The association between maternal lifetime interpersonal trauma experience and perceived mother-infant bonding

BACKGROUND

Interpersonal traumas are common among expectant and new mothers and are found to have considerable impacts on women's mental health. These experiences may disrupt maternal perceptions of the mother-infant relationship, which is essential for healthy infant development, but findings are inconsistent. This study aims to explore associations between lifetime interpersonal traumas and their impact on self-reported mother-infant bonding.

METHODS

Secondary data analysis of a representative cohort of 453 women attending at a South London maternity service. Lifetime interpersonal trauma experience and its association with self-reported mother-infant bonding (Postpartum Bonding Questionnaire) was assessed in uni- and multivariable linear regressions, the latter adjusted to account for antenatal depressive and posttraumatic symptoms, measured using the Edinburgh Postnatal Depression Scale and Posttraumatic Stress Disorder Scale, and key sociodemographic risk factors.

RESULTS

Maternal lifetime trauma was not associated with perceived difficulties in mother-infant bonding at three months postnatal; however antenatal depressive symptoms, both with continuous EPDS score (0.33, 95% CI 0.17-0.50, p<0.001) and clinical cut-off ≥13 (4.26, 95% CI 2.02-6.49, p<0.001) were associated with self-reported bonding difficulties.

LIMITATIONS

The composite trauma measurement did not allow for a comprehensive assessment of individual trauma types.

CONCLUSIONS

There was no evidence for a link between maternal lifetime trauma experiences and self-reported bonding difficulties. However, an association between antenatal depressive symptoms and perceived postpartum bonding impairment was found. This highlights the importance of identification and treatment of depressive symptoms during pregnancy and offering women support in facilitating a positive mother-infant relationship.

An exploratory parallel-group randomised controlled trial of antenatal Guided Self-Help (plus usual care) versus usual care alone for pregnant women with depression: DAWN trial

BACKGROUND

Depression is a common antenatal mental disorder associated with significant maternal morbidity and adverse fetal outcomes. However, there is a lack of research on the effectiveness or cost-effectiveness of psychological interventions for antenatal depression.

METHODS

A parallel-group, exploratory randomised controlled trial across five hospitals. The trial compared Guided Self-Help, modified for pregnancy, plus usual care with usual care alone for pregnant women meeting DSM-IV criteria for mild-moderate depression. The trial objectives were to establish recruitment/follow-up rates, compliance and acceptability, and to provide preliminary evidence of intervention efficacy and cost-effectiveness. The primary outcome of depressive symptoms was assessed by blinded researchers using the Edinburgh Postnatal Depression Scale at 14-weeks post-randomisation.

RESULTS

620 women were screened, 114 women were eligible and 53 (46.5%) were randomised. 26 women received Guided Self-Help - 18 (69%) attending ≥4 sessions - and 27 usual care; n = 3 women were lost to follow-up (follow-up rate for primary outcome 92%). Women receiving Guided Self-Help reported fewer depressive symptoms at follow-up than women receiving usual care (adjusted effect size -0.64 (95%CI: -1.30, 0.06) p = 0.07). There were no trial-related adverse events. The cost-effectiveness acceptability curve showed the probability of Guided Self-Help being cost-effective compared with usual care ranged from 10 to 50% with a willingness-to-pay range from £0 to £50,000.

CONCLUSIONS AND LIMITATIONS

Despite intense efforts we did not meet our anticipated recruitment target. However, high levels of acceptability, a lack of adverse events and a trend towards improvements in symptoms of depression post-treatment indicates this intervention is suitable for talking therapy services.

Young pregnant women and risk for mental disorders: findings from an early pregnancy cohort

BACKGROUND

Young women aged 16-24 are at high risk of common mental disorders (CMDs), but the risk during pregnancy is unclear.AimsTo compare the population prevalence of CMDs in pregnant women aged 16-24 with pregnant women ≥25 years in a representative cohort, hypothesising that younger women are at higher risk of CMDs (depression, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder), and that this is associated with low social support, higher rates of lifetime abuse and unemployment.

METHOD

Analysis of cross-sectional baseline data from a cohort of 545 women (of whom 57 were aged 16-24 years), attending a South London maternity service, with recruitment stratified by endorsement of questions on low mood, interviewed with the Structured Clinical Interview DSM-IV-TR.

RESULTS

Population prevalence estimates of CMDs were 45.1% (95% CI 23.5-68.7) in young women and 15.5% (95% CI 12.0-19.8) in women ≥25, and for 'any mental disorder' 67.2% (95% CI 41.7-85.4) and 21.2% (95% CI 17.0-26.1), respectively. Young women had greater odds of having a CMD (adjusted odds ratio (aOR) = 5.8, 95% CI 1.8-18.6) and CMDs were associated with living alone (aOR = 3.0, 95% CI 1.1-8.0) and abuse (aOR = 1.5, 95% CI 0.8-2.8).

CONCLUSIONS

Pregnant women between 16 and 24 years are at very high risk of mental disorders; services need to target resources for pregnant women under 25, including those in their early 20s. Interventions enhancing social networks, addressing abuse and providing adequate mental health treatment may minimise adverse outcomes for young women and their children.Declaration of interestNone.

Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy

BACKGROUND

There is limited evidence on the prevalence and identification of antenatal mental disorders. Aims To investigate the prevalence of mental disorders in early pregnancy and the diagnostic accuracy of depression-screening (Whooley) questions compared with the Edinburgh Postnatal Depression Scale (EPDS), against the Structured Clinical Interview DSM-IV-TR.

METHOD

Cross-sectional survey of women responding to Whooley questions asked at their first antenatal appointment. Women responding positively and a random sample of women responding negatively were invited to participate.

