• 1.
  

  a) F b) F c) F d) T e) F

CAM treatment use among US adults is common. About 40% of US adults use at least one CAM treatment annually.

• 2.
  

  a) T b) T c) T d) F e) F

Bright light therapy has been shown to be efficacious in the treatment of seasonal and non-seasonal MDD. It is commonly well-tolerated, however, considering the high prevalence of mood episodes during pregnancy and the postpartum in the course of bipolar disorder, even if not previously diagnosed; patients should be monitored carefully for emergent symptoms of hypomania or mania, sleep disturbance, and agitation when bright light therapy is initiated. Bright light therapy is not known to be associated with hepatic or renal toxicity.

• 3.
  

  a) T b) F c) F d) T e) F

Mental illness associated with childbearing has long been recognised. Although the blues resolves on its own, the other perinatal disorders resolve over a much longer period of time and require psychological or medical intervention. Perinatal mental illness refers to non-psychotic disorders in addition to psychotic disorders. The perinatal period includes all of pregnancy, not just post-partum.

• 4.
  

  a) F b) T c) T d) F e) F

The expression of perinatal depression is similar to the expression of depression at other times in a woman’s life. No special criteria are used for diagnosing depression in the perinatal period. Depression and anxiety symptoms frequently co-exist. Perinatal depressions can often be severe and impairing. The UK and US diagnostic criteria vary and many parts of the world have no distinct perinatal criteria.

• 5.
  

  a) T b) F c) T d) T e) F

Postpartum psychosis is relatively rare but serious, usually requiring inpatient care. It frequently presents soon after childbirth sometimes within the first week. A few women will believe that their infant is better off dead. Bipolar disorder is the most common presentation of postpartum psychosis and is also by far the most likely pre-existing mental disorder.

• 6.
  

  a) T b) T c) T d) T e) T

History of depressive or anxiety disorders are significant risk factors for perinatal depression.

Stressful life events increase risk for depression at any time in a woman’s life. Although all women experience oestradiol withdrawal after delivery, some women are more sensitive neurobiologically to these effects than most women. The partner relationship is quite important for pregnant and postpartum women and conflict often affects a woman’s self-esteem and mood. Alcohol or other drug misuse is often seen co-morbidly with many of the above conditions and is also a risk factor.

• 7.
  

  a) F b) F c) T d) T e) F

Her child is at increased risk but most children are not affected. Measurement of cortisol does not show if her child is likely to be affected, particularly in later pregnancy as the hypothalamic-pituitary-adrenal axis becomes de-sensitised to stress. No biological test has been yet developed to indicate if the child is likely to be affected. Mild stress, such as from daily hassles, has been shown to affect child outcome. It is not just extreme stress that is important. If the mother is anxious or depressed while she is pregnant, her child is indeed more likely to be mixed handed. Different outcomes seem to have different times of sensitivity. Stress in the first trimester has been shown to the increase risk for schizophrenia. Increased risk for other problems such as conduct disorder, have been associated with stress later in pregnancy.

• 8.
  

  a) F b) F c) F d) T e) F

The effects on the child are associated with a much broader range of problems, including symptoms of anxiety or depression, a bad relationship with the partner, or a bereavement. Although specially trained nurses probably do help to reduce stress, the described programme was not designed with this aim. Unfortunately, this is not true, as the relevant trials have not yet been carried out. It will, however, help the mother anyway and may help the child too. Both sitting down quietly in a chair and listening to music have indeed been shown to reduce the pregnant mother’s plasma cortisol. Some evidence shows that about 15% of women have symptoms of anxiety or depression that are of clinical concern, and the children of these top 15% have about double the risk of a probably mental disorder later. We should be aiming to help about 15% of pregnant women.

• 9.
  

  a) F b) T c) F d) F e) F

Neonatal behavioural disturbances in this context vary in severity and duration. Given the overlap with reported effects of exposure to maternal prenatal mood disturbances, it is difficult to distinguish between the two influences. Once a broad differential diagnosis has been considered to ensure that other neurological and infectious causes have been ruled out, making a precise distinction between the two is less important than recognising the effect of the dual risks. Beyond the few single reports that have examined changes in neurotransmitter and related metabolite levels, pharmacological and genetic moderators, identification of biomarkers that assist in determining who is at risk and who is not remains unclear. Future research clarifying risk factors for PNAS would be useful for clinical decision making and treatment after delivery. To date, pharmacological factors have not proven to be key risk factors that determine the risk profile for exposed neonates. Symptoms of PNAS are the final common pathway of a number of key factors that include fetal drug exposure. PNAS symptoms by definition are short lived and managed with symptomatic treatment. Emerging reports suggest that behavioural disturbances in early childhood may be associated with a history of PNAS, but who is at risk, how maternal mood plays a role in predicting developmental outcomes, as well as the mechanisms underlying these associations, remain to be studied. Symptoms of PNAS must offer us another ‘index of suspicion’ that should remind us of the need for long-term developmental follow up.

