Article

A Pilot Study of Heart Rate Variability Biofeedback Therapy in the Treatment of Perinatal Depression on a Specialized Perinatal Psychiatry Inpatient Unit

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Abstract

Heart rate variability biofeedback (HRVB) therapy may be useful in treating the prominent anxiety features of perinatal depression. We investigated the use of this non-pharmacologic therapy among women hospitalized with severe perinatal depression. Three questionnaires, the State Trait Anxiety Inventory (STAI), Warwick-Edinburgh Mental Well-Being Scale, and Linear Analog Self Assessment, were administered to 15 women in a specialized inpatient perinatal psychiatry unit. Participants were also contacted by telephone after discharge to assess continued use of HRVB techniques. The use of HRVB was associated with an improvement in all three scales. The greatest improvement (-13.867, p < 0.001 and -11.533, p < 0.001) was among STAI scores. A majority (81.9 %, n = 9) of women surveyed by telephone also reported continued frequent use at least once per week, and over half (54.6 %, n = 6) described the use of HRVB techniques as very or extremely beneficial. The use of HRVB was associated with statistically significant improvement on all instrument scores, the greatest of which was STAI scores, and most women reported frequent continued use of HRVB techniques after discharge. These results suggest that HRVB may be particularly beneficial in the treatment of the prominent anxiety features of perinatal depression, both in inpatient and outpatient settings.

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... The clinical efficacy of biofeedback has been investigated in a range of psychiatric disorders, including; anxiety (Beckham et al. 2013;Kim et al. 2012;Reiner 2008;Meuret et al. 2001;Rice et al. 1993), depression (Walker and Lawson 2013;Siepmann et al. 2008;Uhlmann and Froscher 2001;Baehr et al. 1997), to schizophrenia (Schneider et al. 1992). Schneider (1987) evaluated the cost effectiveness of biofeedback treatment in clinical settings, where reduction in physician visits and/or medication usage, decrease in medical care costs to patients, decrease in frequency and duration of hospital stays and re-hospitalization, decrease in mortality, and increase in quality of life, were considered. ...
... Ten studies utilized HRV/RSA or sole respiration biofeedback (see Table 3), for the treatment of panic disorder (Kim et al. 2012;Wollburg et al. 2011;Meuret et al. 2001), depression (Siepmann et al. 2008;Karavidas et al. 2007), anxiety in perinatal depression (Beckham et al. 2013), PTSD (Lande et al. 2010;Zucker et al. 2009), and a mixed anxiety sample including OCD, GAD, phobia and insomnia patients (Pop-Jordanova 2009;Reiner 2008). Seven studies (Beckham et al. 2013;Lande et al. 2010;Pop-Jordanova 2009;Zucker et al. 2009;Reiner 2008;Siepmann et al. 2008;Karavidas et al. 2007) used Respiratory Sinus Arrhythmia (RSA) biofeedback to alter HRV. ...
... Ten studies utilized HRV/RSA or sole respiration biofeedback (see Table 3), for the treatment of panic disorder (Kim et al. 2012;Wollburg et al. 2011;Meuret et al. 2001), depression (Siepmann et al. 2008;Karavidas et al. 2007), anxiety in perinatal depression (Beckham et al. 2013), PTSD (Lande et al. 2010;Zucker et al. 2009), and a mixed anxiety sample including OCD, GAD, phobia and insomnia patients (Pop-Jordanova 2009;Reiner 2008). Seven studies (Beckham et al. 2013;Lande et al. 2010;Pop-Jordanova 2009;Zucker et al. 2009;Reiner 2008;Siepmann et al. 2008;Karavidas et al. 2007) used Respiratory Sinus Arrhythmia (RSA) biofeedback to alter HRV. HRV/RSA-BF protocols train slow paced breathing in order to increase the amplitude of RSA, a component of HRV. ...
Article
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Biofeedback potentially provides non-invasive, effective psychophysiological interventions for psychiatric disorders. The encompassing purpose of this review was to establish how biofeedback interventions have been used to treat select psychiatric disorders [anxiety, autistic spectrum disorders, depression, dissociation, eating disorders, schizophrenia and psychoses] to date and provide a useful reference for consultation by clinicians and researchers planning to administer a biofeedback treatment. A systematic search of EMBASE, MEDLINE, PsycINFO, and WOK databases and hand searches in Applied Psychophysiology and Biofeedback, and Journal of Neurotherapy, identified 227 articles; 63 of which are included within this review. Electroencephalographic neurofeedback constituted the most investigated modality (31.7 %). Anxiety disorders were the most commonly treated (68.3 %). Multi-modal biofeedback appeared most effective in significantly ameliorating symptoms, suggesting that targeting more than one physiological modality for bio-regulation increases therapeutic efficacy. Overall, 80.9 % of articles reported some level of clinical amelioration related to biofeedback exposure, 65.0 % to a statistically significant (p < .05) level of symptom reduction based on reported standardized clinical parameters. Although the heterogeneity of the included studies warrants caution before explicit efficacy statements can be made. Further development of standardized controlled methodological protocols tailored for specific disorders and guidelines to generate comprehensive reports may contribute towards establishing the value of biofeedback interventions within mainstream psychiatry.
... Exposure time was based on averages taken from previous studies, which were variable. [43][44][45][46][47][48] Participants were contacted weekly to check on usage, questions or concerns. Every effort was made to ensure that each participant received the same amount of contact. ...
... Secondly, it is possible that four weeks was not a sufficient length of time, although several studies in non-CHR anxiety populations did observe an effect with this duration of time or less. 44,46,47,49 However, increasing duration may not be advantageous as participants were most adherent during the first week with a steady decline through the subsequent three weeks. Despite our observation that there was no dose effect, only 20% of participants used the biofeedback for the recommended amount of time and as a result exposure time may have been inadequate. ...
Article
Aim: Anxiety is a common presenting concern for individuals at clinical high risk (CHR) for psychosis. Treatment for CHR is still in the early stages and has focused on transition to psychosis and positive symptom reduction, but little is known about what may be effective in reducing anxiety for these young people. One treatment that may be effective for anxiety is heart rate variability (HRV) biofeedback. The aim of this study was to test the efficacy and feasibility of using HRV biofeedback to reduce anxiety and distress in those at CHR. Methods: Twenty participants who met minimum scores for anxiety and distress completed 4 weeks of an HRV biofeedback intervention and received pre- and post-intervention assessments. Repeated measures were used to examine changes in scores over time. Results: There was a significant decrease in impaired ability to tolerate normal stressors (P ≤ 0.001) and dysphoric mood (P ≤ 0.001) over time. There was no change on self-reported measures of anxiety and distress. However, when two outliers were removed there was a trend towards improvement in self-reported anxiety (P = 0.07). These results were not impacted by including usage time as a covariate. Feedback and adherence were significant. Conclusions: HRV biofeedback may be a feasible treatment option for individuals at CHR who have concerns with impaired stress tolerance and dysphoric mood. Future studies with a randomized controlled trial design will be necessary to further determine efficacy.
... A comprehensive review of the clinical and organizational studies is beyond the scope of this paper and has been discussed elsewhere (McCraty, 2016;McCraty et al., 2009b;McCraty & Childre 2010;McCraty & Zayas, 2014). Numerous studies that have used HRV coherence feedback technology to facilitate skill acquisition of self-regulation techniques have found significantly improved key markers of health, wellness and performance in many healthcare, law enforcement, corporate, military and educational settings (Alabdulgader, 2012;Beckham et al., 2013;Bedell, 2010;Berry et al., 2014;Bradley et al., 2010;Burch et al., 2018;Celka et al., 2020;Criswell et al., 2018;de Visser et al., 2016;Devi & Sheehy, 2012;Dziembowska et al., 2015;Edwards, 2017;Edwards, 2014aEdwards, , 2014bField et al., 2021;Field et al., 2022;Ginsberg, 2010;Hurtado et al., 2020;Jasubhai, 2021;Jester et al., 2018;Kim et al., 2019;Laudenslager et al., 2019;Lemaire, 2011;Li et al., 2022;Lloyd, 2010;Lord et al., 2019;Lutz, 2014;May,et al., 2018;McCraty & Atkinson, 2012;McCraty et al., 2000;McCraty et al., 2009aMcCraty et al., , 2009bMcCraty et al., 2003;McCraty et al., 1999;McCraty et al., 1998;McCraty & Nila, 2017;McLeod & Boyes, 2021;Pyne et al., 2018;Rijken et al., 2016;Saito et al., 2021;Sarabia-Cobo, 2015;Sutarto et al., 2020;Thurber, 2010;Trousselard et al., 2015;Wang et al., 2016;Weltman et al., 2014). ...
Article
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This paper outlines the early history and contributions our laboratory, along with our close advisors and collaborators, has made to the field of heart rate variability and heart rate variability coherence biofeedback. In addition to the many health and wellness benefits of HRV feedback for facilitating skill acquisition of self-regulation techniques for stress reduction and performance enhancement, its applications for increasing social coherence and physiological synchronization among groups is also discussed. Future research directions and applications are also suggested.
... 26 Early HRV biofeedback trials have demonstrated good tolerability and modest symptom improvements in anxiety, mood and substance-use disorders. [27][28][29][30][31] Vagus nerve stimulation (VNS), which involves surgical implants of electrodes to the left vagus nerve, also increases HRV. 32,33 VNS has demonstrated effectiveness in treatment-resistant depression, [34][35][36][37] with the US Food and Drug Administration granting approval for such therapeutic use of VNS in 2005. ...
Article
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The number of publications investigating heart rate variability (HRV) in psychiatry and the behavioral sciences has increased markedly in the last decade. In addition to the significant debates surrounding ideal methods to collect and interpret measures of HRV, standardized reporting of methodology in this field is lacking. Commonly cited recommendations were designed well before recent calls to improve research communication and reproducibility across disciplines. In an effort to standardize reporting, we propose the Guidelines for Reporting Articles on Psychiatry and Heart rate variability (GRAPH), a checklist with four domains:participant selection, interbeat interval collection, data preparation and HRV calculation. This paper provides an overview of these four domains and why their standardized reporting is necessary to suitably evaluate HRV research in psychiatry and related disciplines. Adherence to these communication guidelines will help expedite the translation of HRV research into a potential psychiatric biomarker by improving interpretation, reproducibility and future meta-analyses.
... With the funds and support, these units are able to treat the motherinfant dyad for 1 to 3 months postpartum with programs that include psychoeducation relating to perinatal mood disorder and infant care and attachment (Meltzer-Brody et al., 2014). In 2011, the University of North Carolina health care system opened a U.S.-based inpatient perinatal psychiatry unit to provide intensive psychiatric treatment along with psychoeducation, intensive psychotherapy, family support, mother-infant bonding, and support of lactation to mothers with severe perinatal mood disorders (Beckham, Greene, & Meltzer-Brody, 2013;Meltzer-Brody et al., 2014). ...
In this article, we describe an integrated care model in a perinatal psychiatry program to improve access to care for women who experience mood changes during the perinatal period. A nurse-practitioner trained in psychiatry and obstetrics is embedded in the obstetric clinic, and perinatal nurses, often the first professionals to recognize women who are experiencing mood changes, can easily refer women for follow-up. Barriers, lessons learned, and goals for implementation are described. © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses
... A pilot study of HRV biofeedback found improvement in state anxiety and well-being in 10 hospitalized women with perinatal depression. 47 This study is intriguing, but recommendations for HRV for perinatal mental health will have to await additional results. ...
... 20 Biofeedback constitutes a non-invasive psychological intervention, which showed its efficacy in the treatment of asthma, chronic obstructive pulmonary disease, irritable bowel syndrome, cyclic vomiting, recurrent abdominal pain, fibromyalgia, cardiac rehabilitation, hypertension, chronic muscle pain, pregnancy induced hypertension, depression, anxiety, post-traumatic stress disorder. 21 It was also used to decrease perinatal anxiety and depression in the third trimester 22 and psychological stress during the early postpartum period. 23 To our knowledge, there is no information about the efficacy of group biofeedback on psychosomatic symptoms in the first and early second trimester of pregnancy. ...
Article
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Introduction Hyperemesis gravidarum (HG) is a condition characterised by dehydration, electrolyte imbalance, lack of nutrition and at least 5% loss in body weight, occurring in the first half of pregnancy. The aim of this trial is to examine the efficacy of group biofeedback treatment on patients with HG with psychosomatic symptoms, which will be evaluated through the revised version of Diagnostic Criteria for Psychosomatic Research (DCPR-R). Methods and analysis In this single-blinded randomised controlled clinical trial, 68 patients with HG diagnosed with at least one psychosomatic syndrome according to DCPR-R and aged 18–40 years, will be recruited in a Chinese Maternal and Child Health Hospital. The sample will be randomised (1:1) into two arms: experimental group, which will undergo group biofeedback treatment, psycho-education and treatment as usual (TAU); and control group, which will undergo psycho-education and TAU only. The primary outcomes will be reduction of the frequency of psychosomatic syndromes, severity of nausea/vomiting, quality of life and heart rate variability. The secondary outcomes will include days of hospitalisation, repeated hospitalisation and laboratory investigations. Ethics and dissemination This study has received ethical approval from the Nanjing Medical University (No. 2019/491, granted 22 February 2019). All participants will be required to provide written informed consent. Study outcomes will be disseminated through peer-reviewed publications and academic conferences, and used to confirm a tailored biofeedback intervention for patients with HG with psychosomatic symptoms. Trial registration number Chinese Clinical Trial Registry (ChiCTR2000028754).
