Non-fatal self-harm and suicide following postpartum psychiatric emergency department visits: A population-based retrospective cohort study.

In a population-based cohort of postpartum individuals in Ontario, Canada, this study aimed to determine the risk of non-fatal self-harm and suicide within one year of an initial postpartum psychiatric emergency department (ED) visit (2008-2020), and the key associated factors. Of 16,475 postpartum individuals with psychiatric ED visits, 714 (4.3 %) had non-fatal self-harm within one year, and 23 (0.15 %) died by suicide. Risk was substantially higher for those with self-harm at the initial presentation. Further efforts to connect individuals with postpartum psychiatric ED visits with needed inpatient care and outpatient follow-up are required to reduce non-fatal self-harm and suicide risk.

Reporting of equity in observational epidemiology: A methodological review.

Background: Observational studies can inform how we understand and address persisting health inequities through the collection, reporting and analysis of health equity factors. However, the extent to which the analysis and reporting of equity-relevant aspects in observational research are generally unknown. Thus, we aimed to systematically evaluate how equity-relevant observational studies reported equity considerations in the study design and analyses. Methods: We searched MEDLINE for health equity-relevant observational studies from January 2020 to March 2022, resulting in 16 828 articles. We randomly selected 320 studies, ensuring a balance in focus on populations experiencing inequities, country income settings, and coronavirus disease 2019 (COVID-19) topic. We extracted information on study design and analysis methods. Results: The bulk of the studies were conducted in North America (n = 95, 30%), followed by Europe and Central Asia (n = 55, 17%). Half of the studies (n = 171, 53%) addressed general health and well-being, while 49 (15%) focused on mental health conditions. Two-thirds of the studies (n = 220, 69%) were cross-sectional. Eight (3%) engaged with populations experiencing inequities, while 22 (29%) adapted recruitment methods to reach these populations. Further, 67 studies (21%) examined interaction effects primarily related to race or ethnicity (48%). Two-thirds of the studies (72%) adjusted for characteristics associated with inequities, and 18 studies (6%) used flow diagrams to depict how populations experiencing inequities progressed throughout the studies. Conclusions: Despite over 80% of the equity-focused observational studies providing a rationale for a focus on health equity, reporting of study design features relevant to health equity ranged from 0-95%, with over half of the items reported by less than one-quarter of studies. This methodological study is a baseline assessment to inform the development of an equity-focussed reporting guideline for observational studies as an extension of the well-known Strengthening Reporting of Observational Studies in Epidemiology (STROBE) guideline.

Motivations for investigating health inequities in observational epidemiology: a content analysis of 320 studies.

OBJECTIVES: To enhance equity in clinical and epidemiological research, it is crucial to understand researcher motivations for conducting equity-relevant studies. Therefore, we evaluated author motivations in a randomly selected sample of equity-relevant observational studies published during the COVID-19 pandemic. STUDY DESIGN AND SETTING: We searched MEDLINE for studies from 2020 to 2022, resulting in 16,828 references. We randomly selected 320 studies purposefully sampled across income setting (high vs low-middle-income), COVID-19 topic (vs non-COVID-19), and focus on populations experiencing inequities. Of those, 206 explicitly mentioned motivations which we analyzed thematically. We used discourse analysis to investigate the reasons behind emerging motivations. RESULTS: We identified the following motivations: (1) examining health disparities, (2) tackling social determinants to improve access, and (3) addressing knowledge gaps in health equity. Discourse analysis showed motivations stem from commitments to social justice and recognizing the importance of highlighting it in research. Other discourses included aspiring to improve health-care efficiency, wanting to understand cause-effect relationships, and seeking to contribute to an equitable evidence base. CONCLUSION: Understanding researchers' motivations for assessing health equity can aid in developing guidance that tailors to their needs. We will consider these motivations in developing and sharing equity guidance to better meet researchers' needs.

Risk of Repeat Psychiatric Emergency Department Visits in the Postpartum Period: A Population-Based Retrospective Cohort Study.

