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Tauqeer F, Moen A, Myhr K, Wilson CA, Lupattelli A. Assessing decisional conflict and challenges in decision-making among perinatal women using or considering using antidepressants during pregnancy-a mixed-methods study. Arch Womens Ment Health 2023; 26:669-683. [PMID: 37480405 PMCID: PMC10491504 DOI: 10.1007/s00737-023-01341-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 06/17/2023] [Indexed: 07/24/2023]
Abstract
This study aims to investigate decisional conflict and elucidate challenges in decision-making among perinatal women using or considering using antidepressant (AD) during pregnancy. A sequential, mixed-methods study was employed among pregnant and postnatal women in Norway who had been offered ADs in the last 5 years. Quantitative data were obtained through an electronic questionnaire. Decisional conflict in pregnancy was assessed using the Decisional Conflict Scale (DCS) defined as either low (< 25) or moderate-high ( ≥ 25) (evaluated retrospectively for postnatal women). Logistic regression was used to identify factors associated with moderate-high decisional conflict. Qualitative data were collected through focus groups with pregnant and postnatal women, and an inductive approach was used for data analysis. Among 174 pregnant and 102 postnatal women, 67.8% and 69.6%, respectively, reported moderate-high decisional conflict during pregnancy. Unsatisfactory doctor-patient relationship was associated with greater likelihood of having moderate-high decisional conflict in pregnancy, both in pregnant (aOR = 1.20, 95% CI: 1.00-1.44) and postnatal women (aOR = 1.40, 95% CI: 1.08-1.82). Reported barriers to decision-making regarding AD use in pregnancy encompassed five DCS subscales: uninformed knowledge following contradictory research and unfamiliarity with authorised resources, unclear values due to emotional blunting and fear associated with AD use, inadequate support, uncertainty in decisions and ineffective decisions due to difficulty in finding personalised treatment, and diverging recommendations by the healthcare providers (HCPs). The quality of the interaction with the HCP plays a crucial role in managing decisional conflict and supporting informed decisions in the management of perinatal mental illness. This study highlights the need for increased provision of clear, evidence-based information by HCPs to facilitate shared decision-making and create personalised treatments for perinatal women considering AD use during pregnancy.
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Affiliation(s)
- Fatima Tauqeer
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.
| | - Anne Moen
- Faculty of Medicine, Institute for Health and Society, University of Oslo, Oslo, Norway
| | - Kirsten Myhr
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Claire A Wilson
- Section of Women's Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Angela Lupattelli
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
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Sanders J, Blaylock R, Dean C, Petersen I, Trickey H, Murphy C. Women's experiences of over-the-counter and prescription medication during pregnancy in the UK: findings from survey free-text responses and narrative interviews. BMJ Open 2023; 13:e067987. [PMID: 36858469 PMCID: PMC9990671 DOI: 10.1136/bmjopen-2022-067987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
OBJECTIVES To explore women's experiences of over-the-counter and prescription medication advice and use during pregnancy. DESIGN A study design consisting of an online survey and nested in-depth interviews with a subsample of participants. We analysed data from survey free-text responses and in-depth interviews using thematic analysis. Quantitative survey data is published elsewhere. SETTING The UK. PARTICIPANTS Women were eligible if living in the UK, aged 16-45 years, were pregnant or had been pregnant in the last 5 years regardless of pregnancy outcome. A total of 7090 women completed the survey, and 34 women who collectively had experienced 68 pregnancies were subsequently interviewed. RESULTS Medication prescribing and use during pregnancy was common. The prescribing, dispensing and taking of some advised medications were restricted through women's or prescribers' fear of fetal harm. Lack of adherence to national prescribing guidance, conflicting professional opinion and poor communication resulted in maternal anxiety, avoidable morbidity and women negotiating complex and distressing pathways to obtain recommended medications. In contrast, some women felt overmedicated and that pharmacological treatments were used without exploring other options first. CONCLUSION Increased translation of national guidance into practice and greater personalisation of antenatal care are needed to improve the safety, efficacy and personalisation of prescribing in pregnancy.
