Association of Prepregnancy Substance Use and Substance Use Disorders with Pregnancy Timing and Intention

Background: Limited research exists on the association between substance use disorders (SUDs) and dimensions of pregnancy intention. This study sought to examine the independent relationships between prepregnancy substance use and SUDs with pregnancy timing and intentions. Materials and Methods: Secondary analysis of data from three prenatal care sites in Connecticut, Massachusetts, and Michigan, 2016-2017. Associations were estimated using modified Poisson regression with robust error variance to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs), controlling for relevant covariates. Results: The total sample size was 1115 women. Respectively, 61.1% and 15.5% of women used any substance in the 30 days prepregnancy or had any SUD in the past 12 months. After adjustment, any prepregnancy substance use was associated with a reduced likelihood of a well-timed (aPR 0.85; 95% CI: 0.77-0.93) and intended (aPR 0.80; 95% CI: 0.72-0.89) pregnancy; similarly, any SUD was associated with a reduced likelihood of a well-timed (aPR 0.66; 95% CI: 0.55-0.80) and intended (aPR 0.79; 95% CI: 0.67-0.93) pregnancy. Conclusions: Women with prepregnancy substance use or SUD have decreased prevalence of well-timed and intended pregnancies. Greater efforts are needed to address substance use and family planning in routine, well-woman, prenatal, and postpartum care.

From Stigma to Validation: A Qualitative Assessment of a Novel National Program to Improve Retention of Physician-Scientists with Caregiving Responsibilities

Background: Research is needed to improve understanding of work-life integration issues in academic medicine and to guide the implementation of the Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists (FRCS), a national initiative offering financial support to physician-scientists facing caregiving challenges. Materials and Methods: In 2018, as part of a prospective program evaluation, the authors conducted a qualitative study to examine FRCS program participants' initial impressions, solicit descriptions of their career and caregiving experiences, and inquire how such factors might influence their professional advancement. The authors invited all 33 awardees who had been granted FRCS funding in the first year of the program to participate in the study, of whom 28 agreed to complete an interview. Analysts evaluated de-identified transcripts and explicated the data using a thematic analysis approach. Results: While participants described aspects of a culture that harbor stigma against caregivers and impede satisfactory work-life integration, they also perceived an optimistic cultural shift taking place as a result of programs like the FRCS. Their comments indicated that the FRCS has the potential to influence culture if institutional leadership simultaneously fosters a community that validates individuals both as caregivers and as scientists. Conclusions: Insights garnered from this qualitative study suggest that there is a pressing need for institutional leaders to implement programs that can foster awareness and normalization of caregiving challenges. In addition to providing funding and other tangible resources, interventions should strive to reinforce a broader culture that affirms the presence of work-life integration challenges and openly embraces solutions.

Disordered Eating Among Trans-Masculine Youth: Considerations Through a Developmental Lens

As with male populations more generally, eating disorder symptom expression among trans-masculine youth is understudied. Gender minority individuals are at increased risk for eating disorders; however, culturally responsive and developmentally tailored research is limited. Although all gender minority individuals may experience elevated risk for developing eating disorders, the focus of this article is trans-masculine youth. We provide a theoretical conceptualization of eating disorder symptom expression among this understudied group, and propose novel directions for research, particularly for youth at pubertal onset. Adolescence as a critical developmental period for intervention is highlighted.

The Most Valuable Resource Is Time: Insights From a Novel National Program to Improve Retention of Physician-Scientists With Caregiving Responsibilities

PURPOSE

To enhance understanding of challenges related to work-life integration in academic medicine and to inform the ongoing implementation of an existing program and the development of other interventions to promote success of physician-scientists.

METHOD

This study is part of a prospective analysis of the effects of the Fund to Retain Clinical Scientists (FRCS), a national program launched by the Doris Duke Charitable Foundation at 10 U.S. institutions, which provides financial support to physician-scientists facing caregiving challenges. In early 2018, 28 of 33 program awardees participated in semistructured interviews. Questions were about challenges faced by physician-scientists as caregivers and their early perceptions of the FRCS. Multiple analysts reviewed deidentified transcripts, iteratively revised the coding scheme, and interpreted the data using qualitative thematic analysis.

RESULTS

Participants' rich descriptions illuminated 5 interconnected themes: (1) Time is a critical and limited resource, (2) timing is key, (3) limited time resources and timing conflicts may have a particularly adverse effect on women's careers, (4) flexible funds enable reclamation and repurposing of time resources, and (5) FRCS leaders should be cognizant of time and timing conflicts when developing program-related offerings.

