Complex chronic conditions among children born to women with schizophrenia.

PURPOSE: Maternal schizophrenia is linked to complications in offspring near the time of birth. Whether there is also a higher future risk of the child having a complex chronic condition (CCC) - a pediatric condition affecting any bodily system expected to last at least 12 months that is severe enough to require specialty care and/or a period of hospitalization - is not known. METHODS: In this population-based health administrative data cohort study (Ontario, Canada, 1995-2018), the risk for CCC was compared in 5066 children of women with schizophrenia (the exposed) vs. 2,939,320 unexposed children. Adjusted hazard ratios (aHR) were generated for occurrence of any CCC, by CCC category, and stratified by child sex, and child prematurity. RESULTS: CCC was more frequent in the exposed (7.7 per 1000 person-years [268 children]) than unexposed (4.2 per 100 person-years [124,452 children]) - an aHR of 1.25 (95% CI 1.10-1.41). aHRs were notably higher in 5 of 9 CCC categories: neuromuscular (1.73, 1.28-2.33), cardiovascular (1.94, 1.64-2.29), respiratory (1.83, 1.32-2.54), hematology/immunodeficiency (2.24, 1.24-4.05) and other congenital or genetic defect (1.59, 1.16-2.17). The aHR for CCC was more pronounced among boys (1.32, 1.13-1.55) than girls (1.16, 0.96-1.40), and of similar magnitude in term (1.22, 1.05-1.42) and preterm infants (1.18, 0.95-1.46). CONCLUSIONS: The risk for a CCC appears to be higher in children born to women with schizophrenia. This finding introduces opportunities for targeted preconception counselling, optimization of maternal risk factors, and intervention to support a vulnerable parent population who will experience unique challenges caring for a child with CCCs.

Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) through non-specialist providers and telemedicine: a study protocol for a non-inferiority randomized controlled trial.

BACKGROUND: Depression and anxiety impact up to 1 in 5 pregnant and postpartum women worldwide. Yet, as few as 20% of these women are treated with frontline interventions such as evidence-based psychological treatments. Major barriers to uptake are the limited number of specialized mental health treatment providers in most settings, and problems with accessing in-person care, such as childcare or transportation. Task sharing of treatment to non-specialist providers with delivery on telemedicine platforms could address such barriers. However, the equivalence of these strategies to specialist and in-person models remains unproven. METHODS: This study protocol outlines the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) randomized trial. SUMMIT is a pragmatic, non-inferiority test of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a brief, behavioral activation (BA) treatment for perinatal depressive and anxiety symptoms. Specialists (psychologists, psychiatrists, and social workers with ≥ 5 years of therapy experience) and non-specialists (nurses and midwives with no formal training in mental health care) were trained in the BA protocol, with the latter supervised by a BA expert during treatment delivery. Consenting pregnant and postpartum women with Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 10 (N = 1368) will be randomized to one of four arms (telemedicine specialist, telemedicine non-specialist, in-person specialist, in-person non-specialist), stratified by pregnancy status (antenatal/postnatal) and study site. The primary outcome is participant-reported depressive symptoms (EPDS) at 3 months post-randomization. Secondary outcomes are maternal symptoms of anxiety and trauma symptoms, perceived social support, activation levels and quality of life at 3-, 6-, and 12-month post-randomization, and depressive symptoms at 6- and 12-month post-randomization. Primary analyses are per-protocol and intent-to-treat. The study has successfully continued despite the COVID-19 pandemic, with needed adaptations, including temporary suspension of the in-person arms and ongoing randomization to telemedicine arms. DISCUSSION: The SUMMIT trial is expected to generate evidence on the non-inferiority of BA delivered by a non-specialist provider compared to specialist and telemedicine compared to in-person. If confirmed, results could pave the way to a dramatic increase in access to treatment for perinatal depression and anxiety. TRIAL REGISTRATION: ClinicalTrials.gov NCT04153864 . Registered on November 6, 2019.

Intergenerational teen pregnancy: a population-based cohort study.

