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Women and Infants Mental Health Program

Depression, Anxiety, and Trauma

Depression, anxiety, and other mood fluctuations are commonly experienced by women during significant life changes such as puberty, pregnancy, and menopause. These fluctuations during pregnancy and postpartum can be especially challenging. The perinatal period is a particularly unique time given the changes in hormones, sleep patterns, role transitions, financial and social strains, and increased stress often experienced by women.

Additionally, stress and anxiety can seriously impact how women experience pregnancy, childbirth, and parenting, especially those who have survived child abuse or neglect, sexual assault, violent crime or other traumatic events.  For many women, a history of trauma affects trust in others and in themselves which may impact feelings about the transition into parenthood. 

The WIMH Program emphasizes the importance of trauma-informed approaches to health care. TheProgram is interested in learning more about experiences of these women and researching mood complications during pregnancy and postpartum to better understand the needs, challenges, and outcomes of women, fathers, and infants.

Research Activity:

Interventions, Treatments, and Complimentary Alternative Medicine

Mindfulness Yoga during Pregnancy

Women's mental health during pregnancy has important implications for both mother and baby, but few women receive treatment. The Mindfulness Yoga during Pregnancy (MY Pregnancy) study will examine how a supportive intervention is helpful to pregnant women with a history of depression or anxiety who may be reluctant to participate in traditional mental health treatment, such as psychotherapy or antidepressants.  MY Pregnancy is a 10-session yoga group designed to increase mindful, non-judgment and acceptance of feelings and strengthen the infant-maternal bond while decreasing feelings of isolation, depression and anxiety, particularly related to pregnancy, labor, delivery and transition to motherhood.

The current project has added a control group to the design.  Half the participants will attend the mindfulness yoga class and half will receive a free mindfulness yoga DVD for home practice. 

Findings:
Participants in the 10 week mindfulness yoga intervention were significantly less depressed, and showed significant improvement in mother-baby attachment and mindfulness skills. 

Investigators:
Maria Muzik (PI), Marlene McGrath and Barbara Brooken-Harvey

Mothers, Omega-3 and Mental Health Study (MOMS)

The MOM study is a double blind, placebo-controlled, randomized trial to assess whether omega-3 fatty acid supplementation may prevent depressive symptoms during pregnancy and the postpartum period among pregnant women at risk for depression.  Pregnant women were recruited prior to 20 weeks gestation from prenatal clinics at the University of Michigan Health System & IHA/St. Joseph Mercy Hospital and followed over the course of their pregnancy and up to 6 weeks postpartum.  Enrolled participants will be randomized to one of three groups: 1) EPA-rich fish oil supplement  2) DHA-rich fish oil supplement or 3) a placebo.  Information on changes in depressive symptomatology, omega-3 fatty acid concentrations in maternal plasma, proinflammatory cytokine levels (IL-1β, IL-6, and TNF-α), and antidepressant medication treatment will be gathered at up to 3 time points during pregnancy and at 6 weeks postpartum.

Investigators:
Ellen Mozurkewich (PI), Delia Vazquez, Sheila Marcus, Anjel Vahratian, Zora Djuric, Deborah Berman and Julie Chilimigras

Enhancing Care and Health Outcomes (ECHO): Improving Psychosocial Treatment for Perinatal Depression

The ECHO project aimed to develop a modified depression intervention to reflect the unique issues faced by women during the perinatal period. Specifically, Cognitive Behavioral Therapy (CBT) was adapted based on participant responses. The project was implemented in three phases: 1) determine barriers to participation in treatment through qualitative interviews 2) adjust and further develop CBT based on information learned, and 3) test and refine the adapted intervention through a pilot study.

Findings:
Twenty-three participants, varying in socioeconomic, depression, and pregnancy status were interviewed about their experience with clinician (including nurses, midwives, obstetricians, and social workers) interaction style and which they style was most helpful and favored. Themes that emerged showed women prefer an interaction that conveys:

  • Feeling heard, the clinician effectively listening with a nonjudgmental attitude, and encouraging client control
  • A trusting relationship that is based on genuineness, warmth, and optimism
  • Competence, knowledge, and expertise of clinician
  • The communication of a treatment options that align with patient needs
  • Negative thoughts stemming from unmet high expectations of self as a mother, worry, and negativity about parenting efficacy.
  • Behavioral impacts of limited activity and isolation
  • Interpersonal conflict causing emotional distress
  • Phase three tested the efficacy of the modified CBT (mCBT) in a randomized control trial.  The study aim was for the mCBT group of 30 women to show increased treatment adherence and decreased depression symptoms compared to the control group of 25 women who received treatment as usual. Results indicate:
  • The mCBT group had good adherence rates where 63% of women attended at least 4 treatment sessions and 43% attended at least 7 sessions.
  • Women who received mCBT had a greater reduction in depression scores than women in the control group at 16 weeks after the study start.
  • Women found they could practically apply skills learned in mCBT and reported high levels of satisfaction with treatment received.

Investigators:
Heather Flynn (PI) and Joseph Himle

Publications:
Henshaw, E., Flynn, H., Himle, J., O’Mahen, H., Forman, J., Fedock G. (2011). Patient Preferences for Clinician Interactional Style in Treatment of Perinatal Depression.
Qualitative Health Research, XX(X) 1– 16.