... We identified a few studies, which examined the feasibility and effectiveness of particular interventions in mother and baby units; such as parenting programmes (Butler et al. 2014; UK; qualitative design; N=15) and heart rate variability biofeedback therapy (Beckham et al. 2013; US; RMD; N=15); both interventions had the potential to achieve additional positive outcomes but results were not reported in a way that they could be used for our analysis and further research is needed to confirm their effectiveness. ...
... • anxiety in patients with eating disorders • chronic non-specific lower back pain • adaptation and rehab in brain injury • posttraumatic stress disorder in combat veterans • panic disorder and general anxiety disorder • lowering blood pressure in hypertensive patients • stress management training of elderly patients with congestive heart • psychological health and quality of life in patients with diabetes • non-pharmaceutical treatment of perinatal depression [34] Other studies have examined the effect of Heart Rate Variability Biofeedback Training on healthcare utilization rates and associated costs in workplace populations [19]: ...
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Background: Resilience to stress is critical in today's military service. Past work has shown that experts handle stress in more productive ways compared to novices. Training that specifically addresses stress regulation, such as the Graduated Stress Exposure paradigm, can build individual and unit resilience as well as adaptability so that stressors trigger effective stress coping skills rather than stress injury. Objective: We developed the Stress Resilience Training System (SRTS), a product of of Perceptronics Solutions Inc., to demonstrate that a software training app can provide an effective individualized method for mitigating the negative effects of situational and mission-related stress, at the same time eliciting potentially positive effects on performance. Methods: Seven separate evaluations including a usability study, controlled experiments, and field evaluations have been conducted to date. Results: These studies have shown that the SRTS training system effectively engages users to manage their stress, effectively reduces stress symptoms, and improves job performance. Conclusions: The SRTS system is a highly effective method for individualized training to inoculate professionals against the negative consequences of stress, while teaching them to harness its positive effects. SRTS is a technology that can be widely applied to many professions that are concerned with well-being. We discuss applications to law enforcement, athletics, personal fitness and healthcare in the Appendix.
... For example, there are many studies showing that the practice of breathing at 6 breaths per minute, supported by HRV biofeedback, induces the coherence rhythm and has a wide range of benefits. [183][184][185][186][187][188][189] In addition to clinical applications, HRV coherence feedback training often is used to support self-regulation skill acquisition in educational, corporate, law enforcement and military settings. Several systems that assess the degree of coherence in the user's heart rhythms are available. ...
Technical Report
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This insightful and comprehensive monograph provides fundamental and detailed summaries of HeartMath Institute’s many years of innovative research. It presents brief overviews of heart rate variability, resilience, coherence, heart-brain interactions,intuition and the scientific discoveries that shaped techniques developed to increase fulfillment and effectiveness. Included are summary reports of research conducted in the business, education, health and first responder fields. Both the layperson and science professional will appreciate its simplicity and thoroughness.
... As HRV biofeedback is simple and safe and involves almost no physical stress, several recent studies have considered its application for the treatment of daily anxiety in healthy individuals (Hallman et al. 2011;Henriques et al. 2011;Whited et al. 2014;Ratanasiripong et al. 2015;Dziembowska et al. 2016;Goessl et al. 2017). Furthermore, this approach has been assessed for the treatment or protection of perinatal depression in pregnant women during the last trimester and in puerperant women (Beckham et al. 2013;Kudo et al. 2014;Siepmann et al. 2014). ...
Article
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Anxiety about labor in women at the end of pregnancy sometimes reaches levels that are clinically concerning. We investigated whether low-risk pregnant women with childbirth fear during the last trimester demonstrate specific findings with regard to resting heart rate variability (HRV) and examined whether HRV biofeedback can reduce this fear and alter resting HRV. We measured the levels of childbirth fear (Wijma delivery expectancy/experience questionnaire, W-DEQ) and resting HRV indexes in 97 low-risk pregnant women in their 32nd–34th week of gestation and advised women with W-DEQ scores of ≥ 66 (n = 40) to practice HRV biofeedback (StressEraser) at home. We then reassessed these measures 3–4 weeks later in the 36th–37th week of gestation regardless of whether the women practiced the method. We found that childbirth fear had no significant effect on resting HRV indexes when the W-DEQ cutoff was conventionally set at ≥ 66. However, women with W-DEQ scores of ≥ 90 (n = 5) had a significantly lower high-frequency power than their counterparts (p = 0.028). The W-DEQ scores reduced significantly in women who performed HRV biofeedback (n = 18, p < 0.001), but there was no change in those who did not perform the method (n = 20). These findings suggested that very high W-DEQ scores (≥ 90), but not the conventional criteria (W-DEQ score ≥ 66), of the fear of childbirth were associated with low parasympathetic activity among low-risk pregnant women and that HRV biofeedback intervention can effectively decrease the fear of childbirth in these women.
... We also looked for differences among subjects in negative affect and mood and alcohol use with respect to differential patterns of respiration and self-report of emotional reaction to affect-arousing picture cues. Finally, among practitioners using methods of applied psychophysiology to treat emotional disorders, paced or slow breathing, often in the context of heart rate variability biofeedback, yoga, or qi gong, is frequently used and has been found efficacious as a treatment component for problems involving negative affect, including anxiety (Clark and Hirschman 1990; Franzblau et al. 2008; Henriques et al. 2011; Paul and Garg 2012; Shenefelt 2010; Thurber 2007; Tweeddale et al. 1994; Wells et al. 2012) and depression (Beckham et al. 2013; Brown and Gerbarg 2005; Karavidas et al. 2007; Sato et al. 2011; Siepmann et al. 2008; Tsang et al. 2006; Tweeddale et al. 1994). Preliminary studies have been done for treatment of substance abuse (Chen et al. 2010; Ospina et al. 2008). ...
... For example, there are many studies showing that the practice of breathing at 6 breaths per minute, supported by HRV biofeedback, induces the coherence rhythm and has a wide range of benefits. 111,[131][132][133][134][135][136] In addition to clinical applications, HRV coherence feedback training is often used to support selfregulation skill acquisition in educational, corporate, law enforcement, and military settings. Several systems that assess the degree of coherence in the user's heart rhythms are available. ...
Article
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Heart rate variability, the change in the time intervals between adjacent heartbeats, is an emergent property of interdependent regulatory systems that operates on different time scales to adapt to environmental and psychological challenges. This article briefly reviews neural regulation of the heart and offers some new perspectives on mechanisms underlying the very low frequency rhythm of heart rate variability. Interpretation of heart rate variability rhythms in the context of health risk and physiological and psychological self-regulatory capacity assessment is discussed. The cardiovascular regulatory centers in the spinal cord and medulla integrate inputs from higher brain centers with afferent cardiovascular system inputs to adjust heart rate and blood pressure via sympathetic and parasympathetic efferent pathways. We also discuss the intrinsic cardiac nervous system and the heart-brain connection pathways, through which afferent information can influence activity in the subcortical, frontocortical, and motor cortex areas. In addition, the use of real-time HRV feedback to increase self-regulatory capacity is reviewed. We conclude that the heart's rhythms are characterized by both complexity and stability over longer time scales that reflect both physiological and psychological functional status of these internal self-regulatory systems.
... In a study of the effects of five different types of prayer on HRV, it was found that all types of prayer elicited increased cardiac coherence; however, prayers of gratefulness and prayers that focused on heart felt love resulted in definitively higher coherence levels (Stanley, 2009). There are also many studies showing that the practice of breathing at 6 breaths per minute, supported by HRV biofeedback, induces the coherence rhythm and has a wide range of benefits (Lehrer et al., 2003(Lehrer et al., , 2006Siepmann et al., 2008;Hallman et al., 2011;Henriques et al., 2011;Ratanasiripong et al., 2012;Beckham et al., 2013;Li et al., 2013). It has also been shown that tensing the large muscles in the legs in a rhythmical manner at a 10 seconds rhythm can induce a coherent heart rhythm (Lehrer et al., 2009). ...
Article
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The ability to alter one's emotional responses is central to overall well-being and to effectively meeting the demands of life. One of the chief symptoms of events such as trauma, that overwhelm our capacities to successfully handle and adapt to them, is a shift in our internal baseline reference such that there ensues a repetitive activation of the traumatic event. This can result in high vigilance and over-sensitivity to environmental signals which are reflected in inappropriate emotional responses and autonomic nervous system dynamics. In this article we discuss the perspective that one's ability to self-regulate the quality of feeling and emotion of one's moment-to-moment experience is intimately tied to our physiology, and the reciprocal interactions among physiological, cognitive, and emotional systems. These interactions form the basis of information processing networks in which communication between systems occurs through the generation and transmission of rhythms and patterns of activity. Our discussion emphasizes the communication pathways between the heart and brain, as well as how these are related to cognitive and emotional function and self-regulatory capacity. We discuss the hypothesis that self-induced positive emotions increase the coherence in bodily processes, which is reflected in the pattern of the heart's rhythm. This shift in the heart rhythm in turn plays an important role in facilitating higher cognitive functions, creating emotional stability and facilitating states of calm. Over time, this establishes a new inner-baseline reference, a type of implicit memory that organizes perception, feelings, and behavior. Without establishing a new baseline reference, people are at risk of getting "stuck" in familiar, yet unhealthy emotional and behavioral patterns and living their lives through the automatic filters of past familiar or traumatic experience.
... In support for this, a recent study in humans found that depressed participants with high RSA reported fewer symptoms of depression than those with low RSA 6 months postevaluation only under conditions of high social support (Hopp et al., 2013). A number of treatment studies have also investigated RSA and HRV biofeedback-an approach that has produced significant improvement in both anxiety and depression (Beckham, Greene, & Meltzer-Brody, 2013;Karavidas et al., 2007;Siepmann, Aykac, Unterdörfer, Petrowski, & Mueck-Weymann, 2008). ...
Article
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Depression is characterized by disturbed sleep and eating, a variety of other nonspecific somatic symptoms, and significant somatic comorbidities. Why there is such close association between cognitive and somatic dysfunction in depression is nonetheless poorly understood. An explosion of research in the area of interoception—the perception and interpretation of bodily signals— over the last decade nonetheless holds promise for illuminating what have until now been obscure links between the social, cognitive–affective, and somatic features of depression. This article reviews rapidly accumulating evidence that both somatic signaling and interoception are frequently altered in depression. This includes comparative studies showing vagus-mediated effects on depression-like behaviors in rodent models as well as studies in humans indicating both dysfunction in the neural substrates for interoception (e.g., vagus, insula, anterior cingulate cortex) and reduced sensitivity to bodily stimuli in depression. An integrative framework for organizing and interpreting this evidence is put forward which incorporates (a) multiple potential pathways to interoceptive dysfunction; (b) interaction with individual, gender, and cultural differences in interoception; and (c) a developmental psychobiological systems perspective, emphasizing likely differential susceptibility to somatic and interoceptive dysfunction across the lifespan. Combined with current theory and evidence, it is suggested that core symptoms of depression (e.g., anhedonia, social deficits) may be products of disturbed interoceptive– exteroceptive integration. More research is nonetheless needed to fully elucidate the relationship between mind, body, and social context in depression.
... Heart rate variability (HRV) biofeedback is a training method to control one's breathing to the resonate frequency of about five to six breaths per minute, at which the amplitude of HRV is maximized; this may strengthen the baroreflex, thus improving autonomic functioning (Lehrer et al. 2003;Vaschillo et al. 2006). HRV biofeedback has been shown to contribute to the treatment of a variety of diseases with autonomic dysfunctions, including stressrelated psychiatric disorders Reiner 2008;Siepmann et al. 2008;Zucker et al. 2009;Weber et al. 2010;Tan et al. 2011;Beckham et al. 2013) or stressrelated chronic pain (Hassett et al. 2007;Hallman et al. 2011). Furthermore, HRV biofeedback may be available as a stress management method for healthy subjects under relatively stressful conditions (Henriques et al. 2011;Ratanasiripong et al. 2012;Whited et al. 2014). ...