CONCLUSIONS

Programs such as the FRCS are instrumental in supporting individuals to delegate time-consuming tasks and to control how they spend their valuable time. Qualitative analysis suggests that access to and command of valuable time resources are crucial to career advancement, research productivity, and work-life flexibility, especially during critical time points along the physician-scientist trajectory.

Pregnancy context and women's health-related quality of life

OBJECTIVE

The objective was to quantify the association of pregnancy context and health-related quality of life (HRQoL).

STUDY DESIGN

English- or Spanish-speaking women, aged 16-44, with pregnancies <24 weeks' gestation were enrolled in this cross-sectional study between June 2014 and June 2015. Participants completed self-assessments of pregnancy "context," including timing, intention, wantedness, desirability, happiness, and planning (measured with the London Measure of Unplanned Pregnancy). HRQoL was measured using the Patient Reported Outcomes Measurement Information System Global Short Form. Associations between measures of pregnancy context and HRQoL scores in the lowest tertile were examined using multivariable logistic regression to adjust for potential confounding variables.

RESULTS

We enrolled 161 participants (mean age=27.2±6.6 years). Only 14% self-identified as White, non-Hispanic; 42% Hispanic; 37% Black, non-Hispanic; and 7% multiracial. Most (79%) participants were unmarried, and 75% were parenting. Mean gestational age was 9±4.6 weeks. In unadjusted models, women reporting mixed feelings about wanting to have a baby, an undesired pregnancy or feeling unhappy about learning of their pregnancy more frequently had low mental and physical HRQoL compared to women reporting wanted, desired, happy pregnancies. Women with an unplanned pregnancy or pregnancy occurring at the wrong time also had lower physical HRQoL than women reporting pregnancies that were planned or happened at the right time. However, after multivariate adjustment, including history of depression, pregnancy contexts were not associated with low mental or physical HRQoL.

CONCLUSIONS

After adjusting for multiple confounders, pregnancy context is not significantly associated with HRQoL.

IMPLICATIONS

The focus on pregnancy intention in public health programs may not sufficiently assess multidimensional aspects of pregnancy context and may not align with patient-centered outcomes such as HRQoL.

The role of screening, brief intervention, and referral to treatment in the perinatal period

Substance use during pregnancy is at least as common as many of the medical conditions screened for and managed during pregnancy. While harmful and costly, it is often ignored or managed poorly. Screening, brief intervention, and referral to treatment is an evidence-based approach to manage substance use. In September 2012, the US Centers for Disease Control and Prevention convened an Expert Meeting on Perinatal Illicit Drug Abuse to help address key issues around drug use in pregnancy in the United States. This article reflects the formal conclusions of the expert panel that discussed the use of screening, brief intervention, and referral to treatment during pregnancy. Screening for substance use during pregnancy should be universal. It allows stratification of women into zones of risk given their pattern of use. Low-risk women should receive brief advice, those classified as moderate risk should receive a brief intervention, whereas those who are high risk need referral to specialty care. A brief intervention is a patient-centered form of counseling using the principles of motivational interviewing. Screening, brief intervention, and referral to treatment has the potential to reduce the burden of substance use in pregnancy and should be integrated into prenatal care.

A meta-analysis of the relationship between antidepressant use in pregnancy and the risk of preterm birth and low birth weight

OBJECTIVES

To examine the relationship between antidepressant use in pregnancy and low birth weight (LBW) and preterm birth (PTB).

DATA SOURCES AND STUDY SELECTION

We searched English and non-English language articles via PubMed, CINAHL and PsychINFO (from their start dates through December 1st, 2012). We used the following keywords and their combinations: antidepressant, selective serotonin reuptake inhibitor (SSRI), pregnancy, antenatal, prenatal, birthweight, birth weight, preterm, prematurity, gestational age, fetal growth restriction, intrauterine growth restriction, and small-for-gestational age. Published studies were considered eligible if they examined exposure to antidepressant medication use during pregnancy and reported data on at least one birth outcome of interest: PTB (<37 weeks gestation) or LBW (<2500 g). Of the 222 reviewed studies, 28 published studies met the selection criteria.

DATA EXTRACTION

Two authors independently extracted study characteristics from eligible studies.

