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Weingarten SJ, Osborne LM. Review of the Assessment and Management of Perinatal Mood and Anxiety Disorders. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:16-24. [PMID: 38694149 PMCID: PMC11058917 DOI: 10.1176/appi.focus.20230023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
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.
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Affiliation(s)
- Sarah J Weingarten
- Department of Obstetrics and Gynecology (Weingarten, Osborne) and Department of Psychiatry (Osborne), Weill Cornell Medicine at NewYork-Presbyterian Hospital, New York, NY
| | - Lauren M Osborne
- Department of Obstetrics and Gynecology (Weingarten, Osborne) and Department of Psychiatry (Osborne), Weill Cornell Medicine at NewYork-Presbyterian Hospital, New York, NY
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O'Connor EA, Henninger ML, Perdue LA, Coppola EL, Thomas RG, Gaynes BN. Anxiety Screening: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2023; 329:2171-2184. [PMID: 37338868 DOI: 10.1001/jama.2023.6369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Importance Anxiety is commonly seen in primary care and associated with substantial burden. Objective To review the benefits and harms of screening and treatment for anxiety and the accuracy of instruments to detect anxiety among primary care patients. Data Sources MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022. Study Selection English-language original studies and systematic reviews of screening or treatment compared with control conditions and test accuracy studies of a priori-selected screening instruments were included. Two investigators independently reviewed abstracts and full-text articles for inclusion. Two investigators independently rated study quality. Data Extraction and Synthesis One investigator abstracted data; a second checked accuracy. Meta-analysis results were included from existing systematic reviews where available; meta-analyses were conducted on original research when evidence was sufficient. Main Outcomes and Measures Anxiety and depression outcomes; global quality of life and functioning; sensitivity and specificity of screening tools. Results Of the 59 publications included, 40 were original studies (N = 275 489) and 19 were systematic reviews (including ≈483 studies [N≈81 507]). Two screening studies found no benefit for screening for anxiety. Among test accuracy studies, only the Generalized Anxiety Disorder (GAD) GAD-2 and GAD-7 screening instruments were evaluated by more than 1 study. Both screening instruments had adequate accuracy for detecting generalized anxiety disorder (eg, across 3 studies the GAD-7 at a cutoff of 10 had a pooled sensitivity of 0.79 [95% CI, 0.69 to 0.94] and specificity of 0.89 [95% CI, 0.83 to 0.94]). Evidence was limited for other instruments and other anxiety disorders. A large body of evidence supported the benefit of treatment for anxiety. For example, psychological interventions were associated with a small pooled standardized mean difference of -0.41 in anxiety symptom severity in primary care patients with anxiety (95% CI, -0.58 to -0.23]; 10 RCTs [n = 2075]; I2 = 40.2%); larger effects were found in general adult populations. Conclusions and Relevance Evidence was insufficient to draw conclusions about the benefits or harms of anxiety screening programs. However, clear evidence exists that treatment for anxiety is beneficial, and more limited evidence indicates that some anxiety screening instruments have acceptable accuracy to detect generalized anxiety disorder.
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Affiliation(s)
- Elizabeth A O'Connor
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Michelle L Henninger
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Erin L Coppola
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Rachel G Thomas
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Bradley N Gaynes
- Gillings School of Global Public Health, University of North Carolina School of Medicine, Chapel Hill
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O'Connor EA, Perdue LA, Coppola EL, Henninger ML, Thomas RG, Gaynes BN. Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2023; 329:2068-2085. [PMID: 37338873 DOI: 10.1001/jama.2023.7787] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Importance Depression is common and associated with substantial burden. Suicide rates have increased over the past decade, and both suicide attempts and deaths have devastating effects on individuals and families. Objective To review the benefits and harms of screening and treatment for depression and suicide risk and the accuracy of instruments to detect these conditions among primary care patients. Data Sources MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022. Study Selection English-language studies of screening or treatment compared with control conditions, or test accuracy of screening instruments (for depression, instruments were selected a priori; for suicide risk, all were included). Existing systematic reviews were used for treatment and test accuracy for depression. Data Extraction and Synthesis One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Findings were synthesized qualitatively, including reporting of meta-analysis results from existing systematic reviews; meta-analyses were conducted on original research when evidence was sufficient. Main Outcomes and Measures Depression outcomes; suicidal ideation, attempts, and deaths; sensitivity and specificity of screening tools. Results For depression, 105 studies were included: 32 original studies (N=385 607) and 73 systematic reviews (including ≈2138 studies [N ≈ 9.8 million]). Depression screening interventions, many of which included additional components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptomatology after 6 to 12 months (pooled odds ratio, 0.60 [95% CI, 0.50-0.73]; reported in 8 randomized clinical trials [n=10 244]; I2 = 0%). Several instruments demonstrated adequate test accuracy (eg, for the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, the pooled sensitivity was 0.85 [95% CI, 0.79-0.89] and specificity was 0.85 [95% CI, 0.82-0.88]; reported in 47 studies [n = 11 234]). A large body of evidence supported benefits of psychological and pharmacologic treatment of depression. A pooled estimate from trials used for US Food and Drug Administration approval suggested a very small increase in the absolute risk of a suicide attempt with second-generation antidepressants (odds ratio, 1.53 [95% CI, 1.09-2.15]; n = 40 857; 0.7% of antidepressant users had a suicide attempt vs 0.3% of placebo users; median follow-up, 8 weeks). Twenty-seven studies (n = 24 826) addressed suicide risk. One randomized clinical trial (n=443) of a suicide risk screening intervention found no difference in suicidal ideation after 2 weeks between primary care patients who were and were not screened for suicide risk. Three studies of suicide risk test accuracy were included; none included replication of any instrument. The included suicide prevention studies generally did not demonstrate an improvement over usual care, which typically included specialty mental health treatment. Conclusions and Relevance Evidence supported depression screening in primary care settings, including during pregnancy and postpartum. There are numerous important gaps in the evidence for suicide risk screening in primary care settings.
