Tidigare forskning visar att det finns ett samband mellan depressionssymtom och svårigheter i partnerrelationer. Forskning visar att deltagare efter parterapi har en ökad grad av relationsnöjdhet och en lägre grad av depressionssymtom. Uppsatsen genomfördes inom DANA-projektet (IKBT vid antenatal depression) och syftet var att analysera hur relationsnöjdhet hänger ihop med behandlingsutfall, följsamhet i behandling samt vilja att arbeta med relationer i behandling. Syftet var även att analysera vilka sociodemografiska och kliniska faktorer hos gravida med depression som har ett samband med relationsnöjdhet. I resultatet framkom inget signifikant samband mellan relationsnöjdhet och behandlingsutfall, följsamhet eller val att arbeta med relationer i behandlingen. I resultatet framkom ett signifikant samband mellan högre relationsnöjdhet och högre ekonomi, högre relationsnöjdhet och högre graviditetsönskan, samt högre relationsnöjdhet och lägre grad av depressionssymtom. För att kunna dra säkrare slutsatser över hur relationsnöjdhet och större fokus på relationer påverkar behandlingsutfall vid depressionsbehandling, behövs fortsatt forskning. Fortsatt forskning behövs även för att undersöka bakomliggande faktorer och hur dessa påverkar paret och deras mående. / Previous research shows a connection between symptoms of depression and difficulties in partner-relations. It also shows that the participants relationship satisfaction increased after couples-therapy and that their symptoms of depression decreased. This thesis was conducted in the DANA-project (ICBT during antenatal depression) and the intention was to examine the effect of relationship satisfaction on treatment outcome, adherence, and motivation to work with relationships in treatment. The intention was also to analyze the connection between relationship satisfaction and sociodemographic and clinical factors during pregnancy. The result presented no significant connection between relationship satisfaction and treatment outcome, adherence, or motivation to work with relationships in treatment. Furthermore, the result presented a significant connection between higher relationship satisfaction and higher economic status, higher relationship satisfaction and higher pregnancy desire and higher relationship satisfaction and lower symptoms of depression. Further research is needed to examine how more focus on relations in treatment and relationship satisfaction effects treatment outcome. Further research is also needed to examine underlying factors and how these effect the couple and their well-being.

<b>Introduction</b>: 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 <b>Methods</b> 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). <b>Results</b> 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 <b>Conclusion</b>: 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.

During pregnancy, 4 - 7% of women suffer from major depressive disorder. When antidepressive treatment is needed, selective serotonin reuptake inhibitors (SSRIs) are the most commonly used. Although severe complications from SSRI treatment are rare, association with a number of adverse pregnancy and fetal outcomes has been found. Also, antenatal depression per se has been shown to affect pregnancy outcomes. The overall aim of this thesis was to examine the effects of SSRIs on human placenta and embryo. In the first study, gene expression was investigated in placenta from depressed, SSRI-treated and healthy pregnant women, using microarray analysis. Antenatal depression and SSRI treatment induced alterations in gene expression, but only 20 genes in common were noted. Validation with qRT-PCR showed that six out of seven selected genes were altered in SSRI-treated women compared with controls, and two genes were altered between depressed women and controls. In study two, the protein levels in placenta from depressed, SSRI-treated and healthy pregnant women were investigated, focusing on the NGF signaling pathway. NGF, phosphorylated Raf-1, ROCK2 and phosphorylated ROCK2, were altered in both SSRI-treated and depressed women, although the proteins were regulated differently in the two groups. In the third study, human embryos were treated with fluoxetine. Embryo development and protein expression were studied. Fluoxetine had some effect on the timing of embryo developmental stages. Also, several proteins were uniquely found in fluoxetine-treated embryos compared with untreated embryos. Fluoxetine also altered the levels of proteins secreted from the embryo. In the fourth study, the human neuroblastoma cell line SH-SY5Y/TrkA was treated with TPA and NGF. The activation of Raf-1 was investigated and the involvement of Ras and PKC was studied. Both NGF and TPA activated Raf-1, but to a different extent and via different pathways. The NGF-induced activation of Raf-1 was mediated via Ras, while TPA induced signaling via PKC. In conclusion, SSRI treatment and antenatal depression influence placental gene and protein expression. These findings may affect placental development and function, which in turn could affect fetal development. Also, direct exposure of embryos to fluoxetine has some effects on embryo development and protein expression, which may affect the development of the fetus.

