Factors affecting female sexual well-being: a 5-year follow-up of a randomised clinical trial on post-abortion contraception

INTRODUCTION

Sexual well-being is associated with general well-being. Several factors, such as overweight, infertility, anxiety and sex hormones, also play a role, but the effects of hormonal contraception remain a point of debate. We characterised the factors associated with sexual well-being in fertile-aged women following induced abortion.

METHODS

A 5-year follow-up of a nested, longitudinal, cohort study examining the effects of routine provision of intrauterine contraception as part of abortion care. Sexual well-being, anxiety and quality of life were assessed annually using validated questionnaires (McCoy Female Sexuality Questionnaire, State-Trait Anxiety Inventory and EuroQoL), along with data on general and reproductive health, and relationship status. Of the 742 women participating in the trial, 290 (39%) provided sufficient follow-up data and were included in this study.

RESULTS

Based on trajectories of McCoy scores across the 5-year follow-up, two groups were identified: those with stable and higher (n=223, 76.9%) and those with declining sexual well-being (n=67, 23.1%). Women in the group of declining sexual well-being had significantly higher levels of anxiety and lower quality of life at all time points. They also had chronic diseases more often and were less happy in their relationships. No differences were found in method of contraception when classified as hormonal versus non-hormonal, or long-acting versus short-acting reversible contraception.

CONCLUSIONS

Lower anxiety and higher quality of life are associated with stable and higher sexual well-being. Method of contraception or relationship status are not associated with sexual well-being during long-term follow-up in fertile-aged women.

Contraceptive plans and purchase after an induced abortion: A nationwide register study from Finland

OBJECTIVES

To examine the types of hormonal contraceptive methods chosen at the time of the abortion, and how they correspond to post-abortion hormonal contraceptive purchase.

STUDY DESIGN

This was a prospective register-based study. We identified the present cohort of 8428 women undergoing induced abortion between July 1, 2017 and December 31, 2018, using the Prescription Centre, Social Insurance Institution database and the Finnish National Register of Induced Abortions. From the Register of Induced Abortions, we gathered information on planned post-abortion contraception. The redeemed prescriptions of hormonal contraception were identified from the Prescription Centre until December 31, 2019. We analyzed the hormonal contraceptive methods planned at the time of the abortion, and how they corresponded to hormonal contraceptive purchase during the 1-year follow-up. We also assessed factors (age, socioeconomic status, education, civil status, and reproductive history) affecting post-abortion contraceptive purchase by using Poisson regression models.

RESULTS

At the time of the abortion, 83% (n = 7023) of the women were planning to start using hormonal contraception. Planning any hormonal contraception at the time of the abortion was associated with a higher probability to purchase hormonal contraception after the abortion (incidence rate ratio [IRR] 2.30, 95% confidence intervals [CI] 2.07-2.55), especially in cases of the vaginal ring (IRR 42.66, 95% CI 33.89-53.71) and contraceptive patch (IRR 156.33, 95% CI 111.31-219.55). The following variables were associated with lower incidence rates for purchasing hormonal contraception after the abortion: educational level of bachelor at the highest or missing information on education, civil status as married or divorced, and history of delivery or induced abortion.

CONCLUSIONS

The majority of women undergoing abortion plan to use hormonal contraceptive method for post-abortion contraception. Planning any hormonal contraceptive method at the time of an induced abortion is an important predictor of purchasing the method within the year after the abortion.

IMPLICATIONS

Hormonal contraceptive purchase after an abortion is associated with pre-abortion contraceptive planning. Many background factors for not purchasing hormonal contraception can be identified, which may guide counseling dedicated to these groups.

The Relationship Between Mood and Sleep in Different Female Reproductive States

Mood and sleep are tightly interrelated. Mood and sleep symptoms and disorders are more common in women than in men and often associated with reproductive events. This article reviews the current literature on the reciprocal relationships between mood and sleep across reproductive phases in women, such as menstrual cycle and related disorders, pregnancy, climacteric, and use of hormonal contraception and hormone replacement therapy. Mood and sleep symptoms seem to covary in relation to physiologic and pathologic reproductive conditions, although the relationship seems more clear for subjective than objective sleep.

Hormonal contraception use and insomnia: A nested case-control study

Evidence is limited concerning possible associations between the use of hormonal contraception and insomnia. We applied the nested case-control design on a nationwide sample of women, aged 15-49 years, derived from national health care registries to characterize the association between the use of hormonal contraception and the occurrence of insomnia. There were altogether 294,356 users and 294,356 non-users of hormonal contraception. 11,105 new cases of insomnia emerged among the 1,148,969 person-years of the follow-up period of two years. All the significant associations of hormonal contraception with insomnia emerged among the participants aged 34 years or younger, and if only the tertiary care data was concerned, among the those aged 15-19 years. The users of the fixed combination of drospirenone and ethinylestradiol as well as that of cyproterone and ethinylestradiol had significantly decreased odds for insomnia, whereas the users levonorgestrel-releasing intrauterine devise as well as those of vaginal ring with etonogestrel and ethinylestradiol had significantly increased odds for insomnia as compared with non-users. Our findings suggest that different products prescribed for hormonal contraception may be differentially associated with the occurrence of insomnia.

Metabolomics profile of 5649 users and non-users of hormonal intrauterine devices in Finland

BACKGROUND

Use of hormonal intrauterine devices has grown during the last decades. Although the hormonal intrauterine devices act mostly via local effects on uterus, measurable concentrations of levonorgestrel are absorbed into the systemic circulation. The possible metabolic changes and large scale biomarker profiles associated with the hormonal intrauterine devices have not yet been studied in detail.

