Impact of omission of routine blood monitoring of stable patients living with HIV during the coronavirus pandemic.

INTRODUCTION: The British HIV Association (BHIVA) guidelines were amended during the coronavirus (COVID-19) pandemic, allowing for less frequent monitoring of routine bloods. We assessed the impact of this on patient outcomes. METHODS: Between April 2020 and March 2021, routine blood appointments at our HIV clinic were replaced by virtual consultations in 'stable' people living with HIV (PLWH), defined using standard operating procedure (SOP) criteria. All had an undetectable HIV viral load (VL) (<50 copies/mL). Demographic, HIV clinical information, and antiretroviral treatment (ART) data were collated using the electronic patient record (EPR). Blood results from before (baseline) and after (follow-up) the omitted appointment were analysed for each parameter. RESULTS: In all, 791/2395 PLWH were scheduled to have blood tests omitted; 381 were excluded for reasons including not fitting the SOP criteria or presenting to clinic early, and 410 were included in analysis. The demographics of the group were consistent with our whole HIV cohort. HIV VL became detectable in 8/410 individuals (1.95%, range 51-730 copies/mL). VL resuppressed in 6/8 after a median of 29 days. VL remained detectable in two individuals, both of whom remain in care. Routine blood monitoring revealed baseline and follow-up blood parameters that were largely within normal range. Four out of 12 parameters had statistically significant changes but were not considered clinically significant; 59/410 (14.4%) changed ART, most commonly for simplification. CONCLUSION: For the majority of stable PLWH included in our evaluation, the omission of routine blood monitoring during the pandemic did not have a negative impact on HIV suppression or blood monitoring outcomes. ART switch was uncommon.

The causal association between maternal depression, anxiety, and infection in pregnancy and neurodevelopmental disorders among 410 461 children: a population study using quasi-negative control cohorts and sibling analysis.

BACKGROUND: To address if the long-standing association between maternal infection, depression/anxiety in pregnancy, and offspring neurodevelopmental disorder (NDD) is causal, we conducted two negative-control studies. METHODS: Four primary care cohorts of UK children (pregnancy, 1 and 2 years prior to pregnancy, and siblings) born between 1 January 1990 and 31 December 2017 were constructed. NDD included autism/autism spectrum disorder, attention-deficit/hyperactivity disorder, intellectual disability, cerebral palsy, and epilepsy. Maternal exposures included depression/anxiety and/or infection. Maternal (age, smoking status, comorbidities, body mass index, NDD); child (gender, ethnicity, birth year); and area-level (region and level of deprivation) confounders were captured. The NDD incidence rate among (1) children exposed during or outside of pregnancy and (2) siblings discordant for exposure in pregnancy was compared using Cox-regression models, unadjusted and adjusted for confounders. RESULTS: The analysis included 410 461 children of 297 426 mothers and 2 793 018 person-years of follow-up with 8900 NDD cases (incidence rate = 3.2/1000 person years). After adjustments, depression and anxiety consistently associated with NDD (pregnancy-adjusted HR = 1.58, 95% CI 1.46-1.72; 1-year adj. HR = 1.49, 95% CI 1.39-1.60; 2-year adj. HR = 1.62, 95% CI 1.50-1.74); and to a lesser extent, of infection (pregnancy adj. HR = 1.16, 95% CI 1.10-1.22; 1-year adj. HR = 1.20, 95% CI 1.14-1.27; 2-year adj. HR = 1.19, 95% CI 1.12-1.25). NDD risk did not differ among siblings discordant for pregnancy exposure to mental illness HR = 0.97, 95% CI 0.77-1.21 or infection HR = 0.99, 95% CI 0.90-1.08. CONCLUSIONS: Maternal risk appears to be unspecific to pregnancy: our study provided no evidence of a specific, and therefore causal, link between in-utero exposure to infection, common mental illness, and later development of NDD.

Trends in antipsychotic prescribing to children and adolescents in England: cohort study using 2000-19 primary care data.

BACKGROUND: The prescription of antipsychotics to children and adolescents has been increasing worldwide. We described up-to-date trends in antipsychotic prescribing and identified likely indications in a contemporary English cohort. METHODS: We used a large primary care database, the Clinical Practice Research Datalink (CPRD) Aurum database, and we included all children and adolescents aged 3-18 years in the database and registered in England between Jan 1, 2000, and Dec 31, 2019, excluding those whose gender was recorded as indeterminate. Participants were followed up until the earliest of Dec 31, 2019, June 30 of the year they turned 18 years, their death, when they transferred from the primary care practice, or when the practice left the database. Data were not collected on ethnicity. We recorded antipsychotic prescriptions using the date a prescription was issued. As CPRD prescriptions are not linked to indications, we developed an algorithm to ascertain the most likely indication associated with participants' first antipsychotic prescription using clinical codes. We reported prescribing trends as annual period prevalence and the rate of first antipsychotic prescription, and we used joinpoint regression analysis to identify changes in the outcome trend. We stratified prevalence estimates by age group, gender, and Index of Multiple Deprivation quintiles, we reported frequencies of likely indications associated with incident prescriptions, and we explored clinical preference for typical versus atypical antipsychotics within deprivation quintiles. FINDINGS: Between Jan 1, 2000, and Dec 31, 2019, we included 7 216 791 children and adolescents, of whom 3 480 730 (48·2%) were girls and 3 736 061 (51·8%) were boys, with a mean age at the start of follow-up of 7·3 years (SD 4·9; range 3-18). Median follow-up was 4·1 years (IQR 1·5-8·5). 19 496 (0·3%) individuals received 243 529 antipsychotic prescriptions over follow-up, including 225 710 (92·7%) atypical and 17 819 (7·3%) typical antipsychotic prescriptions. The annual period prevalence of antipsychotic prescriptions rose from 0·057% (95% CI 0·052-0·063%) in 2000 to 0·105% (0·100-0·111%) in 2019. From joinpoint analyses, the period prevalence of all antipsychotic prescriptions increased by an average of 3·3% per year (2·2-4·9%) and the rate of first prescriptions increased by 2·2% per year (1·7-2·7%). The most likely indications of the first identified antipsychotic prescriptions were for autism spectrum disorder (2477 [12·7%]), non-affective psychosis (1669 [8·6%]), anxiety disorders (1466 [7·5%]), ADHD (1391 [7·1%]), depression (1256 [6·4%]), and conduct disorders (1181 [6·1%]). INTERPRETATION: The observed increase in antipsychotic prescriptions over 20 years results from the accumulation of repeated prescriptions to the same individuals combined with an increase in new prescriptions. These findings highlight the need for continued monitoring of trends in antipsychotic use and, although this was not examined in this paper, the findings highlights the need for better information about long-term antipsychotic safety. FUNDING: None.

