Research

Women and Infants Mental Health

The Women and Infants Mental Health (WIMH) Program was born out of research aimed at improving understanding of Mood Disorders in women throughout the lifespan, such as:

  • improving detection and treatment of untreated depression and anxiety during the childbearing years
  • improving access to effective treatments for perinatal depression/anxiety
  • understanding how treated versus un-treated depression and anxiety impacts women and their children
  • understanding the neurobiological and psychological interplay between mothers and their children

The WIMH Program research team is comprised of faculty, trainees, and staff from Psychiatry, Psychology, Obstetrics / Gynecology, Social Work, Pediatrics, Neurology, and Public Health. However, without the help and collaboration of women and their families who choose to participate in research, our improved understanding of mental health issues would not be possible. Visit UMClinicalStudies.org to explore participation opportunities.

Research Areas

Depression, Anxiety, and Trauma

Depression, anxiety, and other mood fluctuations are commonly experienced by women during significant life changes such as puberty, pregnancy, and menopause. These fluctuations during pregnancy and postpartum can be especially challenging. The perinatal period is a particularly unique time given the changes in hormones, sleep patterns, role transitions, financial and social strains, and increased stress often experienced by women.

Additionally, stress and anxiety can seriously impact how women experience pregnancy, childbirth, and parenting, especially those who have survived child abuse or neglect, sexual assault, violent crime or other traumatic events.  For many women, a history of trauma affects trust in others and in themselves which may impact feelings about the transition into parenthood. 

The WIMH Program emphasizes the importance of trauma-informed approaches to health care. TheProgram is interested in learning more about experiences of these women and researching mood complications during pregnancy and postpartum to better understand the needs, challenges, and outcomes of women, fathers, and infants.

Research Activity:

Interventions, Treatments, and Complimentary Alternative Medicine

Mindfulness Yoga during Pregnancy

Women's mental health during pregnancy has important implications for both mother and baby, but few women receive treatment. The Mindfulness Yoga during Pregnancy (MY Pregnancy) study will examine how a supportive intervention is helpful to pregnant women with a history of depression or anxiety who may be reluctant to participate in traditional mental health treatment, such as psychotherapy or antidepressants.  MY Pregnancy is a 10-session yoga group designed to increase mindful, non-judgment and acceptance of feelings and strengthen the infant-maternal bond while decreasing feelings of isolation, depression and anxiety, particularly related to pregnancy, labor, delivery and transition to motherhood.

The current project has added a control group to the design.  Half the participants will attend the mindfulness yoga class and half will receive a free mindfulness yoga DVD for home practice. 

Findings: 
Participants in the 10 week mindfulness yoga intervention were significantly less depressed, and showed significant improvement in mother-baby attachment and mindfulness skills. 

Investigators: 
Maria Muzik (PI), Marlene McGrath and Barbara Brooken-Harvey

Mothers, Omega-3 and Mental Health Study (MOMS)

The MOM study is a double blind, placebo-controlled, randomized trial to assess whether omega-3 fatty acid supplementation may prevent depressive symptoms during pregnancy and the postpartum period among pregnant women at risk for depression.  Pregnant women were recruited prior to 20 weeks gestation from prenatal clinics at the University of Michigan Health System & IHA/St. Joseph Mercy Hospital and followed over the course of their pregnancy and up to 6 weeks postpartum.  Enrolled participants will be randomized to one of three groups: 1) EPA-rich fish oil supplement  2) DHA-rich fish oil supplement or 3) a placebo.  Information on changes in depressive symptomatology, omega-3 fatty acid concentrations in maternal plasma, proinflammatory cytokine levels (IL-1β, IL-6, and TNF-α), and antidepressant medication treatment will be gathered at up to 3 time points during pregnancy and at 6 weeks postpartum.

Investigators: 
Ellen Mozurkewich (PI), Delia Vazquez, Sheila Marcus, Anjel Vahratian, Zora Djuric, Deborah Berman and Julie Chilimigras

Enhancing Care and Health Outcomes (ECHO): Improving Psychosocial Treatment for Perinatal Depression

The ECHO project aimed to develop a modified depression intervention to reflect the unique issues faced by women during the perinatal period. Specifically, Cognitive Behavioral Therapy (CBT) was adapted based on participant responses. The project was implemented in three phases: 1) determine barriers to participation in treatment through qualitative interviews 2) adjust and further develop CBT based on information learned, and 3) test and refine the adapted intervention through a pilot study.

Findings:
Twenty-three participants, varying in socioeconomic, depression, and pregnancy status were interviewed about their experience with clinician (including nurses, midwives, obstetricians, and social workers) interaction style and which they style was most helpful and favored. Themes that emerged showed women prefer an interaction that conveys:

  • Feeling heard, the clinician effectively listening with a nonjudgmental attitude, and encouraging client control
  • A trusting relationship that is based on genuineness, warmth, and optimism
  • Competence, knowledge, and expertise of clinician
  • The communication of a treatment options that align with patient needs
  • Negative thoughts stemming from unmet high expectations of self as a mother, worry, and negativity about parenting efficacy.
  • Behavioral impacts of limited activity and isolation
  • Interpersonal conflict causing emotional distress
  • Phase three tested the efficacy of the modified CBT (mCBT) in a randomized control trial.  The study aim was for the mCBT group of 30 women to show increased treatment adherence and decreased depression symptoms compared to the control group of 25 women who received treatment as usual. Results indicate:
  • The mCBT group had good adherence rates where 63% of women attended at least 4 treatment sessions and 43% attended at least 7 sessions.
  • Women who received mCBT had a greater reduction in depression scores than women in the control group at 16 weeks after the study start.
  • Women found they could practically apply skills learned in mCBT and reported high levels of satisfaction with treatment received.

Investigators:
Heather Flynn (PI) and Joseph Himle

Publications: 
Henshaw, E., Flynn, H., Himle, J., O’Mahen, H., Forman, J., Fedock G. (2011). Patient Preferences for Clinician Interactional Style in Treatment of Perinatal Depression. 
Qualitative Health Research, XX(X) 1– 16.

Henshaw, E., Flynn, H., Himle, J., O’Mahen, H., Forman, J., Fedock G. (2012). Modifying CBT for Perinatal Depression: What Do Women Want? A Qualitative Study. Cognitive and Behavioral Practice, 19, 359-371.

