Arch Womens Ment Health (2011) 14 (Suppl 1):S1–S87 DOI 10.1007/s00737-010-0203-1

ABSTRACTS

The Marcé International Society International Biennial General Scientific Meeting “Perinatal Mental Health Research: Harvesting the Potential” October 27–30, 2010 Hosted by the International Marcé Society in Pittsburgh, Women’s Behavioral HealthCARE, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Katherine L. Wisner, MD, MS, President, 2010–2012

SPEAKERS

Kathryn M Abel, MA MBBS FRCP FRCPsych PhD University of Manchester Manchester, United Kingdom

Jennifer L. Barkin, PhD University of Pittsburgh Medical Center Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania, USA

Rena Bina, MSW University of Maryland, Baltimore Ezer Mizion Organization, Givat Shmuel, Israel

Samantha S. Adams, MD University of Oslo Akershus University Hospital Lørenskog, Norway

Diana L. Barnes, PsyD The Center for Postpartum Health Tarzana, California, USA

Antje Bittner, PhD University Hospital Carl Gustav Carus Dresden, Germany

Cynthia L. Battle, PhD Warren Alpert Medical School of Brown University Providence, Rhode Island, USA

Sonia Brandao, MD University of Porto Porto, Portugal

Palo Almond, PhD University of Southhampton Southhampton, United Kingdom Margaret Altemus, MD Cornell University Ithaca, New York, USA Robert T. Ammerman, PhD Cincinnati Children’s Hospital Medical Center & University of Cincinnati College of Medicine Cincinnati, Ohio, USA

Cheryl T. Beck, DNSc, CNM, FAAN University of Connecticut School of Nursing Storrs, Connecticut, USA Toluwalope T. Bella, MD College of Medicine, University of Ibadan, Nigeria Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania, USA

Gisele Apter, MD, PhD Erasme Hospital University Paris Denis Diderot Antony, France

Laura Benni, MD University of Florence Florence, Italy

Marie-Paul Austin, MBBS, MD, FRANZCP University of New South Wales Royal Hospital for Women, Sydney Sidney, Australia

Veerle Bergink, MD Erasmus Medical Center University of Rotterdam The Netherlands

Anna Brandon, PhD The University of Texas Southwestern Medical Center Dallas, Texas, USA Charlotte Brown, PhD University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania Anne E. Buist, MBBS, MMed, MD, FRANZCP University of Melbourne Melbourne, Australia Cynthia Bulik, PhD University of North Carolina Chapel Hill, North Carolina

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K.L. Wisner

Melissa Buttner, MA University of Iowa Iowa City, Iowa

Annette Cycon, LICSW MotherWoman, Inc Amherst, Massachusetts, USA

Heather Flynn, PhD University of Michigan Medical School Ann Arbor, Michigan, USA

Roch Cantwell MB, FRCPsych Glasgow Perinatal Mental Health Service and University of Glasgow Scotland, United Kingdom

Cindy Lee Dennis, PhD University of Toronto Toronto, Ontario, Canada

Ellen Frank PhD University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania, USA

Lorraine Caputo, LCSW Psychotherapist Maplewood, New Jersey, USA Judy Chang, MD Magee-Women’s Hospital Pittsburgh, Pennsylvania, USA Remi Charoth Michigan State University/Kalamazoo Center for Medical Studies Mother's Mind Matters Research Kalamazoo, Michigan, USA Linda H. Chaudron, MD, MS University of Rochester Rochester, New York, USA Roseanne Clark, PhD University of Wisconsin Madison, WI Professor Abram Coen France Lee Cohen, MD Massachusetts General Hospital Boston, Massachusetts, USA Ana Conde, PhD University of Minho Braga, Portugal Michelle L. Costantino, MHA Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania, USA Susan Conroy, CQSW, MSc Kings College London, United Kingdom

Nirmaljit K. Dhami, MD El Camino Hospital Mountain View, CA Sona Dimidjian, PhD University of Colorado, Boulder Boulder, Colorado, USA Clare Dolman Action on Postpartum Psychosis London, United Kingdom Signe Dørheim, MD, PhD Stavanger University Hospital Stavanger, Norway Malin Eberhard-Gran, MD, PhD Division of Mental Health Norwegian Institute of Public Health Adrienne Einarson, RN, MS University of Toronto Toronto, Ontario, Canada C. Neill Epperson, MD University of Pennsylvania School of Medicine Philadelphia, Pennsylvania, USA Michelle C. Fernandes, MB BS Warneford Hospital University of Oxford Oxford, United Kingdom Barbara Figueiredo, PhD University of Minho Campus de Gualtar Braga, Portugal

Elizabeth J. Corwin, PhD University of Colorado Anschutz Medical Campus College of Nursing Aurora, Colorado

Jane RW Fisher, BSc (Hons) PhD MAPS Centre for Women's Health, Gender and Society WHO Collaborating Centre for Women’s Health Melbourne School of Population Health University of Melbourne Victoria, AUSTRALIA

John Cox, DM (Oxon); FRCPsych; FRCP University of Gloucestershire Institute of Psychiatry London, United Kingdom

Laura Flamini, BSN RN Doctoral Nursing Student University of Louisville School of Nursing Louisville, Kentucky, USA

Marlene Freeman, MD Massachusetts General Hospital Boston, Massachusetts, USA Susan Hatters Friedman, MD Case Western Reserve University Cleveland, Ohio, USA Liz Friedman MotherWoman, Inc Amherst, Massachusetts, USA Susan Garthus-Niegel Akershus University Hospital Lørenskog, Norway and Norwegian Institute of Public Health Oslo, Norway Jay Gingrich, MD, PhD Columbia University New York, New York, USA Nine Glangeaud-Freudenthal, PhD CNRS Research Fellow Epidemiological Research Unit on Perinatal Health and Women’s and Children’s Health Villejuif, France Vivette Glover, PhD Imperial College London London, United Kingdom Maria P. Gonçalves, MS Instituto Superior de Ciências de Saúde-Norte Porto, Portugal Sherryl H. Goodman, PhD Emory University Atlanta, Georgia, USA Deepika Goyal, PhD, RN, FNP California State University San Jose, California, USA Judy A. Greene, MD Cambridge Health Alliance Harvard Medical School Cambridge, Massachusetts, USA

The Marcé International Society International Biennial General Scientific Meeting Nancy K. Grote, PHD University of Washington Seattle, Washington, USA Birdie Gunyon Meyer, RN, MA, CLC Postpartum Support International Clarian Health Partners Indianapolis, Indiana, USA Lauren Hale Post Partum Support International Bogart, Georgia, USA Vivienne J. Hanley, PhD Swansea University West Wales, United Kingdom Kellie B. Haworth, MD, Captain United States, Army Elizabethtown, Kentucky Carol A. Henshaw, MB ChB, MD Liverpool Women’s Hospital & Staffordshire University Liverpool, United Kingdom Alison E. Hipwell, PhD, ClinPsyD University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania Jessica Heron, PhD Birmingham & Solihull Mental Health Foundation Trust West Midlands, United Kingdom Jane Honikman, MS Postpartum Support International Santa Barbara, California, USA Simone Honikman, MBChB, MPhil (MCH) University of Cape Town Cape Town, South Africa Louise Howard, PhD, MRCPsych Institute of Psychiatry, King's College London London, United Kingdom Margaret Howard, PhD Brown University Providence, Rhode Island, USA

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Patricia M. Jarrett, MPhil, PGCSSRM, Midwife, RN City University London London, United Kingdom

Pamela Massoudi, MSc University of Gothenburg Kronoberg County Council Växjö, Sweden

Ian Jones, PhD, MRCPsych Cardiff University School of Medicine Cardiff, Wales, United Kingdom

Samantha Meltzer-Brody, MD, MPH University of North Carolina at Chapel Hill Chapel Hill, North Carolina, USA

Juliane Junge-Hoffmeister, PhD Technical University Dresden University Hospital Carl Gustav Carus Dresden, Germany

Jeffrey Meyer, MD PhD FRCP(C) University of Toronto Toronto, Ontario, Canada

Martin Kammerer, MD, PhD Imperial College London Institute of Reproductive and Developmental Biology London, United Kingdom Deborah Kim, MD University of Pennsylvania Philadelphia, Pennsylvania, USA Helen G. Kim, MD Hennepin County Medical Center University of Minnesota Minneapolis, Minnesota, USA Sandraluz Lara-Cinisomo, PhD University of North Carolina Charlotte Charlotte, North Carolina, USA Michael R. Liepman, MD Michigan State University College of Human Medicine Kalamazoo Center for Medical Studies Kalamazoo, Michigan, USA Caroline Lilliecreutz, MD Linköping University Hospital Linköping, Sweden M. Cynthia Logsdon, DNS University of Louisville Louisville, Kentucky, USA Shari I. Lusskin, MD New York University School of Medicine NYU Langone Medical Center New York, NY

Pec Indman, EdD, MFT Postpartum Support International San Jose, California, USA

Judy S. McCay, MD, PhD University of South Carolina Pisgah Institute Asheville, North Carolina

Alice Innocenti, MD Careggi University Hospital Firenze, Italy

Michel Maron, MD Lille University Hospital Lille, France

Laura J. Miller, MD Harvard Medical School Brigham and Women’s Hospital Boston, Massachusetts, USA Dawn Misra, PhD Wayne State University Detroit, Michigan, USA Catherine E. Monk, PhD Columbia University Medical Center New York, NY Eydie Moses-Kolko, MD University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania, USA Trine Munk-Olsen, PhD National Centre for Register-based Research Aarhus University Aarhus C, Denmark Maria Muzik, MD, MS University of Michigan Ann Arbor, Michigan, USA Hedvig Nordeng, PhD School of Pharmacy University of Oslo, Norway Kimberly J. Nylen, PhD University of Michigan Ann Arbor, Michigan, USA Tim F. Oberlander, MD University of British Columbia Vancouver, British Columbia, Canada Thomas G. O’Connor, PhD University of Rochester Medical Center Rochester, New York, USA Michael O’Hara, PhD University of Iowa Iowa City, Iowa, USA

S4 Michele Okun, PhD University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania, USA Ibone Olza, MD, PhD Universidad Autónoma de Madrid Hospital Puerta de Hierro Majadahonda Madrid, Spain Barbara Parry, MD University of California at San Diego San Diego, California, USA Susan J Pawlby, PhD King's College London London, United Kingdom

K.L. Wisner Amy L Salisbury, PhD Brown University Providence, Rhode Island, USA Yoel Sadovsky, MD Magee-Womens Research Institute Pittsburgh, Pennsylvania Crystal E Schiller, MA University of Iowa Iowa City, Iowa, USA Lisa S. Segre, PhD University of Iowa Iowa City, Iowa, USA

Jennifer L. Payne, MD The Johns Hopkins Hospital Baltimore, Maryland, USA

Dorothy Sit, MD University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania, USA

Karolina M. Rabenda-Lacka, MD Prywatny Gabinet Ginekologiczny Zielona Góra, Poland

Margaret Spinelli, MD Columbia University New York, New York, USA

Girish N. Rao, MD National Institute of Mental Health and Neuro Sciences, Bangalore, India

Brian S. Stafford, MD, MPH University of Colorado—Denver The Kempe Center’s Postpartum Depression Intervention Program Denver, Colorado, USA

Emma Robertson Blackmore, PhD University of Rochester Medical Center Rochester, New York, USA Monique Robinson, MPsych Telethon Institute for Child Health Research The University of Western Australia Perth, Australia Annie J. Rohan, RNC, PhDc Columbia University School of Nursing Stony Brook University Hospital New York, New York, USA Jillian Romm RN, LCSW Oregon Health and Science University Portland, Oregon, USA Christine Rubertsson, RN, RM, MA, PhD Uppsala University Hospital Uppsala, Sweden

Zachary Stowe MD Emory University Atlanta, Georgia, USA Scott Stuart MD Associate Professor of Psychiatry and Psychology University of Iowa Iowa City, Iowa, USA Cheryl Squire Flint Healthy Start, Inc. Pittsburgh/Allegheny County and Fayette County Pittsburgh, Pennsylvania, USA Anne-Laure Sutter-Dallay, MD, PhD Perinatal Psychiatry Network Charles Perrens Hospital Bordeaux, France, USA

David Rubinow, MD University of North Carolina Chapel Hill, North Carolina, USA

Holly Swartz MD University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania, USA

Leyla Sahin, MD Food and Drug Administration Washington, DC, USA

Darius Tandon, PhD Johns Hopkins University Baltimore, Maryland

Anam Tareen Michigan State University Kalamazoo Center for Medical Studies Kalamazoo, Michigan, USA R. Shama Tareen, MD Michigan State University Kalamazoo Center for Medical Studies Kalamazoo, Michigan, USA Verta Taylor, PhD University of California Santa Barbara Santa Barbara, California, USA Iva Tendais, MPH School of Psychology University of Minho, Braga, Portugal Florbela Teixeira Instituto Superior de Ciencias da Saude Do Norte Maia, Portugal Teresa M. Twomey, JD PSI Co-Coordinator for State of CT PSI Legal Resources Coordinator Central CT State University New Haven, Connecticut, USA Corinne Urech, Dr. phil. University Women’s Hospital University of Basel Basel, Switzerland Adele Vigueira, MD Cleveland Clinic Cleveland, Ohio, USA Pathik D. Wadhwa, MD, PhD University of California, Irvine, School of Medicine Irvine, California, USA Katherine L. Wisner, MD, MS University of Pittsburgh School of Medicine Western Psychiatric Institute Pittsburgh, Pennsylvania, USA Steve Wisniewski PhD University of Pittsburgh Pittsburgh, Pennsylvania, USA Laura Bradley Yurko MA, LPA Pisgah Institute Asheville, North Carolina, USA Carol A. Zanetti, MBBS, FRANZCP St John of God Healthcare Inc Subiaco, WA, Australia

The Marcé International Society International Biennial General Scientific Meeting ABSTRACTS Oral Presentations The Neural Correlates of Maternal Responsiveness in Schizophrenia KM Abel1, MW Wan1, H Strachan1, D Downey2, A Wieck3, SR Williams2 1

Centre Women’s Mental Health Imaging Sciences 3 University of Manchester, UK Email: [email protected] 2

Background and Objectives: Bowlby suggested parenting behaviour has biological roots which produce unique, powerful emotions experienced by mothers with new infants. We and others have previously reported that an extensive brain circuit is activated when healthy new mothers see their infants, which integrates affective and cognitive information to direct maternal behaviour. We have also described a range of deficits in the capacity of new mothers with schizophrenia to respond to infants. Using fMRI, we examine neural correlates of mother–infant interaction in healthy mothers and compare them to mothers with schizophrenia and present our preliminary findings. Methods: 12 healthy and 11 new mothers with schizophrenia (age, education and infant age-matched) undertook an 8 min fMRI task. Participants viewed alternating 30 sec blocks of pre-recorded video showing their own infant, an unfamiliar (age matched) infant interspersed with neutral video (moving traffic). Whole brain images were acquired on a 1.5 T Philips Intera scanner using a TR of 2.55 s. Data were analysed using SPM5. Mothers also underwent assessment of mother–infant interaction using the global rating scale. Results: First, we replicated our findings in healthy mothers: compared to neutral stimuli, new mothers showed widespread visual activation (e.g. BA19) when viewing infants. Ill mothers viewing own baby vs neutral show decreases in orbitofrontal cortex (OFC) (BA47) and frontal pole (BA10) activation relative to controls. Viewing other baby vs neutral, ill mothers had a decrease in activation in anterior cingulate (AC) and an increase in middle temporal gyrus (BA21) relative to controls. Finally, when viewing just their own babies, healthy mothers showed increased activity in AC (BA32), left amygdala, right frontal pole (BA10), right putamen and hippocampus compared to ill mothers. Conclusions: These findings suggest a blunted response to emotionally salient stimuli in ill mothers which may be related to poor parenting outcomes in mothers with schizophrenia. Further studies aim to relate these effects to behavioural deficits in maternal responsiveness observed in mothers with schizophrenia. Low Birth Weight: The Impact of Maternal Emotional Distress SS Adams1, M Eberhard-Gran1,2, D Hofoss1, A Eskild2,3 1

Health Services Research Centre, Akershus University Hospital, Lorenskog, Norway 2 Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway 3 Department of Gynecology and Obstetrics, Akershus University Hospital, Lorenskog, Norway Email: [email protected]

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Objective: We wished to study the association between emotional distress during pregnancy and low birth weight in the offspring. Intrauterine growth restriction (IUGR) is a leading cause of perinatal morbidity and mortality, and an important cause of childhood and adulthood morbidity. Knowledge of the causes of IUGR is essential for its prevention, but remains limited. Emotional distress in the mother may be an independent risk factor of IUGR in the offspring. Emotional distress activates the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS), increasing the secretion of cortisol and catecholamines, respectively. Elevated levels of cortisol and catecholamines have both been associated with IUGR. Method: 73,757 pregnant women from the Norwegian Mother and Child Cohort Study (MoBa) were included in this prospective study. MoBa data were obtained through self-administered questionnaires in pregnancy week 17 and 30, and linked to the Medical Birth Registry of Norway, which contains information on all births in Norway. Emotional distress was measured by short-forms of the Hopkins Symptom Checklist-25 (HSCL-25). The association of emotional distress at gestational week 17 and 30 with birth weight below 2500 grams was estimated as crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) using logistic regression analysis. Nine potentially confounding factors were included in the adjusted analyses. Results: Emotional distress at gestational week 17 and/or gestational week 30 was significantly associated with giving birth to an infant weighing less than 2500 grams in the crude data analyses. After adjustment for other study factors, only being emotionally distressed at both occasions remained significantly associated with giving birth to a low birth weight infant (adjusted OR 1.55; 95% CI: 1.05–2.30). Conclusion: We found a significant association between emotional distress during pregnancy and subsequent delivery of a low birth weight infant. A Qualitative Examination of Equity in English Oostnatal Depression Service Provision P Almond University of Southampton, Hampshire, England, UK Email: [email protected] Objective: Postnatal (postpartum) depression (PND) is known to be high in immigrant populations. PND can adversely affect the health of the woman’s husband (or partner), and the baby’s cognitive, behavioural, and physical development. Despite this most countries do not have systems in place to ensure that all postnatal women’s are assessed for PND. In England some improvements have been made with health visitors being provided with training in the assessment and treatment of mild to moderate cases. Method: A qualitative case study examined factors affecting equity in provision and access to PND services delivered by health visitors (public health nurses). A primary healthcare trust’s PND policy and related documents were collected. Sixteen health visitors were observed doing 21 home visits to antenatal and postnatal women where they planned to discuss, assess or treat women with PND. Semi-structured interviews were conducted with health visitors; nine with Bengali women (mostly through interpreters); 12 with English women; and 9 with managers and other personnel. Data were collected over an 18 month period. Ritchie and Spencer’s Framework Analysis method was used to analyse documents and interview data. Results: A PND policy had been written which led to all health visitors being trained in the detection and management of PND. More

S6 support groups for women with PND had been provided to improve geographical access. However, findings indicated that many women were still not being assessed, particularly Bangladeshi women, because the policy and training had not taken account of the ethnically diverse population. There was no policy implementation plan, and no additional resources were provided. Other factors causing inequity were, limited-usage of professional interpreters; lack of translated literature; and the PND support groups were not culturally sensitive to the needs of Bangladeshi women. Conclusions: Inequity in primary care services will continue if the needs of diverse populations are not noted in policy and culturally appropriate training is not provided. Staff must be culturally competent if they are to provide equitable perinatal mental health care to all women. Increased Cerebrospinal Fluid Corticotropin Releasing Hormone During Pregnancy M Altemus, B Shaprio, R Yang, J Fong Departments of Psychiatry and Anesthesiology, Weill Medical College, Cornell University Email: [email protected] Objective: Although changes in HPA axis regulation during pregnancy have been well-described, there has been little examination of potential changes in brain CRH. Method: CSF samples were collected from 21 healthy women, 38– 40 weeks pregnant, not in labor, who were receiving spinal anesthesia for an elective cesarian section. In addition, CSF samples were collected from 22 healthy comparison women who were in the follicular phase of the menstrual cycle. Results: Compared to nonpregnant subjects, the pregnant group had 29% higher levels of CSF CRH (p<.02). Plasma and CSF CRH levels were positively correlated in pregnant women (p<.02). In addition, plasma CRH binding protein levels were lower in pregnant women (p<.03). Conclusions: These data demonstrate that CSF levels of CRH are elevated during pregnancy and any central effects of CSF CRH may be amplified by reduced levels of CSF CRH binding protein. Increased central levels of CRH during pregnancy may play a role in depression or anxiety which onsets during pregnancy. A Clinical Trial of an Adapted Treatment of CBT with Depressed Mothers in Home Visitation RT Ammerman1, FW Putnam1, J Stevens2, M Altaye1, JB Van Ginkel1 1

Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Nationwide Children’s Hospital, Columbus, OH Email: [email protected]

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Objective: Only 20–30% of postpartum depressed mothers receive treatment, and there is a pressing need to engage mothers in nontraditional settings. Home visitation, a prevention approach for low income mothers that is designed to optimize child development, is a promising setting in which to screen and treat depressed mothers. We adapted CBT for the home setting and to work collaboratively with ongoing home visitation. The resulting treatment, In-Home Cognitive Behavior Therapy (IH-CBT), was subjected to a clinical trial.

K.L. Wisner Method: As part of an NIMH R34 grant, 77 mothers with MDD as determined by the SCID were enrolled 5 months postpartum and assigned to home visitation + IH-CBT or home visitation + community referral. IH-CBT consisted of 15 sessions plus a one month booster. Mothers were young (mean=22.1), low income, and racially diverse (AA=36%). This paper reports pre-post comparisons on depression, psychopathology, social support, and social network. Results: Using GEE analyses and intention to treat, results indicated that 66.7% of mothers receiving IH-CBT no longer met criteria for MDD at post-treatment relative to controls (24.3%). Mixed model analyses revealed substantial drops in depressive symptoms in the IHCBT group (vs. controls) were found using self-report (BDI-II, EPDS) and clinician ratings (HDRS) of depression (p < .05). Mothers receiving IH-CBT reported decreased psychopathology (BSI) and increased social support (ISEL) in contrast to controls. No group differences were observed on size or diversity of social network. Conclusion: Findings provide support for IH-CBT as a promising treatment for depressed mothers in home visitation. Effect sizes mirrored studies of moderately to severely depressed adults receiving CBT generally. Benefits were broad as shown by improvements in overall psychopathology and social support. IH-CBT did not alter social network, and it is probably that this factor requires a longer time interval to reveal meaningful changes. Taken together, these findings underscore the importance of adapting evidence-based treatments to population, setting, and context to maximize benefits. NOTE: We are unable to present this paper as a poster so please consider it for an Oral Paper Presentation only. Emergency Perinatal Liaison Psychiatry Unit PUMMA: Integrative Management Of Perinatal Mental Health In A Perinatal Health System Network G Apter, M-C Genet, V Garez, C Héroux, M Valente, E Carlberg, D Richer, A Le Nestour Units PPUMA : (Emergency perinatal liaison psychiatry Unit), and Unit RePPEr : (Research Unit in Psychiatry and périnatal Psychopathology), EPS Erasme, 14, rue de l'Abbaye, 92160 Antony, France Email: [email protected] Pumma is a perinatal liaison psychiatry unit that serves various maternity wards in a given geographical territorial area covering approximately 15000 births per year. It is both part of a child and infant psychiatry ward and supported by the Perinatal health Network of the region. Its initial aim was to offer care as early as possible, to families with a newborn, to prevent early distortions of interactions and enhance infant emotional development in at-risk families. As part of a child psychiatry department, families would then, be offered treatments and followed up as long as necessary. Referral was undertaken by the maternity wards themselves and interventions organized on site as early as possible after reporting the case. After two years of existence (430 patients), analysis of population seen, diagnosis, motive of referral, treatment enstored and therapeutic management organized, a number of questions arise. If only 10% of patients had a preceding condition of psychotic disorder, the majority of them had no specialized information concerning the impact of their pregnancy on their illness and/or of their condition on the fetus and infant. Half of those were currently not being seen by a physician on a regular basis or had completely dropped out of treatment. Another 22% of patients had severe personality disorders with or without other

The Marcé International Society International Biennial General Scientific Meeting comorbid conditions. The majority had no therapeutic management prior to or during the early stage of their pregnancy. 35% presented either stressful or traumatic reactions to a major life event during or linked to the pregnancy and 26% were diagnosed with mood disorders during pregnancy whether or not they had a preexisting condition, prior to the prepartum. It seems that Perinatal psychiatry and perinatal care of both mother and infant still need to be implemented. When services are offered, the possibility of both mother and infant medium and long term care in a public service seems to ameliorate professional awareness and continuity of care. Follow-up studies of these patients are necessary. The Impact of Postnatal Depression on the Infant May Be More Complex Than Expected G Apter¹, ², E Devouche ¹, ³, M Gratier¹,4, V Garez¹, A Le Nestour¹ ¹EPS Erasme Hospital, Antony, France ²University Denis Diderot Paris 7 ³University René Descartes Paris 5 4 University Paris-Ouest Nanterre Email: [email protected] The major issue in perinatal psychiatry is how to preserve infant mental health, preventing negative impact of maternal mental health issues while addressing and treating as best as possible maternal psychiatric and psychological issues. With this essential problem in mind multiple studies on maternal postnatal depression have for the past decade occupied researchers and clinicians alike, arousing interest of public health, ob-gyn, pediatric and both child and adult psychiatric professionals. However, up until today it seems that maternal perinatal depression is still far from being systematically screened for and questions on how to go about this are still numerous. Equally problematic is how the infant’s characteristics (gender, regulatory capacities, birth weight etc) are protective or disruptive factors in the mother–infant relationship. To approach some of these issues, we are conducting an ongoing longitudinal study comparing three groups of mothers and infants, control mothers, mothers with postnatal depression without comorbid psychiatric diagnosis and mothers with comorbid personality disorders (N=105). Mothers were recruited during the first weeks postpartum and infants were videotaped at three, six, nine and 14 months. First results at three months already show a gender effect regardless of maternal pathology on different maternal behaviors such as touch, proximity, vocalizations and gaze. How infant and maternal characteristics might reinforce each other to reach discrete thresholds negatively impacting interactions and in what manner this occurs opens a new field for targeted interventions which will be discussed. Perinatal Mental Health Policy and Service Development in Australia: National Clinical Practice Guidelines for Depression and Related Disorders (Anxiety, Bipolar and Puerperal Psychosis) in the Perinatal Period

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health needs of women and their families during pregnancy and in early parenthood. A key recommendation of the Plan was the development of clinical practice guidelines for perinatal mental health. Method: The development of the Guidelines was managed by an Expert Advisory Committee, and was informed by a systematic literature review and expert best practice. Results: The draft beyondblue Clinical Practice Guidelines for Depression and Related Disorders (Anxiety, Bipolar and Puerperal Psychosis) in the Perinatal Period were released for public consultation in Australia in March 2010. The guidelines are primarily intended as a resource for primary health professionals working with women in the perinatal period (pregnancy and the first year after birth) and are of relevance to all pregnant and postnatal women in Australia. The focus of the guidelines is not solely postnatal depression— importantly, the guidelines encompass a spectrum of psychosocial and mental health issues known to impact on women and families during pregnancy and postnatally. Conclusion: The guidelines summarise high level evidence and provide up-to-date evidence-based recommendations and good practice points, and aim to: ▪ facilitate the early identification of depression and related disorders in the perinatal period and their effective management by health professionals; ▪ improve communication between health professionals, women and carers; ▪ assist health professionals to support women and carers in making informed decisions; ▪ inform education and training for health professionals; ▪ assist development of effective models of care in perinatal mental health; ▪ help to identify priority areas for further research. Following final endorsement by Australia’s National Health and Medical Research Council, these guidelines will be implemented within the context of current activity at national, jurisdictional and local levels, and the existing policy framework of the National Perinatal Depression Initiative. Evaluation of the guidelines will assess their contribution to changes in practice and potentially to health outcomes. Prenatal Anxiety Disorder, Maternal Sensitivity and Neurodevelopmental Outcomes in Infants MP Austin2,3, K Grant1, C McMahon1, N Reilly2,3 1

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Centre for Emotional Health, Department of Psychology, Macquarie University, North Ryde, Australia; 2 Perinatal and Women’s Mental Health Unit, St John of God Health Care, Burwood, Australia 3 School of Psychiatry, University of New South Wales, Sydney, Australia Email: [email protected]

Objective: In Australia, the beyondblue National Action Plan for Perinatal Mental Health was developed to address the mental

Objective: Animal studies have shown that prenatal stress exposure and postnatal rearing style act in concert to shape offspring neurodevelopmental outcomes. However, the combination of these maternally-mediated influences has not been studied in human infants. The

M-P Austin1,2, N Highet3, N Reilly1,2 1

Perinatal and Women’s Mental Health Unit, St John of God Health Care School of Psychiatry, University of New South Wales 3 beyondblue: the national depression initiative, Australia Email: [email protected]

S8 aim of this prospective study was to examine the impact of prenatal anxiety disorder and maternal sensitivity on infant HPA axis functioning, behavioral adjustment and neurodevelopment. Method: Women recruited during the third trimester of pregnancy were assessed for anxiety disorder using clinical diagnostic interview. The postnatal follow-up was conducted when their infants were 7-months old. A novel contribution of the study was the use of an interactive stress paradigm (the “still-face” procedure) to measure both maternal behaviour and infant stress reactivity. Maternal and infant behaviours were coded by independent raters from videotapes. Infant HPA reactivity was assessed using salivary cortisol sampled upon arrival at the laboratory, and at 15-, 25-, and 40-minutes following the still-face procedure. Infant cognitive and motor development was assessed using the Bayley Scales of Infant Development administered during a home visit. Results: Although maternal sensitivity did not appear to moderate the association between prenatal anxiety disorder and infant cortisol response, prenatal anxiety and maternal sensitivity emerged as independent, additive moderators of infant cortisol reactivity, after adjusting for the effects of maternal prenatal depression symptoms, and postnatal symptoms of anxiety and depression. Maternal sensitivity to infant distress also moderated the association between maternal prenatal anxiety and infant mental development. Conclusions: These findings are partially consistent with a cumulative risk model suggesting that maternal prenatal anxiety and quality of maternal care act in concert to shape infant outcomes. The Development of the Barkin Index of Maternal Functioning JL Barkin, KL Wisner, JT Bromberger, SR Beach, MA Terry, SR Wisniewski University of Pittsburgh, Pittsburgh, PA, USA Email: [email protected] Objective: Maternal functional status is important to capture in the 12 months following 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 following childbirth affects child development. To date, postpartum maternal 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 following childbirth. Methods: Three focus groups comprised of 31 new mothers (total) were held to elicit women’s concept of functioning in the first postpartum year. Women were asked to discuss the responsibilities associated with new motherhood as well as the circumstances surrounding high and low functioning periods. Results: The qualitative data produced by the focus group discussions was coded by emotive tone and content and translated into item construction for the BIMF, a 20-item self-report measure of functioning intended for use in the year following childbirth. Initial testing revealed adequate internal reliability and construct validity and the BIMF has successfully been implemented in clinical settings. Content validity was achieved via the focus group discussions.

K.L. Wisner Conclusions: The BIMF can be used in tandem with postpartum depression screening in order to assess maternal wellness. While depression and maternal functioning are related, they are not the same construct. Each must be evaluated in order obtain a comprehensive understanding of a woman’s adjustment to motherhood. Home-based Family Treatment for Postpartum Depression CL Battle1,2,3 & IW Miller1,2 1

Alpert Medical School of Brown University Butler Hospital 3 Women & Infants’ Hospital of Rhode Island Email: [email protected] 2

Objective: Postpartum depression (PPD) is a disabling condition affecting approximately 13% of women after giving birth. In spite of known adverse consequences for mothers and children, PPD remains under-treated, in part due to the existence of a number of barriers to treatment engagement. Developing new, more accessible treatments and improving treatment engagement is critical given risks of untreated PPD. Because marital problems have been shown to be risk factors for PPD, it is plausible that a family treatment may prove efficacious; providing treatment in the home may also be appealing to women and increase accessibility. Method: Building on prior focus-group research demonstrating the acceptability of a family treatment for PPD (Battle et al, 2004), we conducted two pilot trials to evaluate the feasibility of such a treatment: (1) an open pilot trial (N=22), and (2) a pilot RCT (N=20). We are currently conducting a home-based version of the RCT. In this presentation, our focus will be on describing the content and structure of Family Treatment for PPD, discussing findings from the open trial, and sharing observations regarding strategies to improve treatment engagement. Results: Eleven women and partners participated in an open trial. Improvements in depression and family functioning were observed over the course of treatment and through 6 months of follow-up. All episodes of depression remitted, and depressive symptoms were reduced by over 50% at post-treatment. These gains remained statistically significant at 6-month follow up. Improvements were also observed in self-reported depressive symptoms among patients and partners, family problem-solving and communication. The small RCT, though not adequately powered, suggested similar trends towards improvement. Conclusions: Our initial research indicates Family Treatment for PPD is an acceptable, feasible option for treatment of PPD; additional research is needed to establish efficacy. Subsequent Childbirth after a Previous Traumatic Birth CT Beck1, S Watson2 1

University of Connecticut, USA Trauma and Birth Stress, New Zealand Email: [email protected] 2

Objective: Nine percent of new mothers in the U.S. who participated in the Listening to Mothers II Postpartum Survey screened positive for meeting the DSM-IV criteria for posttraumatic stress disorder (PTSD)

The Marcé International Society International Biennial General Scientific Meeting following childbirth. Women who have had a traumatic birth experience report fewer subsequent children and also a longer length of time to their second baby. Childbirth related PTSD impacts couples’ physical relationship, communication, conflict, emotions, and bonding with their children. The aim of this study was to describe the meaning of women’s experiences of a subsequent childbirth following a previous traumatic birth. Methods: Phenomenology was the research design used. An international sample of 35 women participated in this Internet study. Fifteen women (43%) were from the USA, 8 (23%) from the United Kingdom, 6 (17%) from New Zealand, 5 (14%) from Australia, and 1 mother (3%) from Canada. Women were asked to “Please describe in as much detail as you can remember your subsequent pregnancy, labor and delivery following your previous traumatic birth.” Colaizzi’s phenomenological data analysis approach was used to analyze the stories of the 35 women. Results: Data analysis yielded four themes: (a) Riding the Turbulent Wave of Panic during Pregnancy, (b) Strategizing: Attempts to Reclaim Their Body and Complete the Journey to Motherhood, (c) Bringing Reverence to the Birthing Process and Empowering Women, and (d) Still Elusive: The Longed for Healing Birth Experience. During the 9 months of pregnancy women rode turbulent waves of panic, terror, and fear that the looming birth could be a repeat of the emotional and/or physical “torture” they had endured with their previous labor and delivery. Women strategized during pregnancy how they could reclaim their bodies that had been violated and traumatized by their previous childbirth. They employed an array of strategies to try to bring a reverence to the birthing process and rectify all that had gone so wrong with their prior childbirth. All these well designed strategies did not ensure, however, that all women would experience the healing childbirth they desperately longed for. Conclusion: Subsequent childbirth after a previous traumatic birth far exceeds the confines of the actual labor and delivery. Subsequent childbirth following a previous birth trauma has the potential to either heal or re-traumatize women. Keywords: birth trauma, PTSD, phenomenology, traumatic childbirth The Burden of Maternal Mental Health Disorders: Perspectives from Nigeria TT Bella1, 2, OO Omigbodun1, CY Adeniyi3 1

University of Ibadan Nigeria University of Pittsburgh USA 3 University College Hospital, Nigeria Email: [email protected] 2

Objectives: There is increasing evidence that maternal mental illness is associated with an increased risk for mortality and morbidity in mothers and children. Unfortunately, in several low income countries with high infant, child and maternal mortality such as Nigeria, maternal mental health does not receive the desired attention. This paper aims to review the epidemiology of maternal mental health disorders, cultural beliefs and practices surrounding maternal mental illness in Nigeria and to describe maternal mental health services. Methods: Existing literature on maternal mental health disorders in Nigeria are analyzed and information on formal and informal mental health services available for women in the perinatal period are reviewed.

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Results: A few small scale studies have been carried out in Nigeria on maternal mental health. Depression and anxiety are the most common mental health disorders among pregnant and post natal women. The rates of these disorders are similar to rates in other parts of the world. An example of a maternal mental health service at the University College Hospital, Ibadan reveals that a combination of physical treatment modalities and psycho—education are used in the treatment of women with mental health disorders in the perinatal period. There is poor recognition of post partum depression. However the more obvious post partum psychotic disorders are more readily recognized in the community. Cultural beliefs which focus on spiritual causation of mental illness influence help seeking behaviors. Conclusion: Though there is still a dearth of knowledge about maternal mental health disorders in Nigeria and a lack of large scale epidemiological surveys. The fact that preliminary data suggests a significant burden suggests a need for wide spread national screening to enable early detection of maternal mental illness especially for less severe cases. Also there is a need for interventions that are culturally sensitive, acceptable, accessible, available and affordable. Depression and Anxiety in Perinatal Period: Prevalence and Risk Factors in an Italian Sample L Benni, A Innocenti, L Giardinelli University of Florence, Italy Email: [email protected] Objective: Despite the widespread, long-standing notion that pregnancy is a time of happiness and emotional well-being, accumulating evidence suggests that pregnancy does not protect women from mental illness. The aim of this study was to asses the prevalence, socio-demographic correlates and the risks factors for perinatal depression and anxiety. Method: We included 590 pregnant women between 28th and the 32sn gestational weeks recruited trough mother’s groups attending the Department of Obstetrics and Gynecology of the Azienda Ospedaliera Universitaria di Careggi in Florence from April 2007 to April 2008. Sociodemographic, obstetric and psychological information was obtained by means of clinical interview. The Edinburgh Postnatal Depression Scale (EPDS) and the State-Trait Anxiety Inventory (STAI-Y) were administered to all women between 28th and the 32sn gestational weeks and three months postnatally. We have also used the Structured Clinical Interview for DSM-IV (SCID-I) to diagnose mood and anxiety disease. Three months after delivery EPDS was administered by telephone interview. Results: The percentages of women with an EPDS score ≥10 were 21.9% (129 women) in antenatal period and 13.2% (78 women) in postnatal period. During pregnancy 121 women (20.5%) were positive for STAI-Y State and 149 women (25.3%) for STAI-Y Trait . The most important risk factors for depression in antenatal period are: foreign nationality, conflictual relationship with family and with partner, psychiatric disorders preceding pregnancy. The principal risk factors for postnatal depression are psychiatric disorders during pregnancy and in vitro fertilization. The psychiatric disorders during and preceding pregnancy are the strongest risk factor for state anxiety and trait anxiety in the antenatal period. Conclusion: Antenatal depressive and anxiety symptoms appears to be as common as postnatal symptoms. Maternal antenatal stress predicts poor obstetric outcome which could have then increased the

S10 risk for behavioural/emotional problems in early childhood. These results provide clinical direction suggesting that early identification and treatment of perinatal anxiety and depression disorders is particularly relevant. High Prevalence of Autoimmune Thyroid Dysfunction in Postpartum Psychosis V Bergink1, SA Kushner1, V Pop2, H Kuijpens2, M Lambregtse-van den Berg1, RC Drexhage1, MW Hengeveld1, W Wiersinga3, WA Nolen4, HA Drexhage1 1

University of Rotterdam University of Tilburg 3 University of Amsterdam 4 University of Groningen, the Netherlands Email: [email protected] 2

Objective: Postpartum psychosis is a life-threatening psychiatric emergency, which often occurs without significant premorbid symptoms. Although many studies have hypothesized an involvement of the immune and endocrine systems in the onset of postpartum psychosis, the specific etiologic factors have remained unknown. Here, we examine the hypothesis that autoimmune thyroid dysfunction may be associated with the onset of postpartum psychosis. Methods: Thirty-one consecutive primiparous women with no prior psychiatric history were referred to our inpatient unit for postpartum psychosis (n=31). Control subjects (n=117) were primiparous women with consecutive deliveries at a community practice from the same general population. Blood sampling was performed in all subjects at 4 weeks and 9 months postpartum. Thyroperoxidase (TPO) antibody levels were quantified as immunological measures of autoimmune thyroid disease (AITD). Thyroid stimulating hormone (TSH) and free thyroxine (fT4) levels were measured to assess clinical thyroid dysfunction. Results: At 4 weeks postpartum and prior to the initiation of mood stabilizers, 19.4% of women with postpartum psychosis had AITD compared to only 5.1% in control subjects. Further, women with both postpartum psychosis and AITD had a dramatically higher risk of progression to clinical thyroid dysfunction (66.7%) than control subjects with AITD (20.0%). Conclusion: Women with postpartum psychosis are not only at higher risk for AITD but also for clinical thyroid failure. Consequently, these data implicate thyroid function as an important clinical outcome in patients with postpartum psychosis. Further, AITD represents a potentially strong etiological factor for the development of postpartum psychosis. Therefore, screening for TPO antibodies is warranted in patients with postpartum psychosis. Enhancing Treatment Utilization for Postpartum Depression R Bina University of Maryland, Baltimore, USA, Ezer Mizion Organization, Israel Email: [email protected] Objective: Postpartum depression (PPD) is a serious disorder that affects many women globally, with prevalence estimated between

K.L. Wisner 10%–20%, and with potentially devastating personal and familial consequences. Although various treatment methods for PPD have been found to be helpful, and despite multiple contacts with healthcare providers during the postpartum period, very few women actually utilize these treatments. The reasons for the under-utilization of treatment for PPD are unclear, and deserve a close investigation. A study was therefore carried out in order to examine factors that may enhance the likelihood that women with PPD will seek and utilize help both professional as well as non-professional. Method: Using a prospective longitudinal design participants were surveyed at three measurement points. One to two days postpartum 1061 women were recruited from the maternity department at a large hospital in Jerusalem, Israel, and were assessed for factors that may predict seeking help for their depression. Participants were then followed up and screened for PPD at 6 weeks postpartum using the Edinburgh Postnatal Depression Scale. Women who screened positive were referred for treatment and were followed up at 6 months postpartum in order to find out whether they utilized mental health care, what type care they utilized, whether they still had PPD, and whether they were satisfied with the help they got. Results: 807 women participated at the 6-week follow up, and 95 of them (11.77%) screened positive for PPD; 84 of the 95 (88%) women who screened positive for PPD participated at the 6-month follow up. All data have been collected and data analyses examining predictors of help seeking will be done in the next few weeks, hence providing all results at the conference. Potential implications for practice and policy: Examining this understudied topic will hopefully promote the awareness of practitioners to the problem of women not seeking help and not being treated for PPD. There is a need to get more women into treatment, and discovering important facilitators to seeking such help should be a priority. Effects of a Cognitive-behavioral Prevention Program for Pregnant Women on Maternal Psychopathology, Cognitive Risk Factors and Perceived Social Support A Bittner, J Richter, J Junge-Hoffmeister, U Schultz, P Joraschky, K Weidner Department of Psychotherapy and Psychosomatic Medicine, University Hospital Dresden, Germany Email: [email protected] Objective. Studies have shown that increased levels of stress, anxiety and depression in pregnancy may have negative impacts on the fetus, birth and neonatal outcomes, and the cognitive and emotional development of the child. Only few studies examined the influences of psychotherapeutic interventions on symptoms of stress, anxiety and depression in pregnant women. The aims of this study were the development and evaluation of a cognitive-behavioral group program for pregnant women with subclinically increased levels of stress, anxiety and depression. The effects of the program on maternal psychopathology, cognitive risk factors for the development of anxiety disorders and depression, and perceived social support were examined. Methods. Within a longitudinal RCT 757 women (1st trimester) were screened regarding stress (PDQ), anxiety (STAI), and depression (BDI-V). Women with moderately increased levels were invited to

The Marcé International Society International Biennial General Scientific Meeting take part in our intervention study and randomized to a treatment (TG N=80) and a control condition. The group-program comprises modules of psycho-education, cognitive elements and behaviouroriented exercises. Follow ups took part after the intervention in the 3rd trimester and 3 month postpartum. Psychopathology of the mother, anxiety sensitivity, dysfunctional attitudes, social support, course of pregnancy, birth and several child related variables (e.g., temperament using the Infant Behavior Questionnaire) were assessed. Results. Data collection will be completed by the end of April. At the conference results on the subjective program evaluation of the participants, maternal psychopathology, cognitive risk factors, and perceived social support as well as predictors for improvement will be presented. First analyses indicate that we did not find on overall positive effect of the group program on maternal psychopathology. However, subgroup-analyses show that the group program has significant effects on psychopathological measures in women with significantly increased levels of anxiety and depression at the preassessment. Conclusions. The intervention seems to have positive effects for subgroups of pregnant women with high levels of stress, anxiety and depression. Studies with larger samples of high-risk pregnant women are needed to further explore the benefit of preventive interventions in pregnancy. Father’s Emotional Involvement with the Neonate: Impact of Childbirth Experience S Brandão1 & B Figueiredo2 1

ICBAS, University of Porto University of Minho, School of Psychology, Porto, Portugal Email: [email protected]

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Objective: Childbirth experience influence father’s emotional involvement with the neonate. Giving the father the opportunity to cut the umbilical cord of his own child at birth is a midwives’ routine procedure, aiming to promote fathers’ emotional involvement with the newborn. However there are no studies confirming this practice promotes fathers’ emotional involvement. The purpose of this study was to explore the impact of the umbilical cord cutting experience in the father’s emotional involvement with the neonate. Method: Participants were 105 fathers randomly recruited in a Maternity Hospital delivery room in Portugal. The “New mother-toinfant Bonding Scale” (Taylor et al., 2005) was used to evaluate the father’s emotional involvement with the neonate in three different moments: before childbirth, first day after childbirth and first month after childbirth. The fathers were split in three different groups depending on their umbilical cord cutting experience. Results: The results showed that father’s emotional involvement with the neonate improved from before, to the first day after childbirth and decreased from the first day after childbirth, to the first month after childbirth. However in the group of fathers to who was provided and who agreed to cut the umbilical cord, an improved of the emotional involvement with the newborn was observed one month later. Conclusions: Presented results suggest that the umbilical cord cutting experience may benefit father’s emotional involvement with the neonate throughout time. Results support the benefices of father’s empowerment and participation in childbirth.