Made available in DSpace on 2016-03-22T17:26:38Z (GMT). No. of bitstreams: 1 Tese F_bio Coelho.pdf: 893978 bytes, checksum: 2b754c3c09e0ebf28b38d7a14eb830f0 (MD5) Previous issue date: 2012-01-16 / Objective: To describe the prevalence of major depressive disorder (MDD) during pregnancy in teenager mothers, and assess its association with sociodemographic characteristics, obstetric history and psychosocial variables. Methods: A cross-sectional study with a sample of pregnant teenagers enrolled in the national public health system in the urban area of Pelotas, southern Brazil. Sample size was estimated in 871 participants. MDD was assessed with the Mini International Neuropsychiatric Interview; the Abuse Assessment Screen was used to identify physical abuse within the last 12 months and during pregnancy; social support was assessed with the Medical Outcomes Survey Social Support Scale. Results: Forty three (4.94%) refused to participate, resulting in 828 participants. Prevalence of MDD was 17.8%; violence within the last 12 months was reported by 9.2%, while 5.8% had suffering violence during pregnancy; mean (SD) overall social support score was 87.40 (±11.75). After adjustment, we found the highest prevalence ratios of MDD in adolescents with less than 8 years of education, followed by those with previous episodes of MDD and in those with lower overall social support. Conclusion: MDD is a relatively common condition in pregnant teenagers and seems to be more frequent in a group of young mothers who were both socioeconomic and psychosocially underprivileged / Objetivo: Descrever a prevalência de transtorno depressivo maior (TDM) durante a gestação em adolescentes e verificar sua associação com características sócio-demográficas obstétricas e psicossociais. Método: Estudo transversal com uma amostra de gestantes adolescentes que recebem acompanhamento pré-natal pelo sistema único de saúde na zona urbana da cidade de Pelotas, RS. O tamanho estimado da amostra foi de 871 participantes. TDM foi avaliado com o Mini International Neuropsychiatric Interview; o Abuse Assessment Screen foi utilizado para identificar abuso físico no ultimo ano e durante a atual gestação; o suporte social foi mensurado com o Medical Outcomes Survey Social Support Scale. Resultados: Quarenta e três (4.94%) recusaram-se a participar, resultando em 828 participantes. A prevalência de TDM foi de 17.8%; violência nos últimos 12 meses foi identificada em 9.2%, enquanto 5.8% sofreram violência durante a gestação; a média (DP) geral na escala de suporte social foi de 87.40 (±11.75). Após ajuste, maiores razões de prevalência de TDM foram encontradas em adolescentes com menos de 8 anos de estudo, seguidas por aquelas com episódios anteriores de depressão e por aquelas com menor suporte social. Conclusão: TDM é uma condição comum in gestantes adolescentes, sendo mais frequente em um grupo de mães desprivilegiadas do ponto de vista sócio-econômico e psicossocial

The aim of this study is to give an in-depth understanding of the representations of a depressed woman who killed her baby. The representations under study is based on “The motherhood constellation” by Stern (1995) and focus on the woman’s representation of her mother as mother-of-herself-as-child, herself-as-mother and her representations of her children. Pregnancy is an important phase in a woman’s life. Parent-infant psychotherapies are a rapidly growing field of infant mental health as many psychological problems have their roots in infancy. Neglect, trauma and abuse and prolonged maternal depression can cause a child to develop a range of problems. The work of Winnicott (1965a) and Bion (1988) put the mother’s fantasy life about her infant as one of the major building blocks of the infant’s construction of a sense of identity (Stern, 1995). Fraiberg (Fraiberg, Adelson&Shapiro, 1980) with her “ghosts in the nursery” revolutionised this perception by placing the maternal representation at the core of the parent-infant clinical situation (Stern, 