A scoping review of non-pharmacological perinatal interventions impacting maternal sleep and maternal mental health.

BACKGROUND: A woman's vulnerability to sleep disruption and mood disturbance is heightened during the perinatal period and there is a strong bidirectional relationship between them. Both sleep disruption and mood disturbance can result in significant adverse outcomes for women and their infant. Thus, supporting and improving sleep in the perinatal period is not only an important outcome in and of itself, but also a pathway through which future mental health outcomes may be altered. METHODS: Using scoping review methodology, we investigated the nature, extent and characteristics of intervention studies conducted during the perinatal period (pregnancy to one-year post-birth) that reported on both maternal sleep and maternal mental health. Numerical and descriptive results are presented on the types of studies, settings, sample characteristics, intervention design (including timeframes, facilitation and delivery), sleep and mood measures and findings. RESULTS: Thirty-seven perinatal interventions were identified and further described according to their primary focus (psychological (n = 9), educational (n = 15), lifestyle (n = 10), chronotherapeutic (n = 3)). Most studies were conducted in developed Western countries and published in the last 9 years. The majority of study samples were women with existing sleep or mental health problems, and participants were predominantly well-educated, not socio-economically disadvantaged, in stable relationships, primiparous and of White race/ethnicity. Interventions were generally delivered across a relatively short period of time, in either the second trimester of pregnancy or the early postnatal period and used the Pittsburgh Sleep Quality Index (PSQI) to measure sleep and the Edinburgh Postnatal Depression Scale (EPDS) to measure mood. Retention rates were high (mean 89%) and where reported, interventions were well accepted by women. Cognitive Behavioural Therapies (CBT) and educational interventions were largely delivered by trained personnel in person, whereas other interventions were often self-delivered after initial explanation. CONCLUSIONS: Future perinatal interventions should consider spanning the perinatal period and using a stepped-care model. Women may be better supported by providing access to a range of information, services and treatment specific to their needs and maternal stage. The development of these interventions must involve and consider the needs of women experiencing disadvantage who are predominantly affected by poor sleep health and poor mental health.

Uncertainty and certainty: perceptions and experiences of prediabetes in New Zealand primary care – a qualitative study.

Introduction Prediabetes is the asymptomatic precursor to type two diabetes mellitus, a significant and growing public health problem in New Zealand (NZ). Little is known about how general practitioners (GPs) and nurses view prediabetes care, and similarly little is known about how people with prediabetes view their condition and care. Aim This study aimed to investigate the views of NZ GPs and nurses, and people with prediabetes about prediabetes and its management. Methods This was a mixed qualitative methods study that is part of a randomised control trial of a prediabetes intervention. Results Three key themes emerged from the health professional data (GPs and nurses) and another three themes emerged from people with prediabetes data. GPs and nurses were uncertain about the progression of prediabetes; they felt prediabetes was not a priority and they were unsure about what to advise. People with prediabetes were uncertain about the diagnosis and information given to them; they were unsure about what to do about prediabetes and they found lifestyle change hard. Discussion GPs, nurses and people with prediabetes, expressed much uncertainty, but also some certainty about prediabetes. All were certain that prediabetes is common and increasing and that sustained lifestyle change was very difficult. But uncertainty prevailed about whether, in reality, prediabetes could be stopped, who would be most likely to benefit from lifestyle interventions and how best to achieve these. Older Maori and Pacific women were keen to promote lifestyle change and this appeared best done through Maori and Pacific peoples' organisations by means of co-designed interventions.

A randomised controlled trial of a probiotic and a prebiotic examining metabolic and mental health outcomes in adults with pre-diabetes.

