Louise M. Howard

Effects of perinatal mental disorders on the fetus and child

Perinatal mental disorders are associated with increased risk of psychological and developmental disturbances in children. However, these disturbances are not inevitable. In this Series paper, we summarise evidence for associations between parental disorders and offspring outcomes from fetal development to adolescence in high-income, middle-income, and low-income countries. We assess evidence for mechanisms underlying transmission of disturbance, the role of mediating variables (underlying links between parent psychopathology and offspring outcomes) and possible moderators (which change the strength of any association), and focus on factors that are potentially modifiable, including parenting quality, social (including partner) and material support, and duration of the parental disorder. We review research of interventions, which are mostly about maternal depression, and emphasise the need to both treat the parents disorder and help with associated caregiving difficulties. We conclude with policy implications and underline the need for early identification of those parents at high risk and for more early interventions and prevention research, especially in socioeconomically disadvantaged populations and low-income countries.

Non-psychotic mental disorders in the perinatal period

Mental disorders are among the most common morbidities of pregnancy and the postnatal period, and can have adverse effects on the mother, her child, and family. This Series paper summarises the evidence about epidemiology, risk factors, identification, and interventions for non-psychotic mental disorders. Although the phenomenology and risk factors for perinatal mental disorders are largely similar to those for the disorders at other times, treatment considerations differ during pregnancy and breastfeeding. Most randomised controlled trials have examined psychosocial and psychological interventions for postnatal depression, with evidence for effectiveness in treating and preventing the disorder. Few high-quality studies exist on the effectiveness or safety of pharmacological treatments in the perinatal period, despite quite high prescription rates. General principles of prescribing of drugs in the perinatal period are provided, but individual risk-benefit analyses are needed for decisions about treatment.

Experiences of domestic violence and mental disorders: a systematic review and meta-analysis.

Background Little is known about the extent to which being a victim of domestic violence is associated with different mental disorders in men and women. We aimed to estimate the prevalence and odds of being a victim of domestic violence by diagnostic category and sex. Methods Study design: Systematic review and meta-analysis. Data Sources: Eighteen biomedical and social sciences databases (including MEDLINE, EMBASE, PsycINFO); journal hand searches; scrutiny of references and citation tracking of included articles; expert recommendations, and an update of a systematic review on victimisation and mental disorder. Inclusion criteria: observational and intervention studies reporting prevalence or odds of being a victim of domestic violence in men and women (aged ≥16 years), using validated diagnostic measures of mental disorder. Procedure: Data were extracted and study quality independently appraised by two reviewers. Analysis: Random effects meta-analyses were used to pool estimates of prevalence and odds. Results Forty-one studies were included. There is a higher risk of experiencing adult lifetime partner violence among women with depressive disorders (OR 2.77 (95% CI 1.96–3.92), anxiety disorders (OR 4.08 (95% CI 2.39–6.97), and PTSD (OR 7.34 95% CI 4.50–11.98), compared to women without mental disorders. Insufficient data were available to calculate pooled odds for other mental disorders, family violence (i.e. violence perpetrated by a non-partner), or violence experienced by men. Individual studies reported increased odds for women and men for all diagnostic categories, including psychoses, with a higher prevalence reported for women. Few longitudinal studies were found so the direction of causality could not be investigated. Conclusions There is a high prevalence and increased likelihood of being a victim of domestic violence in men and women across all diagnostic categories, compared to people without disorders. Longitudinal studies are needed to identify pathways to being a victim of domestic violence to optimise healthcare responses.

Prevalence and Risk of Violence and the Physical, Mental, and Sexual Health Problems Associated with Human Trafficking: Systematic Review

Siân Oram and colleagues conduct a systematic review of the evidence on the health consequences of human trafficking. They describe a limited and poor-quality evidence base, but some evidence suggests a high prevalence of violence and mental distress among women and girls trafficked for sexual exploitation, among other findings.

‘Diagnostic overshadowing’: worse physical health care for people with mental illness

It is now well established that people with mental illness die prematurely and have significantly higher medical co-morbidity compared with the general population (1), and that there are a number of possible reasons for this as discussed by Leucht et al. in the November issue 2007 of the Acta Psychiatrica Scandinavica (2). One of these may be diagnostic overshadowing , a process by which physical symptoms are misattributed to mental illness. This concept has received little attention in the psychiatric literature but mental health service users have reported its widespread occurrence (3) and its potential impact has been emphasized in two recent reports (4, 5).

Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period

The perinatal period is associated with an increased risk of severe mental disorders. We summarise the evidence regarding the epidemiology, risk factors, and treatment of severe mental illness in relation to childbirth, focusing on bipolar disorder, affective psychosis, and schizophrenia. We discuss women with ongoing chronic conditions and those with the onset of new episodes of post-partum psychosis. Despite the importance of perinatal episodes, with suicide a leading cause of maternal death, few studies are available to guide the management of women with severe mental disorders in pregnancy and the post-partum period. However, general principles of management are discussed, including the need for an individual risk-benefit analysis for each woman.

