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Postpartum depression (PPD) remains the most common complication in modern obstetrics, and a leading cause of postpartum mortality in the first year of life. The last 15 years have brought [...]

A growing number of women ask about non-pharmacologic approaches for either the treatment of acute perinatal depression or for relapse prevention during pregnancy. The last several decades have brought an [...]

Postpartum/perinatal depression (PPD) remains the most common complication in modern obstetrics, with a prevalence of 10%-15% based on multiple studies over the last 2 decades. Over those same 2 decades, [...]

When last I wrote this column, I was preparing for travel to professional meetings in the spring, planning a presentation for an upcoming grand rounds, and readying to host a [...]

Much of the focus of reproductive psychiatry over the last 1-2 decades has been on issues regarding risk of fetal exposure to psychiatric medications in the context of the specific [...]

The experience of practicing reproductive psychiatry in the context of the pandemic has highlighted unique situations I've written about in previous columns that have affected pregnant and postpartum women during [...]

For the last 25 years, my colleagues have spent midday on Wednesdays at clinical rounds as a group--a time spent reviewing cases in perinatal psychiatry and important new scientific findings [...]

The last 15 years have brought increased effort to screen for postpartum psychiatric illness. That's exceedingly welcome given the morbidity and potential mortality associated with postpartum psychiatric disorders across the [...]

The last 15 years have brought increased effort to screen for postpartum psychiatric illness. That's exceedingly welcome, given the morbidity and potential mortality associated with postpartum psychiatric disorders across the [...]

Postpartum depression, in many respects, has become a household term. Over the last decade, there has been increasing awareness of the importance of screening for postpartum depression, with increased systematic [...]

The last 15-20 years have brought enormous attention to the relevant clinical issues regarding prescribing antidepressants during pregnancy. Concern about the effects of fetal exposure to selective serotonin reuptake inhibitors [...]

Across this period of the pandemic, we've spent considerable attention focusing on adaptations to clinical care for pregnant and postpartum women across the board. From the start, this has included [...]

Since the start of the pandemic, we have been conducting an extra hour of Virtual Rounds at the Center for Women s Mental Health. Virtual Rounds has been an opportunity [...]

Editor's note: As Ob.Gyn. News celebrates its 50th anniversary, we wanted to know how far the medical community has come in identifying and mitigating drug risks during pregnancy and in [...]

In a previous column, I addressed some of the issues that quickly arose in the context of the COVID-19 pandemic and their implications for reproductive psychiatry. These issues ranged from [...]

Since March 2020, my colleagues and I have conducted Virtual Rounds at the Center for Women's Mental Health at Massachusetts General Hospital, Boston. It has been an opportunity to review [...]

Careful management of bipolar disorder during pregnancy is critical, because for so many patients with this illness, the road to emotional well-being has been a long one, requiring a combination [...]

The last decade has brought appropriate attention to the high prevalence of postpartum mood and anxiety disorders, with postpartum depression (PPD) constituting the most common complication in modern obstetrics. There [...]

Objective: This study estimated the risk of recurrence of mood episodes among women with a history of bipolar disorder who continued or discontinued treatment with mood stabilizers during pregnancy. Method: In a prospective observational clinical cohort study, the authors determined recurrence risk and survival-analysis-based time to recurrence of a new episode in 89 pregnant women with DSM-IV bipolar disorder. Eligible subjects were euthymic at conception and continued mood stabilizer treatment or discontinued treatment proximate to conception. Results: The overall risk of at least one recurrence in pregnancy was 71%. Among women who discontinued versus continued mood stabilizer treatment, recurrence risk was twofold greater, median time to first recurrence was more than fourfold shorter, and the proportion of weeks ill during pregnancy was five times greater. Median recurrence latency was 11 times shorter after abrupt/rapid versus gradual discontinuation of mood stabilizer. Most recurrences were depressive or mixed (74%), and 47% occurred during the first trimester. Predictors of recurrence included bipolar II disorder diagnosis, earlier onset, more recurrences/year, recent illness, use of antidepressants, and use of anticonvulsants versus lithium. Conclusions: Discontinuation of mood stabilizer, particularly abruptly, during pregnancy carries a high risk for new morbidity in women with bipolar disorder, especially for early depressive and dysphoric states. However, this risk is reduced markedly by continued mood stabilizer treatment. Treatment planning for pregnant women with bipolar disorder should consider not only the relative risks of fetal exposure to mood stabilizers but also the high risk of recurrence and morbidity associated with stopping maintenance mood stabilizer treatment.

