Jonathan Rampono

A pilot study of newer antidepressant concentrations in cord and maternal serum and possible effects in the neonate

Antidepressants are often used antenatally, and placental transfer may lead to adverse effects (toxicity) in the neonate. Pregnant women taking fluoxetine (n=4), sertraline (n=4), paroxetine (n=2) or venlafaxine (n=1) in the last trimester were studied. Maternal and cord sera were collected at delivery and infant serum on day 5 after birth for measurement of antidepressant concentrations. Neonatal Abstinence Scores (NAS) were measured in the infants on days 13 after birth. In maternal serum, median drug concentrations were: fluoxetine (96 microg/l), norfluoxetine (110 microg/l), sertraline (11 microg/l), desmethylsertraline (38 microg/l), paroxetine (mean 12 microg/l), venlafaxine (220 microg/l), and O-desmethylvenlafaxine (392 microg/l). Corresponding median values in cord serum were: fluoxetine (65 microg/l), norfluoxetine (81 microg/l), sertraline (10 microg/l), desmethylsertraline (27 microg/l), paroxetine (mean 6 microg/l), venlafaxine (232 microg/l), and O-desmethylvenlafaxine (406 microg/l). Corresponding median cord:maternal concentration ratios were 0.67 for fluoxetine and 0.72 for norfluoxetine, 0.67 for sertraline and 0.63 for demethylsertraline, 0.52 (mean) for paroxetine, and 1.1 and 1.0 for venlafaxine and O-desmethylvenlafaxine respectively. The neonates of two patients taking fluoxetine had high NAS. Only fluoxetine and norfluoxetine were detected in infant serum. Our data show substantial placental transfer of antidepressants, but only fluoxetine persisted in the infants serum. Neonatal toxicity may be associated with serotonin uptake blockade, and also be influenced by neonatal clearance.

Early life origins of obesity.

There is increasing evidence that obesity has its origins in early life. Predisposition is based on interactions between the genome and environmental influences acting through epigenetic modifications. Individuals most at risk are those whose ancestral line has made a rapid transition from a traditional to a Westernized style of life. The process involves not only metabolism, but also behavior. As a result, those people who are most at risk of obesity may be those least likely to respond to educational programs based on lifestyle modification. Understanding the mechanisms and pathways that underpin the early origins of obesity is vital if we are to make progress in addressing this major problem of modern life.

Obstetric and neonatal outcomes of pregnant women with severe mental illness at a specialist antenatal clinic

OBJECTIVE To evaluate the obstetric and neonatal outcomes of pregnant women with severe mental illness (SMI) who attended a specialist multidisciplinary antenatal clinic in Perth, Western Australia. DESIGN, SETTING AND PARTICIPANTS A retrospective case-note audit of outcomes from the Childbirth and Mental Illness Antenatal Clinic (CAMI clinic) at King Edward Memorial Hospital for pregnant women with severe mental illness (SMI), aged 18-41 years, who gave birth between December 2007 and April 2011, and their babies. MAIN OUTCOME MEASURES Obstetric and neonatal outcomes for 138 women and newborns from singleton live births. Data were compared between three diagnostic groups (schizophrenia, bipolar and non-psychotic SMI), and with WA obstetric and perinatal statistics for 2008. RESULTS 44 women with schizophrenia, 56 with bipolar disorder and 38 with non-psychotic SMI attended antenatal care for an average of 7.7 (SD, 3.3) visits. The proportion of women who smoked tobacco was significantly higher than that in the WA antenatal population (46% v 15%; P < 0.0001). Alcohol use, illicit substance use and psychotropic medication exposure during pregnancy were high. The women were at increased risk of developing gestational diabetes mellitus (15% v 4%; P < 0.0001) and pre-eclampsia (9% v 3%; P < 0.0001), and birth complications were more common. Babies born to CAMI clinic women were less likely to have Apgar scores ≥ 8 at 1 minute and 5 minutes. Pregnant women with schizophrenia had more psychiatric relapses during pregnancy, and had more statutory child welfare involvement. Gestational age at birth and infant birth weights were similar for the pregnant women with SMI and the WA population in 2008. CONCLUSIONS Women attending our specialist clinic had increased rates of obstetric and neonatal complications compared with the general population, and were exposed to a cluster of risk factors. We report encouraging trends in antenatal attendance, gestational age at birth, and birth weights. Managing pregnant women with SMI will require a comprehensive approach aimed at early detection of obstetric complications and psychosocial difficulties, as well as neonatal monitoring. Optimising prepregnancy maternal health and welfare may also be of benefit.

In utero exposure to antidepressant medication and neonatal growth outcomes: closer examination of the evidence is needed

Thinh N. Nguyen, King Edward Memorial Hospital, Psychological Medicine, Subiaco, Perth, Western Australia, Deb Faulkner, Clinical Applications Unit, North Metropolitan Area Health Service Mental Health, Mt Claremont, Western Australia, Jonathan Rampono, King Edward Memorial Hospital, Psychological Medicine, Perth, Western Australia and Eve Blair, Centre for Child Health Research, University of Western Australia, Perth, Western Australia.

Managing pregnant women with serious mental illness: using the Edinburgh Postnatal Depression Scale as a marker of anxiety and depressive symptoms

Objective: To examine the course of depressive and anxiety symptoms using serial measurements of the Edinburgh Postnatal Depression Scale (EPDS) in pregnant women with serious mental illness (SMI) attending a specialist multi-disciplinary antenatal clinic in Perth, Western Australia. Method: A retrospective review of case notes was undertaken for 48 Western Australian pregnant women with schizophrenia and related psychoses and bipolar affective disorders who attended the Childbirth and Mental Illness (CAMI) antenatal clinic between December 2007 and November 2009. Of these patients, 27 completed the EPDS at booking (first appointment) and at 32 weeks gestation. Additional variables collected were demographic data, gestation at booking, and attendance rates for these 27 women, and for comparison another 21 women who did not complete the EPDS for one or both screening periods. Results: Mean total EPDS score decreased from 12.2 (SD 7.6) at booking to 8.5 (SD 6.4) at 32 weeks gestation (p = 0.007). Overall mean attendance rates and number of appointments were similar to the non-SMI population and in keeping with standard guidelines. Conclusions: We speculate from these preliminary findings that being managed by a consistent small multi-disciplinary team and knowing that they will be supported throughout their pregnancy could lead to improvement of anxiety and depressive symptoms in pregnant women with SMI, and has the potential to increase their attendance for antenatal care.

A methodology for timing reviews of inpatient hospital stay

OBJECTIVE This paper aims to describe a methodology to inform decisions about the optimal time to schedule reviews of a patients hospital stay and to provide an example of its implementation. METHOD Length of hospital stay was assessed in 1227 consecutive inpatient admissions. Data were transformed to reflect the probability of discharge from hospital in the following 7 days. RESULTS The resulting data reflected the points at which the conditional probability of being discharged were declining, revealing the potentially efficient times to conduct reviews of inpatient admissions. CONCLUSIONS The methodology outlined appears useful in assisting psychiatrists responsible for inpatient care to decide upon optimal times to review a patients stay in hospital.