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Postpartum depression affects approximately 15% of mothers. Unfortunately, treatment options for postpartum depression are limited. Pharmacological antidepressants such as fluoxetine (FLX) can be controversial due to inconclusive evidence of efficacy during the postpartum and concerns of neonatal exposure to antidepressants. Alternatively, non-pharmacological antidepressants such as exercise may be less controversial but its efficacy in postpartum depression is unclear. To investigate this, we treated rat dams daily with high levels of corticosterone (CORT; 40 mg/kg), to induce a depressive-like phenotype, or oil (vehicle for CORT) during the postpartum period. Within the oil and CORT conditions, four additional antidepressant conditions were created: 1. FLX (10 mg/kg) + exercise (voluntary access to running wheel); 2. FLX + no exercise; 3. Saline (vehicle for FLX) + exercise; 4. Saline + No exercise. We examined maternal care, depressive-like and anxiety-like behavior, stress reactivity, and hippocampal neurogenesis and dams were categorized as "high running" or "low running." FLX treatment, alone or with high running, prevented CORT-induced disruptions in maternal care. As expected, CORT increased depressive-like behavior but exercise, regardless of running amount, reduced depressive-like behavior. Intriguingly, FLX, but not CORT, increased anxiety-like behavior, which was not mitigated by concurrent exercise. FLX treatment slightly but significantly facilitated serum CORT recovery after forced swim stress. CORT and FLX alone reduced neurogenesis, while exercise coupled with FLX increased density of doublecortin-expressing cells. High running increased density of doublecortin-expressing cells (immature neurons) in comparison to controls. Collectively, these findings indicate that FLX and exercise reverse different endophenotypes of depression in dams, which has translational implications for surveying treatment options of postpartum depression., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: There is currently no specific guidance on the role of exercise in managing postpartum depression in the UK and US, and international guidance is inconsistent., Aim: To assess the effectiveness of aerobic exercise on postpartum depressive symptoms., Design and Setting: Systematic review and meta-analysis. There was no restriction to study site or setting., Method: The databases MEDLINE, EMBASE, Cochrane Library, PsycINFO, SportDiscus, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform were searched. Titles and abstracts, then full-text articles, were screened against inclusion criteria: RCTs measuring depressive symptoms in mothers ≤1 year postpartum; and interventions designed to increase aerobic exercise compared with usual care or other comparators. Included studies were assessed using the Cochrane Collaboration's risk of bias tool. Meta-analysis was conducted. Pre-planned subgroup analyses explored heterogeneity., Results: Thirteen RCTs were included, with 1734 eligible participants. Exercise significantly reduced depressive symptoms when all trials were combined (standardised mean difference -0.44; 95% confidence interval = -0.75 to -0.12). Exploration of heterogeneity did not find significant differences in effect size between women with possible depression and in general postpartum populations; exercise only and exercise with co-interventions; and group exercise and exercise counselling., Conclusion: This systematic review provides support for the effectiveness of exercise in reducing postpartum depressive symptoms. Group exercise, participant-chosen exercise, and exercise with co-interventions all may be effective interventions. These results should be interpreted with caution because of substantial heterogeneity and risk of bias., (© British Journal of General Practice 2017.)

Purpose: To compare the preferences of those who accept a mental health assessment and those who do not., Design and Methods: Thirty couples participated in a qualitative study. Nineteen couples accepted a mental health assessment and 11 declined., Findings: Acceptors wanted more contact with professionals. Decliners preferred support from their informal network, parental leave, and exercise. However, acceptors also cited these preferences., Practice Implications: Nurses should tailor care to couples' preferences, helping them identify and utilize preferred resources. Mental health care might be more acceptable to decliners if provided in obstetrical care., (© 2015 Wiley Periodicals, Inc.)

