For a full list of publications, please visit Dr. Stowe’s PubMed list.

Zachary Stowe CV

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Nieser, K. J., Stowe, Z. N., Newport, D. J., Coker, J. L., & Cochran, A. L. (2023). Detection of differential depressive symptom patterns in a cohort of perinatal women: an exploratory factor analysis using a robust statistics approach. EClinicalMedicine, 57, 101830.


Background: Postpartum depression can take many forms. Different symptom patterns could have divergent implications for how we screen, diagnose, and treat postpartum depression. We sought to utilise a recently developed robust estimation algorithm to automatically identify differential patterns in depressive symptoms and subsequently characterise the individuals who exhibit different patterns.

Methods: Depressive symptom data (N = 548) were collected from women with neuropsychiatric illnesses at two U.S. urban sites participating in a longitudinal observational study of stress across the perinatal period. Data were collected from Emory University between 1994 and 2012 and from the University of Arkansas for Medical Sciences between 2012 and 2017. We conducted an exploratory factor analysis of Beck Depression Inventory (BDI) items using a robust expectation-maximization algorithm, rather than a conventional expectation-maximization algorithm. This recently developed method enabled automatic detection of differential symptom patterns. We described differences in symptom patterns and conducted unadjusted and adjusted analyses of associations of symptom patterns with demographics and psychiatric histories.

Findings: 53 (9.7%) participants were identified by the algorithm as having a different pattern of reported symptoms compared to other participants. This group had more severe symptoms across all items-especially items related to thoughts of self-harm and self-judgement-and differed in how their symptoms related to underlying psychological constructs. History of social anxiety disorder (OR: 4.0; 95% CI [1.9, 8.1]) and history of childhood trauma (for each 5-point increase, OR: 1.2; 95% CI [1.1, 1.3]) were significantly associated with this differential pattern after adjustment for other covariates.

Interpretation: Social anxiety disorder and childhood trauma are associated with differential patterns of severe postpartum depressive symptoms, which might warrant tailored strategies for screening, diagnosis, and treatment to address these comorbid conditions.

Detection of differential depressive symptom patterns in a cohort of perinatal women

Poehlmann, J. R., Stowe, Z. N., Godecker, A., Xiong, P. T., Broman, A. T., & Antony, K. M. (2022). The impact of preexisting maternal anxiety on pain and opioid use following cesarean delivery: a retrospective cohort study. American journal of obstetrics & gynecology MFM, 4(3), 100576.


Background: Anxiety disorders are the most common mental health condition. They are associated with negative pain experiences and can hinder rehabilitation in the hospital setting. Anxiety has been shown to be predictive of increased postoperative pain in patients undergoing nonobstetrical surgery.

Objective: To evaluate the impact of preexisting maternal anxiety disorders on average self-reported pain scores and opioid use in the first 24 hours following cesarean delivery

Study Design: This was a single-center retrospective cohort study of cesarean deliveries between January 1, 2016 and December 31, 2017. The primary outcome was average pain, calculated by averaging all documented self-reported pain scores (0-10 scale) during the first 24 hours postdelivery. The secondary outcome included the oral morphine milligram equivalents used in the first 24 hours postdelivery. Analysis of the impact of anxiety disorders on these outcomes was performed using multivariable linear regression to control for confounding variables.

Results: A total of 2228 cesarean deliveries were analyzed, of which 578 (25.9%) had an anxiety disorder documented. Women with a diagnosis of anxiety had higher average pain scores (3.9 vs 3.5; P<.001) and morphine milligram equivalents use (110.4 mg vs 102.2 mg; P<.001) than women without anxiety.

Conclusion: Patients with preexisting anxiety diagnoses reported higher average pain scores and opioid pain medication use in the first 24 hours following cesarean delivery.

The impact of preexisting maternal anxiety on pain and opioid use following cesarean delivery

Babineau, V., McCormack, C. A., Feng, T., Lee, S., Berry, O., Knight, B. T., Newport, J. D., Stowe, Z. N., & Monk, C. (2022). Pregnant women with bipolar disorder who have a history of childhood maltreatment: Intergenerational effects of trauma on fetal neurodevelopment and birth outcomes. Bipolar Disord., 24, 671–682.


Objectives: Intergenerational transmission of trauma occurs when the effects of childhood maltreatment (CM) influence the next generation’s development and health; prenatal programming via maternal mood symptoms is a potential pathway. CM is a risk factor for bipolar disorder which is present in 1.8% of pregnant women. Mood symptoms are likely to increase during pregnancy, particularly for those with a history of CM. We examined whether there was evidence for intergenerational transmission of trauma in utero in this population, and whether maternal mood was a transmission pathway.