RESULTS

Population prevalence was 27% (95% CI 22-32): 11% (95% CI 8-14) depression; 15% (95% CI 11-19) anxiety disorders; 2% (95% CI 1-4) obsessive-compulsive disorder; 0.8% (95% CI 0-1) post-traumatic stress disorder; 2% (95% CI 0.4-3) eating disorders; 0.3% (95% CI 0.1-1) bipolar disorder I, 0.3% (95% CI 0.1-1%) bipolar disorder II; 0.7% (95% CI 0-1) borderline personality disorder. For identification of depression, likelihood ratios were 8.2 (Whooley) and 9.8 (EPDS). Diagnostic accuracy was similar in identifying any disorder (likelihood ratios 5.8 and 6).

CONCLUSIONS

Endorsement of Whooley questions in pregnancy indicates the need for a clinical assessment of diagnosis and could be implemented when maternity professionals have been appropriately trained on how to ask the questions sensitively, in settings where a clear referral and care pathway is available. Declaration of interest L.M.H. chaired the National Institute for Health and Care Excellence CG192 guidelines development group on antenatal and postnatal mental health in 2012-2014.

Impact of dysfunctional maternal personality traits on risk of offspring depression, anxiety and self-harm at age 18 years: a population-based longitudinal study

BACKGROUND

The impact of underlying parental psychological vulnerability on the future mental health of offspring is not fully understood. Using a prospective cohort design, we investigated the association between dysfunctional parental personality traits and risks of offspring self-harm, depression and anxiety.

METHODS

The association between dysfunctional parental personality traits (monotony avoidance, impulsivity, anger, suspicion, and detachment), measured in both mothers and fathers when offspring were age 9 years, and risk of offspring depression, anxiety and self-harm at age 18 years, was investigated in a population-based cohort (ALSPAC) from over 8000 parents and children.

RESULTS

Higher levels of dysfunctional maternal, but not paternal, personality traits were associated with an increased risk of self-harm, depression, and anxiety in offspring. Maternal associations were best explained by the accumulation of dysfunctional traits. Associations were strongest for offspring depression: Offspring of mothers with three or more dysfunctional personality traits were 2.27 (1.45-3.54, p < 0.001) times as likely to be depressed, compared with offspring of mothers with no dysfunctional personality traits, independently of maternal depression and other variables.

CONCLUSIONS

The accumulation of dysfunctional maternal personality traits is associated with the risk of self-harm, depression, anxiety in offspring independently of maternal depression and other confounding variables. The absence of associations for equivalent paternal traits makes a genetic explanation for the findings unlikely. Further research is required to elucidate the underlying mechanism. Mothers with high levels of dysfunctional personality traits may benefit from additional support to reduce the risk of adverse psychological outcomes occurring in their offspring.

Depression: an exploratory parallel-group randomised controlled trial of Antenatal guided self help for WomeN (DAWN): study protocol for a randomised controlled trial

BACKGROUND

Depression is a common antenatal mental disorder and is associated with an increased risk of adverse effects on the fetus and significant morbidity for the mother; if untreated it can also continue into the post-natal period and affect mother-infant interactions. There has been little research evaluating the effectiveness or cost-effectiveness of antenatal psychological interventions for antenatal depression, particularly for mild to moderate disorders. International guidelines recommend a stepped care approach starting with Guided Self Help, and the aim of this exploratory trial is to investigate Guided Self Help modified for pregnancy.

METHODS

The DAWN trial is an exploratory randomised controlled trial of the effectiveness and cost-effectiveness of antenatal Guided Self Help, modified for pregnancy and delivered by National Health Service Psychological Wellbeing Practitioners. Antenatal Guided Self Help, in addition to usual care, is compared with usual care for pregnant women diagnosed with mild to moderate depression and mixed anxiety and depression, using the Structured Clinical Interview for DSM-IV Disorders. Modifications for pregnancy include perinatal mental health training, addressing pregnancy-specific worries and including sections on health issues in pregnancy and planning for parenthood. Women allocated to Guided Self Help will be seen for up to eight sessions by a Psychological Wellbeing Practitioner (including an initial assessment session); there will also be an appointment at 12 weeks after delivery. Research measures including the Edinburgh Postnatal Depression Scale (primary outcome) and other measures of depression, anxiety, quality of life and service use will be collected from women before random allocation, 14 weeks after random allocation and at 12 weeks after delivery. Potential psychological mechanisms of the intervention will be explored using the Pregnancy-Related Thoughts Questionnaire and the Metacognitive Awareness Questionnaire.

DISCUSSION

The DAWN trial is the first exploratory trial to investigate the efficacy of antenatal Guided Self Help for pregnant women with mild to moderate depression meeting DSM-IV diagnostic criteria. Recruitment started January 2015 and is expected to be completed by July 2016.

TRIAL REGISTRATION

ISRCTN registry: ISRCTN83768230 . Registered on 8 August 2014.

Perinatal psychiatric episodes: a population-based study on treatment incidence and prevalence

Perinatal psychiatric episodes comprise various disorders and symptom severity, which are diagnosed and treated in multiple treatment settings. To date, no studies have quantified the incidence and prevalence of perinatal psychiatric episodes treated in primary and secondary care, which we aimed to do in the present study. We designed a descriptive prospective study and included information from Danish population registers to study first-time ever and recurrent psychiatric episodes during the perinatal period, including treatment at psychiatric facilities and general practitioners (GPs). This was done for all women who had records of one or more singleton births from 1998 until 2012. In total, we had information on 822 439 children born to 491 242 unique mothers. Results showed first-time psychiatric episodes treated at inpatient facilities were rare during pregnancy, but increased significantly shortly following childbirth (0.02 vs 0.25 per 1000 births). In comparison, first-time psychiatric episodes treated at outpatient facilities were more common, and showed little variation across pregnancy and postpartum. For every single birth resulting in postpartum episodes treated at inpatient psychiatric facilities, 2.5 births were followed by an episode treated at outpatient psychiatric facility and 12 births by GP-provided pharmacological treatment. We interpret our results the following way: treated severe and moderate psychiatric disorders have different risk patterns in relation to pregnancy and childbirth, which suggests differences in the underlying etiology. We further speculate varying treatment incidence and prevalence in pregnancy vs postpartum may indicate that the current Diagnostic and Statistical Manual of Mental Disorders-5 peripartum specifier not adequately describes at-risk periods across moderate and severe perinatal psychiatric episodes.

