Thèses sur le sujet « Perinatal psychiatry »

Background: Asthma now affects up to 10% of pregnant women in high income countries and international prevalence is rising. It is already one of the commonest chronic diseases that can complicate pregnancy and previous studies have raised concern that women with asthma have increased pregnancy risks. Precise estimates of the magnitude of these risks and the extent to which they may differ by asthma severity and asthma exacerbation rates, have not been determined. Aim: The overall aim of this thesis was to investigate the impact of asthma and asthma therapies on pregnancy and perinatal outcomes in the general female population. Methods: The Health Improvement Network primary care database from the United Kingdom was used to develop a dataset of women matched to their liveborn children and all data on these pregnancies and on pregnancies ending in stillbirth, miscarriage or therapeutic abortion, were extracted for analysis. Three separate studies were carried out using the developed dataset. First, a cohort design was used to compare fertility rates of women with and without asthma or other allergic disease. Secondly, a cross-sectional design was used to compare risks of adverse pregnancy outcomes and obstetric complications in women with and without asthma. Thirdly, a case-control design was used to compare the risk of congenital malformation in children born to women with and without asthma, and to assess whether asthma medications are teratogenic. Results: A study population of 1,059,246 women was obtained and pregnancies ending in 268,601 matched live births, 986 stillbirths, 35,272 miscarriages and 37,118 therapeutic abortions were identified. Women with asthma or other allergic disease had similar fertility rates (live births per 1,000 person-years) to women in the general population. Women with asthma also had a similar risk of pregnancy ending in stillbirth (Odds Ratio (OR)=1.04, 95% confidence interval (CI) 0.86-1.24)) or therapeutic abortion (OR=0.95, 95%CI 0.92-0.99), but had a small relative increase in risk of pregnancy ending in miscarriage (OR=1.10, 95%CI 1.06-1.13), compared with women without asthma. Risks of most obstetric complications were similar in women with and without asthma, regardless of asthma severity or acute exacerbations, with the exception of increased risks of antepartum haemorrhage (OR=1.20, 95%CI 1.08-1.34), postpartum haemorrhage (OR=1.38, 95%CI 1.21-1.57), depression in pregnancy (OR=1.52, 95%CI 1.36-1.69), caesarean section delivery (OR=1.11, 95%CI 1.07-1.16), preterm delivery (OR=1.15, 95%CI 1.06-1.24) and low birth weight (OR=1.18, 95%CI 1.05-1.32) in their offspring. Compared with children born to mothers without asthma, children born to mothers with asthma had a small increased risk of major congenital malformation (OR=1.10, 95%CI 1.01-1.20), however, this was not found for mothers with currently treated asthma (OR=1.06, 95%CI 0.94-1.20). Gestational exposure to asthma medications was safe apart from cromones which may increase the risk of musculoskeletal malformation. Conclusions: These findings indicate that women with asthma do not have substantially increased risks associated with pregnancy or with perinatal outcomes. Treatment with asthma medications before pregnancy and during gestation also appear to be safe for the mother and for the unborn child, providing support for the current practice of optimal pharmacological management of asthma in women of childbearing age.

This thesis presents two papers. The first is a systematic review of the literature exploring the relationship between perinatal paternal mental health difficulties and child outcomes in preadolescence. Eighteen papers were reviewed. The review found fairly consistent evidence for internalising and externalising problems and mixed evidence for socio-emotional and cognitive difficulties and child temperament. More research is required regarding mental health in fathers during this period more generally as well as how preadolescent child outcomes may be affected. The second paper is an empirical study exploring whether perfectionism was related to experiences of postnatal distress (depression, anxiety and OCD) in first time mothers and whether this relationship could be explained by antenatal maternal orientation. Furthermore, whether the strength of any relationships were affected by participants’ experience of becoming a mother. Eighty-four women completed questionnaires during their third trimester of pregnancy and fifty-nine six-to-twelve weeks after birth. A relationship between socially prescribed perfectionism and postnatal depression and anxiety was observed. Antenatal maternal orientation did not mediate this relationship. Mental health in pregnancy, the impact of sleep deprivation, feelings of control and powerlessness, perceived relationship with baby and levels of social support predicted depression, anxiety and OCD in the postnatal period.

