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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.

Hilary K Brown,1– 5 Andrew Wilton,5 Ning Liu,5 Joel G Ray,5,6 Cindy-Lee Dennis,6,7 Simone N Vigod3– 5 1Department of Health & Society, University of Toronto Scarborough, Toronto, ON, Canada; 2Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; 3Department of Psychiatry, University of Toronto, Toronto, ON, Canada; 4Women’s College Research Institute, Women’s College Hospital, Toronto, ON, Canada; 5ICES, Toronto, ON, Canada; 6Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada; 7Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, CanadaCorrespondence: Hilary K BrownDepartment of Health & Society, University of Toronto Scarborough, 1265 Military Trail, Toronto, ON, M1C 1A4, CanadaTel +1 416 208 2239Email hk.brown@utoronto.caBackground: Studies have demonstrated elevated risk for autoimmune disease associated with perinatal mental illness, but the extent to which this risk is specific to mental illness arising perinatally, and not mental illness generally, is unknown. Our objective was to compare the risk of autoimmune disease in women with mental illness arising within the perinatal period to (1) women with mental illness arising outside the perinatal period and (2) women who did not develop mental illness.Methods: We conducted a population-based matched cohort study of women aged 15– 49 years with no history of mental illness or autoimmune disease in Ontario, Canada, 1998– 2018. The exposed, 60,701 women with mental illness arising between conception and 365 days postpartum were propensity score-matched to (1) 264,864 women with mental illness arising non-perinatally and (2) 469,164 women who did not develop mental illness. Hazard ratios (HR) for autoimmune disease were generated using Cox proportional hazards models.Results: The incidence of autoimmune disease was similar among women with mental illness arising perinatally compared to those with mental illness arising non-perinatally (138.4 vs 140.7 per 100,000 person-years; HR 0.98, 95% CI 0.92– 1.05), and elevated among women with mental illness arising perinatally compared to those who did not develop mental illness (138.4 vs 88.9 per 100,000 person-years; HR 1.54, 95% CI 1.44– 1.64). The HR for the latter comparison was more pronounced for autoimmune disease with brain-reactive antibodies than other autoimmune disease.Conclusion: Perinatal mental illness is associated with increased risk of autoimmune disease that is no different than that of mental illness arising non-perinatally. Women with mental illness, regardless of the timing of onset, could benefit from early detection of autoimmune disease.Keywords: autoimmune diseases, cohort studies, mental disorders, women’s health

Background Methods Results Conclusions Population studies have shown that rates of depressive and anxious symptoms have increased as a result of COVID‐19. We analyzed trends in the dispensing rates of antidepressants and benzodiazepines in Canada to determine whether the pandemic has caused changes in rates of pharmacological treatment for depression and anxiety.We conducted a population‐based, cross‐sectional time‐series analysis of antidepressants and benzodiazepines dispensed monthly by Canadian community pharmacies between January 2017 and December 2020. We used March 2020 as the intervention month to determine if there were any significant changes in the national rate of antidepressant and benzodiazepine tablets dispensed as the result of the COVID‐19 pandemic.There was a temporary reduction in the dispensing rate of antidepressants in April 2020 (from 489 tablets per 100 in March 2020 to 356 tablets per 100 in April 2020;p ≤ .0001);however, the rate returned to its previous level by August 2020. There were no detectable deviations in benzodiazepine dispensing after the declaration of the state of emergency in Ontario.Despite the increased reporting of depressive and anxious symptoms during the COVID‐19 pandemic, there have been no changes in the dispensing trends of medications used to treat these disorders. As the pandemic continues to evolve, future research is needed to monitor the prevalence of depression and anxiety, and associated medication use, in the Canadian population. [ FROM AUTHOR] Copyright of Depression & Anxiety (1091-4269) is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

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.

Background 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. Methods 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. Results 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). Conclusions 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.

To what extent the COVID-19 pandemic and its containment measures influenced mental health in the general population is still unclear.To assess the trajectory of mental health symptoms during the first year of the pandemic and examine dose-response relations with characteristics of the pandemic and its containment.Relevant articles were identified from the living evidence database of the COVID-19 Open Access Project, which indexes COVID-19-related publications from MEDLINE via PubMed, Embase via Ovid, and PsycInfo. Preprint publications were not considered.Longitudinal studies that reported data on the general population's mental health using validated scales and that were published before 31 March 2021 were eligible.An international crowd of 109 trained reviewers screened references and extracted study characteristics, participant characteristics, and symptom scores at each timepoint. Data were also included for the following country-specific variables: days since the first case of SARS-CoV-2 infection, the stringency of governmental containment measures, and the cumulative numbers of cases and deaths.In a total of 43 studies (331 628 participants), changes in symptoms of psychological distress, sleep disturbances, and mental well-being varied substantially across studies. On average, depression and anxiety symptoms worsened in the first 2 months of the pandemic (standardized mean difference at 60 days, -0.39 [95% credible interval, -0.76 to -0.03]); thereafter, the trajectories were heterogeneous. There was a linear association of worsening depression and anxiety with increasing numbers of reported cases of SARS-CoV-2 infection and increasing stringency in governmental measures. Gender, age, country, deprivation, inequalities, risk of bias, and study design did not modify these associations.The certainty of the evidence was low because of the high risk of bias in included studies and the large amount of heterogeneity. Stringency measures and surges in cases were strongly correlated and changed over time. The observed associations should not be interpreted as causal relationships.Although an initial increase in average symptoms of depression and anxiety and an association between higher numbers of reported cases and more stringent measures were found, changes in mental health symptoms varied substantially across studies after the first 2 months of the pandemic. This suggests that different populations responded differently to the psychological stress generated by the pandemic and its containment measures.Swiss National Science Foundation. (PROSPERO: CRD42020180049).

