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Breastfeeding provides infants with nutrients required for optimal growth and development. We aimed to examine breastfeeding practices and supports that promote exclusive breastfeeding during the birth hospital stay among birthing parents with physical disabilities, sensory disabilities, intellectual or developmental disabilities, and multiple disabilities compared with those without a disability.This population-based cohort study was done in Ontario, Canada. We accessed and analysed health administrative data from ICES and the Better Outcomes RegistryNetwork. We included all birthing parents aged 15-49 years who had a singleton livebirth between April 1, 2012, and March 31, 2018. The study outcomes were breastfeeding practices and supports that promoted exclusive breastfeeding during the birth hospital stay, conceptualised based on WHO-UNICEF Baby Friendly Hospital Initiative guidelines. Individuals with a physical disability, sensory disability, intellectual or developmental disability, or two or more (multiple) disabilities, identified using diagnostic algorithms, were compared with individuals without disabilities on the opportunity to initiate breastfeeding, in-hospital breastfeeding, exclusive breastfeeding at hospital discharge, skin-to-skin contact, and provision of breastfeeding assistance. Relative risks (RRs) were estimated using modified Poisson regression.Our cohort included 634 111 birthing parents, of whom 54 476 (8·6%) had a physical disability, 19 227 (3·0%) had a sensory disability, 1048 (0·2%) had an intellectual or developmental disability, 4050 (0·6%) had multiple disabilities, and 555 310 (87·6%) had no disability. Individuals with intellectual or developmental disabilities were less likely than those without a disability to have an opportunity to initiate breastfeeding (adjusted RR 0·82, 95% CI 0·76-0·88), any in-hospital breastfeeding (0·85, 0·81-0·88), exclusive breastfeeding at hospital discharge (0·73, 0·67-0·79), skin-to-skin contact (0·90, 0·87-0·94), and breastfeeding assistance (0·85, 0·79-0·91). Those with multiple disabilities were less likely to have an opportunity to initiate breastfeeding (0·93, 0·91-0·96), any in-hospital breastfeeding (0·93, 0·92-0·95), exclusive breastfeeding at hospital discharge (0·90, 0·87-0·93), skin-to-skin contact (0·93, 0·91-0·95), and breastfeeding assistance (0·95, 0·92-0·98). Differences for individuals with a physical or sensory disability only were mostly non-significant.Our findings show disparities in breastfeeding outcomes between individuals without a disability and individuals with intellectual or developmental disabilities or multiple disabilities, but not individuals with physical or sensory disabilities. There is a need for further research on the factors that contribute to breastfeeding intentions, practices, and supports in people with intellectual or developmental disabilities and multiple disabilities, especially factors that affect breastfeeding decision making.National Institutes of Health and the Canada Research Chairs Program.

There is a critical need to better understand psychological treatments from a culturally sensitive lens. Using a process-oriented model, we examined treatment satisfaction among perinatal patients who received behavioral activation (BA) within a large psychotherapy trial for perinatal depression and anxiety, and explored how to optimize culturally sensitive delivery through a multistakeholder perspective.In this mixed methods study, we estimated treatment satisfaction through mean client satisfaction scores (Client Satisfaction Questionnaire [CSQ]-8) among perinatal participants (CSQ-8 scores were similar across ethnic groups,BA offers one psychotherapeutic model that uses an idiosyncratic and process-oriented approach that fosters intersectional humility and benefits from cultural humility, comfort, and opportunities. We identify key recommendations to inform culturally sensitive, evidence-based psychological treatments that include explicitly acknowledging and eliciting topics of race, ethnicity, and culture during sessions and supervision and ongoing training and supervision. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Background and Hypothesis Maternal schizophrenia heightens the risk for certain perinatal complications, yet it is not known to what degree future childhood chronic health conditions (Childhood-CC) might arise. Study Design This population-based cohort study using health administrative data from Ontario, Canada (1995–2018) compared 5066 children of mothers with schizophrenia to 25 324 children of mothers without schizophrenia, propensity-matched on birth-year, maternal age, parity, immigrant status, income, region of residence, and maternal medical and psychiatric conditions other than schizophrenia. Cox proportional hazard models generated hazard ratios (HR) and 95% confidence intervals (CI) for incident Childhood-CCs, and all-cause mortality, up to age 19 years. Study Results Six hundred and fifty-six children exposed to maternal schizophrenia developed a Childhood-CC (20.5/1000 person-years) vs. 2872 unexposed children (17.1/1000 person-years)—an HR of 1.18, 95% CI 1.08–1.28. Corresponding rates were 3.3 vs. 1.9/1000 person-years (1.77, 1.44–2.18) for mental health Childhood-CC, and 18.0 vs. 15.7/1000 person-years (1.13, 1.04–1.24) for non-mental health Childhood-CC. All-cause mortality rates were 1.2 vs. 0.8/1000 person-years (1.34, 0.96–1.89). Risk for children exposed to maternal schizophrenia was similar whether or not children were discharged to social service care. From age 1 year, risk was greater for children whose mothers were diagnosed with schizophrenia prior to pregnancy than for children whose mothers were diagnosed with schizophrenia postnatally. Conclusions A child exposed to maternal schizophrenia is at elevated risk of chronic health conditions including mental and physical subtypes. Future research should examine what explains the increased risk particularly for physical health conditions, and what preventive and treatment efforts are needed for these children.

Emergency department visits for a psychiatric reason in the post-partum period represent an acute need for mental health care at a crucial time, but little is known about the extent of timely outpatient follow-up after these visits or how individual and intersecting social determinants of health influence this outcome. This study aimed to examine outpatient mental health care follow-up by a physician in the 30 days after an individual attended the emergency department for a psychiatric reason in the post-partum period and understand how social determinants of health affect who receives follow-up care.In this population-based cohort study, routinely collected health data from Ontario, Canada were accessed through ICES to identify all post-partum individuals whose sex was listed as female on their health card and who had attended an emergency department in Ontario before the COVID-19 pandemic for a psychiatric reason. Individuals admitted to hospital at the time of the emergency department visit, who died during the visit, or who left without being seen were excluded from the study. Ethnicity data for individuals were not collected. The primary outcome was the proportion of individuals with any outpatient physician (psychiatrist or family physician) visit for a mental health reason within 30 days of the index emergency department visit. Family physician mental health visits were identified using a validated algorithm for Ontario Health Insurance Plan-billed visits and mental health diagnostic codes for community health centre visits. We examined the associations between social determinants of health (age, neighbourhood income, community size, immigration, neighbourhood ethnic diversity) and who received an outpatient mental health visit. We used modified Poisson regression adjusting for the other social determinants of health, clinical, and health services characteristics to examine independent associations with follow-up, and conditional inference trees to explore how social determinants of health intersect with each other and with clinical and health services characteristics in relation to follow-up.We analysed data collected between April 1, 2008, and March 10, 2020, after exclusions we identified 12 158 people who had attended the emergency department for a psychiatric reason in the post-partum period (mean age 26·9 years [SD 6·2]; range 13-47); 9848 individuals lived in an urban area, among these 1518 (15·5%) were immigrants and 2587 (26·3%) lived in areas with high ethnic diversity. 5442 (44·8%) of 12 158 individuals received 30-day follow-up. In modified Poisson regression models, younger age, lower neighbourhood income, smaller community size, and being an immigrant were associated with a lower likelihood of follow-up. In the CTREE, similar variables were important, with several intersections between social determinants of health and between social determinants of health and other variables.Fewer than half of emergency department visits for a psychiatric reason in the post-partum period were followed by timely outpatient care, with social-determinants-of-health-based disparities in access to care. Improvements in equitable access to post-emergency department mental health care are urgently needed in this high-risk post-partum population.Department of Psychiatry, University of Toronto; Canadian Institutes of Health Research.

Background: Chronic disease is associated with increased risk of postpartum mental illness, but the mechanisms underlying this association are unclear. Our aim was to explore the mediating role of ...

Background We examined the implementation of a brief, behavioural activation (BA) model, via telemedicine, for perinatal populations during a confluence of significant global events in 2020. We conducted a rigorous qualitative study to identify relevant barriers and facilitators from the perspectives of both perinatal participants and treatment providers. We also present two case studies where BA was used and adapted to provide patient-centered care. Methods Within the ongoing SUMMIT non-inferiority randomized controlled trial in Canada and USA, we interviewed a random selection of perinatal participants (n = 23) and all treatment providers (n = 28). A content analysis framework was developed to identify relevant barriers and facilitators and frequencies were calculated for each emergent theme within and across respondent groups. Results Key facilitators reported by participants receiving BA were that BA helped with support and social connection (73.9%), creative problem solving (26.1%) and attending to pandemic-related symptoms (21.7%). Key facilitators endorsed by providers delivering BA were the use of telemedicine (35.7%) and loosening of government restrictions (21.4%). Both participant groups reported similar barriers to BA during the pandemic such as a lack of privacy and limited activities due to pandemic restrictions. However, providers were more likely to endorse pandemic-related life stressors as a barrier to treatment delivery compared to participants (64.3% vs. 34.8%). Both participant groups experienced explicit discussion of race and the racial justice movements during sessions as beneficial and reported harms of not doing so to the therapeutic alliance. Conclusions BA offers a person-centered model to facilitate social connection through creative problem-solving for women with perinatal depressive and anxiety symptoms within the context of the COVID-19 pandemic. Explicit discussion of race and racial injustice during sessions is an important and helpful aspect in psychological treatments.

