Search

Objective: To examine child developmental outcomes in preschool-aged children exposed to antidepressant medication in pregnancy and compare their outcomes to children not exposed. Method: A prospective case-controlled study of 20 children exposed to antidepressants in pregnancy and 21 unexposed controls was available from the Victorian Psychotropic Registry. Child development outcomes at 4 years of age were assessed using the Wechsler Preschool and Primary Scale of Intelligence, third edition; the Movement Assessment Battery for Children; Behaviour Rating Inventory of Executive Functioning–Preschool; and the Child Behavior Checklist (1.5–5 years). Maternal depression was assessed using the Beck Depression Inventory-II in pregnancy and at four time points across infancy and early childhood. Results: Children exposed to antidepressants in pregnancy had no statistically significant differences compared to unexposed children on any of the measures of child development undertaken. There was a trend to slightly lower scores in motor development with a small effect size for two scales of the Movement Assessment Battery for Children: balance – Cohen’s d=0.36; aiming and catching – Cohen’s d=0.34. Conclusions: The finding of no effect on cognition and behaviour are consistent with other previous studies conducted with younger children. Likewise, the trend towards lower motor development is similar to earlier findings from this study and a number of other similar studies. Given this trend there is a need for future research that focuses on this area of development in older children using robust measures of motor development.

Objectives: Both antidepressant medications and psychological therapy are common treatments for depression in postpartum women. Antidepressant treatment may have a number of practical disadvantages, including a preference by women to avoid medication while breastfeeding. Consequently, more information about the relative benefits of the two modalities in the perinatal period is helpful. In the treatment of depressive disorders there is some evidence that combination therapies (pharmacological plus psychological treatment) may be more efficacious than either form of mono-therapy in isolation. However, in the treatment of postnatal depression, such evidence is limited. Method: Forty five postpartum women with a DSM-IV diagnosis of depression were randomised to receive either: 1) cognitive behavioural therapy (CBT); 2) sertraline, or 3) a combination of both treatment modalities. Psychometric measures were collected weekly for 12 weeks, with a follow-up at 24 weeks. Results: Symptoms of depression and anxiety were reduced to a significant degree following all three treatments. CBT mono-therapy was found to be superior to both sertraline mono-therapy and combination therapy after 12 weeks. The CBT mono-therapy group appeared to display the most rapid initial gains after treatment commencement. Conclusions: In this sample, a specialised CBT program for postnatal depression was found to be superior as a mono-therapy compared to sertraline, a commonly prescribed SSRI antidepressant. This is in contrast to previous studies which have found no detectable difference in the efficacies of drug and psychological treatment for postnatal depression. Unlike some previous work, this study allowed a statistically independent evaluation of CBT mono-therapy for postnatal depression compared to both antidepressant and combination therapy. In line with previous studies in postpartum women, there was no detectable advantage of combining pharmacological and psychological treatments in the short term.

BackgroundUniversal screening for postpartum depression is recommended in many countries. Knowledge of whether the disclosure of depressive symptoms in the postpartum period differs across cultures could improve detection and provide new insights into the pathogenesis. Moreover, it is a necessary step to evaluate the universal use of screening instruments in research and clinical practice. In the current study we sought to assess whether the Edinburgh Postnatal Depression Scale (EPDS), the most widely used screening tool for postpartum depression, measures the same underlying construct across cultural groups in a large international dataset.MethodOrdinal regression and measurement invariance were used to explore the association between culture, operationalized as education, ethnicity/race and continent, and endorsement of depressive symptoms using the EPDS on 8209 new mothers from Europe and the USA.ResultsEducation, but not ethnicity/race, influenced the reporting of postpartum depression [difference between robust comparative fit indexes (∆*CFI) < 0.01]. The structure of EPDS responses significantly differed between Europe and the USA (∆*CFI > 0.01), but not between European countries (∆*CFI < 0.01).ConclusionsInvestigators and clinicians should be aware of the potential differences in expression of phenotype of postpartum depression that women of different educational backgrounds may manifest. The increasing cultural heterogeneity of societies together with the tendency towards globalization requires a culturally sensitive approach to patients, research and policies, that takes into account, beyond rhetoric, the context of a person's experiences and the context in which the research is conducted.

Background: Around 20% of birthing women report high levels of childbirth fear. Fear potentially impacts women’s emotional health, preparation for birth, and birth outcomes. Evidence suggests that personal and external factors contribute to childbirth fear, however results vary. Aim: To identify pyscho-social factors associated with childbirth fear and possible antenatal predictors of childbirth fear according to women’s parity. Method: 1410 women in second trimester and attending one of three public hospitals in south-east Queensland were screened for childbirth fear using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). Other measures included the Edinburgh Depression Scale (EPDS), Decisional Conflict Scale (DCS) and items from the EuroQol (EQ-5D) targeting Anxiety/Depression and Pain/Discomfort. In addition items measuring a previous mental health condition, social support and knowledge were used. Preferred mode of birth was also collected. Psycho-social factors were analysed to determine associations with childbirth fear. Multivariate analysis was used to determine predictors of fear. Results: Thirty-one percent (n = 190/604) of nulliparous and 18% (n = 143/782) of multiparous women reported high fear levels. Having a mental health history, desiring a caesarean section, reporting moderate to high pain during pregnancy, having a non-supportive partner and perceiving less childbirth knowledge than peers, were associated with childbirth fear. Standard multiple regression analyses by parity determined that depression, decisional conflict, low social support and less perceived knowledge predicted levels of childbirth fear. The model explained 32.4% of variance in childbirth fear for nulliparous and 29.4% for multiparous women. Conclusion: Psychosocial factors are significantly associated with childbirth fear. The identification of predictive psychosocial factors for childbirth fear indicates the importance of observing, assessing, and developing support strategies for women. Such strategies are required to decrease anxiety and depression for women during pregnancy, promote normal birth, and build social support to improve women’s feelings and positive expectations of birth.