Methods: CM and maternal mood were self-reported by N = 82 pregnant women in treatment for bipolar disorder. Fetal heart rate variability (FHRV) was measured at 24, 30, and 36 weeks’ gestation. Gestational age at birth and birth weight were obtained from medical charts.

Results: A cluster analysis yielded two groups, Symptom+ (18.29%) and Euthymic (81.71%), who differed on severe mood symptoms (p < 0.001) but not on medication use. The Symptom+ group had more CM exposures (p < 0.001), a trend of lower FHRV (p = 0.077), and greater birth complications (33.3% vs. 6.07% born preterm p < 0.01). Maternal prenatal mood mediated the association between maternal CM and birth weight in both sexes and at trend level for gestational age at birth in females.

Conclusions: This is the first study to identify intergenerational effects of maternal CM prior to postnatal influences in a sample of pregnant women with bipolar disorder. These findings underscore the potential enduring impact of CM for women with severe psychiatric illness and their children.

Pregnant women with bipolar disorder who have a history of childhood maltreatment

Ray-Griffith, S. L., Chopra, D., Stowe, Z. N., & Martin, B. C. (2019). Claims for contraceptive services among young women filling chronic opioid prescriptions. Contraception, 99(5), 296–299.


Objective: To describe claims for contraceptive services among reproductive-aged women filling chronic opioid prescriptions.

Study design: Using a large US commercial claims database, IMS Lifelink+, we identified women aged 15-44 years who filled chronic opioid prescriptions (defined as a 90-day supply of opioids without a 30-day gap over a 180-day time period) and had continuous pharmacy and medical enrollment for at least 90 days prior to and 180 days following their index opioid prescription. After excluding women with any claims for pregnancy-related services, we describe claims for contraceptive prescriptions.

Results: We identified 16,074 women with claims for chronic opioids who had filled an average of 135±28-day supply of opioids over a 180-day period. Of these, 23.4% (n=3759) had a claim for prescription contraception in the 90 days prior or 180 days following their index opioid claim. Of those who had claims for prescription contraception, 70% (n=2642) received oral contraceptives; only 2% had claims related to a long-acting reversible contraceptive (i.e., a contraceptive implant or intrauterine device).

Conclusions: Commercially insured women filling chronic opioid prescriptions may have unmet needs for prescription contraception.

Implications: Efforts are needed to ensure that the reproductive health needs of women filling chronic opioid prescriptions are met.

Claims for contraceptive services among young women filling chronic opioid prescriptions

Steele, J. S., Bush, K., Stowe, Z. N., James, G. A., Smitherman, S., Kilts, C. D., & Cisler, J. (2018). Implicit emotion regulation in adolescent girls: An exploratory investigation of Hidden Markov Modeling and its neural correlates. PLOS ONE, 13(2), e0192318.


Numerous data demonstrate that distracting emotional stimuli cause behavioral slowing (i.e. emotional conflict) and that behavior dynamically adapts to such distractors. However, the cognitive and neural mechanisms that mediate these behavioral findings are poorly understood. Several theoretical models have been developed that attempt to explain these phenomena, but these models have not been directly tested on human behavior nor compared. A potential tool to overcome this limitation is Hidden Markov Modeling (HMM), which is a computational approach to modeling indirectly observed systems. Here, we administered an emotional Stroop task to a sample of healthy adolescent girls (N = 24) during fMRI and used HMM to implement theoretical behavioral models. We then compared the model fits and tested for neural representations of the hidden states of the most supported model. We found that a modified variant of the model posited by Mathews et al. (1998) was most concordant with observed behavior and that brain activity was related to the model-based hidden states. Particularly, while the valences of the stimuli themselves were encoded primarily in the ventral visual cortex, the model-based detection of threatening targets was associated with increased activity in the bilateral anterior insula, while task effort (i.e. adaptation) was associated with reduction in the activity of these areas. These findings suggest that emotional target detection and adaptation are accomplished partly through increases and decreases, respectively, in the perceived immediate relevance of threatening cues and also demonstrate the efficacy of using HMM to apply theoretical models to human behavior.

Implicit emotion regulation in adolescent girls: An exploratory investigation of Hidden Markov Modeling

House, S. J., Coker, J. L., & Stowe, Z. N. (2016). Perinatal substance abuse: At the clinical crossroads of policy and practice. The American Journal of Psychiatry, 173(11), 1077–1080.


