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BACKGROUND: Misuse of drugs is a public health problem which can lead to poor health outcomes. Drug use during pregnancy could potentially harm the unborn baby. Pregnancy usually triggers women to visit their general practitioner (GP) which may provide an opportunity for drug use to be raised and recorded. To date, there are no UK studies with large sample sizes to estimate the burden of drug use during pregnancy. Therefore, my aim was to describe and understand drug use and opioid substitution treatment in and around pregnancy using electronic health records. METHODS: Using a mixed methods design, I firstly, utilized The Health Improvement Network (THIN) to estimate GP recording rates of individuals who use drugs and/or are prescribed opioid substitution treatment in the general population, of women in and around pregnancy and infants with neonatal abstinence syndrome (NAS). Next, I compared rates with national surveys and hospital birth data. Finally, I conducted qualitative interviews to gain GPs’ perspectives regarding their decisions about recording drug-use. RESULTS: GP recording trends for the general population were in keeping with national surveys, but with lower rates. Recording was relatively low in and around pregnancy. GP recording of NAS was similar to hospital data, however rates were lower. Finally, qualitative interview analysis identified that influences on recording drug use were complex and related to pressures at the individual as well as organisational (general practices, Clinical Commissioning Groups) and governmental levels in the shape of government policies. CONCLUSIONS: In conclusion, evidence from the thesis supports the use of THIN as a suitable tool for monitoring trends but not rates of problem drug use in the general population. Electronic primary health records could potentially be used to monitor the impact of problematic drug use in and around pregnancy. The thesis also supports utilising THIN for researching drug use and opioid substitution treatment in the general population.

Background: Antiepileptic drugs are prescribed for chronic conditions such as epilepsy and bipolar disorder. Without adequate management, such conditions can have detrimental effects in pregnancy. However, first trimester use of some antiepileptic drugs is associated with a two-threefold increase in the risk of major congenital malformations. When women and their health care professionals consider treatment regimens, quantified relative risks can help decide which drug, if any, would be taken during pregnancy. / Methods: Three studies were performed using UK primary care data from The Health Improvement Network (THIN). Prescribing patterns of antiepileptic drugs in pregnancy were examined. A validation study for recording of major congenital malformations and perinatal death was performed. Lastly, a cohort study of pregnant women prescribed antiepileptic drugs prior to pregnancy was conducted to examine the risk of major congenital malformations or perinatal death in different first trimester antiepileptic drugs regimens. / Results: One in 200 women were prescribed antiepileptic drugs in pregnancy. Carbamazepine, sodium valproate and lamotrigine were the most commonly used antiepileptic drugs in pregnancy between 1994 and 2012. In this period, 353,171 pregnancies were identified in THIN. The incidence of major congenital malformations was 1.9% and perinatal death was 0.4%. Amongst 1,633 pregnant women regularly prescribed antiepileptic drugs before pregnancy, there were 54 cases of major congenital malformations and perinatal deaths (3.3%, 95% CI 2.5-4.3%). The risk amongst women prescribed sodium valproate polytherapy was 12% (95% CI 5.9-21.0%) - significantly greater than those prescribed carbamazepine monotherapy (IRR 2.72, 95% CI 1.23-5.99), 5 sodium valproate monotherapy (IRR 3.42, 95% CI 1.35-8.66) and lamotrigine monotherapy (IRR 5.03, 95% CI 1.99-12.74). / Conclusions: Women taking sodium valproate polytherapy face a greater risk of major congenital malformations or perinatal death compared to other common monotherapy regimens. Further research is needed to corroborate these findings, however women and their physicians should aim to avoid sodium valproate polytherapy if possible.

Background: Although depression can affect anyone at any time, the first year after the birth of a child appears to be a time when both parents are more likely to experience depression. Research has mainly focussed on maternal perinatal or early depression which has an estimated incidence of 10-15%. Less is known about early paternal depression or early comorbid depression, where both parents experience depression. Methods: I conduct a systematic review on the prevalence of early comorbid parental depression and associated childhood outcomes. Next, I explore adolescent depression recording in UK primary care, and trends over time. Finally, I use structural equation modelling to provide a quantitative analysis of the association between early comorbid parental depression and adolescent outcomes, focussing on the effects of recurrent parental depression and internalizing behaviours in childhood. I examine depression and its intergenerational transmission using data from a large UK primary care database, The Health Improvement Network (THIN). Results: Prevalence of early comorbid depression in parents ranged from 0 to 20%. However, it was not feasible to perform a meta-analysis due to measurement variation and study quality. I identified only two studies assessing child outcomes. Diagnoses of adolescent depression and antidepressant prescribing have increased in recent years despite a temporary drop in 2002-2005. Symptom recording increased steadily between 1995-2009. I did not find evidence for an association between early comorbid parental depression and adolescent depression (OR: 2.02, 95% CI: 0.42-9.67). Early maternal depression does increase the risk of adolescent depression. The effect is mainly indirect, mediated by recurrent parental depression (OR: 1.54, 95% CI: 1.26-1.87), as opposed to direct (OR: 1.06, 95% CI: 0.69-1.63). Childhood internalizing behaviour might be an early indicator of depression risk. Conclusion: Early parental depression increases the risk of adolescent depression, but the effect is strongly mediated by recurrent parental depression.