The effect of maternal prenatal tobacco smoking on offspring academic achievement: A systematic review and meta-analysis.

BACKGROUND: Previous epidemiological studies examining the prospective association between maternal prenatal tobacco smoking and offspring academic achievement have reported conflicting results. Therefore, this systematic review and meta-analysis was conducted to examine the magnitude and consistency of association reported by those studies. METHODS: This systematic review and meta-analysis was guided by the PRISMA protocol. Relevant epidemiological studies on the topic were extracted from four main databases (PubMed/Medline, Embase, PsycINFO, and Scopus). The Newcastle-Ottawa Scale (NOS) was used to appraise the methodological quality of the included studies. We conducted a narrative assessment of the studies that did not report effect estimates. Inverse variance-weighted random effect meta-analysis was used to combine studies reporting effect sizes to estimate pooled adjusted odds ratio with 95% confidence intervals (95% CI). The review was prospectively registered in PROSPERO (CRD42022350901). RESULTS: Nineteen observational studies, published between 1973 and 2021 with a total of 1.25 million study participants were included in the final review. Of these, fifteen studies (79 %) reported reduced academic achievement in offspring exposed to maternal prenatal tobacco smoking. The eight primary studies (sample size = 723,877) included in the meta-analysis together suggested a 49 % higher risk of reduced academic achievement in offspring exposed to maternal prenatal tobacco smoking when compared to non-exposed offspring (Pooled odds ratio = 1.49, 95 % CI:1.17-1.91). CONCLUSION: Our review found a positive association between maternal prenatal tobacco smoking and offspring reduced academic achievement. However, variation in the adjustment of potential confounders and significant heterogeneity across included studies limited more conclusive inference. Mechanistic studies to identify causal pathways and specific academic impacts are needed to inform targeted developmental programs to assist child learning and academic performance.

Development and validation of a machine learning-based tool to predict autism among children.

Autism is a lifelong condition for which intervention must occur as early as possible to improve social functioning. Thus, there is great interest in improving our ability to diagnose autism as early as possible. We take a novel approach to this challenge by combining machine learning with maternal and infant health administrative data to construct a prediction model capable of predicting autism disorder (defined as ICD10 84.0) in the general population. The sample included all mother-offspring pairs from the Australian state of New South Wales (NSW) between January 2003 and December 2005 (n = 262,650 offspring), linked across three health administrative data sets including the NSW perinatal data collection (PDC); the NSW admitted patient data collection (APDC) and the NSW mental health ambulatory data collection (MHADC). Our most successful model was able to predict autism disorder with an area under the receiver operating curve of 0.73, with the strongest risk factors for diagnoses found to include offspring gender, maternal age at birth, delivery analgesia, maternal prenatal tobacco disorders, and low 5-min APGAR score. Our findings indicate that the combination of machine learning and routinely collected admin data, with further refinement and increased accuracy than achieved by us, may play a role in the early detection of autism disorders.

Average treatment effect of maternal prenatal tobacco smoking on offspring developmental vulnerability in early childhood.

BACKGROUND: Early childhood developmental vulnerability has been closely related to the predictors of relatively good health, social and educational outcomes later in adulthood. However, the impacts of prenatal tobacco exposure on childhood developmental vulnerability have been rarely examined. Further, a few of the studies that have investigated maternal prenatal tobacco smoking and child developmental vulnerability have reported mixed results and there are currently no published estimates derived from causal epidemiological methods. METHODS: We conducted a retrospective population-based cohort study on the association between maternal prenatal tobacco smoking and developmental vulnerability in children born in Western Australia (WA). De-identified individual-level maternal, infant and birth records were obtained from the Midwives Notification System (MNS), a statutory record of all births in WA. WA register for Developmental Anomalies (WARDA) were also obtained from the WA Data Linkage. Records on early childhood developmental vulnerability at the median age of 5 years were obtained from the Australian Early Development Census (AEDC). We used a doubly robust estimator to estimate the causal effects. RESULTS: Complete data were available for 64,558 mothers-children's pairs. Approximately 16% of children were exposed to maternal prenatal tobacco smoking. Children exposed to maternal prenatal tobacco smoking were more likely to be classified as developmentally vulnerable/at-risk on the physical health and wellbeing (RR = 1.40, 95%CI:1.36-1.45), social competence (RR = 1.42, 95%CI: 1.38-1.47), emotional maturity (RR = 1.34, 95%CI:1.30-1.39), language and cognitive skills (RR = 1.50, 95%CI:1.45-1.54), and communication skills and general knowledge (RR = 1.37, 95%CI:1.33-1.42) domains. CONCLUSION: Maternal prenatal exposure to tobacco may influence early childhood developmental vulnerability. Early intervention to quit tobacco smoking before becoming pregnant could potentially reduce later childhood developmental vulnerability on multiple domains.

