Publications by authors named "Louise M Howard"

176 Publications

Developing a Natural Language Processing tool to identify perinatal self-harm in electronic healthcare records.

PLoS One 2021 4;16(8):e0253809. Epub 2021 Aug 4.

South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Kent, London, United Kingdom.

Background: Self-harm occurring within pregnancy and the postnatal year ("perinatal self-harm") is a clinically important yet under-researched topic. Current research likely under-estimates prevalence due to methodological limitations. Electronic healthcare records (EHRs) provide a source of clinically rich data on perinatal self-harm.

Aims: (1) To create a Natural Language Processing (NLP) tool that can, with acceptable precision and recall, identify mentions of acts of perinatal self-harm within EHRs. (2) To use this tool to identify service-users who have self-harmed perinatally, based on their EHRs.

Methods: We used the Clinical Record Interactive Search system to extract de-identified EHRs of secondary mental healthcare service-users at South London and Maudsley NHS Foundation Trust. We developed a tool that applied several layers of linguistic processing based on the spaCy NLP library for Python. We evaluated mention-level performance in the following domains: span, status, temporality and polarity. Evaluation was done against a manually coded reference standard. Mention-level performance was reported as precision, recall, F-score and Cohen's kappa for each domain. Performance was also assessed at 'service-user' level and explored whether a heuristic rule improved this. We report per-class statistics for service-user performance, as well as likelihood ratios and post-test probabilities.

Results: Mention-level performance: micro-averaged F-score, precision and recall for span, polarity and temporality >0.8. Kappa for status 0.68, temporality 0.62, polarity 0.91. Service-user level performance with heuristic: F-score, precision, recall of minority class 0.69, macro-averaged F-score 0.81, positive LR 9.4 (4.8-19), post-test probability 69.0% (53-82%). Considering the task difficulty, the tool performs well, although temporality was the attribute with the lowest level of annotator agreement.

Conclusions: It is feasible to develop an NLP tool that identifies, with acceptable validity, mentions of perinatal self-harm within EHRs, although with limitations regarding temporality. Using a heuristic rule, it can also function at a service-user-level.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253809PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336818PMC
August 2021

Developing a Natural Language Processing tool to identify perinatal self-harm in electronic healthcare records.

PLoS One 2021 4;16(8):e0253809. Epub 2021 Aug 4.

South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Kent, London, United Kingdom.

Background: Self-harm occurring within pregnancy and the postnatal year ("perinatal self-harm") is a clinically important yet under-researched topic. Current research likely under-estimates prevalence due to methodological limitations. Electronic healthcare records (EHRs) provide a source of clinically rich data on perinatal self-harm.

Aims: (1) To create a Natural Language Processing (NLP) tool that can, with acceptable precision and recall, identify mentions of acts of perinatal self-harm within EHRs. (2) To use this tool to identify service-users who have self-harmed perinatally, based on their EHRs.

Methods: We used the Clinical Record Interactive Search system to extract de-identified EHRs of secondary mental healthcare service-users at South London and Maudsley NHS Foundation Trust. We developed a tool that applied several layers of linguistic processing based on the spaCy NLP library for Python. We evaluated mention-level performance in the following domains: span, status, temporality and polarity. Evaluation was done against a manually coded reference standard. Mention-level performance was reported as precision, recall, F-score and Cohen's kappa for each domain. Performance was also assessed at 'service-user' level and explored whether a heuristic rule improved this. We report per-class statistics for service-user performance, as well as likelihood ratios and post-test probabilities.

Results: Mention-level performance: micro-averaged F-score, precision and recall for span, polarity and temporality >0.8. Kappa for status 0.68, temporality 0.62, polarity 0.91. Service-user level performance with heuristic: F-score, precision, recall of minority class 0.69, macro-averaged F-score 0.81, positive LR 9.4 (4.8-19), post-test probability 69.0% (53-82%). Considering the task difficulty, the tool performs well, although temporality was the attribute with the lowest level of annotator agreement.

Conclusions: It is feasible to develop an NLP tool that identifies, with acceptable validity, mentions of perinatal self-harm within EHRs, although with limitations regarding temporality. Using a heuristic rule, it can also function at a service-user-level.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253809PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336818PMC
August 2021

Maternal perceived bonding towards the infant and parenting stress in women at risk of postpartum psychosis with and without a postpartum relapse.

J Affect Disord 2021 Nov 5;294:210-219. Epub 2021 Jun 5.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RX, UK; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK.

Background: Postpartum psychosis (PP) is the most severe psychiatric disorder associated with childbirth. However, there is little research on maternal bonding towards the infant and parenting stress in this clinical population.

Methods: We investigated maternal bonding during pregnancy and post-partum in 75 women: 46 at risk of PP (AR), because of a DSM-IV diagnosis of bipolar disorder, schizoaffective disorder or previous PP, and 29 healthy controls. Of the AR women, 19 developed a psychiatric relapse within 4 weeks' post-partum (AR-unwell), while 27 remained symptom-free (AR-well). We investigated childhood maltreatment, parenting stress and psychiatric symptoms as potential predictors of maternal bonding.

Results: In pregnancy, AR-unwell women reported a more negative affective experience towards their infants than AR-well women (d = 0.87, p = .001), while postnatally there was no significant difference in bonding. In contrast, AR women as a group reported a more negative affective experience than HC postnatally (d = 0.69, p = .002; d = 0.70, p = .010), but not antenatally. Parenting stress and psychiatric symptoms significantly predicted less optimal postnatal bonding (b = -0.10, t = -4.29, p < .001; b = -0.37, t = -4.85, p < .001) but only psychiatric symptoms explained the difference in bonding between AR and HC (b = -1.18, 95% BCa CI [-2.70,-0.04]).

Limitations: A relatively small sample size precluded a more in-depth investigation of underlying pathways.

Conclusion: This study provides new information on maternal bonding in women at risk of PP, and particularly in those that do and do not develop a postpartum relapse. The results suggest that improving maternal symptoms and parenting stress in the perinatal period in women at risk of PP could also have positive effects on bonding.
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http://dx.doi.org/10.1016/j.jad.2021.05.076DOI Listing
November 2021

Maternal perceived bonding towards the infant and parenting stress in women at risk of postpartum psychosis with and without a postpartum relapse.

J Affect Disord 2021 Nov 5;294:210-219. Epub 2021 Jun 5.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RX, UK; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK.