Objective: Current practice guidelines discourage use of lithium during breast-feeding, despite limited data. This study aimed to quantify lithium exposure in nursing infants. Method: In 10 mother-infant pairs, the authors obtained assays of lithium in maternal serum, breast milk, and infant serum and indices of infant renal and thyroid function. Results: Maternal serum, breast milk, and infant serum daily trough concentrations of lithium averaged 0.76, 0.35, and 0.16 meq/liter, respectively, each lithium level lower than the preceding level by approximately one-half. No serious adverse events were observed, and elevations of thyroid-stimulating hormone, blood urea nitrogen, and creatinine were few, minor, and transient. Conclusions: Serum lithium levels in nursing infants were low and well tolerated. No significant adverse clinical or behavioral effects in the infants were noted. These findings encourage reassessment of recommendations against lithium during breastfeeding and underscore the importance of close clinical monitoring of nursing infants.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2005.09.042 Byline: Lee S. Cohen, Claudio N. Soares, Hadine Joffe Keywords: Antidepressants; Depression; Estrogens; Hormone therapy; Hot flashes; Menopause Abstract: Recent census data indicate that, in the United States, an increasing number of women -- almost 1.5 million each year -- are reaching menopause. The menopausal transition is marked by intense hormonal fluctuations, and may be accompanied by vasomotor complaints, sleep disturbances, changes in sexual function, and increased risk for osteoporosis and cardiovascular disease. In addition, there is evidence of increased risk for developing depression, even among women who never experienced depressive symptoms before. Thus depression during the perimenopause may have a substantial impact on personal, family, and professional spheres of life. A challenge to clinicians and health professionals lies in the identification of the most tolerable treatments to manage depression and improve quality of life in an aging population. Any treatment strategy should take into account not only the spectrum of side effects that may complicate treatment but also other menopause-related factors (e.g., vasomotor symptoms, psychosocial stressors) that may modulate risk for the development of mood disturbance. This article reviews the current literature on the prevalence and risk factors associated with depression during the menopausal transition. The benefits and risks of using hormonal and nonhormonal strategies for the management of depression and other menopause-related somatic symptoms are critically reviewed. Author Affiliation: Department of Perinatal and Reproductive Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA Article Note: (footnote) The opinions offered at the National Institutes of Health (NIH) State-of-the-Science Conference on Management of Menopause-Related Symptoms and published herein are not necessarily those of the National Institute on Aging (NIA) and the Office of Medical Applications of Research (OMAR) or any of the cosponsoring institutes, offices, or centers of the NIH. Although the NIA and OMAR organized this meeting, this article is not intended as a statement of Federal guidelines or policy. Publication of the online supplement was made possible by funding from the NIA and the National Center for Complementary and Alternative Medicine of the NIH, US Department of Health & Human Services.

Objective: Lithium has been used during pregnancy for more than four decades, but quantification of fetal lithium exposure and clinical correlations of such exposure are limited. The study objectives were to 1) quantify the rate of lithium placental passage, 2) assess any association between plasma concentration of lithium at delivery and adverse perinatal events, and 3) determine whether lithium concentrations can be reduced by briefly suspending therapy proximate to delivery. Method: Maternal blood and umbilical cord blood were obtained at delivery for assay of lithium concentrations, and obstetrical outcome data were collected prospectively for 10 participants. These data were combined with results from MEDLINE and PsycINFO searches that identified 32 cases in which maternal lithium was administered throughout delivery. Statistical analysis of the pooled data was conducted. Results: The ratio of lithium concentrations in umbilical cord blood to maternal blood (mean=1.05, SD=0.13) was uniform across a wide range of maternal concentrations (0.2-2.6 meq/liter). Significantly lower Apgar scores, longer hospital stays, and higher rates of CNS and neuromuscular complications were observed in infants with higher lithium concentrations (>0.64 meq/liter) at delivery. Withholding lithium therapy for 24-48 hours before delivery resulted in a 0.28 meq/liter reduction in maternal lithium concentration. Conclusions: Lithium completely equilibrates across the placenta. Higher lithium concentrations at delivery are associated with more perinatal complications, and lithium concentrations can be reduced by brief suspension of therapy proximate to delivery. Treatment guidelines are proposed to improve neonatal well-being when lithium use is indicated in late pregnancy.

Cigarette smoking and smokeless tobacco (SLT) use are associated with numerous health hazards and economic costs, and rates of tobacco use have recently increased among young adults. In this study, the authors compared predictors of smoking and SLT use among college students (N = 21,410) from 13 Texas universities using a Web-based survey. Results revealed that sex, belonging to a fraternity or sorority, participation in intercollegiate sports, peer influences, and ethnicity predicted smoking and SLT use. Although common factors predicted both lifetime and current smoking and SLT use, patterns of prediction differed across dependent variables. The authors discuss implications for developing tobacco prevention programs targeting specific risk factors salient to the young adult population. Key Words: college students, smokeless tobacco, smoking, tobacco, Tobacco use, including smoking and using smokeless tobacco (SLT), has devastating health and economic consequences. It accounts for approximately 440,000 deaths per year, which makes it the leading preventable cause [...]

