Denial of reproductive potential: a predictor of unperceived pregnancy in an Austrian neonaticide sample.

PURPOSE: This study aims to describe the phenomenon of unperceived pregnancy followed by neonaticide with a focus on the lack of awareness of reproductive potential in an Austrian sample. METHODS: An explorative comparative study of neonaticide cases with single and repeat perpetrators was conducted using nationwide register-based data from 1995 to 2017. A total number of 55 cases out of 66 were included in the analysis. A standardized coding sheet was used and calculations were performed. RESULTS: 48 women gave birth to 101 children, of which 55 were killed, 23 children lived out of home care and 23 lived with the perpetrator We found a higher fertility rate in both neonaticide perpetrators in the single (1,9) and the repeat group (4,25) in comparison to the general population (1,4). The use of contraception was only 31% among neonaticide perpetrators, deviating substantially from the general Austrian population age group (16-29yrs) which used contraception in 91%. The neonaticide perpetrators used an effective contraception method (pearl-index < 4) in only 2%, whereas 20% of the general population did so. The number of unperceived pregnancies was high in both groups (50/55) 91%. CONCLUSION: Future case reports and forensic evaluations should take reproductive behavior into account, as it may offer valuable insights into the events leading up to neonaticide. Our findings suggest that denial of reproductive potential often precedes unperceived pregnancies. In the Austrian cohort, women who experienced unperceived pregnancies resulting in unassisted births and subsequent neonaticide showed a low prevalence of contraceptive use. This is particularly noteworthy given that the primary motive for neonaticide is unwanted pregnancy.

Restorative justice in a case of traumatic birth following an unperceived pregnancy.

PURPOSE: Pregnancy can be denied or better "unperceived" by women in up to 1:300 pregnancies and poses the mother and her unborn at high risk when an unassisted birth follows. The importance of recognizing unperceived pregnancy and the risk of unassisted births for both mothers and their babies are described. METHODS: Description of a case of unperceived pregnancy and traumatic unassisted birth. RESULTS: A pregnant woman was not diagnosed in a clinic despite being at the verge of giving birth. She was turned away, was on her way to another hospital, and gave birth in a toilet in a dissociative state. The baby survived, but the mother was declared guilty of attempted manslaughter and received a 6-year prison sentence. The expertise of a perinatal psychiatrist reversed the verdict and the court apologized to the mother, now living with her son. CONCLUSIONS: This case shows the severe consequences when pregnancy and labor are not recognized by health professionals. The reversal of the original sentence is considered a pioneer case of restorative justice in the context of unperceived pregnancy and obstetric violence. Health providers and courts need to be informed by perinatal mental health professionals about the impact of unperceived pregnancy and obstetric violence.

Repeated neonaticide: differences and similarities to single neonaticide events.

This study aims to identify differences between single and repeat perpetrators of filicide by using register-based data. The study used register-based, comprehensive, nationwide data from both Austria and Finland. The current study covers 23 perpetrators, 20 single and 3 repeat perpetrators, with a total of 28 victims. All victims had a maximum age of 24 h and all perpetrators were women. Every third victim of neonaticide was a victim of a repeat case. The repeat perpetrators were older; had a higher number of children over their lifespan, some of whom lived with them; were more likely to live within established family structures; had higher levels of education and employment; had a higher proportion of personality disorders; and were more likely to identify stress factors during pregnancy. One unexpected finding was low levels of awareness about pregnancy within the perpetrator's circle remain a risk factor, especially for repeat perpetrators. Arguably, the quality of interpersonal relationships these women have may be affected by their own mental health issues and life experience and vice versa.

Foetal abuse.

Pregnancy and motherhood are often presented as natural and unproblematic for women. The fact that there are some women who engage in violent behaviour towards their unborn child suggests that motherhood is not as unproblematic as we are led to believe. This paper presents six previously unpublished cases of foetal abuse that is physical assaults on the foetus by the mothers themselves, and examines how the prevailing myth of the good mother might be further endangering mothers and their unborn children. So far, the research suggests there are some common, possibly co-occurring, features that might be an antecedent to foetal abuse: unplanned pregnancies, prior mental health issues in the mother, trauma, pregnancy denial up to 20 weeks or until birth, and ideation of harm correlated to in utero movements.