Article
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This study examined the effectiveness of heart rate variability (HRV) biofeedback intervention for reduction of psychological stress in women in the early postpartum period. On postpartum day 4, 55 healthy subjects received a brief explanation about HRV biofeedback using a portable device. Among them, 25 mothers who agreed to implement HRV biofeedback at home were grouped as the biofeedback group, and other 30 mothers were grouped as the control group. At 1 month postpartum, there was a significant decrease in total Edinburgh Postnatal Depression Scale score (P < 0.001) in the biofeedback group; this change was brought about mainly by decreases in items related to anxiety or difficulty sleeping. There was also a significant increase in standard deviation of the normal heartbeat interval (P < 0.01) of the resting HRV measures in the biofeedback group after adjusting for potential covariates. In conclusion, postpartum women who implemented HRV biofeedback after delivery were relatively free from anxiety and complained less of difficulties sleeping at 1 month postpartum. Although the positive effects of HRV biofeedback may be partly attributable to intervention effects, due to its clinical outcome, HRV biofeedback appears to be recommendable for many postpartum women as a feasible health-promoting measure after childbirth.
... Due to the relatively short length of stay (LOS) that characterizes inpatient psychiatry units in general in the United States, and consistent with the approximately seven day LOS of this PPIU cohort, programming was developed with a strong focus on teaching skills and tools to manage anxiety and distress post-discharge (Hendrick, Altshuler et al. 2000;Bernstein, Rush et al. 2008;Paul, Downs et al. 2013). Heart-rate variability biofeedback (HRVB) therapy, an effective tool for demonstrating to the patient the physiological effects of anxiety (Karavidas, Lehrer et al. 2007), has been particularly effective as patients see first-hand how relaxation training, diaphragmatic breathing, and mindfulness techniques combat their distress (Beckham, Greene et al. 2013). Individual psychotherapy sessions allow one-to-one targeting of triggers for symptoms and planning for the unique post-discharge challenges each woman will address. ...
Article
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Women experiencing severe perinatal mental illness during pregnancy or postpartum have unique needs when psychiatric hospitalization is indicated. Although many countries have established mother-baby psychiatric units, similar facilities have not been available in the US. In 2011, the University of North Carolina at Chapel Hill inaugurated the first Perinatal Psychiatry Inpatient Unit in the US. We describe the unique characteristics of the patient population and report clinical outcomes guiding development and refinement of treatment protocols. Ninety-two perinatal patients were admitted between September 2011 and September 2012, and 91 completed self-report measures at admission and discharge. Perinatal unipolar mood disorder was the most frequent primary diagnosis (60.43 %), and 11 patients (12 %) were admitted with psychosis. The data document clinically and statistically significant improvements in symptoms of depression, anxiety, and active suicidal ideation between admission and discharge (p < 0.0001), as assessed by the Edinburgh Postnatal Depression Scale, Patient Health Questionnaire, and Generalized Anxiety Disorder Scale. Overall functioning was also improved, demonstrated by a significant mean difference of -10.96 in total scores of the Work and Social Adjustment Scale (p < 0.0001). Data suggest that delivering specialized and targeted interventions for severe maternal mental illness in a safe and supportive setting produces positive patient outcomes.
... HRV biofeedback is one such intervention; a number of HRV biofeedback studies have documented that biofeedback training to increase HRV produces acute and long-term gains. 6,7 These biofeedback protocols have led to significant decreases in symptoms of perinatal depression, 8 chronic fatigue, 9 and post-traumatic stress disorder, 10 among others. A recent meta-analysis found that HRV biofeedback training is associated with decreases in self-reported stress and anxiety. ...
Article
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Background: Below average heart rate variability (HRV) has been associated with sexual arousal dysfunction and overall sexual dysfunction in women. Autogenic training, a psychophysiologic relaxation technique, has been shown to increase HRV. In a recent study, sexually healthy women experienced acute increases in physiologic (ie, genital) and subjective sexual arousal after 1 brief session of autogenic training. Aim: To build on these findings by testing the effects of a single session of autogenic training on sexual arousal in a sample of women who reported decreased or absent sexual arousal for at least 6 months. Methods: Genital sexual arousal, subjective sexual arousal, and perceived genital sensations were assessed in 25 women 20 to 44 years old before and after listening to a 22-minute autogenic training recording. HRV was assessed with electrocardiography. Outcomes: Change in genital sexual arousal, subjective sexual arousal, and perceived genital sensations from the pre-manipulation erotic film to the post-manipulation erotic film. Results: Marginally significant increases in discrete subjective sexual arousal (P = .051) and significant increases in perceived genital sensations (P = .018) were observed. In addition, degree of change in HRV significantly moderated increases in subjective arousal measured continuously over time (P < .0001). There were no significant increases in genital arousal after the manipulation. Clinical implications: The results of this study suggest that autogenic training, and other interventions that aim to increase HRV, could be a useful addition to treatment protocols for women who are reporting a lack of subjective arousal or decreased genital sensations. Strengths and limitations: There are few treatment options for women with arousal problems. We report on a new psychosocial intervention that could improve arousal. Limitations include a relatively small sample and the lack of a control group. Conclusion: Our findings indicate that autogenic training significantly improves acute subjective arousal and increases perceived genital sensations in premenopausal women with self-reported arousal concerns. Stanton AM, Hixon JG, Nichols LM, Meston CM. One Session of Autogenic Training Increases Acute Subjective Sexual Arousal in Premenopausal Women Reporting Sexual Arousal Problems. J Sex Med 2018;15:64-76.
... HRV biofeedback is one such intervention; a number of HRV biofeedback studies have documented that biofeedback training to increase HRV produces acute and long-term gains. 6,7 These biofeedback protocols have led to significant decreases in symptoms of perinatal depression, 8 chronic fatigue, 9 and post-traumatic stress disorder, 10 among others. A recent meta-analysis found that HRV biofeedback training is associated with decreases in self-reported stress and anxiety. ...
Article
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Presented at the 2017 Annual Meeting of the International Society for the Study of Women’s Sexual Health
... HRV and PNG are thought to operate primarily via the vagus nerve, while EMG, EEG, STB and EDA are thought to operate via other means (Lehrer et al. 1994). The clinical efficacy of biofeedback has been investigated in a range of psychiatric disorders including anxiety (Beckham et al. 2013;Kim et al. 2012;Reiner 2008;Meuret et al. 2001;Rice et al. 1993), depression (Walker and Lawson 2013;Siepmann et al. 2008;Uhlmann and Froscher 2001;Baehr et al. 1997), ADHD (Butnik 2005) and schizophrenia (Schneider et al. 1992). Its use with children and adolescents has also been well documented (Delaney et al. 1992;Delk et al. 1994;Dikel and Olness 1980;Labbe and Williamson 1990;Labbe et al. 1993;Suter and Loughry-Machado 1981). ...
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Children and adolescents with long-term physical conditions are at increased risk of psychological problems, particularly anxiety and depression, and they have limited access to evidence-based treatment for these issues. Biofeedback interventions may be useful for treating symptoms of both psychological and physical conditions. A systematic review of studies of biofeedback interventions that addressed anxiety or depression in this population was undertaken via MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials databases. Primary outcomes included changes in anxiety and depression symptoms and 'caseness'. Secondary outcomes included changes in symptoms of the associated physical condition and acceptability of the biofeedback intervention. Of 1876 identified citations, 9 studies (4 RCTs, 5 non-RCTs; of which all measured changes in anxiety and 3 of which measured changes in depression) were included in the final analysis and involved participants aged 8-25 years with a range of long-term physical conditions. Due to the heterogeneity of study design and reporting, risk of bias was judged as unclear for all studies and meta-analysis of findings was not undertaken. Within the identified sample, multiple modalities of biofeedback including heart rate variability (HRV), biofeedback assisted relaxation therapy and electroencephalography were found to be effective in reducing symptoms of anxiety. HRV was also found to be effective in reducing symptoms of depression in two studies. A range of modalities was effective in improving symptoms of long-term physical conditions. Two studies that assessed acceptability provided generally positive feedback. There is currently limited evidence to support the use of biofeedback interventions for addressing anxiety and depression in children and adolescents with long-term physical conditions. Although promising, further research using more stringent methodology and reporting is required before biofeedback interventions can be recommended for clinical use instead or in addition to existing evidence-based modalities of treatment.
... Dysautonomia in PE may be alleviated by an easy-to-learn technique, the heart rate variability biofeedback. It has been shown to improve both autonomic functioning and perinatal anxiety and depression (75,76). ...
Article
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Background: Preeclampsia (PE) is a major obstetric complication that leads to severe maternal and fetal morbidity. Early detection of preeclampsia can reduce the severity of complications and improve clinical outcomes. It is believed that the autonomic nervous system (ANS) is involved in the pathogenesis of PE. We aimed to review the current literature on the prevalence and nature of ANS dysfunction in women with PE and the possible prognostic value of ANS testing in the early detection of PE. Methods: Literature search was performed using Medline (1966–2018), EMBase (1947–2018), Google Scholar (1970–2018), BIOSIS (1926–2018), Web of science (1900–2018); CINAHL (1937–2018); Cochrane Library, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Methodology Register (1999–2018). Additionally, the reference lists of articles included were screened. Results: A total of 26 studies were included in the present review presenting data of 1,854 pregnant women. Among these women, 453 were diagnosed with PE, 93.6% (424/453) of which displayed autonomic dysfunction. ANS function was assessed by cardiovascular reflex tests (n = 9), heart rate variability (n = 11), cardiac baroreflex gain (n = 5), muscle sympathetic nerve activity (MSNA) (n = 3), and biomarkers of sympathetic activity (n = 4). Overall, 21 studies (80.8%) reported at least one of the following abnormalities in ANS function in women diagnosed with PE compared to healthy pregnant control women: reduced parasympathetic activity (n = 16/21, 76%), increased sympathetic activity (n = 12/20, 60%), or reduced baroreflex gain (n = 4/5, 80%). Some of these studies indicated that pressor and orthostatic stress test may be useful in early pregnancy to help estimate the risk of developing PE. However, autonomic function tests seem not to be able to differentiate between mild and severe PE. Conclusions: Current evidence suggests that autonomic dysfunction is highly prevalent in pre-eclamptic women. Among autonomic functions, cardiovascular reflexes appear to be predominantly affected, seen as reduced cardiac parasympathetic activity and elevated cardiac sympathetic activity. The diagnostic value of autonomic testing in the prediction and monitoring of autonomic failure in pre-eclamptic women remains to be determined.
... Medium-to-large effect size decreases in anxiety and stress have been observed in response to HRV biofeedback and resonance paced breathing [25•, 26], consistent with positive modulatory effects on brain regions dually involved in autonomic nervous system control [31] and addiction [5••, 32]. A substantial body of work indicates HRV biofeedback benefits individuals with difficulty regulating affect such as depressive disorders [e.g., [33][34][35][36] and PTSD [e.g., [37][38][39][40][41], both of which are highly co-morbid with SUD. Such interventions need not be seen as stand-alone measures; rather, interventions that enhance baroreflex sensitivity may facilitate cognitive, behavioral, and motivational therapies for SUD. ...
Article
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Purpose of Review: Addiction and excessive substance use contribute to poor mental and physical health. Much research focuses tightly on neural underpinnings and centrally-acting interventions. To broaden this perspective, this review focuses on bidirectional pathways between the brain and cardiovascular system that are well-documented and provide innovative, malleable targets to bolster recovery and alter substance use behaviors. Recent Findings: Cardiovascular signals are integrated via afferent pathways in networks of distributed brain regions that contribute to cognition, as well as emotion and behavior regulation, and are key antecedents and drivers of substance use behaviors. Heart rate variability (HRV), a biomarker of efficient neurocardiac regulatory control, is diminished by heavy substance use and substance use disorders. Promising evidence-based adjunctive interventions that enhance neurocardiac regulation include HRV biofeedback, resonance paced breathing, and some addiction medications. Summary: Cardiovascular communication with the brain through bidirectional pathways contributes to cognitive and emotional processing but is rarely discussed in addiction treatment. New evidence supports cardiovascular-focused adjunctive interventions for problematic substance use and addiction.
... The processing of these signals provides information regarding the individual's physiological activity, which in turn allows her/him to respond accordingly [55]. For example, biofeedback on heart rate variability has been proven effective in reducing depression symptomatology during the perinatal period, as measured by Edinburgh Postnatal Depression Scale scores [56,57]. ...
