Creating a Multisite Perinatal Psychiatry Databank: Purpose and Development.

Mental health issues during the perinatal period are common; up to 29% of pregnant and 15% of postpartum women meet psychiatric diagnostic criteria. Despite its ubiquity, little is known about the longitudinal trajectories of perinatal psychiatric illness. This paper describes a collaboration among six perinatal mental health services in Quebec, Canada, to create an electronic databank that captures longitudinal patient data over the course of the perinatal period. The collaborating sites met to identify research interests and to select a standardized set of variables to be collected during clinical appointments. Procedures were implemented for creating a databank that serves both research and clinical purposes. The resulting databank allows pregnant and postpartum patients to complete self-report questionnaires on medical and psychosocial variables during their intake appointment in conjunction with their clinicians who fill in relevant medical information. All participants are followed until 6 months postpartum. The databank represents an opportunity to examine illness trajectories and to study rare mental disorders and the relationship between biological and psychosocial variables.

Anaemia and depletion of iron stores as risk factors for postpartum depression: a literature review.

PURPOSE: Iron-deficiency and anaemia are common in pregnant and postpartum women because of increasing iron demand and blood loss. Many women also enter pregnancy with pre-depleted iron stores. We reviewed the evidence linking anaemia and/or iron-deficiency to postpartum depression (PPD). METHODS: We identified seventeen studies in four databases including randomized-controlled trials (RCTs) and observational studies assessing the impact of anaemia, iron-deficiency and iron supplementation on the risk of PPD. We extracted data on sample size, geographical region, obstetrical complications, measures of depression, haemoglobin, iron levels and intake of iron supplementation and critically appraised the results from the studies. RESULTS: Eight out of ten studies found higher risk for PPD (r - 0.19 to -0.43 and ORs 1.70-4.64) in anaemic women. Low ferritin in the postpartum period but not during pregnancy was associated with increased risk of PPD. Iron supplementation in the postpartum period decreased risk of PPD in four out of five studies, whereas it did not protect from PPD if given during pregnancy. Limitations include study heterogeneity, discrepancy of prevalence of PPD and usage of a screening tool for evaluation of PPD. CONCLUSION: Anaemia and/or iron-deficiency may contribute to PPD in at-risk women. Further studies should elucidate the association between these entities.

Protocol for evaluation of the continuum of primary care in the case of a miscarriage in the emergency room: a mixed-method study.

BACKGROUND: In Quebec (Canada), nearly 20,000 pregnancies end in miscarriage, and the majority of the miscarriages are dealt with in an emergency unit. Although there are studies documenting the effects of this type of grief on mental health, men's experiences are much less discussed than those of women. Similarly, no study has evaluated best practices in terms of service continuity, from emergency care to community resources. The aim of this study is to better understand the relationships that exist between the organization of emergency room and primary care health services for women presenting with miscarriage, on the one hand, and the positions and experiences of women and men within these services, on the other. METHODS: The general objective of this mixed-method study can be broken down into three methodological sections. Focus 1. Institutional discourses and practices. This section is structured as a multiple case study of the mandates of five participant institutions. The study will involve (a) a documentary analysis; (b) a quantitative survey (N: 200) and (c) group interviews (N: 75) with caregivers and emergency unit managers. Focus 2. Women's and men's experiences of miscarriages and the institutional response. This section includes (a) a survey (N: 232) and (b) individual interviews (N: 80) designed to identify best practices in emergency involving women and their partners in each area. Focus 3. This section will integrate the information furnished by the first two sections in order to create an ethnographic overview of the situation. DISCUSSION: This innovative project will provide answers to critical questions on how to improve the effectiveness and quality of interdisciplinary and multisectoral interventions to promote the mental health and psychosocial well-being of couples having experienced a miscarriage. It will have a material effect on the organization of emergency services and of the primary care pathway for women experiencing a miscarriage and for their partners. TRIAL REGISTRATION: Not applicable. This study involves a retrospective view of usual health care interventions. This study is not a clinical trial that prospectively assigns human participants or groups of humans to one or more health-related interventions to evaluate the effects on health outcomes.

Prenatal maternal depression and child serotonin transporter linked polymorphic region (5-HTTLPR) and dopamine receptor D4 (DRD4) genotype predict negative emotionality from 3 to 36 months.

