Temporal trends in general and age-specific fertility rates among women with schizophrenia (1996-2009): a population-based study in Ontario, Canada

Adverse obstetric and neonatal outcomes associated with maternal schizophrenia-spectrum disorders and prenatal antipsychotic use: a meta-analysis of 37,214,330 pregnancy deliveries and propensity-score weighted population-based cohort study assessing confounder dependency of risk estimates

Studies demonstrated increased obstetric and neonatal complications in women with schizophrenia-spectrum disorder (SSD), but most inadequately addressed confounders and rarely considered antipsychotic effects. We conducted a meta-analysis and a population-based cohort study evaluating associations of adverse obstetric/neonatal outcomes with SSD and prenatal antipsychotic use. In the meta-analysis, we searched four databases from inception to October-31-2023 and generated pooled risk estimates using random-effect models. In the cohort study, we identified women aged 15-50 years with SSD-diagnosis from electronic-heath-record database of public healthcare-services who delivered first/singleton children between 2003 and 2018 in Hong Kong. Propensity-score weighted regression-analyses incorporating important confounders including maternal pre-existing and gestational morbidities, substance/alcohol abuse, and psychotropic use, were performed to assess risk of adverse obstetric/neonatal outcomes in SSD-women versus non-SSD-women, and subsequently treated-SSD and untreated-SSD subgroups to disentangle effects of SSD from antipsychotic exposure. The meta-analysis (studies = 18, women = 37,214,330, including 42,926 SSD-women) found significant associations of SSD with 12 of 17 analyzed negative obstetric/neonatal outcomes (with pooled relative risk ranged:1.12-2.10), including placental complications, induced labor, Caesarean delivery, fetal distress, stillbirth, preterm birth, small-for-gestational-age, low birth weight, low APGAR scores, neonatal and post-neonatal deaths. However, the cohort study (466,358 women, including 804 SSD-women) revealed that elevated risk of most study outcomes in unadjusted-models were markedly-attenuated or became non-significant in propensity-score weighted adjusted-models, except index-delivery hospitalization ≥7 days (odds ratio [OR] = 1.76 [95% CI = 1.33-2.34]), preterm birth (OR = 1.48 [95% CI = 1.09-2.00]) and neonatal special-care admission (OR = 1.65 [95% CI = 1.35-2.01]). Apart from higher neonatal special-care admission in treated-SSD than untreated-SSD women (OR = 1.75 [95% CI = 1.23-2.52]), no significant between-group differences emerged in other outcomes. In sum, elevated risk of most obstetric/neonatal complications reported in SSD-women might largely be explained by maternal physical comorbidities, substance/alcohol use disorders and other confounders. Interventions targeting modifiable maternal risk factors should be incorporated in prenatal care for SSD-women to minimize avoidable adverse outcomes.

Prevalence and associated factors of abortion among women with severe mental disorders

BACKGROUND

Abortion behaviors among individuals with mental disorders presented major obstacles to women's health. However, few studies reported the prevalence and associated factors of abortion among women with severe mental disorders in China. Consequently, this study aims to investigate the prevalence of abortion among female patients in rural communities and identify potential health risks.

METHOD

This was a cross-sectional study of 276 women aged 18 years and older with severe mental disorders in rural areas of Shandong Province, China. The pregnancy history, abortion history and socio-demographic characteristics of women were investigated by questionnaire. Logistic regression analysis was employed to examine the associated factors for different abortion behaviors.

RESULT

The study showed that 82.61 % (228/276) of patients had a pregnancy history. Among the patients with a pregnancy history, 43.42 % (99/228) reported having had at least one abortion, and 15.79 % (36/228) had more than one. In the other side, 31.58 % (72/228) of them experienced spontaneous abortion, while 12.72 % (29/228) experienced induced abortion. Age at first gestation (aOR 0.80, 95 % CI 0.70-0.90) and age at last gestation (aOR 1.17, 95 % CI 1.07-1.27) were both associated with abortion. Anxiety was related to spontaneous (aOR 1.08, 95 % CI 1.02-1.15) and repeat abortions (aOR 1.10, 95 % CI 1.01-1.19). In addition, religion (aOR 10.47, 95 % CI 2.81-39.01), number of children≥2 (aOR 0.18, 95 % CI 0.04-0.77), and family functioning (aOR 1.31, 95 % CI 1.06-1.63) were associated with induced abortion.

CONCLUSION

Women with severe mental disorders in rural regions have notably higher rates of abortion compared to the general female population, particularly for spontaneous abortions. Gestational age and anxiety of pregnant patients deserve attention and preventive measures to avoid the outcomes of abortion.

Reproductive Health Among Those with Schizophrenia Spectrum Disorders: An Overview of Considerations Related to the Premenopausal Period, Pregnancy and Postpartum, and the Menopausal Transition, with a Focus on Recent Findings

PURPOSE OF REVIEW

Schizophrenia spectrum disorders (SSD) impact many aspects of reproductive health for women and non-binary and transgender individuals assigned female at birth. In this narrative review, we highlight considerations and recent research related to (1) the premenopausal period, (2) pregnancy and postpartum, and (3) the menopausal transition.

RECENT FINDINGS

Most recent research has focused on pregnancy and the postpartum period, and specifically on elucidating perinatal risk factors, adverse obstetrical and neonatal outcomes (and modifiable contributors such as smoking), long-term child health, and psychotropic medications (with reassuring results related antipsychotic-associated gestational diabetes mellitus and neurodevelopmental outcomes). Much less recent focus has been on menstruation and menopause, although some research has highlighted the relative worsening of illness peri-menstrually and peri-menopausally. Despite the many important reproductive considerations for those with SSD, many aspects including menstruation and menopause have received very little attention. Further research is needed on how to best support women, non-binary, and transgender people assigned female at birth with SSD throughout the lifespan.

Adverse perinatal pregnancy outcomes in women with schizophrenia: A systematic review and meta-analysis

INTRODUCTION

Schizophrenia is a severe mental illness that affects a significant proportion of the global population, particularly those of childbearing age. Several studies have attempted to find an association between schizophrenia and obstetric complications, with varying results.

OBJECTIVE

The primary objective of this systematic review and meta-analyses was to summarize the relationship between maternal schizophrenia and perinatal pregnancy outcomes.

DATA SOURCES

PubMed, Web of Science and Ovid EMBASE were searched from January 2001 to September 2022 using keywords related to pregnancy, women, schizophrenia.

STUDY SELECTION

A total of 23 independent studies across 21,253 individuals with schizophrenia were identified and included in the analysis.

DATA EXTRACTION

The following data were extracted: author, year of publication, country/continent of data collection, study design, demographic characteristics, diagnoses criteria, related complications. Data were analyzed using random-effects pairwise meta-analysis and were reported as prevalence and odd ratios (OR). Statistical heterogeneity was quantified with the I2 statistic.

RESULTS

The prevalence of adverse perinatal pregnancy outcomes was represented in descending order: cesarean section (26.0 %); labor induction (24.0 %); small for gestational age (10.5 %); gestational diabetes mellitus (9.2 %); preterm birth (9.1 %); low birth weight (7.8 %); preterm rupture of membranes (6.1 %); 1-Minute Apgar Score < 7 (5.6 %); large for gestational age (5.5 %); birth defect (5.4 %); antepartum hemorrhage (4.4 %);preeclampsia/eclampsia (4.8 %); postpartum hemorrhage (3.9 %); 5-Minute Apgar Score < 7 (3.6 %); gestational hypertension (3.3 %); placental abruption (1.0 %); placenta previa (0.6 %); thromboembolic disease (0.4 %); neonatal mortality (0.3 %) (P ≤ 0.05). There was a higher risk of adverse outcomes including gestational diabetes mellitus, preeclampsia/eclampsia, placental abruption, thromboembolic disease, preterm birth, birth defect, 1-Minute Apgar score < 7, small for gestational age, low birth weight and neonatal mortality compared with non-schizophrenia population (P ≤ 0.05).

