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Andrade C, Varadharajan N, Bascarane S, Menon V. Gestational exposure to benzodiazepines or z-hypnotics and neurodevelopmental disorders in offspring: Systematic review and meta-analysis. Acta Psychiatr Scand 2024; 150:65-77. [PMID: 38751163 DOI: 10.1111/acps.13696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/29/2024] [Accepted: 05/06/2024] [Indexed: 07/04/2024]
Abstract
INTRODUCTION Benzodiazepine (BDZP) and/or z-hypnotic dispensing during pregnancy has increased globally, as have rates of autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD). This systematic review and meta-analysis aimed to estimate the association between gestational exposure to BDZP and/or z-hypnotics and diagnosis of ASD or ADHD in offspring. METHODS We searched MEDLINE, EMBASE, and SCOPUS from inception till December 2023 for relevant English-language articles. Outcomes of interest were risk of ASD and ADHD, two independent primary outcomes, in children exposed anytime during pregnancy to BDZP and/or z-hypnotics versus those unexposed. Secondary outcomes were trimester-wise analyses. Using a random effects model, we pooled the overall and trimester-wise hazard ratios (HRs), with 95% confidence intervals (CIs), separately for risk of ASD and ADHD. RESULTS We found six eligible retrospective cohort studies and no case-control studies. There was no increased risk of ASD associated with anytime gestational BDZP and/or z-hypnotic exposure (primary outcome, HR, 1.10; 95% CI, 0.81-1.50; 4 studies; n = 3,783,417; 80,270 exposed, 3,703,147 unexposed) nor after first trimester exposure (HR, 1.15; 95% CI, 0.83-1.58; 3 studies; n = 1,539,335; 70,737 exposed, 1,468,598 unexposed) or later trimester exposures. A very small but significantly increased risk of ADHD was noted with anytime gestational exposure to these drugs (primary outcome, HR, 1.07; 95% CI, 1.03-1.12; 4 studies; n = 2,000,777; 78,912 exposed, 1,921,865 unexposed) and also with (only) second trimester exposure (HR, 1.07; 95% CI, 1.03-1.12; 3 studies; n = 1,539,281; 33,355 exposed, 1,505,926 unexposed). Findings were consistent in sensitivity analyses. CONCLUSION Gestational exposure to benzodiazepines or z-hypnotics was not associated with an increased risk of ASD and with only a marginally increased risk of ADHD in offspring. Given the likelihood of confounding by indication and by unmeasured variables in the original studies, our findings should reassure women who need these medications for severe anxiety or insomnia during pregnancy.
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Affiliation(s)
- Chittaranjan Andrade
- Department of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Natarajan Varadharajan
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sharmi Bascarane
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Vikas Menon
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Thela L, Paruk S, Bhengu B, Chiliza B. Psychiatric emergencies during pregnancy and puerperium in low - And middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102478. [PMID: 38401484 DOI: 10.1016/j.bpobgyn.2024.102478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/29/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
Pregnancy and puerperium are critical points in women's health, and various psychiatric emergencies may worsen or manifest (for the first time) during this period. In the presence of a psychiatric emergency, the pregnancy and puerperium outcomes may be compromised. In addition to the mother being at risk, the health of the fetus and the newborn may also be compromised if the psychiatric emergency is not managed appropriately. Early detection and collaborative approaches between mental health practitioners and obstetricians are of utmost importance in women who are at risk and those living with psychiatric illnesses during pregnancy and puerperium. Practitioners should also ensure that women with impaired capacity due to psychiatric disease are treated in a non-judgmental and respectful manner, even if their autonomies have been overridden.
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Affiliation(s)
- Lindokuhle Thela
- University of KwaZulu Natal, School of Clinical Medicine, Discipline of Psychiatry, South Africa.
| | - Saeeda Paruk
- University of KwaZulu Natal, School of Clinical Medicine, Discipline of Psychiatry, South Africa
| | - Busisiwe Bhengu
- University of KwaZulu Natal, School of Clinical Medicine, Discipline of Psychiatry, South Africa
| | - Bonginkosi Chiliza
- University of KwaZulu Natal, School of Clinical Medicine, Discipline of Psychiatry, South Africa
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Meng LC, Lin CW, Chuang HM, Chen YY, Shang CY, Wu CY, Chen LK, Hsiao FY. Prescription Patterns and Predisposing Factors of Benzodiazepine and Z-Hypnotic Use During Pregnancy: A Nationwide Cohort Study. Pharmacoepidemiol Drug Saf 2024; 33:e5847. [PMID: 38898542 DOI: 10.1002/pds.5847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/04/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE The use of benzodiazepines and Z-hypnotics during pregnancy has raised significant concerns in recent years. However, there are limited data that capture the prescription patterns and predisposing factors in use of these drugs, particularly among women who have been long-term users of benzodiazepines and Z-hypnotics before pregnancy. METHODS This population-based cohort study comprised 2 930 988 pregnancies between 2004 and 2018 in Taiwan. Women who were dispensed benzodiazepines or Z-hypnotics during pregnancy were identified and further stratified into groups based on their status before pregnancy: long-term users (with a supply of more than 180 days within a year), short-term users (with a supply of less than 180 days within a year), and nonusers. Trends in the use of benzodiazepines or Z-hypnotics and concomitant use with antidepressants or opioids were assessed. Logistic regression models were utilized to identify factors associated with use of these drugs during pregnancy, and interrupted time series analyses (ITSA) were employed to evaluate utilization patterns of these drugs across different pregnancy-related periods. RESULTS The overall prevalence of benzodiazepine and Z-hypnotic use was 3.5% during pregnancy. Among prepregnancy long-term users, an upward trend was observed. The concomitant use of antidepressants or opioids among exposed women increased threefold (from 8.6% to 23.1%) and sixfold (from 0.3% to 1.7%) from 2004 to 2018, respectively. Women with unhealthy lifestyle behaviors, such as alcohol abuse (OR 2.48; 95% CI, 2.02-3.03), drug abuse (OR 10.34; 95% CI, 8.46-12.64), and tobacco use (OR 2.19; 95% CI, 1.96-2.45), as well as those with psychiatric disorders like anxiety (OR 6.99; 95% CI, 6.77-7.22), insomnia (OR 15.99; 95% CI, 15.55-16.45), depression (OR 9.43; 95% CI, 9.07-9.80), and schizophrenia (OR 21.08; 95% CI, 18.76-23.69), and higher healthcare utilization, were more likely to use benzodiazepines or Z-hypnotics during pregnancy. ITSA revealed a sudden decrease in use of benzodiazepines and Z-hypnotics after recognition of pregnancy (level change -0.55 percentage point; 95% CI, -0.59 to -0.51). In contrast, exposures to benzodiazepines and Z-hypnotics increased significantly after delivery (level change 0.12 percentage point; 95% CI, 0.09 to 0.16). CONCLUSIONS In this cohort study, an increased trend of benzodiazepine and Z-hypnotic use during pregnancy among prepregnancy long-term users, as well as concomitant use with antidepressants or opioids were found. The findings have highlighted the existence of various risk factors associated with the use of these drugs during pregnancy. Utilization patterns varied across different stages of pregnancy, highlighting the need for prescription guidelines and educational services for women using these drugs during pregnancy.
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Affiliation(s)
- Lin-Chieh Meng
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Hui-Min Chuang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Taiwan Drug Relief Foundation, Taipei, Taiwan
| | - Yi-Yung Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chi-Yung Shang
- Department of Psychiatry, National Taiwan University Hospital, and College of Medicine, Taipei, Taiwan
| | - Chia-Yi Wu
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
- Taiwanese Society of Suicidology, Taiwan Suicide Prevention Center, Taipei, Taiwan
| | - Liang-Kung Chen
- Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
- Taipei Municipal Gan-Dau Hospital Managed by Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School of Pharmacy, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
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Westberg SM, Arellano R, Cieri-Hutcherson NE, Heinrich NT, Herman AM, Lodise NM, McBane S, Ofili TU, O'Grady N, Sankey KH. Pharmacotherapy of Chronic Neuropsychiatric Conditions During Pregnancy. Nurs Womens Health 2024; 28:227-241. [PMID: 38702041 DOI: 10.1016/j.nwh.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/08/2023] [Accepted: 03/28/2024] [Indexed: 05/06/2024]
Abstract
Many pregnant persons will experience neuropsychiatric conditions during pregnancy, including migraine, attention deficit disorder, depression, and anxiety. Treatment of each of these conditions requires shared decision-making among the individual, family, and health care team. Although medications may include risk, the benefits often outweigh the potential fetal risks. In this article, we review pharmacologic treatment options for each of these conditions and appropriate use in pregnancy to maintain the stability of conditions and to optimize maternal and fetal outcomes.
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Sargi J, Hachem C, Richa S, Amil CE. Prevalence of benzodiazepines use during pregnancy in Lebanon. L'ENCEPHALE 2024:S0013-7006(24)00097-6. [PMID: 38824048 DOI: 10.1016/j.encep.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/16/2024] [Accepted: 02/23/2024] [Indexed: 06/03/2024]
Abstract
Pregnancy is a period of heightened risk period for many psychiatric disorders, particularly anxiety disorders. However, there is limited knowledge regarding the usage of psychotropic medications during pregnancy. Over the past decade there has been a notable increase in the use of medications during pregnancy, with benzodiazepines being the primary choice for alleviating anxiety. It is important to note, though, that benzodiazepines have been associated with various risks for both pregnancy and newborns. In Lebanon, to date, there has been no study estimating the prevalence of the use of benzodiazepines during pregnancy. Our study aims to find the prevalence of benzodiazepines use in a population of pregnant women in Hôtel-Dieu Hospital, a tertiary care center in Beirut, and the medical center of Saint-Joseph University and to compare our results to international literature. To accomplish our objectives we administered questionnaires to over two hundred women who had recently given birth in the gynecology department. These forms encompassed inquiries about benzodiazepine consumption, as well as various medical and socio demographic details. In total, we interviewed 225 women who gave birth at the Hôtel-Dieu de France between the months of December 2019 and February 2020 and between the months of February 2021 and October 2021 in the gynecology department. The questionnaires included socio demographic, medical, and psychiatric information as well as questions about the use of benzodiazepines. We found a significantly lower prevalence of benzodiazepine use among these women compared to the figures reported in international literature. The approval of the ethics committee was obtained on December 19, 2019 after making sure that this study raised no ethical objections. (File number: CEHDF 1533).