Prenatal maternal depression and a multilocus genetic profile of two susceptibility genes implicated in the stress response were examined in an interaction model predicting negative emotionality in the first 3 years. In 179 mother-infant dyads from the Maternal Adversity, Vulnerability, and Neurodevelopment cohort, prenatal depression (Center for Epidemiologic Studies Depressions Scale) was assessed at 24 to 36 weeks. The multilocus genetic profile score consisted of the number of susceptibility alleles from the serotonin transporter linked polymorphic region gene (5-HTTLPR): no long-rs25531(A) (LA: short/short, short/long-rs25531(G) [LG], or LG/LG] vs. any LA) and the dopamine receptor D4 gene (six to eight repeats vs. two to five repeats). Negative emotionality was extracted from the Infant Behaviour Questionnaire-Revised at 3 and 6 months and the Early Child Behavior Questionnaire at 18 and 36 months. Mixed and confirmatory regression analyses indicated that prenatal depression and the multilocus genetic profile interacted to predict negative emotionality from 3 to 36 months. The results were characterized by a differential susceptibility model at 3 and 6 months and by a diathesis-stress model at 36 months.

Child attachment and sensory regulation in psychiatric clinic-referred preschoolers.

BACKGROUND: Individuals with sensory regulation disorders present with many difficulties in terms of managing emotions, behavior, and motor control. Children with such difficulties are often referred to psychiatric clinics for assessment of their behavioral and emotional problems. Few studies have investigated the role of environmental factors on sensory dysfunctions, and none have specifically studied its association with child attachment in a clinical sample. OBJECTIVE: In this cross-sectional study, we examined the association between sensory regulation and child attachment among preschoolers referred to a psychiatric clinic. METHOD: A sample of 60 preschoolers and their mothers were recruited through a child psychiatric clinic. Child attachment was assessed with the gold standard separation-reunion procedure for preschoolers. Parents completed the sensory profile, which assesses the presence of child hypersensitivity (sensitivity and avoidant scale) and hyposensitivity (sensory seeking and registration scale). RESULTS: Data showed that 57% of the children were presented with clinical symptoms of sensory regulation. In addition, 53% of the children were classified insecure behaviorally disorganized or insecure disorganized controlling. In particular, results revealed that children classified as insecure disorganized controlling were significantly more likely to show hypersensitivity avoidance and sensory-seeking behaviors. CONCLUSION: This study underscores the importance of the parent-child relationship for children with sensory regulation difficulties.

ANXIETY AND ATTACHMENT TO THE MOTHER IN PRESCHOOLERS RECEIVING PSYCHIATRIC CARE: THE FATHER-CHILD ACTIVATION RELATIONSHIP AS A PROTECTIVE FACTOR.

This 49-family study is the first to explore the father-child relationship in a clinical population of preschoolers (at a tertiary care child psychiatry clinic) and to examine its relation to child anxiety and attachment to the mother. A moderation model of the father-child activation relationship on the relation between attachment to the mother and child anxiety was tested and discussed. Analyses confirmed the expected independence between mother-child attachment and father-child activation as well as the association between mother-child attachment and anxiety. The highest levels of anxiety were found in insecure children, and more specifically, in insecure-ambivalent children and insecure disorganized-controlling children of the caregiving subtype. Hypotheses regarding the relation between anxiety and activation were only partially confirmed. Finally, the activation relationship with the father was shown to have a moderating effect on the relation between attachment to the mother and child anxiety; activation by the father may be considered either a protective or a risk factor. Results for this clinical population of young children are discussed in the light of attachment theory and activation relationship theory. The study's findings have the potential to contribute to the development of preventative, diagnostic, and intervention programs that take both parental figures into account.

Impact of maternal prenatal and parental postnatal stress on 1-year-old child development: results from the OTIS antidepressants in pregnancy study.