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Affiliation(s)
- Elizabeth A O'Connor
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Erin L Coppola
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Michelle L Henninger
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Rachel G Thomas
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Bradley N Gaynes
- Gillings School of Global Public Health, University of North Carolina School of Medicine, Chapel Hill
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Nicholson J, Mazel S, Faughnan K, Silverman A. Mothers with Intellectual/Developmental Disabilities and Behavioral Health Conditions and Community Experts Provide Recommendations for Treatment/Services, Systems, and Research. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105876. [PMID: 37239601 DOI: 10.3390/ijerph20105876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/28/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
Mothers with intellectual and developmental disabilities (IDD) are vulnerable to perinatal complications and adverse outcomes. Their vulnerabilities may also be exacerbated by co-occurring behavioral health (BH) conditions. Their wellbeing may be compromised by a lack of tailored treatments or by treatments and services that are inaccessible, irrelevant, and/or ineffective. A five-session virtual Ideas Lab workshop series was implemented to bring together diverse community experts (n = 30), including mothers with IDD/BH, to discuss the experiences of mothers and set priorities for treatment/services, systems, and research. Participants completed background and evaluation surveys and brainstormed, grouped, and ranked items of importance, which fell into two broad categories: (1) cross-cutting themes drawn from lived experience with recommendations applicable to all substantive domains (i.e., accessibility, diversity, adverse experiences and trauma, and trust) and (2) substantive themes with specific recommendations for treatment/services and systems (i.e., services and supports, peer support, provider practices and training, and systems navigation/transformation). Research recommendations were generated in all discussions and emerged in relation to all themes, underscoring the importance of including mother-driven questions and priorities in research agendas and strengthening researcher training and skills to engage mothers with IDD/BH and other community members actively, and in meaningful ways.
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Affiliation(s)
- Joanne Nicholson
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02453, USA
| | - Shayna Mazel
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02453, USA
| | - Kristen Faughnan
- Schneider Institutes for Health Policy and Research, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02453, USA
| | - Allie Silverman
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02453, USA
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Runkle JD, Risley K, Roy M, Sugg MM. Association Between Perinatal Mental Health and Pregnancy and Neonatal Complications: A Retrospective Birth Cohort Study. Womens Health Issues 2023; 33:289-299. [PMID: 36621340 PMCID: PMC10213085 DOI: 10.1016/j.whi.2022.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 11/30/2022] [Accepted: 12/09/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Maternal mental health as an important precursor to reproductive and neonatal complications remains understudied in the United States, particularly in the Southeastern region, despite high medical costs, maternal morbidity, and infant burden. This study sought to estimate the incidence of perinatal mental health disorders and the associated increased risk of leading pregnancy and infant complications. METHODS A population-based retrospective birth cohort of childbirth hospitalizations and readmissions was constructed for women in South Carolina, 1999 to 2017. Prevalence rates were calculated for perinatal mood and anxiety disorders (PMAD), severe mental illness, and mental disorders of pregnancy (MDP). Poisson regression models using generalized estimating equations were used to estimate adjusted relative risks for the association between mental health conditions and severe maternal morbidity, hypertensive disorders of pregnancy, gestational diabetes, cesarean section, preterm birth, and low birthweight. RESULTS The most prevalent maternal mental condition was MDP (3.9%), followed by PMAD (2.7%) and severe mental illness (0.13%). PMAD was associated with a higher risk of severe maternal morbidity, hypertensive disorders of pregnancy, and cesarean section, as well as a higher risk of preterm birth and low birthweight infants. Severe mental illness was associated with low birthweight, hypertensive disorders of pregnancy, and cesarean section. Pregnant populations with MDP were more at risk for severe maternal morbidity, preterm birth, hypertensive disorders of pregnancy, low birthweight, and cesarean section. Each maternal mental health outcome was associated with an increased risk for hospital readmissions up to 45 days after childbirth. CONCLUSIONS Results demonstrate the escalating burden of PMAD and MDP for pregnant populations over time, with important consequences related to maternal and infant morbidity.
