Publications by authors named "Hannah K Betcher"

13 Publications

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Perinatal Mood and Anxiety Disorder Management in Multicenter Community Practices: Clinicians' Training, Current Practices and Perceived Strategies to Improve Future Implementation.

J Prim Care Community Health 2021 Jan-Dec;12:2150132721996888

Mayo Clinic, Rochester, MN, USA.

Background: This study aimed to explore clinicians' perspectives on the current practice of perinatal mood and anxiety disorder (PMAD) management and strategies to improve future implementation.

Methods: This study had a cross-sectional, descriptive design. A 35-item electronic survey was sent to clinicians (N = 118) who treated perinatal women and practiced at several community clinics at an academic medical center in the United States.

Results: Among clinicians who provided care for perinatal women, 34.7% reported never receiving PMAD management training and 66.3% had less than 10 years of experience. Out of 10 patients who reported psychiatric symptoms, 47.8% of clinicians on average reported providing PMAD management to 1 to 3 patients and 40.7% noted that they conducted screening only when patient expresses PMAD symptoms. Suggested future improvements were providing training, developing a referral list, and establishing integrated behavioral health services.

Conclusions: Results from this study indicated that while PMAD screening and management was implemented, improvements are warranted to meet established guidelines. Additionally, clinicians endorsed providing PMAD management to a small percentage of perinatal patients. Suggested strategies to increase adoption and implementation of PMAD management should be explored to improve access to behavioral health services for perinatal women.
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http://dx.doi.org/10.1177/2150132721996888DOI Listing
February 2021

Long-term lithium therapy and risk of chronic kidney disease in bipolar disorder: A historical cohort study.

Bipolar Disord 2021 Feb 6. Epub 2021 Feb 6.

Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA.

Aims: Long-term lithium-therapy (LTLT) has been associated with kidney insufficiency in bipolar disorder (BD). We aimed to investigate the risk factors of chronic kidney disease (CKD) development and progression among BD patients receiving LTLT.

Methods: We included adult patients with BD on LTLT (≥1year) who were enrolled in the Mayo Clinic Bipolar Biobank, Rochester, Minnesota. We reviewed electronic medical records to extract information related to lithium therapy and kidney-related data to assess changes in the estimated glomerular filtration rate (eGFR). CKD severity was assessed based on eGFR.

Results: Among 154 patients who received LTLT, 41 patients (27%) developed CKD, of which 20 (49%) patients continued lithium (continuers) and 19 (46%) discontinued it (discontinuers). The median time to stage-3 CKD development was 21.74 years from the start of Li treatment. Type-2 diabetes mellitus and benzodiazepine use were independent predictors for CKD development in the survival analysis, after controlling for age. The subsequent CKD progression rate did not differ between continuers and discontinuers (mean GFR 48.6 vs. 44.1, p=0.13) at the end of follow-up duration (mean duration: 3.5± 4.4years for continuers and 4.9±5.3years for discontinuers).

Conclusion: CKD was observed in one-fourth of patients with BD receiving LTLT. There was no significant difference in the progression of CKD among Li continuers vs. discontinuers, at the mean follow-up duration of 4.2 years, after the CKD diagnosis. Progression of CKD could be influenced by existing comorbidities and may not necessarily be due to lithium alone.
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http://dx.doi.org/10.1111/bdi.13052DOI Listing
February 2021

Contraception for Women With Psychiatric Disorders.

Am J Psychiatry 2021 Mar 10;178(3):247-255. Epub 2020 Nov 10.

Department of Psychiatry, Asher Center for the Study and Treatment of Depressive Disorders (Wisner; formerly Betcher, Cattan), and Department of Obstetrics and Gynecology (McCloskey, Stika, Kiley), Feinberg School of Medicine, Northwestern University, Chicago; Mayo Clinic, Rochester, Minn. (Betcher); AbbVie, Inc., North Chicago (Cattan).

Objective: Mental health care for women includes decision support to prepare for major life events, including preconception planning for treatment during pregnancy and the postpartum period. The authors discuss contraceptive choices and their effectiveness, side effects, and impact on psychiatric symptoms. The Centers for Disease Control and Prevention's recommendations, Medical Eligibility Criteria for Contraceptive Use, provided the structure for review of contraceptive choices.