Is infertility really associated with higher levels of mental distress in the female population? Results from the North-Trøndelag Health Study and the Medical Birth Registry of Norway

OBJECTIVE

To explore the effect of ever having tried to conceive for more than 12 months on levels of anxiety and depressive symptoms and to investigate if symptom levels of anxiety and depression in infertile women who remain childless, or go on to have children, respectively, differ from symptom levels in mothers without reports of infertility.

METHODS

Analyses were based on information from 12 584 Norwegian women aged 19-45 years who participated in the North-Trøndelag Health Study from 1995 to 1997 and data from the Medical Birth Registry of Norway. Anxiety and depressive symptoms were measured by the Hospital Anxiety and Depression Scale.

RESULTS

Having tried to conceive for more than 12 months (ever) was weakly associated with higher levels of depressive symptoms. In the categorical analyses, women with resolved infertility had higher levels of anxiety symptoms (B = 0.25 (95% confidence interval (CI) = 0.04-0.47)) and voluntarily childfree had lower levels of depressive symptoms (B = -0.05 (95% CI = -0.50 to -0.21)) than mothers without infertility. However, women with current primary or current secondary infertility had levels of anxiety and depression not significantly different from mothers without infertility.

CONCLUSION

At the population level, and from a longitudinal perspective, unresolved infertility is less burdensome than findings from studies on women seeking help for infertility would suggest.

Violent and non-violent crime against adults with severe mental illness

BACKGROUND

Little is known about the relative extent of crime against people with severe mental illness (SMI).

AIMS

To assess the prevalence and impact of crime among people with SMI compared with the general population.

METHOD

A total of 361 psychiatric patients were interviewed using the national crime survey questionnaire, and findings compared with those from 3138 general population controls participating in the contemporaneous national crime survey.

RESULTS

Past-year crime was experienced by 40% of patients v. 14% of controls (adjusted odds ratio (OR) = 2.8, 95% CI 2.0-3.8); and violent assaults by 19% of patients v. 3% of controls (adjusted OR = 5.3, 95% CI 3.1-8.8). Women with SMI had four-, ten- and four-fold increases in the odds of experiencing domestic, community and sexual violence, respectively. Victims with SMI were more likely to report psychosocial morbidity following violence than victims from the general population.

CONCLUSIONS

People with SMI are at greatly increased risk of crime and associated morbidity. Violence prevention policies should be particularly focused on people with SMI.

Mental illness and domestic homicide: a population-based descriptive study

OBJECTIVE

Approximately 10% of convicted homicide perpetrators in England and Wales have symptoms of mental illness at the time of homicide. The prevalence among perpetrators of adult domestic homicide is unclear.

METHODS

The study was a consecutive case series of all convicted adult domestic homicide perpetrators in England and Wales between 1997 and 2008. Sociodemographic, clinical, and offense characteristics were gathered from the United Kingdom Home Office, the Police National Computer, psychiatric court reports, and, for psychiatric patients, questionnaires completed by supervising clinicians.

RESULTS

A total of 1,180 perpetrators were convicted of intimate partner homicide, and 251 were convicted of homicide of an adult family member. Fourteen percent of perpetrators of intimate partner homicide and 23% of perpetrators of adult family homicide had been in contact with mental health services in the year before the offense; 20% of intimate partner homicide perpetrators and 34% of adult family homicide perpetrators had symptoms of mental illness at the time of offense. Perpetrators with symptoms of mental illness at the time of offense were less likely than perpetrators without symptoms to have previous violence convictions or history of alcohol abuse.

CONCLUSIONS

A significant minority of adult domestic homicide perpetrators had symptoms of mental illness at the time of the homicide. Most perpetrators, including those with mental illnesses, were not in contact with mental health services in the year before the offense. Risk reduction could be achieved through initiatives that encourage individuals with mental health problems to access mental health services and that develop closer interagency working, including between mental health services, police, social services, and domestic violence services.

Prevalence of experiences of domestic violence among psychiatric patients: systematic review

BACKGROUND

Domestic violence has been linked with many mental disorders, including anxiety, depression, post-traumatic stress disorder, eating disorders and psychosis.

AIMS

To estimate the prevalence (adult lifetime and past year) of different types of domestic violence experienced by men and women receiving psychiatric treatment.

METHOD

In a systematic review, a search of 18 electronic databases was supplemented by hand searching, citation tracking and updating a recent systematic review of criminal victimisation in psychiatric populations. Two reviewers independently extracted data and appraised study quality.

RESULTS

Forty-two studies were included. The median prevalence of lifetime partner violence reported in high-quality papers was 30% (interquartile range (IQR) 26-39) among female in-patients and 33% (IQR 21-53) among female out-patients. Among male patients, one high-quality study reported a lifetime prevalence of 32% across mixed psychiatric settings. No study included a control group.

CONCLUSIONS

Psychiatric patients experience a high prevalence of domestic violence but there is limited information on family (non-partner) domestic violence, the prevalence of emotional abuse and the extent of risk compared with non-psychiatric controls.

Smoking cessation in pregnant women with mental disorders: a cohort and nested qualitative study

OBJECTIVE

To investigate whether 1) pregnant smokers with mental disorders are less likely to accept referrals to smoking cessation services compared with pregnant smokers without disorders; 2) they experience specific barriers to smoking cessation.

DESIGN

Cohort study supplemented by cross-sectional survey and nested qualitative study.

SETTING

Three maternity services, London, UK.

POPULATION

Pregnant smokers with and without mental disorders.

METHODS

Case notes were examined on a cohort of 400 consecutive pregnant smokers; data were triangulated with routinely collected data on 845 pregnant smokers at two other sites; 27 pregnant smokers were interviewed using qualitative methods.

MAIN OUTCOME MEASURES

Acceptance of referral to smoking cessation services; perceived barriers to quitting.