Background: Postpartum psychosis (PP) is the most severe psychiatric disorder associated with childbirth. However, there is little research on maternal bonding towards the infant and parenting stress in this clinical population.

Methods: We investigated maternal bonding during pregnancy and post-partum in 75 women: 46 at risk of PP (AR), because of a DSM-IV diagnosis of bipolar disorder, schizoaffective disorder or previous PP, and 29 healthy controls. Of the AR women, 19 developed a psychiatric relapse within 4 weeks' post-partum (AR-unwell), while 27 remained symptom-free (AR-well). We investigated childhood maltreatment, parenting stress and psychiatric symptoms as potential predictors of maternal bonding.

Results: In pregnancy, AR-unwell women reported a more negative affective experience towards their infants than AR-well women (d = 0.87, p = .001), while postnatally there was no significant difference in bonding. In contrast, AR women as a group reported a more negative affective experience than HC postnatally (d = 0.69, p = .002; d = 0.70, p = .010), but not antenatally. Parenting stress and psychiatric symptoms significantly predicted less optimal postnatal bonding (b = -0.10, t = -4.29, p < .001; b = -0.37, t = -4.85, p < .001) but only psychiatric symptoms explained the difference in bonding between AR and HC (b = -1.18, 95% BCa CI [-2.70,-0.04]).

Limitations: A relatively small sample size precluded a more in-depth investigation of underlying pathways.

Conclusion: This study provides new information on maternal bonding in women at risk of PP, and particularly in those that do and do not develop a postpartum relapse. The results suggest that improving maternal symptoms and parenting stress in the perinatal period in women at risk of PP could also have positive effects on bonding.
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http://dx.doi.org/10.1016/j.jad.2021.05.076DOI Listing
November 2021

Maternal thoughts of self-harm and their association with future offspring mental health problems.

J Affect Disord 2021 10 4;293:422-428. Epub 2021 Jul 4.

Section of Women's Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.

Introduction: Depression and self-harm are leading causes of disability in young people, but prospective data on how maternal depression and self-harm thoughts contribute to these outcomes, and how they may interact is lacking.

Methods: The study sample consisted of 8,425 mothers and offspring from the Avon Longitudinal Study of Parents and Children, an ongoing birth cohort study. Exposures were maternal self-harm ideation and depression measured using the Edinburgh Postnatal Depression Scale, collected at eleven time points over the period 18 weeks' gestation to 18 years post-partum. Outcomes were offspring past-year major depressive disorder and lifetime self-harm assessed at age 24.

Results: Nearly one-fifth (16.7%) of mothers reported thoughts of self-harm on at least one of the eleven assessment points. The frequency of maternal self-harm ideation was related to both outcomes in a dose-response manner. Young adults whose mothers had self-harm ideation on 5-11 occasions were over three times more likely (Odds ratio (OR), 3.32; 95% CI, 1.63-6.76) to be depressed and over 1.5 times as likely (OR, 1.55; 95% CI, 0.73, 3.29) to have self-harmed than their peers whose mothers had never reported self-harm thoughts. Maternal self-harm thoughts remained associated with both offspring outcomes independent of maternal depression, and no evidence was found for an interaction between the two exposures.

Discussion: Clinicians collecting data on maternal depression may consider paying attention to questions about self-harm ideation in assessments. Examining accumulated maternal self-harm ideation over time may provide insights into which children are most at risk for later self-harm and depression.
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http://dx.doi.org/10.1016/j.jad.2021.06.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370273PMC
October 2021

Mums Alone: Exploring the Role of Isolation and Loneliness in the Narratives of Women Diagnosed with Perinatal Depression.

J Clin Med 2021 May 24;10(11). Epub 2021 May 24.

Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, De Crespigny Park, London SE5 8AF, UK.

In this study, we explore the role that isolation and loneliness play in the narratives of women diagnosed with perinatal depression. Isolation and loneliness are increasingly seen as risk factors for depression, including in the perinatal period, but little is known about whether, and in what ways, women themselves associate isolation or loneliness with perinatal distress. Based on the thematic analysis of semi-structured interviews with fourteen mothers in England, we found that women often connected feelings of depression during and after pregnancy to feeling dislocated from their previous identities and relationships. Women felt lost, confined to their homes, and often unsupported by their partners and families. However, fears of being judged to be inadequate mothers made it difficult for women to make authentic connections with others or to express negative feelings, increasing isolation and depression. We drew on the intersectionality theory to illustrate how the intersect between motherhood and other aspects of women's identities (being young, single, deprived and/or from an ethnic minority) could leave some women particularly isolated and marginalised. Our conclusions emphasise the need to challenge social constructions of the good/bad mother, advocate for social change to lessen pressures on mothers, and develop support that addresses women's interpersonal contexts and social networks.
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http://dx.doi.org/10.3390/jcm10112271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8197355PMC
May 2021

Healthcare experiences of perpetrators of domestic violence and abuse: a systematic review and meta-synthesis.

BMJ Open 2021 05 19;11(5):e043183. Epub 2021 May 19.

Section of Women's Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Objectives: Domestic violence and abuse (DVA) is highly prevalent, with severe adverse consequences to the health and well-being of survivors. There is a smaller evidence base on the health of DVA perpetrators and their engagement with healthcare services. This review examines the experiences of perpetrators of DVA of accessing healthcare services and the barriers and facilitators to their disclosure of abusive behaviours in these settings.

Design: A systematic review and meta-synthesis of qualitative studies.

Data Sources: A systematic search was conducted in Cochrane, MEDLINE, Embase, PsycINFO, HMIC, BNID, CINAHL, ASSIA, IBSS, SSCI (peer-reviewed literature) and NDLTD, OpenGrey and SCIE Online (grey literature). Each database was searched from its start date to 15 March 2020. Eligibility criteria required that studies used qualitative or mixed methods to report on the experiences of healthcare use by perpetrators of DVA. A meta-ethnographic method was used to analyse the extracted data.

Results: Of 30,663 papers identified, six studies (n=125 participants; 124 men, 1 woman) met the inclusion criteria. Barriers to disclosure of DVA to healthcare staff included perpetrators' negative emotions and attitudes towards their abusive behaviours; fear of consequences of disclosure; and lack of trust in healthcare services' ability to address DVA. Facilitators of disclosure of DVA and engagement with healthcare services were experiencing social consequences of abusive behaviours; feeling listened to by healthcare professionals; and offers of emotional and practical support for relationship problems by healthcare staff.