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Partner Assisted Therapy (PAT) for Perinatal Depression: A Feasibility Trial AR Brandon1, NL Ceccotti1, G Shivakumar1,2, N Johnson1, RB Jarrett1 1

University of Texas Southwestern Medical Center, Dallas VA Medical Center Email: [email protected]

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Objective: Poor partner support has been identified as a key risk factor for depression in perinatal women, but past research has not included partners in treatment beyond psychoeducation. A Mentored PatientOriented Research award (NIMH [1K23MH085007-02]) enabled a feasibility trial of “Partner-Assisted Therapy (PAT)” at the Women’s Mental Health Center of the University of Texas Southwestern Medical Center. Based upon two existing treatments for depression, Interpersonal Psychotherapy (IPT) and Emotionally Focused Couple Therapy (EFCT), PAT includes the partner as an active participant in eight acute psychotherapy sessions and one follow-up session. Method: Women ≥8 weeks estimated gestational age and ≤12 weeks postpartum referred to the Principal Investigator for psychiatric assessment who fulfilled DSM-IV criteria for Major Depressive Disorder (SCID), reported at least moderate symptom severity (Ham-D17 > 16), and met study criteria attended eight weekly psychotherapy sessions and one follow-up session held 6–8 weeks after the acute phase ended. Partners attended each session and completed study measures also. Evaluated were: relationship satisfaction (Dyadic Adjustment Scale), partner support (Antenatal and Postpartum Partner Support Scale), antenatal attachment (Maternal/ Paternal Antenatal Attachment Scale), partner assessment of symptoms (Edinburgh Depression Scale, Partner Version), and parental assessment of infant temperament (Infant Behavior Questionnaire). Results: Twelve couples consented to participate; one couple failed screening (untreated partner bipolar disorder), one couple was excluded and referred for treatment (partner violence), and ten couples completed the 8-session acute phase. Nine couples completed both the acute phase and attended one follow-up session. Although sample size prevents meaningful interpretation of data, nine of ten women met criteria for response (Ham-D17 ≤7) at the conclusion of acute phase treatment, and all ten met criteria for recovery at the 6-week follow-up assessment. There was a trend for improvement in relationship satisfaction and partner support. Conclusion: Incorporating partners in the treatment of Major Depressive Disorder during the transition to parenthood is safe and feasible, and a future RCT is necessary to evaluate efficacy and the incremental benefit of including the partner. The Use of Video Feedback in Women with Postnatal Depression AE Buist1, JLC Bilszta2, N Rusydina Zulkefli3, F Wang3 1

Professor/Director Women’s Mental Health, University of Melbourne, Austin Health and Northpark Hospitals 2 Research Fellow, Department of Psychiatry, University of Melbourne & Austin Health 3 Medical Student, School of Medicine, University of Melbourne Email: [email protected] Aim: This project aims: 1. To investigate the effectiveness of a brief video feedback intervention in an inpatient setting for depressed

S12 mothers in improving mother–infant interaction compared to verbalonly feedback and mothers who receive standard care. 2. To investigate the effectiveness of a 12 week video feedback intervention (‘Babylove’) in an outpatient group program setting for depressed mothers diagnosed in improving mother–child interaction compared to a standard CBT based program 3. To determine the acceptability of video feedback intervention. Methodology: Mothers were recruited from two inpatient PND treatment programs. Women were randomly allocated to either a video or verbal feedback intervention or to a control (standard care). On discharge women were invited to attend either ‘Babylove’ or the standard CBT program . Changes in attitudes toward the infant, parenting confidence and mental health status pre and post-intervention were assessed. Results: Seventy-four women treated as inpatients for PND were recruited; 25 to video, 26 to verbal and 23 to standard care, respectively. Significant improvements in mental health status and parenting confidence were observed post intervention within all groups, but no changes in infant perception were detected. Comparison between the three interventions showed no significant difference in any of the measures used. More mothers receiving video feedback thought this intervention was useful in helping them understand infant behaviour, but there was a trend that at least initially these women lost parenting confidence. Pilot data from the outpatient group—18 in the video group and 15 in the standard care group—will also be presented. Conclusions: Being too short and limitations in the parenting/ attachment measures used may be responsible for the lack of significant differences between the inpatient interventions. Vulnerable women, however, may be at risk of loosing parenting confidence initially and will need ongoing support to fully benefit. The inpatient intervention may have been too short to bring about significant change in attitudes toward the infant; the longer outpatient group may help clarify this aspect. Pregnancy and Eating Disorders: Reproductive and Psychiatric Outcomes CM Bulik University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Email: [email protected] Objective: Two related bodies of research suggest that women with eating disorders experience pregnancy complications more frequently than healthy women and are more likely to have a history of birth complications themselves. More specifically, women with eating disorders have a higher rate of perinatal complications, cesarean deliveries, and postpartum depression and their offspring tend to weigh less than offspring of women without eating disorders and experience more problems with growth and development. Method: We have systematically explored the impact of eating disorders, eating disorder-related behaviors, and nutrition during the perinatal period on pregnancy outcome in the Norwegian Mother and Child Cohort Study (MoBa)—a prospective population-based study of 100,000 births throughout Norway. Assessments are extensive and include psychosocial factors, infections, use of medication, nutrition, life styles, occupational exposure, use of health services, substance abuse, socioeconomic factors, as well as chemical and physical factors in the environment. Health variables include fetal ultrasound at

K.L. Wisner 17 weeks, maternal and paternal history, and health outcomes for mother and child, detected during and after pregnancy. Eating disorders are assessed at 17 week’s pregnancy and 18 months postpartum. Results: We have systematically evaluated the association of anorexia nervosa, bulimia nervosa, eating disorder not otherwise specifiedpurging subtype, and binge eating disorder with pregnancy-related diet and supplement intake, pregnancy outcome, fetal outcome, breastfeeding, maternal feeding styles, and child growth and development. We have also explored the course of eating disorders during pregnancy to document patterns of remission, continuation, and incidence. Conclusion: The MoBa study provides a rich prospective longitudinal database allowing us to address a series of questions of central relevance to elucidating genetic and environmental contributions to the etiology of eating disorders. Our prospective design will allow us to follow the offspring through the risk period for developing eating disorders and enable an exploration of the cross-generational “cycle of risk” for eating disorders. Extrapolating from these population-based data, we have taken our findings into the clinic and discuss the importance of screening for eating disorders and recommendations for nutritional and psychological support during pregnancy and after birth in women with active or remitted eating disorders. Seeking Care for Perinatal Depression: What Do Women Really Worry About? M Buttner, RC Kopelman, SP Stuart University of Iowa, USA Email: [email protected] Objective: Perinatal depression is a significant public health problem that disproportionately affects low-income women. Despite its negative consequences for women and their families, it is often undiagnosed and untreated. The accessibility and acceptability of depression treatment for perinatal women, particularly those who are low-income, have not been adequately examined. The purpose of this study is to further develop our understanding of women’s experiences seeking care for perinatal depression, with an emphasis on lowincome women, by assessing barriers to care, treatment preferences and associated factors. Methods: Using a sequential mixed-methods design, 310 perinatal women receiving care at publicly funded maternal health agencies completed measures of depressive symptomatology and treatment history. Women also completed assessments of perceived barriers to care, treatment preferences and trust in care providers that included perinatal and population specific questions informed by quantitative transformation of focus group (n=19) findings. Results: Overall, the most highly endorsed barrier to care among women with Edinburgh Postnatal Depression Scale scores ≥12 (indicating probable depression) was worry about taking medications while pregnant, surpassing previously documented financial and logistical barriers for this population. Women with EPDS scores ≥12 were more likely than women with lower scores to endorse barriers related to cost, insurance, stigma and accessibility of care. Past treatment history with medications or counseling and insurance status (public, private or uninsured) impacted endorsement of barriers to care and treatment preferences. Women endorsed difficulties in trusting

The Marcé International Society International Biennial General Scientific Meeting provider opinions and provider expertise on mental health treatments for perinatal women. The impact of trust in providers on barrier endorsement and treatment preference is also examined. Conclusion: The development of interventions grounded in the views of low-income perinatal women cared for in public maternal health settings may provide a significant contribution to addressing the unmet mental health needs of childbearing women. Addressing women’s concerns about medication safety in the perinatal period and development of alternative treatments is indicated. Implications for the conduct of future research and provision of services in this field will be discussed. Managing BP Women in Pregnancy and the Postpartum: A Critical Review of Practice Guidelines. R Cantwell Glasgow Perinatal Mental Health Service, Department of Psychiatry, Southern General Hospital, Glasgow Email: [email protected] Objective: The link between childbirth and bipolar disorder is increasingly recognized in clinical practice and research. This has resulted in a number of practice guidelines over recent years that have focused on how women with bipolar disorder should be managed with regard to pregnancy. Method and Results: In this talk I will critically review the existing guidelines for both (i) the management of bipolar disorder in pregnancy and the postpartum period, and (ii) the identification of women in the antenatal period at high risk of a severe postpartum episode. I will highlight what is consistent in the advice they give and explore their differences. In addition I will preview two guidelines that are due to be published later this year—the revised Scottish Intercollegiate Guidelines Network (SIGN) guidelines on postnatal depression and puerperal psychosis and The Royal College of Obstetrics and Gynaecology guidelines on perinatal mental health. Conclusion: There are a number of consistent and increasingly evidence based recommendations made by guidelines with regard to the management of bipolar women in pregnancy and the identification of women at high risk in the postnatal period. However, there are still considerable uncertainties that need to be addressed in future research. The Accuracy of the PHQ-9 and CES-D for Postpartum Depression in an Urban Pediatric Clinic LH Chaudron1, PG Szilagyi1, W Tang1, N Talbot1, E Anson2, KL Wisner3 1

University of Rochester School of Medicine and Dentistry University of Rochester School of Nursing 3 University of Pittsburgh School of Medicine Email: [email protected] 2

Objective: Many pediatricians are screening mothers for postpartum depression and national experts recommend systematic screening. The accuracy of two common screening tools, the PHQ-9 and CES-D, has not been established among low-income, urban mothers in pediatric

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clinic setting. We assessed the accuracy, sensitivity, specificity and optimal cut-points of both screening instruments compared to a diagnostic interview for major or minor depression in a sample of lowincome, urban mothers attending well child-care visits during their infant’s first year of life. Methods: Mothers, ages 18 and older, whose children were cared for at an urban primary care clinic and who attended a WCC visit between 0–14 months were eligible to participate. They were asked to complete the Structured Clinical Interview for DSM-IV, the CES-D, PHQ-9 and other measures. The sensitivity and specificity of each tool were calculated in comparison to diagnoses of major depressive disorder (MDD) or major or minor depressive disorder (MDD/MnDD). Receiver operating characteristic (ROC) curves were calculated and the areas under the curves (AUCs) of each tool were compared to assess accuracy and calculate optimal cut-points. Results: 101 women completed the PHQ-9, CES-D and SCID. Participants were mostly in their mid-20’s (mean 25, SD 5.7), Black (65%) and receiving public insurance (82%). The AUCs for MDD were PHQ-9=0.837 (95% CI 0.755, 0.919) and CES-D=0.843 (95% CI, 0.761, 0.925). The AUCs for MDD/MnDD were PHQ-9=0.891 (95% CI 0.828, 0.954) and CES-D=0.828 (95% CI, 0.747, 0.909). There are no statistically significant differences between the AUCs for MDD or MDD/MnDD. Optimal cut-points for MDD 7.5 for the PHQ9 and 14.5 for the CES-D; for MDD/MnDD the optimal cut-points were 4.5 and 12. 5 respectively. Conclusions: Both the PHQ-9 and CES-D exhibit high levels of accuracy in identifying MDD among low-income urban women with postpartum depression attending first year well-child care visits in a pediatric clinic. These tools may be added to clinicians’ options when choosing tools to screen mothers for postpartum depression. Exploring the Nexus Between Intimate Partner Violence, Depression and Breastfeeding LH Chaudron, C Cerulli, N Chin University of Rochester School of Medicine and Dentistry, USA Email: [email protected] Objective: Intimate partner violence (IPV) has long lasting effects on the lives of victims and their children. Current community surveys estimate that 20% of women are exposed over their lifetime. Pregnant women are at particularly high risk for IPV, and perpetrators often control victims’ contraception choices and reproductive health. Given the long lasting effects of IPV on mental health, and correlations to postpartum depression (PPD), it is possible that IPV and PPD may interact to effect mother’s choices regarding breastfeeding. Due to the health benefits of breastfeeding for both the mother and child, inquiry is warranted on how these public health issues impact infant feeding choices. Method: This secondary analysis utilizes data collected for a cross sectional study of postpartum mothers designed to describe the phenomenology of postpartum depression. 188 low-income, minority mothers of infants (<14 months) attending well childcare visits agreed to complete a psychiatric diagnostic interview and an IPV assessment between April 1, 2003 and August 31, 2005. Results: Of the 188 mothers, 75% of the participants with IPV, defined as self-report of experiencing verbal or physical abuse within the past year, initiated breastfeeding, compared to 64% of those who

S14 did not report IPV. Among participants diagnosed with major depression, 70% initiated breastfeeding compared to 63% without a diagnosis. At the time of the interview, 16% of women without major depression were breastfeeding compared with 24% of those with major depression. Although IPV victims and depressed patients began breastfeeding, many abandoned their efforts shortly after beginning. Future mulitivariate analysis will assess for a possible interaction between depression and IPV status, controlling for sociodemographic factors. Conclusion: Depression diagnosis and IPV status do not appear to impede mother’s attempts to breastfeed their infants. Further research is needed to understand why they abandon these efforts, whether the barriers are internal or external, and whether those barriers may be overcome with additional supports. Feasibility of a Collaborative Care Model for Postpartum Depression in an Urban Pediatrics Clinic LH Chaudron,1 PG Szilagyi1, N Talbot1, MH Kearney2, KL Wisner3 1

University of Rochester School of Medicine and Dentistry University of Rochester School of Nursing 3 University of Pittsburgh School of Medicine , USA Email: [email protected] 2

Objective: Collaborative care for postpartum depression treatment may help low-income, urban women access care. However, lowincome women face many challenges to engaging in care, even when logistic barriers are removed and individual needs are accommodated. The objective was to establish the feasibility of providing a standard collaborative care depression treatment for low-income, urban mothers with perinatal depression in a pediatric clinic, and to adapt the model to their specific needs in preparation for a larger trial to test whether the model leads to increased engagement in and adherence to treatment. Methods: Mothers of infants ≤12 months who scored high on the Edinburgh Postnatal Depression Scale, were not in mental health treatment, and were 18 years or older were invited to participate in the mother–Infant Treatment Team (MITT). The MITT (a psychiatric nurse practitioner, pediatric social worker, and outreach worker) is colocated in the pediatric clinic to provide on-site mental health care. Mothers were provided 12 weeks of mental health assessment and treatment within 18 weeks from enrollment. We adapted the model to the needs of the women. We collected data regarding the logistical feasibility, efforts to engage and maintain women in care, engagement and adherence rates, barriers to attending treatment, and provider and maternal satisfaction. Results: We present the results of 15 women who were enrolled in the feasibility trial. We describe the changes made to the model as well as to recruitment strategies. We also present outcome data including engagement and adherence rates, the impact of changes in recruitment strategy and the model, changes in EPDS scores with treatment, and maternal and provider feedback. Conclusions: The MITT collaborative care model for low-income mothers in a pediatric clinic is feasible but multiple changes to the model were required to meet the needs of these mothers. The “lessons learned” and the final model will influence future collaborative care models for low-income postpartum women in pediatrics.

K.L. Wisner Theoretical Basis, Development, Structure and Efficacy of the Mother–infant Therapy Group Model of Treatment for Postpartum Depression R Clark University of Wisconsin, Madison, WI Email: [email protected] Objective: Traditional approaches for treating postpartum depression have included medication and individual psychotherapy for the mother. Although effective, these interventions ignore the impact of depression on the mother’s relationships with her infant and parenting partner. Method: The mother–Infant Therapy Group (M-ITG) treatment for postpartum depression is a manualized approach based on theory and findings from empirical studies that have demonstrated risk for the developing infant and for impairments in family relationships associated with postpartum depression. Maternal sensitivity and responsiveness specifically has been found to be a powerful moderator of child outcomes. Three separate therapy components address the emotional needs of mothers, infants, and family members as well as their needs in mother–infant and family relationships. During the first 105 minutes, women meet in a Mothers’ Group while their infants are cared for in a Developmental Group; this is followed by a 45 minute mother–Infant Group. M-ITG is a 15 week intervention that includes individual initial, intermediate, and final family sessions and a video replay with the mother to engage her in the development of goals for mother–infant therapy. Results: A pilot study found M-ITG to be highly successful in ameliorating depressive symptoms, in reducing parenting stress and in improving the quality of mother–infant interactions when compared to a waitlist control group. An NIMH-funded R-01 randomized clinical trial comparing M-ITG with Interpersonal Therapy was conducted. As predicted, treatment groups were equivalent in the amelioration of depressive symptoms and in rates of remission at post treatment as well as in recurrences of depressive episodes in the 12 months following treatment. The effects of comorbid disorders, mediating and moderating factors affecting infant development, and mother–infant relationship quality will also be presented. Conclusion: An intervention for postpartum depression designed to address parenting and partnering relationships and social isolation in group therapy are equally successful in treating depression as individual models, and may be more successful in demonstrating improvements in the social-emotional functioning of the infants. Use of Antidepressants and Mood Stabilizers During Pregnancy: Lessons from the Last Two Decades L Cohen Massachusetts General Hospital, Boston, MA Email: [email protected] Historically, pregnancy was described as a “protective” state against psychiatric disorders. However, there is substantial evidence that pregnancy appears to have neither a “protective” nor “risk-enhancing” effect for women, as recurrence risks in pregnant and nonpregnant

The Marcé International Society International Biennial General Scientific Meeting women are noted to be similar. Sustaining euthymia during pregnancy for women with major depressive or bipolar disorder is particularly critical since relapse of illness during gestation dramatically increases risk for puerperal illness and may contribute to adverse outcomes including obstetrical and neonatal complications. Management of these disorders during pregnancy can be particularly challenging, as the mainstay of pharmacologic therapy consists of multiple compounds where reproductive safety is either 1) relatively well established or 2) where medicines are known teratogens. For some medicines, reproductive safety data are particularly sparse. Risk of relapse during pregnancy in women with mood disorders must be weighed against the potential risks associated with treatment using antidepressant and mood stabilizers during gestation. The last few years have brought a growing number of published reports regarding the safety of antidepressant and mood stabilizer use during pregnancy, including concerns regarding teratogenicity of these agents, acute neonatal effects, and potential long-term consequences of fetal exposure to these medicines. The relative risks of fetal exposure to medicines used to treat psychiatric illness during pregnancy need to be weighed against the morbidity of untreated maternal illness. Physicians and patients must collaborate to make treatment decisions about psychotropic drug use during pregnancy realizing that no decision is perfect and that no treatment is risk free. Fathers’ Cortisol Levels During Pregnancy and the Postpartum Period A Conde, B Figueiredo School of Psychology, University of Minho, Portugal Email: [email protected] Objective: Several psychological and physiological changes occur during pregnancy and the postpartum period; however, less is known about hormones changes in fathers. This study aimed to analyze changes in fathers’ cortisol levels during pregnancy and the first months postpartum. Method: Repeated measures of 24-hour urinary free cortisol were obtained at the 2nd and 3rd trimesters of pregnancy and at 3 months postpartum from 48 couples recruited at an antenatal obstetric unit in Oporto (Portugal). Results: 1) Same significant changes were observed in both father’s and mother’s 24-hour urinary free cortisol over pregnancy and the first postpartum months: higher levels at the 3rd trimester compared to the 2nd trimester and the three months postpartum; 2) Significant gender and parity differences were found in the pattern of hormones changes between the 3rd pregnancy trimester and 3 months postpartum: higher cortisol levels at the 3rd trimester compared to the 2nd trimester, both in the first time fathers and mothers; lower cortisol levels at postpartum compared to the 3rd trimester in the first time mothers and fathers; however, while lower cortisol levels at 3 months postpartum compared to the 3rd trimester in the second time mothers, higher cortisol levels were observed in second time fathers, between these time points. Conclusions: Higher cortisol levels were found by the end of pregnancy compared to middle pregnancy and early postpartum, both in men and women, suggesting the physiological adjustment of new parents to the birth of the child. Parity and gender effects in hormones changes during this period were revealed.

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Father’s Attachment Style and Psychological Adjustment During Pregnancy and the Postpartum Period A Conde1, B Figueiredo1, A Bifulco2 1

School of Psychology, University of Minho, Portugal Royal Holloway, University of London, UK Email: [email protected]

2

Objective: Attachment style is an important determinant of mother’s perinatal mental health in mothers; less is known about the role of this in the psychological adjustment of fathers. Present study aimed to examine the effect of antenatal s attachment style in anxiety and depression symptoms of fathers during pregnancy and prospectively at three months postpartum. Method: The Attachment Style Interview (ASI) was administered separately to both members of a couple (N=126) during the second trimester of pregnancy together with measures of stateanxiety (STAI-S) and depression (EPDS), repeated at three months postpartum. Results: 1) Insecure attachment style was related to higher anxiety [F(1, 122)=14.20, p=.000] and depression [F(1, 122)=17.99, p=.000] symptoms in fathers, both at the second trimester of pregnancy and three months postpartum; 2) A significant effect of poor partner support was found for father’s anxiety symptoms, both antenatally [F(1,61)=5.37, p=.02] and postnatally [F(1,59)=5.39, p=.02]; and 3) Insecure styles in both partners was associated to increased depression symptoms in fathers during pregnancy [F(4, 118)=2.98, p=.02], but not postnatally [F(4, 114)=1.15, p=.34]. Conclusion: Attachment style shape the father’s psychological adjustment during the pregnancy and birth of a child, as previously observed for mothers, with insecure attached and lower supported men exhibiting higher anxiety and/or depression symptoms compared to the secure one, both in prenatal and postnatal period. Associations Between Maternal Personality Disorder and Depression and Infant Development at 18 months S Conroy, M Marks, R Schacht, H Davies, S Farrelly, P Moran Kings College London, UK Email: [email protected] Objective: Previous studies have reported detrimental effects of maternal postpartum depression on infant development but have not taken into account the potential confounding effects of co-morbid personality disorder. We aimed to examine the independent effects of maternal depression and personality disorder on infant development at 18 months. Method: Assessments were conducted with 170 infants whose mothers had a diagnosis at two months postpartum, of depression, personality disorder, both conditions, or neither condition. Infant assessments at 18 months included security of attachment and attachment disorganisation, as assessed in the Strange Situation, cognitive performance, as assessed by the Bayley II, and social and emotional development and behaviour problems, as assessed by the Infant Toddler Social and Emotional Assessment (ITSEA; Carter et al, 2003). The internalizing, externalizing and dysregu-

S16 lation domains of the ITSEA, a 166-item parent report measure of social-emotional/behavioral problems and competencies in 12- to 48-month-olds, were examined in relation to maternal postpartum diagnosis. Results: Multivariate analyses showed that higher externalising behaviour scores at 18 months were associated with a postpartum diagnosis of maternal personality disorder (F= 4.31, p< 0.05), while higher internalising behaviour scores were predicted by a postpartum diagnosis of maternal depression (F=10.08, p<0.01). Higher dysregulation scores were predicted by both depression and personality disorder (F=7.34, p<0.01 and F=10.90, p<0.001). A striking finding was that almost all children whose scores were in the Of concern range for the externalising, internalising, dysregulation and competence domains of behaviour had mothers with both depression and personality disorder at two months (all p values <0.05). In multivariate analyses attachment security, attachment disorganisation, and cognitive performance were not associated with maternal diagnosis. Conclusion: Maternal personality disorder may contribute to infant behaviour problems, especially externalising and dysregulation problems, and should be taken into account when assessing potential effects of maternal depression on infant and child development, especially when postpartum depression is comorbid with personality disorder. Postpartum Depression: Is Exaggerated Inflammation the Key Factor? EJ Corwin1, B Stafford1, K Pajer2, D McCarthy2, M Weber1 1

University of Colorado Ohio State University, USA Email: [email protected]

2

Objective: Postpartum depression (PPD) occurs in 12–15% of women after childbirth and may carry lifelong consequences. Although contributing psychosocial variables have been identified, the underlying biological etiology of PPD remains unknown. We propose an exaggerated pro-inflammatory immune response and/or dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis—both affected by childbirth and both known to contribute to depression in other populations—increase a woman’s risk of PPD. Method: Women completed depression surveys and provided blood and saliva samples for measurement of pro-and antiinflammatory cytokines and cortisol once during the 3rd trimester and on postpartum days 7 and 14, and months 1, 2, 3, and 6. To evaluate diurnal cortisol pattern, participants collected saliva 5 times the day preceding each blood draw. Depressive symptoms were evaluated in light of these variables independently and in relation to each other. Results: Of 45 women enrolled, 13 have completed through 6 months postpartum. Linear regression indicates an elevated interferon-gamma to interleukin 10 ratio (IFN/IL10) at 1 month postpartum and elevated interleukin 1beta at 3 months postpartum together explain 69% of the variance in depressive symptoms at 3 months. By adding to the model 3-month plasma cortisol and salivary cortisol levels measured 30-minutes post-awakening, 83% of symptom variance is explained. This model is not affected by age, race, marital or income status. Data further suggest that key to

K.L. Wisner the occurrence of depressive symptoms is disruption in the balance between pro-inflammatory cytokines and circulating cortisol, with depressive symptoms strongly linked to pro-inflammatory dominance at 2 and 3 months postpartum. Conclusion: An exaggerated pro-inflammatory immune response early in the postpartum period increases the risk of depressive symptoms in this small sample of women, a finding independent of social variables. Symptoms appear triggered by dysregulation in the interaction between the immune and HPA systems occurring at a critical time during postpartum recovery. Identifying the biological underpinnings of PPD will enable health care providers to identify and effectively treat women at risk for this disorder. Post-birth Screening in Pittsburgh, PA: Results from an NIMH-funded Study ML Costantino Western Psychiatric Institute and Clinic, Pittsburgh, PA E-mail: [email protected] Objective: We conducted a large scale postpartum depression screening program at an urban obstetrical hospital to determine the feasibility of screening a broad population of non-treatment seeking postpartum women. The study implemented a centralized (rather than practice-based) postpartum depression screening to tap the efficiency of volume and infrastructure development for depression referral services. Method: Women who delivered a live infant at the University of Pittsburgh Magee Womens Hospital were visited by a nurse or social worker and provided with education about postpartum depression. They were offered a telephone screening by our research team at 4–6 weeks post-birth using the Edinburgh Postnatal Depression Scale (EPDS), with a cutpoint of ≥10. Women who screened positive were scheduled for an in-home visit, during which they were evaluated diagnostically with the Structured Clinical Interview for DSM-IV (SCID). If a woman refused the home visit, she was offered a diagnostic phone interview. Results: Of eligible women, 13,442 (77.1%) were reached, 10,000 (74.4%) of these eligible women were screened with the EPDS by phone, and 1396 (14.0%) of screened postpartum women had EPDS scores ≥10. In the 826 women who received a home visit assessment, the onset of the episode was: postpartum, N=331 (40.1%); during pregnancy, N=276 (33.4%); prior to pregnancy, N=219 (26.5%). Item 10 of the EPDS, an assessment of suicidality, showed that 3.19% of screened women had suicidal ideation, the majority at the lowest level of intensity. Conclusions: The majority of non-treatment seeking women identified at delivery accepted the offer of telephone screening for postpartum depression at 4–6 weeks after birth. Women were also reasonably amenable to being evaluated by a mental health professional either through a home visitation or by a phone diagnostic interview. The distribution of EPDS scores shows that EPDS ≥10 identified 14% of the women and 98% of identified women had an Axis 1 disorder. The percentage of women who endorsed any thoughts of self-harm was 3.19%, which is important for training personnel and

The Marcé International Society International Biennial General Scientific Meeting resource management. Our work suggests that we can serve a large group of depressed women who are unlikely to get assistance otherwise.

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Mindfulness Based Prevention of Perinatal Depression: Innovative Treatment Development S Dimidjian1, SD Goodman2

Prospective Economic Evaluation of a Peer Support Intervention for Prevention of Postpartum Depression Among High Risk Women CL Dennis1,2 , D Dukhovny3,4, E Hodnett1, L Kenton1, J Weston1, DE Stewart2, A Kiss, PhD5, W Mao4, JAF Zupancic4 1

Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada 2 Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada 3 Division of Newborn Medicine, Harvard Medical School, Boston, MA, United States 4 Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, United States; and 5 Department of Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Email: [email protected] Background: Recently, a multisite, randomized, controlled trial of a peer support intervention, compared to usual care for prevention of postpartum depression demonstrated a reduction in depression symptoms at 12 weeks postpartum (BMJ, 2009; 338: a3064). Although this was a volunteer program, the true cost implications from a societal perspective must be explored prior to universal implementation of such an intervention. Objective: To determine the cost-effectiveness of a volunteer peer support intervention compared to usual care in women at high risk for postpartum depression, at 12 weeks postpartum. Methods: We undertook a prospective economic evaluation alongside the clinical trial to determine the cost per case of postpartum depression averted, using individual patient data and a societal perspective. The analysis captured the cost incurred by departments of public health for administration of the program, including the screening of 14,101 women to identify those at highest risk for depression. For high risk women who proceeded to randomization (n=612), we examined comprehensive direct medical costs, as well as the opportunity cost of lost wages for family members and volunteers. We obtained resource utilization data from a modified version of the Health Service Utilization and Cost of Care Questionnaire, administered to patients during the clinical trial at the time of 12 week follow up. Wages and physician fees were obtained from Statistics Canada and the Ontario Health Insurance Program, respectively. All costs were expressed in 2005 Canadian dollars. The time horizon extended to 12 weeks postpartum to match the primary outcome of the clinical trial. Results: The mean cost per woman was $3,774 in the peer support group and $2,904 in the usual care group (difference of $870, adjusted p=<0.0001). There was a 95% probability that the program would cost less than $16,000 per case of postpartum depression averted. Conclusions: Although this is a volunteer based program, it still results in a net cost to the healthcare system and society. However, this cost is well within the range for other accepted interventions for this patient population.

1

University of Colorado, Boulder Emory University Email: [email protected]

2

Objective: Depression during pregnancy and the postpartum is a prevalent problem that can have enduring adverse consequences for women and their children. The clear benefit of averting such outcomes underscores the potential value of preventive interventions during pregnancy, and the limitations of extant prevention models make developing novel prevention approaches particularly important. Mindfulness-Based Cognitive Therapy (MBCT) has been found to significantly reduce rates of relapse of recurrent depression among general adult samples and has high relevance to the prevention of perinatal depression. MBCT provides an important alternative to both pharmacological intervention and traditional one-on-one individual psychotherapy models. It also is based on a clear conceptual and empirical relationship between the specific intervention strategies and the most robust risk factor for perinatal depression, namely depressive history. Method: A two site treatment development study was implemented in order to develop and test a brief behavioral group intervention designed to prevent depressive relapse among pregnant women at high risk for perinatal depression, with risk based on previous history of depression. The study includes three phases, implemented in the obstetrics clinics of a large HMO in both sites: 1) conceptualizing the intervention based on theory and empirical research, 2) developing and standardizing the intervention in the context of an open trial, and 3) pilot testing its efficacy in a randomized controlled trial targeting the prevention of relapse among perinatal women with histories of depression. Results: As of March 2010, we have enrolled 42 women in the open trial and preliminary results suggest promise for the prevention intervention. The findings support the feasibility of both recruiting and retaining at risk pregnant women in the intervention. Positive outcomes are evident on outcomes such as depressive severity, stress, and social support. Participants report high satisfaction with the intervention. Conclusion: The adaptation of MBCT for PD is a novel and promising strategy for the prevention of perinatal depression. Sleep and Depression Among Postnatal Women—A Population Based Questionnaire Study Supplemented by Sleep Diary and Actigraphy S Dørheim1, GT Bondevik2, M Eberhard-Gran3, B Bjorvatn2,4 1

Stavanger University Hospital University of Bergen 3 Norwegian Institute of Public Health 4 Haukeland University Hospital, Norway Email: [email protected] 2

Objective: Women sleep less in the postnatal period, and mothers diagnosed with depression could alternatively be suffering from the effects of chronic sleep deprivation. Population based studies of depressive symptoms along with prospective sleep reports and objective sleep registrations have been lacking. Our aim was to study the

S18 prevalences of sleep problems and depressive symptoms in a normal population of postnatal women to identify risk factors, and to compare retrospective reports with objective and prospective sleep registrations. Method: All women (4191) delivering at Stavanger University Hospital, Norway during one year were mailed a questionnaire 7 weeks after delivery, 2831 (67%) participated. Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep, and depressive symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS). A sub-study using sleep diaries and actigraphy recordings for 14 days was performed among 42 women, of whom 21 scored ≥10 on the EPDS. Results: The prevalence of PSQI >5 was 57.4%, and the prevalence of EPDS ≥10 was 16.5%. The mothers slept on average 6.5 hours at night, with 73% sleep efficiency. Depression was associated with poor partner relationship, previous depression, depression during pregnancy and stressful life events, also when adjusted for poor sleep quality. Depression, previous sleep problems, being primipara, not exclusively breastfeeding, or younger or male infant were factors associated with poor sleep. Sleep disturbances and subjective sleep quality were the aspects of sleep most strongly associated with depression. Prospective sleep diary and actigraphy registrations showed that women with depression did not have worse sleep than non-depressed women, but depressed women had lower daytime energy. Conclusion: Although reporting poorer sleep at the PSQI, postnatal women with depression did not show worse sleep parameters than non-depressed women when measured objectively and prospectively. Women complaining of poor sleep or fatigue in the postnatal period should be evaluated for possible depression. Fear of Childbirth: Causes and Consequences M Eberhard-Gran1,2, S Opjordsmoen3, J Sundet5, C Nielsen1, L Torgersen1, A Eskild1,2 1

Norwegian Institute of Public Health Akershus University Hospital 3 Oslo University Hospital 4 University of Oslo Email: [email protected] 2

Objective: It is assumed that approximately 20% of all pregnant women fear giving birth, and steadily increasing numbers of women are requesting caesarean sections due to childbirth-related anxiety. Hence, fear of child birth is an important women’s health issue. The fear may overshadow the entire pregnancy and complicate labour. Although a common clinical problem, little is known of the causes and consequences of the fear of childbirth. Aim: In a prospective study, we intend to study 1) risk factors for selfperceived fear of childbirth, 2) whether fear of childbirth affects the delivery or the child. The Akershus Birth Cohort will be presented, as well as some preliminary results. Methods: The target population is all women giving birth at the Department of Obstetrics, Akershus University Hospital in the period 2009-10 (n≈4000 women). Data is being collected using three questionnaires to the women at pregnancy weeks 17 and 32 and 8 weeks after delivery. The questionnaires include several mental health measures, and standardized questions about expectations and feelings associated with childbirth. Data on delivery and pregnancy outcomes is obtained through linkage to the electronic patients’ records at the Department of Obstetrics.

K.L. Wisner Scientific value: This will be one the largest studies focusing on risk factors and consequences of fear of childbirth. The combination of a wide range of mental health measures with detailed obstetrical outcome variables makes this study unique. Results from the study will provide increased knowledge on fear of childbirth and may contribute to improved pre- and postnatal care. Rates of Spontaneous Abortion and Preterm Birth in Women Who Took an Antidepressant During Pregnancy: A Comparison Between Continuers and Discontinuers A Einarson1, PBozzo1, GKoren1, TREinarson1,2 1 The Motherisk Program, The Hospital for Sick Children, Toronto, Canada 2 The Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada Email: [email protected]

Objective: Results from recent studies have reported a small, but significant increased risk for both spontaneous abortions (SA) and preterm births associated with the use of antidepressants during pregnancy. We wanted to examine whether this increase in risk differs between women who continued or discontinued antidepressant therapy during pregnancy. Methods: We compared two groups in our prospectively collected database of women exposed to antidepressants during pregnancy (n=1243), and compared rates of spontaneous abortion and preterm births between those who continued and those who discontinued pharmacotherapy. Results: In the discontinuer group there were 132/459 (28.8%) SA and 27/651 (4.1%) in the continuer group (RR=6.93, CI95%:4.66– 10.31). The average time of SA following antidepressant discontinuation (n=30) was 4.9±3.3 weeks. Overall preterm (≤37 weeks) birth rates were similar between groups; 31/326 (9.5%) in discontinuers and 82/622 (13.2%) in continuers (RR=0.72, CI95%:0.49–1.07). However, there were twice as many extremely premature births (≤30 weeks) in discontinuers (1.4%) compared to continuers (0.5%) although not statistically significant. Conclusion: There was almost a seven-fold increase risk for SA associated with discontinuation of antidepressant treatment in the first trimester of pregnancy. This suggests that perhaps untreated depression rather than use of an antidepressant is associated with an increased risk for SA. A larger sample size is required to further investigate the association with discontinuation of the antidepressant and the extremely premature birth group Exposure to Maternal Psychosocial Stress in Utero is Associated with Metabolic, Endocrine, Immune and Cognitive Dysfunction in Adult Life. S Entringer, C Buss, PD Wadhwa University of California, Irvine, School of Medicine, Departments of Psychiatry, Pediatrics, OB/GYN, Epidemiology, and the UC Irvine Development, Health and Disease Research Program Email: [email protected] Objective: To conduct a translational study in humans on the concept of developmental programming of adult health and disease risk by

The Marcé International Society International Biennial General Scientific Meeting testing the specific hypothesis that exposure to high maternal psychosocial stress in utero is associated with altered physiological phenotypes in adult life that confer increased risk for common complex disorders that confer a major burden of disease in society. Methods: The study was conducted in a sample of N=85 healthy young adults born to women with healthy uneventful pregnancies. One half of the study population was born to mothers who had experienced a major stressful life event during the index pregnancy (prenatal stress group; PS), whereas the other half was a sociodemographically-matched population with no history of maternal exposure to prenatal stress (comparison group; CG). Assessments were performed to examine (i) body composition and glucose-insulin metabolism (ii) immune function (iii) endocrine function, and (iv) cognitive function (working memory under basal and hydrocortisone conditions). Results: Young adults in the prenatal stress group consistently exhibited a significant dysregulation of all the above physiological parameters. Specifically, individuals in the PS group exhibited higher BMI and percent body fat, primary insulin resistance and a lipid profile consistent with the metabolic syndrome [Entringer et al, 2008a], altered immune function with a Th2 shift in the Th1/Th2 balance (consistent with increased risk of asthma and autoimmune disorders [Entringer et al, 2008b], altered endocrine function, with an increased ACTH and reduced cortisol response to stress [Entringer et al, 2009a], and impaired prefrontal cortex (PFC)-related cognitive performance (impairments in working memory performance after hydrocortisone administration) [Entringer et al, 2009b]. Conclusions: These findings suggest (a) that in utero exposure to prenatal stress may confer negative long-term physiological consequences that place individuals at increased risk for developing clinical disorders, and (b) the effects of prenatal stress may directly influence adult health without necessarily being mediated by adverse birth phenotypes such as low birth weight. This research was supported, in part, by US PHS (NIH) grants HD047609, HD-041696 and HD-33506 to PDW. Prenatal Depression: Effects on Fetal Cardiac Physiology and Growth in Rural South India MC Fernandes1, AL Stein1, K Srinivasan2, G Menezes3, PG Ramchandani1 1 Section of Child & Adolescent Psychiatry, Dept. of Psychiatry, University of Oxford, UK 2 St. John’s Research Institute, Bangalore, India, 3Snehalaya Hospital, Solur, India Email: [email protected]

Background: The effect of depression during pregnancy on fetal growth and infant development has been increasingly studied in western populations. However, few inquiries exist from the developing world where high rates of prenatal depression (24–45%) are reported. There is also limited understanding of the mechanisms responsible for these effects. Objective: To determine the prevalence of prenatal depression in rural South India and to investigate its association with fetal neurodevelopment (as measured through habituation patterns in fetal heart rate responses) and obstetric outcome Methods: 194 women in their third trimester of pregnancy were assessed for depression using the Edinburgh postnatal Depression Scale (EPDS), the Kessler-10 Scale (K10) and a structured clinical interview. 67 high

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scorers and 66 controls underwent continuous foetal heart rate monitoring for 30 minutes. Fetal heart rate was recorded at (i) baseline (ii) in response to the presentation of a vibroacoustic stimulus and (iii) post-stimulus. Data on perinatal complications, birth weight and gestational age at birth was extracted from hospital records. Results: 36.6% (n=71) women were found to score high on the screening questionnaires. 39.4% (n=28) of these met criteria for a major depressive episode. Results pertaining to fetal heart rate patterns are currently being analysed and are expected shortly. Babies of high scorers had significantly lower birth weights (difference=56 gms. ± 14) than controls (F=4.64; p=0.03), this association was more for those with a clinical diagnoses (65 gms. ± 171; F=5.70; p=0.01). We did not find any significant association between prenatal depression and preterm birth. Conclusion: Our study reports a high prevalence of prenatal depression in rural South India with implications on fetal development and obstetric outcome. Further investigation into the mechanisms of prenatal stress effects and strategies of primary prevention is needed. Father’s Postpartum Depression: A Longitudinal Study from Early Pregnancy to 3-Month Postpartum B Figueiredo, V Costa University of Minho, School of Psychology, Braga, Portugal Email: [email protected] Background: Pregnancy and the postpartum period are related to increased psychological morbidity in both, the mother and the father. Methods: The Edinburgh Postnatal Depression Scale (EPDS, Cox, Hoden, & Sagowsky, 1987) was administered to 255 fathers-to-be in an Out-patients Unit (Oporto, Portugal). Results: Depression decreased in fathers from the first to the second pregnancy trimester, and again between childbirth and 3 months postpartum. Depressed fathers at 3 months postpartum presented more depressive symptoms during all pregnancy trimesters and an increase of symptoms after childbirth, not observed in postpartum nondepressed fathers. Postpartum depressed fathers were more depressed during pregnancy, childbirth and postpartum, and presented an increase in symptoms from childbirth, not observed in non-depressed fathers at 3 months postpartum. Depression at childbirth was the best predictor of postpartum depression in fathers. Conclusions: Postpartum depression in fathers seems to be related to a depressive reaction to childbirth. Childbirth may be the most appropriate moment to screening for fathers at risk for postpartum depression. Common Perinatal Mental Disorders in the North of Viet Nam: Community Prevalence and Health Care Use J Fisher1, T Tran2, L Buoi2, 3, K Kriitmaa1, D Rosenthal1, T Tuan2 1

Centre for Women’s Health, Gender and Society, WHO Collaborating Centre in Women’s Health, Melbourne School of Population Health, University of Melbourne, Australia 3010 2 Research and Training Centre for Community Development, Hanoi, Viet Nam. 3 TuNa Clinic, Hanoi, Viet Nam. Email: [email protected] Objective To establish the prevalence of the common perinatal mental disorders of depression, anxiety and adjustment disorders with

S20 depressed and/ or anxious mood; their determinants, and associations with preventive health care use among women in one rural and one urban province in the north of Viet Nam. Methods: A cross-sectional survey of systematically recruited cohorts of pregnant women and mothers-of-newborns in ten randomlyselected communes in rural and urban provinces in North Vietnam. Data were collected by psychiatrist-administered Structured Clinical Interviews for DSM IV Diagnoses and structured interviews assessing sociodemographic factors, reproductive health, intimate relationships, family violence and use of preventative and psychiatric health care. Results: In total 364/392 (93%) eligible women were recruited, 29.9% [95% CI 25.2% to 34.7%] were diagnosed with a CPMD. Pregnancy and postpartum CMD rates were the same. CPMD prevalence was higher in rural than urban provinces [OR 2.1, 95% CI 1.2 to 3.8, p=0.01]; in those experiencing intimate partner violence [OR 2.1, 95% CI 1.1 to 3.9, p=0.02]; who feared other family members [OR 3.2, 95% CI 1.0 to 10.3, p = 0.05] and had coincidental life adversity [OR 4.0, 95% CI 2.3 to 7.3, p<0.001]. None had ever received mental health care. Failure to use iron supplements was more common in women with, than without CMD [OR 1.8, 95% CI 1.0 to 3.2, p=0.05]. Conclusion Perinatal depression and anxiety are prevalent in women in the north of Viet Nam. These conditions are predominantly determined by social factors, including rural residence, poverty and exposure to family violence. At present the needs of women with common perinatal mental disorders are unrecognized and unassisted and their participation in essential antenatal preventive care appears to be compromised. What Were We Thinking! An Innovative Psycho-educational Program to Prevent Common Postpartum Mental Disorders in Women J Fisher, H Rowe, K Wynter Centre for Women’s Health, Gender and Society, Melbourne School of Population Health, University of Melbourne, Melbourne, Australia Email: [email protected] Objective: Universal postnatal interventions for the prevention of maternal mental health problems have had limited success. The aim of this study was to determine whether a brief couple-focused, psychoeducational program for mothers, fathers and first newborns which was facilitated by trained Maternal and Child Health Nurses and addressed learning needs about unsettled infant behaviour and poor partner relationship reduced the incidence of postpartum depression, anxiety and adjustment disorders in women. Methods: A controlled before-and-after study was conducted in 7 local government areas in Victoria, Australia. Consecutively-recruited English-speaking couples completed structured telephone interviews 4 weeks and 6 months postpartum; control and intervention groups were recruited and followed sequentially. Both groups received standard care, but intervention group participants were also invited to attend a half-day program in groups of up to 5 couples with their four-week-old first babies. The main outcome was any CIDI diagnosis of depression, anxiety or adjustment disorder in the first six months postpartum. A logistic regression model was fitted controlling for potential confounders; analysis was by intention to treat Results: In total, 399/646 (62%) eligible women were recruited; 210 received standard care only and 189 also attended the intervention; 364 (91.2%) were retained at follow up. Anonymous participant evaluation questionnaires completed by 98/120 (82%) women at the

K.L. Wisner end of the intervention program revealed that 92 (94%) reported increased understanding of infant sleep needs, 81 (83%) of infant temperament, 91 (93 of infant sleep and settling strategies, 71 (72%) could now talk more effectively about parenting with their partners and 64 (66%) already reported increased confidence in infant care. In women without a psychiatric history (232/364; 64%), 36/125 (29%) met diagnostic criteria for depression, anxiety and adjustment disorders in the first six months postpartum in the standard care arm compared with 16/107 (15%) in the intervention arm. In women with no psychiatric history, the odds of a diagnosis were significantly reduced for those in the intervention group (adjusted OR 0.43; 95% CI 0.21, 0.89) compared with the standard care arm. Conclusions: A brief psycho-educational group program for parents and first babies in primary care reduces new onset of mental disorders. A universal approach with additional strategies may be more beneficial for women with a psychiatric history. Mental Health Themes in Online Social Networking Forums by Adolescent Mothers LG Flamini, JL Gregg, MC Logsdon University of Louisville, KY Email: [email protected] Objective: In the United States approximately 500,000 adolescent mothers give birth each year. Adolescent mothers are frequently stressed and many develop symptoms of depression. Depression symptoms can negatively impact the adolescent’s functioning at work and school and her relationships with her baby and significant others. Similar to other female adolescents in their desire for peer interactions, many adolescent mothers turn to online social networking environments for social support and for health information. At least 5 sites are dedicated to adolescent mothers. However, the accuracy of the health information and the nature of the supportive interactions are not known. Our research team questioned if the social networks were health promoting or if inaccurate information and negative feedback could serve as barriers to use of mental health services in adolescent mothers with depressive symptoms. Therefore, the purpose of this study was to analyze the content of the interactions over a one year period of five online social networking environments. Erik Erikson’s adolescent development theory and Social Capital Theory were used to frame the study. Method: A content analysis was performed during Spring 2010 on five active social networking forums that were targeted toward teen mothers. All forums were of the message board type, where a member could pose a question or make a statement, and other members could respond with support or answers. Discussions were also analyzed for accuracy of information shared and to determine communication styles used among members. Results: As of March 2010, initial analysis of the forums revealed several prominent mental health-related themes within online message board discussions among postpartum adolescents. These variables include “conflict,” “depression,” “advice to seek professional help,” and “stress related to physical knowledge deficit.” Further analysis is ongoing at this time. Conclusion: Online social networking environments may provide a valuable resource for social support and mental health information sharing among adolescent mothers depending upon the accuracy of information shared as well as the directness of question and response styles used.

The Marcé International Society International Biennial General Scientific Meeting The Trajectory of Perinatal Depression, Psychosocial and Neuroedocrine Measures and the Impact of Treatment on Maternal and Infant Outcomes HA Flynn, M Sexton, D Vazquez, J Lopez, SM Marcus University of Michigan Medical School Email: [email protected] Objective: Little is known about the course of depression from pregnancy through postpartum, but also about the longitudinal associations of depression with key maternal and infant psychological and neurobiological outcomes. This information is important in order to understand the impact of depression and related indices on outcomes as well as to inform clinical interventions. Method: This presentation will provide results of a longitudinal study of 187 women assessed from 28 weeks of pregnancy through 6 weeks postpartum. Longitudinal assessments of maternal depressive symptoms (Beck Depression Inventory-II; BDI-II), were conducted at 28 wks, 32 wks, and 37 weeks gestation and again at 2 and 6 weeks postpartum (alpha=0.93 and test-retest r=0.74). Other psychosocial measures at 28 weeks of pregnancy included measures of marital satisfaction, life stress and health behaviors, maternal plasma ACTH and cortisol. Neonatal measures included umbilical cord blood ACTH and cortisol, as well as the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) at 2 weeks. An additional 33 women using the identical protocol were enrolled in an ancillary psychotherapy trial to examine the effect of treatment on outcomes observed from the naturalistic arm. Results: Three trajectories of depression were observed in the naturalistic study (low/stable, intermediate, and high/increasing). Infants born to women of the high/increasing depression group had significant elevations in cord blood ACTH at birth. On NNNS examination, these infants were more hypotonic and habituated to stimuli more quickly. Only pregnancy BDI-II (but not demographics or psychosocial variables) predicted postpartum depression. Significantly fewer women who achieved remission in the psychotherapy study by the end of treatment had infants who experienced respiratory distress at delivery than those who did not remit (2.1% vs 5%; X2(1)= 3.8, p=.05), with no other significant infant outcome differences found. Conclusions: Women have varying trajectories of perinatal depressive symptoms which appear to impact maternal and infant neurobiological outcomes and are predicted by depression in early pregnancy. Women who respond to treatment may show protection against these potentially harmful neurobiological effects. Interpersonal and Social Rhythm Therapy (IPSRT) for Women in the Childbearing Years E Frank, H Swartz Western Psychiatric Institute and Clinic, Pittsburgh, PA E-mail: [email protected] Overall Objectives: At the conclusion of the workshop participants will be able to 1) understand the links between regularity of daily routines or social rhythm stability and mood stability, 2) understand the principles of interpersonal and social rhythm therapy, and 3)

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provide patients suffering from mood disorders during the childbearing years with a rationale and set of strategies for improving their social rhythm stability. Interpersonal and Social Rhythm Therapy (IPSRT) was built on the principles of interpersonal psychotherapy (IPT) for unipolar depression and theories about the link between circadian rhythm biology and mood. IPSRT helps to minimize the impact of disruptive life events on social rhythms, while addressing interpersonal difficulties as they arise in the context of a mood disorder. The rationale for IPSRT posits that for biologically atrisk individuals, recovery from even slight perturbations in schedules is difficult. Further, it suggests that the relative absence of routines may also represent a risk factor for mood episodes. In a broader sense, IPSRT strives to dampen extreme oscillations of mood and energy by helping patients to manage provocative social and environmental factors more effectively. The treatment integrates psychoeducational, interpersonal, and behavioral strategies in order to reduce symptoms, improve functioning and prevent recurrence of episodes. This course will explain the rationale for IPSRT in the childbearing years and introduce participants to the strategies and techniques used in the therapy. Video tape demonstration will be used to acquaint participants with basic IPSRT techniques such as construction of the illness timeline and assessment of social rhythm stability utilizing the Social Rhythm Metric. Participants who complete this workshop will have an increased understanding of the role of social rhythm dysregulation in the genesis of mood episodes and will be able to use components of IPSRT with their own patients suffering from mood episodes during the childbearing years. Perinatal Depression: Evidence-based Integrative Medicine MP Freeman Massachusetts General Hospital, Boston, MA E-mail: [email protected] Objective: Perinatal Major Depressive Disorder (MDD) is common and poses treatment dilemmas. Women are more likely than men to both suffer from MDD and use CAM, or integrative approaches. Complementary and Alternative Medicine (CAM) treatments are widely used, accessible, and understudied for clearly defined psychiatric indications. Methods: Content is informed by systematic literature review of published studies in English language 1965- present. The presenter will also discuss the recent American Psychiatric Association’s Task Force on CAM report. Results: A general discussion of integrative medicine, prevalence of use, and research methodology will be discussed. CAM treatments that will be discussed include: omega-3 fatty acids, exercise, folate, s-adenosylmethionine (SAMe), St. John’s Wort (hypericum), light therapy and acupuncture. Research findings from studies of MDD and specifically perinatal depression where available will be discussed, as well as safety considerations. Based on evidence, the role of each will be discussed in the treatment of MDD during pregnancy and the postpartum. Conclusions: Further studies are required so that psychiatrists and other health care providers can offer safe, effective, and accessible treatment options for perinatal depression. Health care providers and the public need to understand the potential benefits and risks of integrative treatment options in perinatal depression.

S22 The Wijma Delivery Expectancy Questionnaire: A Revalidation S Garthus-Niegel1,2, HT Størksen2, L Torgersen1,3 , T von Soest1,3, M Eberhard-Gran1,2 1

Norwegian Institute of Public Health Akershus University Hospital 3 Norwegian Social Research, Norway Email: [email protected] 2

Objective: About 20% of pregnant women fear giving birth and the number of planned caesarean sections performed due to fear of childbirth (FOC) has increased markedly in recent years. Hence, fear of childbirth is an important women’s health issue. The Wijma Delivery Expectancy Questionnaire (W-DEQ) was constructed to measure different aspects of FOC, but is conceptualized as a uni-dimensional instrument. The aim of the present study was to investigate the underlying factor structure of the W-DEQ. Investigating its sub-dimensions could improve the predictive validity of this instrument. Method: This study is part of the Akershus Birth Cohort (ABC), targeting all women scheduled to give birth at Akershus University Hospital during 2009 and 2010. A total of 1200 women filled in the W-DEQ in the third trimester. Validity and reliability were estimated by means of exploratory and confirmatory factor analysis, as well as correlations with other relevant variables and internal consistency measures. Results: In accordance with our assumptions, a multidimensional structure of the W-DEQ could be confirmed, whereas a uni-dimensional model yielded a very poor fit. Six factors, covering different psychological domains, could be extracted: “Fear”, “Lack of Self-efficacy”, “Negative affectivity”, “Loneliness”, “Lack of normativity” and “Concerns for the child”. The final model resulted in a shorter version of the instrument with 25 items and acceptable psychometric properties. Discriminant validity was demonstrated as the sub-factors correlated differently with a number of relevant covariates. The “Fear” factor, particularly, could predict the wish for caesarean section and anesthesia, in addition to perceived fear during labor. Conclusion: This study has demonstrated the sophistication of the WDEQ, as each sub-factor has more predictive power than the W-DEQ overall. In studies with space restrictions, researchers can limit the use of the W-DEQ to its relevant domains. Related Circuitry J Gingrich New York State Psychiatric Institute, School of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY Email: [email protected] Objective: Serotonin transporters (5-HTT) regulate extracellular serotonin (5-HT) levels. Humans carrying a lower-expressing variant of the 5-htt gene exhibit increased vulnerability to depression and anxiety-related behaviors. Likewise, 5-htt-/- mice exhibit an affective behavioral phenotype. The impact of reduced 5-htt function may occur during early brain development as pharmacological blockade of 5-HTT during early life (postnatal fluoxetine; PNFLX) mimics the 5-htt-/- phenotype. Methods: To better understand the neural substrates of these behavioral changes we examined the dendritic morphology using

K.L. Wisner Golgi staining of neurons in the hippocampus and medial prefrontal cortex (mPFC)—regions that are structurally and functionally abnormal in depressed patients and “s” allele carriers. Results: We examined dendrite morphology in 5-htt-/- mice and found that the anterior cingulate (AC) neurons had more complex apical and basilar dendritic arbors than their 5-htt+/+ littermates. 5-htt-/- infralimbic (IL) neurons also displayed increased arborization, but this was specific to the apical dendrites. No effect of genotype was detected for prelimbic (PL) neurons. In hippocampal regions, 5-htt-/dentate gyrus (DG) neurons had significantly less complex arbors, while no differences were detected for the CA1 region. Additionally, both the apical and basilar dendritic trees of 5-htt-/- CA3 pyramidal neurons were significantly more complex, compared to 5-htt+/+ mice. To determine whether P4-21 5-HTT blockade also affected dendrite morphology, we examined dendritic trees in P4-21 fluoxetine treated mice. We found no significant differences in arbor complexity of AC, IL or DG neurons. However, developmental 5-HTT blockade increased both the apical and basilar dendritic complexity of CA3 neurons. Conclusion: Because increased complexity of the CA3 dendritic arbor is elicited by both lifelong (genetic) and developmental (pharmacologic) 5-HTT blockade, this shared anatomical anomaly may represent a mechanism for the depressive and anxiety-like behaviors observed in both manipulations. Interestingly, CA3 is implicated in novelty detection and the complexity of its dendritic arbor is reduced by stressful experiences. Taken together, these observations suggest that serotonin-driven changes in CA3 dendrite morphology underlie the behavioral abnormalities seen in 5HTT knockout mice and mice with developmental inhibition of 5HTT function. Baby’s Father’s Place and Care Within Inpatient Mother–baby Units N MC Glangeaud-Freudenthal1,2 & MBU-SMF Working Group3 (1) INSERM, UMRS 953, Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, F-94807, Villejuif, France;(2) UMPC Univ Paris 06, UMR S 953, F-75005, Paris, France; (3) Email: [email protected] Purpose: This study describes place and care of women’s partner / baby’s fathers within inpatient mother-baby units in France, Belgium and Luxembourg Methods: A questionnaire “French Marcé checklist” was sent to all psychiatric Mother–Baby Units (MBUs) in France, Belgium and Luxembourg to assess all inpatient admissions of a women and her child, between 2001 and 2007. Information has also been collected on mental health care and support for partner/baby’s father and on how baby’s fathers participate to babies care and everyday life in MBUs. Results: In patient MBUs women are living with a partner in 66% of cases (39% married couple). Partner/Father had no known pathology (past or present) for less than half of them; in 21% of cases, partner/ father were presenting a known pathology (187 cases among 1018 inpatient mother–baby admissions studied); and there was no precise information on their mental health in 29% of cases. Partner/father’s diagnosis were: 43 bipolar or depressive disorders, 29 schizophrenia and other psychotic disorders, 74 behavioral disorders and 84 other disorders (including 54 cases of alcohol and drug abuse, and 10 cases of cognitive disability). In 10% of cases when there was a partner and 60% of cases when woman was not living with a partner, professionals of MBUs could not get any information on their mental

The Marcé International Society International Biennial General Scientific Meeting health. There are different care setups for fathers among MBUs. However, all MBUs are trying to involve partners/fathers in day care of babies and in women’s psychiatric care project. Some MBUs offer a specific care project for fathers (focus groups, personal therapy). There are some cases of inpatient admissions of fathers with mother and child. Conclusion: Advantage and inconvenient for fathers’ participation in baby care and for their mental health care within units have to be discussed specially according to how this helps for caring for women and for facilitating positive issues for children in MBUs. References Glangeaud-Freudenthal N. M.-C, Sutter-Dallay A.-L., Thieulin A.-C., Dagens-Lafont V., Zimmermann M-A, Debourg A, Massari B, Cazas O, Cammas R, Rainelli C, Poinso F, Maron M, Nezelof S, Ancel P.-Y., Khoshnood B. Inpatient mother and child postpartum psychiatric care : factors associated with maternal mental health improvement. European Psychiatry 2010 (in press) Glangeaud-Freudenthal N MC. (2009) Les pères lors de l’hospitalisation conjointe mère-bébé en psychiatrie.: caractéristiques et implications. Confrontations Psychiatriques, ISSN : 0153-9329 (2010 in press) Glangeaud-Freudenthal NMC. Mother–Baby psychiatric units (MBUs): national data collection in France and in Belgium (1999– 2000). Arch Womens Ment Health. 2004 Feb;7(1):59–64. Cazas O, Glangeaud-Freudenthal NMC. The history of Mother– Baby Units (MBUs) in France and Belgium and of the French version of the Marcé checklist. Arch Womens Ment Health. 2004 Feb;7(1):53–8. Inpatient Mother-and-child Postpartum Psychiatric Care: Factors Associated with Improvement in Maternal Mental Health NM-C Glangeaud-Freudenthal1,2, A-LSutter3,4, A-C Thieulin1,2, V Dagens-Lafont5, M-A Zimmermann6, A Debourg7, B Massari8, O Cazas9, R Cammas10, C Rainelli11, F Poinso12, M Maron13, S Nezelof14, R Claude15, A Chauvin16, P-Y Ancel1,2, B Khoshnood1,2 1 INSERM, UMRS 953, Epidemiological Research Unit on Perinatal Health and Women’s and Children's Health, F-94807, Villejuif, France 2 UMPC Univ Paris 06, UMR S 953, F-75005, Paris, France 3 Pôle de Universitaire Psychiatrie Adulte, Réseau de Psychiatrie Périnatale, CH Charles Perrens, Bordeaux 4 EA 4139 Université Victor Segalen Bordeaux 2, Bordeaux 5 Unité mère-bébé, CH Théophile Roussel, Montesson 6 CHU, Hôpital civil, Clinique Psychiatrique de Strasbourg 7 Unité mère-enfant, Hôpital du Vésinet 8 Unité mère-bébé, CHIC, Créteil 9 Unité mère-bébé, Hôpital Paul Brousse, Villejuif 10 Unité d'hospitalisation mère-bébé “LA POMME”, Paris 11 Unité mère-bébé, CH Esquirol, Limoges 12 Unité d'Hospitalisation Parents-enfants, Marseille 13 Unité Marcé, CHRU Lille 14 Service de psychiatrie infanto-juvénile, Besançon 15 Fondation Bon Sauveur, Alby 16 Unité mère-bébé La Frimousse, Brumath E-mail: [email protected]

Objective: This study assessed the underexplored factors associated with significant improvement in mothers’ mental health during postpartum inpatient psychiatric care.

