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Since the 1980's the uses, and thus mining, of Rare EarthElements (REE) have grown exponentially. This has led toquestions about the impact of REE on the environment, and REEbeing designated emerging pollutants. Currently, knowledgeabout the behaviour of REE in the environment is stillincomplete. For example, there are few studies on REEadsorption on iron (Fe) (oxy)hydroxides, which are consideredkey carriers of metal pollution, and on the other factorscontrolling this adsorption [1-4]. Knowing that in natural(oxy)hydroxides, Fe is frequently substituted by other elementsin the environment in which they form, we were interested in theeffect of these substitutions on the adsorption capacity of(oxy)hydroxides towards REE.This study focusses on aluminium (Al, common in naturalenvironments and easily substituted into Fe-oxyhydroxides) andgallium (Ga, chemical analogue to Al) substitutions in goethite(Goe), representative of commonly found Fe-(oxy)hydroxideswhose well-defined structure allows for modelling of sorptionand surface interactions. For this purpose, experiments of REEwere conducted on pure and substituted goethites (Goe) withvarying Al and Ga content.A characterisation of these goethites, shows that thesubstitution does not affect the shape, size, and specific surfacearea significantly. Nevertheless, the REE adsorption patterns areaffected by substitutions: 5% substitution decreases the sorptioncapacity of the goethite, and at 10% substitution the preferredadsorption of the mid and heavy REE diminishes, resulting in a'flatter' pattern. Meanwhile, the Neodymium (Nd) L3-edgeEXAFS experiments show no modification of its binding modeto the Goe surfaces, forming corner sharing bidentate-binuclearcomplexes regardless of the substitution rate. However, TEMobservations and Cerium (Ce) L 3-edge XANES experimentsdemonstrate that the Ga substitution favours a higher Ce(IV)O2adsorption, while the Al substitution favours Ce(III) adsorptioncompared to the pure Goe.These results reveal the large impact of substitutions on thereactivity of goethite towards REE.

Objective: This article describes the development of an interpersonal psychotherapy group which has been adapted to address the mother–child relationship in the context of postnatal depression (PND). Background: When PND develops, the child of the sufferer is also at risk for deleterious outcomes. It is thought that this is because the mother–baby bonding process is interrupted, affected, or reduced in quality by the existence of depression in addition to genetics and biological effects of exposure to illness in utero. Past approaches to mitigating this risk have focused on treating the depression as the primary issue and the mother–baby relationship as secondary. This article makes the argument that interpersonal psychotherapy has neglected this relationship despite the evidence that this is a key precipitating/perpetuating factor in PND, and that targeting this relationship has benefits for both mother and baby. Method: An interpersonal psychotherapy protocol was developed, modified to incorpora...

Background: Mother–baby units are innovative and important models of care that allow inpatient treatment of postpartum maternal mental disorders whilst preserving and promoting the attachment relationship with their young infants. Objectives: To report data across five public mother–baby units in Australia in order to explore similarities and distinguishing features of each model. Method: Each unit also provided 12 months of data on key characteristics of their unit. Results: Despite the geographic differences, the diagnostic profiling, length of stay, and child protection involvement were similar across the units. Conclusions: Acute care for perinatal mental illness offered in public mother–baby units in Australia shows consistency across units, raising concerns for where such treatment is unavailable.

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.