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Affiliation(s)
- Juliana Sargi
- Department of Psychiatry, Faculty of Medicine, Saint-Joseph University, P.O. Box 17-5208, 11-5076, Beirut, Lebanon.
| | - Charline Hachem
- Department of Psychiatry, Faculty of Medicine, Saint-Joseph University, P.O. Box 17-5208, 11-5076, Beirut, Lebanon
| | - Sami Richa
- Department of Psychiatry, Faculty of Medicine, Saint-Joseph University, P.O. Box 17-5208, 11-5076, Beirut, Lebanon
| | - Chanel El Amil
- Department of Psychiatry, Faculty of Medicine, Saint-Joseph University, P.O. Box 17-5208, 11-5076, Beirut, Lebanon
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Serretti A. Stroke, COVID-19, and other somatic aspects of psychiatric disorders treatments. Int Clin Psychopharmacol 2024; 39:123-126. [PMID: 38527157 DOI: 10.1097/yic.0000000000000547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
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Pallanti S. The role of benzodiazepines in common conditions: a narrative review focusing on lormetazepam. Int Clin Psychopharmacol 2024; 39:139-147. [PMID: 38277240 DOI: 10.1097/yic.0000000000000529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
This review aimed to examine the place of benzodiazepines, specifically lormetazepam, in the treatment of insomnia, including during pregnancy or in patients with psychodermatoses. PubMed was searched for the term "lormetazepam" in association with MeSH terms encompassing anxiety, insomnia/sleep disorders, pregnancy/gestation, and psychodermatoses/skin disorders. English-language articles up to 31 July 2022 were identified. Ad hoc searches for relevant literature were performed at later stages of review development. Multiple randomized, placebo-controlled studies have demonstrated that lormetazepam dose-dependently increases total sleep time, decreases wakefulness over a dosing range of 0.5-2.0 mg, and improves subjective assessments of sleep quality. Lormetazepam is as effective as other benzodiazepines in improving sleep duration and quality, but is better tolerated than the long-acting agents with minimal next-day effects. Benzodiazepines can be used as short-term monotherapy at the lowest effective dose during the second or third trimesters of pregnancy; lormetazepam is also a reasonable choice due to its limited transplacental passage. Insomnia associated with skin disorders or pregnancy can be managed by effective symptom control (especially itching), sleep hygiene, treatment of anxiety/depression, and a short course of hypnotics.
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Affiliation(s)
- Stefano Pallanti
- Department of Psychiatry and Behavioral Science, Albert Einstein College of Medicine, Bronx, New York, USA
- Istituto di Neuroscienze Firenze, Florence, Italy
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Meng LC, Lin CW, Chuang HM, Chen LK, Hsiao FY. Benzodiazepine Use During Pregnancy and Risk of Miscarriage. JAMA Psychiatry 2024; 81:366-373. [PMID: 38150230 PMCID: PMC10753441 DOI: 10.1001/jamapsychiatry.2023.4912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/30/2023] [Indexed: 12/28/2023]
Abstract
Importance Benzodiazepine use during pregnancy has raised significant concerns due to the potential harmful effects of this drug class on neonates. Studies on the association between benzodiazepine use and the risk of miscarriage are limited. Objective To quantify the risk of miscarriage associated with benzodiazepine use during pregnancy after controlling for unmeasured confounders and exposure time trends. Design, Setting, and Participants This was a nationwide, population-based case-time-control study using Taiwan's National Birth Certificate Application database and the National Health Insurance database. Pregnancies resulting in miscarriage between 2004 and 2018 were included in the case group and were 1:1 matched with exposure time-trend control individuals using disease risk score, considering demographic characteristics and prepregnancy comorbidities. Data were analyzed from August 2022 to March 2023. Exposures Discordant exposures to benzodiazepines during risk period (1-28 days before miscarriage) and 2 reference periods (31-58 days and 181-208 days before the last menstrual period) were compared for each pregnancy. Main Outcomes and Measures Miscarriage was defined as any pregnancy loss occurring between the first prenatal care visit (usually 8 weeks) and the 19th completed week of pregnancy. Results This study comprised a total of 3 067 122 pregnancies among 1 957 601 women, 136 134 of which (4.4%) resulted in miscarriage. The mean (SD) age of the study population was 30.61 (5.91) years. The use of benzodiazepines during pregnancy was associated with an increased risk of miscarriage (odds ratio [OR], 1.69; 95% CI, 1.52-1.87), and consistent findings were observed across multiple sensitivity analyses considering different time windows and accounting for misclassification. In subgroup analyses, an increased risk of miscarriage was associated with each commonly used individual benzodiazepine, ranging from case-time-control ORs of 1.39 (95% CI, 1.17-1.66) for alprazolam to 2.52 (95% CI, 1.89-3.36) for fludiazepam. Conclusions and Relevance This nationwide case-time-control study revealed an increased risk of miscarriage associated with benzodiazepine use during pregnancy after accounting for measurable confounders, and results were unlikely to be due to unmeasured confounding. These findings underscore the necessity for health care professionals to meticulously balance the risk-benefit ratio when considering the use of benzodiazepines to treat psychiatric and sleep disorders during pregnancy.
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Affiliation(s)
- Lin-Chieh Meng
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Hui-Min Chuang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Liang-Kung Chen
- Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
- Taipei Municipal Gan-Dau Hospital (Managed by Taipei Veterans General Hospital), Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School of Pharmacy, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
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Dos Santos MM, Ferreira SA, de Macedo GT, Claro MT, Müller TE, Prestes ADS, da Rocha JBT, Núñez-Figueredo Y, Barbosa NDV. JM-20 potently prevents the onset of caffeine-induced anxiogenic phenotypes in zebrafish (Danio rerio). Comp Biochem Physiol C Toxicol Pharmacol 2024; 277:109843. [PMID: 38237841 DOI: 10.1016/j.cbpc.2024.109843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/29/2023] [Accepted: 01/11/2024] [Indexed: 01/21/2024]
Abstract
Anxiety is among the most prevalent mental disorders present in the general population. Benzodiazepines are the most commonly prescribed drugs for the treatment of anxiety. Using zebrafish as a model organism, we investigated the anxiolytic activity of JM-20, a novel hybrid molecule with a 1,5-benzodiazepine ring fused to a dihydropyridine moiety. Firstly, we carried out some assays to analyze the possible toxicity mediated by JM-20. For this, zebrafish were exposed to different JM-20 concentrations (0-5 μM) for 96 h. Then, using the novel tank test, we evaluated both locomotor and anxiety-like behavior of the animals. Furthermore, brain, liver and plasma were removed to assess toxicity parameters. JM-20 exposure did not cause changes on novel tank, and also did not alter brain viability, hepatic LDH and plasma ALT levels. Afterward, we investigated whether a pre-exposure to JM-20 would prevent the anxiogenic effect evoked by caffeine. In the novel tank test, caffeine significantly decreased the time spent at the top, as well as the number of transitions to the top area. Moreover, caffeine decreased both the total and average time spent in the lit area, as well as increased the number of risk episodes evaluated by the light-dark test. Whole-body cortisol levels were also increased by caffeine exposure. Interestingly, pre-treatment with JM-20 abolished all alterations induced by caffeine. The anxiolytic effect profile of JM-20 was similar to those found for diazepam (positive control). Our findings show, for the first time, the anxiolytic effect of JM-20 in zebrafish, and its relationship with cortisol regulation.
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Affiliation(s)
- Matheus Mülling Dos Santos
- Programa de Pós-graduação em Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), Avenida Roraima, 1000, 97105-900 Santa Maria, RS, Brazil; Instituto de Oceanografia, Universidade Federal do Rio Grande (FURG), 96203-900 Rio Grande, RS, Brazil.
| | - Sabrina Antunes Ferreira
- Programa de Pós-graduação em Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), Avenida Roraima, 1000, 97105-900 Santa Maria, RS, Brazil
| | - Gabriel Teixeira de Macedo
- Programa de Pós-graduação em Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), Avenida Roraima, 1000, 97105-900 Santa Maria, RS, Brazil
| | - Mariana Torri Claro
- Programa de Pós-graduação em Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), Avenida Roraima, 1000, 97105-900 Santa Maria, RS, Brazil
| | - Talise Ellwanger Müller
- Programa de Pós-graduação em Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), Avenida Roraima, 1000, 97105-900 Santa Maria, RS, Brazil
| | - Alessandro de Souza Prestes
- Programa de Pós-graduação em Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), Avenida Roraima, 1000, 97105-900 Santa Maria, RS, Brazil
| | - João Batista Teixeira da Rocha
- Programa de Pós-graduação em Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), Avenida Roraima, 1000, 97105-900 Santa Maria, RS, Brazil
| | - Yanier Núñez-Figueredo
- Centro de Investigación y Desarrollo de Medicamentos (CIDEM), Ave 26, No. 1605. Boyeros y Puentes Grandes, CP 10600, La Habana, Cuba
| | - Nilda de Vargas Barbosa
- Programa de Pós-graduação em Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), Avenida Roraima, 1000, 97105-900 Santa Maria, RS, Brazil
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Mastrolorito F, Togo MV, Gambacorta N, Trisciuzzi D, Giannuzzi V, Bonifazi F, Liantonio A, Imbrici P, De Luca A, Altomare CD, Ciriaco F, Amoroso N, Nicolotti O. TISBE: A Public Web Platform for the Consensus-Based Explainable Prediction of Developmental Toxicity. Chem Res Toxicol 2024; 37:323-339. [PMID: 38200616 DOI: 10.1021/acs.chemrestox.3c00310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Despite being extremely relevant for the protection of prenatal and neonatal health, the developmental toxicity (Dev Tox) is a highly complex endpoint whose molecular rationale is still largely unknown. The lack of availability of high-quality data as well as robust nontesting methods makes its understanding even more difficult. Thus, the application of new explainable alternative methods is of utmost importance, with Dev Tox being one of the most animal-intensive research themes of regulatory toxicology. Descending from TIRESIA (Toxicology Intelligence and Regulatory Evaluations for Scientific and Industry Applications), the present work describes TISBE (TIRESIA Improved on Structure-Based Explainability), a new public web platform implementing four fundamental advancements for in silico analyses: a three times larger dataset, a transparent XAI (explainable artificial intelligence) framework employing a fragment-based fingerprint coding, a novel consensus classifier based on five independent machine learning models, and a new applicability domain (AD) method based on a double top-down approach for better estimating the prediction reliability. The training set (TS) includes as many as 1008 chemicals annotated with experimental toxicity values. Based on a 5-fold cross-validation, a median value of 0.410 for the Matthews correlation coefficient was calculated; TISBE was very effective, with a median value of sensitivity and specificity equal to 0.984 and 0.274, respectively. TISBE was applied on two external pools made of 1484 bioactive compounds and 85 pediatric drugs taken from ChEMBL (Chemical European Molecular Biology Laboratory) and TEDDY (Task-Force in Europe for Drug Development in the Young) repositories, respectively. Notably, TISBE gives users the option to clearly spot the molecular fragments responsible for the toxicity or the safety of a given chemical query and is available for free at https://prometheus.farmacia.uniba.it/tisbe.
