Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period

Antipsychotic use during pregnancy and outcomes in pregnant individuals and newborns

BACKGROUND

Despite the increasing use of antipsychotics during pregnancy, comprehensive evaluations of their individual safety profiles using global data remain limited. This study aimed to assess the safety of various antipsychotics during pregnancy by comparing them to quetiapine, which has a relatively large body of safety data.

METHOD

Utilizing the World Health Organization pharmacovigilance database (1968-2023; n = 131,255,418 reports), we identified 11,406 reports of antipsychotic exposure during pregnancy. A disproportionality analysis was performed to calculate reporting odds ratios (RORs) for adverse pregnancy, fetal, or neonatal outcomes associated with haloperidol, ziprasidone, clozapine, olanzapine, risperidone, aripiprazole, and paliperidone, compared to quetiapine.

RESULTS

Haloperidol had a significantly higher reporting frequency for congenital malformations compared to quetiapine (ROR 3.83; 95 % CI, 2.62-5.59). No statistically significant differences were found for other antipsychotics regarding congenital malformations or neonatal complications compared to quetiapine. All studied antipsychotics had lower reporting frequencies for gestational diabetes mellitus than quetiapine (overall ROR 0.22; 95 % CI, 0.18-0.28). Haloperidol, clozapine, olanzapine, risperidone, and aripiprazole were more frequently reported for abortion or stillbirth. Paliperidone and ziprasidone had similar or lower reporting frequencies for major adverse outcomes compared to quetiapine, though conclusions regarding ziprasidone are limited by the small number of reports and the relatively high proportion mentioning adverse pregnancy outcomes.

LIMITATIONS

Incomplete data and reporting bias hinder establishing causality.

CONCLUSIONS

Compared to quetiapine, several antipsychotics with less established safety data, particularly ziprasidone and paliperidone, have the potential to serve as safe alternatives for use during pregnancy. However, further research is needed to verify these findings and ensure the safety of these antipsychotics as treatment options during pregnancy.

"Bad timing for illness relapse!" Mood symptoms, challenges and strategies for wellbeing in the first year postpartum among infant mothers with bipolar disorder: a mixed-methods study

BACKGROUND

The postpartum period is associated with a high risk of illness episodes in women with bipolar disorder (BD) and is a critical developmental phase for both a new mother and her infant. This mixed-methods study aimed to investigate the occurrence of mood symptoms among infant mothers with BD in the first year postpartum, as well as their perceptions of the first year, their challenges and their strategies for wellbeing.

METHODS

Twenty-six women with BD participated. Mood symptoms were assessed at 3 and 12 months postpartum with the Inventory of Depressive Symptomatology and Young Mania Rating Scale. Occurrences of additional postpartum mood deviations were investigated through an interview at 12 months, which also covered the women's postpartum experiences. Thematic analysis was applied to the qualitative dataset (interviews and field notes).

RESULTS

42% of the women were euthymic or had only mild mood symptoms at 3 and 12 months. 58% had moderate to severe symptoms at either or both time points. A positive (38%) vs. mixed (62%) perception of the first year was strongly associated with euthymia-mild vs. moderate-severe mood deviations, as was the experience of maternal developmental achievement vs. struggles. The women experienced postpartum mood deviations and illness episodes as being particularly poorly timed. Further challenges included balancing self-care and infant mothering, familial relations, and negative experiences with the health and care systems. Illness acceptance with mindfulness of one's own and the infant's needs was a primary strategy for wellbeing, which was complemented by the support of one's partner and family and postpartum treatment.

CONCLUSIONS

Our findings propose that without impeding mood deviations and concomitant challenges, infant mothers with BD can enjoy their new motherhood and experience phase-specific growth equally to healthy mothers. On the other hand, moderate to severe mood deviations can adversely impact the experience of the postpartum year and one's own sense of mothering. Efforts to prevent postpartum mood deviations need to be complemented with interventions that target phase-specific BD challenges and support wellbeing strategies for both the mother and her infant. In summary, women's needs to function as infant mothers must be considered in the postpartum treatment of BD.

Perinatal mental illness in Ontario (2007-2021): A population-based repeated cross-sectional surveillance study

OBJECTIVE

Perinatal mental illness can negatively impact pregnant and postpartum women and gender-diverse birthing persons, their children, and families. This study aimed to describe population-level trends in perinatal mental health service use, including outpatient and acute care contacts, to guide decisions about investments in evidence-based treatment.

METHODS

In this repeated cross-sectional population-based surveillance study in Ontario, Canada, we measured monthly rates of mental health service use for perinatal people (conception to 1 year postpartum) from January 2007 to December 2021. Event rates were calculated by dividing the number of contacts in a given month by the total eligible perinatal time for that month expressed in per 1000 person-months. Rates by service type (outpatient, acute care), diagnosis, and sociodemographic characteristics, and by history of pre-existing mental illness were also calculated.

RESULTS

In total, 22-28% of perinatal people had perinatal mental health service use annually (10-15% in pregnancy, 17-21% in postpartum). Perinatal mental health outpatient care rates decreased initially (2007-2012), stabilized, and then increased after March 2020. Acute care rates were stable from 2007 to 2015, then increased (especially for anxiety and substance/alcohol use disorders). Across all contact types, the highest rates were in postpartum vs. pregnancy, those aged < 25 and > 40 years, non-immigrants, urban-dwellers, and those with pre-existing mental illness.

CONCLUSION

Ensuring rapid access to evidence-based supports and services for perinatal mental illness is essential. Groups with increased need based on sociodemographic and clinical characteristics may benefit from targeted supports and services to ensure optimal treatment and prevent adverse outcomes.

Efficacy of bright light therapy improves outcomes of perinatal depression: A systematic review and meta-analysis of randomized controlled trials

The efficacy of bright light therapy (BLT) in the context of perinatal depression remains underexplored. This meta-analysis aimed to systematically assess the effectiveness of BLT among perinatal depression. A comprehensive literature search was performed across several databases, including the Cochrane Central Register of Controlled Trials, PubMed, Embase, CNKI and the clinical trials registry platform, covering the period from the inception of each database up to January 2024. The Cochrane Collaboration's bias assessment tool was employed to evaluate the quality of the included studies. Review Manager 5.3 Software was utilized to conduct the meta-analysis. Six trials, encompassed a total of 167 participants diagnosed with perinatal depression were incorporated quantitative analysis, all of those have been published in English, with no restriction on publication year, and used BLT and dim light therapy (DLT) as intervention. The relative risk (RR) of BLT compared to DLT for perinatal depression is 1.46 (fixed effects model, p = 0.04, 95 % CI = [1.02, 2.10]), indicating a significant improvement in depression outcomes compared to DLT groups. The heterogeneity test yielded an I2 value of 41 % (p = 0.13), indicated a low degree of heterogeneity. Considering the small sample size, we conducted a sensitivity analysis, found RR increased to 2.33 (fixed effects model, p = 0.001, CI = 1.39-3.92). Cochrane Risk of Bias Tool showed only a single study was deemed high quality. This study indicates a beneficial impact of BLT on perinatal depression, subgroup analysis finds no significant mediation effects of different parameters after sensitivity analyses. It is recommended that future studies with larger samples be conducted to explore the effects of BLT on perinatal depression.

Neuropsychological performance in women at risk of postpartum depression and postpartum psychosis

PURPOSE

While neuropsychological deficits are commonly observed in affective and psychotic disorders, this remains unexplored in these disorders when they occur during pregnancy and the postpartum period.

METHODS

A neuropsychological test battery was administered to women defined at risk of postpartum depression (PD, N = 53) because having either a current or past diagnosis of major depressive disorder, women at risk of postpartum psychosis (PP, N = 43) because of a diagnosis of bipolar disorder or schizoaffective disorder and/or a previous episode of PP and women not at risk (NR, N = 48) in the third trimester of pregnancy. Generalized and specific cognitive abilities were compared between groups.

RESULTS

Women at risk of PP presented worse executive functions and processing speed compared to NR and worse performance compared to women at risk of PD across all cognitive domains. In addition, women at risk of PP who developed a psychiatric relapse in the first four weeks post-partum showed worse verbal learning and memory, visual memory, executive functions and processing speed in pregnancy compared to NR, whereas women at risk of PP who remained well presented neuropsychological performance that was intermediate between that of the women NR and those at risk of PP who developed symptoms. There were no differences in performance between women at risk of PD and the NR women, even if 31 women at risk of PD presented depressive symptoms at the time of cognitive assessment.

CONCLUSIONS

Our findings in women at risk of PP align with neuropsychological findings in individuals with, or at risk of psychosis unrelated to pregnancy. In addition, initial evidence that women at risk of PP who develop a psychiatric relapse in the postpartum show a particularly poor neuropsychological performance in pregnancy suggests that this could be considered part of a phenotype for the disease and help guiding future preventive strategies in this clinical population. In women at risk of PD, the presence of depressive symptoms did not influence cognitive performance.

