Suicide Attempts during Pregnancy and Postpartum: A Systematic Review and Meta-Analysis.

PURPOSE: Suicide attempts (SA) during perinatal period have the potential to adversely affect a woman's health and her developing infant. To date, little is known about perinatal SA and their risk factors. This study aimed to synthetize the evidence on risk factors of SA in pregnant and postpartum women. METHODS: We systematically reviewed studies retrieved from PubMed/Medline, PsycINFO, and CINAHL, following the PRISMA guidelines for reporting. A meta-analysis was conducted only for risk factors examined in at least three distinct samples. RESULTS: A total of ten studies were eligible for inclusion. All the studies found significant associations in regression models between perinatal SA and other variables (sociodemographic, clinical factors obstetric, neonatal, and psychosocial). The meta-analysis showed that unmarried women (pooled OR = 1.87, 95% CI = 1.26-2.78), with no higher education (pooled OR = 1.89, 95% CI = 1.31-2.74) and affected by a mood disorder (pooled OR = 11.43, 95% CI = 1.56-83.87) have a higher risk of postpartum SA; women who smoke during pregnancy (pooled OR = 3.87, 95% CI = 1.35-11.11) have a higher risk of SA in pregnancy; and women with previous suicidal behavior(pooled OR = 38.04, 95% CI = 3.36-431.17) have a higher risk of perinatal SA, whether during pregnancy or in the postpartum period. The type of sample, whether community or clinical, is a relevant moderating factor. CONCLUSION: Our study extends prior reviews about suicidal behaviors in women by studying perinatal suicide attempts independently, as well as it synthesized data on some sociodemographic, clinical, and obstetric/neonatal risk factors. Further studies about specific risk factors for perinatal SA are needed in order to improve early detection and intervention of women at risk.

SIGNIFICANCE: Suicide attempts during pregnancy and the postpartum period pose a severe risk to the health of women and the development of their infants. Despite their importance, little is known about specific risk factors for these attempts during the perinatal period. This study is the first meta-analysis to synthesize risk factors associated with suicide attempts in pregnant and postpartum women. We found that unmarried women, those without higher education, and those with mood disorders are at higher risk for postpartum suicide attempts; women who smoke during pregnancy are at higher risk for suicide attempts during pregnancy; and those with previous suicidal behavior are at higher risk for perinatal suicide attempts. Our study extends prior reviews by independently examining perinatal suicide attempts and synthesizing data on sociodemographic, clinical, and obstetric/neonatal risk factors. Further studies on specific risk factors for perinatal suicide attempts are needed to improve early detection and intervention for women at risk.

Forensic mental health in Europe: some key figures.

PURPOSE: While the number of forensic beds and the duration of psychiatric forensic psychiatric treatment have increased in several European Union (EU) states, this is not observed in others. Patient demographics, average lengths of stay and legal frameworks also differ substantially. The lack of basic epidemiological information on forensic patients and of shared indicators on forensic care within Europe is an obstacle to comparative research. The reasons for such variation are not well understood. METHODS: Experts from seventeen EU states submitted data on forensic bed prevalence rates, gender distributions and average length of stay in forensic in-patient facilities. Average length of stay and bed prevalence rates were examined for associations with country-level variables including Gross Domestic Product (GDP), expenditure on healthcare, prison population, general psychiatric bed prevalence rates and democracy index scores. RESULTS: The data demonstrated substantial differences between states. Average length of stay was approximately ten times greater in the Netherlands than Slovenia. In England and Wales, 18% of patients were female compared to 5% in Slovenia. There was a 17-fold difference in forensic bed rates per 100,000 between the Netherlands and Spain. Exploratory analyses suggested average length of stay was associated with GDP, expenditure on healthcare and democracy index scores. CONCLUSION: The data presented in this study represent the most recent overview of key epidemiological data in forensic services across seventeen EU states. However, systematically collected epidemiological data of good quality remain elusive in forensic psychiatry. States need to develop common definitions and recording practices and contribute to a publicly available database of such epidemiological indicators.

[Analysis of the activities of the network of the Family Care Centres to relaunch their role: main results of the 2017 CCM Project]. / Analisi delle attività della rete dei consultori familiari per una rivalutazione del loro ruolo: principali risultati del Progetto CCM 2017.

