Category: Depression

 Increased levels of depression as a result of discrimination could contribute to low birth weight babies.

Given the well-documented relationship between low birth weight and the increased risk of health problems throughout one’s lifespan, it is vital to reduce any potential contributors to low birth weight.  A new study by Valerie Earnshaw and her colleagues from Yale University sheds light on one possible causal factor.  Their findings, published online in Springer's journal, the Annals of Behavioral Medicine, suggest that chronic, everyday instances of discrimination against pregnant, urban women of color may play a significant role in contributing to low birth weight babies.

Twice as many black women give birth to low birth weight babies than white or Latina women in the U.S.  Reasons for this disparity are, as yet, unclear. But initial evidence suggests a link may exist between discrimination experienced while pregnant and the incidence of low birth weight.  In addition, experiences of discrimination have also been linked to depression, which causes physiological changes that can have a negative effect on a pregnancy.

Earnshaw and her colleagues interviewed 420, 14- to 21-year-old black and Latina women at 14 community health centers and hospitals in New York, during the second and third trimesters of their pregnancies, and at six and 12 months after their babies had been born.  They measured their reported experiences of discrimination.  They also measured their depressive symptoms, pregnancy distress and pregnancy symptoms.

Levels of everyday discrimination reported were generally low.  However, the impact of discrimination was the same in all the participants regardless of age, ethnicity or type of discrimination reported.  Women reporting greater levels of discrimination were more prone to depressive symptoms, and ultimately went on to have babies with lower birth weights than those reporting lower levels of discrimination.  This has implications for healthcare providers who work with pregnant teens and young women during the pre-natal period, while they have the opportunity to try and reduce the potential impacts discrimination on the pregnancy.

The authors conclude that "Given the associations between birth weight and health across the life span, it is critical to reduce discrimination directed at urban youth of color so that all children are able to begin life with greater promise for health.  In doing so, we have the possibility to eliminate disparities not only in birth weight, but in health outcomes across the lifespan."

Data for this study came from the Centering Pregnancy Plus project, funded by the National Institute of Mental Health, and conducted in collaboration with Clinical Directors’ Network and the Centering Healthcare Institute.

Spouses of people who suffer a sudden heart attack (an acute myocardial infarction) have an increased risk of depression, anxiety, or suicide after the event, even if their partner survives, according to new research published online in the European Heart Journal. They suffer more than spouses of people who die from, or survive, other conditions.

The study, which is the first to investigate this and to compare it with people whose spouse died or survived from something other than a heart attack, also found that men were more susceptible to depression and suicide after their wife's survival or death from an acute myocardial infarction (AMI), than women.

Using Danish registries, including the National Civil Status Registry that shows whether people are married or not, researchers in the USA and Denmark compared 16,506 spouses of people who died from an AMI between 1997 and 2008 with 49,518 spouses of people who died from causes unrelated to AMI. They also matched 44,566 spouses of patients who suffered a non-fatal AMI with 131,563 spouses of people admitted to hospital for a non-fatal condition unrelated to AMI. They looked at the use of antidepressants and benzodiazepines (used for treating anxiety) before and up to a year after the event, records of contact with the health system for depression, and suicide.

"We found that more than three times the number of people whose spouses died from an AMI were using antidepressants in the year after the event compared with the year before. In addition, nearly 50 times as many spouses used a benzodiazepine after the event compared to before. For people whose spouse had died from a non-AMI cause, we saw a much higher rate of medication use than for other causes and they had an approximately 50% higher likelihood of claiming a prescription for these drugs," said the first author of the study, Dr Emil Fosbøl. "Those whose spouse survived an AMI had a 17% higher use of antidepressants after the event, whereas spouses of patients surviving some other, non-AMI related condition had an unchanged use of antidepressants after the event compared to before."

Dr Fosbøl, who was a cardiology research fellow at Duke Clinical Research Institute, Duke University Medical Center, North Carolina (USA) at the time of the research, but has now returned to Denmark to work as a cardiologist in Copenhagen, continued: "Overall, the rates of depression were significantly higher after the event in the fatal AMI group and in the fatal non-AMI group. Although the rates were low, those who had lost a spouse to a fatal AMI or whose spouse survived an AMI more often committed suicide than those with spouses who died from, or survived, a non-AMI-related event. We also found that men were more likely to suffer depression and commit suicide after an event than women."