OBJECTIVES

To examine, through the metabolomics approach, the metabolic profile of the hormonal intrauterine device use, its associations as a function of the duration of use, as well as those with after discontinuation of the hormonal intrauterine device use.

STUDY DESIGN

The study consists of cross-sectional analyses of five population-based surveys (FINRISK and FinHealth studies), spanning 1997-2017. All fertile aged (18-49 years) participants in the surveys with available information on hormonal contraceptive use and metabolomics data (n=5649), were included in the study. Altogether 211 metabolic measures in users of hormonal intrauterine devices (n=1006) were compared to those in non-users of hormonal contraception (n=4643) via multivariable linear regression models. In order to allow the comparison across multiple measures, association magnitudes are reported in SD units of difference in biomarker concentration compared to the reference group.

RESULTS

After adjustment for covariates, levels of 141 metabolites differed in current users of hormonal intrauterine devices compared to non-users of hormonal contraception (median difference in biomarker concentration: 0.09 SD): lower levels of particle concentration of larger lipoprotein subclasses, triglycerides, cholesterol and derivatives, apolipoproteins A and B, fatty acids, glycoprotein acetyls and aromatic amino acids. The metabolic pattern of the hormonal intrauterine device use did not change according to the duration of use. When comparing previous users and never-users of hormonal intrauterine devices, no significant metabolic differences emerged.

CONCLUSIONS

The use of hormonal intrauterine devices was associated with several moderate metabolic changes, previously associated with reduced arterial cardiometabolic risk. The metabolic effects were independent of the duration of use of the hormonal intrauterine devices. Moreover, the metabolic profiles were similar after discontinuation of the hormonal intrauterine devices and in never-users.

Are empathy profiles and perceived social support associated with depressive and grief-related symptoms in suicide survivors?

OBJECTIVE

To investigate the link between empathy, perceived social support, and depressive and grieving symptoms in suicide survivors.

METHODS

Scores on the Beck Depression Inventory (BDI), Inventory of Complicated Grief (ICG), Prolonged Grief Disorder (PGD), Interpersonal Reactivity Index (IRI), and the Social Support section of the Interpersonal Questionnaire were collected from 265 survivors. Relations were tested via multivariate regression models.

RESULTS

Lower Perspective Taking (PT) was related with higher levels of BDI score, and higher Personal Distress (PD) was associated with higher BDI, ICG, and PGD scores. Higher levels of Social Support were related with higher BDI and ICG (but not PGD) scores.

CONCLUSION

Empathic PD and PT, and perceived social support are differently associated with depression and grief-related symptoms. Empathy-focused psychotherapies and empowerment of social support may reduce symptoms in suicide survivors.

Use of hormonal contraception and attempted suicide: a nested case-control study

Introduction

In Finland more than 40% of fertile aged women used some type of hormonal contraception (HC) in the period 2010-2013. A proportion of women using HC complains of side effects, including mood symptoms. The relationship between the use of HC and the risk of attempted suicide (AS) is still a matter of debate.

Objectives

To assess the association of the use of HC with the risk of AS during 2017-2019.

Methods

Data were retrieved from the Prescription Centre, Care Register of Health Care, Register of Primary Health Care Visits and Statistics Finland. A total of 587 823 women, aged 15-49 years, using and not using HC in 2017 were analysed in the initial incidence study. All incident AS cases during 2018-2019, and their 4:1 age-matched controls (1 174 346 person-years) were analysed in a nested case-control setting via conditional logistic regression models.

Results

Altogether 818 AS cases occurred during the follow-up (incidence rate: 0.70/1000 person-years, 95% CI 0.65–0.75), with an IRR of HC vs. no-HC use of 0.73 (0.63–0.83). Current use (in the 180 days before the event) of estradiol- or ethinylestradiol-containing HC was associated with a lower risk of AS (0.53, 0.33–0.87; 0.49, 0.37–0.64, respectively) compared to non-use of HC. After controlling for covariates (marital and socioeconomic status, education level, use of psychotropic medications), only current use of HC containing ethinylestradiol remained significant (0.39, 0.23–0.65).

Conclusions

A lower risk of AS is associated with the use of HC, and specifically of ethinylestradiol-containing HC.

Disclosure

No significant relationships.

Systemic hormonal contraception and risk of venous thromboembolism

INTRODUCTION

The increased risk of venous thromboembolism associated with the use of hormonal contraception is well recognized, but evidence regarding hormonal contraception containing natural estradiol is limited. This study aimed to assess the associations between the patterns of use of different systemic hormonal contraceptives and the risk of venous thromboembolism during 2017-2019.

MATERIAL AND METHODS

All fertile-aged women (15-49 years) living in Finland in 2017 and using hormonal contraception in 2017 and their 1:1 age- and residence-matched controls not using hormonal contraception in 2017 (altogether 587 559 women) were selected from the Prescription Centre. All incident venous thromboembolism cases during 2018-2019 and their 4:1 age-matched controls were further analyzed in a prospective nested case-control design to assess the associations between the use (starting, stopping, continuous vs no use) of different hormonal contraception types and venous thromboembolism.