Conclusions: DVA perpetration is a complex issue with multiple barriers to healthcare engagement and disclosure. However, healthcare services can create positive conditions for the engagement of individuals who perpetrate abuse.

Prospero Registration Number: CRD42017073818.
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http://dx.doi.org/10.1136/bmjopen-2020-043183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137202PMC
May 2021

Sex differences in experiences of multiple traumas and mental health problems in the UK Biobank cohort.

Soc Psychiatry Psychiatr Epidemiol 2021 May 10. Epub 2021 May 10.

Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK.

Purpose: Experiences of reported trauma are common and are associated with a range of mental health problems. Sex differences in how reported traumas are experienced over the life course in relation to mental health require further exploration.

Methods: 157,358 participants contributed data for the UK Biobank Mental Health Questionnaire (MHQ). Stratified Latent Class Analysis (LCA) was used to analyse combinations of reported traumatic experiences in males and females separately, and associations with mental health.

Results: In females, five trauma classes were identified: a low-risk class (58.6%), a childhood trauma class (13.5%), an intimate partner violence class (12.9%), a sexual violence class (9.1%), and a high-risk class (5.9%). In males, a three-class solution was preferred: a low-risk class (72.6%), a physical and emotional trauma class (21.9%), and a sexual violence class (5.5%). In comparison to the low-risk class in each sex, all trauma classes were associated with increased odds of current depression, anxiety, and hazardous/harmful alcohol use after adjustment for covariates. The high-risk class in females and the sexual violence class in males produced significantly increased odds for recent psychotic experiences.

Conclusion: There are sex differences in how reported traumatic experiences co-occur across a lifespan, with females at the greatest risk. However, reporting either sexual violence or multiple types of trauma was associated with increased odds of mental health problems for both males and females. Findings emphasise the public mental health importance of identifying and responding to both men and women's experiences of trauma, including sexual violence.
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http://dx.doi.org/10.1007/s00127-021-02092-yDOI Listing
May 2021

Preventing postnatal depression: a causal mediation analysis of a 20-year preconception cohort.

Philos Trans R Soc Lond B Biol Sci 2021 06 3;376(1827):20200028. Epub 2021 May 3.

Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria 3052, Australia.

Postnatal depression (PND) is common and predicts a range of adverse maternal and offspring outcomes. PND rates are highest among women with persistent mental health problems before pregnancy, and antenatal healthcare provides ideal opportunity to intervene. We examined antenatal perceived social support as a potential intervention target in preventing PND symptoms among women with prior mental health problems. A total of 398 Australian women (600 pregnancies) were assessed repeatedly for mental health problems before pregnancy (ages 14-29 years, 1992-2006), and again during pregnancy, two months postpartum and one year postpartum (2006-2014). Causal mediation analysis found that intervention on perceived antenatal social support has the potential to reduce rates of PND symptoms by up to 3% (from 15 to 12%) in women with persistent preconception symptoms. Supplementary analyses found that the role of low antenatal social support was independent of concurrent antenatal depressive symptoms. Combined, these two factors mediated up to more than half of the association between preconception mental health problems and PND symptoms. Trialling dual interventions on antenatal depressive symptoms and perceived social support represents one promising strategy to prevent PND in women with persistent preconception symptoms. Interventions promoting mental health before pregnancy may yield an even greater reduction in PND symptoms by disrupting a developmental cascade of risks via these and other pathways. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.
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http://dx.doi.org/10.1098/rstb.2020.0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8090815PMC
June 2021

Optimising psychological treatment for Anxiety DisordErs in Pregnancy (ADEPT): study protocol for a feasibility trial of time-intensive CBT versus weekly CBT.

Pilot Feasibility Stud 2021 Apr 30;7(1):101. Epub 2021 Apr 30.

Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.

Background: Moderate to severe anxiety disorders such as obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social phobia and panic disorder are common, and affect approximately 11-16% of women in pregnancy. Psychological treatments for anxiety disorders, primarily cognitive behaviour therapy (CBT), have a substantial evidence base and recently time-intensive versions have been found as effective as weekly treatments. However, this has not been trialled in women who are pregnant, where a shorter intervention may be desirable.

Methods: The ADEPT study is a feasibility randomised controlled trial with two parallel intervention groups. Time-intensive one-to-one CBT and standard weekly one-to-one CBT delivered during pregnancy will be compared. Feasibility outcomes including participation and follow-up rates will be assessed, alongside the acceptability of the interventions using qualitative methods.

Discussion: The study will provide preliminary data to inform the design of a full-scale randomised controlled trial of a time-intensive intervention for anxiety during pregnancy. This will include information on the acceptability of time-intensive interventions for pregnant women with anxiety disorders.

Trial Registration: https://doi.org/10.1186/ISRCTN81203286 prospectively registered 27/6/2019.
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http://dx.doi.org/10.1186/s40814-021-00838-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085465PMC
April 2021

Risk factors for postpartum relapse in women at risk of postpartum psychosis: The role of psychosocial stress and the biological stress system.

Psychoneuroendocrinology 2021 06 3;128:105218. Epub 2021 Apr 3.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK. Electronic address:

Background: Postpartum psychosis is the most severe psychiatric disorder associated with childbirth, and the risk is particularly high for women with a history of bipolar disorder, schizoaffective disorder or those who have suffered a previous episode of postpartum psychosis. Whilst there is a lot of evidence linking stress to psychosis unrelated to childbirth, the role of stress in the onset of postpartum psychosis has not been fully investigated.

Methods: A prospective longitudinal study of 112 pregnant women, 51 at risk of postpartum psychosis because of a DSM-IV diagnosis of bipolar disorder (n = 41), schizoaffective disorder (n = 6) or a previous postpartum psychosis (n = 4) and 61 healthy women with no past or current DSM-IV diagnosis and no family history of postpartum psychosis. Women were followed up from the third trimester of pregnancy to 4 weeks' post partum. Women at risk who had a psychiatric relapse in the first 4 weeks' post partum (AR-unwell) (n = 22), were compared with those at risk who remained well (AR-well) (n = 29) on measures of psychosocial stress (severe childhood maltreatment and stressful life events) and biological stress (cortisol and inflammatory biomarkers).

