-PND) was set up to develop a set of instruments to facilitate such research. METHOD: Seven research instruments were piloted in studies carried out in ten centres in eight countries. A qualitative study looked at the cross-cultural equivalence of the concept of postnatal depression. RESULTS: The results are reported in the individual papers in this supplement. CONCLUSIONS: Reliable and culturally valid measures are now available for future comparative research into postnatal depression within different health systems and countries.

Contextual Assessment of the Maternity Experience: development of an instrument for cross-cultural research.

BACKGROUND: There is evidence that stressors may trigger the onset of a depressive episode in vulnerable women. A new UK interview measure, the Contextual Assessment of the Maternity Experience (CAME), was designed to assess major risk factors for emotional disturbances, especially depression, during pregnancy and post-partum. AIMS: With in the context of a cross-cultural study, to establish the usefulness of the CAME, and to test expected associations of the measure with characteristics of the social context and with major or minor depression. METHOD: The CAME was administered antenatally and postnatally in ten study sites, respectively to 296 and 249 women. Affective disorder throughout pregnancy and up to 6 months postnatally was assessed by means of the Structured Clinical Interview for DSM-IVAxis I Disorders. RESULTS: Adversity, poor relationship with either a partner or a confidant, and negative feelings about the pregnancy all predicted onset of depression during the perinatal period. CONCLUSIONS: The CAME was able to assess major domains relevant to the psychosocial context of the maternity experience in different cultures. Overall, the instrument showed acceptable psychometric properties in its first use in different cultural settings.

Menstrual cycle effects on hypothalamic dopamine receptor function in women with a history of puerperal bipolar disorder.

Neuroendocrine challenge tests of hypothalamic dopamine receptor function in the early postpartum period suggest that the sensitivity of these receptors is increased in women with a history of bipolar disorder after childbirth. We tested the hypothesis that, in women predisposed to bipolar disorder in the puerperium, hypothalamic dopamine receptor function is more sensitive to changes in circulating ovarian hormone concentrations than in women without such histories. Eight fully recovered and drug-free women who had had at least one episode of bipolar illness following childbirth were compared with nine normal controls. Growth hormone (GH) responses to apomorphine (APO 0.005 mg s.c.) were measured in the early follicular phase, when plasma concentrations of ovarian hormones are low, and in the mid-luteal phase, when they are relatively high. The recovered bipolar subjects and the controls did not differ from each other in their follicular and midluteal oestrogen and progesterone concentrations. In the midluteal phase, both groups had increased oestrogen and progesterone levels. The recovered bipolar subjects did not differ from controls in baseline concentrations of GH in either of the menstrual phases. The APO-GH responses of the two groups did not differ in the follicular phase, but in the midluteal phase, when female sex steroids are relatively increased, the recovered group had significantly enhanced APO-GH responses [MANOVA for repeated measures: (i) area under the curve, group by phase effect: p < 0.04; (ii) GH peak rise after APO, group by phase effect: p < 0.056] and the responses were not related to concurrent measures of mood. The results of this small study of women predisposed to bipolar disorder in the puerperium shows an increased dopaminergic receptor sensitivity in the luteal phase of the menstrual cycle. It suggests that their dopaminergic systems have increased sensitivity to changes in circulating female sex steroids. This may be aetiologically relevant to the pathogenesis of puerperal bipolar disorder.

Can we prevent postnatal depression? A randomized controlled trial to assess the effect of continuity of midwifery care on rates of postnatal depression in high-risk women.

OBJECTIVE: To evaluate the effectiveness of continuous midwifery care in reducing rates of postnatal depression in women with histories of depression. METHODS: Fifty-one women from a sample of 98 pregnant women with histories of major depressive disorder were randomly allocated, at antenatal booking, to continuous midwifery care. The remaining 47 women received standard maternity care. A total of 87 women (44 treatment, 43 control) completed baseline assessments (after randomization) and outcome assessments (at 3 months postpartum). RESULTS: Of the women allocated to continuous midwifery care, 88% complied in full with their allocated treatment protocol. Forty-nine percent of women had an episode of illness in pregnancy (DSM-III-R case of major or minor depression), 26% developed a new episode of illness after antenatal booking, and 23% were depressed in the first 3 months postpartum. There were no differences between treatment conditions in total rates, or rates within the context of social adversity, of antenatal depression, depressions which occurred post-booking, postnatal depression, and the duration of depressive episodes. CONCLUSIONS: While continuous midwifery care had no impact on psychiatric outcome, it was highly successful at engaging women in treatment and therefore has an important contribution to make in the care of child-bearing women with mental health problems.