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Affiliation(s)
- Jennifer D Runkle
- North Carolina Institute for Climate Studies, North Carolina State University, Asheville, North Carolina.
| | - Kendra Risley
- North Carolina Institute for Climate Studies, North Carolina State University, Asheville, North Carolina
| | - Manan Roy
- Department of Nutrition and Health Care Management, Appalachian State University, Boone, North Carolina
| | - Margaret M Sugg
- Department of Geography and Planning, Appalachian State University, Boone, North Carolina
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Janiri D, Sampogna G, Albert U, Caraci F, Martinotti G, Serafini G, Tortorella A, Zuddas A, Fiorillo A, Sani G. Lithium use in childhood and adolescence, peripartum, and old age: an umbrella review. Int J Bipolar Disord 2023; 11:8. [PMID: 36781741 PMCID: PMC9925650 DOI: 10.1186/s40345-023-00287-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Lithium is one of the most consistently effective treatment for mood disorders. However, patients may show a high level of heterogeneity in treatment response across the lifespan. In particular, the benefits of lithium use may vary in special clinical conditions. The aim of this study was to test this hypothesis by conducting an umbrella review on the efficacy and safety of lithium in childhood and adolescence, peripartum and old age. METHODS We applied the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria (PRISMA) to identify systematic reviews/meta-analyses on the efficacy and/or safety of lithium in mood disorders in special clinical conditions: (i) childhood and adolescence; (ii) peripartum (pregnancy, postpartum and lactation); (iii) old age. The Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) tool was used to assess the risk of bias. Overlap in primary studies across systematic reviews was calculated through the Corrected Covered Area (CCA). RESULTS We included 20 independent studies, for a total of 8209 individuals treated with lithium. Regarding paediatric age, efficacy and safety results suggested that lithium may be superior to placebo in bipolar disorders (BD) and not associated with serious adverse events. Nevertheless, primary available data are very limited. Efficacy in paediatric major depressive disorder (MDD) is not clear. During peripartum, lithium use was superior to non-lithium in preventing mood episodes and it was associated with low risk of congenital anomalies and with normal child neurodevelopment. Regarding old age, limited evidence supported lithium as an effective treatment in BD and resistant MDD; low doses should be used in this population. Systematic reviews on paediatric age showed the lowest risk of bias (80% of the studies at low risk). The CCA range of included studies was 13-47%. CONCLUSIONS This umbrella review supports the use of lithium across the lifespan, including special clinical condition. Nevertheless, more studies with increased methodological homogeneity are needed.
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Affiliation(s)
- Delfina Janiri
- grid.8142.f0000 0001 0941 3192Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy ,grid.411075.60000 0004 1760 4193Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gaia Sampogna
- grid.9841.40000 0001 2200 8888Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Umberto Albert
- grid.5133.40000 0001 1941 4308Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy ,Department of Mental Health, Azienda Sanitaria Universitaria Giuliano Isontina - ASUGI, Trieste, Italy
| | - Filippo Caraci
- grid.8158.40000 0004 1757 1969Department of Drug and Health Sciences, University of Catania, 95125 Catania, Italy ,grid.419843.30000 0001 1250 7659Oasi Research Institute-IRCCS, 94018 Troina, Italy
| | - Giovanni Martinotti
- grid.412451.70000 0001 2181 4941Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D’Annunzio, 66100 Chieti, Italy
| | - Gianluca Serafini
- grid.5606.50000 0001 2151 3065Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy ,grid.410345.70000 0004 1756 7871IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alfonso Tortorella
- grid.9027.c0000 0004 1757 3630Department of Psychiatry, University of Perugia, Perugia, Italy
| | - Alessandro Zuddas
- grid.7763.50000 0004 1755 3242Department of Biomedical Sciences, Section of Neuroscience & Clinical Pharmacology, University of Cagliari, Cagliari, Italy ,Child & Adolescent Neuropsychiatry Unit, “A. Cao” Paediatric Hospital, Cagliari, Italy
| | - Andrea Fiorillo
- grid.9841.40000 0001 2200 8888Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Gabriele Sani
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168, Rome, Italy. .,Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
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Pharmacologic Treatment for Perinatal Mental Health Disorders. Obstet Gynecol 2022; 139:297-303. [DOI: 10.1097/aog.0000000000004638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022]
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