OBJECTIVE: To estimate the intergenerational association in teenage pregnancy, and whether there is a coupling tendency between a mother and daughter in how their teen pregnancies end, such as a termination of pregnancy (TOP) versus a live birth. DESIGN: Population-based cohort study. SETTING: Ontario, Canada. POPULATION: A total of 15 097 mothers and their 16 177 daughters. METHODS: Generalised estimating equations generated adjusted odds ratios (aOR) of a daughter experiencing a teen pregnancy in relation to the number of teen pregnancies her mother had. Multinomial logistic regression estimated the odds that a teen pregnancy ended with TOP among both mother and daughter. All models were adjusted for maternal age and world region of origin, the daughter's socio-demographic characteristics and comorbidities, mother-daughter cohabitation, and neighbourhood-level teen pregnancy rate. MAIN OUTCOME MEASURES: Teen pregnancy in the daughter, between ages 15 and 19 years, and also the nature of the daughter's teen pregnancy, categorised as (1) no teen pregnancy, (2) at least one teen pregnancy, all exclusively ending with a live birth, and (3) at least one teen pregnancy, with at least one teen pregnancy ending with a TOP. RESULTS: The proportion of daughters having a teen pregnancy among those whose mother had zero, one, two, or at least three teen pregnancies was 16.3, 24.9, 33.5 and 36.3%, respectively. The aOR of a daughter having a teen pregnancy was 1.42 (95% CI 1.25-1.61) if her mother had one, 1.97 (95% CI 1.71-2.26) if she had two, and 2.17 (95% CI 1.84-2.56) if her mother had three or more teen pregnancies, relative to none. If a mother had at least one teen pregnancy ending with TOP, then her daughter had an aOR of 2.12 (95% CI 1.76-2.56) for having a teen pregnancy also ending with TOP; whereas, if a mother had at least one teen pregnancy, all ending with a live birth, then her daughter had an aOR of 1.73 (95% CI 1.46-2.05) for that same outcome. CONCLUSION: There is a strong intergenerational occurrence of teenage pregnancy between a mother and daughter, including a coupling tendency in how the pregnancy ends. TWEETABLE ABSTRACT: Strong intergenerational association for teenage pregnancy between mother and daughter.

Low medical morbidity and mortality after acute courses of electroconvulsive therapy in a population-based sample.

BACKGROUND: To determine event rates for specific medical events and mortality among individuals receiving electroconvulsive therapy (ECT). METHOD: Population-based cohort study using health administrative data of acute ECT treatments delivered in Ontario, Canada, from 2003 to 2011. We measured the following medical event rates, per 10 000 ECT treatments, up to 7 and 30 days post-treatment: stroke, seizure, acute myocardial infarction, arrhythmia, pneumonia, pulmonary embolus, deep vein thrombosis, gastrointestinal bleeding, falls, hip fracture, and mortality. RESULTS: A total of 135 831 ECT treatments were delivered to 8810 unique patients. Overall medical event rates were 9.1 and 16.8 per 10 000 ECT treatments respectively. The most common medical events were falls (2.7 and 5.5 per 10 000 ECT treatments) and pneumonia (1.8 and 3.8 per 10 000 ECT treatments). Fewer than six deaths occurred on the day of an ECT treatment. This corresponded to a mortality rate of less than 0.4 per 10 000 treatments. Deaths within 7 and 30 days of an ECT treatment, excluding deaths due to external causes (e.g., accidental and intentional causes of death), were 1.0 and 2.4 per 10 000 ECT treatments respectively. CONCLUSION: Morbidity and mortality events after ECT treatments were relatively low, supporting ECT as a low-risk medical procedure.

Maternal and offspring outcomes in women with intellectual and developmental disabilities: a population-based cohort study.

OBJECTIVE: To compare the risks for adverse maternal and offspring outcomes in women with and without intellectual and developmental disabilities. DESIGN: Population-based cohort study. SETTING: Ontario, Canada. POPULATION: Singleton obstetrical deliveries to 18- to 49-year-old women with and without intellectual and developmental disabilities (n = 3932 in the exposed cohort, n = 382 774 in the unexposed cohort; 2002-2011 fiscal years). METHODS: Women with intellectual and developmental disabilities were identified based on diagnoses in health administrative data or receipt of disability income support. The unexposed cohort comprised women without intellectual and developmental disabilities. Modified Poisson regression was used to compute adjusted relative risks (aRR) and 95% confidence intervals (CI) comparing the two cohorts. MAIN OUTCOME MEASURES: Primary maternal outcomes were: gestational diabetes, gestational hypertension, pre-eclampsia, eclampsia, and venous thromboembolism. Primary offspring outcomes were: preterm birth, small for gestational age, and large for gestational age. RESULTS: The exposed cohort, compared with the unexposed cohort, had increased risks for pre-eclampsia (aRR 1.47, 95% CI 1.11-1.93) and venous thromboembolism (aRR 1.60, 95% CI 1.17-2.19). Their offspring had increased risks for preterm birth (aRR 1.63, 95% CI 1.47-1.80) and small for gestational age (aRR 1.35, 95% CI 1.25-1.45). CONCLUSIONS: These findings suggest that there is a need to address modifiable risk factors for adverse outcomes among women with intellectual and developmental disabilities prior to and during pregnancy. Moreover, there is a need to enhance monitoring for maternal and offspring complications in this population. TWEETABLE ABSTRACT: Large cohort study: intellectual and developmental disabilities predispose women/babies to adverse outcomes.