Objective To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization. Method Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1–18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization. Results In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P Conclusions Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

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.

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.

Autistic children experience high rates of anxiety. Insistence on sameness behaviour (IS) is a core feature of autism that appears correlated with anxiety severity. The objective of this study was to examine the longitudinal relations between anxiety and IS in autistic children using a developmental cascade model. A longitudinal cohort of 421 autistic children was followed between 4 and 11 years of age. Anxiety was quantified using items from the Anxiety Problems subscale of the Child Behavior Checklist; sameness behaviours were measured using the Repetitive Behavior Scale-Revised, Ritualistic/sameness subscale (both parent-report measures). Structural equation modelling was used to examine the longitudinal and directional associations between anxiety and IS at four time-points, through cross-lagged panel models (CLPM) with and without a random-intercepts component (RI-CLPM). Both the CLPM and the RI-CLPM had good fit. Significant directional associations were detected whereby elevated or increasing IS preceded elevated or increasing anxiety symptoms 1-2 years later, respectively. Stable baseline tendencies towards anxiety and IS as between-person traits (intercepts) were strongly associated (standardized estimate = 0.69, p 0.001). The magnitude of the cross-sectional associations between anxiety and IS appeared to lessen with age. IS and anxiety symptoms in autism are closely related. They appear to be shared traits that mirror each other particularly in younger children. Increasing IS may be a sign of emerging future anxiety. Interventions that target IS to reduce or prevent anxiety amongst school-aged autistic children merit further study.

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.

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.

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.

ImportanceResiding in a low-income neighborhood is generally associated with worse pregnancy outcomes. It is not known if moving from a low- to higher-income area between 2 pregnancies alters the risk of adverse birth outcomes in the subsequent birth compared with women who remain in low-income areas for both births.ObjectiveTo compare the risk of adverse maternal and newborn outcomes among women who achieved upward area-level income mobility vs those who did not.Design, Setting, and ParticipantsThis population-based cohort study was completed in Ontario, Canada, from 2002 to 2019, where there is universal health care. Included were all nulliparous women with a first-time singleton birth at 20 to 42 weeks’ gestation, each residing in a low-income urban neighborhood at the time of the first birth. All women were then assessed at their second birth. Statistical analysis was conducted from August 2022 to April 2023.ExposureMovement from a lowest-income quintile (Q1) neighborhood to any higher-income quintile neighborhood (Q2-Q5) between the first and second birth.Main Outcomes and MeasuresThe maternal outcome was severe maternal morbidity or mortality (SMM-M) at the second birth hospitalization or up to 42 days post partum. The primary perinatal outcome was severe neonatal morbidity or mortality (SNM-M) within 27 days of the second birth. Relative risks (aRR) and absolute risk differences (aARD) were estimated by adjusting for maternal and infant characteristics.ResultsA total of 42 208 (44.1%) women (mean [SD] age at second birth, 30.0 [5.2] years) experienced upward area-level income mobility, and 53 409 (55.9%) women (age at second birth, 29.0 [5.4] years) remained in income Q1 between births. Relative to women who remained in income Q1 between births, those with upward mobility had a lower associated risk of SMM-M (12.0 vs 13.3 per 1000 births), with an aRR of 0.86 (95% CI, 0.78 to 0.93) and aARD of −2.09 per 1000 (95% CI, −3.1 to −0.9 per 1000 ). Likewise, their newborns experienced lower respective rates of SNM-M (48.0 vs 50.9 per 1000 live births), with an aRR of 0.91 (95% CI, 0.87 to 0.95) and aARD of −4.7 per 1000 (95% CI, −6.8 to −2.6 per 1000).Conclusions and RelevanceIn this cohort study of nulliparous women living in low-income areas, those who moved to a higher-income area between births experienced less morbidity and death in their second pregnancy, as did their newborns, compared with those who remained in low-income areas between births. Research is needed to determine whether financial incentives or enhancement of neighborhood factors can reduce adverse maternal and perinatal outcomes.

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 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.