BACKGROUND: The perinatal period is a time of high risk for onset of depressive disorders and is associated with substantial morbidity and mortality, including maternal suicide. Perinatal depression comprises a heterogeneous group of clinical subtypes, and further refinement is needed to improve treatment outcomes. We sought to empirically identify and describe clinically relevant phenotypic subtypes of perinatal depression, and further characterise subtypes by time of symptom onset within pregnancy and three post-partum periods.METHODS: Data were assembled from a subset of seven of 19 international sites in the Postpartum Depression: Action Towards Causes and Treatment (PACT) Consortium. In this analysis, the cohort was restricted to women aged 19-40 years with information about onset of depressive symptoms in the perinatal period and complete prospective data for the 10-item Edinburgh postnatal depression scale (EPDS). Principal components and common factor analysis were used to identify symptom dimensions in the EPDS. The National Institute of Mental Health research domain criteria (RDoC) functional constructs of negative valence and arousal were applied to the EPDS dimensions that reflect states of depressed mood, anhedonia, and anxiety. We used k-means clustering to identify subtypes of women sharing symptom patterns. Univariate and bivariate statistics were used to describe the subtypes.FINDINGS: Data for 663 women were included in these analyses. We found evidence for three underlying dimensions measured by the EPDS: depressed mood, anxiety, and anhedonia. On the basis of these dimensions, we identified five distinct subtypes of perinatal depression: severe anxious depression, moderate anxious depression, anxious anhedonia, pure anhedonia, and resolved depression. These subtypes have clear differences in symptom quality and time of onset. Anxiety and anhedonia emerged as prominent symptom dimensions with post-partum onset and were notably severe.INTERPRETATION: Our findings show that there might be different types and severity of perinatal depression with varying time of onset throughout pregnancy and post partum. These findings support the need for tailored treatments that improve outcomes for women with perinatal depression.FUNDING: Janssen Research & Development.

This study utilizes video feedback to improve maternal parenting behavior in clinically depressed mothers admitted to a perinatal inpatient psychiatric unit. Depressed mothers (n = 74) were randomized to "video" (n = 25), "verbal" (n = 26), or "standard care" (n = 23). "Video" mothers were taped playing with their infant; interaction was reviewed with a mental health specialist. "Verbal" mothers only discussed interaction with their infant. "Standard care" mothers received only routine inpatient care. Mothers were assessed for mental health status, perceptions of baby behavior, and parenting competence. There was significant improvement in mental health status of all participants, regardless of intervention. Neither intervention had an advantage, compared to standard care, in improving parenting confidence or perceptions of infant behavior. Video mothers were more likely to report no change in their parenting confidence the more feedback sessions completed. The number of intervention sessions for each participant was limited by the duration of their inpatient admission. Most participants were on simultaneous pharmacotherapy and psychotherapy, as well as receiving intensive mothercraft assistance; this may have influenced intervention effectiveness. Results suggest that this type of intervention may be beneficial, but in the current format does not add sufficiently to standard care to be detected by the measures used.

There are limited studies of generalized anxiety disorder (GAD) across pregnancy.Women (n = 2793) were enrolled in the Yale Pink and Blue study, a cohort enriched with subjects who suffered from major depressive disorder (MDD) within the past five years or used antidepressants in the past year. Subjects were evaluated with the Composite International Diagnostic Interview at three time points: twice in pregnancy and once after delivery. We defined a generalized anxiety disorder (GAD) episode as per DSM IV but with required duration reduced to one month or longer. Course and correlates of GAD were examined in women who had: 1) no GAD during the 6 months prior or in pregnancy (Group A), 2) GAD in the 6 months prior to but not in pregnancy (Group B), 3) GAD in pregnancy only (Group C) and 4) GAD both in the 6 months prior to and during pregnancy (Group D).9.5% of the cohort suffered from GAD at some point in pregnancy. Anxiety symptoms were highest in the first trimester and decreased across pregnancy. Regression analysis revealed that previous GAD episodes, education, social support and a history of child abuse distinguished between membership in the four groups.The sample may not be representational, as it was enhanced with those at risk, and had relatively low representation of socio-economically disadvantaged women.Identification of anxious patients during pregnancy may provide an opportunity to engage those in need of psychiatric treatment.

Objective: The aim of this paper was to collect feedback on a specialist parent-infant psychiatric service in terms of client satisfaction with inpatient treatment, and the impact on health outcomes of providing written information about available support options in the community following discharge. Methods: Women (n = 37) from consecutive admissions between January 2006 and December 2007 were contacted by telephone and administered a service quality evaluation questionnaire. Results: Women were happy with the quality of inpatient care provided but suggested areas of improvement included continuity of staff during the inpatient stay and better communication between inpatient and outpatient services post-discharge. At discharge, women were not confident with their ability in coping with motherhood but confidence with parenting skills increased post-discharge. Use of recommended post-discharge community support and/or health services was poor. Conclusion: As adherence with discharge recommendations was less than ideal, greater involvement of primary/community health care professionals, and active participation of clients and carers, in discharge planning is required. Increased emphasis on the practical skills of motherhood as well as opportunities to develop the mother-infant relationship may assist mothers in gaining confidence to interact with their baby and pick up infant cues.

