Contraception for Women With Psychiatric Disorders

Pilot study of a novel, alternative subdermal scapular insertion site for the etonogestrel contraceptive implant

OBJECTIVES

To assess the pharmacokinetics and pharmacodynamics of the etonogestrel (ENG) contraceptive implant when inserted at an alternative scapular site.

STUDY DESIGN

We conducted a pilot study of healthy, reproductive-age females who underwent subdermal insertion of an ENG implant over the inferior edge of the nondominant scapula (scapular insertion). We measured serum ENG levels over 1 year at nine time points. Participants completed questionnaires on insertion site and bleeding side effects. We collected photographs and video recordings of insertion and removal techniques.

RESULTS

We enrolled five participants (as prespecified), their median age was 26.0 years (range: 19.6-30.3), and median body mass index was 25.0 kg/m2 (range: 22.0-28.0). All serum ENG concentrations remained >90 pg/mL and were within the range of published data for arm insertion of ENG implant at all time points. The mean serum ENG level was 511.7 pg/mL (±168.2) at 1 week and 136.6 pg/mL (±21.8) at 12 months. During the first week after insertion, four of five participants noted insertion site pain with a median pain score of 2 (range 1-3), but all noted resolution by week two. Participants reported variable bleeding patterns consistent with standard ENG implant placement. At the end of the study, all participants reported satisfaction with the implant and would recommend scapular insertion to a friend.

CONCLUSIONS

Scapular insertion of the ENG contraceptive implant has similar pharmacokinetics to arm insertion over 1 year of use. This novel, alternative site was well tolerated and demonstrated similar bleeding side effects to standard arm insertion.

IMPLICATIONS

Subdermal scapular insertion of the etonogestrel contraceptive implant demonstrated similar pharmacokinetics to arm insertion over 1 year of use. Our pilot data support scapular insertion as an alternative site for ENG contraceptive implants, which could be beneficial for certain patient populations.

Trends in different contraception methods among women attending the Melbourne Sexual Health Centre from 2011 to 2020

OBJECTIVES

The efficacy and availability of contraception have changed in the last several decades; however, unintended pregnancies continue to be an issue in Australia. This study aimed to describe trends in contraception in women attending a sexual health service over 9 years.

STUDY DESIGN

Repeated cross-sectional study.

METHODS

Women aged 16-49 years attending Melbourne Sexual Health Centre between 2011 and 2020 were included. Women were asked what methods of contraception they currently use. Contraception were categorised into long-acting reversible contraception (LARC; e.g. intrauterine devices and implants classified as highly effective), moderately effective contraception (e.g. oral contraception pill), less effective contraception (e.g. condom and withdrawal) and no contraception, as defined by US Centers for Disease Control and Prevention guidelines. Multivariable logistic regression was used to examine the factors associated with the use of moderate-high-efficacy contraception.

RESULTS

A total of 38,288 women were included with a median age of 25 (interquartile range: 22-29). Between 2011 and 2020, there was a decreasing trend in condom (63.3%-56.1%; Ptrend <0.001) and oral contraception (27.2%-20.5%; Ptrend <0.001) use, whilst there was an increasing trend in the use of LARCs: implant (4.6%-6.0%; Ptrend = 0.002) and intrauterine device (2.8%-11.8%; Ptrend <0.001). Increasing age was associated with decreased odds of using moderate-high-efficacy contraception (Ptrend <0.001). Compared with Oceanian-born women, Asian (adjusted odds ratios [aOR] = 0.63, 95% confidence interval [CI]: 0.56-0.72) and Middle Eastern-born women (aOR = 0.60, 95% CI: 0.48-0.74) had lower odds of using moderate-high-efficacy contraception, whilst European (aOR = 1.23, 95% CI:1.07-1.41) and North American-born women (aOR = 1.51, 95% CI: 1.22-1.87) had higher odds of using moderate-high-efficacy contraception.

CONCLUSIONS

Between 2011 and 2020, LARC use has increased, whilst less effective contraceptives, such as condom and oral contraception, have decreased among women at Melbourne Sexual Health Centre. Further research is required to understand age and ethnic disparities in contraception methods for future family planning programmes.

Post-Roe v Wade psychiatry: legal, clinical, and ethical challenges in psychiatry under abortion bans

In recent history, the world has witnessed a trend towards liberalization of abortion laws driven by an increasing understanding of the negative personal and public health consequences of criminalizing abortion. By contrast, several countries have recently implemented restrictive reproductive laws, joining the 112 countries where access to abortion care is banned completely or with narrow exceptions. On June 24, 2022, the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization overturned its landmark decisions in Roe v Wade that established abortion until the point of viability of the fetus as a constitutional right. After Roe v Wade having been overturned, it is projected that many women in the USA will be prevented from accessing safe abortion care. Importantly, abortion bans not only impose constraints on patient autonomy, they also restrict physicians' ability to practice evidence-based medicine, which will negatively impact psychiatric care. It is therefore crucial for the practicing psychiatrist to be familiar with this new legal landscape. In this Personal View, we aim to provide a topical overview to help clinicians gain a clear understanding of legal, clinical, and ethical responsibilities, focusing on the USA. We also discuss the reality that psychiatrists might be called upon to determine medical necessity for an abortion on psychiatric grounds, which is new for most US psychiatrists. We predict that psychiatrists will be confronted with very difficult situations in which lawful and ethical conduct might be incongruent, and that abortion bans will result in greater numbers of patients needing psychiatric care from a system that is ill-prepared for additional demands.