Connecting Women with Care

There is evidence that depression in women of childbearing age is often undetected and untreated. This study investigated whether an intervention added to routine health care provider and patient interaction will improve the likelihood of perinatal patients seeking and following through with mental health treatment.  Studying these kinds of interventions is important since most women at-risk for depression do not receive proper care, and receiving adequate care can significantly improve the lives of women and their children. This studied compared 2 groups; a control group and an intervention group. The control group completed a depression screening instrument and diagnostic interview if significant symptoms are reported. Health care providers and patients will be notified of their depression status and current protocol of standard prenatal care will continue. For the intervention group, if significant depression symptoms are found after screening:  feedback and treatment and/or referral to a specialty clinic will be initiated by the nurse practitioner in the clinic. In addition those with positive screens will participate in the diagnostic interview with the research assistant. Two additional follow-up interview will be conducted with the patient by the research assistant.

Findings:
The majority (65%) of pregnant women with current major depressive disorder (MDD) were not receiving any depression treatment throughout the study period. Overall, women with high depression scores on a depression screenings (EDPS; scores >= 10) who reported that their physician discussed depression with them (67%) were significantly more likely to seek treatment (compared with those who did not report physician discussion of depression with them) by the 1 month prenatal follow-up but not by the 6 weeks postpartum follow-up. Initial depression severity and treatment use prior to screening were the strongest predictors of subsequent depression treatment use. Depression screening combined with systematic clinician follow-up showed a modest short-term impact on depression treatment use for perinatal depression but did not affect depression outcomes. Most women with MDD were not engaged in treatment throughout the follow-up period despite the interventions. More intensive and repeated monitoring might enhance the effect of clinician interventions to improve treatment use.

Investigators: 
Heather Flynn (PI) and Sheila Marcus

Publication: 
Flynn, H., O'Mahen, H., Massey, L., Marcus, S. (2006). The Impact of a Brief Obstetrics Clinic-Based Intervention on Treatment Use for Perinatal Depression. Journal of Women's Health, 15(10), 1195-1204.

Infant Outcomes and Depression Treatment in Pregnancy

The aims of this project are to determine whether clinical stability following depression treatment in pregnant women normalizes neuroendocrine function, as well as infant neuroendocrine status, birth outcomes, and state regulation through 7 months of age. Following screening in obstetrics clinics, pregnant women diagnosed with Major Depressive Disorder or high risk for depression will receive a course of Interpersonal Therapy (IPT) with or without treatment with an SSRI, beginning at 28 gestational weeks and continuing through 7 months. Maternal outcome variables include symptom severity, psychosocial variables, neuroendocrine measures, and pregnancy characteristics. Infant outcome variables include birth outcomes (weight, gestational age, APGAR scores), neonatal neurologic assessments, cord blood and salivary neuroendocrine measures, state regulation variables (feeding, sleep, crying) and developmental measures through 7 months of age.

Investigators: 
Sheila Marcus (PI), Heather Flynn, Kate Rosenblum, and Delia Vazquez.

Selected Publications:
Muzik, M., Hamilton, S. E., Rosenblum, K. L., Waxler, E., & Hadi, Z. (2012). Mindfulness yoga during pregnancy for psychiatrically at-risk women: Preliminary results from a pilot feasibility study. Complementary Therapies in Clinical Practice (in press). 

Muzik, M., & Hamilton, S. (2012). Psychiatric illness during pregnancy: early detection, individualized care can promote health for mother and infant. Current Psychiatry, 11(2), 23.  

Sexton, M., Flynn, H., Lancaster, C., Marcus, S., McDonough, S., Volling, B.,  Lopez, J., Kaciroti, N., Vazquez, D. (2012) Predictors of Recovery from Prenatal Depressive Symptoms from Pregnancy Through Postpartum.  J Women's Health, 21(1),  43-49.

Flynn, H. (2011). Setting the Stage for the Integration of Motivational Interviewing With Cognitive Behavioral Therapy in the Treatment of Depression. Cognitive and Behavioral Practice, 18, 46–54.

Mozurkewich, E., Chilimigras, J., Klemens, C., Keeton, K., Allbaugh, L., Hamilton, S., Berman, D., Vazquez, D., Marcus, S., Djuric, Z., & Vahratian, A. (2011). The mothers, Omega-3 and mental health study. BMC Pregnancy & Childbirth, 11, 46-46.

Lancaster, C., Flynn, H. Johnson, T., Marcus, S., Davis, M. (2010). Peripartum Length of Stay for Women with Depressive Symptoms during Pregnancy. Journal of Women's Health, 19(1), 31-37.

O’Mahen, H., Flynn, H., Nolen-Hoeksema, S. (2010). Rumination and Interpersonal Functioning In Perinatal Depression. Journal of Social and Clinical Psychology, 29(6), 646-667.

Muzik, M., Marcus, S., Heringhausen, J. E., & Flynn, H. (2009). When Depression Complicates Childbearing: Guidelines for Screening and Treatment During Antenatal and Postpartum Obstetric Care. Obstetrics and Gynecology Clinics of North America, 36(4), 771-788.

Marcus, S., Flynn, H. (2008). Depression, antidepressant medication, and functioning outcomes among pregnant women. International Journal of Gynecology and Obstetrics, 100, 248–251. 

Parenting and Fatherhood

It has been said that having a child changes everything.  During pregnancy and the early postpartum period, parents are adjusting to major role transitions in their families, at work and within their communities, all while caring for a child.  Attachment, or the important relationship that develops between parents and children, is based on the emotional tone and quality of day-to-day interactions.  Securely attached children are able to rely on their parents for generally consistent, responsive, and sensitive care, and are able to use their parents as a “secure base” when exploring the environment and as a “safe haven” in times or distress or vulnerability.  A parents’ capacity for sensitive responsiveness is key for promoting young children’s resilience to stress, self-esteem, ability to self-soothe, problem solving skills and success in future relationships.  TheWIMH Program is interested in learning more about the needs of parents and children during this vulnerable time and designing effective interventions that address those needs.