CONCLUSIONS

Women with schizophrenia are at higher risk of adverse perinatal pregnancy outcomes. It is imperative that research efforts continue to focus on the reproductive safety of women with schizophrenia during their childbearing years.

Video-based e-learning program for schoolteachers to support children of parents with mental illness: a cluster randomized trial

BACKGROUND

Some children of parents with mental illness need support. This study aimed to develop and test the effectiveness of an e-learning program for training elementary schoolteachers to support children of parents with mental illness.

METHODS

The program, which included a 30-min video-based e-learning program, aimed to help schoolteachers gain basic knowledge about mental illness and children of parents with mental illness, recognize children in need of support, and gain confidence in supporting them. A school-based cluster randomized controlled trial was conducted, and the schools were randomly divided into intervention and control groups. The teachers at these schools signed up for the program and participated individually. The outcome measures for the schoolteachers were evaluated at three time points: baseline (T1), post (T2), and one month later (T3). Along with the Sense of Coping Difficulty subscale (primary outcome measure), the following self-developed outcome measures were used: actual behaviors and attitude toward supporting children, knowledge, and self-assessment of program goals achievement. The Sense of Coping Difficulty subscale results at T3 were compared between the groups. Effectiveness over time was assessed for all the outcome measures. The interaction between baseline and intervention effects on the Sense of Coping Difficulty subscale was analyzed. As a part of the process evaluation, open-ended text responses were analyzed qualitatively.

RESULTS

Baseline responses were collected from 87 participants in the intervention group and 84 in the control group. The total score of the Sense of Coping Difficulty subscale at T3 was significantly lower in the intervention group than in the control group (p = 0.007). Over time, a significant effect was observed on the Sense of Coping Difficulty subscale, actual behavior, knowledge of onset timing and probability of onset, and achievement of all program goals. Exploratory analysis was particularly effective for those who encountered a high level of difficulty in supporting children. The participants' text responses indicated that they planned to look carefully at children's backgrounds and stay close to them in the future.

CONCLUSIONS

The program was effective for schoolteachers in supporting children of parents with mental illness.

TRIAL REGISTRATION

UMIN000045483; 14/09/2021.

Aripiprazole, brexpiprazole, and cariprazine can affect milk supply: Advice to breastfeeding mothers

OBJECTIVE

We sought to review the effects of Dopamine Receptor Partial Agonist (DRPA) antipsychotic medications on milk supply and breastfeeding.

METHOD

Narrative review of selected literature including animal and human data.

RESULTS

Scant case study evidence suggests that DRPAs may lead to reduced milk supply for some.

CONCLUSIONS

Women taking DRPAs should be advised of the possibility that these may affect milk supply, and reporting should be encouraged to aid future research.

General and age-specific fertility rates in non-affective psychosis: population-based analysis of Scottish women

PURPOSE

Women diagnosed with non-affective psychosis have a lower general fertility rate (GFR) and age-specific fertility rate (ASFR) than women in the general population. Contemporary data on GFR in this group remain limited, despite substantive changes in prescribing and management. We calculated contemporary estimates of the GFR and ASFR for women diagnosed with non-affective psychosis compared with the general population of women without this diagnosis.

METHODS

A population-based design combined routinely collected historical maternity and psychiatric data from two representative areas of Scotland. Women were included from the NHS Grampian or Greater Glasgow and Clyde areas and were aged 15-44 between 2005 and 2013 inclusive. The 'exposed' group had a diagnosis of non-affective psychosis (ICD-10 F20-F29) and was compared to the general population of 'unexposed' women in the same geographical areas.

RESULTS

Annual GFR between 2005 and 2013 for women with non-affective psychosis varied from 9.6 to 21.3 live births/1000 women per year in the exposed cohort and 52.7 to 57.8 live births/1000 women per year in the unexposed cohort, a rate ratio (RR) of 0.28 [p < 0.001; 95% CI (0.24, 0.32)]. ASFR for all 5-year age groups was lower in the exposed cohort than amongst unexposed women.

CONCLUSION

We highlight continued low fertility rates in women with a diagnosis of non-affective psychosis, despite widespread availability of prolactin-sparing atypical antipsychotics. Accurate estimation of fertility rates remains crucial in developing needs-matched perinatal care for these women. Methodological improvements using routine datasets to investigate perinatal mental health are also urgently needed.

Maternal Schizophrenia and the Risk of a Childhood Chronic Condition

BACKGROUND AND HYPOTHESIS

Maternal schizophrenia heightens the risk for certain perinatal complications, yet it is not known to what degree future childhood chronic health conditions (Childhood-CC) might arise.

STUDY DESIGN

This population-based cohort study using health administrative data from Ontario, Canada (1995-2018) compared 5066 children of mothers with schizophrenia to 25 324 children of mothers without schizophrenia, propensity-matched on birth-year, maternal age, parity, immigrant status, income, region of residence, and maternal medical and psychiatric conditions other than schizophrenia. Cox proportional hazard models generated hazard ratios (HR) and 95% confidence intervals (CI) for incident Childhood-CCs, and all-cause mortality, up to age 19 years.

STUDY RESULTS

Six hundred and fifty-six children exposed to maternal schizophrenia developed a Childhood-CC (20.5/1000 person-years) vs. 2872 unexposed children (17.1/1000 person-years)-an HR of 1.18, 95% CI 1.08-1.28. Corresponding rates were 3.3 vs. 1.9/1000 person-years (1.77, 1.44-2.18) for mental health Childhood-CC, and 18.0 vs. 15.7/1000 person-years (1.13, 1.04-1.24) for non-mental health Childhood-CC. All-cause mortality rates were 1.2 vs. 0.8/1000 person-years (1.34, 0.96-1.89). Risk for children exposed to maternal schizophrenia was similar whether or not children were discharged to social service care. From age 1 year, risk was greater for children whose mothers were diagnosed with schizophrenia prior to pregnancy than for children whose mothers were diagnosed with schizophrenia postnatally.

CONCLUSIONS

A child exposed to maternal schizophrenia is at elevated risk of chronic health conditions including mental and physical subtypes. Future research should examine what explains the increased risk particularly for physical health conditions, and what preventive and treatment efforts are needed for these children.

Management of schizophrenia in women during the perinatal period: a synthesis of international recommendations

INTRODUCTION

The perinatal period in schizophrenia is associated with high risk of psychotic relapse and pregnancy/child outcomes. The extent to which antipsychotics may potentially affect the fetus or the child development is unclear and debated. Even though guidelines have been developed, there is a lack of consensual recommendations regarding the optimal strategy to manage schizophrenia during the perinatal period.

AREAS COVERED

This systematic review describes the current state of evidence with respect to the impact of recommended interventions for schizophrenia during the perinatal period, including childbearing age, pregnancy and post-partum. It compares recent international treatment guidelines for this specific group of women. Last, this review presents a set of major points to be discussed with patients and relatives for shared-decision making and a summary of key recommendations from the international guidelines.

EXPERT OPINION

Although treatment guidelines may be of significant help, discrepancies exist across them regarding the management of antipsychotics for schizophrenia women during the perinatal period. Shared decision-making and advance directives represent useful patient-centered approaches during this specific period. Further cohort-based evidence is needed to better identify maternal and fetal risks associated to antipsychotic treatment exposure.

A systematic review of maternal and infant outcomes after clozapine continuation in pregnancy

OBJECTIVE

While there is a general lack of evidence of the safety of antipsychotic medications in pregnancy, there is a specific reluctance to continue clozapine in treatment resistant patients who become pregnant. Our aim is to systematically review adverse maternal and infant outcomes following clozapine use during pregnancy.

METHOD

A systematic review of all observational and intervention studies which highlighted adverse maternal and infant outcomes following clozapine continuation in pregnancy was undertaken. Article selection and quality were independently assessed and PRISMA guidelines adhered to.

RESULTS

Of 481 studies identified only two studies met the inclusion criteria. Both were rated as poor quality. The first found no significant increase in any adverse maternal or infant outcomes associated with antipsychotic exposure, except an increased rate of low birth weight in antipsychotic exposed babies. The number of patients exposed to clozapine was too small for separate statistical analysis. The second study found higher APGAR scoring at one minute for the clozapine group, but the scores were not statistically different at five-minutes.