Prioritizing Maternal Mental Health in Addressing Morbidity and Mortality

Importance

The rate of maternal mortality in the United States is 2-fold to 3-fold greater than that in other high-income countries. While many national initiatives have been developed to combat maternal mortality, these efforts often fail to include mental illness.

Objective

To highlight the underrecognized contribution of mental illness to maternal mortality, which is nearly double that of postpartum hemorrhage.

Evidence Review

A topic outline was developed to include challenges in measuring perinatal mental conditions and mortality rates; contributions of social determinants of health to mental conditions and mortality; perinatal psychiatric disorder characterization; mechanisms by which maternal mental illness increases mortality, specifically, suicide and addictive disorders; access limitations and care "deserts"; prenatal stress and its impact on reproductive outcomes; increasing clinician expertise through cross-disciplinary education; intervention sites and models; and asserting that mental health is fundamental to maternal health. Publications in the last 3 years were prioritized, particularly those relating to policy. References were selected through consensus. Sources were PubMed, Ovid, direct data published on government websites, and health policy sources such as the Policy Center for Maternal Mental Health.

Findings

Priority was given to recent sources. Citations from 2022-2023 numbered 26; within the last 5 years, 14; and historical references, 15. Recommendations to address each topic area serve as concluding statements for each section. To mitigate the contributions of mental illness to the maternal mortality risk, a coordinated effort is required across professional and governmental organizations.

Conclusions and Relevance

Concrete programmatic and policy changes are needed to reduce perinatal stress and address trauma, standardize the collection of social determinant of health data among perinatal patients, increase access to reproductive psychiatry curricula among prescribers, reduce perinatal mental health and obstetrical deserts, institute paid parental leave, and support seamless integration of perinatal and behavioral health care. Moreover, instead of focusing on a relatively minor portion of the contributors to health that current medical practice targets, fortifying the social foundation strengthens the prospects for the health of families for our current and future generations.

Addressing Pregnancy And Parenting In Mental Health Care: Perspectives Of Women With Serious Mental Illness

Women living with serious mental illness (SMI) are at increased risk for adverse pregnancy and parenting outcomes. However, little is known about the experiences and preferences of women with SMI related to addressing pregnancy and parenting with their mental health providers. We conducted semistructured interviews with twenty-two reproductive-age cisgender women patients living with SMI. Participants characterized discussions about pregnancy and medication teratogenicity with their mental health providers as limited or unsatisfactory. Participants' openness to discussing pregnancy varied by topic and its perceived relevance to their individual circumstances, and it hinged on participants' trust in their providers. Participants characterized discussions about parenting with their mental health providers as helpful and identified additional opportunities for parenting support. Our findings highlight critical gaps in the delivery of information, support, and resources that can inform efforts to increase providers' capacity to address pregnancy and parenting with women living with SMI.

Mental health conditions and contraception: current landscape, reproductive health and obstetric outcomes, and clinical guidance

PURPOSE OF REVIEW

This review presents the epidemiology of mental health conditions among reproductive aged people, common adverse reproductive outcomes, the hormonal profile of contraception and its relationship with psychiatric outcomes, and updated information for clinicians providing contraceptive counselling for this population.

RECENT FINDINGS

There is variability among contraceptive behaviours and patterns across those who have mental health conditions, impacting reproductive, psychiatric, and perinatal outcomes. The endocrinology of hormonal contraceptives is well understood, however, the impacts of steroidal hormones on mental health outcomes continue to be less understood. Overall, hormonal contraceptives are safe to use among those with mental health conditions, and among those using selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. Additional considerations are needed when prescribing contraception among people who may be at risk of poor adherence, who use certain classes of antidepressants, antipsychotics, antiepileptics, and who are <6 weeks postpartum.

SUMMARY

Barriers to effective contraceptive use should be addressed and myths on negative psychiatric impacts of hormonal contraceptives should be dispelled. Healthcare clinicians should seek out opportunities to become proficient in contraception counselling to improve health outcomes among people with mental health conditions.

Use of progestogens and the risk of intracranial meningioma: national case-control study

OBJECTIVE

To assess the risk of intracranial meningioma associated with the use of selected progestogens.

DESIGN

National case-control study.

SETTING

French National Health Data System (ie, Système National des Données de Santé).

PARTICIPANTS

Of 108 366 women overall, 18 061 women living in France who had intracranial surgery for meningioma between 1 January 2009 and 31 December 2018 (restricted inclusion periods for intrauterine systems) were deemed to be in the case group. Each case was matched to five controls for year of birth and area of residence (90 305 controls).

MAIN OUTCOME MEASURES

Selected progestogens were used: progesterone, hydroxyprogesterone, dydrogesterone, medrogestone, medroxyprogesterone acetate, promegestone, dienogest, and intrauterine levonorgestrel. For each progestogen, use was defined by at least one dispensation within the year before the index date (within three years for 13.5 mg levonorgestrel intrauterine systems and five years for 52 mg). Conditional logistic regression was used to calculate odds ratio for each progestogen meningioma association.

