Christina L. Wichman

Congenital Heart Disease Associated With Selective Serotonin Reuptake Inhibitor Use During Pregnancy

OBJECTIVE To determine the risk of congenital cardiac abnormalities associated with use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy. PATIENTS AND METHODS We conducted a retrospective review of the medical records of all pregnant women presenting at Mayo Clinics site in Rochester, MN, from January 1, 1993, to July 15, 2005, and identified 25,214 deliveries. A total of 808 mothers were treated with SSRIs at some point during their pregnancy. We reviewed the medical records of the newborns exposed to SSRIs during pregnancy to analyze their outcomes, specifically for congenital heart disease and persistent pulmonary hypertension of the newborn. RESULTS Of the study patients, 808 (3.2%) took an SSRI at some point during the antenatal period. Of the 25,214 deliveries, 208 newborns (0.8%) were diagnosed as having congenital heart disease. Of the 808 women exposed to SSRI during pregnancy, 3 (0.4%) had congenital heart disease compared with 205 (0.8%) of the 24,406 women not exposed to an SSRI (P=.23). Of the total number of deliveries, 16 newborns were diagnosed as having persistent pulmonary hypertension of the newborn, none of whom had exposure to SSRIs (P>.99). CONCLUSION Our data are reassuring regarding the safety of using SSRIs during pregnancy.

Managing Your Own Mood Lability: Use of Mood Stabilizers and Antipsychotics in Pregnancy

AbstractThe management of psychiatric disorders during the perinatal period can be difficult; psychiatric decompensation during pregnancy can affect not only the mother but also the fetus and neonate. It is imperative that psychiatric providers proactively discuss pregnancy planning, and be able to thoughtfully weigh the risks of untreated psychiatric illness and psychotropic medications in pregnancy and breast-feeding. With the exception of valproate and carbamazepine, several mood stabilizers and antipsychotics can be utilized during pregnancy with minimal risk to the fetus and neonate in terms of major malformations; there is a growing body of evidence regarding the risk profile of use of these medications in pregnancy. Key PointsPreconception planning is very helpful when it can be done; consider discussion and documentation of risks at time of administration of psychotropic medications for any reproductive-aged women, regardless of plans for conception.Continued psychiatric stability through the perinatal period is imperative; the risks of an untreated psychiatric disorder are just as important, if not more so important, than the risks of psychotropic medication exposure.Exposure to one psychotropic medication is safer than exposure to multiple medications.Utilize lowest effective dose of medication; most risks are not dose dependent, therefore would typically prefer higher dose of medication, rather than emergence of psychiatric symptoms, in order to avoid exposure of the fetus to both psychotropic medications and psychiatric symptoms.General recommendations are to avoid valproate and carbamazepine in reproductive-aged women.With close monitoring, lithium can be safely utilized in pregnancy.Preliminary data regarding use of atypical antipsychotics is reassuring in regards to major malformations; however, larger numbers of participants are needed to provide more complete reproductive safety data with this class.Clearly document risks of an untreated psychiatric illness as well as risks of psychotropic medication management to the mother and developing fetus/neonate.

Comparison of multiple psychological distress measures between men and women preparing for in vitro fertilization.

OBJECTIVE To compare multiple measures of psychological distress between men and women preparing for IVF. DESIGN Retrospective cohort study. SETTING Outpatient, academic infertility clinic. PATIENT(S) One hundred sixty-two consecutive couples presenting for infertility treatment with IVF. INTERVENTION(S) Measures were completed as part of a routine, infertility-focused psychological evaluation, including the Beck Depression Inventory, State-Trait Anxiety Inventory, State-Trait Anger Inventory, and Impact of Events Scale. MAIN OUTCOME MEASURE(S) Scores of above psychological questionnaires. RESULT(S) Psychological distress scores were statistically significantly higher among women than men for symptoms of depression, state anxiety, infertility specific distress, and general perceived stress. However, aside from infertility-specific distress (d = .43), effect sizes for the paired differences between females and males ranged from d = .18 to .23. CONCLUSION(S) Women consistently scored higher on multiple measures of psychological distress than their male partners in the context of preparing for IVF. Comparison of infertility-specific distress scores yielded the largest statistically and clinically significant difference compared with traditional measures of general depression and anxiety symptoms.

Takotsubo Cardiomyopathy After Electroconvulsive Therapy

Background Takotsubo cardiomyopathy is a novel acute cardiac syndrome characterized by transient regional systolic dysfunction of the left-ventricular apex and mid-ventricle, with hyperkinesis of the basal left ventricular segments, which has been associated with severe emotional or physical stress. Method This is the second published case report of takotsubo cardiomyopathy occurring in the setting of electroconvulsive therapy (ECT). Results The patient, a 52-year-old woman, experienced chest pain and discomfort shortly after ECT treatment. She was shown to have moderate left-ventricular dysfunction, with mid-cavity left-ventricular hypo- to akinesis, and hyperkinesis in the basilar region, consistent with a diagnosis of takotsubo cardiomyopathy. There was full resolution of her symptoms within 48 hours of the initial event. Discussion This report highlights a previously undocumented complication of ECT and adds to the growing list of stressors responsible for cases of takotsubo cardiomyopathy. The prognosis is favorable, and recovery is generally complete, especially with early recognition of the syndrome and proper supportive treatment.