Volume 1: Research component There are three papers contained in this volume, all concerned with maternal mental health problems in the perinatal period. The first is a review that examines the existing literature on eating disorders in the perinatal period. It examines prevalence, symptomatology levels across the perinatal period and factors associated with development and remission from eating disorders in the perinatal period. The second paper is a report of research, carried out by the author, investigating obsessive compulsive disorder, bonding and meta-cognitions in new mothers. It specifically examines whether bonding is impaired in new mothers with OCD when compared with mothers who have no symptoms of OCD, a subject that has not been investigated in previous research. Both papers have been prepared for submission to Archives of Women‟s Mental Health. The final paper is a public domain paper describing the literature review and empirical papers and has been used to disseminate the findings of the research amongst participants, mother and baby organisations and mental health professionals. The appendices contain information regarding ethical approval, measures used and instructions to authors from the Archives of Women‟s Mental Health. Volume 2: Clinical component This volume contains five clinical practice reports (CPR) submitted during the doctorate course. These reports reflect the training of the course and the work completed over the three years of the course. CPR 1 and 2 were conducted during a child and adolescent placement. CPR 1 describes a doctor phobia in a five year old girl, formulated from a behavioural and a systemic perspective. CPR 2 reports a single case experimental design study on a narrative intervention for sleep difficulties in a nine year old boy. CPR 3 describes a qualitative service evaluation of a waiting list initiative and changes to the referral system to a Psychological Therapies Service within an adult mental health service. CPR 4 is a case study of a CBT intervention for a client with OCD in a specialist adult service. The abstract of CPR 5, a presentation on a CBT and narrative intervention for anger in a woman with a learning disability in an inpatient setting. The names and identifying details have been changed or removed from these reports to protect anonymity.

Introduction: Maternal antenatal depression has been associated with an increased risk of offspring psychopathology and more recently with disturbed infant sleep; in particular, shorter sleep duration, more awakenings and sleep problems. The exact mechanisms through which risk may be transmitted remain unknown, as does the question of whether all infants are equally susceptible to the effects of antenatal depression. The primary objectives of this thesis were to examine: i) The role of two potential moderators on the association between antenatal depression and infant sleep: infant reactive temperament and the serotonin transporter polymorphism 5-HTTLPR ii) The association between antenatal depression and infant sleep using objective behavioural and physiological measures. iii) Infant sleep and temperament in a pilot randomised controlled trial (RCT) following treatment of antenatal depression Methods i) The role of infant reactivity and 5-HTTLPR as potential moderators was examined in two large longitudinal cohorts: the Avon Longitudinal Study of Parents And Children (ALSPAC) and the Generation R study, based in the UK and The Netherlands respectively (n=8,991 and n=2,441). ii) An Oxford based pilot longitudinal family study (n=16) iii) A pilot randomised controlled trial of women with antenatal depression who received Cognitive Behavioural Therapy (CBT) or Care as Usual (n=25). Results i) There was evidence that reactive temperament moderated the association between antenatal depression and infant sleep; boys seemed to be most affected exhibiting more awakenings, sleep problems and shorter sleep duration. 5-HTTLPR did not moderate this association. ii) Antenatal depression was associated with shorter infant sleep duration 5 months postpartum iii) Improvement in depression was associated with shorter infant sleep duration and easier temperament 2 months postpartum Conclusion: This thesis suggests that not all infants are equally susceptible to environmental influences and this may prove important in targeting interventions. The role of genetic factors in conferring any susceptibility remains unclear. Actigraphy offering accurate representation of activity levels and timing during the day and night was a significant methodological advantage, but recruitment to a study incorporating these proved challenging. Finally, psychological interventions during pregnancy appear to have beneficial effects for child development.