Methods: A search of PsycINFO, PubMed, Embase, and Scopus was conducted for publications on the management of contraception for women with mental illness. Publications were selected if they included, based on the authors' consensus, data supporting evidence-based care important for psychiatrists who treat women desiring contraceptives.

Results: The majority of women choose combined oral contraceptives. Although long-acting reversible contraceptives (implants, intrauterine devices) are associated with low failure rates, favorable safety profiles, rapid return to fertility after removal, and few contraindications, they are chosen by only 14% of women. All methods are acceptable for women with depression, although medical comorbidities may dictate a specific type. The impact of hormonal contraceptives on the risk for depression is controversial; however, clinical studies and randomized placebo-controlled trials of women with psychiatric disorders have generally reported similar or lower rates of mood symptoms in hormonal contraceptive users compared with nonusers. Although interactions between psychotropic drugs and contraceptives are rare, clozapine, anticonvulsants, and St. John's Wort are exceptions.

Conclusions: Proactive management of mental illness, contraception, and pregnancy improves a woman's capacity to function and optimizes her mental and reproductive health.
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http://dx.doi.org/10.1176/appi.ajp.2020.20020154DOI Listing
March 2021

Potential pharmacogenomic targets in bipolar disorder: considerations for current testing and the development of decision support tools to individualize treatment selection.

Int J Bipolar Disord 2020 Jul 4;8(1):23. Epub 2020 Jul 4.

Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.

Background: Treatment in bipolar disorder (BD) is commonly applied as a multimodal therapy based on decision algorithms that lack an integrative understanding of molecular mechanisms or a biomarker associated clinical outcome measure. Pharmacogenetics/genomics study the individual genetic variation associated with drug response. This selective review of pharmacogenomics and pharmacogenomic testing (PGT) in BD will focus on candidate genes and genome wide association studies of pharmacokinetic drug metabolism and pharmacodynamic drug response/adverse event, and the potential role of decision support tools that incorporate multiple genotype/phenotype drug recommendations.

Main Body: We searched PubMed from January 2013 to May 2019, to identify studies reporting on BD and pharmacogenetics, pharmacogenomics and PGT. Studies were selected considering their contribution to the field. We summarize our findings in: targeted candidate genes of pharmacokinetic and pharmacodynamic pathways, genome-wide association studies and, PGT platforms, related to BD treatment. This field has grown from studies of metabolizing enzymes (i.e., pharmacokinetics) and drug transporters (i.e., pharmacodynamics), to untargeted investigations across the entire genome with the potential to merge genomic data with additional biological information.

Conclusions: The complexity of BD genetics and, the heterogeneity in BD drug-related phenotypes, are important considerations for the design and interpretation of BD PGT. The clinical applicability of PGT in psychiatry is in its infancy and is far from reaching the robust impact it has in other medical disciplines. Nonetheless, promising findings are discovered with increasing frequency with remarkable relevance in neuroscience, pharmacology and biology.
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http://dx.doi.org/10.1186/s40345-020-00184-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338319PMC
July 2020

Potential pharmacogenomic targets in bipolar disorder: considerations for current testing and the development of decision support tools to individualize treatment selection.

Int J Bipolar Disord 2020 Jul 4;8(1):23. Epub 2020 Jul 4.

Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.

Background: Treatment in bipolar disorder (BD) is commonly applied as a multimodal therapy based on decision algorithms that lack an integrative understanding of molecular mechanisms or a biomarker associated clinical outcome measure. Pharmacogenetics/genomics study the individual genetic variation associated with drug response. This selective review of pharmacogenomics and pharmacogenomic testing (PGT) in BD will focus on candidate genes and genome wide association studies of pharmacokinetic drug metabolism and pharmacodynamic drug response/adverse event, and the potential role of decision support tools that incorporate multiple genotype/phenotype drug recommendations.