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Method: This study analyzed clinical improvement in a prospective cohort of 869 women jointly admitted with their infant to 13 psychiatric Mother–Baby Units (MBUs) in France between 2001 and 2007. Predictive variables tested were: maternal mental illness (ICD-10), socio-demographic characteristics, mental illness and childhood abuse history, acute or chronic disorder, pregnancy and birth data, characteristics and mental health of the mother's partner, and MBU characteristics. Results: Two thirds of the women improved significantly by discharge. Admission for 25% was for a first acute episode very early after childbirth. Independent factors associated with marked improvement at discharge were bipolar or depressive disorder, a first acute episode or relapse of such an episode. Schizophrenia, a personality disorder, and poor social integration (as measured by occupational status) were all related to poor clinical outcomes. Conclusion: Most women improved significantly while under care in MBUs. Our results emphasize the importance of the type of disease but also its chronicity and the social integration when providing postpartum psychiatric care. Prenatal Anxiety, Behavioral and Cortisol Outcomes in the Child: Evidence from the ALSPAC Cohort V Glover1, K O’Donnell1, ED Barker, TG O’Connor2 1

IRDB, Imperial College London, Du Cane Road, London W12 ONN, UK University of Rochester Medical Center, Rochester Email: [email protected]

2

Objectives: Our first aim was to study the association between maternal anxiety during pregnancy and the long term behavioral outcomes for the child. The second aim was to study whether any associations were due to prenatal maternal mood, rather than confounding factors such as postnatal mood and maternal attitudes. The association with the diurnal cortisol pattern at adolescence was also studied. Methods: We used information from the Avon Longitudinal Study of Parents and Children (ALSPAC) population cohort, which has detailed questionnaire data, including maternal anxiety at 18 and 32 weeks of pregnancy using the Crown Crisp questionnaire, and child behavioral data from maternal report using the Strengths and Difficulties questionnaire from 4 to 13 years. Based on our previous studies we compared the outcome for the children of the 15% most anxious women at 32 weeks gestation with the rest. We also collected diurnal saliva from a subgroup of 1,000 of the children, aged 15 years, for cortisol assay. Results: Growth curve modeling showed that the substantially increased levels of conduct and emotional problems, and symptoms of ADHD, associated with prenatal anxiety, persisted until the children were 13 years. Levels of conduct problems and symptoms of ADHD were higher in boys, and emotional problems in girls. Although the growth patterns were altered by postnatal maternal mood and maternal attitudes, associations with prenatal anxiety persisted. Diurnal cortisol levels were higher in girls than boys. Multilevel modelling of the cortisol data showed that the children of the more anxious mothers at 32 weeks showed a small but significant decrease in the cortisol awakening response, which persisted after covarying postnatal anxiety. Conclusions: This study adds further support to the concept of the fetal programming of child behaviour, and that the environment in the womb can have long term effects on the neurodevelopment and

S24 hormonal functioning of the child. A major implication is that all mothers should be screened for emotional problems, including anxiety, during pregnancy, and appropriate interventions initiated. This should have benefit both for the mother herself and her future child. Postnatal Depression in Mothers And Fathers: Correlation with Psychosocial and Hormonal Variables MP Gonçalves1,2, F Teixeira1,2, A Monteiro1,2, EP Fonseca1,2, MEG Areias1,3 1

Department of Psychology of ISCS-N, Instituto Superior de Ciências da Saúde—Norte (CESPU) 2 UNIPSA, Unidade de Investigação em Psicologia e Saúde 3 CINEICC, Centro de Investigação do Núcleo de Estudos e Intervenção Cognitivo-Comportamental, Rio Tinto, Portugal Email: [email protected] Objectives: The aim of this study was to analyze the correlation of postnatal depression (PND) in mothers and fathers with psychosocial (such as social support and traits of personality), clinical and hormonal variables. Method: Two hundred women, seventy-five with lifetime history of MD and one hundred twenty-five with no prior episode of Depression who were attending obstetrics services in a central hospital in Oporto, Portugal, and one hundred fifty-three of their partners participated in a longitudinal study of their mental health. All subjects were interviewed with the semi-structured clinical interview SADS-L (lifetime version) at 37 weeks of pregnancy, 6th postnatal week and one year postpartum. In all these periods and also at 2 weeks of postpartum, mothers and fathers were also completed a translated version of a selfrating scale for depression, the Edinburgh Postnatal Depression Scale (EPDS) and a series of other questionnaires to measure different psychosocial variables. Hormonal variables (cortisol, estrogen, progesterone) were also measured. Results: PND in mothers associates strongly with previous history of MD (p<0,05), neuroticism (p<0,01), with low optimism (p<0,01), number of life events (p<0,05); at six weeks postnatally, associates with low practical social support (p<0,05) and progesterone levels (p<0,05). PND in fathers showed positive association with previous history of MD in the partner (p<0,01), neuroticism (p<0,01) and with low optimism (p<0,01). No association was found between PND and social support, number of life events and the level of cortisol. Conclusion: Some variables, such as the previous history of major depression, greatly increase the risk to get depressed after childbirth in the own or in the partner. Therefore, it is very important to introduce sensitive screenings during pregnancy and early postnatal period in order to make better monitoring of this pathology. Contributions of Developmental Psychopathology to the Field of Perinatal Mental Health S Goodman Emory University, Atlanta, GA Email: [email protected] In this plenary talk, I will introduce the key constructs and processes of developmental psychopathology and provide examples of how this

K.L. Wisner framework has been applied to the field of perinatal mental health research, with a particular focus on infants of perinatally depressed mothers. Developmental psychopathology is a relatively new field and is still emerging. It represents the contributions of principles of normal development to the understanding of the origins and course of individual patterns of adaptation and maladaptation and behavior change. A developmental psychopathology perspective invites one to consider: How can knowledge of normal development inform our efforts to elucidate the etiology of disorders, to assess and classify psychopathology, and to develop effective treatments? Key constructs that will be presented include risk and protective factors, competence, continuity and discontinuity, and transactional processes. The overall aim of the talk is to invite listeners to consider the advantages of this integrative perspective and to think creatively about the opportunities provided by this perspective in terms of the potential research and clinical contributions that may evolve from it. The Developmental Implications of Postpartum Depression and Integration with Clinical Intervention S Goodman1, S Dimidjian2 Emory University Atlanta, GA 2 University of Colorado, Boulder, Boulder, CO Email: [email protected] Objective: Postpartum depression (PPD) is a major public health problem that occurs in 1 of every 7 women in the first 3 months after birth. Untreated postpartum depression has significant implications for children’s cognitive and socio-emotional development. Left untreated, PPD can persist for months to years and lead to adverse consequences for both mother and child. A significant amount of research on the effects of postpartum and maternal depression on the developing infant lends itself to integration so that clinical interventions can be designed to take these findings into account. Method: A review, synthesis, and analysis of the literature on the developmental and psychopathological outcomes of infants exposed to postpartum and maternal depression was completed. A mediational or mechanistic model that explains the development of psychopathology in the child was developed to explain associations between maternal depression and the emergence of psychopathology in children. Additionally, a review of evidence based interventions for postpartum depression was completed. This work was summarized recently in reviews for the National Research Council Institute of Medicine (2009) and Clinical Obstetrics and Gynecology (2009). Results: The Integrative Model for the Transmission of Risk to Children of Depressed Mothers includes four mechanisms: heritability; innate dysfunctional neuroregulatory mechanisms; exposure to mother’s negative and/or maladaptive cognitions, behaviors, and affect; and exposure to stressful environments. Moderators to the transmission of pathology were also identified and include maternal, paternal, and child characteristics. Trends in clinical research on the efficacy of interventions for postpartum depression were identified. Conclusions regarding the transmission of risk and methods of intervention will be integrated, with a focus on recommendations for future research, treatment and public policy. Conclusion: An understanding of the complexities of the nature of the risk (having a mother with depression), mechanisms, moderators, and transactional processes provides a sober reminder of the challenges faced by designers of clinical interventions and clinical research. At

The Marcé International Society International Biennial General Scientific Meeting present, few clinical interventions targeting women with postpartum depression have attempted to integrate a transactional approach that includes not only the woman, but also her infant, parenting partner, and relationships between these individuals as a focus and potential beneficiaries of treatment. Perinatal Depression and Antidepressant Usage: Associations with 12-Month-old Infant Bayley Scores SH Goodman, DJ Newport, MH Rouse, CM Lusby, A Pennock, Z Stowe Emory University, USA Email: [email protected] Objective: The association between maternal depression and adverse child outcomes is well documented (National Research Council and Institute of Medicine, 2009). Although less often studied than postpartum depression, antenatal depression is of particular concern given possible interference with fetal development of stress regulatory systems, with potentially enduring effects on neurodevelopment. Of further concern are the effects on infants of antidepressant medications. The aim of this talk is to present data on a model of the independent and interacting roles of antenatal depression, stress, anxiety, and antidepressant exposures in the prediction of mental and motor development in infants at 12 months. Method: In a longitudinal study, women with histories of depression are studied during pregnancy and the postpartum and their infants are assessed at 12-months of age (current N=59; on target to be at least 80 by October 2010). Data include multiple measures of depression, stress, and anxiety administered at least three times during pregnancy and again in the first year postpartum, week-by-week prospective records of prenatal medication exposures, and the Bayley Scales at infant age 12 months. In all, 54% of the women were taking SSRI’s at least some time in pregnancy Results: Preliminary analyses of bivariate correlations revealed that Bayley scores are not significantly associated with prenatal depression symptom level, anxiety or stress (peak or adjusted Area under the Curve). More prenatal exposure to SSRI’s (adjusted AUC for weeks exposed) is associated with lower Bayley scores. Conclusion: Antenatal depression’s effects on infants’ cognitive abilities may be masked by antidepressant exposures. Further conclusions will be drawn from the results of planned analyses on the expanded data set, including examining moderated relationships, comparing treated/remitted with treated/not remitted women, testing the role of gestational timing of antidepressant exposure (particularly ‘on-off’ antidepressants and early exposure in the pregnancy relative to minimal or no exposure or exposure only late in pregnancy), and testing the role of postpartum depression. Clinically Identified Postpartum Depression in Asian American Mothers D Goyal1, J Shen2, E Wong2, E Wang2, L Palaniappan2 1

California State University, San Jose Palo Alto Medical Foundation Email: [email protected]

2

Objective: Postpartum depression (PPD) affects up to 20% of all postpartum mothers. Many U.S. studies have examined PPD, however

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the majority of the research has focused on non-Hispanic White populations. The diagnosis rates for PPD in Asian American women, particularly in Asian subgroups, remain relatively unknown. The purpose of this study was to identify the diagnosis rate of PPD in subgroups of Asian American mothers (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) compared to non-Hispanic White mothers in clinical setting. Methods: We examined electronic health records of 4,389 mothers aged 18–45 who had delivered a single live infant from December 2006—September 2009 at the Palo Alto Medical Foundation. All women are routinely screened for PPD at well-child visits at 1, 2, and 4 months using the Edinburgh Postnatal Depression Scale. Appropriate procedure and diagnosis codes were used to determine delivery date and PPD diagnosis respectively. Race/ethnic classification was determined by self-report and supplemented with given names and surnames using a validated algorithm when missing or unknown. Results: The cohort included non Hispanic White (n=2602), Asian Indian (n = 716), Chinese (n = 659), Filipino (n = 180), Japanese (n=69), Korean (n=93), and Vietnamese (n=70) mothers. Mean age of the group was 33 (4) years, ranging from 31 (4) years in Asian Indian) to 35 (4) years in Japanese. In age-adjusted logistic models the PPD diagnosis rate for Asian American mothers (3%) was significantly lower than the diagnosis rate in non-Hispanic White mothers (8%), (p<0.0001). Of the six Asian American subgroups, the ageadjusted PPD diagnosis rate for Asian Indian (2%), Chinese (3%), and Filipino (2%) mothers were significantly lower than non-Hispanic White mothers (Asian Indian, Chinese p<.0001, Filipino p=0.0128). Conclusions: In this insured population, PPD diagnosis rates are lower among Asian American women. It is unclear whether these results are due to underreporting, underdiagnosis, or lower incidence in this setting. Our results indicate important race/ethnic differences in PPD diagnosis rates across Asian American subgroups, and future studies on PPD should strive to disaggregate these disparate groups. Differences in Referral for Services and Mental Health Care Utilization in Postpartum Depression: A Comparison by Racial/ Ethnic Group and Language Of Care J A Greene, L E Fried, K Harney Cambridge Health Alliance, Cambridge MA, USA Email: [email protected] Objective: Postpartum depression (PPD) affects women from all cultures. Studies suggest the prevalence of PPD in ethnic minority groups is higher than in those with European ancestry. In a literature review, no studies to-date were found comparing differences in referral for mental health services for PPD between ethnic minorities compared to Caucasians. Cambridge Health Alliance (CHA) presents an important opportunity to study disparities in referral for, and utilization of, mental health services for PPD. The goal of this project is to determine if provider referrals for mental health care, differed by ethnic group and language of care. A second goal of the project is to determine if utilization of mental health services differs by ethnic group and language of care. Method: Data was collected from the CHA EMR based on all postpartum women, in 2009, who completed the PHQ-9. The provider referral and no-show rate was obtained from the EMR.

S26 Results: Preliminary data show that 5% of women in 2009 had scores greater than9, in the six weeks after delivery, indicating depressive symptoms. Analyses of 2009 data demonstrated disparities in PPD rates across race/ethnicity. Ten percent of African American women, 7% of women with “other” race/ethnicity, and 4% of White women had depressive symptoms. The “other” category includes Asian and American Indian women, and those who categorized themselves as “other.” PPD symptoms by language of care showed that 8% of women who chose Spanish, 7% Portuguese, 6% English, 6% Haitian Creole had PPD symptoms. Data regarding rates of completing of referral are pending Conclusion: This study will allow us to test our hypothesis about disparities in mental health care utilization for PPD. The results will be used to improve use of mental health services for women with postpartum depression. Possible interventions include providing patient education to reduce the stigma of accepting mental health treatment and providing in-home services. A Meta-analysis of Depression During Pregnancy and the Risk of Preterm Birth, Low Birth Weight, and Intrauterine Growth Restriction NK Grote1, JA Bridge2, A Gavin1, JL Melville1, S Iyengar3, WJ Katon1 University of Washington1, The Ohio State University2, University of Pittsburgh3 Email: [email protected] Objective: Maternal depressive symptoms during pregnancy have been reported in some, but not all, studies to be associated with an increased risk of preterm birth (PTB), low birth weight (LBW), and intrauterine growth restriction (IUGR). The aim of the meta-analysis was to estimate the risk of PTB, LBW, and IUGR associated with antenatal depression. Method: Search for English- and non-English language articles via MEDLINE, PsycINFO, CINAHL, and Social Work Abstracts (1980 to December 2009). We aimed to include prospective studies reporting data on antenatal depression and at least one adverse birth outcome: PTB(<37 weeks gestation), LBW(<2500 grams), and IUGR(<10th percentile for gestational age). From 862 reviewed studies, 29 US and non-US published studies met selection criteria. Information was extracted on study characteristics, antenatal depression measurement, and other biopsychosocial risk factors and reviewed twice to minimize error. Information was extracted on study characteristics, antenatal depression measurement, and other biopsychosocial risk factors and reviewed twice to minimize error. Results: In studies of PTB, LBW, and IUGR that used a categorical depression measure, pooled effect sizes were significantly larger (pooled RR [95% CI]:1.39[1.19–1.61],1.49[1.25–1.77],1.45[1.05– 2.02],respectively) compared with studies that used a continuous depression measure (1.03[1.00–1.06],1.04 [0.99–1.09],1.02[1.00– 1.04],respectively). The estimates of risk for categorical-defined antenatal depression and PTB and LBW remained significant when the trim-and-fill procedure was used to correct for publication bias. The risk of LBW associated with antenatal depression was significantly larger in developing countries(RR, 2.05;95%CI,1.43–2.93) compared to the US(RR,1.10;95%CI,1.01–1.21) or European social democracies(RR,1.16; 95% CI,0.92–1.47). Categorical-defined antenatal depression also tended to be associated with an increased risk of PTB among women of lower socioeconomic status in the US.

K.L. Wisner Conclusion: Women with depression during pregnancy are at increased risk for PTB and LBW, although the magnitude of the effect varies as a function of depression measurement, country location, and socioeconomic status within the US. Culturally Relevant Psychotherapy for Perinatal Depression NK Grote1, HA Swartz2, S Geibel2, E Frank2 1

University of Washington University of Pittsburgh Email: [email protected]

2

Objective: The overall aim of this randomized pilot study was to investigate the effects of using a culturally relevant model of care to treat antenatal depression and prevent postpartum depression in pregnant, socio-economically disadvantaged women receiving services in a public care Ob/Gyn clinic in a large Pittsburgh hospital. The model of care consisted of pre-treatment engagement session based on principles of motivational and ethnographic interviewing designed to foster treatment engagement and followed by brief Interpersonal Psychotherapy. IPT-B was enhanced to make it culturally relevant to women disadvantaged by race and/or poverty and to reduce racial and economic disparities in access to and engagement in mental health treatment. Methods: Using a randomized, controlled trial design, 53 pregnant, depressed African American and White women on low-incomes were randomly assigned to the engagement session and 8 weekly sessions of IPT-B(n=25) delivered on site in the Ob/Gyn clinic or to a referral to treatment-as-usual (TAU) at a behavioral health center also located on site in the clinic(n=28). Both groups received written psychoeducational materials about depression. Results: Of the 25 women in the engagement plus IPT-B condition, 24 out of 25 (96%) attended an initial treatment session, 21 out of 25 (84%) attended at least 4 treatment sessions and 17 out of 25(68%) received a full course of treatment (7–8 sessions). In the TAU condition, 10 out of 28(36%) attended an initial treatment session and 2 out of 28(7%) attended 4 treatment sessions or 7–8 treatment sessions. At the post-treatment and 6-month postpartum assessments, intent-to-treat analyses showed that women in the IPT-B group displayed a significant reduction in depressive and anxiety symptoms, in depression diagnoses, and an improvement in social functioning, compared to those in the TAU group. Conclusions: Findings suggest that a culturally relevant model of care (engagement session plus IPT-B) may not only ameliorate antenatal depression and improve social functioning, but also may reduce racial and economic disparities in access to and engagement in treatment for perinatal depression. Comedy Videos on Perinatal Mental Health Disorders, Specifically Designed for Men VJ Hanley Swansea University, School of Human and Health Sciences, Wales, Carmarthen, Wales, UK E-mail: [email protected] ‘What soap is to the body, laughter is to the soul’ Jewish Proverb

The Marcé International Society International Biennial General Scientific Meeting Objective: There is little information for men on the impact of maternal mental health disorders on themselves and their family. Often these needs and the importance of men’s involvement are marginalised. One study explored the quality and content of international videos on postnatal depression. From the 17 viewed only one video made specific references to men and dedicated time for their attitudes and views on the subject. The men reacted with threads humour complaining, with a wry grins that the ‘Worse thing was helplessness, everything I tried to say or do was wrong’. These glimpses of humour as a means of communication facilitated the production of 3 comic videos. Method: The script was research based. It involved script writers, director, cameraman and 3 professional comic actors. The scripts took 3 weekends to write and a whole day to shoot and edit individually. Results: The films are funny and intended to heighten awareness of the difficulties encountered by men as fathers and as partners of depressed women. One film addresses a father whose wife has PND, one highlights the importance of father /infant attachment and one father complains that he is suffering from PND. Overall the films have been well received by ‘Fathers’ Groups’, students and colleagues Conclusion: As ‘trigger’ videos they provide a valuable resource and are useful teaching aids which facilitate discussion and improve knowledge. The videos are in the process of being evaluated for content and validity to generate further videos and expand the topic area. Longitudinal Follow Up of Postpartum Blues and Depression: Long Term Morbidity in Women and Children? CA Henshaw1, DM Foreman2, JL Cox3 1

Liverpool Women’s Hospital & Staffordshire University, UK Royal Holloway, University of London, Institute of Psychiatry, Noble’s Hospital, Isle of Man Government, UK 3 Keele University, UK Email: [email protected] 2

Objective: Severe postpartum blues are a risk factor for PPD in the first 6 months after delivery, suggesting they may be a marker for affective vulnerability in some women. It is not known if this vulnerability increases over time and if so, whether it is specific to postpartum depression, to depression unrelated to childbearing or whether it confers long term morbidity on the child. Method: 103 women with severe blues and controls (with no blues) who participated in the original study were contacted. Those who consented were interviewed using the Structured Clinical Interview for DSM IV (SCID) and completed the Premenstrual Assessment Form, the Work, Leisure & Family Life Questionnaire (WLFQ), Short Form 36 Health Survey Questionnaire (SF36) and the Strengths and Difficulties Questionnaire (SDQ relating to their first-born child). We present an analysis of the relationship between postpartum blues, subsequent caseness, child psychopathology measured by the SDQ, and maternal impairment as measured by the WLFLQ. These variables were modelled as a directed acyclic graph (DAG): blues was considered prior to SCID caseness, and caseness considered prior to both SDQ and WLFLQ totals. Modelling was by the specialist graphical modelling package MIM version 3.2.0.7

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Results: 146 (71%) of the original sample were interviewed (mean 13.9 years after birth of their first child). 84% of those interviewed met SCID caseness criteria at follow-up interview. A single best model was found: blues predicted caseness (p=.0003); caseness predicted SDQ scores only (p=.017); SDQ and WLFLQ were associated (p=.001); no other edges were significant. Conclusion: The high level of caseness suggests that childbirth itself increases vulnerability to long-term mental health problems, with blues an early marker of high vulnerability. However, impairment resulting from caseness appears to be mediated by the mental health of the child. Experiences of Recovering from Postpartum Psychosis: A Service User Led Research Project. J Heron1; N Gilbert; C Dolman; S Shah2; S Dearden; I Beare; N Muckelroy; I Jones3, and Jonathan Ives 2 1 Perinatal Research Programme, Birmingham & Solihull Mental Health Foundation Trust; UK 2 Dept of Primary Care, University of Birmingham, UK 3 Dept of Psychological Medicine, Cardiff University, Wales. Email: [email protected]

Introduction: Every year, over 1300 women in the UK suffer a psychotic episode following childbirth. Known as ‘puerperal psychosis’ or ‘postpartum psychosis’, these episodes onset suddenly in the days after having a baby and can be a frightening experience for women, their partners, friends and family. Despite good clinical recovery, women report that coming to terms with the experience is a lengthy process. Pilot work found that recovering women search the internet for information, but find it limited, misleading or sensationalist. Objective: To develop web-based information on recovery from PP and to identify aspects of management of importance to service users. A secondary objective was to explore the implications of user led research for service users researchers and for the research process. Methods: Shared experience may improve the quality of in-depth qualitative data through increased empathy and trust, and by ensuring that the research is directed towards areas of importance to service users. Five women from ‘Action on Postpartum Psychosis’ who had expressed an interest in learning about research, took part in a workshop in qualitative research methodology. On day one, training in theory and interviewing skills was provided. On day two, a study was designed and topic guide questions determined. Service user researchers (SURs) then conducted in-depth interviews with each other about their experiences of postpartum psychosis and recovery. Interviews were audiorecorded and transcribed following the workshop by an SUR with previous experience of transcription. Results: Analysis was conducted following the workshop by a team of two SURs, a perinatal researcher and two qualitative researchers using a grounded analytic induction approach. Thematic validation was carried out by the other SURs. Web based information was developed based on qualitative findings by the study team. Conclusion: Project outputs include a YouTube film, academic paper, and web-based leaflets to address the need for accessible information.

S28 Satisfaction with Perinatal Care: A Comparison of Mother and Baby Units and Other Models of Postpartum Psychiatric Care J Heron1, L Lewis2, G Berrisford1, Ian Jones3 1 Perinatal Research Programme, Birmingham & Solihull Mental Health Foundation Trust; UK 2 Medical School, University of Birmingham, UK 3 Dept of Psychological Medicine, Cardiff University, Wales. Email: [email protected]

Introduction: Perinatal psychiatric care varies widely throughout the UK. In some areas there are dedicated Mother & Baby Units (MBUs), whilst in others, mothers are cared for in general psychiatric units without their baby. MBU care is generally regarded as the highest standard of care, however, formal evidence is lacking to demonstrate this. Numerous studies report outcomes for women admitted to MBU, but appropriate comparison samples have proved practically difficult to ascertain, and randomisation would be unfeasible. Objective: The aim of this study is to compare outcome and satisfaction with care following severe postpartum psychiatric illness, in women admitted to Mother and Baby Units and in women admitted to general psychiatric hospitals. Methods: Women with a history of severe postpartum episodes were recruited from a service user organisation: Action on Puerperal Psychosis. Women were sent a self report questionnaire with their annual newsletter assessing their satisfaction with care received, time to recovery, and bonding problems experienced. In addition, free text items were used to elicit women’s views on postnatal psychiatric care. Results: 193 women who had experienced at least one episode of puerperal psychosis returned completed questionnaires. Qualitative and quantitative data will be presented comparing women admitted to Mother and Baby Units and women with other models of postpartum care. Conclusion: Whilst there are important limitations of recruiting women from service user organisations, this study provides a first piece of evidence comparing co-joined admission with other models of postpartum care, in women who have experienced severe postnatal mental illness. The importance of best practice maternal mental health care in this group cannot be overstated. The stakes are high if not managed appropriately, both in terms of maternal outcome (including risk of suicide) and child outcome (including rare and tragic cases of infanticide). Childhood Risks for PPD and Impairments in Caregiving Among Teenage Mothers AE Hipwell1, S Stepp1, and K Keenan2 1

University of Pittsburgh University of Chicago, USA Email: [email protected] 2

Objective: There is a severe lack of information about the timing and development of childhood-onset depressive disorders and psychosocial stress that increase risk for postpartum depression (PPD) and parenting difficulties. Such information is critical for the development of targeted prevention programs for high-risk groups. Teenage mothers are one such high-risk group that have been largely absent from studies of PPD.

K.L. Wisner Method: Thirty-five teenage mothers (11–16 years) have been identified thus far from the ongoing Pittsburgh Girls Study (N=2,451); a prospective study of the development of psychopathology that began in 2000 when the girls were aged 5–8 years. Teenage mothers visited the research laboratory at 4 and 12 months when interviews to assess PPD, emotion regulation, parenting attitudes were administered and the quality of mother–infant interaction was filmed. Results: Preliminary analyses utilized 7 annual waves of PGS data on depression severity to predict PPD. Latent variable growth curve modeling showed that the rate of increase in depression severity across childhood predicted PPD severity at 4 months (β=.44, p<.05). In addition, high levels of empathic concern (β=.48, p<.05) and early parenting experiences (β=.42, p<.05) in wave 4 predicted PPD severity. Generalized linear models showed that reliable observations of low maternal empathic concern were predicted by depression severity (B=.04, Wald χ2 =7.27, p<.01), guilt-proneness (B=.64, Wald χ2 =4.79, p<.05), low parental involvement (B=.17, Wald χ2 =5.59, p<.02), and harsh parental punishment (B=.08, Wald χ2 =3.93, p<.05) during childhood. Conclusion: There are high levels of continuity between childhoodonset depressive disorders and PPD. Important information can already be gained about risks for PPD and parenting difficulties in childhood. Postpartum Support International (PSI) Position Paper on Infanticide J Honikman Postpartum Support International, USA Email: [email protected] Objective: Worldwide infanticide and infant mortality rates are grossly underestimated. Systematic data on the prevalence of infant murder is rare. Sentences for women who commit infanticide vary remarkably because insanity laws differ from state to state and lack input from the psychiatric community. To date, effective strategies for identification, intervention and prevention are glaringly absent from the continuum of antenatal and postnatal care and services. We continue to miss warning signs of tragedy in our most available populations in health care. Postpartum Support International (PSI) is a nonprofit organization established in 1987. It believes that further research and greater accountability for these tragedies will increase public awareness and potential for prevention. Method: Following the 2004 Postpartum Support International (PSI) Annual Conference a Position Paper on infanticide associated with postpartum mental illness was written and published on its website. It outlines four distinct problem areas and presents the organization’s advocacy responses. These problems are: 1) DSM4 diagnostic criteria, 2) American legislation, 3) mental illness and the law, and 4) early identification, treatment and prevention. PSI statement reflects the role that public recognition, awareness, education and advocacy play in social change. Results: Defendants with mental illness deserve a defense based on scientific fact. Diagnostic guidelines will enhance shared knowledge between psychiatry and the law to focus on prevention and treatment in lieu of punishment. Contemporary neuroscience must be applied to archaic insanity laws by reconsideration of contemporary American legislation. Scientific and biologically based knowledge must be conveyed to the jury so that their decisions can be made on informed facts.

The Marcé International Society International Biennial General Scientific Meeting Conclusion: Postpartum psychiatric illness is a major public health problem that is predictable, identifiable, treatable and therefore, preventable. Research methodology must be designed to substantiate a cluster of identifiable symptoms for diagnosis to pave the way for treatment strategies and rehabilitation. Antepartum and postpartum screening are optimum times to assess risk for puerperal illness and associated infant morbidity and mortality. Postpartum Support International’s (PSI) Pen Pal Network for Incarcerated Moms J Honikman for C Reilly Postpartum Support International, USA Email: [email protected] Objective: PSI’s Pen Pal Network for Incarcerated Moms, is a unique support group that operates entirely through the mail to serve imprisoned women, most of whom committed infanticide as a result of postpartum psychosis. The pen pal network serves as a vital source of support for incarcerated women who believe they’ve suffered from postpartum mental illness. The majority of members believe they experienced postpartum psychosis and many are serving long sentences for committing infanticide. The network aims to connect women who have experienced the worst consequences of postpartum mental illness, showing them that they are not alone and not to blame. Method: The Pen Pal Network includes 36 women who live in jails, prisons and state hospitals across the country. They communicate entirely through the mail. Some women correspond directly with one another. The network serves only to connect its members. I personally correspond with all of the women and send out regular newsletters to the entire group, providing members with each other’s news and personal messages. Many prisons don’t allow them to send and receive mail from other inmates; the newsletters help those members to connect. Results: Friendship, non-judgment, information and a better understanding of their experience is a path for healing and self-forgiveness. Many women in the group believed they were alone in their experience. Even after their arrests, some had never heard of postpartum psychosis. Learning that others have had nearly identical experiences reinforces the notion that our members are not to blame for what happened to them and that their tragedies were the result of a diagnosable illness. Conclusion: The network is a place for activism, a place to feel like they’re making a difference. Many members take comfort that their tragedies might serve to raise awareness or help others. They take pride in welcoming and supporting new members who are struggling to make sense of their experiences. They also use the network to share ideas about how they can help to raise awareness about postpartum psychosis from inside prison. Mood changes at the Perinatal Mental Health Project, Cape Town S Honikman1, S Field1, Z Kafaar

2

1

University of Cape Town University of Stellenbosch, Cape Town, South Africa Email: [email protected]

2

Objective: In South Africa, perinatal mental health disorders appear to be at least three times the levels found in developed country

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settings. The Perinatal Mental Health Project (PMHP) has developed a model for providing integrated mental health care within the obstetric health facilities. All women during pregnancy were screened by nurses using a risk factor assessment and the Edinburgh Depression Scale (EDS). Based on this screening, all women who met the cut-off of >12 on EDS or >2 risk factors, were offered on-site counseling by one of a team of trained volunteers. This study aimed to evaluate antenatal versus postnatal EDS scores in women screened by the PMHP. Method: A sample of 157 women screened by the PMHP were contacted telephonically between 4 and 16 weeks postpartum. A survey was conducted using a semi-structured questionnaire that included the EDS. Scores for the EDS were compared antenatally and postnatally for different categories of client service-use and correlations sought with demographic and risk factors. Results: Women who qualified for counseling were categorized into those who attended counseling and those who did not. Postnatally, the scores for both client groups were below the cut-off. There was no significant difference between the two groups with respect to income, education, number of existing risk factors or number of intervening life events. However, those who attended had a higher mean antenatal EDS score than those who did not (15.63 vs.12.46, p<0.05) and were more likely (OR 1.82, CI 1.24–2.68) to have no birth companion (chisquare=4.33, p<0.05). The mean number of sessions per woman receiving counseling was 1.8. The mean EDS scores of those who attended, dropped significantly from above cut-off antenatally to below cut-off postnatally (15.63 vs .10.53, p<0.05). Conclusion: At the PMHP, those women who qualify for counseling and do not take up this service seem to be self-selecting appropriately. The brief antenatal counseling intervention offered improves postnatal mood despite women experiencing labor without birth companions. Antenatal Domestic Violence, Psychiatric Morbidity and Subsequent Child Behaviour L Howard1, C Flach1, J Heron2, J Evans2, D Sharp2, G Feder2 and the ALSPAC team 1

Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK 2 University of Bristol, UK Email: [email protected] Objective: To investigate the long term impact of antenatal domestic violence on maternal psychiatric morbidity and child behaviour problems. Method: The Avon Longitudinal Study of Parents and Children, a birth cohort of 13,617 children and mother dyads from Avon followed to 42 months of age. Postal questionnaires were used to gather information on experiences of domestic violence and depression at 18 weeks gestation and at 2, 8, 21 and 33 months since the birth along with other maternal, paternal and child characteristics. Child behaviour problems were assessed at 42 months using the Revised Rutter Questionnaire. Results: Antenatal domestic violence was found to be associated with antenatal and postnatal depression after adjustment for potential confounders. Antenatal domestic violence was highly correlated with domestic violence after the birth. Antenatal domestic violence predicted future behaviour problems at 42 months in the child before adjustment for possible confounding and mediating factors, however

S30 this association was removed after adjustment for antenatal depression, postnatal depression or domestic violence after the birth. Conclusions: Antenatal domestic violence is associated with both antenatal and postnatal depression. Domestic violence during pregnancy is also associated with postnatal violence and both are associated with subsequent behavioural problems in the child at 42 months. This is at least partly mediated by maternal depression, both during pregnancy and in the postnatal period. The RESPOND Trial: A Randomized Evaluation of Antidepressants and Support for Women with Postnatal Depression L Howard1, CA Chew-Graham2, A Tylee1, G Lewis3, I Anderson2, K Abel2, KM Turner3, SP Hollinghurst3, D Tallon3, A McCarthy3, TJ Peters3, D Sharp3 1

Institute of Psychiatry, King’s College London University of Manchester 3 University of Bristol Email: [email protected] 2

Objectives: 1) To evaluate the effectiveness at 4 weeks of antidepressant therapy for mothers with postnatal depression compared with general supportive care 2) To compare the outcome at 18 weeks of those randomised to antidepressant therapy versus those randomised to listening visits as the first intervention. 3) To assess the acceptability of the interventions to women and health professionals. Method: Women who fulfilled ICD-10 criteria for major depression in the first six months postnatal were recruited from primary care. Women were randomised to receive an antidepressant or non-directive counselling (listening visits) from a specially trained research health visitor. The primary outcome, at 4 weeks and 18 weeks postrandomisation, was the proportion of women improved on the Edinburgh Postnatal Depression Scale (EPDS) i.e. scoring <13. Secondary outcomes were changes in mean EPDS, quality of life, maternal adjustment and attitudes and marital satisfaction. A nested qualitative study investigated health professionals’ and women’s views of the interventions. Results: At 4 weeks, women (n=254) randomised to antidepressants were more likely to have improved compared with women randomised to listening visits which started after the 4 week follow-up, i.e. after receiving general supportive care (45% v 20%, OR 3.4 (95% CI 1.8, 6.5) p<0.001). At 18 weeks the proportion of women improving was 11% greater in the antidepressant group, but logistic regression showed no clear benefit for either group (62% v 51%, OR 1.5 (95% CI 0.8,2.6) p=0.19). Many women received both interventions by 18 weeks. Qualitative interviews with women revealed a preference for listening visits but an acceptance that antidepressants might in some instances be necessary. Conclusions: At 4 weeks, antidepressants are significantly superior to general supportive care, so early treatment with antidepressants leads to clinical benefit for women with postnatal depression.. The lack of evidence for differences at 18 weeks may be due to a combination of reduced power and the considerable degree of switching across the two interventions by the later follow-up. Women found both antidepressants and listening visits effective depending on their circumstances and preferences.

K.L. Wisner Partner Abuse in Perinatal Women Involved in Psychiatric Treatment M Howard, S Creech, N Capezza, C Fiorito, T Pearlstein, C Zlotnick Brown University/Women & Infants’ Hospital, Providence, Rhode Island Email: [email protected] Objective:Women during their peak childbearing years are especially vulnerable to experiences of partner abuse (PA). Although PA at any time during a woman’s life is devastating, women who experience PA during the perinatal period endure risk to not only their own health but also to that of their fetus/offspring. Since PA is associated with psychiatric morbidity, perinatal women with PA are likely to present for treatment with complex clinical profiles. To date, there has been virtually no research on the treatment needs of perinatal women with PA. Method:A retrospective chart review of 229 female patients who were admitted to a mother–baby perinatal psychiatric partial hospital between 2007 and 2009 was conducted. Data on current PA (i.e., verbal threats of harm, sexual or physical abuse), psychiatric morbidity, current level of depressive symptoms at intake and discharge, as well as type of program discharge (planned or unplanned) was collected. Results:Twenty-six percent of the total sample were pregnant and the remaining were postpartum. Eighteen percent reported current partner abuse; the majority reported verbal threats of harm. Most, of both groups, met criteria for a major depressive disorder (73%) at intake. Women who were victims of current PA, compared to women without abuse were more likely to have a past psychiatric diagnosis, (chisquare = 7.52; p = .023), past suicide attempt (chi-square = 6.49; p = .039), and past self-injurious behavior, (chi-square = 16.71; p= .010). There were no differences on severity of depressive symptoms at either intake or discharge. Women with current PA were more likely than non-victims to have an unplanned discharge (chisquare=9.16, p=.057). Conclusion:This retrospective chart review revealed that of a sample of perinatal women admitted for psychiatric partial hospitalization, nearly one in six reported current PA, predominantly in the form of verbal threats of harm. These women, compared to their non-victim counterparts appear to have more lifetime psychiatric morbidity and appear to be at risk for terminating treatment prematurely. Screening and specialized treatment approaches with this population will be discussed. Ten Years Later: Changes in Clinical and Demographic Profile of Perinatal Women Seeking Day Hospital Treatment M Howard, C Battle, S Creech, C Fiorito, T Pearlstein, C Zlotnick Brown University/Women & Infants’ Hospital, Providence, Rhode Island Email: [email protected] Objective: The Women & Infants Postpartum Depression Day Hospital is a specialized mother–baby partial hospital program that has been providing psychiatric and psychosocial treatment to perinatal women for the past ten years. Clinical observation over the course of the past decade has been that our patient population has evolved both clinically and demographically.

The Marcé International Society International Biennial General Scientific Meeting Method: This presentation will combine clinical observations from 10 years of administering a mother–baby day hospital with results of two independent retrospective chart reviews that investigated clinical and demographic characteristics of the patient population. Specifically a chart review of 398 patients who were admitted from 2000 through 2002 (Battle et al, 2006) was compared with a second more recent retrospective review of 231 patients who were admitted from 2007 through 2009. Results: While the proportion of pregnant to postpartum women remain unchanged, diagnostic and ethnic diversity differences between the two samples emerged along with changes in incidence of prior psychiatric treatment, reported childhood sexual abuse and suicidal ideation. Conclusion: Chart review data supported clinical observation of changing demographic and clinical patterns of women admitted to a specialized perinatal mother–baby psychiatric partial hospital program. Similarities and differences between the two samples and potential factors influencing these will be explored. Discussion will also focus on implications for outreach, screening, targeted treatment strategies and future research and legislative initiatives. Women Who Present with Mental Health Problems During Pregnancy: How Can Midwives be Helped to Manage Their Care? PM Jarrett City University, London, UK Email: [email protected] Objective: Mental health problems affect about 1 in 10 pregnant women and can have serious adverse effects on the mother, the fetus and neonate. Despite this, mental health problems in pregnancy are poorly understood and women often remain undiagnosed. Previous research has focused on the adverse consequences of mental health problems with little research focusing on women’s’ subjective experience and how their care might be improved. Method: The study was conducted in two phases, using qualitative methods. Phase 1 used internet generated data to explore womens’ experience of mental distress during pregnancy and the factors that influence disclosure of their symptoms. Phase 2 used focus group discussions to explore midwives’ perceptions and experiences of caring for women with mental health problems. Data were analysed using thematic analysis and the findings from phase one were integrated and analysed with data collected from phase two. Results: Analysis of internet postings from women indicated a lack of understanding of the symptoms they were experiencing and a reluctance to disclose mental distress to midwives. When women did receive help they reported a lack of confidence in the responses and treatment offered by health professionals. Midwives reported ways in which they were able to support pregnant women, for example through modification of antenatal appointments; however lack of training and lack of resources were identified as barriers to providing good care. Midwives also felt that women’s failure to disclose was a factor in preventing delivery of care. Conclusion: Parallels were identified in the experience of pregnant women with mental health problems with those of midwives providing care a) pregnant women with mental health problems often failed to disclose the symptoms they were experiencing b) health professionals require specialist training in order to care for pregnant women with mental health problems. Strategies were identified which

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could be implemented into maternity services to improve care, for example, providing information to pregnant women and providing midwives with training in counseling and listening skills. A Genome Wide Association Study of Vulnerability to Puerperal Triggering In Bipolar Women 1

I Jones, E Green1, 2E Robertson, 3J Heron, 1N Craddock

1

MRC Centre in Neuropsychiatric Genetics and Genomics, Cardiff University, UK 2 Department of Psychiatry, University of Rochester, Rochester NY 3 Birmingham University and Birmingham and Sollihul Mental Health NHS Trust Email: [email protected] Objective: It has long been recognised that childbirth is a time of considerable risk for women with bipolar disorder, with severe postpartum episodes (postpartum / puerperal psychosis) occurring following approximately 25% of deliveries. This represents a many hundred-fold increase compared with the general population rate of around 1 in 1000, and highlights the importance of considering issues regarding pregnancy and childbirth in women with bipolar disorder. Studies have confirmed that women with bipolar disorder are at very high risk of episodes of severe postpartum affective disorder, and that familial (genetic) factors influence vulnerability to the puerperal trigger. Method: Based on these findings, we have conducted molecular genetic studies using both candidate gene and linkage approaches that have previously implicated regions of chromosomes 16 and 8 as harbouring genetic variants that may predispose women to bipolar affective puerperal psychosis. The Wellcome Trust Case Control Consortium (WTCCC) study is a genome wide association study of seven complex genetic diseases that has genotyped 14000 cases and 3000 controls at 500,000 genetic variants. Over 1800 individuals with bipolar disorder have been included in this study and this includes 186 women who have suffered an episode of puerperal psychosis. Results: Analysis of the women with puerperal psychosis compared to controls reveals a number of positive associations for genes involved in vascular endothelial growth factor receptor activity. Conclusion: It is hoped that this line of research will uncover the nature of the puerperal trigger, allow a more individualised estimation of risk for women with bipolar disorder, and provide further information relating to the aetiology of mood disorders in both the puerperium and at other times. Postpartum Psychosis—Known Knowns, Known Unknowns and Unknown Unknowns I Jones1, A DiFloria1, E Robertson2, J Heron3, N Craddock1 1

MRC Centre in Neuropsychiatric Genetics and Genomics, Cardiff University, UK 2 Department of Psychiatry, University of Rochester, Rochester NY 3 Birmingham University and Birmingham and Sollihul Mental Health NHS Trust Email: [email protected] Objective: Despite the diagnoses of postpartum / postnatal depression and postpartum / puerperal psychosis (PP) being written out of both

S32 DSM and ICD classification systems, the terms have refused to go away and remain popular labels with both women who suffer with mood disorders following childbirth and the professionals who are involved in their care. Both classification systems treat postpartum mood episodes in the same way as episodes not related to childbirth, although DSMIV does allow a postpartum onset specifier to be rated. For postpartum psychosis in particular, there are strong cases that can be made for both its recognition as a separate diagnostic category and also for its continuing classification as an episode of bipolar disorder. Method: In this talk I will examine the relationship between episodes of postpartum psychosis and bipolar disorder employing data from our large clinical and genetic studies of mood disorders. In a sample of 1170 women with BP spectrum disorders we were able to compare the clinical characteristics of 189 women who experienced a severe postpartum episode (postpartum psychosis) with 311 women who experienced a less severe mood episode in pregnancy or the postpartum and 226 parous women who did not experience episodes of mood disorder in relation to childbirth. Results: Preliminary analysis has revealed some important distinctions between the groups with, for example, neuroticism scores predicting widely defined perinatal mood episodes in BP women but, interestingly, not episodes of PP. Conclusion: The available data supports a very close relationship between BP disorder and severe mood episodes in the postpartum. If a separate nosological entity of postpartum psychosis is not indicated, then the continued recognition of the postpartum onset for bipolar episodes is vital to retain in the next iterations of the classification systems. Preventing Peripartal Psychosomatic Symptoms in Pregnant Women—Is There An Impact on Pregnancy and Birth Complications or Neonatal Outcomes? J Junge-Hoffmeister, A Bittner, J Richter, U Schultz, P Joraschky, K Weidner Department of Psychotherapy and Psychosomatic Medicine, University Hospital Dresden, Germany Email: [email protected] Objective: Stress, anxiety and depression during pregnancy may have negative influences on the fetus, the course of pregnancy, birth and neonatal outcomes. Given such a transgenerational importance they should serve as targets for preventive interventions concerning mother and child. Consequently the aim of our intervention study was to investigate the preventive impact of a newly developed cognitivebehavioral group program for pregnant women with subclinically elevated levels of anxiety, depression and/or stress. Outcomes of interest were maternal psychosomatic symptoms, pregnancy and obstetric complication as well as infant variables (e.g., health, temperament, mother–child bonding). Methods: Within a longitudinal RCT 757 women (1st trimester) were screened regarding stress (PDQ), anxiety (STAI), and depression (BDI-V). Women with moderately increased levels were invited to take part in our intervention study and randomized to a treatment (TG N=80) and a control condition (CG N=84). Follow ups took part in the 3rd trimester and 3 month postpartum. A range of psychopathological variables of the mother, course of pregnancy, birth and several child related variables (e.g., neonatal condition) were assessed.