INTRODUCTION: in 2017, the Italian Ministry of Health funded the project "Analysis of the activities of the network of the Family Care Centers (FCCs) to relaunch their role" aimed at updating the state of the art of the national FCCs. The project was coordinated by the Italian National Institute of Health (INIH). The present paper focuses on a selection of the project's results. OBJECTIVES: to describe some characteristics of the regional and Local Health Unit governance of the FCCs, and the care offered by the FCCs in different fields of activity. DESIGN: online census survey on three organizational levels of the FCCs: regional governance, coordination at the Local Health Unit level, and at the single FCC level. Data were collected through dedicated web forms via a national network of reference professionals. SETTING AND PARTICIPANTS: all the Italian Regions and Autonomous Provinces, 207 Local Health Unit coordinators, and 1,859 FCC's professionals were involved. Nineteen Regions (response rate: 100%), 183 coordinators (response rate: 88.4%), and 1,557 FCCs professionals (response rate: 83.7%) participated in the survey. RESULTS: the project found a lack of FCCs and of FCCs health professionals throughout the country compared to the national reference standards for these services, and a great interregional variability in the FCCs governance. Women's health according to a life-course approach is the centre of the FCCs activities, although assistance modalities differ by geographic area. CONCLUSIONS: to relaunch the FCCs role, it is urgent to strengthen their network throughout the country, their multidisciplinary teams, and their integration with other social and health services.

Women undergoing peripartum hysterectomy due to obstetric hemorrhage: A prospective population-based study.

INTRODUCTION: Peripartum hysterectomy is usually undertaken in cases of life-threatening obstetric hemorrhage to prevent the death of the mother. Near-miss events are still under-researched and inappropriate care continues to be a critical issue, even in countries with advanced obstetric surveillance systems. The aim of the present study was to estimate the prevalence, associated factors, management and intraoperative and postoperative complications of peripartum hysterectomy due to obstetric hemorrhage. MATERIAL AND METHODS: A prospective population-based study has been conducted in six Italian regions covering 49% of births in Italy. The study population comprised all women aged 11-59 years undergoing peripartum hysterectomy, from September 2014 to August 2016, due to obstetric hemorrhage within 7 days of delivery. In each maternity unit a trained reference person reported incident cases using electronic data collection forms. The background population comprised all women who delivered in the participating regions during the study period. RESULTS: The overall peripartum hysterectomy prevalence was 1.09 per 1000 maternities, with a large variability among regions, ranging from 0.52 to 1.60. Previous cesarean section (relative risk [RR] 4.97, 95% CI 4.13-5.96), assisted reproductive technology (RR 5.99, 95% CI 4.42-8.11) multiple pregnancy (RR 5.03, 95% CI 3.57-7.09) and maternal age ≥35 years (RR 2.69, 95% CI 2.25-3.21) were the main associated factors for hysterectomy. The most common causes of peripartum hysterectomy were uterine atony (45.1%) and abnormally invasive placentation (40.2%). Intensive care unit admission was reported in 49.9% of cases, 16.8% of women suffered severe morbidity and 5 women died. CONCLUSIONS: The rate of peripartum hysterectomy in Italy was three times higher compared with the UK, the Netherlands and the Nordic countries. The wide difference may be associated with women's characteristics, such as age at delivery and previous cesarean section, and with different management options leading to peripartum hysterectomy.

Maternal suicide in Italy.

Suicide has been identified as one of the most common causes of death among women within 1 year after the end of pregnancy in several high-income countries. The aim of this study was to provide the first estimate of the maternal suicide ratio and a description of the characteristics of women who died by suicide during pregnancy or within 1 year after giving birth, induced abortion or miscarriage (i.e., maternal suicide) in 10 Italian regions, covering 77% of total national births. Maternal suicides were identified through the linkage between regional death registries and hospital discharge databases. Background population data was collected from the national hospital discharge, abortion and mortality databases. The previous psychiatric history of the women who died by maternal suicide was retrieved from the regionally available data sources. A total of 67 cases of maternal suicide were identified, corresponding to a maternal suicide ratio of 2.30 per 100,000 live births in 2006-2012. The suicide rate was 1.18 per 100,000 after giving birth (n = 2,876,193), 2.77 after an induced abortion (n = 650,549) and 2.90 after a miscarriage (n = 379,583). The majority of the women who died by maternal suicide (34/57) had a previous psychiatric history; 15/18 previously diagnosed mental disorders were not registered along with the index pregnancy obstetric records. Suicide is a relevant cause of maternal death in Italy. The continuity of care between primary, mental health and maternity care were found to be critical. Clinicians should be aware of the issue, as they may play an important role in preventing suicide in their patients.