Perinatal psychological stress has been associated with unfavorable maternal and neonatal outcomes. We aimed to assess the impact of perinatal stress on infant development at 1 year of age. We recruited pregnant women calling North American Teratogen Information Services or attending outpatient clinics at CHU Sainte Justine (Montreal) between 2008 and 2010 and their spouses. To be part of our study, women had to be (1) >18 years of age, (2) <15 weeks of gestational age at recruitment, (3) living within 250-km radius of Montreal, and (4) taking antidepressants or non-teratogenic drugs. Stress was assessed using the telephone-administered four-item perceived stress scale during pregnancy in mothers and at 2 months postpartum in both parents. Child development at 1 year of age was evaluated with the Bayley III scales. Socio-demographic and potential confounders were collected through telephone interviews. Multivariable linear regression models were built to assess the association between perinatal parental stress and child development. Overall, 71 couples and their infants were included. When adjusted for potential confounders, maternal prenatal stress was positively associated with motor development (adjusted ß = 1.85, CI 95 % (0.01, 3.70)). Postpartum maternal and paternal stresses were negatively associated with motor and socio-emotional development, respectively (adjusted ß = -1.54, CI 95 % (-3.07, -0.01) and adjusted ß = -1.67, CI 95 % (-3.25, -0.10), respectively). Maternal and paternal postnatal stress seems to be harmful for the motor and socio-emotional development in 1-year-old children. No association was demonstrated between parental stress and cognitive, language, and adaptive behavioral development. However, prenatal maternal stress appears to improve motor skills.

The interplay of birth weight, dopamine receptor D4 gene (DRD4), and early maternal care in the prediction of disorganized attachment at 36 months of age.

Disorganized attachment is an important early risk factor for socioemotional problems throughout childhood and into adulthood. Prevailing models of the etiology of disorganized attachment emphasize the role of highly dysfunctional parenting, to the exclusion of complex models examining the interplay of child and parental factors. Decades of research have established that extreme child birth weight may have long-term effects on developmental processes. These effects are typically negative, but this is not always the case. Recent studies have also identified the dopamine D4 receptor (DRD4) as a moderator of childrearing effects on the development of disorganized attachment. However, there are inconsistent findings concerning which variant of the polymorphism (seven-repeat long-form allele or non-seven-repeat short-form allele) is most likely to interact with caregiving in predicting disorganized versus organized attachment. In this study, we examined possible two- and three-way interactions and child DRD4 polymorphisms and birth weight and maternal caregiving at age 6 months in longitudinally predicting attachment disorganization at 36 months. Our sample is from the Maternal Adversity, Vulnerability and Neurodevelopment project, a sample of 650 mother-child dyads. Birth weight was cross-referenced with normative data to calculate birth weight percentile. Infant DRD4 was obtained with buccal swabs and categorized according to the presence of the putative allele seven repeat. Macroanalytic and microanalytic measures of maternal behavior were extracted from a videotaped session of 20 min of nonfeeding interaction followed by a 10-min divided attention maternal task at 6 months. Attachment was assessed at 36 months using the Strange Situation procedure, and categorized into disorganized attachment and others. The results indicated that a main effect for DRD4 and a two-way interaction of birth weight and 6-month maternal attention (frequency of maternal looking away behavior) and sensitivity predicted disorganized attachment in robust logistic regression models adjusted for social demographic covariates. Specifically, children in the midrange of birth weight were more likely to develop a disorganized attachment when exposed to less attentive maternal care. However, the association reversed with extreme birth weight (low and high). The DRD4 seven-repeat allele was associated with less disorganized attachment (protective), while non-seven-repeat children were more likely to be classified as disorganized attachment. The implications for understanding inconsistencies in the literature about which DRD4 genotype is the risk direction are also considered. Suggestions for intervention with families with infants at different levels of biological risk and caregiving risk are also discussed.

The ASQ and R-PDQ telephone-administered validation within the OTIS antidepressant in pregnancy study.

This study aimed to assess the telephone administration of the 12-month Ages and Stages Questionnaire (ASQ) and the 9- to 24-month Revised Prescreening Denver Questionnaire (R-PDQ) using the Antidepressants in Pregnancy Study cohort from the Organization of Teratology Information Specialists. The ASQ includes five domains (communication, gross motor, fine motor, problem-solving, and personal-social). The R-PDQ tests four areas of development (gross motor, fine motor, personal-social, and language). Both instruments were self and telephone-administered to mothers at 12 months postpartum. Concordance between the telephone and self-administration was assessed with intraclass correlation coefficients (ICCs) with 95% CIs. For the ASQ, concordance between test scores was substantial for the communication scale (ICC = 0.76, 95% CI [0.63, 0.85]), almost perfect for the gross motor scale (ICC = 0.83, 95% CI [0.73, 0.89]), and moderate for the fine motor, problem-solving, and personal-social scales (ICC = 0.43, 95% CI [0.19, 0.61]; ICC = 0.42, 95% CI [0.19, 0.61]; and ICC = 0.50, 95% CI [0.29, 0.67], respectively). Regarding the R-PDQ, concordance between test scores was as follows: gross motor (ICC = 0.90, 95% CI [0.83, 0.94]), language (ICC = 0.57, 95% CI [0.36, 0.73]), and personal-social scales (ICC = 0.26, 95% CI [0.00, 0.49]). For the fine motor scale, the correlation between both modes was 100%. The 12-month ASQ telephone administration could be an alternative for children developmental screening. Except the personal-social scale, the 9- to 24-month R-PDQ could be telephone-administered for prescreening development.