[Language development in children with migration background and parental reading to children]. / Sprachentwicklung bei Kindern mit Migrationshintergrund und elterliches Vorlesen.

Introduction: The majority of children with a migration background suffer from language deficits in one or both languages. The aim of our study was to describe the patterns of language acquisition in children with Turkish background in Austria and to find factors which influence these Patterns. Method: Fifty-two children at the age of 5 to 6 years and their parents were assessed. Inclusion criteria for parents were Turkish migration background and use of Turkish at home. Inclusion criteria for children: no hearing impairment, no blindness, no chronic disease, average cognitive development, born in Austria, and attending a kindergarten. Language competence was measured with Havas 5. Parents were administered a questionnaire about socio-demographics and their child centered literacy orientation (CCLO). Results: There was a significant difference between language patterns in Turkish and German. Moreover, language competence was higher in both Turkish and German, the more parents tended to read to their children in Turkish. Discussion: Children acquired a grammatically correct but simple Turkish, while their competence in German was reduced. Reading to the children seems to stimulate language development not only of their natural language, but also of German. Conclusion: Early literacy in migrant languages should be integrated in training programs.

Anonymous birth law saves babies--optimization, sustainability and public awareness.

The aims of this study are to assess the impact of Austria's anonymous birth law from the time relevant statistical records are available and to evaluate the use of hatches versus anonymous hospital delivery. This study is a complete census of police-reported neonaticides (1975-2012) as well as anonymous births including baby hatches in Austria during 2002-2012. The time trends of neonaticide rates, anonymous births and baby hatches were analysed by means of Poisson and logistic regression model. Predicted and observed rates were derived and compared using a Bayesian Poisson regression model. Predicted numbers of neonaticides for the period of the active awareness campaign, 2002-2004, were more than three times larger than the observed number (p = 0.0067). Of the 365 women who benefitted from this legislation, only 11.5% chose to put their babies in a baby hatch. Since the law was introduced, a significant decreasing tendency of numbers of anonymous births (p = 047) was observed, while there was significant increase of neonaticide rates (p = 0.0001). The implementation of the anonymous delivery law is associated with a decrease in the number of police-reported neonaticides. The subsequent significantly decreasing numbers of anonymous births with an accompanying increase of neonaticides represents additional evidence for the effectiveness of the measure.

Correlates of electroencephalographic resting states and erythrocyte membrane docosahexaenoic and eicosapentaenoic acid levels in individuals at ultra-high risk of psychosis.

OBJECTIVE: Abnormal levels of polyunsaturated fatty acids (PUFAs) have been reported in individuals suffering from schizophrenia. The main aim of the present study was to investigate the relationship between erythrocyte membrane fatty acid levels and resting-state brain activity occurring in individuals at ultra-high risk (UHR) of psychosis. METHOD: The association between erythrocyte membrane fatty acids levels and resting-state brain activity and its value in predicting psychosis was examined in 72 UHR individuals. RESULTS: In the frontal area, the activity in the fast frequency band Beta2 was positively associated with docosahexaenoic acid (DHA) levels (R = 0.321, P = 0.017), and in the fronto-central area, Beta2 activity showed a positive correlation with eicosapentaenoic acid (EPA) levels (R = 0.305, P = 0.009), regardless of psychosis transition status. Conversely, the slow frequency band Theta was significantly negatively associated with EPA levels in the parieto-occipital region (R = -0.251, P = 0.033. Results also showed that Alpha power was negatively correlated with DHA levels in UHR individuals who did not transition to psychosis, while this correlation was not present in individuals who later transitioned. CONCLUSION: Our results suggest that individuals at UHR for psychosis who have higher basal omega-3 fatty acids levels present with resting EEG features associated with better states of alertness and vigilance. Furthermore, the improvement in the Alpha synchrony observed along with increased DHA levels in participants who did not transition to psychosis is disturbed in those who did transition. However, these interesting results are limited by the small sample size and low statistical power of the study.