Experiences during the postpartum period are often studied from the maternal perspective. However, fathers also experience significant changes in life after childbirth, many of which are similar to the experiences mothers and are often overshadowed. Fathers must also adjust to an array of new and demanding roles and tasks during the early postpartum period. This critically depends on the level and quality of cooperation between the mother and father. Clearly, the postnatal experience poses many challenges to men’s as well as women’s lives and mental health. Research at the WIMH Program examines men’s experiences in fatherhood.

Research Activity:

Interventions, Treatments, and Complimentary Alternative Medicine

Swaddled Babies, Happy Families

The “Swaddled Babies, Happy Families” program is an extension of Dr Harvey Karp's Happiest Baby on the Block for couples with a focus on first time fathers aiming to increase their confidence and skill set around the needs of both a new mother and a newborn baby.   The goal of this project is to evaluate a group called “Swaddled Babies, Happy Families” for first time parents and their newborns in Ypsilanti and Ann Arbor, MI. This program is an educational intervention for couples with a focus on increasing new fathers’ confidence and skill sets around the needs of both a new mother and a newborn baby.  This program meets the needs of high-risk families by inviting them to come together to support the developing exploration of what fatherhood means to the dad, how to make sense of his roles and learn how he can positively contribute to the mother’s, and his own, postpartum mental health, particularly by reducing the infant’s crying. All participants will be assessed through questionnaires and interviews to be conducted before and after the group.    

Investigators: 
Maria Muzik (PI), Nicole Miller, Emily Stanton

Mom Power

Mom Power is a parenting and attachment skills group for mothers receiving Medicaid and their children under age 6 who are interested in learning more about parenting. Mothers participate in a 10-week educational curriculum that helps mothers from a variety of backgrounds and skill levels to safely cope with their current stressful life circumstances and mental health symptoms, all of which may pose risk to their parenting and child’s safety.  Each week has a different focus related to parenting and the mother’s emotional needs. Topics include child development, understanding how past traumatic stress affects parenting skills and mother/child bonding, self-care skills (including breathing and relaxation techniques and medications), and how to connect and play with children. At each session the child receives an age-appropriate toy or book that moms are encouraged to use as a way to engage with their child, and mothers are reimbursed for their travel. Moms receive a certificate at the end of the group proclaiming them “powerful moms’.

Findings:
On average, two thirds of graduates of Mom Power are connected with care within the community following the intervention. Mothers self-rating of depression and PTSD symptoms, as well as parenting competence improve after Mom Power.

Investigators: 
Maria Muzik (PI), Katherine Rosenblum, and Sheila Marcus

Partnering for the Future

The Partnering for the Future project enrolled pregnant women with an active substance use disorder receiving care at a high-risk OB clinic.  In addition to standard-of-care medical and psychological services, participants received several interventions to enhance maternal-infant bonding, including enhanced ultrasounds, a hospital tour/baby shower and a psychoeducational group (Mom Power-Substance Abuse), integrating attachment-based parenting, substance abuse treatment and self-care skills.  This project, which was a collaboration with Home of New Vision, was completed in 2011.

The current project is focused on delivering the Mom Power-Substance Abuse intervention to similar women, starting in pregnancy.  Recruitment is on-going.

Findings: 
This population is very difficult to engage and retain, due to profound trauma and the nature of their addiction disorders. However, building an atmosphere of non-judgment and empathy, combined with supportive interventions such as the structured ultrasounds and baby shower, is crucial for seizing upon this time of expectedly high motivation for sobriety.  Despite a small sample size (N=21), all interventions were well received.  The psychoeducational group fostered an enhanced commitment to sobriety, supported the development of higher parental reflectivity and provided a rare source of peer support, which participants found enormously helpful in seeking treatment and reducing the powerful stigma surrounding being pregnant while in recovery.  Qualitatively, women said that the ultrasound interventions made the baby “more real” to them and that these feelings of attachment helped them maintain their sobriety. Finally, study participation significantly reduced symptoms of depression and post-traumatic stress disorder (PTSD). 

Investigators: 
Maria Muzik (PI), Patrick Gibbons, Jennie Jester, Sheila Marcus, Susan McDonough, Katherine Rosenblum and Marjorie Treadwell

STRoNG Military Families

Parenting across the deployment cycle raises special challenges for military families with young children. The STRoNG Military Familiesparenting group program is offered for military service members, their spouses or partners, and their children birth to 8 years old. STRoNG Military Families provides a 10-week parent and child group experience designed to support and enhance the resilience of military families by creating opportunities for families to come together to learn, support one another, and grow in their ability to navigate the unique challenges they face.  Each group session includes dinner which the whole group eats together; separate play time for the children at which time they are interacting with a trained therapists; sessions on parenting skills with group discussion for the adults; and interaction time with children and parents together at the end of the session.

Investigators:
Katherine Rosenblum (PI), Michelle Kees, Sheila Marcus and Susan McDonough

Circle of Security

The Circle of Security study is a 12-week attachment-based parenting intervention group that aims to shift patterns of attachment/caregiving interactions in high-risk mother-child dyads to more developmentally appropriate pathways. Pre- and post- group assessments are conducted in hopes of establishing statistical evidence for the use of the COS Program in enhancing parental coping, improving parental behavior, and developing attachment security between dyads. Such assessment covers several domains of parenting and group treatment efficacy, including: videotaped mother-child interactions, genetic and biological data, semi-structured maternal interviews, child emotion-regulation tasks, and maternal fMRI brain scans. For more information on COS, please see the fMRI/Brain Behavior section.

Investigators: 
Maria Muzik (PI), Katherine Rosenblum and Sheila Marcus

Consultants: 
Robert Marvin and William Whelan, The Mary D. Ainsworth Child-Parent Attachment Clinic, University of Virginia

Other Research

Family Transitions Study: Family Transitions Following the Birth of a Sibling

FTS is a longitudinal investigation of 241 families expecting their second child. The main goal of FTS was to examine changes in the firstborn child’s adjustment following the infant sibling’s birth and changes in family relationship functioning including marital relationships, parental well-being, family social supports, and work-family stress. The study involved five assessment periods starting in the last trimester of the mother’s pregnancy with the second born (Prenatal assessment) and then again when the infant was 1, 4, 8, and 12 months of age. Families were visited predominantly in their homes throughout the course of the study where we conducted parent interviews, videotaped observations of parent, sibling, and marital interaction, and assessments of children’s social understanding.