Results: Logistic regression analyses revealed that severe childhood maltreatment (OR = 4.9, 95% CI 0.5-49.2) and higher daily cortisol in the third trimester of pregnancy (OR=3.7, 95% CI 1.2-11.6) predicted psychiatric relapse in the first 4 weeks' post partum in women at risk of postpartum psychosis after adjusting for clinical and sociodemographic covariates.

Conclusion: The current study provides evidence for the role of psychosocial stress and the biological stress system in the risk of postpartum relapse in women at risk of postpartum psychosis.
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http://dx.doi.org/10.1016/j.psyneuen.2021.105218DOI Listing
June 2021

New perspectives in perinatal mental health models: facing challenge for Italian health services. Preface.

Ann Ist Super Sanita 2021 Jan-Mar;57(1):37-39

Dipartimento Salute Mentale e Dipendenze Patologiche, AUSL Modena, Modena, Italy.

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http://dx.doi.org/10.4415/ANN_21_01_06DOI Listing
April 2021

Mental health problems and fear of childbirth: A cohort study of women in an inner-city maternity service.

Birth 2021 06 17;48(2):230-241. Epub 2021 Mar 17.

Health Service and Population Research Department, Section of Women's Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Objectives: To estimate the population prevalence of severe fear of childbirth (FOC) during pregnancy and investigate its association with: (a) antenatal common mental disorders (depression and anxiety disorder) and (b) elective cesarean birth.

Methods: 545 participants from an inner-city London maternity population were interviewed soon after their first antenatal appointment (mean gestation: 14 weeks). Current mental disorders were assessed using the Structured Clinical Interview DSM-IV. FOC was measured using the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ-A) at approximately 28 weeks gestation (n = 377), with severe FOC defined using a cutoff of WDEQ-A ≥ 85. Birth mode information was collected at 3 months post-delivery using an adapted Adult Service Use Schedule. Linear regressions were used to model associations, adjusting for the effects of covariates (age, parity, relationship status, education, and planned pregnancy). Sampling weights were used to adjust for bias introduced by the stratified sampling. We also accounted for missing data within the analysis.

Results: The estimated population prevalence of severe FOC was 3% (95% CI: 2%-6%) (n = 377). Depression and anxiety were significantly associated with severe FOC after adjustment for covariates (45% vs 11%; coefficient: 15.75, 95% CI: 8.08-23.42, P < .001). There was a weak association between severe FOC and elective cesarean birth.

Conclusions: Severe FOC occurs in around 3% of the population. Depression and anxiety are associated with FOC. Pregnant people with depression and anxiety may be at increased risk of experiencing severe FOC. Attitudes toward childbirth should be assessed as part of routine clinical assessment of pregnant people in contact with mental health services.
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http://dx.doi.org/10.1111/birt.12532DOI Listing
June 2021

Antidepressant treatment for postnatal depression.

Cochrane Database Syst Rev 2021 02 13;2:CD013560. Epub 2021 Feb 13.

Section of Women's Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: Depression is one of the most common morbidities of the postnatal period. It has been associated with adverse outcomes for women, children, the wider family and society as a whole. Treatment is with psychosocial interventions or antidepressant medication, or both. The aim of this review is to evaluate the effectiveness of different antidepressants and to compare their effectiveness with placebo, treatment as usual or other forms of treatment. This is an update of a review last published in 2014.

Objectives: To assess the effectiveness and safety of antidepressant drugs in comparison with any other treatment (psychological, psychosocial, or pharmacological), placebo, or treatment as usual for postnatal depression.

Search Methods: We searched Cochrane Common Mental Disorders's Specialized Register, CENTRAL, MEDLINE, Embase and PsycINFO in May 2020. We also searched international trials registries and contacted experts in the field.

Selection Criteria: We included randomised controlled trials (RCTs) of women with depression during the first 12 months postpartum that compared antidepressant treatment (alone or in combination with another treatment) with any other treatment, placebo or treatment as usual.

Data Collection And Analysis: Two review authors independently extracted data from the study reports. We requested missing information from study authors wherever possible. We sought data to allow an intention-to-treat analysis. Where we identified sufficient comparable studies we pooled data and conducted random-effects meta-analyses.

Main Results: We identified 11 RCTs (1016 women), the majority of which were from English-speaking, high-income countries; two were from middle-income countries. Women were recruited from a mix of community-based, primary care, maternity and outpatient settings. Most studies used selective serotonin reuptake inhibitors (SSRIs), with treatment duration ranging from 4 to 12 weeks. Meta-analysis showed that there may be a benefit of SSRIs over placebo in response (55% versus 43%; pooled risk ratio (RR) 1.27, 95% confidence interval (CI) 0.97 to 1.66); remission (42% versus 27%; RR 1.54, 95% CI 0.99 to 2.41); and reduced depressive symptoms (standardised mean difference (SMD) -0.30, 95% CI -0.55 to -0.05; 4 studies, 251 women), at 5 to 12 weeks' follow-up. We were unable to conduct meta-analysis for adverse events due to variation in the reporting of this between studies. There was no evidence of a difference between acceptability of SSRI and placebo (27% versus 27%; RR 1.10, 95% CI 0.74 to 1.64; 4 studies; 233 women). The certainty of all the evidence for SSRIs was low or very low due to the small number of included studies and a number of potential sources of bias, including high rates of attrition. There was insufficient evidence to assess the efficacy of SSRIs compared with other classes of antidepressants and of antidepressants compared with other pharmacological interventions, complementary medicines, psychological and psychosocial interventions or treatment as usual. A substantial proportion of women experienced adverse effects but there was no evidence of differences in the number of adverse effects between treatment groups in any of the studies. Data on effects on children, including breastfed infants, parenting, and the wider family were limited, although no adverse effects were noted.

Authors' Conclusions: There remains limited evidence regarding the effectiveness and safety of antidepressants in the management of postnatal depression, particularly for those with more severe depression. We found low-certainty evidence that SSRI antidepressants may be more effective in treating postnatal depression than placebo as measured by response and remission rates. However, the low certainty of the evidence suggests that further research is very likely to have an important impact on our effect estimate. There is a continued imperative to better understand whether, and for whom, antidepressants or other treatments are more effective for postnatal depression, and whether some antidepressants are more effective or better tolerated than others. In clinical practice, the findings of this review need to be contextualised by the extensive broader literature on antidepressants in the general population and perinatal clinical guidance, to inform an individualised risk-benefit clinical decision. Future RCTs should focus on larger samples, longer follow-up, comparisons with alternative treatment modalities and inclusion of child and parenting outcomes.
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http://dx.doi.org/10.1002/14651858.CD013560.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094614PMC
February 2021

Addressing inequities in maternal health among women living in communities of social disadvantage and ethnic diversity.