Postpartum Psychosis (PP) is a severe and debilitating psychiatric illness with acute onset in the days following childbirth. Recovering from an episode can be a long and difficult process. The aim of this study was to gain an understanding of the difficulties faced by recovering women and to inform the planning of post-discharge information and support services. A study was designed collaboratively by service user and academic researchers. Women with experience of PP were trained in qualitative research methodology. Service user researchers (SURs) led in-depth interviews into women's experiences of recovery. PP is a life-changing experience that challenges women's sense of personal and social identity. Recovery themes are organised around ruminating and rationalising, rebuilding social confidence, gaining appropriate health service support, the facilitation of family functioning, obtaining appropriate information, and understanding that recovery will take time. Women suffering from PP must be adequately supported following discharge from psychiatric hospital if we are to address maternal suicide rates. We describe a successful collaboration between academics and service users exploring the needs of women and their families.

The internet offers an accessible and cost-effective way to help women suffering with various types of postnatal mental illness and also can provide resources for healthcare professionals. Many websites on postnatal mental illness are available, but there is little information on the range or quality of information and resources offered. The current study therefore aimed to review postnatal health websites and evaluate their quality on a variety of dimensions. A systematic review of postnatal health websites was conducted. Searches were carried out on four search engines (Google, Yahoo, Ask Jeeves and Bing) which are used by 98% of web users. The first 25 websites found for each key word and their hyperlinks were assessed for inclusion in the review. Websites had to be exclusively dedicated to postnatal mental health or have substantial information on postnatal mental illness. Eligible websites (n=114) were evaluated for accuracy of information, available resources and quality. Results showed that information was largely incomplete and difficult to read; available help was limited and website quality was variable. The top five postnatal mental illness websites were identified for (1) postnatal mental illness sufferers and (2) healthcare professionals. It is hoped these top websites can be used by healthcare professionals both for their own information and to advise patients on quality online resources.

This review covers research on the negative effects of prenatal depression and cortisol on fetal growth, prematurity and low birthweight. Although prenatal depression and cortisol were typically measured at around 20 weeks gestation, other research suggests the stability of depression and cortisol levels across pregnancy. Women with Dysthymia as compared to Major Depression Disorder had higher cortisol levels, and their newborns had lower gestational age and birthweight. The cortisol effects in these studies were unfortunately confounded by low serotonin and low dopamine levels which in themselves could contribute to non-optimal pregnancy outcomes. The negative effects of depression and cortisol were also potentially confounded by comorbid anxiety, by demographic factors including younger age, less education and lower SES of the mothers and by the absence of a partner or a partner who was unhappy about the pregnancy or a partner who was depressed. Substance use (especially caffeine use) was still another risk factor. All of these problems including prenatal depression, elevated cortisol, prematurity and low birthweight and even postpartum depression have been reduced by prenatal massage therapy provided by the women's partners. Massage therapy combined with group interpersonal psychotherapy was also effective for reducing depression and cortisol levels. Several limitations of these studies were noted and suggestions for future research included exploring other predictor variables like progesterone/estriol ratios, immune factors and genetic determinants. Further research is needed both on the potential use of cortisol as a screening measure and the use of other therapies that might reduce prenatal depression and cortisol in the women and prematurity and low birthweight in their infants., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Integrative approach to treatment of psychiatric patients incorporates a variety of therapeutic procedures that overlap and are not mutually exclusive. Their objective is unique: to heal and to restore patients' proper functioning in their family, work and social environments alike. Treatment often requires integration of various therapeutic approaches. In this paper we report the efficacy of an integrative model in the case of a female patient who developed a clinical picture of psychotic depression after giving birth. Taking an individual approach alongside the continuous use of psycho pharmacotherapy enabled us to look for an appropriate model of hospital and ambulatory treatment, namely psychotherapeutic setting. This example proved individual psychotherapy to be a complementary method to psycho pharmacotherapy. This was due to a strong feeling of shame that prevented the patient from opening up and dealing with her inner conflict in the previous group treatment. Integrative and personalised treatment has resulted in a relatively quick recovery and return to her everyday duties.