AIMS: To evaluate the effect of the probiotic Lactobacillus rhamnosus HN001 and/or cereal enriched with oat-derived beta-glucan (OBG) on metabolic and mental health outcomes when administered to adults with pre-diabetes. DESIGN: 2×2 factorial design randomised, parallel-groups placebo-controlled; double-blinded for probiotic, single-blinded for cereals. PARTICIPANTS: Community-dwelling adults aged 18-80 years with pre-diabetes: glycated haemoglobin (HbA1c) 41-49 mmol/mol. INTERVENTIONS: Capsules containing Lactobacillus rhamnosus (HN001) (6×109 colony-forming units/day), or placebo capsules; and cereal containing 4 g/day OBG or calorie-matched control cereal, taken daily, for 6 months. Study groups were: (A) HN001 capsules+OBG cereal; (B) HN001 capsules+control cereal; (C) placebo capsules+OBG cereal and (D) placebo capsules+control cereal. OUTCOME MEASURES: Primary outcome: HbA1c at 6 months. SECONDARY OUTCOMES: fasting plasma glucose, fasting insulin, homeostatic model assessment of insulin resistance, fasting lipids, blood pressure, body weight, waist circumference, body mass index and mental well-being. RESULTS: 153 participants were randomised. There was complete HbA1c outcome data available for 129 participants. At 6 months the mean (SD) HbA1c was 45.9 (4.4) mmol/mol, n=66 for HN001, and 46.7 (4.3) mmol/mol, n=63 for placebo capsules; 46.5 (4.0) mmol/mol, n=67 for OBG and 46.0 (4.6) mmol/mol n=62 for control cereal. The estimated difference between HN001-placebo capsules was -0.83, 95% CI -1.93 to 0.27 mmol/mol, p=0.63, and between OBG-control cereals -0.17, 95% CI -1.28 to 0.94 mmol/mol, p=0.76. There was no significant interaction between treatments p=0.79. There were no differences between groups or significant interactions between treatments for any of the secondary outcomes. CONCLUSIONS: This study found no evidence of clinical benefit from the supplementation with either HN001 and/or cereal containing 4 g OBG on HbA1c and all secondary outcomes relevant to adults with pre-diabetes. TRIAL REGISTRATION NUMBER: Australian New Zealand Clincial Trials Registry number ACTRN12617000990325.

Sleep HAPi: A Feasibility and Descriptive Analysis of an Early and Longitudinal Sleep Education Intervention for Pregnant Women.

Background: Poor sleep and prior depression are key predictors of perinatal depression, with research suggesting depressive symptoms may emerge in early pregnancy. Sleep is a potentially modifiable risk factor for depression. This pilot study examined the feasibility and acceptability of a six-month sleep education intervention designed to optimize sleep and minimize depressive symptoms throughout pregnancy. Sleep measures and depressive symptoms are described from 12 weeks gestation to 12 weeks postpartum.Participants: A community sample of nulliparous pregnant women with a history of depression were recruited prior to 14 weeks gestation.Methods: An individualized sleep education program was developed and participants engaged in three trimester specific sleep education sessions. Feasibility and acceptability were determined via recruitment and retention rates and participant feedback. Depressive symptoms and sleep were measured at five time points throughout the study.Results: 22 women enrolled in the study and 15 completed the intervention. Participants reported the intervention as highly acceptable. There was minimal change in all dimensions of sleep across pregnancy, but sleep measures were significantly worse at six weeks postpartum and improved by 12 weeks postpartum. Depressive symptoms were significantly lower at the conclusion of the intervention and 12 weeks postpartum compared to trimester 1.Conclusions: This sleep education program appears feasible, acceptable and may be effective in minimizing depressive symptoms in pregnant women with a history of depression. Trials with larger and more diverse samples are warranted and further studies to ascertain efficacy should be undertaken with a control group.

Multiple dimensions of sleep are consistently associated with chronically elevated depressive symptoms from late pregnancy to 3 years postnatal in Indigenous and non-Indigenous New Zealand women.