RESULTS

Using random-effects models, antidepressant use in pregnancy was significantly associated with LBW (RR: 1.44, 95% confidence interval (CI): 1.21-1.70) and PTB (RR: 1.69, 95% CI: 1.52-1.88). Studies varied widely in design, populations, control groups and methods. There was a high level of heterogeneity as measured by I2 statistics for both outcomes examined. The relationship between antidepressant exposure in pregnancy and adverse birth outcomes did not differ significantly when taking into account drug type (SSRI vs. other or mixed) or study design (prospective vs. retrospective). There was a significant association between antidepressant exposure and PTB for different types of control status used (depressed, mixed or nondepressed).

CONCLUSIONS

Antidepressant use during pregnancy significantly increases the risk for LBW and PTB.

Criteria for premenstrual dysphoric disorder: secondary analyses of relevant data sets

CONTEXT

There is substantial information that premenstrual dysphoric disorder (PMDD) is a clinically significant disorder with biological underpinnings that differ from other psychiatric disorders. However, data regarding the symptoms noted in DSM-IV and timing of their expression in the menstrual cycle have had little empirical support.

OBJECTIVE

To provide evidence informing the definitional criteria for PMDD.

DESIGN

Prospective surveys.

SETTING

General community and clinical settings.

PARTICIPANTS

Two cohorts that included a representative sample and a self-identified treatment-seeking cohort. Main Outcome Measure  Daily ratings of perimenstrual symptoms and functioning.

RESULTS

Mood and physical symptoms were most severe and were accompanied by impairment in the 4 days before through the first 2 days of menses for the self-identified group and in the 3 days before through the first 3 days of menses in the community sample. The most problematic symptoms endorsed were those listed in DSM-IV, but depressed mood was less frequent than other affective symptoms. In the combined sample, 4 or more symptoms was the optimal cutoff point for maximizing both sensitivity and specificity when predicting impairment.

CONCLUSIONS

This is informative for DSM-5 in that the most symptomatic period typically includes the few days before through the first 3 days of menses rather than only the premenstrual phase. Further, we validated the salience of PMDD symptoms included in DSM-IV. Although the number of symptoms most associated with distress and impairment differed between the 2 cohorts, results from the combined cohort suggest that 4 symptoms are linked with impairment from PMDD symptoms.

Symptom features of postpartum depression: are they distinct?

The clinical features of postpartum depression and depression occurring outside of the postpartum period have rarely been compared. The 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR(16)) provides a means to assess core depressive symptoms. Item response theory and classical test theory analyses were conducted to examine differences between postpartum (n=95) and nonpostpartum (n=50) women using the QIDS-SR(16). The two groups of females were matched on the basis of age. All met DSM-IV criteria for nonpsychotic major depressive disorder. Low energy level and restlessness/agitation were major characteristics of depression in both groups. The nonpostpartum group reported more sad mood, more suicidal ideation, and more reduced interest. In contrast, for postpartum depression sad mood was less prominent, while psychomotor symptoms (restlessness/agitation) and impaired concentration/decision-making were most prominent. These symptomatic differences between postpartum and other depressives suggest the need to include agitation/restlessness and impaired concentration/decision-making among screening questions for postpartum depression.

Clinical diagnostic criteria for premenstrual syndrome and guidelines for their quantification for research studies

Premenstrual syndrome (PMS) encompasses a variety of symptoms appearing during the luteal phase of the menstrual cycle. Although PMS is widely recognized, the etiology remains unclear and it lacks definitive, universally accepted diagnostic criteria. To address these issues an international multidisciplinary group of experts evaluated the current definitions and diagnostic criteria of PMS and premenstrual dysphoric disorder (PMDD). Following extensive correspondence, a consensus meeting was held with the aim of producing updated diagnostic criteria for PMS and guidelines for clinical and research applications. This report presents the conclusions and recommendations of the group. It is hoped that the criteria proposed by the group will become widely accepted and eventually be incorporated into the next edition of the World Health Organization's International Classification of Diseases (ICD-11). It is also hoped that the proposed guidelines for quantification of criteria will be used by clinicians and investigators to facilitate diagnostic uniformity in the field as well as adequate treatment modalities when warranted.

Evaluating the Criteria Used for Identification of PMS

OBJECTIVE

Criteria for defining premenstrual syndrome (PMS) were assessed by comparing a reference definition previously demonstrated to be associated with reduced health-related quality of life and impaired productivity with alternative definitions based on criteria stringency variations.