BACKGROUND: Maternal depression in the postpartum period confers substantial morbidity and mortality, but the definition of postpartum depression remains controversial. We investigated the heterogeneity of symptoms with the aim of identifying clinical subtypes of postpartum depression.METHODS: Data were aggregated from the international perinatal psychiatry consortium Postpartum Depression: Action Towards Causes and Treatment, which represents 19 institutions in seven countries. 17,912 unique subject records with phenotypic data were submitted. We applied latent class analyses in a two-tiered approach to assess the validity of empirically defined subtypes of postpartum depression. Tier one assessed heterogeneity in women with complete data on the Edinburgh postnatal depression scale (EPDS) and tier two in those with postpartum depression case status.FINDINGS: 6556 individuals were assessed in tier one and 4245 in tier two. A final model with three latent classes was optimum for both tiers. The most striking characteristics associated with postpartum depression were severity, timing of onset, comorbid anxiety, and suicidal ideation. Women in class 1 had the least severe symptoms (mean EPDS score 10·5), followed by those in class 2 (mean EPDS score 14·8) and those in class 3 (mean EPDS score 20·1). The most severe symptoms of postpartum depression were significantly associated with poor mood (mean EPDS score 20·1), increased anxiety, onset of symptoms during pregnancy, obstetric complications, and suicidal ideation. In class 2, most women (62%) reported symptom onset within 4 weeks postpartum and had more pregnancy complications than in other two classes (69% vs 67% in class 1 and 29% in class 3).INTERPRETATION: PPD seems to have several distinct phenotypes. Further assessment of PPD heterogeneity to identify more precise phenotypes will be important for future biological and genetic investigations.FUNDING: Sources of funding are listed at the end of the article.

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.

Objective to describe perceptions of participating in a study testing the effectiveness of a perinatal emotional support intervention (Promoting Resilience in Mothers Emotions; PRIME) by women identified as experiencing emotional distress after birth. Design qualitative descriptive approach. Semi-structured telephone interviews with 33 women recruited as part of a larger RCT to test the efficacy of a counselling intervention (PRIME). Women who received either (1) the intervention (counselling (or PRIME)) ( n =16), (2) active control (Parenting support) ( n =12), or (3) matched control (standard care) ( n =5), were interviewed at 12 months postpartum. Thematic analysis of data was used. Findings ‘promoting reflection' and ‘feeling cared for', were phrases that all participants used to describe their experience in the project regardless of group allocation. Women receiving PRIME reported ‘getting in touch with (their) feelings' and ‘moving on' as beneficial outcomes. Two women who received counselling reported ‘having things left unresolved' indicating that their needs had not been met. Some women in both the active control and intervention identified that contact was ‘nice but not hugely helpful or needed'. Implications and conclusions positive outcomes of PRIME were evident and most participants desired postpartum contact. Some women needed additional follow up and targeted assistance. Findings support the importance of providing personalised postnatal care that addresses women's emotional health needs.

Women with bipolar disorder have a high risk of relapse following childbirth. The risk of relapse can be reduced by mood stabilisers, but they are potentially harmful to the developing fetus.The objective of this article is to provide an up-to-date review of the strategies for managing women with bipolar disorder over the perinatal period.Discussing the risks of taking mood stabilisers or having a medication-free pregnancy is essential for women with bipolar disorder. The latter, with careful monitoring, is suggested for women with less severe illness and good supports. Full or partial prophylaxis with a mood stabiliser is recommended for women at higher risk of relapse. Careful monitoring during pregnancy, psychosocial interventions and planning for the postnatal period will aid in preventing bipolar disorder relapse. The general practitioner is ideally placed to take a key management role in liaising with the obstetric and mental health teams, and planning for the postnatal period.

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.

High levels of childbirth fear impact birth preparation, obstetric outcomes and emotional wellbeing for around one in five women living in developed countries. Higher rates of obstetric intervention and caesarean section (CS) are experienced in fearful women. The efficacy of interventions to reduce childbirth fear is unclear, with no previous randomised controlled trials reporting birth outcomes or postnatal psychological wellbeing following a midwife led intervention. Between May 2012 and June 2013 women in their second trimester of pregnancy were recruited. Women with a fear score ≥ 66 on the Wijma Delivery Expectancy / Experience Questionnaire (W-DEQ) were randomised to receive telephone psycho-education by a midwife, or usual maternity care. A two armed non-blinded parallel (1:1) multi-site randomised controlled trial with participants allocated in blocks of ten and stratified by hospital site and parity using an electronic centralised computer service. The outcomes of the RCT on obstetric outcomes, maternal psychological well-being, parenting confidence, birth satisfaction, and future birth preference were analysed by intention to treat and reported here. 1410 women were screened for high childbirth fear (W-DEQ ≥66). Three hundred and thirty-nine (n = 339) women were randomised (intervention n = 170; controls n = 169). One hundred and eighty-four women (54 %) returned data for final analysis at 6 weeks postpartum (intervention n = 91; controls n = 93). Compared to controls the intervention group had a clinically meaningful but not statistically significant reduction in overall caesarean section (34 % vs 42 %, p = 0.27) and emergency CS rates (18 % vs 25 %, p = 0.23). Fewer women in the intervention group preferred caesarean section for a future pregnancy (18 % vs 30 %, p = 0.04). All other obstetric variables remained similar. There were no differences in postnatal depression symptoms scores, parenting confidence, or satisfaction with maternity care between groups, but a lower incidence of flashbacks about their birth in the intervention group compared to controls (14 % vs 26 %, p = 0.05). Postnatally women who received psycho-education reported that the ‘decision aid’ helped reduce their fear (53 % vs 37 %, p = 0.02). Following a brief antenatal midwife-led psycho-education intervention for childbirth fear women were less likely to experience distressing flashbacks of birth and preferred a normal birth in a future pregnancy. A reduction in overall CS rates was also found. Psycho-education for fearful women has clinical benefits for the current birth and expectations of future pregnancies. Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17th May 2012

