The impact of docosahexaenoic acid on maternal mental health: scoping review

Nu ición Hospi ala ia ISSN (elec ónico): 1699-5198 - ISSN (papel): 0212-1611 - CODEN NUHOEQ S.V.R. 318 ©Copy igh 2023 SENPE y ©A án Ediciones S.L. Es e es un a ículo Open Access bajo la licencia CC BY-NC-SA (h p://c ea i ecommons.o g/licenses/by-nc-sa/4.0/). he impac o docosahexaenoic acid on ma e nal men al heal h: scoping e iew El impac o del ácido docosahexaenoico en la salud men al ma e na: e isión sis ema izada de la li e a u a Olga Maso 1,2, Julio José Ochoa He e a3, Elena Pa aíso Pueyo1,2, Judi h Roca1,2, Jèssica Mi anda1,2, Ana La edán San ama ía1,2 1Depa men o Nu sing and Physio he apy. Uni e sidad de Lleida. Lleida, Spain. 2Heal h Ca e Resea ch G oup (GRECS). Ins i u o de In es igación Biomédica de Lleida Fundación D . Pi a é. IRBLleida. Lleida, Spain. 3Ins i u o de Nu ición y Tecnología de los Alimen os José Ma aix Ve dú (INYTA). Depa men o Physiology. Uni e sidad de G anada. G anada, Spain Con lic o in e es : he au ho s decla e no con lic o in e es . Maso O, Ochoa He e a JJ, Pa aíso Pueyo E, Roca J, Mi anda J, La edán San ama ía A. The impac o docosahexaenoic acid on ma e nal men al heal h: scoping e iew. Nu Hosp 2023;40(4):848-857 DOI: h p://dx.doi.o g/10.20960/nh.04523 Recei ed: 28/01/2023 • Accep ed: 20/03/2023 Co espondence: Elena Pa aíso Pueyo. Depa men o Nu sing and Physio he apy. Uni e sidad de Lleida. C/ Mon se a Roig, 2. 25198 Lleida, Spain e-mail: [email p o ec ed] Re isión Abs ac Docosahexaenoic acid (DHA) is a polyunsa u a ed essen ial a y acid om he omega-3 se ies ha appea s o be key o pe ina al men al heal h. Fo his, he aim o his e iew is o e alua e he e ec o DHA on ma e nal men al heal h du ing p egnancy and lac a ion wi h espec o dep ession and anxie y. The p esen scoping e iew was ca ied ou ollowing he me hodology o A ksey and O’Malley (2005). The selec ion o s udies was ca ied ou in acco dance wi h PRISMA by means o sys ema ic sea ches in he PubMed, Scopus, PsycINFO and Medline da abases. The esul s classi ied acco ding o he e ec i eness o DHA. In mos (n = 9) o he 14 s udies inally included, DHA plasma le els wi h o wi hou o he polyunsa u a ed omega-3 a y acids we e signi ican ly lowe in p egnan women wi h dep essi e and anxie y symp oms. Howe e , no s udy epo ed a bene icial e ec o DHA on men al heal h du ing he pos pa um pe iod. The majo i y used de ec ion me hod was he Edinbu gh Pos pa um Dep ession Scale (n = 11). The p e alence o dep essi e symp oms anged be ween 5.9% and 50%. As a conclusion, al hough mo e esea ch is needed in his a ea, hese explo a o y esul s sugges ha DHA could play an impo an ole in p e en ing he pa hogenesis o dep ession and anxie y du ing ges a ion. Keywo ds: Docosahexaenoic acid. Dep ession. Anxie y. P egnancy. Pos pa um. Re iew. Resumen El ácido docosahexaenoico (DHA) es un ácido g aso esencial poliinsa u ado de la se ie omega-3 que pa ece se cla e pa a la salud men al pe ina al. Po ello, el obje i o de es a e isión es e alua el e ec o del DHA sob e la salud men al ma e na du an e el emba azo y la lac ancia con espec o a la dep esión y la ansiedad. La p esen e e isión se lle ó a cabo siguiendo la me odología de A ksey y O’Malley (2005). La selección de es udios se ealizó de acue do con PRISMA median e búsquedas sis emá icas en las bases de da os PubMed, Scopus, PsycINFO y Medline. Los esul ados se ca aloga on según la e icacia del DHA. En la mayo ía (n = 9) de los 14 es udios inalmen e incluidos, los ni eles plasmá icos de DHA con o sin o os ácidos g asos omega-3 poliinsa u ados ue on signi ica i amen e más bajos en muje es emba azadas con sín omas de dep esión y ansiedad. Sin emba go, ningún es udio in o mó un e ec o bene icioso del DHA sob e la salud men al du an e el pe iodo pospa o. El mé odo de de ección más u ilizado ue la Escala de Dep esión Pospa o de Edimbu go (n = 11). La p e alencia de sín omas dep esi os osciló en e el 5,9% y el 50%. Como conclusión, aunque se necesi a más in es igación en es e ámbi o, los esul ados explo a o ios pa ecen indica que el DHA juega un papel impo an e en la p e ención de la pa ogenia de la dep esión y la ansiedad du an e el pe iodo de ges ación. Palab as cla e: Ácido docosahexaenoico. Dep esión. Ansiedad. Emba azo. Pospa o. Re isión. 