RESULTS

Altogether, 1334 venous thromboembolism cases occurred during the follow-up period (incidence rate 1.14 per 1000 person-years, 95% confidence interval [CI] 1.08-1.20), with an incidence rate ratio of hormonal contraception vs no hormonal contraception use of 1.42 (95% CI 1.27-1.58). Compared with non-use, starting the use of gestodene and ethinylestradiol (adjusted odds ratio [aOR] 2.85; 95% CI 1.62-5.03), drospirenone and ethinylestradiol (aOR 1.55; 95% CI 0.98-2.44), desogestrel and ethinylestradiol (aOR 1.97; 95% CI 0.99-3.92), and transdermal patch releasing norelgestromin and ethinylestradiol (aOR 5.10; 95% CI 1.12-23.16), as well as continuing the use of gestodene and ethinylestradiol (aOR 2.60; 95% CI 1.61-4.21), drospirenone and ethinylestradiol (aOR 1.55; 95% CI 1.02-2.37), cyproterone-acetate and estrogen/ethinylestradiol (aOR 1.66; 95% CI 1.06-2.61), and vaginal ring releasing etonogestrel and ethinylestradiol (aOR 3.27; 95% CI 1.95-5.48) were associated with venous thromboembolism risk. Regarding the type of estrogen, the highest risk was associated with current use (vs non use in the previous 180 days) of ethinylestradiol-containing preparations (aOR 2.20; 95% CI 1.82-2.65), followed by estradiol-containing preparations (aOR 1.39; 95% CI 1.04-1.87) with no risk for progestin-only hormonal contraception. Current use of estradiol-containing preparations was not associated with venous thromboembolism risk after exclusion of cyproterone-acetate and estrogen/ethinylestradiol (aOR 1.05; 95% CI 0.66-1.66).

CONCLUSIONS

An increased risk of venous thromboembolism is associated with ethinylestradiol-containing combined preparations. The use of estradiol-containing combined preparations confers only a slightly increased risk, possibly driven by cyproterone-containing combined oral contraceptives, whereas the use of progestin-only contraception is not associated with venous thromboembolism.

Associations between use of psychotropic medications and use of hormonal contraception among girls and women aged 15-49 years in Finland: a nationwide, register-based, matched case-control study

OBJECTIVES

The relationship between the use of contraception and of psychiatric medications is understudied. We examined whether the current and past use of psychotropic medications is associated with the use and type of hormonal contraception (HC).

DESIGN

Nationwide register-based matched case-control study.

SETTINGS

All fertile-aged (15-49 years) girls and women living in Finland in 2017; data from several national registers.

PARTICIPANTS

294 356 girls and women with a redeemed prescription of HC in 2017, and their same-sized control group of non-users (n=294 356) identified through the Prescription Centre.

MAIN OUTCOME MEASURES

Associations between the use of psychotropic medications and the use of HC, and the type of HC tested in logistic regression models.

RESULTS

Altogether 19.5% of the HC users, and 18% of the HC non-users received at least one prescription for a psychotropic medication in 2017. Among HC users, the proportions of occasional and regular users of psychotropic medications in 2013-2016 were 4.5% and 14.8%, while among HC non-users the respective figures were 4.3% and 14.6%, respectively. In multivariable logistic regression models both the use of psychotropic medications in 2017, and their occasional or regular use between 2013-2016 were associated with higher odds of HC use, although with small to very small effect sizes (ORs between 1.37 and 1.06 and 95% CIs 1.22 to 1.53, and 1.03 to 1.09, respectively). After adjustment for covariates, when fixed combinations of progestogens and oestrogens for systemic use was the reference category, women using almost any class of psychotropic medications had higher odds of using other types of HC.

CONCLUSIONS

Fertile-aged girls and women with current and past use of psychotropic medications have higher odds of using HC, with a specific pattern in the type of contraceptives used. Further research is warranted to examine whether our observations indicate a reduction of unwanted pregnancies in women with psychiatric disorders.

The impact of postpartum depressive symptoms on self-reported infant health and analgesic consumption at the age of 12 months: A prospective cohort study

The infants of mothers with elevated depressive symptoms (EDS) postpartum appear to be at increased risk of somatic health problems during their first 12 months of life in low- and lower-middle-income countries. However, in higher-income countries, knowledge of this association is scarce. We sought to examine whether maternal reports of infant health problems, adherence to vaccination schedules and analgesic supply to the infant during the first 12 months of life differ between mothers with and without postpartum EDS. Altogether, 969 women who were enrolled in the Kuopio Birth Cohort study (www.kubico.fi) during 2012-2017 were included in this investigation. Depressive symptoms were measured with the Edinburgh Postnatal Depression Scale during pregnancy (1st and/or 3rd trimester) and at eight weeks postpartum. Infant health data were collected as a part of a 12-month online follow-up questionnaire for mothers and were based on self-reports of either maternal observations or physician-determined diagnoses. Postpartum EDS were associated with a 2- to 5-fold increased likelihood of abnormal crying and paroxysmal wheezing (based on parental observations), as well as gastroesophageal reflux and food allergy (based on physician-determined diagnoses). Mothers with postpartum EDS also supplied their infants with analgesic medication for longer periods. Adherence to vaccination schedules was similar between the examined groups. In conclusion, infants of mothers with postpartum EDS may be more likely to experience health problems or to be perceived by their mother as having health problems, and thus receive more medications.

Population-level indicators associated with hormonal contraception use: a register-based matched case-control study

Background

Monitoring factors related to hormonal contraception (HC) use is essential to evaluating public health strategies and promoting access to contraception. We aimed to examine municipal social and health indicators of HC use at the population level, and to identify patterns of inequality across Finnish municipalities.

