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Abstract
The goal of this special issue entitled, “Perinatal mood symptoms and postpartum maternal
functioning: Describing the evidence related to effective and ineffective interventions,”
was to highlight interventions that have been evaluated in peer-reviewed research
in regards to their efficacy toward improving perinatal mood symptoms and/or postpartum
maternal functioning. While there is a comparatively rich body of research surrounding
perinatal depression and anxiety, postpartum maternal functioning has exacted less
attention, to date (1–3). There are several reasons for this including: (1) an early
and almost exclusive focus on postpartum depression (PPD) as the primary mental health
concern of interest in new mothers (4), (2) a lack of current, quick, and accurate
tools to assess postpartum functional status (2), (3) inadequate attention paid to
mothers and their needs post childbirth (5, 6), and a predominant focus on infant
health and the clinical outcomes of the pregnancy (5). However, over the past 10 years,
assessment of maternal functioning has made its way into the conversation, and also
into domestic (7–10), international (11–13), and industry-sponsored studies (14, 15).
Though the evidence base is still growing, we do know that some interventions seem
to improve maternal functioning. For example, women who participated in the Visiting
Moms® program in Waltham, Massachusetts (n = 149), scored, on average, 16 points higher
on the Barkin Index of Maternal Functioning (BIMF) (1) at program completion (relative
to program intake) (4). This intervention included weekly home visits from trained
volunteers through the baby's first year of life and corroborates the knowledge base
indicating that social support is a protective factor (4). Postpartum patient education
via the Skills Training Approach (STA) also appeared efficacious at improving maternal
functioning—across all domains—in a small randomized controlled (n = 68) trial of
Iranian women (11). In fact, the group of women who received maternal skills training
shortly after childbirth had an average BIMF score of 95.8 vs. 70.3 in the control
group (11). Stated differently, the women who received postpartum education were functioning,
on average, 25 points higher than those who received usual care, making the case for
more education-centered approaches to functional improvement. Clinical interventions
such as the Hennepin Healthcare Mother-Baby Day Hospital, where perinatal women with
severe to moderate psychiatric illness receive trauma-informed group-based therapy
and psychiatric care, have shown great promise and significant improvements in depression,
anxiety, and maternal functioning (16). Intensive Outpatient Programs (I.O.P.s) have
likewise reported success in achieving functional improvement in postpartum women
(17).
Through this special issue, both promising interventions and risk/protective factors
associated with perinatal mental health are explored. For example, Deif et al. examine
the complex role of breastfeeding in relation to maternal mood (18), via a literature
review focused on Dysphoric Milk Ejection Reflex (D-MER). Likewise, Iodice et al.
consider the role of Oxytocin, concluding that the hormone may play a protective role
in the development of perinatal depression. In a hygiene-focused study, Jiang et al.
explored the association between caregiver hand washing practice and postpartum mental
health; results from this cross-sectional study implicate suboptimal hand washing
practice as a risk factor for maternal depression, anxiety, and stress. In terms of
new behavioral health interventions, Flynn et al., Monteiro et al., and Peifer et
al. each report compelling results and innovative programming. The special issue is
nicely rounded out with an opinion piece by Albanese et al. who call for more patient-centered
research and interventions for new mothers, whose mental health needs have been historically
minimized (9).
While we continue to think about ways to support pregnant and postpartum women toward
holistic mental health and optimal daily functioning, there is a looming threat (risk
factor) on the horizon and its name is the climate crisis (5). In fact, the World
Bank recently issued a report estimating that more then 200 million people are likely
to be displaced due to climate change/extreme weather events (EWEs) over the next
30 years (19). We also know that women and children are vulnerable subgroups and are
disproportionately affected (20). As the climate crisis intensifies, more pregnant
and postpartum women will be impacted economically, socially, mentally, and physically.
Organizations that assist new mothers, such as Postpartum Support International (PSI)
(21), should strongly consider incorporation of climate change effects into their
programming. Healthcare providers serving the perinatal population will need to consider
environmental factors, including extreme heat, when assessing their patients' mental
(and physical) wellness.
Author contributions
The author confirms being the sole contributor of this work and has approved it for
publication.
Conflict of interest
The author declares that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.
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Post-partum depression is a serious mood disorder in women that might be triggered by peripartum fluctuations in reproductive hormones. This phase 2 study investigated brexanolone (USAN; formerly SAGE-547 injection), an intravenous formulation of allopregnanolone, a positive allosteric modulator of γ-aminobutyric acid (GABAA) receptors, for the treatment of post-partum depression.