[Family Care Centres for health protection and promotion of individuals and communities: a reflection at the time of the Coronavirus]. / Il consultorio familiare per la tutela e promozione della salute dei singoli e delle comunità: una riflessione ai tempi del Coronavirus.

THE CONTEXT: among the community health services representing a resource to face the COVID-19 emergency, there are the Family Care Centres (FCCs). A national study coordinated by the Italian National Institute of Health (ISS) and funded by the Italian Ministry of Health, recently described their activities and needs, highlighting a large interregional variability in the number of centres and staff availability. Ante and post-natal care, cervical cancer screening and actions addressed at teenagers are the FCCs strategic activities. THE CF IN FRONT OF COVID-19: despite the need to limit the offer of care to the services that cannot be postponed during the lockdown, many FCCs have been exemplary in promptly reorganizing activities in the new context. The paper presents a selection of experiences carried out from March to June 2020 by some FCCs in different Italian Regions concerning FCCs strategic activities. CONCLUSIONS: the combined reading of some of the results of the ISS study and of the activities implemented during the COVID-19 pandemic offers a measure of the ability of the FCCs to respond to the needs of the community and to adapt to change. These services based on an innovative health model deserve enhancement and support.

Maternal mortality in Italy: Results and perspectives of record-linkage analysis.

INTRODUCTION: Accurate estimates and reliable classification of maternal deaths are imperative steps in the chain of actions targeted at reducing avoidable maternal mortality. The aims of this study were to estimate the maternal mortality ratio (MMR) in 10 Italian regions covering 77% of total national births and to identify the most suitable approach to classify the causes of death. MATERIAL AND METHODS: Deaths during and within 1 year after pregnancy have been identified through linkage between death registry and hospital discharge database. Regional and national data sources from 2006 to 2012 were used. The MMR has been estimated and deaths were classified as direct or indirect and according to their primary causes. RESULTS: A total of 277 maternal deaths within 42 days after pregnancy were identified: 149 direct, 102 indirect causes and 26 unclassified-resulting in a MMR of 9.18 per 100 000 live births. The under-reporting rate of official MMR figures in the participating regions is 60.3%. Hemorrhage (MMR 1.92), hypertensive disorders of pregnancy and cardiac diseases (MMR 1.06) were the leading causes of deaths occurring within 42 days after pregnancy, whereas malignancy (39%) and violent deaths (17%) were the most frequent of the 543 late maternal deaths. CONCLUSIONS: Record-linkage is an efficient and reliable method to estimate maternal mortality and to identify causes of maternal deaths. Both the indirect/direct and the classification by primary cause have a role in countries where direct deaths exceed indirect maternal mortality. Building upon linkage data, confidential enquiries further increase the likelihood of reducing maternal mortality.

Drug prescribing during pregnancy in a central region of Italy, 2008-2012.

BACKGROUND: Drug consumption during pregnancy is a matter of concern, especially regarding drugs known or suspected to be teratogens. Little is known about drug use in pregnant women in Italy. The present study is aimed at examining the prevalence, and to detect potential inappropriateness of drug prescribing among pregnant women in Latium, a region of central Italy. METHODS: This retrospective study was conducted on a cohort of women aged 18-45 years who delivered between 2008 and 2012 in public hospitals. Women were enrolled through the Regional Birth Register. After linking the regional Health Information Systems and the Regional Drug Claims Register, women's clinical data and prescribed medications were analyzed. Italian Medicine Agency (AIFA) and US Food and Drug Administration (FDA) evidence were used to investigate inappropriate prescribing and teratogenic risk. RESULTS: Excluding vitamins and minerals, 80.6% (n = 153,079) of the women were prescribed at least one drug during pregnancy, with an average of 4.6 medications per pregnancy. Drugs for blood and hematopoietic organs were the most commonly prescribed (53.0%,), followed by anti-infectives for systemic use (50.7%). Among the inappropriate prescriptions, progestogen supplementation was given in 20.1% of pregnancies; teratogen drugs were prescribed in 0.8%, mostly angiotensin co-enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) (0.3%). CONCLUSIONS: In Latium, drugs are widely used in pregnancy. Prescriptions of inappropriate drugs are observed in more than a fifth of pregnancies, and teratogens are still used, despite their known risk. Continuous updates of information provided to practitioners and an increased availability of information to women might reduce inappropriate prescribing.