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Affiliation(s)
- Julia Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Rebecca Blaylock
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
| | | | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
| | | | - Clare Murphy
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
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Effectiveness of patient decision aids in women considering psychotropic medication use during pregnancy: a literature review. Arch Womens Ment Health 2021; 24:569-578. [PMID: 33751206 DOI: 10.1007/s00737-021-01118-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 02/26/2021] [Indexed: 10/22/2022]
Abstract
Women face complicated decisions regarding psychotropic medication use during pregnancy. Patient decision aids (PDAs) could be a valuable tool to assist with decision-making. The objective of this review was to evaluate the effectiveness of PDAs in this population. A systematic search of the literature was conducted using PRISMA guidelines. Three major databases were searched to identify articles published between 2006 and June 2020. Studies were included if they evaluated use of a PDA for women considering medication for mental illness during pregnancy. A total of 4629 titles were returned from the search; however, only three studies met inclusion criteria and were selected for analysis. Two were pilot randomised controlled trials in women considering antidepressant use during pregnancy, and one was a non-randomised study in women considering medication for the treatment of opioid use disorder (OUD). The PDAs had good acceptability across all three studies. The randomised trials assessed knowledge, decisional conflict, depression, and anxiety, with non-significant trends towards reduced decisional conflict and anxiety in the PDA groups. PDAs have the potential to assist women with mental illnesses to make decisions regarding medication use during pregnancy; however, current evidence is too limited to evaluate the effectiveness of PDAs for this population.
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Abstract
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.
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Affiliation(s)
- Louise M. Howard
- Section of Women's Mental Health, Health Service and Population Research DepartmentInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Hind Khalifeh
- Section of Women's Mental Health, Health Service and Population Research DepartmentInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
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Kaar SJ, Gobjila C, Butler E, Henderson C, Howes OD. Making decisions about antipsychotics: a qualitative study of patient experience and the development of a decision aid. BMC Psychiatry 2019; 19:309. [PMID: 31646985 PMCID: PMC6806500 DOI: 10.1186/s12888-019-2304-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 09/23/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Shared decision making is a widely accepted standard of patient-centred care that leads to improved clinical outcomes, yet it is commonly underutilised in the field of mental health. Furthermore, little is known regarding patient decision making around antipsychotic medication, which is often poorly adhered to. We aim to explore psychiatric patients' experiences of antipsychotic medication decision making in order to develop a patient decision aid to promote shared decision making. METHODS Focus groups were conducted with patients with chronic psychotic illnesses (n = 20) who had previously made a decision about taking or changing antipsychotic medication. Transcripts were coded and analysed for thematic content and continued until thematic saturation. These themes subsequently informed the development of a decision aid with the help of expert guidance. Further patient input was sought using the think aloud method (n = 3). RESULTS Twenty-three patients participated in the study. Thematic analysis revealed that 'adverse effects' was the most common theme identified by patients surrounding antipsychotic medication decision-making followed by 'mode and time of administration', 'symptom control' and 'autonomy'. The final decision aid is included to provoke further discussion and development of such aids. CONCLUSIONS Patients commonly report negative experiences of antipsychotic medication, in particular side-effects, which remain critical to future decision making around antipsychotic medication. Clinical encounters that increase patient knowledge and maximise autonomy in order to prevent early negative experiences with antipsychotic medication are likely to be beneficial.
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Affiliation(s)
- S J Kaar
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, PO63 De Crespigny Park, London, SE5 8AF, UK.