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Affiliation(s)
- Fabrizio Mastrolorito
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
| | - Maria Vittoria Togo
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
| | - Nicola Gambacorta
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
| | - Daniela Trisciuzzi
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
| | - Viviana Giannuzzi
- Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, 70010 Valenzano (BA), Italy
| | - Fedele Bonifazi
- Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, 70010 Valenzano (BA), Italy
| | - Antonella Liantonio
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
| | - Paola Imbrici
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
| | - Annamaria De Luca
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
| | - Cosimo Damiano Altomare
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
| | - Fulvio Ciriaco
- Dipartimento di Chimica, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
| | - Nicola Amoroso
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
- Istituto Nazionale di Fisica Nucleare, Sezione di Bari, 70125 Bari, Italy
| | - Orazio Nicolotti
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, 70125 Bari, Italy
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Traugott P, Medina A, Parker JM. Navigating the Complexity of a Bipolar Pregnant Patient With Multiple Comorbidities. Cureus 2024; 16:e51510. [PMID: 38304661 PMCID: PMC10831191 DOI: 10.7759/cureus.51510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/03/2024] Open
Abstract
Bipolar disorder I (BDI) is a psychiatric disorder characterized by the occurrence of at least one manic episode. Within the scope of neurological disorders, epilepsy and psychogenic nonepileptic seizures (PNES) share clinical features and can be differentiated using electroencephalogram (EEG). Substance use disorder is a condition defined by impaired control, risky use, social impairment, and addictive behaviors. We present the case of a 20-year-old pregnant woman with BDI associated with a history of epilepsy, PNES, and polyvalent substance use. The patient presented to the emergency department via the Baker Act involuntary hold multiple times throughout her pregnancy. Recognizing that the welfare of the mother and child was at risk, the court ordered a two-month commitment of inpatient psychiatric treatment at 30 weeks' gestation to ensure safe delivery. Comprehensive inpatient treatment, including risperidone, levetiracetam, lacosamide, haloperidol, diphenhydramine, lorazepam, and later clozapine, and a discharge plan for both the mother and the child are described in detail. Our goal is to contribute to the growing body of knowledge on the management of complex pregnant patients with psychiatric conditions in order to optimize outcomes for maternal and fetal health.
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Affiliation(s)
| | - Adriana Medina
- Surgery, Ross University School of Medicine, Miramar, USA
| | - Jonathan M Parker
- Psychiatry, Jackson Behavioral Health Hospital/University of Miami Health System, Miami, USA
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Csihi L, Ungvari GS, Caroff SN, Mann SC, Gazdag G. Catatonia during pregnancy and the postpartum period. Schizophr Res 2024; 263:257-264. [PMID: 36064493 DOI: 10.1016/j.schres.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 10/14/2022]
Abstract
While the psychopathology of mental disorders during pregnancy and the postpartum period is a growing area of research, the prevalence and significance of catatonic symptoms has been relatively neglected. To address this gap in knowledge, a systematic review of articles on catatonia occurring during pregnancy and the postpartum period was conducted. PubMed, Excerpta Medica, (later EMBASE) databases were queried for articles published in English from their inception in 1966 and 1946, respectively to May 31. 2022 using the terms "catatonia", AND "perinatal", "puerperal", "postpartum", "antepartum" "lactation" "pregnancy" or "pregnancy-related", supplemented by a manual search of references. This review failed to identify any well-designed, prospective, or controlled studies addressing the subject of catatonia during pregnancy or the postpartum period; only one retrospective chart review, a single small case series, and twenty single case reports were found. The limited literature suggests that the clinical presentation and treatment response during pregnancy and after childbirth are similar to catatonia observed in other contexts. Catatonic signs and symptoms could affect physical and mental health, markedly compromising a mother's ability to take care of and bond with her infant. Further studies are needed to advance understanding of the role of catatonia in the pathogenesis, diagnosis and treatment of perinatal mental disorders.
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Affiliation(s)
- Levente Csihi
- Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Budapest, Hungary
| | - Gabor S Ungvari
- Division of Psychiatry, School of Medicine, University of Western Australia, Crawley, Australia; Section of Psychiatry, University of Notre Dame, Fremantle, Australia
| | - Stanley N Caroff
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Stephan C Mann
- Central Montgomery Behavioral Health, Norristown, PA, USA
| | - Gábor Gazdag
- Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Budapest, Hungary; Department of Psychiatry and Psychotherapy, Faculty of Medicine, Semmelweis University, Budapest, Hungary.
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Zhu X, Luo T, Wang D, Zhao Y, Jin Y, Yang G. The occurrence of typical psychotropic drugs in the aquatic environments and their potential toxicity to aquatic organisms - A review. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 900:165732. [PMID: 37495145 DOI: 10.1016/j.scitotenv.2023.165732] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 07/28/2023]
Abstract
Psychotropic drugs (PDs) and their bioactive metabolites often persist in aquatic environments due to their typical physical properties, which made them resistant to removal by traditional wastewater treatment plants (WWTPs). Consequently, such drugs and/or their metabolites are frequently detected in both aquatic environments and organisms. Even at low concentrations, these drugs can exhibit toxic effects on non-target organisms including bony fish (zebrafish (Danio rerio) and fathead minnows) and bivalves (freshwater mussels and clams). This narrative review focuses on the quintessential representatives of three different categories of PDs-antiepileptics, antidepressants, and antipsychotics. The data regarding their concentrations occurring in the environment, patterns of distribution, the degree of enrichment in various tissues of aquatic organisms, and the toxicological effects on them are summarized. The toxicological assessments of these drugs included the evaluation of their effects on the reproductive, embryonic development, oxidative stress-related, neurobehavioral, and genetic functions in various experimental models. However, the mechanisms underlying the toxicity of PDs to aquatic organisms and their potential health risks to humans remain unclear. Most studies have focused on the effects caused by acute short-term exposure due to limitations in the experimental conditions, thus making it necessary to investigate the chronic toxic effects at concentrations that are in coherence with those occurring in the environment. Additionally, this review aims to raise awareness and stimulate further research efforts by highlighting the gaps in the understanding of the mechanisms behind PD-induced toxicity and potential health risks. Ultimately, the study underscores the importance of developing advanced remediation methods for the removal of PDs in WWTPs and encourages a broader discussion on mitigating their environmental impacts.
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Affiliation(s)
- Xianghai Zhu
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310032, China; State Key Laboratory for Managing Biotic and Chemical Threats to the Quality and Safety of Agro-products, Laboratory (Hangzhou) for Risk Assessment of Agricultural Products of Ministry of Agriculture, Institute of Agro-product Safety and Nutrition, Zhejiang Academy of Agricultural Sciences, Hangzhou 310021, Zhejiang, China
| | - Ting Luo
- State Key Laboratory for Managing Biotic and Chemical Threats to the Quality and Safety of Agro-products, Laboratory (Hangzhou) for Risk Assessment of Agricultural Products of Ministry of Agriculture, Institute of Agro-product Safety and Nutrition, Zhejiang Academy of Agricultural Sciences, Hangzhou 310021, Zhejiang, China
| | - Dou Wang
- State Key Laboratory for Managing Biotic and Chemical Threats to the Quality and Safety of Agro-products, Laboratory (Hangzhou) for Risk Assessment of Agricultural Products of Ministry of Agriculture, Institute of Agro-product Safety and Nutrition, Zhejiang Academy of Agricultural Sciences, Hangzhou 310021, Zhejiang, China
| | - Yao Zhao
- State Key Laboratory for Managing Biotic and Chemical Threats to the Quality and Safety of Agro-products, Laboratory (Hangzhou) for Risk Assessment of Agricultural Products of Ministry of Agriculture, Institute of Agro-product Safety and Nutrition, Zhejiang Academy of Agricultural Sciences, Hangzhou 310021, Zhejiang, China
| | - Yuanxiang Jin
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310032, China; Xianghu Laboratory, Hangzhou, 311231, China
| | - Guiling Yang
- State Key Laboratory for Managing Biotic and Chemical Threats to the Quality and Safety of Agro-products, Laboratory (Hangzhou) for Risk Assessment of Agricultural Products of Ministry of Agriculture, Institute of Agro-product Safety and Nutrition, Zhejiang Academy of Agricultural Sciences, Hangzhou 310021, Zhejiang, China; Xianghu Laboratory, Hangzhou, 311231, China.
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Harris M, Schiff DM, Saia K, Muftu S, Standish KR, Wachman EM. Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023). Breastfeed Med 2023; 18:715-733. [PMID: 37856658 PMCID: PMC10775244 DOI: 10.1089/bfm.2023.29256.abm] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.
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Affiliation(s)
- Miriam Harris
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
| | - Davida M. Schiff
- Divisions of Newborn Medicine and Mass General Hospital for Children, Boston, Massachusetts, USA
- Divisions of General Academic Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Kelley Saia
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, Chobanian & Avedisian Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Serra Muftu
- Divisions of Newborn Medicine and Mass General Hospital for Children, Boston, Massachusetts, USA
- Divisions of General Academic Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Katherine R. Standish
- Department of Family Medicine, and Chobanian & Avedisian Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Elisha M. Wachman
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Department of Pediatrics, Chobanian & Avedisian Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
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Knobbe H, Damer EA, Edens MA, Nij Bijvank BSWA, Hemels MAC, Ter Horst PGJ. Maternal and neonatal outcomes after benzodiazepine and benzodiazepine agonist exposure during pregnancy in women with mental disorders. Br J Clin Pharmacol 2023; 89:3005-3015. [PMID: 37218067 DOI: 10.1111/bcp.15795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
AIMS To compare the gestational age of neonates in utero exposed to benzodiazepines (BDZs) with nonexposed controls. Secondary objectives were birth weight, presence of congenital malformations, APGAR score and the need for >3 months (prolonged) maternal psychiatric care. METHODS A retrospective cohort study of women and neonates from 2013 to 2021 with univariate and multivariable analysis to study the associations between BDZ exposure and gestational age compared to nonexposed women with mental health problems. RESULTS We found that BDZ exposure was not associated with a lower gestational age. We found that women in the exposed group had an increased risk of psychiatric care (adjusted odds ratio 2.58 [95% confidence interval 1.71-3.91], P < .001). CONCLUSION We found that in utero BDZ exposure was not associated with a significantly lower gestational age of the neonates and was associated with prolonged psychiatric care of their mothers.
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Affiliation(s)
- Hennique Knobbe
- Department of Clinical Pharmacy, Isala, Zwolle, The Netherlands
| | - Elvera A Damer
- Department of Psychiatry, Isala, Zwolle, The Netherlands
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Kurtz T, Smid MC. Office-Based Management of Perinatal Substance Use and Substance Use Disorder for the General Obstetrician-Gynecologist. Obstet Gynecol Clin North Am 2023; 50:609-627. [PMID: 37500220 DOI: 10.1016/j.ogc.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
This is a review of substance use and substance use disorder in pregnancy, intended for the generalist obstetrician-gynecologist. Herein, the authors discuss legal considerations, outline definitions, review screening tools, introduce special considerations and harm reduction, caution the use of urinary toxicology testing, and touch on the screening, brief intervention, and referral to treatment model. Furthermore, the authors provide a brief overview of the prevalence, maternal and neonatal risks, and treatment approaches for commonly used substances.
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Affiliation(s)
- Theresa Kurtz
- Department of Obstetrics and Gynecology, University of Utah Health, 30 North 1900 East #2B200 SOM, Salt Lake City, UT 84132, USA.
