Laura M. Robertson

Serum Concentrations of Antidepressants and Benzodiazepines in Nursing Infants: A Case Series

Objective. The relative risk of psychotropic medication use in women with puerperal psychiatric illness who are breastfeeding has yet to be quantified adequately. Although the emotional and medical benefits of breastfeeding and adverse effects of maternal depression on infant development are well described, how these absolute benefits weigh against the potential effects of psychotropic drug use during lactation to ultimately guide clinical decisions is still unclear. The objective of this report was to evaluate the extent that psychotropic medications were present in the serum of infants breastfed by mothers treated with antidepressants and benzodiazepines. Design. Serum samples were obtained from 35 nursing infants whose mothers were treated with psychotropic medications while breastfeeding. When a detectable concentration of medication was reported, information regarding infant behavior was obtained by maternal report. Setting. The Perinatal and Reproductive Psychiatry Program at Massachusetts General Hospital serves as a regional consultation center for the treatment of psychiatric disorders during pregnancy and the postpartum period. Patients. Subjects were mothers referred to the Perinatal Psychiatry Program for consultation regarding the relative safety of psychotropic medication use while breastfeeding. Primary Outcome Measures. Presence of detectable levels of medication in infants whose mothers breastfed while taking psychotropic medications during pregnancy and/or during the puerperium and the well-being (based on maternal report) of infants who had detectable serum concentrations of medication. Results. Seventy-four percent (n = 26) of infants had serum medication concentrations below the laboratory limit of detection (assay sensitivity 5–50 ng/mL). In the remaining 26% of the sample (n = 9), serum concentrations of psychotropic medications and/or active metabolites were detected. In each of these cases, infants had been exposed to the medication during pregnancy. Medications were not detected in infant serum when mothers had taken these agents solely during the postpartum period. No readily apparent difficulties with the infants were reported by mothers. Conclusions. These data support the low incidence of infant toxicity and adverse effects associated with antidepressant and benzodiazepine use during breastfeeding. These data also suggest that infant serum monitoring is helpful in the assessment of medication exposure in children of mothers who breastfeed while using psychotropic medications. Given the limited accumulated data regarding serum concentrations of psychotropic medications in breastfeeding infants, no single agent seems to be safer than another. Therefore, choice of pharmacologic treatment should be guided by the likelihood that it will result in restoration of maternal psychiatric well-being.

Course of panic disorder during pregnancy and the puerperium: A preliminary study

Pregnancy has been referred to as a time of well-being for patients with psychiatric disorder. However, this impression is derived primarily from anecdotal reports and retrospective studies, rather than systematic prospective evaluation. In this study, 10 pregnant women with previous histories of panic disorder were evaluated prospectively across pregnancy and the postpartum period using the Structured Clinical Interview for DSM-III-R and the Clinical Global Impression. Information regarding pharmacotherapy received was also recorded. Seven of 10 subjects continued to meet DSM-III-R criteria for panic disorder at all trimester visits. Symptoms persisted for some patients even in the context of treatment with antipanic medications. Most subjects (n = 9) met DSM-III-R criteria at 1-3 months postpartum despite nearly uniform intensification of antipanic treatment. Although some women may experience diminished symptoms of panic during pregnancy, in this sample most continued to experience panic attacks and to require antipanic treatment to control symptoms.

Low prevalence of antibody to hepatitis C virus in an urban adolescent population

We tested 869 subjects attending either an urban adolescent medicine clinic or a school-based clinic for antibody to hepatitis C virus. Demographic data indicated a representative study sample, and behaviors associated with hepatitis C virus transmission. One subject (0.1%) was seropositive for antibody to hepatitis C virus, indicating a very low prevalence of hepatitis C virus exposure in adolescents.

Use of hormonal methods of birth control among sexually active adolescent girls.