CONCLUSION

Limited evidence was found to show significant adverse maternal and infant outcomes in pregnancy following clozapine continuation.Key messagesLimited evidence to show that clozapine has adverse effects on mother and infant when used during pregnancy.Risk/benefit analysis should be done thoroughly for each individual patient regarding clozapine continuation when pregnancy is confirmed.Close monitoring of mother and infant during perinatal period when clozapine is continued.Further research is needed to more clearly define the effects of clozapine on mother and infant during pregnancy and into the postnatal period.

Complex chronic conditions among children born to women with schizophrenia

PURPOSE

Maternal schizophrenia is linked to complications in offspring near the time of birth. Whether there is also a higher future risk of the child having a complex chronic condition (CCC) - a pediatric condition affecting any bodily system expected to last at least 12 months that is severe enough to require specialty care and/or a period of hospitalization - is not known.

METHODS

In this population-based health administrative data cohort study (Ontario, Canada, 1995-2018), the risk for CCC was compared in 5066 children of women with schizophrenia (the exposed) vs. 2,939,320 unexposed children. Adjusted hazard ratios (aHR) were generated for occurrence of any CCC, by CCC category, and stratified by child sex, and child prematurity.

RESULTS

CCC was more frequent in the exposed (7.7 per 1000 person-years [268 children]) than unexposed (4.2 per 100 person-years [124,452 children]) - an aHR of 1.25 (95% CI 1.10-1.41). aHRs were notably higher in 5 of 9 CCC categories: neuromuscular (1.73, 1.28-2.33), cardiovascular (1.94, 1.64-2.29), respiratory (1.83, 1.32-2.54), hematology/immunodeficiency (2.24, 1.24-4.05) and other congenital or genetic defect (1.59, 1.16-2.17). The aHR for CCC was more pronounced among boys (1.32, 1.13-1.55) than girls (1.16, 0.96-1.40), and of similar magnitude in term (1.22, 1.05-1.42) and preterm infants (1.18, 0.95-1.46).

CONCLUSIONS

The risk for a CCC appears to be higher in children born to women with schizophrenia. This finding introduces opportunities for targeted preconception counselling, optimization of maternal risk factors, and intervention to support a vulnerable parent population who will experience unique challenges caring for a child with CCCs.

Severe mental illness and pregnancy outcomes in Australia. A population-based study of 595 792 singleton births 2009-2016

BACKGROUND

Women with Severe Mental Illness (SMI) may have more complex pregnancies and pregnancy outcomes that require different care and management, but this has not been extensively studied. The aim of this study was to explore associations between SMI and adverse maternal and infant outcomes in the state of Victoria, Australia.

METHODS

Our sample included all reported live singleton births in Victoria 2009-2016 (N = 595 792). Associations between SMI and adverse pregnancy outcomes were explored using Odds Ratios (OR), adjusted for sociodemographic and lifestyle factors, and co-morbidities, including any other mental illness.

RESULTS

Of all singleton births, 2046 (0.34%) were to a mother diagnosed with a SMI. We found evidence of an association between SMI and a range of adverse maternal and infant outcomes. Compared to women without SMI, women with a SMI had higher adjusted odds of being admitted to a High Dependency Unit or Intensive Care Unit (aOR 1.83, 1.37-2.43), having gestational diabetes mellitus (1.57, 1.34-1.84), undergoing an unplanned caesarean section (1.17, 1.02-1.33), induction of labour (1.17, 1.05-1.30) and postpartum haemorrhage (1.15, 1.03-1.29). Newborns of women with SMI had higher adjusted odds of being admitted to Special Care Nursery (aOR 1.61, 1.43-1.80), a low Apgar score at 5 minutes (1.50, 1.19-1.90), preterm birth (1.40, 1.20-1.63), and low birthweight (1.26, 1.06-1.49).

CONCLUSION

Women with SMI are at higher risk for a range of adverse maternal and infant outcomes and are a population that may benefit from targeted early identification and enhanced antenatal care.

The sexual and reproductive health of women with mental illness: a primary care registry study

The purpose of this study is to characterise the sexual and reproductive health risks associated with mental illness among women. This was a retrospective cohort study of 2,680,149 women aged 14 to 45 years in the Clinical Practice Research Datalink, a UK primary care register, linked to 1,702,211 pregnancies that ended between the 1st January 1990 and 31st December 2017. Mental illness was identified in primary care and categorised into the following: common mental illness (depression/anxiety); addiction (alcohol/drug misuse); serious mental illness (affective/non-affective psychosis); other mental illness (eating/personality disorders). Logistic regression estimated the association between mental illness and subsequent risk of recurrent miscarriage and termination. Cox proportional hazards estimated the association between mental illness and time to gynaecological diseases, sexually transmitted infections, reproductive cancers, cervical screen, contraception and emergency contraception. Models were adjusted for calendar year, year of birth, smoking status and ethnicity, region and index of socioeconomic status. Compared to women without mental illness, exposed women were more likely to experience recurrent miscarriage (adjOR = 1.50, 95%CI 1.41 to 1.60), termination (adjOR = 1.48, 95%CI 1.45 to 1.50), gynaecological diseases (adjHR = 1.39, 95%CI 1.37 to 1.40), sexually transmitted infections (adjHR = 1.47, 95%CI 1.43 to 1.51), reproductive cancers (adjHR = 1.10, 95%CI 1.02 to 1.19), contraception (adjHR = 1.28 95%CI 1.26 to 1.29) and emergency contraception (adjHR = 2.30, 95%CI 2.26 to 2.34), and less likely to attend for cervical screening (adjHR = 0.91, 95%CI 0.90 to 0.92). Currently, the sexual and reproductive health needs of women with mental illness are unmet representing significant health inequalities. Clinicians must create opportunities to engage with women in primary care and mental health services to address this gap.

Sociodemographic characteristics associated with parenthood amongst patients with a psychotic diagnosis: a cross-sectional study using patient clinical records

PURPOSE

Estimates of parenthood in individuals with psychosis range from 27 to 63%. This number has likely increased due to the introduction of newer anti-psychotics and shorter hospital stays. The problems of psychosis can affect patients' capacity to offer the consistent, responsive care required for healthy child development. The following research questions were assessed: (1) what proportion of these patients have their children correctly recorded in their clinical notes, (2) what proportion of patients in secondary care with a psychotic diagnosis have children, and (3) what sociodemographic characteristics are associated with parenthood in this population.

METHODS

This study used CRIS (Clinical Record Interactive Search) to search for patients with a diagnosis of non-affective or affective psychosis (F20-29, F31.2 or F31.5) within a UK NHS Trust. A binomial regression model was fitted to identify the variables associated with parenthood.

RESULTS

Fewer than half of the parents in the sample had their children recorded in the correct field in their clinical notes. Of 5173 patients with psychosis, 2006 (38.8%) were parents. Characteristics associated with parenthood included being female, older age, higher socioeconomic status, renting or owning, having ever been married, being unemployed, not being White (British) and not having a diagnosis of schizophrenia.

CONCLUSION

Over one-third of patients with psychosis were parents, and the study indicates that not all NHS Trusts are recording dependants accurately. Many variables were strongly associated with parenthood and these findings may help target interventions for this population.

COVID-19 second wave: District level study of concentration of confirmed cases and fatality in India

The paper aims to reveal the spatial pattern of the concentration of COVID-19 confirmed cases and the spread of the pandemic from the Case Fatality Ratio. The study has been accomplished with district-level data. The analysis of the spatial pattern decoding has been done considering the Global and Local Moran's I statistics comprising the linear trend of spatial autocorrelation for the whole India. The timeframe has been divided considering the surge of the second wave in March, 2021 and the peak of the wave in May 2021. The spatial clustering technique presents both the concentration of confirmed cases using Location Quotient analysis and the pattern of spread of the infection-related fatality throughout the country. The high Location Quotient of the confirmed cases strongly clustered around the Mumbai-Puna region, Kerala-Karnataka region, Garhwal Himachal, NCT of Delhi and Ladakh-Kashmir-Himachal Pradesh region during the period of the study. In May, the concentration has randomly clustered around the middle part of India. The Case Fatality Ratio was high in Maharashtra, Madhya Pradesh, Punjab and Haryana at the surge of the second wave. During the peak (May), two significant clusters of high Case Fatality Ratio are observed in and around the Mumbai urban (Maharashtra) and NCT of Delhi (including Punjab-Haryana).