To determine the prevalence of comorbid depression and anxiety symptoms in fathers and investigate the predictors for comorbidity during the first- and second-year following birth.In a longitudinal Canadian study, couples were recruited within 3 weeks of childbirth. Fathers completed a survey after the birth of their child followed by questionnaires at 3, 6, 9, 12, 18, and 24 months postpartum on paternal depression and anxiety symptoms and potential risk factors. Sequential logistic regression was used for analysis.Of the 3217 enrolled fathers, 2544 (79.08%) provided data for at least one time point during the first year postpartum and 2442 (75.29%) in the second year. Overall, 569 fathers (22.4%) had comorbid depression and anxiety symptoms at some point during the first year postpartum (2.2% at baseline to 8.9% at 6 months), and 323 fathers (13.2%) had comorbidity at some point during their second year postpartum (8.1% at 18 months and 8.6% at 24 months). Strongest risk factors associated with paternal comorbidity were poor or fair perceived health at 4 weeks postpartum, depression before pregnancy, anxiety in the current pregnancy, significant adverse childhood experiences, positive ADHD screen, and victim of intimate partner violence.High rates of comorbidity among fathers in the first 2 years postpartum demonstrate the importance of perinatal mental health management at a family level. The identification of important modifiable comorbidity risk factors highlights areas for further research and the development of interventions to support paternal mental health to optimize child and family outcomes.

Background The extent to which heightened distress during the COVID-19 pandemic translated to increases in severe mental health outcomes is unknown. We examined trends in psychiatric presentations to acute care settings in the first 12 months after onset of the pandemic. Methods This was a trends analysis of administrative population data in Ontario, Canada. We examined rates of hospitalizations and emergency department visits for mental health diagnoses overall and stratified by sex, age and diagnostic grouping (e.g., mood disorders, anxiety disorders, psychotic disorders), as well as visits for intentional self-injury for people aged 10 to 105 years, from January 2019 to March 2021. We used Joinpoint regression to identify significant inflection points after the onset of the pandemic in March 2020. Results Among the 12 968 100 people included in our analysis, rates of mental health-related hospitalizations and emergency department visits declined immediately after the onset of the pandemic (peak overall decline of 30% [hospitalizations] and 37% [emergency department visits] compared to April 2019) and returned to near prepandemic levels by March 2021. Compared to April 2019, visits for intentional self-injury declined by 33% and remained below prepandemic levels until March 2021. We observed the largest declines in service use among adolescents aged 14 to 17 years (55% decline in hospitalizations, 58% decline in emergency department visits) and 10 to 13 years (56% decline in self-injury), and for those with substance-related disorders (33% decline in emergency department visits) and anxiety disorders (61% decline in hospitalizations). Interpretation Contrary to expectations, the abrupt decline in acute mental health service use immediately after the onset of the pandemic and the return to near prepandemic levels that we observed suggest that changes and stressors in the first 12 months of the pandemic did not translate to increased service use. Continued surveillance of acute mental health service use is warranted.

Postpartum depression (PPD) is a serious condition associated with potentially tragic outcomes, and in an ideal world PPDs should be prevented. Risk prediction models have been developed in psychiatry estimating an individual’s probability of developing a specific condition, and recently a few models have also emerged within the field of PPD research, although none are implemented in clinical care. For the present study we aimed to develop and validate a prediction model to assess individualized risk of PPD and provide a tentative template for individualized risk calculation offering opportunities for additional external validation of this tool. Danish population registers served as our data sources and PPD was defined as recorded contact to a psychiatric treatment facility (ICD-10 code DF32-33) or redeemed antidepressant prescriptions (ATC code N06A), resulting in a sample of 6,402 PPD cases (development sample) and 2,379 (validation sample). Candidate predictors covered background information including cohabitating status, age, education, and previous psychiatric episodes in index mother (Core model), additional variables related to pregnancy and childbirth (Extended model), and further health information about the mother and her family (Extended+ model). Results indicated our recalibrated Extended model with 14 variables achieved highest performance with satisfying calibration and discrimination. Previous psychiatric history, maternal age, low education, and hyperemesis gravidarum were the most important predictors. Moving forward, external validation of the model represents the next step, while considering who will benefit from preventive PPD interventions, as well as considering potential consequences from false positive and negative test results, defined through different threshold values.

OBJECTIVE: To determine common sources of concern among pregnant individuals during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: A cross-sectional, open, online electronic survey from May 9, 2020, to June 14, 2020. SETTING: Electronic survey open internationally and advertised through Canadian-based social media platforms. PARTICIPANTS: Eligible participants understood English and had been pregnant during the COVID-19 pandemic (ie, were pregnant at the time of survey completion or had delivered an infant on or after March 11, 2020). MAIN OUTCOME MEASURES: Potential sources of concern related to the pandemic, calculated as the proportion of participants who endorsed each concern among those for whom the concern was relevant. Differences in the proportion of individuals endorsing each concern were compared by parity using modified Poisson regression. Frequency of concerns was examined in terms of level of distress, as per the Kessler Psychological Distress Scale (K6), using multivariable linear regression. RESULTS: Out of 1477 participants, 87.3% were Canadian. Top concerns included the following: hospital policies related to support persons during labour (80.9%), not being able to introduce the baby to family and friends (80.1%), and developing COVID-19 while pregnant (79.2%). Primiparous participants were more likely than multiparous participants to be concerned about accessing in-person prenatal classes (51.5% vs 13.3%; relative risk = 3.88; 95% CI 2.02 to 4.98) and cancellation of hospital tours (35.0% vs 5.6%, relative risk = 6.26; 95% CI 4.25 to 9.20), among other concerns. The mean (SD) K6 score was 6.7 (3.8) within the moderate to high distress range. Number of concerns reported was associated with K6 score in both primiparous (β = 0.24; 95% CI 0.20 to 0.29; P < .0001) and multiparous (β = 0.30; 95% CI 0.24 to 0.36; P < .0001) individuals. CONCLUSION: Pregnant individuals have unique concerns during the COVID-19 pandemic and the findings indicate the importance of targeted support strategies to meet the particular needs of both primiparous and multiparous pregnant individuals.

Background Asthma is a risk factor for mental illness, but few studies have explored this association around the time of pregnancy. We studied the association between asthma and perinatal mental illness and explored the modifying effects of social and medical complexities. Methods In a population-based cohort of 846 155 women in Ontario, Canada, with a singleton live birth in 2005–2015 and no recent history of mental illness, modified Poisson regression models were constructed to examine the association between asthma diagnosed before pregnancy and perinatal mental illness, controlling for socio-demographics and medical history. We explored the modifying effects of social and medical complexities using relative excess risk due to interaction. Additional analyses examined the association between asthma and perinatal mental illness by timing and type of mental illness. Results Women with asthma were more likely than those without asthma to have perinatal mental illness [adjusted relative risk (aRR) 1.14; 95% (confidence interval) CI: 1.13, 1.16]. Asthma was associated with increased risk of diagnosis of mental illness prenatally (aRR 1.11; 95% CI: 1.08, 1.13) and post-partum (aRR 1.17; 95% CI: 1.15, 1.19) and specifically diagnoses of mood and anxiety disorders (aRR 1.14; 95% CI: 1.13, 1.16), psychotic disorders (aRR 1.20; 95% CI: 1.10, 1.31) and substance- or alcohol-use disorders (aRR 1.24; 95% CI: 1.14, 1.36). There was no effect modification related to social or medical complexity for these outcomes. Conclusions Women with asthma predating pregnancy are at slightly increased risk of mental illness in pregnancy and post-partum. A multidisciplinary management strategy may be required to ensure timely identification and treatment.

The extent of peritoneal metastases (PM) largely determines the possibility of complete or optimal cytoreductive surgery in advanced ovarian cancer. An objective scoring system to quantify the extent of PM can help clinicians to decide whether or not to embark on CRS. Therefore several scoring systems have been developed by different research teams and this review summarizes their performance in predicting a complete or optimal cytoreduction in patients with advanced ovarian cancer. A systematic search in the MEDLINE database revealed 19 articles that described a total of five main scoring systems to predict the completeness of CRS in patients with FIGO stage III-IV ovarian cancer based on the surgical exploration of the abdominal cavity; PCI, PIV, Eisenkop, Espada, and Kasper. The Peritoneal Cancer Index (PCI) and the Predictive Index Value (PIV) were mentioned most frequently and showed AUCs of 0.69-0.92 and 0.66-0.98, respectively. Due to the use of different cut-offs sensitivities and specificities greatly varied. Therefore with the current data, no scoring system could be identified as best. An objective measure of the extent of disease can be of great clinical use for identifying ovarian cancer patients for which a complete (or optimal) CRS is achievable, however due to local differences in treatment strategies and surgical policy a widely adopted objective scoring system with a standard cutoff value is not feasible. Nevertheless, objective scoring systems can play an important role to guide treatment decisions. (C) 2021 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Previous studies examining the risk of medical complications from electroconvulsive therapy have been confounded and this might contribute to its underuse. This study aimed to compare the risk of serious medical events, defined as those resulting in hospitalisation or death, among patients with depression who received electroconvulsive therapy versus patients who did not receive electroconvulsive therapy.This was a propensity score-matched, retrospective cohort study using linked population-based administrative health data for adults admitted to designated psychiatric facilities in Ontario, Canada, for more than 3 days with depression between April 1, 2007, to Feb 28, 2017. Electroconvulsive therapy exposure was defined as one or more physician billing procedure codes during hospitalisation. The unit of analysis was individual admissions and propensity score matching was used to match each exposed admission to an unexposed admission to estimate the average treatment effect of electroconvulsive therapy among those treated. The primary outcome was serious medical events, a composite of hospitalisation for medical (ie, non-psychiatric) reasons or non-suicide death within 30 days from electroconvulsive therapy exposure or matched date in the unexposed group. Effect modification was examined using tests of interaction for three clinically relevant prespecified subgroups (sex, presence of psychotic symptoms, and illness polarity). Secondary outcomes were medical hospitalisation and non-suicide death separately, suicide death, and specific serious medical events.In propensity score matched analyses, there were 10 016 psychiatric hospitalisation records (6628 women, 3388 men) with mean age 56·6 years (SD 16·3) and no ethnicity data available. 65 818 admissions were eligible for matching and 5008 were matched (1:1) in each exposure group. In the propensity score matched cohort, the incidence of serious medical events was 0·25 per person-year in the exposed group and 0·33 per person-year in the unexposed group (cause-specific hazard ratio 0·78 [95% CI 0·61-1·00]). Suicide death as a competing risk did not alter this finding. The risk of suicide death was significantly lower in the exposed (≤5 of 5008 admissions) versus the unexposed group (11 [0·2%] of 5008 admissions; p0·03). Bipolar depression, compared with unipolar depression, was associated with a greater reduction in the risk of serious medical events with electroconvulsive therapy. Electroconvulsive therapy was not associated with medical hospitalisation or non-suicide death separately, nor with any specific serious medical event.Among individuals hospitalised with depression, we found no evidence for a clinically significant increased risk for serious medical events with exposure to electroconvulsive therapy, and the risk of suicide was found to be significantly reduced, suggesting the benefits of electroconvulsive therapy for depression outcomes might outweigh its risks in this population.Norris Scholars Award, Department of Psychiatry, University of Toronto; the Canadian Institutes for Health Research.