STUDY OBJECTIVE: Approximately 1 in 100 postpartum individuals visit an emergency department (ED) for a psychiatric reason. Repeat visits can signify problems with the quality of care received during or after the initial visit; this study aimed to understand risk for repeat postpartum psychiatric ED visits. METHODS: This population-based cohort study used Ontario, Canada health administrative data available through ICES (formerly the Institute for Clinical Evaluative Sciences) to identify all individuals discharged from postpartum psychiatric ED visits (2008 to 2021) and measured the proportion with one or more repeat psychiatric ED visit within 30 days. Using modified Poisson regression, we calculated the association between one or more repeat visits and sociodemographic, medical, obstetric, infant, continuity of care, past service use, and index ED visit characteristics both overall and stratified by psychiatric diagnosis. RESULTS: Of 14,100 individuals, 11.7% had one or more repeat psychiatric ED visits within 30 days. Repeat visit risk was highest for those with schizophrenia-spectrum disorders (28.2%, adjusted risk ratio 2.41; 95% confidence interval 1.88 to 3.08, versus 9.5% anxiety referent). Low (versus no) psychiatric care continuity, prior psychiatric ED visits and admissions, and initial visits within 90 days postpartum were also associated with increased risk, whereas intentional self-injury was associated with reduced risk. In diagnosis-stratified analyses, the factors most consistently associated with repeat ED visits were past psychiatric ED visits and admissions, and initial visits within 90 days postpartum. CONCLUSIONS: Over 1 in 10 postpartum psychiatric ED visits are followed by a repeat visit within 30 days. Targeted approaches are needed across clinical populations to reduce repeat ED visits in this population with young infants.

Experiences of Sexual and Reproductive Health Care Access for Women and Nonbinary People With Early Psychosis: Towards an Integrated Perspective of Service Users and Clinicians.

OBJECTIVE: Individuals with psychosis are at elevated risk of adverse sexual and reproductive health (SRH) outcomes, and not receiving adequate SRH care. SRH is important for youth, yet little is known about SRH care access and experiences among those with early psychosis. This study explored SRH care experiences among women and nonbinary individuals with early psychosis. METHOD: We conducted semistructured qualitative interviews with 19 service users (cisgender and transgender women, nonbinary individuals) receiving care in 2 early psychosis programs in Ontario, Canada. We also conducted semistructured interviews and focus groups with 36 clinicians providing SRH or mental health care to this population. Participants were asked about SRH care access/provision experiences and the interplay with psychosis. Using a social interactionist orientation, a thematic analysis described and explained service user and clinician perspectives regarding SRH care. RESULTS: Amongst both service users and clinician groups, common themes developed: (a) diversity of settings: SRH services are accessed in a large range of spaces across the health care system, (b) barriers in nonpsychiatric SRH care settings: psychosis impacts the ability to engage with existing SRH services, (c) invisibility of SRH in psychiatric settings: SRH is rarely addressed in psychiatric care, (d) variability of informal SRH-related conversations and supports, and cutting across all of the above themes, (e) intersecting social and cultural factors impacted SRH services access. CONCLUSIONS: SRH is important for health and wellbeing; improvements are urgently needed across the healthcare system and within early psychosis programs to meet this population's multifaceted SRH needs.

A virtual mother-infant postpartum psychotherapy group for mothers with a history of adverse childhood experiences: open-label feasibility study.

OBJECTIVES: Mothers with a history of adverse childhood experiences (ACE) are at elevated risk for postpartum mental illness and impairment in the mother-infant relationship. Interventions attending to maternal-infant interactions may improve outcomes for these parents and their children, but barriers to accessing in-person postpartum care limit uptake. We adapted a postpartum psychotherapy group for mothers with mental illness (e.g., mood, anxiety, trauma-related disorders) and ACE for live video-based delivery, and evaluated feasibility, acceptability, and preliminary efficacy in an open-label pilot study. METHODS: We recruited adults with children (6-18 months) from a perinatal psychiatry program in Toronto, Canada. The intervention was a live video-based 12-week interactive psychotherapy group focused on maternal symptoms and maternal-infant relationships. The primary outcome was feasibility, including feasibility of recruitment and retention, fidelity of the intervention, and acceptability to patients and group providers. Maternal clinical outcomes were compared pre- to post-intervention, as secondary outcomes. RESULTS: We recruited 31 participants (mean age 36.5 years (SD 3.9)) into 6 groups; 93.6% (n = 29) completed post-group questionnaires, and n = 20 completed an optional post-group acceptability interview. Mean weekly group attendance was 83% (IQR 80-87); one participant (3.2%) dropped out. All group components were implemented as planned, except for dyadic exercises where facilitator observation of dyads was replaced with unobserved mother-infant exercises followed by in-group reflection. Participant acceptability was high (100% indicated the virtual group was easy to access, beneficial, and reduced barriers to care). Mean maternal depressive [Edinburgh Postnatal Depression Scale: 14.6 (SD 4.2) vs. 11.8 (SD 4.2), paired t, p = 0.005] and post-traumatic stress [Posttraumatic Stress Disorder Checklist for DSM-5: 35.5 (SD 19.0) vs. 27.1 (SD 16.7)], paired t, p = 0.01] symptoms were significantly lower post vs. pre-group. No differences were observed on mean measures of anxiety, emotion regulation or parenting stress. CONCLUSIONS: Recruitment and retention met a priori feasibility criteria. There were significant pre- to post-group reductions in maternal depressive and post-traumatic symptoms, supporting proceeding to larger-scale implementation and evaluation of the intervention, with adaptation of dyadic exercises.