INTRODUCTION: Poor sleep and depressive symptoms are common throughout the perinatal period, but little is known about the extended time course of depression and the sleep dimensions associated with these trajectories. OBJECTIVE: This study investigated different depression trajectories in New Zealand Maori and non-Maori women from late pregnancy to 3 years postnatal. Relationships between multiple dimensions of sleep and these depression trajectories were also investigated. METHODS: Data from 856 women (30.6% Maori and 69.4% non-Maori) from the longitudinal Moe Kura cohort study were used. Depressive symptoms and multiple dimensions of sleep (quality, duration, latency, continuity and daytime sleepiness) were collected at 36 weeks' gestation, 12 weeks postnatal and 3 years postnatal. Trajectory analysis was completed using latent class analysis. RESULTS: Latent class analysis revealed two distinct groups of depressive symptom trajectories: 'chronic high' and 'stable mild' for both Maori and non-Maori women. Maori women in both trajectories were more likely than non-Maori women to have clinically significant depressive symptoms at every time point. Poorer sleep quality, latency, continuity and greater daytime sleepiness were consistently associated with the chronic high depressive symptom trajectory at all three time points, after controlling for sociodemographic factors. CONCLUSION: A significant proportion of Maori and non-Maori women experience chronically high depressive symptoms during the perinatal period and the following years. Across this extended time frame, Maori women have a higher probability of experiencing clinically significant depressive symptoms compared to non-Maori women. These persistent patterns of depressive symptoms occur concurrently with multiple dimensions of poor sleep. Given the well-described impact of maternal depression on the mother, child, family and community, this highlights the importance of healthcare professionals asking about mothers' sleep quality, continuity, latency and daytime sleepiness as potential indicators of long-term mood outcomes.

A pilot longitudinal sleep education intervention from early pregnancy and its effect on optimizing sleep and minimizing depressive symptoms.

OBJECTIVES: Investigate the efficacy of a pilot longitudinal sleep education program for optimizing sleep and minimizing depressive symptoms in nulliparous pregnant women. DESIGN: Early and longitudinal sleep education intervention pilot study. SETTING: Community-based convenience sample of New Zealand women. PARTICIPANTS: 15 nulliparous women who were involved in a pilot of a longitudinal sleep education intervention during pregnancy (N = 15) were compared to a comparison group (n = 76) from another observational study with the same time points. Groups were matched on depression history and parity. INTERVENTION: A longitudinal sleep education program was developed. Women in the intervention group participated in three individualized and trimester specific education sessions designed to increase sleep knowledge and improve sleep practices. The comparison group received no sleep education. MEASUREMENTS: Self-reports of depressive symptoms and five dimensions of sleep (duration, quality, continuity, latency, daytime sleepiness) were compared between groups using linear mixed model analysis of variance. RESULTS: At the conclusion of the intervention, the intervention group had fewer depressive symptoms with none experiencing clinically significant depressive symptoms, while 21% of the comparison group were considered to have clinically significant depressive symptoms. The intervention group also had better sleep quality, sleep initiation and sleep continuity than the comparison group at late pregnancy. CONCLUSIONS: Findings suggest that a longitudinal sleep education intervention commencing early in pregnancy may be effective in optimizing sleep and minimizing depressive symptoms for nulliparous women with a history of depression. Further investigation of sleep education interventions to improve maternal mental health in pregnancy and postnatally is warranted.

Experiences of Weight-Loss Surgery in People With Serious Mental Illness: A Qualitative Study.

BACKGROUND: Bariatric surgery is seldom accessed by people with serious mental illness, despite high rates of obesity in this population. It is sometimes assumed that patients with complex psychiatric histories will have poor post-surgical weight loss or exacerbation of psychiatric symptoms, although this is unsubstantiated. OBJECTIVES: A qualitative descriptive study to explore personal experiences and the impact of bariatric surgery on physical and mental well-being and life-quality in individuals with serious mental illness. METHODS: Nine adults with a history of bariatric surgery and concurrent severe depressive disorder, bipolar disorder, or schizoaffective disorder were interviewed about their experiences of bariatric surgery and its outcomes using semi-structured interview schedules. Data were transcribed and inductive thematic analysis undertaken. RESULTS: Five broad themes emerged: (1) surgery was highly effective for weight loss, and resulted in subjective improvements in physical health, quality of life, and mental health described as being able to live a life; (2) recovering from surgery was a tough road, notably in the post-operative period where negative sequelae often anteceded benefits; (3) post-operative support was important, but sometimes insufficient, including from families, mental health services, and surgical teams; (4) most considered surgery life-changing, recommending it to others with mental illness and obesity, two had different experiences; (5) participants considered it discriminatory that people with mental illness were not referred or declined weight loss surgery. CONCLUSIONS: Participants benefited from bariatric surgery and felt it should be offered to others with mental illness, but with additional care and support.