The authors surveyed a convenience sample of 208 undergraduate students who reported that they smoked cigarettes. The primary hypothesis they tested was whether gender predicted nicotine dependence. They further tested whether depression and attachment would mediate or moderate this relationship. Hierarchical regression analyses with social desirability and smoking stage of change entered as covariates indicated that women exhibited greater nicotine dependence than men did (p < .01). Lower attachment scores fully mediated this relationship, whereas elevated depression scores moderated the relationship. These findings suggest that depression and the inability to bond with peers may promote nicotine dependence among young female students. Key Words: attachment, cigarette smoking, depression, mood regulation, nicotine dependence, Although men and women smoke at comparable rates, evidence suggests that, on average, girls who begin smoking during their adolescent years continue smoking for 20 years, 4 years longer than [...]

Objective: Bipolar disorder affects 0.5%-1.5% of individuals in the United States. The typical age at onset is late adolescence or early adulthood, placing women at risk for episodes throughout their reproductive years. General guidelines for the treatment of bipolar disorder are available from the American Psychiatric Association, but additional issues arise when these guidelines are applied in the treatment of peripartum women. The authors summarize knowledge regarding the management of bipolar disorder during pregnancy and the postpartum period, with a focus on managing mania, hypomania, and the psychotic components of the illness. Method: An expert panel reviewed articles that address the management of bipolar disorder and the consequences of the use of mood stabilizers during pregnancy, and a consensus document was generated. Results: The treatment of bipolar disorder in pregnant women involves significant challenges. Some mood stabilizers, e.g., sodium valproate and carbamazepine, are human teratogens. On the other hand, the teratogenicity associated with lithium may have been overestimated in the past. Conclusions: Since treatment can be managed most effectively if pregnancy is planned, clinicians should discuss the issue of pregnancy and its management with every bipolar disorder patient who has childbearing potential, regardless of future reproductive plans. Additional research should address the risks of disturbed sleep to pregnant and postpartum women with bipolar disorder, as well as structural and behavioral consequences to offspring when mood stabilizers are used during pregnancy. Longitudinal and cohort studies can promote these efforts. Given the rate of bipolar disorder in the general population, research efforts will need to be broad based and include multiple collaborating centers.

Although the last decades has brought appropriate increased interest in the diagnosis and treatment of postpartum depression, with screening initiatives across more than 40 states in place and even new [...]

Objective: The authors examined the effect of a 4-week course of estrogen therapy on depression in perimenopausal and post-menopausal women. Method: Twenty-two depressed women who were either perimenopausal (N=10) or postmenopausal (N=12) received open-label treatment with transdermal 17[beta]-estradiol (100 [micro]g/day) for 4 weeks. The Montgomery-Asberg Depression Rating Scale and the Beck Depression Inventory were used to assess depressive symptoms, the Greene Climacteric Scale was used to assess menopause-related symptoms, and the Clinical Global Impression (CGI) was used to assess global clinical improvement in these women at baseline and after treatment. Remission of depression was defined as a score Results: Remission of depression was noted in eight of the 20 women who completed the study; two of these women were postmenopausal, and six were perimenopausal. Antidepressant response was not associated with severity or subtypes of depression at study entry or with concomitant improvement in menopause-related symptoms. Conclusions: Some perimenopausal women with depression may benefit from short-term use of estrogen therapy, and its role for postmenopausal depressed women warrants further investigation. Antidepressant benefit associated with estrogen therapy may be independent of improvement in physical symptoms.

Pregnant women who are depressed are no more likely to have a cesarean delivery than those who are not, according to a study of 1,697 pregnant women. Some researchers believe that the fatigue that many depressed patients feel would make depressed pregnant women want a cesarean. This study does not support that belief.