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, University of Utah Health, 30 North 1900 East #2B200 SOM, Salt Lake City, UT 84132, USA
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Bishop L, Almquist YB, Pitkänen J, Martikainen P. Offspring hospitalization for substance use and changes in parental mental health: A Finnish register-based study. ADVANCES IN LIFE COURSE RESEARCH 2023; 57:100561. [PMID: 38054862 DOI: 10.1016/j.alcr.2023.100561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 12/07/2023]
Abstract
Prior research indicates that parental psychiatric disorders increase their offspring's risk of substance use problems. Though the association is likely bidirectional, the effects of an adult child's substance use on parental mental health remain understudied. We examined parents' psychotropic medication use trajectories by parental sex and educational attainment before and after a child's alcohol- or narcotics-attributable hospitalization. We identified Finnish residents, born 1979-1988, with a first hospitalization for substance use during emerging adulthood (ages 18-29, n = 12,851). Their biological mothers (n = 12,283) and/or fathers (n = 10,765) were followed for the two years before and after the hospitalization. Psychotropic medication use was measured in three-month periods centered around the time of child's hospitalization, and the probability of psychotropic medication use at each time point was assessed using generalized estimating equations logit models. Among mothers, the prevalence of psychotropic medication use increased during the year before, peaked during the 0-3 months after hospitalization, and remained at a similarly elevated level until the end of follow-up. The prevalence among fathers increased gradually and linearly across follow-up, with minimal changes evident either directly before or after the hospitalization. Parents' educational attainment did not modify these trajectories. Our results highlight the importance of considering linked lives when quantifying substance use-attributable harms and underscore the need for future research examining the intergenerational spillover effects of substance use in both directions, particularly in mother-child dyads.
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Affiliation(s)
- Lauren Bishop
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, 00014 Helsinki, Finland; Max Planck-University of Helsinki Center for Social Inequalities in Population Health, 00014 Helsinki, Finland; Department of Public Health Sciences, Stockholm University, 10691 Stockholm, Sweden; International Max Planck Research School for Population, Health and Data Science, Max Planck Institute for Demographic Research, 18057 Rostock, Germany.
| | - Ylva B Almquist
- Department of Public Health Sciences, Stockholm University, 10691 Stockholm, Sweden
| | - Joonas Pitkänen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, 00014 Helsinki, Finland; Max Planck-University of Helsinki Center for Social Inequalities in Population Health, 00014 Helsinki, Finland; International Max Planck Research School for Population, Health and Data Science, Max Planck Institute for Demographic Research, 18057 Rostock, Germany
| | - Pekka Martikainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, 00014 Helsinki, Finland; Max Planck-University of Helsinki Center for Social Inequalities in Population Health, 00014 Helsinki, Finland; Max Planck Institute for Demographic Research, 18057 Rostock, Germany
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18
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Kelty E, Chitty K, Preen DB. Safety of Alprazolam Use in Pregnancy in Western Australia: A Retrospective Cohort Study Using Linked Health Data. J Psychoactive Drugs 2023:1-7. [PMID: 37504800 DOI: 10.1080/02791072.2023.2241465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023]
Abstract
The use of alprazolam in pregnancy can adversely affect maternal and neonatal health. This study examined neonatal outcomes following exposure to alprazolam in pregnancy. Women prescribed alprazolam during pregnancy (n = 48) between 2014 and 2018 were identified from routinely-collected state administrative prescribing records and perinatal data. Two comparison groups of women; 1) prescribed alprazolam outside of pregnancy (n = 96) and 2) women never prescribed alprazolam (n = 96) were also identified. The health of women and their children was examined using administrative hospital, mortality and perinatal data and compared to the comparison groups using generalized linear models. Prenatal alprazolam exposure was not associated with a reduction in average birth weight or gestational age. However, neonates prenatally exposed to alprazolam were more likely be classified as having low birth weight for gestational age compared with alprazolam comparison group (OR: 4.46, 95% CI: 1.54-12.95) and the non-alprazolam comparison group (OR: 3.27, 95% CI: 1.22-8.79). There were no cases of perinatal mortality or floppy baby syndrome in alprazolam-exposed neonates. While the use of alprazolam during pregnancy was not associated with an increased risk of severe adverse neonatal outcomes (e.g. perinatal mortality), it was associated with neonates being born with a low birth weight for gestational age.
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Affiliation(s)
- Erin Kelty
- School of Population & Global Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Kate Chitty
- School of Population & Global Health, The University of Western Australia, Crawley, Western Australia, Australia
- School of Medical Sciences, The University of Sydney, Camperdown, New South Wales, Australia
| | - David B Preen
- School of Population & Global Health, The University of Western Australia, Crawley, Western Australia, Australia
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Meng LC, Lin CW, Lin YC, Huang ST, Chen YY, Shang CY, Wu CY, Chen LK, Chan KA, Hsiao FY. Association between maternal benzodiazepine or Z-hypnotic use in early pregnancy and the risk of stillbirth, preterm birth, and small for gestational age: a nationwide, population-based cohort study in Taiwan. Lancet Psychiatry 2023; 10:499-508. [PMID: 37353262 DOI: 10.1016/s2215-0366(23)00148-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Benzodiazepines and Z-hypnotics are commonly prescribed for anxiety and insomnia during pregnancy, but the evidence regarding potential adverse neonatal outcomes is insufficient because of poor control for confounding factors in previous studies. We therefore aimed to evaluate the association between the use of benzodiazepines or Z-hypnotics during early pregnancy and adverse neonatal outcomes (stillbirth, preterm birth, and small for gestational age). METHODS We did a nationwide, population-based cohort study in Taiwan using three data sources: Taiwan's National Birth Certificate Application database, the National Health Insurance database, and the Maternal and Child Health Database. The study cohort included all singleton pregnancies of females aged 15-50 years who gave birth between Jan 1, 2004, and Dec 31, 2018. Pregnancies without valid information were excluded. Benzodiazepine and Z-hypnotic use was defined as at least one benzodiazepine or Z-hypnotic prescription during early pregnancy (the first 20 weeks of pregnancy). The primary outcomes were stillbirth (fetal death at or after 20 weeks' gestation), preterm birth (<37 weeks' gestation), and small for gestational age (birthweight below the 10th percentile for gestational age by sex). Logistic regression models with propensity score fine stratification weighting were used to control for potential confounders and examine the association between benzodiazepines or Z-hypnotics use during early pregnancy and the risk of adverse neonatal outcomes. Odds ratios (ORs) and 95% CIs were reported. We used confounding by indication control analyses, a sibling control study, and a paternal negative control design to account for unmeasured confounders. The risk associated with exposure during late pregnancy was also assessed. FINDINGS Between Oct 7, 2021, and June 10, 2022, we analysed the study data. The cohort included 2 882 292 singleton pregnancies; of which, 75 655 (2·6%) of the mothers were dispensed one or more benzodiazepines or Z-hypnotics during early pregnancy. Women exposed during pregnancy were older (mean age at delivery was 31·0 years [SD 5·3] for exposed women vs 30·6 years [4·9] for unexposed women), had a higher prevalence of psychiatric disorders, and were more likely to have unhealthy lifestyle behaviours than unexposed women. Information about ethnicity was not available. Early pregnancy exposure was associated with adverse neonatal outcomes compared with non-exposure. The propensity score-weighted OR was 1·19 (95% CI 1·10-1·28) for stillbirth, 1·19 (1·16-1·23) for preterm birth, and 1·16 (1·13-1·19) for small for gestational age. After controlling for confounding by indication, there was no significant association between drug exposure and stillbirth risk; however, this attenuation was not observed for preterm birth and small for gestational age. In models with sibling controls that accounted for familial confounding and genetic factors, early exposure to benzodiazepines or Z-hypnotics was not associated with an increased risk of stillbirth and preterm birth, but it remained significantly associated with small for gestational age. The paternal negative control analyses with point estimates close to the null indicated no strong evidence of unmeasured confounding shared by the mother and the father. Substantially increased risks of stillbirth and preterm birth were observed for late pregnancy exposure. INTERPRETATION Benzodiazepine or Z-hypnotic use in early pregnancy is not associated with a substantial increase in the risk of stillbirth and preterm birth after accounting for unmeasured confounding factors. Clinicians should be aware of the increased risk of small for gestational age and caution should be taken when prescribing these medications during late pregnancy. FUNDING National Science and Technology Council, Taiwan. TRANSLATION For the Taiwanese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Lin-Chieh Meng
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Yi-Chin Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Tsung Huang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Yung Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chi-Yung Shang
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Yi Wu
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan; School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan; Taiwanese Society of Suicidology & Taiwan Suicide Prevention Center, Taipei, Taiwan
| | - Liang-Kung Chen
- Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan; Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan; Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan
| | - K Arnold Chan
- Institute of Epidemiology and Prevention Medicine, National Taiwan University, Taipei, Taiwan; TriNetX LLX, London, UK
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan.
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Huang WL. Safety of benzodiazepine or Z-hypnotic exposure in early pregnancy. Lancet Psychiatry 2023; 10:473-474. [PMID: 37353251 DOI: 10.1016/s2215-0366(23)00158-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 06/25/2023]
Affiliation(s)
- Wei-Lieh Huang
- Department of Psychiatry and Cerebellar Research Center, National Taiwan University Hospital Yunlin Branch, Yunlin 64041, Taiwan.
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Barber CM, Terplan M. Principles of care for pregnant and parenting people with substance use disorder: the obstetrician gynecologist perspective. Front Pediatr 2023; 11:1045745. [PMID: 37292372 PMCID: PMC10246753 DOI: 10.3389/fped.2023.1045745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 04/17/2023] [Indexed: 06/10/2023] Open
Abstract
Substance use in pregnant and parenting persons is common, yet still underdiagnosed. Substance use disorder (SUD) is one of the most stigmatized and undertreated chronic medical conditions, and this is exacerbated in the perinatal period. Many providers are not sufficiently trained in screening or treatment for substance use, so gaps in care for this population persist. Punitive policies towards substance use in pregnancy have proliferated, lead to decreased prenatal care, do not improve birth outcomes, and disproportionately impact Black, Indigenous, and other families of color. We discuss the importance of understanding the unique barriers of pregnancy-capable persons and drug overdose as one of the leading causes of maternal death in the United States. We highlight the principles of care from the obstetrician-gynecologist perspective including care for the dyad, person-centered language, and current medical terminology. We then review treatment of the most common substances, discuss SUD during the birthing hospitalization, and highlight the high risk of mortality in the postpartum period.
