Maternal mental illness and child atopy: a UK population-based, primary care cohort study.

BACKGROUND: The number of children exposed to maternal mental illness is rapidly increasing and little is known about the effects of maternal mental illness on childhood atopy. AIM: To investigate the association between maternal mental illness and risk of atopy among offspring. DESIGN AND SETTING: Retrospective cohort study using a UK primary care database (674 general practices). METHOD: In total, 590 778 children (born 1 January 1993 to 30 November 2017) were followed until their 18th birthday, with 359 611 linked to their hospital records. Time-varying exposure was captured for common (depression and anxiety), serious (psychosis), addiction (alcohol and substance misuse), and other (eating and personality disorder) maternal mental illness from 6 months before pregnancy. Using Cox regression models, incidence rates of atopy were calculated and compared for the exposed and unexposed children in primary (asthma, eczema, allergic rhinitis, and food allergies) and secondary (asthma and food allergies) care, adjusted for maternal (age, atopy history, smoking, and antibiotic use), child (sex, ethnicity, and birth year/season), and area covariates (deprivation and region). RESULTS: Children exposed to common maternal mental illness were at highest risk of developing asthma (adjusted hazard ratio [aHR] 1.17, 95% confidence interval [CI] = 1.15 to 1.20) and allergic rhinitis (aHR 1.17, 95% CI = 1.13 to 1.21), as well as a hospital admission for asthma (aHR 1.29, 95% CI = 1.20 to 1.38). Children exposed to addiction disorders were 9% less likely to develop eczema (aHR 0.91, 95% CI = 0.85 to 0.97) and 35% less likely to develop food allergies (aHR 0.65, 95% CI = 0.45 to 0.93). CONCLUSION: The finding that risk of atopy varies by type of maternal mental illness prompts important aetiological questions. The link between common mental illness and childhood atopy requires GPs and policymakers to act and support vulnerable women to access preventive (for example, smoking cessation) services earlier.

Self-harm risk in pregnancy: recurrent-event survival analysis using UK primary care data.

BACKGROUND: Perinatal self-harm is of concern but poorly understood. AIMS: To determine if women's risk of self-harm changes in pregnancy and the first postpartum year, and if risk varies by mental illness, age and birth outcome. METHOD: This was a retrospective cohort study of 2 666 088 women aged 15-45 years from the 1 January 1990 to 31 December 2017 linked to 1 102 040 pregnancies and their outcomes, utilising the Clinical Practice Research Datalink and Pregnancy Register. We identified self-harm events and mental illness (depression/anxiety/addiction/affective/non-affective psychosis/eating/personality disorders) from clinical records and grouped women's age into 5-year bands. They calculated the rate of self-harm during discrete non-perinatal, pregnant and postpartum periods. We used a gap-time, stratified Cox model to manage multiple self-harm events, and calculated the unadjusted and adjusted hazard ratios (adjHR) of self-harm associated with pregnancy and the postpartum compared with non-perinatal periods. Pre-planned interactions tested if risk varied by mental illness, age and birth outcome. RESULTS: The analysis included 57 791 self-harm events and 14 712 319 person-years of follow-up. The risk of self-harm shrank in pregnancy (2.07 v. 4.01 events/1000 person-years, adjHR = 0.53, 95% CI 0.49-0.58) for all women except for 15- to 19-year-olds (adjHR = 0.95, 95% CI 0.84-1.07) and the risk reduced most for women with mental illness (adjHR = 0.40, 95% CI 0.36-0.44). Postpartum, self-harm risk peaked at 6-12 months (adjHR = 1.08, 95% CI 1.02-1.15), at-risk groups included young women and women with a pregnancy loss or termination. CONCLUSIONS: Maternity and perinatal mental health services are valuable. Family planning services might have psychological benefit, particularly for young women.

Childhood Allergies: The Role of Maternal Depression and Anxiety, and Family Strain.

Maternal mental disorder and a negative family emotional climate are a great source of stress for many children, yet their role in the childhood development or expression of asthma and allergies remains poorly understood, particularly beyond the first 1-2 years of life. The current study tested whether childhood allergy onset and symptomatology would be predicted by (1) perinatal and any time exposure to maternal depression or anxiety and (2) current family emotional strain (whole family, mother-child). UK mothers of children aged 2-12 years (N = 328) living with them completed an online survey of measures. Children exposed to maternal depression were almost twice as likely to be diagnosed and almost five times as likely to screen positive for an allergic disorder. Perinatal depression was linked to childhood allergies, but more moderately. Any anxiety exposure, and not specific to the perinatal period, predicted allergy status. Family emotional strain contributed independently to variance in concurrent child allergic symptomatology. All results were independent of potential confounders and current mental distress. The findings highlight the importance of maternal mental health and family function in the child's neuro-immune development, and that these factors need to be addressed in the treatment of childhood allergic disorders.