Henshaw, E., Flynn, H., Himle, J., O’Mahen, H., Forman, J., Fedock G. (2012). Modifying CBT for Perinatal Depression: What Do Women Want? A Qualitative Study. Cognitive and Behavioral Practice, 19, 359-371.

Connecting Women with Care

There is evidence that depression in women of childbearing age is often undetected and untreated. This study investigated whether an intervention added to routine health care provider and patient interaction will improve the likelihood of perinatal patients seeking and following through with mental health treatment.  Studying these kinds of interventions is important since most women at-risk for depression do not receive proper care, and receiving adequate care can significantly improve the lives of women and their children. This studied compared 2 groups; a control group and an intervention group. The control group completed a depression screening instrument and diagnostic interview if significant symptoms are reported. Health care providers and patients will be notified of their depression status and current protocol of standard prenatal care will continue. For the intervention group, if significant depression symptoms are found after screening:  feedback and treatment and/or referral to a specialty clinic will be initiated by the nurse practitioner in the clinic. In addition those with positive screens will participate in the diagnostic interview with the research assistant. Two additional follow-up interview will be conducted with the patient by the research assistant.

Findings:
The majority (65%) of pregnant women with current major depressive disorder (MDD) were not receiving any depression treatment throughout the study period. Overall, women with high depression scores on a depression screenings (EDPS; scores >= 10) who reported that their physician discussed depression with them (67%) were significantly more likely to seek treatment (compared with those who did not report physician discussion of depression with them) by the 1 month prenatal follow-up but not by the 6 weeks postpartum follow-up. Initial depression severity and treatment use prior to screening were the strongest predictors of subsequent depression treatment use. Depression screening combined with systematic clinician follow-up showed a modest short-term impact on depression treatment use for perinatal depression but did not affect depression outcomes. Most women with MDD were not engaged in treatment throughout the follow-up period despite the interventions. More intensive and repeated monitoring might enhance the effect of clinician interventions to improve treatment use.

Investigators:
Heather Flynn (PI) and Sheila Marcus

Publication:
Flynn, H., O'Mahen, H., Massey, L., Marcus, S. (2006). The Impact of a Brief Obstetrics Clinic-Based Intervention on Treatment Use for Perinatal Depression. Journal of Women's Health, 15(10), 1195-1204.

Infant Outcomes and Depression Treatment in Pregnancy

The aims of this project are to determine whether clinical stability following depression treatment in pregnant women normalizes neuroendocrine function, as well as infant neuroendocrine status, birth outcomes, and state regulation through 7 months of age. Following screening in obstetrics clinics, pregnant women diagnosed with Major Depressive Disorder or high risk for depression will receive a course of Interpersonal Therapy (IPT) with or without treatment with an SSRI, beginning at 28 gestational weeks and continuing through 7 months. Maternal outcome variables include symptom severity, psychosocial variables, neuroendocrine measures, and pregnancy characteristics. Infant outcome variables include birth outcomes (weight, gestational age, APGAR scores), neonatal neurologic assessments, cord blood and salivary neuroendocrine measures, state regulation variables (feeding, sleep, crying) and developmental measures through 7 months of age.

Investigators:
Sheila Marcus (PI), Heather Flynn, Kate Rosenblum, and Delia Vazquez.

Selected Publications:
Muzik, M., Hamilton, S. E., Rosenblum, K. L., Waxler, E., & Hadi, Z. (2012). Mindfulness yoga during pregnancy for psychiatrically at-risk women: Preliminary results from a pilot feasibility study. Complementary Therapies in Clinical Practice (in press). 

Muzik, M., & Hamilton, S. (2012). Psychiatric illness during pregnancy: early detection, individualized care can promote health for mother and infant. Current Psychiatry, 11(2), 23.  

Sexton, M., Flynn, H., Lancaster, C., Marcus, S., McDonough, S., Volling, B.,  Lopez, J., Kaciroti, N., Vazquez, D. (2012) Predictors of Recovery from Prenatal Depressive Symptoms from Pregnancy Through Postpartum.  J Women's Health, 21(1),  43-49.

Flynn, H. (2011). Setting the Stage for the Integration of Motivational Interviewing With Cognitive Behavioral Therapy in the Treatment of Depression. Cognitive and Behavioral Practice, 18, 46–54.

Mozurkewich, E., Chilimigras, J., Klemens, C., Keeton, K., Allbaugh, L., Hamilton, S., Berman, D., Vazquez, D., Marcus, S., Djuric, Z., & Vahratian, A. (2011). The mothers, Omega-3 and mental health study. BMC Pregnancy & Childbirth, 11, 46-46.

Lancaster, C., Flynn, H. Johnson, T., Marcus, S., Davis, M. (2010). Peripartum Length of Stay for Women with Depressive Symptoms during Pregnancy. Journal of Women's Health, 19(1), 31-37.

O’Mahen, H., Flynn, H., Nolen-Hoeksema, S. (2010). Rumination and Interpersonal Functioning In Perinatal Depression. Journal of Social and Clinical Psychology, 29(6), 646-667.

Muzik, M., Marcus, S., Heringhausen, J. E., & Flynn, H. (2009). When Depression Complicates Childbearing: Guidelines for Screening and Treatment During Antenatal and Postpartum Obstetric Care. Obstetrics and Gynecology Clinics of North America, 36(4), 771-788.

Marcus, S., Flynn, H. (2008). Depression, antidepressant medication, and functioning outcomes among pregnant women. International Journal of Gynecology and Obstetrics, 100, 248–251.