849THE IMPACT OF DOCOSAHEXAENOIC ACID ON MATERNAL MENTAL HEALTH: SCOPING REVIEW [Nu Hosp 2023;40(4):848-857] INTRODUCTION Docosahexaenoic acid (DHA o 22:6n-3) is an omega n-3 polyunsa u a ed a y acid (PUFA). Chemically, i is a ca boxylic acid like all a y acids (FAs). DHA is conside ed as he mos im- po an long-chain PUFA o he n-3 amily. Physiologically, he human body is able o me abolize DHA h ough con e sion in he o ganism o alpha linolenic acid (ALA), ano he n-3 PUFA. This con e sion akes place p incipally in he li e and i is anspo ed as a phospholipid by plasma albumin, almos exclusi ely, o he b ain and e ina. In cases o p egnancy, adipose issue also ac s as a empo a y ese e, bu he deg ee o con e sion is educed, making i di icul o mee ecommended le els o DHA, con- side ed o be an essen ial p ena al nu ien (1). Fo his eason, he Eu opean Food Sa e y Au ho i y (EFSA) (2) ecommenda ion anges om 100 o 200 mg/day. Fac o s ha can in luence low DHA in ake in p egnan emales include le el o educa ion, olde age, smoking and insu icien ish and sea ood consump ion, especially in he second and hi d imes e s (3). DHA is ound in ish oil and some algae. In u n, mos DHA in ish and o he complex o ganisms comes om hei access o pho osyn he ic he e o ophic mic oalgae. Foods ha con ain i include cold-wa e ish (like salmon, he ing o ancho- y), una and cod ish oil (1). As i can be di icul o each he ec- ommended amoun s h ough die a y in ake, he consump ion o DHA supplemen s wi h o wi hou o he FAs is ad ised. I should also be no ed ha omega-3 a y acid supplemen s a e well ole - a ed by p egnan and lac a ing women (4). In his g oup o women, his n-3 PUFA pa icipa es in di e en unc ions (5,6). In e ms o men al heal h, signi ican ly lowe le els o DHA, EPA and o al n-3 PUFAs ha e been ound in adul pa ien s wi h dep ession, sugges ing ha n-3 PUFAs play a ole in he pa ho- genesis o his illness (7), pa icipa ing in neu obiological p ocesses including con ol o se o one gic and dopamine gic unc ion, modu- la ion o b ain-de i ed neu o ophic ac o in he hippocampus, egu- la ion o he hypo halamic-pi ui a y-ad enal axis, and wi h e ec s on neu oin lamma ion (8). In his ega d, Lin e al. (7) a gued he need o s udies examining he speci ic unc ions o DHA in di e en popu- la ion g oups wi h dep essi e symp oms. In his con ex , he p esen s udy ocuses on ma e nal men al heal h. One possible solu ion o men al heal h issues in such si ua- ions is he applica ion o p esc ip ion d ugs. Howe e , because o hei po en ial oxic, e a ogenic o e en le hal e ec s on he e us, he use o many o hem is no ecommended du ing p eg- nancy. In addi ion, he physiological changes inhe en o p eg- nancy and lac a ion condi ion he abso p ion, ans e , exc e ion and me abolism o an ipsycho ics (9). Fo his eason, nu i ion- based ea men s ha e been p oposed as an aid o alle ia e and/ o p e en p ena al anxie y and dep ession (10). The e is he e- o e an e iden need o know he eal e ec o DHA on men al heal h du ing p egnancy and he pos pa um pe iod. None heless, despi e he indings o he e e enced s udies, he ela ionship be ween DHA and i s e ec on men al heal h in he p ena al s age is no ully clea (7). I can be specula ed ha di e en ac ions can occu simul aneously. On one hand, by main aining and inc easing he b ain s uc u es and p ese ing hei unc ion by in e ac ing wi h phospholipid me abolism and, hence, he modula ion o signal ansduc ion. On he o he hand, p e en ing o dec easing he in lamma o y s a us occu ing du ing dep ession (11). The aim o his scoping e iew is he e o e o e alua e he e ec o DHA du ing p egnancy and he pos pa um pe iod on ma e nal men- al heal h in e ms o dep essi e symp oms and anxie y. MATERIAL AND METHODS The scoping e iew amewo k adop ed was based on he me h- odological model o A ksey and O’Malley (12), wi h con ibu ions om he P e e ed Repo ing I ems o Sys ema ic e iews and Me a-Anal- yses ex ension o Scoping Re iews (PRISMA-ScR) (13). Following he model, he me hodological p ocess was di ided in o i e s ages. IDENTIFYING THE RESEARCH QUESTION The esea ch ques ion ha was o mula ed was as ollows: wha a e he e ec s o DHA du ing p egnancy and he pos pa um pe iod on ma e nal men al heal h in e ms o dep ession and anxie y? IDENTIFYING RELEVANT STUDIES Rele an s udies we e iden i ied by sea ching ecen li e a u e published