BACKGROUND: It is unclear whether the clinical burden of postpartum mental illness has increased during the COVID-19 pandemic. We sought to compare physician visit rates for postpartum mental illness in Ontario, Canada, during the pandemic with rates expected based on prepandemic patterns. METHODS: In this population-based, repeated cross-sectional study using linked health administrative databases in Ontario, Canada, we used negative binomial regression to model expected visit rates per 1000 postpartum people for March–November 2020 based on prepandemic data (January 2016–February 2020). We compared observed visit rates to expected visit rates for each month of the pandemic period, generating absolute rate differences, incidence rate ratios (IRRs) and their 95% confidence intervals (CIs). The primary outcome was a visit to a primary care physician or a psychiatrist for any mental disorder. We stratified analyses by maternal sociodemographic characteristics. RESULTS: In March 2020, the visit rate was 43.5/1000, with a rate difference of 3.11/1000 (95% CI 1.25–4.89) and an IRR of 1.08 (95% CI 1.03–1.13) compared with the expected rate. In April, the rate difference (10.9/1000, 95% CI 9.14–12.6) and IRR (1.30, 95% CI 1.24–1.36) were higher; this level was generally sustained through November 2020. From April–November, we observed elevated visit rates across provider types and for diagnoses of anxiety, depressive and alcohol or substance use disorders. Observed increases from expected visit rates were greater for people 0–90 days postpartum compared with 91–365 days postpartum; increases were small among people living in low-income neighbourhoods. Public health units in the northern areas of the province did not see sustained elevations in visit rates after July; southern health units had elevated rates through to November. INTERPRETATION: Increased visits for mental health conditions among postpartum people during the first 9 months of the COVID-19 pandemic suggest an increased need for effective and accessible mental health care for this population as the pandemic progresses.

Objective Quantify the association between experiencing a major depressive episode (MDE) and employment earnings over the following decade among working-aged Canadian men and women. Methods Ten national Canadian Community Health Survey (CCHS 2003-2014) cycles were linked to administrative tax records (1997-2016) for individuals 18-54 years old with information on past year MDE defined by the Composite International Diagnostic Interview Short Form (n=85,155) measured at baseline. Subsequent earnings were measured annually two to ten years post-MDE. MDE cases were matched with adult controls without MDE using 1:1 greedy nearest-neighbour without replacement propensity score matching for women and men. Results Using random-effects longitudinal modelling, among women (n=6,974) in the matched cohort (average initial earnings ~$52,119/annum, 2016 Canadian real dollars), experiencing an MDE was associated with average earnings of $4,473 less in the year the MDE was reported (95%CI=-$3,215,-$5,731) and an additional $363 less/year over the following decade (95%CI=-$132,-$594). Among men (n=3,620, average initial earnings ~$76,110/annum), an MDE was associated with an initial reduction in earnings of $5,023 (95%CI=-$2,453,-$7,593) followed by an earnings decline starting with $730/year, increasing to ~$1,810/year at ten years post-MDE. Limitations Residual confounding by measures excluded from the propensity score. Only one MDE measurement limited exploring earnings trajectories of those with multiple episodes. Conclusions Consistently lower earnings were seen for ten years after experiencing one MDE. The magnitude of earnings difference immediately after the MDE was similar for men and women. Findings reveal the critical period surrounding an MDE where effective clinical treatment and labor policy may help buffer longstanding earnings loss.

While an increasing number of girls and women are being identified with autism, we know little about the health of reproductive-aged autistic women. Our objectives were to (1) describe health characteristics of reproductive-aged autistic women who could potentially become pregnant and (2) compare these characteristics with those of non-autistic women. We conducted a population-based cross-sectional study using 2017–2018 administrative health data from Ontario, Canada. A total of 6,870 fifteen- to 44-year-old autistic women were identified and compared with 2,686,160 non-autistic women. Variables of interest included social determinants of health (neighborhood income, residential instability, material deprivation, rurality), health (co-occurring medical and psychiatric conditions, use of potentially teratogenic medications, history of assault), and health care factors (continuity of primary care). Overall, reproductive-aged autistic women had poorer health compared with non-autistic women, including increased rates of material deprivation, chronic medical conditions, psychiatric conditions, use of potentially teratogenic medications, and history of assault. These findings highlight the need for health interventions tailored to the needs of reproductive-aged autistic women. Lay abstract While an increasing number of girls and women are being identified with autism, we know little about reproductive-aged autistic women’s health. This study used administrative data from Ontario, Canada, to compare the health of reproductive-aged autistic women with non-autistic women. Overall, reproductive-aged autistic women had poorer health compared with non-autistic women, including increased rates of material deprivation, chronic medical conditions, psychiatric conditions, history of assault, and use of potentially teratogenic medications (i.e. drugs that can be harmful to the development of an embryo or fetus). These findings suggest that there is a need for health interventions tailored to the needs of reproductive-aged autistic women.

Introduction The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery (CRS) improves recurrence-free (RFS) and overall survival (OS) in patients with FIGO stage III ovarian cancer. We evaluated the effect of HIPEC on patient's health-related quality of life (HRQoL) in the OVHIPEC trial. Materials and methods OVHIPEC was a multicentre, open-label, randomized phase III trial for patients with stage III ovarian cancer. Patients were randomly assigned (1:1) to receive interval CRS with or without HIPEC with cisplatin. HRQoL was assessed using the EORTC QLQ-C30, and the ovarian (QLQ-OV28) and colorectal cancer (QLQ-CR38) modules. HRQoL questionnaires were administered at baseline, after surgery, after end of treatment, and every three months thereafter. HRQoL was a secondary endpoint, with the prespecified focus on the QLQ-C30 summary score and symptom scores on fatigue, neuropathy and gastro-intestinal symptoms. HRQoL was analysed using linear and non-linear mixed effect models. Results In total, 245 patients were randomized. One-hundred-ninety-seven patients (80%) completed at least one questionnaire. No significant difference over time in the QLQ-C30 summary scores was observed between the study arms (p-values for linear and non-linear growth: p > 0.133). The pattern over time for fatigue, neuropathy and gastro-intestinal symptoms did not significantly differ between treatment arms. Conclusion The addition of HIPEC to interval CRS does not negatively impact HRQoL in patients with stage III ovarian cancer who are treated with interval CRS due to the extent of disease. These HRQoL results, together with the improvement in RFS and OS, support the viability of HIPEC as an important treatment option in this patient population. ClinicalTrials.gov number NCT00426257 . EudraCT number 2006-003466-34.

To compare the risk of interpersonal violence experienced by pregnant and postpartum individuals with physical disabilities, sensory disabilities, or intellectual or developmental disabilities with those without disabilities, and to examine whether a prepregnancy history of interpersonal violence puts individuals with disabilities, at excess risk of interpersonal violence in the perinatal period.This population-based study included all individuals aged 15-49 years with births in Ontario, Canada, from 2004 to 2019. Individuals with physical (n=147,414), sensory (n=47,459), intellectual or developmental (n=2,557), or multiple disabilities (n=9,598) were compared with 1,594,441 individuals without disabilities. The outcome was any emergency department visit, hospital admission, or death related to physical, sexual, or psychological violence between fertilization and 365 days postpartum. Relative risks (RRs) were adjusted for baseline social and health characteristics. Relative excess risk due to interaction (RERI) was estimated from the joint effects of disability and prepregnancy violence history; RERIgt;0 indicated positive interaction.Individuals with physical (0.8%), sensory (0.7%), intellectual or developmental (5.3%), or multiple disabilities (1.8%) were more likely than those without disabilities (0.5%) to experience perinatal interpersonal violence. The adjusted RR was 1.40 (95% CI 1.31-1.50) in those with physical disabilities, 2.39 (95% CI 1.98-2.88) in those with intellectual or developmental disabilities, and 1.96 (95% CI 1.66-2.30) in those with multiple disabilities. Having both a disability and any violence history produced a positive interaction for perinatal interpersonal violence (adjusted RERI 0.87; 95% CI 0.47-1.29).The perinatal period is a time of relative high risk for interpersonal violence among individuals with pre-existing disabilities, especially those with a history of interpersonal violence.

To examine the risk of perinatal mental illness, including new-onset disorders and recurrent or ongoing use of mental health care, comparing women with physical, sensory, intellectual/developmental, and multiple disabilities to those without a disability.From all women aged 15-49 years with a singleton birth in Ontario, Canada (2003-2018), those with physical (n = 144,972), sensory (n = 45,249), intellectual/developmental (n = 2,227), and ≥ 2 of these disabilities ("multiple disabilities"; n = 8,883), were compared to 1,601,363 without a disability on risk of healthcare system contact for mental illness from conception to 365 days postpartum. The cohort was stratified into: (1) no pre-pregnancy mental illness (to identify new-onset illness), (2) distal mental illness ( 2 years pre-pregnancy, to identify recurrent illness), and (3) recent mental illness (0-2 years pre-pregnancy, to identify ongoing contact). Modified Poisson regression generated relative risks (aRR), adjusted for age, parity, income quintile, and rural residence.About 14.7, 26.5, and 56.6% of women with no disabilities had new-onset, recurrent, and ongoing contact for mental illness, respectively, perinatally. Risks were elevated across disability groups for new-onset (physical: aRR 1.18, 95% CI 1.16-1.20; sensory: 1.11, 1.08-1.15; intellectual/developmental: 1.38, 1.17-1.62; multiple: 1.24, 1.15-1.33), recurrent (physical: 1.10, 1.08-1.12; sensory 1.06, 1.02-1.09; intellectual/developmental: 1.24, 1.11-1.37; multiple: 1.16, 1.09-1.23), and ongoing contact (physical: 1.09, 1.08-1.10; sensory: 1.08, 1.06-1.10; intellectual/developmental: 1.31, 1.26-1.37; multiple: 1.20, 1.16-1.23).The heightened use of new, recurrent, and ongoing mental health care across disability groups in the perinatal period suggests that adapted screening and intervention approaches are critical to optimize perinatal mental health in this population.