RESULTS

Mean age was 57.6 years (standard deviation 12.8). Analyses showed excess risk of meningioma with use of medrogestone (42 exposed cases/18 061 cases (0.2%) v 79 exposed controls/90 305 controls (0.1%), odds ratio 3.49 (95% confidence interval 2.38 to 5.10)), medroxyprogesterone acetate (injectable, 9/18 061 (0.05%) v 11/90 305 (0.01%), 5.55 (2.27 to 13.56)), and promegestone (83/18 061 (0.5%) v 225/90 305 (0.2 %), 2.39 (1.85 to 3.09)). This excess risk was driven by prolonged use (≥one year). Results showed no excess risk of intracranial meningioma for progesterone, dydrogesterone, or levonorgestrel intrauterine systems. No conclusions could be drawn concerning dienogest or hydroxyprogesterone because of the small number of individuals who received these drugs. A highly increased risk of meningioma was observed for cyproterone acetate (891/18 061 (4.9%) v 256/90 305 (0.3%), odds ratio 19.21 (95% confidence interval 16.61 to 22.22)), nomegestrol acetate (925/18 061 (5.1%) v 1121/90 305 (1.2%), 4.93 (4.50 to 5.41)), and chlormadinone acetate (628/18 061 (3.5%) v 946/90 305 (1.0%), 3.87 (3.48 to 4.30)), which were used as positive controls for use.

CONCLUSIONS

Prolonged use of medrogestone, medroxyprogesterone acetate, and promegestone was found to increase the risk of intracranial meningioma. The increased risk associated with the use of injectable medroxyprogesterone acetate, a widely used contraceptive, and the safety of levonorgestrel intrauterine systems are important new findings.

Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic

Importance

Knowledge about characteristics of US pregnancy-associated decedents is needed to guide responses.

Objective

To examine individual sociodemographic characteristics and residing county's health care resources and socioeconomic factors among pregnancy-associated overdose decedents in comparison with obstetric decedents and overdose decedents who were not pregnant in the past year.

Design, Setting, and Participants

This cross-sectional, exploratory study included 1457 pregnant and postpartum overdose decedents, 4796 obstetric decedents, and 11 205 nonpregnant overdose decedents aged 10 to 44 years from 2018 to 2021. Data were analyzed August 2023.

Exposures

Decedents from the 2018-2021 Multiple Cause of Death Files linked to the 2021 Area Health Resources Files and the 2018-2021 County Health Rankings data at the county level.

Main Outcomes and Measures

Pregnancy-associated deaths were defined as deaths during pregnancy or within 1 year of pregnancy termination. This study focused on unintentional drug overdoses or drug overdoses with undetermined intent involving the most common psychotropic drugs of misuse.

Results

From 2018 to 2021, across the pregnancy-postpartum continuum, pregnancy-associated overdose mortality ratios consistently increased among women aged 10 to 44 years. Mortality ratio more than tripled among pregnant and postpartum women aged 35 to 44 years from 4.9 (95% CI, 3.0-8.0) per 100 000 mothers aged 35 to 44 years with a live birth in January to June 2018 to 15.8 (95% CI, 12.3-20.4) in July to December 2021 (average semiannual percentage changes, 15.9; 95% CI, 8.7-23.6; P < .001). Compared with pregnant obstetric decedents, pregnant overdose decedents had increased odds of being aged 10 to 34 years (75.4% vs 59.5%; range of odds ratios [ORs], 1.8 [95% CI, 1.3-2.5] for ages 10 to 24 years to 2.2 [95% CI, 1.7-2.8] for ages 25 to 34 years), being non-college graduates (72.1% vs 59.4%; range of ORs, 2.7 [95% CI, 1.7-4.3] for those with some college education to 3.9 [95% CI, 2.4-6.1] for those with less than high school education), being unmarried (88.0% vs 62.1%; OR, 4.5; 95% CI, 3.7-6.0), and dying in nonhome, non-health care settings (25.9% vs 4.5%; OR, 2.5; 95% CI, 1.8-3.6) and were associated with decreased odds of dying in health care settings (34.7% vs 77.6%; range of ORs, 0.1 [95% CI, 0.1-0.1] for those who died in hospital inpatient settings to 0.4 [95% CI, 0.3-0.6] for those who died in hospital outpatient/emergency room settings).

Conclusions and Relevance

From 2018 to 2021, the mortality ratio more than tripled among pregnant and postpartum women aged 35 to 44 years, consistent with increases in overdose mortality across US populations. Most pregnancy-associated overdose deaths occurred outside health care settings, indicating the need for strengthening community outreach and maternal medical support. To reduce pregnancy-associated overdose mortality, evidence-based interventions are urgently needed at individual, health care, local, and national levels, along with nonpunitive approaches incentivizing pregnant and postpartum women to seek substance use disorder treatments.