Sensorimotor and cognitive development of infants of mothers with schizophrenia.

BACKGROUND: The parenting environment provided by mothers with schizophrenia is likely to contribute to the cognitive impairment observed in their offspring. AIMS: To assess the relative contribution of maternal schizophrenia, obstetric factors and mothers' lifestyle to the cognitive development of infants in their first year. METHOD: The Bayley Scales of Infant Development were administered to 19 infants of mothers with schizophrenia, 34 with non-psychotic depression in the mother, 29 with affective psychosis in the mother and 24 normal controls when the babies were two and seven months of age. RESULTS: At two months, infants of mothers with schizophrenia and of those with affective psychosis had lower mental development index (MDI) scores than controls. At seven months, infants of mothers with schizophrenia had lower MDI scores than all other groups. When infant birth weight and mothers' social class were taken into account there was no effect of maternal schizophrenia on infants' MDI scores. CONCLUSIONS: Infants of mothers with schizophrenia are likely to have impaired cognitive development. This may be due in part to environmental factors such as the mother's lifestyle.

Postnatal depression in Japanese women who have given birth in England.

A total of 98 Japanese mothers who became pregnant in England were monitored from 36 weeks gestation to 3 months postpartum. Psychiatric status was assessed by self-report, using a Japanese translation of the Edinburgh Postnatal Depression Scale (EPDS) and by an interview with Japanese psychiatrists, using Japanese translations of the Schedule for Affective Disorders and Schizophrenia (SADS) and Research Diagnostic Criteria (RDC). Rates of depression were similar to those observed in Japanese women having babies in Japan. Twelve mothers (12%) were categorised as having new onsets of depression (six major and six minor depressive disorder) during the 3 months following delivery. Depression was associated with having had a stressful life event or obstetric but without grandmothers' support-depressed and non-depressed women were equally likely to have had their mothers visit England to attend the delivery. Women who became depressed had significantly higher EPDS scores at 1 month postpartum than those who remained well. However, depressions were not detected when the EPDS was used as a screening instrument. With an EPDS cut-off of greater than 12, the criterion used in western samples, sensitivity was zero. Lowering the criterion to improve the instrument's sensitivity merely reduced its specificity. These results suggest that Japanese women may be less likely to express depressive symptoms by self-report, at least when instruments designed for western samples are used.

Smoking in pregnancy: a study of psychosocial and reproductive risk factors.

Smoking during pregnancy is a well-recognized public health problem and several associated variables to smoking have been identified such as low socioeconomic status, low educational attainment, low social support, younger age and unplanned pregnancy. The purpose of this research was to further examine possible risk factors associated with smoking in pregnancy. One hundred and nineteen pregnant women who were having their first babies had been recruited in early pregnancy from a General Hospital Obstetric Service and were followed up throughout the pregnancy and then until 4 years after the birth of the baby. The findings of this longitudinal study have already been reported in relation to maternal postnatal depression and to child development and in the analyses of smoking behavior which are reported here, it was possible to control for several confounding variables in the search for possible risk factors. Women who smoked during pregnancy were more likely to have had previous miscarriages and terminations and to have taken longer to conceive this pregnancy. They were also more likely to report marital difficulties and more likely to physically discipline their 1-year-old infants. These results point to a possible different perspective in trying to understand this intransigent unhealthy behavior.

The growth hormone response to apomorphine at 4 days postpartum in women with a history of major depression.

We have examined the responsiveness of dopamine sensitive neurones in the postpartum period in woman with a history of major depression who are at high risk of experiencing a recurrence of illness in the postpartum period. Fourteen women were assessed at 36 weeks of pregnancy and during the 3 months following delivery, using the Schedule for Affective Disorders and Schizophrenia, including its change version. They were not depressed at initial assessment. Five of the 14 women went on to experience a postpartum relapse (2 major depressive disorder, 2 generalised anxiety disorder, 1 panic disorder). On the fourth day postpartum, i.e., before relapse, the growth hormone response to the dopamine agonist apomorphine was measured as an index of the functional state of hypothalamic dopamine D2 receptors. Women who subsequently relapsed had a significantly greater growth hormone response to apomorphine than those who remained well. This was particularly marked in women with anxiety/panic. The development of increased sensitivity of hypothalamic dopamine D2 receptors in the postpartum period appears to predict the onset of depressive and anxiety disorders.