RESULTS

Pregnant smokers with a mental disorder recorded by midwives were one-quarter of the cohort (97, 23%), were more likely to accept referral to smoking cessation services (69% versus 56%, adjusted odds ratio 1.70, 95% confidence interval 1.03-2.79), but more likely to still smoke at delivery (69% versus 56%, adjusted odds ratio 2.63, 95% confidence interval 1.41-4.92). Discussion about smoking was documented in 7.7% of subsequent antenatal visits in women with or without mental disorders. Pregnant smokers with diagnosed mental disorders reported that they and health practitioners did not prioritise smoking advice because of concern about adversely impacting mental health.

CONCLUSIONS

Pregnant women with mental disorders appear more motivated, yet find it more difficult, to stop smoking. Prioritisation of mental health over smoking may therefore lead to increasing health inequality for this group. Research into effective smoking cessation interventions is required for those with mental disorders.

Experiences of persons with type II diabetes receiving health coaching: an exploratory qualitative study

INTRODUCTION

The objective of this exploratory qualitative study was to examine the experience of persons living with type II diabetes who participated in a health coaching intervention.

METHODS

The researchers used a qualitative phenomenological hermeneutic research design to explore the experiences of people undergoing health coaching for self-management of their diabetes.

RESULTS

Qualitative data analysis resulted in three themes that best described participants' experience of health coaching for diabetes: (1) "the driving force," which described how health coaches helped clients to find powerful motivators for change; (2) "I'm not a child," which described how people wanted to be treated by the health coaches; and (3) "meeting the inner coach," which described how health coaches helped clients develop their own inner wisdom.

DISCUSSION

The participants' descriptions of coaching challenge a more traditional paradigm of expert-driven and information-laden diabetes education practices. The findings suggest that the process of health coaching may help persons with diabetes become confident self-managers of their diabetes.

Antenatal domestic violence, maternal mental health and subsequent child behaviour: a cohort study

OBJECTIVE

To investigate the long-term impact of antenatal domestic violence on maternal psychiatric morbidity and child behaviour.

DESIGN

Cohort study.

SETTING

Avon, UK.

POPULATION OR SAMPLE

A birth cohort of 13,617 children and mother dyads were followed to 42 months of age.

METHODS

Experiences of domestic violence and depressive symptoms were gathered at 18 weeks of gestation and up to 33 months after birth, together with maternal, paternal and child characteristics.

MAIN OUTCOME MEASURES

Child behavioural problems were assessed at 42 months using the Revised Rutter Questionnaire.

ANALYSIS

Logistic regression with the use of multiple imputation employing chained equations for missing data.

RESULTS

Antenatal domestic violence was associated with high levels of maternal antenatal (odds ratio [OR], 4.02; 95% confidence interval [CI], 3.4-4.8) and postnatal (OR, 1.29; 95% CI, 1.02-1.63) depressive symptoms after adjustment for potential confounders. Antenatal domestic violence predicted future behavioural problems at 42 months in the child before adjustment for possible confounding and mediating factors (OR, 1.87; 95% CI, 1.45-2.40); this association was not significant after adjustment for high levels of maternal antenatal depressive symptoms, postnatal depressive symptoms or domestic violence since birth.

CONCLUSIONS

Antenatal domestic violence is associated with high levels of both maternal antenatal and postnatal depressive symptoms. It is also associated with postnatal violence, and both are associated with future behavioural problems in the child at 42 months. This is partly mediated by maternal depressive symptoms in the ante- or postnatal period.

Domestic violence: responding to the needs of patients

Victims of domestic violence have increased contact with healthcare services, but may not always be identified as experiencing abuse. Guidelines advocate that healthcare professionals should enquire about abuse and receive training on how to respond appropriately to any disclosures. This article examines how improved identification and response to domestic violence by healthcare staff can improve care for patients.

Domestic violence and severe psychiatric disorders: prevalence and interventions

BACKGROUND

The lifetime prevalence of domestic violence in women is 20-25%. There is increasing recognition of the increased vulnerability of psychiatric populations to domestic violence. We therefore aimed to review studies on the prevalence of, and the evidence for the effectiveness of interventions in, psychiatric patients experiencing domestic violence.

METHOD

Literature search using Medline, PsycINFO and EMBASE applying the following inclusion criteria: English-language papers, data provided on the prevalence of or interventions for domestic violence, adults in contact with mental health services.

RESULTS

Reported lifetime prevalence of severe domestic violence among psychiatric in-patients ranged from 30% to 60%. Lower rates are reported for men when prevalence is reported by gender. No controlled studies were identified. Low rates of detection of domestic violence occur in routine clinical practice and there is some evidence that, when routine enquiry is introduced into services, detection rates improve, but identification of domestic violence is rarely used in treatment planning. There is a lack of evidence on the effectiveness of routine enquiry in terms of morbidity and mortality, and there have been no studies investigating specific domestic violence interventions for psychiatric patients.

CONCLUSIONS

There is a high prevalence of domestic violence in psychiatric populations but the extent of the increased risk in psychiatric patients compared with other populations is not clear because of the limitations of the methodology used in the studies identified. There is also very limited evidence on how to address domestic violence with respect to the identification and provision of evidence-based interventions in mental health services.

The impact of climate change on mental health (but will mental health be discussed at Copenhagen?)

Climate change will shortly be assuming centre stage when Copenhagen hosts the United Nations Climate Change Conference in early December 2009. In Copenhagen, delegates will discuss the international response to climate change (i.e. the ongoing increase in the Earth's average surface temperature) and the meeting is widely viewed as the most important of its kind ever held (http://en.cop15.dk/). International agreement will be sought on a treaty to replace the 1997 Kyoto Protocol. At the time of writing it is not known whether agreement will be reached on the main issues of reducing greenhouse gas emissions and financing the impacts of climate change, and it appears that the impact of climate change on mental health is unlikely to be on the agenda. We discuss here how climate change could have consequences for global mental health and consider the implications for future research and policy.