A Perspective on Hormonal Contraception Usage in Central Nervous System Injury

Naturally occurring life stages in women are associated with changes in the milieu of endogenous ovarian hormones. Women of childbearing age may be exposed to exogenous ovarian hormone(s) because of their use of varying combinations of estrogen and progesterone hormones-containing oral contraceptives (OC; also known as "the pill"). If women have central nervous system (CNS) injury such as spinal cord injury (SCI) and traumatic brain injury (TBI) during their childbearing age, they are likely to retain their reproductive capabilities and may use OC. Many deleterious side effects of long-term OC use have been reported, such as aberrant blood clotting and endothelial dysfunction that consequently increase the risk of myocardial infarction, venous thromboembolism, and ischemic brain injury. Although controversial, studies have suggested that OC use is associated with neuropsychiatric ramifications, including uncontrollable mood swings and poorer cognitive performance. Our understanding about how the combination of endogenous hormones and OC-conferred exogenous hormones affect outcomes after CNS injuries remains limited. Therefore, understanding the impact of OC use on CNS injury outcomes needs further investigation to reveal underlying mechanisms, promote reporting in clinical or epidemiological studies, and raise awareness of possible compounded consequences. The goal of the current review is to discuss the impacts of CNS injury on endogenous ovarian hormones and vice-versa, as well as the putative consequences of exogenous ovarian hormones (OC) on the CNS to identify potential gaps in our knowledge to consider for future laboratory, epidemiological, and clinical studies.

Striking the Balance: Bipolar Disorder in the Perinatal Period

The authors reviewed the literature, published between 2018 and 2023, on treating bipolar disorder in the perinatal period in order to summarize current treatment perspectives. Mood episodes occur during pregnancy and there are high rates of both initial onset and recurrence in the postpartum period. Bipolar disorder itself is associated with higher risks of adverse pregnancy outcomes, including gestational hypertension, hemorrhage, cesarean delivery, and small for gestational age infants. A general principle of perinatal treatment includes maintaining psychiatric stability of the pregnant person while reducing medication exposure risk to the fetus. A variety of factors can compromise psychiatric stability, including rapid discontinuation of stabilizing medications, decreased efficacy due to physiologic changes of pregnancy, and exacerbation of underlying psychiatric illness. Psychosocial interventions include optimizing sleep, increasing support, and reducing stress. The American College of Obstetricians and Gynecologists recommends against discontinuing or withholding medications solely due to pregnancy or lactation status. Individualized treatment involves a discussion of the risks of undertreated bipolar disorder weighed against the risks of individual medication choice based on available evidence regarding congenital malformations, adverse neonatal and obstetrical events, and neurodevelopmental outcomes. Valproate is not a first-line treatment due to higher risks. Data are lacking on safety for many newer medications. The authors review current safety data regarding lithium, lamotrigine, and antipsychotics, which are the most commonly used treatments for managing bipolar disorder in the perinatal period. Due to physiologic changes during pregnancy, frequent therapeutic drug monitoring and dose adjustments are required.

Guidelines on the use of sex and gender in cardiovascular research

In cardiovascular research, sex and gender have not typically been considered in research design and reporting until recently. This has resulted in clinical research findings from which not only all women, but also gender-diverse individuals have been excluded. The resulting dearth of data has led to a lack of sex- and gender-specific clinical guidelines and raises serious questions about evidence-based care. Basic research has also excluded considerations of sex. Including sex and/or gender as research variables not only has the potential to improve the health of society overall now, but it also provides a foundation of knowledge on which to build future advances. The goal of this guidelines article is to provide advice on best practices to include sex and gender considerations in study design, as well as data collection, analysis, and interpretation to optimally establish rigor and reproducibility needed to inform clinical decision-making and improve outcomes. In cardiovascular physiology, incorporating sex and gender is a necessary component when optimally designing and executing research plans. The guidelines serve as the first guidance on how to include sex and gender in cardiovascular research. We provide here a beginning path toward achieving this goal and improve the ability of the research community to interpret results through a sex and gender lens to enable comparison across studies and laboratories, resulting in better health for all.

The Association between Immediate Postpartum Depot Medroxyprogesterone Acetate Use and Postpartum Depressive Symptoms

OBJECTIVE

While postpartum depot medroxyprogesterone acetate (DMPA) is a highly effective form of contraception, some data suggest an association with depressive symptoms. Our objective was to evaluate the relationship between receipt of DMPA in the immediate postpartum period and postpartum depressive symptoms.

STUDY DESIGN

This retrospective cohort study included all women who received prenatal and postpartum care at academic obstetric clinics affiliated with a tertiary care institution between January 1, 2008 and December 31, 2014. All women were counseled on contraception prior to hospital discharge. DMPA was available in the hospital pharmacy, and its utilization was documented in the electronic health record. The Patient Health Questionnaire 9 (PHQ-9) was used to screen for postpartum depression for all women at all postpartum visits. A score of 10 or greater was categorized as positive. Bivariable and multivariable analyses were used to identify the association between immediate postpartum DMPA use and a positive postpartum depression screen.

RESULTS

Of the 5,073 women who met inclusion criteria, 410 (8.1%) received DMPA prior to hospital discharge. Compared with women who did not receive DMPA, women who received DMPA prior to hospital discharge were younger, more likely to identify as Black race or Latinx ethnicity, and more likely to be publicly insured. Clinical characteristics also differed. Women who received DMPA were more likely to be obese and to have experienced prenatal depressive symptoms, been diagnosed with a hypertensive disorder of pregnancy, delivered preterm, and delivered vaginally. Receipt of immediate postpartum DMPA was not associated with having a positive screen for postpartum depression in bivariable (5.4 vs. 6.0%, p = 0.29) or multivariable (adjusted odds ratio 0.94, confidence interval 0.53-1.68) analyses.