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Affiliation(s)
- Cecily May Barber
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, United States
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, MA, United States
| | - Mishka Terplan
- Friends Research Institute, Baltimore, MD, United States
- Department of Family and Community Medicine, University of California, San Francisco, CA, United States
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Lupattelli A, Trinh NTH, Nordeng H. Association of maternal personality traits with medication use during pregnancy to appraise unmeasured confounding in long-term pharmacoepidemiological safety studies. Front Pharmacol 2023; 14:1160168. [PMID: 37256227 PMCID: PMC10225644 DOI: 10.3389/fphar.2023.1160168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/26/2023] [Indexed: 06/01/2023] Open
Abstract
Maternal personality is a possible confounder on the association between prenatal medication exposure and long-term developmental outcomes in offspring, but it is often unmeasured. This study aimed to (i) estimate the association between five maternal personality traits and prenatal use of acetaminophen (including extended use), opioid analgesics, antidepressants, benzodiazepines/z-hypnotics, and antipsychotics; (ii) evaluate, using an applied example, whether unmeasured confounding by maternal neuroticism would make the association between prenatal antidepressant-child ADHD null, using the E-value framework. We used data from 8,879 pregnant women and recent mothers who participated in the Multinational Medication Use in Pregnancy Study, a web-based cross-sectional study performed within the period from 1-Oct-2011 to 29-Feb-2012 in Europe, North America and Australia. Medication use in pregnancy was self-reported by the women. Personality was assessed with the Big Five Inventory, capturing the dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness. Adjusted logistic regression analyses were conducted for each trait-medication pair, using the survey weighting. There was a strong association between having high neuroticism and prenatal use of antidepressants (Odds Ratio (OR): 5.63, 95% Confidence Interval (CI): 3.96-8.01), benzodiazepines/z-hypnotics (OR: 6.66, 95% CI: 4.05-10.95), and analgesic opioids (OR: 2.24, 95% CI: 1.41-3.56), but not with antipsychotics. Among women with mental illness, this association attenuated for benzodiazepines/z-hypnotics, but decreased to the null for antidepressants. High neuroticism (OR: 1.31, 95% CI: 1.08-1.59) and high openness (OR: 0.77, 95% CI: 0.64-0.93) were associated with extended use of acetaminophen. The E-value for the Hazard Ratio 1.93 in the applied example was 3.27. If the example study was conducted using a population comparison group, high maternal neuroticism could have explained away the association antidepressant-ADHD. Because the example study included only women with a mental illness, this risk of bias was assessed as minimal. Various personality dispositions in the mother are associated, with a different degree, to prenatal use of medication. The strength of these association can aid researchers in evaluating the influence of uncontrolled confounding by maternal personality in long-term safety studies in pregnancy, using the E-value. This assessment should always be performed in addition to a rigorous study design using approaches to triangulate the evidence.
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Affiliation(s)
- Angela Lupattelli
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Nhung T. H. Trinh
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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da Silva Junior CA, Marques DA, Patrone LGA, Biancardi V, Bícego KC, Gargaglioni LH. Intra-uterine diazepam exposure decreases the number of catecholaminergic and serotoninergic neurons of neonate rats. Neurosci Lett 2023; 795:137014. [PMID: 36521643 DOI: 10.1016/j.neulet.2022.137014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022]
Abstract
Benzodiazepines, such as diazepam (DZP), are used to treat anxiety disorders, and are prescribed to pregnant woman for therapeutic purposes. Concerns regarding their consequences on postnatal development rise as they cross the placenta and interact with the embryo. Occurrence of malformation and behavioral syndromes have been reported for different ages, but little is known about their effects on the brain after exposure during intrauterine life. Thus, we sought to evaluate the effects of intrauterine exposure to DZP on the number of brainstem's catecholaminergic and serotonergic neurons, implicated in respiratory control, in male and female rats on postnatal (P) day 12-13, using immunofluorescence labeling for tyrosine-hydroxylase (TH) and serotonin (5-HT). We observed a reduction in the number of catecholaminergic neurons for males and females. Special attention is given to the reduction in the density of neurons in the A6 region, involved in ventilatory responses to CO2. Interestingly, only males showed a reduction in the number of serotonergic neurons, while females were not affected. These findings suggest that in utero exposure to DZP results in deleterious neuroanatomical effects on P12-13 rats and raises a note of concern for women clinicians to make more informed choices about the use of anxiolytic treatments during gestation.
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Affiliation(s)
- Carlos Aparecido da Silva Junior
- Department of Applied Science, William & Mary, Williamsburg, VA, United States; Department of Animal Morphology and Physiology, FCAV - UNESP - São Paulo State University, Jaboticabal, SP, Brazil
| | - Danuzia A Marques
- Department of Pediatrics, Québec Heart and Lung Institute, Université Laval, Québec, QC, Canada
| | - Luís Gustavo A Patrone
- Department of Animal Morphology and Physiology, FCAV - UNESP - São Paulo State University, Jaboticabal, SP, Brazil
| | - Vivian Biancardi
- Department of Physiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kênia C Bícego
- Department of Animal Morphology and Physiology, FCAV - UNESP - São Paulo State University, Jaboticabal, SP, Brazil
| | - Luciane H Gargaglioni
- Department of Animal Morphology and Physiology, FCAV - UNESP - São Paulo State University, Jaboticabal, SP, Brazil.
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Suarez EA, Bushnell GA. Association Between Attention-Deficit/Hyperactivity Disorder and Benzodiazepines and Z-Hypnotics in Pregnancy-Questions Remain. JAMA Netw Open 2022; 5:e2246896. [PMID: 36520443 DOI: 10.1001/jamanetworkopen.2022.46896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Elizabeth A Suarez
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, New Brunswick, New Jersey
| | - Greta A Bushnell
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, New Brunswick, New Jersey
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Lin Y, Chen M, Chang Y, Chen L, Hsiung CA, Wu S. Prevalence of exposure to benzodiazepines among pregnant women in Taiwan: A nationwide longitudinal study. J Sleep Res 2022; 31:e13678. [PMID: 35775446 PMCID: PMC9788177 DOI: 10.1111/jsr.13678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/23/2022] [Accepted: 06/02/2022] [Indexed: 12/30/2022]
Abstract
Although more than one hundred studies have examined the prevalence of the use of benzodiazepines and benzodiazepine-like Z-hypnotics (BZDs) among pregnancy events, further analysis of the effects of dosage or type of BZDs is needed. The aim of this study was to examine the prevalence rate of BZDs use in pregnancy events, stratified by trimester over time, with characteristics of the dosage and type of BZDs. This is a retrospective population study based on linking three national databases. We examined the prevalence rates from 2004 to 2017, and contrasted the results based on >0 defined daily dose (DDD) and ≥0.5 DDD. We identified 2,630,944 pregnancy events with live births; 89,897 (3.4%) of the associated pregnancy events had used some form of BZD during pregnancy. The prevalence of BZDs use, as defined by >0 DDD, decreased from 4.1% in 2004 to 2.9% in 2017, indicating a decrease in sporadic use and an increase in stable use within therapeutic doses. Meanwhile, BZDs use defined by ≥0.5 DDD increased from 0.1% in 2004 to 0.4% in 2017. Zolpidem was the most frequently prescribed BZDs, as defined by >0 DDD or ≥0.5 DDD. This national cohort study demonstrates the importance of average dosage in the definition of BZDs use in pregnancy events, and it found opposite trends in the prevalence of use between different dosages.
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Affiliation(s)
- Yu‐Hsuan Lin
- Institute of Population Health SciencesNational Health Research InstitutesMiaoli CountyTaiwan,Department of PsychiatryNational Taiwan University HospitalTaipeiTaiwan,Department of Psychiatry, College of MedicineNational Taiwan UniversityTaipeiTaiwan,Institute of Health Behaviors and Community Sciences, College of Public HealthNational Taiwan UniversityTaipeiTaiwan
| | - Mei‐Huei Chen
- Institute of Population Health SciencesNational Health Research InstitutesMiaoli CountyTaiwan,Department of PediatricsNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Ya‐Chen Chang
- Institute of Population Health SciencesNational Health Research InstitutesMiaoli CountyTaiwan
| | - Likwang Chen
- Institute of Population Health SciencesNational Health Research InstitutesMiaoli CountyTaiwan
| | - Chao A. Hsiung
- Institute of Population Health SciencesNational Health Research InstitutesMiaoli CountyTaiwan
| | - Shiow‐Ing Wu
- Institute of Population Health SciencesNational Health Research InstitutesMiaoli CountyTaiwan
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Sundbakk LM, Gran JM, Wood ME, Handal M, Skurtveit S, Nordeng H. Association of Prenatal Exposure to Benzodiazepines and Z-Hypnotics With Risk of Attention-Deficit/Hyperactivity Disorder in Childhood. JAMA Netw Open 2022; 5:e2246889. [PMID: 36520439 PMCID: PMC9856385 DOI: 10.1001/jamanetworkopen.2022.46889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Evidence is limited regarding the safety of prenatal benzodiazepine and z-hypnotic exposure and its association with long-term neurodevelopment in childhood. OBJECTIVE To quantify the associations of the timing and number of intervals of prenatal exposure to benzodiazepines and/or z-hypnotics with the risk of attention-deficit/hyperactivity disorder (ADHD) in childhood. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the 1999 to 2008 population-based Norwegian Mother, Father and Child Cohort Study, which are linked to the Medical Birth Registry of Norway, Norwegian Patient Registry, and Norwegian Prescription Database. Two populations of participants were created: a full sample and a mental health sample. The full sample included mothers and their live-born singletons, whereas the mental health sample was restricted to offspring of mothers who reported anxiety, depression, or sleeping problems during pregnancy or 6 months before pregnancy. Data were analyzed from September 2021 to February 2022. EXPOSURES Maternal self-report of benzodiazepine and/or z-hypnotic use during pregnancy was grouped into early pregnancy exposure and middle and/or late pregnancy exposure for analysis of the association with timing of exposure, and number of 4-week intervals of exposure was classified (single [1] vs multiple [≥2]) for analysis of the association with number of exposed intervals. MAIN OUTCOME AND MEASURES The outcome was ADHD, defined as time to ADHD diagnosis or filled prescription for ADHD medication. To control for confounding, inverse probability of treatment-weighted Cox proportional hazards regression models were used. Hazard ratios and 95% CIs were estimated. The weights were derived from propensity score modeling of the probability of benzodiazepine and/or z-hypnotic exposure as a function of potential confounders between the exposure and the outcome, including maternal symptoms of depression and anxiety. RESULTS The full sample comprised 82 201 pregnancies, and the mental health sample included 19 585 pregnancies. In total, 681 offspring (0.8%) in the full sample and 468 offspring (2.4%) in the mental health sample were prenatally exposed to benzodiazepines and/or z-hypnotics. After weighting, exposure in early (hazard ratio, 0.74; 95% CI, 0.39-1.94) and middle and/or late (hazard ratio, 0.76; 95% CI, 0.35-1.61) pregnancy was not associated with increased risk of childhood ADHD. There was no evidence of substantial association between the number of exposed intervals during pregnancy and childhood ADHD. CONCLUSIONS AND RELEVANCE Results of this study suggest that there may be no increased risk of childhood ADHD associated with prenatal exposure to benzodiazepines and/or z-hypnotics, regardless of timing of exposure and number of exposed intervals. However, these findings should be interpreted with caution due to low study power.