Perinatal psychiatric emergencies in rural Australia: In urgent need of attention

OBJECTIVES

The burden of perinatal mental illness is a significant global concern, affecting approximately 10-20% of women at this stage of life. It is well recognised that Rural Australia has far less health services and mental health specialists per capita than metropolitan regions. While women have more babies in rural settings, their access to maternal health care is conversely limited or absent. We highlight the urgent need for research, adaptation of clinical practice guidelines and service development to address the lack of specialist perinatal mental health services for women in rural Australia for emergency episodes of mental ill health in the perinatal period. While telehealth services have been utilised to bridge the gap in service provision, in this paper we articulate the need for innovative research to identify suitable and sustainable models of care in rural settings.

CONCLUSION

Perinatal psychiatric emergencies represent a highly interventional area of psychiatry. Across the spectrum of psychiatric disorders, few can be attributed with such specificity in anticipated time of disease onset and severity of outcome. It is imperative that we address the lack of access to speciality perinatal psychiatric care for women who reside in rural Australia.

Maternal mental health matters: Indicators for perinatal mental health-A scoping review

Perinatal mental health disorders are a significant contributor to morbidity and mortality in childbearing women. The World Health Organization recommends all women be screened for mental health disorders postnatally and have diagnostic and management services available. There are, however, currently no global indicators in use which measure the status and progress of perinatal mental health. The aim of this scoping review was to identify existing perinatal mental health indicators and propose a core set which could be used at a global level. We used the Global Perinatal Mental Health Theory of Change as the conceptual framework. We found 25 indicators for PMH aligned with the Global Perinatal Mental Health Theory of Change, which were condensed to form a core set of nine indicators These core indicators include the proportion of women with depression, anxiety, post-traumatic stress disorder, psychosis, or adjustment disorders in the perinatal period; the proportion of women screened for these services; the proportion who have access to services following a positive diagnosis; and, the proportion of healthcare providers trained to provide mental health care. This review forms part of the foundational work for the development of a global monitoring framework which would be able to monitor progress towards the provision of universal high quality perinatal mental health care.

Partner military deployment and war conditions increase perinatal depression and decrease postpartum mother-infant bonding

The pregnancy and postpartum period represents a time of potentially heightened psychological vulnerability with implications for the offspring. Knowledge of the mental health of perinatal women exposed to armed conflict when their partner is in military deployment is scarce. This matched-control, survey-based study included a sample of 429 women recruited during the first months of the Israel-Hamas War who were pregnant or within six months postpartum. Women reporting partner in military deployment (n=250) were matched on background factors to women whose partner was no longer deployed (n=179). We found that nearly 44% of pregnant women with partner deployed endorsed depression symptoms at a clinical level. This group was more than two times as likely to endorse depression symptoms than matched controls. Postpartum women with partner deployed had significantly lower levels of mother-infant bonding than the matched group of partners not deployed. Mediation models revealed that social support mediated the relationship between study group and these maternal outcomes. Our findings suggest that war-exposed spouses of partners who are deployed are at increased risk for psychiatric morbidity and problems with attachment to the infant. Attention to optimizing social support in perinatal population is warranted during times of war and other large-scale traumas.

Antipsychotic continuation during pregnancy and risk of postpartum relapse in women with schizophrenia: nationwide register-based study

BACKGROUND

Women with schizophrenia frequently discontinue antipsychotic medications during pregnancy. However, evidence on the risk of postpartum relapse associated with antipsychotic use during pregnancy is lacking.

AIMS

To investigate the within-individual association between antipsychotic continuation during pregnancy and postpartum relapse in women with schizophrenia.

METHOD

This retrospective cohort study used data of women with schizophrenia who gave live birth between 2007 and 2018 identified from the National Health Information Database of South Korea. Women were classified according to antipsychotic use patterns during the 12 months before delivery as non-users, discontinuers and continuers. Relapse was defined as admission for psychosis (ICD-10, F20-29). The incidence rate ratio (IRR) for admission for psychosis in the 6-month postpartum period was estimated using conditional Poisson regression, with the reference period set between 2 and 1 years before delivery. Additionally, we calculated the relative risk ratios (RRRs) for the IRRs of different antipsychotic use patterns.

RESULTS

Among the 3026 women included in the analysis (median age 34 years, interquartile range 31-37), the within-individual risk of admission for psychosis in the 6-month postpartum period was 0.56 times (RRR, 95% CI 0.36-0.87) lower in continuers (IRR = 1.31, 95% CI 0.89-1.72) than in discontinuers (IRR = 2.34, 95% CI 1.87-2.91). Among discontinuers, the IRRs of admission for psychosis in the 6-month postpartum period did not change significantly with the timing of discontinuation (trend P = 0.946).

CONCLUSIONS

Antipsychotic continuation during pregnancy was associated with a reduced risk of postpartum relapse in women with schizophrenia. Continuing antipsychotics during pregnancy would be recommended after a risk-benefit assessment.

Enhancing Access to Mental Health Services for Antepartum and Postpartum Women Through Telemental Health Services at Wellbeing Centers in Selected Health Facilities in Bangladesh: Implementation Research

BACKGROUND

Globally, 10% of pregnant women and 13% of postpartum women experience mental disorders. In Bangladesh, nearly 50% of mothers face common mental disorders, but mental health services and trained professionals to serve their needs are scarce. To address this, the government of Bangladesh's Non-Communicable Disease Control program initiated "Wellbeing Centers," telemental health services in selected public hospitals.

OBJECTIVE

This study examines implementation outcomes, including adoption, accessibility, acceptability, feasibility, usefulness, need, experience, perception, and expectations of the Wellbeing Centers, with a focus on antepartum and postpartum women.

METHODS

Between January 2023 and August 2024, we interviewed 911 antepartum and postpartum women receiving mental health services and 168 health care providers at 6 Wellbeing Centers in 4 districts in Bangladesh. Data collection involved both quantitative and qualitative methods. Implementation outcomes were measured following the World Health Organization's implementation research framework. Depression and anxiety symptoms were assessed using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 questionnaires. Descriptive statistics and adjusted odds ratios (aORs) with 95% CIs were used to evaluate the implementation outcomes. Qualitative information was obtained through in-depth interviews and key-informant interviews.

RESULTS

Almost all health care providers (165/168, 98.2%) reported that the Wellbeing Centers were feasible to implement in their health facilities; however, about half (84/168, 50%) felt that trained staff to operate them were insufficient. Almost all women agreed that the Wellbeing Centers were acceptable (906/911, 99.8%), useful (909/911, 99.8%), and enhanced access to mental health care (906/911, 99.5%). Patients visiting district-level hospitals had higher odds of access (aOR 1.5, 95% CI 1.1-2.0) to Wellbeing Centers. Moreover, 77.4% (705/911) of women experienced depression symptoms, and 76.7% (699/911) experienced anxiety symptoms. About 51.8% (472/911) experienced tiredness or lack of energy, 50.9% (464/911) felt nervous, anxious, or on edge, 57.2% (521/911) felt worried, and 3.8% (35/911) had suicidal ideation almost every day. Patients visiting district hospitals had higher odds (aOR 2.6, 95% CI 1.8-3.78) of depression and anxiety symptoms compared to the patients visiting subdistrict-level hospitals. Decreasing trends in Patient Health Questionnaire-9 scores (from mean 14.4, SD 0.47 to mean 12.9, SD 0.47) and Generalized Anxiety Disorder-7 scores (from mean 13.3, SD 0.49 to mean 12.5, SD 0.48) between 2 counseling sessions indicated improved mental health in the antepartum and postpartum women. The Wellbeing Centers' services were appreciated for their privacy and being free and accessible. However, stigma, postpartum illness, and long waiting times prevented some women from using these services.

CONCLUSIONS

To our knowledge, this is the first implementation research assessing telemental health in public health facilities involving trained psychologists and psychiatrists. Our study highlighted the increased accessibility, feasibility, acceptability, and utility of Wellbeing Centers for antepartum and postpartum women in Bangladesh, supporting their scale-up in similar settings.