K.L. Wisner Results: Currently data collections are finalized. At the conference results concerning the nature and amount of pregnancy and obstetric complications as well as neonatal outcomes will be presented. As independent variables the psychopathological status of the women and participation in the preventive intervention will be used. Subgroup analyses will especially focus on those women who had a benefit through the participation in the program with regard to psychological symptoms. Conclusions: Preliminary analyses suggest that effects of such an intervention depend on the psychopathological status of the women as well as issues of screening and intervention planning. If those are appropriately considered preventive interventions like ours may be a promising approach to reduce burden for mother and child during the perinatal period. Diurnal Pattern of Cortisol and Amylase Output in Postnatal Depression M Kammerer1,2,, A Taylor3, N Khalife1, K O’Donnell1, M Marks2 and V Glover1 1

Imperial College London King’s College London Email: [email protected]

2

Objective: This study investigated the diurnal output of saliva cortisol and saliva amylase in women with symptoms of depression postnatally. Method: Twenty one depressed and 30 non depressed women at 7.5 weeks postpartum, and 21 non perinatal controls, collected saliva at waking, 30 minutes, and three and twelve hours post waking. Results: Women who were not depressed postnatally showed a pattern of cortisol secretion over the day similar to non perinatal controls. There was a significant difference in diurnal pattern between postnatally depressed and postnatally non depressed women, due to a difference in the first two time points (waking and +30 mins): compared to the other two groups who each had a significant increase in cortisol levels from waking to +30 minutes, the depressed women had significantly higher cortisol levels at waking and no increase at +30 minutes. Analyses of amylase are underway and will be presented. Conclusion: The lack of a morning rise in the depressed women is similar to that reported for Post-traumatic Stress Disorder and chronic fatigue syndrome and may reflect a response, in vulnerable women, to the marked cortisol withdrawal that occurs after delivery. Alternatively it could be a trait marker for women at risk of developing postnatal depression. Rationale for and Treatment of Perinatal Women with Transcranial Magnetic Stimulation DR Kim, CN Epperson, JP O’Reardon University of Pennsylvania, Department of Psychiatry Email: [email protected] Objective: Despite the data that major depressive disorder (MDD) is common during pregnancy and that pregnant women prefer nonmedication treatment options, there is a paucity of research examining

The Marcé International Society International Biennial General Scientific Meeting alternative treatments for this special population. We present the results of an open label pilot study examining treatment with transcranial magnetic stimulation (TMS) in pregnant women with MDD. Methods: 10 women with MDD in the 2nd or 3rd trimester of pregnancy were treated with 20 sessions of 1 Hz TMS at 100% of motor threshold to the right prefrontal dorsolateral cortex. The total study dose was 6000 pulses. Antenatal monitoring was performed during treatment sessions 1, 10 and 20. Results: 7/10 (70%) subjects responded (≥ 50% in Hamilton Depression Rating Scale (HDRS-17) scores). No adverse pregnancy or fetal outcomes were observed. All infants were admitted to the well baby nursery and were discharged with the mother. Mild headache was the only common adverse event and was reported by 4/10 (40%) subjects. Conclusion: TMS appears to be a promising treatment option for pregnant women who do not wish to take antidepressant medications. Screening for Postpartum Depression Among Low-Income Mothers Using An Interactive Voice Response System HG Kim1; DB Cutts2; VR Lupo3; J Geppert, MPH2; T Quan2; Y Bracha4 Hennepin County Medical Center (HCMC) 1Dept of Psychiatry, 2Dept of Pediatrics, 3 Dept of Ob/Gyn, and 4Center for Urban Health, Minneapolis, MN Email: [email protected] Objective: This study tested the feasibility of using an interactive voice response (IVR) phone system to screen for postpartum depression among low income English- and Spanish-speaking mothers. Methods: Newly delivered mothers were consented to call an automated phone system at least 7 days postpartum and complete an IVR version of the Edinburgh Postnatal Depression Screen (EPDS). During the phone screen, subjects were branched to different closing narratives based on their depression scores which were later posted to a password protected website. Logistic regression was used to assess relationships between clinical and psychosocial factors, IVR participation, and depression scores. Results: Among 838 ethnically diverse, low income postpartum mothers, 324 (39%) called into the automated phone screening system. Those who called were more likely to have at least a high school education (57.6% vs. 45.4%, p=0.001), be employed (30.7% vs. 23.0%, p=0.01) and have food secure households (82.2% vs. 75.4% , p=0.02) There was no statistically significant difference between callers and non-callers in terms of marital status, race/ ethnicity, parity, or gestational age at delivery. Using an EPDS cutoff of >10, postpartum depression symptoms were present in 17.0% (n=55) and were associated with temporary housing (AOR 2.35, 95% CI 1.30, 4.26 p=0.005), being single (AOR 2.41, 95% CI 1.29, 4.50, p=0.006), first time mother status (AOR 2.43, 95% CI 1.34, 4.40 p=0.003), history of anxiety (AOR 2.79, 95% CI 1.69, 6.67, p=0.021), and history of self-harm (AOR 2.66, 95% CI, 1.01, 6.99, p=0.047). Conclusions: Automated phone screening for postpartum depression is feasible among disadvantaged mothers. Be removing the need for a clinic visit, accommodating low literacy patients, and offering flexibility and privacy, an IVR option for postpartum depression

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screening could supplement office-based and home visit-based screening protocols. Understanding Postpartum Depression: A Qualitative Look at Hispanic Mothers S Lara-Cinisomo1, K Wisner2, R Burns3, D Chavez-Gnecco2 1

UNC Charlotte University of Pittsburgh 3 RAND Email: [email protected] 2

Specific Aims. Postpartum depression is a significant mental health condition that may lead to serious health and mental health outcomes for mothers and their children. There has been a growth in the number of studies examining treatment options for PPD including the use of antidepressants and psychotherapy. However, most of the studies have focused primarily on white women, which means we do not know if Hispanic women prefer antidepressants, individual psychotherapy or interventions offered within the context of their community or homes. It is vital that we first determine these preferences if we are to effectively treat Hispanic mothers appropriately. At address this gap, we conducted a pilot study with Hispanic mothers to identify barriers and facilitators to treating postpartum depression and to establish guidelines for implementing their preferred mental health treatments. Methods. Focus group interviews were conducted with 21 prenatal and postpartum Hispanic women. Participants were recruited at approved medical and community settings. A standardized interview protocol available in Spanish and English was used to guide the interviews. Five areas of inquiry guided the interviews: Defining depression and postpartum depression, Treatment Preferences, Barriers to Treatment, and Suggestions for treatment delivery. Demographic data was collected using a survey after each focus group interview. Qualitative data analyses were conducted with the focus group interview as the unit of analysis. Principal Findings. Our analyses revealed three primary symptoms of depression as defined by participants as follows: crying, irritability and withdrawal. In coping with these symptoms, we found that three primary approaches were reported, such as seeking social support from family, friends, using distraction (i.e., focus on a task) and withdrawing from others. With regard to treatment preferences, participants identified a hierarchy of treatment preferences, with use of their own coping, social support, and third, yet less desirable, seek help from a mental health profession. However, there were a lot of misconceptions about what a mental health provider can do to help. There were also a number of fears and noted risks associated with seeking professional mental health care, such as feeling pressured to take antidepressants or losing custody of their child. The use of antidepressants as a treatment option was not endorsed or embraced by the vast majority of focus group participants. However, participants said they would be more willing to take antidepressants after the birth of their child than during pregnancy. Policy Implications. If we are to address the mental health needs of Hispanic mothers, it will be vital that we take great care in providing culturally appropriate health care services that meet the social and mental needs of this population. Clearly, health care providers and researchers must take steps toward establishing trust within the Hispanic community prior to introducing an intervention. In order to

S34 establish this trust, we must ensure that the programs and services we propose address the preference Hispanic women cited, such as engaging in talking rather than pushing therapy, proposing constructive activities such as activities encouraged in didactic therapy, and encouraging women to take care of themselves by taking time out and allowing themselves to feel the range of emotions that come with pregnancy and motherhood all the while making ourselves available for support when necessary. Community-Wide Intervention Reduces Post Partum Depression Through Promotion of Perinatal Screening and Treatment MR Liepman1, CL Kothari1, RS Tareen1, PM Florian1, RM Charoth1, LC Sweezy2, SS Haas1, JW McKean3 1

Michigan State University/Kalamazoo Center for Medical Studies Healthy Babies Healthy Start 3 Western Michigan University, Kalamazoo, MI, USA Email: [email protected] 2

Objective: To evaluate a community-wide educational and advocacy intervention to improve care for women with perinatal mood disorders by increasing and standardizing earlier screening by prenatal care providers, improving referral and acceptance of identified cases, enhancing community understanding and awareness of resources for this condition. Methods: Over 18-months (2007–2009), nearly 500 area health care and social service providers attended trainings on perinatal mood disorders. Topics included epidemiology, screening, treatment, referral, and safety of various psychotropic drugs during pregnancy and lactation. A list of interested mental health providers and support groups was distributed. A Women’s Behavioral Health Clinic was established to evaluate complex cases, offer consultative advice to prenatal providers, and to train future psychiatrists on caring for this population. Public service announcements about perinatal mood disorders played on local radio stations. Health promoters and case managers disseminated these messages. Literature was printed and distributed widely. Using the same procedures, in 2002 and 2009, we enrolled two random 10% samples of hospitalized postpartum women (N2002=332 and N2009=326), who were interviewed at two weeks and two months postpartum. We also abstracted their prenatal records. For statistical analysis we used Chi Square, Wilcoxin and T-tests with p<0.05 and linear modeling. Results: In prenatal records, documented screening for depression increased 8.6-fold from 10.6% to 91.4%; identification of depression increased 6.1-fold from 2.4% to 14.7%; and treatment increased 3.6-fold from 3.0% to 10.7%. Survey respondents’ recall of being asked about mood by prenatal care providers increased 3.6-fold from 14.2% to 50.9% (all p’s<0.001). The average depression (EPDS) scores of the group dropped from 7.53 to 5.08, and the frequency of answering “yes” to a suicidal thoughts question dropped from 7.1% to 3.5% (p <0.001). Reporting professional help was the strongest predictor of less depression. Intimate partner abuse and stress were strong predictors of depression. Conclusion: A community-wide educational and advocacy intervention accompanied by treatment support positively altered behaviors of healthcare providers to raise the community standard of care, which in turn reduced depression and suicidality levels of postpartum women across the community.

K.L. Wisner It’s Not A Secret Anymore: Perinatal Women’s Disclosure of Intimate Partner Abuse MR Liepman1, CL Kothari1, RS Tareen1, PM Florian4, LC Sweezy2, SS Haas1, RM Charoth1, A Moe3, A Kamboj1 Michigan State University/Kalamazoo Center for Medical Studies1, Healthy Babies-Healthy Start2, Western Michigan University3, Family & Children Services4, Kalamazoo, Michigan, USA. Email: [email protected] Objective: The perinatal period is a vulnerable time for intimate partner abuse (IPA) and maternal depression. What is less is understood is the differential impact that different types of abuse and their timing relative to the perinatal period have upon women’s mental health. Study goals were (1) to examine whether the type of abuse (emotional versus physical/sexual) is associated with different levels of depression, and (2) whether the timing of IPA (prior versus perinatal) is associated with different levels of depression. Methods: This study was mixed-methods, using prenatal medical records retrospective review for demographics, obstetric history, and documented mental health history, and using phone interviews at twomonths postpartum for postpartum depression, life stressors and IPA. This representative community sample of 301 women was recruited from hospital postpartum units. Bivariate analyses used Pearson Chi Square. Results: IPA was disclosed by 64 women (21.3%); all 64 experienced IPA before pregnancy, but only 25% during pregnancy and postpartum. Some form of emotional abuse (put downs, threats, control of food/appearance/movements, isolation, financial control) was universal (100%), with 86.7% suffering systemic abuse (emotional abuse coupled with physical (74.6%) and/or sexual abuse (38.1%)). IPA victims were more likely to experience depression compared to nonvictims (57.8% vs. 24.5%, p<.001). Among victims, women experiencing perinatal IPA were more likely to screen positive for postpartum depression than women experiencing IPA only in the past (37.5% vs. 11.4%, p=.021). Otherwise, type and timing had no significant associations with depression, before, during or after pregnancy. Conclusions: IPA, either current or previous, is a common experience among perinatal women. Most IPA victims have suffered multiple types of abuse, including physical assaults, sexual abuse and various forms of emotional abuse. IPA is strongly linked to depression, with current, ongoing abuse being most strongly associated with postpartum depression. Any form of abuse at any point in time puts a woman at 2–3 times greater risk of depression. Thus, depression can be a marker for IPA, suggesting that when perinatal depression is discovered, assessment for IPA should be performed. Diurnal Rhythm of Salivary Cortisol in Pregnant Women Suffering from Blood- and Injection Phobia C Lilliecreutz, E Theodorsson, G Sydsjö, A Josefsson Div. Obstetrics and Gynecology, dep. Clinical and Experimental Medicine, Linköping University, Sweden Email: [email protected] Objective: Stress or anxiety during pregnancy affects maternal and fetal well-being and can i.e. cause premature delivery and

The Marcé International Society International Biennial General Scientific Meeting development problems in the child. Women suffering from phobias related to sight of blood and injections are prone to high levels of stress with anxiety and sometimes panic attacks during pregnancy. Cortisol is amongst the mediators through which the neurohormonal expressions of maternal psychological factors may be transferred to the fetus. Animal models show that maternal stress can affect placental function, including regulation of placental 11β-HSD2, the main barrier to the placental passage of cortisol. The aim of the current study was therefore to investigate whether pregnant women suffering from blood-and injection phobia have raised cortisol levels or are characterized by unusual diurnal salivary cortisol profiles. Method: The sample consisted of 65 pregnant women with blood-and injection phobia and 37 pregnant healthy controls. Both groups provided morning and evening saliva samples in week 25 and 36 for the assay of cortisol. In week 25 when blood was drawn for the mandatory blood testing extra blood was taken to analyze, corticotrophin releasing hormone (CRH), adrenocorticotropin hormone (ACTH) and cortisol in serum. Results: The expected diurnal decline in salivary cortisol was observed as well as increased cortisol levels during pregnancy. Pregnant women suffering from blood-and injection phobia had higher cortisol levels in general compared to women without the phobia but no marked difference in the diurnal cortisol rhythm was found between the groups. No differences were seen between the two groups concerning the parameters evaluating the hypothalamuspituritary-adrenal axis. Conclusion: The findings indicate that blood-and injection phobia during pregnancy can change the levels of cortisol with possible consequences for the unborn child. Barriers and Facilitators of Depression Treatment in Adolescent Mothers MC Logsdon1, MD Pinto-Foltz2, WM Usui1, JA Myers1 University of Louisville1, Case Western Reserve University2, USA Email: [email protected] Objective: Over the last decade, our team completed 8 research studies of social support and depression in community samples of low-income, adolescent mothers. The purpose of this presentation is threefold: 1. To summarize data related to barriers to depression treatment in adolescent mothers; 2. To frame findings in terms of theoretical models of adolescent development and health care utilization; 3. To suggest alternative models and approaches for future research and policy initiatives. Method: 1.We first described the rate of depressive symptoms in adolescent mothers at 4–6 weeks postpartum. 2. In a longitudinal study with an experimental design we tested a psycho-educational intervention delivered during pregnancy to reduce postpartum depressive symptoms. 3. We examined rates of treatment for depression at 12 months following a referral for treatment at 4– 6 weeks postpartum. 4. Using the Bioecological Model, we investigated the contribution of contextual variables to development of depressive symptoms. 5. Framed by the Theory of Reasoned Action, we examined predictors of mental health treatment. 6. In a Phase 1 clinical trial with a longitudinal design, we tested an intervention to overcome barriers to depression treatment. 7. Guided by Feminist Theory and using focus groups,

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we explored the context of support for adolescent mothers. 8. In a qualitative study guided by Phenomenology, we investigated individual barriers to depression treatment. Results: Although rates of depressive symptoms ranged from 28– 56%, few adolescent mothers (less than 25 per cent) complied with referrals for depression evaluation and treatment. Adolescent mothers experienced many stressors and threats, and their support providers were often unreliable. Complex lives, and often transient living arrangements, interacted with subjective norms to rend traditional mental health services as unacceptable and unfeasible. Alternatively, adolescent mothers were often very resilient, frequently “piece together” support needed, and tend to be motivated to create a healthy family for themselves and their baby. Conclusion: Health care access models should be reexamined in terms of adolescent developmental theory. Further research is needed to determine facilitators of treatment and outcomes of strength based interventions on the mental health of adolescent mothers. Pain in the Early Postpartum and Postnatal Depression Screening: Symptom or Confounding Factor? M Maron, R Jardri, P Delion, P Thomas Department of Psychiatry, University Hospital CHRU, Hopital Fontan, France Email: [email protected] Objective : Postnatal depression (PND) is one of the most important complications following delivery and screening strategies by first-line healthcare workers as soon as early postpartum are of prime importance. As pain following childbirth has been proposed as a possible risk-marker for later depressive disorder, we tested this assumption and furthermore explored the possible link between pain and overestimation of the PND risk by routine clinical screening in early postpartum. Method : We included 363 mothers in a prospective study. They were assessed between the 3rd and 5th day post-delivery and at 8 weeks post-partum. Midwives were asked to evaluate the risk of later PND upon women’s discharge from the department, while Visual Analogic Scale measurements for pain over the same period were obtained. Risk markers significantly linked to positive MINI-DSM-IV depressive diagnosis at 8 weeks post-partum were identified using a stepwise logistic regression analysis. Results : Multivariate risk analysis showed no statistical link between experiencing physical pain in early post-partum and subsequent PND diagnostic at 8 weeks post-partum. Moreover VAS measurements for pain were significantly higher in the women estimated to be at risk of PND by the midwives. Conclusion : These data suggest the possibility of false-positives in the routine clinical screening for PND and that pain and other clinical features could be considered confounding factors. This issue will be discussed as psychiatrists should encourage midwives to have an empathetic approach to improve the detection of mental and physical suffering in early postpartum. Adequate education programs for early PND screening should be proposed to non-psychiatric staffs, notably to point out that women at risk of PND often show minimal symptoms.

S36 Role of A Mother Baby Unit in Managing Bipolar Disorder Before Pregnancy During Pregnancy and in the Post Partum Period M Maron, K Schoemaker, P Thomas, M Goudemand Department of Adult Psychiatry, University Hospital CHRU, Hospital Fontan, France Email: [email protected] The Mother Baby Unit (MBU) of the University Hospital in Lille, North of France, is a part of a regional resource center for perinatal psychiatry and especially for mothers with bipolar disorders. Until recently, it was designed for treating maternal postnatal psychiatric illnesses and their consequences on mother–baby interactions and the attachment of the baby. However, as bipolar disorder is a cyclic illness, we found useful to hospitalize during relapses mothers with bipolar disorders during pregnancy or/and after childbirth to meet their specifics needs with specific cares when severe clinical symptoms are occurring and to anticipate with the professional network surrounding the family the outcome. As pregnancy does not protect against bipolar recurrences and the postnatal period is well-known for being chaotic and for putting bipolar mothers at risk of symptomatic episodes, it appears that intensive specific cares through hospitalization in a special unit before childbirth and for mothers experiencing clinical recurrences or significant clinical features, is not only a mean of treating the illness but also a way of preparing the birth and the postpartum period with the various social, psychiatric and family partners. It is also the opportunity to adjust a psychotropic treatment and to monitor attentively the evolution of the symptoms. After the birth, hospitalization for mothers and babies in a MBU seems a reliable way of addressing both the needs of an ailing mother who is recovering her psychiatric balance and dealing with her new status, and of a baby whose attachment an emotional development are at stake because of the impaired interaction due to the mother’s illness. It could be possible to describe a pattern of these impaired interactions paralleling the mother’s state. As a part of a perinatal network, every step in the care in the MBU as well as information should be shared with the other caregivers. Assessment and care to the dyad in an MBU during pregnancy and after childbirth seem thus to be a powerful tool to help bipolar mothers during clinical episodes and after when back home. Postnatal Distress in Fathers and Mothers—Prevalence and Correlates in A Swedish Sample P Massoudi1, 2, B Wickberg3 and P Hwang1 1

Department of Psychology, Gothenburg University, Sweden Research and Development Centre, Kronoberg County Council, Sweden 3 Research and Development Unit, South Bohuslän County Council, Sweden Email: [email protected] 2

Objective: Postnatal depression in both mothers and fathers has been shown to have adverse impacts on the child. While routines for the detection and treatment of postnatal depression in mothers have been implemented in Swedish Child Health Care, no systematic methods are used for fathers. We were interested in learning more about the

K.L. Wisner mental health of fathers during the postnatal period; the prevalence of postnatal depression, anxiety and parental stress as well as risk factors and couple morbidity. Method: Child health nurses recruited around 1000 couples at the first home visit after the birth of their child. Mothers and fathers received postal questionnaires when the child was 3 and 6 months old. Postnatal mood was assessed with the EPDS (Edinburgh Postnatal Depression Scale), SPSQ (The Swedish Parental Stress Questionnaire) and the HAD (Hospital Depression and Anxiety Scale). Fathers scoring high on the EPDS and/or the HAD anxiety scale, as well as controls, were interviewed by telephone with a structured diagnostic interview PRIME-MD (Primary Care Evaluation of Mental Disorders). Results: An early estimate showed a high response rate, around 85%. Preliminary results will be presented. Eating Disorders in Women with Perinatal Depression S Meltzer-Brody, S Zerwas, J Leserman, A Von Holle, CM Bulik Department of Psychiatry, University of North Carolina at Chapel Hill Email: [email protected] Objective: Although the prevalence of perinatal depression (depression occurring during pregnancy and postpartum) has been documented at 10%, much less is known about the prevalence of psychiatric co-morbidity in women with perinatal depression. This study examined the prevalence of comorbid eating disorders in women with perinatal depression. Methods: We administered a questionnaire to 159 consecutive women patients seen in a Perinatal Psychiatry Clinic. Women presented during pregnancy (n=100) and the postpartum period (n=59). Measures included SCID-based questions for past eating psychopathology and other validated instruments to assess psychiatric illness including the State/Trait Anxiety Inventory, Patient Health Questionnaire (PHQ), Edinburgh Postnatal Depression Scale (EPDS), and Trauma Inventory. Mean age of participants was 30.2 years (sd=5.9); years of education was 15.3 years (sd=3.1); 79.7% were married; 76.7% were Caucasian. Results: In this cohort, 37.1% had a putative eating disorder history; 10% anorexia nervosa (AN), 10% bulimia nervosa (BN), 10% eating disorder NOS- purging subtype (EDNOS-Purging) and 7.1 binge eating disorder (BED). Women with BN reported higher levels of depression (EPDS score=19.1; sd=4.3, p=.02), more severe depression (PHQ-severity=14.5; sd=7.4; p=.02) and a trend towards higher trait anxiety (STAI-T=71.7; sd=12.4; p=.051) than the referent group of women with perinatal depression and no eating disorder history (EPDS= 13.3; sd=6.1; PHQ= 8.9; sd=6.2 STAI-T=63.7). Women with AN and BN also reported higher rates of both physical and sexual trauma than the referent group; those with AN were more likely to report sexual trauma (62.5%; p<.05) than the referent group (36.1%) and those with BN were more likely report both physical (50.0%; p<.05) and sexual trauma (66.7%; p<.05). Conclusion: In our cohort of women with perinatal depression, we observed significantly high rates of eating disorders. Those with BN demonstrated more severe depression and significant abuse histories compared with the referent group. These findings demonstrate the importance of screening for eating psychopathology in women with perinatal depression.

The Marcé International Society International Biennial General Scientific Meeting Neuroendocrine Pathophysiology in Postpartum Depression and Lactation Failure S Meltzer-Brody, K Grewen, A Stuebe, K Light Department of Psychiatry, University of North Carolina at Chapel Hill, NC Email: [email protected] Background: The first weeks after childbirth are a critical period for mother and infant. Two major clinical problems that present during this time are postpartum depression (PPD) and lactation failure. Approximately 10% of mothers develop PPD and lactation failure is also common; only 14% of US women exclusively breastfeed during the first six months of life. Based on evidence from animal studies and epidemiologic analyses, we hypothesize that PPD and lactation failure may share a common neuroendocrine basis, including alterations in the hypothalamic-pituitary-adrenal (HPA) axis, gonadal steroids, thyroid function, regulation of prolactin and oxytocin, and the autonomic nervous system. Objective: We are conducting a longitudinal investigation of the neuroendocrine mechanisms underlying PPD and lactation failure. Methods: Women with and without perinatal depression at study entry are tested to examine trajectories of depression and lactation behavior in the early postpartum period. Levels of relevant biomarkers, including oxytocin, prolactin, cortisol, CRH, T4 and catecholamines, are assessed at three time points: late 3rd trimester (36-38 weeks gestation), and 2 and 8 weeks postpartum. Mothers’ cardiovascular and hormone responses to infant feeding at 2 and 8 weeks, and to a social stressor at 8 weeks are assessed. Preliminary findings suggest that in early postpartum:

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the first three days postpartum, estrogen levels drop 500 fold, which in turn have an inverse relationship with Monoamine Oxidase A (MAO-A) levels. MAO-A binding is elevated during early onset major depressive episodes (MDE). Based upon the inverse relationship between MAO-A levels and estrogen change, it was hypothesized that MAO-A binding will be elevated during the early postpartum period. Methods: MAO-A total distribution volume (MAO-A VT), an index of MAO-A levels, was measured using [11C] harmine Positron Emission Tomography in 15 healthy women who have not recently been postpartum and 15 healthy women who were day 3 to 6 postpartum. MAO-A VT is an index of total brain binding by [11C]harmine at equilibrium with plasma and can be viewed as an index of MAO-A levels. In addition to applying the 2-tissue compartment model (2TCM), MAO-A VT was also measured with the Logan method. A plasma input function corrected for the presence of labeled metabolites (Cp (t)) was used. Results: There was a significant elevation in MAO-A VT (mean: 25 %, p < 0.001) throughout all brain regions (prefrontal cortex, temporal cortex, midbrain, thalamus, anterior cingulate, caudate, putamen, hippocampus), in the immediate postpartum period (day 3–6) in healthy women. The MAO-A VT found with the Logan method correlates highly with the kinetic analysis with a two tissue compartment model, with extremely similar magnitude of values (<2%). Discussion: An elevation in MAO-A during days three to six postpartum can be viewed as a monoamine lowering process which contributes to the mood change of postpartum blues. We propose a neurobiological model composed of estrogen loss, followed by MAO-A binding elevation, low mood, and a period in which risk for major depressive episodes is high. This model is an important step towards understanding and prevention of postpartum depression.

1. greater urinary oxytocin is related to lower depression scores on

2.

3.

the EPDS (r=−0.47, p=.01), and lower maternal blood pressure during infant feeding (r=−0.43, p<.03). greater plasma oxytocin is linked to lower plasma norepinephrine levels (r=−0.41, p<.05,), lower heart rate (r=−0.54), vascular resistance (r = −0.51)and greater stroke volume (r = +0.54) responses to stress (p’s <.01). Lactating mothers have greater levels of salivary, urinary, and plasma oxytocin levels compared with formula-feeding mothers.

We will be presenting mid-study results on ~40 mothers with complete data measuring biomarkers of stress, mood and lactation including reproductive, adrenergic, HPA, and thyroid hormones in maternal response to infant feeding and a social stressor. Conclusion: Our results may lead to new treatment strategies for maternal depression and lactation failure, with the potential to improve health outcomes across two generations. Elevated Monoamine Oxidase A Levels in Newly Postpartum Women JH Meyer, J Sacher, AA Wilson, S Houle, S Hassan, P Rusjan, D Stewart Mood Division, PET-Centre, Centre for Addiction and Mental Health, University of Toronto., Toronto, ON, Canada Email: [email protected] Background: A fourfold increase in the incidence of PPD has been observed in women who experienced severe postpartum blues. Over

Childbearing Women with Schizophrenia LJ Miller Department of Psychiatry, Brigham and Women’s Hospital Email: [email protected] Objective: To summarize clinically relevant data about sexuality, family planning, pregnancy, the postpartum period and parenting in women with schizophrenia. Method: A multidisciplinary, international group of experts was assembled to review published studies relevant to childbearing women with schizophrenia. Each group member was assigned to review one of the following topics: sexuality and social context; fertility and family planning; risks of psychotic symptoms during pregnancy and postpartum;psychotic denial of pregnancy; preconception counseling; prenatal care; antipsychotic medication during pregnancy and postpartum; psychotherapy during pregnancy; inpatient care during pregnancy; parenting; filicide; and ethical issues. Results: Women with schizophrenia may experience specific challenges regarding sexuality, family planning, perinatal risks and parenting. Conclusions: Understanding the challenges and needs of childbearing women with schizophrenia paves the way toward more effective prevention, intervention and support for this group of women.

S38 Biopsychosocial Contributions of Fathers to Pregnancy Outcome DP Misra1, C Caldwell2, A Young, Jr2 1

Wayne State University University of Michigan Email: [email protected]

2

Few studies have considered the impact of paternal factors on birth outcomes or on racial differences therein. We begin by synthesizing the literature from the fields of sociology and psychology to understand the context of fatherhood in the U.S. This includes an examination of the socioeconomic and cultural landscape of Black fatherhood as well as race and the role of Black fathers. Black family structure and intra-family relations often differ from those of nonBlacks. We posit that paternal risk factors may be more frequent and protective factors less frequent in Black families. Furthermore, the maternal risks to which Black women are exposed may increase vulnerability to paternal factors relative to white women. We then describe more broadly a model for paternal effects on birth outcomes that encompasses social, psychosocial, and biomedical factors. This model also explicitly considers family relationships and the pathways between mother and father and birth outcomes. We then turn to a consideration of the literature on paternal factors that may influence birth outcomes and identifying areas where disparities may be rooted. We conclude with limitations of past research and provide recommendations. Depression & Psychotropic Medication Use During Pregnancy: Variation in Uterine Blood Flow Indices C Monk1,2, C McKay2, JH Korotkin3, BT Knight3, DJ Newport3, Z Stowe3 1

New York State Psychiatric Institute, School of Medicine College of Physicians & Surgeons, Columbia University, New York, NY 3 Emory University, School of Medicine, Atlanta, GA Email: [email protected] 2

Objective: Recent research indicates that psychiatric illness during pregnancy may contribute to poor birth outcomes and risk for future mental and physical illness in children. Similarly, data on the prenatal use of serotonin reuptake inhibitors (SRIs) suggest an association with earlier birth, and markers of alterations in neurobehavioral development. It has been hypothesized that both ‘exposures’ may alter outcomes, in part, by inhibiting uterine blood flow (UBF). This study examines indices of UBF in relation to antenatal depression and psychotropic medication use. Method: Seventy–three pregnant women with psychiatric histories (mean gestational age 25 weeks [range 22.0–28.0]) underwent Doppler ultrasound assessment; waveforms were recorded from both uterine arteries and the umbilical artery. Serial measures of depression, stress, and anxiety were collected three or more times during pregnancy (prior to UBF recording) and prospective week-by-week records of psychotropic medication use were obtained. Results: A majority of women were taking psychotropic medication (63/73; 90% were taking a SRI or SNRI), yet 33% (24/73) fulfilled criteria for a current Major Depressive Episode (MDE). There was a significant association between psychotropic use and higher resistance

K.L. Wisner in the right uterine artery (no medication: 0.33±0.11 vs. medication: 0.44±0.13, p<.05). For non-depressed subjects, levels of selfreported depressive symptoms (Edinburgh Postpartum Depression Scale) were positively correlated with overall uterine artery resistance, i.e., mean of left and right arteries (r=.35, p<.05). In the subset of women with current MDE, scores on the Clinical Global Impression scale were positively correlated with overall uterine artery resistance (r=.30, p<.05). Conclusion: In this sample of pregnant women with lifetime histories of major depressive disorder, both psychotropic medication use and greater psychiatric symptomatology were associated with indicators of suboptimal blood flow to the placenta. These findings suggest a pathway by which women’s psychosocial functioning, and the ensuing treatment, might affect birth outcomes and fetal neurobehavioral development. Abnormally Reduced Dorsomedial Prefrontal Cortical Activity and Effective Connectivity with Amygdala to Negative Emotional Faces in Postpartum Depression EL Moses-Kolko1 SB Perlman,1 KL Wisner, ML Phillips1,2

1

J James,2 AT Saul,1

University of Pittsburgh School of Medicine, Dept of Psychiatry1 and Radiology 2 Email:[email protected] 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 post partum depression remain unknown, but brain processing of affective simuli appears to be involved in other affective disorders. Activity to negative emotional faces was therefore examined in dorsomedial prefrontal cortex and amygdala—key emotion regulatory neural regions of importance to both mothering and depression. Method: Postpartum healthy(n=16) and depressed, unmedicated mothers(n=14) underwent fMRI BOLD acquisition during a blockdesigned face versus shape-matching task. A 2-way ANOVA was performed examining main effects of condition and group, and group x condition interaction, on activity in bilateral dorsomedial prefrontal cortical and amygdala regions of interest. Results: Depressed relative to healthy mothers had significantly reduced left dorsomedial prefrontal cortical face-related activity (p < 0.05, corrected). 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(both p< 0.05). There was reliable top-down connectivity from left dorsomedial prefrontal cortex to left amygdala in healthy, but not depressed, mothers. Conclusions: Significantly diminished dorsomedial prefrontal cortex activity and dorsomedial prefrontal cortical-amygdala effective connectivity to negative emotional faces may represent an important neural mechanism, or effect, of postpartum depression. Reduced amygdala activity to negative emotional faces is associated with greater postpartum depression severity and more impaired maternal attachment processes in postpartum depressed mothers.

The Marcé International Society International Biennial General Scientific Meeting Monoamine Receptor Binding in Postpartum Depression EL Moses-Kolko1, CC Meltzer3, SL Berga3, JL Price2, BH Hanusa1, KL Wisner1 University of Pittsburgh School of Medicine, Dept of Psychiatry1 and Radiology, 2 Emory University School of Medicine3 Email:[email protected] Background: Postpartum mood disorders are critical public health problems because they affect one out of 8 American women annually, impede healthy infant and child development, and disrupt families. Greater neurobiological understanding of the illness is needed to guide development of specific and more robust treatments. Study of the serotonin 1A (5HT1A) and dopamine-2 (D2) receptor systems in postpartum depression is of interest because of their mechanistic involvement in depressive disorders and regulation by perinatal and lactational hormones. Methods: Twenty postpartum healthy, 13 postpartum unipolar depressed, and 10 non-postpartum healthy subjects underwent 5HT1A receptor imaging with 90-min dynamic positron emission tomography (PET) using a Siemens/CTI HR+ and i.v. administration of [11-C] WAY100635. 5HT1A receptor binding in lateral orbitofrontal, mesiotemporal and subgenual cingulate cortices was determined with radiometabolite corrected arterial input function and Logan graphical analysis. Thirteen postpartum healthy, 13 postpartum unipolar depressed, and 13 non-postpartum healthy subjects underwent D2 receptor imaging with 60-min dynamic PET and i.v. administration of [11-C]Raclopride. D2 receptor binding was determined for ventral and dorsal striatal subregions with a simplified reference tissue model. Results: Mean depression scores (HAM-25 item=21.7±7.9) revealed mild to moderate depression in the depressed group. Mean duration postpartum was 10–11 wks. For both 5HT1A and D2 receptors, binding was increased by 15% in non-postpartum relative to postpartum healthy women in regions of interest; however, there was no significant group difference in 5HT1A or D2 receptor binding in depressed relative to healthy postpartum women. Estradiol concentrations were inversely related to 5HT1A receptor binding in postpartum subjects (R=−0.35). There was no relationship between breastfeeding status and receptor binding in the postpartum groups. Conclusions: While these data do not reflect 5HT1A or D2 receptor differences in postpartum healthy relative to depressed mothers, they do raise the possibility of neuroplasticity processes that occur in the human maternal brain as a result of recent childbirth, which may increase vulnerability for women at risk for depression. The inverse relationship of estradiol with 5HT1A receptor binding suggests further that steroid hormones may play a modulatory role in these plasticity processes. Are Psychiatric Disorders with Postpartum Onset Early Manifestations of Bipolar Affective Disorder? T Munk-Olsen1, I Jones2, TM Laursen1 1

National Centre for Register-based Research, Aarhus University, Denmark MRC Centre in Neuropsychiatric Genetics and Genomics, Cardiff University, UK Email:[email protected]

2

Objective: Childbirth has an important influence on the onset and course of bipolar affective disorder, but the disorder is frequently

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misdiagnosed and the delay in receiving an accurate diagnosis of bipolar may take years. We aimed to study if psychiatric disorders with postpartum onset are early manifestations of an underlying bipolar disorder. Method: We conducted a register-based cohort study on 2565 women with a first time psychiatric in- or outpatient contact with any type of disorder excluding bipolar affective disorder 0 to 12 months postpartum. Each woman was followed individually from the day of discharge from the postpartum admission and the outcome of interest was readmission with a first time bipolar affective disorder diagnosis during the follow up period. Results: Out of the 2565 women in the study population a total of 113 were readmitted with a bipolar affective disorder diagnoses. The rate of readmission with bipolar affective disorder diagnosis was 3.74 (95% CI: 2.36–5.92) times higher in women with first time psychiatric contact 0–14 days postpartum compared to women with postpartum onset 3 to 12 months postpartum. Conclusion: Women with psychiatric in- or outpatient contacts in the immediate postpartum period are more often diagnosed with bipolar affective disorder later in their lives than women with later postpartum onset. Results indicate that the proximity of onset to childbirth may be an indication of underlying bipolarity. Risk of Mental Disorder Following Induced 1st Trimester Abortion or Childbirth T Munk-Olsen1, TM Laursen, PB Mortensen1

1

CB Pedersen1, O Lidegaard2,

1

National Centre for Register-Based Research, Aarhus University, Denmark 2 Gynaecological Clinic, Rigshospitalet, Copenhagen, Denmark Email:[email protected] Objective: There has been concern raised regarding the potential harm to women’s mental health that might be associated with having an induced abortion. However, it remains unclear whether induced abortion is associated with increased risks for psychiatric problems in contrast to a well documented increased risk of mental disorders after childbirth. Methods: We conducted a population-based cohort study which involved linking information from The Danish Civil Registration system to The Danish Psychiatric Central Register and The Danish National Register of Patients. We included women with no previous records of mental disorders during a study period from 1995 to 2007 who had a first 1st trimester induced abortion or first childbirth. We assessed rates of first time psychiatric in- or outpatient contacts for any type of mental disorder in 12 months after abortion or childbirth, as compared with the nine months preceding either event. Results: Rate of psychiatric contacts was higher in women who subsequently had abortions than in women who subsequently gave birth: Incidence rates per 1000 person years pre and post abortion: 14.61 (95% CI: 13.67; 15.62) and 15.22 (95% CI: 14.41; 16.08), and pre and post partum: 3.94 (95% CI; 3.68; 4.23) and 6.69 (95% CI: 6.40; 7.00). Risks of psychiatric contacts were unchanged from before to after abortion (p=0.19) contrasting risks before and after childbirth (p<0.00001). Conclusions: Risks of psychiatric contacts were similar before and after a 1st trimester abortion contrasting risks before and after

S40 childbirth. Our results do not indicate an increased risk of mental disorders following a first trimester induced abortion *This abstract is under 4th review at New England Journal of Medicine Maternal Perinatal Depression: Impact on Infant Emotion Regulation, Sleep and Subsequent Toddler Behavior Problems M Muzik, E Waxler, Thelen, K Rosenblum University of Michigan Medical School, USA Email:[email protected] Objective: Pre-and Post-natal maternal stress and/or psychopathology can have negative effects on infant temperament and later toddler behavior (Gutteling et al., 2005; Whitaker, Orzol, & Kahn, 2006). Infant temperamental difficulties have been associated with later behaviors problems as children develop (Olson, Bates, Sandy, & Lanthier, 2000; Olson, Bates, Sandy, & Schilling, 2002). The objective of this study was to investigate potential precursors (throughout peripartum) of infant temperament and other child outcomes. Method: The present study utilizes data from a high-risk community sample and explores the links between maternal PTSD and depression during pregnancy and postpartum predicting to their infants’ emotion regulation problems at 7 months of age. The effects of infant sleep, infant gender, family SES risk and the use of psychotropic drugs during pregnancy are also assessed. On a smaller subset we further explore the associations between early emotion regulation problems and subsequent development of pre-school behavior problems. Results: We found that both maternal postpartum depression, and infant sleep problems predict problematic infant temperament at 7-months, and that in turn, infant temperament, infant sleep problems and maternal depression were predictive of toddler behavior problems 12 months later. Psychotropic drugs and family SES risk had no significant effects of infant temperament or later child outcomes. Conclusion: Our data suggests that infant emotionality and infant sleep problems (in the context of maternal psychopathology) may be early precursors to the development of later toddler behavior problems. Safety of Antidepressants During Pregnancy H Nordeng1,2, A Einarson3, M Eberhard-Gran2, Koren G3, O Spigset4 1

School of Pharmacy, University of Oslo, Norway National Institute of Public Health, Norway 3 The Motherisk Program, The Hospital for Sick Children, Toronto, Canada 4 Department of Clinical Pharmacology, St Olav’s University Hospital, Trondheim, Norway Email: [email protected] 2

Objective: Results of previous studies on the safety of antidepressants during pregnancy have been conflicting. The primary aim of this study was to investigate whether exposure to antidepressants and especially SSRI’s was associated with malformations above the baseline risk using two population-based health registries. A secondary objective was to investigate the effects on birth weight, gestational age and perinatal complications.

K.L. Wisner Method: The Medical Birth Registry of Norway (MBRN) and the Norwegian prescription database (NorPD) were linked using the unique 11-didgit personal identification number. The study included women pregnant with one foetus and where the duration of pregnancy was known from 2004–2008. Infants with chromosomal anomalies were excluded. The women were grouped into four categories: 1) antidepressant exposed, 2) depressed controls (women who had used antidepressants, but not during pregnancy), 3) population controls I (women who had other medicine use recorded in the NorPD) and 4) population controls II (women who had no medicine use recorded in the NorPD). The study was approved by the Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate. Results: In total 179 817 pregnant women were included in the study. 2570 (1.4%) pregnant women had used antidepressants during pregnancy and 1497 (0.8%) had used SSRI’s during the first trimester. Univariate and multivariate logistic regression analyses showed similar associations between SSRI exposed and depressed controls with respect to malformations when compared to population controls. The magnitude of these associations varied according to choice of reference group. Conclusions: First trimester SSRI use does not seem to increase the risk of malformations more than can be attributed to the underlying illness or unmeasured factors. Choice of reference group in pharmacoepidemiological studies is important and may affect results significantly. Pregnant women with psychiatric illness during pregnancy should be followed carefully and offered adequate treatment also during pregnancy. Perceived Social Support Interacts with Prenatal Depression to Predict Birth Outcomes KJ Nylen1, MW O’Hara2, J Engeldinger2 University of Michigan1, University of Iowa Email:[email protected] Objective: Depression during pregnancy has been linked to adverse reproductive outcomes including preterm labor and delivery, low birth weight, and a host of other infant outcomes linked with later morbidity. Not all women who experience high levels of distress experience negative reproductive outcomes. Several authors have targeted the effects of social support as a potential factor that may protect against the negative effects of distress. There has been mixed support for this model; however, studies have generally not examined both frequency and adequacy of support across multiple types of relationships, which may have very different implications for outcome. Method: Pregnant women (N=235) who were ≤28 weeks gestation (M=16.93 weeks, SD=6.50) completed self-report questionnaires assessing symptoms of distress (stress, anxiety, and depression). Women also completed questionnaires assessing social support network size and satisfaction with overall level of support, as well as frequency and adequacy of supportive behaviors from partners. Clinical interviews were administered to assess for DSM-IV axis I disorders. Following delivery, maternal and infant reproductive outcomes were extracted from medical records. Results: Of 211 women who completed the SCID, 6.2% (n=13) met criteria for current Major Depression. Depressed women were more likely to have babies who weighed less, were born earlier, and had lower Apgar scores than nondepressed women. Although social support from partners and social networks were not significant predictors

The Marcé International Society International Biennial General Scientific Meeting of birth outcome, partner social support interacted with depression to predict gestational age and Apgar scores. Specifically, depressed women who rated their partners as supporting them less frequently and adequately had babies who were born earlier and had lower Apgar scores than depressed mothers with higher perceived partner support. Conclusion: Prenatal depression had a negative impact on reproductive outcomes; however, more frequent and adequate social support from partners during pregnancy may improve infant outcomes in depressed mothers. Although findings may be limited to our particular sample (e.g. well-educated, middle-class, Caucasian women), they suggest a possible means of intervention amongst depressed women, and are in line with the goals of interpersonal psychotherapy, an efficacious treatment for postpartum depression. Prenatal Exposure to SRI Antidepressants and Depression: Neurobehavioral Outcomes from Gestation to Early Childhood. TF Oberlander University of British Columbia, Vancouver, BC, Canada Email:[email protected] Prenatal exposure to depressed maternal mood and serotonin reuptake inhibitor [SRI] antidepressants may be one of the earliest adverse life events. Both are associated with neurobehavioral disturbances. While neonatal symptoms are typically self-limited, the underlying mechanisms and long-term sequelae are unknown. Emerging evidence highlights that child outcomes from SRI-exposure may differ from the effects of maternal depression alone, appear to be modified by gene x environment interactions, and possibly reflect epigenetic vulnerabilities in addition to increased drug levels, suppressed monoamine neurotransmitter levels, or reflect long term gestational changes in brain development related to altered central serotonergic tone. This session will focus on recent data illustrating how we might begin to understand how multiple factors contribute to neurobehavioral disturbances associated with prenatal SRI exposure. Prenatal anxiety, HPA axis activity, and immune outcomes in the child TG O’Connor1, E Robertson-Blackmore1, M Caserta1, F.Lee1, V Glover2, J Moynihan1 1

University of Rochester Medical Center, Rochester RDB, Imperial College London Email:[email protected]

2

Objectives: Efforts to translate the animal findings on prenatal stress exposure and offspring development for human development have progressed significantly in recent years. There remain, however, a number of animal findings that remain without parallel human research. The current study was designed to tackle two of these: a) the mediating role of prenatal cortisol exposure on HPA axis activity in the child and b) the link between prenatal anxiety and cortisol exposure and specific immune outcomes in the child. Methods: Prenatal mood and cortisol and infant behavioral, endocrinological, and immunological outcomes were collected as part of a prospective study of 200 women recruited from a large, urban OB practice that serves a disproportionate percentage of women at high psychosocial risk; only women with normal risk pregnancies were

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included. Data were collected at 18 and 32 weeks gestation and at 2, 6, and 16 months postnatally. The current presentation will focus on prenatal mood and HPA axis data and infant cortisol response to stress and immune outcomes at 2 months. Results: Results showed that, in this high psychosocial risk sample, there were reliable associations between anxiety symptoms and elevated cortisol in pregnancy. In addition, elevated cortisol in pregnancy was associated with a diminished cortisol response to stress in the infant. Third, prenatal anxiety was associated with markers of the adaptive and innate immune system. Conclusions: The findings provide an important translation of key findings from the animal work on prenatal stress and extend in important ways the human data. Subsequent analyses are needed to examine the potentially moderator role of early caregiving and the persistence of these effects past early infancy. Contributions of Perinatal Mental Health Research to the Field of Psychology MW O’Hara University of Iowa, USA Email:[email protected] Objective: The perinatal period (beginning of pregnancy through the end of the first postpartum year) is a time of significant social, psychological, and biological transition and change for women. Because these changes occur over a relatively brief period of time, the perinatal period offers psychological and clinical scientists significant opportunities to do biopsychosocial research that bears on normal and abnormal behavioral developmental processes occurring the perinatal period. Method: There is a large and accumulating literature on the normal and abnormal psychology of women during pregnancy and the postpartum period. Psychological studies inform our understanding of perinatal psychopathology and these insights in turn inform our models of personality and psychopathology. Research is reviewed that illustrates on the one hand the impact of research on perinatal mental health on psychological theory and on the other hand the impact on of psychological research on knowledge of perinatal mental health. Results: The results of the review of the relevant psychological literature support the contention that perinatal mental health research and clinical practice have made significant contributions to psychology. Conclusion: Significant opportunities for psychological research on issues related to perinatal mental health. These efforts are likely to be spurred by health legislation that was recently enacted. Maternal Stress During Pregnancy: Impact on Maternal and Child Outcomes Over 16-Months MW O’Hara1, S King2, D Laplante2, KJ Nylen3 J McCabe1, JA Williamson1 1

University of Iowa McGill University 3 University of Michigan Email:[email protected] 2

Objective: Maternal stress during pregnancy has been associated with a variety of negative maternal and infant outcomes both in the short

S42 and medium term. Previous research has documented the importance of actual stress in terms of objective ratings and the response of maternal stress hormone levels. What is unclear is the extent to which objective stress experienced during pregnancy interacts with psychopathology during pregnancy and through the postpartum period to impact child functioning as much as 16 months following birth. Method: Pregnant women (N=235) who were ≤28 weeks gestation (M=16.93 weeks, SD=6.50) completed self-report questionnaires assessing symptoms of distress (stress, anxiety, and depression). Women also provided saliva on five occasions on two separate days late in pregnancy to measure cortisol. Women completed questionnaires assessing stressful life events and in particular, stressful life events associated with significant flooding of the communities in which they lived during the time that they were pregnant. Mothers and children were followed up 16 months after birth. Extensive assessments of maternal psychopathology were undertaken to document the course of any psychiatric disorder since birth. Measures of psychosocial functioning of the child were obtained at 16 months of age and were provided by the mother. Results: Data collection is ongoing and will be complete late this summer. Structural equation modeling will be used to characterize the hypothesized relations among the variables. Specifically, it is expected that the stress construct, which will be represented by both self-report and biological measures of stress and maternal depression during pregnancy will have a direct effect on both maternal depression and child behavior during the first 16 months postpartum. We also expect that stress and depression during pregnancy will have an indirect effect on child outcomes acting through depression occurring in the postpartum period. Conclusion: Maternal stress during pregnancy can have short and long term impacts on mother and infant health over an extended period. It is critical to understand these effects so as to provide interventions of prevent or mitigate them. Sleep Disturbances in Depressed and Non-Depressed Pregnant Women ML Okun, K Kierwa, J Luther, S Wisniewski, KL Wisner Department of Psychiatry, University of Pittsburgh School of Medicine Email: [email protected] Sleep disturbances are a common complaint of pregnancy. Depression is also frequently observed among childbearing women. To date, there is little published data on sleep in pregnant women who are depressed. Moreover, there is no data on the sleep in medicated depressed pregnant women. As a result clinicians are not informed as to whether sleep disturbances are a normal facet of pregnancy or if they are exacerbated among depressed pregnant women such that risk of poor outcomes may be increased. This may have implications for risk for adverse outcomes. We describe and compare clinician assessed sleep disturbances in 237 (57 depressed and 180 not-depressed at 20 weeks) community dwelling pregnant women. Eligible women were 26.6 (11) years and primarily Caucasian. They were given the SIGH-ADS at 20, 30 and 36 weeks gestation. Sleep latency, time spent awake at night, sleep duration, time in bed, sleep efficiency and symptoms

K.L. Wisner of insomnia were derived from the SIGH-ADS. We found that depressed women had greater sleep onset latencies and time spent awake at night, while their overall sleep efficiency was significantly worse (p’s <.05). There were no differences on the frequency of insomnia symptoms. We also evaluated sleep parameters in depressed pregnant women who were actively taking antidepressant medication compared to those who were not. Medications did not significantly affect any of the sleep variables. Evaluation of sleep during the gestational period may augment a clinician’s ability to identify women at risk for future depression. The Experience of “APOYOCESAREAS”: Lessons Learned from An Internet-Based Support Group for Spanish Women Recovering from Caesareans I Olza, E Serrano Drozdowskyj. Universitario Puerta de Hierro, Majadahonda. Madrid, Spain. Email: [email protected] Objective: Psychological morbidity of cesarean sections has received increased attention as the prevalence of cesarean childbirth continues rising worldwide despite WHO recommendations. Many mothers suffering psychological distress after traumatic cesarean turn to internet self-help groups for support rather than to perinatal mental health professionals. Ongoing dialogue between self-help groups and perinatal experts would likely improve our understanding of psychological issues of traumatic childbirth and postpartum PTSD. Method: “Apoyocesareas”: A Spanish-speaking internet support group was co-founded by the author in July 2001. The aims of the group were: 1) to offer psychological support to mothers recovering from cesarean, 2) to support breastfeeding after cesarean, and 3) to help mothers prepare for Vaginal Birth After Cesarean or have a more satisfying repeat cesarean when necessary. Results: The forum has received over 54.500 posts between July 2001 and March 2010. Recurrent topics include: difficulties verbalizing / expressing psychic suffering and emotional distress related to childbirth; feelings of having missed out on an integral part of motherhood; grief for the loss of natural birth, breastfeeding, and/or for the first few hours or days of newborn’s life; PTSD symptoms like disruptive flashbacks and nightmares related to the cesarean (especially in emergency intrapartum cesareans); “maternal estrangement” symptoms that could be caused by lack of endogenous oxytocin in planned; anger at health professionals and feelings of rage for what was perceived as an iatrogenic cascade of interventions; fear of never being pregnant again; fear of failing at trying to VBAC; difficulties trusting birth professionals; reports of feeling healed by woman to woman support on the forum and by having a better birth experience the next time. Many of those women went on to become birth activists to try to improve the birth system in Spain. Some of them founded the Association CHILD BIRTH IS OURS. The group became very active in the media and in 2007 the Spanish Ministry of Health launched the “Strategy for assistance at normal childbirth in the National Health System” incorporating many of the changes suggested by both consumers and professional members of the organization.

The Marcé International Society International Biennial General Scientific Meeting Conclusion: Internet-based support groups are a viable alternative for many women suffering from traumatic cesareans who do not consult mental health professionals. Early vs. Late Wake Therapy Effects on Mood and Endocrine Measures in Pregnancy and Postpartum Depression BL Parry, CJ Meliska, DL Sorenson, AM Lopez, HJ Orff, LF Martinez Department of Psychiatry, University of California, San Diego Email: [email protected] Objective: To test the hypothesis that depressed women’s (DW) mood during pregnancy or postpartum would improve more with late wake therapy (LWT) vs. early wake therapy (EWT) and correlate with endocrine measures. Method: 21 DW (7 pregnant, 14 postpartum) and 37 healthy women (HW)(24 pregnant, 13 postpartum), mean age 28 years, were randomized in a cross-over design to EWT (sleep 03:00–07:00 h) vs. LWT (sleep 21:00-01:00 h) followed by a night of recovery sleep (RS-22:30–06:30 h). Mood ratings (Hamilton Depression Rating Scale-HDRS) were administered pre- and post-treatment (after RS). Plasma melatonin and serum cortisol, prolactin, and thyroid stimulating hormone (TSH) were drawn every 30 minutes from 18:00–10:00 h in dim light (<50 lux) and serum estradiol (E2) and progesterone (P4) at 18:00 and 06:00 h. Results: HDRS scores were reduced by LWT in pregnant (p=.045) and postpartum (.016) DW, and by EWT in pregnant (.007) and postpartum (.022) DW. LWT improved HDRS scores by 56.2%; EWT by 29.8% in pregnant and postpartum DW, but the difference was not significant (ns). After LWT, change in HDRS correlated positively with change in melatonin peak and area under the curve in both pregnant and postpartum DW. After EWT, change in HDRS correlated negatively with change in melatonin offset time in pregnant DW; in postpartum DW, change in HDRS correlated negatively with melatonin peak concentration. After LWT, TSH mesor increased in postpartum HW; after EWT, cortisol amplitude and prolactin mesor decreased in postpartum HW. Mean E2 and P4 levels were not different between groups, but in postpartum DW, increased levels of E2 after LWT correlated with improved mood on the HDRS. Conclusion: Both EWT and LWT reduced depressive symptoms as measured by the HDRS in pregnant and postpartum women. The difference between the treatments was ns. Some correction to melatonin, cortisol, prolactin and TSH rhythms was observed, but there were insufficient data to indicate that these changes consistently correlated with mood measures other than the increased estradiol levels associated with improved mood after LWT in postpartum DW. Increasing Sensitivity in Parent–Infant Interaction: AVideo-FeedBack Intervention Package for Parents with Severe Mental Illness and Their Babies SJ Pawlby1, CM Pariante1 R Mycroft2, J Rigby2, G Seneviratne2 1

King’s College London, Institute of Psychiatry South London and Maudsley NHS Foundation Trust Email: [email protected]

2

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Objective: Infants are entirely dependent for their health and wellbeing on those who care for them. Infants whose mothers and/or fathers suffer from a mental illness are at risk of developing difficulties if the care provided does not meet their developmental needs. Pioneering work at the Channi Kumar Mother and Baby Inpatient Unit at the Bethlem Royal Hospital in South London is giving mothers with severe mental illness, and their partners, the opportunity to develop their relationships with their babies. Method: Video-taped recordings are made of play sessions between the mothers/fathers and babies over the course of the mother’s illness, followed by feedback sessions where the clinician and parent together identify sensitive patterns of behaviour—ones that please the infant and increase his/her comfort and attentiveness and reduce his/her distress and disengagement (Crittenden, 2004). The parent is encouraged to see the links between his/her own behaviour and that of the baby and to recognise the baby’s cues and respond appropriately. A manual has been designed to provide professionals with the rationale and tools to administer this treatment package. Results: At this stage, findings, using the Care-Index coding, show that following video feedback the less optimal quality of mother–infant interaction observed in the acute phase of the mothers’ illness improves, so that at discharge the quality of their interaction is no longer different from a well group of mothers and babies. Conclusion: Further training materials are being developed so that health professionals can use the treatment package with mothers, fathers and infants, in both hospital and community settings. The aim is to enhance the care given to babies by parents, where one or both suffer from a mental illness. Post Adoption Depression JL Payne Johns Hopkins School of Medicine, Baltimore, MD Email: [email protected] In order to evaluate the prevalence of and factors associated with post adoption depression, one hundred and twelve adoptive mothers of infants under 12 months of age were recruited from local and national adoption organizations. A modified Edinburgh Postnatal Depression Scale (EPDS) and a questionnaire collecting medical and psychiatric history, perceived stress, and demographics were administered retrospectively. The rates of significant depressive symptoms (defined as EPDS ≥12) were calculated at three time points post adoption, and associations with specific clinical variables (personal or family psychiatric history, stress, and adjustment difficulty) were assessed. Eighty-six mothers were included. Rates of significant depressive symptoms (EPDS ≥12) were found in 27.9% of subjects at 0–4 weeks, 25.6% at 5–12 weeks, and 12.8% at 13–52 weeks post adoption. Significant depressive symptoms were not associated with personal or family psychiatric history but were associated with stress (p=0.0011) and adjustment difficulties (p=0.042) post adoption. Significant depressive symptoms were relatively common in adoptive mothers within the first year after adoption and were associated with environmental stress. Prospective studies are needed to confirm the existence of post adoption depression and the factors associated with it.