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Affiliation(s)
- Lene Maria Sundbakk
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Jon Michael Gran
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Mollie E. Wood
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Marte Handal
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Svetlana Skurtveit
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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Chen VCH, Wu SI, Lin CF, Lu ML, Chen YL, Stewart R. Association of Prenatal Exposure to Benzodiazepines With Development of Autism Spectrum and Attention-Deficit/Hyperactivity Disorders. JAMA Netw Open 2022; 5:e2243282. [PMID: 36413366 PMCID: PMC9682429 DOI: 10.1001/jamanetworkopen.2022.43282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Prenatal exposure to benzodiazepines is reported to be associated with neurodevelopmental disorders among children, but associations of maternal genetic confounding with neurodevelopmental disorders among children have not been taken into consideration. OBJECTIVE To ascertain whether prenatal benzodiazepine exposure was associated with development of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). DESIGN, SETTING, AND PARTICIPANTS This cohort study used linked data from birth certificate registration and the Taiwan National Health Insurance Research Database from January 1, 2004, to December 31, 2017, on 1 138 732 mothers with 1 516 846 live births between January 1, 2004, and December 31, 2017. Data were analyzed between February 20, 2021, and September 19, 2022. EXPOSURE Benzodiazepine exposure during pregnancy (first trimester to third trimester) was defined as having at least one benzodiazepine prescription dispensed. MAIN OUTCOMES AND MEASURES The main outcomes were ADHD and ASD. RESULTS There were 1 516 846 children (mean [SD] gestational age, 38.5 [1.8] years; 789 455 boys [52.0%]) born full term who were younger than 14 years of age and followed up to 2017; 5.0% of the children (n = 76 411) were exposed to a benzodiazepine during pregnancy. Benzodiazepine exposure during pregnancy was associated with increased risks of ADHD (first trimester exposure: hazard ratio [HR], 1.24 [95% CI, 1.20-1.28]; second trimester exposure: HR, 1.27 [95% CI, 1.21-1.34]; third trimester exposure: HR, 1.25 [95% CI, 1.14-1.37]) and ASD (first trimester exposure: HR, 1.13 [95% CI, 1.05-1.21]; second trimester exposure: HR, 1.10 [95% CI, 0.98-1.22]; third trimester exposure: HR, 1.21 [95% CI, 1.00-1.47]). However, no differences were found with unexposed sibling controls during the same time frame for ADHD (first trimester exposure: HR, 0.91 [95% CI, 0.83-1.00]; second trimester exposure: HR, 0.89 [95% CI, 0.78-1.01]; third trimester exposure: HR, 1.08 [95% CI, 0.83-1.41]) or ASD (first trimester exposure: HR, 0.92 [95% CI, 0.75-1.14]; second trimester exposure: HR, 0.97 [95% CI, 0.71-1.33]; third trimester exposure: HR, 1.07 [95% CI, 0.53-2.16]). Similar findings were also noted in the stratification analysis of short-acting and long-acting benzodiazepines. CONCLUSIONS AND RELEVANCE This cohort study suggests that previously described adverse neurodevelopmental outcomes associated with benzodiazepine exposure during pregnancy were likely to be accounted for by maternal genetic confounding.
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Affiliation(s)
- Vincent Chin-Hung Chen
- Department of Psychiatry, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
- Department of Psychiatry, Chang Gung University, Taoyuan, Taiwan
| | - Shu-I Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chiao-Fan Lin
- Department of Psychiatry, Chang Gung University, Taoyuan, Taiwan
- Department of Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Mong-Liang Lu
- Department of Psychiatry, Wan-Fang Hospital & School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Lung Chen
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
- Department of Psychology, Asia University, Taichung, Taiwan
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kindgom
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
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Bjørndal LD, Tauqeer F, Heiervang KS, Clausen HK, Heitmann K, Lupattelli A. Perceived risk of neurodevelopmental outcomes in offspring related to psychotropic and mental illness exposures in pregnancy and breastfeeding: a cross-sectional survey of women with past or current mental illness. BMJ Open 2022; 12:e061159. [PMID: 36180118 PMCID: PMC9528661 DOI: 10.1136/bmjopen-2022-061159] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To investigate the perceived risk of psychotropic and mental illness exposures (1) during pregnancy or (2) while breastfeeding on offspring neurodevelopment, and factors associated with this perception in women with past/current mental illness. DESIGN Cross-sectional, web-based study. SETTING Nationwide in Norway, June 2020-June 2021. PARTICIPANTS Women aged 18-55 years who were pregnant, recent mothers or planning a pregnancy, and had been offered antidepressants in the last 5 years. PRIMARY AND SECONDARY OUTCOME MEASURES Perceived risk of prenatal and breastmilk exposure to psychotropic medications and maternal mental illness on offspring neurodevelopmental outcomes. RESULTS We included 448 women: 234 pregnant, 146 mothers and 68 planning a pregnancy. On a 0-10 scale, women perceived antidepressants as least harmful both (1) in pregnancy (mean score 4.2, 95% CI 3.6 to 4.8) and (2) while breastfeeding (mean score 3.8, 95% CI 3.3 to 4.4), relative to antipsychotics, anxiety/sleeping medication or antiepileptics (mean score range: 6.3-6.5 during pregnancy, 5.5-6.2 while breastfeeding). Many participants were unfamiliar with psychotropics other than antidepressants. The perceived risk of mental illness exposure exceeded that of antidepressants (mean score range 5.6-5.9) in both exposure periods. Using general linear models, factors associated with greater antidepressant risk perception in both exposure periods included having lower education, non-Norwegian native language, and employment status (range mean score difference (β): 2.07-6.07). For pregnant women and mothers, there was an inverse association between perceived risk and the perceived antidepressant effectiveness in both exposure periods (range of β: -0.18 to -0.25). CONCLUSIONS In women with past/current mental illness, the perceived risk of antidepressant exposure on child neurodevelopment was lower than that for maternal mental illness. Other psychotropic medications were perceived as more harmful. As medication risk perception influences the decision-making regarding treatment of mental illness, pre- and pregnancy counselling should target women with characteristics associated with higher perceived risk.
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Affiliation(s)
- Ludvig D Bjørndal
- PROMENTA Research Center, Department of Psychology, University of Oslo, Oslo, Norway
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Fatima Tauqeer
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Kristin S Heiervang
- Department of Research and Development, Mental Health Services, Akershus Universitetssykehus HF, Lorenskog, Norway
| | - Hanne K Clausen
- Department of Research and Development, Mental Health Services, Akershus Universitetssykehus HF, Lorenskog, Norway
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders and Mental Health Division, Innlandet Hospital Trust, Brumunddal, Norway
| | - Kristine Heitmann
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), Department of Medical Biochemistry and Pharmacology, Haukeland Universitetssjukehus, Bergen, Norway
| | - Angela Lupattelli
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
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da Silva Junior CA, Patrone LGA, Biancardi V, Vilela-Costa HH, Marques DA, Cristina-Silva C, da Costa Silva KS, Bícego KC, Szawka RE, Gargaglioni LH. Sexually dimorphic effects of prenatal diazepam exposure on respiratory control and the monoaminergic system of neonate and young rats. Pflugers Arch 2022; 474:1185-1200. [DOI: 10.1007/s00424-022-02730-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/05/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022]
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Kitchin Á, Huerta C, Llorente-García A, Martínez D, Ortega P, Cea-Soriano L. The role of prenatal exposure to antidepressants, anxiolytic, and hypnotics and its underlying illness on the risk of miscarriage using BIFAP database. Pharmacoepidemiol Drug Saf 2022; 31:901-912. [PMID: 35689300 PMCID: PMC9543237 DOI: 10.1002/pds.5488] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/21/2022] [Accepted: 06/05/2022] [Indexed: 12/04/2022]
Abstract
Purpose Despite the notable increase on the prescription of antidepressants and anxiolytics during pregnancy, recommendation on maintaining the treatment during prenatal period is still controversial. We aimed to separately assess the role of effects of the antidepressants and anxiolytic and the underlying illness, controlled by potential confounding associated with miscarriage onset. Methods We used data from a validated pregnant cohort aged 15–49 years from 2002 to 2016 using BIFAP database. All confirmed miscarriages were used to perform a nested control analysis using conditional logistic regression. Women were classified according to use of each drug of interest into four mutually exclusive groups: nonusers, users only during prepregnancy, continuers, and initiators during first trimester. Adjusted odds ratios (aORs) for major confounders during pregnancy such as number of visits to primary care practitioners visits, obesity, smoking, HTA, diabetes with 95% confidence intervals were calculated. Results Compared with nonusers, antidepressants continuers had the highest increased risk of miscarriage aOR (95%) of 1.29 (1.13–1.46), being continuers of paroxetine and fluoxetine the antidepressants with the strongest association. Likewise, continuers of anxiolytics and initiators showed an increased risk of 1.19 (1.04–1.37) and 1.30 (1.13–1.50). When separating the effect between the condition itself or the treatment, women exposed during first trimester, regardless treatment duration and/or the underlying illness, had the highest risk 1.27 (1.08–1.51) for antidepressants and 1.25 (1.13–1.39) for anxiolytics. Conclusions Our analysis showed an association between prenatal exposure to antidepressants and anxiolytics and miscarriage onset after controlling by potential confounding adjusting for confounders and the underlying illness. This association was not supported for hypnotic medications. Further studies are warranted to evaluate the risk of miscarriage among subpopulation of pregnant women requiring these medications.
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Affiliation(s)
- Álvaro Kitchin
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid
| | - Consuelo Huerta
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid
| | - Ana Llorente-García
- BIFAP, Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - David Martínez
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid
| | - Paloma Ortega
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid
| | - Lucía Cea-Soriano
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid
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Prenatal exposure to benzodiazepines and Z-drugs in humans and risk of adverse neurodevelopmental outcomes in offspring: A systematic review. Neurosci Biobehav Rev 2022; 137:104647. [PMID: 35367514 DOI: 10.1016/j.neubiorev.2022.104647] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/22/2022]
Abstract
When used during pregnancy, benzodiazepines (BZDs) and related z-drugs could pass readily through the placenta and the foetal blood-brain barrier, where they can bind to γ-amino butyric acid (GABA) receptors in the developing foetal brain. Yet, data on long-term safety of prenatal BZD and z-drug use and its impact on offspring neurodevelopment are inconclusive. In this systematic review, we qualitatively synthetize the existing evidence on maternal exposure to various BZDs and z-drugs during pregnancy and offspring cognitive, emotional, behavioural, and motor skills developmental outcomes. Nineteen studies were included. We used harvest plots to visualize the directions of reported associations. Despite several associations between distinct types of BZDs and z-drugs and an increased risk of outcomes within different neurodevelopmental domains were observed, a remarkable scarcity of overall research on the topic and considerable discrepancies in methodology, particularly towards controlling for confounding by indication, precluded drawing conclusions with a reasonable degree of certainty. We outline various research strategies to mitigate methodological limitations and provide directions for future empirical studies on the topic.