CONCLUSION

Receipt of postpartum DMPA is not associated with a positive postpartum PHQ-9 screen. Concerns about precipitating postpartum depression should not preclude the utilization of DMPA as a contraceptive agent.

KEY POINTS

· Contraception is an important issue for obstetricians to address with postpartum patients.. · Concerns have been raised over the relationship between DMPA and depression.. · Our study shows that DMPA is not associated with a positive postpartum depression screen..

Changes in hair cortisol concentration in intrauterine device initiators: A prospective cohort study

OBJECTIVES

Prior studies found increased hair cortisol concentration (a surrogate marker for hypothalamic-pituitary-adrenal axis activation) in users of the levonorgestrel intrauterine device (LNG 52 mg IUD). We evaluated change in hair cortisol and psychometric tests in women initiating a copper (CuT380 IUD) or LNG 52 mg IUD.

STUDY DESIGN

We prospectively enrolled healthy women initiating an LNG 52 mg IUD or CuT380 IUD. Participants provided hair and blood samples and completed psychometric inventories (Patient Health Questionnaire-9, Positive and Negative Affect Schedule, and Psychological General Well-Being Index) after IUD insertion and at 6 and 12 months. We used liquid chromatography with tandem mass spectrometry to measure hair cortisol concentrations. We compared hair cortisol concentrations and psychometric test changes from baseline to 6 and 12 months using independent two-sample t tests.

RESULTS

We enrolled 39 of our targeted 86 participants (LNG 52 mg IUD 26, CuT380 IUD 13). Thirty-eight subjects (LNG 52 mg IUD 25, CuT380 IUD 13) completed 6 months of follow-up. We found no difference between cohorts in the mean change in hair cortisol concentrations at 6 months (LNG 52 mg IUD n = 21 [-0.01 pg/mg (95% CI -1.26, 1.23); CuT380 IUD n = 13 [-1.31 pg/mg (-3.36, 0.73)]). While psychometric inventory results remained within normal ranges, LNG 52 mg IUD users reported a trend toward more favorable changes over time.

CONCLUSIONS

We did not find clinically important differences in hair cortisol concentrations following initiation of a CuT380 IUD or LNG 52 mg IUD; psychometric inventories demonstrated no adverse effect of hormonal IUDs on mood.

IMPLICATIONS

Our findings of similar hair cortisol concentrations following the initiation of either the LNG 52 mg IUD or CuT380 IUD suggest that hormonal IUDs do not increase cortisol concentrations or alter stress reactivity, and favorable effects on psychometric inventories provide further reassurance that the LNG 52 mg IUD has no adverse impact on mood.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03499379.

The Relationship Between Mood and Sleep in Different Female Reproductive States

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

Grappling with Issues of Motherhood for Women with Schizophrenia

Despite the fact that most persons with schizophrenia find steady employment difficult to sustain, many women with this diagnosis embrace and fulfill the most difficult task of all-motherhood. The aim of this paper is to specify the challenges of motherhood in this population and review the treatment strategies needed to keep mothers and children safe, protecting health and fostering growth. The review addresses concerns that had been brought to the author's earlier attention during her clinical involvement with an outpatient clinic for women with psychosis. It is, thus, a non-systematic, narrative review of topic areas subjectively assessed as essential to "good enough" mothering in the context of schizophrenia. Questions explored are the stigma against motherhood in this population, mothers' painful choices, issues of contraception, abortion, child custody, foster care and kin placement of children, the effects of antipsychotics, specific perinatal delusional syndromes, and, finally, the availability of parental support. This review is intended for clinicians. Recommendations are that care providers work collaboratively with mothers, take note of their strengths as well as their failings, offer a wide array of family services, monitor households closely for safety and for treatment adherence, appreciating the many challenges women with schizophrenia face daily.

Effects of different doses of esketamine intervention on postpartum depressive symptoms in cesarean section women: A randomized, double-blind, controlled clinical study

BACKGROUND

The optimal dosage and method of esketamine for postpartum depressive symptoms (PDS) are unclear. We conducted a randomized controlled trial (RCT) to investigate the effect of different doses of esketamine on PDS in women undergoing cesarean section, with evidence of prenatal depression.

METHODS

The three groups were high- (2 mg kg-1) and low-dose (1 mg kg-1) esketamine via patient controlled intravenous analgesia (PCIA), following an initial intravenous infusion of 0.25 mg kg-1 esketamine, compared to placebo (0.9 % saline infusion). All groups also received the sufentanil (2.2 μg kg-1). The primary outcome was the incidence of PDS at 7 and 42 days postpartum. The secondary outcomes were: the remission from depression and total EPDS scores at 7 days and 42 days postpartum; mean change from baseline in the EPDS score; postoperative analgesia.

RESULTS

i). 0.25 mg kg-1 of esketamine intravenous infusion combined with 1 mg kg-1 (n = 99) or 2 mg kg-1 (n = 99) esketamine PCIA reduces PDS incidence at 7 days postpartum (p < 0.05), with high-dose esketamine PCIA also reduces PDS incidence 42 days postpartum (p < 0.05), compared to placebo (n = 97). ii). Low- and high-dose esketamine PCIA lowers NRS scores at rest within 48 h postoperatively (p < 0.01), with high-dose esketamine also reducing the NRS score during movement at 48 h postoperatively (p = 0.018). iii). Neither high- nor low-dose esketamine PCIA increased postoperative adverse reactions (p > 0.05).