Perinatal use of aripiprazole: plasma levels, placental transfer, and child outcome in 3 new cases.

The use of new agents of second-generation antipsychotics in childbearing women is increasing and poses an unknown risk to the fetus; thus, information of pregnancy and child outcome are urgently needed. We reviewed the literature of 12 patients, 3 of them were exposed during the first trimester, and added 3 new cases of peripartum use of aripiprazole. No teratogenesis was observed despite all 3 women having received the substance during part or full first trimester. All 3 pregnancies were uncomplicated with spontaneous birth. Dosage had to be changed during the course of gestation from 2.5 to 15 mg and plasma levels (PL) were below recommended levels, although all 3 women remained in stable remission throughout pregnancy and postpartum period.The extent of placental transfer of aripiprazole (mean ratio of 56.2%) is comparable with that of other second-generation antipsychotics.Our observations have clinical implications: antipsychotic PLs show large-scale decreases, which may require dose adjustments during pregnancy. Pregnant women may require lower PLs. In our cases, a PL of one third of the previous effective PL was effective and safe. Repeated therapeutic drug monitoring during late gestation based on individual, previous effective PLs seems to be a feasible way for safe and effective antipsychotic therapy in unplanned pregnancy.

Duration of untreated psychosis in a high-income versus a low- and middle-income region.

OBJECTIVE: Most data on duration of untreated psychosis (DUP) derives from high-income countries. An inverse relationship between DUP and income and a longer DUP in low- and middle-income (LAMI) countries has been reported. The aim of this study was to compare DUP in a high-income country with that in a LAMI country using the same methodology. METHODS: The sample consisted of in- and outpatients, aged 15-35 years for the Vienna site and 18-35 years for the Pakistani sites, with first-episode psychosis (FEP). DUP was evaluated using psychiatric interviews, medical charts and the Nottingham Onset Schedule. Differentiated reporting of duration of untreated illness (DUI) from prodrome to start of treatment, and DUP from manifest psychotic symptoms to start of treatment was ensured. Primary outcome measures, DUI and DUP, were measured at a 0.025 level of significance. RESULTS: Thirty-one FEP patients in Vienna (mean age 20.03 years, SD 4.2) and 60 FEP patients from the Pakistani sites (mean age 26.15 years, SD 5.29) participated. The mean age in Vienna was younger due to the different age range inclusion criteria. The severity of psychopathology was more pronounced in the Pakistani sample. Log DUP was significantly different between groups (i.e. longer in the Pakistani sample (p=0.001)). Log DUI showed a trend for longer duration in the Vienna sample; however, this did not reach statistical significance (p=0.036). The severity of positive psychotic symptoms was associated with length of DUI in both regions. CONCLUSION: The longer DUP in Pakistan confirms the need to provide affordable treatment for psychosis for young FEP patients in Pakistan and in other LAMI countries. The relatively long period from prodrome to treatment initiation in both regions underlines the need to further establish low-threshold early intervention strategies in order to increase detection rates and reduce factors limiting patients seeking treatment.

Tetrahydrocannabinol in Pediatrics: Room for Improvement?

Introduction: The use of medical cannabis in pediatrics is not common in clinical practice, and there is a lack of prospective studies, especially in pediatric subpopulations. This study aimed to provide data on the off-label administration of tetrahydrocannabinol (∆9-THC) in a pediatric tertiary center in Austria. Methods: A retrospective data analysis was performed to assess the use of ∆9-THC at the Department of Pediatrics and Adolescent Medicine at the Comprehensive Center of Pediatrics (Medical University Vienna) from 2016 to 2018. The use of ∆9-THC in the Pediatric Department at the Medical University Vienna between 2016 and 2018 was analyzed using a retrospective design. Results: The most common diagnoses of patients receiving ∆9-THC were brain cancer and genetic diseases, including inborn metabolic disorders. The 32 patients who had received ∆9-THC had an arithmetic mean of 9.42 diagnoses and were treated with an arithmetic mean of 13.52 other drugs. Eleven of the 32 patients died by the end of the study period, indicating palliative use. Conclusion: The data shows that only severely ill patients were treated with ∆9-THC. A lack of information on the drug's indications, duration, and dosage was noticed in the files, which could represent problems for patient safety.