Article
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Women are exposed to increased burden of mental disorders during the perinatal period: 13-19% experience postpartum depression. Perinatal psychological suffering affects early mother-child relationship, impacting child's emotional and cognitive development. Return-to-work brings additional vulnerability given the required balance between parenting and job demands. The MAternal Mental Health in the WORKplace (MAMH@WORK) project aims to develop and evaluate the effectiveness of a brief and sustainable intervention, promoting (a) maternal mental health throughout pregnancy and first 12 months after delivery, and (b) quality of mother-child interactions, child emotional self-regulation, and cognitive self-control, while (c) reducing perinatal absenteeism and presenteeism. MAMH@WORK is a three-arm randomized controlled trial. A short-term cognitive-behavioral therapy-based (CBT-based) psychoeducation plus biofeedback intervention will be implemented by psychiatrists and psychologists, following a standardized procedure manual developed after consensus (Delphi method). Participants (n = 225, primiparous, singleton pregnant women at 28-30 weeks gestational age, aged 18-40 years, employed) will be randomly allocated to arms: CBT-based psychoeducation intervention (including mindfulness); psychoeducation plus biofeedback intervention; and control. Assessments will take place before and after delivery. Main outcomes (and main tools): mental health literacy (MHLS), psychological wellbeing (HADS, EPDS, KBS, CD-RISC, BRIEF COPE), quality of mother-child interaction, child-mother attachment, child emotional self-regulation and cognitive self-control (including PBQ, Strange Situation Procedure, QDIBRB, SGS-II, CARE-Index), job engagement (UWES), and Citation: Costa, J.; Santos, O.; Virgolino, A; Pereira, M.E.; Stefanovska-Petkovska, M.; Silva, H.; Navarro-Costa, P.; Barbosa, M.; César das Neves, R.; Duarte e Silva, I.; et al. MAternal Mental Health in the WORKplace (MAMH@WORK): A Protocol for Promoting Perinatal Maternal Mental Health and Wellbeing. Int.
... Posttreatment participants improved on anxiety and well-being, while perinatal depression score was measured only at baseline and included in the analysis just as a covariate. The majority of participants 6 Neural Plasticity approved continuing using breathing techniques once a week or more frequently and usefulness of this strategy [84]. A sample of Thai depressed inpatients of mean age of 76 who received two 30-minute HRV biofeedback sessions a week, for five weeks, reduced their depression scores (Depressive Cognition Scale and Thai Geriatric Depression Scale), and controls (morning exercises and social activities) did not. ...
Article
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This article is aimed at showing the current level of evidence for the usage of biofeedback and neurofeedback to treat depression along with a detailed review of the studies in the field and a discussion of rationale for utilizing each protocol. La Vaque et al. criteria endorsed by the Association for Applied Psychophysiology and Biofeedback and International Society for Neuroregulation & Research were accepted as a means of study evaluation. Heart rate variability (HRV) biofeedback was found to be moderately supportable as a treatment of MDD while outcome measure was a subjective questionnaire like Beck Depression Inventory (level 3/5, “probably efficacious”). Electroencephalographic (EEG) neurofeedback protocols, namely, alpha-theta, alpha, and sensorimotor rhythm upregulation, all qualify for level 2/5, “possibly efficacious.” Frontal alpha asymmetry protocol also received limited evidence of effect in depression (level 2/5, “possibly efficacious”). Finally, the two most influential real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback protocols targeting the amygdala and the frontal cortices both demonstrate some effectiveness, though lack replications (level 2/5, “possibly efficacious”). Thus, neurofeedback specifically targeting depression is moderately supported by existing studies (all fit level 2/5, “possibly efficacious”). The greatest complication preventing certain protocols from reaching higher evidence levels is a relatively high number of uncontrolled studies and an absence of accurate replications arising from the heterogeneity in protocol details, course lengths, measures of improvement, control conditions, and sample characteristics.
... Preliminary results suggest that portable RSA biofeedback appears to be a promising treatment adjunct for disorders of autonomic arousal and is easily integrated into treatment Reiner (2008). Several studies support that RSA-BT is a promising treatment for several kinds of anxiety disorder, such as post-traumatic stress disorder (PTSD), work stress and perinatal depression Tan et al. (2011);Munafo et al. (2016); Beckham et al. (2013). Recently, guided breathing has been utilized as a mindful intervention for drivers to counteract the stress accumulated at work and the additional stress encountered during driving Paredes et al. (2018). ...
Conference Paper
RSA-BT (Respiratory Sinus Arrhythmia biofeedback-based Breathing Training) is a common cardiorespiratory intervention that has been commonly used as a complementary treatment to diseases (e.g., asthma), and as an effective exercise to reduce anxiety. In this demo, we propose BreathCoach, a smart and unobtrusive system using sensors on smartwatch and smartphone-based VR that enables in-home RSA-BT coaching. Specifically, BreathCoach uses off-the-shelf devices to continuously monitor key bio-signals including breathing pattern (BP), inter-beat interval (IBI), and the amplitude of RSA, and intelligently calculates the optimal breathing pattern based on current and historical measurements. The recommended breathing pattern is then conveyed to the user in the form of an intuitive VR game to provide an immersive training experience. We will showcase a research prototype implemented on Android smartphone and smartwatch with two proof-of-concept VR game designs.
... Sensors that record activity and other health-related data [15][16][17] could support monitoring beyond the clinic and advance functional assessment for ASD. Such sensors could provide continuous monitoring of SIB across contexts, extending into nonclinical settings such as the home and school. ...
Article
Objective: Monitoring technology may assist in managing self-injurious behavior (SIB), a pervasive concern in autism spectrum disorder (ASD). Affiliated stakeholder perspectives should be considered to design effective and accepted SIB monitoring methods. We examined caregiver experiences to generate design guidance for SIB monitoring technology. Materials and methods: Twenty-three educators and 16 parents of individuals with ASD and SIB completed interviews or focus groups to discuss needs related to monitoring SIB and associated technology use. Results: Qualitative content analysis of participant responses revealed 7 main themes associated with SIB and technology: triggers, emotional responses, SIB characteristics, management approaches, caregiver impact, child/student impact, and sensory/technology preferences. Discussion: The derived themes indicated areas of emphasis for design at the intersection of monitoring and SIB. Systems design at this intersection should consider the range of manifestations of and management approaches for SIB. It should also attend to interactions among children with SIB, their caregivers, and the technology. Design should prioritize the transferability of physical technology and behavioral data as well as the safety, durability, and sensory implications of technology. Conclusions: The collected stakeholder perspectives provide preliminary groundwork for an SIB monitoring system responsive to needs as articulated by caregivers. Technology design based on this groundwork should follow an iterative process that meaningfully engages caregivers and individuals with SIB in naturalistic settings.
... Heart rate variability biofeedback has been shown to restore autonomic control that has been acutely repressed by experimental exposure to inflammatory cytokines (Lehrer et al., 2010), and appears to ameliorate a number of disorders characterized by autonomic and/or emotional dysregulation (Lehrer, 2007), including hypertension (Lin et al., 2012;Nolan et al., 2010;Reineke, 2008), asthma (Lehrer et al., 2004), anxiety/stress (Hallman, Olsson, von Scheele, Melin, & Lyskov, 2011;Henriques, Keffer, Abrahamson, & Horst, 2011;Shenefelt, 2010), depression (Beckham, Greene, & Meltzer-Brody, 2013;Karavidas et al., 2007;Patron et al., in press;Siepmann, Aykac, Unterdorfer, Petrowski, & Mueck-Weymann, 2008), and chronic pain (Hallman et al., 2011;Sowder, Gevirtz, Shapiro, & Ebert, 2010;Strine, 2004;Yetwin, 2012), while improving athletic performance (Paul & Garg, 2012). We might, however, theorize that the effects of constant breathing at resonance frequency would not be advantageous. ...
Article
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Systems theory has long been used in psychology, biology, and sociology. This paper applies newer methods of control systems modeling for assessing system stability in health and disease. Control systems can be characterized as open or closed systems with feedback loops. Feedback produces oscillatory activity, and the complexity of naturally occurring oscillatory patterns reflects the multiplicity of feedback mechanisms, such that many mechanisms operate simultaneously to control the system. Unstable systems, often associated with poor health, are characterized by absence of oscillation, random noise, or a very simple pattern of oscillation. This modeling approach can be applied to a diverse range of phenomena, including cardiovascular and brain activity, mood and thermal regulation, and social system stability. External system stressors such as disease, psychological stress, injury, or interpersonal conflict may perturb a system, yet simultaneously stimulate oscillatory processes and exercise control mechanisms. Resonance can occur in systems with negative feedback loops, causing high-amplitude oscillations at a single frequency. Resonance effects can be used to strengthen modulatory oscillations, but may obscure other information and control mechanisms, and weaken system stability. Positive as well as negative feedback loops are important for system function and stability. Examples are presented of oscillatory processes in heart rate variability, and regulation of autonomic, thermal, pancreatic and central nervous system processes, as well as in social/organizational systems such as marriages and business organizations. Resonance in negative feedback loops can help stimulate oscillations and exercise control reflexes, but also can deprive the system of important information. Empirical hypotheses derived from this approach are presented, including that moderate stress may enhance health and functioning.
... In a study of chronic fatigue syndrome HRV-BF also improved depression and fatigue, outperforming graded-exercise therapy on symptoms of depression and mental quality of life (Windthorst et al., 2017). The use of HRV-BF may also improve care in perinatal depression (Beckham, Greene, & Meltzer-Brody, 2013) or medically unexplained physical symptoms (Katsamanis et al., 2011). ...
Article
A consideration of physiology has so far not been very prominent in many forms of psychotherapy. Because some patients do not benefit from highly cognitive-verbal methods, an integration of more physiologically oriented approaches can expand the toolbox of therapists working with dysregulated patients. Physiological disturbances such as vagal and neurovisceral dysregulation, as detailed in polyvagal theory and the neurovisceral integration model, seem to be implicated in psychopathology and can be indexed through heart rate variability (HRV) and cardiac complexity (CC). Evidence so far shows that psychopathology is generally associated with reduced or atypical HRV or CC suggesting reduced capability for complex self-regulation. Interventions that may strengthen self-regulatory processes include therapies incorporating dyadically expanded states of consciousness, targeted autonomic and vagal coregulation, and sensorimotor and somatic approaches as well as HRV-biofeedback.
... In addition, HRV has been found to be a promising complementary method to treat PMAD. HRV biofeedback has shown to decrease anxiety symptoms of perinatal depression in hospitalized patients [62]. ...
Article
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Purpose of Review Our current understanding of the underlying mechanisms and etiologies of perinatal mood and anxiety disorders (PMADs) is not clearly identified. The relationship of stress-induced adaptations (i.e., the hypothalamic-pituitary-adrenal (HPA) axis, the autonomic nervous system (ANS), the immune system) and the microbiota are potential contributors to psychopathology exhibited in women during pregnancy and postpartum and should be investigated. Recent Findings The stress response activates the HPA axis and dysregulates the ANS, leading to the inhibition of the parasympathetic system. Sustained high levels of cortisol, reduced heart variability, and modulated immune responses increase the vulnerability to PMAD. Bidirectional communication between the nervous system and the microbiota is an important factor to alter host homeostasis and development of PMAD. Summary Future research in the relationship between the psychoneuroimmune system, the gut microbiota, and PMAD has the potential to be integrated in clinical practice to improve screening, diagnosis, and treatment.
... Biofeedback easily teaches people to increase the amplitude of HRV, and to stimulate at least two of these reflexes: (a) the baroreflex (Lehrer et al., 2003), which controls blood pressure changes and, indirectly, emotional lability, and (b) respiratory sinus arrhythmia (RSA; Lehrer et al., 2003), which affects efficiency of gas control in the lung by making heart rate oscillate in phase with breathing such that heart rate is highest exactly when the lung is maximally full of oxygen (Vaschillo, Vaschillo, & Lehrer, 2004. Published studies have found that HRV biofeedback helps people with a variety of disorders, including anxiety (Henriques, Keffer, Abrahamson, & Horst, 2011;Prinsloo, Derman, Lambert, & Rauch, 2013), depression (Beckham, Greene, & Meltzer-Brody, 2013;Karavidas et al., 2007), hypertension (Nolan et al., 2012;Reineke, 2008), chronic pain (Hallman, Olsson, von Scheele, Melin, & Lyskov, 2011;Humphreys & Gevirtz, 2000;Stern, Guiles, & Gevirtz, 2014), and other disorders, particularly when they have functional components (Wheat & Larkin, 2010). sEMG biofeedback has also been used to help a number of disorders. ...
Article
Although evidence supports the efficacy of biofeedback for treating a number of disorders and for enhancing performance, significant barriers block both needed research and payer support for this method. Biofeedback has demonstrated effects in changing psychophysiological substrates of various emotional, physical, and psychosomatic problems, but payers are reluctant to reimburse for biofeedback services. A considerable amount of biofeedback research is in the form of relatively small well-controlled trials (Phase II trials). This article argues for greater payer support and research support for larger trials in the “real life” clinical environment (Phase III trials) and meta-analytic reviews.
... In recent years, HRV biofeedback has also shown promise in the treatment of several disorders that are specifically associated with autonomic imbalance, including depression, anxiety, and PTSD (e.g., Beckham, Greene, & Meltzer-Brody, 2013;Henriques, Keffer, Abrahamson, & Horst, 2011;Siepmann, Aykac, Unterdörfer, Petrowski, & Mueck-Weymann, 2008;Tan, Dao, Farmer, Sutherland, & Gevirtz, 2011). The key mechanism believed to be M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT 8 responsible for the beneficial effects of HRV biofeedback is an increase in baroreflex gain (Lehrer et al., 2003). ...
