Journal Article Annotations
2016, 1st Quarter
Annotations by Priyanka Amin, MD and Kristen Eckstrand, MD, PhD
The finding: Women are no more likely to have post-traumatic stress symptoms (PTSS) or be at increased risk of post-traumatic stress disorder (PTSD) if they had an abortion, either close to the legal gestational limit or in the first trimester, versus those that were slightly over the legal limit and unable to have an abortion. This was found at baseline up through and including four years after. PTSS and risk of PTSD decreased in all groups over the course of the four years with no significant difference in the trajectory of the decline. Notably, only 19% of women identified the stressful event causing their symptoms to be the pregnancy, with a minority identifying the abortion experience. More common identified triggers were sexual assault and relationship problems. Correlates with baseline and continued PTSS are being African American or Hispanic/Latina versus being Caucasian, or having a self-reported history of depression and/or anxiety. However, these women had increased PTSS across subgroups.
Strength and weaknesses: This study’s largest strength is that the data are drawn from the landmark Turnaway Study, a five-year prospective cohort of women from 21 states in the US. This is the first study using appropriate comparison groups to study women seeking abortions’ outcomes of having undesired pregnancies and either having or not having a desired abortion. There was a high retention rate in the study with 65% still participating at 4 years. Furthermore, women were able to describe what the trauma(s) producing PTSS was(were) instead of choosing from a list.
Weaknesses include assessment of PTSS and PTSD risk with the Primary Care PTSD Screen (PC-PTSD), a four-question screen unable to make a diagnosis of PTSD. Also, patients were asked to self-report if they had depression or anxiety, and other mental health conditions were not asked about. The study also excluded women who were seeking an abortion due to fetal anomaly, fetal demise, or maternal health issue. The characteristics of PTSS due to the pregnancy and abortion may be different in these groups, as these pregnancies may have been desired. While retention was good, there was a low participation rate for enrolling in the study (37.5%), so there may be a significant difference in the characteristics of women not participating.
Relevance: This publication from data from the Turnaway Study shows that women do not experience more PTSS or are at increased risk of PTSD because they had an abortion. Furthermore, a history of depression or anxiety does not correlate to having more PTSS or PTSD risk due to the abortion. This study helps break down the myth that abortion causes PTSD.
The finding: While previous studies have examined the neural response of women with postpartum depressions (PPD) to negative stimuli, this is the first study to examine their response to positive stimuli. In a sample of women with (n=28) and without (n=17) PPD viewing images of infants during an fMRI task, all women demonstrated greater activation in the amygdala, a region active in determining environmental relevance (e.g., threat, novelty), in response to seeing their own (positive stimulus) infants compared with unfamiliar infants. Women with PPD demonstrated a greater AMY response to viewing unfamiliar infants compared to women without PPD; however, there were no differences in AMY response between women with and without PPD when viewing their own compared with unfamiliar infants. Women with PPD exhibited decreased connectivity between the bilateral AMY and right insular cortex (IC), a functionally diverse brain region important for interceptive and emotional awareness. AMY-IC connectivity was negatively correlated with both anxiety and depressive symptoms, where decreased connectivity—as was observed in women with PPD—was associated with greater depression and anxiety.
Strengths: Notable strengths of this study include the sample, design and analysis of fMRI task, and the relationship of neuroimaging markers to clinically relevant measures. Women participating in this study were matched for age; maternal characteristics including parity, breast-feeding, and delivery method; and education. Women participated 2-5 months postpartum, an appropriate interval given the time limitations of PPD. The fMRI task itself utilized self-relevant positive stimuli in the form of individual mother’s own children, a design that is more likely to elicit a realistic emotional response reflective of the maternal-infant relationship. Further, the study not only examined neural response in the AMY, it examined the AMY connections to elucidate brain circuits that may be affected in PPD. Finally, the relationship of AMY activity and connectivity in response to positive stimuli was correlated with clinically relevant symptoms of depression and anxiety.
Weaknesses: Despite the above strengths, there are several weaknesses to the presented study. First, women recruited into the PPD group were selected based on meeting criteria for DSM-IV major depressive episode with peripartum onset; however, the average Edinburgh Postnatal Depression Scale (EPDS) scores of this group were below the cutoff for PPD. If the premise of the study is truly that PDD may be etiologically different from major depression disorder (MDD), the authors could have stratified groups based on EPDS score rather than major depressive criteria. Secondly, 13 of the women with PPD were taking selective serotonin reuptake inhibitors (SSRIs). While authors did not see a difference in depressive or anxiety symptoms, or AMY activation, based on SSRI usage, they did not report whether AMY-IC connectivity varied with SSRI use; as AMY-IC connectivity was associated with clinical depression and anxiety, interpretation of these results may be affected by SSRI usage. Finally, as the authors mention in their discussion, it will be important to link these neuroimaging findings not just to self-reported depressive and anxiety symptoms, but also to how neural markers are associated with mothering behaviors that may impact offspring development.
Relevance: This study is the first to examine the neural response of women with PPD when viewing positive stimuli. The results presented here suggest that the neural signatures to positive reward may be different between MDD and PDD. The differential brain response in emotionally relevant, interoceptive circuits in women with PDD may be important in understanding how the emotional, cognitive, and behavioral responses in PDD may interfere with mothering and offspring development.