This randomized clinical trial assesses the efficacy and safety of zuranolone, a neuroactive steroid γ-aminobutyric acid receptor–positive allosteric modulator, in individuals with postpartum depression. Question Does treatment with zuranolone reduce depressive symptoms in female individuals experiencing postpartum depression? Findings In this phase 3, double-blind, randomized, placebo-controlled trial of 151 adult women with postpartum depression, patients taking daily zuranolone for 2 weeks displayed greater statistically significant reductions in depressive symptoms compared with placebo at day 15, assessed by change from baseline in the 17-item Hamilton Rating Scale for Depression. Reductions in depressive symptoms were observed by day 3 and sustained at all measured time points through day 45. Meaning Zuranolone provided significant reductions in depressive symptoms and was generally well tolerated, supporting its further development in the treatment of postpartum depression. Importance Postpartum depression (PPD) is one of the most common medical complications during and after pregnancy, negatively affecting both mother and child. Objective To demonstrate the efficacy and safety of zuranolone, a neuroactive steroid γ-aminobutyric acid receptor–positive allosteric modulator, in PPD. Design, Setting, and Participants This phase 3, double-blind, randomized, outpatient, placebo-controlled clinical trial was conducted between January 2017 and December 2018 in 27 enrolling US sites. Participant were women aged 18 to 45 years, 6 months or fewer post partum, with PPD (major depressive episode beginning third trimester or ≤4 weeks postdelivery), and baseline 17-item Hamilton Rating Scale for Depression (HAMD-17) score of 26 or higher. Analysis was intention to treat and began December 2018 and ended March 2019. Interventions Randomization 1:1 to placebo:zuranolone, 30 mg, administered orally each evening for 2 weeks. Main Outcomes and Measures Primary end point was change from baseline in HAMD-17 score for zuranolone vs placebo at day 15. Secondary end points included changes from baseline in HAMD-17 total score at other time points, HAMD-17 response (≥50% score reduction) and remission (score ≤7) rates, Montgomery-Åsberg Depression Rating Scale score, and Hamilton Rating Scale for Anxiety score. Safety was assessed by adverse events and clinical assessments. Results Of 153 randomized patients, the efficacy set comprised 150 patients (mean [SD] age, 28.3 [5.4] years), and 148 (98.7%) completed treatment. A total of 76 patients were randomized to placebo, and 77 were randomized to zuranolone, 30 mg. Zuranolone demonstrated significant day 15 HAMD-17 score improvements from baseline vs placebo (−17.8 vs −13.6; difference, −4.2; 95% CI, −6.9 to −1.5; P = .003). Sustained differences in HAMD-17 scores favoring zuranolone were observed from day 3 (difference, −2.7; 95% CI, −5.1 to −0.3; P = .03) through day 45 (difference, −4.1; 95% CI, −6.7 to −1.4; P = .003). Sustained differences at day 15 favoring zuranolone were observed in HAMD-17 response (odds ratio, 2.63; 95% CI, 1.34-5.16; P = .005), HAMD-17 score remission (odds ratio, 2.53; 95% CI, 1.24-5.17; P = .01), change from baseline for Montgomery-Åsberg Depression Rating Scale score (difference, −4.6; 95% CI, −8.3 to −0.8; P = .02), and Hamilton Rating Scale for Anxiety score (difference, −3.9; 95% CI, −6.7 to −1.1; P = .006). One patient per group experienced a serious adverse event (confusional state in the zuranolone group and pancreatitis in the placebo group). One patient in the zuranolone group discontinued because of an adverse event vs none for placebo. Conclusions and Relevance In this randomized clinical trial, zuranolone improved the core symptoms of depression as measured by HAMD-17 scores in women with PPD and was generally well tolerated, supporting further development of zuranolone in the treatment of PPD. Trial Registration ClinicalTrials.gov Identifier: NCT02978326
Maternal functional status is important to capture in the 12 months after childbirth, as this period marks a critical window for both mother and child. In most cases, mothers are the primary caregivers and are, therefore, responsible for the majority of the work related to infant care tasks, such as feeding, diaper changes, and doctor's appointments. Additionally, the quality of mother-child interaction in the year after childbirth affects child development. To date, postpartum functioning has exacted scarce coverage, with only one instrument claiming to measure the concept explicitly. This necessitated the development of the Barkin Index of Maternal Functioning (BIMF), which was designed to measure functioning in the year after childbirth.
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History
Date
received
: 21
June
2022
Date
accepted
: 01
July
2022
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Editorial on the Research Topic Perinatal mood symptoms and postpartum maternal functioning:
Describing the evidence related to effective and ineffective interventions
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