Young women are the most vulnerable to postpartum mental illness: A retrospective cohort study in UK primary care.

BACKGROUND: Whilst childbirth is a leading cause of mental illness in women, how it affects women at different ages is unknown. AIMS: We examine whether the effect of childbirth on mental illness varies at different ages. METHODS: From 2,657,751 women identified from a UK population-based primary care database, 355,864 postpartum periods, with no history of mental illness, were matched on year of birth and general practice to 1,420,350 non-postpartum periods. Cox regression models were used to compare incident mental illness between postpartum and non-postpartum periods. These were measured using hazard ratios (HR) and hazard ratios adjusted for parity and prior pregnancy loss (aHR). RESULTS: Strong evidence is presented that the effect of livebirth on mental illness was age-dependant for depression (p <0·001), anxiety (p 0·048) and affective psychosis (p 0·031). In 15-19 year olds, depression was over seven times more likely to occur in postpartum periods than non-postpartum periods (aHR 7·09, 95%CI 6·65-7·56); twice the effect in women overall (aHR 3·24 95%CI 3·18-3·29). 15-19 year olds were 50% more likely to develop anxiety in postpartum periods than non-postpartum periods (aHR 1·52, 95%CI 1·38-1·67), with little effect in women overall (aHR 1·07 95%CI 1·04-1·10). Livebirth had over twice the effect on affective psychosis in women aged 15-24 (15-19 year olds: aHR 2·71 95%CI 1·23-5·97; 20-24 year olds: aHR 2·79 95%CI 1·68-4·63) compared to women overall (aHR 1·66, 95%CI 1·29-2·14). CONCLUSIONS: Younger women are far more vulnerable to the effect of childbirth on their mental health, particularly depression and anxiety.

Prevalence of maternal mental illness among children and adolescents in the UK between 2005 and 2017: a national retrospective cohort analysis.

BACKGROUND: Little information exists about the prevalence of children exposed to maternal mental illness. We aimed to estimate the prevalence of children and adolescents exposed to maternal mental illness in the UK between 2005 and 2017 using primary care data. METHODS: In this national retrospective cohort study, we included children aged 0-16 years born between Jan 1, 1991, and Dec 31, 2015, who were linked to their mothers and registered on the primary care Clinical Practice Research Datalink (CPRD) between 2005 and 2017. We extracted data on diagnosis, symptoms, and therapy from the CRPD to define the following maternal mental illnesses: depression, anxiety, non-affective psychosis, affective psychosis, eating disorders, personality disorders, alcohol misuse disorder, and substance misuse disorder. We also extracted data on socioeconomic status from the Index of Multiple Deprivation 2010 and data on ethnicity from the Hospital Episode Statistics dataset. The main outcome was prevalence of maternal mental illness. Prevalence was calculated for each 2-year period of childhood (from age 0-<2 to 14-<16 years) using marginal predictions from a logistic regression model. We used survival analysis to estimate the incidence and cumulative risk of children experiencing maternal mental illness by age 16 years. FINDINGS: We identified 783 710 children registered in the UK CPRD mother-baby link database, and included 547 747 children (381 685 mothers) in our analysis. Overall prevalence of maternal mental illness was 23·2% (95% CI 23·1-23·4), which increased during childhood (21·9%, 21·7-22·1 among the 0-<2 year age group vs 27·3%, 26·8-27·8 among the 14-<16 year age group). Depression and anxiety were the most prevalent maternal mental illnesses. The proportion of children exposed to maternal mental illness increased from 22·2% (21·9-22·4) between 2005 and 2007 to 25·1% (24·8-25·5) between 2015 and 2017. Geographically, the highest prevalence of maternal mental illness was observed in Northern Ireland (29·8%, 29·0-30·5). In England, prevalence of maternal mental illness was highest among children in the most deprived areas (28·3%, 27·8-28·8). The incidence of maternal mental illness was highest between 0-3 months (26·7 per 100 person years, 26·4-27·1). By age 16 years, the cumulative risk of maternal mental illness was 53·1% (52·8-53·3). INTERPRETATION: One in four children aged 0-16 years are exposed to maternal mental illness and the prevalence of diagnosed and treated maternal mental illness is increasing. Policy makers and commissioners should consider this information and channel resources to target individuals in greatest need. FUNDING: The European Research Council and the National Institute for Health Research.