Parental Burden and its Correlates in Families of Children with Autism Spectrum Disorder: A Multicentre Study with Two Comparison Groups.

BACKGROUND: The effects of having a child with Autism Spectrum Disorder (ASD) on parents are multifaceted and pervasive. While ample evidence has been provided that these families are under severe stress, there are still several knowledge gaps and unresolved questions. OBJECTIVE: This study aimed at quantifying the subjective and objective burden of ASD in mothers and fathers, and at improving the understanding of the interplay between parental burden, child's characteristics, and parents' coping resources and strategies. METHODS: The parents of 359 children/adolescents with ASD were compared to parents of age-matched patients with Down syndrome (N=145) and Type 1 diabetes mellitus (N=155). Child's clinical characteristics and parents' caregiving burden, psychological distress, coping resources and strategies were assessed. RESULTS: The parents of children with ASD reported higher objective and subjective burden, more frequent psychological distress, lower social support. Mothers reported greater subjective burden than fathers. Structural equation modeling showed that the most consistent positive and negative predictors of objective and subjective burden were ASD symptom severity and social support, respectively. Other positive predictors were engagement, distraction and disengagement coping, intellectual disability, and adaptive functioning. Other negative predictors were spiritual wellbeing and hardiness. Some effects were indirect through social support and coping strategies. CONCLUSION: This study confirmed that parents of children with ASD carry a huge caregiving burden, and added to our understanding of the factors associated with burden. The findings may help inform the design of effective interventions aimed at reducing burden among the parents of children with ASD.

Monitoring and evaluating the Italian mental health system: the "Progetto Residenze" study and beyond.

Filling an alarming gap in evidence-based data on the post-1978 reformed Italian psychiatric system, two turn-of-millennium nationwide projects, Progetto Residenze (PROGRES) and PROGRES-Acute, provided detailed qualitative-quantitative information about care facilities. In 2000, there were 2.9 residential beds per 10,000 inhabitants, hospital care being delivered through small (15-bed) psychiatric units. Private inpatient facilities had proliferated, private inpatient beds per 10,000 inhabitants outnumbering public beds. In 2002, there were 1.7 acute inpatient beds per 10,000 inhabitants, one of Europe's lowest current ratios. The PROGRES and other subsequent projects showed marked nationwide variation in the provision of residential inpatient and outpatient care, grounds for concern about the quality of such care, and an uneven service use pattern. Although the Italian reform law produced a broad network of facilities to meet diverse mental health care needs, the present overview article confirms that further efforts are required to improve quality, balance public and private sectors, and coordinate resources and agencies.

[Occupational stress and mental health]. / Stress lavorativo e salute mentale.

One fifth of workers reports experiencing stress in the work environment in Europe. A number of studies show that psychosocial stressors in the workplace are associated with adverse physical and mental health outcomes, including symptoms of anxiety and depression. The present paper: briefly describes the characteristics of occupational stress and the main psychosocial stressful risk factors in the work environment; reports the main results of studies on psychosocial risk factors in the work environment as risk factor for common mental disorders; presents findings from an Italian study aimed at assessing prevalence of common mental disorders and workplace psychosocial stressors in a sample of hospital employees; provides the "Working conditions Questionnaire", a validated self-administered instrument to assess perceived stress in the workplace; this questionnaire includes the assessment of organizational justice.

Uptake and Adherence to National Guidelines on Postpartum Haemorrhage in Italy: The MOVIE before-after Observational Study.

