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Objective: Major depressive disorder (MDD) during pregnancy increases the risk of adverse maternal and infant outcomes. Maternal nutritional status may be a modifiable risk factor for antenatal depression. We evaluated the association between patterns in mid-pregnancy nutritional biomarkers and MDD., Design: Prospective cohort study., Setting: Pittsburgh, Pennsylvania, USA., Subjects: Women who enrolled at ≤20 weeks' gestation and had a diagnosis of MDD made with the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) at 20-, 30- and 36-week study visits. A total of 135 women contributed 345 person-visits. Non-fasting blood drawn at enrolment was assayed for red cell essential fatty acids, plasma folate, homocysteine and ascorbic acid; serum 25-hydroxyvitamin D, retinol, vitamin E, carotenoids, ferritin and soluble transferrin receptors. Nutritional biomarkers were entered into principal components analysis., Results: Three factors emerged: Factor 1, Essential Fatty Acids; Factor 2, Micronutrients; and Factor 3, Carotenoids. MDD was prevalent in 21·5 % of women. In longitudinal multivariable logistic models, there was no association between the Essential Fatty Acids or Micronutrients pattern and MDD either before or after adjustment for employment, education or pre-pregnancy BMI. In unadjusted analysis, women with factor scores for Carotenoids in the middle and upper tertiles were 60 % less likely than women in the bottom tertile to have MDD during pregnancy, but after adjustment for confounders the associations were no longer statistically significant., Conclusions: While meaningful patterns were derived using nutritional biomarkers, significant associations with MDD were not observed in multivariable adjusted analyses. Larger, more diverse samples are needed to understand nutrition-depression relationships during pregnancy.

Background: Maternal plasma lipids, including total cholesterol, low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C), increase during pregnancy, remaining elevated over prepregnancy levels through the immediate postpartum period. Triglycerides decrease rapidly to prepregnancy levels after delivery. Few data on postpartum lipid levels are available, and levels in postpartum women with depression have not been evaluated. We sought to determine the cross-sectional levels of total cholesterol, LDL-C, HDL-C, and triglycerides between 1 and 14 weeks postpartum in postpartum women with DSM-4 diagnoses of major depression and determine if they are similarly elevated to published levels in other postpartum populations., Methods: As part of screening for a randomized controlled trial comparing treatments for postpartum depression (PPD), women (n=120) had postpartum fasting lipid levels determined. Linear regression models were used to assess the association between time postpartum and lipid levels. Analysis of covariance models (ANCOVA) assessed the association of baseline characteristics with lipids., Results: Total cholesterol levels were >200 mg/dL in 45% of the sample at baseline. Mean baseline total cholesterol was 196±39 mg/dL. There was an inverse linear relationship between postpartum week and total cholesterol, with cholesterol values decreasing an average of 4.5 mg/dL per week. Similarly, LDL-C and HDL-C trended down over time. Triglycerides were stable and within the normal range during the observation period., Conclusions: Total cholesterol, HDL-C, and LDL-C are significantly elevated in the early postpartum period and do not return to <200 mg/dL until 6 weeks postpartum in women with PPD. The magnitude and duration of elevation are consistent with the sparse published data on nondepressed women.

The early postpartum period is associated with increased risk for affective and psychotic disorders. Because maternal dopaminergic reward system function is altered with perinatal status, dopaminergic system dysregulation may be an important mechanism of postpartum psychiatric disorders. Subjects included were non-postpartum healthy (n=13), postpartum healthy (n=13), non-postpartum unipolar depressed (n=10), non-postpartum bipolar depressed (n=7), postpartum unipolar (n=13), and postpartum bipolar depressed (n=7) women. Subjects underwent 60 min of [¹¹C]raclopride-positron emission tomography imaging to determine the nondisplaceable striatal D₂/₃ receptor binding potential (BP(ND)). Postpartum status and unipolar depression were associated with lower striatal D₂/₃ receptor BP(ND) in the whole striatum (p=0.05 and p=0.02, respectively) that reached a maximum of 7-8% in anteroventral striatum for postpartum status (p=0.02). Unipolar depression showed a nonsignificant trend toward being associated with 5% lower BP(ND) in dorsal striatum (p=0.06). D₂/₃ receptor BP(ND) did not differ significantly between unipolar depressed and healthy postpartum women or between bipolar and healthy subjects; however, D₂/₃ receptor BP(ND) was higher in dorsal striatal regions in bipolar relative to unipolar depressives (p=0.02). In conclusion, lower striatal D₂/₃ receptor BP(ND) in postpartum and unipolar depressed women, primarily in ventral striatum, and higher dorsal striatal D₂/₃ receptor BP(ND) in bipolar relative to unipolar depressives reveal a potential role for the dopamine (DA) system in the physiology of these states. Further studies delineating the mechanisms underlying these differences in D₂/₃ receptor BP(ND), including study of DA system responsivity to rewarding stimuli, and increasing power to assess unipolar vs bipolar-related differences, are needed to better understand the affective role of the DA system in postpartum and depressed women.

Obsessive-compulsive symptoms in the postpartum period often include intrusive thoughts of harming the infant and rituals that result in avoidance of the baby. The differential diagnosis of women who develop these symptoms includes postpartum major mood disorders, obsessive-compulsive disorder, and psychosis with infanticidal thoughts. The treatment of the most common diagnoses, mood disorders and obsessive-compulsive disorder, includes serotonergic drugs, psychoeducation to help the patient understand that she is highly unlikely to harm her infant, and exposure with response prevention therapy. This intervention involves exposure of the patient to the feared situations, which are usually related to infant care, while simultaneously preventing the compulsive rituals.

Objective: Morbidly obese patients frequently present with mood and anxiety disorders, which are often treated with serotonin reuptake inhibitors (SRIs). Having observed that patients treated with SRIs frequently relapse after Roux-en-Y gastric bypass surgery, the authors sought to assess whether SRI bioavailability is reduced postoperatively., Method: Twelve gastric bypass candidates treated with an SRI for primary mood or anxiety disorders were studied prospectively. Timed blood samples for SRI plasma levels were drawn for pharmacokinetic studies before surgery and 1, 6, and 12 months afterward. Maximum concentration, time to maximum concentration, and area under the concentration/time curve (AUC) were determined., Results: In eight of the 12 patients, AUC values 1 month after surgery dropped to an average of 54% (SD=18) of preoperative levels (range=36%-80%); in six of these patients, AUC values returned to baseline levels (or greater) by 6 months. Four patients had an exacerbation of depressive symptoms, which resolved by 12 months in three of them. Three of the four patients had a reduced AUC level at 1 month and either gained weight or failed to lose weight between 6 and 12 months. Normalization of the AUC was associated with improvement in symptom scores., Conclusions: Patients taking SRIs in this study were at risk for reduced drug bioavailability 1 month after Roux-en-Y gastric bypass. The authors recommend close psychiatric monitoring after surgery.