OBJECTIVE To identify factors associated with the use of various birth control methods among sexually active adolescent girls. DESIGN A survey distributed as part of a larger study measuring compliance with hepatitis B vaccination. SETTING A hospital-based and a school-based clinic. MEASURES Demographic and health behavior data including sexual activity, contraceptive method, substance use, condom use, and history of sexually transmitted diseases (STDs) were collected. Birth control method was confirmed by medical record review. Associations with the outcome variable of birth control method were analyzed using chi square, Kruskal-Wallis analyses of variance, and t-tests, followed by logistic regression analysis. RESULTS Among sexually experienced girls, 39% (n = 123) reported using oral contraceptive pills (OCPs), 5.4% (n = 17) used Depo-Provera (medroxyprogesterone acetate) or Norplant (levonorgestrel), and 55.6% (n = 175) used no hormonal method. Logistic regression analysis revealed that the factors most significantly associated with the use of hormonal methods were older age (odds ratio [OR] = 1.19; 95% confidence interval [CI], 1.07-1.33), not using a condom at last intercourse (OR = 0.55; CI, 0.34-0.90), and having had a well visit within 1 year (OR = 2.11; CI, 1.12-3.70). OCP users were less likely than Depo-Provera or Norplant users to have used alcohol (p = 0.041), cigarettes (p = 0.002), or marijuana (p = 0.018) in the past 30 days. OCP users were less likely than nonusers of hormonal methods to have smoked cigarettes (p = 0.034) or marijuana (p = 0.052). The school-based clinic had a greater proportion of subjects using long-acting progestins (p < 0.001). CONCLUSIONS The decreased rate of condom use among those who used hormonal birth control methods and the different rates of health risk behaviors among users of various methods require targeted counseling efforts to decrease pregnancy and STD rates among young women.

Predictors of Seroprotection Rates Achieved 12 Months after Initiating the Hepatitis B Vaccination Series

Predictors of Seroprotection Rates Achieved 12 Months after Initiating the Hepatitis B Vaccination Series

ADOLESCENTS' KNOWLEDGE OF HEALTH INSURANCE. † 32

Objective: To identify factors associated with adolescent knowledge of their health insurance. Design: Data was analyzed from a questionnaire administered to 831 patients at a hospital-based adolescent medicine clinic as part of a study of compliance with the hepatitis B vaccination series. In addition to health insurance coverage, the questionnaire contained items pertaining to demographics, health status, academic achievement, substance use, sexual activity, and transportation to the clinic. Actual health insurance data for the time at which patients completed the questionnaire was available from the hospital database for all but nine patients. The final sample (n=822) was 71.8% female, 45.6% black, 18.2% white, 20.2% Hispanic, and 1.3% Asian. Mean age of participants was 16.4 years (range 11.1-24.9 years). Associations between independent variables and knowledge of health insurance coverage were determined using chi square analysis and unpaired t-tests followed by logistic regression.Results: 50.7% correctly identified their type of health insurance. 65.2% of Medicaid patients and 76.3% of hospital free care patients knew how their medical bills were paid versus 17.9% of self pay patients and 47.3% of patients with private insurance (p<.001). Patients who did not know their type of health insurance (mean age=15.9, SD=2.8) were younger than those who did (mean age=16.8, SD=2.7) (p<.001). Patients using oral contraceptives were more likely to know their insurance (p<.05), while patients with migraine headaches were less likely to know (p<..05). Health risk behaviors positively associated with insurance knowledge include sexual activity(p<.001), history of having had a sexually transmitted disease(STD)(p<.05), and having smoked cigarettes in the last 30 days (p<.05). Cocaine use in the last 30 days (p<.001) and sharing needles to inject drugs (p<.01) were negatively associated with knowing insurance coverage. Logistic regression modeling reveals the most significant covariates of insurance knowledge to be older age (OR=1.12, 95% CI=1.06-1.20), history of having had a STD (OR=1.71, CI=1.04-2.82), recent cigarette use (OR=1.12, CI=1.02-1.23) and cocaine use (OR=0.18, CI=0.05-0.69), self payment of medical bills (OR=0.13, CI=0.08-0.21), and migraine headaches (OR=0.47, CI=0.28-0.79).Conclusions: 49.3% of adolescents do not know how their medical bills are paid. The education of adolescents regarding health insurance coverage is increasingly important with the advent of managed care and need for confidential health services among this patient population.