Translating evidence-based guidelines into clinical practice is a complex challenge. This observational study aimed to assess the adherence to the Italian national guidelines on postpartum haemorrhage (PPH) and describe the clinical management of haemorrhagic events in a selection of maternity units (MUs) in six Italian regions, between January 2019 and October 2020. A twofold study design was adopted: (i) a before-after observational study was used to assess the adherence to national clinical and organisational key recommendations on PPH management, and (ii) a cross-sectional study enrolling prospectively 1100 women with PPH ≥ 1000 mL was used to verify the results of the before-after study. The post-test detected an improved adherence to 16/17 key recommendations of the guidelines, with clinical governance and communication with family members emerging as critical areas. Overall, PPH management emerged as appropriate except for three recommended procedures that emphasise different results between the practices adopted and the difference between what is considered acquired and what is actually practised in daily care. The methodology adopted by the MOVIE project and the adopted training materials and tools have proved effective in improving adherence to the recommended procedures for appropriate PPH management and could be adopted in similar care settings in order to move evidence into practice.

The Italian SEME Surveillance System of Severe Mental Disorders Presenting to Community Mental Health Services.

Mental health is recognized worldwide as a major public health priority for the twenty-first century. Different actions are needed, including developing or strengthening national mental health information systems, based on standardized indicators that allow national and international monitoring. In 2008, the national Centre for Disease prevention and Control of the Italian Ministry of Health and the Mental Health Unit of the Italian National Institute of Health (INIH) jointly launched a mental health information system named SEME (an Italian acronym meaning 'mental health epidemiological surveillance') based upon data collected from trained psychiatrists working in 22 selected sentinel community mental health centers distributed across Italy and covering a total population of 1,941,853 inhabitants, in order to collect and report site-level information on first-contact patients suffering from specific severe mental disorders (schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, bipolar I disorder, anorexia nervosa, major depressive episode with psychotic symptoms or suicide attempt). Strengths of the system are the high reliability of diagnoses and the use of a web-based technique for data collection with data entry forms designed for ease of completion. During the first year of implementation of this system, a total of 343 first-contact patients met criteria for one of the severe mental disorders under surveillance. As the system includes standardized instruments to measure psychiatric symptoms and psychosocial functioning, it may facilitate health services research based on longitudinal measurements aimed at evaluating the continuity of psychiatric care and the effectiveness of innovative therapeutic and rehabilitative programs.

Erratum: Perinatal mental health around the world: priorities for research and service development in Italy - CORRIGENDUM.

[This corrects the article DOI: 10.1192/bji.2019.31.].

The Psychological Impact of COVID-19 among Women Accessing Family Care Centers during Pregnancy and the Postnatal Period in Italy.

There has been concern about the impact of the COVID-19 outbreak on women's mental health during the perinatal period. We conducted a cross-sectional web-based study aimed at evaluating the psychological impact (BSI-18) of the COVID-19 pandemic on this population and collecting information on the perinatal experiences (COPE-IS) during the second Italian wave. Overall, 1168 pregnant women, and 940 within the first six months after childbirth, were recruited in selected Italian Family Care Centers from October 2020 to May 2021. The prevalence of psychological distress symptoms during pregnancy was 12.1% and 9.3% in the postnatal group. Financial difficulties, a previous mood or anxiety disorder and lack of perceived social support and of support provided by health professionals were associated to psychological distress symptoms in both groups. A third of the women felt unsupported by their social network; 61.7% of the pregnant women experienced changes in antenatal care; 21.2% of those in the postnatal period gave birth alone; more than 80% of the participants identified access to medical and mental health care and self-help as important resources in the present context. Health services should assure enhanced support to the most vulnerable women who face the perinatal period during the pandemic.

The Italian Obstetric Surveillance System: Implementation of a bundle of population-based initiatives to reduce haemorrhagic maternal deaths.