The aim of this study was to provide data to aid decision making regarding lithium use during lactation. Three women treated with lithium for bipolar disorder during pregnancy and lactation and their four infants provided lithium levels at 1 month postpartum. Infant levels ranged from 10% to 17% of maternal levels. Two infants experienced early feeding problems which were overcome with breastfeeding education and support. Women taking lithium can be supported to breastfeed, and their infants should be followed closely until breastfeeding is well established.

Pregnant women in methadone maintenance therapy may have poor nutrition during pregnancy. In 2006-2008, methadone-treated pregnant women (n = 22) were recruited at an urban academic medical center and compared with nondrug-using pregnant women (n = 119) at 20-35 weeks' gestation. We measured adiposity using prepregnancy body mass index (BMI), dietary intake using a food frequency questionnaire, and micronutrient and essential fatty acid status using biomarkers. Methadone-treated women had lower BMI, consumed more calories, had lower serum carotenoid concentrations, and higher plasma homocysteine concentrations than controls. The study's limitations and implications for future research are discussed.

Objective: The etiology of preterm birth (PTB) is likely caused by multiple factors, which may include disturbed sleep. We evaluated whether sleep disturbance was associated with PTB and whether the association was affected by other psychosocial risk factors., Methods: Pregnant women (n=217) for whom we had depression and sleep data at 20 or 30 weeks gestation and delivery information were evaluated. Logistic models were used to test the hypotheses that disturbed sleep was associated with PTB., Results: Time in bed at 20 weeks was significantly associated with risk for preterm delivery (odds ratio [OR] 1.43, 95% confidence interval [CI] 1.08-1.88). However, after controlling for depression/selective serotonin reuptake inhibitors (SSRI) status, history of PTB, age, employment, and marital status, this relationship was no longer significant (OR 1.26, 95% CI .92-1.71). No other relationships were significant., Conclusions: We report preliminary evidence suggesting that poor sleep may contribute to risk for PTB. Although it is speculative and additional work is needed to confirm or refute whether sleep is an independent or mediating risk factor for PTB, disturbed sleep does appear to play a role in adverse pregnancy outcomes.

Background: Prenatal serotonin reuptake inhibitor (SRI) exposure has been related to adverse newborn neurobehavioral outcomes; however, these effects have not been compared to those that may arise from prenatal exposure to maternal major depressive disorder (MDD) without SRI treatment. This study examined potential effects of MDD with and without SRI treatment on newborn neurobehavior., Methods: This was a prospective, naturalistic study. Women were seen at an outpatient research center twice during pregnancy (26-28 and 36-38 weeks gestational age (GA)). Psychiatric diagnoses were assessed using the Structured Clinical Interview for the DSM-IV; medication use was measured with the Timeline Follow-Back instrument. Three groups were established based upon MDD diagnosis and SRI use: Control (N = 56), MDD (N = 20), or MDD + SRI (N = 36). Infants were assessed on a single occasion within 3 weeks of birth with the NICU Network Neurobehavioral Assessment Scale. Generalized Linear Modeling was used to examine neurobehavioral outcomes by exposure group and infant age at assessment., Results: Full-term infants exposed to MDD + SRIs had a lower GA than CON or MDD-exposed infants and, controlling for GA, had lower quality of movement and more central nervous system stress signs. In contrast, MDD-exposed infants had the highest quality of movement scores while having lower attention scores than CON and MDD + SRI-exposed infants., Conclusion: MDD + SRI-exposed infants seem to have a different neurobehavioral profile than MDD-exposed infants in the first 3 weeks after delivery; both groups may have different neurobehavioral profiles with increasing age from birth., (© 2011 Wiley Periodicals, Inc.)

Background: Little is known about neural mechanisms of postpartum depression (PPD). Previous research notes ventral striatal activity and dopamine release increases with maternal attachment but decreases in major depressive disorder. This study tests the hypothesis that striatal response to reward is altered in PPD., Methods: Subjects underwent functional magnetic resonance imaging blood oxygenation level-dependent acquisition during a fast event-related card-guessing, monetary reward task. Time series data from an independent sample of 10 healthy mothers were used to establish the ventral striatal region of interest (ROI). Repeated-measures analysis of variance of time series data in the established ROI was then conducted for a discrete group of healthy (n = 12) and depressed, unmedicated mothers (n = 12)., Results: Data from the independent sample of 10 healthy mothers established an ROI in the left ventral striatum (-13, 12, -4, 477 mm(3)), with cluster significance p < .01, corrected. There was a significant quadratic interaction of time × group [F(1,22) = 5.22, p = .032] in this ROI in the healthy (n = 12) and depressed mothers (n = 12). This effect represents a nonlinear attenuation of ventral striatal response with time that was greater in depressed than healthy mothers., Conclusions: Rapid attenuation of ventral striatal response to reward receipt in postpartum depression might represent an important neural mechanism of postpartum depression. Additional study with infant stimuli and in relationship to mother-infant behavior is needed., (Copyright © 2011 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Sleep disturbances and symptoms of depression are common during pregnancy. Both are independent and interrelated risk factors for adverse outcomes. It is unclear the degree to which sleep differs between depressed and nondepressed pregnant women. We sought to (1) describe and compare sleep disturbances in depressed pregnant and nondepressed pregnant women, (2) determine the impact of selective serotonin reuptake inhibitors (SSRI) treatment on sleep, and (3) evaluate whether sleep at 20 weeks is associated with increased depressive symptoms and major depressive disorder (MDD) in later pregnancy., Methods: Pregnant women (N = 240) were recruited in the second trimester (20 weeks gestation) and assigned to depressed (N = 59) and nondepressed (N = 181) groups based on a Structured Clinical Interview for DSM-IV diagnosis of major depressive disorder. The Structured Interview Guide for the Hamilton Rating Scale with Atypical Depression Supplement was administered at 20, 30, and 36 weeks gestation from which the sleep variables were obtained., Results: Depressed women had more fragmented sleep at each assessment (P values≤.05). However, the frequency of insomnia symptoms was greater for depressed women only at 20 weeks gestation. SSRI use, regardless of MDD status, did significantly affect several sleep variables. Among the nondepressed women, those with short or longer sleep duration, symptoms of insomnia and long periods of nocturnal waketime had higher Structured Interview Guide for the Hamilton Rating Scale with Atypical Depression Supplement scores later in pregnancy (P values≤.05)., Conclusions: At 20 and 30 weeks gestation sleep was more disturbed in depressed pregnant women compared to nondepressed pregnant women. At 36 weeks, sleep was disturbed regardless of depression status or SSRI use. Among the nondepressed women, disturbed sleep in conjunction with SSRI use was associated with higher depressive symptoms., (© 2011 Wiley-Liss, Inc.)