Perinatal depression is a major public health issue which contributes significantly to the global burden of disease, especially in low resource settings in South Africa, where there is a shortage of mental health professionals. New psychological interventions delivered by non-specialists are needed to fill the treatment gap. Task sharing of psycho-social interventions for perinatal depression has been shown to be feasible, acceptable and effective in low and middle-income countries. However; there are limited data on process evaluations of task shared interventions for perinatal depression. This thesis attempts to address this gap by presenting four papers based on a study that undertook a qualitative process evaluation on a task shared psycho-social intervention. The thesis integrates all the papers under one primary aim (a process evaluation) which triangulated data from four sources which were published literature, perspectives of local depressed women, and perspectives of the counsellors in the trial and recipients of the intervention in the trial. The thesis will be presented in six chapters. The first chapter provides a background with current issues in global mental health, psycho-social interventions, task sharing in low and middle income countries and the United Kingdom (UK) Medical Research Council (MRC) framework for developing and evaluating interventions. A second chapter presents a systematic review on qualitative evidence of process evaluations of task sharing interventions for perinatal depression in LAMICs in relation to the UK MRC framework for conducting process evaluations. The systematic review reveals a paucity of qualitative evidence of process evaluations together with several crucial factors related to context, implementation and mechanisms of an intervention including: content and understandability, counsellors facilitating trust and motivation to conduct the intervention and participant factors such as motivation to attend the sessions and willingness to learn and change their behaviour. The third chapter provides information on development of the intervention and determining the feasibility in line with the MRC framework. Qualitative semi-structured interviews were conducted with 26 participants, including service providers and service users at a clinic in Khayelitsha. After the semi-structured interviews, a workshop was conducted with mental health experts on evidence-based psychological interventions for depression, together with a document review of counselling manuals for community health workers in South Africa. The feasibility study showed that a task sharing counselling intervention was acceptable and feasible for depressed women in Khayelitsha, under the following conditions: (1) respondents preferred a female counsellor and felt that a clinic based individual sessions should be provided at least once a month by an experienced Xhosa speaking counsellor from the community; and (2) the content of a counselling intervention should include psycho-education on cognitive and behavioural effects of depression, how to cope with interpersonal problems, and financial stressors. Based on these conditions, the review of manuals and expert consultation, key components of the counselling intervention were identified as: psycho-education, problem solving, healthy thinking and behaviour activation. These were included in the final counselling manual. The fourth chapter, presents the first of two perspectives of the post-intervention qualitative process evaluations, with lay counsellors. Post intervention qualitative semi-structured interviews were conducted with six counsellors from the AFrica Focus on Intervention Research for Mental Health (AFFIRM-SA) randomized controlled trial on their perceptions of delivering a task shared psycho-social intervention for perinatal depression. These interviews revealed that facilitating factors in the delivery of the intervention included intervention related factors such as: the content of the intervention, ongoing training and supervision, using a counselling manual, conducting counselling sessions in the local language (isiXhosa) and fidelity to the manual. Counsellor factors including counsellors’ confidence and motivation to conduct the sessions and participant factors included older age, commitment and a desire to be helped. Barriers included contextual factors such as poverty, crime and lack of space to conduct counselling sessions and participant factors such as the nature of the participant’s problem, younger age, and avoidance of contact with counsellors. Fidelity ratings and dropout rates varied substantially between counsellors. The fifth chapter presents the second of two perspectives of post intervention qualitative process evaluation with participants. Stratified purposeful sampling based on non-attendance, partial attendance and complete attendance of the intervention resulted in 34 participants being selected for semi-structured interviews. All interviews were recorded, transcribed and translated. Transcripts were analysed using a framework analysis in NVivo v11. Several factors acted as either barriers or facilitators of the participants’ context, mechanisms of the intervention and the implementation of the intervention. Contextual factors included the nature of problem such as unplanned pregnancy, interpersonal difficulties and location of the counselling. Mechanisms included participant factors such as willingness to learn new skills and change behaviour, counsellor factors such as motivation and empathy and intervention factors such as the content of the intervention. Implementation factors included the perception of the use or inability to use material such as the counselling manual, homework book and relaxation CD. The majority of the participants found the following sessions to be most valuable; “psycho-education for depression”, “problem solving” and “healthy thinking”, although a few participants did not have good recall of the sessions. The final chapter presents a discussion of key findings together with their implications for researchers, policy makers and other stakeholders. The chapter concludes with recommendations for future research in order to understand the contextual, participant, counsellor and intervention factors involved in the implementation of task sharing interventions.