Background: Post-natal depression (PND) is a serious mental health problem that may be reduced by exercise. National Institute for Health and Clinical Excellence in England have recommended that health professions should consider exercise as a treatment for PND., Objective: To evaluate the effectiveness of exercise in the management of PND., Methods: Systematic review and meta-analysis of randomized controlled trials (RCTs). Data sources involved in the study are Cochrane Library (CENTRAL), MEDLINE, EMBASE, PsycINFO, Science Citation Index and Social Science Citation Index, CINAHL and SPORTDiscus. Review methods. Selection criteria are RCTs and quasi-RCTs that compared any type of exercise intervention with other treatments or no treatment in women with PND. Database searches and abstracts were reviewed independently by two authors. The Delphi criteria were used to assess the quality of included studies. Data were abstracted by two reviewers. Data synthesis is meta-analysis. Main outcome measure is post-natal depression., Results: Five studies fulfilled our inclusion criteria. When compared with no exercise, exercise reduced symptoms of PND {SMD = -0.81 [95% confidence interval (CI): -1.53 to -0.10]}. The overall WMD in Edinburgh Post-natal Depression Scale score was -4.00 points (95% CI: -7.64 to -0.35). However, significant heterogeneity was found. The effect size was reduced considerably (non-significant) when the trial that included exercise as a co-intervention with social support was excluded [SMD = -0.42 (95% CI: -0.90 to 0.05)] and heterogeneity was no longer present., Conclusions: Due to heterogeneity, it is uncertain whether exercise reduces symptoms of PND. Caution is also required when interpreting findings from the main analysis as only five small trials were included and CIs were wide. Further research is evidently required.

Objective: The purpose of this retrospective study was to investigate the prevalence of bipolar depression and differentiate the factors that could predict bipolar disorder among filicidal depressive mothers., Method: Among the offenders who were sentenced to undergo treatment at the National Institute of Forensic Psychiatry, Gongju, Korea, for committing filicide or attempting filicide during 1987 to 2006, 45 women were selected whose final diagnoses at discharge were major depressive disorder or bipolar disorder based on DSM-III-R and DSM-IV criteria. Retrospective medical chart review was performed, mainly focusing on the prevalence rate of bipolar depression, including the rate of diagnostic change during admission. We also investigated the characteristic symptoms of depressive episodes that could predict bipolar disorder., Results: At admission, in only 24.4% of the patients (N = 11) was bipolar disorder diagnosed. However, on the basis of diagnosis at discharge, a bipolar disorder prevalence rate of 73.3% (N = 33) was found. Of the patients with major depressive disorder at admission, 64.7% (N = 22) were subsequently reclassified as having bipolar disorder based on newly observed hypomanic or manic episodes during the admission period. The significant (p < .05) depressive symptoms at the time of filicide that could predict bipolar depression were the presence of postpartum-onset depression (95% CI = 1.45 to 160.88), psychotic symptoms (95% CI = 1.94 to 215.81), and nonaltruistic motivation for filicide (95% CI = 1.68 to 133.36)., Conclusion: Our results suggest that mental health professionals should consider the possibility of bipolarity when they examine filicidal depressive mothers with postpartum-onset depression, psychotic symptoms, and nonaltruistic motivation for filicide., (Copyright 2008 Physicians Postgraduate Press, Inc.)