Potential predictors in neonaticide: the impact of the circumstances of pregnancy.

This study aims to evaluate the psychosocial factors of neonaticide, especially the circumstances before delivery, the relationships of the pregnant women, and their social environment awareness of women's pregnancy. This nationwide study was register-based, comprising all known neonaticides in Austria and Finland between 1995 and 2005. Cases (n = 28) were obtained by screening the death certificates from coroner's departments and by analyzing them along with all further available reports. Few women (17.9 %, 5/28) admitted their pregnancy to others. Although most (16/28) offenders were in a relationship, the partner had knowledge of the pregnancy in only three cases. The main motive for negation of the pregnancy (named in 60.8 % of cases) was fear of abandonment/negative response from others. The fertility rate among the women was high, but half of those with children had lost the custody of them. In neonaticide, the lack of awareness surrounding offenders' pregnancy, as well as the awareness of social environment, is more relevant than any other social variable.

Cannabidiol treatment in an adolescent with multiple substance abuse, social anxiety and depression.

In this report, we present a case of a 16,9-year-old patient with multiple substance use disorder (cannabis, MDMA, cocaine, ecstacy), severe depression, social phobia and narcissistic personality disorder.We administered Cannabidiol (CBD) capsules in different dosages (starting dosage 100 mg up to 600 mg over 8 weeks) after unsuccessful treatment with antidepressants.CBD was a safe and well tolerated medication for this patient. Upon treatment with CBD and cessation of the antidepressant medication, the patient improved regarding depressive as well as anxiety symptoms including simple phobias and symptoms of paranoia and dissociation. Furthermore, the patient quit abusing illegal drugs including THC without showing withdrawal symptoms. This is the first report of CBD medication in a patient with multiple substance use disorder with a positive outcome.Until today it is not clear if CBD holds promise as a therapeutic option in substance use disorder as RCTs are lacking, but in this single case the substance seems to work in various domains.

A multirisk approach to predicting chronicity of postpartum depression symptoms.

BACKGROUND: Persistence of postpartum depression (PPD) carries potential adverse implications for the emerging mother-child relationship and for child development. METHODS: This study was designed to investigate factors related to the onset and persistence of PPD; in particular, we examined the cumulative effect of a range of psychosocial risk factors in predicting chronic PPD symptoms. One hundred and five women were interviewed at three assessment periods: within the first days after childbirth, at 6 months, and at 18 months postpartum. RESULTS: Depressive symptoms at 6 months predicted 18 months depressive symptoms, even when controlling for the contribution of maternal depression at birth. Psychosocial risk had a moderating influence on the stability of depressive symptomatology. Women with two or more risk factors at birth were more likely to have stable depressive symptomatology across the infants' first 18 months of life. CONCLUSION: To prevent a chronic course of PPD it may be necessary to identify both depressive symptoms and relevant psychosocial risk factors.

Predictors of longer-term outcome in the Vienna omega-3 high-risk study.

Longer-term data on ω-3 polyunsaturated fatty acids (PUFA) for prevention of psychosis in (ultra high risk) UHR individuals have initially shown promising results. This analysis aimed to assess clinical predictors of longer-term outcome in UHR individuals treated with ω-3 PUFAs versus placebo. Data derived from an RCT in 81 UHR individuals treated with ω-3 PUFAs versus placebo for 12weeks and follow-up assessment after a median of 6.7years. Baseline GAF, baseline PANSS global score, pre-to-post-intervention change in EPA (Eicosapentaenoic acid) level were significant predictors of transition to psychosis, PANSS negative score and baseline MADRS reached trend-levels. In the final multivariate Cox regression analysis change in EPA levels remained the only significant predictor. Taking into account all other significant predictors, changes in EPA levels were found to be the single most significant predictor for transition to psychosis in a longer term observation of UHR individuals.