Antidepressant prevention of postnatal depression

BACKGROUND

Postnatal depression is a common and important complication of childbearing. Untreated depression can lead to potentially negative effects on the foetus and infant, in addition to serious morbidity for the mother. The use of antidepressants during pregnancy for prevention of postnatal depression is unclear, due to the possibility of adverse effects on the mother and developing foetus, and the difficulty of reliably identifying the women who would go on to develop postnatal depression.

OBJECTIVES

To evaluate the effectiveness of different antidepressant drugs in addition to standard clinical care in the prevention of postnatal depression. To compare the effectiveness of different antidepressant drugs and with any other form of intervention for postnatal depression i.e. hormonal, psychological or social support. To assess any adverse effects of antidepressant drugs in either the mother or the foetus/infant.

SEARCH STRATEGY

The register of clinical trials maintained and updated by the Cochrane Depression, Anxiety and Neurosis Group and the Cochrane Pregnancy and Childbirth Group.

SELECTION CRITERIA

Randomised studies of antidepressants alone or in combination with another treatment, compared with placebo or a psychosocial intervention in non-depressed pregnant women or women who had given birth in the previous six weeks (i.e. women at risk of postnatal depression)

DATA COLLECTION AND ANALYSIS

Data were extracted independently from the trial reports by the authors. Missing information was requested from investigators wherever possible. Data were sought to allow an "intention to treat" analysis.

MAIN RESULTS

Two trials fulfilled the inclusion criteria for this review. Both looked at women with a past history of postpartum depression. Nortriptyline (n=26) (Wisner 2001) did not show any benefit over placebo (n=25). Sertraline (n=14) Wisner 2004 reduced the recurrence of postnatal depression and the time to recurrence when compared with placebo (n=8). Intention to treat analyses were not carried out in either trial.

AUTHORS' CONCLUSIONS

It is not possible to draw any clear conclusions about the effectiveness of antidepressants given immediately postpartum in preventing postnatal depression and, therefore, cannot be recommended for prophylaxis of postnatal depression, due to the lack of clear evidence. Larger trials are needed which also include comparisons of antidepressant drugs with other prophylactic treatments to reflect clinical practice, and examine adverse effects for the foetus and infant, as well as assess womens' attitudes to the use of antidepressants at this time.

Psychiatric morbidity and cognitive representations of illness in chronic daily headache

OBJECTIVES

We studied patients with chronic daily headache (CDH) attending a headache clinic. Our hypothesis was that patients with anxiety or depression would have poorer functional status and differing cognitive representations of illness than would those without psychiatric morbidity.

METHODS

The sample consisted of 144 consecutive new patients. Patients underwent a semistructured interview and completed a prospective headache diary, the Hospital Anxiety and Depression Scale (HADS) and other health-related questionnaires.

RESULTS

Sixty patients (42%) were probable cases of anxiety or depression on the basis of their HADS score. These HADS-positive cases had longer, more severe headaches, were more worried about them, were more functionally impaired and believed that their illness would last longer. Principal components analysis revealed that the HADS-positive cases believed that psychological factors play a role in their headaches.

CONCLUSIONS

Psychological morbidity is high amongst CDH patients who attend specialist clinics. In addition to identifying those with high levels of psychological distress, the HADS can be used to predict those likely to have worse headaches and poorer functional ability.

The psychosocial outcome of pregnancy in women with psychotic disorders

OBJECTIVE

To investigate the psychosocial outcome of pregnancies in women with a history of psychotic disorder in an epidemiologically representative sample and to determine the predictors of having a baby looked after by social services in the first year of life.

METHOD

Historical matched controlled cohort study and nested case control study using the General Practice Research Database (GPRD), an anonymised primary care database, in women with a history of psychotic disorders who gave birth in 1996-1998 (199 cases and 787 controls).

RESULTS

Twenty-seven percent of cases had a psychotic episode and a further 38% had nonpsychotic depression in the first year after birth. Women with nonaffective psychoses were at a significantly higher risk of postnatal depression compared with controls (adjusted rate ratio 2.07, 95% CI 1.45-2.96, p<0.001). Cases were well supported with 72% in a cohabiting relationship and only 38% on benefits. The only significant predictor of parenting difficulties was recent contact with psychiatric services.

CONCLUSIONS

Women with a history of psychotic disorder are at high risk of psychiatric illness postpartum, particularly a twofold risk of postnatal depression, even if they have not been in contact with psychiatric services during pregnancy. However, this epidemiologically representative sample has better parenting outcomes than has been previously reported for specialist treated cases. Liaison between all professionals involved in the care of mothers with psychotic disorders during and after pregnancy is essential to optimise care for them and their families.

Predictors of parenting outcome in women with psychotic disorders discharged from mother and baby units

OBJECTIVE

To compare the social and clinical characteristics of mothers with psychotic disorders with parenting difficulties, with mothers with no significant parenting problems.

METHOD

Descriptive and case-control study.

RESULTS

Over half of the women with psychotic disorders admitted to psychiatric mother and baby units had a good outcome at the time of discharge--70% did not need social services supervision, and had no significant parenting problem as judged by clinical staff. Diagnosis was independently associated with all measures of poor parenting; compared with a diagnosis of psychotic depression, a diagnosis of schizophrenia was highly significantly associated with social services supervision [adjusted odds ratio (OR) 25.7; 95% CI 5.97, 111.05], and staff rated problems with emotional responsiveness (adjusted OR 3.39;95% CI 1.42, 8.08), practical baby care (adjusted OR 6.07; 95% CI 2.12, 17.39), and perceived risk of harm to baby (adjusted OR 7.81; 95% CI. 2, 30.53). Low social class and psychiatric illness in the partner were also significantly associated with poor parenting outcomes, including social services supervision (adjusted OR 3.88; 95% CI 2.07, 7.25 and 4.23; 95% CI 2.1, 8.55, respectively).

CONCLUSIONS

Although these associations do not demonstrate causality, these findings suggest preventative interventions targeting socio-economic difficulties, early treatment of psychosis, and detection and treatment of psychiatric problems in the partner may be helpful in improving parenting outcomes in these vulnerable families.