[Preventive staff meetings in maternity ward for women at high medico-psycho-social risk: Qualitative study between 2012 and 2018]

OBJECTIVE

To assess the effectiveness of a multidisciplinary consultation meeting created in collaboration between a perinatal psychiatry team and professionals from a level 3 maternity hospital, whose purpose is to prepare the delivery and postpartum of pregnant women at high medico-psycho-social risk. I) Study the functioning of these multidisciplinary meetings. II) Assess the concordance between the decisions made in antenatal care and the actual management of the delivery and postpartum care.

METHODS

This is a retrospective study of 140 files for which the opinion of the multidisciplinary meeting was requested in the years 2012, 2014, 2016 and 2018. We looked at the psychiatric files of the patients, as well as the summary sheets written after staff meetings.

RESULTS

The selection of files is compliant in 98% of cases and the traceability of information in the summary sheet is over 80% for half of the process indicators. The overall compliance rate between the decisions taken at meetings and their implementation in the post-partum period is 68%. Acute psychiatric episode and reporting could be anticipated.

CONCLUSION

This multidisciplinary consultation meeting is efficient in the early detection of risk situations. The decisions taken during the multidisciplinary meetings in antenatal care are mostly applied postpartum in the Maternity Ward. In cases where they are not applied, the system offers great reactivity to postpartum professionals.

Parenting interventions for people with schizophrenia or related serious mental illness

BACKGROUND

Around a third of people with schizophrenia or related serious mental illness will be a parent. Both the parents and the children in this population are at increased risk of adverse outcomes due to parental mental illness. Parenting interventions are known to improve parenting skills and decrease child disruptive behaviour. This systematic review aimed to synthesise the evidence base for parenting interventions designed specifically for parents who have schizophrenia or related serious mental illness.

OBJECTIVES

To assess the effects of parenting interventions for people with schizophrenia or related serious mental illness.

SEARCH METHODS

On 10 February 2021 we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on the following: Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.Gov, Embase, International Standard Randomised Controlled Trial Number (ISRCTN), MEDLINE, PsycINFO, PubMed, and the World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCTs) that compared parenting interventions with a control condition for people with schizophrenia or related serious mental illness with a child between the ages of 0 and 18 years.

DATA COLLECTION AND ANALYSIS

We independently inspected citations, selected studies, extracted data and appraised study quality. We assessed risk of bias for included studies.

MAIN RESULTS

We only included one trial (n = 50), and it was not possible to extract any data because the authors did not provide any means and standard deviations for our outcomes of interest; they only reported whether outcomes were significant or not at the 0.05 level. Three domains of the trial were rated as having a high risk of bias.

AUTHORS' CONCLUSIONS

The only included trial provided inconclusive evidence. There is insufficient evidence to make recommendations to people with schizophrenia (or related serious mental illness) or clinicians, or for policy changes. Although there is no RCT evidence, parenting interventions for people with schizophrenia or related serious mental illness have been developed. Future research should test these in RCTs in order to improve the evidence base for this population.

Maternal Schizophrenia, Skin-to-Skin Contact, and Infant Feeding Initiation

BACKGROUND

The World Health Organization recommends mothers and infants be in direct skin-to-skin contact immediately after birth and initiate breastfeeding as soon as possible. Little is known in women with schizophrenia.

METHODS

We conducted a population-based cohort study using administrative health data from Ontario, Canada (2012-2014), comparing women with (n = 471) and without schizophrenia (n = 218 435), and their infants, on the primary outcomes of any skin-to-skin contact and opportunity to initiate breastfeeding within the first 2 h after birth. For dyads with available data, secondary outcomes of intention to breastfeed, breastfeeding support, any breastmilk, and exclusive breastmilk at discharge were assessed. Modified Poisson regression was used to generate relative risks (aRR) and 95% confidence intervals (CI), adjusted for maternal age, parity, neighbourhood income, region of residence, smoking in pregnancy, and maternal medical and non-psychotic psychiatric comorbidity for all outcomes.

RESULTS

Maternal schizophrenia was associated with lower likelihood of skin-to-skin contact (65.2% vs 78.1%; aRR 0.88, 95% CI: 0.82-0.94), and breastfeeding initiation post-delivery (38.9% vs 52.6% aRR 0.80, CI: 0.71-0.90) compared to dyads unexposed to maternal schizophrenia. Secondary outcomes followed a similar pattern. The magnitude of the effect was slightly less when restricting the cohort to full-term, vaginal deliveries, not admitted to NICU, and infant not discharged to social services.

CONCLUSIONS

Reduced maternal-infant skin-to-skin contact and breastfeeding initiation immediately after birth may significantly impact maternal-child bonding and the establishment breastfeeding in this population. Mothers with schizophrenia may require individualized support to promote these WHO recommended hospital practices in the early post-natal period.

Accidental injury, self-injury, and assault among children of women with schizophrenia: a population-based cohort study

OBJECTIVE

We aimed to compare the risk for injury overall and by intent (accidental injury, self-injury, and assault) among children born to women with versus without schizophrenia.

METHODS

Using health administrative data from Ontario, Canada, children born from 2003 to 2017 to mothers with (n = 3769) and without (n = 1,830,054) schizophrenia diagnosed prior to their birth were compared on their risk for child injury, captured via emergency department, hospitalization, and vital statistics databases up to age 15 years. Cox proportional hazard models generated hazard ratios for time to first injury event (overall and by intent), adjusted for potential confounders (aHR). We stratified by child sex and age at follow-up: 0-1 (infancy), 2-5 (pre-school), 6-9 (primary school), and 10-15 (early adolescence) planning to collapse age categories as needed to obtain stable and reportable estimates.

RESULTS

Maternal schizophrenia was associated with elevated risk for child injury overall (105.4 vs. 89.4/1000 person-years (py), aHR 1.08, 95% CI 1.03-1.14), accidental injury (104.7 vs. 88.1/1000py, 1.08, 1.03-1.14), for self-injury (0.4 vs. 0.2/1000py, 2.14 1.18-3.85), and assault (1.0 vs. 0.3/1000py, 2.29, 1.45-3.62). By child sex, point estimates were of similar magnitude and direction, though not all remained statistically significant. For accidental injury and self-injury, the risk associated with maternal schizophrenia was most elevated in 10-15-year-olds. For assault, the risk associated with maternal schizophrenia was most elevated among children in the 0-1 and 2-5-year-old age groups.

CONCLUSION

The elevated risk of child injury associated with maternal schizophrenia, especially for self-injury and assault, suggests that targeted monitoring and preventive interventions are warranted.

Long-acting injectable aripiprazole in pregnant women with schizophrenia: a case-series report

Antipsychotic long-acting formulations (LAI-AP) have emerged as a new therapeutic choice to treat patients presenting a severe mental disorder. Despite that, to date, there is a lack of safety data and studies regarding the use of LAI-AP formulations in pregnant women. Here we present the first six-case series of pregnant women with schizophrenia treated with aripiprazole-LAI reported in the literature. All patients remained psychopathologically stable through pregnancy and the postpartum period, and all of them were in treatment with aripiprazole-LAI. To date, all infants remain healthy with normal developmental milestones, without the presence of congenital malformations or adverse effects. Lack of information on safety data regarding the use of new antipsychotic formulations remains important in treating women with mental illness who desire to become pregnant. Further studies in this clinical population with a larger number of patients included remains necessary.

Perinatal mental health: a review of progress and challenges

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high-income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.

[Antipsychotics during pregnancy: a systematic review]

BACKGROUND

The benefits and risks of treatment with antipsychotics during pregnancy must be weighed up carefully and individually because antipsychotics can penetrate the placental barrier and prescription is off-label.