• 10.
  

  a) F b) T c) F d) T e) F

Coronary heart disease has not been consistently reported after prenatal SSRI exposure. Given the current state of the evidence, it is likely that first-trimester paroxetine and fluoxetine use slightly increases the risk of congenital defects; however, some uncertainty remains given that findings are not consistent across all studies. Coronary heart disease risks may be independent from exposure to maternal mood; however, how confounding factors related to maternal depression (ie additional environmental exposures, nutrition) contribute to risk beyond SSRI exposure remains unknown. Although the meta-analysis estimates for first-trimester maternal paroxetine and fluoxetine treatment indicates an increased risk of 1.5- and 1.6-fold respectively, it remains unclear how clinically significant these differences are. The long-term developmental risk associated with prenatal SSRI exposure does not end at birth. Although some infants and exposed children seem to have typical development, one needs to consider the implications of altered fetal 5-HT signalling – particularly in the brain – on long-term neuro-behaviour. To date, what we have is a picture where developmental outcomes do not necessarily reflect a ‘main effects SSRI’ story, where outcomes can be easily attributed to one causal factor (i.e. maternal mood, genetics or the SSRI). Rather, outcomes in this setting reflect an inter-play of psychological, pharmacological, genetic and family or social factors related to the mother and her child. During pregnancy, SSRIs may be prescribed. With the expectation of optimising infant health, coupled with associated improved maternal mood, children may continue to be at risk, as maternal pharmacotherapy might not ‘buffer’ or protect them from ongoing maternal mood disturbances. This is a context of developmental vulnerability as well as plasticity.

• 11.
  

  a) F b) F c) T d) F e) F

The recurrence risk of PPD in women who have suffered one episode of major depression after childbirth is about 25%. About 10–15% of women in the general population will experience PPD. For those women who have suffered one episode of PPD and go on to have a subsequent birth, the risk of developing PPD increases to 25%.

• 12.
  

  a) F b) F c) T d) F e) F

About 14% of women with a first-time psychiatric contact during the first month after delivery converted to bipolar affective disorder within the first 15 years after their initial postpartum episode, which was three times more often than women with initial psychiatric contact at other points.

• 13.
  

  a) T b) T c) T d) T e) F

Depression during pregnancy does increase the risk of postpartum depression. It also confers an increased risk of having lactation difficulties in the postpartum period, and has also been associated with increased risk of both preterm birth and developing gestational diabetes. Depression during pregnancy, however, is not associated with an increased risk of ovarian cancer.

• 14.
  

  a) F b) T c) F d) T e) T

Perinatal depression does not increase the nutritional content of breast milk. The other statements are all true: perinatal mood disorders are associated with decreased initiation and duration of breastfeeding, increased reporting of painful lactation and increased risk of long-term adverse maternal health outcomes.

• 15.
  

  a) T b) F c) F d) T e) F

Individual psychotherapy has been shown to be of benefit for depression during pregnancy and the postpartum period. Pilot studies have shown benefit for telephone-delivered inter-personal psychotherapy (IPT), but no randomised studies of sufficient size have been conducted. Pilot studies have shown benefit for internet-delivered therapy, but again no randomised studies of sufficient size have been conducted. Several prevention studies using group cognitive–behavioural therapy have shown benefit. Pilot studies have shown benefit for IPT with couples, but no randomised studies of sufficient size have been conducted.

• 16.
  

  a) F b) T c) F d) T e) F

No data support this first assertion. Only one study has compared the two, and the psychotherapy was not manualised. Meta-analyses and individual treatment trials support the superiority of psychotherapy to controls. Although specific therapies may be shown in the future to be superior to others for specific populations, head-to-head comparisons of the manualised psychotherapies have generally shown equivalency. Manualised therapies have been supported in individual trials and in meta-analyses. Data strongly suggest that IPT is equivalent to CBT and other well-described manualised treatments.

• 17.
  

  a) T b) T c) T d) F e) F

Psychotherapy has no known adverse effects on fetal development; some studies suggest that medication may be harmful. Although it is often not provided at higher rates, pregnant women greatly prefer psychotherapy if at all possible. More studies support the use of psychotherapy than medication for perinatal depression; the sample sizes of some of the psychotherapy studies are also much larger. No data show that compliance is higher with either, as this question has not been examined. Delivery of psychotherapy requires more time investment and specialised training; medication can be provided by obstetricians and gynaecologists, or general practitioners at routine visits.

