Monday, November 06, 2023

International study led by researchers in Singapore reveals critical insights into timely interventions for maternal depression


Peer-Reviewed Publication

AGENCY FOR SCIENCE, TECHNOLOGY AND RESEARCH (A*STAR), SINGAPORE




SINGAPORE – A large-scale international study spanning three continents, led by researchers from A*STAR’s Translational Neuroscience Programme of the Singapore Institute for Clinical Sciences (SICS) in Singapore, has found that maternal depressive symptoms begin from early pregnancy and can last up to two years after childbirth.

While health professionals often emphasise the postpartum stage after childbirth as a high-risk period for the onset of depression, findings from this latest study reveal a different reality – that maternal depressive symptoms can appear from early pregnancy and therefore timely interventions during pregnancy are needed to better mitigate such symptoms for improved outcomes for both mother and child.

Previous findings from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) project showed clearly that prenatal maternal mental health plays a significant role in the brain development and health of one’s offspring. Research shows that maternal depressive symptoms can negatively affect a child’s nutrition, physical health, cognitive functions, socioemotional development, academic achievement, and also increase the risk of ADHD and depression.

The study was published in the journal JAMA Network Open on 26 Oct 2023, titled Perinatal Trajectories of Maternal Depressive Symptoms in Prospective, Community-Based Cohorts Across 3 Continents. It involved seven prospective observational cohorts across the United Kingdom, Canada, and Singapore. A*STAR researchers analysed the maternal depressive symptom trajectories of 11,563 pregnant women, spanning multiple decades in the largest such analysis to date.

Among the cohorts analysed were three from Singapore: Growing Up in Singapore Towards healthy Outcomes (GUSTO), Singapore PREconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO) and Mapping Antenatal Maternal Stress (MAMS). Each cohort included depressive symptoms measured at multiple perinatal time points and analysed independently. The data was based on prospective maternal self-reports of depressive symptoms, eliminating the potential bias collected from retrospective reports.

The study showed three distinct clusters of mothers with stable low, mild, and high symptom levels over the perinatal period – the period from the beginning of pregnancy up to two years post-birth. The trajectories of depressive symptoms were present for all mothers.  This was true even those who met clinical cut-offs for probable depression indicating that more serious instances of depression in women begin prior to the birth of the child. 

With a more precise grasp of when depressive symptoms begin for mothers, the study underscores the importance of early interventions during pregnancy to mitigate maternal depressive symptoms and their impact on offspring. This paradigm shift has far-reaching implications for healthcare professionals, policymakers, and the general public.

“Several recent studies, including one conducted locally suggest that maternal depressive symptoms may begin before conception, which is why interventions, guidelines for care, and public health policies aimed at alleviating maternal depressive symptoms should target as early as preconception, at least during pregnancy, in addition to the postnatal period, for more effective outcomes,” says Dr Michelle Kee, Research Scientist at A*STAR’s SICS and first author of the paper.

Professor Michael Meaney, the Director of the Translational Neuroscience Programme at SICS, adds, “The medical media continues to refer to maternal depression as ‘postnatal depression’, implying that the onset of symptoms occurs following the birth of the child. This extensive analysis shows that the onset of symptoms is in the prenatal period and remains largely stable thereafter. This is true for women in the community as well as for those experiencing more severe symptom levels. The results of this study point to the early antenatal period as a crucial time point for the identification of stable trajectories of maternal depressive symptoms and emphasises the critical importance of prenatal intervention.”

Associate Professor Helen Chen, Senior Consultant Department of Psychological Medicine, KK Women's and Children's Hospital and Clinical Associate Professor of Duke-NUS Medical School shares, "This study provides strong evidence across populations that it is crucial to address depression during pregnancy so that mothers are well and ready to receive their babies, rather than to wait until the postnatal period, for postnatal depression has traditionally been the focus. Given what we know about the impact of perinatal depression on child development and health outcomes, the paper will help to inform healthcare systems to direct resources upstream to the antenatal period. This will benefit our mothers and their children, and population health of future generations."