be ween Feb ua y and Ma ch 2021 in he PubMed, Sco- pus, PsycINFO and Medline da abases. The ollowing keywo ds we e used: “Docosahexaenoic Acid”; “Fish Oil”; “Die a y Supplemen s”; “P egnancy”; “Ma e nal-Fe al Exchange”; “B eas Feeding”; “De- p ession; “Dep ession, Pos pa um”; “Men al Heal h”; “Beha io al Symp oms”; “S ess, Psychological”; “A ec i e Symp oms”; “Anxi- e y”; “Pos na al dep ession”; and “An ena al dep ession”. A icles included in his scoping e iew me he ollowing speci ied inclusion c i e ia: a) analy ical s udies (i.e., andomised con olled ials [RCT], o mainly obse a ional s udies [c oss- sec ional, coho and case-con ol]); b) e alua ing he e ec o DHA on men al heal h (dep ession and anxie y) in p egnan and/ o lac a ing women; c) published in English o Spanish; and d) published be ween Janua y 2010 and Ma ch 2021. The heal h- ca e le el a which he s udy was ca ied ou was no conside ed as ele an . S udies which we e ca ied ou on animals o which ocused only on o he n-3 PIFAs we e excluded. STUDY SELECTION S udy selec ion was ca ied ou as desc ibed abo e and ol- lowing PRISMA (14). Fi s , he sea ch esul s we e impo ed in o Mendeley (h ps://www.mendeley.com) o pe o m he du- plica ion check, hus elimina ing 563 a icles. O he emaining 964 s udies which we e subsequen ly analyzed acco ding o i le and abs ac , 883 we e disca ded based on he inclusion 850 O. Maso e al. [Nu Hosp 2023;40(4):848-857] and exclusion c i e ia, while 81 we e ound o be po en ially eligi- ble a icles. Subsequen ly, he ele ance o each o he abs ac s was analyzed, elimina ing 46 in his p ocess. Finally, he ull ex o he emaining 35 a icles was examined and 14 we e chosen o inal analysis (Fig. 1). The en i e p ocess was eco ded using an Excel In o ma ion Manage sp eadshee (15). CHARTING THE DATA Fou speci ic componen s we e ex ac ed using a s anda dised o m: a) gene al da a (au ho [s], yea o publica ion and coun- y); b) me hodological elemen s (s udy design and popula ion); c) da a o he in e en ion/obse a ion ca ied ou (i.e., dose o DHA, measu emen o he p esence o dep ession and/o anxie y, e c.); and d) da a e alua ing he e ec o DHA on he men al heal h o p egnan and/o lac a ing women. COLLATING, SUMMARIZING AND REPORTING THE RESULTS The esul s we e classi ied acco ding o whe he o no aking DHA du ing p egnancy was e ec i e o ma e nal men al heal h. O he 14 pape s, nine epo ed bene icial e ec s and i e, no bene icial bene i s. RESULTS The esul s a e se ou in h ee di e en sec ions: cha ac e is- ics o he included s udies, s udies which show he e ec i eness o DHA in e ms o ma e nal men al heal h, and s udies which show no such e ec i eness. CHARACTERISTICS OF INCLUDED STUDIES The 14 pape s came om a o al o 11 coun ies: wo om B azil, Uni ed S a es and Japan; and one each om Aus alia, The Ne he lands, I an, Kenya, Mexico, No way, Uni ed Kingdom and Taiwan. Exac ly hal o he pape s we e published be ween 2016 and 2018 (n = 7). As o he ype o s udy, six we e RCT, ou we e p ospec i e coho s, h ee we e c oss-sec ional s ud- ies and one, a longi udinal case-con ol s udy. These and o he cha ac e is ics o he s udies a e shown in able I. Figu e 1. PRISMA cha . DHA: docosahexaenoic acid; n-3 PUFA: omega-3 polyunsa u a ed a y acids. Iden i icac ion Numbe o in e en on s udies supplemen a ion du ing p egnancy o –n-3 PuFA– (n = 6) Numbe o obse a ional s udies –n-3 PuFA concen a ions in ma e nal blood– (n = 8) Reco ds excluded (n = 46) Full- ex a icles excluded, wi h easons (n = 21): • Made in animals (n = 5) • i is no an o iginal s udy (n = 5) • Does no s udy he e ec o DHA in p egnan o lac a ing women (n = 4) • Dep essi e symp oma ology o anxie y is no examined (n = 7) Sc eening and eligibili yIncluded Reco ds iden i ied h ough da abase sea ching (n = 1527) Reco ds a e duplica es emo ed (n = 964) Reco ds sc eened (n = 81) Full- ex a icles assessed o eligibili y (n = 35) s udies included in quali a i e syn hesis (n = 14) 851THE IMPACT OF DOCOSAHEXAENOIC ACID ON MATERNAL MENTAL HEALTH: SCOPING REVIEW [Nu Hosp 2023;40(4):848-857] Table I. O e iew o included s udies Au ho (s), yea o publica ion Coun y S udy design Popula ion In e en ion/obse a ion DHA e ec S udies whe e DHA was ound o be bene icial o ma e nal men al heal h Ál a ez-Ramí ez e al. (16), 2018 Mexico C oss- sec ional s