Objective: The aim of this paper is to review the clinical, demographic and psychosocial characteristics of consecutive admissions to a specialist inpatient parent-infant psychiatric service during a 2-year period. Methods: Data from consecutive admissions between January 2006 and December 2007 were evaluated in terms of primary and secondary diagnosis, demographics and psychosocial risk, psychiatric history, referral source, inpatient care and child protection involvement. Results: The majority of admissions (n = 149) recorded during the audit period were for a major depressive disorder (n = 69; 46%), schizophrenia (n = 29; 19%) or postnatal psychosis (n = 19; 13%); the most common comorbidities were a physical health problem (35%), substance abuse (24%) or borderline personality disorder (15%). The average length-of-stay was 23.8 ± 15.5 days; the average baby's age at admission was 15.1 ± 11.6 weeks. There were no statistically significant differences between women with a history of a mood disorder and those with no such history, in any of the demographic or psychosocial variables evaluated. Conclusion: This paper provides a unique appraisal of those individuals actively seeking psychiatric assessment and treatment through a specialist perinatal psychiatric service. Such information is useful in promoting better understanding of this population and the complex treatment and management needs of this patient group.

Bilszta JLC, Meyer D, Buist AE. Bipolar affective disorder in the postnatal period: investigating the role of sleep. Bipolar Disord 2010: 12: 568–578. © 2010 The Authors. Journal compilation © 2010 John Wiley & Sons A/S. Objectives: Psychotic disorders have a high rate of relapse in the postpartum period for reasons that are unclear, but may be related to changes in sleep patterns that occur during pregnancy and after birth. Understanding of the influence of sleep on postpartum psychosis presentation is limited. The aim of the current study was to investigate changes in sleep/wake activity during pregnancy and the postpartum period in women with a history of psychosis. Methods: Women with a history of bipolar disorder and/or postpartum psychosis (HxW) were recruited (n = 23) together with a control population (CtW) (n = 15). Data on demographic and psychosocial factors, mental health status, and sleep/wake activity were collected at seven timepoints—the last week of each trimester of pregnancy and four times during the postpartum (weeks 1, 4, and 8, and at month 6). Longitudinal data were analysed using an HLM version 6 repeated-measures multilevel model. Results: No significant differences were noted in sleep/wake activity between HxW and CtW. None of the HxW who were taking a mood stabilizer during their pregnancy, including at delivery, relapsed during the study. Of those taking an antidepressant or antipsychotic, or no medication, 3 relapsed within the first six months and 2 within the first two months. HxW were more likely to report a poor partner relationship than CtW. Conclusion: Results suggest that during the perinatal period, there is no difference in sleep/wake activity in women with a history of a psychotic disorder. Use of mood stabilizer during pregnancy and at delivery appears important in preventing psychotic relapse in the postpartum.

This project sought to gain insight into the experiences, beliefs, attitudes and personal views of postnatal emotional distress, from the perspective of the health professional. A qualitative study involved focus groups with health professionals engaged in the care and treatment of women with a postnatal mood disorder. Broad themes explored included women's recognition of symptoms, barriers to help-seeking, models of postnatal depression, detection and management, and treatment experiences and options. Health professionals identified seven key theme clusters: Coping and failure, Expectations of motherhood, Partners, Treatment experiences, Screening and identification, Framing the issue of perinatal emotional distress, Assistance for health professionals. Professionals view postnatal emotional distress as a response to social and personal pressures and an expression of the tension between becoming a mother and maintaining social standing. There is a significant need for better education to ensure that post...

Perinatal Depression affects 16% of Australian women, with long term potential negative consequences. This article from a key note address at the Women’s International Mental Health conference in Melbourne 2008, reflects on the author’s clinical and research experience and where appropriate with reference to the literature, to make a case for making changes to health system and society to improve outcomes for Australian families.

If possible, women at risk of depression should be identified during pregnancy. They often do not spontaneously seek help. Early intervention is important for the health of the woman and her baby. Psychological interventions such as support groups are often helpful. Involving the woman's partner can also assist. Antidepressants are required in some cases and women with psychotic symptoms need urgent psychiatric assessment and treatment.

Objectives: To describe the postnatal mental health status of women giving birth in Australia 2002–2004 at 6–8 weeks postpartum. Method: Women were recruited from 43 health services across Australia. Women completed a demographic questionnaire and an Edinburgh Postnatal Depression Scale (EPDS) in pregnancy; the latter was repeated at 6–8 weeks following childbirth. Results: A total of 12 361 postnatal women (53.8% of all postnatal women surveyed) completed questionnaires as part of a depression screening programme; 15.5% of women screened had a postnatal EPDS>9 and 7.5% of women had an EPDS>12 at 6–8 weeks following childbirth. There was significant variation between States in the percentage of women scoring as being potentially depressed. The highest percentage of women scoring EPDS>12 were in Queensland and South Australia (both 10.2%) while Western Australia had the lowest point prevalence (5.6%). Women recruited from private health services in Western Australia had a significantly lower prevalence of elevated EPDS scores than those women recruited from the public health service (EPDS >12: 3.6% vs 6.4%, p=0.026); differences in the prevalence of elevated EPDS scores were not significant between public and private in Australian Capital Territory (EPDS>12: 7.6% vs 5.8%, p=0.48), where income and education was significantly higher than other States for both groups. Conclusions: Postnatal depressive symptoms affect a significant number of women giving birth in Australia, and the point prevalence on the EPDS may be higher for women in the public sector, associated with lower incomes and educational levels. Maternity services – particularly those serving women with these risk factors – need to consider how they identify and manage the emotional health needs of women in their care. Specific State-related issues, such as availability of specialist perinatal mental health services and liaison between treating health professionals, also need to be considered.