OBJECTIVES To assess the risk of neonatal complications among women with a disability. METHODS This population-based cohort study comprised all hospital singleton livebirths in Ontario, Canada from 2003 to 2018. Newborns of women with a physical (N = 144 187), sensory (N = 44 988), intellectual or developmental (N = 2207), or ≥2 disabilities (N = 8823) were each compared with 1 593 354 newborns of women without a disability. Outcomes were preterm birth RESULTS Risks for neonatal complications were elevated among newborns of women with disabilities compared with those without disabilities. Adjusted relative risks were especially high for newborns of women with an intellectual or developmental disability, including preterm birth CONCLUSIONS There is a mild to moderate elevated risk for complications among newborns of women with disabilities. These women may need adapted and enhanced preconception and prenatal care, and their newborns may require extra support after birth.

Background: There is growing recognition that preconception health, defined as the health of all reproductive-age individuals, impacts reproductive and perinatal outcomes. Although women with disabilities are becoming pregnant at increasing rates, little is known about their preconception health. Our objective was to describe the preconception health characteristics of women with physical, sensory, and intellectual/developmental disabilities and compare these characteristics with women without disabilities. Materials and Methods: We conducted a population-based cross-sectional study of 15- to 44-year-old women with physical (n = 253,184), sensory (n = 93,170), intellectual/developmental (n = 8,986), and multiple disabilities (n = 29,868), and women without these disabilities (n = 2,307,822) using Ontario health administrative data (2017–2018). We described preconception health variables related to social determinants of health, physical health status, psychosocial well-being, history of assault, medication use, and continuity of primary care and compared women with and without disabilities in crude and age-standardized analyses, with standardized differences >0.10 indicating clinically meaningful results. Results: Women with physical, sensory, intellectual/developmental, and multiple disabilities had poorer preconception health than women without disabilities. Disparities were pronounced for physical health status, psychosocial well-being, use of potentially teratogenic medications, and history of assault. Of all groups, women with intellectual/developmental disabilities had the greatest disparities. Conclusion: Further research is needed to identify contributors to poor preconception health among women with disabilities and to develop tailored preconception health interventions to meet their unique needs and experiences.

Objectives: To examine the relationship between prepregnancy chronic medical conditions (CMCs) and the risk of acute perinatal psychiatric health-care encounters (i.e., psychiatric emergency department visits, hospitalizations) among refugees, nonrefugee immigrants, and long-term residents in Ontario. Methods: We conducted a population-based study of 15- to 49-year-old refugees ( N = 29,189), nonrefugee immigrants ( N = 187,430), and long-term residents ( N = 641,385) with and without CMC in Ontario, Canada, with a singleton live birth in 2005 to 2015 and no treatment for mental illness in the 2 years before pregnancy. Modified Poisson regression was used to estimate the relative risk of a psychiatric emergency department visit or hospitalization from conception until 1 year postpartum among women with versus without CMC, stratified by migrant status. An unstratified model with an interaction term between CMC and migrant status was used to test for multiplicativity of effects. Results: The association between CMC and risk of a psychiatric emergency department visit or hospitalization was stronger among refugees (adjusted relative risk [aRR] = 1.87; 95% confidence interval [CI], 1.36 to 2.58) compared to long-term residents (aRR = 1.39; 95% CI, 1.30 to 1.48; interaction P = 0.047). The strength of the association was no different in nonrefugee immigrants (aRR = 1.26; 95% CI, 1.05 to 1.51) compared to long-term residents (interaction P = 0.45). Conclusion: Our study identifies refugee women with CMC as a high-risk group for acute psychiatric health care in the perinatal period. Preventive psychosocial interventions may be warranted to enhance supportive resources for all women with CMC and, in particular refugee women, to reduce the risk of acute psychiatric health care in the perinatal period.

Background : Antidepressant use in pregnancy is associated with high levels of decision-making difficulty for patients, and psychotherapy may not be effective for severe symptoms. Alternative treatment options are needed. We conducted a systematic review of the clinical effects and tolerability of non-invasive neurostimulation: repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), transcranial alternating current stimulation (tACS), trigeminal nerve stimulation (TNS), and transcutaneous vagus nerve stimulation (tVNS) for the treatment of antenatal depression. Methods : We searched PubMed, Google Scholar and Scopus for published articles in English (1990 to June 2019). Two reviewers reviewed full-text articles, assessed quality, and extracted data on maternal psychiatric, pregnancy and neonatal outcomes. Results : Of 565 articles, 21 met inclusion criteria: two RCTs (1 rTMS; 1 tDCS), four open-label studies (3 rTMS; 1 tDCS), three case series (3 rTMS), and twelve case reports (9 rTMS; 1 tDCS; 1 tACS; 1 TNS). In all but one published study (1 rTMS), non-invasive neurostimulation resulted in either response or remission of antenatal depression. Minor maternal side effects were reported in rTMS and tDCS studies, but not in other modalities. Fetal adverse effects were not reported in any intervention. A small proportion of participants dropped out of treatment (rTMS, tDCS). Limitations : Very few randomized trials have been conducted and there is significant heterogeneity in the parameters of the modalities that have been studied. Conclusions : Non-invasive neurostimulation holds promise as a potentially effective and feasible alternative treatment for antenatal depression. Strategies to enhance recruitment of pregnant women into non-invasive neurostimulation trials that have longitudinal follow-up are needed.

Background: The birth of a child with a major congenital anomaly may create chronic caregiving stress for mothers, yet little is known about their psychiatric outcomes. Aims: To evaluate the association of the birth of a child with a major congenital anomaly with subsequent maternal psychiatric risk. Methods: This Danish nationwide cohort study included mothers who gave birth to an infant with a major congenital anomaly (n = 19 220) between 1997 and 2015. Comparators were randomly selected mothers, matched on maternal age, year of delivery and parity (n = 195 399). The primary outcome was any new-onset psychiatric diagnosis. Secondary outcomes included specific psychiatric diagnoses, psychiatric in-patient admissions and redeemed psychoactive medicines. Cox models were used to estimate hazard ratios (HRs), adjusted for socioeconomic and medical variables. Results: Mothers of affected infants had an elevated risk for a new-onset psychiatric disorder vs. the comparison group (adjusted HR, 1.16, 95% CI 1.11–1.22). The adjusted HR was particularly elevated during the first postpartum year (1.65, 95% CI 1.42–1.90), but remained high for years, especially among mothers of children with multiorgan anomalies (1.37, 95% CI 1.18–1.57). The risk was also elevated for most specific psychiatric diagnoses, admissions and medicines. Conclusions: Mothers who give birth to a child with a major congenital anomaly are at increased risk of new-onset psychiatric disorders, especially shortly after birth and for mothers of children with more severe anomalies. Our study highlights the need to screen for mental illness in this high-risk population, as well as to integrate adult mental health services and paediatric care.

BackgroundThere is substantial variability in involuntary psychiatric admission rates across countries and sub-regions within countries that are not fully explained by patient-level factors. We sought to examine whether in a government-funded health care system, physician payments for filling forms related to an involuntary psychiatric hospitalization were associated with the likelihood of an involuntary admission.MethodsThis is a population-based, cross-sectional study in Ontario, Canada of all adult psychiatric inpatients in Ontario (2009–2015, n = 122 851). We examined the association between the proportion of standardized forms for involuntary admissions that were financially compensated and the odds of a patient being involuntarily admitted. We controlled for socio-demographic characteristics, clinical severity, past-health care system utilization and system resource factors.ResultsInvoluntary admission rates increased from the lowest (Q1, 70.8%) to the highest (Q5, 81.4%) emergency department (ED) quintiles of payment, with the odds of involuntary admission in Q5 being nearly significantly higher than the odds of involuntary admission in Q1 after adjustment (aOR 1.73, 95% CI 0.99–3.01). With payment proportion measured as a continuous variable, the odds of involuntary admission increased by 1.14 (95% CI 1.03–1.27) for each 10% absolute increase in the proportion of financially compensated forms at that ED.ConclusionsWe found that involuntary admission was more likely to occur at EDs with increasing likelihood of financial compensation for invoking involuntary status. This highlights the need to better understand how physician compensation relates to the ethical balance between the right to safety and autonomy for some of the world's most vulnerable patients.

Background Postpartum depression (PPD) is prevalent among adolescent mothers and is associated with negative maternal and infant outcomes. Peer support can improve health outcomes among adult and adolescent populations and involves the provision of informational, emotional, and appraisal support delivered by a peer. Purpose To describe adolescent mothers’ perceptions of a mobile phone-based peer support (MPPS) intervention designed to prevent PPD. Methods This analysis draws on data from the MPPS intervention group of a pilot randomized controlled trial of pregnant adolescents 17 to 24 years old ( n = 16). Maternal perceptions of the intervention were measured using the validated Peer Support Evaluation Inventory at 12 weeks postpartum. Results Participants acknowledged receiving supportive actions including emotional (91%), informational (66%), and appraisal (64%) support. Participants perceived positive relationship qualities with their peer mentor such as trustworthiness (94%), acceptance (75%), empathy (81%), and commitment (81%) and felt their peer mentor possessed social competence (91%) and social skills (91%). Overall, 100% of participants were satisfied with their peer support experience and would recommend this type of support to a friend. Conclusion Participants perceived their experience with the MPPS intervention positively, which lends support to MPPS as an acceptable way to provide support to adolescent mothers.

