Marlene P. Freeman

From The Journal of Clinical Psychiatry:

S we begin a new year, 2 articles in our "Focus on Women's Mental Health" section bring us new data in the areas of postpartum obsessive-compulsive disorder (OCD) (Uguz et al.) and self-injurious behavior in women (Favaro et al.). These areas are obviously important to women's health but, at first glance, are not closely related to each other. Both remind us, however, that even in 2007-with all the advances in psychiatry over the past decades-we are still refining the questions that we ask rather than celebrating our ability to cure. Uguz et al. assessed the prevalence of obsessive-compulsive symptoms at 6 weeks postpartum in a sample of 302 postpartum women. They found that 4% of the sample was suffering from postpartum OCD, higher than the prevalence of OCD in the general population and in women of reproductive age. Favaro et al. assessed a community sample for self-injurious behaviors and associated risk factors. They found high rates of self-injurious behavior, noted in almost a quarter of the women screened. Among psychiatric illnesses, most of which carry the burden of stigma and shame for most patients, postpartum diagnoses and self-injurious behaviors may be particularly stigmatizing. Mood disorders are known to affect from 10% to 20% of women after delivery, but less is known about anxiety disorders. Many of the anxiety disorders are more prevalent among women than men, 1 although interestingly, this is not the case with OCD. Anxiety symptoms appear to be common in the postpartum, and women with postpartum depression appear to be at risk for anxiety symptoms as compared with women who experience depression that is not in the postpartum context. 2,3 Considering the absolute neediness of a newborn baby, an evolutionary need for heightened vigilance in postpartum mothers very likely exists; in women with post partum OCD, it may be the case that normal reactions go awry and produce suffering and difficulty with functioning. As found by Uguz et al., it is not uncommon for obsessions to include aggressive thoughts that may involve harm to the baby. For a new mother with no understanding of what she is experiencing, the symptoms of OCD are frightening and painful. Postpartum obsessions and compulsions can also lead to isolation, as a woman may experience great shame in revealing intrusive and/or aggressive thoughts about her baby. It is too often the case that when she does share such thoughts, lack of understanding and education among health care providers prevents her from accessing and receiving care in an informed way. Several cases of mothers killing their children have come under the media spotlight and emphasize the need for careful evaluation of all aggressive thoughts. The relatively high prevalence of postpartum OCD and its common presentation with aggressive thoughts require that health care providers understand postpartum OCD and its presentation and differentiate aggressive obsessions from homicidal ideation and psychosis. Also, with a prevalence of 4%, postpartum OCD might be considered a common complication of childbirth that should be discussed routinely at obstetrical visits and childbirth courses. Favaro et al. report on the rate of self-injurious behavior in a community sample in Italy. They found that 24% of participants reported self-injurious behaviors, with strong associations with eating disorders and childhood abuse. With such a high representation of women in the community endorsing self-injurious behaviors, it would make sense to screen for such behaviors routinely, and to investigate whether the risk for self-injurious behavior is as high in men as well. Favaro et al. highlight the need for clinicians to screen for common problems such as self-injurious behaviors, disordered

To determine if the available data support the use of omega-3 essential fatty acids (EFA) for clinical use in the prevention and/or treatment of psychiatric disorders. The authors of this article were invited participants in the Omega-3 Fatty Acids Subcommittee, assembled by the Committee on Research on Psychiatric Treatments of the American Psychiatric Association (APA). Published literature and data presented at scientific meetings were reviewed. Specific disorders reviewed included major depressive disorder, bipolar disorder, schizophrenia, dementia, borderline personality disorder and impulsivity, and attention-deficit/hyperactivity disorder. Meta-analyses were conducted in major depressive and bipolar disorders and schizophrenia, as sufficient data were available to conduct such analyses in these areas of interest. The subcommittee prepared the manuscript, which was reviewed and approved by the following APA committees: the Committee on Research on Psychiatric Treatments, the Council on Research, and the Joint Reference Committee. The preponderance of epidemiologic and tissue compositional studies supports a protective effect of omega-3 EFA intake, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), in mood disorders. Meta-analyses of randomized controlled trials demonstrate a statistically significant benefit in unipolar and bipolar depression (p = .02). The results were highly heterogeneous, indicating that it is important to examine the characteristics of each individual study to note the differences in design and execution. There is less evidence of benefit in schizophrenia. EPA and DHA appear to have negligible risks and some potential benefit in major depressive disorder and bipolar disorder, but results remain inconclusive in most areas of interest in psychiatry. Treatment recommendations and directions for future research are described. Health benefits of omega-3 EFA may be especially important in patients with psychiatric disorders, due to high prevalence rates of smoking and obesity and the metabolic side effects of some psychotropic medications.