OBJECTIVE

Evaluation of the risks and benefits of administering antipsychotics during pregnancy or for women who wish to become pregnant regarding teratogenic effects, risk of fetal death and stillbirths, perinatal complications, persisting postnatal impairments or disorders and gestational diabetes.

METHODS

A systematic review of the literature is provided to aid the selection of psychotropic drugs during pregnancy and in determining whether to begin, continue or switch an antipsychotic treatment during pregnancy.

RESULTS

Large, well-designed and controlled studies are missing; however, most studies suggest that the group of antipsychotics seem to be safe in terms of teratogenicity during pregnancy, at least in monotherapy.

CONCLUSION

Treating mental illnesses during pregnancy requires an individual assessment of the benefits and risks. The risk of an untreated mental illness versus the benefit of a suitable treatment with antipsychotics and the potential harm to the infant must be evaluated. If certain rules are observed and a suitable antipsychotic is selected the risk to the newborn child and/or mother during pregnancy can be minimized, however, a decision about subsequent medication can only be indirectly made from the results of this study.

Schizophrenia around the time of pregnancy: leveraging population-based health data and electronic health record data to fill knowledge gaps

BACKGROUND

Research in schizophrenia and pregnancy has traditionally been conducted in small samples. More recently, secondary analysis of routine healthcare data has facilitated access to data on large numbers of women with schizophrenia.

AIMS

To discuss four scientific advances using data from Canada, Denmark and the UK from population-level health registers and clinical data sources.

METHOD

Narrative review of research from these three countries to illustrate key advances in the area of schizophrenia and pregnancy.

RESULTS

Health administrative and clinical data from electronic medical records have been used to identify population-level and clinical cohorts of women with schizophrenia, and follow them longitudinally along with their children. These data have demonstrated that fertility rates in women with schizophrenia have increased over time and have enabled documentation of the course of illness in relation with pregnancy, showing the early postpartum as the time of highest risk. As a result of large sample sizes, we have been able to understand the prevalence of and risk factors for rare outcomes that would be difficult to study in clinical research. Advanced pharmaco-epidemiological methods have been used to address confounding in studies of antipsychotic medications in pregnancy, to provide data about the benefits and risks of treatment for women and their care providers.

CONCLUSIONS

Use of these data has advanced the field of research in schizophrenia and pregnancy. Future developments in use of electronic health records include access to richer data sources and use of modern technical advances such as machine learning and supporting team science.

Fertility trends of women with serious mental illness in the United Kingdom 1992-2017: A primary care cohort study using the clinical practice research datalink

BACKGROUND

Changes in care may mean women with serious mental illness (SMI) are more fertile. We investigated 1) the live-birth and pregnancy rate of women with and without SMI over time, 2) the likelihood of pregnancy when using second or first-generation antipsychotics.

METHOD

Retrospective cohort study of women (15-45 years) registered in Clinical Practice Research Datalink (CPRD) general practices between 1992 and 2017. Each analysis year, women with SMI (affective and non-affective psychotic disorder) were matched with up to four women with no record of SMI on age, calendar year and general practice. Pregnancy and live-birth rates and the rate ratio (RR) comparing women with and without SMI were estimated. The stability of the RR between years was tested. For women with SMI, the pregnancy rates when on or off first or second-generation antipsychotics were calculated and compared using Poisson regression models.

RESULTS

In total, 12,524 women with SMI were matched to 50,074 women without SMI, median age 34 [IQR 28-39] years. Between 1992 and 2017 women with SMI had 50% fewer live-births than women without SMI (RR 0..50, 95%CI 0.45-0.55). The pregnancy rate ratio increased from 0.64 (95%CI 0.48-0.86) (1992-1994) to 1.00 (95%CI 0.81-1.22) (2016-2017), (p < 0.0001), but this change was only seen in women with affective disorders. Women are most likely to become pregnant after discontinuing either a second-generation or first-generation antipsychotic (RR 1.74, 95%CI 1.42-2.13).

CONCLUSIONS

Women with SMI are increasingly experiencing pregnancy but not live-birth, which suggests the reproductive health needs of these women are unmet.

Maternal schizophrenia and adverse birth outcomes: what mediates the risk?

PURPOSE

Maternal schizophrenia is associated with adverse birth outcomes, but the reasons for this remain unclear. In a population-based cohort of infants born to women with schizophrenia, we determined the occurrence of key perinatal outcomes and explored whether factors identifiable in our datasets explained any elevated risk.

METHODS

Using population-level health administrative data linked to clinical birth-registry data in Ontario, Canada (2006-2011), we examined the relative risk (RR) of preterm birth (< 37 weeks), small for gestational age (SGA), and Apgar scores < 8 in infants of women with schizophrenia (n = 4279) versus infants of unaffected women (n = 286,147). Generalized estimating equations determined whether reproductive history, maternal health conditions, pregnancy exposures, and complications explained elevated RRs.

RESULTS

Among infants of women with schizophrenia, risk was higher for prematurity (11.4% vs. 6.9%, aRR 1.64, 95% CI 1.51-1.79), SGA (3.5% vs. 2.5%, aRR 1.40, 95% CI 1.20-1.64), and Apgar score < 8 at 1 (19.0% vs. 12.8%, aRR 1.49, 95% CI 1.40-1.59) and 5 min (5.6% vs. 3.0%, aRR 1.90, 95% CI 1.68-2.16). Smoking, fourfold more common among women with schizophrenia, was the variable that explained the greatest proportion of the elevated aRR for prematurity (9.9%), SGA (28.7%), and Apgar < 8 at 1 and 5 min (9.8%, 5.6%). Illicit substance use, certain reproductive history variables, and pregnancy complications also contributed to the elevated aRR for preterm birth.

CONCLUSIONS

Elevated risks of preterm birth, SGA, and low Apgar scores in infants of women with schizophrenia are partly explained by potentially modifiable factors such as smoking and illicit drug use, suggesting opportunities for targeted intervention.

Sexual health of women with schizophrenia: A review

Women with schizophrenia experience low rates of sexual satisfaction and high rates of sexual dysfunction. They are at high risk for adverse sexual health outcomes including unplanned pregnancies, induced abortions, and human immunodeficiency virus (HIV), and face higher rates of sexual violence and various forms of intimate partner violence. This review explores the complex and intersecting biopsychosocial risk factors that explain these outcomes among women with schizophrenia, including factors related to the illness itself, antipsychotic medications, medical and psychiatric comorbidities, stigma, childhood trauma, and social determinants of health including poverty and housing instability. Sexual health interventions designed to help women with schizophrenia achieve pleasurable and safe sexual experiences, free of coercion, discrimination and violence are few and far between, suggesting opportunities for future development in this area.

Obstetric and perinatal health outcomes related to schizophrenia: A national register-based follow-up study among Finnish women born between 1965 and 1980 and their offspring

Background:

This national register-based study assesses obstetric and perinatal health outcomes in women with schizophrenia and their offspring.

Methods:

Using the Care Register for Health Care, we identified Finnish women who were born in 1965- 1980 and diagnosed with schizophrenia. For each case, five age- and place-of-birth- matched controls were obtained from the Central Population Register of Finland. They were followed from the day when the disorder was diagnosed in specialized health-care (the index day) until 31.12.2013. Information related to births was obtained from the Medical Birth Register and the Register of Congenital Malformations. We focused on singleton pregnancies that led to a delivery after the index day. We restricted the analysis of deliveries in controls to those that occurred after the index day of the case. Maternal age, marital status, smoking status, sex of the newborn, and parity were used as covariates in adjusted models.

Results:

We identified 1162 singleton births among women with schizophrenia and 4683 among controls. Schizophrenic women had a 1.4-fold increased risk of induction of labor, delivery by cesarean section, and delivery by elective cesarean section. Regarding offspring, the risk of premature birth and the risk of low Apgar score at 1 min (<7) were 1.6-fold, of resuscitation 2.5-fold, and of neonatal monitoring 2.1-fold higher.