The general fertility rate in women with psychotic disorders

OBJECTIVE

This study determined the general fertility rate and age-specific fertility rates for women with psychotic disorders.

METHOD

This historical matched-cohort study of patient records from a primary care database (the General Practice Research Database) was carried out for women of childbearing age (15-44 years) with psychotic disorders.

RESULTS

The women with psychotic disorders (N=7,936) had a lower overall general fertility rate than the normal comparison subjects (N=23,023), although fertility was only significantly lower in the women aged 25 and above. This lower fertility rate was less marked in women with affective psychoses. There was no evidence that treatment with neuroleptics influenced the fertility rate in women with non-affective psychoses.

CONCLUSIONS

This study found markedly lower fertility rates in women with psychotic disorders than in matched normal comparison subjects, particularly in women with non-affective disorders. Knowledge of fertility rates in women with psychotic disorders is fundamental for clinicians and researchers, since it has implications for family planning services, prevention of obstetric complications, child-care support, and hypotheses about the etiology of these disorders.

Psychosocial characteristics and needs of mothers with psychotic disorders

BACKGROUND

It is not known whether mothers with psychotic disorders are clinically and socially distinct from women with psychoses who have not had children.

AIMS

To determine the proportion of mothers in an epidemiologically representative population of women with psychotic disorders, to examine the factors associated with having children, and to examine the factors associated with having children 'looked after' by social services.

METHOD

Descriptive analysis and two case-control studies.

RESULTS

Sixty-three per cent of women with psychotic disorders were mothers. There were no clinical differences between women with or without children, but mothers were more likely to be older and live in unsupported accommodation. Having had a 'looked after' child was associated with Mental Health Act detention, younger age, a forensic history and being Black African.

CONCLUSION

Many women with psychoses are mothers. Mothers with psychoses are as disabled and have as many needs as women with psychoses without children.

Autoimmune intervention by CD154 blockade prevents T cell retention and effector function in the target organ

The CD40-CD154 interaction is an attractive target for therapeutic intervention in many autoimmune disorders, including multiple sclerosis. Previously, we showed that CD154 blockade both inhibited the onset of experimental autoimmune encephalomyelitis and blocked clinical disease progression (relapses) in mice with established disease. The mechanism of this protection is poorly understood. Because CD154 plays a role in Th1 development, its blockade has been thought to promote anti-inflammatory Th2 responses. However, these conclusions have primarily been based on extrapolated data from in vitro experiments, which may not accurately reflect the more complex events occurring in vivo. In this paper we determine how the immune response develops under the influence of therapeutic CD154 blockade in vivo. We demonstrate that anti-CD154 treatment does not alter the early expansion of Ag-specific T cells in secondary lymphoid organs or result in deviation to a Th2-dominant response. Interestingly, the late expansion and retention of Th1 cells in the lymph nodes were markedly reduced following immunization of Ab-treated mice, and this coincided with a recompartmentalization of these cells to the spleen. Most importantly, anti-CD154 treatment eliminated the retention/expansion of encephalitogenic Th1 cells, but not their entry into the CNS. These data indicate that a major mechanism by which CD154 blockade protects against autoimmune disease is by controlling the amplitude of acute phase Th1 responses in the draining lymph nodes and by preventing the sustained expansion of effector cells within the target organ.

Quality of life after liver transplantation for alcoholic liver disease

There are few data on predictive factors for alcohol relapse or long-term functional outcome after liver transplantation for alcoholic liver disease (ALD). In all 56 surviving UK patients (47 men, 9 women; mean age: 51 years; range: 33 to 69 years) who underwent transplantation for ALD at King's College Hospital over a 10-year period, alcohol relapse and outcome were assessed by outpatient and case-note review and by postal questionnaire containing (1) the Nottingham Health Profile (NHP), (2) the Short-Form-36 (SF-36) Health Survey, and (3) a drug and alcohol questionnaire. At a median of 2.5 years (range: 0.5 to 10 years), 13 of the 47 respondents (28%) and 2 of the 9 nonrespondents (22%) had evidence of potentially harmful drinking (>3 units daily) at some time posttransplantation. An additional 13 patients admitted to drinking some alcohol at least once, corresponding to an overall relapse rate of 50%. The patients with harmful drinking (1) had started drinking regularly at a younger age (18 v 25 years; P =.01), (2) began drinking heavily at a younger age (30 v 40 years; P =.01), (3) had shorter pretransplantation abstinence periods (10 v 23 months; P =.02), and (4) had a longer time since transplantation (median, 5.7 v 1.5 years; P =.0004) than those with no or mild alcohol relapse. They were also more likely to report sleep disturbance (NHP sleep problem score, 45 v 16; P =.01) and use benzodiazepines regularly (7 of 13 v 3 of 34 patients; P =.002). Despite these differences, health dimension scores in the SF-36 and NHP posttransplantation were similar between the groups and to those of UK community controls. In the long term, at least 50% of the patients will drink again at some time posttransplantation, although at lower levels of alcohol intake than previously. Those patients with multiple predictive factors for alcohol relapse may be at greatest risk for harmful drinking and be the group that would benefit most from professional counseling. Overall, the quality of life after liver transplantation for ALD is high and broadly similar to the levels expected in the normal population.