BMC Public Health 2021 01 21;21(1):176. Epub 2021 Jan 21.

Department of Women and Children's Health, Faculty of Life Science and Medicine, King's College London, London, UK.

The response to the coronavirus outbreak and how the disease and its societal consequences pose risks to already vulnerable groups such those who are socioeconomically disadvantaged and ethnic minority groups. Researchers and community groups analysed how the COVID-19 crisis has exacerbated persisting vulnerabilities, socio-economic and structural disadvantage and discrimination faced by many communities of social disadvantage and ethnic diversity, and discussed future strategies on how best to engage and involve local groups in research to improve outcomes for childbearing women experiencing mental illness and those living in areas of social disadvantage and ethnic diversity. Discussions centred around: access, engagement and quality of care; racism, discrimination and trust; the need for engagement with community stakeholders; and the impact of wider social and economic inequalities. Addressing biomedical factors alone is not sufficient, and integrative and holistic long-term public health strategies that address societal and structural racism and overall disadvantage in society are urgently needed to improve health disparities and can only be implemented in partnership with local communities.
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http://dx.doi.org/10.1186/s12889-021-10182-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817762PMC
January 2021

Obstetric near misses among women with serious mental illness: data linkage cohort study.

Br J Psychiatry 2021 Jan 11:1-7. Epub 2021 Jan 11.

Section of Women's Mental Health, Health Service Research and Population Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.

Background: Investigating obstetric near misses (life-threatening obstetric complications) provides crucial information to prevent maternal mortality and morbidity.

Aims: To investigate the rate and type of obstetric near misses among women with serious mental illness (SMI).

Method: We conducted a historical cohort study, using de-identified electronic mental health records linked with maternity data from Hospital Episode Statistics. The English Maternal Morbidity Outcome Indicator was used to identify obstetric near misses at the time of delivery in two cohorts: (1) exposed cohort - all women with a live or still birth in 2007-2016, and a history of secondary mental healthcare before delivery in south-east London (n = 13 570); (2) unexposed cohort - all women with a live or still birth in 2007-2016, resident within south-east London, with no history of mental healthcare before delivery (n = 223 274).

Results: The rate of obstetric near misses was 884.3/100 000 (95% CI 733.2-1057.4) maternities in the exposed group compared with 575.1/100 000 (95% CI 544.0-607.4) maternities in the unexposed group (adjusted odds ratio 1.6, 95% CI 1.3-2.0, P < 0.001). Highest risks were for acute renal failure (adjusted odds ratio 2.1, 95% CI 1.1-3.8, P = 0.022); cardiac arrest, failure or infarction (adjusted odds ratio 2.3, 95% CI 1.1-4.8, P = 0.028); and obstetric embolism (adjusted odds ratio 3.1, 95% CI 1.6-5.8, P < 0.001).

Conclusions: Findings emphasise the importance of integrated physical and mental healthcare before and during pregnancy for women with SMI.
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http://dx.doi.org/10.1192/bjp.2020.250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387856PMC
January 2021

Shortening the Edinburgh postnatal depression scale using optimal test assembly methods: Development of the EPDS-Dep-5.

Acta Psychiatr Scand 2021 04 19;143(4):348-362. Epub 2021 Jan 19.

Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada.

Aims: This study used a large database to develop a reliable and valid shortened form of the Edinburgh Postnatal Depression Scale (EPDS), a self-report questionnaire used for depression screening in pregnancy and postpartum, based on objective criteria.

Methods: Item responses from the 10-item EPDS were obtained from 5157 participants (765 major depression cases) from 22 primary screening accuracy studies that compared the EPDS to the Structured Clinical Interview for DSM (SCID). Unidimensionality of the EPDS latent construct was verified using confirmatory factor analysis, and an item response theory model was fit. Optimal test assembly (OTA) methods identified a maximally informative shortened form for each possible scale length between 1 and 9 items. The final shortened form was selected based on pre-specified validity and reliability criteria and non-inferiority of screening accuracy of the EPDS as compared to the SCID.

Results: A 5-item short form of the EPDS (EPDS-Dep-5) was selected. The EPDS-Dep-5 had a Cronbach's alpha of 0.82. Sensitivity and specificity of the EPDS-Dep-5 for a cutoff of 4 or greater were 0.83 (95% CI, 0.73, 0.89) and 0.86 (95% CI, 0.80, 0.90) and were statistically non-inferior to the EPDS. The correlation of total scores with the full EPDS was high (r = 0.91).

Conclusion: The EPDS-Dep-5 is a valid short form with minimal loss of information when compared to the full-length EPDS. The EPDS-Dep-5 was developed with OTA methods using objective, pre-specified criteria, but the approach is data-driven and exploratory. Thus, there is a need to replicate results of this study in different populations.
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http://dx.doi.org/10.1111/acps.13272DOI Listing
April 2021

Fear of childbirth during pregnancy: associations with observed mother-infant interactions and perceived bonding.

Arch Womens Ment Health 2021 06 17;24(3):483-492. Epub 2020 Dec 17.

Section of Women's Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, SE5 8AF, London, UK.

Fear of childbirth (FOC) is a common phenomenon that can impair functioning in pregnancy but potential longer term implications for the mother-infant relationship are little understood. This study was aimed at investigating postpartum implications of FOC on the mother-infant relationship. A UK sample of 341 women in a community setting provided data on anxiety, mood and FOC in mid-pregnancy and subsequently completed self-report measures of postnatal bonding in a longitudinal cohort study. Postnatal observations of mother-infant interactions were collected and rated for a subset of 141 women. FOC was associated with maternal perception of impaired bonding, even after controlling for sociodemographic factors, concurrent depression and the presence of anxiety disorders (Coef = 0.10, 95% CI 0.07-0.14, p < 0.001). Observed mother-infant interactions were not associated with FOC (Coef = -0.01-0.03 CI - 0.02 to 0.02, p = 0.46), weakly with concurrent depression (Coef = - 0.10, CI - 0.19 to 0.00, p = 0.06) and not associated with anxiety disorders. The self-efficacy component of FOC was most strongly associated with lower reported bonding (Coef 0.37, 95% CI 0.25-0.49, p < 0.001) FOC makes a distinct contribution to perceived postpartum bonding difficulties but observed mother-infant interaction quality was not affected. This may be due to low self-efficacy impacting psychological adjustment during pregnancy. Targeted interventions during pregnancy focusing both on treatment of key childbirth fears and bonding could help women adjust earlier.
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http://dx.doi.org/10.1007/s00737-020-01098-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116271PMC
June 2021

Association between antipsychotic use in pregnancy and the risk of gestational diabetes: Population-based cohort studies from the United Kingdom and Hong Kong and an updated meta-analysis.