Prenatal depression and 5-HTTLPR interact to predict dysregulation from 3 to 36 months--a differential susceptibility model.

BACKGROUND: Childhood dysregulation, which reflects deficits in the capacity to regulate or control one's thoughts, emotions and behaviours, is associated with psychopathology throughout childhood and into adulthood. Exposures to adversity during the prenatal period, including prenatal depression, can influence the development of dysregulation, and a number of candidate genes have been suggested as moderators of prenatal exposure, including polymorphisms in the promoter region of the serotonin transporter gene (5-HTTLPR). We examined whether prenatal depression and child 5-HTTLPR interact to predict childhood dysregulation. METHOD: Sample of N = 213 mother-child pairs from the Maternal Adversity, Vulnerability and Neurodevelopment (MAVAN) project. Mothers reported the IBQ-R at 3 and 6 months, and the ECBQ at 18 and 36 months, from which measures of dysregulation were extracted. Mothers' self-reported symptoms of depression on the CES-D at 24-36 weeks of gestation, and at 6, 12, 24 and 36 months postnatal. 5-HTTLPR genotype was extracted from buccal swabs. Mixed-model and confirmatory analyses were conducted. RESULTS: Prenatal depression and 5-HTTLPR interacted to predict dysregulation from 3 to 36 months, within a model of strong differential susceptibility. CONCLUSION: Children with S or LG alleles, when exposed to prenatal depression, have higher levels of dysregulation, and when exposed to lower or little prenatal depression, have higher capacity for regulation. Our findings support efforts to identify, support and treat prenatal depression.

Whose Rights Count? Negotiating Practice, Policy, and Legal Dilemmas Regarding Infant-Parent Contact When Infants are in Out-of-Home Care.

This article takes a human rights perspective with a view to articulating the infant's perspective when the infant has been subjected to abuse, neglect, or both and is reliant on the state to ensure his or her health and well-being. When a young child is removed from parental care, important and often difficult decisions have to be made about subsequent contact between child and parent. We consider a number of dilemmas which may arise for practitioners when they are assisting child welfare decision makers in relation to contact, and acknowledge the limited empirical follow-up studies of the impact of child welfare practice and legal decisions on infant outcomes. We draw on the significant and substantive evidence base about infant emotional and cognitive development and infant-parent attachment relationships as well as infant mental health to illuminate the infant's subjective experience in these practice dilemmas. We describe innovations in practice from various countries, which seek to shed light on the challenges often associated with contact.

Clinical Case Rounds in Child and Adolescent Psychiatry: De Novo Self-Mutilation and Depressive Symptoms in a 17-year-old Adolescent Girl Receiving Depot-Medroxyprogesterone Acetate.

INTRODUCTION: Contraception-induced mood changes have been identified since the 1960s. To our knowledge, there has been no reported case about self-mutilation associated to any form of contraception. We report the case of a 17-year-old adolescent girl who presented with de novo self-mutilation and depressive symptoms three and a half weeks after the administration of 150 mg of Depot-Medroxyprogesterone Acetate (DMPA). METHOD: Clinical case report and literature review. Possible confounding factors are reviewed. RESULTS: The patient had no personal psychiatric history and no significant family psychiatric history. A DSM-IV diagnosis of "mood disorder due to DMPA with depressive features" was formulated. There was no evidence of abnormal personality functioning. The mental status exam and collateral information validated the severity of her condition. DISCUSSION: DMPA is a birth control method especially useful for adolescent girls and possible secondary mood symptoms should not limit its access. However, since depressive symptoms substantially interfere with daily functioning and may have unfortunate consequences like self-mutilation and suicidal ideation, it is important to remain vigilant regarding the onset of mood symptoms following contraceptive use in adolescent girls. This vigilance should be more specific regarding adolescent girls with a history of mood disorders, anxiety disorders, self-mutilation or family diathesis of these conditions.