To identify factors that women who have recovered from postnatal depression consider to be important in the recovery process and to measure the consensus among recovered women regarding the importance of those factors. A two-panel, three-round adapted Delphi exercise supplemented by a user-led interpretation work-shop. Panel one consisted of ten women who had been treated by a health visitor for and recovered from postnatal depression. Panel two consisted of 158 women who had recovered from postnatal depression who were London based members of a national support group for postnatal depression. There was a strong consensus among the participants about the 37 success factors that were identified. Factors that were identified as 'essential' in recovery from postnatal depression included: emotional support from partner; sleep; improved communication with partner; the diagnosis; practical support from partner; emotional support from friends; time to bond with the new baby; and prompt assessment by a health visitor. An interpretation group, made up of seven women who had recovered from postnatal depression, condensed the 37 factors into seven categories: diagnosis; positive action (or reaction) to intervene in the recognized problem; provision of support by people you know; professional or outside agency input; relationship between mother and baby; returning to work and continuity of care. There was a strong level of consensus among recovered women regarding a wide range of recovery factors. While all of the factors were considered to be, at least, 'important', social support from family and friends was generally rated more highly than support from health care professionals.

Background: Fatigue is prevalent during the postpartum period and may be heightened in postpartum depressed women., Purpose: To evaluate the efficacy of a home-based exercise intervention in reducing physical and mental fatigue scores in postpartum depressed women., Methods: Eighty-eight women in the postpartum (4-38 weeks) obtaining a score > or =10 on the Edinburgh Postnatal Depression Scale (EPDS) were randomly assigned to a 12-week individualized home-based intervention (n = 46) or a control group (n = 42). All participants completed a cardiovascular fitness test at baseline. Outcomes were physical and mental fatigue scores and were measured at baseline, posttreatment and 3 months posttreatment., Results: On the basis of intent-to-treat analyses, compared to the control group, women in the exercise group showed significantly greater reduction in physical fatigue at posttreatment [mean change = -4.07, (95% CI, (-5.15, -2.98)] and 3 months posttreatment [mean change = -4.24, (95% CI, (-5.36, -3.12)]. Significant reductions in mental fatigue with exercise were observed at posttreatment for women reporting lower physical fatigue at baseline., Conclusions: Fatigue is a common symptom experienced in the postpartum that can be heightened by depression. The findings show that home-based exercise can reduce physical and mental fatigue in postpartum depressed women.

Access barriers to services result in extensive wait times. Distance delivery systems with no face-to-face contact are not yet widely accepted because of uncertainty about whether therapeutic alliance can exist. In this study, 131 participants completed a questionnaire designed to explore their distance treatment experience. The majority described positive comments about the relationship formed with their telephone coach including the strength/quality, coach attributes, and the inapprehension to disclose information to the coach. Moreover, 97% reported preference for distance treatment. Acceptance and integration of evidence-based distance delivery systems are a promising approach to primary healthcare reform.

Aim: This paper reports a qualitative study describing the process of recovery from postpartum depression in Taiwanese women., Methods: We carried out a study using grounded theory with a purposive sample of 23 postnatally depressed women in 2001-2002. The Beck Depression Inventory was used to screen for severe depression. Women with scores higher than 16 at 6 weeks after childbirth were categorized as having postpartum depression. Only two out of the 23 mothers were being treated for depression at the time. The data were analysed by constant comparative method., Findings: 'Being reborn' was the core concept that emerged from the data on the mothers' experience of going through postnatal depression, which was a process of descent into near-death insanity and eventual rebirth. Such postnatally depressed mothers often underwent four stages of coping with the loss of self or loss of former identity and attachment to their new lives as mothers. The four stages were: (1) shattered role identity, (2) feeling trapped and breaking down, (3) struggling for self-integrity and (4) regaining vitality., Conclusion: The experience of postpartum depression should be examined within the social and cultural contexts in which it occurs. These Taiwanese data can be used to develop culturally-sensitive health care. The nursing role is primarily that of reflective listening to help the women adjust to the process of being reborn--an internal process of painful growth represented by motherhood and striving to protect the real self in order to maintain emotional health while negotiating a developmental transition. Preventive interventions might include providing guidance for parenting, counselling of individual mothers, and facilitating the development of support groups.