Introduction Mental illness in pregnancy and postpartum has significant and potentially serious long-term consequences for a mother, her entire family, and in particular, for her infant (Grigoriadis, VonderPorten et al. 2013c). Perinatal mood and anxiety disorders are not culturally bound: they affect women in every society and from every socioeconomic background. The aim of this chapter is to increase awareness among healthcare providers about mood- and anxiety-related disorders in pregnancy and postpartum (the “perinatal” period). To achieve this goal, the chapter provides key information about the presentation of these disorders in the perinatal period, along with research about biological and psychosocial risk factors for illness. Clinical presentations Most psychiatric disorders can occur in the perinatal period, but mood and anxiety disorders are particularly common among women of reproductive age. Pregnancy is not protective against the development or recurrence of these disorders, and evidence suggests that the postpartum period is a time of increased risk for new-onset mood and anxiety problems. In particular, there is a risk of mood-related psychosis in the postpartum period, with women suffering from bipolar disorder at high risk. Further, there is a high risk of comorbidity with mood and anxiety disorders co-occurring (Grigoriadis, et al. 2011). In the 5th edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) mood and anxiety disorders are classified into five separate categories: Depressive disorders, Bipolar and related disorders, Anxiety disorders (including generalized anxiety disorder, panic disorder and social anxiety disorder), Obsessive-compulsive and related disorders, and Trauma and Stressor-related disorders (including adjustment disorder, acute stress disorder and post-traumatic stress disorder [PTSD]) (American Psychiatric Association, 2013). Mood and anxiety disorders occurring in pregnancy or postpartum are not classified as distinct disorders in the DSM-5. However, due to the distinct risks related to perinatal mood disorders, episodes of depressive and bipolar disorders occurring during this time are classified with the use of the specifier: “with peripartum onset.” Specifically, the DSM-5 specifier indicates that “peripartum-onset” pertains only to episodes occurring in pregnancy or with onset in the first four weeks after delivery, although research suggests that risk is likely elevated throughout the first postpartum year.

Introduction: Postnatal depression affects 14% of women, occurring also antenatally, with potential long-term consequences, making it an important disorder to detect and manage early. In this study we sought to examine knowledge and awareness of perinatal depression in health professionals involved in perinatal care throughout Australia prior to the implementation of a comprehensive screening program, aimed at improving detection and access to appropriate management. Methods: A random sample of General Practitioners (GPs) and Maternal Child Health Nurses (MCHNs) and Midwives, in regions throughout Australia to be subsequently targeted by a screening and education program, were invited to participate. Responses to a hypothetical vignette and a knowledge questionnaire, as well as details of experience were completed. Findings: Questionnaires were completed by 246 GPs, 338 MCHNs and 569 midwives, with overall response rates; GP's 23%; MCHN's 55% and midwives 57%. Although knowledge level was similar among professional groups, MCHNs had higher levels of awareness of perinatal depression. Both GPs and MCHNs were more likely than midwives to recognize the need for providing help to women with emotional distress. Depression was more likely to be considered postnatally than antenatally in all groups, with GPs most likely to provide this diagnosis. GPs had a significant propensity to recommend antidepressants, and midwives to select non-specific medications. Conclusions: Health professionals responding to this survey had a high awareness and similar knowledge base. Further education on antenatal depression and the safety risks and alternatives to medication is important for all groups, but particularly important for midwives and GPs. The latter is especially relevant given the preference for women with perinatal depression not to use pharmacological interventions to treat their emotional distress.

This article reviews the women admitted to Mother Baby Psychiatric Units in 2002, in the State of Victoria, Australia, looking at characteristics of postpartum disorders with respect to admission and outcome in a region with a high number of mother-baby unit beds relative to other Australian regions and other cities. Differences among units are noted, including the differential impact of whether the unit is associated with a psychiatric service or an obstetric service. This includes length of stay and referral patterns. Details of diagnosis, admission and outcome are compared to similar admissions in the United Kingdom, with similar factors predictive of poor outcome, defined as separation from the infant. Mother-Baby Units have an important potential role in improving these outcomes, with longer-term studies of these women needed.

Depression is a common problem in the general population and is projected to be one of the major health issues facing the world in 2020 (WHO). Serious consequences exist for the sufferer, and the family. Given that women are twice as likely to suffer from depression, and are at particular risk in the child bearing years, children from infancy may be affected, with long term ramifications. Postnatal depression (PND) occurs in 14% of women, and there may be a similar number affected antenatally. The perinatal period thus is a crucial time to identify depression, and offers an excellent opportunity to screen women due to their increased contact with health services. In order to do so, services need to reevaluate their priorities, and assess barriers to screening. These barriers include attitudes to mental illness, anxiety about how to deal with mental illness in health professionals who are not trained in this area, and--most importantly--resource implications. It is argued that without attempting to address this, identify and remedy the deficiencies, change will not occur. This paper looks to examine the prevalence of depression in the perinatal period, the associated concerns and the difficulties of identification at this time through a review of key relevant papers in this area, and proposes a framework to approach the problem.

Objective: To provide an overview of the current knowledge on the impact of motherhood on women with schizophrenia and schizoaffective disorder. Method: The published literature was selectively reviewed and assessed, based on a complete MEDLINE and PsychLIT (1971 to current) search, including English and non-English journals and books. Results: Research to date into motherhood and schizophrenic illnesses has been limited by a number of methodological constraints, limiting the ability to draw conclusions and the prevention of relapses and mother-infant difficulties. These constraints have included: a paucity of prospective studies with initial, antenatal recruitment; variable definitions of the length of the puerperium; significant changes in psychiatric classification; the heterogeneity of postpartum psychotic disorders, with the majority being mood or schizoaffective disorder rather than schizophrenia; selection biases inherent in studying mother-baby unit inpatients; difficulties in life events research in general, such as its retrospective nature and confounding, illness factors; and the specificity versus non-specificity of childbirth as a unique or discrete life event. Conclusions: Further study is required to explore: the impact of child care, parenting and having a partner on the course of women with schizophrenic and schizoaffective disorders during the first postpartum year; whether women with postpartum relapses of these mental illnesses are likely to have slower recoveries than those women with the same diagnoses but without young children; and protective factors against postpartum relapse.