Background The low utilisation of current treatment services by people with gambling problems highlights the need to explore new modalities of delivering treatment interventions. This protocol presents the design of a pragmatic randomized control trial aimed at assessing the effectiveness and acceptability of cognitive behavioral therapy (CBT) delivered via a mobile app for people with self-reported gambling problems. Methods An innovative CBT mobile app, based on Deakin University’s GamblingLess online program, has been adapted with end-users (Manaaki). Six intervention modules have been created. These are interwoven with visual themes to represent a journey of recovery and include attributes such as avatars, videos, and animations to support end-user engagement. An audio facility is used throughout the app to cater for different learning styles. Personalizing the app has been accomplished by using greetings in the participant’s language and their name (e.g. Kia ora Tāne) and by creating personalized feedback. A pragmatic, randomized control two-arm single-blind trial, will be conducted in New Zealand. We aim to recruit 284 individuals. Eligible participants are ≥18 years old, seeking help for their gambling, have access to a smartphone capable of downloading an app, able to understand the English language and are willing to provide follow-up information at scheduled time points. Allocation is 1:1, stratified by ethnicity, gender, and gambling symptom severity based on the Gambling Symptom Assessment Scale (G-SAS). The intervention group will receive the full mobile cognitive behavioural programme and the waitlist group will receive a simple app that counts down the time left before they have access to the full app and the links to the data collection tools. Data collection for both groups are: baseline, 4-, 8-, and 12-weeks post-randomisation. The primary outcome is a change in G-SAS scores. Secondary measures include changes in gambling urges, frequency, expenditure, and readiness to change. Indices of app engagement, utilisation and acceptability will be collected throughout the delivery of the intervention. Discussion If effective, this study will contribute to the improvement of health outcomes for people experiencing gambling problems and have great potential to reach population groups who do not readily engage with current treatment services. Ethics approval NZ Health and Disability Ethics Committee (Ref: 19/STH/204) Trial registration Australian New Zealand Clinical Trial Registry (ANZCTRN 12619001605189) Registered 1 November 2019.

The authors investigated demographic, clinical, and service-utilization factors that affected the quality of diabetes care among patients with schizophrenia.This was a retrospective cohort study of adults with schizophrenia and diabetes (N=26,259) in Ontario, Canada. Quality of care was based on receipt of three guideline-concordant diabetes care procedures between 2011 and 2013. A cumulative logit regression model was used to determine characteristics associated with optimal testing.Factors associated with optimal diabetes testing included more frequent outpatient psychiatrist visits (odds ratio [OR]=1.28, 95% confidence interval [CI]=1.20-1.37) and primary care visits for nonmental health reasons (OR=2.10, 95% CI=1.85-2.39). High-frequency primary care visits for mental health reasons, any hospitalizations, and emergency visits for mental health reasons were associated with lower odds of testing.Diabetes quality of care may be contingent on receipt of medically focused primary care, psychiatric stability, and receipt of specialist psychiatric care.

Background Decisions about antidepressant use in pregnancy are complex. Little is known about how pregnancy-planning and already pregnant women making these decisions differ. Methods In 95 Canadian women having difficulty deciding whether to take antidepressants in pregnancy, we compared sociodemographic factors, clinical characteristics, and treatment intent between women planning pregnancy (preconception women) and currently-pregnant women. Results About 90% of preconception women (n = 55) were married or cohabitating and university-educated, and over 60% had an annual income of > 80,000 CAD/year; this was not different from currently-pregnant women (n = 40). Almost all women had previously used antidepressants, but preconception women were more likely to report current use (85.5% vs. 45.0%). They were more likely to have high decisional conflict (83.6% vs. 60.0%) and less likely to be under the care of a psychiatrist (29.1% vs. 52.5%). Preconception women were more likely than pregnant women to report the intent to use antidepressants (60% vs. 32.5%, odds ratio 3.11, 95% confidence interval 1.33–7.32); this was partially explained by between-group differences in current antidepressant use. Conclusions Preconception women were more likely than pregnant women to intend to use antidepressants in pregnancy, in part because more of them were already using this treatment. Strategies to enhance support for decision-making about antidepressant medication use in pregnancy may need to be tailored differently for pregnancy-planning and already pregnant women.

Postpartum depression (PPD) and postpartum psychosis (PPP) are linked to negative consequences for women and families. Virtual applications present a solution to the challenge of recruiting large samples for genetic PPD/PPP research. This study aimed to evaluate the feasibility of a protocol for enrolling Canadian women with PPD and PPP to a large international psychiatric genetics study using a mobile application (PPD-ACT), and identify clinically distinct subtypes of PPD in the recruited sample.From April 2017-June 2019, Canadian women provided phenotypic data through the PPD-ACT app. Requests for a genetic sample were made from those with a current or past PPD episode based on an Edinburgh Postnatal Depression Scale (EPDS) score 12 with onset in pregnancy or 0-3 months postpartum, and from those self-reporting lifetime PPP. Latent class analysis (LCA) was used to identify clinically distinct PPD subgroups based on participant responses to the EPDS scale.We identified 797 PPD cases, 404 of whom submitted DNA. There were 109 PPP cases, with 66 submitting DNA. PPD cases (86.7% White, mean 4.7 +/- 7.0 years since their episode) came from across Canadian provinces/territories. LCA identified two PPD classes clinically distinct by symptom severity: [1] moderate-severity (mean EPDS = 18.5+/- 2.5; 8.6% with suicidality), and [2] severe (mean EPDS = 24.5+/- 2.1; 52.8% with suicidality).A mobile application rapidly collected data from individuals with moderate and severe symptoms of PPD, an advantage for genetics where specificity is optimal, as well as from women with a history of PPP, supporting future work using this approach.

STUDY QUESTION Is the risk of attention-deficit hyperactivity disorder (ADHD) increased in children born to mothers with infertility, or after receipt of fertility treatment, compared to mothers with unassisted conception? SUMMARY ANSWER Infertility itself may be associated with ADHD in the offspring, which is not amplified by the use of fertility treatment. WHAT IS KNOWN ALREADY Infertility, and use of fertility treatment, is common. The long-term neurodevelopmental outcome of a child born to a mother with infertility, including the risk of ADHD, remains unclear. STUDY DESIGN, SIZE, DURATION This population-based cohort study comprised all singleton and multiple hospital births in Ontario, Canada, 2006–2014. Outcomes were assessed up to June 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS Linked administrative datasets were used to capture all hospital births in Ontario, maternal health and pregnancy measures, fertility treatment and child outcomes. Included were all children born at ≥24 weeks gestation between 2006 and 2014, and who were alive at age 4 years. The main exposure was mode of conception, namely (i) unassisted conception (reference group), (ii) infertility without fertility treatment (history of an infertility consultation with a physician within 2 years prior to conception but no fertility treatment), (iii) ovulation induction (OI) or intrauterine insemination (IUI) and (iv) IVF or intracytoplasmic sperm injection (ICSI). The main outcome was a diagnosis of ADHD after age 4 years and assessed up to June 2020. Hazard ratios (HRs) were adjusted for maternal age, income quintile, rurality, immigration status, smoking, obesity, parity, any drug or alcohol use, maternal history of mental illness including ADHD, pre-pregnancy diabetes mellitus or chronic hypertension and infant sex. In addition, we performed pre-planned stratified analyses by mode of delivery (vaginal or caesarean delivery), infant sex, multiplicity (singleton or multiple), timing of birth (term or preterm MAIN RESULTS AND THE ROLE OF CHANCE The study included 925 488 children born to 663 144 mothers, of whom 805 748 (87%) were from an unassisted conception, 94 206 (10.2%) followed infertility but no fertility treatment, 11 777 (1.3%) followed OI/IUI and 13 757 (1.5%) followed IVF/ICSI. Starting at age 4 years, children were followed for a median (interquartile range) of 6 (4–8) years. ADHD occurred among 7.0% of offspring in the unassisted conception group, 7.5% in the infertility without fertility treatment group, 6.8% in the OI/IUI group and 6.3% in the IVF/ICSI group. The incidence rate (per 1000 person-years) of ADHD was 12.0 among children in the unassisted conception group, 12.8 in the infertility without fertility treatment group, 12.9 in the OI/IUI group and 12.2 in the IVF/ICSI group. Relative to the unassisted conception group, the adjusted HR for ADHD was 1.19 (95% CI 1.16–1.22) in the infertility without fertility treatment group, 1.09 (95% CI 1.01–1.17) in the OI/IUI group and 1.12 (95% CI 1.04–1.20) in the IVF/ICSI group. In the stratified analyses, these patterns of risk for ADHD were largely preserved. An exception was seen in the sex-stratified analyses, wherein females had lower absolute rates of ADHD but relatively higher HRs compared with that seen among males. LIMITATIONS, REASONS FOR CAUTION Some mothers in the isolated infertility group may have received undocumented OI oral therapy, thereby leading to possible misclassification of their exposure status. Parenting behaviour, schooling and paternal mental health measures were not known, leading to potential residual confounding. WIDER IMPLICATIONS OF THE FINDINGS Infertility, even without treatment, is a modest risk factor for the development of ADHD in childhood. The reason underlying this finding warrants further study. STUDY FUNDING/COMPETING INTEREST(s) This study was made possible with funding from the Canadian Institutes of Health Research, Grant number PJT 165840. The authors report no conflict of interest. TRIAL REGISTRATION NUMBER N/A.