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Low resting heart rate variability (HRV) has been associated with poor sexual arousal function in women. In a recent study, a single session of autogenic training increased HRV and facilitated improvements in both sexual arousal and perceived genital sensations among women experiencing decreased arousal. The current study expands upon these findings by examining the efficacy of HRV biofeedback, with and without autogenic training, as a treatment for sexual arousal dysfunction in an at-home setting. Participants (N = 78) were randomized into one of three conditions: HRV biofeedback, HRV biofeedback + autogenic training, or waitlist control. Each condition included three laboratory sessions; participants in the two active conditions completed 4–6 biofeedback sessions at home, and participants in the HRVB + A condition listened to a 14-min autogenic training recording before completing the biofeedback. Across the three laboratory visits, participants in the three conditions singficnatly differed in their genital arousal, subjective sexual arousal, and their perceived genital sensations. Compared to women in the control group, women who engaged in HRV biofeedback at home, with and without additional autogenic training, experienced increases in genital arousal, subjective sexual arousal, and perceived genital sensations. These results provide preliminary support for the contribution of heart rate variability level to female sexual arousal function and for the use of either of these interventions in the treatment of sexual arousal concerns.
Chapter
This chapter provides a brief overview and suggestions for biofeedback assessment and treatment of various disorders, including major depressive disorder (MDD), heart disease, diabetes, arthritis, and insomnia. It suggests biofeedback modalities to consider. While more randomized controlled studies are necessary to firmly establish the efficacy of heart rate variability (HRV) biofeedback in the treatment of major depressive disorder, the existing evidence is encouraging of the use of HRV biofeedback in treating MDD. Emerging evidence is showing that HRV biofeedback may be effective in improving the physiological function and severity of symptoms of people with heart disease. Thermal and surface electromyography (sEMG) biofeedback may be beneficial in treating arthritis related pain.
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This study examined the relationship of negative affect and alcohol use behaviors to baseline respiration and respiratory response to emotional challenge in young adults (N = 138, 48 % women). Thoracic-to-abdominal ratio, respiratory frequency and variability, and minute volume ventilation were measured during a low-demand baseline task, and emotional challenge (viewing emotionally-valenced, emotionally-neutral, and alcohol-related pictures). Negative mood and alcohol problems principal components were generated from self-report measures of negative affect and mood, alcohol use, and use-related problems. The negative mood component was positively related to a thoracic bias when measured throughout the study (including baseline and picture exposure). There was generally greater respiratory activity in response to the picture cues, although not specifically in response to the content (emotional or alcohol-related) of the picture cues. The alcohol problems component was positively associated with respiratory reactivity to picture cues, when baseline breathing patterns were controlled. Self-report arousal data indicated that higher levels of negative mood, but not alcohol problems, were associated with greater arousal ratings overall. However, those with alcohol problems reported greater arousal to alcohol cues, compared to emotionally neutral cues. These results are consistent with theories relating negative affect and mood to breathing patterns as well as the relationship between alcohol problems and negative emotions, suggesting that the use of respiratory interventions may hold promise for treating problems involving negative affect and mood, as well as drinking problems.
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Maternal stress can perturb physiology and psychiatric health leading to adverse outcomes. This review investigates the effectiveness of several mind-body therapies-namely biofeedback, progressive muscle relaxation, guided imagery, tai chi, and yoga-as interventions in reducing maternal stress and other pregnancy-related conditions. Through randomized trials, these techniques have shown promising benefits for reducing pain, high blood pressure, stress, anxiety, depressive symptoms, labor pain and outcomes, and postpartum mood disturbances. As these interventions are easy to implement, low cost, and safe to perform in pregnancy, they should be considered as alternative, nonpharmaceutical interventions to use during pregnancy and postpartum care.
Thesis
Le stress est un enjeu majeur de santé public, responsable du développement et de l’aggravation d’un grand nombre de troubles somatiques (maladies cardio-vasculaires,cancers, maladies infectieuses …) et psychiatriques (anxiété, dépression …). La gestion du stress par les thérapies comportementales, cognitives et émotionnelles (TCCE) est efficace pour réduire les conséquences négatives du stress et prévenir les troubles chez les sujets àrisque, mais son accès reste limité. Internet et les nouvelles technologies du numérique,notamment les self-help, les e-TCC et le biofeedback de variabilité de fréquence cardiaque(biofeedback de VFC) peuvent enrichir les programmes de gestion du stress par les TCCEet faciliter leur accès. Dans ce contexte, l’objectif de ce travail de thèse était de développeret d’évaluer des formats de traitements novateurs combinant TCCE et nouvellestechnologies.Dans un premier temps, le programme Seren@ctif, premier programme francophone de e-TCC dédié à la gestion du stress, a fait l’objet d’un essai contrôlé randomisé sur 120patients répondant au diagnostic de trouble d’adaptation avec anxiété (TAA) selon lescritères du DSM-5 et venant consulter en service de psychiatrie ambulatoire du CHU deLille. Les résultats ont mis en évidence que la TCCE administrée sur internet et guidée parun temps de contact humain en face-à-face avec un professionnel de santé supervisé(TCCE mixte) est tout aussi efficace que la TCCE entièrement administrée en face-à-facepour le traitement du TAA, par comparaison à un groupe contrôle de patients bénéficiantd’un suivi habituel par leur médecin généraliste.Dans un second temps, un nouveau biofeedback de VFC directement basé sur l’activationvagale, a été élaboré à partir d’une nouvelle mesure d’activation parasympathiquedéveloppée par l’équipe du centre d’investigation clinique, innovations technologiques deLille. Cette thèse présente les étapes d’élaboration de ce nouveau biofeedback, suiviesd’une preuve de concept portant sur plusieurs patients présentant divers troubles anxieuxet dépressifs. Ce nouveau biofeedback de VFC constitue une approche prometteusepermettant de stimuler de manière non-invasive le nerf vague. Il pourrait permettreégalement d’améliorer durablement l’activation vagale et d’objectiver physiologiquementl’effet bénéfique de la Mindful Breathing. Cette approche pourrait être complémentaire autraditionnel biofeedback d’arythmie sinusale respiratoire et permettrait de diversifier lestechniques comportementales associées au biofeedback.Les recherches présentées dans cette thèse contribuent à faire avancer la recherche dans ledomaine des technologies de l’information appliquées à la santé mentale etcomportementale. Elles ouvrent des perspectives innovantes sur une nouvelle façond’administrer les TCCE sur internet, sur l’efficacité potentielle d’un nouveau biofeedbackde VFC, ou encore, sur l’intérêt d’un nouveau marqueur de flexibilité du système nerveuxautonome dans l’évaluation objective de l’efficacité des TCC de troisième vague, notammentla Mindfulness
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Heart rate variability (HRV) biofeedback, a technique which encourages slow meditative breathing, was offered to 25 in-patients with various eating disorder diagnoses-anorexia nervosa, bulimia nervosa and binge eating disorder. We found that this modality had no serious side effects, and was subjectively useful to most participants. An enhanced ability to generate highly coherent HRV patterns in patients with recent onset anorexia nervosa was observed.
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Biofeedback therapy has been reported to be effective in the treatment of migraine. However, previous studies have assessed its effectiveness using paper-and-pencil diaries, which are not very reliable. The objective of the present pilot study was to investigate the feasibility of using computerized ecological momentary assessment (EMA) for evaluating the efficacy of BF treatment for migraine in a randomized controlled trial. The subjects comprised one male and 26 female patients with migraine. They were randomly assigned to either biofeedback or wait-list control groups. Patients were asked to carry a palmtop-type computer to record momentary symptoms for 4 weeks before and after biofeedback treatment. The primary outcome measure was headache intensity. The secondary outcome measures included psychological stress, anxiety, irritation, headache-related disability and the frequency (number of days per month) of migraine attack and of headache of at least moderate intensity (pain rating ≥50). Headache intensity showed significant main effects of period (before vs. after therapy, p = 0.02) and group (biofeedback vs. control groups, p = 0.42) and a significant period × group interaction (p < 0.001). Biofeedback reduced the duration of headaches by 1.9 days, and the frequency of days when headache intensity was ≥50 by 2.4 times. In addition, headache-related disability, psychological stress, depression, anxiety, and irritation were significantly improved. The present study used computerized EMA to show that biofeedback could improve the symptoms of migraine, including psychological stress and headache-related disability.
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to investigate predictors of anxiety for women experiencing hospitalisation during pregnancy and a comparison group of pregnant women (with or without medical complications) in the community. correlational, cross-sectional observational questionnaire study. regional antenatal inpatient unit and community-based settings in New Zealand in 2009 and 2010. 118 pregnant women in hospital and 114 pregnant women in community. women in hospital and community groups completed a battery of questionnaires on pregnancy and health history, life events, anxiety, optimism, coping, and relationship factors. Midwives caring for the women provided ratings of health status and psychological distress. Both groups of women had scores on state anxiety significantly above local norms; women in the hospital were significantly higher than those in the community on state anxiety and worry about their pregnancy. The groups did not differ on factors such as life events, optimism, and coping self-efficacy. Ratings of health and distress made by women and their midwives showed poor agreement. Predictors of acute anxiety differed across the groups: for hospitalised women, anxiety was predicted by their rating of their health and their dispositional optimism; for women in the community, anxiety was predicted by stressful life events, dispositional optimism, and coping self-efficacy. many women hospitalised during pregnancy are extremely anxious, and those most vulnerable are those who are less optimistic and see their health as poor. Health care professionals may not be aware of how anxious women are, and women and their hospital caregivers had poor agreement on ratings of the woman׳s health status. women hospitalised during pregnancy are at risk for high levels of anxiety. Midwives are well placed to help women by recognising their distress, supporting informed optimism, and guiding women toward realistic coping strategies and using existing social support networks. Research is needed on strategies for implementation and effectiveness of brief interventions to support women to manage anxiety and stress during pregnancy both in hospital and in the community. Copyright © 2015 Elsevier Ltd. All rights reserved.
Chapter
Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous clinical syndrome found in 6–8 % of the population (Handa et al. 2012), correlated to smoking habits and social structure. Prevalence of COPD in some countries has started to decline in male population, while prevalence in females is still increasing. Today, COPD is also a disease of lower social classes and the Third World, where smoking habits are different to parts of the industrialized world and particularly to the habits of the middle and upper class.
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Introduction Although hand temperature and electromyograph biofeedback have evidence for migraine prevention, to date, no study has evaluated heartrate variability (HRV) biofeedback for migraine. Methods 2-arm randomized trial comparing an 8-week app-based HRV biofeedback (HeartMath) to waitlist control. Feasibility/acceptability outcomes included number and duration of sessions, satisfaction, barriers and adverse events. Primary clinical outcome was Migraine-Specific Quality of Life Questionnaire (MSQv2). Results There were 52 participants (26/arm). On average, participants randomized to the Hearthmath group completed 29 sessions (SD = 29, range: 2–86) with an average length of 6:43 min over 36 days (SD = 27, range: 0, 88) before discontinuing. 9/29 reported technology barriers. 43% said that they were likely to recommend Heartmath to others. Average MSQv2 decreases were not significant between the Heartmath and waitlist control (estimate = 0.3, 95% CI = −3.1 - 3.6). High users of Heartmath reported a reduction in MSQv2 at day 30 (−12.3 points, p = 0.010) while low users did not (p = 0.765). Discussion App-based HRV biofeedback was feasible and acceptable on a time-limited basis for people with migraine. Changes in the primary clinical outcome did not differ between biofeedback and control; however, high users of the app reported more benefit than low users.
Article
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Negative emotion has a wide range of pernicious impacts on people, ranging from the failure in real-time task performance to the development of chronic health conditions. An unobtrusive wearable biofeedback system for personalized emotional management has been designed and presented in this paper. The system integrated heart rate variability (HRV) biofeedback to wearable biosensor platform, which could function both as an early stress warning system as well as a visual interface to manipulate subject’s affective state. The designed and developed system would help subject to transform the negative emotion state into positive through real-time HRV biofeedback training. The results indicated that the real-time HRV biofeedback is significantly effective in cases of negative emotion. With the aid of the developed biofeedback system, the subhealth subjects could transform heart rhythm from negative emotion to positive emotion-related oscillation mode.