Maternal sleep disturbances in late pregnancy and the association with emergency caesarean section: A prospective cohort study.

OBJECTIVES: To investigate the association between measures of sleep quality, sleep duration and sleep disorder symptoms in late pregnancy and likelihood of emergency caesarean section. DESIGN: Population-based prospective cohort study SETTING: New Zealand PARTICIPANTS: 310 Maori (Indigenous New Zealanders) and 629 non-Maori women MEASUREMENTS: Multivariable logistic regression models were used to investigate the association between type of delivery (emergency caesarean section vs. spontaneous vaginal delivery) and self-reported sleep duration, sleep quality and sleep-related symptoms, (e.g. snoring, breathing pauses during sleep, legs twitching/jerking) in the third trimester of pregnancy. Models were adjusted by ethnicity (ref=non-Maori), age (ref=16-19 y), parity (ref=nulliparous), clinical indicators (any vs. none), area deprivation (ref=least deprived quintile), BMI and for some models smoking. RESULTS: Women who reported poor quality sleep as measured by the General Sleep Disturbance Scale in later pregnancy had almost twice the odds of delivering via emergency caesarean than women with good sleep quality (OR=1.98, 95% CI 1.18-3.31). Reporting current breathing pauses during sleep (OR=3.27, 95% CI 1.38-7.74) or current snoring (OR=1.65, 95% CI 1.00-2.72) were also independently associated with a higher likelihood of an emergency caesarean. Short sleep duration and leg twitching/jerking were not independently associated with emergency caesarean section in this study. CONCLUSIONS: Supporting healthy sleep during pregnancy could be a novel intervention to reduce the risks associated with emergency caesarean section. Research on the effectiveness of sleep interventions for reducing caesarean section risk is required.

Food 4 Health - He Oranga Kai: Assessing the efficacy, acceptability and economic implications of Lactobacillus rhamnosus HN001 and ß-glucan to improve glycated haemoglobin, metabolic health, and general well-being in adults with pre-diabetes: study protocol for a 2 × 2 factorial design, parallel group, placebo-controlled randomized controlled trial, with embedded qualitative study and economic analysis.

BACKGROUND: The rates of pre-diabetes and type 2 diabetes mellitus are increasing worldwide, producing significant burdens for individuals, families, and healthcare systems. In New Zealand, type 2 diabetes mellitus and pre-diabetes disproportionally affect Maori, Pacific, and South Asian peoples. This research evaluates the efficacy, acceptability, and economic impact of a probiotic capsule and a prebiotic cereal intervention in adults with pre-diabetes on metabolic and mental health and well-being outcomes. METHODS: Eligible adults (n = 152) aged 18-80 years with pre-diabetes (glycated haemoglobin 41-49 mmol/mol) will be enrolled in a 2 × 2 factorial design, randomised, parallel-group, placebo-controlled trial. Computer-generated block randomization will be performed independently. Interventions are capsulated Lactobacillus rhamnosus HN001 (6 × 109 colony-forming units/day) (A) and cereal containing 4 g ß-glucan (B), placebo capsules (O1), and calorie-matched control cereal (O2). Eligible participants will receive 6 months intervention in the following groups: AB, AO1, BO2, and O1O2. The primary outcome is glycated haemoglobin after 6 months. Follow-up at 9 months will assess the durability of response. Secondary outcomes are glycated haemoglobin after 3 and 9 months, fasting glucose, insulin resistance, blood pressure, body weight, body mass index, and blood lipid levels. General well-being and quality of life will be measured by the Short-Form Health Survey 36 and Depression Anxiety Stress Scale 21 at 6 and 9 months. Outcome assessors will be blind to capsule allocation. An accompanying qualitative study will include 24 face-to-face semistructured interviews with an ethnically balanced sample from the ß-glucan arms at 2 months, participant focus groups at 6 months, and three health professional focus groups. These will explore how interventions are adopted, their acceptability, and elicit factors that may support the uptake of interventions. A simulation model of the pre-diabetic New Zealand population will be used to estimate the likely impact in quality-adjusted life years and health system costs of the interventions if rolled out in New Zealand. DISCUSSION: This study will examine the efficacy of interventions in a population with pre-diabetes. Qualitative components provide rich description of views on the interventions. When combined with the economic analysis, the study will provide insights into how to translate the interventions into practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12617000990325. Prospectively registered on 10 July 2017.