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Lee H, Koh JW, Kim YA, Chun KC, Han JY, Hwang JH, Choi JS, Joo SH, Kwon HY. Pregnancy and Neonatal Outcomes After Exposure to Alprazolam in Pregnancy. Front Pharmacol 2022; 13:854562. [PMID: 35548333 PMCID: PMC9081603 DOI: 10.3389/fphar.2022.854562] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
Alprazolam is a commonly prescribed benzodiazepine for anxiety or panic disorder, even in pregnant women. Information on the safety of alprazolam during pregnancy is insufficient. We aimed to evaluate pregnancy and neonatal outcomes after exposure to alprazolam during pregnancy. A prospective study was conducted on 725 pregnancies from January 2000 to December 2019. Participants were recruited through the Korean Mother-Safe Program, a service providing information on drug-induced teratogenic risk during pregnancy and breastfeeding. Exposed (N = 96) and non-exposed (N = 629) women to alprazolam during pregnancy were selected and followed-up until delivery. Pregnancy outcomes, including spontaneous abortion, still birth, low birth weight (LBW), preterm birth, Apgar score (at 1 and 5 min), and malformations were measured and compared. Multivariable logistic regression was performed to examine the association between alprazolam exposure and outcomes. The mean age was 32.9 (SD 4.0) years in the alprazolam-exposed group and 31.8 (SD 3.8) years in the unexposed group (p = 0.008). The alprazolam exposure group demonstrated a significantly higher likelihood of pregnancy and neonatal outcomes: spontaneous abortion (OR = 2.38; 95% CI 1.20–4.69), LBW (OR = 3.65; 95% CI 1.22–11.00), and Apgar score at 1 min ≤ 7 (OR = 2.19; 95% CI 1.02–4.67). There was no significant difference in congenital abnormalities between the exposure and non-exposure groups. Our findings confirmed that alprazolam exposure during pregnancy was significantly associated with adverse pregnancy and neonatal outcomes, including spontaneous abortion, low birth weight, and Apgar score at 1 min ≤ 7. Alprazolam during pregnancy should be appropriately regulated and monitored.
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Affiliation(s)
- Hyunji Lee
- Korean Mother-Safe Counselling Center, Pregnancy and Breastfeeding Medicines Information Center, Seoul, Korea
- Department of Obstetrics and Gynecology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jae-Whoan Koh
- Department of Obstetrics and Gynecology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Young-Ah Kim
- Department of Obstetrics and Gynecology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Kyoung-Chul Chun
- Department of Obstetrics and Gynecology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jung Yeol Han
- Korean Mother-Safe Counselling Center, Pregnancy and Breastfeeding Medicines Information Center, Seoul, Korea
- Department of Obstetrics and Gynecology, Inje University Ilsan Paik Hospital, Goyang, Korea
- *Correspondence: Jung Yeol Han, ; Hye-Young Kwon,
| | - Jong Hee Hwang
- Department of Pediatrics, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - June-Seek Choi
- Korean Mother-Safe Counselling Center, Pregnancy and Breastfeeding Medicines Information Center, Seoul, Korea
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Sung Hong Joo
- Korean Mother-Safe Counselling Center, Pregnancy and Breastfeeding Medicines Information Center, Seoul, Korea
- Department of Obstetrics and Gynecology, National Medical Center, Seoul, Korea
| | - Hye-Young Kwon
- Division of Biology and Public Health, Mokwon University, Daejeon, Korea
- *Correspondence: Jung Yeol Han, ; Hye-Young Kwon,
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Noh Y, Lee H, Choi A, Kwon JS, Choe SA, Chae J, Kim DS, Shin JY. First-trimester exposure to benzodiazepines and risk of congenital malformations in offspring: A population-based cohort study in South Korea. PLoS Med 2022; 19:e1003945. [PMID: 35235572 PMCID: PMC8926183 DOI: 10.1371/journal.pmed.1003945] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/16/2022] [Accepted: 02/13/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Benzodiazepines are frequently prescribed during pregnancy; however, evidence about possible teratogenicity is equivocal. We aimed to evaluate the association between first-trimester benzodiazepine use and the risk of major congenital malformations. METHODS AND FINDINGS Using Korea's nationwide healthcare database, we conducted a population-based cohort study of women who gave birth during 2011 to 2018 and their live-born infants. The exposure was defined as one or more benzodiazepine prescriptions during the first trimester. We determined the relative risks (RRs) and confidence intervals (CIs) of overall congenital malformations and 12 types of organ-specific malformations. Infants were followed from birth to death or 31 December 2019, whichever came first (up to 8 years of age). Propensity score fine stratification was employed to control for 45 potential confounders. Among a total of 3,094,227 pregnancies, 40,846 (1.3%) were exposed to benzodiazepines during the first trimester (mean [SD] age, 32.4 [4.1] years). The absolute risk of overall malformations was 65.3 per 1,000 pregnancies exposed to benzodiazepines versus 51.4 per 1,000 unexposed pregnancies. The adjusted RR was 1.09 (95% CI 1.05 to 1.13, p < 0.001) for overall malformations and 1.15 (1.10 to 1.21, p < 0.001) for heart defects. Based on mean daily lorazepam-equivalent doses, the adjusted RRs for overall malformations and heart defects were 1.05 (0.99 to 1.12, p = 0.077) and 1.12 (1.04 to 1.21, p = 0.004) for <1 mg/day and 1.26 (1.17 to 1.36, p < 0.001) and 1.31 (1.19 to 1.45, p < 0.001) for >2.5 mg/day doses, respectively, suggesting a dose-response relationship. A small but significant increase in risk for overall and heart defects was detected with several specific agents (range of adjusted RRs: 1.08 to 2.43). The findings were robust across all sensitivity analyses, and negative control analyses revealed a null association. Study limitations include possible exposure misclassification, residual confounding, and restriction to live births. CONCLUSIONS In this large nationwide cohort study, we found that first-trimester benzodiazepine exposure was associated with a small increased risk of overall malformations and heart defects, particularly at the higher daily dose. The absolute risks and population attributable fractions were modest. The benefits of benzodiazepines for their major indications must be considered despite the potential risks; if their use is necessary, the lowest effective dosage should be prescribed to minimize the risk. TRIAL REGISTRATION ClinicalTrials.gov NCT04856436.
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Affiliation(s)
- Yunha Noh
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Hyesung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Ahhyung Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Jun Soo Kwon
- Department of Psychiatry, Seoul National University College of Medicine, South Korea
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, South Korea
- Institute of Human Behavioral Medicine, Seoul National University Medical Research Center, South Korea
| | - Seung-Ah Choe
- Division of Life Sciences, Korea University, Seoul, South Korea
| | - Jungmi Chae
- Department of Research, Health Insurance Review and Assessment Service, Wonju, South Korea
| | - Dong-Sook Kim
- Department of Research, Health Insurance Review and Assessment Service, Wonju, South Korea
- * E-mail: (DSK); (JYS)
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
- * E-mail: (DSK); (JYS)
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Treatment of Peripartum Depression with Antidepressants and Other Psychotropic Medications: A Synthesis of Clinical Practice Guidelines in Europe. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19041973. [PMID: 35206159 PMCID: PMC8872607 DOI: 10.3390/ijerph19041973] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 01/29/2022] [Accepted: 01/29/2022] [Indexed: 02/04/2023]
Abstract
This study examined (1) the availability and content of national CPGs for treatment of peripartum depression, including comorbid anxiety, with antidepressants and other psychotropics across Europe and (2) antidepressant and other psychotropic utilization data as an indicator of prescribers' compliance to the guidelines. We conducted a search using Medline and the Guidelines International Network database, combined with direct e-mail contact with national Riseup-PPD COST ACTION members and researchers within psychiatry. Of the 48 European countries examined, we screened 41 records and included 14 of them for full-text evaluation. After exclusion of ineligible and duplicate records, we included 12 CPGs. Multiple CPGs recommend antidepressant initiation or continuation based on maternal disease severity, non-response to first-line non-pharmacological interventions, and after risk-benefit assessment. Advice on treatment of comorbid anxiety is largely missing or unspecific. Antidepressant dispensing data suggest general prescribers' compliance with the preferred substances of the CPG, although country-specific differences were noted. To conclude, there is an urgent need for harmonized, up-to-date CPGs for pharmacological management of peripartum depression and comorbid anxiety in Europe. The recommendations need to be informed by the latest available evidence so that healthcare providers and women can make informed, evidence-based decisions about treatment choices.
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Jensen AG, Knudsen SS, Bech BH. Prenatal exposure to benzodiazepines and the development of the offspring – a systematic review. Neurotoxicol Teratol 2022; 91:107078. [DOI: 10.1016/j.ntt.2022.107078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 01/13/2022] [Accepted: 02/15/2022] [Indexed: 11/16/2022]
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What Obstetrician–Gynecologists Should Know About Substance Use Disorders in the Perinatal Period. Obstet Gynecol 2022; 139:317-337. [DOI: 10.1097/aog.0000000000004657] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
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Insomnia evaluation and treatment during peripartum: a joint position paper from the European Insomnia Network task force "Sleep and Women," the Italian Marcè Society and international experts task force for perinatal mental health. Arch Womens Ment Health 2022; 25:561-575. [PMID: 35419652 PMCID: PMC9072480 DOI: 10.1007/s00737-022-01226-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/27/2022] [Indexed: 12/22/2022]
Abstract
Insomnia symptoms are frequent during peripartum and are considered risk factors for peripartum psychopathology. Assessing and treating insomnia and related conditions of sleep loss during peripartum should be a priority in the clinical practice. The aim of this paper was to conduct a systematic review on insomnia evaluation and treatment during peripartum which may be useful for clinicians. The literature review was carried out between January 2000 and May 2021 on the evaluation and treatment of insomnia during the peripartum period. The PubMed, PsycINFO, and Embase electronic databases were searched for literature published according to the PRISMA guidance with several combinations of search terms "insomnia" and "perinatal period" or "pregnancy" or "post partum" or "lactation" or "breastfeeding" and "evaluation" and "treatment." Based on this search, 136 articles about insomnia evaluation and 335 articles on insomnia treatment were found and we conducted at the end a narrative review. According to the inclusion/exclusion criteria, 41 articles were selected for the evaluation part and 22 on the treatment part, including the most recent meta-analyses and systematic reviews. Evaluation of insomnia during peripartum, as for insomnia patients, may be conducted at least throughout a clinical interview, but specific rating scales are available and may be useful for assessment. Cognitive behavioral therapy for insomnia (CBT-I), as for insomnia patients, should be the preferred treatment choice during peripartum, and it may be useful to also improve mood, anxiety symptoms, and fatigue. Pharmacological treatment may be considered when women who present with severe forms of insomnia symptoms do not respond to nonpharmacologic therapy.
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Shin J. Anesthetic Management of the Pregnant Patient: Part 2. Anesth Prog 2021; 68:119-127. [PMID: 34185861 DOI: 10.2344/anpr-68-02-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/18/2021] [Indexed: 11/11/2022] Open
Abstract
Part 2 of "Anesthetic Management of the Pregnant Patient" reviews fetal development and maternal physiologic changes of interest to the dental practitioner. Part 2 of this review focuses on pharmacologic considerations, particularly the potential impact on the developing fetus. Along with a brief overview involving pharmacokinetics and pharmacodynamics of selected drugs, the following discussion focuses on currently accepted therapies and commonly used agents for pain control, sedation, and general anesthesia in the pregnant patient planned for or undergoing dental treatment.