Methods

We identified all women (15–49 years) with a redeemed HC prescription in Finland in 2017 (n = 294,445), and a control group of non-users. Municipal social and health indicators at the population level were retrieved from the nationwide Statistics and Indicator Bank. Differences between the groups across 309 municipalities were calculated, and associations of municipal-specific proportions of HC users with municipal-specific indicators were studied using LASSO (Least Absolute Shrinkage and Selection Operator) models.

Results

Sociodemographic differences between HC users and non-users were non-homogenous across municipalities. Indicators positively associated with HC use included: larger population and higher proportions of population aged 16–24 years, of household-dwelling units with one person, of persons with higher education, and of divorces among those aged 25–64. Lower HC use was associated with higher proportions of Swedish-speaking population, of those aged 7–15 years, of young people not in education/training, and of household-dwelling units in overcrowded conditions. Lower HC use was also associated with indicators of outpatient and inpatient healthcare, and of municipal finances in welfare and healthcare.

Conclusions

Sociodemographic differences in relation to HC use exist across Finnish municipalities. Municipal indicators of social structure, health and welfare, and investment in and use of healthcare services are related to HC use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10512-6.

Nighttime melatonin secretion and sleep architecture: different associations in perimenopausal and postmenopausal women

BACKGROUND

Sleep quality typically decreases after menopause, but the underlying mechanisms are poorly understood. Concentrations of melatonin are lower and its secretion profiles different before and after menopause. However, whether and how melatonin and sleep architecture are associated in women of different reproductive states have not been examined to date.

METHODS

Overnight serum melatonin samples were taken from 17 perimenopausal and 18 postmenopausal healthy women. Sleep quality was measured with all-night polysomnography recordings.

RESULTS

Melatonin concentrations tended to be the lowest during NREM sleep, and were associated with higher odds of transitions from wake to NREM sleep. The curves of predicted overnight melatonin values from linear mixed models varied according to sleep phases (NREM, REM, Wake) in perimenopausal, but not in postmenopausal women. In perimenopause higher melatonin area under curve (AUC) correlated with higher slow-wave activity (p = 0.043), and higher minimum concentrations with shorter slow-wave sleep (SWS) latency (p = 0.029). In postmenopause higher mean and maximum melatonin concentrations and AUC correlated with lower SWS percentage (p = 0.044, p = 0.029, p = 0.032), and higher mean (p = 0.032), maximum (p = 0.032) and minimum (p = 0.037) concentrations with more awakenings from REM sleep. In the age- and BMI- adjusted regression models, the association between higher maximum (p = 0.046) melatonin concentration and lower SWS percentage remained.

CONCLUSIONS

The relationship between melatonin and sleep architecture differed in perimenopausal and postmenopausal women. After menopause, high melatonin concentrations were associated with worse sleep. Whether these different patterns are related to aging of the reproductive system, and to decrease in menopausal sleep quality, remains to be elucidated.

Associations between hormonal contraception use, sociodemographic factors and mental health: a nationwide, register-based, matched case-control study

OBJECTIVES

Sociodemographic and mental health characteristics are associated with contraceptive choices. We aimed to describe the sociodemographic, reproductive and mental health characteristics of all fertile-aged women in Finland who used hormonal contraception (HC) in 2017.

DESIGN

A nationwide, register-based study.

SETTING

All women living in Finland in 2017; data from the Care Register of Health Care, Medical Birth Register, Population Register Centre, Prescription Centre, Register of Induced Abortions.

PARTICIPANTS

All women aged 15-49 with one redeemed HC prescription in 2017 (n=294 356), and a same-sized, age-matched and residence-matched, control group of non-users.

OUTCOMES

Rates of HC use; associations between HC use and mental disorders, sociodemographic and reproductive characteristics.

RESULTS

25.8% of women aged 15-49 years used HC. Women with the lowest socioeconomic levels had lower odds of using HC than women with upper-level statuses (OR, 95% CI students: 0.97, 0.94 to 0.99; entitled to pension: 0.66, 0.63 to 0.69; other: 0.87, 0.85 to 0.89; unknown: 0.90, 0.85 to 0.90). Women with the highest education (secondary: 1.46, 1.43 to 1.48; tertiary: 1.64, 1.58 to 1.70; academic: 1.60, 1.56 to 1.63) and income (second quarter: 1.57, 1.54 to 1.60; third quarter: 1.85, 1.82 to 1.89; fourth quarter: 2.01, 1.97 to 2.06), and unmarried women had higher odds of using HC than women with the lowest education and income levels, and married (0.61, 0.60 to 0.62), divorced (0.86, 0.84 to 0.88), widowed (0.73, 0.65 to 0.83) or other marital status women (0.26, 0.22 to 0.30).Parous women (0.70, 0.69 to 0.71), those with previous induced abortion(s) (0.91, 0.89 to 0.92) or recent eating (0.68, 0.62 to 0.75) or personality (0.89, 0.79 to 0.97) disorders had lower odds of HC use. Absolute risk differences between women with and without mental disorders ranged from 3.1% (anxiety disorders) to 10.1% (eating disorders).

CONCLUSIONS

A quarter of the fertile-aged women use HC in Finland. Sociodemographic disparities persist in relation to HC use, although of small effect size. HC use is less common among women suffering from severe to moderate psychiatric disorders, especially eating disorders.

Maternal depression and inflammation during pregnancy

BACKGROUND

Maternal depression during pregnancy increases the risk for adverse developmental outcomes in children. However, the underpinning biological mechanisms remain unknown. We tested whether depression was associated with levels of and change in the inflammatory state during pregnancy, if early pregnancy overweight/obesity or diabetes/hypertensive pregnancy disorders accounted for/mediated these effects, and if depression added to the inflammation that typically accompanies these conditions.