Objectives: This paper examines the difficulties of identifying depression in the perinatal period and proposes a way forward through a ‘beyondblue’ funded program, the National Postnatal Depression Program. Conclusions: The perinatal period offers an excellent opportunity to identify mental illness and to intervene early to prevent transgenerational problems, particularly given increased links between mental health services, general practitioners and obstetric services. Barriers to doing so include attitudes, anxiety and - most importantly - resource implications, but it is argued that without attempting to address this, identify and remedy the deficiencies, change will not occur. General pactitioners have a crucial role, as do psychiatrists, in supporting them.

This cohort study compared 262 women with high childbirth distress to 138 non-distressed women. At 12 months, high distress women had lower health-related quality of life compared to non-distressed women (EuroQol five-dimensional (EQ-5D) scale 0.90 vs. 0.93, p = 0.008), more visits to general practitioners (3.5 vs. 2.6, p = 0.002) and utilized more additional services (e.g. maternal health clinics), with no differences for infants. Childbirth distress has lasting adverse health effects for mothers and increases health-care utilization.

Background Childbirth fear is associated with increased obstetric interventions and poor emotional and psychological health for women. The purpose of this study is to test an antenatal psycho-education intervention by midwives in reducing women's childbirth fear. Methods Women (n = 1,410) attending three hospitals in South East Queensland, Australia, were recruited into the BELIEF trial. Participants reporting high fear were randomly allocated to intervention (n = 170) or control (n = 169) groups. All women received a decision-aid booklet on childbirth choices. The telephone counseling intervention was offered at 24 and 34 weeks of pregnancy. The control group received usual care offered by public maternity services. Primary outcome was reduction in childbirth fear (WDEQ-A) from second trimester to 36 weeks’ gestation. Secondary outcomes were improved childbirth self-efficacy, and reduced decisional conflict and depressive symptoms. Demographic, obstetric & psychometric measures were administered at recruitment, and 36 weeks of pregnancy. Results There were significant differences between groups on postintervention scores for fear of birth (p

Twenty three women at risk for postpartum depression were offered ten classes in pregnancy and postpartum, focusing on parenting and coping strategies. Twenty one controls attended standard six antenatal classes. Postpartum there were no differences in depression scores, however, anxiety was less at six weeks postpartum in the intervention group. Over time both groups had reduced numbers and reduced satisfaction with supports, but this was greater in the control group. With respect to the marital relationship, this was also less satisfactory postpartum in the control group. The intervention group was well attended and participants satisfied with the alternative antenatal class format; larger studies for all first time mothers are recommended.

Objective: The aim of this paper is to obtain an understanding of the links between maternal postpartum depression, poor parenting and childhood abuse, and the subsequent development of adult psychopathology in children from these families. Method: A literature review was undertaken of studies on postpartum depression looking at parental childhood abuse, parenting and child outcomes, as well as childhood abuse and its association with adult depression and parenting difficulties. Results: Considerable overlap is noted in predisposing factors for major depression, postpartum depression, inadequate parenting and childhood abuse. Links appear to begin in early infancy, suggesting postpartum depression as a possible mechanism for intergenerational transmission of psychopathology. Conclusions: Further research is required to look at the outcome of children of women who are at high risk of chronic or recurrent depression and of difficulties parenting; the postpartum period is the optimum time for identification and intervention.

We investigated the impact of pre-existing mental ill health on postpartum maternal outcomes. Women reporting childbirth trauma received counselling (Promoting Resilience in Mothers' Emotions; n = 137) or parenting support (n = 125) at birth and 6 weeks. The EuroQol Five dimensional (EQ-5D)-measured health-related quality of life at 6 weeks, 6 and 12 months. At 12 months, EQ-5D was better for women without mental health problems receiving PRIME (mean difference (MD) 0.06; 95 % confidence interval (CI) 0.02 to 0.10) or parenting support (MD 0.08; 95 % CI 0.01 to 0.14). Pre-existing mental health conditions influence quality of life in women with childbirth trauma.

Psychiatric disorders, in particular depression, are common Postpartum and have potential long term implications for the woman and her family. Critical to management is identification and early intervention. Management needs to be multifaceted, including hospitalisation in severe cases, psychotherapy (supportive at least) and organisation of community support. A number of factors need to be considered with respect to medication, in particular if the woman is breastfeeding. Women with puerperal psychosis may require antipsychotics, antidepressants and mood stabilisers; ECT achieves good results when available and acceptable. Women with postpartum depression can generally be managed with antidepressants alone. Management needs to take into account that these disorders may be long lasting, with risk of recurrence after subsequent childbirth, and may have significant effects on child development.

Little is known about the practices of primary care physicians regarding the prescribing of antidepressants during pregnancy. An anonymous survey was administered to a group of nonrandomly selected Australian general practitioners (n = 61 out of 77) and randomly selected Canadian family physicians (n = 35 out of 111). Responses to a hypothetical scenario and questions regarding beliefs about the use of antidepressant medication during pregnancy were collected. Physicians from both countries feel strongly that antidepressant use during pregnancy is a decision complicated by conflicting reports of safety and risk.

Objectives: The aim of the present study was to examine neonatal symptoms previously reported to be associated with exposure to antidepressant medication in late pregnancy in a group of infants exposed to antidepressants, using a prospective and controlled design. Method: A prospective case–control study recruited 27 pregnant women taking antidepressant medication and 27 matched controls who were not taking antidepressant medication in pregnancy. Of the 27 women taking medication, 25 remained on medication in the third trimester and, of these, 23 women had complete data available. In pregnancy and after delivery women were assessed with the Beck Depression Inventory-II and a purpose-designed questionnaire. After delivery mothers were asked a set of nine questions pertaining to symptoms of discontinuation in their newborn and questions about pregnancy and delivery complications. Results: There was an increased risk of discontinuation symptoms in neonates exposed to antidepressant medication in late pregnancy and an association with higher dose medication. The study group were found to be significantly more likely to display behaviour such as crying, jitteriness, tremor, feeding, reflux and sneezing and sleep for Conclusions: Exposure to antidepressants in late pregnancy is associated with a range of symptoms in the neonate that are consistent with the effects of exposure to antidepressants in late pregnancy. The clusters of symptoms most highly correlated are the gastrointestinal and central nervous system symptoms. These finding helps to identify the common symptoms associated with a neonatal serotonin discontinuation syndrome.