The role of estrogen and progesterone in depression after birth.

Previous reports suggest that massive hormonal changes that accompany the peripartum period may trigger perinatal depression. We investigated the relationship between magnitude of change and total level of estrogen and progesterone and grade of peripartal depression and depressive symptoms. One hundred and ninety two women were assessed in the 38th week of pregnancy (SDS scores), peripartum period (DSM-III-R diagnosis (n=105); SDS scores) and 6 months postpartum (EPDS; n=89) regarding diagnosis of depression, self-ratings of depressive symptoms and levels of estrogen and progesterone. The comparison of three diagnostic groups (lifetime major depressive disorder MDD (N=7), MDD at birth (N=12), healthy controls (N=70) showed that there were no differences in the magnitude of decline of estrogen and progesterone from day 1 to day 3 after birth . With respect to total levels of estrogen and progesterone, estrogen on day 3 was significantly higher [F(2,92)=6.6, p<0.05] in women with current MDD than in those with lifetime MDD or normal controls. Depression scores were significantly higher at the end of pregnancy (12.6% self-identified as depressed) than in postpartum period (5.8% day 3 p<.0004; 9.2% day 5 p<.008), whereas 13.3% of women received a DSM-III -R diagnosis for MDD 5 days postpartum. The results were in contrast to the current hypotheses of estrogen withdrawal or hypogonadal levels as an etiological factor for peripartum depression. But a limitation of the actual study is the low number of subjects with depression; therefore the current non-significant findings should be interpreted with great caution.

[Early detection of psychotic disorders]. / Früherkennung psychotischer Störungen.

UNLABELLED: Over the last decade there has been considerable interest in early intervention in schizophrenia and other psychotic disorders, driven by observations that early intervention might favorably alter the course of illness. New clinical and research programs have been established around the globe aiming to reduce treatment delays in psychosis and, more recently, to identify and possibly treat individuals in the pre-psychotic phase who are at imminent risk of developing psychosis. Since May 2004, a service for individuals at high risk (HR) for psychosis has been established at Vienna General Hospital. Individuals are offered comprehensive assessment and treatment which includes participation in a RCT investigating the effects of Omega-3 fatty acids versus placebo in addition to standard care. The aim of this article is to describe (1) classification of psychotic symptoms in incipient psychosis and (2) findings of the screening process as well as baseline characteristics in individuals with and without transition to psychosis. INCLUSION CRITERIA: 1. Age 13 to 24 years 2. High Risk (HR) as classified by Yung et al. (1998) HR criteria: one or more of following characteristics occurred within the last 12 months: 1. Frank psychotic symptoms < 1 week 2. Attenuated psychotic symptoms > 1 week, several times per week 3. Drop in GAF of > 30% (>1 months) plus family history of psychosis or individual has schizotypal personality disorder Other psychiatric measures: SCID for DSM-IV, PANSS, MADRS, and the UKU side effect rating scale. Between May 2004 and June 2005, 140 individuals were referred to our service for suspected psychosis. 69 individuals (49,3%) met HR criteria, 21 (15%) were detected with first-episode psychosis at initial presentation; 50 (35,7%) individuals did not meet criteria for HR or DSM-IV psychotic disorder. 42 (60,9%) of 69 individuals with HR agreed to participate in the proposed EPA/DHA treatment trial. Co-morbidity of axis-I disorders was high in the HR group: 54,3% affective disorders, 40% anxiety/obsessive-compulsive disorders, 14,3 substance related disorders, 11,4% eating disorders and 2,9% somatoform disorders. To date 6 (14,3%) individuals have made a transition to psychotic disorder. These subjects scored significantly higher at the negative and at the general psychopathology scale ofPANSS and at the MADRS at time of randomization. Early detection and intervention in psychotic disorders seems to be a feasible goal which can be achieved in an outpatient setting. Individuals with HR can be detected and already show a substantial loss of functioning. In the process of screening for individuals with HR a high number of undiscovered cases of psychosis can be found. Given their high prevalence, treatment of comorbid axis-I conditions should be carefully addressed in HR and studied in relation to the risk of progression to psychosis. In contrast to antipsychotics, Omega-3 fatty acids have a high acceptance among youth and parents. At this stage the role of Omega-3 fatty acids remains unclear because the trial is not finished yet.