Objective: The purpose of this study was to determine the extent of infant medication exposure through breast-feeding during maternal treatment with paroxetine. Method: Breast milk and paired maternal and infant sera were collected after 10 days of maternal treatment with paroxetine at a stable daily dose (10-50 mg/day). All samples were analyzed by means of high-performance liquid chromatography with ultraviolet detection and a limit of detection of 2 ng/ml. Results: Breast milk paroxetine concentrations were highly variable (2-101 ng/ml) and were present in all breast milk samples (N=108). A significant gradient effect was observed, with greater paroxetine concentrations found in later portions of breast milk (hind milk) than in early portions (fore milk). No clear time course of paroxetine excretion into breast milk was demonstrated, although maternal paroxetine daily dose reliably predicted both trough and peak breast milk concentrations over a 24-hour period. In 16 mother and infant serum pairs, no detectable concentrations of paroxetine were found in the serum of the nursing infants. Conclusions: This study extends previous data by demonstrating the presence of paroxetine in the breast milk of nursing women treated with this medication. The low concentrations of paroxetine in infant serum and lack of any observable adverse effects after maternal use of this medication while breast-feeding parallels the available data on other selective serotonin reuptake inhibitors.

Objective: Pregnancy poses major challenges for the treatment of bipolar disorder, and information to guide clinical care remains very sparse. The authors sought to determine the illness recurrence risk for women with bipolar disorder who discontinue lithium maintenance during pregnancy. Method: The authors retrospectively compared recurrence rates and survival functions for 101 women with DSM-IV bipolar disorder (68 type I, 33 type II) during pregnancy and postpartum (N=42) or during equivalent periods (weeks 1-40 and 41-64) for age-matched nonpregnant subjects (N=59) after either rapid (1-14 days) or gradual (15-30 days) discontinuation of lithium. Recurrence rates also were obtained for the year before discontinuing lithium. Results: Rates of recurrence during the first 40 weeks after lithium discontinuation were similar for pregnant (52%) and nonpregnant women (58%) but had been much lower for both in the year before treatment was discontinued (21%). Among subjects who remained stable over the first 40 weeks after lithium discontinuation, postpartum recurrences were 2.9 times more frequent than recurrences in nonpregnant women during weeks 41-64 (70% versus 24%). Depressive or dysphoric-mixed episodes were more prevalent in pregnant than nonpregnant women (63% versus 38% of recurrences). Recurrence risk was greater after rapid than after gradual discontinuation, and for patients with more prior affective episodes, but was similar for diagnostic types land II. Conclusions: Rates of recurrence during the first 40 weeks after lithium discontinuation were similar for pregnant and nonpregnant women but then sharply increased postpartum. Risk was much lower during preceding treatment and less with gradual discontinuation. Treatment planning for potentially pregnant women with bipolar disorder should consider the relative risks of fetal exposure to mood stabilizers versus the high recurrence risks after discontinuing lithium.

The last two decades have seen an ever-growing number of reports on risks of fetal exposure to medicines used to treat depression during pregnancy. These reports have described issues ranging [...]

Objective: Given concerns about use of psychotropic medication during pregnancy, the authors reviewed the literature regarding the effects of prenatal exposure to psychotropic medications on fetal outcome. Method: A MEDLINE search of all articles written in English from 1996 to 1995 was performed to review information on the effects of psychotropic drug use during pregnancy on fetal outcome. Where sufficient data were available and when methodologically appropriate, meta-analyses were performed to assess risk of fetal exposure by psychotropic medication class. Results: Three primary effects are associated with medication use during pregnancy: 1) teratogenicity, 2) perinatal syndromes (neonatal toxicity), and 3) postnatal behavioral sequelae. For many drug classes there are substantial data regarding risk for teratogenicity. Tricyclic antidepressants do not seem to confer increased risk for organ dysgenesis. The available data indicate the first-trimester exposure to low-potency phenothiazines, lithium, certain anticonvulsants, and benzodiazepines may increase the relative risk for congenital anomalies. However, the absolute risk of congenital malformations following prenatal exposure to most psychotropics is low. Conclusions: Exposure to certain psychotropic drugs in utero may increase the risk for some specific congenital anomalies, but the rate of occurrence of these anomalies even with the increased risk remains low. Use of psychotropic medications during pregnancy is appropriate in many clinical situations and should include thoughtful weighing of risk of prenatal exposure versus risk of relapse following drug discontinuation. The authors present disorder-based guidelines for psychotropic drugs use during pregnancy and for psychiatrically ill women who wish to conceive.