Article
RSA-BT (Respiratory Sinus Arrhythmia biofeedback-based Breathing Training) is a cardio-respiratory intervention that has been commonly used as a complementary treatment to respiratory diseases, as well as an exercise to help manage stress and anxiety. Despite its health benefits, today's RSA-BT still relies on in-person sessions and cumbersome sensing devices in a clinical setting, which limits its accessibility. In this paper, we propose BreathCoach, a smart and unobtrusive system that enables effective in-home RSA-BT using sensors on a smartwatch and smartphone-based VR. Specifically, BreathCoach continuously measures key bio-signals including breathing pattern (BP), inter-beat interval (IBI), amplitude of RSA, and intelligently calculates the optimal BP based on current and historical measurements. The recommended BP is conveyed to users through a VR game to provide intuitive guidance. BreathCoach is implemented on a smartphone and a smartwatch with two proof-of-concept VR games. We conducted experiments with 10 participants and evaluated BreathCoach in three aspects: accuracy of physiological measurement, effectiveness of training, and user experience. The results suggest that BreathCoach is able to reliably measure needed bio-signals and intelligently calculate BP recommendations which result in improved performance compared with the traditional approach.
Article
Background Some evidence suggests that heart rate variability (HRV) biofeedback might be an effective way to treat anxiety and stress symptoms. To examine the effect of HRV biofeedback on symptoms of anxiety and stress, we conducted a meta-analysis of studies extracted from PubMed, PsycINFO and the Cochrane Library. Methods The search identified 24 studies totaling 484 participants who received HRV biofeedback training for stress and anxiety. We conducted a random-effects meta-analysis. Results The pre-post within-group effect size (Hedges' g ) was 0.81. The between-groups analysis comparing biofeedback to a control condition yielded Hedges' g = 0.83. Moderator analyses revealed that treatment efficacy was not moderated by study year, risk of study bias, percentage of females, number of sessions, or presence of an anxiety disorder. Conclusions HRV biofeedback training is associated with a large reduction in self-reported stress and anxiety. Although more well-controlled studies are needed, this intervention offers a promising approach for treating stress and anxiety with wearable devices.
Book
This book not only discusses clinical applications, but also links HRV to systems biology and theories of complexity. This publication should be interesting for several groups of clinicians and scientists, including cardiologists, anesthesiologists, intensivists and physiologists. Heart Rate Variability is in principle easy and cheap, making it interesting for all kind of hospitals and private practice. The book will be an example of using translational medicine (bench to bedside) where newest theoretical results are linked to newest clinical research.
Article
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The average prevalence rate of non-psychotic postpartum depression based on the results of a large number of studies is 13%. Prevalence estimates are affected by the nature of the assessment method (larger estimates in studies using self-report measures) and by the length of the postpartum period under evaluation (longer periods predict high prevalences). A meta-analysis was undertaken to determine the sizes of the effects of a number of putative risk factors, measured during pregnancy, for postpartum depression. The strongest predictors of postpartum depression were past history of psychopathology and psychological disturbance during pregnancy, poor marital relationship and low social support, and stressful life events. Finally, indicators of low social status showed a small but significant predictive relation to postpartum depression. In sum, these findings generally mirror the conclusions from earlier qualitative reviews of postpartum depression risk factors.
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The study was based on an index group of 49 mothers who had had depressive disorders in the post-natal year, and 49 control mothers who had been free from any psychiatric disorder since delivery. Nineteen months after childbirth, the interaction between mother and child was assessed by blind assessors using defined observational methods. Compared with controls, index mother-child pairs showed a reduced quality of interaction (e.g. mothers showed less facilitation of their children, children showed less affective sharing and less initial sociability with a stranger). Similar but reduced effects were seen in a subgroup of index mothers and children where the mother had recovered from depression by 19 months. Social and marital difficulties were associated with reduced quality of mother-child interaction.
Article
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Postpartum depressive disorders lead to maternal disability and disturbed mother-infant relationships, but information regarding the rates of major depressive disorder in minority women is noticeably lacking. The goal of this study was to determine whether the risk factors for and rate of postpartum major depressive disorder in a predominantly African American and Hispanic clinic population would be similar to those reported for Caucasian women. Investigators systematically screened all women scheduled for their first postpartum visit on selected days at four publicly funded inner-city community maternal health clinics in Dallas County (N=802). A multistage screening process included the Edinburgh Postnatal Depression Scale, the Inventory of Depressive Symptomatology, and the Structured Clinical Interview for DSM-IV for a maximum of three assessments during the initial 3-5-week postpartum period. The estimated rate of major depressive disorder during the postpartum period among women in this setting was between 6.5% and 8.5%. Only 50% of the depressed women reported onset following birth. Bottle-feeding and not living with one's spouse or significant other were associated with depression at the first evaluation; persistent depressive symptoms were linked with the presence of other young children at home. Greater severity of depressive symptoms at first contact predicted major depressive disorder several weeks later. Rates of postpartum depression among Latina and African American postpartum women are similar to epidemiologic rates for Caucasian postpartum and nonpostpartum women. As previously shown for Caucasian women, major depressive disorder in many Latina and African American postpartum women begins before delivery, revealing the need to screen pregnant women for depression.
Article
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The existence of a separate anxiety and depression dimension within the Edinburgh Postnatal Depression Scale (EPDS) has been reported previously. However, the concurrent validity of this anxiety subscale was never evaluated. We investigated whether (1) this existence of an anxiety subscale could be confirmed and (2) it more highly correlated with other measures of anxiety than the total EPDS. The SCL-90-R, the EPDS, and the State-Trait Anxiety Inventory (STAI) were filled out by 197 pregnant women. A principal component analysis (PCA) was used for confirmation of the subscales and correlations were computed between the (subscales of the) EPDS and the other measures of anxiety. The existence of an anxiety scale within the EPDS was confirmed. However, this subscale did not yield higher correlations with other measures of anxiety than did the total EPDS. Investigators using the EPDS to screen for depression should realise that the instrument does not exclusively measure depression. It seems that both anxiety symptoms and depressive symptoms are more accurately measured when using the total 10-item EPDS than when using the subscales.
Article
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Fibromyalgia (FM) is a non-inflammatory rheumatologic disorder characterized by musculoskeletal pain, fatigue, depression, cognitive dysfunction and sleep disturbance. Research suggests that autonomic dysfunction may account for some of the symptomatology of FM. An open label trial of biofeedback training was conducted to manipulate suboptimal heart rate variability (HRV), a key marker of autonomic dysfunction. Twelve women ages 18-60 with FM completed 10 weekly sessions of HRV biofeedback. They were taught to breathe at their resonant frequency (RF) and asked to practice twice daily. At sessions 1, 10 and 3-month follow-up, physiological and questionnaire data were collected. There were clinically significant decreases in depression and pain and improvement in functioning from Session 1 to a 3-month follow-up. For depression, the improvement occurred by Session 10. HRV and blood pressure variability (BPV) increased during biofeedback tasks. HRV increased from Sessions 1-10, while BPV decreased from Session 1 to the 3 month follow-up. These data suggest that HRV biofeedback may be a useful treatment for FM, perhaps mediated by autonomic changes. While HRV effects were immediate, blood pressure, baroreflex, and therapeutic effects were delayed. This is consistent with data on the relationship among stress, HPA axis activity, and brain function.
Article
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Major depressive disorder (MDD) is a common mood disorder that can result in significant discomfort as well as interpersonal and functional disability. A growing body of research indicates that autonomic function is altered in depression, as evidenced by impaired baroreflex sensitivity, changes in heart rate, and reduced heart rate variability (HRV). Decreased vagal activity and increased sympathetic arousal have been proposed as major contributors to the increased risk of cardiovascular mortality in participants with MDD, and baroreflex gain is decreased. To assess the feasibility of using HRV biofeedback to treat major depression. This was an open-label study in which all eleven participants received the treatment condition. Participants attended 10 weekly sessions. Questionnaires and physiological data were collected in an orientation (baseline) session and Treatment Sessions 1, 4, 7 and 10. Significant improvements were noted in the Hamilton Depression Scale (HAM-D) and the Beck Depression Inventory (BDI-II) by Session 4, with concurrent increases in SDNN, standard deviation of normal cardiac interbeat intervals) an electrocardiographic estimate of overall measure of adaptability. SDNN decreased to baseline levels at the end of treatment and at follow-up, but clinically and statistically significant improvement in depression persisted. Main effects for task and session occurred for low frequency range (LF) and SDNN. Increases in these variables also occurred during breathing at one's resonant frequency, which targets baroreflex function and vagus nerve activity, showing that subjects performed the task correctly. HRV biofeedback appears to be a useful adjunctive treatment for the treatment of MDD, associated with large acute increases in HRV and some chronic increases, suggesting increased cardiovagal activity. It is possible that regular exercise of homeostatic reflexes helps depression even when changes in baseline HRV are smaller. A randomized controlled trial is warranted.
Article
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There is increasing international interest in the concept of mental well-being and its contribution to all aspects of human life. Demand for instruments to monitor mental well-being at a population level and evaluate mental health promotion initiatives is growing. This article describes the development and validation of a new scale, comprised only of positively worded items relating to different aspects of positive mental health: the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS). WEMWBS was developed by an expert panel drawing on current academic literature, qualitative research with focus groups, and psychometric testing of an existing scale. It was validated on a student and representative population sample. Content validity was assessed by reviewing the frequency of complete responses and the distribution of responses to each item. Confirmatory factor analysis was used to test the hypothesis that the scale measured a single construct. Internal consistency was assessed using Cronbach's alpha. Criterion validity was explored in terms of correlations between WEMWBS and other scales and by testing whether the scale discriminated between population groups in line with pre-specified hypotheses. Test-retest reliability was assessed at one week using intra-class correlation coefficients. Susceptibility to bias was measured using the Balanced Inventory of Desired Responding. WEMWBS showed good content validity. Confirmatory factor analysis supported the single factor hypothesis. A Cronbach's alpha score of 0.89 (student sample) and 0.91 (population sample) suggests some item redundancy in the scale. WEMWBS showed high correlations with other mental health and well-being scales and lower correlations with scales measuring overall health. Its distribution was near normal and the scale did not show ceiling effects in a population sample. It discriminated between population groups in a way that is largely consistent with the results of other population surveys. Test-retest reliability at one week was high (0.83). Social desirability bias was lower or similar to that of other comparable scales. WEMWBS is a measure of mental well-being focusing entirely on positive aspects of mental health. As a short and psychometrically robust scale, with no ceiling effects in a population sample, it offers promise as a tool for monitoring mental well-being at a population level. Whilst WEMWBS should appeal to those evaluating mental health promotion initiatives, it is important that the scale's sensitivity to change is established before it is recommended in this context.
Article
Following childbirth, major depression (postpartum depression) affects approximately 8–12% of new mothers. However, little is known about the pharmacological management of postpartum depression, and no studies to date have assessed differences in treatment response between women with postpartum and nonpostpartum major depressionThe authors reviewed the records of 26 women with postpartum major depression and 25 women with major depression unrelated to childbearing (nonpostpartum depression) who presented to them for treatment over a 4-year period. Compared with the nonpostpartum depressed patients, the postpartum depressed women were significantly more likely to present with anxious features. Also, cases of postpartum depression were more severe than cases of nonpostpartum depression. While the postpartum patients were equally as likely to recover (as defined by a Clinical Global Impression score of 1 or 2) compared to the nonpostpartum-depressed patients, their time to response was significantly longer. By 3 weeks of pharmacotherapy, 75% of the nonpostpartum cases had recovered, in contrast to only 36% of the postpartum cases. Further, postpartum patients were significantly more likely to be receiving more than one antidepressant agent at the time of response to treatment. Length of depression prior to treatment did not explain the difference in treatment response. Presence of depressive symptoms during pregnancy and timing of onset of the depression (before vs. after 4 weeks of delivery) did not affect likelihood of treatment response in this sampleWomen with postpartum depression appear to be significantly more likely than the nonpostpartum women to present with anxious features, take longer to respond to pharmacotherapy for depression, and require more antidepressant agents at the time of response to treatment. Depression and Anxiety 11:66–72, 2000. © 2000 Wiley-Liss, Inc
Article
Mind-body interventions like yoga or hypnotherapy may be effective for reducing anxiety. These can be learned to induce mental relaxation and alter negative thinking related to anxiety to change the perception of a stressful event, leading to better adapted behaviour and coping skills. Their effectiveness for treatment or prevention of women’s anxiety during pregnancy needs to be confirmed in clinical trials, as anxiety during the different stages of pregnancy can affect women’s health and have consequences for the child. This review identified few studies that examined this. We included eight randomized controlled studies with 556 women in this review. Based on these studies, there is some not strong evidence for the effectiveness of mind-body interventions in the management of anxiety during pregnancy, labor, or in the first four weeks after giving birth. Compared with usual care, imagery may have a positive effect on anxiety during labor. Another study showed that imagery had a positive effect on anxiety and depression in the immediate postpartum period. Autogenic training might be effective for decreasing women's anxiety before delivering. No harmful effects were reported for any mind-body interventions in the studies included in the review. The studies used different mind-body interventions, sometimes as part of a complex intervention, that they compared with usual care or other potentially active interventions using diverse outcome measures. Several studies were at high risk of bias, had small sample sizes and high dropout rates.