  • How does the older sibling adjust to the arrival of a baby brother or sister?
  • How do parents cope with the changes occurring during this time?
  • What role do fathers play in the family during this developmental transition?
  • How do changes in family life and the older sibling’s adjustment affect the developing infant?

Investigators: 
Brenda L. Volling (PI), Heather Flynn, Richard Gonzalez, Timothy Johnson, Susan Nolen-Hoeksema

For more information on the Family Transitions Study, please visit the lab website.

Muzik. Community-Participatory Teen Parenting Project in Western Wayne County. MDCH. Funded 10/1/2011-9/30/2012

Muzik. Empathic Shifts in Therapy: Changes in Maternal Insightfulness Predict Improvements in Child Attachment Outcomes. American Psychoanalytic Association. Funded 2/1/2011-1/31/2012

Muzik. Infant sleep, stress, and inflammation: Are these valid biomarkers for predicting depression in preschoolers? Rachel Upjohn Clinical Scholars Award, funded 9/1/2010-12/31/2012

Muzik. Infant stress response: effects of maternal PTSD and infant genes. NIMH/NICHD K23, funded 9/22/2008-6/30/2012

Muzik. Transmission of Emotion Regulation:  From Maternal Brain to Child Behavior. MICHR Collaborative Pilot RD 10. Funded 5/1/2011-5/15/2012

Muzik. Young Mothers as Mentors: Community-based Peer Support Program for Mothers with Young Children. MDCH. Funded 10/1/2011-9/30/2012 

Selected Publications:
LePlatte, D., Rosenblum, K. L., Stanton, E., Miller, N., & Muzik, M. (2012). Mental health in primary care for adolescent parents. Mental Health & Family Medicine, In press.

Shah P, Muzik M, Rosenblum KL (2011) Optimizing the Early Parent-Child Relationship: Windows of Opportunity for Parents and Pediatricians. Curr Probl Pediatr Adolesc Health Care. 41:183-187

Marcus, S., Rosenblum, K. L., Fluent, T., McDonough, S., Smith, K., Kees, M., & Muzik, M. (2010). STRoNG Families: A Parenting Intervention offering Support to Restore, Nurture, and Grow Military Families. Paper presented at the American Asssociation of Child and Adolescent Psychiatry/Canadian Asssociation of Child and Adolescent Psychiatry Joint Annual Meeting, Toronto, Canada.

Muzik, M., Hadi, Z., Rosenblum, K. L., Jaffe, A., Stanton, E., & Waxler, E. (2010). Comprehensive care model for mothers and children in need: The Mom Power project. Paper presented at the 12th World Congress of the World Association for Infant Mental Health, Leipzig, Germany.

Kim, P., & Swain, J. E. (2007). Sad dads: paternal postpartum depression. Psychiatry (Edgmont (Pa. : Township)), 4(2), 35-47.

Hoffman, K. T., Marvin, R. S., Cooper, G., & Powell, B. (2006). Changing toddlers' and preschoolers' attachment classifications: the Circle of Security intervention. Journal of consulting and clinical psychology, 74(6), 1017-1026.

Klier, C.M. & Muzik, M. (2004). Mother-Infant Bonding Disorders and the Use of the Parental Bonding Questionnaire in clinical practice. World Psychiatry 3: 102-103.

Miller, A. L., McDonough, S. C., Rosenblum, K. L., & Sameroff, A. J. (2002). Emotion Regulation in Context: Situational Effects on Infant and Caregiver Behavior. Infancy, 3(4), 403-433.

Klier, C., Muzik, M. Mother-child interaction in the postpartum period. In: Klier, C.M., Demal, U., Katschnig, H. (eds). Mutterglück, ­ Mutterleid. Diagnose und Therapie der postpartalen Depression. Facultas Verlag, Wien (2001).

Volling, B. L., & Belsky, J. (1992). The contribution of mother-child and father-child relationships to the quality of sibling interaction: a longitudinal study. Child Dev, 63(5), 1209-1222.

Infant Mental Health and Outcomes

Research suggests that symptoms of depression, anxiety, and other mood disorders experienced by women during pregnancy can carry over into the postpartum period and affect the health, neuro-behavioral, and attachment outcomes of infants.

Research Activity

Maternal Anxiety during the Childbearing Years (MACY)

MACY is a longitudinal study from pregnancy to 18 months postpartum that examines the mechanisms by which maternal posttraumatic stress disorder (PTSD) may influence infants’ psychobiological outcomes. Specifically, MACY is interested in studying how mothers who have had traumatic experiences cope with new stresses, and how stress and trauma may affect parenting, the mother and infant biology, and infant development.  Over the course of their participation, mothers complete surveys and narrative interviews and are videotaped interacting with their children. In addition, DNA and salivary cortisol samples are collected. A subset of participants are invited to participate in a sleep study in which both mother and child wear a watch-like device for a week-long period. This device measures light and motion and will enable us to examine sleep patterns and relate sleep to other psychobiological measures.

Results from this study indicate:

  • Mothers’ stress levels do not differ based on demographics such as age, income, education, race, or marital status.
  • Infants’ stress levels mimic mothers’, meaning babies look to their moms as an indicator of how stressed they should be after completing stress eliciting laboratory tests.
  • Access to supportive family members for childcare is helpful for child outcomes.  Families where mothers have access to a support network are less stressed in postpartum and their babies are better adjusted as well compared to families with less support. For example, babies whose mothers were stressed and anxious/depressed postpartum, were less likely to show distress and poor outcomes themselves when they were also cared for by supportive family member or friend.

Investigators: 
Maria Muzik (PI), Israel Liberzon, Katherine Rosenblum, Hedieh Briggs, Julia Seng, Valerie Simon, Ann Stacks, Alissa Huth-Bocks and Marjorie Beeghly

Perinatal Infant Mother Attachment Cortisol Study (PIMACS)

PIMACS is a longitudinal study of the impact of depression and stress on the mother-infant relationship.  The purpose of this study is to better understand the role of maternal risk for depression on infant stress hormone levels early in life, and the possibility of long-term effects if the hormone levels are different from that which is seen in infants of mothers who are not at risk for depression. Enrolled women completed 4 prenatal study visits, including a baseline clinical interview, surveys and three blood draws at 28, 32 and 37 weeks gestation.  Postpartum visits included a 2 week infant exam, filmed mother-baby play interactions at home visits and a 14 month lab visit (Strange Situation).  Our ultimate goal is to identify pregnant women at risk for depression and determine if these chemicals in the body may help target their high-risk infants for early prevention strategies that would prevent or lessen the risk of development of psychiatric illness. Researchers also examined the factors within the mother's social environment and in the mother-infant relationship that might contribute to depression in the mother or impact the development of their infant. Because stress hormones are high in women who have depression, we are also looking at changes in stress related hormones through pregnancy, delivery, and on the mother and the infant through the first months of life.

