Tag Archive for: depression

Navigating Menopause: Could Better Support Reduce Depression Risk?

Author: Pia Lustig, Psychology student and intern at FemiLab, Lausanne University Hospital, Switzerland | Editor: Romina Garcia de leon (blog coordinator)

Published: May 24th, 2024

There is a wide range of factors that contribue to depression during menopause;  including genetic markersprevious depression history, and menopause symptoms. However, If we look beyond biology, could there be other reasons why women across the world experience menopause so differently? And how much of a factor does society, and the narratives around menopause affect lived experience of this transition?

The natural menopause transition normally starts around mid-forties and continues for 5-10 years. As the body prepares for the “post-fertility” phase, a woman can experience a spectrum of symptoms, including hot flashes and night sweats, insomnia, weight gain, and vaginal dryness. However, there are certain social factors that are also at play. As is the case in many cultures, women are more likely to be caretakers of elderly parents, the primary caretaker of children and household duties. Moreover, women carry out more than 2.5 times more unpaid care work and household duties than men. Balancing the many responsibilities between home, work, and relationships may lead to burn out. When menopause is added to the equation, this becomes further excacerbated. Suddenly, physiological changes come into play. Vasomotor symptoms such as sleeplessness combined with hormonal fluctuations might make everyday life feel like an emotional rollercoaster. Moreover, symptoms like vaginal dryness, hair growth in unwanted places and excessive weight which may lead to feelings of shame and insecurities.

Research shows that women´s self-perception influences overall moods during the menopause transition. If their perception of the transition is more positive, women are less likely to develop depression. The kind of messages women receive from their immediate circle – family and friends –are pivotal in shaping their perceptions and reducing the risk of depression. Can they openly discuss their experiences around menopause, and do they receive the support they need? Equally important is the workplace environment. Are they understanding and accommodating of the possible symptoms women may be facing during working hours?  How is the media representing women in midlife? Are women represented in a way that emphasizes their worth beyond youth, or are they overlooked and deemed less relevant, less attractive? Is menopause even talked about publicly, or does it remain a topic shrouded in silence and shame?

The messages from the environment are closely linked to the broader culture that shapes women’s experiences, including societal attitudes toward women’s health. Globally, the risk of depression is twice as high for women as for men, research shows that women in Western societies experience higher rates of depression during the menopause transition. Furthermore, when looking at self-reported menopausal symptoms, some groups of women in Asia and Latin America hardly report symptoms at all. To understand why women´s experiences are so different, we may need to focus on society´s perceptions about women during this time in their lives, and to what extent the external environment is providing support. In some cultures, status is elevated passing the childbearing years. For example, for Taiwanese women menopause is viewed in a positive and holistic light. If societal perceptions influence menopausal symptoms and depression risk – this is an important avenue to focus on.

Can we support women going through the menopause transition better as a society and as loved ones? Viewing menopause-related risk for depression from a broader perspective could help us better understand how to best support women in these transitional stages. We might discover that support networks and positive messages from the environment may be part of the key that solves the puzzle.

 

 

 

Personality and Sex Differences in Depressive Symptomatology

Authors: Jessica Stewart, PhD Candidate, Health Psychology, University of British Columbia | Editors:  Romina Garcia de leon and Shayda Swann

Published: January 19, 2024

It’s not hard to believe that people with tendencies toward anger or aggression will end up with more health problems than those who have a positive outlook. Many studies have shown that personality traits are associated with physical health and mortality.

Personality traits can be identified as patterns of feelings, thoughts, and behaviours that take shape in one’s childhood and become consistent throughout one’s life.

The Five-Factor Model of personality is a common method of describing personality traits and separates the traits into agreeableness, conscientiousness, extraversion, neuroticism and openness to experience.

Hostility, which is an attribute of neuroticism, is associated with coronary heart disease and mortality, while conscientiousness predicts longevity.

Depressive symptoms, which approximately 350 million people around the world currently experience, have been linked to personality traits. A 2023 study showed that all five dimensions of personality were linked to changes in depressive symptoms but neuroticism has the strongest association with depressive symptoms, with people who are high in neuroticism being more likely to experience depressive symptoms.

Personality traits may also be a cause of the considerable sex difference in depressive disorders that exists between males and females across sociocultural contexts. This difference exists across the lifespan, with females around twice as likely as men to experience depressive disorders from adolescence to late adulthood.

Neuroticism and depression in women

In a 2022 study, neuroticism was correlated with the prevalence of probable major depressive episodes for both men and women. Still, the effect of neuroticism in the incidence and persistence-recurrence of probable major depressive episodes was only found in females. In other words, the study found a neuroticism-related vulnerability in women for the incidence or persistence-recurrence of a major depressive episode.

Past research has suggested one neural mechanism between neuroticism and depression found only in women. It has been described as a correlation between neuroticism and resting-state regional cerebral blood flow in the hippocampus and midbrain, and neuroticism predicted depressive symptoms through greater activity of these regions, which are used in emotional processing and regulation.

Conscientiousness and depression in women

Conscientiousness affects men and women differently as well. In the same 2022 study, the interaction found between gender and conscientiousness for the incidence of depressive symptomatology demonstrated a larger protective effect of conscientiousness for men compared to women. In other words, being high in conscientiousness helps men prevent depressive symptoms more than it does for women.

Considering the impact of personality traits and gender on depressive symptoms, researchers recommend including personality and gender-specific strategies in mental health and depression intervention or prevention programs.

Behind the Science: Examining Inflammation and Depression Through a Bio-Sociological Lens

Interviewee: Tatiana Pakhomova, B.A., M.P.H., Ph.D. student, Simon Fraser University. Authors/Editors: Romina Garcia de leon, Shayda Swann (Blog Co-coordinator).

Published: January 13th, 2023

Could you please briefly explain what your research is about?