Safety of psychotropic medications in pregnancy: an umbrella review

Weighing risks and benefits of the use of psychotropic medications during pregnancy remains a challenge worldwide. We systematically assessed the strength of associations between psychotropic medication use in pregnant people with mental disorders and various adverse health outcomes in both pregnant people and foetuses. Systematic reviews with meta-analyses of observational studies investigating the association between exposure to psychotropic medication in pregnancy and any adverse health outcomes were included. Credibility was graded into convincing, highly suggestive, suggestive, weak or not significant. Quality of the meta-analyses and of individual studies were assessed with A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) the Newcastle-Ottawa Scale (NOS), respectively. We considered 21 meta-analyses encompassing 17,290,755 participants (AMSTAR 2 high = 1, low = 12, or critically low = 8). Evidence was suggestive for: (1) preterm birth in pregnant people with either any mental disorder (equivalent odds ratio 1.62 (95% confidence interval 1.24-2.12) or depression (1.65 [1.34-2.02]) receiving antidepressants during any trimester of pregnancy; (2) small for gestational age for pregnant people with depression receiving a SSRI during any trimester of pregnancy (1.50 [1.19-1.90]); and (3) major congenital malformation (1.24 [1.09-1.40]) or cardiac malformations (1.28 [1.11-1.47]) in babies for pregnant people with depression or anxiety receiving paroxetine during first trimester of pregnancy. Additional associations were supported by weak evidence, or were not statistically significant. This umbrella review found no convincing or highly suggestive level of evidence of adverse health outcomes associated with psychotropic medication use in pregnant people with mental disorders.

Comparative Safety of Antipsychotic Medications and Mood Stabilizers During Pregnancy: A Systematic Review and Network Meta-analysis of Congenital Malformations and Prenatal Outcomes

BACKGROUND

A network meta-analysis was performed to evaluate the risk of congenital malformations and other prenatal outcomes in fetuses after exposure to antipsychotic medications and mood stabilizers during pregnancy.

METHODS

We searched the PubMed, EMBASE, and Cochrane CENTRAL databases up to 15 December 2023, to identify experimental and observational studies comparing antipsychotic and mood stabilizer treatments with control treatments (no exposure). The primary outcome of the study was the incidence of congenital malformations and the secondary outcomes were preterm birth and spontaneous abortion. Additionally, two authors independently assessed the risk of bias in each domain of the included studies using the ROBINS-I tool and evaluated the quality of evidence using the CINeMA rating tool.

RESULTS

The literature search identified 18,334 potential records, and 22 studies involving 3,042,997 pregnant women were ultimately included. Compared with the unexposed group, quetiapine [odds ratio (OR), 1.19; 95% credible interval (CrI), 1.01-1.39], aripiprazole (OR, 1.30; 95% CrI 1.10-1.65), olanzapine (OR, 1.33; 95% CrI 1.11-1.64), risperidone (OR, 1.43; 95% CrI 1.18-1.77), and lithium (OR, 1.61; 95% CrI 1.07-2.30) were associated with a slightly increased risk of congenital malformations. In contrast, lamotrigine (OR, 1.21; 95% CrI 0.86-1.64), ziprasidone (OR, 1.14; 95% CrI 0.73-1.72), and haloperidol (OR, 1.26; 95% CrI 0.90-1.75) did not show significant differences compared with the unexposed group, with narrower credible intervals.

CONCLUSIONS

The evidence from this analysis suggests that, overall, quetiapine has the lowest teratogenic risk when used during pregnancy, making it the safer option for pregnant women. Lamotrigine and haloperidol follow closely behind. At the same time, the use of lurasidone and ziprasidone should be approached with caution, and further clinical studies are necessary to better assess their safety.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD4201811373.

How Does the Pre-Registration Midwifery Programme Prepare the Newly Qualified Midwives for Their Post-Registration Perinatal Mental Health Role? A Mixed Methods Study

OBJECTIVE

In the United Kingdom (UK) and most countries worldwide, midwives are professionally required to undertake an initial perinatal mental health (PMH) risk assessment at every maternity contact. However, studies have found that midwives feel that they are not well-equipped to provide effective care for women with PMH needs. This study explores how the newly qualified midwives (NQMs) are prepared through pre-registration midwifery education and placements to have sufficient confidence in their knowledge, attitude, skills, and habits (KASH) for their post-registration PMH role.

METHODS

This explanatory sequential mixed methods study collected survey data from two independent groups: NQMs (n = 50), who qualified from 10 UK universities, and senior specialist midwives (SSMs) (n = 32). Descriptive and inferential responses were analysed using SPSS. Statistical differences between the ranged Likert scale responses of the NQMs and SSMs were analysed using the Mann-Whitney U test. The p-value of <0.05 was considered statistically significant. The semi-structured interview phase comprised of NQMs (n = 12) and SSMs (n = 8). The qualitative data were thematically analysed using NVivo.

RESULTS

The pre-registration midwifery programme significantly prepared the NQMs to have sufficient confidence in their knowledge of the related PMH role, multidisciplinary team (MDT) role, and available services (p < 0.05) and good attitude towards women with varying PMH conditions (p < 0.0005). The NQMs had sufficient confidence in their skills in using the validated tool for PMH assessment, to build rapport to facilitate disclosure, and recognise deteriorating PMH (p < 0.01). They had regular habits of discussing PMH well-being at booking and made prompt referrals (p < 0.05). The NQMs were not prepared to have sufficient knowledge of PMH medications, perinatal suicide prevention, and the impact of maternal mental health on partners (p < 0.01) including children (p < 0.05); skills in managing PMH emergencies (p < 0.05), and to regularly discuss suicidal thoughts (p < 0.01), issues of self-harm, and debrief women following pregnancy or neonatal losses and traumatic births (p < 0.05). Some aspects were either confirmed or contradicted at the interviews.

CONCLUSIONS AND RECOMMENDATIONS

The pre-registration midwifery programme prepares the NQMs to some extent for their post-registration PMH role. Perceived areas for improvement suggest implications for the development of educational, practice, policy, and preceptorship to facilitate the NQMs' sustainable confidence in their KASH.

Identification of women at high risk of postpartum psychiatric episodes: A population-based study quantifying relative and absolute risks following exposure to selected risk factors and genetic liability

BACKGROUND

We quantified relative and absolute risks of postpartum psychiatric episodes (PPE) following risk factors: Young age, past personal or family history of psychiatric disorders, and genetic liability.

METHODS

We conducted a register-based study using the iPSYCH2012 case-cohort sample. Exposures were personal history of psychiatric episodes prior to childbirth, being a young mother (giving birth before the age of 21.5 years), having a family history of psychiatric disorders, and a high (highest quartile) polygenic score (PGS) for major depression. PPE was defined within 12 months postpartum by prescription of psychotropic medication or in- and outpatient contact to a psychiatric facility. We included primiparous women born 1981-1999, giving birth before January 1st, 2016. We conducted Cox regression to calculate hazard ratios (HRs) of PPE, absolute risks were calculated using cumulative incidence functions.

RESULTS

We included 8174 primiparous women, and the estimated baseline PPE risk was 6.9% (95% CI 6.0%-7.8%, number of PPE cases: 2169). For young mothers with a personal and family history of psychiatric disorders, the absolute risk of PPE was 21.6% (95% CI 15.9%-27.8%). Adding information on high genetic liability to depression, the risk increased to 29.2% (95% CI 21.3%-38.4%) for PPE.

CONCLUSIONS

Information on prior personal and family psychiatric episodes as well as age may assist in estimating a personalized risk of PPE. Furthermore, additional information on genetic liability could add even further to this risk assessment.

Treatment With Long-Acting Injectable Aripiprazole During Pregnancy in Bipolar Disorder: A Scoping Review

BACKGROUND

The management of bipolar disorder during pregnancy presents a significant challenge, particularly regarding the safety and effectiveness of long-acting injectable (LAI) antipsychotics like aripiprazole. Despite the growing use of LAI antipsychotics in psychiatric disorders, data on their use during pregnancy are limited, especially for bipolar disorder. This study aimed to shed light on this issue through a scoping review.

AREAS OF UNCERTAINTY

The level of evidence concerning the safety of second-generation antipsychotics during pregnancy is limited. Data on LAI aripirazole are even more limited.

DATA SOURCES

We conducted a scoping review following the PRISMA-ScR guidelines, systematically searching multiple electronic databases for studies published between January 2008 and February 2024. The review focused on the administration of aripiprazole during pregnancy among patients with psychiatric disorders, examining outcomes related to maternal health, fetal well-being, and neonatal outcomes.

RESULTS

The scoping review identified 11 case reports that met the inclusion criteria and 4 additional studies (prospective and retrospective cohort studies).

CONCLUSIONS

The scoping review emphasizes the need for further research to confirm its safety and efficacy. The limited data underscore the importance of individualized treatment plans and informed decision-making, considering the unique risks and benefits of LAI antipsychotic use during pregnancy. Further studies are imperative to provide more definitive guidance for managing bipolar disorder with LAI antipsychotics in pregnant patients.

The travails of women with severe mental illness and pregnancy

Women with severe mental illness and pregnancy suffer substantial travails in accessing care for mental and perinatal health. Women with psychotic illnesses such as schizophrenia face higher risks of pregnancy and postnatal complications. Similarly, lack of access to holistic psychiatric care presents particular perils for these women and their children. Tailored care for these mothers-to-be and their babies is needed to prevent and ameliorate health complications, mental and physical. This will require targeted funding of services that connect women with and provide continuity of care.