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.

Background. Postnatal depression persists worldwide as a troubling issue for many new mothers and their families. The practice of early discharge within 72 hours after birth from maternity hospitals in Australia requires community-based care of new mothers, typically provided by community midwives initially, and then by maternal and child health nurses (MCHN). This latter workforce encounters the onset of distress/depression in vulnerable women and is expected to manage their care, but their training does not equip sufficiently them to do this. Aims. The aim of the study was to evaluate the effectiveness of brief training for MCHN in early detection and effective management of mildly distressed new mothers. Methods. A controlled comparative longitudinal study was carried out with a group of first-time mothers recruited through antenatal clinics at four major hospitals in a large Australian city. Forty MCHN were allocated to the intervention group. Those in the intervention group received training in the identification and management of distressed mothers. Intervention group nurses also had access to a liaison psychiatric network for consultation and referrals. Other nurses were allocated to the control group, which provided standard management services to new mothers in their catchment areas. Mothers’ outcomes in psychological and psychosocial functioning were assessed; comparing those cared for by the nurses who had received the intervention with those cared for by standard practices. Mothers’ satisfaction with the maternal and child health nurse services was also assessed. Results. Levels of distress peaked in early pregnancy in both groups and reduced over the study period. Rates and group levels of psychological distress and psychosocial functioning did not differ over time between mothers receiving care from the enhanced trained nurses and those receiving standard care. Differential group findings were apparent in attrition, with the more distressed mothers withdrawing from the control group and the less distressed withdrawing from the intervention group. Satisfaction with maternal and child health nurse services was high in both groups. Limitations of the study included events occurring while the study was in progress, such as staffing upheaval and unrest following the introduction of compulsory competitive tendering requirements, heavy workloads and the concurrent introduction of computerized case records that required the rapid familiarization with computer usage. Conclusions. Findings indicate that the extra training of MCHN did not substantially assist in the detection and management of postnatal distress in these new mothers. Unexpected ecological conditions of workforce disruption and extra workloads may have mitigated against the success of the programme. Limitations of the study are examined and the implications for future research are discussed.

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

Perinatal psychiatry has expanded from the traditional focus on mental health in the postpartum period to include a greater understanding that women may become unwell during pregnancy and that the risks to the infant from exposure to illness start before birth. One of the key roles for the general practitioner is to help women with known mental health issues to prepare for pregnancy, as well as identify those at risk and help to guide management choices.This article reviews the issues to consider when managing perinatal illness, focusing on medication.Perinatal mental illness is common. The illness poses a risk to mother and child through treating and not treating. The aim is to identify risks early, manage them assertively but sensitively, and ensure that the mother is as well as possible while minimising risk to the child.