Purpose: To evaluate the content and the technology of Web sites providing information on postpartum depression., Study Design and Methods: Eleven search engines were queried using the words "Postpartum Depression." The top 10 sites in each search engine were evaluated for correct content and technology using the Web Depression Tool, based on the Technology Assessment Model., Results: Of the 36 unique Web sites located, 34 were available to review. Only five Web sites provided >75% correct responses to questions that summarized the current state of the science for postpartum depression. Eleven of the Web sites contained little or no useful information about postpartum depression, despite being among the first 10 Web sites listed by the search engine. Some Web sites contained possibly harmful suggestions for treatment of postpartum depression. In addition, there are many problems with the technology of Web sites providing information on postpartum depression., Clinical Implications: A better Web site for postpartum depression is necessary if we are to meet the needs of consumers for accurate and current information using technology that enhances learning. Since patient education is a core competency for nurses, it is essential that nurses understand how their patients are using the World Wide Web for learning and how we can assist our patients to find appropriate sites containing correct information.

Background: This study prospectively investigated the factors underlying the maintenance and persistence of postnatal depression beyond the first year after birth., Method: One hundred primiparous women who were admitted to a parentcraft hospital for a week were assessed after discharge at 4 and 12 months postpartum. Various measures of mood, interpersonal relationships and defence styles were administered at 4 months and the relation between these measures and clinically elevated symptoms of depression at 12 months was examined., Results: At 12 months, 30% of all mothers and 60% of those diagnosed depressed at 4 months continued to report clinically significant levels of depressive symptomatology. The strongest predictor of depression at 12 months was severity of symptoms at 4 months, and women from a non-English speaking background were significantly more likely to remain depressed. Reports of low maternal care in childhood, marital dissatisfaction at 4 months, an attachment style characterised by anxiety over relationships and immature defence styles were significant predictors of clinically elevated depression scale scores at 12 months. Furthermore, an insecure attachment style was shown to mediate the effect of low maternal care in childhood, while other cognitive and interpersonal factors appeared to contribute additively in maintaining depressive symptoms., Limitations: Self-report measures were used to measure insecure attachment styles and depression at 12 months., Conclusions: Findings demonstrate that both childhood and concurrent relationship difficulties contribute to the maintenance of postpartum depression. Interventions for persistent depression need to address relationship difficulties as well as depressive symptomatology.

Objective: To determine readmission and recurrence rates of women admitted to psychiatric hospital with their babies, and index factors predicting subsequent course., Method: A total of 66 women were followed up after 10 years. Information was obtained from structured interviews or other personal contact, and from general practitioners and hospital notes. Psychiatric diagnoses were made according to Research Diagnostic Criteria (RDC). Outcome and predictive factors were investigated using survival analysis., Results: A recurrence rate of 87.2%, and a readmission rate of 63.3% were found. Readmissions were more common after index schizophrenia than other diagnoses. The strongest predictor of readmission was previous psychiatric history. Among 27 subsequent pregnancies, puerperal recurrence was high among those with index psychoses (75-80%), but lower among those with index depression (27.3%)., Conclusion: The recurrence rate is high, with a moderate readmission rate predicted by past psychiatric history. Continuing clinical vigilance over the long-term is required for these patients.

Background: This prospective cohort study assessed the cost-effectiveness of treating 30 women with postnatal depression (PND) at a specialised psychiatric Parent and Baby Day Unit (PBDU), compared to 30 women treated using routine primary care (RPC)., Methods: Following recruitment, the women were assessed on three occasions (initially, 3- and 6-months), using a variety of social and psychiatric outcome measures. Direct and indirect costs were collated using structured interviews, retrospective analysis of case notes and routinely collated NHS cost data. Sensitivity analysis was also carried out., Results: There was no significant difference between the women in the two groups initially in terms of their socio-demographic characteristics, or scores on the outcome measures. However, at 6-months, 21 women in the PBDU group were no longer depressed compared to only seven women in the RPC group. The total cost was 46,211 pounds for the PBDU group and 18,973 pounds for the RPC group. Moving from RPC to a PBDU would involve an additional expenditure of 27,238 pounds (46,211-18,973) whilst delivering 14 more positive outcomes. The move from RPC to PBDU would incur an additional cost per successfully treated woman of 1945 pounds (27,238/14). This compares favourably with the current cost per successfully treated woman in the RPC group of 2710 pounds (18,973/7)., Conclusions: RPC is dominated on the grounds of cost-effectiveness by PBDU treatment and so PBDU treatment should be recommended to health care decision-makers., Limitations of the Study: The results were sensitive to the inclusion of primary care contacts and the costs of medication.

