Medication Use before, during, and after Pregnancy among Women with Eating Disorders: A Study from the Norwegian Mother and Child Cohort Study

Psychiatric visits during the postpartum year in women with eating disorders who continue or discontinue antidepressant treatment in pregnancy

OBJECTIVE

To determine the association between continued antidepressant use in pregnancy and postpartum psychiatric visits for eating (ED) or mood/anxiety disorders in women with preexisting ED.

METHOD

Using Danish health registry data (1998-2015), we identified 3529 pregnancies in women with ED prepregnancy: (i) 564 with continued antidepressant use before and during pregnancy; (ii) 778 with discontinued antidepressants before pregnancy; (iii) 2137 unexposed. Outpatient and inpatient postpartum visits for an ED or a mood/anxiety disorder constituted the outcome measures. We estimated hazard ratios (HRs) and 95% confidence intervals (CI) using Cox regression with inverse probability of treatment weighting, and performed stratified analyses by antidepressant prescription filling in the first 3 months postpartum.

RESULTS

The weighted cumulative incidence for an ED visit at end of follow-up was 4.5% (continued) and 4.8% (discontinued). We found no association between continued antidepressant and postpartum ED visit, relative to discontinued (HR: 0.89, 95% CI: 0.52-1.52). The HR for postpartum mood/anxiety disorder visit was 1.27 (95% CI: 0.68-2.36) with continued antidepressants versus discontinued but decreased if more than two antidepressant prescriptions were refilled. Continued antidepressant use was associated with a 57% reduced likelihood of a postpartum ED visit versus discontinued use in pregnancies with antidepressant prescription refills in the early postpartum.

CONCLUSION

Among women with preexisting ED, there was no association between continued antidepressant use during pregnancy and the likelihood of postpartum psychiatric visits, relative to discontinued antidepressants before pregnancy. Continuation of treatment into the early postpartum is associated with reduced likelihood of postpartum ED visit.

PUBLIC SIGNIFICANCE

Based on data from the Danish registries, we identified 3529 pregnancies among women with preexisting eating disorders before pregnancy. Women with continued antidepressant treatment both before and during pregnancy did not have a lower probability of having postpartum psychiatric visits for an eating disorder or for mood/anxiety disorders (often coexisting with eating disorders), relative to those who discontinued antidepressants before pregnancy. Further continuation of antidepressant treatment into the early postpartum is associated with improved maternal postpartum outcomes. However, residual confounding by disease severity limits confidence in this conclusion.

Management of anorexia nervosa in pregnancy: a systematic and state-of-the-art review

Anorexia nervosa is a potentially severe, chronic, and relapsing mental disorder that is more common in women and girls during the reproductive years (usually defined as those aged 12-51 years). It is associated with suicide and mortality linked with the physical consequences of starvation. Although anorexia nervosa is a disorder of low prevalence, and even lower prevalence in pregnancy, it is associated with substantial risks for the mother and infant when under-recognised and undermanaged. Despite the complexity and risk of managing anorexia nervosa in pregnancy, few studies are available to guide care. We conducted a systematic review, identifying only eight studies that addressed the management of anorexia nervosa in pregnancy. These studies were case studies or case reports examining narrow aspects of management. Subsequently, we conducted a state-of-the-art review across research in relevant disciplines and areas of expertise for managing anorexia nervosa in pregnancy and synthesised the findings into recommendations and principles for multidisciplinary management of anorexia nervosa in pregnancy. These recommendations included a focus on the specialist mental health, obstetric, medical, and nutritional care required to ensure optimal outcomes for women and their infants. Despite the complexity and risks, a gap exists in the comprehensive guidelines and recommendations for managing anorexia nervosa in pregnancy. This Review provides multidisciplinary recommendations for clinical care in this area. Managing anorexia nervosa in pregnancy is an area of clinical care that requires a multidisciplinary approach and includes those experienced in managing high-risk pregnancies.

Reproductive health outcomes among eating disordered females: a register-based follow-up study among former adolescent psychiatric inpatients

OBJECTIVE

To analyze an association of eating disorders (EDs) to reproductive health outcomes among former adolescent psychiatric inpatients, hospitalized between the ages 13 and 17 years. The register-based follow-up information on psychiatric comorbidity and use of prescribed addictive psychotropic medication up to early adulthood were also explored.

METHODS

A total of 31 (10.3%) women with a diagnosed ED were identified from the initial sample of 300 female adolescents, treated in psychiatric inpatient care between 2001 and 2006. The K-SADS-PL and EuropASI research instruments were used to gather information during the adolescent psychiatric hospitalization. The follow-up data for reproductive health outcomes and psychiatric comorbidity up to early adulthood were obtained from the national health care registers. Information on prescribed addictive psychotropic medication was provided by the Social Insurance Institution of Finland. In analyses, EDs were categorized into anorexia nervosa (AN) and other EDs (OED). AN accounted for 58.1% of all EDs. Of OEDs, the majority (69.1%) were bulimia.

RESULTS

None of the women with AN, but 53.8% of those with OED had undergone medical abortions by early adulthood. Childbirths were emphasized in women with OED (61.5%) and a history of hospital-treated poisonings in women with AN (55.6%). High nicotine dependence in adolescence (30.8%) was a characteristic of women with OED.