Objective: Affective disorder during pregnancy is a common condition requiring careful judgment to treat the depression while minimizing risk to the fetus. Following up on promising pilot trials, we studied the efficacy of light therapy., Method: Twenty-seven pregnant women with nonseasonal major depressive disorder according to DSM-IV (outpatients, university polyclinic) were randomly assigned to 7,000 lux fluorescent bright white or 70 lux dim red (placebo) light administered at home in the morning upon awakening for 1 h/d in a 5-week double-blind trial carried out between October 2004 and October 2008. Clinical state was monitored weekly with the 29-item Structured Interview Guide for the Hamilton Depression Rating Scale (HDRS) with Atypical Depression Supplement (SIGH-ADS). Changes of rating scale scores over time were analyzed with the general linear model. Differences from baseline of SIGH-ADS and 17-item HDRS scores at every time point were the dependent variables, time was the within-subjects factor, and treatment was the between-subjects factor. The model also included baseline score of depression and gestational age at intervention start., Results: The superiority of bright light over dim light placebo was shown for both SIGH-ADS (R² = 0.251; F(3,23) = 3.91; P < .05) and HDRS (R² = 0.338; F(3,23) = 5.42; P < .01) when analyzing the week-by-week change from baseline, and HDRS scores showed a significant interaction of treatment with time (F(4,92) = 2.91; P < .05). Categorical analysis revealed that the response rate (HDRS ≥ 50% improvement) at week 5 was significantly greater for bright light (81.3%, n = 16) than for placebo light (45.5%, n = 11) (P < .05). Remission (final score ≤ 8) was attained by 68.6% versus 36.4%, respectively (P < .05). Expectation ratings did not differ significantly between groups., Conclusions: Bright white light treatment for 5 weeks improved depression during pregnancy significantly more than placebo dim red light. The study provides evidence that light therapy, a simple, cost-effective antidepressant modality with minimal side effects for the mother and no known risk for the unborn child, may be a useful nonpharmacologic approach in this difficult situation., Trial Registration: clinicaltrials.gov Identifier: NCT01043289., (© Copyright 2011 Physicians Postgraduate Press, Inc.)

Background: To explore women's perspectives about the treatment decision-making process for depression during pregnancy and after birth., Method: One hundred pregnant and postpartum women completed an anonymous web-based surveys regarding treatment decision making for depression., Results: Survey data reveal that most women in this sample prefer an active collaborative role in treatment decision making for depression. Sixty-five percent of the sample made a decision for treatment of their major depressive disorder, including a decision for no treatment, and 34% reported not having made a decision or feeling unsure about their decision. More than half of the sample preferred combination treatment with medications and counseling (55%) followed by counseling (22%), no treatment (8%), and medications (8%). Overall, respondents in this sample had low levels of decisional conflict (uncertainty) with younger women in the sample reporting higher levels of decisional conflict., Conclusions: Treatment decision making for depression during the perinatal period is complex. Asking women about their preferences for participation in decision making, their treatment preferences and their decision making needs during the clinical encounter may lead to improved communication, decision making and quality of care., (© 2011 Wiley-Liss, Inc.)

Objective: The authors explored the relationship of cord-maternal antidepressant concentration ratios and maternal depression with perinatal events and preterm birth., Method: The investigators examined 21 mother-infant pairs that had antidepressant exposure during pregnancy. The antidepressants included serotonin reuptake inhibitors (SRIs) and nortriptyline (a norepinephrine inhibitor and mild SRI). The mothers were evaluated with the Structured Clinical Interview for DSM-IV. Depression ratings were repeated at 20, 30, and 36 weeks' pregnancy. At delivery, investigators assessed cord and maternal antidepressant concentrations, neonatal outcomes on the Peripartum Events Scale (PES), and gestational weeks at birth. The investigators performed this study at the Women's Behavioral HealthCARE Program, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pennsylvania, from April 2003 until September 2006., Results: Mean ± SD cord-to-maternal concentration ratios were 0.52 ± 0.35 (range, 0.00-1.64) for the parent drug and 0.54 ± 0.17 (range, 0.28-0.79) for the metabolite. Nine of 21 mothers (43%) had a major depressive episode. From examining the maximum depression ratings, the mean ± SD Structured Interview Guide for the Hamilton Depression Rating Scale, Atypical Depression Symptoms Version score was 16.0 ± 7.6. One third (7/21) of infants had at least 1 perinatal event (PES ≥ 1). The frequency of deliveries complicated by any perinatal event was similar in depressed and nondepressed mothers. There was no significant association between perinatal events and cord-to-maternal antidepressant concentration ratios or maternal depression levels. Exposure to short half-life antidepressants compared to fluoxetine resulted in more perinatal events (7/16 = 44% vs 0/5 = 0%; P = .06). Fourteen percent (3/21) of infants were preterm. Preterm birth was not associated with cord-to-maternal metabolite concentration ratios, depression levels, or exposure to fluoxetine., Conclusions: Antidepressant-exposed infants experienced a limited number of transient perinatal events. No association between cord-maternal concentration ratios or maternal depression and perinatal events could be identified. Contrary to other reports, we detected no increased risk for perinatal events with fluoxetine therapy compared to the short half-life antidepressants., Trial Registration: clinicaltrials.gov Identifier: NCT00279370., (© Copyright 2011 Physicians Postgraduate Press, Inc.)

Objectives: Reports suggest women with bipolar disorder (BD) have high rates of perimenstrual mood worsening. In this prospective study, the authors compared healthy controls and depressed and euthymic BD patients on medications on mood levels, psychosocial function, and physical symptoms in the late luteal versus the early follicular phase., Methods: At baseline, the lifetime diagnosis of bipolar I disorder or bipolar II disorder, current mood episode, and absence of premenstrual dysphoric disorder in controls were confirmed with the Structured Clinical Interview for DSM-IV Disorders. Subjects were assessed across three menstrual cycles during the late luteal and early follicular phases. Clinicians administered the Structured Interview Guide for the Hamilton Depression Rating Scale and the Mania Rating Scale to assess levels of depression and hypomania/mania, respectively. Subjects completed self-report ratings on psychosocial function and perceived stress and tracked daily mood and physical symptoms on the National Institute of Mental Health LifeChart and the Daily Rating Form. Ovulation was verified objectively with mid-cycle luteinizing hormone urine dipsticks and serum progesterone levels., Results: The sample characteristics were similar among the three patient groups of healthy controls (n = 10), BD-euthymic (n = 6), and BD-depressed (n = 5). The two-way analysis of variance indicated a significant difference among the diagnostic groups on depression scores, psychosocial functioning, and levels of perceived stress. There was no significant difference for menstrual phase or the interaction of menstrual phase by diagnostic group., Conclusions: Mood symptom level, psychosocial functioning, perceived stress, and physical discomfort were unrelated to menstrual phase in patients with BD. Appropriate maintenance treatment may prevent menstrual related mood symptoms. Use of an objective marker of ovulation is critical for research involving menstrual related outcomes., (© 2011 John Wiley and Sons A/S.)