My Ph.D. research aims to examine the socio-structural pathways between inflammation and depression. I’m particularly interested in the relationship between depression and chronic inflammation, which refers to persistent immune activation in response to various stressors. We’re interested in looking at socio-structural, biological, and behavioural factors which impact the pathways between chronic inflammation and depression, and their downstream effects. People with chronic inflammation have higher numbers of specific inflammatory markers in their blood associated with increased risk of communicable and non-communicable diseases, like HIV and cardiovascular disease. For my Ph.D. work, I’m interested in how chronic inflammation is associated with an increased risk of poor mental health outcomes. Research shows that people with depression have increased inflammation. However, many pathways are bi-directional, with complex relationships involving hormonal pathways, neurotransmitters, and socio-structural factors. Very little research looks at these relationships in young people or longitudinally. For this reason, we want to look at these long-term trends to better understand this relationship. The study I’m working on is AYAZAZI, a longitudinal cohort across two study sites in Durban and Soweto (South Africa) that was launched in 2014 and investigated intersectional, behavioural, biological, and socio-structural factors that might influence HIV risk among young people aged 16-24. 

What interested you in studying how mental health affects a biological outcome like inflammation?

Part of it is personal. I’ve had episodic depression since my teenage years, but I didn’t seek help or get diagnosed until I was older. Given the barriers to accessing mental health support, my depression was left untreated for a long time. Secondly, from my academic background, my Bachelor’s was in political science and gender studies, and I have always been interested in the political aspect of health. After finishing my B.A., I worked in HIV social services with a regional staff team in Fraser Health for a few years, which led me to do my M.P.H. at Simon Fraser University, where I met Dr. Angela Kaida. I fell in love with the research process and have been fortunate to have worked in research since 2018. I also have a part-time position at the BC Centre for Excellence in HIV, looking at barriers as well as facilitators of healthcare engagement. Given this background, I was very interested in studying mental health from a holistic perspective, considering both the socio-structural and biological factors that interact to influence our health. That’s the great thing about social epidemiology – you get to bring in all of these intersecting concepts, and it’s a much more holistic way to look at health. 

Why do you think it’s important to study women’s health from the social determinants of health lens?

Structural determinants of health are a huge part of my work. Many of the gaps in the literature are centred around factors in the social environment that influence biological relationships. There is evidence out there that indicates that there are both sex and gender differences in inflammation markers among youth and adults, as well as in depression or other mental health outcomes. Gender inequity significantly impacts how people experience life stressors and may influence their health at the biological level, and I am interested in how gender plays a role for both young women as well as young men. As our study participants are aged 16 to 24, we do our work with an understanding that there are numerous fluctuating biological changes in youth and young adulthood that may affect the relationship between inflammation and mental health. 

Could you tell us more about the research projects you’ve worked on before, both in Canada and abroad?

Working with Peer Researchers to co-create knowledge has been a huge highlight of my career. I’ve also been fortunate enough to have a couple of research trips to South Africa. I did my M.P.H. with the AYAZAZI study, which feels like coming back in a circle to finish what I started. My Master’s work was also mental health-focused but focused on factors that are associated with perceived stress. Now, I get to look at mental health outcomes longitudinally. It’s been wonderful to build relationships with researchers in South Africa. I’ve spent a couple of summers at the Perinatal HIV Research Unit in Soweto, which has been an incredibly wonderful experience. 

What impact do you hope to see with your work years from now?

Working from the social determinants of health lens means that a lot of social and structural factors are potentially modifiable. When we’re looking at something like mental health, prevention is key because treatment options are not always accessible for some people. The purpose of this work is to give other researchers, community members, and stakeholders tangible evidence so that they can do something with it. It would be great to see some of this work be applied to policy that is youth-driven and youth-focused, that has real-world impacts, and adds something valuable to the body of research to better understand this important issue. 

Sex Differences and the Brain-heart Connection

Author: Emilie Théberge, MSc. Medical Genetics, Clinical Research Coordinator (University of British Columbia/Vancouver General Hospital)   Editors: Romina Garcia de leon & Shayda Swann (Blog Co-coordinators).

Published: December 30th, 2022.

Note: Biological sex (i.e. female, male) is not the same as gender (i.e. woman, man, nonbinary, Two-Spirit, etc.), which is a social construct. Throughout this blog post, the cited literature considers the term “women” to equate to cisgender females, and the term “men” to cisgender males. This post’s cited conclusions of sex differences are under researched in reference to transgender and non-binary individuals, as well as those with non-conforming gender identities.  Read more 

When does stress overwhelm the body to the point that it causes a state of mental and/or physical illness with an accelerating feedback loop? If the cause of stress is unremovable, how can we adapt and find hope?

A large-scale wildfire may cause short-term (acute) stress to someone nearby, but there is also a defined endpoint when the fire is put out and no longer a threat. However, there can be long-term (chronic) consequences to one’s lungs and the local environmental ecosystem This wildfire metaphor may be translated to the acute and chronic mental and physiological adaptations caused by stressful events. Everyone has different thresholds of stress tolerance based on their lived experiences and  biological (genetic) susceptibility to how their bodies manifest this stress.  

 Despite being half of the world’s population, I am shocked at how little research in psychiatric and neuroscience is dedicated to studying sex differences and women’s health. Approximately one in four Canadians were estimated to have depression in 2021 – and across borders, depression rates are consistently reported twice as high in women (20%) than in men (10%). How much of this is attributed to biological sex differences? Do the physical manifestations of mental stress and depression differ between the sexes? I decided to explore these ideas in my thesis. 

This recently published article on the “immunometabolic theory of depression” piqued my interest. Most literature on depression focuses on dysfunction within the brain, ignoring the context of its link to the cardiovascular and metabolic systems. Recent genetics literature on depression has pointed towards genes and molecular pathways that implicate the immune system, specifically chronic-low-grade inflammation, as a key driver of depression. The brain controls the perception of stress, and the heart reacts to it. Chronic low-grade inflammation is a result of this system staying “on” too long after the perceived threat has passed. 