The healthcare resource impact of maternal mental illness on children and adolescents: UK retrospective cohort study.

BACKGROUND: The general health of children of parents with mental illness is overlooked. AIMS: To quantify the difference in healthcare use of children exposed and unexposed to maternal mental illness (MMI). METHOD: This was a retrospective cohort study of children aged 0-17 years, from 1 April 2007 to 31 July 2017, using a primary care register (Clinical Practice Research Datalink) linked to Hospital Episodes Statistics. MMI included non-affective/affective psychosis and mood, anxiety, addiction, eating and personality disorders. Healthcare use included prescriptions, primary care and secondary care contacts; inflation adjusted costs were applied. The rate and cost was calculated and compared for children exposed and unexposed to MMI using negative binomial regression models. The total annual cost to NHS England of children with MMI was estimated. RESULTS: The study included 489 255 children: 238 106 (48.7%) girls, 112 741 children (23.0%) exposed to MMI. Compared to unexposed children, exposed children had a higher rate of healthcare use (rate ratio 1.27, 95% CI 1.26-1.28), averaging 2.21 extra contacts per exposed child per year (95% CI 2.14-2.29). Increased healthcare use among exposed children occurred in inpatients (rate ratio 1.37, 95% CI 1.32-1.42), emergency care visits (rate ratio 1.34, 95% CI 1.33-1.36), outpatients (rate ratio 1.30, 95% CI 1.28-1.32), prescriptions (rate ratio 1.28, 95% CI 1.26-1.30) and primary care consultations (rate ratio 1.24, 95% CI 1.23-1.25). This costs NHS England an additional £656 million (95% CI £619-£692 million), annually. CONCLUSIONS: Children of mentally ill mothers are a health vulnerable group for whom targeted intervention may create benefit for individuals, families, as well as limited NHS resources.

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.

The influence of maternal mental illness on vaccination uptake in children: a UK population-based cohort study.

Reduced vaccination uptake is a growing and global public health concern. There is limited knowledge about the effect of maternal mental illness (MMI) on rates of childhood vaccination. This retrospective cohort study examined 479,949 mother-baby pairs born between 1993 and 2015 in the Clinical Practice Research Datalink (CPRD GOLD), a UK-based, primary health-care database. The influence of MMI on children's vaccination status at two and five years of age was investigated using logistic regression adjusting for sex of the child, child ethnicity, delivery year, maternal age, practice level deprivation quintile and region. The vaccinations were: 5-in-1 (DTaP/IPV/Hib) and first dose MMR by the age of two; and all three doses of 5-in-1, first and second dose of MMR vaccines by the age of five. Exposure to MMI was defined using recorded clinical events for: depression, anxiety, psychosis, eating disorder, personality disorder and alcohol and substance misuse disorders. The likelihood that a child completed their recommended vaccinations by the age of two and five was significantly lower among children with MMI compared to children with mothers without mental illness [adjusted odds ratio (aOR) 0.86, 95% CI 0.84-0.88, p < 0.001]. The strongest effect was observed for children exposed to maternal alcohol or substance misuse (at two years aOR 0.50, 95% CI 0.44-0.58, p < 0.001). In the UK, an estimated five thousand more children per year would be vaccinated if children with MMI had the same vaccination rates as children with well mothers. Maternal mental illness is a hitherto largely unrecognised reason that children may be missing vital vaccinations at two and five years of age. This risk is highest for those children living with maternal alcohol or substance misuse.

Effects of parental mental illness on children's physical health: systematic review and meta-analysis.