Background: Postpartum depression (PPD) is the most common complication of childbirth. Suicide is a leading cause of maternal death in the first postpartum year. Depressed mothers often have suicidal ideation (SI). Depression and suicidality may vary across the seasons. Previous studies of seasonality and PPD were relatively small or encumbered by study design constraints. We examined the possible relationship between seasonality, depression, and SI in 9,339 new mothers., Methods: From 2006 to 2010, the investigators screened women within 4-6 weeks postpartum with the Edinburgh Postnatal Depression Scale (EPDS). We used spectral analysis to explore seasonal variation in risk for depression and suicidality., Results: The study team screened 9,339 new mothers, of whom 1,316 (14%) women had positive depression scores (EPDS≥10) which suggest PPD risk; 294 (3%) women had SI (item 10≥1). A positive EPDS was associated significantly with SI. PPD risk varied significantly across 12-months-risk was highest in December. We detected no seasonal variation in SI., Conclusions: Effects of seasonal light variation may contribute to increased risk for depressive symptoms. Suicidality could be related to maternal depression but not seasonal variation., (© 2011 Wiley-Liss, Inc.)

Background: Poor sleep quality, dysregulation of hormones and increased inflammatory cytokines are all associated with the risk for postpartum major depression (PPMD). We evaluated change over time in sleep quality and hormones during the first 17 weeks postpartum, as well as a single cytokine measure, and their association with PPMD recurrence., Methods: Participants were pregnant women (N=56), with past histories of MDD/PPMD but not depressed in their current pregnancy. The Pittsburgh Sleep Quality Index (PSQI) and blood samples were collected 8 times during the first 17 weeks postpartum. Estradiol, prolactin and cortisol, and a single measure of IL-6 were assayed. Recurrence was determined by two consecutive 21-item Hamilton Rating Scale for Depression (HRSD) scores≥15 and clinician interview., Results: In the analyses of time to PPMD recurrence, poor sleep quality, but none of the hormones, was associated with PPMD recurrence (p<.05) after controlling for medication assignment. With every one point increase in PSQI scores across time, a woman's risk for recurrence increased by approximately 25% There was no significant association between PSQI scores and IL-6 concentrations in early postpartum (χ(2)=0.98, p=.32)., Conclusions: Poor sleep quality across the first 17 weeks post-delivery increases the risk for recurrent PPMD among women with a history of MDD. Changes in the hormonal milieu were not associated with recurrence. Further exploration of the degree to which poor sleep contributes to hormonal and cytokine dysregulation and how they are involved in the pathophysiology of PPMD is warranted., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Objective: Postpartum major depression is a significant public health problem that strikes 15% of new mothers and confers adverse consequences for mothers, children, and families. The neural mechanisms involved in postpartum depression remain unknown, but brain processing of affective stimuli appears to be involved in other affective disorders. The authors examined activity in response to negative emotional faces in the dorsomedial pre-frontal cortex and amygdala, key emotion regulatory neural regions of importance to both mothering and depression., Method: Postpartum healthy mothers (N=16) and unmedicated depressed mothers (N=14) underwent functional magnetic resonance imaging blood-oxygen-level-dependent acquisition during a block-designed face versus shape matching task. A two-way analysis of variance was performed examining main effects of condition and group and group-by-condition interaction on activity in bilateral dorsomedial prefrontal cortical and amygdala regions of interest., Results: Depressed mothers relative to healthy mothers had significantly reduced left dorsomedial prefrontal cortical face-related activity. In depressed mothers, there was also a significant negative correlation between left amygdala activity and postpartum depression severity and a significant positive correlation between right amygdala activity and absence of infant-related hostility. There was reliable top-down connectivity from the left dorsomedial prefrontal cortex to the left amygdala in healthy, but not depressed, mothers., Conclusions: Significantly diminished dorsomedial prefrontal cortex activity and dorsomedial prefrontal cortical-amygdala effective connectivity in response to negative emotional faces may represent an important neural mechanism, or effect, of postpartum depression. Reduced amygdala activity in response to negative emotional faces is associated with greater postpartum depression severity and more impaired maternal attachment processes in postpartum depressed mothers.

Objective: To add to the limited data on the clinical pharmacology of antidepressants during pregnancy, we examined the dose-corrected chiral and racemic levels (level/dose) of fluoxetine (FLX) and norfluoxetine (NorFLX) during pregnancy and early postpartum., Methods: The authors evaluated 17 pregnant women who received fluoxetine therapy. Doses were recorded weekly across gestation and postpartum. At 20, 30, and 36 weeks of gestation, during delivery, and 12 weeks after delivery, the depression level was assessed with the Hamilton Rating Scale for Depression (HRS-D), and plasma samples were analyzed for levels of S- and R-FLX and S- and R-NorFLX., Results: The mean ratios of the chiral parent drug (S-FLX + R-FLX) to metabolite levels (S-NorFLX + R-NorFLX) decreased across pregnancy. The differences were significant between 20-36 weeks and 30-36 weeks. After delivery, the mean dose-corrected level of the active moiety S-FLX and the mean ratio of the chiral parent drug (S-FLX + R-FLX) to metabolite level (S-NorFLX + R-NorFLX) significantly increased between delivery and 12 weeks postpartum. Most of the fluoxetine-treated subjects experienced remitted depressive episodes and euthymic mood levels during pregnancy and postpartum., Conclusions: The findings extend earlier reports of increased antidepressant metabolism during pregnancy and refractory metabolism after delivery. These data may inform treatment decisions related to dosing in patients who receive fluoxetine during pregnancy.

Background: Assessment of mothers in the year after childbirth is important for a number of reasons, including the well-being of the mother and healthy development of the child. There exists a body of instruments that measure a range of maternal characteristics, such as maternal confidence and self-efficacy. It remains unclear if any of these assessments can be used to measure maternal functioning, which may be a direct indication of potential hazards to the offspring. Accurate assessment of functioning would also aid in identifying women who are struggling in the maternal role. In order to assess whether commonly used maternal assessments extend into the realm of functioning, it is necessary to have an appropriate definition. Therefore, the aims of this analysis are to (1) present a new, patient-centered definition of maternal functional status and (2) evaluate select maternal assessments against this definition., Methods: Three new mother focus groups were held in order to understand women's experiences in the year after childbirth. These experiences informed the definition of maternal functional status, which was used to evaluate select instruments for their capacity to assess maternal functioning., Results: None of the instruments covered all seven domains, and all of the instruments covered at least one domain., Conclusions: Although there are means of assessing depression status in the postpartum, there is no comprehensive way of capturing a woman's quality of life. A new measure is required in order to capture this multifaceted, patient-defined construct of maternal functioning.