Article
To examine the relationship between diverse infant feeding outcomes, e.g. infant feeding method, maternal satisfaction, infant feeding plans, breastfeeding progress and breastfeeding self-efficacy) and postpartum depressive symptomatology using a time-sequenced analysis. As part of a population-based study, 594 participants completed questionnaires at 1, 4 and 8 weeks postpartum. No relationship was found between diverse infant feeding outcomes at 1-week postpartum and the development of depressive symptomatology at 4 or 8 weeks. Conversely, mothers with an Edinburgh Postnatal Depression Score>12 at 1 week postpartum were significantly more likely at 4 and/or 8 weeks to discontinue breastfeeding, be unsatisfied with their infant feeding method, experience significant breastfeeding problems and report lower levels of breastfeeding self-efficacy. The findings from this study suggest that early identification of breastfeeding mothers with depressive symptomatology is needed not only to reduce the morbidity associated with postpartum depression but also in attempt to promote increased rates of breastfeeding duration.
Article
Background: Labour is often associated with pain and discomfort caused by a complex and subjective interaction of multiple factors, and should be understood within a multi-dimensional and multi-disciplinary framework. Within the non-pharmacological approach, biofeedback has focused on the acquisition of control over some physiological responses with the aid of electronic devices, allowing individuals to regulate some physical processes (such as pain) which are not usually under conscious control. The role of this behavioural approach for the management of pain during labour, as an addition to the standard prenatal care, has been never assessed systematically. This review is one in a series of Cochrane reviews examining pain relief in labour, which will contribute to an overview of systematic reviews of pain relief for women in labour (in preparation). Objectives: To examine the effectiveness of the use of biofeedback in prenatal lessons for managing pain during labour. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011), CENTRAL (The Cochrane Library 2011, Issue 1), PubMed (1950 to 20 March 2011), EMBASE (via OVID) (1980 to 24 March 2011), CINAHL (EBSCOhost) (1982 to 24 March 2011), and PsycINFO (via Ovid) (1806 to 24 March 2011). We searched for further studies in the reference lists of identified articles. Selection criteria: Randomised controlled trials of any form of prenatal classes which included biofeedback, in any modality, in women with low-risk pregnancies. Data collection and analysis: Two authors independently assessed trial quality and extracted data. Main results: The review included four trials (186 women) that hugely differed in terms of the diversity of the intervention modalities and outcomes measured. Most trials assessed the effects of electromyographic biofeedback in women who were pregnant for the first time. The trials were judged to be at a high risk of bias due to the lack of data describing the sources of bias assessed. There was no significant evidence of a difference between biofeedback and control groups in terms of assisted vaginal birth, caesarean section, augmentation of labour and the use of pharmacological pain relief. The results of the included trials showed that the use of biofeedback to reduce the pain in women during labour is unproven. Electromyographic biofeedback may have some positive effects early in labour, but as labour progresses there is a need for additional pharmacological analgesia. Authors' conclusions: Despite some positive results shown in the included trials, there is insufficient evidence that biofeedback is effective for the management of pain during labour.
Article
In this paper studies are reviewed from the last decade on postpartum depression effects on early interactions, parenting, safety practices and on early interventions. The interaction disturbances of depressed mothers and their infants appear to be universal, across different cultures and socioeconomic status groups and, include less sensitivity of the mothers and responsivity of the infants. Several caregiving activities also appear to be compromised by postpartum depression including feeding practices, most especially breastfeeding, sleep routines and well-child visits, vaccinations and safety practices. These data highlight the need for universal screening of maternal and paternal depression during the postpartum period. Early interventions reviewed here include psychotherapy and interaction coaching for the mothers, and infant massage for their infants.
Article
Decreased vagal activity and increased sympathetic arousal have been proposed as major contributors to the increased risk of cardiovascular mortality in patients with depression. It was aim of the present study to assess the feasibility of using heart rate variability (HRV) biofeedback to treat moderate to severe depression. This was an open-label study in which 14 patients with different degrees of depression (13 f, 1 m) aged 30 years (18-47; median; range) and 12 healthy volunteers attended 6 sessions of HRV biofeedback over two weeks. Another 12 healthy subjects were observed under an active control condition. At follow up BDI was found significantly decreased (BDI 6; 2-20; median 25%-75% quartile) as compared to baseline conditions (BDI 22;15-29) in patients with depression. In addition, depressed patients had reduced anxiety, decreased heart rate and increased HRV after conduction of biofeedback (p < 0.05). By contrast, no changes were noted in healthy subjects receiving biofeedback nor in normal controls. In conclusion, HRV biofeedback appears to be a useful adjunct for the treatment of depression, associated with increases in HRV.
Article
The development of a 10-item self-report scale (EPDS) to screen for Postnatal Depression in the community is described. After extensive pilot interviews a validation study was carried out on 84 mothers using the Research Diagnostic Criteria for depressive illness obtained from Goldberg's Standardised Psychiatric Interview. The EPDS was found to have satisfactory sensitivity and specificity, and was also sensitive to change in the severity of depression over time. The scale can be completed in about 5 minutes and has a simple method of scoring. The use of the EPDS in the secondary prevention of Postnatal Depression is discussed.
Article
We obtained Hamilton Rating Scale for Depression (HAM-D) scores and recorded 5 minutes of rhythm strip both before and after a therapeutic trial of antidepressant medications in 17 patients diagnosed with major depressive disorder (MDD). We calculated the standard deviation (SD) of interbeat intervals and the mean squared successive difference (MSSD) as measures of heart-rate variability (HRV). We then calculated Spearman rank-ordered correlation coefficients between the HRV measures and the HAM-D scores. Changes in SD and MSSD correlated with post-treatment HAM-D scores and with changes in HAM-D scores. These relationships were strongest in patients who responded positively to nontricyclic antidepressant medications. HRV before treatment was not predictive of treatment response, nor did HRV reliably reflect the severity of depressive symptoms. These findings indicate that pharmacologic treatment leading to improvement in MDD is associated with increased HRV. Hence, brief measures of HRV could be developed as a useful adjunctive, physiologic measure of treatment response to pharmacotherapy in clinical trials and other settings. Further, increased HRV associated with successful treatment of MDD may reflect improved autonomic function, decreasing the risk of cardiovascular mortality found in patients with MDD.
Article
Following childbirth, major depression (postpartum depression) affects approximately 8-12% of new mothers. However, little is known about the pharmacological management of postpartum depression, and no studies to date have assessed differences in treatment response between women with postpartum and nonpostpartum major depression. The authors reviewed the records of 26 women with postpartum major depression and 25 women with major depression unrelated to childbearing (nonpostpartum depression) who presented to them for treatment over a 4-year period. Compared with the nonpostpartum depressed patients, the postpartum depressed women were significantly more likely to present with anxious features. Also, cases of postpartum depression were more severe than cases of nonpostpartum depression. While the postpartum patients were equally as likely to recover (as defined by a Clinical Global Impression score of 1 or 2) compared to the nonpostpartum-depressed patients, their time to response was significantly longer. By 3 weeks of pharmacotherapy, 75% of the nonpostpartum cases had recovered, in contrast to only 36% of the postpartum cases. Further, postpartum patients were significantly more likely to be receiving more than one antidepressant agent at the time of response to treatment. Length of depression prior to treatment did not explain the difference in treatment response. Presence of depressive symptoms during pregnancy and timing of onset of the depression (before vs. after 4 weeks of delivery) did not affect likelihood of treatment response in this sample. Women with postpartum depression appear to be significantly more likely than the nonpostpartum women to present with anxious features, take longer to respond to pharmacotherapy for depression, and require more antidepressant agents at the time of response to treatment.
Article
The results of 46 observational studies were analyzed to assess the strength of the association between depression and parenting behavior and to identify variables that moderated the effects. The association between depression and parenting was manifest most strongly for negative maternal behavior and was evident to a somewhat lesser degree in disengagement from the child. The association between depression and positive maternal behavior was relatively weak, albeit significant. Effects for negative maternal behavior were moderated by timing of the depression: Current depression was associated with the largest effects. However, residual effects of prior depression were apparent for all behaviors. Socioeconomic status, child age, and methodological variables moderated the effects for positive behavior: Effects were strongest for studies of disadvantaged women and mothers of infants. Studies using diagnostic interviews and self-report measures yielded similar effects, suggesting that deficits are not specific to depressive disorder. Research is needed to identify factors that affect the magnitude of parenting deficits among women who are experiencing depression and other psychological difficulties.
Article
To describe infant sleep patterns and investigate relationships between infant sleep problems and maternal well-being in the community setting. Cross-sectional community survey. Setting. Maternal and Child Health Centers in 3 middle-class local government areas in Melbourne, Australia. Mothers of infants 6 to 12 months of age. Maternal well-being (Edinburgh Postnatal Depression Scale) and infant sleep problems (standardized maternal questionnaire). The survey was completed by 738 mothers (94% response rate), of whom 46% reported their infant's sleep as a problem. In the univariate analyses, sleep patterns characterizing a sleep problem included the infant sleeping in the parent's bed, being nursed to sleep, taking longer to fall asleep, waking more often and for longer periods overnight, and taking shorter naps. The same sleep patterns were associated with high depression scores and tended to increase as depression scores increased. Because of positive skew, the Edinburgh Postnatal Depression Score was analyzed in 3 categories (<10, 10-12, and >12) using validated cutoff scores from community and clinical studies. Fifteen percent of mothers scored above 12 on the depression scale, indicating probable clinical depression, and 18% scored between 10 and 12, indicating possible clinical depression. After adjusting for potential confounders and factors significant in the univariate analyses, maternal report of an infant sleep problem remained a significant predictor of a depression score >12 (odds ratio: 2.13; 95% confidence interval: 1.27,3.56) and >10 (odds ratio: 2.88; 95% confidence interval: 1.93,4.31). However, mothers reporting good sleep quality, despite an infant sleep problem, were not more likely to suffer depression. Maternal report of infant sleep problems and depression symptoms are common in middle-class Australian communities. There is a strong association between the 2, even when known depression risk factors are taken into account. Maternal report of good sleep quality attenuates this relationship. Appropriate anticipatory guidance addressing infant sleep could potentially decrease maternal report of depressive symptoms.
Article
Approximately 13% of women experience postpartum depression. Early recognition is one of the most difficult challenges with this mood disorder because of how covertly it is suffered. The purpose of this meta-analysis was to update the findings of an earlier meta-analysis of postpartum depression predictors that had synthesized the results of studies conducted mostly in the 1980s. A meta-analysis of 84 studies published in the decade of the 1990s was conducted to determine the magnitude of the relationships between postpartum depression and various risk factors. Using the software system Advanced Basic Meta-Analysis, effect sizes were calculated three ways: unweighted, weighted by sample size, and weighted by quality index score. Thirteen significant predictors of postpartum depression were revealed. Ten of the 13 risk factors had moderate effect sizes while three predictors had small effect sizes. The mean effect size indicator ranges for each risk factor were as follows: prenatal depression (.44 to .46), self esteem (.45 to. 47), childcare stress (.45 to .46), prenatal anxiety (.41 to .45), life stress (.38 to .40), social support (.36 to .41), marital relationship (.38 to .39), history of previous depression (.38 to .39), infant temperament (.33 to .34), maternity blues (.25 to .31), marital status (.21 to .35), socioeconomic status (.19 to .22), and unplanned/unwanted pregnancy (.14 to .17). Results confirmed findings of an earlier meta-analysis and in addition revealed four new predictors of postpartum depression: self-esteem, marital status, socioeconomic status, and unplanned/unwanted pregnancy.
Article
We investigated the contribution of anxiety symptoms to scores on the Edinburgh Postnatal Depression Scale (EPDS) between 36 weeks gestation and 16 weeks postpartum in 150 women. The 3-item anxiety subscale of the EPDS accounted for 47% of the total score in late pregnancy, and 38% of the total score in the postpartum period. Two categories of anxiety were common in the perinatal period: subsyndromal, situational anxiety (in particular during the last weeks of pregnancy); and clinically significant comorbid anxiety, which was experienced by nearly 50% of clinically depressed pregnant and postpartum women. The close relationship between anxiety and depression raises questions about whether symptoms of anxiety might be more common in the perinatal period than in other depressions. A strong role for anxiety symptoms in postpartum depression, and implications for its etiology and treatment, are discussed.