Depression is a systemic and  whole-body concern that can affect our cardiovascular system. I developed a keen interest in exploring these connections when working with patients who believed that stress triggered their cardiovascular disease onset. Heart disease does not occur overnight. Chest pain to the point of a heart attack comes from a complex interaction of metabolic and immune factors that build up over time from imbalances in the body (i.e. from stress). This can manifest as plaque in the large blood vessels with coronary artery disease or dysfunction of the smallest blood vessels with microvascular dysfunction. Traditional risk factors such as high cholesterol, diabetes, high blood pressure, smoking, and obesity, may also have different effects between men and women. 

In my thesis, I studied a sample of over 16,000 people from the Canadian Longitudinal Study on Aging (CLSA) cohort of 50,000 people and found sex differences in the genetic and cardiometabolic risk factors associated with depression. Women with a history of clinical depression were at higher odds of having comorbid histories of heart disease, diabetes, hypothyroidism (which results in slower metabolism), and a higher “genetic risk score” for depression. However, men with depression did not show significant relationships with these conditions, in comparison to men without depression. Among men, high blood pressure was a significant risk factor, while high genetic risk was not. Younger age and lower annual income contributed the most to my statistical models for both sexes. 

Depression is not just in the head, it’s a whole-body dysfunction to cope with stress. In consultation with your primary health care provider, you can make a habit of checking on your body through regular health examinations and seeking support for your mental health. Mental and physical health are interconnected, and gradual mental and physical decline in our youth have the potential to snowball into early life-threatening heart disease. It is imperative that we talk about the individual and collective actions that we can take to treat depression, especially in this post-COVID era. This can take place in our friend groups, families, and workplaces – as we think about long-term solutions instead of “quick fixes.”

 

Responses to Anxiety and Depression During Pregnancy Require Funding Say Care Providers

Author: Julia Santana Parrilla, MSc Population & Public Health at the University of British Columbia | Editors: Alex Lukey and Arrthy Thayaparan (Blog Coordinators) 

Published: April 23rd, 2021

Perinatal mental health is considered a global public health issue. [17] So, why don’t we talk about it more?

In the Global North, pregnancy care and interventions developed exponentially throughout the twentieth century. [2] The medicalization of pregnancy and childbirth has led to significant innovations in care. It has also problematized the experience in ways that privilege medical expertise and suppress pregnant people’s agency. In the early 1900s, reproduction was commodified as pregnancy supplied the labour force for industrializing societies. [2] Given how babies are produced from our bodies, it is unsurprising that pregnancy was reduced to gestation. Over a century later, these foundations persist in our social imaginations and shape healthcare priority-setting. From research to funding, education to practice, and recommendations to policy, mental health has yet to be integrated in pregnancy care.

Mood and anxiety disorders are the most common types of mental ill-being locally and globally. [6] But, anxiety and depression occur more frequently among women than in men. [6,9,16] This lifetime prevalence is seen across cultures and most often manifests during reproductive years, particularly in times of dramatic hormonal fluctuations, such as during pregnancy and after birth. [10,16] Approximately ⅓ women may experience anxiety symptoms during pregnancy. [19] In British Columbia (BC), up to ⅕ will experience significant depression associated with pregnancy and childbirth. [4]

I dedicated my thesis research to understanding how anxiety and depression are addressed with pregnant people. In BC, people can choose to be cared for throughout pregnancy by a family physician (FP), obstetrician-gynecologist (ObGyn), and/or registered midwife (RM). I interviewed five FPs, four RMs, and three ObGyns practicing in the Lower Mainland to understand their attitudes and perspectives regarding anxiety and depression during pregnancy, those who experience them, and how to address them (identification and management). I perceived providers on the frontlines of pregnancy care to have the power to shape families’ health outcomes and the initiatives and policies that impact them. [13,20] Understanding provider perspectives is the first step in improving our healthcare system’s responsiveness to families’ needs.

Participants reported seeing anxiety and/or depression regularly. Some even expressed expecting to see them given how the journey toward parenthood is a “big change” [RM,7] full of unknowns that can cause much distress and call for psychosocial adjustments. [21,22] As this FP put it:

“[..] the antenatal period is very hard to come to terms with […] there’s just so many changes going on, mentally, physically, emotionally. It’s hard for people to even A: recognize that there is an issue, and B: sort of come to terms or accept that there might be an issue.” [FP,5]

Feeling “[…] sad of the life you left behind, and being anxious of what’s going to happen, being afraid of giving birth […]” [RM,6] was considered natural by most. However, the aggravation of fears by perceived social pressures was a common frustration. As this ObGyn explained:

“[there] is a lot of pressure on women to do everything perfectly during pregnancy and the reality is it can be a lot harder than expected and that the expectation that are created are unrealistic.” [ObGyn,10]

Most participants found that messaging about how to be during pregnancy undermined the capacity for self-compassion essential to cope with unexpected emotions/moods. This requires disruption. As asserted by this FP:

“[…] when society and this culture is telling you so many things about how you have to be as a mom and like there’s so many outside pressures […] what would help? Like, changing that!” [FP,4]

The confluence of this “big life transition” [RM,8] with the stigma that befalls those who are experiencing anything other than the “ideal pregnancy” predicts and worsens anxiety and/or depression. [23] In response, providers centered the normalization of anxiety and depression in encouraging disclosures and supporting management. Often, this involved letting pregnant people know “[…] it’s common” [FP,3], and that they’ll “[…] figure it out together.” [RM,8]

Most participants favoured this approach over-relying on standardized screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS) integrated into their antenatal care forms. [5] This is consistent with previous investigations. [3,7,8,13,14] Many expressed skepticism about the EPDS’ reliability. As an ObGyn with 16 years experience said:

“All of our patients were supposed to be filling it out, but it didn’t seem to be identifying things particularly well for us.” [ObGyn,10]