udy n = 151 p egnan in second semes e DHA in ake: ood equency ques ionnai e Anxie y: STAI; dep ession: EPDS (≥ 12 poin s) A e age daily in ake o DHA: 70 mg/day Anxie y: 44.4%; dep ession: 17.9% Anxie y: ↑ STAI sco e wi h ↓ DHA in ake (p = 0.03) Dep ession: ↑ EPDS sco e wi h ↓ DHA in ake (p = 0.01) Chang e al. (19), 2018 Taiwan C oss- sec ional s udy n = 17 wi h dep ession (DSM-IV) n = 16 wi hou dep ession (CG) All we e in he 2nd o 3 d imes e DHA and o he FAs in blood Pe ina al dep ession: DSM-IV and EPDS (in medians) EPDS: 14.6 poin s (SD: ± 3.6) in he g oup wi h dep ession and 5.3 (SD: ± 3.8) in CG < DHA le els in he dep essed g oup (p = 0.02) Fa shba -Khalili e al. (22), 2016 I an RCT IG: n = 75 CG: n = 75 P egnan IG: 1,000 mg/day o ish oil supplemen s (wi h 120 mg o DHA; 180 mg o EPA and 400 mg o ALA) CG: 1,000 mg/day placebo Follow-up: beginning (WG 16-20), WG 26-30, WG 35- 37, and 30-45 days pos pa um Dep ession: EPDS (in medians); se um le els DHA and EPA A e ollow-up, signi ican di e ences be ween g oups we e in mean EPDS sco e (adjus ed mean di e ence = -1.4 [95% CI: -2.6 o -0.25]) IG: ↓ mean dep ession sco e du ing p egnancy and he pos pa um pe iod (p < 0.05) Pin o e al. (17), 2016 B azil Coho s, p ospec i e n = 172 p egnan DHA and o he FAs in blood; dep ession: EPDS (≥ 11 poin s) Follow-up be ween 5-13, 20-26 and 30-36 WG Dep ession: 1s imes e = 33.7%; 2nd = 18.9%; and 3 d = 17.4% Ad ancemen o p egnancy = > high concen a ions o DHA (OR = 0.96, 95% CI 0.93-0.99) and o he FA and ↓ in dep essi e symp oms (p < 0.05) Shi aishi e al. (18), 2015 Japan C oss- sec ional s udy n = 329 p egnan (WG 19-23) Plasma concen a ions o DHA (48.6-152.4 μg/ml) and EPA (11.6-107.2 μg/ml); die a y his o y: BDHQ du ing he mon h p io o he s udy Dep ession: EPDS (> 8 poin s) Dep ession: 5.9% ↑ EPDS sco e wi h ↓ DHA in ake (p = 0.09) and ↓ plasma DHA concen a ion (p = 0.04) Judge e al. (23), 2014 USA RCT (pilo s udy) IG: n = 20 p egnan CG: n = 22 p egnan IG: DHA (300 mg o DHA) CG: placebo (wi hou DHA, co n oil capsule) Consump ion o capsules om 24 o 40 WG (1 capsule 5 days/week) Dep ession du ing p egnancy: CES-D; pos pa um (up o 6 mon hs): PDSS (in means) CES-D: means IG 12.6 (SD: ± 8.3) and CG 9.5 (SD: ± 8.3) PDSS: means be ween 46.03 and 47.65 ↓ o al PDSS sco es in IG: wi h less anxie y/insecu i y (p = 0.03), emo ional labili y (p = 0.04) and loss o sel (p = 0.02) (Con inues on nex page) 852 O. Maso e al. [Nu Hosp 2023;40(4):848-857] Table I (Con .). O e iew o included s udies Au ho (s), yea o publica ion Coun y S udy design Popula ion In e en ion/obse a ion DHA e ec S udies whe e DHA was ound o be bene icial o ma e nal men al heal h Sallis e al. (29), 2014 UK Coho s, p ospec i e n = 306 wi h pe ina al dep ession n = 2,357 wi hou dep essi e symp oms DHA and EPA: changes in hei p esence in e y h ocy es (1% in DHA and 0.1% in EPA) Pe ina al, an ena al and pos na al dep ession: EPDS (≥ 12 poin s) Pe ina al dep ession: 11.5% Posi i e associa ion o EPA (OR = 1.07, 95% CI: 0.99- 1.15) and DHA (OR = 1.08, 95% CI: 0.98-1.19) wi h pe ina al dep ession The e we e no associa ions wi h he o he ypes o dep ession Ma khus e al. (21), 2013 No way Coho s, p ospec i e n = 35 women who comple ed he ollow-up FA in e y h ocy es (28 WG) Dep ession: EPDS (≥ 10 poin s) measu ed a 3 mon hs pos pa um Dep ession: 6.9% Signi ican associa ion be ween low le els o DHA wi h highe dep ession sco es (p = 0.006) Mozu kewich e al. (24), 2013 USA RCT IG1: n = 39 IG2: n = 38 CG: n = 41 All p egnan a he beginning o p egnancy had isk o dep ession IG1: EPA (1,060 mg EPA + 274 mg DHA) IG2: DHA (900 mg o DHA + 180 mg o EPA) CG: placebo (soybean oil) Dep ession: Beck Dep ession In en o y + Mini In e na ional Neu opsychia ic In e iew a he ime o en olmen , 26-28 WG, 34-36 WG, and 6-8 weeks pos pa um Se um AF: on admission and be ween 34 and 36 WG ↑ DHA (IG2) concen a ions a 34-36 WG, ↓ BDI sco es (p < 0.05) IG1 and CG we e no signi ican S udies ha do no demons a e he e ec i eness o DHA on ma e nal men al heal h U ech e al. (26), 2020 The Ne he lands Case-con ols, longi udinal n = 9 wi h majo dep ession n = 10 wi h anxie y n = 8 wi h mixed anxie y- dep ession diso de CG: 40 heal hy p egnan DHA and o he FAs in ma e nal e y h ocy es and b eas milk Dep ession: EPDS (in means) P ena al anxie y: DSM-IV Mean sco es ↑ in g oups wi h majo dep ession (9.5 ± 6.1), in mixed diso de (7.6 ± 7.6), and wi h anxie y (5.1 ± 1.8) han in heal hy (3.0 ± 3.8) No signi ican associa ions we e ound be ween p ena al dep ession and/o anxie y and DHA in milk o ma e nal e y h ocy es Opiyo e al. (29), 2018 Kenya RCT IG: n = 109 CG: n = 107 All HIV-posi i e p egnan women IG: daily dose o ish oil ich in n-3 (EPA = 2.15 g; DHA = 1.02 g) CG: daily dose o soybean oil (SFA: 0.178 g, MUFA: 0.299 g, PUFA: 0.985 g, wi h aces o EPA: 0.115 g) Follow-up: 8 weeks be ween WG 14 and 27 Dep ession: Beck’s Dep ession In en o y (< 14) Mild dep ession: 95.3% in he IG and 97.9% in he CG The e we e no signi ican di e ences be ween he wo g oups in he educ ion o symp oms o dep ession in HIV-posi i e p egnan women (Con inues on nex page) 853THE IMPACT OF DOCOSAHEXAENOIC ACID ON MATERNAL MENTAL HEALTH: SCOPING REVIEW [Nu Hosp 2023;40(4):848-857] Table I (Con .). O e iew o included s udies Au ho (s), yea o publica ion Coun y S udy design Popula ion In e en ion/obse a ion DHA e ec S udies ha do no demons a e he e ec i eness o DHA on ma e nal men al heal h Dos San os Vaz e al. (30), 2017 B azil RCT IG: n = 32 CG: n = 28 All p egnan a isk o dep ession GI: 1.8 g (1.08 g EPA and 0.72 g DHA) CG: placebo Supplemen a ion began a 22-24 WG (T1) and las ed 16 weeks Dep ession: EPDS (≥ 11 poin s) a 5-13 WG (T0), 22-24 WG (T1), 30-32 WG (T2) and 4-6 weeks pos pa um (T3) Dep ession in IG: 50% (T0), 25% (T1), 28.6% (T2) and 25% (T3) Dep ession in CG: 46.9% (T0), 37.5% (T1), 34.4% (T2) and 25% (T3) The e we e no di e ences be ween IG and CG in he p e alence o dep ession om p egnancy o pos pa um IG women wi h dep ession had a g ea e educ ion in EPDS om he second o he hi d imes e (p = 0.029) Kobayashi e al. (27), 2017 Japan Coho s, p ospec i e n = 967 pue pe al women (1 mon h a e deli e y) n = 710 women (6 mon hs a e deli e y) DHA consump ion du ing 26-40 WG: sFFQ Dep ession: EPDS (≥ 9 poin s) Dep ession: 19.8% and 12.8% in he pue pe ium No signi ican associa ions we e obse ed be ween EPA, DHA, and n-3 PUFA in ake a he end o p egnancy and pos pa um dep ession a bo h one mon h and six mon hs o ollow-up Mak ides e al. (28), 2010 Aus alia RCT GI: n = 1,197 women CG: n = 1,202 women n = 694 newbo ns GI: ish oil capsules wi h DHA (800 mg/day) CG: ege able oil capsules wi hou DHA Bo h om he beginning o he s udy un il bi h Pos pa um dep ession: EPDS (> 12 poin s); cogni i e and language de elopmen o he baby: Bayley scale Pos pa um dep ession: in IG 9.7% and in CG 11.2% IG compa ed o CG did no gi e lowe le els o pos pa um dep ession no did i imp o e cogni i e and language de elopmen in ea ly childhood DSM-IV: Diagnos ic and S a is ical Manual, 4 h edi ion; IG: in e en ion g oup; CG: con ol g oup; WG: ges a ion week; DHA: docosahexaenoic acid; EPA: eicosapen aenoic acid; STAI: S a e-T ai Anxie y In en o y (Spanish e sion); EPDS: Edinbu gh Pos pa um Dep ession Scale; FA: a y acids; ALA: alpha-linolenic acid; BDHQ: sel -adminis e ed die his o y ques ionnai e; CES-D: Cen e o Epidemiologic S udies Dep ession Scale; PDSS: Pos pa um Dep ession Sc eening Scale; HIV: human immunode iciency i us; n-3: omega-3; SFA: sa u a ed a y acids; MUFA: monounsa u a ed a y acids; PUFA: polyunsa u a ed a y acids; sFFQ: semi-quan i a i e ood equency ques ionnai e; n-3 PUFA: omega-3 polyunsa u a ed a y acids. 854 O. Maso e al. [Nu Hosp 2023;40(4):848-857] STUDIES THAT REPORT EFFECTIVENESS OF DHA WITH RESPECT TO MATERNAL MENTAL HEALTH O he 14 analyzed pape s, nine ound ha he consump ion o ei he DHA alone o in combina ion wi h o he FAs du ing p eg- nancy was bene icial o ma e nal men al heal h. O hese, six (16-21) measu ed plasma le els in he mo he while only h ee (22-24) s udied die a y supplemen s du ing he p egnancy. Wi h espec o he consump ion o DHA alone, wi hou o he FAs, his was only pe o med by Judge e al. (23). Signi ican ly lowe sco es (p = 0.016) we e eco ded on he Pos pa um De- p ession Sc eening Scale in he IG (46.03 ± 2.17) compa ed o he con ol g oup (CG) (52.11 ± 2.4). The e ec o he combina ion o DHA wi h o he FAs has also been s udied. Daily in ake o DHA a ied be ween 70 mg/day and 325 mg/day and he p e alence o dep essi e symp oms be ween 5.8% and 33.7% (16-18,21). Pin o e al. (17) epo ed a 5% dec ease in he p