Premesse: Le conoscenze attuali sugli effetti della psicopatologia durante la gravidanza e il postpartum sull'esito mentale nella prole sono molto scarse e si concentrano principalmente su ansia e disturbi depressivi. I disturbi della personalità sono meno indagati. I disturbi borderline e antisociali DP sono quelli maggiormente considerati, sebbene poco analizzati, ma gli altri risultano troppo spesso trascurati. Scopo: L'obiettivo del presente progetto è orientato all'identificazione delle possibili conseguenze nella prole, a causa della psicopatologia materna, in particolare dei disturbi di personalità. Inoltre, cercheremo di identificare eventuali mediatori rispetto all’effetto della personalità, se presenti. Metodi: 108 donne dell’ ambulatorio psichiatrico perinatale ("LUCE"), 152 del CPS, che non hanno avuto problemi specifici nei confronti dei loro figli o maternità (OUTPTS), e 198 controlli sani (HC) sono stati testati con EPDS, BAI, BDI, WHOQOL e CTQ. I loro bambini sono stati testati con CBCL. Risultati: Le donne "LUCE" e OUTPTS non differivano da un punto di vista diagnostico, socioeconomico o farmacologico. I bambini "LUCE" presentavano problemi in tutti i domini sia a livello borderline che clinico, mentre i bambini di OUTPTS avevano difficoltá in pochi domini e ad un livello borderline. I bambini di madri passivo-aggressive sembravano emotivamente più reattivi, quelli delle madri narcisiste&borderline più inclini al ritiro. I bambini di madri passivo-aggressive mostrano una positivitá significativamente maggiore nella maggior parte dei domini clinici rispetto a quelli di madri senza DP, soprattutto ansia/depressione clinica, comportamento ritirato o aggressivo. I bambini delle madri narcisistiche hanno problemi di attenzione ad un livello clinico significativamente maggiori mentre i figli delle madri con disturbo ossessivo-compulsivo DP hanno significativamente più ansia/depressione e disturbi somatici. Un distacco clinicamente significativo differenzia i bambini di madri con differenti PD rispetto a quelle delle madri senza PD. La mediazione EPDS nei bambini "LUCE" ha evidenziato un livello significativamente più alto di ritiro clinico. Un'analisi approfondita del ruolo dell'EPDS nel confrontare i bambini di SCID_II-NEG e di ciascun PD (possibile a livello clinico solo in "LUCE") ha mostrato significato nell'ansia/depressione tra figli di donne con DP paranoide o passivo-aggressivo e SCID_II- NEG e comportamento aggressivo tra passivo-aggressivo e SCID_II-NEG. Un'ulteriore analisi ha mostrato la mancanza di differenze significative in qualsiasi dominio CBCL in ogni PD se EPDS + e - vengono confrontati . Conclusioni: Il presente studio ha lo scopo di indagare i possibili effetti psichici, dovuti alla psicopatologia materna, nella prole di madri affette da disturbi della personalità. Abbiamo selezionato pazienti psichiatrici sia da ambulatori di psichiatria perinatale che territoriali e controlli sani. Un confronto tra i loro figli permette due conclusioni preliminari: i figli di madri con PD hanno esiti peggiori e i figli di madri con una sofferenza psichica nel peripartum hanno un profilo peggiore rispetto a quelli di madri con la stessa diagnosi e trattamento farmacologico. La mediazione di una positività per il rischio di sviluppare una depressione postpartum non sembra sufficiente a giustificare tali risultati. Anche se le donne con quella positività hanno figli che mostrano una maggiore sofferenza, è la difficoltà nel legame madre-figlio o verso la maternità (espressa dalle donne in carico al Dipartimento perinatale) che costituiscono la migliore spiegazione delle maggiori difficoltà dei loro figli. I nostri risultati suggeriscono e sottolineano l'importanza di una rapida identificazione e trattamento delle madri con sofferenza psichica durante la gravidanza al fine di prevenire o almeno ridurre gli esiti psichici nei figli.
Background: Current knowledge on the effects of psychopathology during pregnancy and postpartum on offspring mental outcome is very poor and mainly focused on anxiety and depressive disorders. Personality disorders are less investigated. Borderline and Antisocial PDs are especially considered, but the other PDs are too often neglected. Aim: The aim of the present project drifts towards the identification of possible consequences in offspring, due to maternal psychopathology, particularly personality disorders. Moreover, we will try to identify eventual mediators within personality causal role if any. Methods: 108 women from Perinatal Psychiatric Department (“LUCE”), 152 from Outpatients Psychiatric Department who had no specific issues towards their children or motherhood (OUTPTS) and 198 healthy controls (HC) were tested with EPDS, BAI, BDI, WHOQOL and CTQ. Their children were tested with CBCL. Results: “LUCE” and OUTPTS women did not differ from a diagnostic, socioeconomic and pharmacological point of view. Children of “LUCE” patients showed issues in all the domains both at a borderline and clinical level, while children of OUTPTS patients had only issues in few domains and at a borderline level. Clinical issues are shown especially by children of mothers affected by Passive-aggressive, Paranoid, Narcissistic&Borderline, Obsessive-Compulsive and Narcissistic PDs. In particular, children of PA mothers seemed more emotionally reactive, those of N+B mothers more prone to withdrawn. Children of Passive-Aggressive PD mothers show significance in most of the clinical domains compared to SCID_II-NEG. In particular, it is interesting to underline significance in clinical anxiety/depression, withdrawn and aggressive behavior. Children of Narcissistic mothers have significantly more clinical attention problems while children of Obsessive-Compulsive PD mothers have significantly more clinical anxiety/depression and somatic complaints. Clinical withdrawn differences children of mothers with several PDs compared to those of SCID_II-NEG mothers. Children of “LUCE”-EPDS+ showed clinical issues in all the domains. EPDS mediation in “LUCE” children showed a significant higher level of clinical withdrawn. An in-depth analysis of the role of EPDS in comparing children of SCID_II-NEG and each PDs (possible at a clinical level only in “LUCE”) showed significance in anxiety/depression between PARA or PA and SCID_II-NEG and in aggressive behavior between PA and SCID_II-NEG. A further analysis showed lack of significant differences in any CBCL domain in each PDs if EPDS+ and – were compared. Conclusion: The present study aimed at investigating possible psychic effects in offspring of mothers affected by personality disorders due to maternal psychopathology. We selected psychiatric patients both from Perinatal and Outpatients Departments and healthy controls. A comparison among their children let to highlight two main preliminary conclusion: children of mothers with PDs have worse outcomes and children of mothers with a psychic sufferance in the peripartum have a worse profile compared with those of mothers with the same diagnosis and pharmacological treatment. The mediation of a positivity for the risk of developing postpartum depression does not seem enough to justify such results. Albeit women with that positivity have children that show higher sufferance, it is the difficulty in mother-child bond or toward motherhood (expressed by women admitted to Perinatal Department) that constitute the best explanation to their children higher difficulties. Our results suggest and stress the importance of an early identification and treatment of mothers with psychic sufferance during pregnancy in order to prevent or at least reduce their children psychic outcomes.