Reproductive Health Among Those with Schizophrenia Spectrum Disorders: An Overview of Considerations Related to the Premenopausal Period, Pregnancy and Postpartum, and the Menopausal Transition, with a Focus on Recent Findings.

PURPOSE OF REVIEW: Schizophrenia spectrum disorders (SSD) impact many aspects of reproductive health for women and non-binary and transgender individuals assigned female at birth. In this narrative review, we highlight considerations and recent research related to (1) the premenopausal period, (2) pregnancy and postpartum, and (3) the menopausal transition. RECENT FINDINGS: Most recent research has focused on pregnancy and the postpartum period, and specifically on elucidating perinatal risk factors, adverse obstetrical and neonatal outcomes (and modifiable contributors such as smoking), long-term child health, and psychotropic medications (with reassuring results related antipsychotic-associated gestational diabetes mellitus and neurodevelopmental outcomes). Much less recent focus has been on menstruation and menopause, although some research has highlighted the relative worsening of illness peri-menstrually and peri-menopausally. Despite the many important reproductive considerations for those with SSD, many aspects including menstruation and menopause have received very little attention. Further research is needed on how to best support women, non-binary, and transgender people assigned female at birth with SSD throughout the lifespan.

Sexual health experiences of women and non-binary people with early psychosis: qualitative study.

BACKGROUND: Women and gender-diverse people with early psychosis are at risk for suboptimal sexual health outcomes, yet little research has explored their sexual health experiences. AIMS: This study explored sexual health experiences and related priorities among women and gender-diverse people with early psychosis, to identify opportunities for improvements in sexual health and well-being. METHOD: Semi-structured individual qualitative interviews explored how patient participants (n = 19, aged 18-31 years, cisgender and transgender women and non-binary individuals) receiving clinical care from early psychosis programmes in Ontario, Canada, experienced their sexual health, including sexual function and behaviour. Thematic analysis was conducted, with triangulation from interviews/focus groups with clinicians (n = 36) who provide sexual and mental healthcare for this population. RESULTS: Three key themes were identified based on patient interviews: theme 1 was the impact of psychotic illness and its treatments on sexual function and activity, including variable changes in sex drive, attitudes and behaviours during acute psychosis, vulnerability to trauma and medications; theme 2 related to intimacy and sexual relationships in the context of psychosis, with bidirectional effects between relationships and mental health; and theme 3 comprised autonomy, identity and intersectional considerations, including gender, sexuality, culture and religion, which interplay with psychosis and sexual health. Clinicians raised each of these priority areas, but emphasised risk prevention relative to patients' more holistic view of their sexual health and well-being. CONCLUSIONS: Women and non-binary people with early psychosis have wide-ranging sexual health priorities, affecting many facets of their lives. Clinical care should incorporate this knowledge to optimise sexual health and well-being in this population.

Disparities in Suicide-Related Behaviors Across Sexual Orientations by Gender: A Retrospective Cohort Study Using Linked Health Administrative Data.

OBJECTIVE: The authors used a population-representative sample and health administrative data to quantify suicide-related behavior leading to acute care or deaths across self-identified heterosexual, gay/lesbian, and bisexual individuals. METHODS: Data from a population-based survey (N=123,995) were linked to health administrative data (2002-2019), and differences in time to suicide-related behavior events across sexual orientations were examined using Cox proportional hazards regression. RESULTS: The crude incidence rates of suicide-related behavior events per 100,000 person-years were 224.7 for heterosexuals, 664.7 for gay/lesbian individuals, and 5,911.9 for bisexual individuals. In fully adjusted (gender-combined) models, bisexual individuals were 2.98 times (95% CI=2.08-4.27) more likely to have an event, and gay men and lesbians 2.10 times (95% CI=1.18-3.71) more likely, compared with heterosexual individuals. CONCLUSIONS: In a large population-based sample of Ontario residents, using clinically relevant outcomes, the study found gay/lesbian and bisexual individuals to be at elevated risk of suicide-related behavior events. Increased education among psychiatric professionals is needed to improve awareness of and sensitivity to the elevated risk of suicide-related behavior among sexual minority individuals, and further research on interventions is needed to reduce such behaviors.

Risk of hospital admission after discharge from postpartum psychiatric emergency department visits: A focus on the social determinants of health.