Long-term psychiatric inpatients' perspectives on weight gain, body satisfaction, diet and physical activity: a mixed methods study.

BACKGROUND: Obesity is a significant problem for people with serious mental illness. We aimed to consider body size from the perspective of long-stay psychiatric inpatients, focussing on: weight gain and its causes and impacts; diet and physical activity; and the perceived ability to make meaningful change in these domains. METHOD: A mixed methods study with 51 long-term psychiatric forensic and rehabilitation inpatients using semi-structured interviews combined with biometric and demographic data. RESULTS: 94% of participants were overweight or obese (mean BMI 35.3, SD 8.1). They were concerned about their weight, with 75% of them attempting to lose weight. Qualitative responses indicated low personal effectiveness and self-stigmatisation. Participants viewed their weight gain as something 'done to them' through medication, hospitalisation and leave restrictions. A prevailing theme was that institutional constraints made it difficult to live a healthy life (just the way the system is). Many had an external locus of control, viewing weight loss as desirable but unachievable, inhibited by environmental factors and requiring a quantum of motivation they found hard to muster. Despite this, participants were thoughtful and interested, had sound ideas for weight loss, and wished to be engaged in a shared endeavour to achieve better health outcomes. Consulting people as experts on their experiences, preferences, and goals may help develop new solutions, remove unidentified barriers, and improve motivation. CONCLUSIONS: The importance of an individualised, multifactorial approach in weight loss programmes for this group was clear. Patient-led ideas and co-design should be key principles in programme and environmental design.

Challenging some assumptions about empathy.

BACKGROUND: In New Zealand little nursing or medical curricula time, if any, is specifically devoted to the enhancement of empathy. If being empathic is important in the context of patient care, it is a quality that is already present in students or is learned by students during their practicum in the company of experienced clinicians. This study aimed to compare self-reported empathy ratings between different groups of medical students and one cohort of nursing students who were either exposed or not exposed to explicit empathy training or learning in clinical settings in the presence of patients. METHODS: The Jefferson Scale of Physician Empathy (JSPE) was completed before and after groups of medical and nursing students had been exposed to various extended periods of practicum. Some medical student cohorts undertook brief empathy training, whereas others had no exposure. The nursing student cohort had no formal, explicit empathy training. RESULTS: Irrespective of profession, length of practicum or exposure to specific empathy training, there were no significant differences in the self-reported JSPE scores across the seven different cohorts of students. Empathy is a quality that is already present in students or is learned by students during their practicum DISCUSSION: If empathy is caught rather than taught, then brief efforts to enhance empathy may be futile. To optimise the inherent empathic qualities of aspirant health professionals, explicit consideration should be given to how empathy is influenced by the practicum experience.

The prevalence of symptoms of depression and anxiety, and the level of life stress and worry in New Zealand Maori and non-Maori women in late pregnancy.