Background: Bipolar disorder (BD) is a significant cause of perinatal morbidity and mortality. Because BD is hard to detect and treat, these individuals often go without care. This dissertation was designed to: (1) identify the prevalence rates of BD and bipolar-spectrum mood episodes in perinatal individuals, (2) understand pertinent barriers to mental healthcare, and (3) elucidate how to bridge healthcare gaps. Methods: Data sources included: primary qualitative and quantitative data from obstetric clinicians, encounter data from Massachusetts Child Psychiatry Access Program (MCPAP) for Moms, a program aimed at helping clinicians to provide mental healthcare to perinatal patients. Analyses included: descriptive statistics, systematic review and meta-analysis, qualitative data analyses, longitudinal regression analyses, and group-based trajectory modeling. Results: The prevalence of BD in perinatal individuals was 2.6% (95% CI: 1.2 to 4.5%). Twenty to 54.9% were found to have a bipolar-spectrum mood episode. Barriers to mental healthcare for perinatal patients with BD included the paucity of psychiatric resources, difficulties in assessing BD, and stigma towards pharmacotherapy. Obstetric clinicians reported that MCPAP for Moms has helped them feel more comfortable in treating patients with BD. Longitudinal analyses of encounter data corroborated these findings - utilization of the program predicted increased clinician capacity to treat BD. Conclusion: Clinicians for perinatal individuals are being called upon and stepping up to care for complex illnesses like BD. Programs like MCPAP for Moms can help them feel more confident in this role, helping to bridge gaps in perinatal mental healthcare and ensuring that individuals with BD are able to receive appropriate care.