Academic performance in adolescent offspring of mothers with prenatal and perinatal psychiatric hospitalizations: A register-based, data linkage, cohort study.

BACKGROUND: This is the first study to investigate the longitudinal association between prenatal and perinatal psychiatric hospitalizations and academic achievements in adolescent offspring. METHODS: We conducted an administrative health data-based cohort study of 168, 528 mother-offspring pairs using linked data obtained from health and educational registries in New South Wales, Australia. Prenatal and perinatal maternal psychiatric diagnosis was measured by using ICD-10. The National Assessment Program for Literacy and Numeracy (NAPLAN) was used to assess the educational performance of the offspring. Logistic regression model was used to explore the association. Multivariate models were adjusted for maternal sociodemographic characteristics such as age at birth, marital status, educational status, and occupational status, maternal diabetes and chronic hypertension, maternal smoking during pregnancy, birth weight, and language spoken at home. RESULTS: The findings show that after adjusting for important covariates adolescent offspring of mothers with prenatal and perinatal psychiatric hospitalizations were more likely to perform below the national minimum standard in all domains of academic performance at age 14 years, when compared with the offspring of mothers without such hospitalizations, with the highest odds for numeracy (OR = 2.88; 95% CI: 2.50-3.31) followed by reading (OR = 2.08; 95% CI: 1.81-2.38), spelling (OR = 1.74; 95% CI: 1.51-2.01), and writing (OR = 1.56; 95% CI: 1.34-1.80). There was significant gender interaction such that males were more likely to experience lower rates of academic performance than females in all academic domains. Lower academic achievements were observed among offspring of mothers with all major groupings of psychiatric disorders, with a higher risk for severe psychiatric disorders followed by mental disorders due to substance use or medical conditions. CONCLUSION: In sum, maternal prenatal and perinatal psychiatric hospitalizations are associated with lower academic achievements in adolescent offspring, with a stronger effect on the academic performance of male offspring. Early intervention strategies that aim to enhance educational performance in the exposed offspring are needed.

Exploring the utility of synthetic data to extract more value from sensitive health data assets: A focused example in perinatal epidemiology.

BACKGROUND: Privacy, access and security concerns can hinder the availability of health data for research. The use of synthesised data in place of de-identified electronic health records (EHRs) presents an opportunity to conduct research while minimising privacy concerns. OBJECTIVES: To examine whether synthesised data can replicate two prenatal epidemiological associations: between prenatal smoking and lower birthweight, and between prenatal mood disorders and lower birthweight, using data synthesised from de-identified health administrative data collections. METHODS: We generated two synthetic datasets, using parametric and non-parametric data generating methods, and examined the synthetic data for evidence of privacy concerns. Next, univariable and multivariable logistic regression was utilised to estimate the associations in both synthetic datasets, with results then compared to the real data. RESULTS: Both synthesised datasets performed well in identifying the reduction in birthweight associated with prenatal smoking, while the non-parametric data underestimated the reduction in birthweight associated with prenatal mood disorders. Improbable relationships between some variables were identified in the parametric synthesised data, however, these can be addressed with simple rules during data synthesis. No duplicate rows (i.e., exact copies of de-identified data) were found in the parametric data, while only 0.6% of the rows in the non-parametric data were duplicated. CONCLUSIONS: Both synthesised datasets performed well in replicating the statistical properties of the original data while addressing privacy issues. Data synthesis methods provide an opportunity for researchers to utilise health data while managing privacy and security concerns.

Prenatal tobacco and alcohol exposures and the risk of anxiety symptoms in young adulthood: A population-based cohort study.