OBJECTIVE: Of those with postpartum psychiatric emergency department (ED) visits, a minority of receive hospital admission at their initial visit. Among those discharged, we aimed to determine subsequent risk of psychiatric admission, and understand how social determinants of health (SDOH) - individually and collectively - impact this risk. METHOD: From all postpartum individuals discharged from psychiatric ED visits in Ontario, Canada (2008-2020)(n = 13,130), we generated adjusted relative risks (aRR) for psychiatric inpatient admission within 365 days post-ED visit by four SDOH (age, neighbourhood income, community size, immigration) and other clinical factors. Using latent class analysis (LCA) to identify subgroups based on clustering of SDOH, we then compared adjusted risk across subgroups. RESULTS: Psychiatric admission occurred for 9.5% (n = 1242) within 365 days. Across SDOH, risk was lower among adolescents (vs. ≥35 years aRR 0.80, 95%CI 0.65-0.97) and immigrants (<5 years in Canada vs. Canadian-born/long-term residents 0.70, 0.51-0.96; ≥5 years in Canada 0.79, 0.65-0.95). Among four identified subgroups, compared to the "older/urban/high-income" subgroup (11.1% admission), the "urban/immigrant/low-income" (7.6%; 0.68, 0.55-0.82) and "young/rural/low-income" subgroups (9.7%; 0.78, 0.63-0.96), but not the "semi-urban/middle-income" subgroup (9.5%; 0.86, 0.73-1.01), were at lower admission risk. CONCLUSIONS: Future research is needed to explore reasons for SDOH-based differences in admission risk, and inform equitable postpartum services.

Risk of interpersonal violence during and after pregnancy among people with schizophrenia: a population-based cohort study.

BACKGROUND: Schizophrenia is associated with increased risk of experiencing interpersonal violence. Little is known about risk specifically around the time of pregnancy. METHODS: This population-based cohort study included all individuals (aged 15-49 yr) listed as female on their health cards who had a singleton birth in Ontario, Canada, between 2004 and 2018. We compared those with and without schizophrenia on their risk of an emergency department (ED) visit for interpersonal violence in pregnancy or within 1 year postpartum. We adjusted relative risks (RRs) for demographics, prepregnancy history of substance use disorder and history of interpersonal violence. In a subcohort analysis, we used linked clinical registry data to evaluate interpersonal violence screening and self-reported interpersonal violence during pregnancy. RESULTS: We included 1 802 645 pregnant people, 4470 of whom had a diagnosis of schizophrenia. Overall, 137 (3.1%) of those with schizophrenia had a perinatal ED visit for interpersonal violence, compared with 7598 (0.4%) of those without schizophrenia, for an RR of 6.88 (95% confidence interval [CI] 5.66-8.37) and an adjusted RR of 3.44 (95% CI 2.86-4.15). Results were similar when calculated separately for the pregnancy (adjusted RR 3.47, 95% CI 2.68-4.51) period and the first year postpartum (adjusted RR 3.45, 95% CI 2.75-4.33). Pregnant people with schizophrenia were equally likely to be screened for interpersonal violence (74.3% v. 73.8%; adjusted RR 0.99, 95% CI 0.95-1.04), but more likely to self-report it (10.2% v. 2.4%; adjusted RR 3.38, 95% CI 2.61-4.38), compared with those without schizophrenia. Among patients who did not self-report interpersonal violence, schizophrenia was associated with an increased risk for a perinatal ED visit for interpersonal violence (4.0% v. 0.4%; adjusted RR 6.28, 95% CI 3.94-10.00). INTERPRETATION: Pregnancy and postpartum are periods of higher risk for interpersonal violence among people with schizophrenia compared with those without schizophrenia. Pregnancy is a key period for implementing violence prevention strategies in this population.

Preventive Health Care Among Children of Women With Schizophrenia: A Population-Based Cohort Study.

Objective: To compare well-baby visit and vaccination schedule adherence up to age 24 months in children of mothers with versus without schizophrenia.Methods: Using administrative health data on births in Ontario, Canada (2012-2016), children of mothers with schizophrenia (ICD-9: 295; ICD-10: F20/F25; DSM-IV schizophrenia or schizoaffective disorder) (n = 1,275) were compared to children without maternal schizophrenia (n = 520,831) on (1) well-baby visit attendance, including an enhanced well-baby visit at age 18 months, and (2) vaccine schedule adherence for diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type B (DTaP-IPV-Hib), and measles, mumps, rubella (MMR). Cox proportional hazard regression models were adjusted for each of maternal sociodemographics, maternal health, and child health characteristics in blocks and all together in a fully adjusted model.Results: About 50.3% of children with maternal schizophrenia had an enhanced 18-month well-baby visit versus 58.6% of those without, corresponding to 29.0 versus 33.9 visits/100 person-years (PY), a hazard ratio (HR) of 0.82 (95% CI, 0.76-0.89). The association was dampened after adjustment for maternal sociodemographics, maternal health, and child health factors in blocks and overall, with a fully adjusted HR of 0.91 (95% CI, 0.84-0.98). Full vaccine schedule adherence occurred in 40.0% of children with maternal schizophrenia versus 46.0% of those without (22.6 vs 25.9/100 PY), yielding a HR of 0.86 (95% CI, 0.78-0.94). The association was dampened when adjusted for maternal sociodemographics and child health characteristics and became nonsignificant when adjusted for maternal health characteristics. The fully adjusted HR was 0.95 (95% CI, 0.87-1.04).Conclusions: Increased efforts to ensure that children with maternal schizophrenia receive key early preventive health care services are warranted.