S44 The Prevalence and Risk Factors of Postpartum Depression in Poland KM Rabenda-Lacka Prywatny Gabinet Ginekologiczny, Zielona Góra, Poland Email: [email protected] Objective: The aim of the study was to assess the prevalence of postpartum depression (PPD) in Lubuski province (Poland), and to identify the risk factors in this population. One year observation was conducted to find the possible seasonal differences in prevalence of PPD. Method: The study was conducted from September 2004 until October 2005. 1240 women (from 1259), staying home 3 weeks after delivery, were enrolled by midwives. Polish version of Edinburgh Postnatal Depression Scale (EPDS) was used. The mothers who scored 12 and more in the EPDS were considered to suffer from PPD. 3 weeks later, the women were asked about their mood changes. To find obstetrical, sociodemografical and psychological factors of PPD, 17 questions–interview was constructed. The obtained data was statistically analyzed. Results: 9,5% of examined women were found to suffer from PPD according to EPDS. From the 9,5% with PPD, 40% had an episode of disease longer than 3 weeks. In this study, the risk factors of PPD are: past history of depression, premenstrual tension or dysphoric syndrome, unemployment, being single and premature delivery. The prevalence of PPD varies in different months—it is higher in autumn and winter (for example 22,9% in November and 6,4% in July). No association was found between PPD and; age, parity, education, economic situation, type of delivery, anesthetic method for caesarean section, hospitalization-time, breastfeeding, child health problems, family history of depression. Conclusion: This study confirms that PPD is a common disorder in Poland. One of every ten mothers is affected. The identified risk factors may help in finding a group of women considered to be at risk of developing a PPD. The fact that depression occurs more likely after preterm labor, motivates us to prevent it ever more effectively. The seasonal difference of prevalence of PPD should be taken into account in the next studies. Linking Maternal Mental Health Services and Research: Lessons from A Developing Country GN Rao, PS Chandra, G Gururaj, M Varghese Departments of Epidemiology and Psychiatry National Institute of Mental Health and Neurosciences, Bangalore, INDIA Email: [email protected] Objective: In developing countries, service delivery takes precedence over research; for maternal mental health services, it is an ethical imperative. Combining evidence-based research with service delivery is very much essential and helps in improving pregnancy related outcomes for both mother and child Method: A “problem-solving” approach with a “missed-opportunity” perspective was adopted. Reviewing available evidence regarding maternal mental health problems from the Indian subcontinent, an

K.L. Wisner operational research project was undertaken in an urban health centre. Health care seeking patterns of pregnant mothers were examined and linked with existing health care delivery system of Bangalore city. Additional “evidence” was gathered through purposive exploration regarding burden of psychological distress in antenatal and postnatal women in 2 private, 2 missionary and 1 public sector health care setting,. The knowledge and practice of responders for management of depression and anxiety by health care personnel was assessed using case-vignettes along with key informant interviews. Results: Four-hundred ante-natal women were followed up during delivery and at 4–5 months post-delivery. Psychological distress measured by GHQ12 and EPDS indicated differing proportions during the three reference periods. All screen-negatives were negative, 60 to 80% of the screen-positives were diagnosed as cases by the psychiatrist.. Psychological distress (GHQ positivity) was 26.3% among ante-natal women (n=99) and 39.4% amongst postnatal women (n=99) from the cross-sectional interviews. Case vignettes analysis revealed that the doctors knowledge were limited to labeling the patient as either “depression” or “anxiety” and management strategies were inadequate. The health workers were able to identify women in the case vignettes to have “some mental problem”. Key informants were willing to set up maternal mental health services and also listed the challenges and possible solutions for service delivery. Conclusions: The multi-pronged research has helped in delineating and strengthening maternal mental health services for Bangalore. The focus was to identify service delivery in a “missed-opportunity” model. Ensuring recognition of problem at early stages, continuity-ofcare and quality (addition of a mental health component) in service delivery remain as major concerns. The way forward is through integration of mental health with reporoductive and child health and linking research endeavors with service delivery mechanisms. Correlates of Risk for Recurrent Illness in Women with Postpartum Psychosis E Robertson Blackmore1, N Craddock2, D Rubinow3& I Jones2 1

Department of Psychiatry, University of Rochester, Rochester NY MRC Centre in Neuropsychiatric Genetics and Genomics, Cardiff University, UK 3 UNC School of Medicine, North Carolina, USA Email: [email protected] 2

Objective: It is well established that women who experience an episode of postpartum psychosis are at increased risk of suffering from further episodes, both related and unrelated to childbirth. In order for clinicians and women to make informed decisions regarding future family planning and illness management, it is necessary to ascertain accurate risk estimates for future illness and to determine whether specific clinical predictors can further refine the risk for the individual. Method: Data were obtained from a well-characterized sample of 129 women who had experienced at least one episode of postpartum psychosis. Clinical, psychosocial and obstetric correlates were analyzed in order to model risk. Results: We found that 62% of women experienced at least one affective episode unrelated to childbirth. Having a positive family

The Marcé International Society International Biennial General Scientific Meeting history of mental illness significantly predicted a quicker time to relapse (log rank statistic 6.53, df=1, p<0.01). Half of the women went on to have at least one pregnancy following the index episode of PP. The risk of having a PP episode in the delivery immediately subsequent to the index episode of PP is 61.4%. The mean time between the index and subsequent PP episode was 4.0 years (SD=2.5, 1–12 years) and was not predictive of illness. The biggest predictors of PP in the subsequent delivery were the duration of the index PP episode (OR 1.02, 95% 1.01–1.04) and having a female relative who experienced a postnatal psychiatric illness (OR 4.09, 95%CI 0.69–24.19). The risk of suffering from a further PP in any subsequent delivery was 57%. A comparison of deliveries affected and unaffected by postpartum psychosis found that primiparity (OR 3.76, 95%CI 1.94– 7.27, p<0.001) and experiencing delivery complications (OR 2.68, 95%CI 1.15–6.25, p<0.02) significantly differentiated postpartum psychotic episodes. Conclusions: We found comparable risk of experiencing puerperal and non-puerperal episodes of illness. A positive family history of mental illness appears to increase risk for timing and occurrence of further illness. Trauma But Not Depression is Associated with Pro-Inflammatory Cytokines in Pregnancy Robertson Blackmore E1, Moynihan J1, Rubinow DR2, Pressman EK1, Walton J1, Gilchrist M1 & O’Connor TG1 1

University of Rochester Medical Center, Rochester, NY, 2 UNC Chapel Hill Email: [email protected] Objective: Depression and anxiety during pregnancy affect 15% of women and predict adverse maternal, obstetric and child outcomes. Risk factors include a personal or family history of mood disorder, low social support, and childhood trauma. Inflammation, specifically increased circulating levels of IL-6 and TNF-alpha, may also predict mood symptoms in pregnancy. That is an important possibility given the links between inflammation and poor obstetric outcomes. This study examined the association between mood symptoms and trauma and markers of inflammation, and their prediction of obstetric outcomes. Method: We prospectively followed 126 pregnant women (20– 34 years) considered at high psychosocial risk (74% received Medicaid). Subjects underwent detailed clinical interview at 18 and 32 weeks gestation and reported on dimensional scales of symptoms; blood samples were drawn at each assessment. Results: Results indicated stability of individual differences in IL-6 (r=.64) and TNF-alpha across pregnancy (r=.79), and a mean increase in both (ES =.4 and .26, respectively). There was no reliable association between inflammation and depressive symptoms at either prenatal assessment. However, trauma exposure was significantly associated with elevated levels of TNF-alpha (F(1,124)=4.31, p<.05) in a repeated measures analysis of variance. Conclusions: We found no support for the hypothesis that mood symptoms predict obstetric outcomes via their association with inflammation. The current findings build on and extend research on

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psychoneuroimmunology and perinatal mental illness, and signal trauma exposure as a target in future studies. Prenatal Stress and Risk of Child Behavioural Morbidity: The Influence of the Number, Type and Timing of Stressful Life Events M Robinson1, 2, E Mattes1, WH Oddy1, CE Pennell3, A van Eekelen1, NJ McLean2, P Jacoby1 J Li4, NH de Klerk1, SR Zubrick4, FJ Stanley1 & JP Newnham3 1

Telethon Institute for Child Health Research, Centre for Child Health Research, The University of Western Australia 2 School of Psychology, The University of Western Australia 3 School of Women’s and Infants’ Health, The University of Western Australia at King Edward Memorial Hospital 4 Centre for Developmental Health, Curtin University of Technology Email: [email protected] Objective: The maternal experience of stressful events during pregnancy has been associated with a number of adverse consequences for behavioural development in offspring. However, the measurement and interpretation of prenatal stress varies among reported studies. Further, little was understood about whether and how the number; type; and timing of stressful life events might influence subsequent child behavioural development between two- and 14-years of age. Method: The Western Australian Pregnancy Cohort (Raine) Study recruited 2900 pregnant women and recorded life stress events experienced at 18 and 34 weeks gestation along with extensive sociodemographic data. Behavioural assessments were conducted at ages two, five, eight, ten and 14 years using the Child Behaviour Checklist (CBCL). Logistic regression models with generalized estimating equations were used to assess the relationships between the maternal experience of life stress events and child behavioural problems. Results: The maternal experience of increasing numbers of stressful events during pregnancy was associated with a higher risk of behavioural problems for offspring compared with those who were exposed to none. Events that were defined as independent (e.g. death of a relative, involuntary job loss) and dependent (e.g. financial problems, marital problems) were both significantly associated with greater mental health morbidity between age two- and 14-years. Exposure to stressful events in the first 18 weeks of pregnancy showed stronger associations with total and externalizing morbidity than events occurring between 18 and 34 weeks gestation, although both were significantly predictive of behavioural morbidity. These results were independent of other pre- and postnatal influences, including postnatal stress exposure. Conclusions: The maternal exposure to life stress events during pregnancy has long-lasting consequences for mental health of offspring during childhood and adolescence, independent of later stress exposure. Experiencing multiple stressful events during pregnancy was also associated with: i) an increased likelihood for the mother to be further exposed to stressful events after birth, and; ii) indicators of general social disadvantage. Improved support for women with chronic stress exposure during pregnancy, particularly women with social disadvantage, is likely to improve the mental health of their offspring in later life.

S46 Legal and Ethical Challenges In Research with Pregnant Adolescents AJ Rohan1, C Monk2, K Marder2, N Reame1,2 School of Nursing1, School of Medicine2, College of Physicians & Surgeons, Columbia University, New York Email: [email protected] Objective: On any given day in the United States, more than 1100 adolescents give birth, and massive evidence demonstrates that their children are at increased risk for adverse perintal outcomes. New data for 2006 indicate that the birth rate for U.S. adolescents ages 15– 19 years old increased by 3% since 2005, the first increase since 1991 {Hamilton, 2007 #3174}. The population of adolescent girls is expected to grow by 10% by 2010 {Klein, 2005 #2729}, elevating further the number of births to teens. There is a public health, as well as scientific, imperative to understand the factors contributing to these poor birth outcomes, yet research with this population engenders ethical and legal dilemmas, which vary between states. Our aim is to describe these challenges and possible resolutions to facilitate future research. Method: A description of a recently funded, NIHM study on stress in adolescent pregnancy will provide a case example of the issues encountered when seeking IRB approval for the project. Specifically, the scientific necessity to screen for substance use raised clinical, ethical, and legal issues with respect to mandated reporting laws that are applied to substance-using pregnant women. The history of legislative actions and health care policies in cases of substance-using pregnant women will be reviewed, as well as state-to-state variation in reporting laws, and the added complication of finding substance use in a pregnant minor. Results: A proactive, non-punitive response to a positive toxicology test in a pregnant adolescent research participant, is recommended— one that satisfies legal imperatives, the ethical obligation to address the detection of illicit substance use in a pregnant woman, and the protection of research participants’ confidentiality, at least in most states. Conclusion: In pursuing studies with pregnant adolescents, researchers need to be cognizant of unique ethical and legal demands, and of the circumstances that can trigger legislative intrusion into the confidential relationship between research participant and investigator. The Swedish Validation of Edinburgh Postnatal Depression Scale- EPDS During Pregnancy Rubertsson C1, Börjesson K2, Berglund A3, Josefsson A4, Sydsjö G4 ¹Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala Obstetrics and Gynaecology, ²Division of Obstetrics and Gynaecology, Karolinska University Hospital, Huddinge, 141 86 Stockholm, ³Department of Obstetrics and Gynaecology, Central Hospital, 721 89 Västerå, 4Division of Obstetrics and Gynaecology, Department of Clinical and Experimental Medicine, Linköping, University, 581 83 Linköping Email: [email protected] Objective: During pregnancy or the first year postpartum 10–15% of women suffer from depressive illness. Depression may have negative effects on the woman’s social and personal adjustment, marital

K.L. Wisner relationship and mother–infant interaction. Depression during pregnancy also constitutes a risk for adverse obstetric outcomes such as preterm birth. Postpartum depression is frequently preceded by antepartum depression and anxiety. Both antepartum and postpartum mood disorders represent a separate risk for behavioral and emotional problems in the infant and the developing child. The EPDS is the most frequently used screening tool for detection of depression during the childbearing period of life. However, there are few validation studies during pregnancy. The aim of this study was to validate the EPDS in a pregnant population in order to establish a reliable cut-off for screening purposes in antenatal care settings. Method: In a population based community sample of 1.175 pregnant women, 918 women (78%) answered a questionnaire with EPDS and HADS (Hospital Anxiety and Depression Scale). In all, 121 were interviewed using the PRIME-MD (Primary Care Evaluation of Mental Disorders) for diagnosing depression. The PRIME-MD is a psychiatric structured diagnostic interview designed for primary health care based on the DSM-IV. At the time of interview the women were in mean gestational week thirteen (range 8–21). For the EPDS scale a ROC- curve was calculated for prediction of depression. Pearson’s correlation coefficients were used to investigate the association between the EPDS and the HADS scores. Results: The optimal cut off score on the EPDS scale for detecting depression was ≥13 (standard error coefficient of 1.09 and c-statistics of 0.84) giving a sensitivity of 77 % and specificity of 94%. The EPDS scores correlated strongly with the HADS, Pearson’s correlation was 0.83 (p<0.0001). Conclusion: This study confirms that the EPDS is a valid screening instrument for detection of depressive symptoms during pregnancy. The EPDS shows convincing measuring outcomes with an optimal cut-off at ≥13. Antenatal care should consider screening procedures and follow up routines for depressive symptoms. Contributions of Reproductive and Perinatal Research to the Field of Psychiatry DR Rubinow UNC Healthcare/School of Medicine, USA Email: [email protected] Environmental modulation of neurodevelopment is one of the hottest areas in behavioral neuroscience. The cornerstone of this field of investigation is the report from WC Young’s lab in l959 that postnatal, brief exposure to administered androgens could program the CNS to respond post-pubertally with markedly different behaviors from those in whom prenatal exposure did not occur. These studies gave rise to the organizational and timing hypotheses, which stated that the neural and behavioral consequences of hormone changes/exposure differ dramatically as a function of critical developmental windows and timing following hormonal manipulations. More recently, these hypotheses have been applied to the other member of the perinatal dyad, the mother, in an attempt to understand why the puerperium represents a period of enhanced vulnerability to affective disturbance. Once again, the principles that have emerged from studies of behavior during periods of reproductive endocrine change (and the puerperium in particular) may guide subsequent insights into the neurobiology of affective dysregulation in general: 1) reproductive steroids regulate virtually every system implicated in the pathophysiology of depression; 2) changes in reproductive steroids alter neural receptor

The Marcé International Society International Biennial General Scientific Meeting pharmacology with attendant behavioral consequences (i.e., hormonal dynamics convey CNS regulatory information); 3) reproductive steroids can, in controlled trials, be demonstrated to regulate affective state; 4) reproductive states can unmask genetically-determined behavioral abnormalities; 5) reproductive steroids trigger affective states only in a susceptible population (with both hormonal state and susceptibility constituting contextual factors that dictate whether a depression occurs). The recently demonstrated ability of reproductive steroids to bias brain region-specific activation and regional connectivity suggests a means by which affective state selection or dysregulation may occur in reproductive endocrine-related mood disorders. Elucidation of the contextual effects of reproductive steroids on the brain will better enable us to identify women at risk for perinatal mood disorders. Summary of the Proposed Rule on the FDA Pregnancy and Lactation Labeling L Sahin FDA, Washington, DC Email: [email protected] For the full report, see the website: www.fda.gov/Drugs/DevelopmentApprovalProcess/Development Resources/Labeling/ucm093310.htm Under FDA’s proposed rule, the labeling would contain two subsections: one on pregnancy and one on lactation. The current pregnancy labeling uses five categories—A, B, C, D, and X. The categories may mislead healthcare providers (and the women they counsel) to believe that risk increases from category A to B to C to D to X. In fact, that is not the case, because Categories C, D, and X are based not just on risk, but risk weighed against benefit. That means that a drug in categories C or D may pose risks similar to a drug in Category X. In addition, the categories do not always distinguish between risks based on human versus animal data findings or between differences in frequency, severity, and type of fetal developmental toxicities. The proposed rule would remove the categories from the labeling of all drug products. Both the pregnancy and lactation subsections would have three principal components: a risk summary, clinical considerations, and a data section. Pregnancy Subsection: Fetal risk summary, clinical considerations, inadvertent exposure, prescribing decisions for pregnant women, data (detailed discussion of available data with human data before animal data, with a description of the types of studies available), contact information for pregnancy exposure registries, and a general statement about background risk (all pregnancies have a background risk of birth defects, loss, or other adverse outcome regardless of drug exposure). Lactation Subsection: risk summary, clinical considerations and data. Pregnancy: A Crucial Developmental Phase for Lifelong Health Y Sadovsky University of Pittsburgh, Pittsburgh, PA Email: [email protected] Diverse stressors during pregnancy may perturb critical embryonic gene-environment interactions. Insults to the feto-placental unit, such

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as maternal vascular disease that reduces placenta perfusion, infections, pharmacological or environmental exposures can interfere with fetal progress through normal developmental milestones, culminating in intrauterine death, fetal growth restriction, or medically indicated preterm delivery. Newborns surviving intrauterine insults are at risk of death, lung disease, sepsis, neurological dysfunction, and other complications of low birth weight or prematurity. Later in childhood, these children exhibit a higher incidence of neuro-developmental dysfunction. Recent epidemiological data also indicate that adults exposed to intrauterine insults are at risk of the adult metabolic syndrome, including type-2 diabetes, hyperlipidemia, hypertension, obesity, and related illnesses. Additionally, obstetrical complications that cause intrauterine fetal injury have been associated with abnormal stress response, anxiety, personality changes, and even psychotic disorders later in life. Development of the eutherian fetus is entirely dependent on intact placental function. Within the placenta, the trophoblast layer actively regulates processes that are essential for fetal development, including gas exchange, supply of nutrients, removal of waste products, hormonal support, and immunological defense. Although our insights into molecular pathways that regulate placental development have markedly improved, the mechanisms governing placental response to injury remain largely unknown, impeding breakthroughs in clinical approach to fetal maldevelopment. We will discuss approaches designed to analyze feto-placental adaptations to intrauterine injury. Our studies may shed light on antenatal preventive measures designed to mitigate fetal stress, and thereby reduce the incidence of neonatal, childhood, and adult disease. Examination of Fetal Neurobehavior At the Time of Exposure to Maternal Depression and Antidepressant Use AL Salisbury Departments of Pediatrics & Psychiatry and Human Behavior, Alpert Medical School at Brown University, Brown Center for the Study of Children at Risk, Women and Infants Hospital, 101 Dudley St, Providence Rhode Island 02905, USA Email: [email protected] Objective: Major Depressive Disorder (MDD) occurs in 10–15% of pregnant women, with greater than 30% of affected women choosing to take antidepressant medications for treatment. Although some data exists about the effects of these medications in the newborn, little is known about fetal behavior during the exposure. Method Pregnant women (N=158) were interviewed for current and past psychiatric history using a semi-structured interview (SCID-IVNP). The timing of exposure to medication and psychiatric illness as well as drug doses of SRIs was recorded on a graphic timeline. Fetal neurobehavior was recorded at 26 and 36 weeks gestational age (GA) using ultrasound and fetal actocardiograph monitoring for 60 minutes (40 min baseline, 3 sec stimulus, 20 min post-stimulus). Ultrasound video recordings were played back in the lab and scored in 10 second epochs for the presence of fetal behaviors. Newborn neurobehavior was then examined at 24–48 hours after delivery. Analyses were conducted using 2 (SRI) X 2 (MDD) ANCOVA’s, forming 4 groups: a no-exposure control group, a SRI-exposed, no MDD group, a Major Depression/No SRI group and a group with both exposures (SRI + MDD). Results: Fetuses exposed to SRI antidepressants had more “stresslike” behaviors at both 26 and 36 weeks gestational age, higher

S48 activity levels, and an increased heart rate response to a vibroacoustic stimulus at 36w GA compared to non-exposed fetuses. Fetuses exposed to untreated maternal depression had a lower baseline heart rate and a prolonged FHR reactivity to the stimulus at 36w GA compared to non-MDD exposed. Conclusion: Both prenatal use of SRI medications and maternal depression are associated with less optimal fetal neurobehavior at the time of exposure. Ongoing studies are currently evaluating the longer term implications of these findings. Influences of Maternal Mood, SRI Treatment, Anxiety, and Sleep on Fetal and Infant Neurobehavior AL Salisbury Departments of Pediatrics & Psychiatry and Human Behavior, Alpert Medical School at Brown University, Brown Center for the Study of Children at Risk, Women and Infants Hospital, Providence Rhode Island, USA Email: [email protected] Objective: Major Depressive Disorder (MDD) occurs in 10–15% of pregnant women, with over 30% of affected women choosing treatment with serotonin reuptake inhibitor antidepressants (SRIs). Previous studies have linked both MDD and use of SRIs to transient neurobehavioral disturbances in the newborn. The purpose of this study was to examine the influence of maternal sleep and anxiety on fetal and infant neurobehavior in infants prenatally exposed to MDD and/or SRIs. Method: Pregnant women (N=158), ages 18 to 40 were enrolled in a larger study of neurobehavioral development of fetuses prenatally exposed to maternal MDD and/or SRIs. Women were interviewed using a semi-structured interview (SCID-IV-NP). The timing of exposure to medication and psychiatric illness was recorded on a graphic timeline. Clinical interviewers also rated maternal symptoms of mood and anxiety using the Hamilton Depression Rating Scale (HDRS) and the Hamilton Anxiety Inventory (HAM-A). Mothers filled out self-report measures of mood symptoms (BDI), sleep (PSQI), and anxiety (STAI). Fetal neurobehavior was recorded at 26 and 36 weeks gestational age (GA) using ultrasound and fetal actocardiograph monitoring for 60 minutes. Ultrasound video recordings were played back in the lab and scored for the presence of fetal behaviors. Newborn neurobehavior was examined in the first week after delivery. Analyses were conducted using ANCOVA and Multiple Regression. Results: Women diagnosed with MDD during pregnancy reported more sleep disturbance and higher levels of anxiety through the 3rd trimester than women without MDD, regardless of treatment with SRI medications. Women who were taking SRIs throughout the pregnancy and had MDD remission also reported higher sleep disturbance scores than controls. Higher maternal PSQI scores were related to less optimal fetal and infant neurobehavioral measures, more infant active sleep and less quiet sleep independent of maternal depression and anxiety scores. Conclusion: Women in this sample who were taking SRIs consistently and had remission of mood symptoms still reported significant sleep disturbances during the pregnancy. Although MDD and use of SRIs both contribute to less optimal fetal and newborn neurobehavior, poor maternal sleep was differentially related to measures of arousal and state control in both the fetus and infant.

K.L. Wisner The Hormone Withdrawal Model of Postpartum Depression: A Translational Approach CE Schiller, MW O’Hara, AK Johnson The University of Iowa Department of Psychology, Iowa City, IA, USA Email: [email protected] Objective: This research includes a series of experimental animal studies and a longitudinal human study that are designed to test the hormone withdrawal hypothesis, which attributes the onset of PPD to the rapid postpartum withdrawal of the ovarian hormones estradiol and progesterone. We hypothesize that estradiol and progesterone withdrawal in rodents will cause increased behavioral despair, anhedonia, and anxiety. In the human study, we expect that 1) decreases in estradiol will be prospectively associated with increases in depressed mood, anhedonia, and anxiety; and 2) these associations will be stronger in women with a past episode of PPD compared to those without a history of PPD. Method: In the animal study, rodents’ ovaries are removed, and they receive placebo only or estradiol and progesterone injections for 5 days. Behavioral tests occur during hormone administration and the withdrawal period. Rats are given the forced-swim test to measure behavioral despair; lateral hypothalamic self-stimulation to measure anhedonia; or the elevated plus maze to measure anxiety. In the human study, participants complete interviews and questionnaires during the third trimester and at two weeks postpartum. Women make mood ratings and collect saliva samples every morning starting 20 days before the due date and continuing until 10 days postpartum. Results: Data collection is underway. Preliminary animal results indicate increased anhedonia during estradiol withdrawal [t(5)=2.66, p=0.05; d=1.0]. Preliminary human results show a significant prospective association between estradiol and negative affect in women with a history of PPD (r=−0.57, p=.003), but not in women who have never been depressed (r=−0.05, p=.54). Conclusions: Animal results demonstrate that estradiol withdrawal causes anhedonia in rodents. This finding extends the existing literature, which demonstrates that estradiol withdrawal causes behavioral despair and anxiety. Preliminary human results suggest that perinatal estradiol is inversely associated with negative affect in women with a history of PPD. Conversely, perinatal estradiol and mood symptoms are not associated in women without a history of depression. Taken together, results of the animal and human studies demonstrate that estradiol withdrawal is associated with depressive symptom, suggesting that estradiol withdrawal may be a significant neurobiological mechanism of PPD. Disseminating Perinatal Depression Screening as A Public Health Initiative: S Train-the-Trainer Approach LS Segre1, RL. Brock1, MW O’Hara1, LL Gorman1, J Engeldinger2 1

University of Iowa, USA University of Iowa Hospitals and Clinics, USA Email: [email protected]

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Objective: This presentation will describe the development and implementation of the Train-the-Trainer: Maternal Depression

The Marcé International Society International Biennial General Scientific Meeting Screening Program (TTT), a novel approach to disseminating perinatal depression screening. Method: We trained lay health and social services providers to screen for maternal depression according to a standard pyramid scheme of train-the-trainer programs: three experts trained representatives from social service health care agencies (the TTT trainers), who in turn trained their staff and implemented depression screening at their home agencies. The TTT trainers had little or no prior mental health experience so “enhanced” components were added to ensure thorough instruction. Results: Although TTT was implemented primarily as a services project, we evaluated both the statewide dissemination and the screening rates achieved by TTT programs. Across three cycles 42 trainers from 32 agencies completed the TTT program. These trainers were distributed in 19 counties in Iowa resulting in coverage of 58.2% of the population. In the 16 programs that provided screening data for the three months immediately after implementing screening, the average screening rates were 73.2%, 80.5% and 79%. Comparison of screening rates of TTT programs with those achieved by Healthy Start (where screening was implemented as a result of direct intensive consultation from perinatal depression experts) indicate that screening rates achieved by at least half of TTT agencies were comparable. Conclusion: Our “enhanced” train-the-trainer method is a promising approach for broadly implementing depression-screening programs in agencies serving pregnant and postpartum women. Disposition of Antidepressants Across Childbearing: Impact on Dosing DKY Sit1, J Perel1, J Luther2, J Helsel1, S Wisniewski2, KL Wisner1 Department of Psychiatry, School of Medicine, University of Pittsburgh1; School of Public Health, University of Pittsburgh2 Email: [email protected] Objective: To add to the limited data on the clinical pharmacology of antidepressants during pregnancy, we examined the dose requirements and dose-corrected chiral and racemic levels (level/dose = L/D) of citalopram, escitalopram, sertraline and fluoxetine during pregnancy and after birth. Methods: Doses were charted across each week of gestation and postpartum. At 20, 30 and 36 weeks gestation, delivery and 12 weeks post-delivery, the investigators obtained blood samples and assessed depression levels with the Structured Interview Guide for the Hamilton Depression Rating Scale, Atypical Depression Symptoms Version (SIGH-ADS). Steady-state plasma levels were analyzed for concentrations of the stereospecific parent drug and metabolites. Results: In four of five subjects who received citalopram or escitalopram and five of six 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. The mean ratios of the racemic and chiral fluoxetine to norfluoxetine levels from 17 patients decreased across pregnancy. The differences were significant between 20–36 weeks and 30–36 weeks. The antidepressant L/D ratios increased significantly between delivery and 12 weeks postpartum. Conclusion: The findings extend earlier reports of increased antidepressant metabolism during pregnancy and refractory metabolism after delivery. Dose requirements may increase during

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the second half of pregnancy to offset increased drug turnover and maintain optimal pharmacotherapy. The data inform treatment decisions related to antidepressant dosing in patients during pregnancy. Controlled Clinical Trial of Antepartum Interpersonal Psychotherapy Versus Parenting Education Program at 3 NYC Sites MG Spinelli, J Endicott Columbia University College of Physicians and Surgeons, NYS Psychiatric Institute Email: [email protected] Objectives: The 10–13% prevalence of Antepartum Depression (APD) increases twofold in women with poor social supports, low socioeconomic status (SES) and negative life events. APD causes low birth weight, prematurity and eclampsia and is one of the best predictors of postpartum depression (PPD), which in turn causes impaired infant and childhood emotional and cognitive development. Therefore, treating APD is a method of primary and secondary prevention by treating parents of children at risk. Data from the National Comorbidity Study illustrated that effects of ethnicity and race must be examined in the context of SES and psychosocial variables in order to determine disparities in care and treatment outcome. Methods: Three NYC sites (New York State Psychiatric Institute / New York Presbyterian Hospital at Columbia, New York Presbyterian Hospital at Cornell and St. Luke’s Roosevelt hospital) provided a diverse sample (N=128) and equal proportions of Hispanic, African American and White depressed pregnant women. Each subject was randomized to 12 weeks of Interpersonal Psychotherapy (IPT-P) or Parenting Education Program (PEP), then followed for 6 months postpartum to assess mood and maternal infant attachment. Depressed mood was measured using the Edinburgh Postnatal Depression Scale and the Hamilton Depression Rating Scale. The Clinical Global Impression (CGI) scale measured recovery. Results: According to our preliminary findings at the time of this abstract, both the IPT-P group and the PEP group showed significant improvement from baseline to week 12 on all measures of mood. At this time, there is no significant difference between groups. Final outcomes will be determined when the entire sample (N=150) completes treatment. Conclusions: Interpersonal psychotherapy is an effective method of antidepressant treatment during pregnancy. Parenting education may also have beneficial mood effects during pregnancy. The Dissemination Dilemma: Is Effectiveness Too Far A Reach? B Stafford1, R Clark2, S Goodman3, S Dimidjian4 1

University of Colorado, Denver University of Wisconsin, Madison 3 Emory University 4 University of Colorado, Boulder Email: [email protected] 2

Objective: Basic science research into the effects of postpartum depression on infant development has led to the discovery of significant insights that have led to the development of theoretically

S50 sound clinical interventions. Women who have public insurance have the highest rates of postpartum depression—as high as 50%—and are unlikely to be identified or receive treatment. Whether these clinical interventions have a possibility of demonstrating clinical efficacy in a community service sector is unknown. Method: An intervention should meet several criteria to be chosen for dissemination, including the following characteristics: 1) Incorporates both well validated theory and integrates the findings of empirical studies 2) Has benefits that are easily observable and welldocumented, 3) Is relevant to adopter’s current work[, 4) Knowledge required for its use is easily available or provided, 5) Offers unambiguous advantages in effectiveness relative to current practice and is cost-effective, 6) Is compatible with adopters’ values, norms, needs, 7) Can be adapted, refined, modified for adopter’s and participants’ needs without threatening the validity of the evidence base, 8) Is low risk, 9) Is simple to implement, and 10) Can be experimented with on a trial basis. The dissemination of an evidenced based psychotherapeutic intervention for postpartum depression into two systems, the community mental health center system in Denver and a Hispanic pediatric setting in Chicago will be described. Results: Directors and staff of Community Mental Health and other Health Centers can be engaged around this topic since it can serve as a focus of treatment and prevention, but significant stigma, logistic, public insurance, and access issues can make uptake challenging. The identification of a champion within the system is essential for successful translation to the clinical service sector. Whether such a psychotherapeutic program can succeed in a local mental health center or other health care setting, and the definition of what success is for community perinatal mental health will be discussed. Conclusion: The Mother Infant Therapy Group is a promising model that meets many criteria for dissemination. The challenges to implementing a program itself are significant and will be discussed with ideas for alternative and feasible solutions. The Promise and Perils of Bringing Translational Clinical Research Out of the Research Setting and Into Academic Practice B Stafford The Children’s Hospital; University of Colorado, Denver Email: [email protected] Objective: The implications of the developmental understanding of the effects of postpartum depression on the infant should inform treatment for the family. Few evidenced based psychotherapeutic interventions are available outside of research settings. At present, only one clinical intervention with an evidence-base addresses the mother–infant relationship and the infant’s contribution to parenting stress. Little is known about the ability to bring a researched clinical intervention into a community practice, and whether what is efficacious is also effective. Method: With support from local foundations, our team was trained by Dr Clark in the MITG intervention. Significant system-linking work was completed through the development of a referral network of pediatricians, obstetric providers, and community therapists. The barriers to dissemination of an efficacious intervention dilemma were approached based on current recommendations.

K.L. Wisner Results: Our group launched with significant interest and success. Our program was well-received as a free community therapy group—with engagement rates at 93%, and significant improvement on levels of depressive and anxiety symptomatology. Due to budget constraints, a transition to a more clinical intervention that requires private insurance billing, insurance authorization, and co-pays occurred. The promise and perils of bringing evidenced-based clinical interventions outside the academic research setting given significant health care barriers will be discussed. A new model of treatment that eventually evolved from this process that is more flexible and, ultimately, sustainable will be presented. Conclusion: Clinical psychotherapeutic interventions to treat postpartum depression are successful but, at present, partial approaches given their high recurrence rates, inability to show improvement in parent– child and mother–partner relationships, and lack of adopting a broader transaction theoretical framework. Whether evidenced-based interventions are effective outside of the research setting or whether they can be sustainable are important questions so that efficacious interventions can be suitably selected and supported for dissemination based on population needs and clinical skill. Interpersonal Psychotherapy (One-Day Course) S Stuart, MW O’Hara University of Iowa, USA Email: [email protected] Educational Objectives: At the end of the course, the participants should be able to: 1)Demonstrate knowledge of interpersonal theory and IPT research literature 2) Conduct Interpersonal Psychotherapy (IPT) and utilize IPT techniques. Course Description and Format: This course is designed to instruct participants in the theory and practice of Interpersonal Psychotherapy (IPT). It will consist of didactic presentations and a review of the research evidence supporting IPT, followed by a multimedia presentation of IPT with depressed patients. Interspersed in this section of the presentation will be videotapes of the course director and other experts conducting IPT with depressed individuals. Group discussion will help participants synthesize the information and examples presented. The class is designed for psychotherapists with some experience in dynamic psychotherapy, and presumes that participants are well acquainted with basic psychotherapy principles, such as the ability to effectively engage patients, to formulate cases, and to use specific psychotherapy techniques. Articulation of Mother and Baby Units and Network Cares in Perinatality AL Sutter-Dallay, E Glatigny-Dallay, N Loustau, C Renom, D Grimaldi, H Verdoux University Department of Adult Psychiatry, Perinatal Psychiatry network Charles Perrens Hospital, 121 Rue de la Béchade, 33000 Bordeaux, France Email: [email protected] One of the main characteristic of perinatal psychiatry is the complexity of care, associating curative (helping the mentally ill

The Marcé International Society International Biennial General Scientific Meeting parent(s)) and preventive objectives (preventing risk of dysfunction in parentalization processes and parent–children relationship). Although mother and baby units represent a key component of care, a mother and baby unit alone does not exist. These units can be regarded as the ultimate level of the psychic care in perinatality, a kind of “intensive care unit” used as “reference” centers allowing to take care of the most severe cases of psychic suffering. However the quality of the psychoaffective development of the a priori healthy child mostly depends on the rapidity and on the quality of the care given to the mother. Then, only multidisciplinary network care allows to provide the continuity preserving the child mental health. Such a work should begin during the antenatal period and has to be continued after delivery with pediatricians, child and adult psychiatrists, social and educative services. To illustrate this intervention, we will present the example of the organization of perinatal psychic care in the Aquitaine region (South Western France) with a mother and baby unit articulated within the network of perinatal care (Réseau Périnat Aquitaine) and combining maternity and pediatric liaison psychiatry and links with the other institutions implicated in the psychosocial perinatal care. Evolution of Perinatal Depressives Symptoms in A Low Risk Sample A Two Year Follow-Up of the MATQUID Cohort AL Sutter-Dallay1,2, O Cosnefroy2, H Verdoux1,3, N Rascle2 1

University department of adult psychiatry, Perinatal Psychiatry Network, CH Charles Perrens, Bordeaux, France2, EA 4139, Victor Segalen University, Bordeaux 2, Bordeaux, France, 3INSERM U657, Bordeaux, France Email: [email protected] Objective: Few studies about perinatal depression have considered the evolution of perinatal depressive symptoms (PNDS) all through the perinatal period. The objectives of the present study were (I) to evaluate the existence of different evolutionary profiles of PNDS, (ii) if they exist, to identify possible risk factors for each group. Methods: In a prospective, longitudinal study from 8 months pregnancy to 2 years postpartum, repeated measures of PNDS were made on a sample of 579 women at low risk for PNDS, using the CES-D. Semiparametric mixture models were used to identify subgroups of subjects who followed distinct trajectories of PNDS. In a second step, a multinomial logistic regression was done to identify possible risk factors for each group. Results: Four distinct trajectories of evolution of PNDS were found. 70% of the women never presented depressive symptoms of clinical significance, 5,2% presented depressive symptoms only during the postnatal period, 22% presented symptoms from end of pregnancy to 2 years postpartum, with a higher intensity during pregnancy, and 3% presented stable and of very high intensity symptoms during all the follow-up. The different groups responded to different risk factors profiles. Conclusion: Differentiating subtypes of evolutionary profiles of PNDS is of crucial importance to answer the questions of the specific influence of certain risk factors or psychological at risk profiles, to enhance the development of adapted prevention strategies for maternal and child mental health.

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Influence of Psychotropic Drugs Intake During Pregnancy on Early Newborn Adaptation AL Sutter-Dallay,1,2 I Lacaze1, C Chazaud1, M Rebola3, D Dallay3, N Rascle2, NMC Glangeaud-Freudenthal ,5 H Verdoux1,4 1 Pôle Universitaire de Psychiatrie Adulte, CH Charles Perrens, Bordeaux, France 2 EA 4139, Université Victor Segalen Bordeaux 2, Bordeaux, France 3 Maternity and Pediatric Hospital, University Hospital, Bordeaux, France 4 INSERM U657, Bordeaux, France 5 INSERM UMR, S 953 Villejuif, France Email: [email protected] Objective To assess the impact of psychotropic drugs during pregnancy on newborns health condition. Method The intake of psychotropic drugs (antipsychotics, antidepressants, mood stabilizers, anxiolytics/hypnotics) during pregnancy was retrospectively evaluated in a sample of 187 women hospitalized for psychiatric disorders during postpartum in the Bordeaux's mother and baby unit (MBU working group-Société Marcé Francophone data base). The impact of psychotropic drugs was evaluated through 3 factors: duration of pregnancy, APGAR scores and hospitalization of the baby in neonatal unit. Characteristics of prenatally exposed to psychotropic drugs babies (E) (N=87) were compared with those of unexposed population (NE) (N=100) by univariates analyses. Results The APGAR scores of the E children were significantly lower, independently from premature birth or low birth weight. These children were more frequently hospitalized for neonatal cares. E children’s mothers significantly more frequently used alcohol and/or tobacco and presented more frequently schizo-affective disorders. Regarding therapeutic classes of drugs, the APGAR scores were significantly lower for exposure to all classes; babies were all more often hospitalized, and the duration of pregnancy was shorter for mothers treated with antipsychotics, and/or mood stabilizers and/or anxiolytics. Association at trend level was found between use of mood stabilizers and preterm delivery. Conclusions Newborns whose mothers used psychotropic medications during pregnancy presented with more neonatal health difficulties than those of untreated mothers. Differences of the APGAR scores between the two groups can be related to medication, but also to alcohol and/or tobacco use, which are more frequent among E women. Higher frequency of hospitalizations of those newborns can also be due to the fact that mothers presenting with serious disorders during pregnancy are sometimes hospitalized for maternal competencies evaluation. Lastly, the psychiatric condition motivating the prescription of treatment may also directly impact on the course of the pregnancy. Preventing Perinatal Depression Among Low-Income Home Visiting Clients SD Tandon1, T Mendelson1, D Perry2, K Kemp1, J Leis1 1

Johns Hopkins University, 2Georgetown University Email: [email protected] Objective: While perinatal depression treatment interventions exist in home visiting and other early childhood programs (e.g., Ammerman et al. 2009, Beeber et al., 2010), no studies have integrated a depression

S52 prevention intervention within home visiting programs. The goal of this study was to assess the efficacy of a cognitive behavioral intervention in preventing the onset of postpartum depression and reducing depressive symptoms among low-income women enrolled in home visiting. Method: The sample consisted of 77 women who were pregnant or had a child <6 months and who were assessed to be at risk for perinatal depression due to elevated depressive symptoms and/or personal history of clinical depression. Participants were randomly assigned to receive a 6-week group-based cognitive-behavioral intervention or usual home visiting services and depression information. The group intervention was led by a clinical psychologist or licensed clinical social worker. Home visitors provided 1-on-1 reinforcement of key messages by phone or in person between group sessions. Outcomes were assessed 1 week and 3 months post-intervention. Results: Study participants were predominately African American (87%), unmarried (82%), and unemployed (75%). Among the 60 participants who reached their 3-month post-intervention assessment, 9 of 29 (31%) receiving usual care developed major depressive disorder, compared with 3 of 31 (9.6%) in the intervention condition. Analysis of covariance controlling for baseline depressive symptoms indicated that intervention participants reported fewer depressive symptoms than women in the control group 1-week post-intervention (BDI-II: 11.3 vs. 14.9, p<.05). Intervention and control groups continued to differ significantly at 3-months post-intervention (8.5 vs. 12.2, p < .05). The mean number of sessions attended by intervention participants was 4.8 and the mode was 6. Conclusion: This study provides preliminary data on the efficacy of a cognitive-behavioral intervention to reduce the occurrence of major depressive disorder and depressive symptoms among low-income women in home visiting programs. Given the substantial number of women in home visiting programs nationally, there is great potential to reduce the incidence and burden of perinatal depression among large numbers of at-risk women through embedding our intervention in home visiting. Smoking in Perinatal Women is Associated with Intimate Partner Victimization, Housing Challenges and History of Mental Illness A Tareen, C Kothari, RM Charoth, B Hill, RS Tareen, MR Liepman Michigan State University/Kalamazoo Center for Medical Studies1, Kalamazoo, Michigan, USA Email: [email protected] Objective: The purpose of this study is to examine the relationship between smoking and depression, taking into account other life stressors, among a representative sample of perinatal women. Methods: Study design was mixed methods, combining telephone surveys, conducted at two weeks and two months postpartum, with retrospective review of prenatal and delivery medical records. 326 women (10% of Kalamazoo County birth population) were recruited from the postpartum floors of the two delivery hospitals over a 5month period in 2009. Information collected by survey (Edinburgh Postnatal Depression Scale) included depression symptoms/treatment, and psychosocial life stressors (housing, employment, domestic violence, etc.). Data collected through medical chart review included maternal demographics, birth outcomes, documented health behaviors including smoking. Bivariate statistical analyses were conducted using Chi-Square.

K.L. Wisner Results: Out of the 326 study participants, 50 (15.3%) women currently smoke and 94 (28.8%) previously smoked. Half as many non-smokers (22%) reported a history of mental health problems compared to smokers (44%; p<0.001). While there were fewer nonsmoking than smoking women reporting current mental health problems, the difference (28% vs. 17%) was not statistically significant (p=0.079). Intimate partner abuse was twice as likely to occur among smokers as non-smokers (36% vs. 17%; p=0.006). Housing problems occurred three times more frequently among smokers than nonsmokers (30% vs. 9%; p<0.001). Conclusions: There is an association between smoking and history of mental disorders, intimate partner victimization, and housing challenges. Smoking cessation can lead to exacerbation of depression. Bupropion, an antidepressant can assist smokers in quitting. One could speculate that smoking may be used as a coping strategy for depression or stress. Or it may be more difficult to quit smoking when one is depressed despite being pregnant. Perhaps smoking reduces severity of symptoms of mental illness such as poor concentration, dysphoria, and anxiety. Women who fail at smoking cessation should be assessed for intimate partner victimization, mental illness, and social challenges. Assistance with those problems might enhance success of smoking cessation, an important goal for peripartum women and their families. Impact of Psychiatric Care on Perinatal Mood Disorders RS Tareen1, MR Liepman1, RM Charoth1, SS Haas1, CL Kothari1, P Tatini1, U Suryadevara1, K Fore1, J Randhawa1, N Majumdar1, F Jawed1, S Williams1, B Smith1, R Flikkema2, JW McKean2 1

Michigan State University / Kalamazoo Center for Medical Studies Western Michigan University Kalamazoo, Michigan, USA. Email: [email protected]

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Objective: To determine which demographic, treatment and social variables influence mostly the outcome of psychiatric care for perinatal mood disorders. Methods: The Mother’s Mind Matters project, funded by the Blue Cross Blue Shield of Michigan Foundation, advocated for more early screening and referral of women during prenatal through postpartum care by obstetrics and other providers in the community. Over a 22 month interval, 184 women were referred to the MSU/KCMS Psychiatry’s Women’s Behavioral Health Clinic (WBHC). Edinburgh Postnatal Depression Scale (EPDS) scores were collected on 122 women, 59 of whose records documented at least two DSM-4 Global Assessment of Function (GAF) scores. EPDS and GAF score changes were measured against the following variables: age, race, marital status, insurance type, number of children in the home, unplanned pregnancy, duration of treatment, time for reduction of EPDS to less than 12, and time for GAF to exceed 69. Results: The average number of visits was 5.4(median=4, mode=3). The mean of the baseline EPDS scores was 20.5 and the mean of the most recent EPDS score was 12.38 (p<0.0001). The mean of the initial visit GAF score was 59.02 and the mean of the latest GAF was 62.35 (p<0.0002). The only significantly associated variables with EPDS reduction was race (white > non-white) and insurance type with scores of privately insured women dropping 25 times more rapidly than uninsured or Medicaid covered women. Conclusion: Prompt referral for professional help is beneficial to women suffering from perinatal mood disorders. Brief psychiatric

The Marcé International Society International Biennial General Scientific Meeting intervention with safe medications and psychotherapy represents an effective way to manage many of the most severe cases of perinatal mood disorders in our community. From Infanticide to Activism: Emotions and Identity in Health Movements V Taylor, L Leitz University of California Santa Barbara, USA Email: [email protected] Objective: Social movement scholars working in the political process have tended to overlook the significance of movements concerned with health and mental health issues because their actions purportedly do not constitute a force for political and institutional change. A stream of recent research suggests, however, that self-help, consumer health movements, and mental health movements, are an important source of collective action and a significant force for change in both the cultural and political arenas. Method: We examine one such movement, a pen-pal network of women incarcerated for committing infanticide. The network is part of a larger self-help movement that emerged in the mid-1980s focused on changing medical and legal policy and practice related to the treatment of postpartum psychiatric illness (Taylor 1996). Our study relies upon multiple data sources, including handwritten letters by women serving sentences for infanticide, a survey of imprisoned women, newsletters of the two major social movement organizations, and key informant interviews. Results: We find that the collective identity fostered by the pen-pal network triggered a profound emotional transformation in participants, making it possible for them to convert shame and loneliness into pride and solidarity. Constructing their crimes as illness allowed women both to reclaim an understanding of themselves as good mothers and to deploy their identities as mothers to pursue policy change on behalf of other mothers who kill their children. Conclusion: We conclude that emotions are an integral part of the personal and collective identities associated with self-help, support, and health advocacy groups and discuss briefly how writings on emotions and social movements have the potential to shed light on social movement processes. Incidence and Prevalence of Depression in Women and Men, During Pregnancy and After Childbirth: Comparing the Likelihood to be Depressed in Subsamples of Previously Severely Depressed and Without History of Depression F Teixeira1,2, MP Gonçalves1,2, A Monteiro1,2, EP Fonseca1,2, MEG Areias1,3 1

Department of Psychology of ISCS-N, Instituto Superior de Ciências da Saúde—Norte (CESPU) 2 UNIPSA, Unidade de Investigação em Psicologia e Saúde 3 CINEICC, Centro de Investigação do Núcleo de Estudos e Intervenção Cognitivo-Comportamental Email: [email protected] Objectives: To analyze the incidence of depression in women and men, during pregnancy and along the first year after childbirth; to

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compare the incidence of postnatal depression in women with previous history of major depression (MD) with those without any prior occurrence of depression, and the likelihood of their husbands/ partners to get depressed. Method: Two hundred women, seventy-five with lifetime history of MD and one hundred twenty-five with no prior episode of MD who were attending obstetrics services in a central hospital in Oporto, Portugal, and one hundred fifty-three of their partners participated in a longitudinal study of their mental health. All subjects were interviewed with the semi-structured clinical interview SADS-L (lifetime version) at 37 weeks of pregnancy, 6th postnatal week and one year postpartum. Results: Incidence of PND is higher in women in all evaluated periods. Women with previous history of MD contrasted to women without lifetime history of MD are significantly more likely to be depressed at six weeks (26.7% to 8.8%) and at twelve months after birth (35.9% to 15.7%). Also, the partners of the previously depressed women were more likely to be depressed than partners of those with no history of depression, especially at twelve months after birth. Conclusion: PND has a strong impact on family along the first year of baby's life, it’s thus important to follow-up and prevent negative consequences. Psychological and Marital Adjustment of Twins’ Fathers Conceived Naturally Versus By Assisted Reproduction Treatment I Tendais1, B Figueiredo1, D Ramada 2, N Montenegro3 1

University of Minho, School of Psychology Pedro Hispano Hospital 3 São João Hospital, University of Porto, Portugal Email: [email protected] 2

Objective: Few studies have examined the psychological and marital adjustment of twin fathers after assisted reproduction treatment (ART). Therefore, this study examined anxiety and depression symptoms in fathers of twins conceived naturally or by assisted reproduction treatment (ART). Paternal perception of pregnancy and the baby, sexual activity and satisfaction with the marital relationship were also analyzed. Method: A longitudinal study of twin pregnancies from early pregnancy to postpartum is being conducted among parents of spontaneously conceived twins and ART parents of twins. Anxiety and depression symptoms were assessed using the State Anxiety Inventory and Edinburgh Postnatal Depression Scale. Paternal perception of pregnancy and the baby, sexual activity and satisfaction with the marital relationship were assessed using the Paternal Adjustment and Paternal Attitudes questionnaire. Preliminary results of 11 spontaneous and 8 ART fathers of twins are presented. Results: Significant differences in anxiety and depression symptoms in the postpartum were found between naturally conceived and ART fathers of twins. ART fathers reported higher anxiety than fathers of spontaneously conceived twins, as well as more depression symptoms after childbirth. No between-group differences were observed in paternal perception of pregnancy and the baby, sexual activity and satisfaction with the marital relationship. Conclusions: Preliminary results suggest that ART twins’ fathers may be at increased risk of poorer psychological well-being during the postpartum period.