Article
Postpartum nonpsychotic depression is the most common complication of childbearing, affecting approximately 10-15% of women and, as such, represents a considerable health problem affecting women and their families. This systematic review provides a synthesis of the recent literature pertaining to antenatal risk factors associated with developing this condition. Databases relating to the medical, psychological, and social science literature were searched using specific inclusion criteria and search terms, in order to identify studies examining antenatal risk factors for postpartum depression. Studies were identified and critically appraised in order to synthesize the current findings. The search resulted in the identification of two major meta-analyses conducted on over 14,000 subjects, as well as newer subsequent large-scale clinical studies. The results of these studies were then summarized in terms of effect sizes as defined by Cohen. The findings from the meta-analyses of over 14,000 subjects, and subsequent studies of nearly 10,000 additional subjects found that the following factors were the strongest predictors of postpartum depression: depression during pregnancy, anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, low levels of social support, and a previous history of depression. Critical appraisal of the literature revealed a number of methodological and knowledge gaps that need to be addressed in future research. These include examining specific risk factors in women of lower socioeconomic status, risk factors pertaining to teenage mothers, and the use of appropriate instruments assessing postpartum depression for use within different cultural groups.
Article
We examined the course of maternal depressive symptoms and children's attachment security at 36 months in a large sample of mother-child pairs from 10 sites across the country participating in the NICHD Study of Early Child Care (N = 1077). Maternal depressive symptoms predicted higher rates of insecure attachment. Women who reported intermittent symptoms across the first 36 months had preschoolers who were more likely to be classified as insecure C or D; women with chronic symptoms were more likely to have preschoolers who were classified as insecure D. Symptoms reported only during the first 15 months were not associated with elevated rates of later insecurity. After controlling for potentially confounding demographic variables, maternal sensitivity (observed at 6, 15, 24, and 36 months) did not meaningfully account for links between attachment security and patterns of depressive symptoms. However, the course and timing of maternal depressive symptoms interacted with maternal sensitivity to predict insecurity. Women with late, intermittent, or chronic symptoms who were also low in sensitivity were more likely to have preschoolers who were insecure, in contrast to symptomatic women who were high in sensitivity. These data have implications for understanding the combined impact of maternal depressive symptoms and maternal sensitivity on children's socioemotional development.
Article
A substantial number of women of childbearing age suffer from depression. Despite this, relatively little is known about the safety of antidepressant use during pregnancy. We conducted a meta-analysis of prospective comparative cohort studies to quantify the relationship between maternal exposure to the newer antidepressants and major malformations. We searched Medline, Embase and Reprotox from 1996 to the present for studies comparing outcomes in first trimester exposures to citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, reboxetine, venlafaxine, nefazodone, trazodone, mirtazapine and bupropion to those of non-exposed mothers. Data were combined using a random effects model; heterogeneity was tested with chi2, and publication bias with a funnel plot and the Begg-Mazumdar statistic. Twenty-two studies were identified, 15 were rejected (4 reviews, 4 without comparison groups, 2 third trimester exposures, 2 retrospective database studies, 2 case reports and 1 duplicate); 7 studies (n = 1774) met inclusion criteria. Effects were not heterogeneous (chi2 = 2.04, p = 0.92); funnel plot and test (tau = -0.24, p = 0.45) indicated no publication bias. The summary relative risk was 1.01 (95%CI: 0.57-1.80). As a group, the newer antidepressants are not associated with an increased risk of major malformations above the baseline of 1-3% in the population.
Article
To provide a profile of women suffering from major postpartum depression as assessed by the Postpartum Depression Screening Scale (PDSS). A secondary analysis conducted on a portion of the data collected from an earlier psychometric testing of the PDSS. Private practice in the San Francisco Bay Area of a marriage and family therapist specializing in perinatal mood disorders. One hundred thirty-three women who were diagnosed with major postpartum depression. Each mother completed the PDSS followed by a Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnostic interview. Seven dimensions of postpartum depression: sleeping/eating disturbances, anxiety/insecurity, emotional lability, mental confusion, loss of self, guilt/shame, and suicidal thoughts as measured by the PDSS. Scores on all seven dimensions of the PDSS were elevated. The three top dimensions were emotional lability, mental confusion, and anxiety/insecurity. The mean total PDSS score of 120 was well beyond the recommended cutoff score of 80 for a positive screen for major postpartum depression. Clinicians who come in contact with new mothers need to be alert to the range of possible symptoms that postpartum depressed mothers may experience so that these women are not left to suffer in silence.
Article
We systematically review evidence on the prevalence and incidence of perinatal depression and compare these rates with those of depression in women at non-childbearing times. We searched MEDLINE, CINAHL, PsycINFO, and Sociofile for English-language articles published from 1980 through March 2004, conducted hand searches of bibliographies, and consulted with experts. We included cross-sectional, cohort, and case-control studies from developed countries that assessed women for depression during pregnancy or the first year postpartum with a structured clinical interview. Of the 109 articles reviewed, 28 met our inclusion criteria. For major and minor depression (major depression alone), the combined point prevalence estimates from meta-analyses ranged from 6.5% to 12.9% (1.0-5.6%) at different trimesters of pregnancy and months in the first postpartum year. The combined period prevalence shows that as many as 19.2% (7.1%) of women have a depressive episode (major depressive episode) during the first 3 months postpartum; most of these episodes have onset following delivery. All estimates have wide 95% confidence intervals, showing significant uncertainty in their true levels. No conclusions could be made regarding the relative incidence of depression among pregnant and postpartum women compared with women at non-childbearing times. To better delineate periods of peak prevalence and incidence for perinatal depression and identify high risk subpopulations, we need studies with larger and more representative samples.
Article
To study the effects of selective serotonin reuptake inhibitors (SSRIs) on pregnancy outcome. We performed a population-based study of women exposed to SSRIs during pregnancy (n = 1782). Data were derived from a national project in Finland, established by 3 governmental organizations. In that project, the Drug Reimbursement Register, the Medical Birth Register, the Register of Congenital Malformations, and the Register of Induced Abortions have been linked. Comparisons were made between women with SSRI purchases to matched controls and between women with purchases in different trimesters. Only singleton pregnancies were included. Primary outcomes were major malformations, preterm birth, small for gestational age, low birth weight, and treatment in neonatal special or intensive care unit. Analyses were based on logistic models. Major malformations were not more common in infants or fetuses of women with first trimester SSRI purchases (n = 1,398) when compared with controls with no drug purchases (P = .4). Of infants born to mothers with SSRI purchases in the 3rd trimester, 15.7% were treated in special or intensive care unit compared with 11.2% of infants exposed only during the 1st trimester (P = .009, adjusted odds ratio 1.6, 95% confidence interval 1.1-2.2). We found no increased risk of preterm birth (< 37 weeks), birth 32 weeks of gestation or less, small for gestational age, or low birth weight in women with purchases in each trimester or during the 2nd and 3rd trimesters when compared with women with only 1st trimester purchases. Use of SSRIs during pregnancy is not independently associated with increased risk of adverse perinatal outcome other than need for treatment in neonatal special or intensive care unit.
To determine whether maternal depressive symptoms, reported when infants are 2 to 4 months old, are associated with mothers' early parenting practices. Secondary data analyses collected from the National Evaluation of Healthy Steps for Young Children. Data sources included newborn enrollment questionnaires and parent interviews when infants were 2 to 4 months old. Maternal depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale. Twenty-four pediatric practices across the United States. A total of 5565 families enrolled in Healthy Steps; 4874 mothers (88%) completed 2- to 4-month interviews and provided Center for Epidemiologic Studies Depression Scale data; 17.8% of mothers reported having depressive symptoms. Ten parenting practices assessed in 3 domains: safety (sleep position and lowering water temperature), feeding (cereal, water, or juice; continuing breastfeeding), and practices to promote child development (showing books, playing with infant, talking to infant, and following 2 or more routines). Mothers with and without depressive symptoms reported similar uses of safety and feeding practices. Mothers with depressive symptoms had reduced odds of continuing breastfeeding (adjusted odds ratio [AOR], 0.73; 95% confidence interval [CI], 0.61-0.88), showing books (AOR, 0.81; 95% CI, 0.68-0.97), playing with the infant (AOR, 0.70; 95% CI, 0.54-0.90), talking to the infant (AOR, 0.74; 95% CI, 0.63-0.86), and following routines (AOR, 0.61; 95% CI, 0.52-0.72). Maternal depressive symptoms are common in early infancy and contribute to unfavorable parenting practices.
Article
The purpose of this study was to assess the safety of the use of selective serotonin reuptake inhibitors in pregnancy. We carried out a retrospective cohort study of 972 pregnant women who had been given at least 1 selective serotonin reuptake inhibitor prescription in the year before delivery and 3878 pregnant women who did not receive selective serotonin reuptake inhibitors and who were matched by the year of the infant's birth, the type of institute at birth, and the mother's postal code from 1990 to 2000 in the Canadian province of Saskatchewan. The risks of low birth weight (adjusted odds ratio, 1.58; 95% CI, 1.19, 2.11), preterm birth (adjusted odds ratio, 1.57; 95% CI, 1.28, 1.92), fetal death (adjusted odds ratio, 2.23; 95% CI, 1.01, 4.93), and seizures (adjusted odds ratio, 3.87; 95% CI, 1.00, 14.99) were increased in infants who were born to mothers who had received selective serotonin reuptake inhibitor therapy. The use of selective serotonin reuptake inhibitors in pregnancy may increase the risks of low birth weight, preterm birth, fetal death, and seizures.
Article
Spectral analysis of heart rate variability (HRV) and related measures has been shown to be a reliable noninvasive technique enabling quantitative assessment of cardiovascular autonomic regulatory responses to autonomic regulatory mechanisms; it provides a dynamic probe of sympathetic and parasympathetic tone, reflecting the interactions between the two. Over 20 studies reported abnormalities of HRV in anxiety, and patients with heart disease and anxiety are at increased risk for morbidity and mortality. Psychiatric drugs partly correct abnormalities of HRV and, recently, autonomic drugs (beta-blockers) have been studied in anxiety disorders. The authors call for further studies, especially in patients with co-existing anxiety disorders and heart disease, incorporating assessment of HRV.
Article
The prevalence of maternal depressive symptoms and its associated consequences on parental behaviors, child health, and development are well documented. Researchers have called for additional work to investigate the effects of the timing of maternal depressive symptoms at various stages in the development of the young child on the emergence of developmentally appropriate parenting practices. For clinicians, data are limited about when or how often to screen for maternal depressive symptoms or how to target anticipatory guidance to address parental needs. We sought to determine whether concurrent maternal depressive symptoms have a greater effect than earlier depressive symptoms on the emergence of maternal parenting practices at 30 to 33 months in 3 important domains of child safety, development, and discipline. Secondary analyses from the Healthy Steps National Evaluation were conducted for this study. Data sources included a self-administered enrollment questionnaire and computer-assisted telephone interviews with the mother when the Healthy Steps children were 2 to 4 and 30 to 33 months of age. The 30- to 33-month interview provided information about 4 safety practices (ie, always uses car seat, has electric outlet covers, has safety latches on cabinets, and lowered temperature on the water heater), 6 child development practices (ie, talks daily to child while working, plays daily with child, reads daily to child, limits child television and video watching to <2 hours a day, follows > or = 3 daily routines, and being more nurturing), and 3 discipline practices (ie, uses more reasoning, uses more harsh punishment, and ever slapped child on the face or spanked the child with an object). The parenting practices were selected based on evidence of their importance for child health and development, near complete data, and sample variability. The discipline practices were constructed from the Parental Response to Misbehavior Scale. Maternal depressive symptoms were assessed using a 14-item modified version of the Center for Epidemiologic Studies-Depression Scale. Multiple logistic regression models estimated the effect of depressive symptoms on parenting practices, adjusted for baseline demographic characteristics, Healthy Steps participation, and site. No significant interactions were found when testing analytic models with dummy variables for depressive symptoms at 2 to 4 months only, 30 to 33 months only, and at both times; reported models do not include interaction terms. We report main effects of depressive symptoms at 2 to 4 and 30 to 33 months when both are included in the model. Of 5565 families, 3412 mothers (61%) completed 2- to 4- and 30- to 33-month interviews and provided Center for Epidemiologic Studies-Depression Scale data at both times. Mothers with depressive symptoms at 2 to 4 months had reduced odds of using car seats, lowering the water heater temperature, and playing with the child at 30 to 33 months. Mothers with concurrent depressive symptoms had reduced odds of using electric outlet covers, using safety latches, talking with the child, limiting television or video watching, following daily routines, and being more nurturing. Mothers with concurrent depressive symptoms had increased odds of using harsh punishment and of slapping the child on the face or spanking with an object. The study findings suggest that concurrent maternal depressive symptoms have stronger relations than earlier depressive symptoms, with mothers not initiating recommended age-appropriate safety and child development practices and also using harsh discipline practices for toddlers. Our findings, however, also suggest that for parenting practices that are likely to be established early in the life of the child, it may be reasonable that mothers with early depressive symptoms may continue to affect use of those practices by mothers. The results of our study underscore the importance of clinicians screening for maternal depressive symptoms during the toddler period, as well as the early postpartum period, because these symptoms can appear later independent of earlier screening results. Providing periodic depressive symptom screening of the mothers of young patients has the potential to improve clinician capacity to provide timely and tailored anticipatory guidance about important parenting practices, as well as to make appropriate referrals.