OBJECTIVE: To describe the prevalence of symptoms of depression and anxiety, and the level of life stress and worry in late pregnancy for Maori and non-Maori women. METHODS: In late pregnancy, women completed a questionnaire recording their prior history of mood disorders; self-reported current depressive symptoms (⩾13 on the Edinburgh Postnatal Depression Scale), current anxiety symptoms (⩾6 on the anxiety items from the Edinburgh Postnatal Depression Scale), significant life stress (⩾2 items on life stress scale) and dysfunctional worry (>12 on the Brief Measure of Worry Scale). RESULTS: Data were obtained from 406 Maori women (mean age = 27.6 years, standard deviation=6.3 years) and 738 non-Maori women (mean age = 31.6 years, standard deviation=5.3 years). Depressive symptoms (22% vs 15%), anxiety symptoms (25% vs 20%), significant life stress (55% vs 30%) and a period of poor mood during the current pregnancy (18% vs 14%) were more prevalent for Maori than non-Maori women. Less than 50% of women who had experienced ⩾2 weeks of poor mood during the current pregnancy had sought help. Being young was an independent risk factor for depressive symptoms, significant life stress and dysfunctional worry. A prior history of depression was also consistently associated with a greater risk of negative affect in pregnancy. CONCLUSION: Antenatal mental health requires at least as much attention and resourcing as mental health in the postpartum period. Services need to specifically target Maori women, young women and women with a prior history of depression.

The Porirua Protocol in the Treatment of Clozapine-Induced Gastrointestinal Hypomotility and Constipation: A Pre- and Post-Treatment Study.

BACKGROUND: Clozapine, an antipsychotic used in treatment-resistant schizophrenia, causes slow gastrointestinal transit in 50-80% of patients. Clozapine-induced gastrointestinal hypomotility is both common and serious, and potential complications include severe constipation, ileus, bowel obstruction and related complications, with a higher mortality rate than clozapine-related agranulocytosis. Little evidence exists on its prevention and management. METHOD: Using a well-validated radiopaque marker ('Metcalf') method, we compared colonic transit times (CTTs) of clozapine-treated inpatients not receiving laxatives with their transit times when receiving laxatives, with treatment prescribed according to the Porirua Protocol for clozapine-related constipation (docusate and senna augmented by macrogol 3350 in treatment-resistant cases). RESULTS: The median age of participants was 35 years, and median clozapine dose, plasma level and duration of treatment were 575 mg/day, 506 ng/mL and 2.5 years, respectively. Overall, 14 participants (10 male) were enrolled and all completed the study. Transit times improved markedly with laxative treatment. Median colonic transit without laxatives was 110 h (95% confidence interval [CI] 76-144 h), over four times longer than normative values (p < 0.0001). Median CTT with laxatives was 62 h (95% CI 27-96 h), a 2-day reduction in average transit time (p = 0.009). The prevalence of gastrointestinal hypomotility decreased from 86% pre-treatment to 50% post-treatment (p = 0.061). Severe gastrointestinal hypomotility decreased from 64 to 21% (p = 0.031). Subjective reporting of constipation did not correlate well with objective hypomotility, and did not change significantly with treatment. CONCLUSION: Treating clozapine-treated patients with docusate and senna augmented by macrogol appears effective in reducing CTTs in clozapine-induced constipation. Randomised controlled trials are the next step. Australian New Zealand Clinical Trial Registry ACTRN12616001405404 (registered retrospectively).

Clozapine-treated Patients Have Marked Gastrointestinal Hypomotility, the Probable Basis of Life-threatening Gastrointestinal Complications: A Cross Sectional Study.

BACKGROUND: Gastrointestinal side effects are particularly common with clozapine and occur with other antipsychotics, ranging from mild constipation to fatal bowel obstruction and/or ischemia. While this adverse-effect spectrum has been attributed to 'gastrointestinal hypomotility', gastrointestinal transit times in antipsychotic-treated patients have not previously been measured, making this mechanism speculative. METHODS: Using standardized radiopaque marker ('Metcalf') methods we established colonic transit times of antipsychotic-treated psychiatric inpatients and compared them with population normative values. We analyzed results by antipsychotic type, antipsychotic dose equivalent, anticholinergic load, duration of treatment, gender, ethnicity, and age. OUTCOMES: For patients not prescribed clozapine, median colonic transit time was 23 h. For patients prescribed clozapine, median transit time was 104.5 h, over four times longer than those on other antipsychotics or normative values (p < 0.0001). Eighty percent of clozapine-treated patients had colonic hypomotility, compared with none of those prescribed other antipsychotics (olanzapine, risperidone, paliperidone aripiprazole, zuclopenthixol or haloperidol). In the clozapine group, right colon, left colon and rectosigmoid transit times were all markedly abnormal suggesting pan-colonic pathology. Hypomotility occurred irrespective of gender, age, ethnicity, or length of clozapine treatment. Transit times were positively correlated with clozapine plasma level (rho = 0.451, p = 0.045), but not with duration of treatment, total antipsychotic load or demographic factors. INTERPRETATION: Clozapine, unlike the other antipsychotics examined, causes marked gastrointestinal hypomotility, as previously hypothesized. Pre-emptive laxative treatment is recommended when starting clozapine.