S54 An Exploration of Healing Following Postpartum Psychosis TM Twomey Postpartum Support International, USA Email: [email protected] Objective: After a woman has recovered from the symptoms of postpartum psychosis, she will likely have to cope with emotions that arise from having had this illness. I call this period the “post-recovery recovery.” In the best-case scenario, women would immediately process these emotions in a positive and healing way and achieve a full emotional recovery relatively promptly. It has been my experience that this is rarely the case. The objective of this paper is an exploration of what the emotional healing process is like for women who have had postpartum psychosis Method: A survey of women who have experienced postpartum psychosis was conducted to explore what were the things that have helped them to heal. Understanding the process of emotional healing could lead to better outcomes for women who have had this illness. Results: Although there are common factors in the healing process, many women have not or do not fully recovery emotionally from having had postpartum psychosis. Conclusion: I believe that as more women heal, more will come forward to help dispel the myths and stigma associated with this disorder. That in turn assists with preventative efforts, earlier identification and intervention, fewer tragedies, and where there have been tragedies, better and more just treatment of these women. Psychophysiological Response to Relaxation After Psychosocial Stress During Pregnancy C Urech, C Granado, I Fornaro, I Hoesli, J Bitzer, J Alder University Women’s Hospital, University of Basel, Switzerland Email: [email protected] Objective: While perception of stress increases with any mental disorder, pregnancy in general has been associated with an improved stress “immune” state. However, little is known about how pregnant women with a diagnosed mental disorder react upon stress and to what extent they are able to recover. Therefore, the aim of the present study is to investigate the stress and relaxation reactivity in pregnant women with an anxiety disorder (AD) or a major depression (MD) compared to healthy women after a stressful situation. Method: A sample of 93 pregnant women participated in a prospective study including an experimental paradigm between 32nd–34th week of gestation, which consisted of a standardized stress and relaxation intervention. Self-reported stress and relaxation, cardiovascular, endocrine as well as fetal reactivity was measured at different times during the procedure. Existence of an AD or a MD (n=27) or healthy state (n=66) was assessed with a standardized clinical interview during pregnancy week 29. Statistical analyses were computed with repeated measures analysis of variance (RM ANOVA) and analysis of covariance (ANCOVA). Results: Pregnant women with an AD or MD felt less relaxed during the entire trial (F(1,88)=4.92, p=.029) and had higher levels of anxiety and lower affect values. Healthy pregnant women showed a more pronounced reaction upon the relaxation intervention (lower levels of anxiety (p=.004), less negative affect (p=.050). Concerning

K.L. Wisner the physiological parameters diagnosed women presented significantly higher stress reactions in heart rate (F(1,87)=13.40, p<.001), diastolic blood pressure (F(1,87)=7.24, p=.009) and cortisol (F(1,78)=3.58, p=.062). Though, physiological reaction to the relaxation intervention revealed no differences between pregnant women with or without diagnosis. The analyses of the fetal reactivity are not yet completed but will be presented together with additional psychological data. Conclusion: Pregnant women with an AD or MD show a physiologically higher stress reaction upon a standardized stress situation compared to healthy pregnant women. However, physiologically but not psychologically investigated women showed the same reaction to relaxation. Therefore, specific support of women with mental disorders, for example in the context of a stress reduction program, is reasonable. An Introduction to the Methods of Randomized Clinical Trials SR Wisniewski University of Pittsburgh, Pittsburgh, PA, USA Email: [email protected] Objective: To provide a general overview of issues associated with the design, conduct and analysis of randomized clinical trials. Methods: The workshop will begin with an overview of the concept of a randomized clinical trial and the role that a randomized clinical trial plays in the evaluation of therapeutic treatments. Next design issues will be reviewed including the definition of the hypothesis to be tested and the primary endpoint, the definition of the study population, design options, strategies for randomly assigning study subjects, masking (or blinding), and sample size calculations. Study conduct issues will include discussion on quality control procedures. Finally analysis issues will include interim analyses, primary versus secondary analyses, and methods of handling missing data. Results: At the completion of the workshop, the attendees will have an understanding of the basic issues associated with the design, conduct and analysis of randomized clinical trials. Conclusions: An understanding of the basic issues associated with the design, conduct, and analysis of randomized clinical trials is essential for researchers to carry out this research as well as to critically review the growing scientific literature on therapeutic treatments for the prevention and treatment of mental illness related to childbearing.

ABSTRACTS Special Interest Groups

Perinatal Mood Disorders and the Legal Arena DL Barnes1, B Kinstler2 1 The Center for Postpartum Health, 2 Kohler and Hart, USA Email: [email protected]

Objective: Severe maternal depression carries with it impaired judgment, thought distortions and emotional detachment that increases the risk of child neglect, child abuse and even fatal injury. Four percent of women with postpartum psychosis commit infanticide. As

The Marcé International Society International Biennial General Scientific Meeting the legal community becomes increasingly aware of the impact of perinatal mood disorders on a mother’s state of mind, the question of when to utilize the expertise of a woman’s reproductive mental health specialist becomes particularly salient. Method: Putting a legal defense team together involves close collaboration between an attorney and his/her experts. In 2008, a mother in Milwaukee, Wisconsin, placed her two week old twins in the bathtub hoping she could send them to heaven where she believed they would be better cared for than anything she thought at the time she could provide. Only one of the babies survived. Attorney Brian Kinstler requested my consultation and testimony on this case along with the testimony of psychiatrist Ruta Nonacs, M.D. Our clinical role was to create a “roadmap” by tracking her reproductive and mental health history in order to determine connections between her state of mind and the events surrounding this infanticide. Through testimony, Mr. Kinstler looked to us to explain the impact of postpartum psychosis on her state of mind and how psychosis interfered with her ability to conform her conduct to the requirements of the law. Results: Alisa Evans was acquitted and remanded to a mental health institution for ongoing treatment of the bipolar disorder and severe depressive episodes that had haunted her and left her incapacitated for much of her life. Within two years, she would be able to petition for release and resume her life. Conclusions: A clinician knowledgeable in the diagnosis and assessment of perinatal mood disorders is in the best position to ascertain whether the circumstances surrounding a particular case were driven by symptoms that indicate postpartum depression or psychosis. Appointing an expert trained in women’s reproductive mental health is essential to the defense in terms of fitting together the relevant pieces of a woman’s reproductive and mental health history. Theoretical Ethics in Perinatal Mental Health Research AR Brandon UT Southwestern Medical Center at Dallas, Dallas, TX Email: [email protected] Objective: Although international pregnancy registries exist, as do observational studies, we have few randomized controlled trials (RCTs) in mental health research. Due to fear of fetal harm (even in non-pharmacological research), the regulatory climate is understandably influenced by questions about the ethics of randomization and the safety of no-treatment or wait-list control groups. This fetal protectionism has origins in the historical tragedies of thalidomide, diethylstilbestrol, and Dalkon shield use, tragedies that could have been minimized had the agents undergone clinical investigation prior to use in the community. The unfortunate result is that current research guidelines reflect the ambivalence of regulatory agencies regarding pregnant research participants, and use ambiguous language unhelpful to Institutional Review Boards (IRB). To facilitate the development of a new framework for managing the risks and benefits of participation in research, this project aimed to: 1) Identify ethical issues faced by perinatal mental health investigators and IRB administrators in designing and evaluating research protocols, 2) compare and contrast the issues identified, and 3) catalogue and rank (by perceived importance) the issues. Method: Perinatal investigators at the top 25 research institutions (according to the U S News and World Report) who led intervention

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research between 2004 and 2009 participated in a semi-structured telephone interview. The directors of the respective IRBs were also surveyed. All interviews were audio-taped and transcribed, and thematic analyses were conducted with qualitative software. Results: At least eight broad categories of ethical concerns were confirmed: Informed consent, use of placebos, choice of comparison groups, potential risks to the fetus, potential risks to the mother, choosing adequate inclusion/exclusion criteria, determining community standard of care, and managing conflicts of interest. These categories were ranked in order of frequency and respondent perception of importance. Conclusions: Revised guidelines would improve and strengthen research policy as well as provide appropriate oversight for studies in perinatal mental health. In the service of collaboratively revising current guidelines, data from this pilot is being used in a grant application to fund a larger project including in the survey respondents such as patients, research participants and their partners, community health providers, and funding agencies. Risk Benefit Decision Making Regarding Psychotropic Medication in the Perinatal Period R Cantwell1, I Jones2, Howard L3 University of Glasgow1, University of Cardiff2, Institute of Psychiatry King’s College London3 Email: [email protected] Objectives: 1. To discuss the risks and benefits of psychotropic medication in the perinatal period. 2. To discuss how to make risk: benefit decisions re: prescribing in the perinatal period with women, partners and other professionals Methods: Clinical anonymised cases will be brought as a focal point for discussion; review of evidence on effective use of language and models of decision making Results: National Guidelines will be referred to when discussing cases. Current evidence on models of decision making will also be available and barriers to shared decision making discussed. Conclusions: By the end of this special interest group we hope we will all have learned more on potential ways to help women and their families consider risks and benefits of mediation in the perinatal period. Treating Anna Karenina’s Post-Partum Depression with Interpersonal Psychotherapy: Using Fiction to Develop A Case Formulation L Caputo1, HA Swartz

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Private Practice, NJ, 2University of Pittsburgh, USA Email: [email protected] Objective: Anna Karenina, the tragic protagonist of Leo Tolstoy’s famous, eponymous novel, killed herself by throwing herself in front of a train several years after giving birth to a baby girl. One can infer from the novel that Anna was depressed and that her mood symptoms began soon after the birth of her daughter. Further, her symptoms were exacerbated by numerous interpersonal stressors including ostracism by her peers, conflict with her lover Vronsky, and separation from her son Sergei.

S56 Method: Interpersonal Psychotherapy (IPT) is an evidence-based psychotherapy for post-partum depression that focuses on addressing a specific interpersonal problem area (grief, role transition, role dispute, or interpersonal deficits) as a means of resolving the depressive episode. In the current discussion group, we will argue that Anna Karenina suffered from a postpartum depression (PPD) that would have benefited from treatment with IPT. After a brief introduction to the novel and the principles of IPT, we will encourage participants to develop a putative IPT case formulation to explain Anna Karenina’s depressive symptoms and, ultimately, to propose a psychotherapeutic treatment approach. Results: This exercise will increase participants’ understanding of the role of IPT in the management of PPD as well as bring new a perspective to their understanding of Tolstoy’s novel. Conclusion: Fictional characters can be used as case material to enrich our understanding of PPD and the role of IPT in its management. Round Table on Infanticide: “About Recent Cases of Infanticide in France”

K.L. Wisner each contingent on a more fully integrated person centred relationship based approach. References C Henshaw, JL Cox and J Barton (2009) Modern management of perinatal psychiatric disorders. RCPsych Publications, London S Tyano, M Keren, H Herrman, JL Cox (2010) Parenthood and mental health: a bridge between infant and adult psychiatry. Wiley/Blackwell, Oxford “Who Will Catch Me?” Support Groups: The Essential First Line of Defense for All Mothers A Cycon, L Friedman The Postpartum Support Initiative, MotherWoman Inc. , Amherst, MA “You NEED to know about MotherWoman and their support group model” Jeanne Watson Driscoll, PhD, RN, PC, PSI's President's Advisory Council and MotherWoman's Advisory Board Email: [email protected]

A Coen Objective: Participants will: Email: [email protected]

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Recent series of child murder by their mother in France, raised once again the public debate and the specialised one between psychiatrists and juges about mother’s responsibility. It seem necessary to differentiate infanticide, as child murder and neonaticide, murder of a baby at or after birth. Fundamental questions have been raised: does pregnancy time must be taken in account the crime being then “premeditated”? What about pregnancy denial then? What is required: care or punishment? May it be prevented…

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Person Centred Perinatal Psychiatry (PCPP): Research and Clinical Challenges. Professor John L. Cox, Professor Emeritus, Keele University, UK Email: [email protected] In this policy paper, it is proposed that a “whole person” approach to perinatal medicine is central to an accessible, acceptable and antidiscriminatory perinatal mental health service. It is suggested that if this approach to medicine is not relevant to a perinatal service, then it is only superficial froth on the service of research and clinical work— or is “management speak”, which may not motivate professionals or their consultees. It was argued in two recently published books that to meet the challenges of this approach required an ability to span infant and adult psychiatry, to consider the meaning and narratives of professionals and service users, to be fully aware of the dynamic of human relationships, as well as their sociocultural context—including religious rituals and spiritual practices. Reduction in maternal mortality in the USA and the UK, and buffering the effect of changing family structures on child development, are

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Discuss current research on the effectiveness of support groups in treating perinatal mood disorders Learn the key elements of MotherWoman’s evidence-based perinatal support group model. Discuss the importance of creating networks of high quality, consistent support groups using a replicable model.

Method: MotherWoman has developed and implemented an innovative support group model for mothers at risk for, or experiencing, perinatal mood disorders. Preliminary research shows that the model is effective, replicable and accessible. MotherWoman has developed a network of these support groups in Massachusetts, and offers a thirtyfive hour training for professionals to learn the model and run their own groups. Results:

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MotherWoman’s perinatal support group model is effective in diminishing symptoms of postpartum depression, anxiety and stress. MotherWoman has trained over eighty professionals and community leaders in the implementation of this support group model ensuring consistency of quality and service. In a region with 8000 births annually, we currently have over 10 support groups that are serving mothers in the perinatal period. These groups are specialized for diverse populations of mothers, including mothers who are incarcerated, low income, Latina, or lesbian in rural, urban and suburban settings. MotherWoman support groups are known for consistently high attendance, high efficacy in supporting women through postpartum crisis and are proven to be replicable through professional training.

Conclusion: The research is clear that support groups are an essential first line of defense in treating women with perinatal mood disorders. They are cost effective and have high clinical efficacy. MotherWoman’s Support Group Model is evidence-based, effective and replicable.

The Marcé International Society International Biennial General Scientific Meeting Program Development and Outcome Evaluation of A Hospital-Based Intensive Outpatient Treatment Program for Perinatal Psychiatric Disorders NK Dhami, KL Peterson, BA Mocnik Maternal Outreach Mood Services, El Camino Hospital, Mountain View, CA Email: [email protected] Objective: Despite the prevalence of perinatal mood and anxiety disorders, women affected with these illnesses remain an underserved population, with few treatment options available that are specific to the unique treatment needs of these disorders. Maternal Outreach Mood Services is the second hospital-based day treatment program in the United States developed specifically for the treatment of perinatal psychiatric disorders. Method: Based on task force recommendations, El Camino Hospital proceeded with the development and implementation of Maternal Outreach Mood Services (MOMS), a program offering comprehensive screening, assessment, referral, and treatment services. MOMS provides group, individual and couples counseling, as well as psychiatric evaluation and medication management, bundled into the Intensive Outpatient Program (IOP) level of care. Patients attend program activities three hours per day for three to four days per week. The average length of stay is approximately four to six weeks. In addition to the intensive outpatient treatment program, patients can be referred to higher levels of psychiatric care as need (i.e., full day hospital or inpatient) while maintaining the same treatment team. Results: MOMS has treated patients from twenty different countries and outcome measures have demonstrated the program's effectiveness, with scores on the Edinburgh Postnatal Depression Scale (EPDS) decreasing an average of 9.25 points from admission to discharge (mean admission EPDS=18.25, mean discharge EPDS=9). Patient satisfaction data also reflects the program's success, with an average score of 4.8 out of 5 for overall satisfaction with treatment. Revenue generated by the intensive outpatient program has covered the staffing and operational costs of MOMS. Conclusion: MOMS is the only program of its kind on the West Coast providing focused, intensive and comprehensive treatment for women suffering from perinatal psychiatric disorders. The success of the program from both a patient care and cost-efficiency perspective make it a viable and attractive treatment option by which hospitals nationwide can serve this unique population. Lullaby Therapy in Perinatal Psychiatry Friedman SH1,2, Kaplan R3, Rosenthal MB1,2,3 1

Case Western Reserve University School of Medicine, Cleveland, Ohio, USA 2 Connections Mental Health Center, Beachwood, Ohio, USA 3 The Music Settlement, Cleveland, Ohio, USA Email: [email protected] Objective: Lullabies are a universal and ancient song form that plays an important role in comforting infants and providing a critical

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bonding experience. Goals of this cross-disciplinary novel program include mothers learning to use music for improved self-expression, coping, inspiration, relaxation, calming infants, and in response to their infants’ distress. Method: An innovative lullaby program at The Music Settlement, a community music school, was transported to a Perinatal Mental Health Program at a community mental health center. Women treated in the perinatal program include those with perinatal depression, bipolar disorder, or psychosis. Participants in the music therapy group include those with mental illness who were pregnant or postpartum, their infants, and various team members—nurses, counselors, case managers, or perinatal psychiatrists, in addition to the music therapist. Results: Twenty mothers and mothers-to-be attended the Lullaby therapy group. Participants reported increased relaxation. Barriers to such a program include funding issues, transportation and recruitment. Conclusions: A lullaby music therapy program is a feasible component in the treatment armamentarium for mental illness during pregnancy and the postpartum, which may benefit both mothers and babies. Brainstorming Bridges: Inspiring the Creation of A Cross-Dimensional Network of Professional and Peer Support L Hale, T Twomey Postpartum Support International, USA Email: [email protected] Objective: The Perinatal woman is cared for during pregnancy by an Obstetrician or Midwife. Postpartum, she is primarily observed by a Pediatrician in relation to infant well-visits. Visits to her Pregnancy caregiver decrease significantly. As others have noted, the importance of continuity of care involving knowledgeable medical professionals is crucial to successful intervention and treatment of Postpartum Mood Disorders. Research also indicates postpartum women benefit from peer and social support1. Still, a gap exists between medical professionals in direct contact with the Perinatal woman. Further, a gap also exists between medical professionals and those offering peer and social support, continuing to hinder optimal care for perinatal women. Engaging medical professionals and peer support advocates in networks of partnerships would thereby increase occurrences of effective interventions, improving mental health and quality of life for mother and child. Method: Through informal group discussion, participants will brainstorm how to increase effective communication between medical professionals caring for Perinatal women as well as between professionals and peer support advocates. Included will be topics such as: identifying barriers, opportunities, and possible solutions. Participants will also discuss the creation and maintenance of continuity of care within a multi-dimensional network of local professionals and peer support advocates. Results: Participants will hold a stronger understanding of absolute necessity of closing the current gap in continuity of care for Perinatal women. Offered solutions may provide inspiration and opportunities to create new local networks of medical professionals across the globe.

S58 Conclusion: A partnered discussion of PSI and Marce members has potential to accomplish more than any of us alone. Achieving a strong unified communicative network of medical professionals and those offering peer and social support, can provide more robust, timely, and effective care for mothers struggling with perinatal mood disorders. This session offers an opportunity to brainstorm about how to build a stronger network.

K.L. Wisner A Family Systems Approach to Treating Postpartum Depression and Other Mood Disorders JS McKay1,2, L B Yurko2 1

University of South Carolina Pisgah Institute Asheville North Carolina Email: [email protected]

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Dennis, CL. (2003). The Effect of peer support on postpartum depression: a pilot randomized controlled trial . The Canadian Journal of Psychiatry, 48(2), 115–124.

Postpartum Mood Disorders among Military Beneficiaries Interest Group K Haworth, B Meyer Email: [email protected] Objectives: Postpartum depression affects 14% of women. It is hypothesized that the military population has increased incidence and severity of postpartum depression. This is speculated to be secondary to deployments, frequent moves, and lack of family or social support. The Armed Forces Epidemiological Board estimates that there are 120,000 births of military beneficiaries per year. Using the known statistics from the civilian population, this translates into 16,800 mothers who will suffer from postpartum depression, 240 who will have postpartum psychosis, of which 12 will commit suicide and 9.6 will commit homicide each year. The Army Family Covenant states, “We recognize the strength of our soldiers comes from the strength of their families. We are committed to providing soldiers and families a quality of life that is commensurate with their service. We are committed to providing our families a strong, supportive environment where they can thrive. We are committed to improving family readiness by… standardizing and funding existing family programs and services.” Unfortunately, no specific resources for military women with postpartum depression exist. While some small support groups may be active at individual duty stations, resources vary greatly from post to post and military branch to branch. Method: Interest group discussion regarding perinatal mood disorders among the United States military population. Results: Yet to be determined. Conclusion: Army resources currently include Army OneSource, Army Community Services, New Parent Support Program, Departments of Behavioral Health and Social Work Services, and Primary Care Managers. Unfortunately, an organized support for military beneficiaries suffering with postpartum mood disorders does not currently exist among any of the military branches. It is argued that the close-knit “family” support offered by other military families, increased awareness of mental health issues amongst the military population, and the renewed dedication by the Army to the families of troops are protective for these women. However, one must also consider the amount of non-reporting of symptoms due to fear of jeopardizing their own or their spouse’s military career, the stigma associated with mental health diagnoses, or adopting the “soldier attitude”.

Objective: Historically, treatment for PPD has focused mainly on the mother. Research shows that Postpartum depression (PPD) affects the whole family. Children of untreated (PPD) mothers can develop social and cognitive deficits. Although treating the mother improves her depressive symptoms, it does not always improve the mother–infant relationship. Partners of depressed mothers are susceptible to postpartum depression themselves. When fathers are supportive the mothers often recover faster. The birth of a child adds stress to the family as well as to the couple’s relationship. PPD increases that stress. This Special Interest Group presents a treatment model that focuses on the family as a whole while treating the mother’s depression. Although the term postpartum depression is used all perinatal mood disorders are treated. Method: A Family Systems based Perinatal Mood Disorder Clinic was started at the University of South Carolina. Due to lack of funding it closed after one year. A chart review of that program became the basis for establishing the current Family Systems Program within a multidisciplinary private practice in Western North Carolina. This program has been in operation for 2 1/2 years. At the initial evaluation by the psychiatrist the Family Systems Approach is described to the mother. The program includes individual therapy sessions, medication checks with mother and infant both present, evaluation of the mother– infant interaction and family/couple sessions. The goals of working with the couple are to: 1) help the father understand the mother’s illness; 2) give the father an opportunity to share his feelings; and 3) emphasize the importance of the couple’s relationship. Other services provided include individual therapy for the father and help with parenting and communication skills. Results: Persons attending this Special Interest Group will have an opportunity to share ideas on how this model can be incorporated into their work. Conclusion: Participants will have a broader understanding of the importance of including family members in the treatment of the mother’s postpartum depression. The Circle of Security Approach to Working with Disturbed Attachment Relationships: A Case Presentation CA Zanetti St John of God Healthcare Inc, Western Australia Email: [email protected] Postnatal depression continues to be prevalent, and is associated with longterm adverse outcomes for infant development across many domains. These outcomes appear to be mediated through disturbance in the parent–infant attachment relationship, and tend to persist despite effective treatment for maternal depression. Treatment of parent–infant

The Marcé International Society International Biennial General Scientific Meeting relationship disturbance can be addressed using the Circle of Security Protocol. This model provides an easy to understand framework utilising the basic principles of attachment theory. It makes explicit the ways in which children naturally look to their parents to support them at times when they need a safe haven, and at times when they need a secure base for exploration. The Circle of Security diagram can be readily understood by caregivers and clinicians, and can be used to scaffold caregiver representations and behaviour in a way that supports attachment security in at-risk dyads. The Circle of Security Protocol has been shown to be successful in improving attachment security in high-risk dyads in the USA, but has wide applicability. Of six middle-class dyads participating in the Circle of Security group therapy protocol in Perth, Western Australia, five had disorganised attachment pre-intervention, with the only identifiable risk factor being a history of postnatal depression. This presentation will provide an outline of the Circle of Security approach to understanding and treating disturbed attachment relationships. Video material of mother–child interaction in the Preschool Strange Situation and of the treatment itself will demonstrate how Circle of Security concepts can be used to successfully treat an insecure attachment in one of the mothers in our program.

ABSTRACTS Posters P1 Is Postnatal Depression A Public Health Problem? A Review of the Literature P Almond University of Southampton, Hampshire, England, UK Email: [email protected] Objective: Postnatal (partum) depression (PND) is a condition that is known to affect women after childbirth. It is appears in both the ICD 10 and the DSM 1V. Studies have shown the frequency of PND to be 10–15%. This level of incidence does not make PND a public health problem. Therefore a study was conceived to determine what features of PND and its effects validated it as a public health problem, a claim that is increasingly being made in the literature. Method: An in-depth and comprehensive literature review was undertaken during 2008–2009. Electronic databases, CINAHL, MEDLINE, EMBASE, PSYCHINFO and other resources such as Cochrane and York Centre of Reviews were systematically searched. PND literature published in English relating to incidence, prevalence, epidemiology, aetiology and disease trajectory, and impact was included. Definitions of public health provided other parameters to determine whether or not PND should be seen as a major public health problem. International literature was included to allow analysis of PND as a global public health problem. Results: Many papers were read and analysed and 88 of these were included in the review. Levels of PND morbidity are higher in immigrant populations and there are indications that low to middle income countries face the greatest burden of disease. Mortality rates

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whilst relatively low are often due to suicide. Infanticide also occurs. The adverse effects of PND go beyond the mother and are felt by the husband/partner, baby, and others. Screening methods exist but few countries undertake universal PND screening. There is inequality in the provision and access to PND services within and between countries. Lack of literature did not allow analysis of the costs of treatment, care and impact on society. Conclusion: The review parameters were kept wide for two principle reasons; the term public health is itself broad and all encompassing; and PND is multidimensional and has a wide impact. PND is indeed a global public health problem, it needs to attract greater attention from policy makers and funders of health and social care services. P2 Sample Retention in A Clinical Trial with Depressed Mothers in Home Visitation RT Ammerman1, FW Putnam1, J Stevens2, NR Bose1, JB Van Ginkel1 Cincinnati Children’s Hospital Medical Center1, Cincinnati, OH; Nationwide Children’s Hospital2, Columbus, OH, USA Email: [email protected] Objective: Only 20–30% of postpartum depressed mothers receive treatment, and there is a pressing need to engage mothers in nontraditional settings. Home visitation, a prevention approach for low income mothers that is designed to optimize child development, is a promising setting in which to screen and treat depressed mothers. In fact, a recent study found that 44% of mothers in home visitation exhibited elevated levels of depressive symptoms. Identifying unique issues in the conducting of clinical trials with this population and in the home visitation setting will inform more effective and robust clinical research. Method: As part of an NIMH R34 grant to develop and pilot test InHome Cognitive Behavior Therapy (IH-CBT—an adapted treatment modified for the home setting and home visitation context), a clinical trial with young, low income mothers in home visitation was conducted (Caucasian: 65.4%, African American: 32.1%). The sample consisted of 77 mothers meeting criteria for depression enrolled 5 months postpartum and randomized to home visitation + IH-CBT or home visitation + community referrals. Mothers were followed over 8 months including assessments at pre- and post-treatment and 3 months follow-up. Results: Results indicated that 89.6% of the sample was retained through all 3 assessment points. Five of 8 mothers who did not fully complete the study were retained through post-treatment, yielding 96.1% who received at least 2 assessments. Contrasts between those who were or were not retained revealed that mothers who dropped out had lower incomes and trended in the direction of having fewer home visits prior to study enrollment (p=.06). No differences were found on maternal age, race/ ethnicity, or baseline clinical features (depression severity, social support). Conclusion: Findings suggest that study retention in depressed mothers in ongoing home visitation is robust. These findings dovetail with findings in home visitation generally, in which increased overall program retention is associated with greater psychosocial need. Conducting clinical trials alongside concurrent social service interventions holds promise to generate methodologically rigorous research.

S60 P3 Parental Competence in Depressed Mothers in Infancy. Eyes Wide Shut S Azak University of Oslo, Oslo, Norway Email: [email protected] Objective: Mothers with Major Depressive Disorder (MDD) are reporting more parental stress and judge their parental competence less optimal than healthy mothers. On one hand this might be a part of the negative thought style in depressed women that is underestimating their parental competence. On the other hand it is well documented that depressed mothers are less sensitive in interaction with their infant. This study wants to assess if the depressed mothers are underestimating their own parental competence as compared to healthy mothers as compared to independent raters of maternal interaction. Method: The study recruits mothers in two groups (N=25×2) according to their health or mental and physical healthy. Mothers are screened for depression1 when the children are 3–6 months old. Mothers who screen positively complete a clinical diagnostic interview2,3 when the children are 6 months old. Mothers are asked to evaluate their parental competence through completing the questionnaire Parental Stress Index4. Mothers’ parental competence is also evaluated by independent rating of videotaped parent–child interaction5. Results: This is an ongoing study and the results will be analysed during April.

K.L. Wisner the last four years eight postpartum patients were referred to our inpatient unit as a result of very unstable illness course after treatment with antidepressants. In our opinion concomitant psychotic features might give a clue for the bipolar nature of postpartum depression, even in the absence of (hypo) mania. Therefore in this study patients with postpartum depression with psychotic features were not treated with antidepressants but according to the guidelines for bipolar depression. Method: Between August 2005 and December 2009, we examined all patients referred to the Mother–Baby Inpatient Unit of the Department of Psychiatry (Erasmus MC, Rotterdam) using the Structural Clinical Interview for DSM-IV (SCID). Seven patients were diagnosed with a major depressive disorder postpartum with psychotic features and reported no (hypo) manic symptoms in history. Three patients were treated with antidepressants before admission leading to an exacerbation of symptoms. All patients were treated with lithium and/or antipsychotics, one patient refused treatment. Results: For all except one woman, the depression went into complete remission. The one patient who did not respond to treatment with lithium and antipsychotics received ECT, and her depression subsequently remitted. Conclusion: Psychotic features should be considered an important clue for the bipolar nature of postpartum depression, also in the absence of (hypo) manic symptoms. Lithium and/ or antipsychotics were safe and effective in our case series, whereas antidepressant treatment could have put these patients at risk for exacerbation of symptoms. P5 Mother & Baby Units: Supporting Fathers

References: Radloff, L.S. (1977). The CES-D Scale: A self report depression scale for research in the general population. Journal of Applied Psychological Measures, 1, 385–401. 2. M.I.N.I. Plus 5.0, Mini International Neuropsychiatric Interview. Norwegian translation by Leiknes, K.A., Malt, U., Malt, E.A. & Leganger, S. 3. SCID-II. Structured Clinical Interview for Personality Disorders. Norwegian translation by Friis, S., Havik, O.E., Monsen, J. & Torgersen, S. 4. Abidin, R.R. (1990). Parenting stress index (PSI). Manual. Odessa, FL: Psychological Assessment Resources, Inc. (Norwegian version available). 5. Campbell, S.B., Cohn, J.F., & Meyers, T., (1995). Depression in first-time mothers: Mother–infant interaction and depression chronicity. Developmental Psychology, 31, 349–357. P4 Treatment of Postpartum Depression with Psychotic Features V Bergink, KM Koorengevel Erasmus Medical Centre, University of Rotterdam, the Netherlands Email: [email protected] Objective: Misdiagnosis of bipolar depression as major depressive disorder during the postpartum period appears to be common. Over

G Berrisford, J Heron Birmingham and Solihull Mental Health Foundation NHS Trust Email: [email protected] Introduction: Perinatal mental illness has a tremendous impact, not just upon the individual sufferer, but upon the family as a whole. Partners often have clear expectations of their role in the period following childbirth. When a woman develops postpartum mental illness, the partner often becomes responsible for accessing mental health services and takes on additional responsibilities. Fathers often become the conduit for medical information, responsible for medication, appointments, appropriate care of newborn, care of other children and bringing in money. Often they do not receive adequate paternity leave or compassionate leave. Objective: The aim of this study is to review the evidence on why supporting fathers is important and review what appropriate services need to be developed in order to respond effectively to partner needs. Method: A review of the current literature has been completed. In addition qualitative interviews with women who have experienced severe perinatal mental illness together with their partners have been carried out. These interviews focussed upon what problems are faced by partners and what type of services they think they would have accessed had they been available. Results: Partners do have particular needs at this time. They report that this is a stressful and traumatic experience. Partners emphasise the importance of support which they describe as vital in order to ameliorate the impact on family functioning and upon the relationship

The Marcé International Society International Biennial General Scientific Meeting with the infant. Preliminary evidence suggests fathers groups might not be most appropriate use of resources. There is however, important help we can give, in terms of providing correct information and advice, listening and one-to-one counselling with a problem based focus—ideally with someone with perinatal expertise. Partners state they are more likely to access peer support, by telephone or by E-mail, rather than Fathers’ Groups which are seldom accessed. Conclusions: Support is very much needed. This is probably within the remit of maternal mental health services. We have discussed what further research is needed and describe what future studies are planned following the implementation of intervention on the MBU. P6 Examining the Overlap Between Borderline Personality Disorder Symptoms and Postpartum Depression in Adolescent Mothers JL Bortner, BF Sapotichne, SD Stepp, AK Hinze, S Hemachandra, & AE Hipwell University of Pittsburgh, Pennsylvania, USA Email: [email protected] Objective: A core feature of borderline personality disorder (BPD), affective instability and dysregulation, likely contributes to increased risk of depressive disorders in adult women (American Psychiatric Association [DSM-IV-TR], 2000). BPD symptoms are also known correlates of high-risk sexual behaviors in adolescents (Lavan & Johnson 2002), suggesting that such symptoms may characterize a significant proportion of teenage mothers who are also at heightened risk for postpartum mood disorders (Lanzi 2009). We tested hypotheses that a) teenage pregnancy would be associated with BPD features, b) there would be high rates of comorbidity between BPD and postpartum depressed mood in teenage mothers, and c) that this association would be moderated by negative emotionality. Method. To date, the ongoing longitudinal Pittsburgh Girls Study (PGS; n=2,451) has identified 104 girls ages 11 to 17 who have become pregnant and 30 girls ages 13 to 17 who have become teenage mothers. Self-reported BPD symptoms using the International Personality Disorder Examination (Loranger et al, 1994) and negative emotionality using the Emotionality, Activity, Sociability, and Impulsivity Temperament Survey (Buss & Plomin, 1975) have been assessed as part of the PGS protocol. The Edinburgh Postnatal Depression Scale (Cox, Holden & Sagovsky, 1987) was administered to teenage mothers at 4 months postpartum. Results. Both teenage pregnancy and teenage motherhood were significantly associated with endorsement of BPD symptoms. Pregnancy was associated with higher likelihood of reporting symptoms such as: My urges get me into trouble; under stress, things don’t seem real; and I go to extremes to keep others from leaving. Although teenage mothers showed a similar pattern of heightened risk for BPD features, only one symptom (‘I go to extremes to keep others from leaving’) was associated with higher EPDS score. Preliminary analysis revealed no moderating effect of negative emotionality on this relationship. Conclusion. BPD symptoms appear to be important correlates of teenage pregnancy and motherhood further highlighting the high-risk nature of this population. A larger sample size will be used to replicate and extend these findings and identify subgroups of girls characterized by multiple problems.

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P7 Postpartum Psychopathology and Filicide: Mothers Who Kill A Bramante Center for Cognitive Science, University of Turin, Italy, Centro Depressione Donna, AO. Fatebenefratelli e Oftalmico, Milan, Italy Email: [email protected] It is very difficult to conceive or accept the reason why a woman would kill her child. This act seem so irrational that it is usually assumed to be the result of a disturbed mind. This is why forensic psychiatrists regularly are asked to examine such cases in the hope they will find a psychiatric explanation for them. Although maternal filicide is a rare event, a high proportion of cases occurs in the context of postpartum mental illness, often undiagnosed. Today it often speaks about depressive disorders in the post-partum, of delicate women more and more that have difficulty to face up to their maternity. Who studies these pathologies knows however that there are risk factors be able to increase the possibility to suffer from depressive disorders in the post-partum, factors at times already present and evident during the pregnancy . Foreign study have shown that exist risk factors that can increase the probability to commit filicide, as like protection factors that contrarily reduce it. Since official statistics do not specify the relation between murderer and victim, I’ve also searched the information for my study (maternal neonaticide and filicide in Italy) from the press, despite the shortcomings and possible inaccuracies, taking into consideration the period between 1958 and 2007. The aim of the Research is to identify the most important psychopathology risk factors of pregnancy and post-partum, the most important neonaticide and filicide risk factors, but the most important is the realization of a clinical tool of simple administration, to furnish to the family doctor and the experts that follow woman in the walk of the maternity (gynecologist, pediatrician, etc), to appraise the risk of possible aggressive behaviors and of develop a psychopathology in this "delicate" phase of life of the woman. Psychiatrist have a vital role in recognizing the sign and symptoms of peripartum psychiatric disorders and in early identification of and intervention with at-risk mothers. P8 Perinatal Mood Disorders Task Force: Community Collaboration and Results G Burrus¹, S Murdock² ¹Suffolk Perinatal Coalition ²Postpartum Resource Center of New York, USA Email: [email protected] Objective: To address the major public health concern of perinatal mood disorders (PMD) for the prevention of infant and maternal mortality in a county that has 1.4 million residents with approximately 20,000 births a year. Method: Suffolk Perinatal Coalition (SPC) in October 2003 established a Perinatal Mood Disorders Task Force. The agency gained support from their Community Consortium members, including

S62 partnering with the Postpartum Resource Center of New York (PRCNY). SPC made a commitment to the Task Force and has included it in their agency's annual Work Plan. Results: Key issues agreed to be addressed resulted in the following: 1) Increasing PMD Awareness by a county law with May as PMD Awareness Month including an annual PMD Awareness Event. 2) Compliance of the New York State Public Health Law on PMD 3) Creation and dissemination of a PMD Awareness Poster for minority women in English and Spanish in collaboration with PRCNY and funded by United Way of Long Island 4) Decreasing the time it takes to obtain a mental health appointment (in some cases before the task force 8+ weeks to now 7 days) 5) Department of Health created protocol where they screen, educate 4,000 pregnant and postpartum clients on PMD and treat/refer for treatment. 6) Creation of the PMD Task Force's Resource Directory, a position paper advocating for extension of health insurance coverage and hosting PMD conferences. 7) Suffolk Perinatal Coalition received funding through Suffolk County Department of Health to facilitate the Postpartum Resource Center of New York’s Circle of Caring Pregnancy and Postpartum Depression Support Group Program. Downstate New York Healthy Start programs in Nassau County and Queens are also implementing the groups overseen by Columbia University Mailman School of Public Health. Conclusion: The accomplishments of the Suffolk Perinatal Coaltion's Perinatal Mood Disorders Task Force are an example in how perinatal mood disorders can be effectively and collaboratively addressed on a county level with families, community based organizations, hospitals, county health centers and government. P9 Moving Beyond the EPDS: The Association Between Postpartum Depressive Symptoms and Premenstrual Dysphoric Disorder MM Buttner, S Stuart, MW O’Hara University of Iowa, USA Email: [email protected] Objective: Postpartum depression (PPD) and premenstrual dysphoric disorder (PMDD) are hypothesized to have a common etiological link. Previous investigations have examined the relationship between PPD and PMDD to further our understanding of this potential shared etiology. Evidence suggests that there is an association between history of PMDD and depressive symptoms in the postpartum. The aim of this study was to further explore the hypothesized relationship between history of PMDD and postpartum depressive symptoms. Methods: Postpartum women were recruited through birth records and the Women's Wellness Center at the University of Iowa Hospital and Clinics to participate in an ongoing clinical trial for treatment of PPD. Identified women completed an initial eligibility screen that included the Patient Health Questionnaire (PHQ-9), a well-validated and widely used diagnostic and severity measure of depression. Upon confirming eligibility status, women (N=369) participated in a structured clinical interview which included the Premenstrual Symptoms Screening Tool (PSST), a screening tool that reflects DSM-IV criteria for PMDD.

K.L. Wisner Results: Preliminary data analyses suggest there is a significant association between history of moderate to severe premenstrual symptoms and postpartum depressive symptoms. Additional data analyses are currently underway and will include examination of the association between postpartum depressive symptoms and PMDD using categorical criteria, and examination of PMDD and past history of PPD as potential risk factors for predicting postpartum depressive symptoms. Conclusion: Consistent with previous findings, an association was found between a history of premenstrual symptoms and postpartum depressive symptoms. In additional analyses we predict that PMDD and past history of PPD will be risk factors for postpartum depression. Taken together, we predict that findings from the current study will further replicate and strengthen existing evidence for the association between history of mental illness, hormonal factors (i.e., PMDD), and postpartum depressive symptoms, using the PHQ-9 as a measure of depression. These findings should inform future work in the examination of etiologic correlates of reproductive-related mood disorders, more generally. P10 ‘The Perfect Mother Wouldn’t Have That’: Australian Women’s Experiences of Motherhood and Postnatal Depression CL Chojenta1, DJ Loxton1, J Lucke2 1

Research Centre for Gender, Health and Ageing, University of Newcastle, Australia 2 School of Population Health, University of Queensland, Australia Email: [email protected] Objective: The experience of diagnosis and treatment of PND is under-researched, and is an area currently being reviewed and changed at policy and clinical levels in Australia. A detailed investigation into the thoughts, feelings and experiences of women with PND is therefore timely, in order to understand the underlying factors that influence the development of PND and the efficacy of treatment for PND. Method: In-depth semi structured telephone interviews were conducted with a subsample (n= 40) of women who participate in the Australian Longitudinal Study on Women’s Health (ALSWH). The ALSWH is a multi-disciplinary, nation-wide survey of the health, wellbeing and lifestyle of women that has been collecting mailed survey data since 1996. Participants in the current study were asked to elaborate on their experiences of pregnancy, childbirth and early motherhood, and in particular their emotions during these times. The researchers utilized previous ALSWH survey data when drawing the interview sample and selected both women who had and had not been previously diagnosed with PND. Results: Those participants who had been diagnosed with PND described a limited range of treatment options and support mechanisms available to them after their diagnosis. Many also described the guilt and shame associated with a diagnosis of PND, and the feelings associated with divulging this information to other people. Many women (both those with and without PND) also described problems with coping in early motherhood, and particularly highlighted stresses

The Marcé International Society International Biennial General Scientific Meeting associated with breastfeeding. Facilitators and barriers to treatment access and treatment efficacy were also discussed. Conclusion: The narratives collected in this project highlight that PND is occurring in the context of many stressful events. In addition, the findings suggest that the accessibility and availability of treatment options in Australia has been limited. P11 Use of Antidepressants and Mood Stabilizers During Pregnancy: Lessons from the Last Two Decades LS Cohen Director, Perinatal & Reproductive Psychiatry Massachusetts General Hospital Email: [email protected] Conclusions: Historically, pregnancy was described as a “protective” state against psychiatric disorders. However, there is substantial evidence that pregnancy appears to have neither a “protective” nor “riskenhancing” effect for women, as recurrence risks in pregnant and nonpregnant women are noted to be similar. Sustaining euthymia during pregnancy for women with major depressive or bipolar disorder is particularly critical since relapse of illness during gestation dramatically increases risk for puerperal illness and may contribute to adverse outcomes including obstetrical and neonatal complications. Management of these disorders during pregnancy can be particularly challenging, as the mainstay of pharmacologic therapy consists of multiple compounds where reproductive safety is either 1) relatively well established or 2) where medicines are known teratogens. For some medicines, reproductive safety data are particularly sparse. Risk of relapse during pregnancy in women with mood disorders must be weighed against the potential risks associated with treatment using antidepressant and mood stabilizers during gestation. The last few years have brought a growing number of published reports regarding the safety of antidepressant and mood stabilizer use during pregnancy, including concerns regarding teratogenicity of these agents, acute neonatal effects, and potential long-term consequences of fetal exposure to these medicines. The relative risks of fetal exposure to medicines used to treat psychiatric illness during pregnancy need to be weighed against the morbidity of untreated maternal illness. Physicians and patients must collaborate to make treatment decisions about psychotropic drug use during pregnancy realizing that no decision is perfect and that no treatment is risk free. P12 Community-Based Maternal Mental Health Screening in An Early Intervention Program J. Doering1, K. Pizur-Barnekow2 1

University of Wisconsin-Milwaukee University of Illinois at Chicago, USA Email: [email protected]

2

Objective: Maternal depression is the most common complication of childbirth affecting 13% of the population. Due to additional social

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and economic burdens, the sub-population of mothers who have children with special needs may be at even higher risk for poor mental health outcomes, including depression and birth-related post-traumatic stress disorder (PTSD). Untreated, maternal mental disorders have moderate-severe consequences on child development. Detection of maternal mental health concerns may improve maternal entry into treatment, which, in turn, may improve outcomes for children with special needs and reduce programmatic costs. The objective of this project was threefold. 1. Examine differences in levels of health literacy and symptoms of depression and PTSD across a sample of urban and suburban/rural mothers who have children with special needs. 2. Adapt existing maternal depression screening best-practice standards for use in a community-based early intervention program. 3. Design mental health education materials specifically for mothers of children with special needs. Method: A pilot study examined health literacy levels and symptoms of depression and PTSD in a convenience sample of 25 urban and 25 suburban/rural mothers who had children in an early intervention program. Instruments included the Short Test of Functional Health Literacy, Center for Epidemiological Studies-Depression, and Perinatal PTSD Questionnaire-II. Results: Positive screens for maternal mental health symptoms differed significantly across type of county. The percentage of positive screens for depression and PTSD was high. Health literacy was adequate in 98% of the total sample. Intervention: Pilot study results and best-practice recommendations for maternal mental health screening were used to develop a maternal depression screening algorithm and accompanying consumer brochures on maternal depression and birth-related PTSD in English and Spanish for use within a community-based early intervention program. Conclusion: Early intervention programs guided by family-centered care models should consider the impact of maternal mental health on child development and implement screening programs to detect maternal mental health concerns. P13 The Everyday Experience of Postpartum Fatigue in Lower-Income Urban Women with Depressive Symptomatology J Doering, D Sims University of Wisconsin, Milwaukee, USA Email: [email protected] Objective: Severe fatigue is commonly experienced by postpartum women suffering from depression symptoms. The everyday experience of postpartum fatigue lower-income mothers living with significant depression symptoms is unknown. The objective of this study was to construct a theory explaining the everyday experience of fatigue across the first 6 months postpartum in lower-income urban women with depression symptoms. Method: Using grounded theory methodology, mothers (n=19) screening positive on the Postpartum Depression Screening Scale at 1 month postpartum were interviewed at 1, 3, and 6 months. The sample was on average 27 years, high school educated, partnered (79% boyfriend or married), African–American (63%), and had 2.8 children.

S64 Results: A period of postpartum rest and recovery was essentially non-existent. At 1 month, fatigue was all-consuming and unrelenting; attributed to sleep deprivation and stress securing basic necessities (housing, food). Infant sleep was unpredictable. Infants were ‘mixed up’ on days and nights. Women struggled with multiple stressors, intense worry, irritability, frustration, and expressed an inability to think clearly. Women coped by engaging in ‘Self-Preservation’ in which they withdrew from family and friends and attempted to establish a routine. By 3 months, infant sleep for half of moms became more predictable, easing fatigue. Over half of infants, though, were still ‘mixed up’ remaining awake hours each night. Women ‘Trudged On’ at 3 months. Social support was an essential fatigue management strategy. Immediate and extended families formed a complex, yet functional network, that women maneuvered within seeking respite from fatigue and sleep deprivation and to secure basic necessities. Six months saw dramatic improvements in mood, fatigue, and functioning. Stressors remained, but none were so pressing as they were previously. Happiness, normalcy, and optimism began to work back into life. Conclusions: Postpartum fatigue presented major challenges to everyday functioning. We recommend a strengths-based approach to promote the health of lower-income postpartum women with depression symptoms.

K.L. Wisner Selected Quotes from Participants: “you’re not going to want to just be on the phone, like, yeah I’m suffering from postpartum depression, who do I talk to? You want someone who is expecting the call, like that’s why that person is there and you’re not just blurting it out to anybody who answers the phone. “ “It seems like a lot of the times the partner, husband, or boyfriend would notice this and be more proactive. I don’t know if maybe there would be some way to reach out to them also as a way for them to get help for the mother when they are noticing that something is not right and she’s not able to take the initiative to deal with it. That might help.” Conclusion: Participants described the online PPD screening process as easy, straightforward and personalized. Next steps: evaluating the effectiveness of online screening with an integrated referral system using a family centered model in a larger sample. P15 One Year Design and Implementation of An Integrated System for Screening, Diagnosis, and Treatment of Perinatal Depression at a Large HMO

P14 CL Eaton, KJ Savola-Levin Online Screening for Postpartum Depression: A Pilot Study E Drake, E Hauenstein, R Steeves, G Coolidge, E Kinsey University of Virginia, Charlottesville, VA Email: [email protected] Objective: The goal is to develop an innovative way for women to screen for symptoms of Postpartum Depression (PPD) and then assist them in seeking referral and treatment. The fear and stigma associated with PPD is a major challenge in the treatment of this disease. The Internet may help reach out to new mothers in the convenience and privacy of their own homes particularly those in rural, underserved areas. Method: A descriptive pilot study design was used to explore the feasibility and acceptability of online screening for PPD with postpartum women in the first 2–3 months after delivery (N=19). Phase 1 was a focus group with 4 postpartum women; Phase 2, individual interviews with 5 postpartum women; and Phase 3, usertesting was conducted with 10 postpartum women. PPD was measured using an online version of the Edinburgh Postnatal Depression Scale (EPDS). Feedback and comments from the participants were also analyzed. Results: The sample included women age 18–29; 70% White/ Caucasian; 40% married; 50% low income; majority rural. The EPDS scores ranged from 0–13 (mean 8.0; SD 4.76). Three major themes were identified from analysis of open-ended questions regarding the experience of online screening: 1) the delivery and postpartum experience; 2) user-friendliness and accessibility of online survey for postpartum depression and; 3)help-seeking/resources.

Kaiser Permanente Medical Center, San Francisco, California, USA Email: [email protected] Background: Until recently, there was no integrated system for screening, diagnosis or treatment of Perinatal Depression at Kaiser Permanente Medical Center in San Francisco. Furthermore, expertise was lacking, and no up to date evidence based treatment guidelines existed. Objective: Design and implement a system that would effectively care for the needs of women with Perinatal Depression. Method: In January 2009, a small multidisciplinary group comprised of a Psychiatrist, Obstetrician, Obstetrical Nurse Practioner, and Psychiatric Social Worker convened to design and implement an integrated system of screening, diagnosis, and care of women with Perinatal Depression. Results: By January 2010 the following programs and innovations were fully operational and integrated across medical specialties:

1. Routine screening using the PHQ-9 at the 12 and 28 week prenatal visits and at the 6 week postnatal visit.

2. Weekly drop-in Perinatal Support Group for pregnant and postpar-

3.

4.

5.

tum women led by psychiatrist and psychiatric social worker. Group is free of charge and women may bring their newborns/infants. Creation and distribution of current, evidence-based guidelines regarding treatment with antidepressant medications in pregnancy and lactation. Creation of a Primary Care Psychiatry Consultation Service offering real-time, immediate telephone consultation with psychiatrist for all primary care and ob/gyn clinicians to ensure rapid implementation of appropriate treatment. Fully integrated electronic medical record within Kaiser Permanente to enable seamless multidisciplinary care.

The Marcé International Society International Biennial General Scientific Meeting Conclusion: We have demonstrated that it is possible, with collaboration between medical specialties, and with the aid of a fully integrated electronic medical record, to create and implement an efficient system of screening and care for women with perinatal mood disorders within one year. P16 Evaluation of Pregnancy Outcomes Following Use of Escitalopram in Pregnancy: A Prospective Comparative Cohort Study A Einarson, B Weitzner, C Klieger-Grossmann The Motherisk Program, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada Email: [email protected] Background: escitalopram is a 5-HT reuptake inhibitor prescribed for its antidepressant and anxiolytic activity. To date, no prospective studies reporting on fetal outcome following exposure to escitalopram during pregnancy have been published. Objectives: Primary objective: to determine whether the use of escitalopram during pregnancy is associated with an increased risk of major malformations; secondary objectives: to determine the rates of spontaneous abortions, therapeutic abortions, stillbirths, mean birth weight, low birth weight and preterm births. Methods: A prospective, observational cohort study involving women from Canada and Europe. All pregnant and planning women who contacted the Motherisk Program in Canada and teratogen information services in Italy and Switzerland, between January 2003 and August 2009 requesting information on the safety of escitalopram in pregnancy were contacted by telephone. Pregnancy outcome data was collected via a standardized questionnaire including details of exposure. Two comparison groups of pregnant women exposed to other antidepressant medications (N=213) as well as non-teratogenic exposures (N=213) were matched for maternal age and gestational age at call. Statistical analysis was performed using Fishers exact test and Chi Square statistics. Results: To date, 639 patients have completed the study. Among the 213 escitalopram exposed, 38 (17.6%) reported spontaneous abortion, 3 (1.41%) reported still birth, 19 (8.9%) reported premature birth, and 6 (2.8%) described a major malformation. Mean birth weight of exposed infants was 3198 g while low birth weights were reported in 17 (8%). Comparison group results are pending. Conclusion: Preliminary results reveal that escitalopram exposure during pregnancy does not appear to increase the risk of major malformation above the baseline or affect fetal survival rates, mean birth weights or duration of pregnancy. However, as in other published studies, the risk for spontaneous abortions does appear to be higher.