BACKGROUND: Children of parents with mental disorder face multiple challenges. AIMS: To summarise evidence about parental mental disorder and child physical health. METHOD: We searched seven databases for cohort or case-control studies quantifying associations between parental mental disorders (substance use, psychotic, mood, anxiety, obsessive-compulsive, post-traumatic stress and eating) and offspring physical health. Studies were excluded if: they reported perinatal outcomes only (<28 days) or outcomes after age 18; they measured outcome prior to exposure; or the sample was drawn from diseased children. A meta-analysis was conducted. The protocol was registered on the PROSPERO database (CRD42017072620). RESULTS: Searches revealed 15 945 non-duplicated studies. Forty-one studies met our inclusion criteria: ten investigated accidents/injuries; eight asthma; three other atopic diseases; ten overweight/obesity; ten studied other illnesses (eight from low-and middle-income countries (LMICs)). Half of the studies investigated maternal perinatal mental health, 17% investigated paternal mental disorder and 87% examined maternal depression. Meta-analysis revealed significantly higher rates of injuries (OR = 1.15, 95% CI 1.04-1.26), asthma (OR = 1.26, 95% CI 1.12-1.41) and outcomes recorded in LMICs (malnutrition: OR = 2.55, 95% CI 1.74-3.73; diarrhoea: OR = 2.16, 95% CI 1.65-2.84). Evidence was inconclusive for obesity and other atopic disorders. CONCLUSIONS: Children of parents with mental disorder have health disadvantages; however, the evidence base is limited to risks for offspring following postnatal depression in mothers and there is little focus on fathers in the literature. Understanding the physical health risks of these vulnerable children is vital to improving lives. Future work should focus on discovering mechanisms linking physical and mental health across generations. DECLARATION OF INTEREST: None.

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.

The problem of overcontrol: Perfectionism, emotional inhibition, and personality disorders.

BACKGROUND AND AIMS: Some individuals with Personality Disorders (PD), particularly of a non-Borderline type, present with difficulties relating to over-control of cognitions, emotion and behavior, perfectionistic traits, and impaired social interactions. The current study sought to evaluate the strength of association, and interactions of both emotional inhibition and perfectionism in PD's, after controlling for symptoms and interpersonal problems. METHOD: We recruited a sample of 578 treatment seeking outpatients. Diagnosis of PD was made with the SCID-II. Individual's completed measures of perfectionism (Frost-MPS), Emotional Inhibition (EIS), Depression (BDI-II), Anxiety (STAI-Y), Global symptoms (SCL-90-R), and interpersonal problems (IIP-32). RESULTS: Perfectionism was related to interpersonal problems, to the majority of PD symptomatology and to PD severity via number of SCID-II criteria met. Emotional inhibition was linked to symptoms and interpersonal problems as well as with avoidant, dependent, depressive and paranoid PDs; and with overall PD Severity. Inhibition and perfectionism were correlated with each other. Both variables predicted PD above and beyond other variables assessed. Mediation modeling demonstrated that the effect of emotional inhibition on PD severity was fully mediated by perfectionism and interpersonal problems. CONCLUSIONS: Psychological mechanisms of overcontrol are a maintaining factor in many PDs. Both perfectionism and emotional inhibition impact on a broad range of PDs and there is an urgent need for research into these processes, and to adapt psychological interventions to consider these factors.

Clinical staging model in offspring of parents with bipolar disorder: a systematic review.

OBJECTIVE: We sought to systematically review the literature on the psychiatric risk of offspring of parents with bipolar disorder (OPBD) using a developmental psychopathology framework. The review also sought to establish the utility of clinical stage modelling as a framework for identifying precursor disorders to later onset of bipolar disorder (BD) in OPBD. METHODS: A systematic search was performed using EMBASE, PsychINFO and Medline. Reference lists of included studies and previous reviews were also searched. Studies were included if they reported diagnostic outcomes for child, adolescent and young adult offspring of parents diagnosed with BD. RESULTS: Twenty-six studies were identified representing 21 individual cohorts. The review identified that OBPD present as a high-risk group for a range of mood and non-mood disorders in childhood, adolescence and young adulthood. The trajectory of risk was from non-mood disorders in childhood via non-bipolar mood disorders in early adolescence towards mania/hypomania in late adolescence and early adulthood. From a clinical staging perspective, childhood anxiety disorders were associated with later onset of BD. Recurrent substance use disorder was identified as a risk in OPBD during late adolescence and early adulthood. Quality ratings indicated that studies were methodologically robust. CONCLUSIONS: Our review provides evidence for a developmental psychopathology trajectory of precursor risks to BD in OPBD. There is support for clinical stage modelling as a conceptual framework for understanding developmental risk in OPBD and as a tool for developing early and individualized intervention strategies.