Infanticide in Scotland.

Details from Scottish Office records of all infants under a year who were the victims of homicide in Scotland during 1978-1993 are presented and compared with results from studies of infant homicide in England and Wales. Although Scottish homicide rates in the total population are much higher than those in England and Wales, the annual Scottish infanticide rate (43/million) is remarkably similar to that of England and Wales (45/million). In addition, characteristics of victims and perpetrators are also similar between the two regions. As with England and Wales, in Scotland the younger the infant the greater the risk of becoming the victim of homicide (83% were killed within 6 months of birth); male babies were more frequently killed than female ones; a parent was the most frequent perpetrator (93% of offences); mothers tended to kill neonates but for infants older than a day more fathers than mothers were recorded as the main accused. Mothers and fathers were convicted of similar offences but fathers were less likely to receive non-custodial sentences. Differences in sentencing appeared to be related to either gender-related differences in attributions as to the motivation for the offence, or to the level of violence used against the victim. Offences of mothers were most frequently recorded as being motivated by mental illness, those by fathers as due to rage. Fathers were more likely to have killed by kicking or hitting, mothers by some form of suffocation.

Treatment of major depression with metyrapone and hydrocortisone.

Eight inpatients with Major Depression were treated with metyrapone and hydrocortisone in a balanced order placebo-controlled single-blind cross-over study. The hydrocortisone dose (30 mg daily) was a physiological replacement dose and the metyrapone dose was titrated against plasma cortisol in order to keep cortisol within physiological limits. The treatment resulted in a significant reduction in depressive symptoms. This placebo-controlled study replicates the results of several uncontrolled studies but leaves open for further study the mechanism by which the combined administration of metyrapone and hydrocortisone might exert its antidepressant effect.

Infanticide in England and Wales.

In England and Wales children under one year of age are at four times greater risk of becoming victims of homicide than either older children or the general population. The annual rate of infant homicide (45 per million) has remained relatively constant since the Homicide Act (1957) in contrast with a progressive fall in the infant mortality rate. Details from Home Office records of all infants under a year who were the victims of homicide during 1982-1988 are presented. Infants were most at risk on the first day of life--neonates accounted for 21% of victims and 13% of the victims were between one day and one month old. Thereafter the proportion decreased steadily so that by the final quarter of the first year the risk of becoming a homicide victim equalled that of the general population. Excluding neonates, there were more male victims than female ones, especially in the first three months. A parent was the most likely perpetrator. For all neonaticides the mother was recorded as a suspect, 36% of these mothers were subsequently indicted, all but two were convicted of infanticide and all their convictions resulted in probation. For children over a day marginally more fathers than mothers were recorded as the prime suspect. Mother and father suspects were equally likely to be indicted and also equally likely to be convicted of a homicide offence. However, mothers received both less severe convictions and less severe sentences than fathers. Fathers were more likely than mothers to have killed their infants using violence which wounded. Nonetheless sentences were unrelated to the brutality of the offence: mothers who had killed with wounding violence received less severe penalties than fathers who had killed in a non-wounding way.

Women whose mental illnesses recur after childbirth and partners' levels of expressed emotion during late pregnancy.

Expressed emotion (EE) in the partners of 25 pregnant women with a history of psychosis or severe depression and in 13 pregnant control subjects without any previous psychiatric disorder was assessed in the ninth month of pregnancy. At this time, no patient presented as a case according to RDC. Eleven subjects with a history of psychiatric disorder experienced a further episode of illness in the six months following delivery. Partners of women who became ill had made fewer critical and positive comments about their wives during the pregnancy than the partners of women who remained well. Poor self-rated social adjustment in the partners was also predictive of recurrence of illness after delivery.

Contribution of psychological and social factors to psychotic and non-psychotic relapse after childbirth in women with previous histories of affective disorder.