Main Body: We searched PubMed from January 2013 to May 2019, to identify studies reporting on BD and pharmacogenetics, pharmacogenomics and PGT. Studies were selected considering their contribution to the field. We summarize our findings in: targeted candidate genes of pharmacokinetic and pharmacodynamic pathways, genome-wide association studies and, PGT platforms, related to BD treatment. This field has grown from studies of metabolizing enzymes (i.e., pharmacokinetics) and drug transporters (i.e., pharmacodynamics), to untargeted investigations across the entire genome with the potential to merge genomic data with additional biological information.

Conclusions: The complexity of BD genetics and, the heterogeneity in BD drug-related phenotypes, are important considerations for the design and interpretation of BD PGT. The clinical applicability of PGT in psychiatry is in its infancy and is far from reaching the robust impact it has in other medical disciplines. Nonetheless, promising findings are discovered with increasing frequency with remarkable relevance in neuroscience, pharmacology and biology.
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http://dx.doi.org/10.1186/s40345-020-00184-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338319PMC
July 2020

Interpreting the pharmacoepidemiology literature in obstetrical studies: A guide for clinicians.

Semin Perinatol 2020 04 28;44(3):151225. Epub 2020 Feb 28.

Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL 60611, United States.

Many prescribers are knowledgeable about randomized controlled trials (RCT), but are less familiar with pharmacoepidemiology studies; that is, observational studies in which a pharmacologic agent is the exposure of interest. To date, few clinical trials include pregnant women. With the absence of RCT data, prescribers must largely rely on the pharmacoepidemiology literature to guide prescribing decisions for pregnant patients. We describe different types of pharmacoepidemiology studies and present a flowchart and table checklist to support clinicians to assess the quality of, and thus the validity of conclusions from, pharmacoepidemiology studies. We provide illustrative examples of published observational studies examining antidepressant treatment during pregnancy and fetal and infant outcomes.
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http://dx.doi.org/10.1016/j.semperi.2020.151225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214119PMC
April 2020

A common clinical conundrum: Antidepressant treatment of depression in pregnant women.

Semin Perinatol 2020 04 25;44(3):151229. Epub 2020 Jan 25.

Mayo Clinic, Rochester, MN, United States.

Depression during pregnancy is associated with adverse maternal, pregnancy, and infant outcomes. Treatment during pregnancy requires a balanced discussion of the risks of both drug exposure and untreated depression. An updated review of the epidemiology, outcomes, and management of maternal depression is presented. Adverse outcomes are associated with both maternal depression and antidepressants. Research gaps include data on the longitudinal developmental trajectory of offspring exposed to antidepressants compared to depression, with assessment of in utero symptom exposure and environmental exposures. Additionally, neonatal syndrome associated with antidepressant use during pregnancy has no consensus definition or mechanistic explanation. With sophisticated large-scale epidemiologic studies, there has been progress in distinguishing the impact of depression processes from medication used for treatment. Optimal treatment of perinatal depression includes close symptom monitoring and medication adjustments to maintain symptom remission. This evolving field requires frequent consultation with reproductive data sources included in this article.
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http://dx.doi.org/10.1016/j.semperi.2020.151229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214132PMC
April 2020

Pharmacogenomics in pregnancy.

Semin Perinatol 2020 Apr 25;44(3):151222. Epub 2020 Jan 25.

Department of Pharmacology and Center for Pharmacogenomics, Northwestern University Feinberg School of Medicine, Searle 8-510, 320 East Superior Street, Chicago, IL 60611, USA. Electronic address:

Pregnant women frequently take prescription and over the counter medications. The efficacy of medications is affected by the many physiological changes during pregnancy, and these events may be further impacted by genetic factors. Research on pharmacogenomic and pharmacokinetic influences on drug disposition during pregnancy has lagged behind other fields. Clinical investigators have demonstrated altered activity of several drug metabolizing enzymes during pregnancy. Emerging evidence also supports the influence of pharmacogenomic variability in drug response for many important classes of drugs commonly used in pregnancy. Prescribing medications during pregnancy requires an understanding of the substantial dynamic physiologic and metabolic changes that occur during gestation. Pharmacogenomics also contributes to the inter-individual variability in response to many medications, and more research is needed to understand how best to manage drug therapy in pregnant women.
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http://dx.doi.org/10.1016/j.semperi.2020.151222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214196PMC
April 2020

Psychotropic Treatment During Pregnancy: Research Synthesis and Clinical Care Principles.