Some participants reported refraining from using the EPDS due to perceived harms. They expressed worry about isolating people, giving them a stigmatizing label (i.e. mentally ill), and/or triggering the very issues they are trying to identify, prevent, and manage. One RM referred to screening tools as “systems of triggers” [RM,6] adding, “I feel like it is quite isolating, and I feel like it is quite stigmatizing.”[RM,6]

Discussing mental health openly was considered less alienating than using a screening tool. Participants explained how dialogue feels innocuous (safe) whereas tools feel official (intimidating). They considered identification an important first step toward management and supporting healthy pregnancy outcomes. Unfortunately, the stigmatization and complexity of mental health presents challenges in communication. As this RM said:

“one of the things [providers] find challenging is that […] there’s different ways that you can check in with people and people respond very differently to different types of communication.” [RM,8]

Negative perceptions of mental health and reluctance to talk about it mean that there is “[a] fine line between trying to help and offending people” [RM,7]

This is cause for concern given how anxiety and depression during pregnancy often manifest in avoidance of care, poor adherence to recommendations and poor health habits relating to sleep and nutrition. [11,15,18] All exacerbate mental health conditions and risks of poor health outcomes. [4] Providers expressed concern about keeping clients engaged.

Additionally, feeling underprepared and overburdened in supporting pregnant people experiencing anxiety and/or depression was commonplace. All wished they received the systemic support to “make it easier!”[RM,8] beginning with their training. As this RM said:

“[…] perinatal depression is the number one, uh, issue in pregnancy. Not, you know, preeclampsia, and not, you know, whatever, it’s perinatal depression […] and we’re so not educated in it […]” [RM,6]

Even though some may think of mental health as within the scope of their care responsibilities, it is not perceived to be facilitated. Most reported: 

“[…] I feel like I try to do my best.” [RM,8] but when “[…] people, resources, money and resources that are… scarce.” [RM,7], “[…] healthcare providers take on a lot of responsibility and a lot of worry.” [FP,1]

Generally, there is a sense of insecurity in the quality of care provided given the lack of mental health integration.

When discussing what would be advantageous to their efforts, many echoed this RM in needing a “multi-pronged approach” [RM,9] that allocates resources to provider capacity, specialist availability, and resource accessibility (affordability and relevance). They emphasized this is our systems’ responsibility and insisted that funding translates to care priority. In this RM’s words:

“[…] the government decides how they’re going to fund us and what they’re going to pay for […] if they don’t put funding into programs to support mental health and wellness, then… then just the programs don’t exist for us to refer people to.” [RM,8]

Simply, we need “[to] build a government that supports mental health care” [FP,1]

To create demand for existing structures to change in favour of integrating mental health, we need to think about who has the power to stimulate adaptations by the healthcare system. While I entered this project assuming primary care providers had this power, participants identified that the changes need to happen upstream where the money comes from. It is with sincere alignment with participants that I assert the need to fund perinatal mental health research, training, and care. When perinatal mental health is not represented in priority-setting and decision-making documents and spaces, it minimizes the urgency of the issue, trivializes avoidable adverse health outcomes, and erases the people (and families; communities) experiencing them.

The World Health Organization and the United Nations Population Fund have jointly decreed there can be “no health without mental health”. Perinatal Services British Columbia recognizes that early detection of mental health challenges before, during and after pregnancy offers opportunities to improve health outcomes for parents and families. [5] Mental health promotion, prevention and early intervention show positive investment on returns. [12] Our Ministry and health authorities are responsible for making mental health services available and accessible, from prevention to management. [24] 

Far more than producers of the next generation/s, pregnant people’s care should not be exclusive to physiology and babies’ gestation. To care for populations equitably, we must recognize how the erasure of complexity in people’s experiences perpetuate health and social inequities. We must make room for the experiences that are silenced, erased, and stigmatized to be demystified and supported.

 

Disclaimer: To meaningfully address perinatal mental health disparities, all pregnancy experiences within our colonial, cisgender, ableist, hetero-patriarchy must be accounted for.

 

 

 

 

Bibliography

Santana Parrilla, J. (2020). Addressing anxiety and depression during pregnancy: primary antenatal care provider perspectives. University of British Columbia. http://hdl.handle.net/2429/74143

Al-Gailani, S., & Davis, A. (2014). Introduction to “Transforming pregnancy since 1900.” Studies in History and Philosophy of Biological and Biomedical Sciences, 47(Pt B), 229–232. https://doi.org/10.1016/j.shpsc.2014.07.001

Bayrampour, H., Hapsari, A. P., & Pavlovic, J. (2018). Barriers to addressing perinatal mental health issues in midwifery settings. Midwifery, 59, 47–58. https://doi.org/10.1016/j.midw.2017.12.020

BC Reproductive Mental Health Program. (2006). Addressing Perinatal Depression: A Framework for BC’s Health Authorities (Framework) [Framework]. BC Reproductive Mental Health Program: BC Women’s Hospital & Health Centre, an Agency of the Provincial Health Services Authority. http://www.health.gov.bc.ca/library/publications/year/2006/MHA_PerinatalDepression.pdf

BC Reproductive Mental Health Program, & Perinatal Services BC. (2014). Best Practice Guidelines for Mental Health Disorders in the Perinatal Period. http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/MentalHealthDisordersGuideline.pdf

Canada, P. H. A. of. (2016, May 27). Report from the Canadian Chronic Disease Surveillance System: Mood and Anxiety Disorders in Canada, 2016 [Research]. Aem. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/report-canadian-chronic-disease-surveillance-system-mood-anxiety-disorders-canada-2016.html

Coburn, S. S., Luecken, L. J., Rystad, I. A., Lin, B., Crnic, K. A., & Gonzales, N. A. (2018). Prenatal Maternal Depressive Symptoms Predict Early Infant Health Concerns. Maternal and Child Health Journal, 22(6), 786–793. https://doi.org/10.1007/s10995-018-2448-7