BACKGROUND: Epidemiological studies have linked prenatal tobacco and alcohol exposures to internalizing behaviours in children and adolescents with inconsistent findings. Dearth of epidemiological studies have investigated the associations with the risk of experiencing symptoms of anxiety in young adulthood. METHODS: Study participants (N = 1190) were from the Raine Study, a population-based prospective birth cohort based in Perth, Western Australia. Data on prenatal tobacco and alcohol exposures were available for the first and third trimesters of pregnancy. Experiencing symptoms of anxiety in young adulthood at age 20 years was measured by a short form of the Depression Anxiety Stress Scale (DASS 21). Relative risk (RR) of experiencing symptoms of anxiety in young adulthood for prenatal tobacco and alcohol exposures were estimated with log binomial regression. RESULTS: After adjusting for potential confounders, we observed increased risks of experiencing symptoms of anxiety in young adults exposed to prenatal tobacco in the first trimester [RR = 1.52, 95% CI: 1.12-2.06, p-value < 0.01] and third trimester [RR = 1.53, 95% CI: 1.10-2.13, p-value  = 0.02]. However, we found insufficient statistical evidence for an association between first trimester [RR = 1.01, 95% CI: 0.76-1.22, p-value = 0.90] and third trimester [RR = 1.03, 95% CI: 0.80-1.34, p-value = 0.91] prenatal exposure to alcohol and the risk of experiencing symptoms of anxiety in young adults. There was a dose response association between prenatal tobacco exposure and increasing anxiety symptoms in offspring. CONCLUSION: The findings of this study suggest that an association between prenatal tobacco exposure and risk of anxiety symptoms remains apparent into young adulthood.

Prenatal alcohol and tobacco exposures and the risk of cannabis use in offspring: Findings from a population-based cohort study.

BACKGROUND: There is a paucity of prospective longitudinal studies examining the associations between maternal use of alcohol and tobacco during pregnancy and the risk of cannabis use in offspring. The aim of this study was to examine the association between prenatal alcohol and tobacco exposures and offspring cannabis use. METHODS: Data were from the Raine Study, a longitudinal prospective birth cohort based in Western Australia. Cannabis use at 17 years of age was measured with a self-reported questionnaire developed to capture risky behaviors in adolescents. Associations between prenatal alcohol and tobacco exposures and the risk of cannabis use in offspring were examined using log-binomial regression models, computing relative risk (RR). We also computed the E-values (E) to estimate the extent of unmeasured confounding. RESULTS: After adjusting for potential confounders, we observed increased risks of cannabis use in offspring exposed to first trimester prenatal alcohol use (RR = 1.38, 95% CI: 1.09-1.75; E = 2.10, CI:1.40) and tobacco use (RR = 1.42, 95% CI: 1.08-1.86; E = 2.19, CI:1.37) as well as third trimester prenatal alcohol use (RR = 1.39, 95% CI: 1.09-1.79; E = 2.13, CI:1.40) and tobacco use (RR = 1.39, 95% CI: 1.09-1.79; E = 2.21, CI:1.34]. We also noted dose-response associations in which risk estimates in offspring increased with the level of exposures to prenatal alcohol and tobacco use. CONCLUSION: These findings provide epidemiological evidence for effects of prenatal alcohol and tobacco exposures on offspring cannabis use. Although these results should be confirmed by other studies, the present study adds to the mounting evidence suggesting that women should be encouraged to abstain from alcohol and tobacco during pregnancy.

Prenatal Tobacco Exposure and the Risk of Tobacco Smoking and Dependence in Offspring: a Systematic Review and Meta-Analysis.

BACKGROUND: There is some compelling, though not comprehensive, epidemiological evidence which suggests an association between prenatal tobacco exposure and tobacco smoking/dependence in offspring. We conducted a systematic review and meta-analysis to identify the magnitude and consistency of associations reported between prenatal tobacco exposure and subsequent tobacco smoking/dependence in offspring. METHODS: Using the PRISMA guideline, we systematically searched PubMed, SCOPUS, EMBASE and Psych-INFO to identify relevant studies. The methodological quality of all identified studies was checked by the Newcastle-Ottawa Scale. Inverse variance weighted random effects meta-analysis was used to estimate pooled risk ratio (RR) and 95 % confidence intervals (CI). We stratified outcomes by tobacco smoking initiation, lifetime tobacco smoking, current tobacco smoking and tobacco dependence. We further performed subgroup and leave-one-out sensitivity analyses. The protocol of this review was registered in the PROSPERO. RESULTS: Twenty-six cohort and one case-control study were included in the final meta-analysis. We found elevated pooled risks of tobacco smoking initiation [RR = 2.08, (95 % CI: 1.18-3.68)], ever tobacco smoking [RR = 1.21, (95 % CI: 1.05-1.38)], current tobacco smoking [RR = 1.70, (95 % CI: 1.48-1.95)] and tobacco dependence [RR = 1.50, (95 % CI: 1.31-1.73)] in offspring exposed to maternal prenatal tobacco use compared to non-exposed. We also noted higher risk estimate of current tobacco smoking in offspring exposed to heavy prenatal tobacco smoking [RR = 1.68, (95 % CI: 1.26-2.23)] when compared to prenatal exposure to lighter tobacco use [RR = 1.39, (95 % CI: 1.09-1.78)]. There was no association observed between paternal smoking during pregnancy and tobacco smoking in offspring. CONCLUSION: Offspring exposed to maternal prenatal tobacco smoking are at an increased risk of tobacco smoking/dependence, indicating that tobacco smoking cessation during gestation may be imperative to reduce these risks in offspring.