CONCLUSION

Our study findings suggest that OED may expose affected women to various unfavorable reproductive health outcomes, particularly women with a history of psychiatric admissions. Recognizing the differences in young women with different subtypes of ED is important when discussing contraception and pregnancy.

Prenatal and perinatal factors and risk of eating disorders

BACKGROUND

Among the most disabling and fatal psychiatric illnesses, eating disorders (EDs) often manifest early in life, which encourages investigations into in utero and perinatal environmental risk factors. The objective of this study was to determine whether complications during pregnancy and birth and perinatal conditions are associated with later eating disorder risk in offspring and whether these associations are unique to EDs.

METHODS

All individuals born in Denmark to Danish-born parents 1989-2010 were included in the study and followed from their 6th birthday until the end of 2016. Exposure to factors related to pregnancy, birth, and perinatal conditions was determined using national registers, as were hospital-based diagnoses of anorexia nervosa (AN), bulimia nervosa, and eating disorder not otherwise specified during follow-up. For comparison, diagnoses of depressive, anxiety, and obsessive-compulsive disorders were also included. Cox regression was used to compare hazards of psychiatric disorders in exposed and unexposed individuals.

RESULTS

1 167 043 individuals were included in the analysis. We found that similar to the comparison disorders, prematurity was associated with increased eating disorder risk. Conversely, patterns of increasing risks of EDs, especially in AN, with increasing parental ages differed from the more U-shaped patterns observed for depressive and anxiety disorders.

CONCLUSIONS

Our results suggest that pregnancy and early life are vulnerable developmental periods when exposures may influence offspring mental health, including eating disorder risk, later in life. The results suggest that some events pose more global transdiagnostic risk whereas other patterns, such as increasing parental ages, appear more specific to EDs.

Eating Disorders During Gestation: Implications for Mother's Health, Fetal Outcomes, and Epigenetic Changes

Introduction: Eating disorders (EDs) have increased globally in women of childbearing age, related to the concern for body shape promoted in industrialized countries. Pregnancy may exacerbate a previous ED or conversely may be a chance for improving eating patterns due to the mother's concern for the unborn baby. EDs may impact pregnancy evolution and increase the risk of adverse outcomes such as miscarriage, preterm delivery, poor fetal growth, or malformations, but the knowledge on this topic is limited. Methods: We performed a systematic review of studies on humans in order to clarify the mechanisms underpinning the adverse pregnancy outcomes in patients with EDs. Results: Although unfavorable fetal development could be multifactorial, maternal malnutrition, altered hormonal pathways, low pre-pregnancy body mass index, and poor gestational weight gain, combined with maternal psychopathology and stress, may impair the evolution of pregnancy. Environmental factors such as malnutrition or substance of abuse may also induce epigenetic changes in the fetal epigenome, which mark lifelong health concerns in offspring. Conclusions: The precocious detection of dysfunctional eating behaviors in the pre-pregnancy period and an early multidisciplinary approach comprised of nutritional support, psychotherapeutic techniques, and the use of psychotropics if necessary, would prevent lifelong morbidity for both mother and fetus. Further prospective studies with large sample sizes are needed in order to design a structured intervention during every stage of pregnancy and in the postpartum period.

How Healthy is a Desire to be Fit and Strong? Drives for Thinness, Leanness, and Muscularity in Women in Weight Training

Fitness training to attain the lean body ideal is becoming increasingly popular among women. However, it remains unclear how the drive for leanness (DL), as compared to the drives for thinness (DT) and muscularity (DM), relates to body image pathology and substance use in female weight-trainers. Participants (N = 168) completed a survey assessing DL, DT, DM, eating and body dysmorphic disorder pathology, and substance use. DT and DM were related to eating disorder and body dysmorphic disorder symptoms (all r ≥ .29; all ps < .01), while DL only to the former (r = .19, p < .05). Supplement use was associated with DL and DM (r = .17 and .55; both p < .01) and pharmaceutical use with DT and DM (r ≥ .21; both p < .01). Female weight-trainers should not be neglected in body image disorder prevention, with a particular focus on DT and DM.

Duration of maternal mental health-related outcomes after an infant's death: A retrospective matched cohort study using linkable administrative data

BACKGROUND

Mothers have increased mental illness such as anxiety and depression after the death of a child. We examine the duration of this worsening of mental health.

METHODS

The mental health of all mothers who experience the death of an infant (< 1 years old) in Manitoba, Canada between April 1, 1999 and March 31, 2011 (n = 534) is examined in the 4 years leading up to, and the 4 years following, the death of their child. Mental health-related outcomes of these mothers are compared with a matched (3:1) cohort of mothers who did not experience the death of a child (n = 1,602). Three mental health-related outcomes are examined: depression diagnoses, anxiety diagnoses, and use of psychotropic medications.

RESULTS

Compared with mothers who did not experience the death of a child, mothers experiencing this event had higher rates of anxiety diagnoses and psychotropic prescriptions starting 6 months before the death. Elevated rates of anxiety continued for the first year and elevated rates of psychotropic prescriptions continued for 6 months after the death of the child. Mothers who experienced the death of a child had higher rates of depression diagnoses in the year after the death. Relative rates (RR) of depression (RR = 4.94), anxiety (RR = 2.21), and psychotropic medication use (RR = 3.18) were highest in the 6 months after the child's death.

CONCLUSIONS

Elevated rates of depression, anxiety, and psychotropic medication use after the death of a child end within 1 year of the child's death.