Objective: This study sought to compare the contribution of demographic and psychosocial variables on the prevalence of, and risk for, PND in urban and rural women. Methods: Demographic, psychosocial risk factor and mental health data was collected from urban (n=908) and rural (n=1,058) women attending perinatal health services in Victoria, Australia. Initial analyses determined similarities and significant differences between demographic and psychosocial variables. The association between these variables and PND case/non-case was evaluated using logistic regression analysis. Results: There were a number of significant differences between the two cohorts in terms of socio-economic status (SES), age, marital status and past history of psychopathology Antenatal depression was more common in the urban group compared to the rural group (8.5% vs 3.4%, p=0.006); there was no significant difference in the prevalence of PND (6.6% vs 8.5%, p=0.165). For urban mothers, antenatal EPDS score was the best predictor of PND. For rural mothers antenatal EPDS score, SES and psychiatric history had a significant influence on postnatal mood. Conclusions: Findings confirm the contribution of established risk factors such as past psychopathology, antenatal EPDS score and SES on the development of PND and reiterate the need for procedures to identify and assess psychosocial risk factors for depression in the perinatal period. Other predictors such as efficacy of social support and perceived financial burden may strengthen statistical models used to predict PND for women living in a rural setting.

The anxiety disorders are conventionally subdivided into: generalised anxiety disorder (GAD), panic disorder (PD), social phobia (social anxiety disorder (SAD)), posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD). The current edition of the Diagnostic and Statistical Manual of Mental Disorders, the (DSM)-IV-TR lists 12 anxiety disorders, with broadly similar categories listed in the International Classification of Impairments, Disabilities and Handicaps, 10th revision (ICD-10). Neurochemistry and brain imaging studies have influenced the development of theoretical models of GAD. Current neuroanatomical models of panic disorder draw on the understanding of the functional neuroanatomy of fear conditioning in animals. SAD is second only to specific phobia as the most common anxiety disorder in population-based community studies; onset is in the mid-teenage years and extends into the middle of the third decade. There are a wide range of medical conditions that can cause and perpetuate symptoms of anxiety.

The advisability of continuing breastfeeding is an important issue for women with postpartum depression or psychosis. A review of the literature on psychotropic drugs in breast milk is presented. All of the major classes of psychotropic drugs (antidepressants, antipsychotics, antianxiety agents, lithium, hypnotics) have been shown to pass into breast milk following maternal ingestion. Generally, the doses to which children are exposed from breast milk, calculated from measured milk/plasma ratios, are small. Nevertheless most authors err on the side of caution and suggest that breastfeeding be avoided. There is inadequate research on the excretion of drugs into breast milk and the effects on the infant.

Objective: In the transition to parenthood, lack of social support significantly impacts on maternal mood. This paper compares the influence of single-mother status and level of partner support in a partnered relationship, on antenatal emotional health. Methods: Antenatal demographic, psychosocial and mental health data, as determined by Edinburgh Postnatal Depression Scale (EPDS) score, were collected from 1578 women. The association between these variables, and marital status, was investigated using logistic regression. Results: Sixty-two women (3.9%) were identified as single/unpartnered. Elevated EPDS scores (>12) were found in 15.2% (240/1578) of the total cohort and 25.8% (16/62) of the single/unpartnered women. EPDS scores were significantly lower for single/unpartnered women than for women with unsupportive partners (8.9±5.3 vs 11.9±6.5, p Conclusion: Women in a partnered-relationship with poor partner-derived support were at an increased risk of elevated antenatal EPDS scores compared to single/unpartnered women. A previous history of depression and current emotional problems, rather than single mother status, were significant risk factors for elevated EPDS scores. The present study reiterates the contribution of psychosocial risk factors as important mediators of antenatal emotional health.

Background and aims: This article discusses a collaborative approach to assisting parents with a mental illness who have children aged 5 years and under and explores themes found in the literature, focus groups with consumers and workshops with clinicians working with parents who have a mental illness. Method: Focus groups and workshops were held for consumers and clinicians. The workshops included information about a proposed group intervention and discussions about themes found in the literature review and previous focus groups. Results: Using thematic analysis, the gaps identified in the focus groups and workshops were classified into five main categories — namely, interagency collaboration, a need for accessible support groups, a need for information and resources about mental illness, and parenting issues related to mental illness and independence. This information informed the development of a treatment package. Conclusion: The content of the proposed treatment package has been informed by the findings of the literature review, focus groups and workshops. The sessions focus on topics about parenting and managing mental health and consumers are actively involved at the outset in their own care and the care of their child. The intervention will be trailed in clinical settings to establish efficacy and effectiveness.

Background: This study measured antenatal risk factors for postnatal depression in the Australian population, both singly and in combination. Risk factor data were gathered antenatally and depressive symptoms measured via the beyondblue National Postnatal Depression Program, a large prospective cohort study into perinatal mental health, conducted in all six states of Australia, and in the Australian Capital Territory, between 2002 and 2005. Methods: Pregnant women were screened for symptoms of postnatal depression at antenatal clinics in maternity services around Australia using the Edinburgh Postnatal Depression Scale (EPDS) and a psychosocial risk factor questionnaire that covered key demographic and psychosocial information. Results: From a total of 40,333 participants, we collected antenatal EPDS data from 35,374 women and 3144 of these had a score > 12 (8.9%). Subsequently, efforts were made to follow-up 22,968 women with a postnatal EPDS. Of 12,361 women who completed postnatal EPDS forms, 925 (7.5%) had an EPDS score > 12. Antenatal depression together with a prior history of depression and a low level of partner support were the strongest independent antenatal predictors of a postnatal EPDS score > 12. Limitations: The two main limitations of the study were the use of the EPDS (a self-report screening tool) as the measure of depressive symptoms rather than a clinical diagnosis, and the rate of attrition between antenatal screening and the collection of postnatal follow-up data. Conclusions: Antenatal depressive symptoms appear to be as common as postnatal depressive symptoms. Previous depression, current depression/anxiety, and low partner support are found to be key antenatal risk factors for postnatal depression in this large prospective cohort, consistent with existing meta-analytic surveys. Current depression/anxiety (and to some extent social support) may be amenable to change and can therefore be targeted for intervention.