Investigators:
Delia Vazquez (PI), Heather Flynn, Juan Lopez, Sheila Marcus, Susan McDonough, Niko Kaciroti, Arnold Sameroff, Brenda Volling, Timothy Johnson and Roseanne Armitage

Publication: 
Marcus, S., Vazquez, D., Lopez, J., Flynn, H., et al. (2011). Depressive symptoms during pregnancy: Impact on neuroendocrine and neonatal outcomes. Infant Behavior and Development, 34, 26-34.

Bonding between Mothers and Children study (BMAC)

BMAC is a longitudinal follow-up to the parent studies MACY and PIMAC and aims to follow these children of at-risk mothers into the preschool/school-entry age (ages 3-6 years). We assess child biological and behavioral risk markers, such as sleep and circadian cortisol, as well as mother’s ongoing psychiatric symptoms and life stress. 

Investigators:
Maria Muzik (PI), Delia Vazquez, Katherine Rosenblum, Juan Lopez, Sheila Marcus and Roseanne Armitage

Selected Publications

Hairston, I. S., Waxler, E., Seng, J. S., Fezzey, A. G., Rosenblum, K. L., & Muzik, M. (2011). The role of infant sleep in intergenerational transmission of trauma. Sleep: Journal of Sleep and Sleep Disorders Research, 34(10), 1373-1383.

Muzik, M., Heather G. Cameron, BS, Amanda Fezzey, BS, & Katherine L. Rosenblum, PhD. (2009). Motherhood in the Face of Trauma: PTSD in the Childbearing Year. Zero To Three Journal.

Seng JS, Rauch SM, Resnick H, Reed CD, King A, Low LK, McPherson M, Muzik M, Abelson J, Liberzon I. (2010) Exploring posttraumatic stress disorder symptom profile among pregnant women. J Psychosom Obstet Gynaecol. 31(3):176-187.

Vazquez, D., Neal, C., Paresh, P., Kaciroti, N., and Lopez, J. (2012) Regulation of corticoid and serotonin receptor brain system following early life exposure of glucocorticoids: Long term implications for the neurobiology of mood. Psychoneuroendocrinology, 37(3), 421-437.

Sleep and Circadian Rhythms across the Life Cycle

Current research suggests there is a relationship between sleep disturbance and mood symptoms such as depression. The WIMH Program research efforts focus on the impact of sleep disturbance on mental health outcomes of pregnant women, infant outcomes, effective treatment for sleep disturbance during pregnancy and the postpartum period,  validation of screening tools for sleep-disordered breathing in pregnancy, and prevalence of sleep disruption in pregnant women.  

Much of our research involves The Sleep and Chronophysiology Lab

Research Activity:

Interventions, Treatments, and Complimentary Alternative Medicine

Utility of Positive Airway Pressure in Women with Pre-eclampsia

This study is designed to find out if blood pressure in women with hypertension or pre-eclampsia can be reduced by the standard treatment for sleep apnea, positive airway pressure (PAP). We would like to find out whether it is only helpful in reducing blood pressure if sleep apnea is present or it is helpful even if sleep apnea is not present. We will also determine whether using PAP during pregnancy is associated with better infant outcomes (such as longer pregnancies, improved birth weight, improved infant well-being and fewer admissions to the Neonatal Intensive Care Unit).

Principal Investigator
Louise O’Brien

An Open Pilot of Cognitive-Behavioral Therapy for Insomnia in Women with Postpartum Depression

Women in the postpartum period often experience symptoms of depression as well as significant sleep disturbance.  This study aimed to determine the preliminary efficacy of a modified version of cognitive-behavioral therapy for insomnia (CBT-I) on improving mood and sleep and decreasing daytime fatigue in postpartum women with insomnia and depression in an open pilot study. This study also explored the feasibility of the CBT-I treatment model. Twelve postpartum women who met criteria for major depression and sleep disturbance participated in five weekly individual treatment sessions.  Results suggest that,

  • There is evidence to support the feasibility of this treatment in that all but one participant completed all 5 treatment sessions, and the women who did not complete only missed the last session.
  • Women reported a significant reduction in depression symptoms according to self-report survey scores before treatment compared to after treatment.
  • Women experienced improvements in sleep quality and a reduction in insomnia symptoms. Although total sleep time increased by only 40 minutes, women reported an increase in sleep consolidation, or reduced time taken to fall asleep and better quality sleep.
  • Women also report less physical and mental fatigue during the day and increased activity and motivation.

Investigators
Leslie Swanson, PhD. (PI), Heather Flynn, Jennifer Adams, Roseanne Armitage and Todd Arnedt

Publication:
Manuscript in press at Behavioral Sleep Medicine

Other Research

Sleep, Mood and Pregnancy Outcomes in Postpartum Women and their Infants

Depression occurring around the time of pregnancy is quite common and can lead to problems in functioning within the family.  One of the most common problems linked to depression is sleep disruption for both the mother and her baby.  Treatment for depression has been found to help most people by improving many of their symptoms of depression.  However, treatment does not work fully for all women, and sleep problems may continue even when other symptoms are treated. Therefore, the purpose of this study was to examine whether sleep disruption in the mom and infant is related to depression treatment response, as well as to look at the relationship between sleep patterns in the mothers and their babies.  Participants completed interviews at the beginning and end of treatment.  The interviews included measures of depression, stress, social and treatment issues.  Information about baby’s birth such as birth weight and age at birth was also collected. Sleep and biological rhythms were measured in the home environment during the last trimester of pregnancy and in the first 6 months after delivery.  Sleep, light exposure and rest were recorded from a light and motion sensor device called an actigraph and participants were asked to track their sleep and wake patterns using a sleep log.