Maternal smoking during pregnancy and poor academic performance in adolescent offspring: A registry data-based cohort study.

BACKGROUND: Previous studies have suggested associations between maternal smoking during pregnancy (MSDP) and a range of adverse outcomes in offspring. However, evidence reporting adverse effects on poor academic performance in adolescence is scant. METHODS: This register-based cohort study used linked data obtained from New South Wales (NSW) educational and health registries in Australia. MSDP was assessed using self-reports of smoking during pregnancy. Offspring's educational performance was assessed using the National Assessment Program for Literacy and numeracy (NAPLAN), when students were in grade 9 and approximately aged 14 years. We used multivariable logistic regression models to explore associations. RESULTS: Adolescent offspring exposed to MSDP were at an increased risk of substandard academic performance in all domains, with the highest odds for spelling [OR, 3.12 (95%CI 2.98-3.26)] followed by writing [OR, 2.97 (95%CI 2.84-3.11)], reading [OR, 2.49 (95%CI 2.37-2.62)], and numeracy [OR, 2.43 (95%CI 2.30-2.58)]. In our sex-stratified analysis, MSDP displayed stronger effects on the academic performance of female offspring in all domains. CONCLUSIONS: Our findings showed that MSDP was associated with an increased risk of reduced academic performance in adolescent offspring. The different effects of MSDP on the academic performance of male and female offspring is a new finding, which needs further investigation.

Prenatal tobacco exposure and the risk of conduct disorder symptoms in offspring at the age of 14 years: Findings from the Raine Study.

BACKGROUND: Emerging epidemiological evidence suggests that offspring born to mothers who smoked tobacco during pregnancy may have elevated risk of developing conduct disorder (CD) symptoms. We examined associations between maternal and paternal tobacco smoking during pregnancy and CD symptoms in offspring at the age of 14 years. METHODS: We obtained data from the Raine Study, a multi-generational cohort study based in Western Australia. DSM-oriented scale of the Child Behavior Checklist (CBCL) was used to measure CD symptoms in offspring. Negative binomial regression was used to estimate the rate ratio (risks) (RR) of CD symptoms in offspring. We also produced the E-values to investigate the extent of unmeasured confounding. Paternal smoking during pregnancy was used as a proxy for environmental tobacco smoke exposure. RESULTS: Complete data were available for 1747 mother-offspring and 1711 father-offspring pairs. After adjusting for potential confounders, we found elevated risks (rates) of CD symptoms in offspring born to mothers smoking tobacco during the first trimester [RR 1.52 (95 % CI: 1.24-1.87)], third trimester [RR 1.36 (95 % CI: 1.09-1.69)] and during both trimesters of pregnancy [RR 1.50 (95 % CI: 1.19-1.90)]. The rates of CD symptoms in offspring increased with the level of exposure to maternal smoking during pregnancy. However, we noted insufficient statistical evidence for an association between paternal smoking during pregnancy and CD symptoms in offspring. CONCLUSION: The associations we found for maternal but not paternal smoking may suggest a biological mechanism for intrauterine tobacco exposure on the risk of CD symptoms in offspring. Early interventions assisting pregnant mothers to quit tobacco smoking, or avoid smoking initiation, have potential to contribute health benefits to both mothers and their offspring.

Prenatal exposure to maternal, but not paternal, tobacco smoking is associated with smoking in adolescence.