Fairbrother, N., Corbyn, B., Thordarson, D. S., Ma, A., & Surm, D. (2019). Screening for perinatal anxiety disorders: Room to grow. Journal of Affective Disorders, 250, 363–370. https://doi.org/10.1016/j.jad.2019.03.052

Gobinath, A. R., Mahmoud, R., & Galea, L. A. M. (2015). Influence of sex and stress exposure across the lifespan on endophenotypes of depression: Focus on behavior, glucocorticoids, and hippocampus. Frontiers in Neuroscience, 8. https://doi.org/10.3389/fnins.2014.00420

Hendrick, V., Altshuler, L. L., & Suri, R. (1998). Hormonal Changes in the Postpartum and Implications for Postpartum Depression. Psychosomatics, 39(2), 93–101. https://doi.org/10.1016/S0033-3182(98)71355-6

Kruper, A., & Wichman, C. (2017). Integrated Perinatal Mental Health Care. Psychiatric Annals, 47(7), 368–373. https://doi.org/10.3928/00485713-20170531-01

Mental Health Commission of Canada. (2014). Why investing in mental health will contribute to Canada’s economic prosperity and to the sustainability of our healthcare system (p. 5). Mental Health Commission of Canada. https://www.mentalhealthcommission.ca/English/media/3104

Price, S. K., Corder-Mabe, J., & Austin, K. (2012). Perinatal Depression Screening and Intervention: Enhancing Health Provider Involvement. Journal of Women’s Health, 21(4), 447–455. https://doi.org/10.1089/jwh.2011.3172

Psaros, C., Geller, P. A., Sciscione, A. C., & Bonacquisti, A. (2010). Screening Practices for Postpartum Depression Among Various Health Care Providers. The Journal of Reproductive Medicine, 55, 477–484.

Stewart, D. E. (2011). Depression during Pregnancy. New England Journal of Medicine, 365(17), 1605–1611. https://doi.org/10.1056/NEJMcp1102730

Weissman, M. M., & Olfson, M. (1995). Depression in Women: Implications for Health Care Research. Science, 269(5225), 799–801. JSTOR. http://www.jstor.org/stable/2888484

WHO | Maternal mental health. (n.d.). WHO. Retrieved July 7, 2019, from https://www.who.int/mental_health/maternal-child/maternal_mental_health/en/

World Health Organization. (2008). Improving Maternal Mental Health [Millennium Development Goal 5 – improving maternal Health]. https://www.who.int/mental_health/prevention/suicide/Perinatal_depression_mmh_final.pdf?ua

Lee, A. M., Lam, S. K., Sze Mun Lau, S. M., Chong, C. S. Y., Chui, H. W., & Fong, D. Y. T. (2007). Prevalence, Course, and Risk Factors for Antenatal Anxiety and Depression: Obstetrics & Gynecology, 110(5), 1102–1112. https://doi.org/10.1097/01.AOG.0000287065.59491.70

Selix, N., Henshaw, E., Barrera, A., Botcheva, L., Huie, E., & Kaufman, G. (2017). Interdisciplinary Collaboration in Maternal Mental Health. MCN, The American Journal of Maternal/Child Nursing, 42(4), 226–231. https://doi.org/10.1097/NMC.0000000000000343

Deave, T., Johnson, D., & Ingram, J. (2008). Transition to parenthood: The needs of parents in pregnancy and early parenthood. BMC Pregnancy and Childbirth, 8(1), 30. https://doi.org/10.1186/1471-2393-8-30

George, A., Luz, R. F., De Tychey, C., Thilly, N., & Spitz, E. (2013). Anxiety symptoms and coping strategies in the perinatal period. BMC Pregnancy and Childbirth, 13(1), 233. https://doi.org/10.1186/1471-2393-13-233

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Photo by Janko Ferlič on Unsplash

Mental Health Awareness Beyond Anxiety and Depression: Shedding Light on the Body Image Problem

Author: Kaylee Misener, Clinical Psychology PhD student at University of British Columbia Okanagan | Editors: Alex Lukey and Arrthy Thayaparan (Blog Coordinators) 

Published: January 28th, 2021

In a 2003 New York Times interview, Dr. Susie Orbach, a sociologist at the London School of Economics and Political Science, said “we’re still not fully recognizing that the body-image problem is a public health emergency”. Unfortunately, this statement still rings true today. 

As a graduate student in clinical psychology and the president of the Mental Health Awareness and Advocacy Club at the University of British Columbia Okanagan (UBCO), addressing mental health stigma and promoting positive mental health is a particular passion of mine. However, throughout  my education and work in mental health, I find the same themes continue to receive most of the focus during events like Bell Let’s Talk Day. Events that promote awareness have made profound shifts in our cultural landscape regarding mental health in recent years, particularly for mental health challenges related to depression and anxiety. 

This year, I would like to draw attention to the mental health challenges related to body image and disordered eating. Despite their pervasive and serious nature, as noted by Dr. Orbach, these challenges are massively underrepresented in the broader discussions on mental health awareness. As a body image researcher and advocate, I have seen how these issues are often trivialized, dismissed, and underfunded. 

Why does body image matter?

Body image is a broad term pertaining to thoughts and feelings about one’s body. It also includes body-related behaviours one engages in.[1] Negative thoughts and feelings about one’s body are associated with a myriad of negative psychosocial outcomes including depression, low self-esteem, unsafe sex practices, smoking, increased anxiety, and school avoidance. Negative body image also predicts lower levels of physical activity and disordered eating behaviours, and is associated with increased dieting and weight gain.[7,8] 

Notably, negative body image is also one of the strongest predictors of eating disorders.[9] While less attention is directed towards their study, eating disorders are associated with the highest mortality rate across mental health disorders, outside of substance use disorders.[10] Despite these concerns, negative body image is so pervasive, particularly among women, that it is commonly referred to as “normative discontent,” indicating how normal it is to be unsatisfied in one’s relationship with their body and how much work we have left to do in this area.

What is positive body image?