obabili y o ha ing dep essi e symp oms o each one-week inc ease in he p egnancy. In all (16-18,21), i was ound ha p egnan women wi h lowe die a y in ake and blood concen a ions o DHA had highe sco es on he Edinbu gh Pos pa um Dep ession Scale (EPDS) (p < 0.05). Likewise, lowe plasma concen a ions o o he FAs, such as EPA (16-18,21), docosapen aenoic acid (DPA) (17,21), o al n-3 (17,21), he n- 3/n-6 a io and highly unsa u a ed a (21) we e co ela ed wi h highe sco es on he EPDS. Finally, i should be no ed ha no s a is ically signi ican esul s we e ob ained o he pos pa um pe iod (20,21). As o anxie y, Ál a ez-Ramí ez e al. (16) epo - ed a p e alence o 44.4% (STAI > 40 poin s) and an inc ease in he STAI sco e o p egnan women wi h a lowe in ake o DHA and EPA (p = 0.03). Two obse a ional s udies ca ied ou a ollow-up o a g oup o p egnan emales diagnosed wi h pe ina al dep ession (IG) and ano he wi h no p io pa hology (CG). In he i s o hese, Chang e al. (19) ound ha he IG had signi ican ly lowe le els o DHA (p = 0.020), o al n-3 (p = 0.026), and EPA (p = 0.019). In he second s udy (20), an 11.5% p e alence o pe ina al dep ession was ound, along wi h a posi i e associa ion be ween DHA and EPA, and pe ina al dep ession. Howe e , as in he p e ious cases, no s a is ically signi ican co ela ions we e ound be ween DHA and EPA plasma concen a ions and pos na al dep ession. The inal wo pape s ha epo ed a bene icial e ec o DHA we e RCTs. In he i s o hese (22), a e he ollow-up i was ound ha ish oil supplemen s signi ican ly educed he mean EPDS sco e du ing p egnancy (p < 0.05). In he second s udy, Mozu kewich e al. (24) used wo IGs and a CG (wi h soybean oil). EPA- ich ish oil was adminis e ed o he i s IG and DHA- ich ish oil o he second. A he hi d o ou isi s (a 24-36 weeks’ ges a ion), he Beck Dep ession In en o y (BDI) sco e was signi i- can ly p edic ed by se um DHA (p < 0.05), BDI a en ollmen (p < 0.001) and admission o ha ing s opped aking he capsules (p < 0.01). None o he h ee die a y supplemen s signi ican ly p edic ed he BDI sco es a 6-8 weeks pos pa um. STUDIES THAT REPORTED NO EFFECTIVENESS OF DHA WITH RESPECT TO MATERNAL MENTAL HEALTH In his sec ion, a desc ip ion is o e ed o he i e s udies which epo ed no bene icial e ec o DHA on ma e nal men al heal h. In he obse a ional s udies, an analysis was unde aken o he con- cen a ion o n-3 PUFAs in blood samples. In he mos ecen o he s udies, ca ied ou by U ech e al. (26), a longi udinal ollow-up was made o ou g oups o p egnan women. Mean sco es inc eased mo e in he g oups wi h a men al diso de han in he heal hy g oup (CG). Mo eo e , women wi h a majo dep ession diso de did p es- en lowe le els o n-3 (p = 0.018) and EPA (p = 0.006), and hose diagnosed wi h a mixed anxie y-dep ession diso de had lowe le - els o EPA (p = 0.015) and highe le els o DPA (p = 0.001). No s a is ically signi ican associa ion was ound be ween he anxie y diso de g oup and any FA. In addi ion, no FA was signi ican ly asso- cia ed wi h pos pa um dep ession. In he o he obse a ional s udy (27), a o al o 967 women we e sc eened o pos pa um dep es- sion. Dep ession was eco ded in 19.8% o he women one mon h a e deli e y, a alue which ell o 12.8% a six mon hs. No signi i- can associa ions we e obse ed be ween pos pa um dep ession and in akes o DHA, EPA and n-3 PUFA. Jus one s udy, ha o Mak ides e al. (28), adminis e ed only DHA supplemen s (800 mg/day) o an IG. No signi ican di e - ences we e ound be ween he pe cen age o women who e- po ed dep essi e symp oms du ing he i s six mon hs pos - pa um in he IG and CG (9.67% agains 11.19%; adjus ed OR 0.85; 95% CI: 0.70-1.02; p = 0.09). Dep essi e symp oms we e commone among women wi h a p io o cu en diagnosis o dep ession a en olmen . The wo RCTs in which DHA was s udied in combina ion wi h o he FAs we e published by Opiyo e al. (29) and Dos San os Vaz e al. (30). In he i s o hese (29), all pa icipan s we e HIV-posi i e p egnan women. A he end o he ollow-up, mos o he pa icipan s had mild dep essi e symp oms (95.3% in he IG and 97.9% in he CG), wi h he di e ence no being s a- is ically signi ican . Finally, in he s udy by Dos San os Vaz e al. (30), dep ession was de ec ed using he EPDS (≥ 11 poin s) in di e en ges a ion weeks. A weeks 30-32 o ges a ion, he IG had highe se um concen a ions o