In this before and after cross-sectional analysis, the authors aim to assess the impact of the bundle of research and training initiatives implemented between 2013 and 2018, and coordinated by the Italian Obstetric Surveillance System (ItOSS) to reduce obstetric haemorrhagic emergencies in five selected Italian Regions. To this purpose, the haemorrhagic Maternal Mortality Ratios (MMR) per 100,000 live births were estimated before and after implementing the bundle, through the ItOSS's vital statistic linkage procedures and incident reporting and Confidential Enquiries. The research and training bundle was offered to all health professionals involved in pregnancy and birth care in the selected regions, representing 40% of national live births, and participating in the ItOSS audit cycle since its institution. The haemorrhagic MMR significantly decreased from 2.49/100,000 live births [95% CI 1.75 to 3.43] in the years 2007-2013 prior to the bundle implementation, to 0.77/100,000 live births [95% CI 0.31 to 1.58] in the years 2014-2018 after its implementation. According to the study results, the bundle of population-based initiatives might have contributed to reducing the haemorrhagic MMR in the participating regions, thus improving the quality of care of the major obstetric haemorrhage.

Psychiatric disorders among hospitalized patients deceased with COVID-19 in Italy.

BACKGROUND: there is concern about the increased risk for SARS-CoV-2 infection, COVID-19 severe outcomes and disparity of care among patients with a psychiatric disorder (PD). Based on the Italian COVID-19 death surveillance, which collects data from all the hospitals throughout the country, we aimed to describe clinical features and care pathway of patients dying with COVID-19 and a preceding diagnosis of a PD. METHODS: in this cross-sectional study, the characteristics of a representative sample of patients, who have died with COVID-19 in Italian hospitals between February 21st and August 3rd 2020, were drawn from medical charts, described and analysed by multinomial logistic regression according to the recorded psychiatric diagnosis: no PD, severe PD (SPD) (i.e. schizophrenia and other psychotic disorders, bipolar and related disorders), common mental disorder (CMD) (i.e. depression without psychotic features, anxiety disorders). FINDINGS: the 4020 COVID-19 deaths included in the study took place in 365 hospitals across Italy. Out of the 4020 deceased patients, 84 (2•1%) had a previous SPD, 177 (4.4%) a CMD. The mean age at death was 78.0 (95%CI 77.6-78.3) years among patients without a PD, 71.8 (95%CI 69.3-72.0) among those with an SPD, 79.5 (95%CI 78.0-81.1) in individuals with a CMD. 2253 (61.2%) patients without a PD, 62 (73.8%) with an SPD, and 136 (78.2%) with a CMD were diagnosed with three or more non-psychiatric comorbidities.When we adjusted for clinically relevant variables, including hospital of death, we found that SPD patients died at a younger age than those without a PD (adjusted OR per 1 year increment 0.96; 95% CI 0.94-0.98). Women were significantly more represented among CMD patients compared to patients without previous psychiatric history (aOR 1.56; 95% CI 1.05-2.32). Hospital admission from long-term care facilities (LTCFs) was strongly associated with having an SPD (aOR 9.02; 95% CI 4.99-16.3) or a CMD (aOR 2.09; 95% CI 1.19-3.66). Comorbidity burden, fever, admission to intensive care and time from symptoms' onset to nasopharyngeal swab did not result significantly associated with an SPD or with a CMD in comparison to those without any PD. INTERPRETATION: even where equal treatment is in place, the vulnerability of patients with a PD may reduce their chance of recovering from COVID-19. The promotion of personalised therapeutic projects aimed at including people with PD in the community rather than in non-psychiatric LTCFs should be prioritised.

Hospitalization for anorexia nervosa in Italy.

OBJECTIVE: This study provides: a) rates of hospitalization for anorexia nervosa (AN) in Italy in 2004-2005 period; b) an estimate of the incidence of moderate to severe hospitalized AN in the same period among persons aged 10-19 years. METHOD: 9863 hospital discharges of patients aged 10-59 years with a diagnosis of AN (ICD9CM code 307.1) were extrapolated from the Italian Hospital Discharges Database. Patients aged 10-19 years, first admitted in 2004-2005, never hospitalized for AN in 2001-2003, were assumed to be a reasonable proxy of incident cases. RESULTS: Crude rate of AN associated hospitalization was 24.2 per 100,000 person-years among women and 1.6 per 100,000 person-years among men. Estimated incidence rate of AN was 22.8 per 100,000 among women compared with 2.0 per 100,000 among men in the 10-19 years age group. DISCUSSION: This study provides, for the first time, nationwide incidence estimates of AN in Italy.