Background People with moderate to severe depression in pregnancy must weigh potential risks of untreated or incompletely treated depression against the small, but uncertain risks of fetal antidepressant drug exposure. Clinical support alone appears insufficient for helping individuals with this complex decision. A patient decision aid (PDA) has the potential to be a useful tool for this population. The objective of our work was to use internationally recognized guidelines from the International Patient Decision Aids Standards Collaboration to develop an evidence-based PDA for antidepressant use in pregnancy. Methods A three-phased development process was used whereby, informed by patient and physician perspectives and evidence synthesis, a steering committee commissioned a web-based PDA for those deciding whether or not to start or continue antidepressant treatment for depression in pregnancy (Phase 1). A prototype was developed (Phase 2) and iteratively revised based on feedback during field testing based on a user-centred process (Phase 3). Results We developed a web-based PDA for people deciding whether to start or continue antidepressant use for depression in pregnancy. It has five interactive sections: (1) information on depression and treatment; (2) reasons to start/continue an antidepressant and to start/stop antidepressant medication; (3) user assessment of values regarding each issue; (4) opportunity to reflect on factors that contribute to decision making; and (5) a printable PDF that summarizes the user’s journey through the PDA. Conclusions This tool, which exclusively focuses on depression treatment with Selective Serotonin Reuptake Inhibitors and Serotonin–Norepinephrine Reuptake Inhibitors, can be used by individuals making decisions about antidepressant use to treat depression during pregnancy. Limitations of the PDA are that it is not for other conditions, nor other medications that can be used for depression, and in its pilot form cannot be used by women who do not speak English or who have a visual impairment. Pending further study, it has the potential to enhance quality of care and patient experience.

Background Approaches to address unmet mental health care needs in supportive housing settings are needed. Collaborative approaches to delivering psychiatric care have robust evidence in multiple settings, however such approaches have not been adequately studied in housing settings. This study evaluates the implementation of a shifted outpatient collaborative care initiative in which a psychiatrist was added to existing housing, community mental health, and primary care supports in a women-centered supportive housing complex in Toronto, Canada. Methods The initiative was designed and implemented by stakeholders from an academic hospital and from community housing and mental health agencies. Program activities comprised multidisciplinary support for tenants (e.g. multidisciplinary care teams, case conferences), tenant engagement (psychoeducation sessions), and staff capacity-building (e.g. formal trainings, informal ad hoc questions). This mixed methods implementation evaluation sought to understand (1) program activity delivery including satisfaction with these activities, (2) consistency with team-based tenant-centered care and with pre-specified shared lenses (trauma-informed, culturally safe, harm reduction), and (3) facilitators and barriers to implementation over a one-year period. Quantitative data included reporting of program activity delivery (weekly and monthly), staff surveys, and tenant surveys (post-group surveys following tenant psychoeducation groups and an all-tenant survey). Qualitative data included focus groups with staff and stakeholders, program documents, and free-text survey responses. Results All three program activity domains (multidisciplinary supports, tenant engagement, staff capacity-building) were successfully implemented. Main program activities were multidisciplinary case conferences, direct psychiatric consultation, tenant psychoeducation sessions, formal staff training, and informal staff support. Psychoeducation for tenants and informal/formal staff support were particularly valued. Most activities were team-based. Of the shared lenses, trauma-informed care was the most consistently implemented. Facilitators to implementation were shared lenses, psychiatrist characteristics, shared time/space, balance between structure and flexibility, building trust, logistical support, and the embedded evaluation. Barriers were that the initial model was driven by leadership, confusion in initial processes, different workflows across organizations, and staff turnover; where possible, iterative changes were implemented to address barriers. Conclusions This evaluation highlights the process of successfully implementing a shifted outpatient collaborative mental health care initiative in supportive housing. Further work is warranted to evaluate whether collaborative care adaptations in supportive housing settings lead to improvements in tenant- and program-level outcomes.

Previous studies examining the risk of suicide death after treatment with electroconvulsive therapy have been confounded and the resulting uncertainty around the risk-benefit profile of electroconvulsive therapy might contribute to its underuse. We aimed to compare the risk of death by suicide after psychiatric hospitalisation among individuals with depression who had been exposed to electroconvulsive therapy with those who had not.This was a propensity score-weighted, retrospective cohort study using linked population-level administrative health data for adults with depression who had been admitted to a designated psychiatric bed in Ontario, Canada for more than 3 days between April 1, 2007 and Dec 31, 2017. Electroconvulsive therapy exposure was defined as one or more physician billing procedure codes during hospitalisation. The primary outcome was death by suicide identified using administrative health records within 365 days following discharge. We used cause-specific Cox proportional hazards model to estimate the cause-specific hazard ratio (csHR) for electroconvulsive therapy-exposed and electroconvulsive therapy-unexposed individuals. Secondary outcomes were non-suicide death and all-cause mortality.In the analytic cohort, there were 67 327 psychiatric hospitalisation records (27 231 men and 40 096 women; mean age 45·1 years [SD 16·8; range 18-103]), of whom 4982 were exposed to electroconvulsive therapy and 62 345 were not exposed to electroconvulsive therapy. No ethnicity data were available. In propensity-score weighted analyses, electroconvulsive therapy was associated with a significantly reduced risk of suicide death (csHR 0·53 [95% CI 0·31-0·92]). Accounting for non-suicide death as a competing risk had no effect on the findings. Electroconvulsive therapy was also associated with a significantly reduced risk of all-cause mortality (0·75 [0·58-0·97]), but not non-suicide death (0·83 [0·61-1·12]).Among individuals admitted to hospital with depression, electroconvulsive therapy is associated with a significantly reduced risk of death by suicide in the year after discharge. This study reinforces the importance of electroconvulsive therapy, particularly for people with severe depression.Norris Scholars Award, Department of Psychiatry, University of Toronto, and the Canadian Institutes for Health Research.

IMPORTANCE: Concerns exist about long-term neurodevelopmental consequences of prenatal exposure to antidepressants. OBJECTIVE: To evaluate whether maternal prescription fill for antidepressants in pregnancy was associated with performance in standardized tests among Danish schoolchildren. DESIGN, SETTING, AND PARTICIPANTS: Population-based retrospective cohort study of children born in Denmark between January 1, 1997, and December 31, 2009, attending public primary and lower secondary school. The children included had completed a language or mathematics test as part of the Danish National Test Program between January 1, 2010, and December 31, 2018. The age range of the eligible schoolchildren was 7 to 17 years. EXPOSURES: Maternal prescription fill for antidepressants during pregnancy, obtained from the Danish Prescription Register. MAIN OUTCOMES AND MEASURES: The difference in standardized scores between children with and without maternal prescription fill for antidepressants in mathematics and language tests (scale, 1-100; higher scores indicate better test results) was estimated using linear regression models, adjusted for relevant confounders. Ten sensitivity analyses were performed, including a sibling-controlled analysis. RESULTS: Among the 575 369 children included (51.1% males), 10 198 (1.8%) were born to mothers filling an antidepressant prescription during pregnancy. The mean (SD) age of children at the time of testing spanned from 8.9 (0.4) years in grade 2 to 14.9 (0.4) years in grade 8. Maternal prescription fill for antidepressants was significantly associated with a poorer performance in mathematics (mean test scores for the group exposed to maternal antidepressant fill: 52.1 [95% CI, 51.7-52.6] and for the group not exposed to maternal antidepressant fill: 57.4 [95% CI, 57.3-57.4]; adjusted difference, −2.2 [95% CI, −2.7 to −1.6]), but not in language (mean test scores for the exposed group: 53.4 [95% CI, 53.1-53.7] and for the not exposed group: 56.6 [95% CI, 56.5-56.6]; adjusted difference, −0.1 [95% CI, −0.6 to 0.3]). In the sibling-controlled analysis, the adjusted difference in mathematics (mean scores for the exposed group: 53.5 [95% CI, 52.7-54.3] and for the not exposed group: 59.0 [95% CI, 58.9-59.1]) was −2.8 (95% CI, −4.5 to −1.2) and in language (mean test scores for the exposed group: 53.9 [95% CI, 53.2-54.6] and for the not exposed group: 56.6 [95% CI, 56.5-56.7]) was −0.3 (95% CI, −1.9 to 1.2). CONCLUSIONS AND RELEVANCE: In this study of public schoolchildren in Denmark, children whose mothers had filled prescriptions for antidepressants during pregnancy, compared with children whose mothers did not fill prescriptions for antidepressants during pregnancy, had a 2-point lower standardized test score in mathematics, a difference that was statistically significant, but had no significant difference in language test scores. The magnitude of the difference in the mathematics test score was small and of uncertain clinical importance, and the findings must be weighed against the benefits of treating maternal depression during pregnancy.

Key Points Question How common is nonfatal self-injury (NFSI) after a cancer diagnosis, and what are the associated risk factors? Findings In this cohort study of 806 910 adults with cancer, 0.3% of the population had an NFSI event within 5 years of diagnosis. Age, history of severe psychiatric illness, and prior self-injury were the factors most strongly associated with NFSI. Meaning These findings suggest that age, prior severe psychiatric illness, and prior self-injury could be used to identify patients with cancer at risk of NFSI events., This cohort study examines the risk of nonfatal self-injury following a cancer diagnosis., Importance Psychological distress is a key component of patient-centered cancer care. While a greater risk of suicide among patients with cancer has been reported, more frequent consequences of distress, including nonfatal self-injury (NFSI), remain unknown. Objective To examine the risk of NFSI after a cancer diagnosis. Design, Setting, and Participants This population-based retrospective cohort study used linked administrative databases to identify adults diagnosed with cancer between 2007 and 2019 in Ontario, Canada. Exposures Demographic and clinical factors. Main Outcomes and Measures Cumulative incidence of NFSI, defined as emergency department presentation of self-injury, was computed, accounting for the competing risk of death from all causes. Factors associated with NFSI were assessed using multivariable Fine and Gray models. Results In total, 806 910 patients met inclusion criteria. The mean (SD) age was 65.7 (14.3) years, and 405 161 patients (50.2%) were men. Overall, 2482 (0.3%) had NFSI and 182 (