Conclusions:

Schizophrenia associates with some specific delivery methods, but delivery complications are rare and their prevalence does not differ from that observed among community women. Maternal schizophrenia associates with some negative perinatal health outcomes of the offspring.

Schizophrenia and pregnancy: a national register-based follow-up study among Finnish women born between 1965 and 1980

To assess psychosocial and somatic risk factors related to pregnancy, and pregnancy-related complications or disorders in women with schizophrenia compared to population controls. In this register-based cohort study, we identified all Finnish women who were born in 1965-1980 and diagnosed with schizophrenia in psychiatric care before 31 December 2013. For each case, five age- and place-of-birth matched controls were randomly selected. They were followed from the day when the disorder was diagnosed in specialized health care till the end of 2013. The mean follow-up time was 14.0 + 6.91 vs. 14.3 + 6.89 years. Altogether, 1162 singleton pregnancies were found among affected women and 4683 among controls. Affected women were significantly older and more often single; their body mass index before pregnancy was significantly higher, and they smoked significantly more often both in the beginning of pregnancy and after the first trimester than controls. They showed a significantly higher odds for pathologic oral glucose tolerance test (odds ratio (OR) 1.66, 95% confidence interval (95% CI) 1.27-2.17), initiation of insulin treatment (OR 1.84, 95% CI 1.15-2.93), fast fetal growth (OR 1.62, 95% CI 1.03-2.52), premature contractions (OR 2.42, 95% CI 1.31-4.49), hypertension (OR 1.81, 95% CI 1.01-3.27), and pregnancy-related hospitalizations (OR 1.97, 95% CI 1.66-2.33). Suspected damage to the fetus from alcohol/drugs was significantly more common among affected women than controls. Women with schizophrenia have higher prevalence of psychosocial and somatic risk factors related to pregnancy, as well as pregnancy-related complications and disorders than non-affected women.

A population-based study of the frequency and predictors of induced abortion among women with schizophrenia

BACKGROUND

Induced abortion is an indicator of access to, and quality of reproductive healthcare, but rates are relatively unknown in women with schizophrenia.

AIMS

We examined whether women with schizophrenia experience increased induced abortion compared with those without schizophrenia, and identified factors associated with induced abortion risk.

METHOD

In a population-based, repeated cross-sectional study (2011-2013), we compared women with and without schizophrenia in Ontario, Canada on rates of induced abortions per 1000 women and per 1000 live births. We then followed a longitudinal cohort of women with schizophrenia aged 15-44 years (n = 11 149) from 2011, using modified Poisson regression to identify risk factors for induced abortion.

RESULTS

Women with schizophrenia had higher abortion rates than those without schizophrenia in all years (15.5-17.5 v. 12.8-13.6 per 1000 women; largest rate ratio, 1.33; 95% CI 1.16-1.54). They also had higher abortion ratios (592-736 v. 321-341 per 1000 live births; largest rate ratio, 2.25; 95% CI 1.96-2.59). Younger age (<25 years; adjusted relative risk (aRR), 1.84; 95% CI 1.39-2.44), multiparity (aRR 2.17, 95% CI 1.66-2.83), comorbid non-psychotic mental illness (aRR 2.15, 95% CI 1.34-3.46) and substance misuse disorders (aRR 1.85, 95% CI 1.47-2.34) were associated with increased abortion risk.

CONCLUSIONS

These results demonstrate vulnerability related to reproductive healthcare for women with schizophrenia. Evidence-based interventions to support optimal sexual health, particularly in young women, those with psychiatric and addiction comorbidity, and women who have already had a child, are warranted.

Rapid repeat pregnancy in women with schizophrenia

AIM

Women with schizophrenia are vulnerable to adverse reproductive health outcomes. Short inter-pregnancy interval, or rapid repeat pregnancy, is associated with maternal and infant complications, and may be preventable. Whether women with schizophrenia are at disproportionate risk for rapid repeat pregnancy is unknown.

METHODS

This population-based cohort study in Ontario, Canada (2002-2013) compared women with and without schizophrenia on their risk of rapid repeat pregnancy, defined as pregnancy within 12 months of an index live birth. Among women with public drug coverage, those with and without schizophrenia were compared on their use of non-barrier contraception (hormonal and surgical) post-delivery.

RESULTS

Women with schizophrenia (n = 1565) were at higher risk for rapid repeat pregnancy than women without schizophrenia (n = 924,657) (6.3% vs. 3.9%, adjusted relative risk, aRR 1.31, 95% confidence interval, CI, 1.07-1.59). They had more rapid repeat pregnancies resulting in live births (aRR 1.85, 95% CI 1.26-2.72), but not pregnancy losses (aRR 1.50, 95% CI 0.99-2.29) or induced abortions (aRR 1.07, 95% CI 0.81-1.42). Post-delivery non-barrier contraception use was similar between groups (43.7% vs. 43.6%, aRR 1.06, 95% CI 0.93-1.20), although women with schizophrenia were more likely to use injectable contraception (14.1% vs. 10.1%, aRR 1.67, 95% CI 1.35-2.07).

DISCUSSION

Women with schizophrenia are at higher risk than their peers for rapid repeat pregnancy, but use non-barrier contraception at similar rates. The postnatal period is an opportune time to initiate targeted interventions designed to optimize planning for any future pregnancies, and contribute to improving maternal and child health in this vulnerable group.

[Midwives' feelings about the post-partum care of women with severe mental illness: A qualitative analysis]

BACKGROUND

A significant proportion of women with Severe Mental Illness (SMI) will become mothers during their reproductive life. These pregnancies are, however, more at risk of psychiatric, obstetrical and neonatal complications (increased risks of post-partum depression, relapse, suicide, gestational diabetes, placental abnormalities or low birth weight). Midwives often feel isolated and resourceless when taking care of these women. Specialized units such as mother-infant psychiatric units or the Transversal Unit of Perinatal Care (UTAP) in the Grenoble Alpes University Hospital (CHUGA) enhance the coordination between psychiatric and obstetrical teams and have shown effectiveness in improving maternal and child outcomes.

OBJECTIVES

i) to assess midwives' feelings about the postpartum care of women with SMI; ii) to determine UTAP's impact on this feeling and its determinants; iii) to look for unmet needs.

METHODS

This study is a prospective, exploratory, qualitative analysis. Twenty midwives from Grenoble Alpes University Hospital who took care of one of the selected patients participated in this study. Two women had schizophrenia and one bipolar disorder. Interviews realized with a semi-structured guide were fully transcribed, anonymized and thematically analyzed. Topics have been structured according to the number of occurrences to build a thematic tree.

RESULTS

Midwives felt insecure and resourceless when the postpartum care was unclear, insufficiently anticipated and in case of a danger for the women or the children. They felt uneasy when not feeling able to provide usual care to these patients (due to lack of specific knowledge about SMI and to the impossibility to consider their patient otherwise than through their pathology). Midwives felt at ease and secure when the postpartum care was anticipated. UTAP was identified as a resource for midwives. Specific training and improvements in the organization of the pre and post-natal care could improve midwives' feelings when taking care of women with SMI.

Maternal schizophrenia and out-of-home placements of offspring: A national follow-up study among Finnish women born 1965-1980 and their children

Schizophrenia may affect a mother's ability to parent. We investigated out-of-home placements among children with a biological mother having schizophrenia, and their relation to maternal characteristics and adverse perinatal health outcomes of the offspring. For each Finnish woman born between 1 JAN 1965 - 31 DEC 1980 and diagnosed with schizophrenia before 31 DEC 2013 (n = 5214), five matched controls were randomly selected from the Finnish Central Population Register. Children born to these women were identified and followed till 31 DEC 2013. The Child Welfare Register, the Medical Birth Register and the Register of Congenital Malformations were used to gather information. Altogether 35.1% of children with an affected mother and 3.2% of control children were placed out of home during the follow-up. The incidence rate ratio (IRR) of out-of-home placement among children with an affected mother was 12.6 (95% confidence interval (CI) 10.80-13.46) when children with a non-affected mother served as a reference. Single motherhood (IRR 2.2, 95% Cl 1.88-2.60) and maternal smoking (IRR 1.9, 95% Cl 1.68-2.16), but not an adverse perinatal outcome of the offspring, increased the risk of out-of-home placement. To conclude, maternal schizophrenia is a strong risk factor for placement of children in out-of-home care.