The researchers speculate that it is the sudden and unexpected nature of an AMI that causes the more extreme impact on the spouse. "If your partner dies suddenly from a heart attack, you have no time to prepare psychologically for the death, whereas if someone is ill with, for example, cancer, there is more time to grow used to the idea," said Dr Fosbøl. "The larger psychological impact of a sudden loss is similar to post-traumatic stress disorder."

Dr Fosbøl said their findings have large public health implications as more than seven million people worldwide experience an AMI a year, with around 16% of them dying from it within a month. "This could mean that around 11,000 people would be likely to start antidepressants after a spouse's non-fatal AMI, and 35,000 after their spouse died from an AMI. Moreover, although suicide rates were low, we could expect approximately 1,400 people to take their own life in the year following a spouse's death from a heart attack.

"This is a major public health issue for which there seems to be very little awareness among doctors and policy makers. I think the most important finding of this study is that the system needs to consider the care needs for spouses too, not only when a patient dies from an AMI, but also when the patient is 'just' admitted to hospital with an AMI and survives. Previously, we did not have any data on those patients' spouses where the patient survived the event."

The authors say that there appear to be no mechanisms in place currently to identify spouses at risk and to institute preventive strategies such as screening for depression and grief counselling.

"I think it would be worth conducting a study of a targeted intervention to prevent depression for the spouse," concluded Dr Fosbøl. "I believe that treatment of an acute event also should include screening the spouse for possible psychological effects and a plan should be in place for how to take care of this, if indeed the spouse is severely affected."

The suicide rate in the U.S. Army now exceeds the rate in the general population, and psychiatric admission is now the most common reason for hospitalization in the Army. These concerning trends are described by Timothy Lineberry, M.D., a Mayo Clinic psychiatrist and suicide expert for the Army, in the September edition of Mayo Clinic Proceedings.

In the article, he also outlines steps to assess and address military suicide — an issue he calls a major public health concern. Dr. Lineberry proposes greater use of gun locks, improving primary care for depression, and better monitoring for sleep disturbances, among other steps.

"Despite the anticipated end of large-scale military operations in Afghanistan and Iraq, the effects on the mental health of active-duty service members, reservists, and veterans is only just beginning to be felt," Dr. Lineberry says. "Moreover, the potential effect on service members of their war experiences may manifest indefinitely into the future in the form of emerging psychiatric illnesses."

In the article, Dr. Lineberry integrates published research on increased rates of psychiatric illness in the military during the past decade and highlights the need for ongoing resources for prevention, diagnosis and treatment. While the National Institutes of Health and the Department of Defense have already invested millions of dollars into military suicide prevention and research, some key clinical steps can also be taken to tackle the problem.

Dr. Lineberry outlines four steps based on past research and emerging evidence that he believes could help begin curbing military suicide:

• Reduce access to guns and other means of suicide. Nearly 70 percent of veterans who commit suicide use a gun to do it. Veterans are more likely to own firearms. All veterans with psychiatric illness should be asked about their access to firearms and encouraged to lock up guns, giving someone else the key, or remove them from the home altogether. Just slowing down gun access by a few minutes may be enough to stop the impulse.
• Watch for sleep disturbances. Complaints of insomnia or other sleep disturbances in otherwise healthy soldiers, reservists, or veterans may signal the need for taking a careful history and screening for depression, substance misuse and post-traumatic stress disorder. Sleep disturbances have been previously identified as a risk factor for suicide. These complaints may also serve as opportunities for referring those potentially needing more intensive treatment.
• Prescribe opioid medications carefully and monitor. Unintentional overdose deaths, primarily with opioids, now outnumber traffic fatalities in many states. Individuals with psychiatric illness are overrepresented among those receiving prescriptions for opioids and those taking overdoses. This same trend has been seen in former military personnel. A recent study found that Iraq and Afghanistan veterans with a diagnosis of post-traumatic stress disorder who were prescribed opioids were significantly more likely to have opioid-related accidents and overdoses, alcohol and non-opioid drug-related accidents and overdoses, and self-inflicted and violence-related injuries.
• Improve primary care treatment for depression. Research suggests that patients who die by suicide are more likely to have visited a primary care physician than mental health specialist in the previous month. Programs developed to improve primary care physicians' recognition and treatment of depression could help lower suicide rates.

A parasite thought to be harmless and found in many people may actually be causing subtle changes in the brain, leading to suicide attempts.

New research appearing in the August issue of The Journal of Clinical Psychiatry adds to the growing work linking an infection caused by the Toxoplasma gondii parasite to suicide attempts. Michigan State University's Lena Brundin was one of the lead researchers on the team.