BACKGROUND: Mounting epidemiological evidence suggests an association between prenatal tobacco exposure and an increased risk of tobacco smoking in offspring. However, it is uncertain whether the association is due to the intrauterine or shared environmental exposures. METHODS: Study participants were from the Raine Study, a prospective birth cohort study based in Perth, Western Australia (N = 2730). Tobacco smoking in adolescents, at age 17 years, was measured using a self-reported questionnaire. Log-binomial regression was used to estimate the relative risks (RRs) of tobacco smoking in offspring exposed to maternal prenatal tobacco use during the first and third trimesters of pregnancy. We have also calculated the E-values to investigate the potential effect of unmeasured confounding. Paternal smoking during pregnancy was used as a negative control for comparison. RESULTS: A total of 1210 mothers-offspring pairs were included in the final analysis. After controlling for potential confounders, we found increased risks of tobacco smoking in offspring exposed to maternal prenatal tobacco use during the first trimester [RR 1.50 (95% CI: 1.13-1.97)] (E-value for point estimate = 2.37) and during both trimesters of pregnancy [RR 1.41 (95% CI: 1.03-1.89)] (E-value for point estimate = 2.17). However, we found insufficient statistical evidence for an association between paternal smoking during pregnancy and risk of tobacco smoking in offspring [RR 1.18 (95% CI: 0.84-1.67)]. CONCLUSION: Maternal prenatal tobacco exposure was associated with an increased risk of tobacco smoking in offspring at the age of 17 years. Tobacco smoking cessation at the early stages of gestation may reduce the risk of tobacco smoking in the next generation.

Proposing a new approach to measuring birth size asymmetry.

BACKGROUND: Existing methods of measuring birth size asymmetry based on ratios of growth parameters are clinically useful but simplistic, and as such may have limited usefulness in studies of aetiology. OBJECTIVES: We aimed to develop a novel method of measuring asymmetric fetal growth at birth and demonstrate its utility in characterising the perturbed growth associated with a number of prenatal exposures and neonatal outcomes. METHODS: Data were drawn from the Queensland (QLD) Perinatal Data Collection, which included all livebirths in the Australian state of QLD between July 2010 and December 2015, with analyses restricted to babies born between 32 and 42 weeks of gestation (n = 280 084). Novel measures of asymmetric birthweight, length, and head circumference were developed using a weighted average, representing "how far" an individual's given birth size measure deviated from the sample average and their other birth size measures. Associations among prenatal exposures and neonatal outcomes with the new asymmetry measures and traditional ratio measures (ie ponderal index, brain-to-body weight ratio, and birth length divided by head circumference) were then compared using log-binomial and multinomial regressions. RESULTS: The new asymmetry measures clearly indicated that prenatal smoking was linked to a disproportionate decrease in all birth size measures and that low birthweight asymmetry and low birth head circumference asymmetry were specifically associated with neonatal respiratory distress and chromosomal abnormalities, respectively. When these same associations were tested using the traditional ratios, the estimates were weak, imprecise, and non-specific. CONCLUSIONS: We developed a new approach to measuring fetal growth asymmetry which provides complimentary insights against the existing ratios approach. Associations with the new asymmetry measures were more precise and easier to interpret than the associations obtained using the ratios, and may better reflect the underlying pathological processes, providing an advantage when investigating the aetiologies of perturbed fetal growth.

Association between antenatal screening for depressive symptoms and postpartum psychiatric admissions.

Antenatal depression is the strongest predictor for postpartum depression including psychiatric admission. Universal screening for depressive symptoms during pregnancy may increase the detection of clinical depression and reduce consequent morbidity. We therefore hypothesised that antenatal screening for depressive symptoms could reduce the risk of postpartum psychiatric admissions. We explored the association between antenatal depression screening and postpartum psychiatric admissions using cross-sectional retrospective analysis of state-wide population-based health services administrative data. The analysis included all pregnant women who gave birth to a singleton in Queensland in the second half of 2015 and had information in variables of interest (28,255 women; 95.6% of 29,543 women who gave birth to a singleton during the study period). Women who did not complete antenatal depression screening had increased odds of being admitted to hospital for psychiatric disorders during the first three months after birth (aOR, 2.57; 95% CI, 1.69-3.92), which extended to six months postpartum (aOR, 1.74; 95% CI, 1.10-2.76). We found similar effects for specific psychiatric disorder groups such as mood disorders; schizophrenia, schizotypal and delusional disorders; and mental disorders associated with the puerperium (aOR, 2.65; 95% CI, 1.55-4.54) and mood disorders and puerperal mental disorders (aOR, 3.00; 95% CI, 1.70-5.30). Completion of antenatal depression screening appears to be associated with a decreased risk of psychiatric admission in the first postnatal months. This finding suggests that screening, and associated follow-up interventions, might decrease the severity of depressive symptoms during the perinatal period.