Findings
Total sleep time, sleep latency, sleep efficiency, and number and duration of sleep episodes were computed for nocturnal and daytime sleep in each 24-hour block. The high-risk infants took longer to fall asleep, had lower sleep efficiencies, and had more sleep bouts in the nocturnal sleep period than did low-risk infants. These effects persisted at 6 months postpartum. Maternal depression is associated with significant sleep disturbance in infancy at 2 weeks postpartum that continues through 24 weeks.

Investigators: 
Heather A. Flynn (PI), Sheila M Marcus, M.D., and Roseanne Armitage, Ph.D.

Publication: 
Armitage R; Flynn H; Hoffmann R; Vazquez D; Lopez J; Marcus S. (2009) Early developmental changes in sleep in infants: the impact of maternal depression. SLEEP, 32(5), 693-696.

Selected Publications

Swanson, L. M., Pickett, S. M., Flynn, H., & Armitage, R. (2011). Relationships among
depression, anxiety, and insomnia symptoms in perinatal women seeking mental health treatment. Journal of Women’s Health, 20(4), 333-338.

Swanson, L. M., Flynn, H. A., Wilburn, K, Marcus, S., &Armitage, R. (2010). Maternal
mood and sleep in children of women at risk for perinatal depression. Archives of
Women’s Mental Health, 13(6), 331-334.

Armitage, R., Flynn, H., Hoffmann, R., Vazquez, D., Lopez, J.,& Marcus, 5. (2009). Early developmental changes in sleep in infants: The impact of maternal depression. Sleep: Journal of Sleep and Sleep Disorders Research, 32(5),693-696.

Brain and Behavior/Imaging Studies

Functional magnetic resonance imaging (fMRI) offers a unique window into the brain, allowing researchers to view a person's response to stimuli, such as photos, sounds and words in real time.  Research has shown that mental health disorders such as depression, anxiety and schizophrenia impact certain areas of the brain, and this knowledge has influenced specialized treatments aimed at improving these disorders.   However, not much is known about how parenting affects the brain, especially in parents struggling with mental health disorders, poverty, substance abuse and other stressors.  The WIMH Program research team is using fMRI scans to examine the relationship between brain function and the parenting role.

Research Activity

The Functional Neuroanatomy of Human Parental Care

This study aims to discover the brain structural and functional underpinnings of parental thoughts and behaviors, which are key contributors of parental health and infant development. Eligible participants will complete interviews and functional magnetic resonance (fMRI) brain scanning at two time points (2 - 4 weeks and 3-4 months postpartum). We will collect audio samples of the baby crying and pictures of the baby that will be shown to the parent in the fMRI scanner.   We hypothesize that the level of parental preoccupations regarding their newborn infant and involving anxious, intrusive, obsessive-compulsive-like thoughts will be related to the levels of neural activation and saliva levels of stress hormones in response to infant cries. We further predict that the responses of parent’s brains to stimuli from their own infants will be stronger than from control “stranger” infants. Finally, we will look for differential responses with respect to psychosocial and behavioral variables such as breastfeeding. 

Investigators: 
James Swain (PI), Carolyn Dayton, Nicholas Giardino, Shao-Hsuan Ho, Maria Muzik and Suzanne Perkins

fMRI Caregiving Study

This study examines whether helping an unrelated partner would activate regions in the brain also activated during maternal caregiving , and if this brain activation would be a function of trust between a helper and recipient, a function of parenting experience (parents vs. non-parents), and if brain regions activated in helping are also associated with accelerated stress recovery and down-regulation of areas of the brain associated with stress and threat.  In the fMRI scanner, we will prime parenting/caregiving by showing images of children and audio recordings of children. The participant will also complete a motivated performance task, in order to help herself avoid a potential stressful consequence.  The participant will be given an opportunity to “help” their partner to also avoid a stressful consequence. After the Helping Task, the participants will be told to prepare for a speech in the scanner. In addition to brain imaging, physiological data (heart rate, breathing rate, etc.) will also be collected during this task. After the Stress Task is over, we will continue collecting physiological data when the participants are scanned for anatomical images.  Once all data is collected we will be able to compare parents to non-parents, to see if their responses differed significantly.

Investigators: 
James Swain (PI), Shao-Hsuan Ho

Circle of Security/fMRI

Women enrolled in the Circle of Security study, which is a 12 week attachment-based parenting intervention group that aims to shift patterns of attachment/caregiving interactions in high-risk mother-child dyads to more developmentally appropriate pathways, also completed fMRI brain scans before and after participation. For more information on COS, please see the Interventions/Treatments section.

Findings:
Results suggest a link between maternal psychopathology and diminished neural response in brain regions that are integral in self-reflection.  A history of depression and anxiety appear to alter brain responses that may be important for parenting, suggesting targets for intervention and improved child mental health.

Investigators: 
Maria Muzik (PI), Katherine Rosenblum and Sheila Marcus

Selected Publications

Swain, J. E., & Ho, S. S. (2012). What's in a baby-cry? Locationist and constructionist frameworks in parental brain responses. Behav Brain Sci, 35(3), 167-168.

Kim, P., Feldman, R., Mayes, L. C., Eicher, V., Thompson, N., Leckman, J. F., & Swain, J. E. (2011). Breastfeeding, brain activation to own infant cry, and maternal sensitivity. J Child Psychol Psychiatry, 52(8), 907-915.

Swain, J. E. (2011). Becoming a parent: biobehavioral and brain science perspectives. Curr Probl Pediatr Adolesc Health Care, 41(7), 192-196.

Swain, J. E. (2011). The human parental brain: in vivo neuroimaging. Prog Neuropsychopharmacol Biol Psychiatry, 35(5), 1242-1254.

Swain, J. E., Kim, P., & Ho, S. S. (2011). Neuroendocrinology of parental response to baby-cry. J Neuroendocrinol, 23(11), 1036-1041.

Kim, P., Leckman, J. F., Mayes, L. C., Feldman, R., Wang, X., & Swain, J. E. (2010). The plasticity of human maternal brain: longitudinal changes in brain anatomy during the early postpartum period. Behav Neurosci, 124(5), 695-700.

Kim, P., Leckman, J. F., Mayes, L. C., Newman, M. A., Feldman, R., & Swain, J. E. (2010). Perceived quality of maternal care in childhood and structure and function of mothers' brain. Dev Sci, 13(4), 662-673.