1995). The way the research developed and the nature of the research problem necessitated a pure qualitative mode of enquiry. A single case study was done about the representations (of self-as-mother, mother-as –mother–of–self-as-child- and of the children) in an extreme case where the mother’s depression led to her murdering her baby. Data collection was done through semi-structured interviews and documents from the psychiatric hospitals she attended. Data was also obtained from field notes, before and after the interviews and also while transcribing the audio-taped interviews. Data analysis was done by the procedures of data reduction and organising it into categories on the basis of themes as described by Neuman (2000). Coding and analytic memo writing were done. The relationships between concepts were examined and linked to each other and interweaved into theoretical statements. The researcher argues that not enough is done to enhance the relationship between a mother and her foetus, and later her baby. The concept of maternal representations is the only approach that opens the possibility to start working at the earliest point of prevention, because intervention can start during pregnancy. Intervention during pregnancy is ideal because defence mechanisms are less rigid during pregnancy and women are more in touch with their entire life cycle and the whole system is more open for change. The ghosts can be chased out of the nursery by helping the mother to see the repetition of the past in the present. The affective link, recognising and remembering the feelings help a parent not to repeat the past in the present - “…it is the parent who cannot remember his childhood feelings of pain and anxiety who will need to inflict his pain upon his child” (Fraiberg, Adelson&Shapiro, 1980, p. 182). / Thesis (PhD (Psychotherapy))--University of Pretoria, 2006. / Psychology / unrestricted

Depression drabbar 10–20% av gravida kvinnor och kan leda till konsekvenser för bådebarnet, modern och samhället. IKBT för depression är en effektiv behandling, däremot har patientersom genomgått IKBT uttryckt behov av ytterligare stöd. Syftet med studien var att undersökaupplevelser av att erhålla extrastödsamtal under IKBT inom DANA-studien. Genom en kvalitativansats genomfördes intervjuer med nio deltagare med depression under graviditeten. Tematisk analysanvändes vilket resulterade i två huvudteman; Individanpassning efter behov och Integrering avbehandling. Resultatet visade att extrastödet utgjorde en möjlighet till flexibel individanpassningsamt ett stöd utifrån att IKBT upplevdes som en krävande behandling. Kommunikation upplevdessom avgörande för helhetsupplevelsen av behandlingen och extrastöd utgjorde en möjlighet till flerperspektiv utifrån tillgång till olika yrkeskompetenser. Resultatet ger en ökad förståelse avupplevelsen av extrastödet och dess funktion, samt vad deltagarna upplever som viktigt för att kunnagenomföra behandlingen. / Depression affects 10-20% of pregnant women and can cause consequences for the child,mother, and society. ICBT for depression is an effective treatment, however, patients that haveundergone ICBT have expressed a need for additional support. The purpose of this study was toexamine experiences of receiving extra-counseling during ICBT within the DANA-study. Through aqualitative approach, interviews were conducted with nine participants with depression duringpregnancy. Thematic analysis was used and resulted in two main themes: Adaptation to individualneeds and Integration of treatment. The result shows that extra-counseling provided an opportunityto adapt the treatment to specific needs, while functioning as a support to the ICBT which wasexperienced demanding. Communication was crucial to the overall experience, and extra-counselingwas a possibility to gain perspective from different professions. This provides increasedunderstanding of experiences of extra-counseling, its function, and what is experienced as importantto accomplish the treatment.