"Association between perinatal mood disorders of parents and child health outcomes"

PURPOSE

Perinatal mood disorders affect both parents, impacting their children negatively. Little is known on the association between parental perinatal mood disorders and pediatric outcomes in Japan considering relevant covariates. Our objective was to investigate the association between paternal and maternal perinatal mood disorders and adverse physical and psychological child outcomes by the age of 36 months, adjusting for covariates such as the child's sex, age of parent at child's birth, perinatal mood disorders of the other parent, and perinatal antidepressant use.

METHODS

We identified parents in the JMDC Claims Database in Japan from 2012 to 2020. Perinatal mood disorders were defined using International Classification of Diseases, 10th codes for mood disorders during the perinatal period combined with psychiatric treatment codes. We evaluated the association between parental perinatal mood disorders and pediatric adverse outcomes by the age of 36 months using Cox proportional hazard models adjusted for the covariates.

RESULTS

Of the 116,423 father-mother-child triads, 2.8% of fathers and 2.3% of mothers had perinatal mood disorders. Paternal perinatal mood disorders were not significantly associated with adverse child outcomes. After adjusting for paternal perinatal mood disorders and antidepressant use, maternal perinatal mood disorders were associated with delayed motor development, language development disorders, autism spectrum disorders, and behavioral and emotional disorders (adjusted hazard ratio [95% confidence interval]: 1.65 [1.01-2.69], 2.26 [1.36-3.75], 4.16 [2.64-6.55], and 6.12 [1.35-27.81], respectively).

CONCLUSIONS

Paternal perinatal mood disorders were not associated with adverse child outcomes in this population. Maternal perinatal mood disorders were associated with multiple child outcomes.

Sleep and Pregnancy: Future Perspectives from Circadian and Precision Medicine

Ten years ago, the Society for Women’s Health Research highlighted sleep as a significant area of interest in women’s health research [...]

Relationship between childhood trauma and postpartum psychotic experiences: the role of postnatal anxiety and depression as mediators

BACKGROUND

Postpartum psychosis (PP) is a psychological emergency requiring rapid intervention, hospitalization and psychiatric management. However, PP has been neglected in the postpartum literature. Understanding the detrimental consequences of childhood trauma across mother's life span is crucial to prevent this serious condition. The study's objectives were to demonstrate the relationship between childhood trauma and postpartum psychotic experiences (PPEs) and to look over the mediating role of postnatal depression (PD) and anxiety (PA) in this relationship.

METHODS

This cross-sectional study, which enrolled 438 postpartum females 4-6 weeks after delivery (mean age: 31.23 ± 5.24 years), was carried out from September 2022 to June 2023. The Arabic validated versions of the Postpartum Psychotic Experiences Scale, the Edinburgh Postnatal Depression Scale, the Perinatal Anxiety Screening Scale, and the Child Abuse Self Report Scale were used.

RESULTS

Both PD and PA partially mediated the correlation between psychological abuse and PPEs, and fully mediated the association between neglect and PPEs. Higher psychological abuse and neglect were significantly associated with higher PD (Beta = 1.11) and PA (Beta = 3.94), higher PD (Beta = 0.84) and PA (Beta = 0.26) were significantly associated with higher PPEs in both models, whereas greater child psychological abuse (Beta = 1.37) (but not neglect) was directly and strongly correlated with higher PPEs in all models.

CONCLUSION

The significant mediating effect of PA and PD on the association between childhood adversities and PPEs among postpartum females may offer additional therapeutic avenues to help attenuate various postpartum mental health issues and their potential serious risks on both mother and child.

The neuropsychological presentation of women with epilepsy: Clinical considerations and future directions

Objective: Cognitive, mood, and behavioral changes are common among persons with epilepsy (PWE), resulting in a complex neuropsychological presentation. Women with epilepsy (WWE) represent a distinct cohort within the broader epilepsy population due to sex and gender-specific factors impacting epilepsy semiology and treatment. However, unique neuropsychological profiles among WWE have not been established. This narrative review aims to further define neuropsychological correlates in WWE and promote meaningful discussion related to enhancing the provision of neuropsychological care within this clinical population. Method: Current literature in PWE examining differences in cognitive function, mental health, and quality of life (QoL) between women and men was critically reviewed, emphasizing considerations for neuropsychological practice. Results: WWE demonstrate a preservation of verbal learning and memory compared to men both pre- and post-surgically, with sex-based, neurobiological mechanisms likely contributing to this association. WWE also have elevated risk for affective disorder psychopathology, suicidality, and traumatic experiences. Epidemiology related to psychotic and bipolar spectrum disorders is less clear, and findings are mixed regarding sex-specific behavioral side effects of antiseizure and psychotropic medication. Finally, hormonal and obstetric factors are highlighted as important contributors to neuropsychological symptoms in WWE, with elevated risk for low QoL and increased stigma associated with greater medical and psychiatric comorbidities compared to men. Conclusions: While emerging literature has begun to characterize the neuropsychological presentation of WWE, future research is needed to define sex and gender differences in neuropsychological sequalae among PWE to ensure consistency and quality of care for WWE.

Effect of aripiprazole on neural tube development in early chick embryos

INTRODUCTION

Aripiprazole (ARI) is a recently developed antipsychotic medication that belongs to the second generation of antipsychotics. The literature has contradictory information regarding ARI, which has been classified as pregnant use category C by the FDA.

METHODS

125 pathogen-free fertilized eggs were incubated for 28 h and divided into five groups of 25 eggs each (including the control group), and 18 eggs with intact integrity were selected from each group. After the experimental groups were divided, ARI was administered subblastodermally with a Hamilton micro-injector at 4 different doses (1 mg/kg, 5 mg/kg, 10 mg/kg, 20 mg/kg). At the 48th hour of incubation, all eggs were hatched and embryos were removed from the embryonic membranes. And then morphologic (position of the neural tube (open or closed), crown-rump length, number of somites, embryological development status), histopathologic (apoptosis (caspase 3), cell proliferation (PCNA), in situ recognition of DNA breaks (tunnel)), genetic (BRE gene expression) analyzes were performed.

RESULTS

According to the results of the morphological analysis, when the frequency of neural tube patency was evaluated among the experimental groups, a statistically significant difference was determined between the control group and all groups (p < 0.001). In addition, the mean crown-rump length and somite number of the embryos decreased in a dose-dependent manner compared to the control group. It was determined that mRNA levels of the BRE gene decreased in embryos exposed to ARI compared to the control group (p < 0.001).

CONCLUSION

Morphologically, histopathologically, and genetically, aripiprazole exposure delayed neurogenesis and development in early chick embryos. These findings suggest its use in pregnant women may be teratogenic. We note that these results are preliminary for pregnant women, but they should be expanded and studied with additional and other samples.

Gender differences in clinical and biochemical parameters among patients hospitalized for schizophrenia: towards precision medicine

BACKGROUND

The scientific literature shows some gender differences in the clinical course of schizophrenia. The aim of this study is to identify gender differences in clinical and biochemical parameters in subjects affected by schizophrenia. This would allow for the implementation of individualized treatment strategies.

METHODS

We examined a large set of clinical and biochemical parameters. Data were obtained from clinical charts and blood analyses from a sample of 555 schizophrenia patients consecutively admitted for exacerbation of symptoms to the inpatient clinic of Fondazione IRCCS Policlinico (Milan) or ASST Monza in Italy from 2008 to 2021. Univariate analyses, binary logistic regression, and a final logistic regression model were performed with gender as dependent variable.

RESULTS

The final logistic regression models showed that male patients (compared to females) were more prone to lifetime substance use disorders (p = 0.010). However, they also had higher GAF (global functioning) mean scores (p < 0.001) at the time of hospitalization. Univariate analyses showed that male patients (with respect to females) had an earlier age at onset (p < 0.001), a more frequent family history of multiple psychiatric disorders (p = 0.045), were more often smokers (p < 0.001), had a more frequent comorbidity with at least one psychiatric disorder (p = 0.001), and less often suffered from hypothyroidism (p = 0.011). In addition, men had higher levels of albumin (p < 0.001) and bilirubin (t = 2.139, p = 0.033), but lower levels of total cholesterol (t = 3.755, p < 0.001).

CONCLUSIONS

Our analyses indicate a less severe clinical profile in female patients. This is evident especially in the early years of the disorder, as suggested by less comorbidity with psychiatric disorders or later age at onset; this is consistent with the related literature. In contrast, female patients seem to be more vulnerable to metabolic alterations as demonstrated by more frequent hypercholesterolemia and thyroid dysfunction. Further studies are needed to confirm these results in the framework of precision medicine.