Background Telemedicine adoption has grown significantly due to the coronavirus of 2019 pandemic; however, it remains unclear what the impact of widespread telemedicine use is on healthcare utilization among individuals with psychosis. Objectives To investigate the impact of telemedicine use on changes in healthcare utilization among patients with chronic psychotic disorders (CPDs). Study Design We conducted a population-based, retrospective propensity-matched cohort study using healthcare administrative data in Ontario, Canada. Patients were included if they had at least one ambulatory visit between March 14, 2020 and September 30, 2020 and a CPD diagnosis any time before March 14, 2020. Telemedicine users (2+ virtual visits after March 14, 2020) were propensity score-matched 1:1 with standard care users (minimum of 1 in-person or virtual ambulatory visit and maximum of 1 virtual visit after March 14, 2020) based on several baseline characteristics. Monthly use of various healthcare services was compared between the two groups from 12 months before to 3 months after their index in-person or virtual ambulatory visit after March 14, 2020 using generalized estimating equations (eg, hospitalizations, emergency department [ED] visits, and outpatient physician visits). The slope of change over the study period (ie, rate ratio) as well as a ratio of slopes, were calculated for both telemedicine and standard care groups for each outcome. Study Results A total of 18 333 pairs of telemedicine and standard care patients were identified after matching (60.8% male, mean [SD] age 45.4 [16.3] years). There was a significantly greater decline across time in the telemedicine group compared to the standard care group for ED visits due to any psychiatric conditions (ratio of slopes for telemedicine vs standard care (95% CI), 0.98 (0.98 to 0.99)). However, declines in primary care visit rates (ratio of slopes for telemedicine vs standard care (1.01 (1.01 to 1.02)), mental health outpatient visits with primary care (1.03 (1.03 to 1.04)), and all-cause outpatient visits with primary care (1.01 (1.01 to 1.02)), were steeper among the standard care group than telemedicine group. Conclusions Overall, patients with CPDs appeared to benefit from telemedicine as evidenced by increased outpatient healthcare utilization and reductions in ED visits due to psychiatric conditions. This suggests that telemedicine may have allowed this patient group to have better access and continuity of care during the initial waves of the pandemic.

ImportanceEvidence indicates that immigrant women and women residing within low-income neighborhoods experience higher adversity during pregnancy. Little is known about the comparative risk of severe maternal morbidity or mortality (SMM-M) among immigrant vs nonimmigrant women living in low-income areas.ObjectiveTo compare the risk of SMM-M between immigrant and nonimmigrant women residing exclusively within low-income neighborhoods in Ontario, Canada.Design, Setting, and ParticipantsThis population-based cohort study used administrative data for Ontario, Canada, from April 1, 2002, to December 31, 2019. Included were all 414 337 hospital-based singleton live births and stillbirths occurring between 20 and 42 weeks’ gestation, solely among women residing in an urban neighborhood of the lowest income quintile; all women were receiving universal health care insurance. Statistical analysis was performed from December 2021 to March 2022.ExposuresNonrefugee immigrant status vs nonimmigrant status.Main Outcomes and MeasuresThe primary outcome, SMM-M, was a composite outcome of potentially life-threatening complications or mortality occurring within 42 days of the index birth hospitalization. A secondary outcome was SMM severity, approximated by the number of SMM indicators (0, 1, 2 or ≥3 indicators). Relative risks (RRs), absolute risk differences (ARDs), and odds ratios (ORs) were adjusted for maternal age and parity.ResultsThe cohort included 148 085 births to immigrant women (mean [SD] age at index birth, 30.6 [5.2] years) and 266 252 births to nonimmigrant women (mean [SD] age at index birth, 27.9 [5.9] years). Most immigrant women originated from South Asia (52 447 [35.4%]) and the East Asia and Pacific (35 280 [23.8%]) regions. The most frequent SMM indicators were postpartum hemorrhage with red blood cell transfusion, intensive care unit admission, and puerperal sepsis. The rate of SMM-M was lower among immigrant women (2459 of 148 085 [16.6 per 1000 births]) than nonimmigrant women (4563 of 266 252 [17.1 per 1000 births]), equivalent to an adjusted RR of 0.92 (95% CI, 0.88-0.97) and an adjusted ARD of −1.5 per 1000 births (95% CI, −2.3 to −0.7). Comparing immigrant vs nonimmigrant women, the adjusted OR of having 1 SMM indicator was 0.92 (95% CI, 0.87-0.98), the adjusted OR of having 2 indicators was 0.86 (95% CI, 0.76-0.98), and the adjusted OR of having 3 or more indicators was 1.02 (95% CI, 0.87-1.19).Conclusions and RelevanceThis study suggests that, among universally insured women residing in low-income urban areas, immigrant women have a slightly lower associated risk of SMM-M than their nonimmigrant counterparts. Efforts aimed at improving pregnancy care should focus on all women residing in low-income neighborhoods.