Journal Article Annotations
2022, 1st Quarter

Women’s mental health

Annotations by Jyoti Sachdeva MD
January, 2022

A comparison of symptoms of bipolar and unipolar depression in postpartum women. J Affect Disord.
Trajectories of Depressive and Anxiety Symptoms Across Pregnancy and Postpartum in Selective Serotonin Reuptake Inhibitor‐Treated Women.

PUBLICATION #1 — Women’s mental health

A comparison of symptoms of bipolar and unipolar depression in postpartum women. J Affect Disord.

Crystal T Clark, Dorothy K Sit, Katelyn B Zumpf, Jody D Ciolino, Amy Yang, Sheehan D Fisher, Katherine L Wisner

Abstract: J Affect Disord. 2022 Apr 15;303:82-90. doi: 10.1016/j.jad.2022.01.064. Epub 2022 Jan 15.

Background:
Distinguishing postpartum women with bipolar from unipolar depression remains challenging, particularly in obstetrical and primary care settings. The post-birth period carries the highest lifetime risk for the onset or recurrence of bipolar disorder (BD). Characterization of differences between unipolar and bipolar depression symptom presentation and severity is critical to differentiate the two disorders.

Methods:
We performed a secondary analysis of a study of 10,000 women screened by phone with the Edinburgh Postnatal Depression Scale at 4-6 weeks post-birth. Screen-positive mothers completed the Structured Clinical Interview for DSM-4 and those diagnosed with BD and unipolar Major Depressive Disorder (UD) were included. Depressive symptoms were assessed with the 29-item Structured Interview Guide for the Hamilton Rating Scale for Depression (SIGH-ADS).

Results:
The sample consisted of 728 women with UD and 272 women with BD. Women with BD had significantly elevated levels of depression severity due to the higher scores on 8 of the 29 SIGH-ADS symptoms. Compared to UD, women with BD had significantly higher rates of comorbid anxiety disorders and were twice as likely to report sexual and/or physical abuse.

Limitations:
Only women who screened positive for depression were included in this analysis. Postpartum women with unstable living situations, who were hospitalized or did not respond to contact attempts did not contribute data.

Conclusions:
Severity of specific symptom constellations may be a useful guide for interviewing postpartum depressed women along with the presence of anxiety disorder comorbidity and physical and/or sexual abuse.

Keywords:
Bipolar disorder; Perinatal; Postpartum; Pregnancy; Screening; Unipolar.

Annotation

The finding:
The postpartum period is a period of high vulnerability for first episode or relapse of bipolar disorder (BD), and a significant number of women with postpartum affective instability turn out to have bipolar illness. The Edinburgh Postnatal Depression Scale (EPDS) is commonly used for screening of postpartum mood symptoms but does not capture bipolar disorder; many postpartum women are erroneously diagnosed with unipolar depression (UD) and treated with antidepressant monotherapy. The authors compared the symptoms of 728 postpartum women with UD and 272 postpartum women with BD. These women were identified by a score > 10 on EPDS between 4-6 weeks postpartum and diagnosis later established by full evaluation via Structured clinical interview for DSM-4 (SCID) via phone interview or home-visit. Compared with women with UD, women with BD were more likely to report a history of abuse; a comorbid anxiety disorder; and certain somatic and psychiatric symptoms such as compulsions, paranoia, and suicidal thoughts. The authors proposed a sub-score of Hamilton depression symptoms to identify women at risk of having BD and report its sensitivity to be 52% and specificity to be 82%.

Strength and weaknesses:
This is the first study to differentiate clinical presentation of BD from UD in the postpartum population. Because only women who screened positive on EPDS were included, the study likely missed women who were exhibiting manic or hypomanic symptoms. Inclusion in diagnostic analyses was also affected by exclusion of women who did not have to access to a telephone or stable housing, or who refused SCID evaluation.

Relevance:
These findings help C-L psychiatrists accurately identify women with bipolar disorder in the postpartum setting and thereby initiate appropriate therapy.

PUBLICATION #2 — Women’s mental health

Trajectories of Depressive and Anxiety Symptoms Across Pregnancy and Postpartum in Selective Serotonin Reuptake Inhibitor‐Treated Women.