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Affiliation(s)
- Jaimin Shin
- Dental Anesthesiology, NYU Langone-Brooklyn, New York, New York
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Qato DM, Gandhi AB. Opioid and benzodiazepine dispensing and co-dispensing patterns among commercially insured pregnant women in the United States, 2007-2015. BMC Pregnancy Childbirth 2021; 21:350. [PMID: 33941106 PMCID: PMC8091773 DOI: 10.1186/s12884-021-03787-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 04/09/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Little is known about benzodiazepine and opioid-benzodiazepine co-dispensing patterns among pregnant women. Understanding these patterns is necessary to mitigate high-risk medication use during pregnancy. Our objective in this analysis was to evaluate opioid and benzodiazepine dispensing and co-dispensing patterns among commercially insured pregnant women in the United States. METHODS This retrospective study used a 10% random sample of commercially insured enrollees from the IQVIA™ Adjudicated Health Plan Claims Data from 2007 to 2015. The study included women (12-55 years of age) with completed pregnancies who had continuous medical and prescription drug coverage from 3 months prior to the date of conception through 3 months post-delivery. We estimated the prevalence of opioid and benzodiazepine dispensing and co-dispensing before, during, and after pregnancy, and evaluated trends in dispensing patterns across the study period (2007-2015) using Cochrane-Armitage tests. Chi-square tests were used to examine differences in demographic and clinical characteristics by dispensing and co-dispensing patterns. Among women that received an opioid or benzodiazepine during pregnancy, logistic regression models were used to quantify the association between sample characteristics and dispensing patterns (co-dispensing vs single dispensing). RESULTS Of 168,025 pregnant women that met our inclusion criteria, 10.1% received at least one opioid and 2.0% received at least one benzodiazepine during pregnancy, while 0.5% were co-dispensed these drugs. During the study period (2007 vs 2015), prevalence of opioid dispensing during pregnancy decreased from 11.2 to 8.6% (p < 0.01); while benzodiazepine dispensing increased from 1.3 to 2.9% (p < 0.01), and the prevalence of co-dispensing, while low and stable, increased slightly from 0.39 to 0.44% (p < 0.01). Older age, a higher comorbidity burden, pain diagnosis, anxiety diagnosis, and alcohol, tobacco, and drug use disorders, were all associated with an increased odds of co-dispensing during pregnancy. CONCLUSIONS This study provides evidence that while opioid dispensing during pregnancy has decreased in the past decade, benzodiazepine dispensing has increased. The prevalence of opioid-benzodiazepine co-dispensing was rare and remained fairly stable during our study period. Those co-dispensed both drugs had a higher prevalence of adverse birth outcomes. Further research to establish the potentially causal relationship between opioid and benzodiazepine co-dispensing and adverse birth outcomes should be undertaken.
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Affiliation(s)
- Danya M Qato
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA.
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Aakash Bipin Gandhi
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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López-Rabuñal Á, Lendoiro E, Concheiro-Guisán M, González-Colmenero E, Peñas-Silva P, Concheiro-Guisán A, Macía-Cortiñas M, López-Rivadulla M, de-Castro-Ríos A, Cruz A. Meconium and maternal hair analysis vs. medical records to monitor antidepressants and benzodiazepines exposure during pregnancy. Forensic Toxicol 2021. [DOI: 10.1007/s11419-021-00576-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Björkstedt SM, Kautiainen H, Tuomi U, Gissler M, Pennanen P, Eriksson JG, Laine MK. Maternal use of sedative drugs and its effects on pregnancy outcomes: a Finnish birth cohort study. Sci Rep 2021; 11:4467. [PMID: 33627788 PMCID: PMC7904770 DOI: 10.1038/s41598-021-84151-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/08/2021] [Indexed: 01/08/2023] Open
Abstract
Our aim was to evaluate maternal use of sedative drugs before, during, and after pregnancy and to assess the influence of use of these drugs on pregnancy outcomes. The study cohort (N = 6231) consists of all primiparous women, who lived in the city of Vantaa, Finland, and who delivered a singleton between 2009 and 2015. Data were obtained from Finnish national health registers. Of the women, 3.2% (n = 202) purchased at least once sedative drugs within 90 days before conception, during pregnancy and/or within 90 days after delivery. Sedative drug users were older, less likely to cohabitate, more often smokers, had lower educational attainment and had more mental diseases (for all p < 0.001) compared with non-users. Sedative drug users purchased more often antidepressants and drugs for the alimentary tract, musculoskeletal and nervous system than non-users (for all p < 0.001). No adverse birth or pregnancy outcomes were found in the group using sedative drugs compared with the non-users. Studies in larger cohorts are needed to confirm our study findings.
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Affiliation(s)
- Satu-Maarit Björkstedt
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Social Services and Health Care Division, City of Helsinki, Helsinki, Finland
| | - Hannu Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
| | | | - Mika Gissler
- Finnish Institute for Health and Welfare, Helsinki, Finland
- Karolinska Institute, Stockholm, Sweden
| | | | - Johan G Eriksson
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Department of Obstetrics and Gynecology and Human Potential Translational Research Programme, National University Singapore, Yong Loo Lin School of Medicine, Singapore, Singapore
- Agency for Science, Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
| | - Merja K Laine
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
- Folkhälsan Research Center, Helsinki, Finland.
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Cabaillot A, Bourset A, Mulliez A, Delorme J, Orri M, Vicard-Olagne M, Zenut MC, Tournier M, Gallot D, Authier N, Chenaf C, Laporte C. Trajectories of antidepressant drugs during pregnancy: A cohort study from a community-based sample. Br J Clin Pharmacol 2020; 87:965-987. [PMID: 32755022 DOI: 10.1111/bcp.14449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/30/2020] [Accepted: 06/11/2020] [Indexed: 11/29/2022] Open
Abstract
AIMS The aim of this study was to monitor the trajectories of antidepressant use during pregnancy and the postpartum period among women chronically treated with antidepressants before their pregnancy, and to assess characteristics associated with each trajectory. METHODS This cohort study included all pregnant women whose data were included in the General Sample of Beneficiaries (EGB) database affiliated with the French Health Insurance System, from 2009 to 2014. Women were followed up until 6 months after childbirth. Chronic treatment was defined as exposure over the 6-month period preceding pregnancy. A group-based trajectory model (GBMT) was estimated to identify distinctive longitudinal profiles of antidepressant use. RESULTS Among 760 women chronically treated with antidepressants before their pregnancy, 55.8% stopped their treatment permanently in the first trimester, 20.4% discontinued it for a minimum of 3 months and resumed it postpartum, and 23.8% maintained it throughout pregnancy and postpartum. No sociodemographic or medical characteristics were associated with any trajectory group. Women who maintained treatment presented more frequent obstetric complications and postpartum psychiatric disorders. Among women who interrupted treatment, prescription of benzodiazepines and anxiolytics decreased initially but rose postpartum to a higher level than before pregnancy. CONCLUSIONS Pregnant women treated with antidepressant require a re-evaluation of psychiatric treatment. It is necessary to pay attention to obstetric complications for severely depressed women. Additionally, as relapse was associated with increased benzodiazepine use, it is important to carefully monitor all women who stop antidepressant treatment during pregnancy.
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Affiliation(s)
- Aurélie Cabaillot
- Département de Médecine Générale, UFR de Médicine, Université Clermont Auvergne, Clermont-Ferrand, France.,CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Observatoire Français des Médicaments Antalgiques (OFMA), Institut Analgesia, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Alexandra Bourset
- Département de Médecine Générale, UFR de Médicine, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Aurélien Mulliez
- Délégation à la recherche clinique et à l'innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jessica Delorme
- CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Observatoire Français des Médicaments Antalgiques (OFMA), Institut Analgesia, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Massimiliano Orri
- McGill Group for Suicide Studies, Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montréal, QC, Canada.,Bordeaux Population Health Research Centre, Inserm U1219, Université de Bordeaux, Bordeaux, France
| | - Mathilde Vicard-Olagne
- Département de Médecine Générale, UFR de Médicine, Université Clermont Auvergne, Clermont-Ferrand, France.,Npsysydo, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Marie Christine Zenut
- CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Observatoire Français des Médicaments Antalgiques (OFMA), Institut Analgesia, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Marie Tournier
- Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Université de Bordeaux, Bordeaux, France.,Hospital Charles Perrens, Bordeaux, France
| | - Denis Gallot
- CNRS 6293, INSERM 1103, GReD, QC G1V 0A6 Clermont-Ferrand; Department of Obstetrics and Gynecology, CHU Clermont-Ferrand, Faculty of Medicine, Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Nicolas Authier
- CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Observatoire Français des Médicaments Antalgiques (OFMA), Institut Analgesia, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Chouki Chenaf
- CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Observatoire Français des Médicaments Antalgiques (OFMA), Institut Analgesia, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Catherine Laporte
- Département de Médecine Générale, UFR de Médicine, Université Clermont Auvergne, Clermont-Ferrand, France.,Npsysydo, Université Clermont Auvergne, Clermont-Ferrand, France
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Uguz F, Kirkas A, Aksoy ZK, Yunden S. Use of Psychotropic Medication During Lactation in Postpartum Psychiatric Patients: Results from an 8-Year Clinical Sample. Breastfeed Med 2020; 15:535-537. [PMID: 32522008 DOI: 10.1089/bfm.2020.0111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Objective: The aim of this study was to examine the lactation status and prevalence of use of psychotropic medications in perinatal psychiatric patients. Methods: Clinical data collated for a period of 8 years were retrospectively retrieved from patient registers. The sample included a total of 263 postpartum patients who were followed up for at least 4 weeks. Psychiatric diagnoses were ascertained by a structured clinical interview. Results: The most commonly administered psychotropic medications were paroxetine (43.3%), sertraline (31.9%), olanzapine (12.2%), and quetiapine (6.1%). Of the 242 patients who received psychotropic medication, 41 (16.9%) discontinued breastfeeding. The discontinuation in most cases was not due to psychiatrist's recommendation or adverse events due to medications. Conclusion: Paroxetine and sertraline are frequently used by postpartum psychiatric patients in our clinical sample. In addition, the results suggesting that most psychiatric patients included in this study can continue breastfeeding during pharmacotherapy should be confirmed by data derived from further clinical samples.
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Affiliation(s)
- Faruk Uguz
- Department of Psychiatry, University of Necmettin Erbakan, Meram Faculty of Medicine, Konya, Turkey
| | - Aysegul Kirkas
- Department of Psychiatry, University of Necmettin Erbakan, Meram Faculty of Medicine, Konya, Turkey
| | - Zakire Kubra Aksoy
- Department of Psychiatry, University of Necmettin Erbakan, Meram Faculty of Medicine, Konya, Turkey
| | - Sena Yunden
- Department of Psychiatry, University of Necmettin Erbakan, Meram Faculty of Medicine, Konya, Turkey
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