Domestic violence and severe psychiatric disorders: prevalence and interventions

BACKGROUND The lifetime prevalence of domestic violence in women is 20-25%. There is increasing recognition of the increased vulnerability of psychiatric populations to domestic violence. We therefore aimed to review studies on the prevalence of, and the evidence for the effectiveness of interventions in, psychiatric patients experiencing domestic violence. METHOD Literature search using Medline, PsycINFO and EMBASE applying the following inclusion criteria: English-language papers, data provided on the prevalence of or interventions for domestic violence, adults in contact with mental health services. RESULTS Reported lifetime prevalence of severe domestic violence among psychiatric in-patients ranged from 30% to 60%. Lower rates are reported for men when prevalence is reported by gender. No controlled studies were identified. Low rates of detection of domestic violence occur in routine clinical practice and there is some evidence that, when routine enquiry is introduced into services, detection rates improve, but identification of domestic violence is rarely used in treatment planning. There is a lack of evidence on the effectiveness of routine enquiry in terms of morbidity and mortality, and there have been no studies investigating specific domestic violence interventions for psychiatric patients. CONCLUSIONS There is a high prevalence of domestic violence in psychiatric populations but the extent of the increased risk in psychiatric patients compared with other populations is not clear because of the limitations of the methodology used in the studies identified. There is also very limited evidence on how to address domestic violence with respect to the identification and provision of evidence-based interventions in mental health services.

Refugee, asylum seeker, immigrant women and postnatal depression: rates and risk factors

Postnatal depression (PND) is recognised as a common maternal health problem, but little evidence examines PND among refugee, asylum seeker and immigrant women in developed country settings. This review aimed to identify the rates of PND and highlight common risk factors among this group of women. An iterative and dynamic literature search was conducted across ten databases to identify published articles on PND among immigrant, asylum-seeking and refugee women in developed country settings. Medical Subject Headings (MeSH) and ‘free text’ search terms, as well as thesaurus terms, acronyms and truncation were used where appropriate. Findings suggest that PND may affect up to 42% of migrant women, compared to around 10–15% of native-born women. Common risk factors for PND among migrant women include history of stressful life events, lack of social support and cultural factors. With a growing number of babies born to immigrant mothers, greater awareness of PND among this group is needed in order to respond to their particular maternal mental health needs. Maternity care providers should regard all recent immigrants as at high risk of PND and give closer observation and support as necessary.

Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study

BACKGROUND Mental health service users are at high risk of domestic violence but this is often not detected by mental health services. AIMS To explore the facilitators and barriers to disclosure of domestic violence from a service user and professional perspective. METHOD A qualitative study in a socioeconomically deprived south London borough, UK, with 18 mental health service users and 20 mental health professionals. Purposive sampling of community mental health service users and mental healthcare professionals was used to recruit participants for individual interviews. Thematic analysis was used to determine dominant and subthemes. These were transformed into conceptual maps with accompanying illustrative quotations. RESULTS Service users described barriers to disclosure of domestic violence to professionals including: fear of the consequences, including fear of Social Services involvement and consequent child protection proceedings, fear that disclosure would not be believed, and fear that disclosure would lead to further violence; the hidden nature of the violence; actions of the perpetrator; and feelings of shame. The main themes for professionals concerned role boundaries, competency and confidence. Service users and professionals reported that the medical diagnostic and treatment model with its emphasis on symptoms could act as a barrier to enquiry and disclosure. Both groups reported that enquiry and disclosure were facilitated by a supportive and trusting relationship between the individual and professional. CONCLUSIONS Mental health services are not currently conducive to the disclosure of domestic violence. Training of professionals in how to address domestic violence to increase their confidence and expertise is recommended.

Obesity and Mental Disorders During Pregnancy and Postpartum: A Systematic Review and Meta-analysis

OBJECTIVE: To evaluate the prevalence and risk of antenatal and postpartum mental disorders among obese and overweight women. DATA SOURCES: Seven databases (including MEDLINE and ClinicalTrials.gov) were searched from inception to January 7, 2013, in addition to citation tracking, hand searches, and expert recommendations. METHODS OF STUDY SELECTION: Studies were eligible if antenatal or postpartum mental disorders were assessed with diagnostic or screening tools among women who were obese or overweight at the start of pregnancy. Of the 4,687 screened articles, 62 met the inclusion criteria for the review. The selected studies included a total of 540,373 women. TABULATION, INTEGRATION, AND RESULTS: Unadjusted odds ratios were pooled using random-effects meta-analysis for antenatal depression (n=29), postpartum depression (n=16), and antenatal anxiety (n=10). Obese and overweight women had significantly higher odds of elevated depression symptoms than normal-weight women and higher median prevalence estimates. This was found both during pregnancy (obese odds ratio [OR] 1.43, 95% confidence interval [CI] 1.27–1.61, overweight OR 1.19, 95% CI 1.09–1.31, median prevalence: obese 33.0%, overweight 28.6%, normal-weight 22.6%) and postpartum (obese OR 1.30, 95% CI 1.20–1.42, overweight OR 1.09, 95% CI 1.05–1.13, median prevalence: obese 13.0%, overweight 11.8%, normal-weight 9.9%). Obese women also had higher odds of antenatal anxiety (OR 1.41, 95% CI 1.10–1.80). The few studies identified for postpartum anxiety (n=3), eating disorders (n=2), or serious mental illness (n=2) also suggested increased risk among obese women. CONCLUSION: Health care providers should be aware that women who are obese when they become pregnant are more likely to experience elevated antenatal and postpartum depression symptoms than normal-weight women, with intermediate risks for overweight women.