Self-reported sleep in late pregnancy in relation to birth size and fetal distress: the E Moe, Mama prospective cohort study.

OBJECTIVES: To explore associations between features of sleep during pregnancy and adverse outcomes for the infant. SETTING: E Moe, Mama is a cohort study in Aotearoa/New Zealand that investigates self-reported sleep and maternal health in late pregnancy and the postpartum period. PARTICIPANTS: Women (N=633; 194 Maori) reported detailed information on their sleep duration, quality, disturbances, disorders (snoring, breathing pauses, twitching legs, restless legs) and daytime sleepiness between 35 and 37 weeks gestation. OUTCOME MEASURES: Birthweight and fetal distress during labour were extracted from medical records. Associations between each sleep variable and small or large for gestational age (SGA/LGA) using customised birthweight centile or fetal distress were estimated using multinomial/logistic regression, controlling for potential confounders. Secondary analyses considered differences in associations between Maori and non-Maori women. RESULTS: There was some indication that breathing pauses (a measure of sleep apnoea) were associated with both SGA (OR 2.8, 95% CI 0.9 to 9.0, p=0.08) and LGA (OR 2.0, 95% CI 0.7 to 5.7, p=0.20), with the association for LGA being stronger when only pregnancy-onset breathing pauses were considered (OR 3.5, 95% CI 1.3 to 9.6, p=0.01). There was also some evidence that pregnancy-onset leg twitching (OR 3.3, 95% CI 1.1 to 10.0, p=0.03) and frequent sleep disturbance due to feeling too hot or too cold (OR 1.7, 95% CI 0.9 to 3.6, p=0.13) were associated with higher risk of fetal distress. Other sleep measures, including snoring, were not associated with SGA, LGA or fetal distress. Many of the associations we observed were considerably stronger in Maori compared with non-Maori women. CONCLUSIONS: We did not find evidence of previously reported associations between snoring and SGA. Our findings tentatively suggest that self-reported breathing pauses and leg twitching in late pregnancy are associated with infant outcomes, and highlight ethnic inequalities.

'Is it the crime of the century?': factors for psychiatrists and service users that influence the long-term prescription of hypnosedatives.

Given the longstanding controversy about hypnosedative use, we aimed to investigate the attitudes of prescribing psychiatrists and service users towards long-term use of hypnosedative medication, and their perceptions of barriers to evidence-based nonmedication alternatives. Qualitative data from focus groups in Aotearoa/NZ were analysed thematically. A novel research design involved a service user researcher contributing throughout the research design and process. Service users and psychiatrists met to discuss each other's views, initially separately, and subsequently together. Analysis of the data identified four key themes: the challenge, for both parties, of sleep disturbance among service users with mental health problems; the conceptual and ethical conflicts for service users and psychiatrists in managing this challenge; the significant barriers to service users accessing evidence-based nonmedication alternatives; and the initial sense of disempowerment, shared by both service users and psychiatrists, which was transformed during the research process. Our results raise questions about the relevance of the existing guidelines for this group of service users, highlight the resource and time pressures that discourage participants from embarking on withdrawal regimes and education programmes on alternatives, highlight the lack of knowledge about alternatives and reflect the complex interaction between sleep and mental health problems, which poses a significant dilemma for service users and psychiatrists.