J Womens Health (Larchmt) 2020 03 3;29(3):310-318. Epub 2019 Dec 3.

Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Psychiatric illnesses are common in women of childbearing age. The perinatal period is a particularly high-risk time for depression, bipolar, and anxiety disorders. The scope of the public health problem of perinatal mental disorders is discussed followed by an examination of the specific research methods utilized for the study of birth and developmental outcomes associated with maternal mental illness and its treatment. The evidence on exposure to common psychotropics during pregnancy and breastfeeding is reviewed. Selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitor medications are not associated with higher rates of birth defects or long-term changes in mental development after adjustment for confounding factors associated with underlying psychiatric illness. Lithium exposure is associated with an increased risk for fetal cardiac malformations, but this risk is lower than previously thought (absolute risk of Ebstein's anomaly 6/1,000). Antipsychotics, other than risperidone and potentially paliperidone, have not been associated with an increase in birth defects; olanzapine and quetiapine have been linked with an elevated risk of gestational diabetes. Due to the dramatic physiological changes of pregnancy and enhanced hepatic metabolism, drug doses may need to be adjusted during pregnancy to sustain efficacy. Untreated maternal psychiatric illness also carries substantial risks for the mother, fetus, infant, and family. The goal of perinatal mental health treatment is to optimally provide pharmacotherapy to mitigate the somatic and psychosocial burdens of maternal psychiatric disorders. Regular symptom monitoring during pregnancy and postpartum and medication dose adjustments to sustain efficacy constitutes good practice.
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http://dx.doi.org/10.1089/jwh.2019.7781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207058PMC
March 2020

Effects of Parental Opioid Use: Outcomes of Children of Parents in Medication-Assisted Treatment Compared to Healthy Controls.

Prim Care Companion CNS Disord 2019 Aug 15;21(4). Epub 2019 Aug 15.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA.

Background: Opioid use is a significant national crisis impacting individuals struggling with addiction and their families. The majority of individuals who abuse opioids are of child-rearing age, and critical knowledge gaps remain regarding how this abuse impacts their offspring. Fortunately, treatment for opioid use disorders is available. The primary goal of this study was to evaluate both physical and psychiatric diagnoses of children who have at least 1 parent participating in a buprenorphine-assisted treatment program.

Methods: This retrospective study is based on chart review (January 1, 2010, through June 30, 2018). Children with parents receiving care in a buprenorphine clinic were identified and matched on sex, race, and age in a ratio of 1:5 with controls from the general pediatric clinic population. Data related to health outcomes were extracted from the medical records.

Results: Compared to controls (n = 120), children of parents receiving buprenorphine-assisted treatment (n = 24) were more likely to have been born premature (odds ratio [OR] = 3.3, P = .035), had jaundice after birth (OR = 2.7, P = .034), had enuresis/encopresis (P < .001), and had been the victims of abuse or neglect (OR = 19.7, P = .0005). Children of parents with opioid use disorders were also more likely to utilize emergency services (ie, being seen in the emergency department for fussiness; OR = 4.0, P = .046) and were less likely to be covered by private insurance compared to state-funded insurance (OR = 0.2, P = .0013).

Conclusions: Parental opioid use disorder impacts children. More research is needed to better describe long-term effects of treatment of parental opioid use on their offspring and to help design addiction treatment programs to support whole family units.
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http://dx.doi.org/10.4088/PCC.19m02474DOI Listing
August 2019

Use of Antipsychotic Drugs During Pregnancy.

Curr Treat Options Psychiatry 2019 Mar 30;6(1):17-31. Epub 2019 Jan 30.

Department of Psychiatry, Northwestern University Feinberg School of Medicine 676 N. St. Clair St. Ste 1000, Chicago, IL 60611, USA.

Purpose Of Review: Antipsychotics are frequently prescribed to women of childbearing age and are increasingly prescribed during pregnancy. A small, but growing, body of research on implications for pregnancy and infant outcomes is available to inform the risks and benefits of in utero exposure to antipsychotics. This review examines the existing published research on the use of common typical and atypical antipsychotics in pregnancy and the implications for pregnancy and infant outcomes.