FACTORS ASSOCIATED WITH ADOLESCENTS' COMPLIANCE WITH THE HEPATITIS B VACCINATION SERIES. |[bull]| 24

Objective: To determine the compliance among adolescents and measure the associations of various demographic and behavioral factors with compliance with a standard hepatitis B vaccination series. Design: Eight hundred twenty six patients from a hospital-based adolescent medicine clinic were enrolled. The participants received a standardized education about hepatitis B and the immunization schedule (0,1, and 6 months) and filled out questionnaires investigating demographic factors, risk behaviors, risk factors for obtaining hepatitis B, medication use, chronic illnesses, and experience, knowledge and attitudes about hepatitis B and the immunization series. They then received their first hepatitis B vaccination. Compliance is being followed and is defined as having received the second vaccine within 61 days and the third vaccine within 274 days of enrollment. The associations between the dependent and independent variables were measured using chi square analysis with Mantel-Haentszel test for trend for ordinal covariates, followed by a stepwise logistic regression analysis. Results: 28.5% are male. 18.5% are white, 45.6% black, 20.4% Hispanic, 1.4% Asian, 14.2% other. 18.5% are self-pay, 33.4% Medicaid, 9.7% free care, 38.4% private insurance. The age range of patients is 11.1-24.9 years. 49.9% were compliant with the second vaccine. 46.7% of those who could have been compliant with vaccination 3 were compliant. Factors associated with compliance with the second vaccine on bivariate analysis are female gender (P<0.001), white race (P<0.001), presence of an eating disorder (P=0.043), knowledge that hepatitis B is sexually transmitted (P=0.015), increased travel time to the clinic (P=0.029), the use of birth control pills (P=0.002) and vitamins (P=0.048), knowing someone who had received the series (P=0.018), and academic achievement(P=0.030). Factors associated with noncompliance include Medicaid(P<0.001), marijuana use (P=0.020), and cocaine use (P=0.048). Logistic regression modeling reveals that the covariates with compliance are white race(OR=3.84, 95% CI=2.47-5.96), female gender (OR=1.70, CI=1.20-2.40), knowledge that hepatitis B is sexually transmitted (OR=2.16, CI=0.91-5.12), and self-reported academic achievement (OR=1.12, CI=1.00-1.26).Conclusion: 49.9% of adolescents are compliant with the dosing schedule for the second hepatitis B vaccination. Knowledge of factors related to noncompliance may facilitate targeted interventions for reaching teens at risk.

Postpartum Prophylaxis for Women With Bipolar Disorder

OBJECTIVE The postpartum period has typically been considered a time of heightened vulnerability for development of affective disorders, and women with bipolar disorder have consistently demonstrated vulnerability to puerperal worsening of mood. This retrospective study examined the extent to which mood-stabilizing agents provide prophylactic benefit to bipolar women during the postpartum period. METHOD The clinical course of 27 women meeting the DSM-III-R criteria for bipolar disorder was followed during pregnancy and the postpartum period. Information regarding severity of illness (as measured by number of episodes of mania, depression, or both) was obtained, in addition to data on pharmacotherapy (if any) received before, during, and after pregnancy. The extent to which the prophylactic use of antimanic agents minimized the risk of relapse was explored. RESULTS Only one of the 14 patients taking prophylactic agents during the acute puerperium relapsed within the first 3 months postpartum, while eight of the 13 who did not receive antimanic drugs showed evidence of recurrent affective instability during those 3 months. A survival analysis indicated that the women receiving prophylactic treatment with mood stabilizers maintained well-being significantly longer than the women who did not receive such treatment. CONCLUSIONS Women with bipolar disorder appear to benefit from puerperal prophylaxis with mood stabilizers. Consistent with results of earlier studies, postpartum prophylaxis was associated with lower rates of relapse into affective disorders. The findings have implications for the early identification and treatment of subgroups of women at particular risk for puerperal illness.