The postpartum period has typically been considered a time of heightened vulnerability for development of affective disorders, and women with bipolar disorder have consistently demonstrated vulnerability to puerperal worsening of mood. This retrospective study examined the extent to which mood-stabilizing agents provide prophylactic benefit to bipolar women during the postpartum period. Method: The clinical course of 27 women meeting the DSM-III-R criteria for bipolar disorder was followed during pregnancy and the postpartum period. Information regarding severity of illness (as measured by number of episodes of mania, depression, or both) was obtained, in addition to data on pharmacotherapy (if any) received before, during, and after pregnancy. The extent to which the prophylactic use of antimanic agents minimized the risk of relapse was explored. Results: Only one of the 14 patients taking prophylactic agents during the acute puerperium relapsed within the first 3 months postpartum, while eight of the 13 who did not receive antimanic drugs showed evidence of recurrent affective instability during those 3 months. A survival analysis indicated that the women receiving prophylactic treatment with mood stabilizers maintained well-being significantly longer than the women who did not receive such treatment. Conclusions: Women with bipolar disorder appear to benefit from puerperal prophylaxis with mood stabilizers. Consistent with results of earlier studies, postpartum prophylaxis was associated with lower rates of relapse into affective disorders. The findings have implications for the early identification and treatment of subgroups of women at particular risk for puerperal illness.

The last decade has brought increasing awareness of the need to effectively screen for postpartum depression, with a majority of states across the country now having some sort of formal [...]

The last decade has brought appropriate attention to the high prevalence of postpartum mood and anxiety disorders, with postpartum depression (PPD) constituting the most common complication in modern obstetrics. There [...]

Over the last 2 decades, there has been a growing interest in establishing a rich evidence base for treatment of psychiatric illness in pregnancy and the postpartum period. It seems [...]

Objective: This study ascertained family planning decisions by women with bipolar disorder after psychiatric consultation. Method: The authors surveyed 116 women with DSM-IV bipolar disorder after specialized consultation about treatment options and risks regarding pregnancy. Results: Of 70 respondents, 45% had been advised to avoid pregnancy by a health care professional before consultation. After consultation, 63% decided to pursue pregnancy. Conclusions: Women with bipolar disorder often encounter obstacles from health care professionals regarding pregnancy. Individualized comprehensive review of risks and benefits of treatment options during specialized preconception consultation can support thoughtful clinical planning.

Objective: In a large population-based study, the authors examined the prevalence and correlates of body dysmorphic disorder, a debilitating and chronic condition characterized by an imagined defect in appearance. Method: Rates and diagnostic correlates of body dysmorphic disorder were examined by using data from the Harvard Study of Moods and Cycles. This study used in-person structured clinical interviews to characterize the diagnostic status of a population-based, cross-sectional sample of 318 depressed and 658 nondepressed women between the ages of 36 and 44 who were selected from seven Boston metropolitan area communities. Results: The presence of body dysmorphic disorder was significantly associated with the presence of major depression and anxiety disorders. The authors estimated the overall point prevalence of body dysmorphic disorder as 0.7% in women in this age range in the community. Conclusions: The authors found that the presence of body dysmorphic disorder was linked to the presence of major depression and anxiety disorders, which is similar to findings in clinical studies. Their estimate of the point prevalence of body dysmorphic disorder is consistent with data from a community-based sample of Italian women and suggests a prevalence similar to that of other serious psychiatric disorders in women (e.g., schizophrenia and drug abuse and dependence). These prevalence data encourage the further development of treatment options for this debilitating condition. (Am J Psychiatry 2001; 158:2061-2063)

The management of bipolar disorder during pregnancy is a critical clinical situation demanding great attention to issues such as reproductive safety of psychiatric medications used by women with bipolar disorder [...]

Over the last several years, there's been increasing interest and ultimately a growing number of mandates across dozens of states to screen women for postpartum depression (PPD). As PPD is [...]

AbstractDue to their genomic variants, some individuals are more highly affected by toxicants than others. Toxicant metabolizing and activating variants have been linked with a wide variety of health issues including an increased risk of miscarriages, birth defects, Alzheimer’s, benzene toxicity, mercury toxicity and cancer. The study of genomics allows a clinician to identify pathways that are less effective and then gives the clinician the opportunity to counsel their patients about diet, supplements and lifestyle modifications that can improve the function of these pathways or compensate to some extent for their deficits. This article will review a few of these critical pathways relating to phase I and phase 2 detox such as GSTP1, GPX1, GSTT1 deletions, PON1 and some of the CYP 450 system as examples of how an individual's genomic vulnerabilities to toxicants can be addressed by upregulating or downregulating specific pathways via genomically targeted use of foods, supplements and lifestyle changes.

Objective: This study was designed to determine the seasonality of serotonin functions among adolescents who attempt suicide. Method: Platelet [3H]imipramine binding was assessed over a period of 18 months in 98 adolescents who attempted suicide and a comparison group of 23 never-suicidal youths with conduct disorder. Results: [3H]Imipramine ([B.sub.max]) was uncorrelated with age, but showed considerable seasonal variability over time in those who bad attempted suicide. Conclusions: [3H]Imipramine binding density in adolescents who attempted suicide exhibited significant seasonality, reaching a nadir in late winter/early spring.