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Singapore’s smoke-free law may have warded off 20,000 heart attacks in seniors


First such local study finds extension of smoking ban to communal areas of residential blocks and outdoor spaces linked to monthly fall in heart attack cases


Peer-Reviewed Publication

DUKE-NUS MEDICAL SCHOOL




An extension of the smoking ban to communal areas of residential blocks and other outdoor spaces in Singapore in 2013 may have prevented up to 20,000 heart attacks among those aged 65 and above. This is according to the first local study investigating the effects of expanding such laws to outdoor areas.

The research, published in the open access journal BMJ Global Health, was led by scientists from Duke-NUS Medical School. Their study showed that the extension of the smoking ban was associated with a monthly fall in the rate of heart attacks, with older people and men benefitting the most.

Second-hand smoke exposure is responsible for 1.3 million annual deaths around the globe, many of which are caused by heart attacks. But the existing evidence on the health benefits of comprehensive smoke-free laws, which many countries (67 since 2003) have implemented, is largely confined to indoor smoking bans rather than those for housing estates and outdoor spaces. 

“Residents would likely frequent common areas in housing estates as part of their daily routine or when meeting with their friends and neighbours. If there are smokers around, these residents may be exposed to tobacco smoke. Having smoking bans in these areas would reduce their exposure to the smoke and consequently, reduce their risk of heart attacks,” said Dr Joel Aik, an Adjunct Assistant Professor from the Health Services & Systems Research Programme at Duke-NUS and senior author of the study.

In 2013, Singapore extended smoke-free legislation to all communal areas of residential blocks, where 80 per cent of the population lives, as well as outdoor spaces, including covered linkways, overhead bridges and within 5 metres of bus stops. This was further extended to reservoirs and all residential parks in 2016, and to more educational institutions as well as more types of buses and taxis in 2017.

To assess the impact of the various pieces of legislation on heart attack rates, the researchers analysed monthly reports from the Singapore Myocardial Infarction Registry from January 2010 to December 2019. During this period, 133,868 heart attacks were reported, 87,763 (66 per cent) of which occurred among men and 80,597 (60 per cent) of which occurred among those aged 65 and above.

Before the 2013 extension, the rate of heart attacks among those aged 65 and above was around 10 times that of those under 65 years of age. The rate of cases among men was nearly double that of women. The overall number of heart attacks rose by a rate of 0.9 cases per million people every month before the 2013 extension. But afterwards, this rate fell to 0.6 cases per million people.

Seniors and men were the primary beneficiaries of the extended ban. The monthly fall in heart attack rate among those aged 65 and above was 5.9 cases per million people. This fall in the rate is almost 15 times greater than that in younger individuals, which stood at 0.4 cases per million people.

According to their calculations, the scientists also estimated that an additional 19,591 heart attacks might have occurred in those aged 65 and above, compared with 1,325 in the under-65s had the legislation not been enacted. Potentially, 4,748 cases were averted in men.

The impact was not as clear when studying the impact of legislation in subsequent years. From 2016, the extension of smoke-free laws to reservoirs and more parks was not associated with a significant reduction in the number of heart attacks. This could have been due to better diagnostic technology, which can detect more cases of heart attack.

While the 2017 legislation was not associated with a significant decline in overall heart attack incidence, the researchers found that the average decline in the rates following this prohibition extension to more universities and more types of buses and taxis was consistent among those of different age groups and among men and women. This consistency in findings suggests that the ban may well have been beneficial though more studies are required to validate this.

Professor Patrick Tan, Senior Vice-Dean for Research at Duke-NUS, said: “Smoking remains an unresolved epidemic in Asia, with majority of tobacco consumers being in the region. This study provides additional evidence for policy makers who are looking to expand their smoke-free laws to mitigate the adverse impact of exposure to tobacco smoke and reduce the health burden of heart diseases for their residents.”  

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Reference: Ho, J.S. et al. (2023) ‘Association between the extension of smoke-free legislation and incident acute myocardial infarctions in Singapore from 2010 to 2019: An interrupted time-series analysis’, BMJ Global Health, 8(10). doi:10.1136/bmjgh-2023-012339.

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