Objective: Breastfeeding confers many health benefits to mothers and infants, while depression negatively affects mothers and infants. The aims of this study were to determine relationships between (1) major depressive disorder (MDD) and depressive symptom severity during pregnancy and breastfeeding intention; (2) MDD and depressive symptom severity during pregnancy and breastfeeding initiation and status at 2 and 12 weeks; and (3) serotonin reuptake inhibitor (SRI) use and breastfeeding intention, initiation, and status at 2 and 12 weeks., Method: Women were followed prospectively from pregnancy through 12 weeks postpartum for infant feeding intention (breast, breast and formula, formula, and uncertain), feeding practices and MDD (Structured Clinical Interview for DSM-IV Disorders), and depressive symptom severity (Hamilton Depression Rating Scale). Bivariate analyses and multivariable regression modeling were conducted. The study was conducted from July 2004 to September 2007., Results: Study participants (intention n = 168, initiation n = 151, 2 weeks n = 137, 12 weeks n=103) were well educated (63% college degrees), older (49% ≥ or = 31 years), and predominantly white (77%). At enrollment, 23% had MDD, 21% had significant depressive symptoms, and 16% were taking an SRI. Neither MDD nor depressive symptom severity in pregnancy was related to breastfeeding intention, initiation or duration at 2 and 12 weeks. Intention to exclusively breastfeed was the most significant predictor of breastfeeding initiation and duration. SRI use in pregnancy was negatively associated with breastfeeding intention. SRI use at 2 weeks was negatively associated with 12-week breastfeeding status., Conclusion: Pregnancy is the optimal time to intervene to increase breastfeeding rates. Future research should identify strategies to overcome breastfeeding barriers posed by SRI use., (Copyright 2010 Physicians Postgraduate Press, Inc.)

Objective: To review selected complementary and alternative medicine (CAM) treatments for major depressive disorder (MDD)., Participants: Authors of this report were invited participants in the American Psychiatric Association's Task Force on Complementary and Alternative Medicine., Evidence: The group reviewed the literature on individual CAM treatments for MDD, methodological considerations, and future directions for CAM in psychiatry. Individual CAM treatments were reviewed with regard to efficacy in MDD, as well as risks and benefits. Literature searches included MEDLINE and PsycINFO reviews and manual reference searches; electronic searches were limited to English-language publications from 1965 to January 2010 (but manual searches were not restricted by language). Treatments were selected for this review on the basis of (1) published randomized controlled trials in MDD and (2) widespread use with important clinical safety or public health significance relevant to psychiatric practice. An action plan is presented based on needs pertaining to CAM and psychiatry., Consensus Process: Consensus was reached by group conferences. Written iterations were drafted and sent out among group members prior to discussion, resolution of any differences of interpretation of evidence, and final approval., Conclusions: A review of randomized controlled trials for commonly used CAM treatments such as omega-3 fatty acids, St John's wort (Hypericum), folate, S-adenosyl-L-methionine (SAMe), acupuncture, light therapy, exercise, and mindfulness psychotherapies revealed promising results. More rigorous and larger studies are recommended. Each CAM treatment must be evaluated separately in adequately powered controlled trials. At this time, several CAM treatments appear promising and deserve further study. The greatest risk of pursuing a CAM therapy is the possible delay of other well-established treatments. Clinical, research, and educational initiatives designed to focus on CAM in psychiatry are clearly warranted due to the widespread use of CAM therapies., (2010 Physicians Postgraduate Press, Inc.)

Objective: The goal was to describe the accuracy of the Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory II (BDI-II), and Postpartum Depression Screening Scale (PDSS) in identifying major depressive disorder (MDD) or minor depressive disorder (MnDD) among low-income, urban mothers attending well-child care (WCC) visits during the postpartum year., Methods: Mothers (N = 198) attending WCC visits with their infants 0 to 14 months of age completed a psychiatric diagnostic interview (standard method) and 3 screening tools. The sensitivities and specificities of each screening tool were calculated in comparison with diagnoses of MDD or MDD/MnDD. Receiver operating characteristic curves were calculated and the areas under the curves for each tool were compared to assess accuracy for the entire sample (representing the postpartum year) and subsamples (representing early, middle, and late postpartum time frames). Optimal cutoff scores were calculated., Results: At some point between 2 weeks and 14 months after delivery, 56% of mothers met criteria for either MDD (37%) or MnDD (19%). When used as continuous measures, all scales performed equally well (areas under the curves of > or =0.8). With traditional cutoff scores, the measures did not perform at the expected levels of sensitivity and specificity. Optimal cutoff scores for the BDI-II (> or =14 for MDD and > or =11 for MDD/MnDD) and EPDS (> or =9 for MDD and > or =7 for MDD/MnDD) were lower than currently recommended. For the PDSS, the optimal cutoff score was consistent with current guidelines for MDD (> or =80) but higher than recommended for MDD/MnDD (> or =77)., Conclusions: Large proportions of low-income, urban mothers attending WCC visits experience MDD or MnDD during the postpartum year. The EPDS, BDI-II, and PDSS have high accuracy in identifying depression, but cutoff scores may need to be altered to identify depression more accurately among urban, low-income mothers.

This review approaches the topic of childbirth and mental illness using a model of perinatal health which takes into consideration the multiple determinants of health, approached from a lifespan perspective. The paper seeks to answer four broad questions using this model and available literature: (1) What is the relationship between childbirth and mental disorders? (2) How common are mental disorders during childbearing, and what is the perinatal course of illness? (3) What are the effects of mental illness during childbearing on foetal and infant developmental outcomes? (4) How do you approach the detection and treatment of mental disorders during the perinatal period?

Background: The prevalence and recurrence rates of postpartum depression (PPD) are 13 and 25%, respectively. Despite its detrimental impact on the health of the mother-infant dyad, there is a paucity of data in the literature regarding the efficacy of pharmacological treatment of PPD., Objectives: i) To review the literature on the use of antidepressants and hormonal supplements for the prevention and the treatment of PPD; ii) to give the authors' opinion on the current status of the pharmacological treatment of PPD; and iii) to discuss developments that are likely to be important in the future., Methods: An electronic search was performed by using PubMed, Medline, and PsychINFO. Inclusion criteria were: i) empirical articles in peer-reviewed English-language journals; ii) well-validated measures of depression; and iii) a uniform scoring system for depression among the sample., Results/conclusion: The electronic search yielded a total of 19 articles (12 on treatment and 7 on prevention of PPD) with the following study designs: eight randomized clinical trials (six using placebo control and two using active control groups), and 11 open-label studies. The selection of the specific antidepressant for a woman with PPD should derive from a personalized risk-benefit analysis.