Gabrielle A. Mesches, M.S., Jody D. Ciolino, Ph.D., Catherine S. Stika, M.D., Dorothy K. Sit, M.D., Katelyn Zumpf, M.S., Sheehan Fisher, Ph.D., Crystal T. Clark, M.D., M.Sc., Alfred L. George Jr.,, M.D., Michael J. Avram, Ph.D., Laura J. Rasmussen‐Torvik, Ph.D., M.P.H., Daniel L. Erickson, M.B.A., Steven Caritis, M.D., Dawn Fischer, B.S.N., Raman Venkataramanan, Ph.D., Maged Costantine, M.D., Holly West, D.H.Ed., P.A.‐C., Elizabeth Welch, RN., Shannon Clark, M.D., M.M.S., Katherine L. Wisner, M.D., M.S., Jacqueline K. Gollan, Ph.D.

Abstract: https://prcp.psychiatryonline.org/doi/10.1176/appi.prcp.20210034.

Objective:
Tracking perinatal mood and anxiety disorders is championed by the American Psychiatric Association and the International Marcé Society for Perinatal Mental Health. We conducted this study to examine trajectories of monthly depressive and anxiety symptoms through pregnancy and postpartum.

Methods:
This is a prospective longitudinal observational cohort study of pregnant women interviewed at baseline (≤18th gestational week), every four weeks through delivery and at 6 and 14 weeks postpartum at three urban academic medical centers (N = 85) and a single rural health center (N = 3) from 2016 to 2020. Pregnant women had at least one prior episode of major depressive disorder, were not in a current episode, and were treated with sertraline, fluoxetine, citalopram, or escitalopram. Of 192 women screened, 88 (46%) women enrolled, and 77 (88%) women completed the postpartum follow‐up. Symptom trajectories were generated with scores from the Edinburgh Postnatal Depression Scale, the Quick Inventory of Depressive Symptoms, the Generalized Anxiety Disorder Scale, 7‐item, and the Patient‐Reported Outcomes Measurement Information System Global Health measure. A semi‐parametric, group‐based mixture model (trajectory analysis) was applied.

Results:
Three relatively stable depression trajectories emerged, described as Minimal, Mild, and Subthreshold, in each group across pregnancy. Two of the four anxiety trajectories were stable, including Asymptomatic and Minimal, while the third, termed Breakthrough, was ascending with increasing symptoms and the fourth trajectory, described as Mild, had descending symptoms.

Conclusions:
Screening for anxiety with depression for pregnant women will yield a comprehensive view of psychiatric symptoms and treatment targets in perinatal women.

Annotation

The finding:
This is a prospective longitudinal observational cohort study—Optimizing Medication Management for Mothers with Depression (OPTI‐MOM)—of 88 pregnant women. Questions addressed through the study were, What is the symptom course of SSRI‐treated women across childbearing? Do depressive and anxiety symptoms vary together? Do symptoms increase after birth? Women completed assessments every 4 weeks from study entry until delivery and until 6-14 weeks postpartum.Inclusion criteria were -18 to 45 years of age, singleton pregnancy less than 18 weeks, a lifetime DSM‐IV diagnosis of MDD (any subtype), and current treatment with sertraline, fluoxetine, citalopram, or escitalopram with the intent to continue through pregnancy and postpartum. Exclusions were defined as bipolar or psychotic illness, ongoing substance use, Edinburgh postnatal depression scale (EDPS) >25 and response of 3 on self-harm thoughts question on EPDS. The scales used were the EPDS, Quick Inventory of Depressive Symptoms (QIDS), Generalized Anxiety Disorder Scale, (GAD‐7) and Patient‐Reported Outcomes Measurement Information System Global Health (PROMIS‐GH). Upon study entry, most participants were not in remission despite maintenance drug treatment. Three relatively stable depression trajectories emerged: Minimal (EPDS<5), Mild (EPDS=5), and Subthreshold (EPDS 8 or higher). Anxiety varied across 4 trajectories; 2 of the 4 anxiety trajectories were stable, including Asymptomatic and Minimal, while the third, termed Breakthrough, was ascending with increasing symptoms. A fourth anxiety trajectory, described as Mild, had descending symptoms.

Strength and weaknesses:
This study’s strengths included obtaining novel data from monthly self‐report symptom assessments through pregnancy and after birth in women who were treated with an SSRI at enrollment. The sample was limited: all were SSRI‐treated women and predominantly white, married, and educated women. Secondly, because only SSRI-treated women were included, symptom trajectories for women treated with other classes of antidepressants were not described.

Relevance:
This study demonstrates that the treatment goal to achieve full resolution of maternal depression and anxiety symptoms remains a clinical challenge despite maintenance pharmacological treatment. In the setting of incomplete treatment, the fetus remains exposed to both the illness and the drug. The majority of women also had coexisting anxiety symptoms, which underscores the importance of screening for and treating anxiety in this population. These findings also encourage psychiatrists to implement measures of anxiety and depression throughout the perinatal period to monitor for residual symptoms.