METHODS

We analyzed plasma high-sensitivity C-reactive protein (hsCRP) and glycoprotein acetyls at three consecutive stages during pregnancy, derived history of depression diagnoses before pregnancy from Care Register for Healthcare (HILMO) (N = 375) and self-reports (N = 347) and depressive symptoms during pregnancy using the Center for Epidemiological Studies Depression Scale completed concurrently to blood samplings (N = 295). Data on early pregnancy body mass index (BMI) and diabetes/hypertensive pregnancy disorders came from medical records.

RESULTS

Higher overall hsCRP levels, but not change, during pregnancy were predicted by history of depression diagnosis before pregnancy [HILMO: mean difference (MD) = 0.69 standard deviation (s.d.) units; 95% confidence interval (CI) 0.26-1.11, self-report: MD = 0.56 s.d.; 95% CI 0.17-0.94] and higher depressive symptoms during pregnancy (0.06 s.d. per s.d. increase; 95% CI 0.00-0.13). History of depression diagnosis before pregnancy also predicted higher overall glycoprotein acetyls (HILMO: MD = 0.52 s.d.; 95% CI 0.12-0.93). These associations were not explained by diabetes/hypertensive disorders, but were accounted for and mediated by early pregnancy BMI. Furthermore, in obese women, overall hsCRP levels increased as depressive symptoms during pregnancy increased (p = 0.006 for interaction).

CONCLUSIONS

Depression is associated with a proinflammatory state during pregnancy. These associations are mediated by early pregnancy BMI, and depressive symptoms during pregnancy aggravate the inflammation related to obesity.

Nation-wide profile of women using hormonal contraception in Finland in 2017

Background

Up to 69% of European women use contraception. Nordic countries have traditionally high levels of contraception use, of welfare and social equality. However, the uneven population distribution across the Finnish territory makes the easiness of access to health care structures and trained professionals an important issue in relation to effective contraception use. Understanding the patterns of contraception prescription and their underlying determinants is crucial to guarantee the best contraceptive option for each woman.

Methods

In Finland, users of hormonal contraception (HC) can be identified from register records only starting from 2017. This nationwide, register-based study includes all women with at least one HC prescription in 2017, and a reference cohort of non-users, matched by age and municipality. Through linkages to Finnish National Registers we retrieved sociodemographic data. We calculated national and regional rates and distributions, and compared distributions with t-test, Kruskal Wallis or Chi-squared test.

Results

The HC cohort included 294445 women aged 15-49 years (mean 28.9, SD 8.6), 25.8% of Finnish women of that age range. The majority of them were unmarried (71.8%) and employed (71.6%). Compared to non-users, HC users were more often unmarried, a cohabiting couple without common children, employed, had upper secondary or bachelor level education, and higher annual income (p < 0.001). Differences between HC users and non-users were non-homogenous across 70 Finnish regions.

Conclusions

These preliminary results show different sociodemographic correlates of HC use across Finnish regions. Our findings will guide public health strategies aimed at guaranteeing the best contraceptive option for each woman across the whole country.

Key messages

Sociodemographic correlates of HC use differ across Finnish regions. These differences may reflect differences in access to health care services, in prescribers’ characteristics and in HC methods.

Infant regulatory behavior problems during first month of life and neurobehavioral outcomes in early childhood

Whether infant regulatory behavior problems already in the first month of life indicate an increased risk of childhood neurobehavioral problems, and whether maternal depression in the postpartum and early childhood underpins these associations remain unclear. Altogether, 2049-2364 mothers from the Prediction and Prevention of Pre-eclampsia and Intrauterine Growth Restriction (PREDO) study completed the Neonatal Perception Inventory on regulatory behavior problems at the infant's age of 15.6 days (SD 3.2, range 1-30), the Infant Behavior Questionnaire-Revised on temperament at 6.5 months (SD 0.9, range 4.2-12.4), and the Ages and Stages Questionnaire-3 on developmental milestones and the Child Behavior Checklist on behavioral problems at 3.5 years (SD 0.7, range 1.9-6.0). Maternal depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale (infancy follow-ups) and Beck Depression Inventory-II (childhood follow-up). Father-rated infant temperament and paternal depressive symptoms were also available (n = 1474). Higher levels of infant regulatory behavior problems predicted higher levels of mother- and father-rated negative affectivity temperament (0.13 SD units per SD unit, 95% confidence interval 0.09-0.17; and 0.09, 0.04-0.14, respectively), lower levels of mother-rated orienting/regulation temperament (- 0.09, - 0.13 to - 0.05) and problem-solving skills (- 0.12, - 0.21 to - 0.04), and higher levels of Externalizing (0.07, 0.03-0.11) and Total behavioral problems (0.07, 0.03-0.11). Regulatory behaviors partially mediated the effect of maternal depressive symptoms. Regulatory behavior problems already during the first month of life predict neurobehavioral outcomes, and partially mediate the effect of maternal depressive symptoms. Our study may inform design of interventions aimed at timely prevention in children at risk.

Stigma and psychological distress in suicide survivors

BACKGROUND

Suicide bereavement is frequently related to clinically significant psychological distress and affected by stigma. This study was designed to evaluate the relationship between psychological distress by psychopathological domains and stigma, in a sample of individuals bereaved by suicide (suicide survivors).