Approximately 3% of pregnant women take antidepressant medications. Information on the impact of antidepressants on short- and long-term maternal and offspring outcomes is highly desirable but neglected. The position that the dearth of treatment information is of greater concern than the risks to pregnant subjects involved in medical research is gaining support. Mandating the collection of reproductive outcome data in exposed childbearing women is an overdue step toward societal responsibility to our most vulnerable members.

Postpartum depression (PPD) is the most common medical complication of childbearing. Universal screening maximizes the likelihood of prompt identification of PPD. Obstetrician-gynecologists routinely evaluate postpartum women for a general health examination and review of family planning options at approximately 6 weeks after birth; therefore, they are well positioned to identify PPD. In this study, we review the diagnostic criteria for postpartum depressive disorders and clinical risk factors predictive of PPD. We examine depression screening tools, appropriate cut-points associated with positive screens, the optimal timing for screening, and the acceptability of depression screening in obstetrical settings. Finally, we explore how to manage patients who screen positive for depression and treatment options for women with PPD.

Objective: We assessed the relation between prepregnancy body mass index (BMI) and the likelihood of major depressive disorder (MDD) during pregnancy and tested whether this association was modified by gestational weight gain., Method: Women (N = 242) were enrolled at < 20 weeks gestation into a prospective cohort study. Diagnosis of MDD was made with the Structured Clinical Interview for DSM-IV at 20, 30, and 36 weeks gestation. Gestational weight gain was compared with the 1990 Institute of Medicine weight gain recommendations. To assess the independent association between prepregnancy BMI and the odds of MDD, MDD at each time point was used as the dependent measure in a multivariable longitudinal logistic regression model employing generalized estimating equations. The data were collected from 2003-2007., Results: There was a strong, positive dose-response association between prepregnancy BMI and the likelihood of MDD (P = .002). Compared with a BMI of 18, the adjusted odds ratios (95% confidence interval) for BMIs of 23, 28, and 33 were 1.4 (1.1 to 1.7), 1.9 (1.3 to 2.9), and 2.6 (1.4 to 4.3), respectively. Gestational weight gain significantly modified this effect. Among women with weight gains within and above the 1990 Institute of Medicine recommendations, pregravid overweight was associated with a greater likelihood of MDD. In contrast, all women with weight gains below recommended levels had an elevated odds of depression regardless of their pregravid BMI (P < .05)., Conclusions: Because pregravid overweight, poor gestational weight gain, and MDD all pose substantial risks for fetal development and birth outcomes, health care providers should monitor depression levels in these women to facilitate appropriate depression intervention., (Copyright 2009 Physicians Postgraduate Press, Inc.)

Objective: To address the maternal and neonatal risks of both depression and antidepressant exposure and develop algorithms for periconceptional and antenatal management., Method: Representatives from the American Psychiatric Association, the American College of Obstetricians and Gynecologists and a consulting developmental pediatrician collaborated to review English language articles on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing. Articles were obtained from Medline searches and bibliographies. Search keywords included pregnancy, pregnancy complications, pregnancy outcomes, depressive disorder, depressive disorder/dt, abnormalities/drug-induced/epidemiology, abnormalities/drug-induced/et. Iterative draft manuscripts were reviewed until consensus was achieved., Results: Both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestations, but the majority of studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder. Short-term neonatal irritability and neurobehavioral changes are also linked with maternal depression and antidepressant treatment. Several studies report fetal malformations in association with first trimester antidepressant exposure but there is no specific pattern of defects for individual medications or class of agents. The association between paroxetine and cardiac defects is more often found in studies that included all malformations rather than clinically significant malformations. Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and a low risk for persistent pulmonary hypertension in the newborn. Psychotherapy alone is an appropriate treatment for some pregnant women; however, others prefer pharmacotherapy or may require pharmacological treatment., Conclusions: Antidepressant use in pregnancy is well studied, but available research has not yet adequately controlled for other factors that may influence birth outcomes including maternal illness or problematic health behaviors that can adversely affect pregnancy.

We performed an electronic search by using MEDLINE, PreMEDLINE, Current Contents, Biological Abstracts, and PsycINFO from June 2002 to December 2008 using the following terms: "antidepressant drugs", "antidepressive agents", "human milk", "lactation", and "breastfeeding" and the generic name of each antidepressant. Articles in the English language with reports of antidepressants in maternal serum or breast milk, infant serum, and short-term and long-term clinical outcomes in the infants were obtained. The search yielded a total of 31 empirical papers. Breastfeeding and antidepressant treatments are not mutually exclusive. Sertraline, paroxetine, nortriptyline, and imipramine are the most evidence-based medications for use during breastfeeding.

Unplanned, adverse events during labor or delivery may generate a negative response during the early postpartum period, resulting in disruption of usual functioning and mood. High levels of maternal depressive symptoms are associated with parenting, infant attachment, behavioral problems and cognition (Beck 2002). The purpose of this study was to examine the relationship of adverse events in labor or delivery and depressive symptoms, functional status and infant care at 2-weeks postpartum. The secondary aim was to explore the role of social support as a possible moderator in the relationship between adverse birth events and maternal outcomes. A secondary analysis of data (n = 123) was performed using data collected in a prospective, observational study examining the effects of antidepressant use during pregnancy. Adverse events did not significantly predict depressive symptoms (odds ratio = 1.34, p = .536), functional status (R(2) change = .001, p = .66), or infant care (R(2) change = .004, p = .48) at 2-weeks postpartum when controlling for depression during pregnancy, antidepressant use at delivery, education level, age, and parity. Social support had significant effects on depressive symptoms (p = .02), functional status (p = .014), and infant care (p < .001) but did not moderate the effect of adverse events when predicting depressive symptoms (odds ratio = 1.01, p = .045), functional status (R(2) change = .009, p = .056) and infant care (R(2) change < .001, p = .92). Adverse events did not predict maternal outcomes at 2-weeks postpartum. Social support was related to depressive symptoms, functional status and infant care, but did not moderate the effects of adverse events.

Objective: Selective serotonin reuptake inhibitor (SSRI) use during pregnancy incurs a low absolute risk for major malformations; however, other adverse outcomes have been reported. Major depression also affects reproductive outcomes. This study examined whether 1) minor physical anomalies, 2) maternal weight gain and infant birth weight, 3) preterm birth, and 4) neonatal adaptation are affected by SSRI or depression exposure., Method: This prospective observational investigation included maternal assessments at 20, 30, and 36 weeks of gestation. Neonatal outcomes were obtained by blinded review of delivery records and infant examinations. Pregnant women (N=238) were categorized into three mutually exclusive exposure groups: 1) no SSRI, no depression (N=131); 2) SSRI exposure (N=71), either continuous (N=48) or partial (N=23); and 3) major depressive disorder (N=36), either continuous (N=14) or partial (N=22). The mean depressive symptom level of the group with continuous depression and no SSRI exposure was significantly greater than for all other groups, demonstrating the expected treatment effect of SSRIs. Main outcomes were minor physical anomalies, maternal weight gain, infant birth weight, pregnancy duration, and neonatal characteristics., Results: Infants exposed to either SSRIs or depression continuously across gestation were more likely to be born preterm than infants with partial or no exposure. Neither SSRI nor depression exposure increased risk for minor physical anomalies or reduced maternal weight gain. Mean infant birth weights were equivalent. Other neonatal outcomes were similar, except 5-minute Apgar scores., Conclusions: For depressed pregnant women, both continuous SSRI exposure and continuous untreated depression were associated with preterm birth rates exceeding 20%.