Prevalence of abnormal sleep duration and excessive daytime sleepiness in pregnancy and the role of socio-demographic factors: comparing pregnant women with women in the general population.

OBJECTIVES: To compare the prevalence of self-reported abnormal sleep duration and excessive daytime sleepiness in pregnancy among Maori (indigenous New Zealanders) and non-Maori women versus the general population, and to examine the influence of socio-demographic factors. METHODS: Self-reported total sleep time (TST) in 24-hrs, Epworth Sleepiness Scale scores and socio-demographic information were obtained from nullipara and multipara women aged 20-46 yrs at 35-37 weeks pregnant (358 Maori and 717 non-Maori), and women in the general population (381 Maori and 577 non-Maori). RESULTS: After controlling for ethnicity, age, socio-economic status, and employment status, pregnant women average 30 min less TST than women in the general population. The distribution of TST was also greater in pregnant women, who were 3 times more likely to be short sleepers (≤6 h) and 1.9 times more likely to be long sleepers (>9 h). In addition, pregnant women were 1.8 times more likely to report excessive daytime sleepiness (EDS). Pregnant women >30 years of age experienced greater age-related declines in TST. Identifying as Maori, being unemployed, and working at night increased the likelihood of reporting abnormal sleep duration across all women population in this study. EDS also more likely occurred among Maori women and women who worked at night. CONCLUSIONS: Pregnancy increases the prevalence of abnormal sleep duration and EDS, which are also higher among Maori than non-Maori women and those who do night work. Health professionals responsible for the care of pregnant women need to be well-educated about the importance of sleep and discuss sleep issues with the women they care for.

Madness at the movies: prioritised movies for self-directed learning by medical students.

OBJECTIVE: We aimed to systematically compile a list of 10 movies to facilitate self-directed learning in psychiatry by medical students. METHOD: The selected areas were those of the top five mental health conditions from the Global Burden of Disease 2010 study. The search strategy for movies covered an extensive range of sources (published literature and websites), followed by closer examination and critical viewing of a sample. RESULTS: Out of a total of 503 potential movies that were identified, 23 were selected for viewing and more detailed critique. The final top 10 were: for depressive and anxiety disorders: Ordinary People (1980), Silver Linings Playbook (2012); for illicit drug use: Trainspotting (1996), Winter's Bone (2010), Rachel Getting Married (2008), Half Nelson (2006); for alcohol use disorders: Another Year (2010), Passion Fish (1992); and for schizophrenia: The Devil and Daniel Johnston (2006), and An Angel at My Table (1990). CONCLUSIONS: The final selection of 10 movies all appeared to have relatively high entertainment value together with rich content in terms of psychiatric themes. Further research could evaluate the extent to which medical students actually watch such movies, by assessing the level of withdrawals from a medical school library and surveying student responses.

Dysfunctional cognitions about sleep in psychiatric patients.

The optimal management of sleep problems is a significant challenge, particularly in patients with psychiatric illness, because disturbed sleep is a known risk factor for relapse. This study used the short Dysfunctional Beliefs and Attitudes Scale to assess beliefs about sleep in adults with acute psychiatric disorders (N=100) recruited from inpatient and outpatient clinics. The subjects showed highly dysfunctional beliefs and attitudes about sleep and held diverse opinions about, but had low confidence in, their own capacity for optimal sleep management. They did not report excessive daytime sleepiness. We conclude that individuals with acute psychiatric illness worry significantly about their sleep and hold more dysfunctional beliefs about sleep than people without psychiatric illness. The absence of excessive daytime sleepiness in this sample, although counterintuitive, is consistent with findings in other studies. Given that two thirds of the sample expressed interest in non-pharmacological strategies to better manage their sleep problems, cognitive reshaping therapies appear to have clinical potential as alternatives to hypnosedative medication once a comprehensive sleep workup has excluded a physical sleep disorder such as obstructive sleep apnea. Dysfunctional beliefs and high concern about sleep offer potential targets for psychotherapy.