CONCLUSIONS

Esketamine (0.25 mg kg-1) intravenous infusion combined with 1 mg kg-1 or 2 mg kg-1 esketamine PCIA seems safe and with few adverse effects in the management of PDS and pain in women undergoing cesarean section.

LIMITATIONS

The tolerability and safety of esketamine requires further investigation based on more specific scales; the transient side effects of esketamine could have biased the staff and patients.

TRIAL REGISTRATION

ChiCTR-ROC-2000039069.

Major Depression and Panic Disorder Associated with Implanon Implant: A Case Report

This report presents a case study of a patient who experienced depression and panic disorder symptoms associated with the use of Implanon, a contraceptive implant. This is a rare case of related prevalence data. The purpose of this report is to explore the potential relationship between Implanon and the development of these psychiatric conditions. The findings suggest a possible link between Implanon and the onset or exacerbation of depression and panic disorder symptoms. Further research is warranted to investigate the underlying mechanisms and determine the prevalence of such adverse effects.

Reproductive Planning and the Choice of Long-acting Reversible Contraceptive Primary to Health: A Cross-Sectional Study

OBJECTIVE

 Evaluate the different perspectives that involve the choice of long-acting reversible contraceptives (LARCs), the issues related to this process and the consequences of deciding one method in the women's in the primary health care (PHC) center in Sousas, a district in Campinas, SP (Brazil).

METHODS

 This is an analytical cross-sectional study, it was performed at the PHC in Sousas. Data were collected through the analysis of medical records and interviews with women who live in Sousas and had the insertion of the copper intrauterine device (IUD) (D) from April 2021 to April 2022 or the etonogestrel implant (I) from May to December 2022. The study was approved by the Research Ethics Committee of the Medical Science School at the State University of Campinas (UNICAMP).

RESULTS

 Reason for choosing this LARC: medical (D: 52%; I: 100%), easy adhesion (D: 71%; I: 67%), effectiveness (D: 55%; I: 100%). Indication by health professionals (D: 65%; I: 100%). And improvement of clinical characteristics: mood (D: 77%; I: 67%), body mass index (BMI; D: 52%; I: 33%), and libido (D: 84%; I: 67%).

CONCLUSION

 It is suggested that women tend to decide between LARCs when guided by their doctor or PHC health professionals, and they select LARCs because of the ease of use and low failure rates. Therefore, this study highlights how LARCs can positively interfere in the aspects that pervade contraception, such as BMI, libido, and mood.

Development of an Implementation Blueprint to Scale-Up Contraception Care for Adolescents with Psychiatric Conditions in a Pediatric Hospital

Implementation blueprints are comprehensive plans that describe implementation strategies, goals, timelines, and key personnel necessary for launching new interventions. Although blueprints are a foundational step in driving intervention rollout, little is known about how blueprints are developed, refined, and used in practice. The objective of this study was to describe a systematic, collaborative approach to developing, refining, and utilizing a formal implementation blueprint for scaling up the Contraception Care at Behavioral Health Pavilion (CC@BHP) intervention for adolescents hospitalized in psychiatric units within a pediatric hospital in the United States. In Stage 1 (Planning/Preparation), we assembled a Research Advisory Board (RAB) of 41 multidisciplinary members and conducted a formative evaluation to identify potential barriers to CC@BHP implementation. Barriers were mapped to implementation strategies using the Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change (ERIC) tool and used to create an initial blueprint. In Stage 2 (Development/Implementation), RAB members used activity logs to track implementation activities over the 18-month study period, which were then mapped to formal implementation strategies used to further develop the blueprint. About 30% of strategies were situated in the 'Train and Educate Stakeholders' ERIC category, 20% in 'Use Evaluative and Iterative Strategies,' and 16% in 'Develop Stakeholder Interrelationships' category. In Stage 3 (Synthesis/Refinement), the final blueprint was refined, consisting of 16 goals linked to 10 strategies for pre-implementation and 6 strategies for implementation. Feedback on the blueprint emphasized the role of the project champion in translating the blueprint into smaller, actionable steps for implementers.

The potential association between psychiatric symptoms and the use of levonorgestrel intrauterine devices (LNG-IUDs): A systematic review

BACKGROUND

Levonorgestrel (LNG)-intrauterine devices (IUDs) are an effective method of contraception; however, there is growing evidence regarding potential psychiatric side effects such as depressive symptoms, anxiety, and suicidal thoughts. Therefore, we conducted this systematic review to summarise the psychiatric effects of using LNG-IUDs.

METHODS

We searched six databases (MEDLINE, Web of Science, Scopus, Science Direct, Cochrane Library, and PsycInfo), and we included all study designs. The included studies were extracted, quality assessed, and qualitatively summarised.

RESULTS

Out of the screened studies, only 22 were finally included. While ten studies showed increased depressive symptoms, two studies showed reduced symptoms. Moreover, one study showed increased anxiety, another one reported an increased risk of suicide, four studies concluded no association with depressive symptoms, and four other studies showed uncertainty about a potential association but mentioned other psychiatric symptoms.