METHODS

The data were collected between January 2012 and December 2014 and included information on sociodemographic variables (gender, age, marital status and education level) and responses to the Stigma of Suicide Survivor scale (STOSSS) and the Brief Symptom Inventory (BSI). One hundred and fifty-five suicide survivors completed the evaluation and were included in the study.

RESULTS

Levels of psychological distress in suicide survivors, as measured by BSI, were positively related to levels of perceived stigma toward suicide survivors, as measured by STOSSS. The association was not affected by age and gender, or by marital status, education level, days from suicide or a personal history of suicide attempt. Participants with higher scores on almost all subscales of the BSI, particularly the interpersonal sensitivity and paranoid ideation subscales, reported the highest levels of perceived stigma toward suicide survivors.

CONCLUSION

Levels of distress in subjects bereaved by the suicide of a relative or friend were positively associated with levels of perceived stigma toward suicide survivors. Specific interventions dedicated to the bereavement of suicide survivors might help to alleviate not only psychological distress but also stigma towards loss by suicide.

Associations between conflictual relationships, psychopathology, and the use of psychotropic drugs among older people living in residential facilities

BACKGROUND

Psychiatric symptoms and conflictual relationships (CR) may negatively affect the delivery of care in residential facilities (RF). This study aims to analyze neuropsychiatric symptoms, their correlations with CR among older people living in RF, and their associations with the prescription of psychotropic drugs.

METHODS

A total of 1215 RF residents in five Italian regions were selected for this cross-sectional study. Psychiatric symptoms and CR were assessed with the Neuropsychiatric Inventory and the Resident Assessment Instrument, respectively. Associations between Neuropsychiatric Inventory items, CR, and the use of psychotropic drugs were tested via multiple logistic regressions.

RESULTS

About half (52.7%) of the RF residents experienced one or more clinically relevant neuropsychiatric symptoms. At least one category of CR was reported for 223 residents (19%). Although reciprocal associations were found between different categories of CR, only conflictuality with other residents was associated with the use of antipsychotics (odds ratio (OR) = 2.12). Significant associations were found with irritability (with staff: OR = 2.35; with relatives: OR = 3.09), aberrant motor behaviour (with staff: OR = 2.02), and elation (with relatives: OR = 10.55).

CONCLUSIONS

Neuropsychiatric symptoms and CR are common among RF residents and are reciprocally associated. Further research with longitudinal design is needed to better understand this relationship.

Anxiety and quality of life after first-trimester termination of pregnancy: a prospective study

INTRODUCTION

Possible effects of termination of pregnancy (TOP) on mental health are a matter of debate.

MATERIAL AND METHODS

We assessed anxiety and quality of life during a one-year follow up after first-trimester TOP using the State-Trait Anxiety Inventory (STAI) Scale and EuroQoL Quality of Life Questionnaire (EQ-5D, EQ-VAS) in 742 women participating in a randomized controlled trial on early provision of intrauterine contraception. The measurements were performed before TOP, at 3 months and 1 year after TOP. Inclusion criteria were age ≥18 years, residence in Helsinki, duration of gestation <12 weeks, non-medical indication for TOP, and approval of intrauterine contraception. The trial was registered with Clinical Trials [NCT01223521].

RESULTS

When compared with baseline, the overall anxiety level was significantly lower and quality of life higher at 3 months and at 1 year. Reduction of anxiety and improvement of quality of life was especially evident (p < 0.001) in the 58% of women reporting clinically relevant anxiety at baseline. High levels of anxiety at baseline, history of psychiatric morbidity and smoking predicted significantly greater risk of poorer quality of life and elevated level of anxiety during the follow up.

CONCLUSIONS

TOP is associated with a significant overall reduction of anxiety and an improvement of quality of life among women undergoing it for non-medical indications. High baseline anxiety, history of psychiatric morbidity and smoking are risk factors of persistently high levels of anxiety and poor quality of life after an induced abortion. These data are important when designing and providing post-abortion care.

Purine metabolism is dysregulated in patients with major depressive disorder

INTRODUCTION

The purine cycle and altered purinergic signaling have been suggested to play a role in major depressive disorder (MDD). Nevertheless, data on this topic are scarce. Based on previous studies, we hypothesized that compared with non-depressed controls, MDD patients have distinct purine metabolite profiles.

METHODS

The samples comprised 99 MDD patients and 253 non-depressed controls, aged 20-71 years. Background data were collected with questionnaires. Fasting serum samples were analyzed using ultra-performance liquid chromatography coupled to mass spectrometry (UPLC-MS) to determine seven purine cycle metabolites belonging to the purine cycle. We investigated the levels of these metabolites in three settings: (1) MDD patients vs. non-depressed controls and (2) remitted vs. non-remitted MDD patients, and also (3) within-group changes in metabolite levels during the follow-up period.

RESULTS

In logistic regression adjusted for age, gender, smoking, alcohol use, physical exercise, glycosylated hemoglobin, and high-density lipoprotein cholesterol, lower levels of inosine (OR 0.89, 95% CI 0.82-0.97) and guanosine (OR 0.32, 95% CI 0.17-0.59), and higher levels of xanthine (OR 2.21, 95% CI 1.30-3.75) were associated with MDD vs. the non-depressed group. Levels of several metabolites changed significantly during the follow-up period in the MDD group, but there were no differences between remitted and non-remitted groups.

CONCLUSIONS

We observed altered purine metabolism in MDD patients compared with non-depressed controls. Furthermore, our observations suggest that circulating xanthine may accumulate in MDD patients.