Mechanisms of immunotherapeutic intervention by anti-CD40L (CD154) antibody in an animal model of multiple sclerosis

Relapsing experimental autoimmune encephalomyelitis (R-EAE) in the SJL mouse is a Th1-mediated autoimmune demyelinating disease model for human multiple sclerosis and is characterized by infiltration of the central nervous system (CNS) by Th1 cells and macrophages. Disease relapses are mediated by T cells specific for endogenous myelin epitopes released during acute disease, reflecting a critical role for epitope spreading in the perpetuation of chronic central CNS pathology. We asked whether blockade of the CD40-CD154 (CD40L) costimulatory pathway could suppress relapses in mice with established R-EAE. Anti-CD154 antibody treatment at either the peak of acute disease or during remission effectively blocked clinical disease progression and CNS inflammation. This treatment blocked Th1 differentiation and effector function rather than expansion of myelin-specific T cells. Although T-cell proliferation and production of interleukin (IL)-2, IL-4, IL-5, and IL-10 were normal, antibody treatment severely inhibited interferon-gamma production, myelin peptide-specific delayed-type hypersensitivity responses, and induction of encephalitogenic effector cells. Anti-CD154 antibody treatment also impaired the expression of clinical disease in adoptive recipients of encephalitogenic T cells, suggesting that CD40-CD154 interactions may be involved in directing the CNS migration of these cells and/or in their effector ability to activate CNS macrophages/microglia. Thus, blockade of CD154-CD40 interactions is a promising immunotherapeutic strategy for treatment of ongoing T cell-mediated autoimmune diseases.

The functional significance of epitope spreading and its regulation by co-stimulatory molecules

Epitope spreading is a process whereby epitopes distinct from and non-cross-reactive with an inducing epitope become major targets of an ongoing immune response. This phenomenon has been defined in experimental and natural situations as a consequence of acute or persistent infection and secondary to chronic tissue destruction that occurs during progressive autoimmune disease. We have investigated the functional significance of this process in the chronic stages of both autoimmune and virus-induced central nervous system (CNS) demyelinating disease models in the SJL/J mouse. During the relapsing-remitting course of experimental autoimmune encephalomyelitis (R-EAE) induced with defined encephalitogenic myelin peptides, CD4+ T cells specific for endogenous epitopes on both the initiating myelin protein (intramolecular epitope spreading) and distinct myelin proteins (intermolecular epitope spreading) are primed secondary to myelin destruction during acute disease and play a major functional role in mediating disease relapses. Similarly, epitope spreading to endogenous myelin epitopes appears to play a major functional role in the chronic-progressive course of Theiler's murine encephalomyelitis virus-induced demyelinating disease (TMEV-IDD), a virus-induced CD4+ T-cell-mediated immunopathology. In TMEV-IDD, myelin destruction is initiated by virus-specific CD4+ T cells which target virus epitopes persisting in CNS-derived antigen-presenting cells. However, the chronic stage of this progressive disease is associated with the activation of CD4+ T cells specific for multiple myelin epitopes. In both models, the temporal course of T-cell activation occurs in a hierarchical order of epitope dominance, spreading first to the most immunodominant epitope and progressing to lesser immunodominant epitopes. In addition, epitope spreading in R-EAE is regulated predominantly by CD28/B7-1 co-stimulatory interactions, as antagonism of B7-1-mediated co-stimulation using anti-B7-1 F(ab) fragments is an effective ameliorative therapy for ongoing disease. The process of epitope spreading has obvious important implications for the design of antigen-specific therapies for the treatment of autoimmune disease since these therapies will have to identify and target endogenous self epitopes associated with chronic tissue destruction.

CD72 ligation regulates defective naive newborn B cell responses

The biological basis for reduced Ig production by naive newborn B cells compared to adult peripheral blood B cells is not fully understood. In a Con A + IL-2 T cell-dependent system using "competent" adult T cells, adult B cells produced large amounts of IgM, IgG, and IgA, while cord B cells were restricted to low levels of only IgM production. Cord B cell activation was also diminished. The contribution of specific B-T cell contact-mediated events to the diminished cord B cell response in this system, using mAbs to CD40, CD28, CD80, and CD72, were investigated, as well as regulation of B cell Ig production by cytokines. alphaCD72 ligation increased cord B cell activation and IgM production, but did not affect adult B cells. Blocking alphaCD40 mAb inhibited cord B cell Ig production completely, but only partly inhibited adult B cell Ig production even at high concentration, suggesting a greater sensitivity of cord B cells to disruption of the CD40-CD40L interaction. Addition of IL-10 did not increase cord B cell Ig production, while adult B cell Ig production was increased. However, combined addition of IL-10 and alphaCD72 significantly increased cord B cell Ig production over that in the presence of either alphaCD72 or IL-10 alone, but had no effect on adult B cells over that of IL-10 alone. These data suggest that the diminished T cell-dependent response of cord B cells is due to reduced or absent CD72 ligation. CD72 ligation plays an important role in the induction of primary responses by naive B cells. CD72 modulation of naive B cell sensitivity to IL-10 stimulation may have implications in the induction of class switch, which is deficient in newborn B cells. Since all T cells express CD5 constitutively, these data also suggest the existence of another ligand for CD72.

Psychiatry in the allergy clinic: the nature and management of patients with non-allergic symptoms

Patients with multiple unexplained somatic symptoms attributed to allergy frequently present to physicians and often the physician fails to find evidence for allergic or immunological mechanisms underlying the presenting symptoms. This article discusses the social and cultural background to this disorder. We then consider current explanatory models for symptoms and finally, we consider appropriate management, starting with the initial consultation, the identification of psychiatric disorders when present, and concluding with suggestions for subsequent treatment and guidance on appropriate referral.

The psychiatric assessment of liver transplant patients with alcoholic liver disease: a review

Patients with severe alcoholic liver disease are receiving liver transplants in increasing numbers. Alcoholic liver transplant patients appear to have a good prognosis, yet alcoholic candidates may be rejected on psychiatric grounds alone. The role of the psychiatrist in the multidisciplinary assessment is discussed and the use of a number of predictors of outcome for alcoholic candidates considered. Studies examining these variables have many methodological limitations and it is therefore very difficult to draw any firm conclusions on their validity or reliability. Long-term prospective studies using appropriate measures of outcome should enable the liaison psychiatrist to provide more useful advice on the psychosocial outcome and treatment requirements of this growing group of patients.