Objective: The primary aim of this article is to describe sexual concerns in postpartum women with DSM-IV diagnoses of major depressive disorder (MDD) before and during treatment with antidepressants in an 8-week double-blind randomized trial., Method: Seventy women aged 19-42 years participated and were randomly assigned to either the tricyclic antidepressant nortriptyline (N = 38) or the serotonin selective reuptake inhibitor sertraline (N = 32). Women completed the Arizona Sexual Experience Scale to evaluate sexual concerns at enrollment and weekly during the trial. The outcome measure for depression, Hamilton Rating Scale for Depression, was completed in clinical interviews at the same time points. Comparisons of demographic and other characteristics of women were completed with t tests for continuous measures and with chi-squared or Fisher exact statistics for categorical measures. Mixed-effects regressions were used to test for significance of the main effects of depression symptom scores, drug assignment, weeks treated with medication, and the interactions of these variables. Data were collected from April 1997 to April 2002., Results: At entry into the randomized trial, 73% (N = 51) of the women reported problems in 3 or more areas of sexual concern compared to 37% (N = 26) at week 8. There were no significant differences at study entry in women randomly assigned to nortriptyline compared to those randomly assigned to sertraline in summary scores of sexual function nor in specific sexual concerns at any time point. At week 8, women whose MDD remitted were more likely to report fewer (< 3) sexual concerns than women whose MDD did not remit (76% vs. 24%, p = .006), independent of drug assignment., Conclusions: In postpartum women, sexual concerns are primarily affected by remission of depression rather than side effects of either a tricyclic or serotonergic antidepressant., (©Copyright 2009 Physicians Postgraduate Press, Inc.)

Serum banks from large, decades-old epidemiological studies provide a valuable opportunity to explore the contributions of in utero vitamin D exposure to fetal origins of adult diseases. We compared 25-hydroxyvitamin D (25(OH)D) by race and season (two powerful predictors of vitamin D status) in sera frozen for >or= 40 years with sera frozen for

This study evaluated the relationship between sleep quality in late pregnancy and recurrence of postpartum major depression (PPMD) through 28 weeks postpartum. The Pittsburgh Sleep Quality Index (PSQI) at 36 weeks gestation was assessed in 51 non-depressed women with a history of PPMD; recurrence was determined by the 21-item Hamilton Rating Scale for Depression and the Schedule for Affective Disorders and Schizophrenia. Sleep quality in late pregnancy was not related to recurrence per se, but it was related to timing of recurrence (Kruskal-Wallace = 9.78, p = .008). Rapid recurrence (within 4 weeks post delivery) was preceded by fewer sleep complaints (mean PSQI for early recurrers = 4.8 vs. 7.3 for non-recurrers, p = .09). Recurrence after 4 weeks postpartum was preceded by more sleep complaints in late pregnancy (mean PSQI for late recurrers = 9.9 vs. 7.3 for non-recurrers, p = .02). Sleep quality in late pregnancy may help in identifying women at risk for a PPMD recurrence.

Postpartum depression (PPD) is a major public health problem that occurs in one of every seven women in the first 3 months after birth. Left untreated, PPD can persist for months to years and lead to adverse consequences for both mother and child. Primary care providers have the most medical contact with postpartum women and are well positioned to screen for and identify PPD. However, PPD recognition and treatment is generally not included in physician training, and few continuing education programs on PPD are available. Developed with support from NIMH SBIR contract (# HHSN278200554096C), the Web site MedEdPPD was designed to provide professionals with the tools to successfully engage, screen, diagnose, treat, and refer women with PPD. Resources on the site include CME/CE modules; interactive case studies; classic papers and current literature; provider tools; a comprehensive slide library; events calendar; and resources. MedEdPPD also contains materials for women with PPD, their friends and family members. As of March 2008, the site had over 17,000 visitors who represented both consumers and a broad distribution of health care professional disciplines. The nine CME/CE learning modules on MedEdPPD have been particularly heavily utilized by nurses. The number of repeat and new visitors has increased steadily since the site's launch. User feedback has been consistently positive. Based upon theories of adult education, MedEdPPD offers diverse strategies to facilitate learning. The site promotes education and training in PPD treatment that is flexible, cost-effective, and meets the needs of health care professionals.

Background: Perinatal major depressive disorder (MDD), including antenatal and postpartum depression, is common and has serious consequences. This study was designed to investigate the feasibility, safety, and efficacy of omega-3 fatty acids for perinatal depression in addition to supportive psychotherapy., Methods: Perinatal women with MDD were randomized to eicosapentaenoic (EPA) and docosahexaenoic acids (DHA), 1.9g/day, or placebo for 8weeks. A manualized supportive psychotherapy was provided to all subjects. Symptoms were assessed with the Hamilton Rating Scale for Depression (HAM-D) and Edinburgh Postnatal Depression Scale (EPDS) biweekly., Results: Fifty-nine women enrolled; N = 51 had two data collection points that allowed for evaluation of efficacy. Omega-3 fatty acids were well tolerated. Participants in both groups experienced significant decreases in EPDS and HAM-D scores (p<.0001) from baseline. We did not find a benefit of omega-3 fatty acids over placebo. Dietary omega-3 fatty acid intake was low among participants., Limitations: The ability to detect an effect of omega-3 fatty acids may have been limited by sample size, study length, or dose. The benefits of supportive psychotherapy may have limited the ability to detect an effect of omega-3 fatty acids., Conclusions: There was no significant difference between omega-3 fatty acids and placebo in this study in which all participants received supportive psychotherapy. The manualized supportive psychotherapy warrants further study. The low intake of dietary omega-3 fatty acids among participants is of concern, in consideration of the widely established health advantages in utero and in infants.