Swain, J. E. (2008). Baby stimuli and the parent brain: functional neuroimaging of the neural substrates of parent-infant attachment. Psychiatry, 5(8), 28-36.

Screening, Access to Care, and Clinical Outcomes

A founding research focus of the WIMH Program was to examine methods to improve screening for depression, including identification in primary care settings, and to increase women’s opportunities to receive mental health treatment when needed. Studies about women’s use of mental health treatment during the perinatal period are important since most women at-risk for depression do not receive proper care and when proper care is received, the lives of women and their children can significantly improve.

Research Activity

Interventions, Treatments, and Complimentary Alternative Medicine

Telemedicine

Investigators
Kate Rosenblum, Maria Muzik, Shaun Ho

Other Research

Perinatal Clinical Outcomes Study

The purpose of this study is to utilize clinically relevant outcome data which is largely already being collected from women who seek treatment with the Women and Infants Mental Health Clinic, while at the same time creating a registry of women who are interested in participating in other, more specific research projects for which they may be eligible. The specific aims of this study are to 1) describe characteristics of women seeking treatment with the perinatal clinical team, 2) identify predictors of treatment adherence and treatment response, and 3) establish feasibility of conducting clinical research in the perinatal clinic in psychiatry. This feasibility phase will consist of a naturalistic descriptive study of patient characteristics and outcomes. All women who seek mental health care at the clinic are asked to complete measures in addition to those she completes on MStrides for clinical monitoring. A subset of these measures will be asked again at 3 and 6 months after the initial assessment. The patients’ health record is examined to extract relevant medical comorbidity diagnoses such as diabetes, hypertension, and thyroid irregularities. This data will be used to examine epidemiology, symptom severity, service utilization, treatment response, and medical comorbidity on a large scale. Researchers plan to examine both the direct and indirect (mediation) effects on treatment outcome measures, as well as moderators and duration of the effect on outcomes. Evaluation the effect of the treatments over time from baseline through follow up and test whether such effect varies by the baseline characteristics will provide insight into the appropriate treatments for corresponding symptoms. This study is still recruiting participants from the Women and Infants Mental Health Clinic and is currently in a data collection phase. 

Investigators
Heather Flynn, PhD. (PI), Kate Rosenblum, PhD., and Sheila Marcus, M.D.

Perinatal Mental Health Registry

The purpose of the Perinatal Mental Health Registry is to identify women who are eligible for and interested in participating in ongoing research studies. Additionally, this registry will be helpful in reducing redundancy in screening assessments administered to women who participate in multiple projects. This project targets the female population seeking prenatal care within the University of Michigan Health System. All women seeking prenatal care at one of the 7 clinics in the University of Michigan health system receive the Edinburgh Postnatal Depression Screen (EPDS) to complete, which is standard of care. Additionally, the medical assistants, clerks, or nurses (varies by clinic) hand out the consent form and screening questionnaire to patients during select OB visits (first or third trimester or both depending on the clinic). Women are given the choice to fill out the forms and provide informed consent to be contacted about specific research studies. A research staff member reviews the screens to determine which IRB approved research study recruiting from the registry the women may be eligible for. Contact information for those women who give informed consent are distributed to each individual study. If a woman is eligible for a study, they will be contacted by that study's research staff and asked to sign a consent form to participate in that particular study's research project.

The Women’s Mental Health Registry receives approximately 30 screening forms per week. Out of those, approximately 50% of women agree to be contacted for research. An additional 11% allows their data to be retained anonymously to ensure that those who agree are representative of the population as a whole. Of those with available EPDS scores, 17% score a 9 or higher (indicating risk for depression,) and 8% score a 12 or higher (indicating likely MDD criteria.) Approximately, 47% of women screened are in their first trimester of pregnancy and 19% are in their 3rd trimester of pregnancy.

Investigators: 
Heather Flynn, (PI) and Kate Rosenblum,

OB Study: Does routine screening for depression in obstetrics improve treatment receipt for pregnant women?

This study sought to 1) compare rates of depression and treatment notations in medical charts pre and post screening implementation,  2) examine the impact of routine screening on provider feedback and treatment receipt, and 3) examine depression severity over time as related to treatment receipt. The study implemented routine depression screening in obstetrical settings in an effort to: assess presenting rates of depression in pregnant women; the impact of screening on provider discussion of depression and appropriate referral; and patient follow-through with treatment. In two University affiliated obstetric clinics, pregnant women were administered the Edinburgh Depression Screen (EPDS) as part of routine care. Providers were notified about positive depression risk. Women who screened positive for depression (score of greater than 10) were contacted for a diagnostic interview (SCID-IV). These women were interviewed again one month later.

Findings:  
Over a 12 month period, 1684 women completed an EPDS depression screening at their OB clinic. 16% (n = 269) scored positive for depressive symptoms. Of these women, 35% (n = 94) met criteria for current Major Depressive Disorder, and 28% (n = 75) met criteria for past Major Depressive Disorder (MDD). More than half of the women with current MDD were not receiving any form of treatment (55%), compared to 44% of depressed women reporting current treatment. However, at one month follow-up, only 23% of women overall were receiving treatment suggesting that physician notification did not impact mental health treatment.  Routine screening feasibly identifies depressive risk in obstetrics. Screen notification increases physician discussion of depression, but follow-up mental health care by patients is poor. More efforts may be needed to encourage rapid receipt of mental health services for high-risk women.

Investigators: 
Heather Flynn (PI) and Shelia Marcus.

Barriers Study: Understanding treatment use in pregnancy

Existing research indicates that practical barriers interfere with women’s ability to receive treatment, such as insurance, available treatment, transportation, and ability to pay. New data from recent research projects suggests that even women who don’t have practical barriers still don’t seek treatment; women’s beliefs about themselves impact whether they will seek treatment; and some women seek help from religious persons, friends, and family before or rather than health professionals. This study was designed to further explore the kinds of barriers women might experience in seeking mental health treatment. We are particularly interested in gaining information about women’s expectations for treatment, issues related to stigma; the support they have from others to seek treatment; and other concerns about treatment. In this study, women were screened at University affiliated outpatient OB clinics for depression symptoms using the Edinburgh Postnatal Depression Scale (EPDS). Those women who screened positive for depression (score of >=10), where then mailed a consent form and survey. The survey inquired about asked about recent formal and informal treatment use in prenatal care settings, confidence in the helpfulness of treatment, providers, and settings, and perceived barriers to treatment.