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Objective: Previous research has suggested that maternal and paternal depression can have a negative effect on the strength of the marriage and on child internalizing and externalizing behaviors. There is mixed evidence that suggests that marital adjustment may mediate the relation between maternal/paternal depression and child behavior. The purpose of this study was to examine a longitudinal model that examines the relations among maternal/paternal depression, maternal/ paternal marital adjustment, and child internalizing and externalizing behavior. First, the model is designed to examine whether marital adjustment mediates the relation between maternal/paternal depressive symptoms (postpartum and current) and child behavior. Second, the model examines the potential effect (longitudinal and concurrent) of maternal/paternal depressive symptoms on marital adjustment. Method: Subjects at Time 2 were recruited from a community sample of a previous clinical trial (Clinician-Managed Interpersonal Psychotherapy), based in Iowa. The pool of previous participants consisted of 810 couples. An attempt was made to contact and recruit all subjects from the previous pool. Subjects in this study include 191 couples with a child aged approximately 3 months at Time 1 and 38 to 44 months at Time 2. At Time 1, the Inventory to Diagnose Depression was used to measure maternal/paternal postpartum depressive symptoms. At Time 2, the Inventory of Depression and Anxiety Symptoms, Dyadic Adjustment Scale, and the Child Behavior Checklist were used to measure matnernal/paternal depressive symptoms, marital adjustment, and child behavior problems respectively. Structural equation modeling was used to analyze the data. Results: Time 1 maternal/paternal depression was associated with Time 2 maternal/paternal depression respectively. In turn, Time 2 maternal/paternal depression was associated with each parent’s respective report of child internalizing and externalizing behaviors. However, marital adjustment did not mediate the relation between maternal/paternal depression and child behavior. Time 1 maternal depression and Time 2 maternal/paternal depression were associated with lower levels of marital adjustment. Conclusion: Postpartum depression may have long-term effects on parent’s emotional well-being, which is associated with child behavior problems, but not mediated by marital adjustment. P18 Computerized Skills-Based Psychotherapy for Postpartum Depression Versus Treatment as Usual T Flanagan1, S Mosen1, H White2, S Monk

1

1

The University of Chicago The Chicago School of Professional Psychology Email: [email protected]

2

P17 The Influence of Parental Mood and Marital Adjustment on Child Behavior SD Fisher, MW O’Hara, R Kopelman, RL Brock University of Iowa Email: [email protected]

Objective: Much work remains in the treatment of postpartum depression. In addition, postpartum depressed women faces numerous barriers to treatment, including increased role-strain, social and cultural stigmas, and the responsibility of caring for a newborn. Results from clinical trials of computerized psychotherapy in the treatment of psychopathology have often indicated efficacious results. These treatments are often effective, inexpensive, and able to be completed in a home-environment. In this paper, we report the results

S66 of a randomized controlled trial of a multi-media, computer-based, skills-training psychotherapy that incorporates components of emotion-based psychotherapy and cognitive psychotherapy, Mommy Emotion and Psychological Training Experience (MEPTE). Methods: 122 mothers experiencing postpartum depression were randomly assigned to treatment as usual (TAU) or MEPTE. Measures were taken at 4 occasions: prior to treatment, 5 weeks into treatment, termination of treatment, and 12 weeks follow-up using the Beck Depression Inventory, Postpartum Adjustment Scale, and the Dyadic Adjustment Scale. Patients were allowed to receive medication. Results: Patients who received MEPTE showed greater improvement in depression compared to TAU at end of treatment and follow-up. There were no interactions with treatment and concurrent medication or marital status. However, on the Postpartum Adjustment Scale, we did find that duration of illness interacted with treatment improvement on the MEPTE, indicating that women who were depressed longer responded less to MEPTE. Most importantly, however, there was no interaction between the effects of MEPTE and baseline depression, suggesting that women across the spectrum of postpartum depression severity could benefit from this treatment. Conclusion: This study demonstrates that computerized psychotherapy is effective in improving depression symptoms, postpartum adjustment, and dyadic adjustment in women with postpartum depression, independent of severity of depression and concurrent medication. However, we found that women who had been depressed for longer periods responded less to MEPTE when compared to women who were depressed for shorter periods. Thus, our results indicate that dissemination of a computerized treatment to women who may not be able to pursue standard treatment options may be an excellent treatment option, particularly in newly depressed mothers. P19 Understanding and Overcoming Challenges to Engaging and Retaining Low Income Depressed Women into Treatment in the Context of Obstetrical Care HA Flynn1, HA O’Mahen2, J Himle1, G Fedock1 1

University of Michigan Medical School, USA Exeter University, UK Email: [email protected]

2

Objective: Despite the efficacy of psychological treatments for perinatal depression, most women do not access care. This mixed methods study aimed to understand an array of interpersonal, psychological and psychosocial factors influencing engagement and retention in psychotherapy for depression among women identified and recruited from obstetrics settings. Lessons learned from this three year study in improving retention among low income women into an intervention trial will be presented. Methods: The initial, qualitative phase of this study involved semistructured interviews with 25 purposefully sampled women with Major and Minor Depression living in poverty (52% White, 48% African–American) recruited from urban obstetrics settings. Interviews were aimed at understanding an array of influences on depression treatment engagement and adherence. Data were analyzed and used to modify and test the feasibility of a psychotherapeutic depression treatment as compared to depression screening, psycho-

K.L. Wisner education and referral on treatment use and depression outcomes (n=55) in a randomized, controlled pilot study. Results: A combination of referral process, clinician interactional style, and beliefs about depression and treatment were found to be strong influences on use and retention in depression treatment among low income women. Most women cited pressing psychosocial stressors as primarily interfering with treatment, including housing, transportation, childcare, legal, interpersonal violence, and other economic factors. Most women randomly assigned to depression treatment (85%) completed at least 1 psychotherapy session, and 62% completed at least 4 sessions. Substantial staff resources were required for retention, and the majority of scheduled sessions were canceled or re-scheduled. Half of the women assigned to no-cost, in-home treatment completed all 8 sessions. Conclusion: An array of psychosocial, interpersonal and psychological factors interferes with engaging and retaining low income perinatal women in depression treatment. Interventions must include dedicated outreach staff, maximum flexibility in timing and delivery method (i.e. in-home, telephone) of visits. Most women have multiple psychosocial stressors and needs that highlight the importance of psychoeducation about depression and the impact of effective treatment. P20 Perinatal Depression: A Health Plan Awareness Initiative EM Fox BlueChoice HealthPlan, USA Email: [email protected] Objective: BlueChoice HealthPlan, a managed care organization of approximately 180,000 members, implemented a Perinatal Depression Awareness initiative as a component of its Great Expectations® Maternity program in January 2004. The goal was to increase awareness of and screening for perinatal depression through three main objectives: increase awareness in pregnant women; provide education and screening resources to members and physicians; and increase detection and treatment of depression during and after pregnancy. Method: Several interventions were undertaken to accomplish the defined objectives:

&

&

&

&

Between 32 and 34 weeks gestation, all pregnant members (approximately 1600 per year) are sent an educational packet, including a “Depression During and After Pregnancy” booklet; the Edinburgh Postnatal Depression Scale (EPDS); contact information for our health plan’s behavioral health vendor; and community resource support information. Experienced perinatal clinicians provide telephonic outreach to members during pregnancy and through the postpartum period. Those with current or prior history of depression or postpartum depression (PPD), identified through a maternal health risk assessment are targeted for calls. We sought to partner with contracting physicians in the education of our members. Several initiatives sent to primary care physicians, obstetricians and pediatricians to encourage more timely recognition and treatment, including the EPDS in both English and Spanish, and outcomes data from the initial years of the study. Collaborated with and joined the Midlands Postpartum Coalition; current projects include resource development and educational conference planning.

The Marcé International Society International Biennial General Scientific Meeting Results: Member survey outcomes documented significant increases from our 2003 baseline. Members were queried about talking with their doctor about PPD, where they were encouraged to complete a written questionnaire and related issues. The dramatic increases were evident in the first year and have been maintained, to a slightly lesser degree, through the remaining years of the study. The specific rates of change will be shared during this presentation. Conclusion: These findings indicate that a health plan can positively impact the knowledge of members and perhaps the screening patterns of physicians, for perinatal depression. P21 Prenatal Anxiety is Associated with Reduced Placental Weight L Freeman, K O’Donnell, N Khalife, V Glover Imperial College, Hammersmith Campus, London, UK Email: [email protected] Objective: There is now much evidence that the emotional state of the mother can have an effect on the unborn fetus. Prenatal anxiety in particular, has been shown to increase the risk of impaired neurodevelopmental outcomes in the child; the mechanisms underlying this are still unclear. The objective of this part of our study was to see if prenatal anxiety is associated with on the placental structure, morphology and weight. Method: Women were recruited the day before elective caesarean section and given standardised self-rating questionnaires looking at anxiety and depression during pregnancy. The aim is to correlate this with placental parameters. Results: We have the results from 42 women so far and this has shown an inverse correlation between Spielberger trait anxiety and placental weight (r=−0.358, P=0.02). Using a cutoff of 50 on the trait anxiety scale the placental weight of the more anxious women was 505±33 g (n=8) compared with that of the less anxious women 634± 117 (n=34), P=0.001. There were also similar trends with the Spielberger State anxiety scale and the Edinburgh Depression scale. The sex of the fetus had no effect. Conclusion: Our results suggest that prenatal anxiety may have a substantial effect on the development of the placenta. This in turn may effect the development of the fetus. We will now move on to study the association between prenatal psychological parameters and morphological and molecular aspects of the placenta. P22 Perinatal Psychiatry in the Neonatal Intensive Care Unit SH Friedman, S Nagle-Yang, J Amin, RA Kessler, A Eliason, H Friedman, R Martin, M Hack Case Western Reserve University School of Medicine, Cleveland, Ohio, USA Email: [email protected] Background and Objective: Mothers of infants in the Neonatal Intensive Care Unit (NICU) are at increased risk for clinically significant depression, anxiety, and PTSD. Additionally, the experi-

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ence of the NICU environment can post a significant additional threat to maternal–infant attachment and development. Grieving is also an important issue in this setting. NICU staff members are in a unique position to both observe and support these mothers. Staff working in this setting are trained in pediatrics/ neonatology but often not in psychology/ psychiatry. Unfortunately, the high levels of stress involved in NICU care puts them at risk for burnout. Contributing factors include disenfranchised grief, ethical dilemmas, problematic interdisciplinary relationships and a low sense of accomplishment. Methods: At our academic medical center’s level III NICU, a parttime psychiatrist is available to provide both parental and staff support. Parents are seen for evaluation and psychotherapy, and recommendations are made about future treatment needs. Parent groups have also been offered. Staff support is delivered through educational in-services, groups sessions dealing with challenging parent interactions, grief or ethical dilemmas, and individual meetings as necessary. Results: Parents (primarily mothers) have been evaluated and treated with psychotherapy since 2006. Depression and anxiety are the primary diagnoses. As well, over the course of 3 years, social workers, nurses, nurse practitioners and neonatologists have attended group sessions with the psychiatrists. Fellows, residents and attendings have attended journal clubs. Monthly educational seminars have included topics within maternal mental illness, development in preterm infants and teen parenting. Conclusions: Having a perinatal psychiatrist present in the NICU can help with maternal functioning as well as potentially decreasing jobrelated stress and burnout, enabling NICU specialists to provide optimal care. P23 Baby Steps: Starting a Mental Health Support Group for New & Expecting Moms TA Fulcher1, K Niznik2, L Staiger3, St Clair Hospital, Pittsburgh PA, USA Email: [email protected] Objective: Postpartum Depression is the #1 complication of childbirth. The NIH suggests that 15% of all women will experience one type of perinatal mood disorder and one in eight will have postpartum depression. The impact of this depression has far reaching consequences and alters more than the emotional status of the mother. It impairs mother/infant bonding, delaying the emotional development of the infant and adding stress to the father–mother relationship. Screening for postpartum depression during the maternity stay alerts staff to mothers who are at risk. Timing of follow-up phone calls assists in identifying those with current problems. Referral for immediate treatment and linking mothers to support groups has been known to play an important role in the prevention and treatment of perinatal mood disorders. Method: St. Clair Hospital’s maternity staff RNs identified a growing number of postpartum women experiencing this complication. A community needs assessment revealed an absence of community support programs. Integration of resources from the Centers for Women & Children and Behavioral Health provided an interdisciplinary

S68 team to focus on this task. Development of key community partnerships assisted with meeting planning and marketing. Results: As of December 2008, St. Clair Hospital has facilitated a mental health support group, Baby Steps. Groups are co-lead by a maternity RN and a behavioral health professional. 9 women attend regular monthly meetings, with topics rotating on a 4-week series. Evaluations and feedback show that the support group provides the women with a safe place to share their struggles, without fear of judgment, and offers them support and tools to manage their symptoms and their life activities. Conclusion: Community based supports groups provide an important role to women struggling with perinatal mood disorders. Utilizing internal and external resources provides a solid platform for providing this service. P24 Voices of Women: An Exploration of the Patient-Provider Relationship Through Poetry

K.L. Wisner medical interruptions of pregnancies. The objective of the present work was to organize the care of medical interruptions in a transdisciplinary perspective. Method: Ten yeas of collaboration between obstetricians, midwives, pediatricians, geneticist, social workers, psychologists and psychiatrists at the University Maternity of Bordeaux about this topic has made possible the development of a specific “course of care”, with obstetrician–psychologist joint antenatal consultations. Results: The organization and some cases will be presented and discussed, showing that one of the main result of this type of multidisciplinary work is the diminution of the length of labor Conclusions: A great satisfaction and relief of the professional regarding the emotional support provided by such transdisciplinary work is reported, and women and their partners feel more appeased and grateful thanks to the support they received. P26 Group Treatment of Postpartum Depression: A Systematic Review

C Ghetti JH Goodman University of Pittsburgh, Pittsburgh, PA Email: [email protected] Objective: In a time of technology, corporate and evidence-based medicine, the critical component of our physician-hood—the patientphysician relationship—can at times seem lost. In order to reflect upon the patient-physician relationship, we will explore the lived experiences of women through various stages of life using the voices of female poets. Method: Works by female poets of all ages will be presented. Works focus on key milestones in women’s lives and reveal a range of human emotion. Results: Poetry can help us understand both patient and physician by putting us in touch with people’s humanity. It conveys thoughts, emotions, and experiences in condensed forms. The metaphors, images, rhythms, and sounds of poetry awaken our imagination and emotions and help us probe the intangible realm of spirit and soul in a way that medical literature cannot. Conclusion: The voices of women poets allow us a unique opportunity to rediscover aspects of the patient–physician relationship. By embracing our patients’ humanity and the patient–doctor relationship we may find renewed meaning in our work. P25 Liaison Psychiatry in Maternity: A Medicopsychosocial Approach of Medical Interruption of Pregnancy. E Glatigny-Dallay1, AL Sutter-Dallay1,2, M Dubourg3, E Toussaint 3, MP Darquest3, S Leguen3, D Dallay3, J Horovitz3, R Saura3, M Michel3, S Vallier 3. 1

University Department of Adult Psychiatry, Perinatal psychiatry network, CH Charles Perrens, Bordeaux, France 2 EA 4139, Victor Segalen University, Bordeaux 2, Bordeaux, France 3 Maternity department, University Hospital, Bordeaux, France Email: [email protected] Objective: One of the main issue of liaison psychiatry in University Maternity Departments in France is the psychological approach of

MGH Institute of Health Professions School of Nursing, Boston, MA Email: [email protected] Objective: An estimated 10% to 15% of all women develop postpartum depression (PPD) following childbirth and another 10% of women develop subclinical depressive symptoms in the postpartum period. A frequently recommended treatment is referral to a PPD support or therapy group. The purpose of this study was to review the literature regarding support groups and group therapy for women with postpartum depression to determine the current state of knowledge regarding the efficacy of this treatment modality for reducing depressive symptoms in postpartum women. Method: A systematic review of quantitative studies published in English through March 2010 was conducted using the electronic databases Medline, CINAHL, and PsycINFO using a combination of the terms postpartum or postnatal, with depression, and group therapy, group treatment, or support group. Criteria for study inclusion included: a) tested an intervention targeting PPD, b) included support group or group therapy as an independent variable, and c) included PPD or depressive symptoms as a dependent variable. Studies that employed a preventive intervention for PPD were not included. Data was extracted synthesized using a narrative approach. Results: Sixteen studies were included in the review: 5 randomized controlled trials; 6 quasi-experimental, controlled studies; and 5 pretest post-test, uncontrolled studies. There was considerable variation in study quality, samples, methods used, depression measures used, and interventions tested. Interventions ranged form highly structured, manualized ones to relatively unstructured support groups and included group-based cognitive-behavioral therapy, psychoeducation, interpersonal therapy, psychodynamic therapy, dyadic mother–infant therapy, social support, and supportive therapy or counseling, or a combination of modalities. Conclusions: All but one study showed improvement of postpartum depressive symptoms with group treatment suggesting that group treatment may be effective in reducing postpartum depressive symptoms. It is difficult, however, to draw conclusions about the results due to a number of common limitations that challenge the validity of many of the studies. Furthermore, methodological differ-

The Marcé International Society International Biennial General Scientific Meeting ences among the studies make comparisons difficult. There is a need for further, well-designed research on group therapy for PPD. P27 Postpartum Depressive Symptoms and Life Satisfaction: the Role of Self-Efficacy and Social Support SM Haga1, H Kalkvik1, K Slinning2, P Kraft1,T Steen3, AT Staff3 1

University of Oslo National Network for Infant Mental Health 3 Oslo University Hospital Email: [email protected] 2

Objective: Postpartum depression (PPD) is a serious health issue affecting as many as 10–15% of women. The purpose of the present cross-sectional study was to investigate how general self-efficacy (SE), breastfeeding self-efficacy (BSES) and various dimensions of social support related to both postpartum depressive symptoms (EPDS) and to life satisfaction (SWLS) 6 weeks postpartum. Method: The data were collected with a questionnaire between May 2008 and September 2009, in a sample of 483 new mothers. It was hypothesized that SE, BSES, and social support would correlate negatively with EPDS, and positively with SWLS. Data were analyzed by Spearman correlation coefficient and stepwise regression analyses. Results: Results indicated, as expected, that general self-efficacy and breastfeeding self-efficacy were negatively associated with postpartum depressive symptoms and positively associated with life satisfaction. Interestingly, among the measures of social support, only perceived available support predicted directly both the EPDS and the SWLS. Mediation analyses showed that general self-efficacy and perceived available support partially mediated the effect of one another on life satisfaction. Conclusion: This study illustrates the importance of psychosocial variables with regards to both postpartum depressive symptoms and the experience of life satisfaction in the postpartum period. P28 Jinn Possession During the Postnatal Period J Hanley Swansea University, Wales, UK Email: [email protected] Objective: The incidence of postnatal depression worldwide is significant. Although cultural context shapes mothers’ interpretation of their postnatal experience, the symptoms and manifestations of mothers studied in one Arab culture reflected those of western mother’s experiences. The cultural determinants that exposed Arab mothers to depressive symptoms were explored and the mother’s interpretations of these feelings were examined. Their belief system was based on the occurrence of ‘Jinn’, a corporeal being responsible for misfortune and bad luck. This mythology had a profound importance in society and provided a framework against which social actions and events were regulated.

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Method: This qualitative ethnographic research recorded the responses of ten mothers who were know to be suffering from the effects of Jinn, in the post natal period. An in-depth interview schedule questioned the mother’s attitudes towards themselves, their condition, their families and social circumstances, whilst they were suffering from or had suffered from the Jinn. Informal interviews were also conducted with religious and village leaders. Where it was appropriate, participant-observation took place. Results: The findings suggested there were similarities between the emotions and problems which exacerbated postnatal depression. The support network for Muslim mothers was significantly stronger and the affect of the Jinn was a communal responsibility. Parallels are drawn for comparison with western treatment. Conclusion: The belief system determined Jinn was an external entity, regarded as responsible for the mother’s condition and ensured she was vindicated from all blame. Western culture would benefit from more knowledge of the management and care of the condition, as demonstrated in this Arab culture. P29 Incidence and Severity of Postpartum Depression Among Military Beneficiaries: A Performance Improvement Project K Haworth Ireland Army Community Hospital, Fort Knox, KY Email: [email protected] Objective: Postpartum depression affects an estimated 14% of women. Postpartum suicide attempt and death rates are lower overall, but when deaths do occur, suicides account for 20%. Self-harm ideation is considered to occur 5–14% of the time. It is hypothesized that the military population has increased incidence and severity of postpartum depression. This is speculated to be secondary to deployments, frequent moves, and lack of family or social support. Method: Women qualified to receive care at Ireland Army Community Hospital, Fort Knox (either active duty or dependent) were screened for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) over 20 months. OB/GYN Clinic surveyed at the 6 week postpartum visit (infant ages ranged 2–8 weeks) and Pediatric Clinic at well baby visits (newborn, 2 weeks, 2, 4, 6, and 9 months). A screen was considered positive with total score =/> 10, or score >0 on question #10 (suicidal ideation). For positive screens, further questioning was performed by nursing or provider and referrals and information given. For those with suicidal ideation, immediate evaluation was done by our Behavioral Health Department. Results: 2055 screens obtained from postpartum mothers in Pediatric and OB/GYN clinics represented 959 women. 183 mothers scored positively, giving 19.1% incidence. Significant disparity existed between Pediatrics (11.9%) versus OB/GYN (18.4%), although the same mothers were represented. When comparing screens for women 1 day to 2 months postpartum, a difference remained (Pediatrics 10.8% versus OB/GYN 16.5%). Of women with positive scores, 31.1% answered question #10 (suicidal ideation) positively. Incidence of 5.9% suicidal ideation existed for the entire population screened. Conclusion: Fort Knox’s Ireland Army Community Hospital’s military beneficiaries showed significantly increased postpartum depression rates than civilian (19.1% versus 14%). Noteworthy difference among age-matched EPDS results existed between Pediatric

S70 and OB/GYN clinics. Several mothers with positive screens indicated suicidal ideation present (31.1%). Previously reported incidence among military women was 15%, while civilian comparisons show 5–14%. Organized support for military beneficiaries with postpartum mood disorders does not currently exist. P30 Mental Health Issues in Early Head Start: Impact on Families, Pregnant Mothers, and Babies VM Herman, E Tittnich, University of Pittsburgh, Pittsburgh, PA Email: [email protected] Objective: Early Head Start (EHS) delivers home-based services to enhance the emotional and social development of children ages 0–3. Families can enroll when mothers are pregnant to enable her to prepare for the birth of her infant. EHS serves predominantly high risk families, many of whom are dealing with mental health issues. EHS undertook a qualitative assessment to better understand families’ needs and to examine the impact of families’ mental health issues on the home visitor’ efforts to enhance child and family well-being. Method: An ethnographic approach was used to understand the nature of families’ mental health challenges and the impact of these challenges on children and families. We also examined the effect of familial mental health issues on the EHS providers’ home visits and their interactions with families. Data was gathered through observations of EHS program meetings where staff discussed cases, interviews with home visitors about specific cases where maternal or paternal psychiatric diagnoses were reported, and group interviews with program staff and with mental health providers who serve the program. Results: Data from multiple informants increased the awareness of the impact of psychiatric illness on EHS families. Our data suggest that mental health challenges affect how families participate in the program, how they work towards their goals in the program, and how they work with EHS to help their children achieve developmental milestones. We also found that home visitors, most of whom have little or no professional training in mental health fields, face additional barriers in helping these families with psychiatric illnesses participate fully in the program and meet their goals. Conclusion: Our qualitative study illuminates the multiple ways in which mental health issues impact children and families. These findings will be used to inform possible interventions to strengthen the EHS program and to promote overall well-being for these and similar families. P31 The Lived Experience of Women with A Postpartum Mood Disorder When They Stopped Breastfeeding HW Jones Raritan Valley Community College, J D Kuris and Associates, North Brance, NJ Email: [email protected] Objective: The purpose of this study was to (a) generate a description of the personal experiences of women, diagnosed with a Postpartum

K.L. Wisner Mood Disorder, when weaning their infants; and to (b) describe the impact of weaning on the symptoms of a postpartum mood disorder. Method: A phenomenological method of study was used. The data analysis was a variation of the Stevick-Steven-Colaizzi-Keen-Keen method (Moustakas, 1994) and the Steven-Colaizzi-Keen (1978) method, as used by Beck (1998) in her study of postpartum onset of panic disorders. Verbatim transcripts of all the interviews were analyzed using a qualitative computer program, Atlas/ti, which is a German code-based theory building software package. Results: This study identified the specific and collective phenomenological experiences of the nine primary participants, who had a postpartum mood disorder, when they ceased to breastfeed. Two major categories of quotations emerged: (1) maintaining a sense of maternal competence and maternal role attainment during the weaning experience; and (2) maintaining a sense of power and control over her final decision. Conclusion: Cessation of breastfeeding is a multi-faceted and complicated task that includes emotional, physiological, personal, cultural, and spiritual aspects. Whether weaning is done gradually or precipitously, it may have negative emotional consequences for some mothers, and those negative emotional consequences may affect their infants. These consequences may be especially significant for the mother/infant dyads when the mother has a pre-existing postpartum mental disorder. This information has implications for clinical practice and the health care practitioners who work with breastfeeding mothers. Specific recommendations and interventions are presented. P32 Post Traumatic Stress Disorder Secondary to Childbirth: Birth Doulas, Prevention, and Potential Partnerships— W Karraa¹, H Koss-Nobel², N Robinson³ LA County Perinatal Mental Health Task Force¹, PSI/WA², South Bay Center for Counseling³ Email: [email protected] Objective: Current rates of Post Traumatic Stress Disorder (PTSD) secondary to childbirth near 6%, maternal self-reporting traumatic birth as high as 32%. Common themes noted in research regarding maternal trauma due to childbirth are: perceived lack of communication by medical staff, fear of unsafe care, lack of choice regarding routine medical procedures, lack of continuity of care providers, and care being based solely on delivery outcome. Given the current demands on nurses to care for multiple patients at once, nurses are unable to provide the ongoing, personal care that prevents these perceptions. Research demonstrates when doulas (trained labor assistant) attend births, labors are shorter, there is a decrease in length of hospital stay, fewer medical interventions, lower rates of Cesarean surgery, and babies breastfeed more easily. Birth doulas offer an important tool in preventing birth trauma by offering continuous, mother-focused care during labor, birth and the immediate postpartum period—positively effecting birth outcome, and maternal perception of birth. Methods: Development of local and organizational partnerships between PPMD based social support organizations and international certifying doula organizations to increase client access to birth doulas. Establishing local groupsite collaboratives would connect local coordinators with doulas, current research and training opportunities.

The Marcé International Society International Biennial General Scientific Meeting CEU's should be offered to MFT/LCSW's who attend birth trainings. CEU's should be given to doulas who attend PPMD trainings, or complete web-based trainings. Organizational partnerships could include integrating PPMD web-based adult-education models with doula organizations for doula training and certification standards. Results: Partnerships would: 1) establish research opportunities for examining the relationship between birth doulas and prevention of PTSD secondary to childbirth, 2) increase client access to birth doulas, 3) develop the doula's knowledge of prevalence, symptoms, and screening tools, and 4) increase client access to PPMD resources. Conclusion: Increasing patient access to birth doulas, and establishing partnerships with international doula organizations promises tremendous potential in the prevention of PTSD secondary to childbirth. P33 Help is A Phone Call Away: Characteristics of Calls to A Perinatal Depression Hotline JJ Kim1, 2, LM La Porte1 NorthShore University HealthSystem1, University of Chicago2, USA Email: [email protected]

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P34 The Puzzle of Birth Euphoria: Lessons Learned LD Kruckman, CA White, KB Mahoney, AV Helfer Department of Anthropology, Indiana University of Pennsylvania Email: [email protected] Objective: Negative and subdued self limiting mood disorders observed in the first few days following childbirth, commonly known as the ‘blues,’ have been studied fairly intensely for many decades. The more positive and energized experiences, broadly described as birth euphoria, postnatal elation, birth high, ecstatic state, mystical experience, and so on, have not. Method: This paper investigates research on birth euphoria, reviews its biochemical relationship to the “blues,” frequency, using major data sources such as Pub Med and Human Relations Area Files, and discusses various theories. Conclusion: The paper also looks at lessons learned over the past 25 years and makes suggestions for screening and improved birth outcomes. P35

Objective: Mood and anxiety disorders are among the most common of perinatal complications, occurring in up to 19% of pregnant or postpartum women. Untreated, these disorders can compromise pregnancy outcome, disrupt the parent–infant relationship, and negatively impact childhood development. Women and families impacted by perinatal mood disorders may feel alone, helpless, and uncertain about where to turn for help. Method: The 866-364-MOMS hotline was launched in January 2003 as part of a comprehensive program aimed at identifying and helping women and families impacted by perinatal mood disorders. In 2005 the service expanded throughout the State of Illinois in partnership with the Illinois Department of Healthcare and Family Services. The hotline is a free service staffed 24 hours a day, seven days a week by licensed mental health professionals who can assist callers in any language via an interpretive service. Callers can access support, information, crisis intervention, and referrals to mental health specialists and other community resources based on location and regardless of insurance. Results: The hotline received 2,327 calls between January 2003 and December 2009. Average monthly call volume has increased by 320% since inception. 21% of callers are antepartum and 79% are postpartum. 25% report an outpatient psychiatric history, 6% report a history of inpatient psychiatric admission, and 11% report a history of prior postpartum depression. Current or recent suicidal ideation, homicidal ideation, and psychotic symptoms are reported by 10%, 1% and 2% of callers, respectively. The majority (88%) of callers reside in Illinois; however, the hotline has also served callers from 37 U.S. States, England, and Canada. Most (76%) callers accept community mental health referrals. To date, 138 callers (6%) have been referred directly to their local emergency department for urgent psychiatric evaluation. Pilot program evaluation data indicate high levels of satisfaction with the service. Conclusions: The 866-364-MOMS hotline provides a unique and potentially life-saving service to the perinatal mood disorders community. The hotline is replicable and merits consideration for implementation in other locales.

Retention of Women in Postnatal Depression Prevention Research in Mexico MA Lara Cinisomo, C Navarro, L Navarrete Ramón de la Fuente National Institute of Psychiatry, Mexico Email: [email protected] Objective: Perinatal depression is a significant public mental health problem; consequently, there is a major interest in developing strategies to prevent postpartum depression (PPD). However, the unique experiences associated with the perinatal period make it more difficult to recruit participants at this stage and to retain them over time when assessing prevention interventions. The aim of the study is to examine rates and predictors of retention in a longitudinal, randomized controlled trial (RCT) to prevent postnatal depression in Mexican pregnant women. Method: Pregnant women (N=377) at risk of depression were randomized to intervention or usual care condition and assessed during pregnancy and at 6 weeks and 4–6 months postpartum. The intervention was designed by modifying a previously evaluated one and includes information on normal pregnancy and the postpartum period, from psychoanalytic and risk factors perspectives. It is delivered in eight two-hour weekly group sessions during pregnancy. The measurements included were: the second edition of the Beck Depression Inventory (BDI-II); the anxiety symptoms subscale of the Hopkins Symptoms Checklist (SCL-90), the Social Support Apgar (SSA), a form of 12 items representing potential stressors and the Abbreviated Version of the Dyadic Adjustment Scale (A-DAS). Results: Retention rates were defined in three ways: (1) Total retention (percentage of participants completing the 4–6 month postpartum interview) was 41.7% (31.2% intervention and 61.4% control); (2) Retention from randomization to (a) completion of initial evaluation and attendance of ≥1 intervention sessions was 42.4%; and

S72 (b) completion of initial evaluation (control) was 82.2%; and (3) Follow-up retention: (a) intervention participants attending ≥1 sessions that completed the intervention as well as the 4–6 months postpartum interview was 73.5%; and (b) control participants assessed in this period was 66.6%. For those who came to at least one intervention session 83% completed the intervention. The predictors of total retention were: being single, more educated, and poor partner relationship quality. For the intervention condition, predictors of (a) retention from randomization to attendance to ≥1 sessions were anxiety and stressful life events, and (b) for follow-up retention was being employed. Conclusion: We conclude that rates and predictors of retention differed depending on points of measurement, suggesting different strategies to optimize participation. P36 Understanding Postpartum Depression Treatment Preferences Among Hispanic Mothers S Lara-Cinisomo1, K Wisner2, R Burns3, & D Chavez-Gnecco2 1

UNC Charlotte University of Pittsburgh 3 RAND Email: [email protected] 2

Objective: There has been a growth in the number of studies examining treatment options for postpartum depression including the use of antidepressants and psychotherapy. However, most of the studies have focused primarily on white women making it difficult to determine Hispanic mothers’ treatment preferences. To address this gap, we conducted a pilot study with Hispanic mothers to identify treatment preferences as well as barriers and facilitators to treatment. Method: Focus group interviews were conducted with 21 prenatal and postpartum Hispanic mothers. Participants were recruited at approved medical and community settings. A standardized interview protocol available in Spanish and English was used to guide the interviews. Demographic data was collected using a survey after each focus group interview. Qualitative data analyses were conducted with the focus group interview as the unit of analysis. Results: Our analyses revealed important treatment preferences. We found that participants preferred a hierarchical approach to treatment, with use of their own coping as their first line of defense followed by seeking social support from a trusted professional (e.g., nurse). A third, yet less desirable, approach includes use of a mental health profession. However, there were a number of misconceptions about what a mental health provider can do to help. There were also a number of fears and noted risks associated with seeking professional mental health care, such as feeling pressured to take antidepressants or losing custody of their child. The use of antidepressants as a treatment option was not endorsed or embraced by the vast majority of focus groups. Conclusions: Our results suggest that health care providers and researchers must take steps toward establishing trust within the Hispanic community prior to introducing an intervention. In order to establish trust, we must ensure that proposed programs and services address the preference Hispanic women cited, such as talking rather

K.L. Wisner than pushing antidepressants and that such interventions also encourage didactic therapy while making other resources (e.g., psychotherapy) accessible when necessary. P37 Retention of Low Income Latinas in a Perinatal Depression Prevention Trial HN Le1, L Hochhausen1, DF Perry2 George Washington University1, Georgetown University2, USA Email: [email protected] Objective: Perinatal depression is an important target for prevention efforts. Yet some of the changes that characterize the perinatal period and may contribute to depression also may make it more difficult to recruit participants and to retain them over time, especially if participants are underserved, low income, and ethnic minority status. This study examined retention issues, including rates and demographic and risk predictors of retention in a longitudinal randomized controlled trial aimed at preventing perinatal depression in a sample of low income, predominantly Central American women. Method: With support from the Maternal and Child Health Bureau, 217 participants who met demographic and depression risk criteria were recruited from an urban community public health center and hospital, and randomized into an eight-session culturally adapted cognitive-behavioral group intervention during pregnancy and three individual booster sessions during postpartum (Intervention/INT: n=112) or Usual Care (UC: n=105). Participants completed measures assessing perinatal depression and risk factors across five time points during the perinatal period: pre and post intervention during pregnancy, 6 weeks, 4–6 months, and 12 months postpartum. Multiple and extensive efforts were made to retain participants. Results: Total retention of all participants (percentage of participants completing all 5 time points) was 69% (69% INT; 70% UC). The majority (88%) of INT participants attended at least 1 of 8 sessions; of these, 63% completed the study. Predictors of total retention for all participants included: being born in Mexico, having more gestational weeks, and having higher depressive symptoms scores at baseline. INT participants with higher anxiety levels and who worked fewer hours were significantly more likely to attend ≥1 sessions and complete the study. Conclusion: Efforts to identify the predictors of participants more or less likely to be retained in longitudinal prevention trials are critical. Identifying predictors of women who may need additional support to participate and remain in preventive interventions can guide efforts to scale up in public health settings. P38 Correlates of Maternal Interactive Behavior in Latina Immigrant Mothers of 1-Year Old Infants KL Lieberman1, HN Le1, DF Perry2 1

George Washington University Georgetown University Email: [email protected]

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The Marcé International Society International Biennial General Scientific Meeting Objective: Research has shown that the mother–infant relationship is crucial to the optimal development of infants’ environmental mastery, communication and relationship skills, and emotional and behavioral regulation capacities, and that maternal depression and marital adjustment independently influence maternal parenting behaviors. However, these relationships are understudied in Latina samples, part of the largest minority group and fastest growing population in the U.S. Latina immigrant mothers also face unique risks as a generally young population experiencing stressors associated with immigration and parenting. The purpose of this study is to examine the relationships among depression, marital quality, and mother–infant interactions. Method: Secondary data were taken from a RCT of a prevention intervention trial for perinatal depression in Latinas in Washington DC. Measures of mothers’ functioning (depression and risk factors) were administered at 5 time points, from pregnancy through 1 year postpartum. Data from this study derive from the 1-year time point. Participants included 77 mothers, predominantly Central American (74%), with a mean age of 25.5 (SD=4.5) and an average of 1.95 children. (SD=1.2). They had lived in the U.S. for an average of 5.0 years (SD=4.1), and 59.8% were married or living with a partner. Measures included the Beck Depression Inventory-II (depressive symptoms), the Abbreviated Dyadic Adjustment Scale (marital quality), and the Parent Child Observation Guide (videotaped mother–infant dyads coded by blind independent raters for the behavioral quality of interaction). Results: Marital quality (ADAS) was significantly and positively associated with sensitive parenting (Sensitive Parenting Index of PCOG), r=.33, p<.05. No significant associations were found between depression and parenting, or between depression and marital quality. Conclusion: Consistent with previous research, marital quality was associated with maternal sensitivity to infants’ activities and interests. Previously documented relationships between depression and marital quality and depression and maternal behavior were not found. For this sample of low-income Latina immigrant mothers, findings suggest that marital quality may be more important cross-sectionally for understanding concurrent mother–infant interactions. Future research should expand upon these findings longitudinally and examine possibilities for prevention and treatment.

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P40 Obstetrical Care Providers Knowledge, Attitudes, and Practices Related to Postpartum Depression at Oregon Health & Science University JH Lincoln, M Berlin, J Romm Oregon Health & Science University (OHSU), USA Email: [email protected]

MR Liepman, RS Tareen, LC Sweezy, NJ Roberts, RM Charoth, CL Kothari

Objective: Postpartum depression (PPD), with a prevalence of approximately 12–15%, is one of the most common complications of pregnancy. Despite this, PPD is under diagnosed and subsequently undertreated as many providers do not screen adequately. The goal of our study was to understand the knowledge, attitudes, and practices regarding screening and treatment for postpartum depression by healthcare providers who provide pregnancy and postpartum care at OHSU. These providers include midwifery faculty and students, as well as family medicine and OB/GYN faculty, fellows, and residents. Methods: With IRB approval, eligible participants received an E-mail invitation to participate in an anonymous online survey; a reminder Email was sent 10 days later. Questions about provider demographics, knowledge of PPD, and screening and treatment practices were asked. The survey was based on a validated survey used by LaRoccoCockburn et al in a similar study, with written permission. Descriptive statistics were then reported. Results: Response rates were 50% for midwifery providers, 60% for OB/GYN providers, and 31% for family medicine providers. While >95% of respondents believed providers should routinely screen, only 25–50% reported always screening. Many screened by asking general, non-validated questions. Treatment was felt to be effective by >80% of providers, but only up to 60% felt they had adequate training to treat, with Family Medicine attendings being the exception at 80%. A substantial proportion of midwifery (65%) and resident (30%) providers felt uncomfortable prescribing medication to breastfeeding patients, while only 5–15% of attendings felt similarly. Forty to 70% of providers did not know where to refer patients for ongoing treatment, and cost was of great concern to most respondents. Conclusions: Providers had a good knowledge of PPD, and almost all knew that screening and treatment were effective. However, there was a marked discrepancy between that knowledge, and actual screening and treatment practices. This study sheds light on what areas need to be addressed and improved in obstetric providers’ care of women with PPD.

Email: [email protected]

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The Kalamazoo community in West Michigan initially was inattentive to the special challenges that women face when they encounter mood disorders during pregnancy and postpartum. Efforts of a team transformed the perinatal care system and the mental health and social services systems. Sweeping improvements in the screening practices, treatment and referral processes, community awareness, and outcomes for the women and their families demonstrates the importance of mounting a community-wide initiative to tackle this issue. We will welcome discussion of the components of our efforts as well as hearing what other communities have done.

Multiprofessional Teams for Mentally Frail / Ill Pregnant Women and New Parents—A Collaboration Model in Stockholm

P39 Changing A Community’s Approach to Perinatal Mood Disorders

A Lindfors, K Petersson Södersjukhuset, Stockholm, Sweden Email: [email protected] Background: The presence of psychiatric illness during pregnancy and postpartum period is in various Swedish prevalence studies

S74 known to be between 8–13%. These women/families often have extensive health needs and are known by different caregivers. In absence of coordination between various health care providers, efforts sometimes tend to be of an “acute nature” which can create insecurity and anxiety among patients and relatives and also among staff. Method: Interdisciplinary collaboration between maternity care, child health, social services, adult and child/adolescent psychiatry and obstetric care. Results: During the last ten years 34 locally situated multiprofessional team in Stockholm have started with representatives from the above mentioned caregivers. All the groups use a common, well structured model for the work. They meet once a month to discus cases, health care planning and consultations. The family’s situation and special needs are discussed from a medical, social, psychiatric and psychological perspective. Collaboration takes place on two levels, in the professional’s teams, and in meetings with the family and their private and professional network for health care planning. These network meetings take place at one or several times until the family’s situation is stable or the planed support is established and functioning. The work has resulted in guidelines of care and early identification of the family’s need of support. The different professionals have today an increased knowledge about the importance of acknowledge mental disorders during pregnancy and early parenthood and they have improved the approach towards these women. Pregnant women and families with babies with mental disorders are now a priority group for assessment and treatment at the psychiatric clinic. Conclusion: The multiprofessional approach in a better way meets the patients need, is efficient for caregivers and it also appear to have resulted in a decreased number of acute admissions to psychiatric clinics, during pregnancy and postpartum period. It creates a professional “keeping” that contribute to security for patients, relatives and staff. P42 Perceived Parenting Stress and Child Temperament: the Role of Maternal Anxiety JE McCabe, JA Williamson, MW O’Hara University of Iowa, Department of Psychology, Iowa City, IA Email: [email protected] Objective: Past research shows that maternal depression has a negative impact on the mother, the child, and the mother–child relationship. This includes maternal reports of parenting stress and negative child temperament. Far less attention has been paid to maternal anxiety. Current literature suggests that some symptoms of anxiety are similar to the chronic, pervasive nature of depression symptoms (e.g., uncontrollable worrying). Other anxiety symptoms are characterized by limited distress (e.g., fear of social situations) and thus are less similar to depression. Therefore, the current study will address the impact of maternal anxiety symptoms on reports of both parenting stress and child temperament, while taking into consideration the level of distress associated with the symptoms (i.e., pervasive VS limited). To achieve a contrast between pervasive and limited

K.L. Wisner distress, this study examines symptoms of generalized anxiety (GA) and social anxiety (SA) in mothers. Method: This report is based on an ongoing study of emotional experiences of women during and after pregnancy. At 16-months postpartum, women complete self-report measures of mood and anxiety symptoms, parenting stress, and child temperament. Phone interviews are completed with participants to obtain additional measures of mood and anxiety symptoms based on interviewer ratings. Results: Analyses were conducted on interim data based on a sample size of 102 mothers. These preliminary data show that GA and SA are associated with maternal reports of parenting stress and child temperament. However, only SA shows trends towards predicting these reports independent of depression symptoms. Conclusion: These results emphasize the importance of examining maternal psychopathology more broadly (i.e., beyond depression). Further, it is important that clinicians focus on identifying and treating symptoms of maternal anxiety, including SA, which appears to have a unique impact on maternal reports of parenting stress and difficult child temperament. P43 Psychological and Psychosocial Interventions in An NHS Perinatal Mental Health Service. What Really Happens in A Clinical Setting M McGuinness, F Gopie, E Gasson, M Pursey, R John, G Wainscott & G Berrisford Birmingham Perinatal Mental Health Service, UK Email: [email protected] Objective: Increasingly the majority of publications in the field of mental health, including perinatal mental health, originate from research settings. In the quest to determine which treatments are effective this is both desirable and necessary. In the United Kingdom, however, the vast majority of treatment and therapy is provided in National Health Service clinical settings which are often far removed, both physically and culturally from academic facilities. To fully harvest the potential from innovative research it is essential that researchers and clinicians not only collaborate but, are aware of the realities of each other’s settings and the opportunities and limitations associated with these. The Birmingham Perinatal Mental Health Service was set up in 1992 by Professor Ian Brockington. Although having a regional catchment area the service is based in Birmingham, an ethnically and culturally diverse city located in the United Kingdom’s second most populous urban area. The Birmingham Perinatal Mental Health Service comprises a 9 bedded inpatient unit as well as a busy day service. This poster will describe the realities of the work of the day service with a particular focus on group psychological and psychosocial interventions as they are provided in a naturalistic setting. Method: All referrals to the day service over a 12 month period have been reviewed. Data is collected at the beginning and end of each intervention. This data gives a measure of outcome and utility of the interventions. The main psychological and psychological group interventions are described. Results: Preliminary outcome data (symptomatic, serve user satisfaction and internal audits) will be presented.

The Marcé International Society International Biennial General Scientific Meeting Conclusion: The tensions between providing a clinical service within a finite resource, whilst being aware of the findings from research and adhering to the National Institute for Clinical Excellence Antenatal and Postnatal Mental Health Guidance will be explored. P44 Involuntary Weaning and Its Relationship to Postpartum Mood and Anxiety Disorders L McIntyre1, A Griffen2 1

Postpartum Support International; Catholic University of America Postpartum Support International; Postpartum Support Virginia Email: [email protected]

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Objective: This special interest group will discuss the relationship between breastfeeding, weaning and postpartum mood and anxiety disorders (PMADs), with the aim of encouraging further research into and a better understanding of how early, unplanned, or “involuntary” weaning may contribute to PMADs. Method: Throughout ten combined years leading peer-support groups for women with PMADs, we have observed that breastfeeding difficulties—and especially involuntary weaning—appear to contribute to the onset, severity and duration of PMADs. We estimate that 70–80% of our group members have weaned involuntarily. For the purposes of this special interest group, we define involuntary weaning as a mother discontinuing breastfeeding: (1) earlier than she had intended; (2) against her wishes and; (3) for reasons largely, if not completely, out of her control. Results: Several studies over the past twenty years have found: ▪ Women were beset with feelings of failure, guilt and anger for their inability to breastfeed.9 ▪ “There is a small clinical literature that…the onset of depression, mania, anxiety and panic may be associated with weaning”.8 ▪ Four case studies in which women developed “major depression” within two weeks of weaning, one of whose disorder remitted after she began nursing again.10 ▪ Records of 209 women obtained at four weeks postpartum that showed that not breastfeeding had the highest relative risk factor for postpartum depression of the six factors studied.6 Despite this and additional compelling evidence, breastfeeding issues are/or involuntary weaning are not included in any of the major lists of “risk factors” for PMADs.3, 4, 5, 7, 11 Conclusion: There may be a causal relationship between involuntary weaning and PMADs. As one study so eloquently stated, “…one cannot listen to the stories of mothers such as our participants and not be compelled to argue forcefully for recognition of the possible longterm aspects of ‘breastfeeding failure.’” Thus we raise the issue of involuntary weaning as a potential risk factor for PMADs and encourage further study into this phenomenon. References Abrams, L. S. & Curran, L. (2007). Not just a middle-class affliction: Crafting a social work research agenda on postpartum depression. Health & Social Work, 32(4), 289–296.

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Beck, C.T. (2001). Predictors of postpartum depression: An update. Nursing Research, 50(5), 275–285. 5 Mayo Clinic. (n.d.). Postpartum depression: Risk Factors. Retrieved February 15, 2009 from http://www.mayoclinic.com/health/postpartumdepression/DS00546/DSECTION=risk-factors. 6 McCoy, S. J. B., Beal, J. M., Shipman, S. B., Payton, M. E., & Watson, G. H. (2006). Risk factors for postpartum depression: A retrospective investigation at 4-weeks postnatal and a review of the literature. Journal of the American Osteopathic Association, 106(4), 193–198. 7 Medscape. (2001). Postpartum depression: Risk factors. Retrieved February 15, 2009 from http://www.medscape.com/viewarticle/ 408688_5. 8 Mezzacappa, E. S., & Katkin, E. S. (2002). Breast-feeding is associated with reduced perceived stress and negative mood in mothers. Health Psychology, 21(2), 187–193. 9 Mozingo, J. N., Davis, M. W., Droppleman, P. G., & Merideth, A. (2000). “It wasn’t working”: Women’s experiences with short-term breastfeeding. The American Journal of Maternal/Child Nursing, 25 (3), 120–126. 10 Susman, V. L. & Katz, J. L. (1988). Weaning and depression: Another postpartum complication. The American Journal of Psychiatry, 145(4), 498–501. 11 Wisner, K. L., Parry, B. L., and Piontek, C. M. (2002). Postpartum depression. The New England Journal of Medicine, 347(3), 194–199. P45 The Communications Pattern of the Woman and the Husband Suffering from Postpartum Depression in Japan H Miyazaki Fukushima College Graduate School of Clinical Psychology, Division of Clinical Psychology Master's Course, Japan Email: [email protected] Objective: Postpartum depression (PPD) is a big problem on the public health and Psycological problem that occurs in one of 10 mothers the first 3–4 months after the baby-birth, in Japan. PPD has a serious problem for many months and years between married couple's communications and relationships. However, the doctor and the clinical psychologist couldn’t enogh to care and training the communications of the married couple suffering from PPD. Website “www.mama-blue.net” was developed as a mutual self-help group on the website. In “www.mama-blue.net” has Interactive case study, Classic document and current literature,Event calendar,and the resource. Moreover, this website contains the material for the woman suffering from PPD ,their hasbands and relative. However, the resource of the site oesn't contain the psychoeducation module to the woman and the husband after the baby-birth. Results: Web site “www.mama-blue.net” members suffering from PPD were about 4300 people, in March, 2010. We were analyzed these sentences, and could know that Mother’s communication patterns for the husband. Conclusion: The communications pattern of the married couple suffering from PPD in Japan can see the result of this analysis. The program of the psycho-education of communications will be made.

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However, the mechanism through which the risk is transmitted remains unidentified. Expressed Emotion (EE), a measure of family environment, has been investigated in children and adolescents and has been associated to child psychopathology. EE has also been found to mediate the relationship between maternal depression and child externalizing behaviours. There exists no research however examining EE in the context of paternal depression. The primary aims of the study were: a) To examine differences in EE in depressed and non-depressed fathers andb) To investigate whether EE mediates the relationship between paternal depression and child externalizing behaviours. Methods: EE was examined in families of one year old infants. Families where fathers had experienced an episode of major depression within the first postnatal year (n=24) were compared to families whose fathers (n=79) had no history of depression. EE was measured using the preschool version of the Five-Minute Speech Sample (pFMSS). The measure was shown to have good code-re-code and inter-rater reliability. Both parents completed the EE assessment and the externalizing scale of the Child Behavior Checklist. Results: Depressed fathers expressed fewer positive comments towards their infants than non-depressed fathers but did not differ in other aspects of EE. Depression predicted externalizing behaviours, but the relationship was not mediated by EE. Maternal EE revealed no differences in families with a depressed and non-depressed father. Conclusion: This is the first study to examine EE in the context of paternal depression and to report depressed fathers to be less positive towards their infants. Even though EE did not mediate the relationship between paternal depression and child externalizing behaviours; the low rates of positivity in families of depressed fathers may negatively impact on child development and therefore warrant further exploration.

Impact of Parental Depression Over Cognitive and Psychomotor Development of Babies During the First Year of Life AG Monteiro1,2, ME Areias1,3, MP Gonçalves1,2, F Teixeira1,2, E Fonseca1,2 1 Department of Psychology of ISCS-N, Instituto Superior de Ciências da Saúde—Norte (CESPU) 2 UNIPSA, Unidade de Investigação em Psicologia e Saúde 3 CINEICC, Centro de Investigação do Núcleo de Estudos e Intervenção Cognitivo-Comportamental, Paredes, Portugal Email: [email protected]

Postnatal Depression (PND) is a highly prevalent disorder in mothers and fathers, but its impact upon the baby is not fully understood. Objective: to compare children of depressed and non-depressed parents in relation to the parameters of cognitive and psychomotor development. Methods: The subjects of this study were 200 mothers, 153 fathers, and 202 babies, from the Oporto geographical area, Portugal. The participants were followed from the 37th week of pregnancy, 2nd week, 6th week and 12th month postpartum. Mothers and fathers were interviewed with the semi-structured clinical interview SADS-L and filled a translated version of the Edinburgh Postnatal Depression Scale at 37 weeks of pregnancy, 6th postnatal week and one year postpartum. Basic demographic data were obtained in the initial interview; infants were assessed at 12th month with the Griffiths Mental Development Scale and at that time we collected data on psychomotor development from the baby bulletin, which is filled by doctors in the routine general practice consultations. Results: PND in mothers associated with some parameters of psychomotor development in their babies, namely the age to seat (p=0,022) and to finger grabbing for the first time (p=0,014); there were no significant associations with parameters of cognitive development. PND in fathers associated with one parameter of psychomotor development (the age to drag the body for the first time: p=0,042) and again there were no significant associations with the cognitive development of the baby. Conclusion: Parents’ depression should be considered risk factor for physical and emotional neglect and be given attention for diagnosis and treatment. Issues such as the duration of the depression and whether mother and father are depressed simultaneously deserve special concern. Our results suggest that parental depression may cause changes, even subtle, in their children. P47 Paternal Depression and Infant Outcomes: The Role of Expressed Emotion E Netsi, L Psychogiou, PG Ramchandani Department of Psychiatry, University of Oxford, UK Email: [email protected] Objective: Paternal depression in the postnatal period has been shown to place children at risk for emotional and behavioural problems.