To evaluate the psychological and psychosocial functioning of couples undergoing their first pregnancy, 327 couples from Melbourne, Victoria completed measures of depression, anger, anxiety, positive and negative affect, current social support, perceived quality of couple's relationship, and recalled childhood family relationships during the early third trimester of pregnancy. To examine the nature of the pregnant couples' experience of pregnancy, an exploratory factor analysis was conducted separately for males and females. Four similar but not identical clusters were identified for both the men and women. The first large general factor for both sexes was concerned with psychological dysphoria (anxiety, anger and gender role stress). Three group factors were concerned separately with the individual's relationship functioning, their social support from family and friends, and the quality of their recalled childhood family relationships. Confirmatory factor analysis indicated these four-dimensional solutions showed good fit to the data and indicated differences between the female and male underlying structures. The differences between the men and women's factor structure are examined and implications of these findings are discussed.

The objective of the study was to examine moods and adjustment through the transition to parenthood as an issue affecting the couple; to examine not only the postpartum but also the pregnancy experience and to explore how each partner's experiences interact with those of the other. A longitudinal repeated measures design was utilized with 327 healthy couples with a first-time pregnancy who were from Melbourne, Victoria in 1995-98. Each partner was interviewed on four occasions: mid- and late pregnancy, early postpartum and 4 months postnatally. Twenty per cent of mothers and 12% of fathers were significantly distressed at mid-pregnancy (Time 1) and this persisted until the early postpartum (Time 3) phase. Young age (particularly in women), negative mood, poor relationship functioning, gender role stress (particularly performance failure regarding work and sex in males) and low social support predicted distress in mid-pregnancy (Time 1). Negative mood in partner and self, and poor relationship functioning at mid-pregnancy predicted vulnerability to postnatal distress (Time 3 and/or Time 4). The incidence of distress in couples during mid- and late pregnancy is of concern and highlights the importance of considering the total transition to parenthood, not only the onset of postnatal distress. The analyses of predictors of postnatal distress from prenatal variables suggest that a 'contagion of distress' may operate in some couples. The standard management provided for couples experiencing pregnancy may be inadequate for many couples. These findings suggest that it is important to consider the mood and relationship quality of both partners and to offer intervention services as early as possible to offset possible progression into postnatal depression.

Paired blood and breast-milk samples were collected from 10 nursing mothers receiving sertraline. Samples were collected at steady state when the patients had been taking stable doses of 50-150 mg/day over several weeks. Sertraline concentrations in both fluids were determined using a specific, validated HPLC method. Plasma and milk concentrations showed a wide inter-individual variability for the same dose. Mean plasma concentrations were linearly related to dose, but this was not the case for breast-milk concentrations. An overall milk to plasma ratio of 1.76+/-1.72 was recorded. The average dose to the infants ranged from 1.1 to 31.1 mg/kg, which is less than 2 per cent of the maternal dose per day. Further studies are necessary to determine if these doses are detrimental to the development of the infant. Copyright 2000 John Wiley & Sons, Ltd.

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.

Plasma and breast milk concentrations of the monoamine oxidase-A inhibitor, moclobemide were measured in eight women being treated for post-partum depression. The main milk to plasma ratio was 0·68, with a range of 0·39–1·21. There was no correlation between this ratio and dose of the drug. Based on the milk to plasma ratio, the infants were exposed to

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.

Objective: To examine the developmental outcomes in children exposed to antidepressants in utero and compare those to children not exposed to these medications Method: A prospective case-controlled study of children exposed to antidepressants in pregnancy assessed 22 exposed and 19 not exposed children using the Bayley Scales of Infant Development, third edition. The control group was measured at a mean age of 23.09 (SD 3.82) months and the medicated group at 28.53 months (SD 6.22). Maternal variables were assessed using a purpose-designed questionnaire and the Beck Depression Inventory (II) in pregnancy and at three assessments in the postpartum. Results: Children exposed to antidepressant medication in pregnancy scored lower on motor subscales in particular on fine motor scores than non-exposed children with a moderate effect size of Cohen's d = 0.47 fine motor and Cohen's d = 0.43 for gross motor. Due to lack of power these findings did not reach conventional criteria for statistical significance. There was no association found between maternal depression and neurodevelopment. Conclusions: This finding of a possible effect from antidepressant exposure in pregnancy on children's motor development is similar to the findings from a previous study. Future research is needed which assesses children at an older age using specific assessments of motor development.

