產後憂鬱與焦慮可能會影響嬰兒發展


  August 20, 2009 — 一篇新研究指出,婚姻關係穩定、產下健康足月嬰兒、有受教育的中產階級婦女,有不同比率的產後憂鬱。
  
  研究第一作者、以色列Bar-Ilan大學社區嬰兒門診主任、心理與神經科學教授Ruth Feldman博士表示,即使是社區世代中的低風險婦女,我們仍發現有20%婦女的產後憂鬱症狀嚴重到需要臨床注意的程度。
  
  Feldman博士向Medscape Psychiatry表示,這項研究結果很重要,因為產後憂鬱對於嬰兒發展中的恐懼反應以及社會互動會有負面影響。
  
  該研究發現,健康的、有受教育的婦女中,嚴重憂鬱症狀的比率為3.6%,焦慮比率為12.2%。
  
  該研究發表於8月的美國兒童青少年精神醫學會期刊(Journal of the American Academy of Child and Adolescent Psychiatry)。
  
  【早期症狀】
  研究者一開始的研究對象是971名在產後第2天即報告有憂鬱和焦慮症狀的新手媽媽。產後6個月時,研究者郵寄有關焦慮和憂鬱的問卷,給代表憂鬱症狀連續演變狀態的360名婦女。
  
  回覆問卷的215名母親中,研究者聯繫屬於憂鬱症狀連續狀態上限和下限的150人進行追蹤。
  
  最後,在9個月時的樣本包括100名婦女,其中45%是第一次當媽媽,她們的平均年紀為30.7歲,平均接受過15.8年的教育。
  
  臨床組的41名母親中,22人有嚴重憂鬱異常,19人有焦慮異常。嚴重憂鬱異常組中的7名母親、以及焦慮異常組中的3名母親有接受藥物治療。極少人接受心理治療。
  
  【控制組】
  樣本群也包括與臨床組之年紀、教育、為人父母的經驗、嬰兒出生體重和性別等相仿的59名母親組成的控制組。
  
  9個月時的評估包括兩次家庭訪視。第一次時,使用精神疾病診斷與統計手冊第四版修訂版評估這些母親們,檢視她們的異常和完成自我報告檢測。第二次訪視時,研究者拍攝這些母親和嬰兒的自由遊戲情況。他們也監測嬰兒面對恐怖面具時的恐懼反應,並採取唾液樣本以測量母親和嬰兒的可體松值。
  
  該研究顯示,9個月時有憂鬱之母親的嬰兒,在敏感性、侵犯性、社會參與、退縮等相關行為測量、以及恐懼調適和可體松反應力等方面,分數都是最差的。這三大類型的測量都與嬰兒的社會-情緒成長有關。
  
  【社會參與】
  新手媽媽可能會因為憂鬱降低了她的敏感性,因而限縮了其嬰兒之社會技能的發展。Feldman博士表示,我們透過典範學習(有樣學樣)來學習社會參與,嬰兒從3個月大就開始學習那些非語言(動作類型)的「腳本」。
  
  在本研究中,於恐懼面具測試中,憂鬱母親的嬰兒比其他嬰兒更容易哭鬧和緊張不安。 Feldman博士解釋,恐懼反應是嬰兒適應環境改變良好與否一個很好的指標。
  
  他表示,正常的話,母親們透過她們的敏感性而成為小孩和環境的緩衝劑。她們知道何時會刺激、小孩何時需要休息、如何組織小孩的環境、如何與社會互動。如此,世界上的新事物對小孩來說就不會那麼令人恐懼。
  
  【恐懼反應】
  Feldman博士表示,未能學得如何調適恐懼反應的小孩,之後比較容易出現焦慮。研究發現,那些在9個月時的測試中,出現負面反應的小孩,到了青春期時,變得更焦慮且比較害羞。
  
  焦慮母親的嬰兒也有發展方面的問題。在這項研究中,焦慮婦女的後代,在嬰兒的社會參與方面略遜於控制組對象的小孩,焦慮母親的敏感性也比控制組的母親們差。焦慮母親之侵犯性的分數最高,但是其小孩的恐懼調適與控制組的小孩相似。
  
