The peripartum human brain: Current understanding and future perspectives

https://doi.org/10.1016/j.yfrne.2020.100859Get rights and content

Highlights

  • Endogenous ovarian hormones affect the human brain.

  • Hormonal transitions phases, such as the peripartum period, can have long lasting impact on brain plasticity.

  • Multimodal neuroimaging can provide valuable insight into the peripartum human brain.

  • Embracing the heterogeneity of peripartum mood disorders is critical for better maternal health care.

Abstract

The peripartum period offers a unique opportunity to improve our understanding of how dramatic fluctuations in endogenous ovarian hormones affect the human brain and behavior. This notwithstanding, peripartum depression remains an underdiagnosed and undertreated disorder. Here, we review recent neuroimaging findings with respect to the neuroplastic changes in the maternal brain during pregnancy and the postpartum period. We seek to provide an overview of multimodal neuroimaging designs of current peripartum depression models of hormone withdrawal, changes in monoaminergic signaling, and maladaptive neuroplasticity, which likely lead to the development of a condition that puts the lives of mother and infant at risk. We discuss the need to effectively integrate the available information on psychosocial and neurobiological risk factors contributing to individual vulnerability. Finally, we propose a systematic approach to neuroimaging the peripartum brain that acknowledges important co-morbidities and variation in disease onset.

Introduction

The peripartum period is a complex and tumultuous phase in a woman’s life. While fundamental changes in physiology and psychological functioning during and after pregnancy are normal, they can render many women more vulnerable to mental health problems. Increased levels of depression and anxiety are the most prevalent clinical conditions during the peripartum phase, with depression rates ranging from approximately 13 percent in high-income countries to 20 percent in the developing ones (Fisher et al., 2012; O’Hara and McCabe, 2013), and anxiety rates of approximately 10 percent (Dennis et al., 2017) (for a more detailed overview, see Fig. 1). Despite being a major public health concern, peripartum mental health disorders are both understudied and underdiagnosed (Payne and Maguire, 2019). About half of all cases of postpartum depression (PPD) and anxiety go undetected (for review, see Halbreich et al., 2006), and many patients diagnosed with peripartum mood or anxiety disorders fail to receive evidence-based forms of treatment (Bauer et al., 2014).

In the immediate postpartum period, up to 85 percent of women experience mood swings and feelings of sadness, which are known as postpartum blues, or, more commonly, baby blues, although in most cases the symptoms last only briefly and resolve spontaneously within the first few days of childbirth (O’Hara et al., 1991a, O’Hara et al., 1991b). Women with postpartum blues have a 4-fold risk of developing PPD, which is defined as a major depressive episode (MDE) starting within the first year of childbirth, and a greater severity of postpartum blues is associated with a higher risk for PPD (Adewuya, 2006; Pitt, 1968). With a 13% prevalence rate, PPD is the most common pregnancy-related complication (O’Hara and Swain, 1996a). The early stages of PPD often remain undiagnosed due to time constraints, social stigma, misperception of diagnosis and treatment, and lack of standardized screening. Diagnosis may be further complicated by the overlapping timeframes of postpartum blues and PPD, which create an additional nuance that is difficult to distinguish, requiring better training and increased awareness of maternal healthcare providers (Hadfield and Wittkowski, 2017; Knights et al., 2016).

In summary, peripartum mental health disorders are still underdiagnosed and undertreated. Women seeking peripartum mental healthcare face barriers such as societal stigma, inadequate social support, and insufficient knowledge about peripartum mental health (Dennis and Chung-Lee, 2006). There is a strong consensus among peripartum care providers that mental health screenings must increase across the entire peripartum period to help close this gap in maternal and infant care (Committee Opinion, 2015). In this review, we seek to address the issue by means of a brief introduction to the current diagnostic criteria for PPD, followed by a comprehensive overview of the available knowledge of the human peripartum brain in health and PPD pathology, with an emphasis on the neurobiological models of risk. We also discuss the application of multimodal neuroimaging techniques to investigate the human peripartum brain, providing fresh perspectives on developing potentially more effective screening and individualized care by integrating basic and clinical research.

Section snippets

What is postpartum depression (PPD)?

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), postpartum depression is a “Major Depressive Disorder, with peripartum onset” (APA, 2013), as 18–50 percent of major depressive episodes that are first detected postpartum actually have an onset during pregnancy (Altemus et al., 2012; Wisner et al., 2013). The peripartum specifier indicates that symptom onset must occur during pregnancy or within the first four weeks postpartum. However, this four-week postpartum

Current state of human peripartum brain research: Models of risk

One of the first meta-analyses related to the rates and risk factors of postpartum depression (O’Hara and Swain, 1996b) cited history of psychopathology and psychological disturbance during pregnancy, poor marital relationship, inadequate social support and stressful life events as the strongest predictors of postpartum depression. The revised version of the Postpartum Depression Predictors Inventory (PDPI), based on the meta-analysis data by Beck (2002), includes 13 main predictors to assess

Perspectives: From models of risk to models of resilience

While PPD is increasingly seen as a heterogeneous disorder with different subtypes (Galea and Frokjaer, 2019), the heterogeneity of the disease has not yet been properly assessed due to the limited clinical group sizes and narrow observation timeframes (only during pregnancy, only postpartum, or at different times within 6–12 months postpartum) used by most studies. Furthermore, this pathophysiological concept has yet to be successfully translated to a systematic approach to peripartum

Summary and conclusions

The peripartum period is a complex transition period characterized by fundamental changes in psychological functioning and physiology. It also offers a unique opportunity for us to improve our understanding of how dramatic fluctuations in endogenous ovarian hormones affect the human brain and behavior, and thus move from models of risk to models of resilience. Although evidence suggests that the peripartum brain is plastic, a more integrative, multimodal approach is needed to better understand

Acknowledgements

Preparation of this article was supported by The Branco Weiss Fellowship–Society in Science, National Association for Research on Schizophrenia and Depression (NARSAD) Young Investigator Grant 25032 from the Brain & Behavior Research Foundation, and by a Minerva Research Group grant from the Max Planck Society (Dr Sacher). We thank Eugene Datta for proofreading this manuscript.

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