• 18.
  

  a) T b) T c) T d) F e) F

In the stress-buffering model of social relationships and health, social support is hypothesised to prevent or modulate responses to stressful life events that are damaging to health. Support may thus act on several different points in the pathway between stressful life events and eventual mental illness. The perceived availability of social support in the face of a stressful event may lead to a more benign appraisal of the situation, thereby preventing a cascade of ensuing negative emotional and behavioural responses. This may dampen the physiological or behavioural response to stress. Thoits suggests that the effectiveness of social support as a stress buffer requires actually received or enacted support and is based on specific combinations of type and source of support. Specifically, emotional support (e.g. love, caring, sympathy) and instrumental support are likely to be the most effective stress buffers when coming from significant others (e.g. experientially dissimilar), whereas informational and appraisal support (e.g. validation of feelings, advice, and role modelling) are most helpful coming from similar others (e.g. experientially similar).

• 19.
  

  a) F b) F c) T d) F e) T

Three studies evaluated the effectiveness of professionally facilitated support groups. Unfortunately, theoretical limitations (e.g. the inclusion of both depressed and non-depressed women) and methodological weaknesses (e.g. non-random group allocation, significant differences in group sizes, weak measure of postpartum depression, and small sample sizes) render the results equivocal. No studies evaluated the effect of self-help groups (i.e. groups not facilitated by a health professional) in the treatment of postpartum depression. One pilot trial evaluated the effect of telephone-based peer support on postpartum depression symptomatology. Significant group differences in depressive symptomatology (Edinburgh Postnatal Depression Scale [EPDS] scores above 12) were found at both the 4-week and 8-week assessments. The results suggest that telephone-based peer support may be an effective intervention for treating postpartum depression and well-designed trials with large samples are warranted. Only one study evaluated the effect of partner support in the treatment of mothers with postpartum depression. No significant group differences were found in mean EPDS scores between the intervention and control groups immediately after treatment; however, a significant group difference in EPDS scores was found at the 4-week follow up, suggesting a possible benefit of partner support interventions.

• 20.
  

  a) F b) T c) T d) T e) F

Five European trials evaluated non-directive counselling with positive results, suggesting that this treatment approach may be a viable option for women with mild-to-moderate depression. Although this research has highlighted the feasibility of population-based screening and the application of home visiting, the small sample size in all but one trial and contextual factors decrease the applicability of the results. One trial compared antidepressants and non-directive counselling (listening visits) after 4 weeks of general supportive care. At 4 weeks, women were more likely to have improved if they had been randomised to antidepressants compared with listening visits, which started after 4 weeks. Overall, a significant difference was found between the groups in favour of antidepressants at 4 weeks, which was reduced at 18 weeks. This study had serious methodological limitations (e.g. no true control group after 4 weeks, change in study protocol before completion and high number of women in both groups received the interventions); thus the results are questionable. One study evaluated the effect of home visits by mental health nurses in the treatment of postpartum depression. At 1-week after the intervention, five (71.4%) women in the intervention group had fully recovered according to DSM-IV criteria compared with only three (33.3%) women in the control group. Unfortunately, methodological limitations (small sample size, data analysis was not intent-to-treat, and the number of women who received psychiatric treatment unknown) render the results questionable. Only one pilot study evaluated a stepped collaborative care model for women with postpartum depression. For the subgroup who were diagnosed with postpartum depression, the intervention improved women’s knowledge of their diagnosis and their receipt of treatment. The formal diagnostic procedures (Structured Clinical Interview for DSM-III-R) missed many women whose depressed mood interfered with their health and function.

• 21.
  

  a) T b) T c) T d) F e) T

Postpartum depression is the most frequent mental health disorder in the postpartum period (incidence of 11–20%). It is, therefore, a major public health concern. To meet DSM criteria for parent–infant psychotherapy, depressive symptoms must be consistent with a diagnosis of major depression with onset within 4 weeks after delivery. Infants of depressed mothers are at increased risk for a large array of negative outcomes, including attachment insecurity (particularly disorganised attachment), social skills deficits, cognitive difficulties, behaviour problems, and psychopathology in later childhood and adolescence. Mothers with parent–infant psychotherapy are frequently difficult to reach, as they frequently do not recognise and accept themselves as being depressed. Their assumption might be that one cannot be a ‘good enough’ mother if depressed. A mother of a young baby might feel that she has no ‘right’ to be depressed. These feelings might make her feel lonely, which are seldom acknowledged and shared, even with close relatives. The fear of losing a child to social services as well as the pervasive feeling of doing harm to the development of their child are often quite strong.