P48 A Follow-Up Study for Relationship Between PMDD and Postnatal Depression T Okano1, T Minamida1, M Kokubu2 1 Mie Unversity, 2Humanitec College of Midwife, JAPAN Email: [email protected]

Objective: Onset age of premenstrual dysphoric disorder (PMDD) is reported at the peak from late twenties to early thirties. This period seem to be corresponding with reproductive period. There can be seen some women with postnatal depression (PND) developed into first PMDD episode after delivery. However, the relationship between PND and the new episode of PMDD after delivery is still unclear. The aim of the present study was to examine the frequencies of PMDD of a number of postnatal depression. Method: Women (n=46) with first postnatal depressive episode were selected for 5 years in Mie University Hospital and followed at least after 1–3 year after parturition. Their average age is 31.83±3.92. Of all, 35 diagnosed major depression and 11 as minor depression according to DSM-IV-TR. A structured diagnostic interview was performed within few months after delivery to assess for the presence of PMDD. Results: Of 46 women with postnatal depressive disorders, 34.8 % reported severe premenstrual symptoms including PMDD. Past premenstrual tension syndrome, and primiparae, were also found to be significant risk factors for PMDD. Conclusion: First episode of PMDD after delivery seems to be common in women with PND, and there being the pathogenesis of

The Marcé International Society International Biennial General Scientific Meeting psycho-endocrine relationship between mood disorder and PMDD after postpartum period. Further evidence-based study about this relationship and underlying mechanisms should be investigated. P49 Preventing Postpartum Depression: A Web-Based Intervention E Olsen Changetech AS, Norway Email: [email protected] Objective: 10–15 % of mothers develop Postpartum depression (PPD). At least one third of postpartum depressions start during pregnancy. There are certain factors that seem to increase the risk for developing PPD, among them are psycho-social factors like self-efficacy, partner conflicts and social support. In recent years a number of studies have shown that interactive internet-based interventions can provide a rich, stimulating, engaging and actively supportive environment. Web—based interventions has the potential to help large groups of people in an effective way with support and therapy at a low cost. Thus, the objective is to develop an interactive, digital intervention to prevent and screen for PPD. Method: In cooperation with Norwegian Women’s Public Health Association and Centre for Child and Adolescent Mental Health Eastern and Southern Norway, Changetech AS is currently developing a tunneled, individualized and interactive intervention to prevent postpartum depression. The intervention will consist of three parts. The first part, is a psycho-educative component to prepare parents for child birth and to support mother–child attachment during and after pregnancy. Part two comprise the screening tool Edinburgh Postnatal Depression Scale to assess symptoms of postpartum depression every fourth week during pregnancy and up to 6 months after birth. Based on the results from the screening the intervention will provide individualized meta-cognitive therapy to decrease symptoms of depression. Part three of the intervention is based on positive psychology and the purpose will be mainly to raise social support for the mother. Thus, the father is invited to take part in this part intervention, and he will receive psycho-educational components about the importance of giving care and support for the mother during pregnancy and after birth. Results: The intervention will be presented at the International Marce Society Conference 2010. Conclusion: An intervention to screen for and prevent PPD is being developed and will be implemented as part of the primary health care system in Norway. P50 Maternal and Neonatal Attachment Behavior 24 Hours After Birth During An Experimental Situation After Labor Induction I Olza, AM Malalana Martínez, MA Marín Gabriel, F López Sánchez, V Costarelli, M Durán Duque, A Fernández-Cañadas Morillo, B Martínez Rodríguez Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain Email: [email protected] Objective: Early attachment behavior of human newborns includes a specific sequence of behaviors oriented at breastfeeding that haven

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summarized as neonatal primitive reflexes. Maternal early attachment behavior to newborn includes talking, gazing or saying loving words to newborn. The objective of the study was to evaluate interaction between neonatal and maternal attachment behavior in the first two days of life. Method: Observational descriptive study approved by Local Ethical Committee. 22 women with their first term pregnancies were studied. All labors were induced or augmented with intravenous oxytocin. All had singleton, healthy pregnancies. Newborns were vaginal delivered and immediately placed in skin-to-skin contact (SSC) with the mother. Patients were excluded if no immediately SSC was applied (n=7), caesarean section was made after study inclusion (n=3) or newborn was admitted in NICU (n=1). Mother and newborn interaction was filmed during a 20 minutes experimental situation designed to observe spontaneous newborn and maternal attachment behavior during SSC in a biological nurturing position. The videos were assessed by a blind observer. 16 neonatal primitive reflexes were coded. 8 Maternal behavior items were coded. Patients were asked to sign a letter of consent. Results: Mean maternal age 32,27, (SD 6,95) Mean GA 39,09 (SD 1,375). Mean Oxytocin dose: 1748,81mUl. There was a positive significant correlation between maternal and neonatal attachment behavior (r=0.62; p=0.03). There was no significant difference on the effect depending on the dose of oxytocin mothers had received intrapartum. A trend towards a negative correlation was observed between maternal behaviour and intrapartum OT administration (r=−.56; p=0.07). Conclusion: Maternal and neonatal attachment behaviors are positively correlated early in the postpartum period. Intrapartum OT administration may have influence on maternal behavior 24–48 hours after birth. However more studies are needed to compare maternal behavior between mothers who did not receive intrapartum OT with mothers whose labors were induced or augmented. P51 Clinical Audit of Antenatal Depression Management in Singapore LL Ong, TE Chua, J Wang, Roshayati M, L Ang, H Chen KK Women’s and Children’s Hospital, Singapore Email: [email protected] Objective: Antepartum depression is a major public health problem that occurs in up to 12% of Singaporean women, and is well known to be associated with a whole range of adverse maternal outcomes. Untreated antenatal depression continues into the postpartum period in up to 50% of the cases, with continuing adverse consequences for both mother and child. Without any prior perinatal mental health service locally, we developed a perinatal psychiatric team using a case management model to cater to the mental health needs of pregnant women, and present here a clinical audit of our experience. Method: From May 2006 to Nov 2009, 118 depressed pregnant women participated in a clinical audit at the KKH Mental Wellness Service. They received ambulatory clinical intervention, incorporating case management to provide integrated and individualized care together with the psychiatrist, thus ensuring continuity of care through the different phases of the illness. Supportive counseling was the mainstay of treatment, with medications considered for those with depression of moderate severity, or worse. Multidisciplinary input

S78 with psychological, occupational and social intervention was provided as needed for each individual case. Support group intervention was also available, as this has been shown to be beneficial for selected women. Results: The majority of the cohort were Chinese(68%), married (94%), and working women(61%). As many as half the women had unplanned pregnancies, and one third had past psychiatric history, but only 17% smoked, whilst only 3% drank or used drugs during pregnancy. All women received supportive counseling, whilst 43.6% received antidepressant medication, of which the most frequently used in the second and third trimester was Dothiepin, a tricyclic antidepressant. Antidepressants were avoided in the first trimester, whilst antihistamines were typically used for sedation and anxiolytic effect. Neonatal outcomes were measurable in a subgroup of the cohort, and apart from sedation, no other severe adverse outcomes were observed. Conclusion: With a better understanding of the presentation and clinical management of Antepartum Depression in Singaporean women, future research can be planned to improve our mental healthcare of pregnant women. P52 The Smiling Mask: Truths About Postpartum Depression and Parenthood C O’Reilly, E Paterson and T Bird A book and documentary detailing the lives of three women and their families now thriving from Postpartum Depression Mood Disorders ranging from panic and anxiety, to depression, to Obsessive Compulsive Disorder, to Postpartum Psychosis Email: [email protected] Objective: To share with the wider audience the book and our latest edition, a 40-minute documentary entitled, “The Smiling Mask: Truths about Postpartum Depression and Parenthood,” so that we may further educate and validate the seriousness of postpartum difficulties. Our vision is to inspire healing, hope and harmony by sharing our “truths” so that others will find validation and courage to use their own voices and begin their healing journeys. Our mission is to create awareness, understanding and acceptance of postpartum difficulties; bring inner peace and validation, and engage, enrich and empower families and community in the life-changing experience of parenthood. Method: Our documentary presentation followed by a question and answer session that will involve both husbands and wives. We will shed light on the realities that many families face when their lives are devastated with postpartum disorders. It is our mission to use our voices to raise awareness to prevent and/or reduce the affects of Postpartum Depression on future generations (e.g.: marital difficulties or divorce, prolonged depression, suicide and/or infanticide, child abuse, etc.) Results: As of December 2009, over 1,000 of our books have been sold, along with numerous speeches given to the medical and educational communities. Our website www.thesmilingmask.com has also received hits, globally, since its inception in July 2008. User feedback for the website, book and documentary has been consistently positive and inspirational for many. Conclusion: Our book and documentary assist families struggling with Postpartum

K.L. Wisner P53 Development of A Support Program to Address the Mental Health Needs of Women Along the Continuum of Perinatal Care AA Palmer Elliot Health System, Manchester, NH Email: [email protected] Objective: Amidst demanding office schedules and hospital stays, obstetric providers focus on the physical well being of the mother and fetus/newborn to ensure a safe pregnancy and birth. The multifaceted psychosocial needs of these women, and therefore, perinatal mood disorders can often be overlooked. This presentation examines the development of a hospital-based perinatal mental health support program, including components of screening, referral, education, phone and group support, and community-based taskforce initiatives. Method: A 300-bed, level-III perinatal center implemented an “Inpatient Postpartum Depression Risk Assessment Program” to provide universal screening of all new mothers for risk factors that may predispose them to postpartum depression. An 11-item selfassessment questionnaire is distributed to EVERY new mother after birth. Moms “at-risk” view a PPD video, receive targeted PPD education, follow up phone calls at home, are offered VNA visits, and invited to attend the weekly PPD Support Group if needed. Our multidisciplinary taskforce assists practice settings in establishing care pathways and protocols to guide practice, enhances referral resources for reproductive mental health, and collaborates with our psychiatric and emergency departments on models of care for perinatal patients admitted for acute psychiatric illness. Results: While screening over 2500 patients for postpartum depression risk factors, referrals to the support group, behavioral health, and inpatient consults have greatly increased. The support group provides a safe, non-judgmental forum in which mothers may share feelings of depression and anxiety, while benefiting from social support and learning about self-care practices to enhance their current treatment. A grant from the Endowment for Health was recently awarded to our taskforce to develop an evidence-based standard of care that will be applied along the continuum of women’s birth experiences, from prenatal appointments, through labor and delivery, and for the first year following delivery, and coordinated across systems of care. Conclusion: Development of our postpartum support program, has led to improved identification and treatment of women with perinatal depression, and we anticipate that the standard of care model we develop can be disseminated throughout our state. P54 Effectiveness of Postpartum Adjustment Support Groups: A Stress Management Model M Pesserl Walden University, Farmington Hills, MI, USA Email: [email protected] Objective: Sleep deprivation, fatigue, hormonal imbalance and inflammatory processes during the postpartum period create a

The Marcé International Society International Biennial General Scientific Meeting psychoneuroimmunologic environment conducive to developing symptoms of postpartum depression. This environment could be improved by reducing stress. Stress management treatments may be cost effective, broadly reaching, and empowering ways of alleviating postpartum symptoms Two theories serve as conceptual framework for the proposed study, the transtheoretical theory of behavioral change and Cheryl T. Beck’s theory of postpartum depression, used to inform the topics and nature of the interventions proposed by the present study. The study will try to establish the effectiveness of postpartum depression support groups in general, and specifically of a stress management intervention based on Beck’s core issues. Method: This is a two-phase, sequential, mixed methods study. First, a quasi experimental, repeated measures design using the Edinburgh Postnatal Depression Scale will test the effect of group support participation on reducing postpartum depression symptoms. Subsequently, phase, a grounded theory design will be applied to identify similarities and discrepancies with Beck’s Theory, and to evaluate the stress management model. The study will be conducted at the weekly postpartum adjustment groups offered by the Tree of Hope Foundation at seven different locations in the metropolitan Detroit area.. Results: The study is currently in its first stages. Preliminary results are expected to be available by the time of the presentation at the conference. Conclusion: The interventions studied in this research are low cost, easy to implement resources that can help raise awareness in the medical community and reduce the stigma associated with the disorder. The use of the stress management intervention proposed in this study could be adapted and expanded to the antenatal and the inhospital period as a primary prevention strategy. This research could be the first of a series of studies focusing on other integrative approaches and uses such as primary prevention by providing coping skills and as a complementary aspect of therapy. Interesting in this study is also the development of a guided imagery protocol especially designed for the needs of the postpartum woman. P55 Addressing Mental Health Needs of Pregnant Women: Transforming Policy into Practice in New Jersey L Pinete, I Polanco-Ventura Northern New Jersey Maternal Child Health Consortium, USA Email: [email protected] Background: In 2006 legislation took effect in New Jersey requiring healthcare professionals to educate and screen all new mothers for Postpartum Depression (PPD). New Jersey is the first state to enact policy addressing the need for PPD screening and education. The Northern New Jersey Maternal Child Health Consortium (NC) is a non-profit organization licensed by the New Jersey Department of Health and Senior Services (NJDHSS) to provide prevention activities, consumer and professional education, total quality management, and data analysis. The NC was designated by NJDHSS to provide PPD education, support, and technical assistance to hospitals and other healthcare organizations located in the Northern region of the state. Methods: The NC provides support for PPD activities including: 1) Development and implementation support of hospital PPD policy; 2) Development of a PPD Task Force 3) Provision of PPD education to

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healthcare professionals and consumers 4) Development of a PPD resource center; 5) Initiation of New Mother's Groups as an alternative to mental health services. Results: All hospitals (7) in the NC region have developed PPD policies and shared them in an effort to promote best practice; communication and collaboration has been fostered among healthcare professionals from a variety of disciplines; over 500 healthcare professionals and 800 consumers have received education on PPD in 2009; 4 support groups for new mothers have been created. Conclusion: PPD legislation in New Jersey has led to an increase in screening women for PPD and educational activities focused on perinatal mood disorders. P56 Postpartum Depression Toolkit for Program Development N Roberts Spectrum Health Medical Center, Grand Rapids, MI, USA Email: [email protected] Objective: Postpartum depression (PPD) is a major public health problem. Primary care providers and health centers are well positioned to develop screening and educational awareness programs. However, few models exist for others to replicate. Method: A model PPD program at Spectrum Health Medical Center has created a step by step toolkit to advise others who wish to emulate it in their communities. It was designed to provide professionals with the tools to successfully engage, screen, diagnose, treat, and refer women with PPD. Resources in this toolkit include continuing education modules; information on developing screening programs and PPD support groups, a slide library of related PPD lecture topics; 4 books, 2 DVD’s, 2 CD’s and resources. This toolkit also contains materials for women with PPD, their friends and family members. Results: As of January, 2010, the toolkit has been utilized in the development of at least 24 hospital PPD programs, primarily in Michigan. User feedback has been consistently positive. Conclusion: Based upon theories of adult education, this Postpartum Depression Toolkit offers diverse strategies to facilitate learning. This toolkit promotes education and training in PPD program development that is flexible, cost-effective, and meets the needs of health care professionals. P57 Postpartum International Model Programs in Michigan N Roberts RN CCE Spectrum Health Medical Center, Grand Rapids, MI USA Email: [email protected] Objective: Postpartum depression (PPD) is a major public health problem. Primary care providers and health centers are well positioned to develop screening and educational awareness programs. However, few models exist for others to replicate. Method: Two model PPD programs in Michigan at Spectrum Health Medical Center and at Beaumont Hospital have each created

S80 successful screening and educational programs. Many other healthcare centers have reported a desire to emulate these programs. Both are designed to provide professionals with the tools to successfully engage, screen, diagnose, treat, and refer women using a PPD toolkit for Program Development, available from Spectrum Health Medical Center. Results: As of January, 2010, both programs have successfully screened over 40,000 new mothers and have provided education to over 5,000 healthcare providers. Feedback has been consistently positive. Conclusion: Based upon theories of adult education, these Postpartum Depression Programs serve as models for others to replicate. These programs promote education and screening in the acute care setting that is flexible, cost-effective, and has met the needs of health care professionals and new families. P58 The Association Between Prefrontal Activation of Pregnant Women to Affective Stimuli and Hormones A Roos1, F Robertson2, C Lochner1, B Vythilingum1, DJ Stein1 1

Stellenbosch University University of Cape Town, South Africa Email: [email protected]

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Objective: Near-Infrared Spectroscopy (NIRS) detects real-time upper cortical vascular responses to neuro-activation by infrared spectrum light transmitted through diodes placed on the scalp. The prefrontal cortex (PFC) has been shown to be involved in the regulation of emotions. Specifically, functional Magnetic Resonance Imaging and Positron Emission Tomography studies in non-pregnant subjects have demonstrated that the PFC is activated by positive and negative emotional facial expressions. Furthermore, hormones within the neuronal circuitry such as cortisol, progesterone and testosterone have been shown to alter these responses. However, whether this also occurs in pregnancy is not known. The aim of this investigation was to determine if an association exists between hormone levels and PFC activation in response to affective stimuli in pregnant women using NIRS. Method: Pregnant women (trimester 1, n=10; trimester 2, n=11; trimester 3, n=10) underwent NIRS imaging with a DYNOT system (DYnamic Near-infrared Optical Tomography; NIRx Medical Technologies, NY) while viewing dynamic emotional facial expressions of fear and anger. Regions of interest included the left prefrontal cortex (L-PFC), right prefrontal cortex (R-PFC), and medial PFC (MPFC). Bloods and saliva samples were collected to determine levels of cortisol; estrogen, progesterone and testosterone, at each trimester. Near Infrared Analysis, Visualization and Imaging (NAVI version 2.1; NIRx Medical Technologies, New York), Statistical Parametric Mapping (SPM version 5) and MRIcro software were used to investigate associations between hormones and PFC activation. Results: Higher cortisol, progesterone and testosterone levels were significantly associated with greater PFC activation to fearful faces. Higher progesterone levels were significantly associated with greater PFC activation to angry faces. There were no significant differences by trimester.

K.L. Wisner P59 Antenatal Depression and Newborn Outcome: Case Study E Serrano Drozdowskyj Hospital universitario Puerta de Hierro Majahahonda, Madrid, SPAIN Email: [email protected] Background: Pregnancy, as recent studies show, is a period of special vulnerability for affective disorders. Depression during pregnancy could threaten both maternal and child health. This case is an example of how the psychiatric intervention could change depression negative effects on pregnancy outcome. Clinical Vignette: A Caucasian 39 years-old six months pregnant woman was referred to a psychiatric outpatient clinic for depressive symptoms. As she explained, one month ago, she started with unmotivated crying, restlessness, , irritability, sensitivity to rejection, social withdrawal, lack of concentration, feelings of insecurity and blame (“am I doing something wrong?”), worries about her fetus health and her husband safety, insomnia and hiporexia. She was criticized by her family because of no gaining weight. Indeed the fetus’ twentieth week echographic parameters were under normal scores. Two month ago, considering potential fetus exposure to toxic products (she worked in a gas station), the general practitioner recommended her to apply for a sick leave. This wasn’t supported by her Employer. She attributed her current stress to this mistreatment. Giving the case we proposed her to start a psychiatric treatment. Regarding the pharmacological patient’s reluctance, non-pharmacological guidelines were recommended. Fifteen days later, because of mild improvement, loracepam 1 mg per night was prescribed until two weeks before the delivery. Fifteen days latter full remission of symptoms took place except worries. It coincided with the thirtieth week ecography: fetus parameters were normal and she had gained seven kilograms. Two month latter a healthy baby was born. Conclusions: Depression during pregnancy is an under diagnosed and mistreated condition. As recent studies show, is the most important factor to develop post pregnancy depression. Early detection and accurate medical intervention would improve child and maternal outcome. Regarding the dramatic consequences of untreated maternal depression, the capability to detect and treat depression during pregnancy might be encourage among professionals. P60 Role of Circadian Rhythm Disruption in Postpartum Depression—A Pilot Study KM Sharkey, TB Pearlstein Department of Medicine, Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA Email: [email protected] Objective: The relationship between circadian rhythms and postpartum depression is poorly understood, despite known links between circadian rhythm disruption and mood disorders in other populations. The purpose of the present study is to describe changes that occur in

The Marcé International Society International Biennial General Scientific Meeting endogenous circadian rhythms during the perinatal period and to test the hypothesis that circadian rhythm changes are associated with postpartum depressive symptoms. Method: The study uses a prospective, repeated-measures design to examine circadian phase and mood in women with a history of depression (confirmed with the Structured Clinical Interview for DSM-IV-TR Axis 1 Disorders) who are not in a current mood episode at recruitment during 3rd trimester of pregnancy. We measure sleep-wake behavior using continuous ambulatory monitoring of activity and light exposure along with sleep diaries for one week during 3rd trimester of pregnancy and one week at postpartum week 6. At the end of each week, depressive mood symptoms are assessed with the Inventory of Depressive Symptomatology (IDS) and circadian phase is determined using salivary dim light melatonin onset (DLMO). Results: Data collection is ongoing. Preliminary results available in October, 2010 will include 3rd trimester and postpartum week 6 mood symptoms, salivary melatonin profiles, light exposure patterns, and sleep-wake times. Differences between 3rd trimester and postpartum mood symptoms (IDS scores), circadian phase (DLMO times), sleep onset, sleep offset, total sleep time, and sleep efficiency will be tested using t-tests with within-subjects factor of week (3rd trimester, postpartum week 6). We will present Pearson correlations that examine the association of mood symptoms to changes in circadian phase (DLMO), sleep timing, and sleep duration. P61 Screening to Treatment: Obstacles and Predictors in Perinatal Depression (STOP-PPD) G Shivakumar1,2, AR Brandon1, NL Johnson1, E Guillum3, R Bhore1, and MP Freeman4 University of Texas Southwestern Medical Center1, Dallas VA Medical Center2, Parkland Health and Hospital System3, and Massachusetts General Hospital4 Email: [email protected] Objective: Routine screening for postpartum depression (PPD) is already required in some U.S. states and will soon be implemented at a national level. Although screening is a widely recognized first step in early detection and treatment of PPD, current knowledge is limited regarding treatment utilization across different settings for prenatal and postpartum depression. Specifically, information is needed on patient treatment preferences and barriers to care. Method: This pilot study is a collaborative initiative of the Women’s Mental Health Center of UT Southwestern (UTSW) and the Dallas Healthy Start (DHS) Program. All women enrolled in DHS are routinely screened for prenatal/postpartum depression and referred for services when indicated. We sought to quantify the rates of follow-up for PPD treatment following systematically provided referrals for women who screened positive for PPD (EPDS ≥11). We further assessed types of providers utilized (primary care physician, psychiatrist, Ob/Gyn, social work/counselor, and support group) and explored predictors/ barriers to seeking care. Results: Between April and November 2009, we had 26 potential eligible study participants out of 164 active DHS clients who screened

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positive for PPD. Of which, twelve consented and participated in the longitudinal follow up and rest were excluded either due to study ineligibility or lost to follow up. The prevalence of probable PPD (based on EPDS screening) is 16%. Rates of follow up to treatment with a provider type is 58% for total sample, and homebased counselors/social work type were most frequently used (85%) followed by Ob/Gyn providers. Exploratory analyses are currently underway to identify frequently reported barriers and predictors towards seeking further evaluation and/or treatment for PPD. Conclusion: In the DHS program, rates of follow up for prenatal and postpartum depression are relatively better compared to rates reported in other Healthy Start programs. Women are more likely to see homebased counselors and/or social workers types who also provided services in other areas of perinatal care, while physician providers are least preferred group. P62 Seasonal Effects on EPDS Positivity and Suicidal Symptoms in Women DKY Sit1, KL Wisner1, H Seltman2 1

Department of Psychiatry, School of Medicine, University of Pittsburgh, 2Department of Statistics, Carnegie Mellon University Email: [email protected] Objective: We examined the effects of seasonal variation on depression risk and risk for suicidal ideation in postpartum women. We hypothesized that the Spring and Fall months will be associated with an increased frequency of depression risk and suicidal symptoms compared to other times of the year. Methods: From 2006–2010, the investigators screened women 4–6 weeks after delivery with the Edinburgh Postnatal Depression Scale (EPDS). The outcome variables of interest were: EPDS ≥10 which suggests increased depression risk and EPDS item10 ≥1 which suggests suicidality. The explanatory variable included the calendar months of the year. Analysis of variance and spectral analysis were used to explore seasonal variations in risk for depression and suicidality. Results: The investigators telephone-screened 9339 women; 1316 (14%) women had scores on the EPDS ≥10 which suggested possible risk for postpartum depression. Suicide risk (EPDS item 10 ≥1) was identified in 294 women (3%). The risk for suicidal symptoms peaked in March/April and September (Figure1). Depression risk peaked in November/December (Figure2). Conclusion: The data suggest a bimodal pattern of heightened suicide risk in the Spring and Fall; the risk for postpartum depression peaked in the late Fall/early Winter. A majority of women with postpartum major depression respond rapidly and robustly to treatment with serotonergic agents such as sertraline. This suggests that postpartum patients may have reduced activation of the serotonergic pathways; a subset of the patients could be at risk for suicidal symptoms. The effects of seasonal light on the serotonin pathways may contribute to heightened risk for suicidal symptoms and depression in certain patients. Note: We continue to collect telephone screening data (estimate 200/ month); the additional data will be included in the poster presentation.

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fourth child and was given lithium and sertraline on the first day after delivery and experienced no post natal depression at all or any recurrence of her amphetamine or alcohol addictions and was able to keep her 4th child. Message: Lithium can help in prophylaxis in resistant and recurrent post natal depressions where other antidepressants have failed Case 2: A patient is described who had a 9 year history of recurrent admissions for a schizophrenic illness or possibly a schizo-affective disorder. After some years of going in and out of hospital she was stabilised on a depot preparation ( Zuclopenthixol). She then fell pregnant and her specialist consulted the drug company who advised to stop the depot. The patient was monitored for the rest of her pregnancy without drugs After delivery she seemed well until the 7th day when she held the baby upside down and became disturbed in front of her partner who called the police The baby died, and post mortem revealed multiple fractures and a probable death by smothering. She was admitted to hospital for the next 7 months with a severe puerperal psychosis. During her next pregnancy she took oral olanzapine throughout the pregnancy and continued it afterward delivery and had no trouble at all. However the social services still removed the second child because she had probably killed the first one. Message: If a patient is on a depot antipsychotic , and this is stopped in pregnancy then it is important to switch to oral antipsychotics as the risk for relapse, sometimes with disastrous consequences, is extremely high. Guidelines should be modified to take this case into account.

How to Get the Wheel Moving: The Six Essential Spokes for Perinatal Mental Health System Development BS Stafford The Children’s Hospital; University of Colorado, Denver Email: [email protected] Objective: Very few women in the United States ever receive treatment for their perinatal mood disorders. The shift in care providers, lack of mental health training for primary care and public health professionals, and lack of public awareness of these conditions lend the public health issue of perinatal mood disorders for a systems approach. Method: Beginning in January 2008 and with support from Colorado foundations, the development of a regional perinatal mental health system of care began, first in the Medicaid system, then in the Kaiser HMO system and, finally, in the private insurance sector. The System Model, that of a wheel with an academic hub and with the spokes of: 1) mental health expertise, 2) primary care and public health screening, 3) public awareness, 4) system linkages, 5) legislative advocacy, and 6) system linkages was developed to get all uninterested, interested, and essential partners in collaboration. Results: As of March 2010, three 3 separate perinatal mental health systems of care have been developed in the Denver metropolitan region—one for publicly and un/underinsured women, one for women in the Kaiser HMO system, and one for women with other private insurance. The role of the academic hub and lessons learned as a consultant to these disparate systems will be discussed. Strengths, limitations, and adaptations to the model will also be discussed. Conclusion: Based on a simple intuitive model created from the scientific literature, regions without any previous perinatal mental health care access can develop functioning systems that can reach women with perinatal mood disorders, regardless of their insurance issues. The model led to the development of a community toolkit and model that can be adapted for use by a champion in any community, no matter what part of the system represent. P64 Lessons in Peri-Natal Psychopharmacology from Cases in Child Protection Medico-Legal Practice G Stein London, England Email: [email protected] Two cases are presented which are both rare and unusual which teach important lessons on the use of drugs in the post natal period Case 1: A 26 year old women with a 10 year history of amphetamine addiction and alcohol abuse had 3 episodes of severe post natal depression each associated with an overdose. Her depressions. failed to respond to citalopram or amitryptilene in high doses, and because of her alcoholism and frequent drunkeness the social services removed her three children from her care. She then became pregnant with a

P65 Comprehensive Perinatal Mood/Anxiety Screening Protocol in Community Based Hospital Setting: Design and Implementation DL Tompkins, PsyD, T Jones-Bendel RN, L Huelke-Pfleger, LCPC Edward Hospital and Linden Oaks Hospital, Naperville Illinois USA Email: [email protected] Objective: Recent legislation and awareness of perinatal mood/ anxiety disorders requires medical providers to identify women at risk. Risk for development of these mood and anxiety disorders is now established as the period spanning pregnancy through one year postpartum. An interdisciplinary effort at coordination of education to medical providers, tools for screening, and appropriate linkage to mental health providers has yet to be identified and developed in a community setting as has been in university based medical systems. Method: Edward Hospital delivers 4,000 babies a year, the 2nd largest in the state of Illinois with the participation of 34 Obstetricians, 90 Pediatricians and 63 Family Practice Physicians. In coordination with Linden Oaks Hospital and community providers, a pilot for a comprehensive screening and referral network that attempts to screen women up to six points in time from the fist prenatal visit, through delivery, and then through subsequent pediatric care for up to one year postnatal was developed. Resources include education, training and methodology to physician (obstetrics and pediatrics) offices, two screening tools, and contact and referral service for identified at risk mothers that guarantees clinical follow up within a 24 hour period following identification.

The Marcé International Society International Biennial General Scientific Meeting Results: Developed in a three part modular format between the prenatal, delivery and then postnatal experience, the protocol systematically involved multidisciplinary effort between nursing, obstetrics, pediatrics and mental health providers. This effort produced a successful comprehensive education and advocacy effort to identify and treat perinatal mood and anxiety disorders in a community based setting. Further, it afforded the professional community the opportunity to identify and address impediments to comprehensive screening and delivery of care to at risk mothers. Conclusion: Efforts to screen and treat at risk mothers in a community based setting is complex yet possible with the coordination between providers who have contact with mothers across the prenatal, delivery and postpartum period. For such a program to be successful, the effort must include coordination of both medical and mental health providers, institutional and community members, and be comprehensive in scope. A model for implementation is offered. P66 Social Support and Maternal Distress Among Low-Income Pregnant Latina Adolescents AP Vazzano, L Kurzius, W Marquis, MT Kinsella, C Monk Columbia University, New York, NY Email: [email protected] Objective: Adolescent pregnancy carries considerable health risks for both the mother and infant, including increased susceptibility to maternal depression. While postpartum depression has dominated pregnancy-related research, little attention has been paid to the trajectories of antenatal distress and its precursors, particularly in low-income, adolescent samples. In this study, we aim to identify contributors to prenatal distress and to examine its stability over the course of pregnancy. Method: Forty-seven pregnant Latina adolescents (mean age=18, SD = 1.2) completed self-report questionnaires once during each trimester as part of an ongoing study. The Social Support Questionnaire (SSQ) was completed during the initial visit. The Perceived Stress Scale (PSS) and Prenatal Distress Questionnaire (PDQ) were completed at each time point. Cumulative distress scores at the three time points were created by averaging both the PSS and PDQ standard scores. Results: Pearson correlations demonstrated that the SSQ was significantly negatively correlated with cumulative distress scores at time points 1 and 3 (r=−.32, p<.05; r=−.63, p<.05, respectively). Each of the three time points revealed significant correlations between cumulative distress scores for time points 1–2 (r=.53, p<.05) and 2–3 (r=.49, p<.05). Conclusion: Preliminary results indicate that a lack of satisfaction with social support may be a risk factor for distress in adolescent pregnancies. In addition, these data suggest that distress in early pregnancy is predictive of distress at later stages of pregnancy, emphasizing the importance of early detection and intervention. As the study continues and the sample size increases, future analyses will examine the patterns and stability of distress over time with the aim of further identifying implications for the timing of clinical prevention and intervention.

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P67 Depression, Stress and Substance Use in South African Pregnant Women B Vythilingum1,2, A Roos2, SC Faure2, L Geerts3, DJ Stein1,2 1

Department of Psychiatry, University of Cape Town MRC Research Unit on Anxiety and Stress Disorders 3 Department of Obstetrics and Gynecology, University of Stellenbosch, South Africa Email: [email protected] 2

Background: South African women have high rates of postnatal depression, yet there is little data available on depression and stress during pregnancy. We therefore examined the prevalence and correlates of depression, stress and substance use in a South African antenatal population. Methods: All women presenting for their first antenatal visit at a Midwife Obstetric Unit (MOU) in the East Metropole district, Cape Town were approached to participate in the study. Subjects who consented completed a self report questionnaire comprised of the following instruments : EPDS, PSS, AUDIT, DUDIT, demographic and lifestyle questionnaire. Statistical analyses using descriptive statistics, ANOVA, Chi square were performed as appropriate Results: Three and hundred and twenty three (323) women completed the questionnaire. Using EPDS cutoff scores of 12 and 16 respectively, 48.9% and 28.8% of the sample scored above the cutoff. During pregnancy 36.8% of women smoked, 20.2% used alcohol and 4% used substances. EPDS scores were significantly positively correlated with AUDIT as well as PSS scores. Depression, as identified by both EPDS cutoff scores above 12 as well as those above 16 were significantly associated with alcohol use during pregnancy. Discussion: The main findings of this study were 1) High rates of antenatal depression 2) Depression during pregnancy was significantly associated with antenatal alcohol use This suggests that combined interventions for antenatal alcohol use and depression should be considered. P68 Screening for Psychiatric Disorders in Pregnancy—A South African Perspective B Vythilingum1, S Honikman2, S Field2, D Fincham3, L Sanders2 DJ Stein1 1

Dept of Psychiatry and Mental Health, University of Cape Town Perinatal Mental Health Project 3 MRC Research Unit on Anxiety and Stress Disorders, South Africa Email: [email protected] 2

Introduction: In low resource settings, screening all women for antenatal mental illness can pose a significant burden on psychiatric services. This has been used as an argument not to implement screening in these settings. Our experience with antenatal screening has been that most women identified by screening have social or

S84 relationship problems that can be resolved by counselling and do not require a psychiatric referral. A screening program, therefore would necessarily overburden psychiatric services. Consequently, we sought (1) to describe which patients required referral to a psychiatrist and (2) to identify factors at screening that can be used to identify these patients, and therefore fast track their referral to psychiatry. Methods: The Perinatal Mental Health Project is a holistic mental health service that provide antenatal screening for mental illness. Patients are screened using the Edinburgh Depression Scale (EDS) and an 11 item Risk Factor Analysis (RFA). Descriptive analyses were performed on the psychiatric patients. Psychiatric patients were then compared to the entire control group. They were also compared to those patients who qualified for counselling. Chi square and ANOVA was used to examine difference in demographic factors as well as RFA and EDS total scores. Four separate backward likelihood regression analyses were then performed to determine if specific items on the EDS, RFA and a combination of the scales could be used to distinguish psychiatry patients from the control group as well as those who qualified for counselling only. Results: Scores and item selection on these scales in patients referred to a psychiatrist (n=58) were compared to all patients not referred to a psychiatrist (n=1008) as well as those patients who qualified for counselling only (n=316). Psychiatric patients, had higher mean EDS and RFA scores than both the entire control group (EDS 17.1, SD 6.6 vs 9.0 SD 5.4 p<0.001; RFA 3.8 SD 1.9 vs 1.4 SD 2.0 p<0.001) as well as those who were qualified for counselling but did not see a psychiatrist (counselled only group) (EDS 17.1, SD 6.6 vs 14.9 SD 4.5, p<0.001; RFA 3.8 SD 1.9 vs 2.9 SD 2.6 p<0.001). Using regression analyses the best items (in order of importance) to distinguish patients referred to psychiatry from those who qualified for counselling were RFA 11, EDS 8, RFA1.A positive score on 1 or more of these items gives sensitivity of 95% and a specificity of 71%. ROC analysis showed AUC of 0.89. Using these criteria, 50 (4.9%) of patients from the control group (11.2% of those who qualified for counselling) would need more urgent referral to a psychiatrist. Conclusion: Pregnant women needing psychiatric referral can thus be easily identified at screening. Implementation of such a practice would decrease the overall referral burden while ensuring that those women who need it most are seen timeously. This may be particularly important in low resource settings. P69 Mother & Baby Units: Historical and Theoretical Perspectives G Wainscott Birmingham and Solihull Mental Health Foundation NHS Trust Email: [email protected] Objective: Mother and Baby Inpatient Units (MBUs) are an accepted core component of perinatal mental health services in the UK. However, there is an uneven distribution of these units across the country. Units exist in other countries, but again with varying frequency. The aim of this project is to review the history of MBUs—how and why they were devised and to explore their theoretical importance in the treatment of perinatal mental illness. The available evidence will be evaluated in relation to the use of MBUs.

K.L. Wisner Methods: A literature review has been completed looking at all articles describing the conception of MBUs and evaluating the utility of MBUs. Results: The history of MBUs around the world and in the UK will be described exploring the role of key proponents and where their units were initially established. The theories behind the development of this innovation will be explored; looking at mother–infant interactions, the critical period for mother–baby bonding, consequences for the infant and the mother if bonding is disrupted and the development of parenting skills. There is very little evidence supporting the idea that they are best practice. There are many outcome papers reporting the nature of admissions to MBUs and even long term follow up. Comparing groups of women admitted into different settings is practically difficult, whilst randomisation would be unethical. There is however anecdotal evidence such as the Confidential Enquiry into maternal deaths in the UK which show that there are fewer suicides amongst women who are admitted into MBUs. In addition there is the empirical evidence deduced from theoretical approaches to infant mental health, that MBUs are beneficial. Conclusion—More studies are needed. J Heron is reviewing women who have experienced severe post natal mental illness and exploring their perspectives on MBUs versus other inpatient units. We ‘feel’ they are a better, more humane form of care & reports from women indicate they are very important. However costs are high and so robust evidence is needed. P70 Evaluation of A Home-Based Psychosocial Support Intervention for Symptoms of Postpartum Depression NE Webster Frontier School of Midwifery and Family Nursing, Tucson, AZ Email: [email protected] Objective: Postpartum depression (PPD) has significant negative health consequences for women and families. Many women are reluctant to use pharmacologic and psychotherapeutic interventions for PPD; hence, alternative interventions are needed to meet their needs and preferences for treatment. In this outcomes evaluation project, home-based doula care for PPD was evaluated for its effectiveness compared with psychotherapy. The doula care as a psychosocial support intervention included emotional, instrumental, information, and appraisal or validation components. Methods: The setting was a small, community-based program offering two evidence-based interventions, psychotherapy or homebased doula care, for symptoms of depression in postpartum women. Participants were screened for PPD at three time intervals. The outcome measure was depressive symptoms as measured by the Edinburgh Postnatal Depression Scale (EPDS). The data was analyzed using the two-way mixed methods analysis of variance (ANOVA) F test. Chi-square tests were used to identify differences between the groups for history of a treated mood disorder and past or present mood disorder medication use. Results: Doula care and psychotherapy were both effective interventions for PPD; there was a comparable and significant reduction in depressive symptoms in both groups. There was also a moderate association between intervention group and mood disorder medication

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use at the time of enrollment. There was no medication use in the doula care group, whereas more than half of the psychotherapy group was taking medication upon enrollment. Small sample size was a limitation, prohibiting identification of differences between the two groups; chi-square results lacked significance for both history of mood disorder and history of mood disorder medication use. Conclusion: Doula care for PPD is an evidence-based, cost-effective alternative intervention that effectively reduces depressive symptoms, and should be an available community resource option for postpartum women, especially those reluctant to use more conventional treatments. Projects with a larger sample size would allow evaluation of the differences between the interventions, and provide further validation for the effectiveness of home-based psychosocial support as an intervention option for women with PPD.

Conclusions: Results support the fetal programming hypothesis, and suggest further examination of the unique contributions that maternal prenatal and postpartum factors may play in the formation of infant reactivity style.

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Objective: The objective was to overcome barriers to quality mental health care that was sensitive to our population's needs, so that more of our women would chose to receive services. Our program participants face barriers such as transportation, child care, lack of or insufficient health insurance, a shortage of psychiatrists which extends the waiting time for an appointment to at least 6 weeks, and mistrust of the medical system. Method: The population to be served was either pregnant or postpartum women who were enrolled in our maternal and child health home visiting program and scored high enough on the depression screen to warrant evaluation by a psychiatrist. Healthy Start partnered with Women’s Behavioral HealthCARE at the Western Psychiatric Institute and Clinic to provide free psychiatric services one afternoon per week for 5 months. Office space for the services was colocated within our program’s offices. Child care and transportation to our office were provided. During the office visits, the participant was allowed to have any or all of her Healthy Start home visitors present with her. Letters were sent to the participant's PCP to inform him or her of the participant's treatment status. Home visiting continued during the participant's treatment. Results: Half of the participants who were referred to the project came for services, which is more than twice the number who would normally arrange to receive community mental health services on their own. The average wait for an appointment with the psychiatrist was 2 weeks. Ten participants lowered their scores on the depression screen. Participants who accepted medication as part of their treatment received prescriptions that were affordable and easy to attain. The Healthy Start staffs maintained home visits with the participants, implementing the treatment strategies that were devised at the office visits. Client satisfaction surveys showed a high rate of satisfaction. Conclusions: When Healthy Start and Women's Behavioral HealthCARE were able to break down barriers between participants and services, more women readily accepted mental health care.

Maternal Age is A Significant Predictor of Infant Temperament: The Contribution of Prenatal and Postpartum Factors on Infant Reactivity EA Werner 1,L Evans2, L Leotti3, & C Monk1 1

Columbia University, New York, NY Albany College of Pharmacy,Albany, New York 3 Rutgers University, New Brunswick, NJ Email: [email protected] 2

Objective: Studies have measured maternal prenatal cortisol to understand the relationship between maternal psychological states and an index of emerging emotion regulation—infant reactivity to novel stimuli. No studies controlled for mother’s age, which can affect HPAaxis activity as well as postnatal caregiving. This study measured pregnant women’s mood and cortisol levels, and the quality of postpartum parenting and their influence on infant reactivity as measured by laboratory observation. We hypothesized that more maternal prenatal stress, anxiety, and depression, and higher cortisol levels would predict more infant motor/crying responses to novelty, and that these relationships would be moderated by maternal caregiving. Method: Ninety-two 3rd trimester pregnant women ages 18–40 years completed Speilberger State-Trait Anxiety Inventory, Pregnancy Experience Scale, Center for Epidemiologic Studies Depression Scale, and Perceived Stress Scale, and morning salivary cortisol samples. At 4-months, infants underwent the Harvard Infant Behavioral Reactivity Protocol during which their cry/motor responses to novel stimuli were coded. Mother–infant play session was coded for Emotional Availability. Results: Logistic regression analyses examining relationships between infant reactivity and maternal antenatal and postpartum mood scores, cortisol levels, maternal emotional availability postpartum and maternal age revealed that younger maternal age and higher postpartum hostility were significant predictors of higher infant reactivity (ps <.05). Age was significantly negatively correlated with basal cortisol levels, perceived stress in pregnancy, anxiety during pregnancy, and antenatal and postpartum depression (ps < .05). Age was significantly positively correlated with income, education level, higher emotional availability to their infant (ps < .05). To control for age, a subset (N=50, ages 20–29) and their offspring were examined. In this subset, higher prenatal maternal cortisol and higher postpartum hostility and emotional availability predicted greater infant reactivity (ps < .05).

P72 Co-Location of Psychiatric Services Within A Home Visiting Agency JS White1, KL Wisner2 1

Healthy Start, Inc. University of Pittsburgh Email: [email protected]

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P73 Parenting Outcomes on A Mother & A Baby Unit: Incidence and Predictors of Parenting Concern J Whitmore, J Heron & G Wainscott Birmingham and Solihull Mental Health Foundation NHS Trust Email: [email protected]

S86 Objective: One of the key roles of MBUs is to support bonding and the development of parenting skills in women with long term or acute onset mental health problems in the perinatal period. The aim of this study was to review the characteristics of 462 mothers consecutively admitted to a co-joined Mother & Baby Unit and to examine the incidence and predictors of social services input and of separate discharge. Method: Admissions to the Birmingham Mother & Baby Unit from 1998 to 2007 were reviewed. Demographic and clinical information, social services involvement and parenting outcome data were collected from case-notes and computerised records. The case notes of the mothers whose infants were removed were interrogated in further detail for additional clinical details and factors contributing to separate discharge. Results: 462 mothers were admitted to the Mother & Baby Unit over the 10 year period. 146 women received some form of social services input (32%). 44 cases of separate discharge were identified (10%). A diagnosis of Schizophrenia, Personality Disorder and Primary Bonding Disorder as well as involuntary admission, single status, younger age, Afro–Caribbean ethnicity and social services referral predicted parenting concern. Only 9% of separations were to women suffering a new postpartum mental illness: most were to women experiencing a continuation of an existing illness. Poor parenting skills, behavioural disturbance due to ongoing psychiatric illness, absence of a good partner relationship, and alcohol/substance misuse were frequently reported in those discharged without their baby. Conclusion: The incidence of separate discharge is somewhat lower than expected in this population: we discuss potential reasons for this difference. Further work must be conducted to understand the social and regional inequities in social service intervention during perinatal psychiatric admission and determine if parenting outcomes can be improved in women at risk of separation. The management of mothers who are not able to gain admission to specialist Mother & Baby Units is a matter for concern as one would predict that with early periods of separation and without special parenting support, the rate of separation might be higher. P74 Contextual Measurement of Psychosocial Factors Related to Depression and Anxiety in Early Motherhood JA Williamson, JE McCabe, MW O’Hara University of Iowa, Iowa City, IA Email: [email protected] Objective: Previous research has suggested that life stress may precipitate the onset of depression after child–birth whereas social support may protect mothers from depressive episodes. However, research in this area has been dominated by self-report measures of stress and support which have been shown to yield assessments of the subjects’ experience which are significantly imprecise and biased by personality factors such as neuroticism. Far less research has been conducted on the psychosocial context of anxiety in early motherhood and none using interviewer-rated psychosocial variables. Method: Subjects from a previous study are contacted when their child reaches 16 months of age and are asked to complete a self-report measure of the depression and anxiety symptoms they have

K.L. Wisner experienced over the past two weeks. They then complete a telephone interview in which the presence, onset, and offset of depression and anxiety disorders during the life of their child is established. A second interview is then conducted to identify severe life events, chronic life difficulties, and the extent to which the subject receives practical and emotional support from her two closest confidants including her romantic partner if she has one. The descriptions of stress and support provided by the subject are rated by the interviewer relative to previously rated case examples Results: As of March 2010, complete data have been acquired from 55 subjects with data expected from approximately 170 subjects by September 2010 given our current retention rate. Logistic time-series regression in which each month after the subject is born is treated as an independent observation will be used to test the association between the onset of depression and anxiety disorders and the experience of severe life stress during the previous six months. The association between life stress and social support and current depression and anxiety symptoms will also be measured. Conclusion: Contextually-based assessment of life stress and social support will permit a more accurate estimation of the association between these factors and depression and anxiety in early motherhood. P75 Transdermal Estradiol for Postpartum Major Depression KL Wisner, M Costantino, DK Sit, CS Famy, M McShea, E Prairie University of Pittsburgh School of Medicine, Pittsburgh, PA USA Email: [email protected] Objective: The majority of women with perinatal depression are neither identified nor treated. Although antidepressant medication and psychotherapy are efficacious, these treatments are often not acceptable or accessible to women. Methods: Dr. Katherine Wisner and the research staff at Women’s Behavioral HealthCARE of the University of Pittsburgh are conducting a research study on the use of estradiol skin patches to treat postpartum depression. This study, entitled Transdermal Estradiol for Postpartum Major Depression, is funded by the National Institute of Mental Health and was designed to increase therapeutic options for postpartum women. In this double-blind randomized controlled trial, participants receive either estradiol patch, sertraline (Zoloft), or careful monitoring for eight weeks. The dosage of study treatment is increased every other week in the acute phase as indicated by response. Women who are full responders at week 8 continue on their established dose of blind treatment for an additional 20 weeks. Nonresponders discontinue study treatment and establish a disposition with the assistance of experienced clinicians. Infant growth is measured throughout the study and a developmental assessment is administered when the baby is 28 weeks old. Results: The study is in the active recruitment phase, with 43 women randomized as of September 22, 2010. No major adverse events have occurred. The study will include 300 women. Conclusions: Please refer women with postpartum depression! Eligible women are 18–45 years and who are less than 3 months postpartum. Participants can be seen in Pittsburgh, Hermitage or Dubois, Pennsylvania, or in most cases, in their homes. Additional information at www.womensbehavioralhealth.org or 1-800- 436-2461.

The Marcé International Society International Biennial General Scientific Meeting P76 Hospitalization for Mental Health Morbidity during Pregnancy and the Postpartum Period: Does the Peak Start Late in Pregnancy? F Xu1, M-P Austin2, N Reilly2, L Hilder1, EA Sullivan1 1

PRERU, University of New South Wales, Randwick, Australia Perinatal & Women’s Mental Health Unit, University of New South Wales, Burwood, Australia Email: [email protected]

2

Objective: To describe patterns of mental health morbidity (both psychiatric and substance use) across the perinatal period for women giving birth in New South Wales (NSW), Australia. To examined the pattern of increase in mental health morbidity from pregnancy to the first postpartum year. Method: This study used population data linked from the NSW Midwives Collection, the NSW Admitted Patients Data Collection and Pharmaceutical Drugs of Addiction System. The study population were primiparous women who gave birth in NSW between 1 January 2002 and 31 December 2005 (N=243,237). The primary outcome measure was inpatient admission/s (to any facility for any condition including delivery) with a ‘principal’ or ‘stay’ mental health diagnosis during pregnancy and the first year postpartum. Results: During the perinatal period, the total incidence of hospital admissions with an ICD-10 psychiatric or substance use diagnosis was as follows: 1.01% (N=2,447) for high prevalence disorders (mood, anxiety and adjustment disorders); 0.19% (N=455) for low prevalence disorders (psychosis and bipolar disorders); 0.48% (N=1,176) for substance use disorders; and, 0.04% (N=96) for personality disorders. As per earlier studies, the greatest incidence of hospital admissions occurred within 30 days postpartum for low prevalence disorders (0.06%) and substance use disorders (0.16%), and within 90 days postpartum for high prevalence disorders (0.13%). Importantly however, this study also demonstrated that the increase in incidence of both high and low prevalence disorders, and Opioids use disorder began in late pregnancy (0.05%, 0.02%, and 0.04%, respectively) and increased to a peak within the first few weeks postpartum. Conclusion: The results suggest that the incidence of psychiatric morbidity increases from late pregnancy and provides further evidence to support early intervention initiatives which begin in the antenatal period. The relatively high incidence of admission with a substance dependence diagnosis postpartum is of particular concern. P77 The Lived Experience of Postpartum Depression in Orthodox Jewish Women CR Zauderer Capella University, Dix Hills, NY Email: [email protected]

S87

Objective: The purpose of this study was to gain an understanding of postpartum depression as experienced by Orthodox Jewish women. Using a phenomenological approach, a sample of twelve Orthodox Jewish women who had experienced postpartum depression within five years preceding data collection were interviewed. A diagnosis of postpartum depression had been made by a mental health professional. The women reported common symptoms such as disconnect from reality, and having difficulty eating and sleeping. Some of the participants also reported having frightening and suicidal thoughts. The participants expressed the importance of family and community support in relieving their symptoms. The interviewees stated that anti-depressant medications and therapy were most helpful in overcoming their condition. Many reported feeling a stigma attached to postpartum depression and insufficient awareness in Orthodox Jewish communities. Analysis of the participants’ responses revealed the following themes: (a) Orthodox perceptions of postpartum depression; (b) post-birth support; (c) postpartum depression symptoms; and (d) types of treatment. Postpartum depression in Orthodox Jewish women is a disorder that negatively affects Orthodox Jewish women and their families. Health care professionals can play a key role in assisting this population of women through proper screening, education, and support for the women, their families, and the community. Method: The study was qualitative and utilized a phenomenological approach. The study illustrated the reflections and thoughts of twelve Orthodox Jewish women who have experienced postpartum depression. The methodology model used was Moustakas’. The inquiry focused on exploring and interpreting interview data of the women’s lived experiences. Phenomenology was the appropriate method to use for this investigation since it allowed the researcher to gain insight and understanding of a phenomenon from the perspective of those who have experienced it. Results: Analysis of the participants’ transcribed responses revealed four categories of themes or meaning units: (a) Orthodox perceptions of postpartum depression, (b) post-birth support, (c) postpartum depression symptoms, and (d) types of treatment. Conclusion: All of the subsequent interviews and analysis were performed in an attempt to provide more information on this question. As was previously noted, there is a very limited amount of literature on the subject. The twelve women that were interviewed have helped to provide rich and meaningful insights into their experiences of postpartum depression within an Orthodox Jewish community. Their answers, opinions, experiences, and explanations provided some context for a deeper understanding of postpartum depression as it is experienced in an Orthodox Jewish community, whether it is in the United States, Israel, or in Canada. Although many of the women in the study felt there was some degree of stigma attached to postpartum depression within their communities, they were hopeful that recounting their experience might be helpful to other women. Interviewees reported feeling disconnected from reality, having eating and sleeping problems. They highlighted the importance of community and family support in relieving their stress and anxiety, and stated that antidepressant medications had been, along with therapy and support groups, instrumental in their recovery.