Schizophr Res 2021 03 24;229:55-62. Epub 2020 Nov 24.

Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom. Electronic address:

Aims: To investigate whether exposure to antipsychotic medications during pregnancy is associated with gestational diabetes mellitus (GDM) in United Kingdom (UK) and Hong Kong (HK) population cohorts.

Methods: Two population-based cohort studies were conducted using data from the UK The Health Improvement Network (THIN) and HK Clinical Data Analysis and Reporting System (CDARS). Nondiabetic women who received any type of antipsychotic medicine before their first pregnancy were included in our cohorts. The exposed group comprised women who continued using antipsychotics from the start of pregnancy to delivery (continuers), while the comparison group included women who were prescribed antipsychotics before the start of pregnancy but stopped during pregnancy (discontinuers). GDM was identified using GDM diagnosis and/or clinicians reported GDM. Odds ratios (ORs) with a 95% confidence interval (CI) were calculated to assess the association between antipsychotic use during pregnancy and GDM. Propensity Score fine-stratification weighting was used to adjust for potential confounding factors.

Results: 3114 women with registered first pregnancies (2351 in THIN and 763 in CDARS) were included. 5.49% (2.55% in THIN and 14.55% in CDARS) were diagnosed with GDM. The adjusted OR of GDM in continuers was 0.73 (95% CI: 0.43-1.25) in THIN and 1.16 (95% CI: 0.78-1.73) in CDARS compared with discontinuers.

Conclusions: Our results do not suggest an increased risk of GDM in women who continued using antipsychotics during pregnancy compared to women who stopped. Based on these results, women should not stop their regular antipsychotics prescriptions in pregnancy due to the fear of GDM.
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http://dx.doi.org/10.1016/j.schres.2020.11.021DOI Listing
March 2021

Assessing the Acceptability, Feasibility and Sustainability of an Intervention to Increase Detection of Domestic Violence and Abuse in Patients Suffering From Severe Mental Illness: A Qualitative Study.

Front Psychiatry 2020 28;11:581031. Epub 2020 Oct 28.

Department of Psychiatry, Epidemiological and Social Psychiatric Research Institute, Erasmus University Medical Centre Rotterdam, Rotterdam, Netherlands.

Despite interventions to improve detection rates, domestic violence, and abuse (DVA) remains largely undetected by healthcare services. We therefore aimed to examine the acceptability, feasibility, and sustainability of an intervention aiming to improve DVA detection rates, which included a clear referral pathway (i.e., the BRAVE intervention) and to explore the acceptability and feasibility of DVA management and referrals in general, in the context of low detection rates. Qualitative study design with four focus groups of 16 community mental health (CMH) clinicians from both control and intervention arms. The focus groups discussed managing DVA in clinical practice and staff experiences with the BRAVE intervention in particular. Focus groups continued until saturation of the subject was reached. Interviews were analyzed using a thematic analysis approach. DVA was seen to be highly relevant to mental healthcare but is also a very sensitive subject. Barriers in CMH professionals, institutions, and society meant CMH professionals often refrained from asking about DVA in patients. Barriers included communication difficulties between CMH professionals and DVA professionals, a fear of disrupting the therapeutic alliance with the patient, and a lack of appropriate services to help victims of DVA. The BRAVE intervention was acceptable but not feasible or sustainable. Personal, institutional, and public barriers make it not feasible for CMH professionals to detect DVA in mental healthcare. To increase the detection of DVA, professional standards should be combined with training, feedback sessions with peers and DVA counselors, and routine enquiry about DVA. ISRCTN, trial registration number: ISRCTN14115257.
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http://dx.doi.org/10.3389/fpsyt.2020.581031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655979PMC
October 2020

Parental mental health before and during pregnancy and offspring birth outcomes: A 20-year preconception cohort of maternal and paternal exposure.

EClinicalMedicine 2020 Oct 12;27:100564. Epub 2020 Oct 12.

Murdoch Children's Research Institute, Melbourne, Australia.

Background: Preterm birth (PTB) and small for gestational age (SGA) are increasingly prevalent, with major consequences for health and development into later life. There is emerging evidence that some risk processes begin before pregnancy. We report on associations between maternal and paternal common mental disorders (CMD) before and during pregnancy and offspring PTB and SGA.

Methods: 398 women with 609 infants and 267 men with 421 infants were assessed repeatedly for CMD symptoms before pregnancy between age 14 and 29 and during pregnancy. Associations between preconception and antenatal CMD symptoms and offspring gestational age/PTB and size for gestational age/SGA were estimated using linear and Poisson regression.

Findings: In men, persistent preconception CMD across adolescence and young adulthood predicted offspring PTB after adjustment for ethnicity, education, BMI and adolescent substance use (adjusted RR 7·0, 95% CI 1·8,26·8), corresponding to a population attributable fraction of 31% of preterm births. In women, antenatal CMD symptoms predicted offspring PTB (adjusted RR 4·4, 95% CI 1·4,14·1). There was little evidence of associations with SGA.

Interpretation: This first report of an association between paternal preconception mental health and offspring gestational age, while requiring replication in larger samples, complements earlier work on stress in animals, and further strengthens the case for expanding preconception mental health care to both men and women.

Funding: National Health and Medical Research Council (Australia), Victorian Health Promotion Foundation, Australian Rotary Health, Colonial Foundation, Perpetual Trustees, Financial Markets Foundation for Children (Australia), Royal Children's Hospital Foundation, Murdoch Children's Research Institute, Australian Research Council.
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http://dx.doi.org/10.1016/j.eclinm.2020.100564DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599306PMC
October 2020

Overestimation of Postpartum Depression Prevalence Based on a 5-item Version of the EPDS: Systematic Review and Individual Participant Data Meta-analysis.

Can J Psychiatry 2020 12 26;65(12):835-844. Epub 2020 Oct 26.