Abstract Early risk factors of the antenatal period and infancy have been increasingly linked to psychiatric disorders. The aim of this thesis was to study the associations between very early parental separation and maternal depressed mood in pregnancy on the other hand, and schizophrenia and criminality in the offspring in adolescence and adulthood, on the other, in two data sets. In the Christmas Seal Home Children Study the index cohort consisted of 3 020 subjects born in Finland in 1945–65 who were temporarily isolated from their family immediately after birth to nursing homes, the Christmas Seal Homes, due to tuberculosis in the family. The average separation time was seven months. For every index subject, two reference subjects were matched for sex, year of birth and place of birth. Data were obtained on schizophrenia from the Finnish Hospital Discharge Register (FHDR) in 1971–98 and on criminal offences from Statistics Finland in 1977–98. The 28-year cumulative incidence of schizophrenia was 1.6% both in the index cohort and in the reference cohort (RR 1.0; 95% CI 0.8–1.4). Both male and female index subjects had committed crimes more commonly than the reference subjects (in men RR 1.3; 95% CI 1.2–1.4; in women RR 1.5; 1.2–2.0). Of the male index subjects 12.1% as compared with only 7.1% of the reference cohort had committed violent offences (RR 1.7; 1.4–2.1). In the Northern Finland 1966 Birth Cohort mothers of 12 058 babies were asked at mid-gestation at the antenatal clinic if they felt depressed. This general population birth cohort of the children was followed up for 31 years being record-linked with the FHDR covering the years 1982–97 and with the criminal register of the Ministry of Justice up to 1998. We divided the schizophrenia patients into those having a psychotic first-degree relative (schizophrenia patients with familial risk for psychosis FR) and those without one. The cumulative incidence of hospital-treated schizophrenia was 1.3% among the offspring of depressed mothers and 0.9% among the descendants of non-depressed mothers (RR 1.5; 95% CI 0.9–2.4). The prevalence of antenatal depression was 35% in mothers of schizophrenia patients with FR. The respective prevalence was 14% both in the mothers of schizophrenia patients without FR and in the mothers of other cohort members. Both male and female offspring of antenatally depressed mothers were more commonly criminal offenders than offspring of non-depressed mothers (in men adjusted OR 1.5; 95% CI 1.2–1.9; in women OR 1.5; 0.8–3.0). In males, 6.5% with depressed mothers and 3.2% with non-depressed mothers had committed violent offences (adjusted OR 1.6; 1.1–2.4). Very early separation and mothers' depressed mood in pregnancy are per se unlikely to increase the risk for schizophrenia in the offspring, but seem to be connected to criminal behaviour, especially violent criminality in men. / Tiivistelmä Raskaus- ja imeväisajan varhaiset tekijät on lisääntyvästi yhdistetty lapsen tuleviin mielenterveyshäiriöihin. Tarkoituksena oli tutkia hyvin varhaisen eron (separaation) ja äidin raskaudenaikaisen masentuneen mielialan yhteyttä lasten skitsofreniaan ja rikollisuuteen nuoruudessa ja aikuisuudessa kahdessa eri aineistossa. Joulumerkkikoti-lasten tutkimuksessa indeksikohortti koostui 1945–65 syntyneistä 3 020 tutkittavasta, jotka erotettiin väliaikaisesti perheistään heti syntymän jälkeen hoitokoteihin, Joulumerkkikoteihin, perheen tuberkuloosin takia. Ero vanhemmista kesti keskimäärin seitsemän kuukautta. Jokaiselle indeksitutkittavalle valittiin kaksi sukupuolen, syntymävuoden ja -paikan mukaan kaltaistettua verrokkitutkittavaa. Tieto skitsofreniaan sairastumisesta hankittiin sairaaloiden poistoilmoitusrekisteristä vv. 1971–98 ja rikoksista Tilastokeskuksesta 1977–98. 28 vuoden kumulatiivinen sairastuvuus skitsofreniaan oli 1,6 % sekä indeksi- että verrokkikohortilla (riskisuhde RR 1.0; 95 %:n luottamusväli CI 0,8–1,4). Sekä miehistä että naisista indeksitutkittavat olivat tehneet useammin rikoksia kuin vertailuryhmä (miehillä RR 1,3; 1,2–1,4; naisilla RR 1,5; 1,2–2,0). Miehistä 12,1 % indeksitutkittavista ja vain 7,1 % vertailuryhmästä oli tehnyt väkivaltarikoksen (RR 1,7; 1,4–2,1). Pohjois-Suomen 1966 syntymäkohortin 12 058 lapsen äideiltä kysyttiin keskiraskauden aikana äitiysneuvolassa, kokivatko he mielialansa masentuneeksi. Tämän väestötason syntymäkohortin (siis lasten) tietoja hankittiin 31-vuotisseurannassa sairaaloiden poistoilmoitusrekisteristä vuosilta 1982–97 ja oikeusministeriön rikosrekisteristä vuoteen 1998. Skitsofreniaan sairastuneet jaettiin niihin, joiden 1. asteen sukulainen oli ollut / ei ollut ollut psykoottinen. Sairaalahoitoa vaatineen