Maternal Stress Mediates Association of Infant Socioemotional Development with Perinatal Mental Health in Socioeconomically Vulnerable Peruvian Settings

Increased maternal mental health during the perinatal period has been widely associated with a variety of positive outcomes for both mothers and infants. However, no studies in Peru have yet focused on studying maternal mental health and related psychological variables during this stage. Thus, the aim of this study was to test a model to associate a mother's parental stress with infant socioemotional difficulties and maternal mental health. The sample included 988 mothers of infants aged 6 to 18 months from Peru, all from socioeconomically vulnerable settings. The findings showed that infant socioemotional difficulties were associated with poorer maternal mental health through the mother's parental stress (χ2(7) = 28.89, p < 0.001, CFI = 0.98, RMSEA = 0.06, SRMR = 0.03). These results provide a better understanding of the key elements associated with maternal mental health during the perinatal period in Peru and offer valuable insights for developing interventions and support strategies for socioeconomically vulnerable mothers and their young children.

Improvements in Maternal Cardiovascular Health Over the Perinatal Period Longitudinally Predict Lower Postpartum Psychological Distress Among Individuals Who Began Their Pregnancies With Overweight or Obesity

BACKGROUND

Adverse cardiovascular events during pregnancy (eg, preeclampsia) occur at higher rates among individuals with overweight or obesity (body mass index ≥25 kg/m2) and have been associated with postpartum depression. The present study examined whether changes in cardiovascular health (CVH) during the perinatal period, as defined by the American Heart Association's Life's Essential 8 framework, predicted postpartum psychological functioning among individuals with prepregnancy body mass index ≥25 kg/m2.

METHODS AND RESULTS

Pregnant individuals (N = 226; mean ± SD age = 28.43 ± 5.4 years; mean body mass index = 34.17 ± 7.15 kg/m2) were recruited at 12 to 20 weeks of gestation (mean, 15.64 ± 2.45 weeks) for a longitudinal study of health and well-being. Participants completed ratings of depression and perceived stress and reported on CVH behaviors (dietary intake, physical activity, nicotine exposure, and sleep) at baseline and at 6 months postpartum. Body mass index and CVH behaviors were used to calculate a composite CVH score at both time points. Linear regression analyses were performed to examine whether change in CVH related to postpartum symptom scores. Because sleep was measured in only a subset of participants (n = 114), analyses were conducted with and without sleep. Improved CVH was associated with lower postpartum depression (β = -0.18, P<0.01) and perceived stress (β = -0.13, P=0.02) scores. However, when including sleep, these relationships were no longer significant (all P>0.4).

CONCLUSIONS

Improvements in CVH from early pregnancy to 6 months postpartum were associated with lower postpartum depressive symptoms and perceived stress but not when including sleep in the CVH metric, potentially due to the large reduction in sample size. These data suggest that intervening during pregnancy to promote CVH may improve postpartum psychological functioning among high-risk individuals.

Association of Postpartum Mental Illness Diagnoses with Severe Maternal Morbidity

Background: This study aimed to determine whether birthing people who experience severe maternal morbidity (SMM) are more likely to be diagnosed with a postpartum mental illness. Materials and Methods: Using the Massachusetts All Payer Claims Database, this study used modified Poisson regression analysis to assess the association of SMM with mental illness diagnosis during the postpartum year, accounting for prenatal mental illness diagnoses and other patient characteristics. Results: There were 128,161 deliveries identified, with 55.0% covered by Medicaid. Of these, 3.1% experienced SMM during pregnancy and/or delivery hospitalization, and 20.1% had a mental illness diagnosis within 1 year postpartum. In adjusted regression analyses, individuals with SMM had a 10.6% increased risk of having any mental illness diagnosis compared to individuals without SMM, primarily due to an increased risk of a depression or post-traumatic stress disorder diagnosis among people with SMM than those without SMM. Conclusions: Individuals who experienced SMM had a higher risk of a mental illness diagnosis in the postpartum year. Given increases in SMM in the United States in recent decades, policies to mitigate mental health sequelae of SMM are urgently needed.

Mindfulness in Pregnancy and Postpartum: Protocol of a Pilot Randomized Trial of Virtually Delivered Mindfulness-Based Cognitive Therapy to Promote Well-Being during the Perinatal Period

BACKGROUND

During the period from pregnancy through the first year postpartum, vulnerable individuals are at elevated risk for the onset or worsening of psychological distress, and accessible (e.g., virtually delivered) mental health interventions are needed. Research suggests that Mindfulness-Based Cognitive Therapy (MBCT) can effectively mitigate psychological distress, although few studies have evaluated MBCT in the perinatal period, and samples have been clinically homogenous. Thus, we have designed and are conducting a pilot trial of virtually delivered MBCT with pregnant individuals experiencing a range of psychological symptoms to assess its feasibility and preliminarily explore its effectiveness. Here, we present the study protocol.

METHODS

Eligible participants (target N = 70) are ≥18 years with pregnancies between 12 and 30 weeks of gestation. Participants complete a diagnostic interview, self-report symptom ratings, and a computerized cognitive battery assessing self-regulation at the baseline. Participants are then randomized to either MBCT or care as usual. The MBCT intervention involves eight weekly group sessions delivered virtually, with each session focusing on a mindfulness practice followed by group discussion and skill development. Participants in the intervention group are also encouraged to practice mindfulness skills between sessions. Participants in the control condition are provided with information about mindfulness and treatment resources. Baseline measures are repeated following the eight-week intervention period and at three months postpartum.

CONCLUSIONS

This pilot study is designed to evaluate the feasibility of virtually delivered MBCT and explore group differences in psychological symptoms during the perinatal period, and will lay the foundation for a larger clinical trial focused on optimizing this intervention to improve psychological functioning among diverse pregnant individuals.

Postpartum Psychiatric Outcomes following Severe Maternal Morbidity in an Urban Safety-Net Hospital

OBJECTIVE

Severe maternal morbidity (SMM) may be associated with postpartum psychiatric morbidity. However, the direction and strength of this relationship remain unclear. Our goal was to estimate the association between SMM and postpartum inpatient mental health care utilization.

STUDY DESIGN

We examined all liveborn deliveries at a large, safety-net hospital in Atlanta, Georgia, from 2013 to 2021. SMM at or within 42 days of delivery was identified using International Classification of Disease codes. The primary outcome of interest was hospitalization with a psychiatric diagnosis in the year following the delivery. We used inverse probability of treatment weighting based on propensity scores to adjust for demographics, index delivery characteristics, and medical, psychiatric, and obstetric history. We fit log-binomial models with generalized estimating equations to calculate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs).

RESULTS

Among 22,233 deliveries, the rates of SMM and postpartum hospitalization with a psychiatric diagnosis, respectively, were 6.8% (n = 1,149) and 0.8% (n = 169). The most common psychiatric diagnosis was nonpsychotic mood disorders (without SMM 0.4%, n = 79; with SMM 1.7% n = 24). After weighting, 2.2% of deliveries with SMM had a postpartum readmission with a psychiatric diagnosis, compared with 0.7% of deliveries without SMM (aRR: 3.2, 95% CI: [2.0, 5.2]). Associations were stronger among individuals without previous psychiatric hospitalization.

CONCLUSION

Experiencing SMM was associated with an elevated risk of postpartum psychiatric morbidity. These findings support screening and treatment for mild and moderate postpartum psychiatric disorders in the antenatal period.

KEY POINTS

· Experiencing SMM was associated with three-fold excess risk of postpartum psychiatric admission.. · Experiencing SMM was not associated with an elevated risk of outpatient psychiatric care use.. · Experience SMM was not associated with outpatient psychiatric morbidity diagnoses..

Association between maternal mental health-related hospitalisation in the 5 years prior to or during pregnancy and adverse birth outcomes: a population-based retrospective cohort data linkage study in the Northern Territory of Australia

Background

Mental health conditions prior to or during pregnancy that are not addressed can have adverse consequences for pregnancy and birth outcomes. This study aimed to determine the extent to which women's mental health-related hospitalisation (MHrH) prior to or during pregnancy was associated with a risk of adverse birth outcomes.

Methods

We linked the perinatal data register for all births in the Northern Territory, Australia, from the year 1999 to 2017, to hospital admissions records to create a cohort of births to women aged 15-44 years with and without MHrH prior to or during pregnancy. We used Modified Poisson Regression and Latent Class Analysis to assess the association between maternal MHrH and adverse birth outcomes (i.e., stillbirth, preterm birth, low birth weight, and short birth length). We explored a mediation effect of covariates on theoretical causal paths. We calculated the adjusted Population Attributable Fraction (PAF) and Preventive Fractions for the Population (PFP) for valid associations.