While the findings noted above underscore the prevalence and severity of body image concerns, we also know that positive body image can significantly benefit overall health and well-being. For example, positive body image predicts favourable health outcomes such as increased physical activity, and decreased dieting, smoking and alcohol use.[11] Positive body image is also associated with lower rates of depression, higher self-esteem, and even greater use of sun protection.[12] 

Positive body image is commonly misunderstood as simply loving one’s appearance. However, this misconception misses the true essence of positive body image. Rather, it encompasses respecting the body by attending to its needs, accepting the body despite its perceived flaws, appreciating the body for its functionality, and working to protect ourselves from harmful outside influences such as those included in the media or physical harms.[13] 

How can we move toward positive body image?

Given the significant concerns associated with negative body image and the notable benefits associated with positive body image, it is tempting to wish we could wave a magic wand and create universal positive changes in body image overnight. While we may not have that magic wand, there are evidence-based strategies that can be used to improve one’s relationship with their body. 

  1. Positive People: Surround yourself with body positive people and minimize the time you spend engaging with dieting friends and diet culture. 
  2. Focus on Values: List the things you like about yourself and others that have nothing to do with physical appearance. 
  3. Be Critical: Be a critical consumer of the media and messages from the diet industry. Consider who profits from you feeling like you need to change. 
  4. What Will You Give Up: Consider what you give up to pursue idealized body shapes. Would you rather spend that time with friends, pursuing your dreams, or enjoying your life?
  5. Enjoy Movement: Engage in types of physical activity that you enjoy. Consider movement in the context of taking care of your body instead of punishing it. 
  6. Focus on Functionality: Celebrate all the things your body does for you. Make a list of everything and reflect on why those functions are important to you. 
  7. Hit Unfollow: Unfollow anyone on social media that makes you feel bad about yourself. Use social media to your benefit by following accounts which make you feel good. 
  8. Self-compassion: Try responding to yourself as you would a dear friend. Try self-compassion meditations or a workbook. 
  9. Mindfulness: Stay in the present moment and meet it without judgement. That includes your body.  

The above suggestions are just the tip of the body image iceberg. Often, the first step is simply starting the discussion on body image issues, particularly in the context of mental health. Everyone has a body and everyone has a relationship with their body. It is only through increased awareness and stigma reduction that societal-level shifts can be made to promote positive body image. By starting on the individual level and starting small, we can be part of this necessary wave of change. 

References
  1. Cash, T. F. (2004). Body image: Past, present, and future. Body Image, 1, 1-5. doi:10.1016/S1740-1445(03)00011-1
  2. Paxton, S. J., Neumark-Sztainer, D., Hannan, P. J., & Eisenberg, M. E. (2006). Body dissatisfaction prospectively predicts depressive mood and low self-esteem in adolescent girls and boys. Journal of Clinical Child & Adolescent Psychology, 35, 539–549. doi:10.1207/s15374424jccp3504_5
  3. Schooler, D. (2013). Early adolescent body image predicts subsequent condom use behavior among girls. Sexuality Research and Social Policy, 10, 52-61. doi:10.1007/s13178-012-0099-9
  4. Howe, L. J., Trela-Larsen, L., Taylor, M., Heron, J., Munafò, M. R., & Taylor, A. E. (2017). Body mass index, body dissatisfaction and adolescent smoking initiation. Drug and Alcohol Dependence, 178, 143–149. doi:10.1016/J.DRUGALCDEP.2017.04.008
  5. Vannucci, A., & Ohannessian, C. M. (2018). Body image dissatisfaction and anxiety trajectories during adolescence. Journal of Clinical Child and Adolescent Psychology, 47, 785–795. doi:10.1080/15374416.2017.1390755
  6. Neumark-Sztainer, D., Paxton, S. J., Hannan, P. J., Haines, J., & Story, M. (2006). Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. Journal of Adolescent Health, 39, 244-251. doi:10.1016/j.jadohealth.2005.12.001
  7. Hayden-Wade, H. A., Stein, R. I., Ghaderi, A., Saelens, B. E., Zabinski, M. F., & Wilfley, D. E. (2005). Prevalence, characteristics, and correlates of teasing experiences among overweight children vs. non-overweight peers. Obesity Research, 13, 1381–1392. doi:10.1038/oby.2005.167
  8. Sonneville, K. R., Calzo, J. P., Horton, N. J., Haines, J., Austin, S. B., & Field, A. E. (2012). Body satisfaction, weight gain and binge eating among overweight adolescent girls. International Journal of Obesity, 36, 944–949. doi:10.1038/ijo.2012.68
  9. Rosenvinge, J. H., & Pettersen, G. (2014). Epidemiology of eating disorders part II: An update with a special reference to the DSM-5. Advances in Eating Disorders, 3, 198-220. doi:10.1080/21662630.2014.940549
  10. Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders: A meta-review. World Psychiatry, 13, 153-160. doi:10.1002/wps.20128
  11. Andrew, R., Tiggemann, M., & Clark, L. (2016). Predictors and health-related outcomes of positive body image in adolescent girls: A prospective study. Developmental Psychology, 52, 463–474. doi:10.1037/dev0000095
  12. Gillen, M. M. (2015). Associations between positive body image and indicators of men’s and women’s mental and physical health. Body Image, 13, 67-74. doi:10.1016/j.bodyim.2015.01.002
  13. Tylka, T.L. (2011) ‘Positive psychology perspectives on body image’, in T.F. Cash and L. Smolak (Eds) Body image: A handbook of science, practice and prevention, 2nd edition (pp. 56–67), New York: Guilford.
  14. Neighbors, L. A., & Sobal, J. (2007). Prevalence and magnitude of body weight and shape dissatisfaction among university students. Eating Behaviors, 8, 429-439. doi:10.1016/j.eatbeh.2007.03.003
  15. Stice, E., & Shaw, H. (2002). Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. Journal of Psychosomatic Research, 53, 985-993. doi:10.1016/S0022-3999(02)00488-9
  16. Duenwald, M. (2003, June 22). Body Image: One size definitely does not fit all. The New York Times. https://www.nytimes.com/2003/06/22/health/body-and-image-one-size-definitely-does-not-fit-all.html

Women’s Brain Health Series: Symposium 2 Summary

 

Author: Alex Lukey (@AlexandraLukey) – Registered Nurse, Master of Science in Nursing (UBC) and Women’s Health Blog Co-Coordinator | Editor: Arrthy Thayaparan, Women’s Health Blog Co-Coordinator

Published: December 14th, 2020

This past year has been a time of unprecedented change and constant adjustments. For the Women’s Health Research Cluster (WHRC) a lot of our work has shifted online to better serve our cluster members. In particular, the WHRC’s annual women’s health conference went from a single-day event to a series of 10 monthly sessions.