A Clinical Review of the Use of Common Psychiatric Medications in Pregnancy: Guidelines for Obstetrical Providers.

Psychotropic medications are commonly prescribed in pregnancy, and obstetrical providers should be informed about how and when to use them. The current narrative review addresses the use of some of the most commonly prescribed psychotropic medications-antidepressants, sedatives and hypnotics, and antipsychotic drugs. The aim is neither a complete review of psychiatric disorders in pregnancy nor all possible psychological and pharmacological treatments for mental illness around the time of pregnancy. Rather, the focus is on therapeutic considerations for general obstetrical providers.

Patient reported symptoms and adverse outcomes seen in Canada's first vaginoplasty postoperative care clinic.

IMPORTANCE: Vaginoplasty is a relatively common gender-affirming surgery with approximately 200 Ontarians seeking this surgery annually. Although Ontario now offers vaginoplasty in province, the capacity is not meeting demand; the majority of trans and gender-diverse patients continue to seek vaginoplasty out of province. Out-of-province surgery presents a barrier to accessing postsurgical follow-up care leaving most patients to seek support from their primary care providers or providers with little experience in gender-affirming surgery. OBJECTIVE: To provide an account of the common postoperative care needs and neovaginal concerns of Ontarians who underwent penile inversion vaginoplasty out of province and presented for care at a gender-affirming surgery postoperative care clinic. DESIGN, SETTINGS, AND PARTICIPANTS: A retrospective chart review of the first 80 patients presenting to a gender-affirming surgery postoperative care clinic who had undergone vaginoplasty at an outside surgical center was performed. Descriptive analyses were performed for all variables. RESULTS: The sample consisted of 80 individuals with the mean age of 39 years (19-73). Most patients had surgery at another surgical center in Canada (76.3%). Many patients (22.5%) accessed care in the first 3 months after surgery, with the majority (55%) seeking care within the first perioperative year. Most patients (61.3%) were seen for more than one visit and presented with more than two symptoms or concerns. Common patient-reported symptoms during clinical visit included pain (53.8%), dilation concerns (46.3%), and surgical site/vaginal bleeding (42.5%). Sexual function concerns were also common (33.8%) with anorgasmia (11.3%) and dyspareunia (11.3%) being the most frequent complications. The most common adverse outcomes identified by health care providers included hypergranulation (38.8%), urinary dysfunction (18.8%), and wound healing issues (12.5%). CONCLUSIONS AND RELEVANCE: Findings from chart review offer valuable insights into the postoperative needs and neovaginal concerns of Ontarians who have had vaginoplasty out of province. This study demonstrates the need for routine postoperative care in patients undergoing vaginoplasty. Patients experience numerous symptoms and concerns that often correlate with clinical findings and require multiple follow-up appointments. Health care providers may benefit from further education on the more common nonsurgical issues identified in this study.

The use of key social determinants of health variables in psychiatric research using routinely collected health data: a systematic analysis.

PURPOSE: Social determinants of health (SDoH) impact psychiatric conditions. Routinely collected health data are frequently used to evaluate important psychiatric clinical and health services outcomes. This study explored how key SDoH are used in psychiatric research employing routinely collected health data. METHODS: A search was conducted in PubMed for English-language articles published in 2019 that used routinely collected health data to study psychiatric conditions. Studies (n = 19,513) were randomly ordered for title/abstract review; the first 150 meeting criteria progressed to full-text review. Three key SDoH categories were assessed: (1) gender and sex, (2) race and ethnicity, and (3) socioeconomic status. Within each category, data were extracted on how variables were included, defined, and used in study design and analysis. RESULTS: All studies (n = 103) reported on at least one of the key SDoH variables; 102 (99.0%) studies included a gender and/or sex variable, 30 (29.1%) included a race and/or ethnicity variable, and 55 (53.4%) included a socioeconomic status variable. No studies explicitly differentiated between gender and sex, and SDoH were often defined only as binary variables. SDoH were used to define the target population in 14 (13.6%) studies. Within analysis, SDoH were most often included as confounders (n = 65, 63.1%), exposures or predictors (n = 23, 22.3%), and effect modifiers (n = 14, 13.6%). Only 21 studies (20.4%) disaggregated results by SDoH and 7 (6.8%) considered intersections between SDoH. CONCLUSIONS: Results suggest improvements are needed in how key SDoH are used in routinely collected health data-based psychiatric research, to ensure relevance to diverse populations and improve equity-oriented research.

Surgical interventions for bilateral congenital cataract in children aged two years and under.