Findings
Pregnant women overall reported low rates of formal treatment use but frequently sought help from informal sources, such as friends, family, and printed materials. All women expressed greatest confidence in psychosocial treatments and lowest confidence in antidepressants. African American women reported less confidence in advice from family and friends and in antidepressants than did white women. Women expressed greatest confidence in treatments delivered by mental health professionals and religious leaders. African American women sought help more frequently and had significantly more confidence in religious leaders as treatment deliverers than white women. Women had greatest confidence in treatments delivered in professional and home settings, with African American women expressing greater confidence in religious settings than white women. All women reported greatest concern with structural barriers, compared with attitudinal and knowledge barriers.

Investigators
Heather Flynn (PI), Heather O'Mahen

Publication: 
Flynn, H., O'Mahen, H. (2008). Preferences and Perceived Barriers to Treatment for Depression during the Perinatal Period. Journal of Women's Health, 17(8), 1301-1309.

OB CARES: The Obstetric Clinics and Resources National Provider Survey: Practice Patterns in the Treatment of Depression during Pregnancy

The American College of Obstetricians and Gynecologists has issued recommendations for routine depression screening during each trimester as well as treatment algorithms for depression during pregnancy. Yet, little research exists as to optimal strategies for the delivery of depression care in everyday obstetric practice. In addition, we know little of provider decision-making in the treatment of depression during pregnancy. In order to implement these evidence-based recommendations in everyday prenatal care we need to understand how to influence provider behavior in addressing depression. Therefore, we propose a national survey of prenatal care providers to evaluate the determinants of provider decisions regarding the provision of depression care during pregnancy. Specifically, our project aims to: (1) To describe prenatal care providers’ practice patterns in managing depression during pregnancy; (2) To understand the role of contextual factors in provider decisions to treat depression during pregnancy and to evaluate the relative importance of internally versus externally-derived factors upon these treatment decisions; and (3) To determine whether perceived control over these factors affects provider decisions in addressing depression during pregnancy.
This project involves a national survey of a random sample of obstetricians, family physicians, and certified nurse-midwives. Survey content will focus on factors that are perceived to facilitate or impede the delivery of depression care and treatment preferences in response to standardized patient scenarios. Data collection for this project is ongoing. However, subsamples of 20 prenatal care providers from six obstetric clinics were interviewed to understand how prenatal care providers perceive influences on their delivery of perinatal depression care. After thematic analysis, including within-case and cross-case comparisons, researchers built a conceptual model of provider decision making from the data.

Findings: 
Although depression screening protocols were in place at our study clinics, we found that decisions to address perinatal depression were largely made at the level of the individual provider and were undefined on a clinic level, resulting in highly variable practice patterns. In addition, while providers acknowledged externally derived influences, such as logistical resources and coordination of care, they spoke of internally derived influences, including familiarity with consultants, personal engagement styles and perceptions of role identity, as more directly relevant to their decision making. These results highlight the pivotal role of internal factors in decisions to deliver perinatal depression care. Future interventions in obstetric settings should target the intrinsic motivations of providers.

Investigators
Heather Flynn (PI) and Christie Lancaster Palladino

Publication
Christie Lancaster-Palladino, C., Fedock, G., Forman, J., Davis, M., Henshaw, E., Flynn, H. (2011) OB CARES — The Obstetric Clinics and Resources Study: providers perceptions of addressing perinatal depression—a qualitative study. General Hospital Psychiatry, 33, 267-278.

Identification of Health Factors in Pregnancy

Detection and adequate treatment of antenatal depression are a critical public health issues that must be addressed. Depression in pregnancy has been associated with poor maternal functioning and birth outcomes, yet most depressed pregnant women are not detected or treated. The purpose of this study was to provide information on rates of depression treatment among pregnant women at risk for depression and among those with clinician-diagnosed current major depressive disorder (MDD) and to examine predictors of depression treatment seeking and use. Participants in this study were recruited after being screened for depression and other health behaviors while waiting for their prenatal care visit at outpatient OB/GYN clinic sites. Researchers contacted participants for a prenatal interview via telephone. The interview assessed depressive diagnostic status, depression severity, medication use, depression treatment use and health functioning.  Women with current depression symptoms were then contacted for two follow-up interviews. Women reporting substance use were contacted for one follow up interview. All participants were later contacted for an additional follow up interview via mail.  

Findings: 
Results: Of women screened, 20% (n 5 689) scored as at-risk of depression on a depression symptoms scale (CES-D) and only 13.8% of those women reported receiving any formal treatment for depression. Past history of depression, poorer overall health, greater alcohol use consequences, smoking, being unmarried, unemployment, and lower educational attainment were significantly associated with symptoms of depression during pregnancy. These data show that a substantial number of pregnant women screened in obstetrics settings have significant symptoms of depression, and most of them are not being monitored in treatment during this vulnerable time. This information may be used to justify and streamline systematic screening for depression in clinical encounters with pregnant women as a first step in determining which women may require further treatment for their mood symptoms. As elevations in depressive symptomatology have been associated with adverse maternal and infant outcomes, further study of the impact of psychiatric treatment in pregnant women is essential.

Investigators: 
Heather Flynn (PI), Fred Blow, and Sheila Marcus

Publications: 
Marcus, S., Flynn, H., Blow, F., Barry, K. (2003). Depressive Symptoms among Pregnant Women Screened in Obstetrics Settings. J Women's Health, 12(4), 373-380.

Flynn, H., Marcus, S., Blow, F. (2006). Rates and predictors of depression treatment among pregnant women in hospital-affiliated obstetrics practices. General Hospital Psychiatry, 28, 289– 295.

Selected Publications

O’Mahen, H., Henshaw, E., Jones, J., Flynn, H. (2011). Stigma and Depression During Pregnancy: Does Race Matter? Journal of Nervous and Mental Disease, 199(4), 257-262.

O’Mahen, H., Flynn, H., Marcus, S., Chermack, S. (2009) Illness perceptions associated with perinatal depression treatment use. Archives of Women's Mental Health, 12, 447-450.