Identity in Personal Recovery for Mothers With a Mental Illness

Developing a "positive identity" is considered a core component of personal recovery, and mothering offers meaning in life and a valued identity. Few studies have highlighted the factors influencing identity within a personal recovery paradigm for mothers with mental illness. This study explores how mothers describe their identity in relation to recovery, including the factors that influence identity. Using constructivist grounded theory methodology, in-depth interviews were conducted with 17 women who were mothers and experienced mental illness. Women defined their self-concept broadly, accentuating motherhood, but also including vocational, community and social roles. Analysis revealed six categories: defining self, becoming a mother, being a "good" mum, feeling different, doing it my way and speaking out. Valuing identity in parenting was found to be linked to recovery. Services may facilitate personal recovery by supporting mothers to enhance a self-concept associated with mothering, as well as other diverse attributes and roles.

Psychopharmacological prescribing practices in pregnancy for women with severe mental illness: A multicentre study

There is little known about real world psychopharmacological prescribing practices in managing pregnant women with severe mental illness (SMI). This study utilised a sample of 535 women with a SMI across two hospitals in Australia. This included women with psychotic disorders, bipolar disorder and a range of non-psychotic disorders. The majority of women with a SMI in pregnancy were prescribed psychotropic medication as part of their management. Furthermore, more than one class of agent was prescribed for 31% of women with psychotic disorders and 30% of women with bipolar disorder. Differences between sites were identified in prescribing practices across the mental disorders. This included the variation in rates of use of multiple agents and pattern of use across pregnancy. This study also identified that women with a SMI had elevated rates of gestational hypertension, gestational diabetes mellitus, smoking and obesity in pregnancy and neonates admitted following delivery compared with the Australian average. These findings suggest that studies that examine associated risks for severe mental disorders or their treatments on pregnancy and infant outcomes should take into account the prescribing practices including the likelihood of exposure to polypharmacy and a range of potential confounding co-morbidities and exposures. The discrepancies in reported findings for pregnancy and infant outcomes following use of antipsychotic and mood stabiliser agents such as lithium may be at least partially accounted for by the complexity of multiple exposures that includes use of multiple psychopharmacological agents, co-exposures such as smoking and co-morbid conditions such as obesity.

Women who suffer from schizophrenia: Critical issues

Many brain diseases, including schizophrenia, affect men and women unequally - either more or less frequently, or at different times in the life cycle, or to varied degrees of severity. With updates from recent findings, this paper reviews the work of my research group over the last 40 years and underscores issues that remain critical to the optimal care of women with schizophrenia, issues that overlap with, but are not identical to, the cares and concerns of men with the same diagnosis. Clinicians need to be alert not only to the overarching needs of diagnostic groups, but also to the often unique needs of women and men.

Predictors of severe relapse in pregnant women with psychotic or bipolar disorders

Pregnancy in women with severe mental illness is associated with adverse outcomes for mother and infant. There are limited data on prevalence and predictors of relapse in pregnancy. A historical cohort study using anonymised comprehensive electronic health records from secondary mental health care linked with national maternity data was carried out. Women with a history of serious mental illness who were pregnant (2007-2011), and in remission at the start of pregnancy, were studied; severe relapse was defined as admission to acute care or self-harm. Predictors of relapse were analysed using random effects logistic regression to account for repeated measures in women with more than one pregnancy in the study period. In 454 pregnancies (389 women) there were 58 (24%) relapses in women with non-affective psychoses and 25 (12%) in women with affective psychotic or bipolar disorders. Independent predictors of relapse included non-affective psychosis (adjusted OR = 2.03; 95% CI = 1.16-3.54), number of recent admissions (1.37; 1.03-1.84), recent self-harm (2.24; 1.15-4.34), substance use (2.15; 1.13-4.08), smoking (2.52; 1.26-5.02) and non-white ethnicity (black ethnicity: 2.37; 1.23-4.57, mixed/other ethnicity: 2.94; 1.32-6.56). Women on no regular medication throughout first trimester were also at greater risk of relapse in pregnancy (1.99; 1.05-3.75). There was no interaction between severity of illness and medication status as relapse predictors. Therefore, women with non-affective psychosis and higher number of recent acute admissions are at significant risk of severe relapse in pregnancy. Continuation of medication in women with severe mental illness who become pregnant may be protective.

Schizophrenia and induced abortions: A national register-based follow-up study among Finnish women born between 1965-1980 with schizophrenia or schizoaffective disorder

BACKGROUND

The objectives of this study were to investigate, in women with schizophrenia or schizoaffective disorder, the number and incidence of induced abortions (= pregnancy terminations performed by a physician), their demographic characteristics, use of contraceptives, plus indications of and complications related to pregnancy termination.

METHODS

Using the Care Register for Health Care, we identified Finnish women born between the years 1965-1980 who were diagnosed with either schizophrenia or schizoaffective disorder during the follow-up period ending 31.12.2013. For each case, five age- and place-of-birth- matched controls were obtained from the Population Register of Finland. Information about births and induced abortions were obtained from the Medical Birth Register and the Induced Abortion Register.

RESULTS

The number and incidence of induced abortions per 1000 follow-up years did not differ between cases and their controls. However, due to fewer pregnancies, cases exhibited an over 2-fold increased risk of pregnancy termination (RR 2.28; 95% CI 2.20-2.36). Cases were younger, were more often without a partner at the time of induced abortion, and their pregnancies resulted more often from a lack of contraception. Among cases, the indication for pregnancy termination was more often mother-to-be's medical condition. Induced abortions after 12weeks gestation were more common among cases. However, cases had no more complications related to termination.

CONCLUSIONS

The incidence of induced abortions among Finnish women with schizophrenia or schizoaffective disorder is similar to the general population, but their risk per pregnancy over two-fold. They need effective, affordable family planning services and long-term premeditated contraception.

Psychopharmacological treatment of schizophrenia during pregnancy and lactation

PURPOSE OF REVIEW

It is necessary, in every-day clinical life when treating pregnant women with mental diseases, to reach quick decisions derived from recent comprehensive information. The knowledge of the use of antipsychotics in pregnancy has increased considerably in the last years. This review tries to summarize important considerations and facilitate clinical decisions.

RECENT FINDINGS

This review will cover not only the effects of exposure during pregnancy on outcomes, postnatal adaption syndrome and lactation, but also pharmacokinetic considerations on the use of antipsychotics during pregnancy.

SUMMARY

The recent publications have found only minimally increased risks for certain malformations, after using ever more sophisticated statistical models of analysis and reassuring amounts of data. Taken together, the quality of the studies has greatly improved and the results are reassuring with respect to the safety of the use of antipsychotics during pregnancy. The rates of weight gain and gestational diabetes warrant closer attention in the clinical setting.

Parenthood among patients with psychotic disorders: gender differences in a non-selective clinical sample

A large proportion of people with psychotic disorders have children and also live with them. However, research has rarely studied this in clinical populations and included male patients. This exploratory study used routine data of all 709 patients with a psychotic disorder treated in a psychiatric inpatient service in Austria between 2012 and 2015. Socio-demographic and clinical characteristics, number and age of children, and living arrangements were assessed and analysed. More female patients than male patients had children in the total sample (56% vs. 30%), and in diagnostic subgroups with bipolar disorder (71%, 53%), schizoaffective disorder (65%, 24%), and schizophrenia (45%, 21%). Being female, higher age, and living with a partner were associated with having children. Unlike female patients, most male patients with underage children (≤18 years) did not live with them, especially when patients had a diagnosis of schizophrenia. The gender specific differences in parenthood and custody arrangements identified in this study indicate different support needs of mothers and fathers with psychotic disorders. Not living with a child and having limited access might come with feelings of guilt and loss, which should be addressed in research and practice.