EPA, DHA and lowe n-6/n-3 a io compa ed o he CG. Howe e , he e we e no di e ences be ween he IG and CG in he p e alence o EPDS sco es o e ime. Only women in he IG wi h a p e ious his o y o dep ession had a highe educ ion in he EPDS sco e be ween he second and hi d imes e compa ed o he CG (p = 0.038). In hei conclusions, he au ho s a gued ha a daily die a y supplemen o 1.8 g o n-3 PUFAs du ing 16 weeks had no e ec in e ms o p e en ing ma e nal dep essi e symp oms. DISCUSSION The esul s we e classi ied acco ding o whe he he s udies showed bene icial e ec s o o he wise o he in ake o DHA du - 855THE IMPACT OF DOCOSAHEXAENOIC ACID ON MATERNAL MENTAL HEALTH: SCOPING REVIEW [Nu Hosp 2023;40(4):848-857] ing p egnancy on ma e nal men al heal h in e ms o dep essi e symp oms and anxie y. The obse a ional ones almos all show ha he DHA has an impo an e ec in ela ion o ma e nal men- al heal h (6 yes, 2 no). On he o he hand, he expe imen al ones do no show ha e ec so clea (3 yes, 3 no). This lowe e ec in he expe imen al ones may be due o a ious causes (i.e., he di e en doses, he sample size and e en he di e en coun ies in which he s udies ha e been pe o med, since i is known ha he e a e clea di e ences in die s [31]). Acco ding o he analysis o he pape s ha has been unde - aken, dose is one o he condi ioning ac o s ha may a ec he e ec i eness o DHA. Di e en doses we e adminis e ed in he RCTs (22-24) (Table I). These doses mee he ecommended daily DHA in ake o he EFSA (2) (a ange om 100 o 200 mg/ day). I should also be no ed ha he e ec i eness o DHA e- po ed in hese s udies may be a ec ed by he exclusion c i e ia o a p io his o y o dep ession, anxie y o ce ain o he illnesses. In o he RCTs wi h highe doses o DHA, no bene icial e ec on men al heal h was epo ed, hough his may be due o how he s udies we e de eloped. In he case o Dos San os Vaz e al. (30), he inclusion c i e ia we e a p io his o y o isk o dep ession. Like- wise, in he s udy o HIV-posi i e p egnan women (29), he illness i sel could imply a bias in he esul s gi en he di e en physiologi- cal and psychological condi ioning ac o s o his g oup o women. Finally, i should be no ed ha in he s udy by Mak ides e al. (28), a die a y DHA supplemen o 800 mg/day was ound o be ine ec- i e in he p e en ion o educ ion o dep essi e symp oms. How- e e , as limi a ions o hei s udy, he au ho s epo ed ha hey did no e i y he clinical diagnosis o dep ession be o e he s a o he RCT. In addi ion, hey associa ed he lowe han expec ed a e o dep essi e symp oms in he CG o he so-called Haw ho ne e ec (33), acco ding o which he me e ac o pa icipa ion in a ial wi h a high deg ee o con ac wi h esea che s helps o p e- en such symp oms. Finally, in ela ion o he non-e ec i eness o DHA in p egnan women wi h an es ablished diagnosis o p ena al dep ession, a ecen s udy by Mezquida e al. (34) epo ed he associa ion o a speci ic pa e n o obs e ic complica ions wi h a mo e se e e clinical symp omology like dep ession. All o his may be in luen ial in e ms o he esul s o he non-e ec i eness o DHA in his popula ion wi h a his o y o men al illness. On he o he hand, Mak ides e al. (28) only analyzed he e ec o DHA in he pos pa um pe iod, while he e ec i eness o DHA was only ound o be s a is ically signi ican in o he s udies du ing p egnancy (16-24). In his ega d, a o al o i e s udies (24,26-29) ound, a e analyzing he e ec o DHA in he pos pa um pe iod, no posi i e e ec in e ms o he p e en ion o educ ion o dep essi e o anxie y symp oms. This may be because he die a y supplemen s we e adminis e ed du ing p egnancy and, he e o e, he concen a- ions o DHA would ha e lowe ed conside ably in he pos pa um pe iod. Howe e , he impo ance o DHA o ma e nal men al heal h in he hi d imes e has been shown. This appea s o be a c i i- cal pe iod o ensu e adequa e le els o ma e nal DHA o acili a e op imal cogni i e de elopmen a he end o in ancy (35). In his ega d, he po en ial e ec s o DHA du ing in ancy and adul hood a e becoming mo e widely ecognized, sugges ing a he same ime ha DHA le els can play a ole in cogni i e decline and in ela ion o he main psychia ic diso de s (36). The e ec may be ela ed o he in ake o DHA supplemen s inc easing he concen a ions o 17-hyd oxy-docosahexaenoic acid in ma e nal and umbilical co d blood (p = 0.02) (37). Finally, ano he