CONCLUSION

Despite unreliable data, many studies report psychiatric symptoms associated with LNG-IUDs, predominantly depression. Gynaecologists, general practitioners, and psychiatrists should therefore be aware of these potential risks, especially depressive symptoms and suicidality. Counselling patients about these risks should be mandatory. Further studies should investigate the absolute risk of mental disorders associated with LNG-IUDs and other hormonal contraceptives.KEY MESSAGESMany researchers are reporting adverse psychiatric events associated with levonorgestrel intrauterine devices (LNG-IUDs).Despite their effectiveness, a proper psychiatric assessment should be done before inserting LNG-IUDs.Proper counselling regarding the depressive symptoms and suicidality should be done by the treating obstetrician.Further studies should investigate the absolute risk of mental disorders associated with LNG-IUDs and other hormonal contraceptives.

Depressive Symptoms and Control of Emotions among Polish Women with Polycystic Ovary Syndrome

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a disorder that substantially affects women's health. It is particularly diagnosed in young patients. Women with PCOS are burdened with excessive weight gain, overweight and obesity (74%) compared to a healthy female population. Excessive weight influences psychological state and emotional well-being, whereas in the meantime, psychological and behavioral dysfunction is increasingly being diagnosed among patients with PCOS.

AIM

To assess depressive symptoms and emotional control among women with PCOS in relation to BMI.

METHODS

The study was conducted among 671 self-reported PCOS women. The standardized Beck Depression Inventory (BDI) was used to assess depressive disorders. Emotion control was assessed using the Courtauld Emotional Control Scale (CECS).

RESULTS

Moderate and severe depressive symptoms were more common in PCOS women with abnormal BMI compared to normal BMI subjects (p < 0.01). In total, 27.1% of obese women had moderate depression and 28.8% had severe depression. Among overweight women, 19.9% suffered from moderate and 25% from severe depressive symptoms. Underweight women also reported moderate (25.6%) and severe (33.3%) depressive signs. There were no statistically significant differences between the body weight of the women studied and the CECS scores.

CONCLUSIONS

Depressive symptoms are more common in women with PCOS and abnormal BMI than in women with PCOS and proper BMI. The severity of depressive symptoms increases with BMI, but underweight women with PCOS are also at risk of depressive disorders. The level of suppression of negative emotions is independent of BMI in women with PCOS.

Prevalence and correlates of depressive symptoms, and points of intervention, in rural central Uganda: results from a cross-sectional population-based survey of women and men

OBJECTIVES

The present study aimed to identify the prevalence and correlates of depressive symptoms and potential intervention points among women and men from a population-based sample in rural central Uganda.

DESIGN

A cross-sectional study.

SETTING

Four districts in rural Uganda.

PARTICIPANTS

Women and men aged 15-59 residing in four districts in rural Uganda accepting home-based HIV testing who completed a baseline survey at the time of testing.

PRIMARY OUTCOME MEASURES

Depressive symptoms measured by the 10-item Center for Epidemiological Studies Depression Scale using a cut-off score of 13 for significant depressive symptoms.

RESULTS

Among a sample of 9609 women and 6059 men, 1415 (14.7%) women and 727 (12.0%) men met criteria for significant depressive symptoms. Having ever received mental health services was associated with lower odds of significant depressive symptoms (women: adjusted OR (adjOR)=0.32, 95% CI=0.22 to 0.47; men: adjOR=0.36, 95% CI=0.18 to 0.62). Having received outpatient (women: adjOR=3.64, 95% CI=3.14 to 4.22; men: adjOR=3.37, 95% CI=2.78 to 4.07) or inpatient (women: adjOR=5.44, 95% CI=4.24 to 6.97; men: adjOR=3.42, 95% CI=2.21 to 5.28) care in the prior 6 months was associated with greater odds of significant depressive symptoms. For women only, known HIV positive status (adjOR=1.37, 95% CI=1.05 to 1.77), and for men only, alcohol misuse (adjOR=1.38, 95% CI=1.12 to 1.70), were associated with increased odds of significant depressive symptoms.

CONCLUSION

Our findings suggest that depression screening within outpatient and inpatient settings may help to identify people in need of mental health services. Routine screening in outpatient or inpatient clinics along with the implementation of evidence-based interventions could ultimately help close the mental health gap for depression in this and similar settings.

Antipsychotic medication for women with schizophrenia spectrum disorders

There are significant differences between men and women in the efficacy and tolerability of antipsychotic drugs. Here, we provide a comprehensive overview of what is currently known about the pharmacokinetics and pharmacodynamics of antipsychotics in women with schizophrenia spectrum disorders (SSDs) and translate these insights into considerations for clinical practice. Slower drug absorption, metabolism and excretion in women all lead to higher plasma levels, which increase the risk for side-effects. Moreover, women reach higher dopamine receptor occupancy compared to men at similar serum levels, since oestrogens increase dopamine sensitivity. As current treatment guidelines are based on studies predominantly conducted in men, women are likely to be overmedicated by default. The risk of overmedicating generally increases when sex hormone levels are high (e.g. during ovulation and gestation), whereas higher doses may be required during low-hormonal phases (e.g. during menstruation and menopause). For premenopausal women, with the exceptions of quetiapine and lurasidone, doses of antipsychotics should be lower with largest adjustments required for olanzapine. Clinicians should be wary of side-effects that are particularly harmful in women, such as hyperprolactinaemia which can cause oestrogen deficiency and metabolic symptoms that may cause cardiovascular diseases. Given the protective effects of oestrogens on the course of SSD, oestrogen replacement therapy should be considered for postmenopausal patients, who are more vulnerable to side-effects and yet require higher dosages of most antipsychotics to reach similar efficacy. In conclusion, there is a need for tailored, female-specific prescription guidelines, which take into account adjustments required across different phases of life.