Findings

From 72,518 births, 70,425 births (36.4% for Aboriginal women) were included in the analysis. The Latent Class Analys identified two classes: high (membership probability of 10.5%) and low adverse birth outcomes. Births to Aboriginal women with MHrH were around two times more likely to be in the class of high adverse birth outcomes. MHrH prior to or during pregnancy increased the risk of all adverse birth outcomes in both populations with risk ranging from 1.19 (95% CI: 1.05, 1.35) to 7.89 (1.17, 53.37). Eight or more antenatal care visits and intrauterine growth restriction mostly played a significant mediation role between maternal MHrH and adverse birth outcomes with mediation effects ranging from 1.04 (1.01, 1.08) to 1.39 (1.14, 1.69). MHrH had a low to high population impact with a PAF ranging from 16.1% (5.1%, 25.7%) to 87.3% (14.3%, 98.1%). Eight or above antenatal care visits avert extra adverse birth outcomes that range from 723 (332-765) stillbirths to 3003 (1972-4434) preterm births.

Interpretation

Maternal MHrH is a modifiable risk factor that explained a low to moderate risk of adverse birth outcomes in the Northern Territory. The knowledge highlights the need for the development and implementation of preconception mental health care into routine health services.

Funding

The Child and Youth Development Research Partnership (CYDRP) data repository is supported by a grant from the Northern Territory Government.

Mental Health Treatment Rates During Pregnancy and Post Partum in US Military Service Members

Importance

Although new parents' mental health is known to decline, less is known about changes in therapy attendance, especially among military service members.

Objective

To investigate changes in therapy attendance among new parents and by parental leave length.

Design, Setting, and Participants

This cohort study of US Army and Navy service members from January 1, 2013, to December 31, 2019, compared parents' monthly therapy attendance with matched nonparents' across childbirth and compared mothers' weekly therapy attendance before vs after returning to work. Eligible monthly sample members included service members with first births from January 1, 2014, to December 31, 2017, and 12 months of data before to 24 months after birth and nonparents with 36 months of data. Eligible weekly sample members included mothers with first births from January 1, 2013, to June 30, 2019, and data from 12 months before to 6 months after birth and nonparents with 18 months of data. Data analysis was performed from July 1, 2023, to January 15, 2024.

Exposure

Those exposed to parenthood had no prior children, acquired a dependent younger than 1 year, and, for mothers, had an inpatient birth. Unexposed matches did not add a dependent younger than 1 year.

Main Outcomes and Measures

Monthly counts of mental health therapy sessions and any therapy sessions (weekly).

Results

The monthly sample included 15 554 193 person-month observations, representing 321 200 parents and matches, including 10 193 mothers (3.2%; mean [SD] age, 25.0 [4.9] years), 50 865 nonmother matches (15.8%; mean [SD] age, 25.0 [5.0] years), 43 365 fathers (13.5%; mean [SD] age, 26.4 [4.8] years), and 216 777 nonfather matches (67.5%; mean [SD] age, 26.4 [4.8] years). The weekly sample included 17 464 mothers. Mothers went to 0.0712 fewer sessions at 1 month post partum (95% CI, -0.0846 to -0.0579) compared with 10 months before birth. Fathers went to 0.0154 fewer sessions in the month of birth (95% CI, -0.0194 to -0.0114) compared with 10 months before. Parents with preexisting treatment needs had larger decreases in treatment. Weekly therapy attendance increased by 0.555 percentage points (95% CI, 0.257-0.852) when mothers returned to work from 6 weeks of leave and 0.953 percentage points (95% CI, 0.610-1.297) after 12 weeks of leave.

Conclusions and Relevance

In this cohort study of new parents, therapy attendance decreased around childbirth, especially among parents with prior mental health needs and mothers with longer maternity leaves. These findings suggest that more accessible treatment, including home visits or telehealth appointments, is needed.

Addressing Pregnancy And Parenting In Mental Health Care: Perspectives Of Women With Serious Mental Illness

Women living with serious mental illness (SMI) are at increased risk for adverse pregnancy and parenting outcomes. However, little is known about the experiences and preferences of women with SMI related to addressing pregnancy and parenting with their mental health providers. We conducted semistructured interviews with twenty-two reproductive-age cisgender women patients living with SMI. Participants characterized discussions about pregnancy and medication teratogenicity with their mental health providers as limited or unsatisfactory. Participants' openness to discussing pregnancy varied by topic and its perceived relevance to their individual circumstances, and it hinged on participants' trust in their providers. Participants characterized discussions about parenting with their mental health providers as helpful and identified additional opportunities for parenting support. Our findings highlight critical gaps in the delivery of information, support, and resources that can inform efforts to increase providers' capacity to address pregnancy and parenting with women living with SMI.

An exploration of service use pattern changes and cost analysis following implementation of community perinatal mental health teams in pregnant women with a history of specialist mental healthcare in England: a national population-based cohort study

BACKGROUND

The National Health Service in England pledged >£365 million to improve access to mental healthcare services via Community Perinatal Mental Health Teams (CPMHTs) and reduce the rate of perinatal relapse in women with severe mental illness. This study aimed to explore changes in service use patterns following the implementation of CPMHTs in pregnant women with a history of specialist mental healthcare in England, and conduct a cost-analysis on these changes.

METHODS

This study used a longitudinal cohort design based on existing routine administrative data. The study population was all women residing in England with an onset of pregnancy on or after 1st April 2016 and who gave birth on or before 31st March 2018 with pre-existing mental illness (N = 70,323). Resource use and costs were compared before and after the implementation of CPMHTs. The economic perspective was limited to secondary mental health services, and the time horizon was the perinatal period (from the start of pregnancy to 1-year post-birth, ~ 21 months).

RESULTS

The percentage of women using community mental healthcare services over the perinatal period was higher for areas with CPMHTs (30.96%, n=9,653) compared to areas without CPMHTs (24.72%, n=9,615). The overall percentage of women using acute care services (inpatient and crisis resolution teams) over the perinatal period was lower for areas with CPMHTs (4.94%, n=1,540 vs. 5.58%, n=2,171), comprising reduced crisis resolution team contacts (4.41%, n=1,375 vs. 5.23%, n=2,035) but increased psychiatric admissions (1.43%, n=445 vs. 1.13%, n=441). Total mental healthcare costs over the perinatal period were significantly higher for areas with CPMHTs (fully adjusted incremental cost £111, 95% CI £29 to £192, p-value 0.008).

CONCLUSIONS

Following implementation of CPMHTs, the percentage of women using acute care decreased while the percentage of women using community care increased. However, the greater use of inpatient admissions alongside greater use of community care resulted in a significantly higher mean cost of secondary mental health service use for women in the CPMHT group compared with no CPMHT. Increased costs must be considered with caution as no data was available on relevant outcomes such as quality of life or satisfaction with services.

Video feedback for young babies and maternal perinatal mental illness: intervention adaptation, feasibility and acceptability

AIMS/BACKGROUND

We aimed to adapt, pilot and explore experiences of receiving and delivering the video feedback intervention for positive parenting (VIPP) for 2 to 6 month old babies, mothers experiencing moderate to severe perinatal mental health difficulties and perinatal mental health clinicians.

DESIGN/METHODS

The VIPP intervention was adapted to include developmentally appropriate activities and developmental psychoeducation for 2 to 6 month olds, alongside psychoeducation on emotion regulation, and then piloted in 14 mothers experiencing moderate to severe perinatal mental health difficulties (registration ISRCTN64237883). Observational and self-reported pre-post outcome data on parenting and parent-infant mental health was collected, and post-intervention qualitative interviews were conducted with participating mothers and clinicians.

RESULTS

Consent (67%), intervention completion (79%) and follow-up rates (93%) were high. Effect sizes on pre-post outcome measures indicated large improvements in parenting confidence and perceptions of the parent-infant relationship, and a medium-size improvement in maternal sensitivity. In qualitative interviews, clinicians and mothers described how mothers' initial anxieties about being filmed were allayed through receiving positive and strengths-focussed feedback, boosting their self-confidence, and that the video feedback facilitated identification of young babies' subtle behavioural cues and moments of mother-infant connection. Streamlining the information provided on maternal emotion regulation, and allowing increased use of clinical judgement to tailor intervention delivery, were suggested to optimise intervention feasibility and acceptability.

CONCLUSION

It is feasible and acceptable to implement VIPP with very young babies and their mothers experiencing perinatal mental health difficulties. A fully powered randomised controlled trial is required to establish intervention efficacy.

Predictive factors and treatment of postpartum mania: a representative case

Postpartum mania and psychosis puts both the person giving birth and their child at significant risk, so predicting its onset and determining effective treatment is crucial. Here, a representative case is presented of a patient started on an antidepressant during her pregnancy who suffered a postpartum manic episode with psychosis. The case describes many of the risk factors and treatment issues faced by clinicians when caring for patients with these symptoms in the postpartum period. Subsequent discussion provides guidance for clinicians to help predict postpartum mania and reviews factors that may increase the risk of its onset. The evidence for psychiatric treatment is also reviewed to both prevent and treat postpartum mania and psychosis.