The relationship between mood and sleep in different female reproductive states

BACKGROUND

Sleep is disrupted in depressed subjects, but it also deteriorates with age and possibly with the transition to menopause. The nature of interaction between mood, sleep, age and reproductive state is not well-defined. The aim of this study was to evaluate the relationship between mood and sleep among healthy women in different reproductive states.

METHODS

We analyzed data from 11 younger (20-26 years), 21 perimenopausal (43-51 years) and 29 postmenopausal (58-71 years) healthy women who participated in a study on menopause, sleep and cognition. The 21-item Beck Depression Inventory (BDI) was administered to assess mood. Subjective sleep quality was assessed with the Basic Nordic Sleep Questionnaire (BNSQ). Objective sleep was measured with all-night polysomnography (PSG) recordings. Perimenopausal and younger women were examined during the first days of their menstrual cycle at the follicular phase.

RESULTS

Among younger women, less arousals associated with higher BDI total scores (p = 0.026), and higher SWS percentages with more dissatisfaction (p = 0.001) and depressive-somatic symptoms (p = 0.025), but with less depressive-emotional symptoms (p = 0.001). In specific, less awakenings either from REM sleep or SWS, respectively, associated with more punishment (p = 0.005; p = 0.036), more dissatisfaction (p < 0.001; p = 0.001) and more depressive-somatic symptoms (p = 0.001; p = 0.009), but with less depressive-emotional symptoms (p = 0.002; p = 0.003). In perimenopausal women, higher BNSQ insomnia scores (p = 0.005), lower sleep efficiencies (p = 0.022) and shorter total sleep times (p = 0.024) associated with higher BDI scores, longer sleep latencies with more depressive-somatic symptoms (p = 0.032) and longer REM latencies with more dissatisfaction (p = 0.017). In postmenopausal women, higher REM percentages associated with higher BDI total scores (p = 0.019) and more depressive-somatic symptoms (p = 0.005), and longer SWS latencies with more depressive-somatic symptoms (p = 0.030).

CONCLUSIONS

Depressive symptoms measured with the total BDI scores associated with sleep impairment in both perimenopausal and postmenopausal women. In younger women, specific BDI factors revealed minor associations, suggesting that the type of sleep impairment can vary in relation to different depressive features. Our data indicate that associations between sleep and depressed mood may change in conjunction with hormonal milestones.

Suicide in elderly South Tyroleans in various residential settings at the time of death: a psychological autopsy study

BACKGROUND

Completed suicide is more frequent among older adults than any other age group. Data on suicide in nursing homes and other residential facilities are inconsistent. This work aims to describe the characteristics of elderly suicide victims in different residential settings compared to young suicide victims.

METHODS

Data on people who died by suicide in the South Tyrol (Alto Adige) region of Italy between 2000 and 2009 were gathered from the local Provincial Mortality Register. Further detailed information was collected via questionnaires to mental health departments and psychological services, family physicians and relatives of the deceased.

RESULTS

A total of 525 cases of suicide were recorded, with a linearly decreasing trend during the study period. About one-third of the suicides occurred in those aged 60 years and over. Suicide in the elderly was associated with low education level (odds ratio (OR) = 7.1, P < 0.001), living in a one-person household (OR = 2.4, P < 0.01), not having economic troubles (OR = 6.1, P < 0.01), having seen a doctor in the past month (OR = 2.4, P < 0.01) and living in a residential facility (OR = 2.6, P < 0.05). Twenty-four (17.9%) suicide victims aged 60 years and over were in a residential facility/hospital at the time of the death. They were more likely to be women, not married, and to die by jumping from a height.

CONCLUSIONS

The suicide risk should be carefully assessed in the elderly who live alone or are institutionalized or hospitalized. Efforts are warranted to reduce seniors' access to high places in hospitals and facilities.

The effect of hormone therapy on serum melatonin concentrations in premenopausal and postmenopausal women: a randomized, double-blind, placebo-controlled study

OBJECTIVES

Melatonin levels decrease physiologically with age, and possibly with the transition to menopause. The plausible influence of hormone therapy (HT) on melatonin is poorly understood. The aim of this randomized, placebo-controlled, double-blind trial was to investigate the effect of HT administration on serum melatonin concentrations in late premenopausal and postmenopausal women.

STUDY DESIGN

Analyses were carried out among 17 late premenopausal and 18 postmenopausal healthy women who participated in a prospective HT study in Finland. Serum melatonin was sampled at 20-min (21:00-24:00 h; 06:00-09:00 h) and 1-h (24:00-06:00 h) intervals at baseline and after 6 months with HT or placebo.

MAIN OUTCOME MEASURES

Melatonin levels and secretion profile after 6 months of HT compared to placebo.

RESULTS

Mean melatonin levels, mean melatonin exposure level (area under curve, AUC) and mean duration of melatonin secretion did not differ after 6 months with HT vs. placebo, irrespectively of the reproductive state. However, in postmenopausal women the melatonin peak time (acrophase) was delayed by 2.4h (2 h 21 min) on average after 6 months with HT vs. placebo (p<0.05). No interaction between time and group was detected when melatonin level was modelled before or after treatment.

CONCLUSIONS

Administration of HT to postmenopausal women alters melatonin peak time, but not melatonin levels. Further research on larger clinical samples is needed to better understand the effects of HT on melatonin profile.