Objective Growing evidence suggests asthma increases perinatal mental illness risk, but few studies have explored the impact of asthma severity and control. Our objective was to explore the association between asthma severity and control and perinatal mental illness risk and the impact of asthma exacerbations during pregnancy on postpartum mental illness risk. Methods This was a population-based retrospective cohort study of all women in Ontario, Canada, from 2005 to 2015 with a singleton live birth who used public drug insurance, excluding women with recent history of mental illness. We constructed modified Poisson regression models to assess the risk of perinatal mental illness, defined as a mood or anxiety, psychotic or substance use disorder, self-harm or other mental illness diagnosed from conception to 365 days postnatally. Models controlled for socio-demographic factors and medical history. Results There were 62,583 women in the cohort (46.7% between 15 − 24 years), of whom 22.7% had asthma (94.3% mild, 5.7% moderate/severe; 86.5% controlled and 13.5% uncontrolled). After adjustment, there was increased risk of perinatal mental illness with mild asthma (adjusted relative risk [RR]: 1.12; 95% confidence interval [CI], 1.09 to 1.16) and moderate/severe asthma (aRR: 1.16; 95% CI, 1.04 to 1.30) compared to no asthma. Controlled asthma (aRR: 1.11; 95% CI, 1.08 to 1.15) and uncontrolled asthma (aRR: 1.19; 95% CI, 1.11 to 1.27) were also associated with increased perinatal mental illness risk compared to no asthma. Women with worsened asthma during pregnancy had the highest risk of postpartum mental illness compared to no change in asthma status (by severity: aRR: 1.57; 95% CI, 1.36 to 1.80; by control: aRR: 1.37; 95% CI, 1.22 to 1.54). Conclusion Asthma is associated with increased risk of perinatal mental illness, particularly in the presence of asthma exacerbations in pregnancy. The results support multidisciplinary collaborative care programmes throughout the perinatal period, especially among women with asthma exacerbations during pregnancy.

Background Persons with mental illness are more at risk for sedentary behaviour and associated consequences. We assessed the feasibility of outdoor walking during psychotherapy sessions in an outpatient trauma therapy program to challenge sedentary behaviour. Methods In this pilot trial in Toronto, Canada, female therapists and patients >18 years, were encouraged to walk during 12 consecutive trauma therapy sessions. Both groups were provided wearable pedometers. We assessed protocol feasibility and desirability, and 12-week changes in patient post-traumatic stress [PTSD check-list for DSM-5 (PCL-5)], and depression, anxiety, and stress symptoms [Depression, Anxiety and Stress Scale (DASS)]. Results 91% (20/22) of patients approached for the study consented to participate and 17 (85%) completed follow-up questionnaires. There was walking in 132/197 (67%) of total therapy sessions (mean 7.3 out of 10.9 sessions per participant). Inclement weather was the predominant reason for in-office sessions. At 12-week follow-up, PCL-5 mean scores decreased from 38.4 [standard deviation, ((SD) 11.8) to 30.7 (SD 14.7)], [mean difference (MD) 7.7, 95% CI: 1.5 to 13.8]; 41% (7/17) participants had a clinically significant PCL-5 score reduction of >10 points. DASS-stress mean scores decreased from 19.0 to 16.0 (MD 3.0, 95% CI: 0.3 to 5.6). No changes were observed for DASS depression (MD -0.9, 95% CI: −5.1 to 3.3) nor DASS anxiety (MD -0.2, 95% CI: −3.1 to 2.7). Daily step reporting was inconsistent and not analyzed. There was high acceptability amongst patients and therapists to walk, but not to record daily steps. There were no adverse outcomes. Conclusions It was feasible and acceptable to incorporate outdoor walking during trauma therapy sessions for patients and therapists. Weather was the greatest barrier to implementation. Further randomized-control study to compare seated and walking psychotherapy can clarify if there are psychotherapeutic and physical benefits with walking.

Background The World Health Organization recommends mothers and infants be in direct skin-to-skin contact immediately after birth and initiate breastfeeding as soon as possible. Little is known in women with schizophrenia. Methods We conducted a population-based cohort study using administrative health data from Ontario, Canada (2012–2014), comparing women with (n = 471) and without schizophrenia (n = 218 435), and their infants, on the primary outcomes of any skin-to-skin contact and opportunity to initiate breastfeeding within the first 2 h after birth. For dyads with available data, secondary outcomes of intention to breastfeed, breastfeeding support, any breastmilk, and exclusive breastmilk at discharge were assessed. Modified Poisson regression was used to generate relative risks (aRR) and 95% confidence intervals (CI), adjusted for maternal age, parity, neighbourhood income, region of residence, smoking in pregnancy, and maternal medical and non-psychotic psychiatric comorbidity for all outcomes. Results Maternal schizophrenia was associated with lower likelihood of skin-to-skin contact (65.2% vs 78.1%; aRR 0.88, 95% CI: 0.82–0.94), and breastfeeding initiation post-delivery (38.9% vs 52.6% aRR 0.80, CI: 0.71–0.90) compared to dyads unexposed to maternal schizophrenia. Secondary outcomes followed a similar pattern. The magnitude of the effect was slightly less when restricting the cohort to full-term, vaginal deliveries, not admitted to NICU, and infant not discharged to social services. Conclusions Reduced maternal-infant skin-to-skin contact and breastfeeding initiation immediately after birth may significantly impact maternal–child bonding and the establishment breastfeeding in this population. Mothers with schizophrenia may require individualized support to promote these WHO recommended hospital practices in the early post-natal period.

Introduction Comprehensive, population-based investigations of the extent and temporality of associations between common neurological and psychiatric disorders are scarce. Methods This retrospective cohort study used linked health administrative data for Ontarians aged 40–85 years on 1 April 2002, to estimate the adjusted rate of incident dementia, Parkinson’s disease (PD), stroke or mood/anxiety disorder (over 14 years) according to the presence and time since diagnosis of a prior disorder. Sex differences in the cumulative incidence of a later disorder were also examined. Results The cohort included 5,283,546 Ontarians (mean age 56.2 ± 12.1 years, 52% female). The rate of dementia was significantly higher for those with prior PD (adjusted hazard ratio [adjHR] 4.05, 95% confidence interval [CI] 3.99–4.11); stroke (adjHR 2.49, CI 2.47–2.52) and psychiatric disorder (adjHR 1.79, CI 1.78–1.80). The rate of PD was significantly higher for those with prior dementia (adjHR 2.23, CI 2.17–2.30) and psychiatric disorder (adjHR 1.77, CI 1.74–1.81). The rate of stroke was significantly higher among those with prior dementia (adjHR 1.56, CI 1.53–1.58). Prior dementia (adjHR 2.36, CI 2.33–2.39), PD (adjHR 1.80, CI 1.75–1.85) and stroke (adjHR 1.47, CI 1.45–1.49) were associated with a higher rate of an incident psychiatric disorder. Generally, associations were strongest in the 6 months following a prior diagnosis and demonstrated a J-shape relationship over time. Significant sex differences were evident in the absolute risks for several disorders. Conclusions The observed nature of bidirectional associations between these neurological and psychiatric disorders indicates opportunities for earlier diagnosis and interventions to improve patient care.

We examined the risk of any perinatal mental illness associated with prepregnancy diabetes and identified how diabetes duration, complexity, and intensity of care affect this risk. We performed a population-based study of women aged 15–49 years with (n = 14,186) and without (n = 843,818) prepregnancy diabetes who had a singleton livebirth (Ontario, Canada, 2005–2015) and no recent mental illness. Modified Poisson regression estimated perinatal mental illness risk between conception and 1 year postpartum in women with versus without diabetes and in diabetes groups, defined by a latent class analysis of diabetes duration, complexity, and intensity-of-care variables, versus women without diabetes. Women with diabetes were more likely than those without to develop perinatal mental illness (18.1% vs. 16.0%; adjusted relative risk = 1.11, 95% confidence interval: 1.07, 1.15). Latent classes of women with diabetes were: uncomplicated and not receiving regular care (59.7%); complicated, with longstanding diabetes, and receiving regular care (16.4%); and recently diagnosed, with comorbidities, and receiving regular care (23.9%). Perinatal mental illness risk was elevated in all classes versus women without diabetes (adjusted relative risks: 1.09–1.12), but results for class 2 were nonsignificant after adjustment. Women with diabetes could benefit from preconception and perinatal strategies to reduce their mental illness risk.

Background Depression in pregnancy negatively affects maternal-child health. Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation treatment for depression, has not been evaluated in pregnancy. Objective To conduct a pilot randomized controlled trial (RCT) to evaluate tDCS for antenatal depression. Methods In this pilot RCT in Toronto, Ontario (October 2014 to December 2016), adult pregnant women 14–32 weeks gestation with major depressive disorder who had declined antidepressant medication were considered for inclusion. Participants were randomly assigned 1:1 to tDCS or sham-control. Active tDCS comprised 30-min sessions of 2 mAmp direct current delivered over the dorsolateral prefrontal cortex, 5 days per week, for 3 weeks. Sham was administered similarly, but with current turned off after 30 s. Main outcomes were feasibility, acceptability, and protocol adherence. Maternal Montgomery Asperg Depression Rating Scale (MADRS) was measured post-treatment and at 4 and 12 weeks postpartum. Results Of 20 women randomized, 16 completed treatment and provided data (124 tDCS, 122 sham sessions). Views of treatment were positive with no serious adverse events. Post-treatment estimated marginal mean MADRS scores were 11.8 (standard error, SE 2.66) for tDCS and 15.4 (SE 2.51) for sham (p = 0.34). At 4 weeks postpartum, 75.0% of tDCS women were remitted versus 12.5% sham-control (p = 0.04). Conclusions Results support proceeding to a definitive RCT to evaluate tDCS for antenatal depression. The preliminary efficacy estimates immediately post-treatment and in the postpartum, are encouraging with respect to the potential use of tDCS to improve treatment rates in this population. The trial was registered at: clinical trials.gov (NCT02116127).