Efforts to improve inclusion in research have included mandating the recruitment of ethnic minorities and women into NIH funded studies. However, little research has been completed on who attends such interventions. This is particularly worrisome in populations for which attendance to interventions can have dire consequences. HIV is a public health concern for pregnant women in substance using communities, as pregnant women are much less likely to use condoms during intercourse to prevent HIV. Group modular HIV prevention interventions have long been the standard for HIV prevention. However, little attention in research on HIV prevention interventions RCTs has been focused on attendance to these interventions. This study examined predictors of intervention and control group attendance in a randomized controlled trial comparing a 5-session Safer Sex Skill Building (SSB) intervention to a 1-session HIV education control group in a sample of pregnant women at risk for prenatal substance use. This study identified psychosocial and mental health variables associated with both 1 session control group and 5-session SSB intervention attendance as well as endeavored to identify the number of sessions necessary to attend to achieve an adequate dose in treatment. Findings include younger age and marital status as being predictive of participation in the one session HE control group and having a trade, skill, or profession as being predictive of participation in the five session SSB intervention group. Further research is needed to understand what factors may impact five-session SSB group attendance.

Depression is the leading cause of disability among women of reproductive age worldwide. Upwards of 1 in 5 women suffer from perinatal depression. This condition has deleterious effects on several birth outcomes, infant attachment, and children’s behavior/development. Maternal suicide causes 20% of postpartum deaths in depressed women. Although the vast majority of perinatal women are amenable to being screened for depression, screening alone does not improve treatment rates or patient outcomes. Obstetrics/Gynecology (Ob/Gyn) clinics need supports in place to adequately address depression in their patient populations. The primary goal of this thesis is to develop, refine, and pilot test a new low-cost and sustainable stepped care program for Ob/Gyn clinics that will improve perinatal women’s depression treatment rates and outcomes. We developed and beta tested the Rapid Access to Perinatal Psychiatric Care in Depression (RAPPID) Program, to create a comprehensive intervention that is proactive, multifaceted, and practical. RAPPID aims to improve perinatal depression treatment and treatment response rates through: (1) access to immediate resource provision/referrals and psychiatric telephone consultation for Ob/Gyn providers; (2) clinic-specific implementation of depression care, including training support and toolkits; and (3) proactive depression screening, assessment, and treatment in OB/Gyn clinics. RAPPID builds on a low-cost and widely disseminated population-based model for delivering psychiatric care in primary care settings. Formative data and feedback from key stakeholders also informed the development of RAPPID. Our formative and pilot work in real-world settings suggests RAPPID is feasible and has the potential to improve depression detection and treatment in Ob/Gyn settings. The next step will be to compare two active interventions, RAPPID vs. enhanced usual care (access to resource provision/referrals and psychiatric telephone consultation) in a cluster-randomized trial in which we will randomize 12 Ob/Gyn clinics to either RAPPID or enhanced usual care.

Depression is the leading cause of disability among women of reproductive age worldwide. Upwards of 1 in 5 women suffer from perinatal depression. This condition has deleterious effects on several birth outcomes, infant attachment, and children’s behavior/development. Maternal suicide causes 20% of postpartum deaths in depressed women. Although the vast majority of perinatal women are amenable to being screened for depression, screening alone does not improve treatment rates or patient outcomes. Obstetrics/Gynecology (Ob/Gyn) clinics need supports in place to adequately address depression in their patient populations. The primary goal of this thesis is to develop, refine, and pilot test a new low-cost and sustainable stepped care program for Ob/Gyn clinics that will improve perinatal women’s depression treatment rates and outcomes. We developed and beta tested the Rapid Access to Perinatal Psychiatric Care in Depression (RAPPID) Program, to create a comprehensive intervention that is proactive, multifaceted, and practical. RAPPID aims to improve perinatal depression treatment and treatment response rates through: (1) access to immediate resource provision/referrals and psychiatric telephone consultation for Ob/Gyn providers; (2) clinic-specific implementation of depression care, including training support and toolkits; and (3) proactive depression screening, assessment, and treatment in OB/Gyn clinics. RAPPID builds on a low-cost and widely disseminated population-based model for delivering psychiatric care in primary care settings. Formative data and feedback from key stakeholders also informed the development of RAPPID. Our formative and pilot work in real-world settings suggests RAPPID is feasible and has the potential to improve depression detection and treatment in Ob/Gyn settings. The next step will be to compare two active interventions, RAPPID vs. enhanced usual care (access to resource provision/referrals and psychiatric telephone consultation) in a cluster-randomized trial in which we will randomize 12 Ob/Gyn clinics to either RAPPID or enhanced usual care.

