Jonathan Schaffir, NASPOG President-Elect, has compiled a collection of notable publications from 2011 in the field of psychosocial ob/gyn.

Marc I, Toureche N, Ernst E et al. Mind-body interventions during pregnancy for preventing or treating women's anxiety. Cochrane Database of Systematic Reviews 2011, Issue 7, Art. No. CD007559.

Summary

This Cochrane review compiled data from eight randomized controlled trials that involved mind-body interventions in the treatment of anxiety in pregnancy, compared with either standard interventions or no treatment at all. Trials analyzed involved five of imagery and one each of hypnotherapy, autogenic training, and yoga. Because of the small number of trials, no meta-analysis was performed. Individual studies revealed a significant reduction of anxiety in laboring women using imagery and possibly autogenic training, and an improvement in both anxiety and depression in postpartum women using imagery. The authors conclude that there is some, but not strong, evidence for the use of mind-body interventions for the management of anxiety during pregnancy.

Commentary

As the authors of this review point out, there is a dearth of well-conducted trials examining these interventions, which aim to reduce negative thinking related to anxiety that is associated with a stressful event, and improve adaptational behavior and coping skills. The types of stressors and nature of anxiety may differ substantially between the different stages of pregnancy, parturition, and the postpartum period, leading to different results for the use of mind-body interventions. Nevertheless, these results provide encouragement to women who seek a non-pharmacological or non-traditional alternative to anxiety treatment, and it is worthwhile to note that no harmful effects were reported from these interventions in any of the studies cited.

McMahon CA, Boivin J, Gibson FL et al. Older first-time mothers and early postpartum depression: a prospective cohort study of women conceiving spontaneously or with assisted reproductive technologies. Fertility and Sterility 2011; 96: 1218-24.

Summary

This prospective cohort study examined whether women having their first baby later in life were more likely to be depressed postpartum than younger counterparts. 295 women who conceived spontaneously were compared with 297 women using assisted reproductive technology, further stratified into three age groups. With an overall prevalence of depression in 7.9% of these women within 4 months after birth, no differences were seen in rates of depression based on age or mode of conception.

Commentary

While the biological consequences of delaying childbirth until later in life are well-described, there is considerably less written on the psychosocial issues. Many health professionals have anecdotally perceived a more difficult adjustment to motherhood in older women, perhaps influenced by factors such as increased anxiety surrounding a high-risk pregnancy, increased physical morbidity postpartum that may affect bonding and psychosocial adjustment, and a lack of peer support by contemporaries who may have already completed childbearing. Offsetting these concerns, older mothers may have greater financial and social stability, and greater appreciation of a favorable outcome after a longer effort at getting pregnant. This study adds to a small and reassuring body of literature that demonstrates that older age is not in and of itself a risk factor for postpartum depression.

Learman LA, Gregorich SE, Schembri M et al. Symptom resolution after hysterectomy and alternative treatments for chronic pelvic pain: does depression make a difference? American Journal of Obstetrics and Gynecology 2011; 204: 269.e1-9.

Summary

This subanalysis of a large prospective cohort study of women undergoing treatment for gynecological problems examined the 701 women in the study with chronic pelvic pain. 22% of these subjects met criteria for major depressive disorder, and they were compared with the pain patients who were not depressed. The biggest predictors for symptom improvement were hysterectomy or undergoing menopause during the study period. However, depression had no significant effect on symptom resolution, sexual functioning, or other aspects of health-related quality of life.

Commentary

The association between chronic pain and depression is well known, and depression may lead to poorer outcomes in many chronic illnesses. For this reason, many propose that treatment of depression should be a priority in chronic pain treatments. The current study suggests that the presence of depression, while still an important factor in the treatment of the whole individual, will not blunt the salutary effects of other effective treatments including surgery. Screening and treatment for depression should remain an important part of treating patients with chronic pain, but it should not delay the implementation of other treatments.

Kim S-Y, Park H-J, Lee H, Lee H. Acupuncture for premenstrual syndrome: a systematic review and meta-analysis of randomized controlled trials. British Journal of Obstetrics and Gynaecology 2011; 118: 899-915.

Summary

The authors identified ten randomized controlled trials comparing acupuncture with other treatments for women with PMS, and combined the results of eight into a meta-analysis. They demonstrate a significant improvement in symptom relief for women who underwent acupuncture when compared with hormonal therapy, anxiolytics, or sham acupuncture. They propose that acupuncture should be considered as a promising treatment for PMS with no adverse effects.

Commentary

The danger of drawing conclusions from a meta-analysis is that the conclusions are only as strong as the original research that was examined. In this case, the criteria for diagnosing PMS were poorly defined in several of the studies, with some using DSM-IV criteria and others using "Chinese standards for diagnosis". Furthermore, the measurements in symptom improvement do not specify how much somatic symptoms were alleviated versus psychological or emotional symptoms. While there may certainly be a role for complementary and alternative therapies in the treatment of PMS, more stringent research will have to be done before acupuncture can be viewed as having a reliable effect.

Coleman PK. Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009. British Journal of Psychiatry 2011; 199: 180-6.

Summary

This paper quantitatively synthesized data from 22 studies that examined the relationship between elective pregnancy termination and mental health, comprising a total of 877, 181 subjects. The results demonstrated an 81% higher risk of any mental health problem (substance abuse, anxiety, depression) for women who had an abortion compared to those who did not. The author calculates that nearly 10% of these problems are directly attributable to having had an abortion, with 21% of suicidal behaviors directly attributable to having had an abortion.

Commentary

This controversial paper has stirred up vigorous debate on both sides of the Atlantic, with some hailing it as a vindication for those who decry the evils of abortion, and others arguing that it incorrectly manipulates statistics in such a way as to give ammunition to those who seek to chip away at women's reproductive rights. This paper is at odds with other literature reviews that have concluded that there is no significant association between abortion and adverse mental health effects. Such scientific exploration becomes increasingly important as legislation is considered that dictates how physicians should counsel their patients who inquire about pregnancy termination options, and there is no doubt that this will not be the last word on the subject. In fact, the journal has received so many letters about this paper that they have promised to dedicate an entire issue to the subject!