Originally meant to be held in May 2020, this year’s conference focused on women’s brain health. The purpose of the conference was to highlight how women have unique health needs and are more susceptible to specific brain diseases. The fourth session of the Women’s Brain Health Virtual Conference Series was held on December 4th and welcomed experts to discuss the intersection between women’s health and mental health. A variety of ideas were considered during the session, which our blog coordinator, Alex Lukey, has summarized for our esteemed readers:

Dr. Shau-Ming Wei, NIH/NIMH

Mood disorders during Reproductive Transitions: Circuit and Cellular Substrates of Risk 

Many women experience Pre-Menstrual Syndrom (PMS) but for some women, the mood shifts can be so severe that they damage work and family relationships. When this happens what they may be experiencing is known as Premenstrual Dysphoria Disorder (PMDD); a far more severe form of PMS.

Dr. Wei presented research that shows that there may be differences at both the brain and cellular response to hormones in women with PMDD. This early research is exciting because it is evidence that the extreme psychological symptoms that some women experience have a biological basis. This also means that PMDD may be treatable.

The research showed that there were differences in blood flow to an area of the brain (subgenual cingulate) indicated in major depression disorder when exposed to high levels of estrogen and progesterone compared to women without PMDD. This means that the brains of women with PMDD respond differently to the normal fluctuations of hormones than women without PMDD. Early evidence from Dr. Wei also showed that when estrogen was suppressed in women with PMDD that there was as much as a 70% reduction in symptoms.

To treat a disorder we must first understand the biological reasons for the illness. That’s why this research is critical for us to better understand how to treat women with PMDD.

Dr. Cindy Lee Dennis, University of Toronto

Mental Health across the Perinatal Period starting Preconception

Perinatal mental health pertains to the period of time immediately before and after mother’s give birth. Research in this area is still in it’s early stages of conception – having only been addressed in the last 30 years. Dr. Dennis presented research that is critical to the effective treatment of perinatal anxiety and depression.

Due to public health efforts, there is an increased awareness of post-natal depression, commonly known as “baby blues.” What is less known is that depression and anxiety often start during pregnancy and can last several years after if not treated. According to Dr Dennis, at least a ⅓ of women had symptoms DURING and another ⅓ before pregnancy. Further one of the strongest risk factors for perinatal depression is a previous major depressive episode. Yet, screening and interventions are usually not completed until after the baby is born. Dr. Dennis advocated that screening and interventions must be aimed much earlier for better outcomes.

Anxiety is also not commonly addressed in women both during and after pregnancy. About 1/4 of women reported a major anxiety episode into their pregnancy. There were factors that reduced anxiety and depression according to Dr Davis. Two factors which reduced anxiety and depression in women were partner support and self-efficacy in breastfeeding. Both of these factors can be targeted for intervention.

Partner support is an important component to focus on as well because men also experience increased anxiety and depression. Dr. Dennis highlighted the importance of studying the effects and experiences of men with anxiety and depression during the perinatal period. Risk factors for paternal perinatal mental health issues varied from emotional abuse, financial instability, paternal ADHD, and obesity. Yet there is much less research and support for partners of women.

The main take-away message from this conversation? Perinatal mental health is not exclusive to mothers, but is a family affair. Thus, the imporatance to initiate interventions before pregnancy becomes even more vital. It really is never too early to address perinatal mental health. Especially considering that the first contact with antenatal care is usually too late to target major risk factors.

Dr. Benicio Frey, McMaster University

Mood Disorders and Reproductive Live Events: Translating Research into Clinical Practice

Dr. Frey started his talk with three clear objectives for the audience to understand:

  1. There are major links between mood disorders getting worse and premenstrual, postpartum and menopausal disorders
  2. The link between mood and premenstrual disorders is associated with worse clinical outcomes. In extreme cases even increased suicide rates
  3. Hormonal treatments may be one option to help improve symptoms and clinical outcomes

What do these conclusions mean? For women with serious mood disorders such as bipolar disorder, major hormonal changes such as pregnancy are risky. This could mean a relapse or worsening of their condition. Research also shows that with treatment this risk is significantly reduced. Unfortunately, according to Dr. Frey, hormonal changes as a risk factor for psychiatric emergencies is not widely taught to mental health professionals.

Dr Frey also discussed the connection between PMDD (Prementrual Dysphoric Disorder) and bipolar disorder.  A staggaring meta-analysis of 32 papers showed a 26% increase in suicide deaths at menstruation. This is further evidence that the effects of hormones are serious for women with mood disorders.

Dr Liisa Galea asked a follow up question for the women in the audience: What should a woman do if she thinks that she might have PMDD? Dr Frey suggested that women track their symptoms for two cycles using either an app or paper tracker. It is much harder for healthcare providers to dismiss symptoms when presented with a numerical measurement.

Alex’s main takeaways:

The talks although different in focus and topic had a clear message: We have a lot of work to do to understand the causes of mental health challenges in women. The hopeful message is that there are biological mechanisms specific to women that treatments can be aimed at. The talks by Dr Wei, Dr Dennis and Dr Frey are evidence of the immense progress being made in this field. Hopefully in the years to come, these essential conversations will bring to fruition results that will drive change in our understanding and treatment of women’s mental health.