Factors associated with postpartum psychiatric admission in a population-based cohort of women with schizophrenia

OBJECTIVE

We aimed to identify factors associated with postpartum psychiatric admission in schizophrenia.

METHOD

In a population-based cohort study of 1433 mothers with schizophrenia in Ontario, Canada (2003-2011), we compared women with and without psychiatric admission in the 1st year postpartum on demographic, maternal medical/obstetrical, infant and psychiatric factors and identified factors independently associated with admission.

RESULTS

Admitted women (n = 275, 19%) were less likely to be adolescents, more likely to be low income and less likely to have received prenatal ultrasound before 20 weeks gestation compared to non-admitted women. They also had higher rates of predelivery psychiatric comorbidity and mental health service use. Factors independently associated with postpartum admission were age (<20 vs. ≥35 years: adjusted risk ratio, aRR, 0.48, 95% CI 0.24-0.96), income (lowest vs. highest income: aRR 1.67, 1.13-2.47) and the following mental health service use factors in pregnancy: admission (≥35 days/year vs. no days, aRR 4.54, 3.65-5.65), outpatient mental health care (no visits vs. ≥2 visits aRR 0.35, 0.27-0.47) and presence of a consistent mental health care provider during pregnancy (aRR 0.69, 0.54-0.89).

CONCLUSION

Certain subgroups of women with schizophrenia may benefit from targeted intervention to mitigate risk for postpartum admission.

'Big data' in mental health research: current status and emerging possibilities

PURPOSE

'Big data' are accumulating in a multitude of domains and offer novel opportunities for research. The role of these resources in mental health investigations remains relatively unexplored, although a number of datasets are in use and supporting a range of projects. We sought to review big data resources and their use in mental health research to characterise applications to date and consider directions for innovation in future.

METHODS

A narrative review.

RESULTS

Clear disparities were evident in geographic regions covered and in the disorders and interventions receiving most attention.

DISCUSSION

We discuss the strengths and weaknesses of the use of different types of data and the challenges of big data in general. Current research output from big data is still predominantly determined by the information and resources available and there is a need to reverse the situation so that big data platforms are more driven by the needs of clinical services and service users.

The preconception needs of women with severe mental illness: a consecutive clinical case series

INTRODUCTION

Women with severe mental illness (SMI) are having babies at an increasing rate, but continue to face many challenges across the perinatal period. There is little research into the preconception needs of women with SMI and the aim of this study was to investigate the social circumstances, general health, mental health and reproductive health care needs in these at risk women.

METHOD

Women with SMI referred for specialist preconception counselling at a tertiary obstetric hospital in 2012 were eligible to participate. The data source was a semi-structured study-specific interview schedule with open-ended questions incorporated into the routine assessment protocol.

RESULTS

In a one-year period, 23 women were referred to the service and 22 consented to data from the interview being pooled for the study. All women were taking at least one psychotropic medication at the time of referral. Overall, 40% (n = 9) were aged at least 35 years, 36% (n = 8) smoked cigarettes daily and over half (54.5% n = 12) reported their body mass index as being in the overweight or obese range. Thematic analysis revealed the importance of maternal desire, and concerns relating to age and biological time pressure, the impact of the illness and medication on pregnancy and motherhood.

CONCLUSION

Our data indicate that preconception counselling should be routine in the care of women with SMI of reproductive age, and should take into account the potential centrality of motherhood in the woman's rehabilitation, as well as the complex appraisals of risks, general health and support.

Pregnancy in Women With Intellectual and Developmental Disabilities

OBJECTIVE

Our objectives were to describe the general fertility rate (GFR) and age-specific fertility rates (ASFRs) of women with intellectual and developmental disabilities (IDD) and the social and health characteristics of those with a singleton live birth, and to compare these to women without IDD.

METHODS

In this population-based retrospective cohort study using linked Ontario health and social services administrative data, we identified 18- to 49-year-old women with IDD (N = 21 181) and without IDD (N = 990 776). The GFR and ASFRs (2009) were calculated for both groups and compared using rate ratios (RR) and 95% confidence intervals (CI). Among women with a singleton live birth (N = 423 with, N = 42 439 without IDD), social and health characteristics were compared using Pearson's Chi square tests.

RESULTS

The GFR in women with IDD (20.3 per 1000) was lower than that in women without IDD (43.4 per 1000) (RR 0.47; 95% CI 0.43 to 0.51). ASFRs in 18- to 24-year-olds were similar in both groups. Among women with a singleton live birth, those with IDD were younger and had higher rates of poverty, epilepsy, obesity, and mental health issues. They also had high rates of medication use during pregnancy.

CONCLUSION

In the largest study of fertility in women with IDD to date, we found that ASFRs are similar in young women with and without IDD. Women with IDD with a singleton live birth experience significant social and health disparities during pregnancy. These findings suggest the need to develop services to support the reproductive health of this vulnerable group.

How to support patients with severe mental illness in their parenting role with children aged over 1 year? A systematic review of interventions

PURPOSE

There are well-established risks for parents with severe mental illness (i.e. psychotic and bipolar disorders), both for their children and themselves. Interventions to help parents fulfil their role should therefore be a public health objective, but their implementation needs to be underpinned by research evidence. This systematic review determines what is known about the nature and effectiveness of interventions for parents with severe mental illness.

METHODS

We conducted a narrative synthesis of controlled and uncontrolled studies reporting interventions for this patient group after the post-natal period (i.e. after the child has turned 1 year old).

RESULTS

Eighteen publications reported data from 15 studies. All but two studies were rated as low quality studies. Interventions included home visiting programmes, complex community programmes, residential treatments, and online interventions. Interventions targeted diverse areas, with parenting skills and understanding the impact of mental illness on parenting most frequently addressed. Both parent and child-related outcomes improved, but children were only assessed via observers and follow-up times were short.

CONCLUSIONS

Interventions were diverse with respect to their nature and effectiveness. Future interventions should combine different intervention strategies to target multiple areas in a flexible manner. The addition of positively focussed and resource-oriented components should be investigated. Trials should include direct assessments of both parents and children, outcomes that are relevant from a public health perspective, and establish the long-term effects ideally until children have reached 18 years of age.

Risk of Fetal Death after Treatment with Antipsychotic Medications during Pregnancy

Background

Antipsychotic medications are increasingly used during pregnancy. Nevertheless, fetal risks are still not fully studied. It is currently unclear whether the antipsychotic treatment might induce a higher risk of fetal death. We aimed to determine if use of antipsychotic medication during pregnancy is associated with an increased risk of spontaneous abortion or stillbirth.

Methods

In a historical cohort study, we identified all clinically recognized pregnancies registered in the nationwide Danish registries from 1997 to 2008 (N = 1,005,319). Exposure was defined as any prescription of antipsychotic medications redeemed by the pregnant women during the exposure window, and recorded in the Danish National Prescription Register. Outcome was defined as any spontaneous abortion or stillbirth recorded in the Danish National Hospital Register and the Danish Medical Birth Register respectively.

Results

Women exposed to antipsychotic medications during pregnancy had a 34% higher risk of spontaneous abortion (adjusted relative risk = 1.34; 95% confidence interval = 1.22; 1.46) compared to unexposed women, but a similar risk compared to women exposed prior to (but not during) pregnancy (adjusted relative risk = 1.04; 95% confidence interval = 0.93; 1.17). The risk of spontaneous abortion was not increased in exposed pregnancies when compared to unexposed pregnancies in the same women (adjusted hazard ratio = 1.11; 95% CI = 0.94; 1.31). A twofold higher risk of stillbirth was found in women exposed to antipsychotic medications compared with unexposed women (relative risk = 2.27; 95% confidence interval = 1.45; 3.55) and compared with women exposed only prior to pregnancy (relative risk = 2.06; 95% confidence interval = 1.01; 4.19).

Conclusions

The increased risk of spontaneous abortion found in women treated with antipsychotic medications during pregnancy is most likely due to confounding factors. The risk of stillbirth was twofold higher in pregnancies exposed to antipsychotic medication during pregnancy. Treatment with antipsychotic medications during pregnancy requires careful consideration.