Associations of maternal prenatal psychological symptoms and saliva cortisol with neonatal meconium microbiota: A cross-sectional study

Alterations in the diversity and relative abundances of the gut microbiome have been associated with a broad spectrum of medical conditions. Maternal psychological symptoms during pregnancy may impact on offspring development by altering the maternal and the foetal gut microbiome. We aimed to investigate whether self-reported maternal anxiety, depressive symptoms, and distress as well as saliva cortisol levels in late pregnancy alter the bacterial composition of the infant's meconium.

METHODS

A total of N = 100 mother-infant pairs were included. Maternal psychological symptoms were measured using psychological questionnaires (EPDS, PSS-10, STAI) at 34-36 weeks gestation and salivary cortisol was measured at 34-36 and 38 weeks gestation. Infant meconium samples were collected in the first five days postpartum and analysed using 16S rRNA amplicon sequencing.

RESULTS

Correlations showed that lower alpha diversity of the meconium microbiome was significantly associated with increased maternal prenatal depressive symptoms in late gestation (τ = -0.15, p = .04). Increased saliva cortisol AUCg at T2 was significantly related to higher beta diversity of the meconium samples (Pr(>F) = 0.003*). Pseudomonas was the most abundant phylum and was associated with maternal saliva cortisol total decline. No other associations were found.

CONCLUSIONS

Maternal prenatal depressive symptoms are associated with infant faecal microbiome alpha diversity, whereas maternal saliva cortisol AUCg is linked to increased beta diversity and total decline related to increased Psuedomonas. Future studies are warranted to understand how these microbiota community alterations are linked to child health outcomes.

Working with suicidal mothers during the perinatal period: a reflexive thematic analysis study with mental health professionals

BACKGROUND

Suicide is the leading cause of death in mothers postpartum and one of the most common causes of death during pregnancy. Mental health professionals who work in perinatal services can offer insights into the factors they perceive as being linked to mothers' suicidal ideation and behaviour, support offered to mothers and improvements to current practices. We aimed to explore the experiences and perceptions of perinatal mental health professionals who have worked with suicidal mothers during the perinatal period.

METHOD

Semi-structured interviews were conducted face-to-face or via telephone with mental health professionals working in perinatal mental health inpatient or community services across England. Data were analysed using reflexive thematic analysis.

RESULTS

From the professionals' (n = 15) accounts three main themes were developed from their interview data. The first, factors linked to suicidal ideation and behaviour, overarched two sub-themes: (1.1) the mother's context and (1.2) what the baby represents and what this means for the mother. These sub-themes described factors that professionals assessed or deemed contributory in relation to suicidal ideation and behaviour when a mother was under their care. The second main theme, communicating about and identifying suicidal ideation and behaviour, which outlined how professionals enquired about, and perceived, different suicidal experiences, encapsulated two sub-themes: (2.1) how to talk about suicide and (2.2) types of suicidal ideation and attempts. The third main theme, reducing suicidal ideation through changing how a mother views her baby and herself, focused on how professionals supported mothers to reframe the ways in which they viewed their babies and in turn themselves to reduce suicidal ideation.

CONCLUSION

Professionals highlighted many factors that should be considered when responding to a mother's risk of suicide during the perinatal period, such as the support around her, whether the pregnancy was planned and what the baby represented for the mother. Professionals' narratives stressed the importance of adopting a tailored approach to discussing suicidal experiences with mothers to encourage disclosure. Our findings also identified psychological factors that professionals perceived as being linked to suicidal outcomes for mothers, such as self-efficacy; these factors should be investigated further.

Postpartum Psychosis: A Proposed Treatment Algorithm

Background

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

Methods

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

Objective

To provide a treatment algorithm for the management of PPP based on available evidence.

Results

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

Conclusion

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.Reprinted from J Psychopharmacol 2023; 37:960-970, with permission from Sage Journals. Copyright © 2023.

Review of the Assessment and Management of Perinatal Mood and Anxiety Disorders

Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth. When poorly controlled, they are associated with worse obstetric outcomes, such as higher rates of preterm birth and unplanned cesarean delivery. They are also associated with suicide, a leading cause of perinatal maternal death. This article provides an overview of evidence-based recommendations for screening, assessment, and management of PMADs, including suicide risk assessment and management and pharmacological and nonpharmacological treatment options compatible with pregnancy and lactation. Although specialized reproductive psychiatrists can provide expert guidance for the management of PMADs, their scarcity means that most patients will not have access to this expert care and instead will seek guidance from general psychiatrists. This article provides a clinical guide for generalists that is based on the best current evidence, including recently released treatment guidelines.

Microglia are necessary for probiotics supplementation to improve impaired fear extinction caused by pregnancy stress in adult offspring of rats

The prevention and treatment of fear-related disorders in offspring affected by pregnancy stress remains challenging at clinic. Here, we examined the effects of gut microbiota of stressed pregnant rats on the fear extinction of their offsprings, and the potential mechanisms. We found that gut microbiota transplantation from rats with pregnancy stress to normal pregnant rats impaired fear extinction, induced microglial activation and synaptic phagocytosis, increased synapse loss in offsprings. Probiotics supplement during pregnancy stress partly normalized pregnancy stress-induced gut microbiota dysbiosis of pregnant rats, and promoted fear memory extinction, inhibited fear memory reappearance, and limited microglial activation and synaptic phagocytosis in offsprings. These data revealed that gut microbiota of stressed pregnant mother improved the development of fear-related disorders of offspring, which may be associated with microglial synaptic pruning.

Catatonia in the peripartum: A cohort study using electronic health records

BACKGROUND

Due to limited existing literature available on the presentation and treatment of catatonia in the peripartum, this retrospective descriptive cohort study aimed to examine demographic data, catatonic features, diagnoses pre- and post-catatonic episodes, treatment and the presence of obstetric complications.

METHODS

Individuals with catatonia were identified in a previous study using anonymised electronic healthcare records from a large mental health trust in South-East London. The presence of features from the Bush-Francis Catatonia Screening Instrument was coded by the investigators and longitudinal data were extracted from structured fields and free text.

RESULTS

21 individuals were identified from the larger cohort, each of whom experienced one episode of catatonia in the postpartum period, and all had had an inpatient psychiatric admission. 13 patients (62 %) presented after their first pregnancy and 12 (57 %) experienced obstetric complications. 11 (53 %) attempted breastfeeding and 10 (48 %) received a diagnosis of a depressive disorder following the episode of catatonia. The majority presented with immobility or stupor, mutism, staring and withdrawal. All were treated with antipsychotics and 19 (90 %) received benzodiazepines.

CONCLUSIONS

This study suggests that signs and symptoms of catatonia during the peripartum are similar to other catatonic presentations. However, the postpartum may be a period of high risk for catatonia and obstetric factors, such as birth complications, may be relevant.

National policies and programs for perinatal mental health in India: A systematic review

BACKGROUND

India is the most populous country in the world with millions of births annually. Perinatal mental disorders (PMDs) are prevalent worldwide including in India. This study was undertaken to evaluate how mental health is addressed in national maternity and mental health policies and programs in India.

METHODS

We conducted a systematic review of the national policies and programs in India related to maternity care and mental health. The identified policies and programs were analysed using health policy triangle framework.

RESULTS

Our search yielded 11 relevant documents and no peer reviewed publications. No specific national policy or program on maternal mental health could be identified. Universal access to health and mental health including for women and children was clearly articulated in both national mental health and maternity policies, which emphasised that access to mental health care and treatment is a fundamental right. There were few details about how the programs and policies were developed and no accounts of consultations with community members or service providers in their formation.

CONCLUSION

National maternity and mental health policies and programs in India appear not to consider perinatal mental health. There are promising state-based initiatives, but, given the disease burden of PMDs in India, the absence of a national policy leads to unrecognized and unmet needs of women in the states without these measures. These inequalities can be effectively minimized by well implemented national policies for perinatal mental health, accompanied by evidence-based locally tailored programs and interventions across the country.

Improvements in cardiovascular health over the perinatal period predicts lower postpartum psychological distress

Background

Adverse cardiovascular events during pregnancy (e.g., pre-eclampsia) occur at higher rates among individuals with pre-pregnancy overweight or obesity (body mass index [BMI]≥25kg/m2) and have been associated with postpartum depression. However, it is unclear whether cardiovascular health (CVH), defined more holistically than the absence of cardiovascular conditions in pregnancy, relates to postpartum psychological functioning. The present study examined whether changes in CVH during the perinatal period predicted postpartum psychological functioning among individuals with pre-pregnancy BMI≥25kg/m2.

Methods

Individuals (N=226; Mage=28.43±5.4 years; MBMI=34.17±7.15kg/m2) were recruited when their pregnancies were 12-20 weeks gestation (M=15.64±2.45 weeks) for a longitudinal study of health and well-being. Participants completed the Center for Epidemiological Studies Depression Scale (CES-D) and Perceived Stress Scale (PSS) and reported on CVH behaviors (dietary intake, physical activity, nicotine exposure, and sleep) at baseline and at 6-months postpartum. BMI and CVH behaviors were coded according to the American Heart Association's Life's Essential 8 to create a CVH score at both timepoints. Linear regression analyses were performed to examine whether change in CVH related to postpartum CES-D and PSS scores. Because sleep was only measured in a subset of participants (n=114), analyses were conducted with and without sleep included. Baseline CVH, CES-D and PSS scores, and demographic factors were included as covariates in all models.