METHODS

Health-related quality of life data were collected from the Medical Outcomes Study Short Form-36 (SF-36) for women aged 18-64 years. Women maintained daily calendars of emotional and physical symptoms and work productivity. PMS prevalence and differences in health-related quality of life and work productivity between women with and without PMS were compared using alternative definitions.

RESULTS

Across criteria, PMS prevalence ranged from 19% to 30%. Regardless of the criteria used, PMS was associated with reductions in health-related quality of life, with Mental Components Subscale scores 5-12 points lower for women with PMS compared to those without PMS. Likewise, across definitions, women with PMS had greater work productivity impairment than women without PMS, netting 4 additional days with reduced productivity per month.

CONCLUSIONS

PMS prevalence varies based on criteria used to define illness. However, PMS is associated with reductions in health-related quality of life and work productivity impairment regardless of the criteria used.

Expert Guidelines for the Treatment of Severe PMS, PMDD, and Comorbidities: The Role of SSRIs

The hallmark feature of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) is the predictable, cyclic nature of symptoms or distinct on/offness that begins in the late luteal phase of the menstrual cycle and remits shortly after the onset of menstruation. PMDD is distinguished from PMS by the severity of symptoms, predominance of mood symptoms, and role dysfunction, particularly in personal relationships and marital/family domains. Several treatment modalities are beneficial in PMDD and severe PMS, but the selective serotonin reuptake inhibitors (SSRIs) have emerged as first-line therapy. The SSRIs can be administered continuously throughout the entire month, intermittently from ovulation to the onset of menstruation, or semi-intermittently with dosage increases during the late luteal phase. These guidelines present practical treatment algorithms for the use of SSRIs in women with pure PMDD or severe PMS, PMDD and underlying subsyndromal clinical features of mood or anxiety, or premenstrual exacerbation of a mood/anxiety disorder.

A multicenter, double-blind comparison of the effects of nefazodone and fluoxetine on sleep architecture and quality of sleep in depressed outpatients

This study was an 8-week, randomized, double-blind, parallel-group investigation that compared the effects of nefazodone and fluoxetine on sleep architecture and on clinician- and patient-rated sleep measures in 43 outpatients with moderate to severe, nonpsychotic major depressive disorder and insomnia. Twenty-two patients received nefazodone 200 mg daily for 1 week, followed by 400 mg daily for 7 weeks. Twenty-one patients received fluoxetine 20 mg daily. Dosage increases (to 500 mg/day for nefazodone and 40 mg/day for fluoxetine) were available after day 29, depending on clinician judgement. Sleep parameters were measured during baseline phase, while patients were unmeasured and symptomatic, and at weeks 2, 4, and 8 of treatment. Nefazodone and fluoxetine were equally effective as antidepressants. However, compared with baseline, nefazodone increased sleep efficiency and reduced the number of awakenings and percent awake and movement time, whereas fluoxetine increased the number of awakenings and did not significantly alter sleep efficiency or percent awake and movement time. Although fluoxetine increased stage 1 sleep and rapid eye movement (REM) latency and reduced total percent REM sleep, nefazodone increased REM sleep, decreased REM latency, and did not alter stage 1 sleep. Differences between treatment groups, based on change from baseline, revealed greater sleep efficiency, fewer awakenings, less percent awake and movement time, less percent stage 1 and more REM sleep, and shorter REM latency for nefazodone compared with fluoxetine. Significantly greater improvement in clinician- and patient-rated sleep disturbance was found with nefazodone compared with fluoxetine. Nefazodone was associated with better sleep quality.

Double-blind comparison of sertraline, imipramine, and placebo in the treatment of dysthymia: psychosocial outcomes

OBJECTIVE

The purpose of this study was to determine the effects of antidepressant pharmacotherapy on mood symptoms and psychosocial outcomes in dysthymia.

METHOD

In a multicenter, double-blind, parallel-group trial, 416 patients with a diagnosis of early-onset primary dysthymia (DSM-III-R) of at least 5 years' duration without concurrent major depression were randomly assigned to 12 weeks of acute-phase therapy with sertraline, imipramine, or placebo. The psychosocial outcome measures used in the study were the Global Assessment of Functioning Scale, the Social Adjustment Scale, the Longitudinal Interval Follow-up Evaluation psychosocial ratings, and the Quality of Life Enjoyment and Satisfaction Questionnaire.

RESULTS

Sertraline and imipramine were significantly better than placebo in improving psychosocial outcomes as measured by the first three instruments. The Quality of Life Enjoyment and Satisfaction Questionnaire scores demonstrated significant improvements from baseline, and both active treatments produced significantly greater improvements than placebo. Significantly fewer patients discontinued sertraline (6.0%) than discontinued imipramine (18.4%) because of adverse events.