BACKGROUND: Congenital cataracts are lens opacities in one or both eyes of babies or children present at birth. These may cause a reduction in vision severe enough to require surgery. Cataracts are proportionally the most treatable cause of visual loss in childhood, and are a particular problem in low-income countries, where early intervention may not be possible. Paediatric cataracts provide different challenges to those in adults. Intense inflammation, amblyopia (vision is obstructed by cataract from birth which prevents normal development of the visual system), posterior capsule opacification and uncertainty about the final trajectory of ocular growth parameters can affect results of treatment. Two options currently considered for children under 2 years of age with bilateral congenital cataracts are: (i) intraocular lens (IOL) implantation; or (ii) leaving a child with primary aphakia (no lens in the eye), necessitating the need for contact lenses or aphakic glasses. Other important considerations regarding surgery include the prevention of visual axis opacification (VAO), glaucoma and the route used to perform lensectomy. OBJECTIVES: To assess the effectiveness of infant cataract surgery or lensectomy to no surgery for bilateral congenital cataracts in children aged 2 years and under. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 1); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 25 January 2022. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) that compared infant cataract surgery or lensectomy to no surgery, in children with bilateral congenital cataracts aged 2 years and younger. This update (of a review published in 2001 and updated in 2006) does not include children over 2 years of age because they have a wider variety of aetiologies, and are therefore managed differently, and have contrasting outcomes. DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane. Two review authors extracted data independently. We assessed the risk of bias of included studies using RoB 1 and assessed the certainty of the evidence using GRADE. MAIN RESULTS: We identified three RCTs that met our inclusion criteria with each trial comparing a different aspect of surgical intervention for this condition. The trials included a total of 79 participants under 2 years of age, were conducted in India and follow-up ranged from 1 to 5 years. Study participants and outcome assessors were not masked in these trials. One study (60 children) compared primary IOL implantation with primary aphakia. The results from this study suggest that there may be little or no difference in visual acuity at 5 years comparing children with pseudophakia (mean logMAR 0.50) and aphakia (mean logMAR 0.59) (mean difference (MD) -0.09 logMAR, 95% confidence intervals (CIs) -0.24 to 0.06; 54 participants; very low-certainty evidence), but the evidence is very uncertain. The evidence is very uncertain as to the effect of IOL implantation compared with aphakia on visual axis opacification (VAO) (risk ratio (RR) 1.29, 95% CI 0.23 to 7.13; 54 participants; very low-certainty evidence). The trial investigators did not report on the cases of amblyopia. There was little evidence of a difference betwen the two groups in cases of glaucoma at 5 years follow-up (RR 0.86, 95% CI 0.24 to 3.10; 54 participants; very low-certainty evidence). Cases of retinal detachment and reoperation rates were not reported. The impact of IOL implantation on adverse effects is very uncertain because of the sparse data available: of the children who were pseudophakic, 1/29  needed a trabeculectomy and 8/29 developed posterior synechiae. In comparison, no trabeculectomies were needed in the aphakic group and 2/25 children had posterior synechiae (54 participants; very low-certainty evidence).  The second study (14 eyes of 7 children under 2 years of age) compared posterior optic capture of IOL without vitrectomy versus endocapsular implantations with anterior vitrectomy (commonly called 'in-the-bag surgery'). The authors did not report on visual acuity, amblyopia, glaucoma and reoperation rate. They had no cases of VAO in either group. The evidence is very uncertain as to the effect of in-the-bag implantation in children aged under 1 year. There was a higher incidence of inflammatory sequelae: 4/7 in-the-bag implantation eyes and 1/7 in optic capture eyes (P = 0.04, 7 participants; very low-certainty evidence). We graded the certainty of evidence as low or very low for imprecision in all outcomes because their statistical analysis reported that a sample size of 13 was needed in each group to achieve a power of 80%, whereas their subset of children under the age of 1 year had only 7 eyes in each group. The third study (24 eyes of 12 children) compared a transcorneal versus pars plana route using a 25-gauge transconjunctival sutureless vitrectomy system. The evidence is very uncertain as to the effect of the route chosen on the incidence of VAO, with no cases reported at 1 year follow-up in either group. The investigators did not report on visual acuity, amblyopia, glaucoma, retinal detachment and reoperation rate. The pars plana route had the adverse effects of posterior capsule rupture in 2/12 eyes, and 1/12 eyes needing sutures. Conversely, 1/12 eyes operated on by the transcorneal route needed sutures. We graded the outcomes with very low-certainty because of the small sample size and the absence of a priori sample size calculation. AUTHORS' CONCLUSIONS: There is no high level evidence for the effectiveness of one type of surgery for bilateral congenital cataracts over another, or whether surgery itself is better than primary aphakia. Further RCTs are required to inform modern practice about concerns, including the timing of surgery, age at which surgery should be undertaken, age for implantation of an IOL and development of complications, such as reoperations, glaucoma and retinal detachment. Standardising the methods used to measure visual function, along with objective monitoring of compliance with the use of aphakic glasses/contact lenses would greatly improve the quality of study data and enable more reliable interpretation of outcomes.