  新手媽媽的焦慮對於嬰兒之可體松值的負面影響和憂鬱媽媽一樣。開始時,憂鬱媽媽的此一數值最高,其次是焦慮媽媽,而在測試期間依舊升高。
  
  Feldman博士表示,重點在於瞭解母親的心情如何影響嬰兒的心理。之前的動物研究與其他從嬰兒出生追蹤到青春期的研究都顯示,如果身體的壓力管理系統、壓力荷爾蒙改變,生活通常也會改變。
  
  【更大的預期】
  Feldman博士表示,產後憂鬱的發生率看來仍在增加中。幾年前,研究者估計此一盛行率約為12%至15%,但是在已開發國家,數據逼近18%至20%。
  
  增加的原因很多。問題可能是研究增加、婦女生育年齡延後(研究顯示憂鬱與母親年紀有關)。
  
  此外,現今的婦女在母親和祖母的角色上面對更多的期待。Feldman博士表示,現代社會中,婦女被期許在產後恢復苗條與美麗、還要能立即活動。她們也被期待可以有不錯的、有趣的職業,還同時可以成為不錯的媽媽。
  
  Feldman博士相信,產後憂鬱未獲重視。她表示,想想看,我們現在對自閉症的關注程度這麼大,而其發生率至多只有1.5%。
  
  【適合臨床經驗】
  明尼蘇達大學醫學院兒童與青少年精神科主任教授Gail A. Bernstein醫師受邀接受Medscape Psychiatry對該研究發表評論時表示,研究結果符合她的臨床經驗,看到這個使用有科學立論的測量和觀察進行的前瞻性研究很令人欣慰。
  
  Bernstein醫師表示,她和同事、助理教授Kathryn Cullen醫師,對於該研究印象深刻。我們認為它有不錯的前瞻性研究設計,我們很樂於見到社區樣本的成果。研究結果清楚顯示,母親的產後憂鬱和焦慮對於嬰兒的早期發展有影響,對於嬰兒有負面的後遺症,特別是憂鬱母親。
  
  Cullen醫師指出,研究母親的憂鬱和焦慮對於幼童之影響的研究是值得關注的,因為專家們只能等這些嬰兒長大才能看到這些孩子。她表示,我們只有在小孩8歲、10歲或青少年時才會看到他們,所以我們不知道他們在早期發育時期的神經生物學狀態。
  
  作者們宣告沒有相關財務關係。
  
  J Am Acad Child Adolesc Psychiatry. 2009;48:919–927.
  

Postpartum Depression, Anxiety, May Affect Infant Development

By Pauline Anderson
Medscape Medical News

August 20, 2009 — Healthy, educated, middle-class women who are in stable relationships and who give birth to healthy, full-term babies experience disturbing rates of postpartum depression, according to a new study.

"Even in women who are as low risk as you can get in a community cohort, we find approximately 20% of women reporting symptoms of postpartum depression high enough to merit some clinical attention," said the study's lead author, Ruth Feldman, PhD, professor of psychology and neuroscience, and director, community-based infant clinic, Bar-Ilan University, Ramat-Gan, Israel.

This is important because, as the study suggests, postpartum depression can have a negative effect on infant development in terms of fear response and social interaction, Dr. Feldman told Medscape Psychiatry.

The study found that the rate of severe depressive symptoms among healthy educated women was 3.6%, and the rate of anxiety was 12.2%.

The study is published in the August issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Early Symptoms

The researchers started with a sample of 971 new mothers who reported symptoms of depression and anxiety on the second day after giving birth. At 6 months postpartum, the researchers mailed questionnaires on anxiety and depression to 360 women representing both the top and bottom of the depressive symptom continuum.

Of the 215 mothers who returned these questionnaires, the researchers contacted 150 at the upper and lower ends of the depressive symptom continuum for follow-up.

The final sample at 9 months included 100 women, 45% of whom were first-time mothers. Their average age was 30.7 years, and they had completed an average of 15.8 years of education.

Of the 41 mothers composing the clinical group, 22 had a major depressive disorder, and 19 had an anxiety disorder. Seven mothers in the major depressive disorder group and 3 in the anxiety group were treated with medication. Very few were undergoing psychotherapy.