Plasma and breast‐milk concentrations of dothiepin and its metabolite northiaden were measured in 20 lactating women receiving the drug for post‐partum depression. Samples were collected at steady‐state and both compounds quantitated by HPLC. Doses of dothiepin varied from 75 mg/day to 225 mg/day. Accordingly a wide range of plasma and breast‐milk concentrations of dothiepin and northiaden were determined. Most determinations were made for women receiving 150 mg/day. At this dose mean (± SD) plasma concentrations of dothiepin and northiaden were 56(±27)mg/l and 72(±79)mg/l respectively while breast‐milk concentrations were 95(±71) mg/l and 40(±29) mg/l for dothiepin and northiaden respectively. The data reflect the well recognised inter‐individual variability in plasma concentrations for subjects receiving the same oral dose. Similar variability was noted in breast‐milk concentrations at all doses of dothiepin. Dothiepin passes into the breast‐milk of lactating women receiving the drug for post‐partum depression. In this respect the drug is similar to other tricyclic antidepressants. The inter‐individual variability of results recorded here suggest the need to determine drug concentrations on an individual basis before reaching a decision about breastfeeding. Perceived side effects in the infant are clear criteria for cessation of breastfeeding; high levels of drug in breastmilk where the infant is unaffected, warrant monitoring in view of our inadequate knowledge regarding long term effects of these drugs. Copyright © 1993 John Wiley & Sons, Ltd.

To undertake a systematic review of the effects of exposure to mood stabilizer medication in pregnancy, evaluating teratogenicity and other outcomes for mother and child. This was one of three concurrent systematic reviews of psychotropic medication exposure in pregnancy.A systematic search was carried out of electronic databases, reference books and other sources for original research studies which examined the effects of commonly used mood stabilizers (sodium valproate, carbamazepine, lamotrigine and lithium carbonate) on pregnancy outcomes. These included malformations, pregnancy complications, neonatal complications and longer term developmental outcomes for children exposed.All mood stabilizers were found to be associated with a risk of malformation and perinatal complications. Studies which examined longer term neurodevelopmental outcomes found poorer outcomes for those children exposed to sodium valproate or polytherapy in pregnancy than for other individual AEDs. The data available for longer term child outcomes with lithium exposure is too limited to draw any conclusions.This review found that exposure in pregnancy to all four commonly used mood stabilizers may be teratogenic, and is associated with increased rates of pregnancy and neonatal complications. There was also more limited information that sodium valproate may be associated with poorer longer term child developmental outcomes. These findings must be balanced with the risk of relapse and poor pregnancy and child outcomes with untreated maternal bipolar disorder. The information obtained from these reviews of psychotropic medications will assist clinicians in managing women with mental illness in pregnancy.

Objective: There is evidence of increasing prescription of antidepressant medication in pregnant women. This has arisen from the recognition of the importance of treating maternal depression. This must be balanced, however, with information on outcomes for infants and children exposed to antidepressants in pregnancy. The aim of the present study was to examine whether neonatal outcomes including gestational age at birth, neonatal growth outcomes at birth and then at 1 month postpartum were altered by in utero exposure to antidepressant medication 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 at an obstetric hospital in Melbourne, Australia. Of the 27 women taking medication, 25 remained on medication in the third trimester. A purpose-designed self-report questionnaire and the Beck Depression Inventory-II were completed in pregnancy, after birth and at one month postpartum. In addition information was collected on exposed and non-exposed infants including Apgar scores, birthweight/length/head circumference and gestational age at birth. Weight/length/head circumference was again collected at 1 month of age. Results: Infants exposed to antidepressants in utero were eightfold more likely to be born at a premature gestational age, had significantly lower birthweight and were smaller in length and head circumference than non-exposed infants. There was no association between birth outcomes and maternal depression. At 1 month, the difference in weight in the exposed group became significantly greater than the control group. Conclusion: Antidepressant exposure in utero may affect gestational age at birth and neonatal outcomes independently of antenatal maternal depression. Further studies are needed to examine whether these findings vary according to the type of antidepressant prescribed and follow up growth and development in exposed infants beyond 1 month.

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.