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

OBJECTIVES

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

DESIGN

Nationwide register-based matched case-control study.

SETTINGS

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Hypogonadism in Women with Prader-Willi Syndrome-Clinical Recommendations Based on a Dutch Cohort Study, Review of the Literature and an International Expert Panel Discussion

Prader-Willi syndrome (PWS) is a rare neuroendocrine genetic syndrome. Characteristics of PWS include hyperphagia, hypotonia, and intellectual disability. Pituitary hormone deficiencies, caused by hypothalamic dysfunction, are common and hypogonadism is the most prevalent. Untreated hypogonadism can cause osteoporosis, which is already an important issue in PWS. Therefore, timely detection and treatment of hypogonadism is crucial. To increase understanding and prevent undertreatment, we (1) performed a cohort study in the Dutch PWS population, (2) thoroughly reviewed the literature on female hypogonadism in PWS and (3) provide clinical recommendations on behalf of an international expert panel. For the cohort study, we retrospectively collected results of a systematic health screening in 64 female adults with PWS, which included a medical questionnaire, medical file search, medical interview, physical examination and biochemical measurements. Our data show that hypogonadism is frequent in females with PWS (94%), but is often undiagnosed and untreated. This could be related to unfamiliarity with the syndrome, fear of behavioral changes, hygienic concerns, or drug interactions. To prevent underdiagnosis and undertreatment, we provide practical recommendations for the screening and treatment of hypogonadism in females with PWS.

Provision of long-acting reversible contraception at surgical abortion-A cross-sectional nationwide register study

INTRODUCTION

Provision of long-acting reversible contraception (LARC) at surgical abortion is safe, practical, and leads to higher user rates than does delayed provision. The aim of this study was to explore whether provision of LARC at surgical abortion is associated with known risk factors for subsequent abortions and inconsistent use of contraception, including sociodemographic factors and psychiatric disorders.

MATERIAL AND METHODS

This was a register-based cross-sectional study of 6251 women having a surgical abortion in Sweden. Data were collected from National health and population registers. Women with procedure codes for surgical abortion were identified in the National Patient Register from October 2016 to December 2018. Information from Statistics Sweden, the National Patient Register, and the Swedish prescribed drug register on sociodemographic factors, psychiatric disorders, and dispensed LARC was added and linked on an individual level. Associations of sociodemographic factors and psychiatric disorders with LARC provision were explored with generalized logit mixed models and presented as crude and adjusted odds ratios with 95% confidence intervals (CIs).

RESULTS

The overall rate of LARC provision at the time of the abortion was 2515/6251 (40.2%). Younger age and lower level of education were associated with an increased likelihood of LARC provision. In the study population, 2624/6251 (42.0%) patients had a pre- or post-abortion psychiatric disorder, a factor associated with an increased likelihood of LARC provision compared with women with no such disorders (adjusted odds ratio 1.21; 95% CI 1.08-1.34). The highest rates and odds were seen among women with personality, substance use, and/or neurodevelopmental disorders and among women with multiple psychiatric disorders.

CONCLUSIONS

Sociodemographic risk factors and psychiatric disorders were associated with increased LARC provision at surgical abortion, indicating that women at high risk of unwanted pregnancies are provided with effective contraception. Still, less than half of all women undergoing surgical abortion were provided with LARC, suggesting that contraceptive access and counseling prior to a surgical abortion can be improved.

Premenstrual Exacerbations of Mood Disorders: Findings and Knowledge Gaps

PURPOSE OF REVIEW

In contrast to premenstrual dysphoric disorder (PMDD), premenstrual exacerbations (PMEs) of ongoing mood disorders are understudied. The aim of this review is to describe diagnostic issues, epidemiology, underlying mechanisms, and treatment for PME in unipolar depression and bipolar disorder, and to discuss clinical and research implications.

RECENT FINDINGS

Community-based and clinical studies estimate that in women with mood disorders around 60% report PME, while some women with bipolar disorder also show symptom exacerbations around ovulation. In general, PME predicts a more severe illness course and an increased burden. While heightened sensitivity to fluctuations of sex hormone levels across the menstrual cycle appears to contribute to PME and PMDD, the overlap of their underlying biological mechanisms remains unclear. Beneficial treatments for PMDD show less or no efficacy in PME. Pharmacological treatments for PME in mood disorders predominantly seem to profit from adjustable augmentation of treatment dosages during the luteal phase for the underlying disorder. However, the evidence is sparse and mainly based on earlier small studies and case reports. Previous research is mainly limited by the lack of a clear differentiation between PME and PMDD comorbidity with mood disorders. More systematic research with uniformly defined and prospectively assessed subgroups of PME in larger epidemiological and clinical samples is needed to receive reliable prevalence estimates and information on the clinical impact of PME of mood disorders, and to uncover underlying mechanisms. In addition, larger randomized controlled trials are warranted to identify efficacious pharmacological and psychotherapeutic treatments for affected women.