Clinical challenges of adoption: Views from Montreal and Tel Aviv.

Adoption is accompanied by well-known risk factors that contribute to unique clinical challenges for children, parents, and clinicians. Adoption also serves to illustrate issues that remain relatively "silent" in the typical transition to parenthood. In this article, the authors review the normal developmental challenges that parents face during adoption, the adoption-related risk factors that may impinge on the child's development and attachment process, and the impact of adoption on the child's development of identity and filiations. We will review and illustrate clinical conditions often associated with adoption. In many countries, adoptive parents are reluctant to consult mental health clinicians during the first year of the adoption. The cases presented here illustrates the need to implement routine clinical programs for early detection and intervention of adoptive parent-infant dyads and triads at risk.

Association between antidepressant use during pregnancy and infants born small for gestational age.

OBJECTIVE: To measure the association between the class of antidepressant (AD) used according to trimester of exposure during pregnancy and infants born small for gestational age (SGA). METHODS: A case-control study was performed using data from the Quebec Pregnancy Registry, which includes 152,107 pregnant women between January 1, 1998, and December 31, 2002. For this study, eligible women were aged 15 to 45 years on the first day of gestation, had drug plan coverage from the Régie de l'Assurance Maladie du Québec for 12 months or more prior to and during pregnancy, had at least 1 psychiatric disorder diagnosis before pregnancy, used ADs for at least 30 days in the year prior to pregnancy, and delivered a live singleton. AD exposure during pregnancy was defined according to trimester of use and class (selective serotonin reuptake inhibitors [SSRIs], tricyclic AD, or other ADs). SGA cases were defined as newborns with a birth weight of less than the 10th percentile according to Canadian charts. Relative risks, adjusted for potential confounders, were estimated using modified Poisson regression. RESULTS: Among the 938 eligible pregnancies, 128 (13.6%) infants were born SGA. Other ADs, mainly venlafaxine, used by women during the second trimester were associated with an increased risk of infants born SGA, compared with nonusers of ADs (adjusted relative risk = 2.41; 95% CI 1.07 to 5.43). Regardless of the trimester of use, no association was found between SSRIs or tricyclics and the risk of SGA. CONCLUSIONS: This study suggests that use of venlafaxine during the second trimester of pregnancy may increase the risk of infants born SGA.

Duration of antidepressant use during pregnancy and risk of major congenital malformations.

BACKGROUND: Antidepressant use during the gestational period is a controversial topic. AIMS: To determine whether duration of antidepressant use during the first trimester increases the risk of major congenital malformations in offspring of women diagnosed with psychiatric disorders. METHOD: A case-control study was performed among women who had been pregnant between January 1998 and December 2002. Data were obtained from a Medication and Pregnancy registry, built by linking three databases from the province of Quebec, and a self-administered questionnaire. Women eligible for this study had to be 15-45 years old at the beginning of pregnancy, have at least one diagnosis of psychiatric disorder before pregnancy, have used antidepressants for > or =30 days in the year prior to pregnancy and have a pregnancy ending with a delivery. Cases were defined as any major congenital malformation diagnosed in the offspring's first year of life. Odds ratios, adjusted for relevant confounders, were estimated using logistic regression. RESULTS: Among the 2329 women meeting the inclusion criteria, 189 (8.1%) infants were born with a major congenital malformation. Duration of antidepressant use during the first trimester of pregnancy was not associated with an increased risk of major congenital malformations: 1-30 days v. 0 day, adjusted OR=1.23 (95% CI 0.77-1.98); 31-60 days v. 0 day, adjusted OR=1.03 (95% CI 0.63-1.69); > or =61 days v. 0 day, adjusted OR=0.92 (95% CI 0.50-1.69). CONCLUSIONS: These data do not support an association between duration of antidepressant use during the first trimester of pregnancy and major congenital malformations in the offspring of women with psychiatric disorders. These findings should help clinicians decide whether to continue antidepressant therapy during pregnancy.