• 22.
  

  a) F b) T c) F d) F e) F

The definition of perinatal depression was proposed in an evidence-based report by the US Agency of Health Care Research and Quality. As many as 14.5% of pregnant women have a new episode of major or minor depression during pregnancy or during the first 3 months postpartum. Perinatal depression increases the risk for adverse child development outcomes even if criteria for major depression are not met. This is an important public health concern as interventions are known to be most effective and efficient if implemented early on. Several validated screening tools are available that can be used during pregnancy and the first year postpartum (e.g. the Edinburgh Postnatal Depression Screen). Nanzer et al.’s Parenthood Centered Psychotherapy is a form of parent–infant therapy that is implemented during pregnancy.

• 23.
  

  a) T b) T c) F d) T e) F

Good planning cannot be done if potential risks to the woman’s mental health have not been identified. Although many high-risk women will make a smooth adjustment in the postpartum period, having a plan in place will ease family anxiety and ensure immediate and appropriate care if it is needed. Although psychiatrists and psychologists are essential members of the mental health team, the obstetrician must stay involved to oversee the welfare of the woman and her fetus during pregnancy and the mother–infant dyad in the early postpartum period. It is rarely a good idea to stop psychiatric medication that is working well as there will potentially be much more harm to a mother who relapses.

• 24.
  

  a) F b) T c) F d) T e) T

Mother and baby units on balance are still relatively uncommon in the developed world. Most mother and baby units are found in European countries, particularly France and the UK. There are very few mother and baby units in the USA. There are some in Sri Lanka and India, but not many and hardly any in other developing countries.

• 25.
  

  a) F b) T c) F d) T e) T

It is rare for admission to mother and baby units to be made on the basis of self-referral. Usually referrals are made by health or mental health professionals. Admission is undertaken because care in the mother-baby unit is regarded as the best treatment option for the mother and her infant. Not every mother–infant dyad is best treated in a mother and baby unit. Moreover, treatment needs to be tailored to the dyad’s needs. It is not always clear whether the mother will be able to parent once treated so admission for treatment and subsequent re-assessment of parenting ability can be appropriate.

• 26.
  

  a) T b) T c) T d) F e) T

One of the central purposes is to ensure the development of a positive mother–infant relationship through supporting the mother in her positive parenting during her hospitalisation. Mothers receive active psychiatric care to ensure that they are able to function well once they are discharged and protect them from self harm and suicide. Staff members ensure that mothers are well prepared to provide good care to the infant and keep it safe. The purpose of a mother and baby unit is to support the mother and baby not the extended family, who will be expected to provide much support after hospital discharge.

• 27.
  

  a) F b) T c) F d) F e) F

Despite the fact that OSA is a risk factor for preeclampsia, no association with eclampsia has been found. Several studies have shown a strong and independent association between OSA and pregnancy-induced hypertension or preeclampsia even in non-obese women. The only cardiovascular conditions in pregnancy that has been shown to be associated with OSA have been hypertension and preeclampsia. PE in non-obese women with OSA is no more common than in women without OSA.

• 28.
  

  a) F b) T c) F d) T e) T

gRLS has a prevalence of 12–26% compared with 5–8% of chronic RLS. Sixty per cent of women who have gRLS in one pregnancy experience it in subsequent pregnancies, and the risk of developing chronic RLS later in life increases fourfold. Seventy per cent of women with gRLS report resolution of symptoms 2 months postpartum, whereas the severity among the remainder decreases by 50% or more. gRLS starts in the middle of the second trimester and worsens as the pregnancy progresses.

• 29.
  

  a) T b) F c) F d) F e) T

A history of smoking is a strong predictor of insomnia in both the late pre-partum and postpartum periods increasing the risk of insomnia 1.6-fold. Breast feeding increases overall sleep duration by an average of 45 minutes compared with bottle feeding, even though it does not significantly change subjective sleep complaints. Co-bedding increases the risk of insomnia among new mothers. Women who undergo Caesarean Section are more likely to complain of postpartum insomnia than those who deliver vaginally.

• 30.
  

  a) F b) T c) T d) F e) F

Body mass index is higher in women with narcolepsy compared with controls. A recent large cohort study has shown an increased incidence of mild obstetric complications during narcolepsy, including a higher incidence of impaired glucose tolerance and anaemia. Cataplexy is rare during delivery, occurring in only 0.9% of all pregnancies in a recent cohort study. All current medications for narcolepsy, including sodium oxybate, have not undergone human testing for use during pregnancy, and are not recommended for use during pregnancy or lactation.