condi ioning ac o ha may ha e a ec ed he esul s is he way dep essi e symp oms we e measu ed. One o he scales used, in he s udy by Judge e al. (23), was he Cen e o Epidemiologic S udies Dep ession scale (CES-D) (38). In he s udy, a C onbach’s α coe icien o 0.89 in he IG and 0.90 in he CG was epo ed. A no ewo hy esul i compa ed wi h he o iginal coe icien s o 0.85 and 0.9, espec i ely (38). Fo his eason, Judge e al. (23) concluded ha he ma e nal CES-D sco e du ing p egnancy was a signi ican p edic o o pos pa - um dep essi e symp oms. This inding also suppo s p e ious esea ch ha iden i ied psychological dis u bance du ing he p ena al pe iod as a signi ican p edic o o pos pa um dep es- sion (39,40). Howe e , his scale was no used in he o he s ud- ies, whe e he mos commonly used scale was he EPDS (25) (n = 11). This scale measu es dep ession and he emo ional eel- ings o mo he s in he las weeks o ges a ion. The p e alence o dep ession anged be ween 5.9% and 50% (16-22,24,26- 28,30). The EPDS has been used wi h di e en cu -o alues (≥ 12 poin s, ≥ 11, ≥ 10, ≥ 9 and > 8) o simply he mean alues. Al hough a high EPDS sco e (25) canno con i m a diagnosis o dep ession, i is conside ed ha a sco e highe han 12 may indica e a p obable dep essi e diso de (28). A sco e o 10 o 12 ep esen s a c osso e poin and a sco e o 0 o 9, he absence o pos pa um dep ession (41). In con as , Ma khus e al. (21) a gue ha he cu -o alue should be ≥ 10, as his is he alue commonly used in P ima y Ca e se ings. LIMITATIONS The selec ed s udies we e ca ied ou in di e en coun ies wi h la ge sociocul u al and die a y di e ences, making gene al- iza ions di icul . In addi ion, he e a e impo an gaps in he body o knowledge wi h espec o he in luence o o he nu ien de i- ciencies (i.e., gene ic polymo phisms ha a ec he syn hesis o n-3 FAs and he o al in ake o FAs) o he eal in luence o o he n-3 FAs (i.e., EPA) in ma e nal men al heal h. Da a on die a y in ake o a s and measu es o a y acid s a us in blood a e no collec ed o , a leas , no speci ied in mos pape s. The s udies a e also limi ed in many ins ances by a small sam- ple numbe o he inclusion/exclusion c i e ia ha we e used in ela ion o men al heal h issues p io o p egnancy. Fo he abo e easons, he esul s o hese s udies canno be conside ed o be conclusi e. CONCLUSIONS This scoping e iew ocuses on iden i ying he e ec i eness o DHA wi h espec o ma e nal men al heal h. In mos o he 856 O. Maso e al. [Nu Hosp 2023;40(4):848-857] s udies analyzed (n = 9), highe se um concen a ions o his n-3 PUFA, whe he due o a high na u al in ake o die a y sup- plemen s, we e shown o in luence educing he p e alence o dep essi e and anxie y symp oms. Al hough mo e esea ch is needed, hese explo a o y esul s he e o e seem o indica e ha DHA plays an impo an ole in he p e en ion o he pa hogen- esis o hese wo men al illnesses du ing he ges a ion pe iod. Howe e , i appea s o lose e ec i eness in he pos pa um pe iod, since no s udies analyzed in his e iew had shown an e ec o DHA on dep essi e o anxie y symp oms. The indings lend suppo o he hypo hesis o he implica ion o phospholipids in dep ession. Howe e , u he esea ch in his a ea is equi ed. Fu u e in es iga ions should aim o eplica e indings in la ge da a se s and cla i y possible pa hophysiological mechanisms. Ano he esea ch line would be o in es iga e wha happens wi h mul iple p egnancies gi en ha all he s udies made o da e ha e concen a ed on single on p egnancies. I should also be no ed ha e y ew o he pape s ha e conside ed only he use o DHA, wi h mos s udying DHA in combina ion wi h o he PUFAs like EPA. Fu he esea ch is he e o e equi ed o know he indi idual e ec o DHA on ma e nal men al heal h. Finally, di e en scales we e used o de ec dep essi e symp- oms, wi h he EPDS being he mos equen ly employed. How- e e , he e appea s o be no consensus on he cu -o alue. Cla i ying his ques ion is key in e ms o he heal hca e impli- ca ions o he sys ema ic de ec ion o dep ession du ing p eg- nancy and he pos na al pe iod and, in his way, ensu ing ea ly in e en ion and he co ec ackling o he diso de . REFERENCES 1. Innis SM. Pe ina al biochemis y and physiology o long-chain polyun- sa u a ed a y acids. J Pedia 2003;143(4):1-8. DOI: 10.1067/S0022- 3476(03)00396-2 2. 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