I have presented to our support system, which mainly utilizes the Edinburgh Postnatal Depression Scale (EPDS) at 4 days and 1 month for mothers in the perinatal period and newborn babies, who have been under the care of the Morioka Red Cross Hospital. The perinatal system for mothers and babies, which has evolved over the past 9 years at the Morioka Red Cross Hospital. I explained the case of a 25-year-old woman who had already been suffering from depression before her pregnancy, and the course of improvement she experienced under this support system. In particular, I have shown a means of support, which can be provided by the obstetrics staff and is available to patient and families without making them feel hesitant. We take care of childbirth, and after baby care has started, we encourage depressive mothers to visit the Psychiatric Department. As a result, depression is no longer problematic, and the mothers recover sufficiently to be able to take good care of their babies. Even now, we are keeping track of these mothers and babies, while working together with the public health centers in communities. In the future, we will place emphasis on the implementation of SCID and on the careful observations of mothers and especially, babies, under the room-in system. We are also planning to begin lactation guidance at an earlier stage than before.

Infant massage by the mother has been popular in many cultures, especially India, and is growing in popularity in the West. Mothers with postnatal depression often have problems interacting with their infants. A small controlled study has shown that attending a massage class can help such mothers relate better to their babies. The mechanisms by which this is achieved are not clear but may include learning to understand their babies' cues and the release of oxytocin.

Background: Postnatal depression affects one in ten women within 6 months of childbirth. The most effective treatment strategy for postnatal depression is not clear., Methods: This prospective, naturalistic study of the treatment of postnatal depression compared 30 women treated at a specialised psychiatric day hospital with 30 women treated using routine primary care (RPC). Clinical, marital and social adjustment were assessed on three occasions over 6 months using: the Edinburgh Postnatal Depression Questionnaire (EPDS); the Clinical Interview schedule (CIS); the Anxiety Subscale of the Hospital Anxiety and Depression Scale; the Dyadic Adjustment Scale (DAS); and the Work Leisure and Family Life Questionnaire-Modified (WLFLQ-M)., Results: There were no significant differences between the two groups at baseline. However, there were significant differences in outcome at 3 and 6 months follow-up for all outcome measures except the DAS. At 6 month follow-up 21 of the PBDU group were no longer depressed compared with 7 of the RPC group., Conclusions: A specialised day hospital is a more effective treatment setting for postnatal depression than routine primary care., Limitations of the Study: The study is not an RCT, so systematic bias is possible. The sample size is relatively small and the duration of follow-up relatively short.

Objective: To review the question of whether an infant should be admitted to psychiatric services when a severe psychiatric disorder necessitates admission of the mother., Method: All available literature on mother-infant joint admission was reviewed and arguments for and against are summarised., Results: Early reports favoured joint admission, then opinions changed, possibly for economic reasons. Recent thinking encompasses research data on (i) longer-term adverse effects of postnatal depression on the children, and (ii) the finding of psychological and psychiatric morbidity in many of the fathers. Joint admission to designated special units is valuable, but such facilities are only cost-efficient and effective if established as part of an appropriate broader plan for managing postpartum, psychiatric disorder., Conclusions: (1) Further research is needed to answer this question definitively. (2) Services at primary and secondary level require expansion. (3) All services should target the whole family.