A phase II trial of alternating chemotherapy in patients with inoperable non-small cell lung cancer

We assessed the efficacy and toxicity of alternating non-cross-resistant chemotherapy in the treatment of advanced NSCLC. Cycles of cisplatin, methotrexate, doxorubicin, and cyclophosphamide were alternated monthly with cisplatin and etoposide. Patients had measurable disease, ECOG performance status 0-3, no previous chemotherapy, and stage II (inoperable), III, or IV disease without brain metastases. Between 1988 and 1990, 28 patients were entered in the study: 20 patients (71%) had stage IV disease, 19 (68%) were evaluable for response and toxicity; 4 (21%) responded. There were 3 partial responders (16%) and 1 complete responder (5%). The mean duration of response was 60.5 weeks (range: 32-105+ weeks), and the median time to progression was 12 weeks (range: 8-105+ weeks). The median survival time for all 28 patients was 24 weeks (range: 3-153+ weeks). The most significant toxicity was grade 3-4 leukopenia experienced by 63% of patients, but there were no episodes of sepsis and no treatment-related deaths. This regimen of alternating cycles of cisplatin-containing chemotherapy is safe, but its efficacy is not superior to other combination chemotherapy regimens.

Hereditary spherocytosis and hematologic malignancy

We report the development of myeloproliferative disorders in two patients with hereditary spherocytosis diagnosed in adulthood. Eight previously reported cases of the coexistence of hereditary spherocytosis and hematologic malignancy are reviewed.

Public and private donor financing for health in developing countries

Among the many variables that influence the outcome of national health status in both developed and developing countries, the availability and efficiency of financing is critical. For 148 developing countries, annual public and private expenditures from domestic sources (1983) were estimated to be approximately $100 billion. For the United States alone, annual public and private costs for medical care are almost five times larger ($478 billion, 1988). In contrast to domestic expenditures, the total flow of donor assistance for health in 1986 was estimated to be $4 billion, approximately 5% of total current domestic expenditures by developing countries. Direct donor assistance for development purposes by the United States Government approximates 0.5% of the US federal budget (1988). Approximately 10% of all United States development assistance is allocated for health, nutrition, and population planning purposes. While the total health sector contribution is on the order of $500 million annually, the US contribution represents about 13% of health contributions by all external donors. In sub-Saharan Africa, all donor health allocations only reach 3.4% of total development assistance. While available data suggest that private and voluntary organizations contribute approximately 20% of total global health assistance, data reporting methods from private agencies are not sufficiently specific to provide accurate global estimates. Clearly, developing countries as a whole are dependent on the efficient use of their own resources because external financing remains a small fraction of total domestic financing. Nevertheless, improvement in health sector performance often depends on the sharing of western experience and technology, services available through external donor cooperation. In this effort, the available supply of donor financing for health is not restricted entirely by donor policy, but also by the official demand for external financing as submitted by developing countries. In perspective, the supply of financing for health greatly exceeds the receipt of well-articulated and officially approved proposals from developing countries. The major constraints that produce this imbalance are unfamiliarity of ministries of health with potential donor sources; passive approaches to external financing; unfamiliarity with proposal preparation; increasing competition within developing countries by competing sectors, such as industry and agriculture; limited numbers of trained personnel; and absence of an international system which is able to support developing countries in mobilizing external financing. Tested solutions to these issues have been applied in one geographic region.(ABSTRACT TRUNCATED AT 400 WORDS)

Captopril enhances in vitro human lymphocyte thymidine incorporation

Angiotensin-converting enzyme activity is present in human sarcoid as well as murine schistosome granulomas. Inhibition of angiotensin-converting enzyme by captopril results in decreased granuloma size in animals. Since captopril is used clinically to treat hypertension, its effect on human lymphocyte thymidine incorporation was determined. It was found that 5 X 10(-5) M and 10(-4) M captopril enhances lymphocyte thymidine uptake induced by 25 micrograms/ml phytohaemagglutinin-P. This suggests that captopril can alter immunological reactivity in man and that angiotensin-converting enzyme may have an immunological function.

Quantitative selectivity of contact-mediated intercellular communication in a metastatic mouse mammary tumor line

We have examined contact-mediated intercellular communication by measuring the transfer of thioguanine sensitivity to a hypoxanthine phosphoribosyltransferase (EC 2.4.2.8)-negative clone (66cl-4) selected from one subline isolated previously from a spontaneously arising mammary tumor of a BALB/cfC3H mouse. We tested other sublines from the same tumor and unrelated cell types for their ability to serve as 6-thioguanine nucleotide donors to 66cl-4 cells. The degree of communication, measured by the number of donor cells required to reduce the number of thioguanine-resistant colonies, varied with the donor cell type. The 66cl-4 line communicated with the parent cell line from which the thioguanine-resistant cell was selected and with other sublines from the parent tumor, with some unrelated tumor cells, and with some nonneoplastic cells (3T3, hamster kidney and lung fibroblasts, and mouse mammary epithelial cells). There was a quantitative difference in the amount of communication which took place with the various cells tested, but no pattern of difference could be discerned. Line 66cl-4 did not preferentially communicate with cells of epithelial versus fibroblast morphology, nor with tumor versus nontumor cells. The 66cl-4 cells retained the ability of their parent line to form metastatic tumors when injected s.c. into BALB/c mice. A quantitative selectivity of communication is thus expressed in these malignant metastatic cells, but it is apparently unrelated to either the morphological or malignant phenotype of the donor. Contact-mediated communication between tumor subpopulations may differentially affect growth and drug sensitivity within a tumor.

Evaluation of drug counselor training: a pilot study

A pilot evaluation study was conducted to explore the impact of a training course aimed at helping drug counselors establish effective therapeutic relationships with their clients. Counselor abilities to reflect accurate empathy, sensitivity to client values and attitudes, and use of specified problem-solving techniques were measured before and after training through counselor self-ratings and ratings of counselor behaviors provided by clients and supervisors. The preliminary findings reveal a trend toward improved drug counselor functioning along these dimensions following training. However, the findings also suggest that the greatest impact of training may be a shift in drug counselor self-perceptions toward more confidence in their own capability to establish effective therapeutic relationships.