Includes abstract.
Includes bibliographical references.
The Highly Active Antiretroviral Therapy (HAART) era in the mid-nineties signalled a dramatic change in the long-term outcome of Human Immunodeficiency Virus (HIV). Many children have shown significant neurologic benefit, and in particular, a decline in the incidence of HIV encephalopathy. As increasing numbers of children have survived into adolescence and early adulthood new challenges have arisen, such as the detection and characterization of milder forms of HIV-associated neurocognitive deficits in children previously thought to be asymptomatic...

The purpose of this dissertation was to examine patterns of antenatal stressful life events (SLEs) experienced by women in the United States (U.S.) and their association with postpartum depression (PPD). It further explored the role of women's state-level socio-economic status (SES) on PPD; the racial/ethnic dispartites in SLE-PPD relationship; and the role of provider communication on perinatal depression. Data from 2009–11 Pregnancy Risk Assessment Monitoring System (PRAMS) and SES indicators published by the Institute of Women’s Policy Research (IWPR) were used. Latent class analysis (LCA) was performed to identify unobserved class membership based on antenatal SLEs. Multilevel generalized linear mixed models examined whether state-level SES moderated the antenatal SLE-PPD relationship. Of 116,595 respondents to the PRAMS 2009-11, the sample size for our analyses ranged from 78% to 99%. The majority (64%) of participants were in low-stress class. The illness/death related-stress class (13%) had a high prevalence of severe illness (77%) and death (63%) of a family member or someone very close to them, while those in the multiple-stress (22%) class endorsed most other SLEs. Eleven percent had PPD; women who experienced all types of stressors, had the highest odds (adjusted odds ratio [aOR]: 5.43; 95% confidence interval [CI]: 5.36, 5.51) of PPD. The odds of PPD decreased with increasing state-level social/economic autonomy index (aOR: 0.75; 95% CI: 0.64, 0.88), with significant cross-level interaction between stressors and state-level SES. Among non-Hispanic blacks and non-Hispanic whites, husband/partner not wanting the pregnancy (aOR: 1.47; 95% CI: 1.14, 1.90) and drug/drinking problems of someone close (aOR: 1.37; 95% CI: 1.21, 1.55) were respectively associated with PPD. Provider communication was protective. That 1 out of every 5 and 1 out of every 8 women were in the high- and emotional-stress classes suggests that SLEs are common among pregnant women. Our results suggest that screening for antenatal SLEs might help identify women at risk for PPD. The finding that the odds of PPD decrease with increasing social/economic autonomy, could have policy implications and motivate efforts to improve these indices. This study also indicates the benefits of antenatal health care provider communication on perinatal depression.

Background Up to 34% of perinatal individuals experience childbirth as traumatic. These individuals are at increased risk for developing depression, anxiety, and posttraumatic stress disorder (PTSD) after the traumatic event. The objective of this study was to elicit the perspectives of individuals with a traumatic birth experience on barriers and facilitators to receiving mental health support in the postpartum period after a traumatic delivery. Methods Individuals who delivered within the last three years and perceived their birth experience to be traumatic (n=32) completed an hour-long semi-structured phone interview. The interview included screening for PTSD, depression, and anxiety with validated instruments including the Posttraumatic Stress Disorder Checklist for DSM-V (PCL-5), the Patient Health Questionnaire depression scale (PHQ-8), and the Generalized Anxiety Disorder scale (GAD-7), respectively. Qualitative data was analyzed using a modified grounded theory characterizing participants’ barriers and recommendations for mental health support after traumatic births. Results Among participants, 34.4% screened positive for PTSD, 18.8% screened positive for major depressive disorder, and 34.4% screened positive for anxiety. Qualitative themes revealed multi-level barriers involving lack of communication, education, and resources which prevented obstetric professionals from recognizing and supporting patients’ mental health needs after a traumatic birth. Recommendations from participants included that 1) obstetric professionals should acknowledge trauma experienced by any individual after childbirth, 2) providers of multiple disciplines need to be integrated into postpartum care, and 3) mental health support is needed before the ambulatory postpartum visit. Conclusions There are multi-level barriers toward detecting and responding to individuals’ mental health needs after a traumatic birth. Obstetric professionals need to use a trauma-informed approach and proactively follow-up and assess mental health care in the postpartum period.