Objectives: Postpartum depression, the most prevalent complication of childbirth, is often unrecognized. Our objective was to compare the effectiveness of three screening instruments--Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire (PHQ-9), and the 7-item screen of the Postpartum Depression Screening Scale (PDSS)--for identifying women with postpartum depression in the first 6 months after delivery., Methods: We administered the three instruments via telephone to women who were > or =18 years and had delivered infants 6-8 weeks earlier. We arranged home interviews to confirm DSM-IV criteria current major depressive disorder (MDD) in women who had an above-threshold score on any of the instruments. For women who screened negative on the 6-8 week call, we repeated the screening at 3 months and 6 months to identify emergent symptoms. The primary outcome measures were the screening scores and DSM-IV diagnoses., Results: Of 135 women reached, 123 (91%) were screened, 29 (24%) had home visits, and 13 (11%) had an MDD within 6 months of delivery. Analyses of the scores at 6-8 weeks postpartum and the DSM-IV diagnoses indicated the EPDS at a cutoff point of > or =10 identified 8 (62%) of cases, the PHQ-9 at a cutoff point of > or =10 identified 4 (31%), and the PDSS 7-item Short Form (PDSS&#95;SF) at a cutoff point of > or =14 identified 12 (92%). However, 15 of 16 (94%) women without current MDD screened positive on the PDSS&#95;SF. The EPDS was significantly more accurate (p = 0.01) than the PDSS&#95;SF and PHQ-9 with the cutoff points used. After correcting for verification bias, we found the EPDS and the PDSS&#95;SF were significantly more accurate than the PHQ-9 (p < 0.03)., Conclusions: Administering the EPDS by phone at 6-8 weeks postpartum is an efficient and accurate way to identify women at high risk for postpartum depression within the first 6 months after delivery.

Objective: Little information about the disposition of individual antidepressant drugs during pregnancy has been published. We examined the dose requirements and level-to-dose (L/D) ratios of citalopram, escitalopram, and sertraline during pregnancy and after birth., Method: Women aged from 32 to 43 years with major depressive disorder according to the Structured Clinical Interview for DSM-IV Axis I Disorders participated in the study. Doses were charted across each week of gestation and post-partum. Samples were collected at 20, 30, and 36 weeks' gestation; delivery; and at 2 and 12 weeks postpartum. Plasma trough levels were obtained 8 to 15 hours after dose intake. Across pregnancy and postpartum, the mean dose-corrected plasma concentrations (L/D ratios) of S- and R-citalopram and S-sertraline, and the corresponding primary chiral metabolites S- and R-desmethylcitalopram and N-desmethylsertra-line were assessed. The samples were analyzed for concentrations of stereospecific parent drug and metabolites. The study was conducted from 2003 to 2006., Results: Three women received citalopram, 2 women were treated with escitalopram, and 6 women received sertraline. In 4 of 5 subjects who received citalopram or escitalopram and 5 of 6 subjects who received sertraline, the L/D ratios for the stereoisomers of the parent compound and primary metabolite decreased between 20 weeks gestation and delivery, which reflects increased drug metabolism. By 12 weeks postpartum the L/D ratios were similar to those detected at 20 weeks gestation., Conclusions: Our cases illustrate that dose requirements frequently increase during the second half of pregnancy to offset increased drug turnover and maintain optimal pharmacotherapy. These findings replicate and extend earlier published data with other antidepressants., Trial Registration: clinicaltrials.gov Identifier: NCT00279370.

Objective: To measure brain serotonin-1A (5HT1A) receptor binding potential (BP) in healthy and depressed postpartum women., Design: 5HT1A receptor BP was measured with positron emission tomography by using [(11)C]WAY100635 a single time. Multivariate analysis of variance was used to determine depression effects on 5HT1A receptor BP in relevant brain regions., Setting: An academic research environment., Patient(s): Seven postpartum healthy controls and nine postpartum depressed (PD) subjects with perinatal (antepartum or postpartum) depression onset. Of the nine PD subjects, five had unipolar depression, and four had bipolar disorder., Intervention(s): None., Main Outcome Measure(s): 5HT1A receptor BP., Result(s): Age, time since delivery, and reproductive hormones did not differ between groups. Postsynaptic 5HT1A receptor binding in postpartum depression was reduced 20%-28% relative to controls, with most significant reductions in anterior cingulate and mesiotemporal cortices., Conclusion(s): Postsynaptic 5HT1A receptor binding is reduced in PD women by a similar magnitude as has been shown in other depression samples. The postpartum hormonal milieu and the large proportion of bipolar spectrum subjects in the PD group may have accentuated this finding in this small sample. Recognition of this neurobiological deficit in postpartum depression may be useful in the development of treatments and prevention strategies for this disabling disorder.

Objectives: To perform a dose-ranging safety and efficacy study of bright light therapy for depression in women with bipolar disorder (BD)., Methods: Nine women with DSM-IV BD I or II in the depressed phase were exposed to 50 lux (illuminance at the receiving surface) red light for two weeks, after which they received 7,000 lux light therapy for two-week epochs of 15, 30 and 45 min daily. The Structured Interview Guide for the Hamilton Depression Rating Scale with Atypical Depression Supplement and the Mania Rating Scale were used to assess mood symptoms. Four patients received morning light and five patients received midday light., Results: Three of the four subjects treated with morning light developed mixed states. The fourth subject achieved a full, sustained response. To decrease the risk of inducing mixed episodes, we changed the time of light exposure to midday. Of the five women who received midday light therapy, two achieved full response and two showed early improvement but required a dose increase to sustain response. One woman remained depressed with 45 min of midday light but responded fully to a switch to morning light, 30 min daily., Conclusions: Women with bipolar illness are highly sensitive to morning bright light treatment; the induction of mixed states is a substantial risk. Initiating treatment with a brief duration (15 min) of midday light for bipolar depression is advisable.

Background: Hypercortisolaemia is associated with certain depressive disorders. Mifepristone has possible antidepressant properties related to its anti-glucocorticoid activity. To explore the possible mood effects of mifepristone, we examined the mood outcomes after surgical and medical (mifepristone-misoprostol) abortion. The objectives were to determine post-abortion depression risk, evaluate risk factors for post-abortion depression and to explore the relationship between cortisol and depression., Methods: We enrolled 47 surgical and 31 medical abortion patients. Women were assessed pre-abortion and 1 month post-abortion with the Edinburgh Postnatal Depression Scale (EPDS) and salivary cortisol levels., Results: Pre-abortion, 36% (17/47) of surgical and 35% (11/31) of medical patients had high depression risk (EPDS > or = 10; (chi(2) = 0.31, df = 1, P = 0.58). At follow-up, 17% (7/42) of surgical and 21% (5/24) of medical patients had an EPDS > or = 10 (chi(2) = 0.18, df = 1, P = 0.67). The decline post-abortion in the women with EPDS > or = 10 was significant (P = 0.01). Women with past psychiatric history (Fisher's exact P = 0.05) or anxiety disorders (Fisher's exact P = 0.005) had elevated risk for post-abortion depression. Change in cortisol levels was not correlated with change in EPDS (r = 0.10, P = 0.28)., Conclusions: Most patients experienced post-abortion mood improvement. Mifepristone did not offer additional antidepressant effects. The lack of correlation between cortisol and depression could represent hypersuppression of the hypothalamic-pituitary-adrenal (HPA) axis or insufficient mifepristone dose to alter HPA axis activity.