7712University of Connecticut School of Nursing, Mansfield, CT, USA.

Objective: The Maternal Mental Health in Canada, 2018/2019, survey reported that 18% of 7,085 mothers who recently gave birth reported "feelings consistent with postpartum depression" based on scores ≥7 on a 5-item version of the Edinburgh Postpartum Depression Scale (EPDS-5). The EPDS-5 was designed as a screening questionnaire, not to classify disorders or estimate prevalence; the extent to which EPDS-5 results reflect depression prevalence is unknown. We investigated EPDS-5 ≥7 performance relative to major depression prevalence based on a validated diagnostic interview, the Structured Clinical Interview for DSM (SCID).

Methods: We searched Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO, and the Web of Science Core Collection through June 2016 for studies with data sets with item response data to calculate EPDS-5 scores and that used the SCID to ascertain depression status. We conducted an individual participant data meta-analysis to estimate pooled percentage of EPDS-5 ≥7, pooled SCID major depression prevalence, and the pooled difference in prevalence.

Results: A total of 3,958 participants from 19 primary studies were included. Pooled prevalence of SCID major depression was 9.2% (95% confidence interval [CI] 6.0% to 13.7%), pooled percentage of participants with EPDS-5 ≥7 was 16.2% (95% CI 10.7% to 23.8%), and pooled difference was 8.0% (95% CI 2.9% to 13.2%). In the 19 included studies, mean and median ratios of EPDS-5 to SCID prevalence were 2.1 and 1.4 times.

Conclusions: Prevalence estimated based on EPDS-5 ≥7 appears to be substantially higher than the prevalence of major depression. Validated diagnostic interviews should be used to establish prevalence.
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http://dx.doi.org/10.1177/0706743720934959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7658422PMC
December 2020

Depression prevalence based on the Edinburgh Postnatal Depression Scale compared to Structured Clinical Interview for DSM DIsorders classification: Systematic review and individual participant data meta-analysis.

Int J Methods Psychiatr Res 2021 03 22;30(1):e1860. Epub 2020 Oct 22.

Department of Psychiatry, Rajarajeswari Medical College and Hospital, Bengaluru, Karnataka, India.

Objectives: Estimates of depression prevalence in pregnancy and postpartum are based on the Edinburgh Postnatal Depression Scale (EPDS) more than on any other method. We aimed to determine if any EPDS cutoff can accurately and consistently estimate depression prevalence in individual studies.

Methods: We analyzed datasets that compared EPDS scores to Structured Clinical Interview for DSM (SCID) major depression status. Random-effects meta-analysis was used to compare prevalence with EPDS cutoffs versus the SCID.

Results: Seven thousand three hundred and fifteen participants (1017 SCID major depression) from 29 primary studies were included. For EPDS cutoffs used to estimate prevalence in recent studies (≥9 to ≥14), pooled prevalence estimates ranged from 27.8% (95% CI: 22.0%-34.5%) for EPDS ≥ 9 to 9.0% (95% CI: 6.8%-11.9%) for EPDS ≥ 14; pooled SCID major depression prevalence was 9.0% (95% CI: 6.5%-12.3%). EPDS ≥14 provided pooled prevalence closest to SCID-based prevalence but differed from SCID prevalence in individual studies by a mean absolute difference of 5.1% (95% prediction interval: -13.7%, 12.3%).

Conclusion: EPDS ≥14 approximated SCID-based prevalence overall, but considerable heterogeneity in individual studies is a barrier to using it for prevalence estimation.
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http://dx.doi.org/10.1002/mpr.1860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7992289PMC
March 2021

The experience of health and welfare workers in identifying and responding to domestic abuse among military personnel in the UK.

BMC Health Serv Res 2020 Oct 15;20(1):947. Epub 2020 Oct 15.

Forensic and Neurodevelopmental Science Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, 16 De Crespigny Park, London, SE5 8AF, UK.

Background: Awareness of domestic violence and abuse (DVA) as a problem among military personnel (serving and veterans) has grown in recent years, and there is a need for research to inform improvements in the identification of and response to DVA in this population. This study aimed to explore the experience of health and welfare professionals in identifying and responding to DVA among the UK military population (serving personnel and veterans).

Methods: Thirty-five semi-structured telephone interviews were conducted with health and welfare staff who work with serving UK military personnel and veterans. Interviews were analysed using thematic analysis.

Results: Three superordinate themes were identified: i) patterns of DVA observed by health and welfare workers (perceived gender differences in DVA experiences and role of mental health and alcohol); (ii) barriers to identification of and response to DVA (attitudinal/knowledge-based barriers and practical barriers), and iii) resource issues (training needs and access to services). Participants discussed how factors such as a culture of hypermasculinity, under-reporting of DVA, the perception of DVA as a "private matter" among military personnel, and lack of knowledge and awareness of emotional abuse and coercive controlling behaviour as abuse constitute barriers to identification and management of DVA. Healthcare providers highlighted the need for more integrated working between civilian and military services, to increase access to support and provide effective care to both victims and perpetrators. Furthermore, healthcare and welfare staff reflected on their training needs in the screening and management of DVA to improve practice.

Conclusions: There is a need for increased awareness of DVA, particularly of non-physical forms of abuse, and of male victimisation in the military. Standardised protocols for DVA management and systematic training are required to promote a consistent and appropriate response to DVA. There is a particular training need among healthcare and first-line welfare staff, who are largely relied upon to identify cases of DVA in the military. Employing DVA advocates within military and civilian healthcare settings may be useful in improving DVA awareness, management and access to specialist support.
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http://dx.doi.org/10.1186/s12913-020-05672-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7559780PMC
October 2020

Lockdown, domestic abuse perpetration, and mental health care: gaps in training, research, and policy.

Lancet Psychiatry 2021 03 28;8(3):172-174. Epub 2020 Sep 28.

Section of Women's Mental Health, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK; South London and Maudsley NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1016/S2215-0366(20)30397-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521882PMC
March 2021

Perinatal mental health: a review of progress and challenges.

World Psychiatry 2020 Oct;19(3):313-327

Section of Women's Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high-income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.
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http://dx.doi.org/10.1002/wps.20769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491613PMC
October 2020

Schizophrenia around the time of pregnancy: leveraging population-based health data and electronic health record data to fill knowledge gaps.

BJPsych Open 2020 Aug 28;6(5):e97. Epub 2020 Aug 28.