Objective:There is limited information to guide health-care service providers and policy makers on the burden of mental disorders and addictions across the Canadian provinces. This study compares interprovincial prevalence of major depressive disorder (MDD), bipolar disorder, generalized anxiety disorder (GAD), alcohol use disorder, substance use disorders, and suicidality.Method:Data were extracted from the 2012 Canadian Community Health Survey—Mental Health ( n = 25,113), a representative sample of Canadians over the age of 15 years across all provinces. Cross tabulations and logistic regression were used to determine the prevalence and odds of the above disorders for each province. Adjustments for provincial sociodemographic factors were performed.Results:The past-year prevalence of all measured mental disorders and suicidality, excluding GAD, demonstrated significant interprovincial differences. Manitoba exhibited the highest prevalence of any mental disorder (13.6%), reflecting high prevalence of MDD and alcohol use disorder compared to the other provinces (7.0% and 3.8%, respectively). Nova Scotia exhibited the highest prevalence of substance use disorders (2.9%). Quebec and Prince Edward Island exhibited the lowest prevalence of any mental disorder (8.5% and 7.7%, respectively). Manitoba also exhibited the highest prevalence of suicidal ideation (5.1%); however, British Columbia and Ontario exhibited the highest prevalence of suicidal planning (1.4% and 1.3%, respectively), and Ontario alone exhibited the highest prevalence of suicide attempts (0.7%).Conclusions:Significant interprovincial differences were found in the past-year prevalence of mental disorders and suicidality in Canada. More research is necessary to explore these differences and how they impact the need for mental health services.

Background Mothers with intellectual and developmental disabilities (IDD) frequently experience mental health problems. Yet, they are excluded from broader women's mental health efforts, and few services exist to support their unique mental health needs. Objectives Our objective was to identify key risk, protective, and resilience factors that affect mental health among mothers with IDD. Methods We interviewed mothers with IDD on: (1) a quantitative measure to assess demographics and depressive symptoms and (2) qualitative focus groups on parenting and mental health (analyzed through thematic analysis). There were three focus groups, for a total sample of 12 mothers with IDD. Results The 12 women in the sample had a total of 28 children, with a mean age of 11.3 years (SD = 9.9). The mean depressive symptom score in the sample was 13.8 (SD = 5.5), with 7 women scoring above the cut-off for clinically significant symptoms. Nine thematic categories were identified, organized into risks, protective factors, and resilience factors. Risks were parenting stress, life stressors, feelings of powerlessness with the child welfare system, and feeling judged. Protective factors were formal and informal supports. Resilience factors were motherhood enjoyment, having a good family life, and wishing to be independent. Conclusions Efforts to improve mental health among mothers with IDD should minimize risks that undermine adaptive capabilities and promote resilience to restore efficacy of protective systems. Better training of service-providers working with individuals with IDD, using strength-based approaches and developing alternative, autonomy-building sources of support in the form of peer support groups is recommended.

The aim of this study was to investigate the feasibility and impact of an action and coping planning intervention deployed in gambling venues to improve adherence to expenditure limits. We conducted a 2-group parallel-block randomised controlled trial comparing one 20-min session of action and coping planning to an assessment alone. Gamblers who were intending to set a monetary limit on EGMs (n = 184) were recruited in venues and administered the intervention prior to gambling. Measures were adherence to self-identified gambling limits and adherence to expenditure intentions at 30-days post-intervention using the Time Line Follow-Back. The intervention was feasible in terms of recruitment and willingness of gamblers to engage in a pre-gambling intervention. Most gamblers enacted strategies to limit their gambling prior to entering the venue, albeit these limits were on average higher than the Australian low risk gambling guidelines. In terms of impact, the intervention did not improve adherence to limits at post or 30-day follow-up assessment. However, Moderate Risk/Problem Gamblers in the Intervention group spent less (a median of $60 less) than intended (median $100) within the venue. All intervention participants intended to spend significantly less in the 30 days after the intervention compared to the amount spent in the 30 days prior to the intervention. This reduction was not found for participants in the control group. A simple brief intervention appears feasible in gambling venues and have an impact on gambling intentions over the short term.

Intimate partner violence (IPV) is common worldwide and occurs in more than one-third of American women and psychiatric patients. As well as physical injuries, it may cause mental health sequelae, such as depression, anxiety, posttraumatic stress disorder, psychosis, inability to trust others, self-harm, and a host of psychosomatic conditions, that may be referred to psychiatrists. It is imperative that psychiatrists know the risk factors, how to assist disclosure of IPV, and how to safely respond. Psychiatrists must know the best evidence-based management of IPV and its mental health sequelae to best assist patients who have been exposed to IPV.

Objective:To estimate the rates of suicide and self-harm among recent immigrants and to determine which immigrant-specific risk factors are associated with these outcomes.Methods:Population-based cohort study using linked health administrative data sets (2003 to 2017) in Ontario, Canada which included adults ≥18 years, living in Ontario ( N = 9,055,079). The main exposure was immigrant status (long-term resident vs. recent immigrant). Immigrant-specific exposures included visa class and country of origin. Outcome measures were death by suicide or emergency department visit for self-harm. Cox proportional hazards estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).Results:We included 590,289 recent immigrants and 8,464,790 long-term residents. Suicide rates were lower among immigrants ( n = 130 suicides, 3.3/100,000) than long-term residents ( n = 6,354 suicides, 11.8/100,000) with aHR 0.3, 95% CI, 0.2 to 0.3. Male–female ratios in suicide rates were attenuated in immigrants. Refugees had 2.1 (95% CI, 1.3 to 3.6; rate 6.1/100,000) and 2.8 (95% CI, 2.5 to 3.2) times the likelihood of suicide and self-harm, respectively, compared with nonrefugee immigrants. Self-harm rate was lower among immigrants ( n = 2,256 events, 4.4/10,000) than long-term residents ( n = 68,039 events, 9.7/10,000 person-years; aHR 0.3; 95% CI, 0.3 to 0.3). Unlike long-term residents, where low income was associated with high suicide rates, income was not associated with suicide among immigrants and there was an attenuated income gradient for self-harm. Country of origin-specific analyses showed wide ranges in suicide rates (1.4 to 9.9/100,000) and self-harm (1.8 to 14.9/10,000).Conclusion:Recent immigrants have lower rates of suicide and self-harm and different sociodemographic predictors compared with long-term residents. Analysis of contextual factors including immigrant class, origin, and destination should be considered for all immigrant suicide risk assessment.

Chronic stress is a known suppressor of female reproductive function. However, attempts to isolate single causal links between stress and reproductive dysfunction have not yet been successful due to their multi-faceted aetiologies. The gut-derived hormone ghrelin regulates stress and reproductive function and may therefore be pivotal in the neuroendocrine integration of the hypothalamic–pituitary–adrenal (HPA) and –gonadal (HPG) axes. Here, we hypothesised that chronic stress disrupts ovarian follicle maturation and that this effect is mediated by a stress-induced increase in acyl ghrelin and activation of the growth hormone secretatogue receptor (GHSR). We gave C57BL/6J female mice 30 min daily chronic predator stress for 4 weeks, or no stress, and gave them daily GHSR antagonist (d-Lys3-GHRP-6) or saline. Exposure to chronic predator stress reduced circulating corticosterone, elevated acyl ghrelin levels and led to significantly depleted primordial follicle numbers. GHSR antagonism stress-dependently altered the expression of genes regulating ovarian responsiveness to gonadotropins and was able to attenuate the stress-induced depletion of primordial follicles. These findings suggest that chronic stress-induced elevations of acyl ghrelin may be detrimental for ovarian follicle maturation.

Background Myocardial infarction (MI) elicits an intense acute inflammatory response that is essential for cardiac repair. However, an excessive inflammatory response also favors myocardial apoptosis, cardiac remodeling, and cardiovascular mortality. Omega-3 polyunsaturated fatty acids (ω-3) bear anti-inflammatory effects, which may mitigate the inflammatory response during MI. This study investigated whether ω-3 intake is associated with attenuation of the MI-related inflammatory response and cardiac remodeling. Methods ST-elevation MI (STEMI) patients (n = 421) underwent clinical, biochemical, nutritional, 3D echocardiogram, Cardiac Magnetic Resonance imaging (CMRi) at 30 days and 3D echocardiogram imaging at six months after the MI. Blood tests were performed at day one (D1) and day five (D5) of hospitalization. Changes in inflammatory markers (ΔD5-D1) were calculated. A validated food frequency questionnaire estimated the nutritional consumption and ω-3 intake in the last 3 months before admission. Results The intake of ω-3 below the median (

Background Decisions about antidepressant use in pregnancy are complex. We performed a pilot randomized controlled trial assessing the feasibility of a trial protocol for an online patient decision aid (PDA) for women deciding about antidepressant use in pregnancy. Methods 96 preconception and pregnant Canadian women recruited from specialist (n = 51) and non-specialist (n = 45) settings with Decisional Conflict Scale (DCS, range 0–100) score of ≥25 signifying moderate-to-high decisional conflict were randomly allocated to either the PDA or a control condition that guided participants to publicly available resources for advice around antidepressants and pregnancy. Follow-up data were collected at 4 weeks post-randomization. Results About 88.9% of eligible participants consented to participate. Women's views of the tool were positive; 88.7% of participants provided follow-up data. At follow-up, mean DCS score had decreased by 19.9 points in the PDA group vs. 13.3 in controls (adjusted mean difference, MD, 7.01, 95% CI −14.3 to 0.30). In the non-specialist setting, DCS scores decreased more for PDA users (25.5 points) than controls (10.5 points; adjusted MD −15.1, 95% CI −25.6 to −4.55); the MD was negligible in the specialist setting. Limitations The main limitation is the highly educated, high-income nature of our sample. Conclusions Evaluation of an online PDA for antidepressant use in pregnancy with national recruitment is feasible. Pilot results suggest that the tool is acceptable and reduces decisional conflict more than clinical care alone in a non-specialist setting. Evaluation of the PDA's impact on longer-term maternal and child clinical outcomes is a key next step.