Although much of the focus in treatment of psychiatric illness in pregnancy has been on mood disorders, the prevalence of substance abuse rivals that of major depressive disorder during pregnancy (1). A survey of drug use and health indicated that 5.4% of pregnant women ages 15–44 used illicit drugs (marijuana, cocaine, heroin, hallucinogens, inhalants, or non-medical use of prescription medications) at the time of the study (2). Illicit drug use occurred more frequently during the first and second trimesters than during the third trimester, and it was highest among respondents ages 15–17 (2). However, the clinical identification of substance abuse during pregnancy largely relies on patient report, and the rigor and documentation of screening varies. Despite discordant data, evidence supports an increased potential for adverse effects associated with prenatal exposure to both licit and illicit substances (3).The long-term consequences of neonatal abstinence syndrome (NAS) are not well characterized, however. Prescription medication abuse represents an unknown hazard for the offspring, subject to scrutiny under the legal statutes for substance abuse in the perinatal period. The prevalence of substance abuse, combined with its possible consequences, has led jurisdictions to adopt a variety of approaches in dealing with this problem. State supreme court rulings in Alabama, Mississippi, and New Jersey (4–7), along with legislation in Tennessee (8), spurred significant debate regarding the criminalization of perinatal substance abuse. Practitioners should be aware of their districts’ legal requirements involving perinatal substance abuse. The interface of legal issues and clinical care for this population has led many medical societies to publish position statements on this issue.

Perinatal Substance Abuse-At the Clinical Crossroads of Policy and Practice

Juul, S. H., Hendrix, C., Robinson, B., Stowe, Z. N., Newport, D. J., Brennan, P. A., & Johnson, K. C. (2016). Maternal early-life trauma and affective parenting style: the mediating role of HPA-axis function. Archives of women's mental health, 19(1), 17–23.


A history of childhood trauma is associated with increased risk for psychopathology and interpersonal difficulties in adulthood and, for those who have children, impairments in parenting and increased risk of negative outcomes in offspring. Physiological and behavioral mechanisms are poorly understood. In the current study, maternal history of childhood trauma was hypothesized to predict differences in maternal affect and HPA axis functioning. Mother-infant dyads (N = 255) were assessed at 6 months postpartum. Mothers were videotaped during a 3-min naturalistic interaction, and their behavior was coded for positive, neutral, and negative affect. Maternal salivary cortisol was measured six times across the study visit, which also included an infant stressor paradigm. Results showed that childhood trauma history predicted increased neutral affect and decreased mean cortisol in the mothers and that cortisol mediated the association between trauma history and maternal affect. Maternal depression was not associated with affective measures or cortisol. Results suggest that early childhood trauma may disrupt the development of the HPA axis, which in turn impairs affective expression during mother-infant interactions in postpartum women. Interventions aimed at treating psychiatric illness in postpartum women may benefit from specific components to assess and treat trauma-related symptoms and prevent secondary effects on parenting.

Maternal early-life trauma and affective parenting style: The mediating role of HPA-axis functioning

Bourke, C. H., Stowe, Z. N., & Owens, M. J. (2014). Prenatal antidepressant exposure: Clinical and preclinical findings. Pharmacological reviews, 66(2), 435–465.


Pharmacological treatment of any maternal illness during pregnancy warrants consideration of the consequences of the illness and/or medication for both the mother and unborn child. In the case of major depressive disorder, which affects up to 10-20% of pregnant women, the deleterious effects of untreated depression on the offspring can be profound and long lasting. Progress has been made in our understanding of the mechanism(s) of action of antidepressants, fetal exposure to these medications, and serotonin’s role in development. New technologies and careful study designs have enabled the accurate sampling of maternal serum, breast milk, umbilical cord serum, and infant serum psychotropic medication concentrations to characterize the magnitude of placental transfer and exposure through human breast milk. Despite this progress, the extant clinical literature is largely composed of case series, population-based patient registry data that are reliant on nonobjective means and retrospective recall to determine both medication and maternal depression exposure, and limited inclusion of suitable control groups for maternal depression. Conclusions drawn from such studies often fail to incorporate embryology/neurotransmitter ontogeny, appropriate gestational windows, or a critical discussion of statistically versus clinically significant. Similarly, preclinical studies have predominantly relied on dosing models, leading to exposures that may not be clinically relevant. The elucidation of a defined teratological effect or mechanism, if any, has yet to be conclusively demonstrated. The extant literature indicates that, in many cases, the benefits of antidepressant use during pregnancy for a depressed pregnant woman may outweigh potential risks.

Prenatal antidepressant exposure: Clinical and preclinical findings