Prenatal alcohol and tobacco use and the risk of depression in offspring at age of 17 years: findings from the Raine Study.

BACKGROUND: Prenatal alcohol and tobacco exposures have been associated with adverse mental health consequences in offspring. The objective of this study was to test the associations between maternal prenatal alcohol and tobacco exposures and depressive symptoms in the offspring, adjusting for a wide range of potential confounders. METHODS: We used data from 1168 mother-offspring pairs from the Raine Study based in Perth, Western Australia. Depressive symptoms at age 17 years were measured using the Beck Depression Inventory for Youth (BDI-Y). Associations between prenatal alcohol and tobacco use and the risk of depressive symptoms in offspring were estimated by risk ratios (RR) derived with multivariable log-binomial regression. RESULTS: Among offspring who were assessed for depressive symptoms, 5% were born to mothers who consumed six or more standard drinks of alcohol per week during pregnancy and 20% were exposed to prenatal tobacco. After adjustment for confounders, depressive symptoms at the age of 17 years remained associated with maternal alcohol use of six or more standard drinks per week [RR 1.59 (95% CI: 1.11-2.26)] and any tobacco use [RR 1.36 (95% CI: 1.05-1.79)] during the first trimester of pregnancy. CONCLUSION: Offspring exposed to prenatal alcohol and tobacco use had greater risks of depressive symptoms compared with unexposed offspring, suggesting early screening and prevention of these exposures could possibly reduce depressive symptoms in offspring.

Prenatal tobacco use and the risk of mood disorders in offspring: a systematic review and meta-analysis.

PURPOSE: It is plausible that offspring born to mothers using tobacco during pregnancy may have increased risk of mood disorders (depression and bipolar disorders); however, mixed results have been reported. We conducted a systematic review and meta-analysis to investigate the magnitude and consistency of associations reported between prenatal tobacco use and mood disorders in offspring. METHODS: We systematically searched EMBASE, SCOPUS, PubMed and Psych-INFO for studies on mood disorders and prenatal tobacco use. Methodological quality of studies was assessed with the revised Newcastle-Ottawa Scale. We estimated pooled relative risk (RR) with inverse variance weighted random-effects meta-analysis. We performed leave-one-out analyses, and stratified analyses by a subgroup (depression and bipolar disorder). Potential publication bias was assessed by inspection of the funnel plot and Egger's test for regression asymmetry. This study protocol was prospectively registered in PROSPERO (CRD42017060037). RESULTS: Eight cohort and two case-control studies were included in the final meta-analysis. We found an increased pooled relative risk of mood disorders in offspring exposed to maternal prenatal tobacco use RRs 1.43 (95% CI 1.27-1.60) compared to no prenatal tobacco use. Similarly, the pooled relative risks of bipolar and depressive disorders in offspring were 1.44, (95% CI 1.15-1.80) and 1.44, (95% CI 1.21-1.71), respectively. Moreover, the pooled estimated risk of mood disorders was not significantly attenuated in the studies that reported sibling comparison results [RR = 1.21 (95% CI 1.04-1.41)]. CONCLUSION: Taken together, there was strong evidence for a small (RR < 2) association between prenatal tobacco use and mood disorders in offspring.

Screening for perinatal depression and predictors of underscreening: findings of the Born in Queensland study.