Preparing psychiatric residents for the "real world": a practice management curriculum.

ObjectiveThe authors describe a course designed for residents to develop the knowledge and skills necessary to collaborate and successfully compete in today’s complex health care environment and to achieve competency in systems-based practice.MethodsPostgraduation surveys demonstrated a need for improvement in preparing residents for practice management issues. The authors outline a 32-week practice management curriculum for postgraduate-year 3 (PGY 3) psychiatric residents.ResultsThe course was rated highly by residents in terms of topics covered, faculty involvement, and overall expectations. The project assignments completed by the residents were effective in creating objective change in the resident outpatient practice.ConclusionPractice management is an essential part of residency training and can be successfully integrated into the residents’ clinical practice experience. Future steps include assessment of the graduates at 1 and 5 years postgraduation to evaluate the long-term efficacy of the course.

Postpartum Depression Screening Initial Implementation in a Multispecialty Practice With Collaborative Care Managers

Postpartum depression (PPD) has emerged as an important issue for pediatricians and family practitioners because of detrimental effects on children. PPD occurs in 10% to 22% of women who have recently given birth, but fewer than half of cases are recognized. Despite the impact of PPD, many primary care clinicians do not have systemic screening approaches implemented. This paper will review the development of a screening protocol for PPD in a multispecialty clinic, with the implementation utilizing depression care managers and the preliminary results of our process. Of the 333 screened examinations during the 4-month study, 38.1% (n = 127) were performed for the 2-month well child examination; 33.6% (n = 112) were for the 4-month examination, with 28.2% (n = 94) being performed for the 6-month well child examination. Only 15 (4.5%) were positive for possible depression with a screening compliance rate of 47.9%. No significant difference was noted in the timing of the well child visit with a positive screening test result, nor was there any difference in family medicine versus pediatric colleagues in the utilization of the screening or diagnosis of PPD. Implementation of PPD screening in a multispecialty clinic can be effective, given utilization of depression care managers.

Updates in Psychosomatic Medicine: 2014

BACKGROUND The amount of literature published annually related to psychosomatic medicine is vast; this poses a challenge for practitioners to keep up-to-date in all but a small area of expertise. OBJECTIVES To introduce how a group process using volunteer experts can be harnessed to provide clinicians with a manageable selection of important publications in psychosomatic medicine, organized by specialty area, for 2014. METHODS We used quarterly annotated abstracts selected by experts from the Academy of Psychosomatic Medicine and the European Association of Psychosomatic Medicine in 15 subspecialties to create a list of important articles. RESULTS In 2014, subspecialty experts selected 88 articles of interest for practitioners of psychosomatic medicine. For this review, 14 articles were chosen. CONCLUSIONS A group process can be used to whittle down the vast literature in psychosomatic medicine and compile a list of important articles for individual practitioners. Such an approach is consistent with the idea of physicians as lifelong learners and educators.

NEEDS AND CHALLENGES OF HOME VISITORS CONDUCTING PERINATAL DEPRESSION SCREENING

This article describes the needs and challenges faced by home visitors, supervisors, and clients when conducting perinatal depression screening. Home visitors (n = 11), supervisors (n = 5), and clients (n = 9) representing rural and urban practice settings in Wisconsin were recruited into three separate focus groups. Themes were identified from the transcribed audio-recorded interviews using content analysis. Results indicate that a trusting relationship was leveraged to facilitate depression screening and referral. Home visitors personalized care to a clients context and to protect confidentiality. Home-visiting practice demanded flexibility and negotiation in decision-making with clients and families. Coordinating access to mental health evaluation in areas of limited access was a common challenge. Participants reported a need for further training on safety management. With adequate training and support, home visitors are well-positioned to promote access to mental health services in vulnerable families to support infant mental health.

Encephalopathy With Psychosis Following Group A Streptococcal Sepsis—An Immune-Mediated Phenomenon?

Group A streptococcal (GAS) infections are a well-known cause of post-infectious immunemediated conditions, which may present with a variety of symptoms including neuropsychiatric symptoms, movement disturbances, and obsessive-compulsive features. We report a case of a 31 year-old woman who presented with acute psychosis characterized by severe aggression, hypersexuality, and hyper-religiosity following invasive GAS infection. Laboratory and imaging evaluation failed to identify an etiology of her psychosis. She was treated empirically with high dose corticosteroids and IVIG and had rapid clinical improvement, thereby supporting the diagnosis of a GAS-induced, immune-mediated encephalopathy. Our case depicts a unique manifestation of psychosis in an adult patient that enhances the literature on immune-mediated neuropsychiatric complications following GAS infection and reveals an overlap with other autoimmune encephalitis syndromes.