Objective. To assess the impact that education through participation in a depression screening program has on mental health literacy and help seeking behavior in perinatal women. Methods. Responses to a hypothetical case of depression, help seeking behavior, and screening levels for risk of depression using the Edinburgh Postnatal Depression Scale were compared between two groups of postnatal women; one group who had participated in a screening program and the other who had not. Those who participated in the screening program were also asked to evaluate the educational material they had received. Results. A total of 1309 women, broadly representative of postnatal women, answered one or more questionnaires. Those who had participated in the screening program were better able to recognize depression in a hypothetical case, and also assess their own mental state more appropriately. Those women who had been part of the program and did not score high on the EPDS were less likely to seek help, were more satisfied when they did and tended to benefit more from the educational booklet. Conclusions. Participation in a screening program with educational material had significant benefits for mental health literacy and the health service use for perinatal women at risk for depression.

Routine screening was introduced as a joint research/public-health initiative across 43 health services in Australia, funded by beyondblue, the National Australian Depression Initiative. This program included assessing risk factors and prevalence of depression in perinatal women. Other objectives included increasing awareness of the condition, training of relevant staff, and assessing the feasibility of a screening program. Women were screened antenatally and postnatally with a demographic questionnaire and the Edinburgh Postnatal Depression Scale. A subgroup of women and health professionals was surveyed. Over 40,000 women participated directly in the program. Data and issues for specific groups are presented. There was a high level of acceptability to women and health professionals involved. Screening is acceptable and feasible as part of the mental-health management of perinatal women. It needs to be supplemented with information for women and education and support for staff.

This chapter outlines the ways of identifying women at risk and/or women who already show signs and symptoms of depression/anxiety associated with childbearing; and suggest treatment options and preventive measures. Depression during pregnancy is common, with reports suggesting that approximately 10-20" of pregnant women meet criteria for a major or minor depressive disorder. Postpartum psychosis may have any of the features of acute schizophreniform disorder, but most frequently resembles an episode of bipolar disorder, with an early manic phase and later depressive swing. Prevention is considered to be the first line of treatment for postpartum depression. A majority of women have significant psychological issues associated with their transition to motherhood. Interpersonal psychotherapy (IPT) has also shown promise in the treatment of depression, both during pregnancy and in the postnatal period. A number of studies have looked at hormonal treatment and prevention of perinatal psychiatric disorders.

Background: To assess the acceptability of routine screening for perinatal depression. Method: Postnatal women (n=860) and health professionals (n=916) were surveyed after 3 years of routine perinatal (antenatal and postnatal) use of the Edinburgh Postnatal Depression Scale (EPDS). Results: Over 90% of women had the screening explained to them and found the EPDS easy to complete; 85% had no difficulties completing it. Discomfort with screening was significantly related to having a higher EPDS score. A majority of health professionals using the EPDS was comfortable and found it useful. Limitations: The sample involved only maternity services supporting depression screening. In addition, the response rate from GPs was low. Conclusions: Routine screening with the EPDS is acceptable to most women and health professionals. Sensitive explanation, along with staff training and support, is essential in implementing depression screening.

Objective: To assess factors affecting first-time fathers' transition to parenthood. Design: A longitudinal repeated measures study in which participants were interviewed in mid-pregnancy and completed assessments in late pregnancy, in early postpartum, and at 4 months postpartum. Setting and Participants: Two hundred twenty-five first-time fathers were recruited from a major obstetric hospital in Melbourne, Victoria, from 1995 to 1998, via their partners. Main Outcome Measures: Men were seen separately from their spouses, and questionnaires assessing parity history, social support, marital satisfaction, anger, anxiety, and gender role stress were completed at each time. Prenatal and postnatal distress were measured by the Edinburgh Postnatal Depression Scale. Results: Men's peak period of distress was at the first assessment in pregnancy, where there was an overrepresentation of younger men, who were employed part-time and in shorter relationships. For most of the men, their anxieties decreased steadily postpartum. Lower relationship satisfaction was associated with distress, as was gender role stress, both antenatally and postpartum. Distress was also seen to affect men's attachment to their infants. Conclusions: Although most men deal effectively with the transition to fatherhood, a small group of distressed men may have continued problems in their role as a parent and partner. If more attention can be paid to their anxieties antenatally, it might benefit the men, their partners, and their infants.

* Significant perinatal distress and depression affects 14% of women, producing short and long term consequences for the family. This suggests that measures for early detection are important, and non-identification of these women may exacerbate difficulties. * Screening provides an opportunity to access large numbers of women and facilitate pathways to best-practice care. * A valid, reliable, economical screening tool (the Edinburgh Postnatal Depression Scale, EPDS) is available. * Arguments against screening pertain largely to lack of evidence about the acceptability of routine use of the EPDS during pregnancy and the postnatal period, and inadequate evidence regarding outcomes and cost-effectiveness. * To address these concerns, the National Postnatal Depression Prevention and Early Intervention Program will evaluate outcomes of screening in terms of acceptability, cost-effectiveness, access and satisfaction with management in up to 100 000 women.