Identifying women at risk for postpartum anxiety: a prospective population-based study.

OBJECTIVE: To develop a multifactorial model to predict anxiety symptomatology at 8 weeks postpartum. METHOD: In a population-based study, 522 women in a health region near Vancouver, Canada, completed questionnaires at 1, 4, and 8 weeks postpartum. Questionnaires included risk factors measured at 1 week (sociodemographic, biological, pregnancy-related, life stressors, social support, obstetric, and maternal adjustment). Sequential logistic regression was completed to develop a predictive model of anxiety symptomatology at 8 weeks (State-Trait Anxiety Inventory score >40). RESULTS: The prevalence of anxiety symptomatology at 1, 4, and 8 weeks postpartum was 22.6%, 17.2%, and 14.8% respectively. In multivariable models, anxiety symptomatology at 1 week (aOR 2.78, 95% CI: 1.04-7.43), multiparous parity (aOR 3.29, 95% CI: 1.28-8.48), history of psychiatric problems (aOR 3.07, 95% CI: 1.19-7.97), perceived stress (1 SD increase: aOR 4.92, 95% CI: 2.62-9.26), and childcare stress (1 SD increase: aOR 1.63, 95% CI: 1.01-2.64) were independent predictors of anxiety symptomatology at 8 weeks. CONCLUSION: While a significant proportion of women experience anxiety symptomatology following childbirth, multiparous women with a psychiatric history who have high levels of diverse stress are at greatest risk. These key factors may be used to promote early identification and secondary preventive interventions.

Factors associated with postpartum psychiatric admission in a population-based cohort of women with schizophrenia.

OBJECTIVE: We aimed to identify factors associated with postpartum psychiatric admission in schizophrenia. METHOD: In a population-based cohort study of 1433 mothers with schizophrenia in Ontario, Canada (2003-2011), we compared women with and without psychiatric admission in the 1st year postpartum on demographic, maternal medical/obstetrical, infant and psychiatric factors and identified factors independently associated with admission. RESULTS: Admitted women (n = 275, 19%) were less likely to be adolescents, more likely to be low income and less likely to have received prenatal ultrasound before 20 weeks gestation compared to non-admitted women. They also had higher rates of predelivery psychiatric comorbidity and mental health service use. Factors independently associated with postpartum admission were age (<20 vs. ≥35 years: adjusted risk ratio, aRR, 0.48, 95% CI 0.24-0.96), income (lowest vs. highest income: aRR 1.67, 1.13-2.47) and the following mental health service use factors in pregnancy: admission (≥35 days/year vs. no days, aRR 4.54, 3.65-5.65), outpatient mental health care (no visits vs. ≥2 visits aRR 0.35, 0.27-0.47) and presence of a consistent mental health care provider during pregnancy (aRR 0.69, 0.54-0.89). CONCLUSION: Certain subgroups of women with schizophrenia may benefit from targeted intervention to mitigate risk for postpartum admission.

Neurobiological mechanisms of repetitive transcranial magnetic stimulation of the dorsolateral prefrontal cortex in depression: a systematic review.