Usefulness of the CAPE-P15 for detecting people at ultra-high risk for psychosis: Psychometric properties and cut-off values.

A need for a brief, easy to complete self-report questionnaire to detect people at ultra-high risk for psychosis (UHR) in busy clinical settings has been recognised. Our aim was to explore whether the Community Assessment of Psychic Experiences - Positive 15-items Scale (CAPE-P15) could be used as a screening tool to identify people at UHR in a clinical setting. Our objectives were to confirm the CAPE-P15 factorial structure as well as its reliability and determine cut-off values for the detection of such individuals using the Comprehensive Assessment of At-Risk Mental States (CAARMS), a commonly used clinical interview for the detection of UHR. 165 participants aged between 13 and 18 referred to the General Hospital of Vienna were included in the analysis. 50.9% of the sample were "CAARMS-positive" and 49.1% "CAARMS-negative". The Youden method determined CAPE-P15 cut-off values for UHR detection of 1.47 for both frequency of and distress associated with psychotic experiences. The cut-off value of 1.47 for frequency showed sensitivity of 77%, specificity of 58%, a positive predictive value of 66% and a negative predictive value of 71%; whilst for distress it showed sensitivity of 73%, specificity of 63%, a positive predictive value of 69% and a negative predictive value of 66%. Good reliability and the previously suggested three-correlated factor model as well as an alternative bi-factor model of the CAPE-P15 were confirmed. The CAPE-P15 seems to be a promising screening tool for identifying people who might be at UHR in busy clinical settings.

St. John's wort (Hypericum perforatum) and breastfeeding: plasma and breast milk concentrations of hyperforin for 5 mothers and 2 infants.

BACKGROUND: Herbal preparations for depression, such as St. John's wort, are often preferred over pharmaceutical preparations by mothers and midwives after childbirth because these preparations are available to patients as over-the-counter "natural" treatments and are popularly assumed to be safe. The only existing report on St. John's wort excretion into human milk showed that only 1 active component (hyperforin) was detectable in breast milk, but was not detectable in the infants' plasma. Another report found more cases of minor problems in infants breast-fed by women taking St. John's wort. However, significance was reached only in comparison with disease-matched women (p<.01), not healthy controls (p=.20). METHOD: Five mothers who were taking 300 mg of St. John's wort 3 times daily (LI 160 [Jarsin], Lichtwer Pharma GmbH; Berlin, Germany) and their breastfed infants were assessed. Thirty-six breast milk samples (foremilk and hindmilk collected during an 18-hour period) and 5 mothers' and 2 infants' plasma samples were analyzed for hyperforin levels by tandem mass spectrometry (LC/MS/MS; limit of quantification=0.1 ng/mL). Data were gathered from January 2001 to February 2002. RESULTS: Hyperforin is excreted into breast milk at low levels. However, the compound was at the limit of quantification in the 2 infants' plasma samples (0.1 ng/mL). Milk/plasma ratios ranged from 0.04 to 0.13. The relative infant doses of 0.9% to 2.5% indicate that infant exposure to hyperforin through milk is comparable to levels reported in most studies assessing anti-depressants or neuroleptics. No side effects were seen in the mothers or infants. CONCLUSION: These results add to the evidence of the relative safety of St. John's wort while breast-feeding found in previous observational studies.