Twenty-six women with a history of bipolar or schizoaffective disorder, 17 women with histories of major depressive disorder and 45 control women without any previous psychiatric history were assessed in the 9th month of pregnancy on selected psychosocial measures. No subject was a 'case' as defined by the Research Diagnostic Criteria (RDC) from this time until the delivery. Within 6 months postpartum, 22 (51%) of the women with histories of mental illness were categorised as having relapsed (RDC case). Twelve women developed a psychosis (mania, hypomania or schizomania) and these illnesses occurred only in women with histories of affective or schizoaffective psychosis whereas 10 other women who became depressed after delivery came equally from the women with histories of psychosis (N = 5) as from those with histories of major depression (N = 5). Three (7%) control women also developed postpartum non-psychotic depressive disorders. Multivariate analyses suggest that different psychosocial factors contribute to the recurrence of affective and schizoaffective psychosis after delivery as opposed to non-psychotic postpartum affective disorders. A non-psychotic illness was predicted by antenatal neuroticism and a severe life event before illness onset. A recurrence of psychosis postpartum was predicted by a history of mania, hypomania or schizomania, a more recent psychiatric admission and reported marital difficulties. In this sample of women, life stress led to postpartum depression irrespective of the subject's past history and the high rates of recurrence of affective or schizoaffective psychosis (47%) probably mainly reflected a pre-existing physiological or psychological vulnerability which may have been exacerbated by, or contributed to, marital difficulties.

Increased sensitivity of dopamine receptors and recurrence of affective psychosis after childbirth.

OBJECTIVE: To test the hypothesis that affective psychosis after childbirth is associated with an altered sensitivity to dopaminergic stimulation. DESIGN: Prospective study of pregnant women at high risk of developing an affective psychosis after childbirth. Clinical assessments in pregnancy and after delivery were made by using a semistructured interview (schedule for affective disorders and schizophrenia) and psychiatric illnesses were categorised according to operational criteria (research diagnostic criteria). SETTING: Obstetric and psychiatric departments in and around Greater London. SUBJECTS: 29 pregnant women with a history of bipolar or schizoaffective psychosis and 47 control pregnant women. Of these, 16 from each group participated in a growth hormone challenge test and the results for 15 women in each group were analysed. INTERVENTIONS: On the fourth day postpartum women participating in the hormone challenge test were given a subcutaneous injection of a small dose (0.005 mg/kg) of the dopamine agonist apomorphine. MAIN OUTCOME MEASURES: Growth hormone secretion in response to apomorphine as an index of the functional state of hypothalamic dopamine receptors. RESULTS: Eight of the 15 women at risk of psychosis subsequently had a recurrence of illness (five bipolar, one schizomanic, and two major depressive illnesses); these women had significantly greater growth hormone responses to apomorphine than the seven at risk women who remained well and the 15 controls, and there were no significant differences between groups in average baseline growth hormone concentrations. The mean (SD) concentrations for women with recurrence, women at risk who remained well, and control women respectively were: average baseline concentrations 1.06 (1.14), 1.44 (1.39), and 0.90 (1.34) mU/l; peak increase in concentrations 13.68 (12.95), 3.46 (4.68), and 3.40 (3.83) mU/l (between group difference p less than 0.05); average increase in concentrations 6.74 (7.01), 1.78 (3.39), and 1.40 (2.05) mU/l (p less than 0.05). CONCLUSIONS: The onset of affective psychosis after childbirth was associated with increased sensitivity of dopamine receptors in the hypothalamus and possibly elsewhere in the brain. Such changes may be triggered by the sharp fall in circulating oestrogen concentrations after delivery.

Life stress and post-partum psychosis: a preliminary report.

This is a preliminary report from a prospective study of the influence of psychosocial stressors on post-natal relapse in women at high risk of psychiatric disorder after childbirth. Forty-three index subjects with a previous history of psychosis or severe depression were compared with 45 pregnant control subjects without any previous psychiatric disorder. After delivery 51% of index subjects relapsed (RDC diagnoses): 28% were categorised as psychotic and 23% non-psychotic. All psychotic relapses were in women with a previous history of bipolar or schizoaffective disorder (46% of this subgroup). Only the non-psychotic post-partum relapses (mostly depressions) were associated with an increased likelihood of a severe life event in the 12 months preceding illness onset.