skitsofrenian kumulatiivinen sairastuvuus oli 1,3 % masentuneiden ja 0,9 % masentumattomien äitien lapsilla (RR 1,5; 0,9–2,4). Raskaudenaikaisen masentuneen mielialan esiintyvyys oli 35 % niiden skitsofreniapotilaiden äideillä, joilla oli ollut lähisuvussa psykoosia. Vastaavasti masentunutta mielialaa esiintyi 14 %:lla sekä niiden skitsofrenia-potilaiden äideistä, joilla ei ollut sukurasitusta, että muiden kohorttitutkittavien äideistä. Sekä masentuneiden äitien pojista että tyttäristä useampi oli tehnyt rikoksen kuin masentumattomien äitien lapset (miehillä vakioitu vedonlyöntisuhde OR 1,5; 1,2–1,9; naisilla OR 1,5; 0,8–3,0). Masentuneiden äitien pojista 6,5 % ja masentumattomien äitien pojista 3,2 % oli tehnyt väkivaltarikoksen (vakioitu OR 1,6; 1,1–2,4). Hyvin varhainen ero ja äidin masentunut mieliala raskauden aikana eivät todennäköisesti sinänsä lisää skitsofrenian vaaraa lapsilla, mutta näyttävät olevan yhteydessä lasten rikolliseen käyttäytymiseen, erityisesti väkivaltarikoksiin miehillä.

Background: Antenatal Psychosocial Assessment (APA) has recently been introduced into routine antenatal care, but the ways in which maternity service providers assess and respond to maternal stress are subject of debate. There is a lack of consensus on the instrument(s) of choice and lack of evidence regarding appropriate interventions. Further, national guidelines have not kept apace with the conceptual shift from ‘postnatal depression’ to ‘perinatal anxiety and depression’. Adopting the Medical Research Council Complex Interventions Framework, the ARMS research aimed to inform the development of interventions that support women who are experiencing, or at risk of, mild-moderate mental health disorder in pregnancy. Methods: A mixed methods approach was adopted. In the quantitative element (Study Part 1) participants (n=191) completed a questionnaire when attending for their first formal antenatal appointment, using a procedure and materials that had been previously tested in a pilot study. Details including mental health assessment and referrals were obtained from their health records, following delivery. In the qualitative element (Study Part 2) a sub-sample of women (n=22) experiencing high levels of maternal stress took part in up to three serial in-depth interviews during pregnancy and the early postnatal period.Findings: Maternal stress was found to be common. Using the Edinburgh Postnatal Depression Scale (EPDS) threshold of ≥10, approximately 1 in 4 women were classed as high depression (halving to 1 in 8 at the more conservative threshold of ≥13). Almost 1 in 3 women were classed as high anxiety, using the state scale of the State-Trait Anxiety Inventory (STAI-S, threshold ≥41), compared with 1 in 5 using the two-item GAD (threshold ≥3). Fewer than half of the women identified as high anxiety were identified by both measures. Factor analyses of the symptom measures were consistent with wider literature suggesting a three-item anxiety component of the EPDS; however, concurrent validation using regression analyses did not indicate that the EPDS could be used as an anxiety case finding instrument. Women reported that maternal stress had significant impact on their lives that may not be captured with existing clinical approaches. Women commonly found it difficult to self-assess severity of maternal stress and the assessment process could itself act as an intervention. The research provided the first validation of the depression case finding questions in UK clinical practice. The Whooley items completed in clinical practice identified only half of the possible cases identified by the EPDS, at both commonly adopted EPDS thresholds. Inclusion of the Arroll 'help' question as a criterion improved specificity of the assessment completed in clinical practice but substantially compromised sensitivity, missing 9 in 10 possible cases. Women’s mental health history and treatment history were similarly under-reported, particularly concerning anxiety. APA was introduced into routine clinical practice without attention to topics of relevance to women, context of disclosure or to provision of adequate resources for consistently responding to identified need. Women experiencing, or at risk of, mild-moderate disorder were thus usually ineligible for further support. Implications: Care pathways are needed that encompass both assessing and responding to maternal stress, where communication with health professionals, subsequent referral and management are addressed. The development, implementation and evaluation of low-cost resources embedded in such pathways are a priority and the research presented in the thesis offers a foundation on which to build.