Recent Findings: The majority of studies do not show associations with major malformations and antipsychotic use in pregnancy, with the possible exception of risperidone. There is concern that atypical antipsychotics may be associated with gestational diabetes. Metabolic changes during pregnancy may necessitate dose adjustments.

Summary: In general, it is recommended that women who need to take an antipsychotic during pregnancy continue the antipsychotic that has been most effective for symptom remission. Further study on risperidone is needed to better understand its association with malformations and it is not considered a first-line agent for use during pregnancy.
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http://dx.doi.org/10.1007/s40501-019-0165-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410162PMC
March 2019

Use of a Gabapentin Protocol for the Management of Alcohol Withdrawal: A Preliminary Experience Expanding From the Consultation-Liaison Psychiatry Service.

Psychosomatics 2018 Sep - Oct;59(5):496-505. Epub 2018 Mar 21.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.

Background: Benzodiazepines are the conventional mainstay to manage alcohol withdrawal; however, patients are subsequently at increased risk for poor sleep, cravings, and return to drinking. Research on alternative pharmacologic agents to facilitate safe alcohol withdrawal is scant. Gabapentin is one medication shown in small studies to reduce the need for benzodiazepines in the setting of alcohol withdrawal. The continuation of gabapentin after alcohol withdrawal appears to be safe during early sobriety and may aid in reducing alcohol-related cravings or returning to alcohol consumption. Use of a gabapentin-based, benzodiazepine-sparing protool began in early 2015 by the Mayo Clinic, Rochester, Consultation-Liaison Psychiatry Service.

Objective: A retrospective chart review was conducted to detect any safety concerns with use of a gabapentin protocol for alcohol withdrawal syndrome.

Methods: Secondary outcomes were derived by comparing a matched cohort of patients who received benzodiazepines for alcohol withdrawal syndrome.

Results: Seventy-seven patients had their alcohol withdrawal managed via a gabapentin protocol during the study period. No patients required transfer to a higher level of care or had a documented withdrawal seizure. Length of stay between the gabapentin protocol group and benzodiazepine group were similar.

Conclusion: This preliminary data has supported the frequent use of this protocol in the general internal medicine practice and formalization of an institutional order set of this protocol for mild to moderate alcohol withdrawal syndrome. Prospective studies are required to validate findings.
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http://dx.doi.org/10.1016/j.psym.2018.03.002DOI Listing
May 2019

Mirtazapine for Symptomatic Relief on a Psychiatric Consultation Service: A Case Series.

Psychosomatics 2016 Jul-Aug;57(4):409-13. Epub 2016 Mar 2.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.

Background: With a complex pharmacologic profile, mirtazapine may promote sleep, stimulate appetite, improve nausea, and reduce pain. Some practitioners working on the Mayo Clinic inpatient psychiatric consultation/liaison service have recommended mirtazapine in medically ill patients with or without formal psychiatric comorbidity to target these symptoms.

Objective: To assess the success of this practice, we conducted a retrospective chart review covering a 4.5-year period.

Methods: For patients recommended to start mirtazapine, global improvement in specific symptoms and suspected side effects were recorded.

Results: During the study period, 528 medically ill patients started mirtazapine following a recommendation from the psychiatric consultation service. In total, 475 patients were provided mirtazapine to specifically target sleep, nausea, pain, or appetite. There was documented improvement in these symptoms for 37.7%, 37.0%, 36.4%, and 23.5% of the patients, respectively. These rates of improvement are conservative for the 229 patients without documented response, i.e., 48% of the patients who were given the medication for a somatic symptom were counted as having no improvement. Commonly documented adverse effects were daytime sedation (5.3%), worsening mental status (2.3%), and nightmares (1%).

Conclusions: Despite the limitations of this retrospective, qualitative study, these data confirm that mirtazapine is generally well tolerated and can provide at least short-term relief of certain symptoms in medically ill patients. Controlled trials are needed to assess these benefits more systematically, and it is not clear how long mirtazapine should be used for these symptoms.
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http://dx.doi.org/10.1016/j.psym.2016.02.012DOI Listing
August 2017