OBJECTIVES: To investigate screening with the Edinburgh Postnatal Depression Scale (EPDS) as part of Queensland prenatal care services, as well as maternal and socio-demographic factors associated with not being screened. DESIGN, SETTING: Cross-sectional retrospective analysis of data from the Queensland population-based Perinatal Data Collection for July 2015 - December 2015. PARTICIPANTS: All women giving birth in Queensland during the second half of 2015. MAIN OUTCOME MEASURES: Screening with the EPDS, with the values "yes" (health professional recorded an EPDS score), "no" (health professional reported it was not performed), and "not stated". RESULTS: Of 30 468 women who gave birth in Queensland, 21 735 (71.3%) completed the EPDS during pregnancy; 18 942 pregnant women were enrolled as public patients (91.0%) and 2762 as private patients (28.8%). After adjusting for other socio-demographic factors, screening was less likely for women who were aged 36 years or more (v 25 years or younger: adjusted odds ratio [OR], 0.69; 95% CI, 0.60-0.79), enrolled as private patients (aOR, 0.05; 95% CI, 0.05-0.06), born overseas (aOR, 0.75; 95% CI, 0.68-0.82), Indigenous Australians (aOR, 0.47; 95% CI, 0.39-0.56), single or separated (aOR, 0.83; 95% CI, 0.73-0.94), or of higher socio-economic status. CONCLUSIONS: Four years after clinical guidelines recommending universal screening with the EPDS were published, screening rates for private and public health care patients differed markedly. Our results may inform future comparisons and analyses of the impact on screening of recent changes to Medicare definitions intended to increase that of women in private health care.

Prescription Opioid Fatalities: Examining Why the Healer Could be the Culprit.

Prescription opioid use has increased rapidly in developed countries, as have fatalities and other related adverse events. This review examines the intrinsic characteristics of opioids, including their mechanisms of action and pharmacokinetic and pharmacodynamic properties, to determine how the use of a regonised pharmacological remedy for a medically confirmed ailment could result in an accidental fatality. Opioids trigger biological processes that inhibit their own therapeutic effect. Prolonged use of opioids can result in activation of pronociceptive systems, leading to opioid-induced hyperalgesia and tolerance, while opioid metabolites can antagonise the antinociceptive action of the parent drug, also leading to opioid-induced hyperalgesia and tolerance. Pain stimulates respiration and counteracts the respiratory depression effect of opioids. Analgesia from opioids leads to loss of this protective mechanism, leading to increased risk of death due to respiratory failure. Increased patient counseling during opioid prescribing and dispensing, and limiting prescription to short-term use in non-malignant pain, may decrease the adverse effects of opioids. The vast majority of patients who unintentionally experience serious adverse events from pharmaceutical opioids do not start out as drug seekers. Even opioid use within prescribing guidelines can place some patients at risk of death and may prevent patients from seeking help for prescription opioid dependence.

Prescribed Dose of Opioids and Overdose: A Systematic Review and Meta-Analysis of Unintentional Prescription Opioid Overdose.

BACKGROUND: The rate of an unintentional drug overdose involving prescription opioids continues to rise. An understanding of the threshold dose and dose(s) associated with unintentional prescription opioid overdose will help to mitigate this epidemic. OBJECTIVE: The objective of this systematic review is to systematically synthesise and meta-analyse studies on doses of prescription opioids and ascertain the doses of opioids that are associated with increased risk of severe opioid poisoning or mortality. DATA SOURCES: A search of PubMed, EMBASE, CINAHL and Web of Science from inception to 16 January 2017 was conducted using search strategies and the MeSH (Medical Subject Headings) terms for studies of adult patients using prescription opioids who experienced an accidental overdose. STUDY SELECTION: Of the 1332 studies identified, 117 were selected for full article review. Ten met the inclusion criteria for qualitative analysis, but only seven studies were meta-analysed. The included studies were in English, and participants met predetermined International Classification of Diseases (ICD) codes. Studies were excluded if they included only paediatric participants or the participants met the ICD code for intentional self-harm. DATA EXTRACTION AND SYNTHESIS: Two researchers elaborated and validated a data extraction form. Data were then independently extracted by both reviewers as per this form. We assessed study quality using the Newcastle-Ottawa Scale (NOS) for non-randomised studies in meta-analyses. We performed a meta-regression using a random-effect model and summarised the results using relative risk (RR) and 95% confidence intervals (CIs). The threshold dose for an unintentional overdose is 20 morphine milligram equivalents (MME)/day. There were higher risks with larger doses: (1) ≤ 20 versus ≥ 21 MME/day: RR 2.81, 95% CI 1.09-7.22, p < 0.001; (2) ≤ 50 versus > 50 MME/day: RR 3.87, 95% CI 2.36-6.33, p < 0.001; (3) ≤ 100 versus > 100 MME/day: RR 4.28, 95% CI 2.61-7.1, p < 0.001; and (4) ≤ 50 versus > 50-100 MME/day: RR 3.09, 95% CI 1.84-5.18, p < 0.001). Heterogeneity was explained by the type of overdose event, inpatient or outpatient status, and length of observation. Type of pain (cancer or non-cancer pain) had no impact on heterogeneity. LIMITATIONS: The definition of exposure in studies included in the meta-analysis was heterogeneous. Some studies defined exposure as the filling of a prescription while others defined exposure as the prescription of an opioid to the patient, and all studies assumed that patients took the prescribed opioid. Medications that may contribute to overdose, such as benzodiazepines and other drugs, were not considered. CONCLUSIONS: A significantly increased risk of inadvertent prescription opioid overdose was found with 20-50 MME/day, with fatality more likely with opioid doses above 50 MME/day, although extensive heterogeneity was found with the dose comparisons. Clinicians should inform patients of this risk and monitor them closely. PROTOCOL REGISTRATION: This protocol was registered with PROSPERO 2017: CRD42017058426.