| | - C Gobjila
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, PO63 De Crespigny Park, London, SE5 8AF, UK
| | - E Butler
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, PO63 De Crespigny Park, London, SE5 8AF, UK
| | - C Henderson
- Health Service and Population Research, Psychological and Systems Sciences, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, SE5 8AZ, UK
| | - O D Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, PO63 De Crespigny Park, London, SE5 8AF, UK.,Psychiatric Imaging Group, MRC London Institute of Medical Sciences, Imperial College, Hammersmith Hospital, London, UK
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Litzky JF, Marsit CJ. Epigenetically regulated imprinted gene expression associated with IVF and infertility: possible influence of prenatal stress and depression. J Assist Reprod Genet 2019; 36:1299-1313. [PMID: 31127477 PMCID: PMC6642239 DOI: 10.1007/s10815-019-01483-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 05/09/2019] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Despite the growing body of research implying an impact of in vitro fertilization (IVF) on imprinted genes and epigenetics, few studies have examined the effects of underlying subfertility or prenatal stress on epigenetics, particularly in terms of their role in determining infant birthweights. Both subfertility and prenatal stressors have been found to impact epigenetics and may be confounding the effect of IVF on epigenetics and imprinted genes. Like IVF, both of these exposures-infertility and prenatal stressors-have been associated with lower infant birthweights. The placenta, and specifically epigenetically regulated placental imprinted genes, provides an ideal but understudied mechanism for evaluating the relationship between underlying genetics, environmental exposures, and birthweight. METHODS AND RESULTS In this review, we discuss the impacts of IVF and infertility on birthweight, epigenetic mechanisms and genomic imprinting, and the role of these mechanisms in the IVF population and discuss the role and importance of the placenta in infant development. We then highlight recent work on the relationships between infertility, IVF, and prenatal stressors in terms of placental imprinting. CONCLUSIONS In combination, the studies discussed, as well as two recent projects of our own on placental imprinted gene expression, suggest that lower birthweights in IVF infants are secondary to a combination of exposures including the infertility and prenatal stress that couples undergoing IVF are experiencing. The work highlighted herein emphasizes the need for appropriate control populations that take infertility into account and also for consideration of prenatal psychosocial stressors as confounders and causes of variation in IVF infant outcomes.
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Affiliation(s)
- Julia F Litzky
- Department of Epidemiology, Geisel School of Medicine at Dartmouth College, Hanover, NH, 03755, USA
| | - Carmen J Marsit
- Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, CNR 202, Atlanta, GA, 30322, USA.
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Breadon C, Kulkarni J. An update on medication management of women with schizophrenia in pregnancy. Expert Opin Pharmacother 2019; 20:1365-1376. [DOI: 10.1080/14656566.2019.1612876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Carolyn Breadon
- Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Australia
| | - Jayashri Kulkarni
- Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Australia
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Zullino S, Simoncini T. Impact of selective serotonin reuptake inhibitors (SSRIs) during pregnancy and lactation: a focus on short and long-term vascular effects. Vascul Pharmacol 2018; 108:74-76. [PMID: 29803894 DOI: 10.1016/j.vph.2018.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
SSRIs are the first choice for the treatment of mood disorders during pregnancy and lactation. Despite the known side effects, the benefits/risks balance suggests their use. Hypertensive disorders of pregnancy (HDP) and Intrauterine growth restriction (IUGR) are the main vascular effects of these drugs, with mechanisms that involves endothelial dysfunction in feto-placental system. These data are supported by animal models, even if
preliminary findings are not yet adequately supported by molecular and clinical data.
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Affiliation(s)
- S Zullino
- Department of Experimental and Clinical Medicine, Division of Obstetrics and Gynecology, University of Pisa, Italy.
| | - T Simoncini
- Department of Experimental and Clinical Medicine, Division of Obstetrics and Gynecology, University of Pisa, Italy
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Abstract
This article describes psychiatric emergencies in pregnant women. The perinatal period is a time of psychiatric vulnerability. Up to 1 in 6 pregnant women experience major depressive disorder, and 1 in 4 pregnant women with bipolar disorder experience mood exacerbation. We discuss the management of severe mental illness in pregnancy, risk to mother and child of untreated psychiatric illness in pregnancy, risk of relapse of psychiatric disorders in pregnancy with medication discontinuation, psychopharmacologic considerations of teratogenicity and other fetal adverse effects, acute agitation in the pregnant patient, suicidality in pregnancy, and emergency considerations related to substance use disorders.