Effects of selective serotonin reuptake inhibitors and venlafaxine during pregnancy in term and preterm neonates.

OBJECTIVES: Our goals were to (a) describe neonatal behavioral signs in a group of newborns exposed in utero to selective serotonin reuptake inhibitors or venlafaxine at the time of delivery, (b) compare the rate of neonatal behavioral signs, prematurity, and admission to specialized neonatal care between a group of exposed and unexposed newborns, and (c) compare the effects in exposed preterm and term newborns. PATIENTS AND METHODS: This was a retrospective cohort study including mothers taking selective serotonin reuptake inhibitors or venlafaxine during the third trimester and mothers who were not taking any antidepressants, psychotropic agents, or benzodiazepines at the time of delivery of their newborns. Neonatal behavioral signs included central nervous, respiratory, and digestive systems, as well as hypoglycemia and the need for phototherapy. RESULTS: Seventy-six mothers taking antidepressants and 90 untreated mothers and their newborns were analyzed. Smoking, alcohol intake, and substance abuse were more frequent among treated mothers. In infants in the exposed group, signs involving the central nervous and the respiratory systems were often observed (63.2% and 40.8%, respectively). These signs appeared during the first day of life, with a median duration of 3 days for exposed newborns. The signs resolved in 75% of cases within 3 to 5 days for term and premature newborns, respectively. All exposed premature newborns presented behavioral manifestations compared with 69.1% of term exposed newborns. Median length of stay was almost 4 times longer for exposed premature newborns than for those who were unexposed (14.5 vs 3.7 days). CONCLUSIONS: Neonatal behavioral signs were frequently found in exposed newborns, but symptoms were transient and self-limited. Premature infants could be more susceptible to the effects of selective serotonin reuptake inhibitors and venlafaxine.

First trimester exposure to paroxetine and risk of cardiac malformations in infants: the importance of dosage.

BACKGROUND: Conflicting findings with regard to the teratogenic risks of first trimester use of paroxetine have prompted the FDA, Health Canada, and the manufacturer of the drug to issue warnings against its use during pregnancy. Given that untreated depression during pregnancy can lead to deleterious effect on the mother and her unborn fetus, data on the relationship between the dose and the range of malformations is warranted. This study attempts to quantify the association between first trimester exposure to paroxetine and congenital cardiac malformations, adjusting for possible confounders, and to quantify the dose-response relationship between paroxetine use and cardiac defects. METHODS: The Medication and Pregnancy registry was used. This population-based registry was built by linking three administrative databases (RAMQ, Med-Echo, and ISQ), and includes all pregnancies in Quebec between 01/01/1997 and 06/30/2003. Date of entry in the registry is the date of the first day of the last menstrual period. To be eligible for this study, women had to: 1) be 15-45 years of age at entry; 2) be covered by the RAMQ drug plan >or=12 months before and during pregnancy; 3) be using only one type of antidepressant during the first trimester; and 4) have a live birth. Two nested case-control studies were carried out comparing the prevalence of paroxetine use in the first trimester of pregnancy to the prevalence of other antidepressant exposures during the same time period. Cases were defined as: 1) any major malformations; or 2) any cardiac malformations diagnosed in the first year of life; controls were defined as no major or minor malformations. Multivariate logistic regression techniques were used to analyze data. RESULTS: Among the 1,403 women meeting inclusion criteria, 101 infants with major congenital malformations were identified; 24 had cardiac malformations. Adjusting for possible confounders, the use of paroxetine (odds ratio [OR] = 1.38, 95% confidence interval [CI] = 0.49-3.92), and the use of other SSRIs (OR = 0.89, 95% CI = 0.28-2.84) during the first trimester of pregnancy did not increase the risk of congenital cardiac malformations compared with the use of non-SSRI antidepressants. When considering the dose, however, a dose-response relationship was observed, thus women exposed to >25 mg/day of paroxetine during the first trimester of pregnancy were at increased risk of having an infant with major congenital malformations (adjusted [adj] OR = 2.23, 95% CI = 1.19, 4.17), or major cardiac malformations (adj OR = 3.07, 95% CI = 1.00, 9.42). CONCLUSIONS: Gestational exposure to paroxetine is associated with major congenital malformations and major cardiac malformations for only first trimester exposure above 25 mg/day.