Misuse of pharmaceuticals by regular psychostimulant users is linked to mental health problems / El uso indebido de psicofármacos entre los usuarios regulares de psicoestimulantes está relacionado con problemas de salud mental

Abstract: Introduction: Misuse of pharmaceutical drugs, particularly by young people, is an issue of rising concern. Poly-substance use is common among regular psychostimulant users (RPU), and mental health problems are associated with pharmaceutical misuse, but RPU do not generally acknowledge their use as problematic. Objective: To examine links between mental health and misuse of non-prescription pharmaceuticals in a group of regular users of illicit psychostimulants. Method: Face to face structured interviews were conducted in April 2015 with 763 regular users of illicit psychostimulants as part of the Annual Ecstasy and Related Drugs Reporting System study in Australia. Results: At least half of the RPU in this study reported extra-medical or misuse of pharmaceuticals in the last six months in addition to regular use of illicit psychostimulants. Higher levels of psychological distress were recorded for RPU who also reported recent illicit use of opioids, antidepressants, benzodiazepines, or over-the-counter (OTC) codeine. Recent misuse of benzodiazepines or OTC codeine was associated with self-reported mental health problems and having attended a mental health professional. Those reporting recent misuse of opioids were at increased risk of mental health problems and more likely to record high levels of psychological distress, but less likely to have received prescription medications for their mental health problem. Discussion and conclusion: Regular users of illicit psychostimulants who also misuse pharmaceuticals are at increased risk of mental health problems, even after accounting for their use of illicit psychostimulants. Screening of this group for mental health problems is recommended.

Resumen: Introducción: El uso indebido de psicofármacos, particularmente entre los jóvenes, es un tema de creciente preocupación. El policonsumo de sustancias es común entre los usuarios regulares de psicoestimulantes (URP), y, pese a que hay problemas de salud mental asociados con el uso indebido de medicamentos, los URP generalmente no reconocen su consumo como problemático. Objetivo: Examinar las relaciones entre la salud mental y el uso indebido de psicofármacos no prescritos en un grupo de URP. Método: Se realizaron entrevistas cara a cara con 763 URP como parte del Estudio Anual del Sistema de Reporte de Éxtasis y Drogas Relacionadas en Australia. Resultados: Al menos la mitad de los URP en este estudio informaron el uso extramédico o indebido de psicofármacos en los últimos seis meses, además del uso regular de psicoestimulantes ilícitos. Se hallaron niveles más altos de distrés psicológico para los URP, quienes también informaron de un uso ilícito reciente de codeína, opiáceos, antidepresivos o benzodiazepinas sin prescripción médica. El uso indebido reciente de codeína o benzodiazepinas sin prescripción se asoció a problemas autorreportados de salud mental y a asistencia a consulta con un profesional de salud mental. Aquellos que informaron el uso indebido reciente de opioides mostraron mayor riesgo de problemas de salud mental y mayor probabilidad de registrar altos niveles de distrés psicológico, pero menor probabilidad de haber recibido psicofármacos prescritos para su problema de salud mental. Discusión y conclusión: Los URP que también consumen indebidamente psicofármacos están en mayor riesgo de presentar problemas de salud mental, incluso después de considerar su consumo de psicoestimulantes ilícitos. Se recomienda una evaluación por tamizaje para problemas de salud mental en este grupo.