 

Pregnancy and Mental Health: New Research Paves the Way for Better Treatment

Authors: Wansu Qiu (Ph.D. candidate), Liisa A.M. Galea (PhD, Graduate Program in Neuroscience, Department of Psychology. Djavad Mowafaghian Centre for Brain Health, University of British Columbia) & Katherine Moore (Adv. Dip., BA)

Pregnancy and postpartum are two periods in a person’s lifetime that cause major changes to the body and brain. Anyone who has been pregnant will no doubt be fully aware of the dramatic changes to their bodies. But what is perhaps less well known is that there are also changes that occur in the brain. Indeed, you may be familiar with the term “baby brain” or “maternal amnesia”. These terms are often used in a derogatory way towards new parents, but people need to be aware that changes to the brain do occur and can have a significant impact on mental health.

Unfortunately, many of the natural brain changes that occur during pregnancy and the postpartum period are similar to what we see in people with major depression. These changes include, but are not limited to, reductions in brain volumeincreased inflammationhormonal profile changes, and metabolism changes. So, it is natural to wonder whether and how these natural changes contribute to greater susceptibility to depression during pregnancy or the postpartum.

It turns out that the perinatal period (pregnancy and the postpartum) is a particular time of risk to develop depression. Perinatal depression is defined as depression that occurs during pregnancy or in the first few months following childbirth and affects approximately 15% of new parents. However, not all people that experience perinatal depression develop symptoms at the same time or have the same symptoms. For example, the majority of people with perinatal depression experienced depression at least once before their pregnancy. However, 40% of people with perinatal depression experienced depression for the first time in their lives in the early postpartum period. Unfortunately, research has typically not separated findings according to when depression starts. This is problematic because knowing when depressive symptoms begin can help us determine the cause of depression (etiology), as well as how to properly treat it. In fact, studies that separate findings by depression onset (e.g. during pregnancy versus postpartum) and include whether there was a previous history of depression, show that the success of antidepressants vary depending on these factors. Thus, the distinct biological changes between pregnancy and postpartum may be the reason why drug effectiveness changes during these periods.

Yet, very little research exists on the connection between these biological mechanisms, depression that starts during the perinatal period and treatment efficacy. Our lack of understanding is partially due to the misidentification of perinatal depression as just another form of major depression. This issue stems from the fact that current diagnostic manuals, such as the DSM-V, do not distinguish between depression onset during pregnancy versus depression onset during postpartum. Furthermore, they only consider depression occurring in the first four weeks after birth as the postpartum period, when in fact many distinct physiological changes occur well into the first year of motherhood that may impact depression susceptibility. Considering the large number of people that live with postpartum depression, but whom have never experienced depression before, it is pertinent to determine why this period has such a high risk for depression onset. Even more troubling, antidepressant treatments may be less effective when treating perinatal depression compared to treating depression at other times. Indeed, the effectiveness of antidepressants is even worse in the postpartum period compared to other periods of pregnancy such as preconception.

 

Sadly, pregnant and postpartum people are not often studied and are left out of clinical trials. The lack of females in research is troubling enough given the greater number of pharmaceutical side effects they experience and misdiagnosis they receive compared to men. This is compounded by the lack of data on the safety and efficacy of drugs during the perinatal period. Interestingly, there has been a surge in preclinical animal models of perinatal depression over the last 20 years. These studies have also shown that antidepressants are less effective when depression onset is during the postpartum. Specifically, using a preclinical model of first-time postpartum depression onset, researchers found that high stress hormone levels cause depressive-like symptoms including passive coping, reduced maternal care (e.g. more time spent away from the nest) and decreased plasticity in the hippocampus. Interestingly, the hippocampus is an area of the brain that is affected by depression in human populations too. In a series of studies, researchers also found that a common antidepressant, fluoxetine (Prozac), shows limited effectiveness in treating these symptoms in the postpartum. This mirrors previous findings in humans on antidepressant use during postpartum. Astonishingly, they found that fluoxetine reversed the decrease in maternal care behaviour in the early postpartum but did not reverse depressive symptoms (e.g. brain changes, passive coping) in the later postpartum, suggesting that fluoxetine may lose its effectiveness over time.

In a recent article, cluster member (Wansu Qiu: @WQiuPhoenix) wanted to understand what mechanisms or biomarkers may be limiting the efficacy of fluoxetine in the postpartum.  Using this same preclinical model, Qiu and colleagues discovered that inflammation and metabolism may play a role in the lack of antidepressant efficacy during the postpartum in females. Inflammation is important to examine because depression has been linked to increase inflammatory signalling and antidepressant effectiveness has been linked to decreased inflammatory signalling. Fluoxetine treatment in the postpartum increased a proinflammatory signal, IL-1β (a cytokine), in the hippocampus and decreased tryptophan concentrations. This is notable as fluoxetine usually decreases cytokines when it reverses symptoms, and decreased tryptophan is often found in depression in females. More alarmingly, they found that the effects of fluoxetine were still present when rat moms were given a high dose. Thus, the authors suggest that the lack of treatment efficacy is not due to how antidepressants are metabolized in the maternal body, but due to changes in drug action on inflammation and metabolism. Overall, these new findings suggest that the lack of effectiveness of fluoxetine to reverse symptoms in the postpartum may be related to tryptophan metabolism, possibly acting via inflammation in rodent moms. This new research can lead to a better understanding of postpartum depression and antidepressant efficacy, possibly paving new ways for better treatment options.

The bottom line: scientists need more research funding to study the distinct presentations of perinatal depression (pregnancy onset versus postpartum onset) and we need more researchers to take on these kinds of projects. Clinicians need to be on the lookout for perinatal mood disorders, and we need governments to develop a national strategy for perinatal mental health. As a society, we all need to support people not just during pregnancy but also in the postpartum—as they say, it takes a village.