Comparison of Healthcare Utilization Between Telemedicine and Standard Care: A Propensity-Score Matched Cohort Study Among Individuals With Chronic Psychotic Disorders in Ontario, Canada.

Background: Telemedicine adoption has grown significantly due to the coronavirus of 2019 pandemic; however, it remains unclear what the impact of widespread telemedicine use is on healthcare utilization among individuals with psychosis. Objectives: To investigate the impact of telemedicine use on changes in healthcare utilization among patients with chronic psychotic disorders (CPDs). Study Design: We conducted a population-based, retrospective propensity-matched cohort study using healthcare administrative data in Ontario, Canada. Patients were included if they had at least one ambulatory visit between March 14, 2020 and September 30, 2020 and a CPD diagnosis any time before March 14, 2020. Telemedicine users (2+ virtual visits after March 14, 2020) were propensity score-matched 1:1 with standard care users (minimum of 1 in-person or virtual ambulatory visit and maximum of 1 virtual visit after March 14, 2020) based on several baseline characteristics. Monthly use of various healthcare services was compared between the two groups from 12 months before to 3 months after their index in-person or virtual ambulatory visit after March 14, 2020 using generalized estimating equations (eg, hospitalizations, emergency department [ED] visits, and outpatient physician visits). The slope of change over the study period (ie, rate ratio) as well as a ratio of slopes, were calculated for both telemedicine and standard care groups for each outcome. Study Results: A total of 18 333 pairs of telemedicine and standard care patients were identified after matching (60.8% male, mean [SD] age 45.4 [16.3] years). There was a significantly greater decline across time in the telemedicine group compared to the standard care group for ED visits due to any psychiatric conditions (ratio of slopes for telemedicine vs standard care (95% CI), 0.98 (0.98 to 0.99)). However, declines in primary care visit rates (ratio of slopes for telemedicine vs standard care (1.01 (1.01 to 1.02)), mental health outpatient visits with primary care (1.03 (1.03 to 1.04)), and all-cause outpatient visits with primary care (1.01 (1.01 to 1.02)), were steeper among the standard care group than telemedicine group. Conclusions: Overall, patients with CPDs appeared to benefit from telemedicine as evidenced by increased outpatient healthcare utilization and reductions in ED visits due to psychiatric conditions. This suggests that telemedicine may have allowed this patient group to have better access and continuity of care during the initial waves of the pandemic.

Maternal Schizophrenia and the Risk of a Childhood Chronic Condition.

BACKGROUND AND HYPOTHESIS: Maternal schizophrenia heightens the risk for certain perinatal complications, yet it is not known to what degree future childhood chronic health conditions (Childhood-CC) might arise. STUDY DESIGN: This population-based cohort study using health administrative data from Ontario, Canada (1995-2018) compared 5066 children of mothers with schizophrenia to 25 324 children of mothers without schizophrenia, propensity-matched on birth-year, maternal age, parity, immigrant status, income, region of residence, and maternal medical and psychiatric conditions other than schizophrenia. Cox proportional hazard models generated hazard ratios (HR) and 95% confidence intervals (CI) for incident Childhood-CCs, and all-cause mortality, up to age 19 years. STUDY RESULTS: Six hundred and fifty-six children exposed to maternal schizophrenia developed a Childhood-CC (20.5/1000 person-years) vs. 2872 unexposed children (17.1/1000 person-years)-an HR of 1.18, 95% CI 1.08-1.28. Corresponding rates were 3.3 vs. 1.9/1000 person-years (1.77, 1.44-2.18) for mental health Childhood-CC, and 18.0 vs. 15.7/1000 person-years (1.13, 1.04-1.24) for non-mental health Childhood-CC. All-cause mortality rates were 1.2 vs. 0.8/1000 person-years (1.34, 0.96-1.89). Risk for children exposed to maternal schizophrenia was similar whether or not children were discharged to social service care. From age 1 year, risk was greater for children whose mothers were diagnosed with schizophrenia prior to pregnancy than for children whose mothers were diagnosed with schizophrenia postnatally. CONCLUSIONS: A child exposed to maternal schizophrenia is at elevated risk of chronic health conditions including mental and physical subtypes. Future research should examine what explains the increased risk particularly for physical health conditions, and what preventive and treatment efforts are needed for these children.

Follow-up after post-partum psychiatric emergency department visits: an equity-focused population-based study in Canada.