Control Group

The sample also included a control group of 59 mothers who were matched to the clinical group in age, education, parenting experience, and infant birth weight and sex.

The 9-month assessment included 2 home visits. During the first visit, mothers were assessed for Diagnostic and Statistical Manual of Mental Disorders, 4th edition, disorders and completed self-report measures. During the second visit, investigators videotaped mothers and infants while they engaged in free play. They also monitored fear reactions in infants while showing them increasingly scary masks and took saliva samples to test for cortisol levels in both mothers and infants.

The study showed that infants of mothers who were depressed at 9 months scored the poorest on relational behavior measures including sensitivity, intrusiveness, social engagement, and withdrawal, as well as fear regulation and cortisol reactivity. These 3 measures are central to the social-emotional growth of infants.

Social Engagement

A new mother's depression might diminish her sensitivity, which in turn could stall the development of her infant's social skills. "We learn social engagement through modeling," said Dr. Feldman, adding that babies learn nonverbal "scripts" starting from about 3 months of age.

In the study, babies of depressed mothers cried and fussed more than other babies during the scary mask test. Fear response is a good indicator of how well a baby adapts to changes in his environment, explained Dr. Feldman.

"Normally, mothers would be able to provide some kind of a buffer between the child and the environment through their sensitive approach. They know when to stimulate, they know when the child needs rest, they know how to organize the child's environment and how to interact socially. When this is the case, the novelty in the world is not so scary for the child," he said.

Fear Response

Children who do not learn how to regulate their fear response become anxiety-prone later on, said Dr. Feldman. "Studies have found that those kids who show negative reaction on the same things that we measured at 9 months go on to become much more anxious and shy children in adolescence."

Babies of anxious mothers also show developmental problems. In the current study, offspring of anxious women did less well than children of control participants on infant social engagement, and the anxious mothers did worse than control participants on testing for maternal sensitivity. Mothers with anxiety scored the highest in intrusiveness, but fear regulation among their children was similar to that of children of control patients.

Anxiety in new mothers had the same negative effect on infant cortisol levels as maternal depression. These levels were highest at baseline among depressed women, followed by anxious moms, and rose still higher during testing.

It is important to know that a mother's mood is affecting the infant's physiology, said Dr. Feldman. Previous animal studies and studies that followed up children from birth to adolescence have shown that if the stress hormone, which is the body's stress management system, is altered, it is usually for life, she said.

Greater Expectations

The incidence of postpartum depression appears to be on the rise. Just a few years ago, researchers estimated the prevalence rate to be 12% to 15% but more recent research puts the figure at closer to 18% to 20% in developed countries, said Dr. Feldman.

There are likely many reasons for this rise. The problem is being studied more, and women are waiting longer to bear children (research shows depression may be related to maternal age).

In addition, women today face many more expectations than their mothers and grandmothers. "In modern society, women are expected to be thin and pretty and active right away after birth," said Dr. Feldman. They are also expected to have "this fabulous interesting career and to be this fabulous mom."

Dr. Feldman believes postpartum depression is not getting the attention it merits "Think about how much attention is being paid to autism now, and we're talking about — at most — 1.5% prevalence," she said.

Fits Clinical Experience

Asked by Medscape Psychiatry to comment on the study, Gail A. Bernstein, MD, professor and head, Division of Child and Adolescent Psychiatry, University of Minnesota Medical School, Minneapolis, said the study results fit her clinical experience, "but it was very nice to see this demonstrated with a prospective study using measures and observation that were scientifically based."

Dr. Bernstein said she and colleague Kathryn Cullen, MD, assistant professor in the same division, were very impressed with the study. "We thought it had a nice prospective study design, and we liked the fact it was a community sample. It seemed pretty clear that the study demonstrated the effects of maternal postpartum anxiety and depression on early infant development, that there were negative sequelae for infants, especially of depressed moms."

It was interesting to see a study on the effect of maternal depression and anxiety on very young babies because specialists do not see these children until they are older, added Dr. Cullen. "We don't see the children until they're perhaps 8 or 10 years old, or teenagers, so we wouldn't know what's happening in neurobiology at the early developmental stages," she said.

The authors have disclose

    
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