Women have a relatively high risk of experiencing depressive episodes during the perimenopause. Indications for and acceptance of hormone replacement therapy (HRT) are increasingly controversial, and serotonin reuptake inhibitor antidepressants are an attractive potential treatment option for both the mood and somatic symptoms of perimenopause. This study is an open-label, 8-week trial of escitalopram for perimenopausal depression and somatic symptoms associated with perimenopause. Twenty women received escitalopram and were serially assessed with the Hamilton Rating Scale for Depression (HAMD, 30-item), the Greene Climacteric Scale (GCS), and the Clinical Global Impression (CGI). There were significant differences between pretest and posttest scores for each measure, as demonstrated in an intent-to-treat analysis: GCS (p < 0.0001), HAM-D30 (p < 0.0001), and CGI (p < 0.0001). Two subjects dropped out prior to the second visit because of drug side effects. In this study, benefits of treatment were observed in several domains of perimenopausal symptoms, including those representative of psychological, vasomotor, and somatic symptoms. The limitations of this study are small sample size and lack of placebo control. Larger, long-term, controlled trials of antidepressants are warranted for the treatment of perimenopausal depression and associated somatic symptoms.

Objective:: In this flexible-dose, open-label trial, we examined the efficacy of omega-3 fatty acids for the treatment of depression during pregnancy.Methods:: Fifteen pregnant women with major depressive episodes participated. Subjects initially received two capsules per day [0.93 g of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)]; the dose could be increased by one capsule per day every 2 weeks to a maximal dose of 2.8 g. Subjects were assessed with the Edinburgh Postnatal Depression Scale (EPDS) and Hamilton Rating Scale for Depression (HRSD).Results:: Average duration of participation in this treatment trial was 8.3 weeks (SD ± 7.1). Average final dose of EPA + DHA in this flexible dose trial was 1.9 g per day (±0.5). The mean reduction in EPDS scores was 40.9% (SD ± 21.9); the mean decrease in HRSD score was 34.1% (SD ± 27.1).Conclusions:: This open trial provides data to support the need for randomized controlled dose-finding trials of omega-3 fatty acids in major depressive episodes during pregnancy.

Postpartum depression (PPD) is a disorder with broad public health implications and consequences that impact almost every aspect of child development. In this pilot study, study participants were 96 women who brought their babies to the University of Arizona Pediatrics Clinic for their 8-week well-baby visit. Participants completed a packet that consisted of questions about demographics, potential correlates of PPD, and the Edinburgh Postpartum Depression Scale (EPDS). English and Spanish versions were available. Of a total of 172 women who brought their babies in for their 8-week well-baby visit, 96 women completed the packets, for an overall response rate of 56.9%. Observed EPDS scores ranged from 0 to 18, with a mean of 5.44 and a standard deviation (SD) of 4.83. Using the cutoff of EPDS > or = 12, 14.6% of participants were likely suffering from clinically significant depression. Higher EPDS scores and also categorical depression classification were statistically associated with reported smoking and a family history of mental health problems. We conclude that screening for mothers at well-baby visits is feasible and that the data collected are of sufficient quality to identify reliable predictors even with small sample sizes.

Objective:  Postpartum depression (PPD) affects 10–15% of mothers. Omega‐3 fatty acids are an intriguing potential treatment for PPD.Method:  The efficacy of omega‐3 fatty acids for PPD was assessed in an 8‐week dose‐ranging trial. Subjects were randomized to 0.5 g/day (n = 6), 1.4 g/day (n = 3), or 2.8 g/day (n = 7).Results:  Across groups, pretreatment Edinburgh Postnatal Depression Scale (EPDS) and Hamilton Rating Scale for Depression (HRSD) mean scores were 18.1 and 19.1 respectively; post‐treatment mean scores were 9.3 and 10.0. Percent decreases on the EPDS and HRSD were 51.5% and 48.8%, respectively; changes from baseline were significant within each group and when combining groups. Groups did not significantly differ in pre‐ or post‐test scores, or change in scores. The treatment was well tolerated.Conclusion:  This study was limited by small sample size and lack of placebo group. However, these results support further study of omega‐3 fatty acids as a treatment for PPD.

Objective:  Bipolar disorders are prevalent in women. Women with bipolar disorder often present with different clinical features than men. Reproductive events and hormonal treatments may impact the course of bipolar disorder. Our main objectives are to i) assess the impact of reproductive events on the course of the disorder, and ii) to discuss the relationships between reproductive events and psychiatric treatments.Method:  A literature search was conducted of MEDLINE journals from 1965 to present. Manual literature searches were also conducted. We review the presentation, clinical course, and treatment considerations of bipolar disorder in women, with emphasis on treatment considerations in the context of reproductive events. Treatment‐related issues such as teratogenicity, breastfeeding, polycystic ovarian syndrome, weight gain and obesity, and medication interactions with oral contraceptives are reviewed.Results:  Women with bipolar disorder may be more vulnerable to mood episodes in the context of reproductive events, particularly postpartum. In women of reproductive age, mood stabilizers must be selected with teratogenic risks in mind, with the highest reported risks in pregnancy with valproate, and the greatest concern during breastfeeding with lithium use. In the areas of the perimenopause and polycycstic ovarian syndrome, more data are needed to advise treatment decisions.Conclusion:  We urgently need further study in these areas to deliver care that is appropriate to women with bipolar disorder.