Objective: This study is the second and final phase of a 3-year follow-up study of women who had been admitted with a major depressive episode in the postpartum period, along with their children and partners where present. The effect of a maternal sexual abuse history on the women’s well-being and child outcome compared to those women without such a history is highlighted. Method: Forty-five of an original cohort of 56 women were seen with their child where possible, when the child was an average of 36.8 months old. Twenty-two women had no history of sexual abuse, and 23 gave a history of childhood sexual abuse. Women were assessed with respect to well-being, relationships, parenting stress and psychiatric history since recruitment. The child’s behavior and cognitive development was also assessed. Results: Women with a history of sexual abuse rated higher depression and anxiety scores (p < .05), and had greater life stresses (p < .05). Their partners rated themselves as more comforting and their children as more disturbed (p < .05). Over time, this group had failed to improve as much as the nonabuse group on these measures. There was no difference in child cognitive scores between groups. Conclusions: A history of sexual abuse in women who become depressed postpartum may have long term implications for the woman’s mental health, her relationship with her child, as well as the emotional development of her child. It is critical to offer women in this high-risk group supports in an attempt to minimize these difficulties and any long-term adverse effects.

Pregnancy is a time of great emotional change for a woman, producing increased stress and anxiety. Medication may be required for the treatment of anxiety disorders at this time. Given the fact that psychotropic drugs readily cross the placenta and could have important implications for the developing fetus, it is necessary to balance the possible effects of medication against the potential effects to both the mother and fetus if the anxiety disorder is left untreated. Despite the widespread use of psychotropic drugs such as benzodiazepines and antidepressants during pregnancy, there is a paucity of information regarding the effect of such exposure on the developing fetus. From a review of the literature it is clear that the issue of safety of psychotropic drugs during pregnancy is far from resolved. While some of the findings from animal studies are alarming, these studies cannot be directly extrapolated to humans. In addition, varying sample sizes and multiple drug exposures further complicate interpretation of human studies. Nonpharmacological treatments such as cognitive behavioural therapy should be employed whenever possible for the treatment of anxiety disorders during pregnancy. However, if medication is required pregnant women should be prescribed the lowest dosage for the minimum amount of time.

From menstruation to menopause, both biologically and psychologically, this symposium brought international experts together to celebrate the life work in women’s health by Professor Lorraine Dennerstein, who retires as Director of the Office of Gender and Health, University of Melbourne (Melbourne, Australia) after 30 years. All those presenting, from the USA, Italy, Belgium, Norway and Australia, have worked with Lorraine and present international perspectives on an area where she was one of the pioneers. Included are latest research and clinical understanding of premenstrual disorders, perinatal depression and menopausal transition, including mood, physical and cognitive changes, effect on the skeleton and the role of hormones. This festschrift took the participant through an update of clinical issues for women through their reproductive life. John Randolph from the University of Michigan (MI, USA) began, setting the stage for the rest of the day, by relating reproductive physiology with behavior. He highlighted Dennerstein’s work as a driving force in transforming the illdefined domain of women’s health into a recognized field of study, first with her work on oral contraceptives and sexuality, following through the early 1970s with the increasingly clear data linking affect to the menstrual cycle, and into the 1980s when she established that, rather than abnormal levels of hormones in those who suffered cyclically, it was an abnormal response to normal cyclic changes that characterized premenstrual syndrome (PMS). Jeanne Leventhal Alexander (Director of Psychiatry and Women’s Health, Kaiser Permanente Northern California, Alexander Foundation for Women’s Health, CA, USA) discussed PMS and premenstrual dysphoric disorder (PMDD) further, discussing the effect of the woman with PMDD having a ‘vulnerable brain’ to depression and the roles that PMS and PMDD play as risks for a symptomatic menopausal transition. The other time of great hormonal change and increased mental health risk – the perinatal period – was summarized by myself. Dennerstein, herself a psychiatrist (although from the array of her collaborators’ backgrounds this could easily come as a surprise), was responsible for the first two mother–baby units in Australia. Victoria still has the highest number per head of inpatient mother–baby psychiatric beds in the world – one at Larundel Hospital, established in 1983 with Burrows, and the second at the Mercy Hospital for Women, established in 1989 – when I began working with her. From her risk factors’ research across three continents in 1989, we have now progressed to the largest screening study funded by beyondblue, which assessed over 40,000 women. This found that 16% of women suffer from depression and anxiety perinatally, ranging from 5 to 25% depending on region. Risk factors include past and family history of affective disorder, lack of support, multiple stresses, low socioeconomic background, and history of abuse. The importance of early identification and

While the link between childhood sexual abuse and adult psychiatric disorder has been documented, such research has not looked at any association with postpartum depression. Admissions to the Mercy Mother-Baby Unit are reviewed with respect to a possible link, with case examples presented. An aetiological model is proposed and clinical implications are highlighted.

BackgroundThis study looks at the outcome of infants exposed to dothiepin in breast milk in an attempt to guide clinicians on the risk-benefit ratio of breast-feeding when on antidepressants.MethodThirty women, who had had HDRS scores > 15 within the first five years postpartum from the same women's hospital, were assessed with their children 3–5 years postpartum; half had breast-fed while on dothiepin (study group). Thirty-six non-depressed women were also assessed. Rating scales assessed depression, anxiety, self-esteem, personality, social support, marital relationship, child behaviour and temperament. The children were assessed by the McCarthy Scale.ResultsComparisons of the two depressed groups showed no significant differences on any measures except marital conflict and child behaviour, which were the most disturbed in the study group (P < 0.001). Overall cognitive scores for the children did not differ between the groups. Higher levels of dothiepin and northiaden were associated with higher cognitive scores on subscales (P = 0.02).ConclusionsWe are cautiously optimistic about the lack of any negative associations between cognitive development and exposure to dothiepin via breast milk.