CONCLUSIONS

Pharmacotherapy is an effective treatment for dysthymia in terms of psychosocial functioning as well as depressive symptoms, even when the dysthymia is long-standing.

The infrequency of "pure culture" diagnoses among the anxiety disorders

BACKGROUND

Anxiety disorders are known to commonly coexist in individuals, both with other anxiety disorders and with mental disorders from other groupings, such as affective disorders. We questioned how frequently anxiety disorders actually occur in isolation, as "pure cultures."

METHOD

We examined diagnostic patterns among the 711 subjects entered into a large, multicenter study of anxiety disorders, the Harvard/ Brown Anxiety Disorders Research Program (HARP), which focused on panic, agoraphobia, generalized anxiety disorder, and social phobias as "index disorders" required for intake.

RESULTS

We used various definitions for "pure culture." By all definitions, subjects with "pure culture" represented a minority, especially in cases of generalized anxiety disorder and social phobia, where comorbidity was virtually ubiquitous. "Pure culture" status was associated with later onset of illness and less chronicity.

CONCLUSION

Future studies of anxiety disorder should aim to document the extensive comorbidity, rather than eliminate it by restrictive diagnostic exclusion criteria, lest they yield atypical or even misrepresented groups of patients. Clinicians should not stop at identifying only the "main" diagnosis but look for other, comorbid diagnoses that are often present.

Low plasma gamma-aminobutyric acid levels during the late luteal phase of women with premenstrual dysphoric disorder

OBJECTIVE

Plasma gamma-aminobutyric acid (GABA) levels have been reported to be low in some patients with major depressive disorder. Premenstrual dysphoric disorder is often associated with major depressive disorder. Therefore, the authors sought to determine whether women with premenstrual dysphoric disorder with or without prior major depressive disorder also had low plasma GABA levels.

METHOD

Plasma GABA levels were measured in 27 women with premenstrual dysphoric disorder and 21 comparison women during the the mid-follicular and late luteal phases of the menstrual cycle.

RESULTS

In comparison women, plasma GABA levels increased from the mid-follicular to the late luteal phase. Women with premenstrual dysphoric disorder and a past history of major depressive disorder had low plasma GABA levels during both phases. In women with premenstrual dysphoric disorder but no past major depressive disorder, plasma GABA levels decreased from the nonsymptomatic, mid-follicular phase to the symptomatic, late luteal phase.

CONCLUSIONS

Decreased GABA function may represent a common biological link between subtypes of depressive and premenstrual dysphoric disorders. A trait in major depressive disorder and a state-dependent decrease in premenstrual dysphoric disorder might imply a possible continuum between the two disorders.

Hormone-induced conformational changes in the hepatic insulin receptor

The insulin receptor can exist in either a lower or a higher affinity state. Hormone binding alters the equilibrium between the two states of the insulin receptor, favoring the formation of that of higher affinity (Corin, R.E., and Donner, D.B. (1982), J. Biol. Chem. 257, 104-110). After brief or extended incubations with hormone, during which the fraction of higher affinity receptors increased, 125I-insulin was covalently coupled to the alpha subunits of its receptor using disuccinimidyl suberate. Some 125I-insulin remained bound to higher affinity receptors after dissociation of hormone from lower affinity sites. This hormone could also be covalently coupled to the alpha subunit of the receptor. During extended incubations between 125I-insulin and liver plasma membranes, components of the receptor were cleaved to yield degradation products of 120,000 and 23,000 Da. The significance of this process remains undetermined. Unoccupied insulin receptors were cleaved by trypsin to produce fragments of 94,000 and 37,000 Da which remained membrane-bound and could be covalently coupled to 125I-insulin. Trypsin treatment after binding yielded an additional receptor fragment of 64,000 Da. As the incubation time between 125I-insulin and membranes was lengthened, components of the receptor became progressively less sensitive to trypsin. Higher affinity binding sites isolated after release of rapid dissociating insulin were less sensitive to trypsin than were mixtures of higher and lower affinity receptors. These observations suggest that hormone binding produces two conformational changes (alterations of tryptic lability) in the hepatic insulin receptor. The first change is rapid and exposes parts of the receptor to tryptic degradation. The second, slower conformational change renders the receptor less sensitive to trypsin and occurs with the same time course as the increase of receptor affinity mediated by site occupancy.