About 10-20 percent of people in the United States have Toxoplasma gondii, or T. gondii, in their bodies, but in most it was thought to lie dormant, said Brundin, an associate professor of experimental psychiatry in MSU's College of Human Medicine. In fact, it appears the parasite can cause inflammation over time, which produces harmful metabolites that can damage brain cells.

"Previous research has found signs of inflammation in the brains of suicide victims and people battling depression, and there also are previous reports linking Toxoplasma gondii to suicide attempts," she said. "In our study we found that if you are positive for the parasite, you are seven times more likely to attempt suicide."

The work by Brundin and colleagues is the first to measure scores on a suicide assessment scale from people infected with the parasite, some of whom had attempted suicide.

The results found those infected with T. gondii scored significantly higher on the scale, indicative of a more severe disease and greater risk for future suicide attempts. However, Brundin stresses the majority of those infected with the parasite will not attempt suicide: "Some individuals may for some reason be more susceptible to develop symptoms," she said.

"Suicide is major health problem," said Brundin, noting the 36,909 deaths in 2009 in America, or one every 14 minutes. "It is estimated 90 percent of people who attempt suicide have a diagnosed psychiatric disorder. If we could identify those people infected with this parasite, it could help us predict who is at a higher risk."

T. gondii is a parasite found in cells that reproduces in its primary host, any member of the cat family. It is transmitted to humans primarily through ingesting water and food contaminated with the eggs of the parasite, or, since the parasite can be present in other mammals as well, through consuming undercooked raw meat or food.

Brundin has been looking at the link between depression and inflammation in the brain for a decade, beginning with work she did on Parkinson's disease. Typically, a class of antidepressants called selective serotonin re-uptake inhibitors, or SSRIs, have been the preferred treatment for depression. SSRIs are believed to increase the level of a neurotransmitter called serotonin but are effective in only about half of depressed patients.

Brundin's research indicates a reduction in the brain's serotonin might be a symptom rather than the root cause of depression. Inflammation, possibly from an infection or a parasite, likely causes changes in the brain's chemistry, leading to depression and, in some cases, thoughts of suicide, she said.

"I think it's very positive that we are finding biological changes in suicidal patients," she said. "It means we can develop new treatments to prevent suicides, and patients can feel hope that maybe we can help them.

"It's a great opportunity to develop new treatments tailored at specific biological mechanisms."

Brundin and co-senior investigator Teodor Postolache of the University of Maryland led the research team. Funding for the project came from several sources, most notably the Swedish Research Council and American Foundation for Suicide Prevention.

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Journal Reference:

1. Yuanfen Zhang, Lil Träskman-Bendz, Shorena Janelidze, Patricia Langenberg, Ahmed Saleh, Niel Constantine, Olaoluwa Okusaga, Cecilie Bay-Richter, Lena Brundin, Teodor T. Postolache. Toxoplasma gondiiImmunoglobulin G Antibodies and Nonfatal Suicidal Self-Directed Violence. The Journal of Clinical Psychiatry, 2012; DOI: 10.4088/JCP.11m07532

Major depression affects as many as 16% of reproductive-aged women in the U.S. Yet pregnant women have a higher rate of undiagnosed depression than nonpregnant women, according to a study published in Journal of Women's Health, a peer-reviewed publication from Mary Ann Liebert, Inc., publishers.

Jean Ko, PhD and coauthors from the Centers for Disease Control and Prevention (CDC), Atlanta, GA, found that more than 1 in 10 women ages 18-44 years had a major depressive event during the previous year — representing about 1.2 million U.S. women — but more than half of those women did not receive a diagnosis of depression and nearly half did not receive any mental health treatment. The article "Depression and Treatment among U.S. Pregnant and Nonpregnant Women of Reproductive Age, 2005-2009," further reports that disparities in receiving a diagnosis and treatment were associated with younger age, belonging to a racial/ethnic minority, and insurance status.

The accompanying Editorial entitled "Depression: Is Pregnancy Protective?" by Jennifer Payne, MD, Johns Hopkins School of Medicine, Baltimore, MD, explores the ongoing challenges in the adequate diagnosis and treatment of major depression, the additional factors that come into play during pregnancy, and the implications of the Ko et al. study results.

"As health care providers, we simply must do a better job at diagnosing depression and referring women for mental health treatment. Reproductive health care visits provide an opportune time to address this ," says Susan G. Kornstein, MD, Editor-in-Chief of Journal of Women's Health, Executive Director of the Virginia Commonwealth University Institute for Women's Health, Richmond, VA, and President of the Academy of Women's Health.