BACKGROUND: Emergency department visits for a psychiatric reason in the post-partum period represent an acute need for mental health care at a crucial time, but little is known about the extent of timely outpatient follow-up after these visits or how individual and intersecting social determinants of health influence this outcome. This study aimed to examine outpatient mental health care follow-up by a physician in the 30 days after an individual attended the emergency department for a psychiatric reason in the post-partum period and understand how social determinants of health affect who receives follow-up care. METHODS: In this population-based cohort study, routinely collected health data from Ontario, Canada were accessed through ICES to identify all post-partum individuals whose sex was listed as female on their health card and who had attended an emergency department in Ontario before the COVID-19 pandemic for a psychiatric reason. Individuals admitted to hospital at the time of the emergency department visit, who died during the visit, or who left without being seen were excluded from the study. Ethnicity data for individuals were not collected. The primary outcome was the proportion of individuals with any outpatient physician (psychiatrist or family physician) visit for a mental health reason within 30 days of the index emergency department visit. Family physician mental health visits were identified using a validated algorithm for Ontario Health Insurance Plan-billed visits and mental health diagnostic codes for community health centre visits. We examined the associations between social determinants of health (age, neighbourhood income, community size, immigration, neighbourhood ethnic diversity) and who received an outpatient mental health visit. We used modified Poisson regression adjusting for the other social determinants of health, clinical, and health services characteristics to examine independent associations with follow-up, and conditional inference trees to explore how social determinants of health intersect with each other and with clinical and health services characteristics in relation to follow-up. FINDINGS: We analysed data collected between April 1, 2008, and March 10, 2020, after exclusions we identified 12 158 people who had attended the emergency department for a psychiatric reason in the post-partum period (mean age 26·9 years [SD 6·2]; range 13-47); 9848 individuals lived in an urban area, among these 1518 (15·5%) were immigrants and 2587 (26·3%) lived in areas with high ethnic diversity. 5442 (44·8%) of 12 158 individuals received 30-day follow-up. In modified Poisson regression models, younger age, lower neighbourhood income, smaller community size, and being an immigrant were associated with a lower likelihood of follow-up. In the CTREE, similar variables were important, with several intersections between social determinants of health and between social determinants of health and other variables. INTERPRETATION: Fewer than half of emergency department visits for a psychiatric reason in the post-partum period were followed by timely outpatient care, with social-determinants-of-health-based disparities in access to care. Improvements in equitable access to post-emergency department mental health care are urgently needed in this high-risk post-partum population. FUNDING: Department of Psychiatry, University of Toronto; Canadian Institutes of Health Research.

Delivering collaborative mental health care within supportive housing: implementation evaluation of a community-hospital partnership.

BACKGROUND: Approaches to address unmet mental health care needs in supportive housing settings are needed. Collaborative approaches to delivering psychiatric care have robust evidence in multiple settings, however such approaches have not been adequately studied in housing settings. This study evaluates the implementation of a shifted outpatient collaborative care initiative in which a psychiatrist was added to existing housing, community mental health, and primary care supports in a women-centered supportive housing complex in Toronto, Canada. METHODS: The initiative was designed and implemented by stakeholders from an academic hospital and from community housing and mental health agencies. Program activities comprised multidisciplinary support for tenants (e.g. multidisciplinary care teams, case conferences), tenant engagement (psychoeducation sessions), and staff capacity-building (e.g. formal trainings, informal ad hoc questions). This mixed methods implementation evaluation sought to understand (1) program activity delivery including satisfaction with these activities, (2) consistency with team-based tenant-centered care and with pre-specified shared lenses (trauma-informed, culturally safe, harm reduction), and (3) facilitators and barriers to implementation over a one-year period. Quantitative data included reporting of program activity delivery (weekly and monthly), staff surveys, and tenant surveys (post-group surveys following tenant psychoeducation groups and an all-tenant survey). Qualitative data included focus groups with staff and stakeholders, program documents, and free-text survey responses. RESULTS: All three program activity domains (multidisciplinary supports, tenant engagement, staff capacity-building) were successfully implemented. Main program activities were multidisciplinary case conferences, direct psychiatric consultation, tenant psychoeducation sessions, formal staff training, and informal staff support. Psychoeducation for tenants and informal/formal staff support were particularly valued. Most activities were team-based. Of the shared lenses, trauma-informed care was the most consistently implemented. Facilitators to implementation were shared lenses, psychiatrist characteristics, shared time/space, balance between structure and flexibility, building trust, logistical support, and the embedded evaluation. Barriers were that the initial model was driven by leadership, confusion in initial processes, different workflows across organizations, and staff turnover; where possible, iterative changes were implemented to address barriers. CONCLUSIONS: This evaluation highlights the process of successfully implementing a shifted outpatient collaborative mental health care initiative in supportive housing. Further work is warranted to evaluate whether collaborative care adaptations in supportive housing settings lead to improvements in tenant- and program-level outcomes.