Miscarriage and mental health: results of two population-based studies

A miscarriage may have a sustained negative effect on mental health. Our aim was to analyze the association of the history and, if any, the number of miscarriages with mental health. The participants were women from two population-based studies, the Finnish Health 2000 survey and the National FINRISK 2002 Survey. Data were collected with a set of self-reported questionnaires, a clinical health examination and/or a home interview. A modified Beck Depression Inventory (BDI), the 12-item General Health Questionnaire (GHQ-12), the Munich-Composite International Diagnostic Interview (M-CIDI) and other non-structured interviews were used for the assessment of mental health. A diagnosis of depressive disorder and the presence of depressive symptoms were more prevalent among women with a history of miscarriage. In both datasets the higher the number of miscarriages was, the worse the current state of mood was and the higher the frequency of a psychiatric diagnosis was. These results suggest that a miscarriage, and in particular the number of miscarriages, contributes to mental health in a negative way for long.

Stigma of Suicide Attempt (STOSA) scale and Stigma of Suicide and Suicide Survivor (STOSASS) scale: two new assessment tools

This study aimed at validating two new assessment tools, the Stigma of Suicide Attempt (STOSA) scale and the Stigma of Suicide and Suicide Survivor (STOSASS) scale. The Devaluation-Discrimination scale of Link et al. was translated into Italian and adapted to measure stigma towards suicidal behavior. Both scales were administered to a mixed sample including members of the general population (n=282), patients with a mental disorder (n=113), suicide attempters (n=57) and people who had lost a significant other to suicide (n=75). Reliability of the scales was good in terms of both internal coherence and test-retest stability. Factor analysis produced an acceptable solution for the STOSA-scale. Items were distributed into two factors, one grouping items to measure supportive, respectful and caring attitudes, the other factor grouping items oriented towards stigmatizing attitudes and beliefs. The clinical populations were more inclined towards stigmatization of suicide than were people from the general population, who might be less aware of the stigma attached to suicide. The two scales may be helpful to quantify stigma at individual level in order to provide targeted supportive interventions, and at population level to measure changes in the beliefs and attitudes of the general population.

[Psychiatrists' emotional reactions to a patient's suicide: a case series]

AIM

The aim of this study is to describe the emotional reactions experienced by a group of psychiatrists following the suicidal death of a patient.

METHODS

The study was carried out between February 2005 and January 2006 within the Mental Health Department of Padova. Data were collected through a questionnaire administered to the reference psychiatrist at least two weeks after the suicide of a patient. The aim of the tool was to assess emotional reaction when told about the suicide and when filling in the questionnaire.

RESULTS

All the interviewed psychiatrists (n = 11) reported emotions, mostly self-doubt, sadness, disbelief, guilt, fear, shock and helplessness. Some differences were found between residents and consultant psychiatrists. Of the 11 psychiatrists, 7 did not blame anyone for their patient's death, and 6 of them judged the suicide to have been unpreventable. All the therapists sought conversation about the event; a team case review was conducted in 8 cases.

DISCUSSION

A patient's suicide is a significant event in a psychiatrist's professional life, particularly among resident psychiatrists. The emotional process only partly overlaps the usual grief process. Discussions with peer/senior colleagues and team case reviews are helpful tools in the grief process of psychiatrists and should become part of the working practice of every Mental Health Department.

How the psychiatrists of a mental health department managed their patients before an attempted suicide

AIMS

The aim of this survey was to describe patients in care at a large mental health department in northern Italy who attempted suicide, and the clinical management adopted by their psychiatrists before the event.

METHODS

Data collection was based on a questionnaire administered to the reference psychiatrists.

RESULTS

Over a period of 12 months, 166 catchment area residents attempted suicide. Sixty-six (40%) had contacted the mental health department in the previous two years and completed data were obtained on 63. Twenty-nine (46%) suffered from mood, 26 (41%) from personality and 11 (18%) from schizophrenic disorders. Thirty-four attempts occurred within one year of psychiatric ward discharge, mostly in the first quarter. The reference psychiatrists reported that, at the last evaluation, 38 of 63 patients (60%) presented no change in clinical conditions, and 41 of 63 (68%) were considered at no immediate risk of suicide. Most of the attempted suicides in question (45, 72%) were judged to be unpreventable. In the two logistic regression analyses carried out, no independent variables were able to statistically significantly explain the variance in judged suicidal risk or the preventability of the index attempted suicide.

CONCLUSIONS

According to the psychiatrists' descriptions of their last contact with the patients, most attempted suicides have not been preceded by a change in clinical conditions. Moreover, psychiatrists, irrespective of their age and gender, and of patient diagnosis, frequently judged the attempts to have been unpreventable.

[Group interpersonal psychotherapy: a review]

Interpersonal Psychotherapy was conceived as a psychotherapeutic approach to treating Depression, but has since now been broadly used to treat many other disorders. It has also recently been adapted to delivery in the group setting, with both advantages and disadvantages as other group psychotherapies. This adaptation, first used by Wilfley and colleagues, maintained the main features of IPT, i.e. the central role of the interpersonal focus and identification of one (or two) out of four problem interpersonal areas (Grief; Role Transition; Role Disputes; Interpersonal Deficits). It also kept the active role of the therapist and individual patient within the group. To date, G-IPT has been used for several diseases (Eating Disorders not Otherwise Specified, Bulimia Nervosa, Depressive Disorder, Posttraumatic Stress Disorder) and several populations (Adolescents, Older People, Pregnant Women or "New-Mothers," Substance-abusing Female Prisoners). Although the overall quality of most of outcome studies is to date quite poor, the review of the current state of knowledge shows the G-IPT may be helpful and present a number of advantages to treat different psychiatric disorders in several populations of patients.