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Leong C, Raymond C, Château D, Dahl M, Alessi-Severini S, Falk J, Bugden S, Katz A. Psychotropic Drug Use before, during, and after Pregnancy: A Population-Based Study in a Canadian Cohort (2001-2013). CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:543-550. [PMID: 28545329 PMCID: PMC5546669 DOI: 10.1177/0706743717711168] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe the extent of increase in use and the rate of continuation versus discontinuation of psychotropic agents before, during, and after pregnancy. METHODS Rates of psychotropic use (antidepressants, anxiolytic/sedative-hypnotics, antiepileptics, antipsychotics, lithium, stimulants) among women with a hospital-recorded pregnancy outcome were assessed using databases at the Manitoba Centre for Health Policy. Rate of use was defined as ≥1 prescription over the total number of pregnancies in the 3-12 months before pregnancy, 0-3 months before pregnancy, during pregnancy, or 3 months after pregnancy. Continued use was defined as ≥2 prescriptions with gap ≤14 days. Poisson regression was used to analyze trends. RESULTS Over the study period, a psychotropic drug was used before, during, or after pregnancy in 41,923 of 224,762 pregnancies. From 2001 to 2013, psychotropic use increased 1.5-fold from 11.1% to 16.2% ( p < 0.0001) in the 3-12 months before pregnancy, 1.6-fold from 6.4% to 10.5% ( p < 0.0001) in the 3 months before pregnancy, 1.8-fold from 3.3% to 6.0% ( p < 0.0001) during pregnancy, and 1.5-fold from 6.2% to 9.5% ( p < 0.0001) in the 3 months postpartum. Among the 13,579 women who received at least 1 psychotropic agent in the 3 months prior to pregnancy, 38.5% stopped the agent prior to pregnancy and only 10.3% continued use throughout pregnancy. Continued use throughout pregnancy was higher (56.9%) among the 6693 women who received at least 2 prescriptions for a psychotropic agent and were at least 80% adherent in the 3 months prior to pregnancy. CONCLUSION The use of psychotropic agents increased over 12 years. The safety of continuing versus discontinuing these agents during pregnancy remains uncertain, but we observed a decrease in psychotropic drug use during the pregnancy period.
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Affiliation(s)
- Christine Leong
- 1 College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Colette Raymond
- 2 Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Dan Château
- 2 Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Matthew Dahl
- 2 Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Silvia Alessi-Severini
- 1 College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Jamie Falk
- 1 College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Shawn Bugden
- 1 College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Alan Katz
- 2 Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
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Development of a mother and baby unit contraception assessment tool. Arch Womens Ment Health 2016; 19:1129-1140. [PMID: 27664103 DOI: 10.1007/s00737-016-0665-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/02/2016] [Indexed: 10/21/2022]
Abstract
Unplanned pregnancies are a unique, yet significant risk factor in perinatal mental health. Our aim was to create an assessment tool to assess mother's views on contraception as part of the discharge planning process. We used a quantitative-qualitative approach. A clinician-guided questionnaire was completed by patients prior to their discharge from hospital and analysed using Microsoft Excel. Semi-structured interviews were used to explore views regarding family planning in greater depth. Interviews were recorded and transcribed verbatim onto Microsoft Word. Emerging themes were identified using a grounded theory thematic analysis approach. Eighteen inpatients were assessed at the Bethlem Mother and Baby Unit over a 4-month period (May-August 2015). Half of the women stated that the pregnancy was unplanned. The most common contraception methods used were condoms, followed by no method/natural cycle technique. Forty-four percent felt unsure of contraception options available and were keen for further advice and referral to family planning services. Interestingly, almost all the women interviewed stated that their experience of perinatal mental illness had changed their views on having more children. The contraception assessment tool is a short, simple questionnaire that can be adopted across inpatient and community settings. In cooperating family, planning into the discharge care plan could be protective in preventing future unplanned pregnancies in women at high risk of perinatal mental illness relapse. Performing the assessment also provided an added opportunity for psycho-education regarding reproductive health and medication use during the perinatal period. The tool also encouraged liaison with GPs and local family planning services.
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