Results

Improved CVH was associated with lower postpartum CES-D (β=-0.18, p<0.01) and PSS (β=-0.13, p=0.02) scores when excluding sleep. Compared to those whose CVH improved by >1SD from pregnancy to 6-months postpartum, individuals whose CVH worsened by >1SD scored 6.42 points higher on the CESD (MCESD=15.25±10.92 vs. 8.52±6.90) and 6.12 points higher on the PSS (MPSS=24.45±8.29 vs. 17.83±8.70). However, when including sleep, these relationships were no longer significant (ps>0.4).

Conclusions

Improvements in CVH from early pregnancy to 6-months postpartum were associated with lower postpartum depressive symptoms and perceived stress. However, these relationships were no longer significant when including sleep in the CVH metric, potentially due to the large reduction in sample size. These data suggest that intervening during pregnancy to promote CVH may improve postpartum psychological functioning among high-risk individuals.

High psychological stress levels related to delivery can increase the occurrence of postpartum mental disorders

Objective

The study sought to explore the relationship between high psychological stress levels related to delivery and postpartum mental disorders.

Methods

A total of 284 parturients were included in the study from July 2021 to January 2022. The stress level at 1 month postpartum was assessed by the Impact of Event Scale-Revised (IES-R). Parturients with an IES-R score ≤ 9 were included in the low psychological stress level group, and those with an IES-R score > 9 were included in the high psychological stress level group. The Edinburgh Postnatal Depression Scale (EPDS), Union Physio-Psycho-Social Assessment Questionnaire (UPPSAQ-70), Symptom Checklist-90 (SCL-90) and Mini-International Neuropsychiatric Interview (M.I.N.I.) were conducted at 42 ± 7 days postpartum to assess the mental health of parturients.The parturients' mental health after birth was assessed by the EPDS, UPPSAQ-70, and SCL-90. Semi-structured diagnostic interviews were conducted at 42 ± 7 days postpartum by using the M.I.N.I.

Results

The incidence rate of postpartum mental disorders was 20.42% (58/284), the incidence rates of postpartum depression, anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder were 17.96% (51/284), 11.97% (34/284), 4.58% (13/284) and 1.41% (4/284), respectively, and the comorbidity rate was 58.62% (34/58). A history of mental disorders and pregnancy complications were risk factors for postpartum depression (p = 0.028, p = 0.040, respectively); a history of mental disorders, a lack of physical exercise, partner violence and pregnancy complications were risk factors for postpartum anxiety disorders (p = 0.003, p = 0.007, p = 0.031, p = 0.048, respectively); and the delivery of female infants was a risk factor for postpartum obsessive-compulsive disorder (p = 0.022).The risk of postpartum depression, anxiety disorders and obsessive-compulsive disorder was 9.125 times (95% CI = 3.900 ~ 21.349, p < 0.01), 7.310 times (95% CI = 2.588 ~ 20.649, p < 0.01) and 6.259 times (95% CI = 1.347 ~ 29.093, p < 0.01) higher in postpartum women with high psychological stress levels related to delivery than in those with low psychological stress levels, respectively.

Conclusion

The incidence of postpartum mental disorders is high and has a positive correlation with the level of psychological stress. This may lead to a new perspective of the effect of psychological stress on postpartum mental disorders and attract more attention to other mental disorders in addition to postpartum depression.

Applications of dialectical behavioural therapy in the perinatal period: A scoping review

Psychological distress is the most common complication of pregnancy. High-risk concerns can include severe emotion dysregulation, suicidality and self-injury, and health risk behaviours, which bear substantial consequences for caregivers and families. Yet, effective, comprehensive interventions for high-risk caregivers have received limited attention. Dialectical behaviour therapy (DBT) is a frontline treatment for such concerns. Accordingly, we conducted a scoping review on the implementation of DBT in the perinatal period. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Seven studies were identified; study designs included case studies and single-arm pilot trials. Most studies used DBT-informed protocols with significant adaptations, few included multiple components of DBT (i.e. skills group, individual therapy, phone coaching and consultation team), and none met criteria for adherent delivery of all four modes of DBT treatment. Findings suggest DBT-informed interventions may be successfully implemented to treat a range of perinatal mental health symptoms, including borderline personality disorder, depression, anxiety, and post-traumatic stress, and to promote emotion regulation and positive parenting behaviours. While results provide preliminary support for perinatal DBT, this literature is scant and empirical rigour considerably lacking. Clinical implications and future directions are outlined to aid researchers and providers in addressing the ongoing perinatal mental health crisis and developing sorely needed interventions to address the needs of high-risk caregivers.

Compassion focused therapy for women in the perinatal period: a summary of the current literature

Introduction

Compassion focused therapy (CFT) is emerging as an effective psychological intervention to treat those experiencing mental health difficulties. CFT was adapted for women who are mothers during the perinatal period (from conception to 2 year postpartum). Although CFT is being delivered in NHS perinatal mental health services in the United Kingdom (UK), its current evidence-base for the treatment of women's mental health problems is unclear. As part of this Mini Review, we aimed to identify the current findings relating to CFT for women in the perinatal period (with or without a mental health condition) in order to identify any associated future research and clinical implications.

Method

A systematic search of two databases was undertaken. Included studies were required to meet the following criteria: (1) offered an intervention using CFT or perinatal CFT (P-CFT), (2) participants were women in the perinatal period, and (3) studies used a pre- and post-intervention study design. No language restrictions were used. A narrative synthesis was then conducted.

Results

Five studies, dating from 2018 to 2023, met the inclusion criteria. A total of 1,258 participants were included across those studies. Significant improvements in compassion-based outcomes (i.e., self-compassion, self-criticism/self-reassurance) were observed. However, these findings were primarily derived from non-clinical samples (n = 4) and could only be seen as preliminary.

Conclusion

Although these results are encouraging for mothers presenting with sub-clinical mental health symptoms, further research is clearly warranted to determine whether CFT/P-CFT may benefit mothers, including those presenting with more significant perinatal mental health difficulties.

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.

Development and preliminary validation of the Postpartum Psychotic Experiences Scale (PPES)

Despite the emerging research interest in postpartum psychotic experiences, there is still a lack of measures for specifically measuring this construct. The contribution of this paper is to design and validate a novel self-report measure, the Postpartum Psychotic Experiences Scale (PPES), to screen for attenuated psychotic symptoms during postpartum. This cross-sectional study was conducted from September 2022 until June 2023, enrolling 438 women 4-6 weeks after delivery. Starting from an initial pool of 22 items, both Exploratory Factor Analysis and Confirmatory Factor Analysis suggested that remaining 15 items loaded on one factor (α = 0.95). The PPES showed good convergent validity with the Prodromal Questionnaire-Brief scale (correlations >0.8) and good concurrent validity with postpartum depression and anxiety scales. A PPSE score of 8.5 (sensitivity=85.2%, specificity=78.6%) was defined as the optimal cutoff point. At this cutoff, 47% of participating women were considered at possible risk for postpartum psychosis. This study provides, for the first time, a specific self-report measure to assess postpartum PEs reliably and validly. We hope that the PPES will facilitate routine screening for PEs after childbirth among women who are predisposed to developing postpartum psychosis.

Psychiatric illness and pregnancy: A literature review

Background

Women of reproductive age frequently suffer from psychiatric disorders. The risk of developing anxiety, bipolar, and depressive disorders is especially significant during the perinatal period.

Objectives

This article aims to identify and discuss the different psychiatric conditions that might affect pregnant women and update the mother's carers about the recent and updated bidirectional relationship between psychiatric disease and adverse pregnancy outcomes, As well as the most updates in diagnostic and management strategies.

Methods

A thorough analysis of the literature was conducted using database searches in EMBASE, Science Direct, Google Scholar, Scopus, and PubMed to obtain the objectives and aim of the study.

Results

The presence of maternal mental illness during pregnancy has been linked to preterm delivery, newborn hypoglycemia, poor neurodevelopmental outcomes, and disturbed attachment. Placental anomalies, small-for-gestational-age foetuses, foetal discomfort, and stillbirth are among more undesirable perinatal outcomes.

Conclusions

Pregnancy-related psychiatric disorders are frequent. The outcomes for pregnant women, infants, and women's health are all improved by proper diagnosis and treatment of psychiatric problems.

Postpartum psychosis: A proposed treatment algorithm

BACKGROUND

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

METHODS

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

OBJECTIVE

To provide a treatment algorithm for the management of PPP based on available evidence.

RESULTS

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

CONCLUSION

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.