Women's College Research Institute, Women's College Hospital, Canada.

Background: Research in schizophrenia and pregnancy has traditionally been conducted in small samples. More recently, secondary analysis of routine healthcare data has facilitated access to data on large numbers of women with schizophrenia.

Aims: To discuss four scientific advances using data from Canada, Denmark and the UK from population-level health registers and clinical data sources.

Method: Narrative review of research from these three countries to illustrate key advances in the area of schizophrenia and pregnancy.

Results: Health administrative and clinical data from electronic medical records have been used to identify population-level and clinical cohorts of women with schizophrenia, and follow them longitudinally along with their children. These data have demonstrated that fertility rates in women with schizophrenia have increased over time and have enabled documentation of the course of illness in relation with pregnancy, showing the early postpartum as the time of highest risk. As a result of large sample sizes, we have been able to understand the prevalence of and risk factors for rare outcomes that would be difficult to study in clinical research. Advanced pharmaco-epidemiological methods have been used to address confounding in studies of antipsychotic medications in pregnancy, to provide data about the benefits and risks of treatment for women and their care providers.

Conclusions: Use of these data has advanced the field of research in schizophrenia and pregnancy. Future developments in use of electronic health records include access to richer data sources and use of modern technical advances such as machine learning and supporting team science.
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http://dx.doi.org/10.1192/bjo.2020.78DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488329PMC
August 2020

Is there an association between anxiety and depression prior to and during pregnancy and gestational diabetes? An analysis of the Born in Bradford cohort.

J Affect Disord 2020 11 18;276:345-350. Epub 2020 Jul 18.

Section of Women's Mental Health, King's College London and South London and Maudsley NHS Foundation Trust, PO31 King's College London, De Crespigny Park, London, SE5 8AF, UK.

Background: anxiety and depression are common in women with gestational diabetes but it is not clear whether they are more likely to precede the onset of gestational diabetes or to co-occur with it. Our aims were to compare the strength of association between common mental disorders of anxiety and depression (i) before pregnancy and (ii) during pregnancy in women with and without gestational diabetes.

Methods: the sample comprised 12,239 women with 13,539 pregnancies from the UK's Born in Bradford cohort. Gestational diabetes was diagnosed by oral glucose tolerance test (OGTT). Indicators of common mental disorders were obtained from linked primary care records. Multivariable robust Poisson and logistic regression were employed. Multiple imputation by chained equations was implemented to handle missing data. Models were adjusted for maternal age, ethnicity, education and obstetric complications. Analyses of common mental disorders during pregnancy were additionally adjusted for maternal smoking, pre-pregnancy BMI, multiple pregnancy and common mental disorders prior to pregnancy.

Results: there was no evidence for an association between common mental disorders prior to pregnancy and gestational diabetes (adjusted RR 0.96; 95% CI 0.80,1.15) or between gestational diabetes and common mental disorders during pregnancy (adjusted OR 0.91; 95% CI 0.73,1.12).

Limitations: high levels of deprivation and multi-ethnic composition of the cohort may limit generalisability of these findings to other populations.

Conclusions: routine primary care records did not identify an increased risk of gestational diabetes in women with common mental disorders prior to pregnancy or of gestational diabetes in women with common mental disorders during pregnancy.
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http://dx.doi.org/10.1016/j.jad.2020.07.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477491PMC
November 2020

The association between neighbourhood characteristics and physical victimisation in men and women with mental disorders.

BJPsych Open 2020 Jul 16;6(4):e73. Epub 2020 Jul 16.

Section of Women's Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK.

Background: How neighbourhood characteristics affect the physical safety of people with mental illness is unclear.

Aims: To examine neighbourhood effects on physical victimisation towards people using mental health services.

Method: We developed and evaluated a machine-learning-derived free-text-based natural language processing (NLP) algorithm to ascertain clinical text referring to physical victimisation. This was applied to records on all patients attending National Health Service mental health services in Southeast London. Sociodemographic and clinical data, and diagnostic information on use of acute hospital care (from Hospital Episode Statistics, linked to Clinical Record Interactive Search), were collected in this group, defined as 'cases' and concurrently sampled controls. Multilevel logistic regression models estimated associations (odds ratios, ORs) between neighbourhood-level fragmentation, crime, income deprivation, and population density and physical victimisation.

Results: Based on a human-rated gold standard, the NLP algorithm had a positive predictive value of 0.92 and sensitivity of 0.98 for (clinically recorded) physical victimisation. A 1 s.d. increase in neighbourhood crime was accompanied by a 7% increase in odds of physical victimisation in women and an 13% increase in men (adjusted OR (aOR) for women: 1.07, 95% CI 1.01-1.14, aOR for men: 1.13, 95% CI 1.06-1.21, P for gender interaction, 0.218). Although small, adjusted associations for neighbourhood fragmentation appeared greater in magnitude for women (aOR = 1.05, 95% CI 1.01-1.11) than men, where this association was not statistically significant (aOR = 1.00, 95% CI 0.95-1.04, P for gender interaction, 0.096). Neighbourhood income deprivation was associated with victimisation in men and women with similar magnitudes of association.

Conclusions: Neighbourhood factors influencing safety, as well as individual characteristics including gender, may be relevant to understanding pathways to physical victimisation towards people with mental illness.
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http://dx.doi.org/10.1192/bjo.2020.52DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7443921PMC
July 2020

Mental Health Support in the Perinatal Period for Women With a Personality Disorder Diagnosis: A Qualitative Study of Women's Experiences.

J Pers Disord 2021 08 15;35(4):589-604. Epub 2020 Jun 15.

Division of Psychiatry, University College London, London, UK.

Women who receive a diagnosis of personality disorder may face particular challenges in the context of having a baby. However, this area has received little attention. This study aimed to qualitatively explore experiences of mental health support during the perinatal period in a group of mothers who self-reported having a personality disorder diagnosis. Semistructured interviews were conducted with 12 women who received mental health support during the perinatal period. These data were analyzed thematically. Key themes related to women feeling judged to be unfit mothers; not feeling heard or understood by services; feeling that services struggled with the complexity of their needs; valuing specialist support to cope with their struggles in motherhood; and valuing professional relationships that resembled real-life friendships. Our findings raise questions about how best to provide support to this group of women and about the use and consequences of the diagnosis of personality disorder among new mothers.
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http://dx.doi.org/10.1521/pedi_2020_34_482DOI Listing
August 2021
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