Prescription of Sodium Valproate as a Mood Stabiliser in Pregnancy.

This essay was submitted for the Royal College of Psychiatry's perinatal psychiatry medical student essay prize in 2017. The essay considers the choices available to women with bipolar disorder who become pregnant while taking sodium valproate to treat mania or for mood stabilisation. The implications of three options are considered: to stop all treatment, to switch to a different mood stabiliser or to continue on sodium valproate. The implications for the fetus, on the mother's wellbeing and the ethics of patient choice are discussed. BACKGROUND: Pregnancy can be especially challenging for women with bipolar disorder, predominantly because of the heightened probability of relapse, potential fetal harm caused by bipolar medication, and a 250-fold risk of puerperal psychosis compared to the general population. Sodium valproate is a known teratogen, and is discouraged in pregnancy, but what choice is open to women who rely on this medication to stabilise their mood? CONCLUSIONS: The large majority of women of childbearing age with bipolar disorder should not be prescribed sodium valproate as the risks to the unborn fetus far outweigh the benefits of the medication, as other drugs have similar if not better efficacy to stabilize the mother's mood, with lower risks to the fetus. In the small minority of women for whom valproate may be the only effective treatment, she must be fully informed of the teratogenic and neurodevelopmental risks, as well as the ways in which the pregnancy can be managed to reduce such risks.

What are the risks associated with the use of NSAIDs as an adjunct to SSRIs for treatment of depression? An evaluation of current evidence.

BACKGROUND: Over the past twenty years, psychiatric researchers have recognised the important role played by inflammation in the pathogenesis of depression. There has been increasing interest in the use of anti-inflammatory drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs), as a way to enhance the efficacy of antidepressant treatments. It is essential that psychiatrists and GPs who prescribe these drugs in conjunction, understand possible interactions, particularly the risk of bleeding. SUBJECTS AND METHODS: This paper is a literature review regarding NSAID co-prescription with SSRIs and the potential risks and benefits. The objectives of this systematic review are to assess the evidence for the use of NSAIDs as an adjunct to standard antidepressant drugs and evaluate this against the evidence contraindicating such a treatment combination. RESULTS: Our research suggests that there is evidence to support both the anti-inflammatory benefits of NSAIDs for treating depression, as well as evidence suggesting that NSAIDs increases the risk of bleeding when co-prescribed with SSRIs. CONCLUSIONS: When a broad consideration of the risks and benefits is done, the review is inconclusive about guidelines for co-prescription. More research is required to make strong claims about whether the type of NSAID and duration of treatment influences the risk (or benefit) of co-prescription.

What are the risks associated with different Selective Serotonin Re-uptake Inhibitors (SSRIs) to treat depression and anxiety in pregnancy? An evaluation of current evidence.

A literature review was conducted to elucidate the respective reproductive safety profiles of different SSRIs to inform the prescribing practices of doctors treating pregnant women with anxiety and depression. BACKGROUND: Women are most likely to be diagnosed with depression or anxiety between the ages of 25 and 44 years, which are also the years of childbearing potential (Burke et al., 1991). Therefore a substantial number of women face a decision about whether or not to take an antidepressant or anxiolytic during pregnancy. There are no psychotropic medications that have UK marketing authorisation (NICE, 2014), no clear clinical consensus has been reached regarding the use of SSRIs in pregnancy, and clinicians lack a resource which discusses the reproductive safety profiles of different SSRIs rather than the class of drugs as a whole. SUBJECTS AND METHODS: We performed a search for the English language literature indexed on MEDLINE/PubMed for the period 2012 to 2017, using the following key terms: fluoxetine, prozac, paxil, oxactin, paroxetine, seroxat, sertraline, lustral, citalopram, cipramil, escitalopram, cipralex, fluvoxamine, faverin, with 'pregnant woman', 'pregnant women', pregnancy. We excluded general SSRI and pregnancy articles (although we did read these papers for valuable background information) because we are interested in elucidating the differences between the drugs in this class, rather than the general effects of the SRRI class as a whole. RESULTS: The literature shows that paroxetine and fluoxetine have the strongest association with negative outcomes (significant malformations, PPHN and PNAS) whilst the associations between sertraline and citalopram with negative outcomes remains mixed and generally unsubstantiated when studies that show an association are controlled for the effects of maternal depression and associated factors. There are too few studies to draw definite conclusions regarding the safety of escitalopram and fluvoxamine. CONCLUSIONS: Sertraline and citalopram should be first-line drug treatments for anxiety and depression in pregnant women in the SSRI class. Sertraline can be continued in breast-feeding as the concentration found in breast milk is very low and has not been linked to infant complications. Furthermore, it would be useful to assess GPs current knowledge and confidence levels about prescribing, to see whether further education is needed in this area to encourage an open discussion of the risks and benefits of medication or no medication. It would also be useful to conduct further research on escitalopram which is likely to grow in popularity in the coming years as it came off patent in 2012. When these holes are filled, a clinical protocol for treating anxiety and depression in pregnant women should be created and implemented for the UK population.

'Can You Be a Doctor, Even if You Faint?' The Tacit Lessons of Cadaveric Dissection.