Depression is one of the most prevalent mental illnesses worldwide and a leading cause of disability, especially in the setting of treatment resistance. In recent years, repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising alternative strategy for treatment-resistant depression and its clinical efficacy has been investigated intensively across the world. However, the underlying neurobiological mechanisms of the antidepressant effect of rTMS are still not fully understood. This review aims to systematically synthesize the literature on the neurobiological mechanisms of treatment response to rTMS in patients with depression. Medline (1996-2014), Embase (1980-2014) and PsycINFO (1806-2014) were searched under set terms. Three authors reviewed each article and came to consensus on the inclusion and exclusion criteria. All eligible studies were reviewed, duplicates were removed, and data were extracted individually. Of 1647 articles identified, 66 studies met both inclusion and exclusion criteria. rTMS affects various biological factors that can be measured by current biological techniques. Although a number of studies have explored the neurobiological mechanisms of rTMS, a large variety of rTMS protocols and parameters limits the ability to synthesize these findings into a coherent understanding. However, a convergence of findings suggest that rTMS exerts its therapeutic effects by altering levels of various neurochemicals, electrophysiology as well as blood flow and activity in the brain in a frequency-dependent manner. More research is needed to delineate the neurobiological mechanisms of the antidepressant effect of rTMS. The incorporation of biological assessments into future rTMS clinical trials will help in this regard.

Maternal and newborn outcomes among women with schizophrenia: a retrospective population-based cohort study.

OBJECTIVE: More women with schizophrenia are becoming pregnant, such that contemporary data are needed about maternal and newborn outcomes in this potentially vulnerable group. We aimed to quantify maternal and newborn health outcomes among women with schizophrenia. DESIGN: Retrospective cohort study. SETTING: Population based in Ontario, Canada, from 2002 to 2011. POPULATION: Ontario women aged 15-49 years who gave birth to a liveborn or stillborn singleton infant. METHODS: Women with schizophrenia (n = 1391) were identified based on either an inpatient diagnosis or two or more outpatient physician service claims for schizophrenia within 5 years prior to conception. The reference group comprised 432 358 women without diagnosed mental illness within the 5 years preceding conception in the index pregnancy. MAIN OUTCOME MEASURES: The primary maternal outcomes were gestational diabetes mellitus, gestational hypertension, pre-eclampsia/eclampsia, and venous thromboembolism. The primary neonatal outcomes were preterm birth, and small and large birthweight for gestational age (SGA and LGA). Secondary outcomes included additional key perinatal health indicators. RESULTS: Schizophrenia was associated with a higher risk of pre-eclampsia (adjusted odds ratio, aOR 1.84; 95% confidence interval, 95% CI 1.28-2.66), venous thromboembolism (aOR 1.72, 95% CI 1.04-2.85), preterm birth (aOR 1.75, 95% CI 1.46-2.08), SGA (aOR 1.49, 95% CI 1.19-1.86), and LGA (aOR 1.53, 95% CI 1.17-1.99). Women with schizophrenia also required more intensive hospital resources, including operative delivery and admission to a maternal intensive care unit, paralleled by higher neonatal morbidity. CONCLUSIONS: Women with schizophrenia are at higher risk of multiple adverse pregnancy outcomes, paralleled by higher neonatal morbidity. Attention should focus on interventions to reduce the identified health disparities.

Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review.

BACKGROUND: Although much is known about the risk factors for postpartum depression (PPD), the role of giving birth to a preterm or low-birth-weight infant has not been reviewed systematically. OBJECTIVE: To review systematically the prevalence and risk factors for PPD among women with preterm infants. SEARCH STRATEGY: Medline, CINAHL, EMBASE, PsycINFO and the Cochrane Library were searched from their start dates to August 2008 using keywords relevant to depression and prematurity. SELECTION CRITERIA: Peer-reviewed articles were eligible for inclusion if a standardised assessment of depression was administered between delivery and 52 weeks postpartum to mothers of preterm infants. DATA COLLECTION AND ANALYSIS: Data on either the prevalence of PPD or mean depression score in the target population and available comparison groups were extracted from the 26 articles included in the review. Risk factors for PPD were also extracted where reported. MAIN RESULTS: The rates of PPD were as high as 40% in the early postpartum period among women with premature infants. Sustained depression was associated with earlier gestational age, lower birth weight, ongoing infant illness/disability and perceived lack of social support. The main limitation was that most studies failed to consider depression in pregnancy as a confounding variable. AUTHOR'S CONCLUSIONS: Mothers of preterm infants are at higher risk of depression than mothers of term infants in the immediate postpartum period, with continued risk throughout the first postpartum year for mothers of very-low-birth-weight infants. Targeted clinical interventions to identify and prevent PPD in this vulnerable obstetric population are warranted.