BACKGROUND: The undergraduate Medicine course at the University of Cambridge has included cadaveric dissection as part of its anatomy teaching for over three centuries. In recent years, medical schools in the UK and the US have debated whether cadaveric dissection is a useful and efficient way of teaching anatomy. Existing research on this subject has focused narrowly on the knowledge-acquisition for medical students afforded through dissection, and thus we have broadened the scope of such considerations to include the emotional responses of medical students to the dissection process. SUBJECTS AND METHODS: The basis for this paper is a phenomenological analysis of response data gathered from 56 first year medical students at the University of Cambridge through written questionnaires and discussion groups before and after their first experiences of cadaveric dissection. RESULTS: Our research suggests that there are in fact many more lessons taught and acquired through studying in the dissection room: they are tacit, emotional, experiential and dispositional. CONCLUSIONS: When this wider picture of the value of dissection is considered, a much stronger case for the continued inclusion of cadaveric dissection in the medical curriculum can be made, as it is a valuable and unique educational experience.

Integrating sex and gender into biomedical research requires policy and culture change.

Most biomedical, health and care research does not adequately account for sex and gender dimensions of health and illness. Overlooking and disregarding the influence of sex and gender in research reduces scientific rigour and reproducibility, which leads to less effective treatments and worse health outcomes for all, particularly women and sex and gender diverse people. Historically, there has been minimal sex and gender policy innovation in UK medical research. To address this, stakeholders from across the UK research sector have been collaborating since spring 2023 to co-design a sex and gender policy framework to be implemented by research funders, as part of the MESSAGE (Medical Science Sex and Gender Equity) project. In the first Policy Lab, held in London in May 2023, 50 participants, including representatives from funding organisations, medical journals, regulators, clinicians, academics and people with lived experience, identified two key priorities for future action: 1) A whole system approach to policy change, and 2) Technical capacity-building and wider culture change efforts. In pursuing these priorities and collaborating cross-sectorally, UK stakeholders are engaged in an internationally innovative approach aimed at realising sustainable and impactful sex and gender policy change. Drawing on MESSAGE Policy Lab discussions, we set out key actions needed for the UK research sector to embed meaningful accounting for sex and gender as a new norm for research practice.

Tackling inequality in maternal health: Beyond the postpartum.

Healthcare systems prioritise antenatal and intrapartum care over the postpartum period. This is reflected in clinical resource allocation and in research agendas. But from metabolic disease to mental health, many pregnancy-associated conditions significantly affect patients' lifelong health. Women from black and ethnic minority backgrounds and lower socioeconomic groups are at greater risk of physical and psychiatric complications of pregnancy compared to white British women. Without sufficiently tailored and accessible education about risk factors, and robust mechanisms for follow-up beyond the traditional 6-week postpartum period, these inequalities are further entrenched. Identifying approaches to address the needs of these patient populations is not only the responsibility of obstetricians and midwives; improvement requires cooperation from healthcare professionals from a wide range of specialties. Healthcare systems must encourage data collection on the long-term effects of metabolic and psychiatric conditions after the postpartum, and s support research that results in evidence-based care for the neglected field of women's postpartum health.

Representation of Women Among Editors in Chief of Leading Medical Journals.

Importance: Women remain underrepresented among editors of scientific journals, particularly in senior positions. However, to what extent this applies to medical journals of different specialties remains unclear. Objective: To investigate the gender distribution of the editors in chief at leading medical journals. Design, Setting, and Participants: Cross-sectional study of the editors in chief at the top 10 international medical journals of 41 categories related to the medical specialties of the Clarivate Analytics Web of Science Journal Citation Reports in 2019. Main Outcomes and Measures: Proportion of women as editors in chief. Results: This study found that, overall, women represented 21% (94 of 44) of the editors in chief, with wide variation across medical specialties from 0% to 82%. There were 5 categories for which none of the editors in chief were women (dentistry, oral surgery and medicine; allergy; psychiatry; anesthesiology; and ophthalmology) and only 3 categories for which women outnumbered men as editors in chief (primary health care, microbiology, and genetics and heredity). In 27 of the 41 categories, women represented less than a third of the editors in chief (eg, 1 of 10 for critical care medicine, 2 of 10 for gastroenterology and hepatology, and 3 of 10 for endocrinology and metabolism). Conclusions and Relevance: This study found that women are underrepresented among editors in chief of leading medical journals. For the benefit of medical research, a joint effort from editorial boards, publishers, authors, and academic institutions is required to address this gender gap.

Sex and Gender in COVID-19 Vaccine Research: Substantial Evidence Gaps Remain.

Since the start of the COVID-19 pandemic there has been a global call for sex/gender-disaggregated data to be made available, which has uncovered important findings about COVID-19 testing, incidence, severity, hospitalisations, and deaths. This mini review scopes the evidence base for efficacy, effectiveness, and safety of COVID-19 vaccines from both experimental and observational research, and asks whether (1) women and men were equally recruited and represented in vaccine research, (2) the outcomes of studies were presented or analysed by sex and/or gender, and (3) there is evidence of sex and/or gender differences in outcomes. Following a PubMed search, 41 articles were eligible for inclusion, including seven randomised controlled trials (RCTs), 11 cohort studies, eight cross-sectional surveys, eight routine surveillance studies, and seven case series. Overall, the RCTs contained equal representation of women and men; however, the observational studies contained a higher percentage of women. Of 10 studies with efficacy data, only three (30%) presented sex/gender-disaggregated results. Safety data was included in 35 studies and only 12 (34%) of these presented data by sex/gender. For those that did present disaggregated data, overall, the majority of participants reporting adverse events were women. There is a paucity of reporting and analysis of COVID-19 vaccine data by sex/gender. Research should be designed in a gender-sensitive way to present and, where possible analyse, data by sex/gender to ensure that there is a robust and specific evidence base of efficacy and safety data to assist in building public confidence and promote high vaccine coverage.