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Pregnancy is a complex and vulnerable period that presents a number of challenges to women, including the development of postpartum psychiatric disorders (PPDs). These disorders can include postpartum depression and anxiety, which are relatively common, and the rare but more severe postpartum psychosis. In addition, other PPDs can include obsessive-compulsive disorder, post-traumatic stress disorder and eating disorders. The aetiology of PPDs is a complex interaction of psychological, social and biological factors, in addition to genetic and environmental factors. The goals of treating postpartum mental illness are reducing maternal symptoms and supporting maternal-child and family functioning. Women and their families should receive psychoeducation about the illness, including evidence-based discussions about the risks and benefits of each treatment option. Developing effective strategies in global settings that allow the delivery of targeted therapies to women with different clinical phenotypes and severities of PPDs is essential.

Background: Single parent families, including families headed by single fathers, are becoming increasingly common around the world. Previous evidence suggests that single parenthood is associated with adverse health outcomes and increased mortality; however, most studies have focused on single mothers, with little known about the health of single fathers. This study aimed to examine mortality in a large population-based sample of Canadian single fathers compared with single mothers and partnered fathers and mothers., Methods: We used a representative sample of 871 single fathers, 4590 single mothers, 16 341 partnered fathers, and 18 688 partnered mothers from the Canadian Community Health Survey (cycles 2001-12; earliest survey date: Sept 5, 2000; latest survey date: Dec 24, 2012). We anonymously linked survey participants to health administrative database records to ascertain health status at baseline and mortality from survey date up to Oct 28, 2016. We included individuals who were aged 15 years or older, living in a household with one or more biological or adopted child younger than 25 years, and living in Ontario, and we excluded those who left Ontario during the study period or had data discrepancies. Single parents were defined as those who were divorced, separated, widowed, or single, never-married, and non-cohabitating, and partnered parents were defined as those who were married or common-law partners. We investigated differences in mortality using Cox proportional hazards models with adjustment for sociodemographic, lifestyle, and clinical factors., Findings: Median follow-up was 11·10 years (IQR 7·36-13·54). Mortality in single fathers (5·8 per 1000 person-years) was three-times higher than rates in single mothers (1·74 per 1000 person-years) and partnered fathers (1·94 per 1000 person-years). Single fathers had a significantly higher adjusted risk of dying than both single mothers (hazard ratio [HR] 2·49, 95% CI 1·20-5·15; p=0·01) and partnered fathers (2·06, 1·11-3·83; p=0·02)., Interpretation: In this first head-to-head comparison of mortality across single and partnered parent groups, we found that single fathers had the least favourable risk factor profile and greatest risk of mortality. Social histories might help physicians identify these high-risk patients. Further work is needed to understand the causes of this high mortality risk and how clinical and public health interventions can improve lifestyle and behavioural risk factors., Funding: Ontario Ministry of Health and Long-Term Care., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Involuntary admissions to psychiatric hospitals are common; however, research examining the trends in prevalence over time and predictors is limited. Aims To examine trends in prevalence and risk factors for involuntary admissions in Ontario, Canada., Method: We conducted an analysis of all mental health bed admissions from 2009 to 2013 and assessed the association between patient sociodemographics, service utilisation, pathway to care and severity characteristics for involuntary admissions using a modified Poisson regression., Results: We found a high and increasing prevalence of involuntary admissions (70.7% in 2009, 77.1% in 2013, 74.1% overall). Individuals with police contact in the prior week (risk ratio (RR) = 1.20) and immigrants both experienced greater likelihood of being involuntarily admitted, regardless of control for other characteristics (RR = 1.07) (both P < 0.0001)., Conclusions: We identified numerous modifiable and non-modifiable risk factors for involuntary admissions. The prevalence of involuntary admissions was high, linearly increasing over time. Declaration of interest The authors have completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. This study was conducted using funding entirely from public sources. P.K. has received operational support via an Ontario Ministry of Health and Long-Term Care (MOHLTC) Health Services Research Fund Capacity Award to support this project. The Institute for Clinical Evaluative Sciences (ICES) is funded by the Ontario MOHLTC. The study results and conclusions are those of the authors, and should not be attributed to any of the funding agencies or sponsoring agencies. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. All decisions regarding study design, publication, and data analysis were made independent of the funding agencies.

Background: People with schizophrenia have an increased burden of cardiovascular diseases (CVD); however, little is known about the cardiovascular risk factor profiles of non-institutionalised individuals with schizophrenia. This study estimated the prevalence of CVD risk factors in a population-based sample of Canadians with and without schizophrenia., Methods: Ontario respondents of the Canadian Community Health Survey were linked to administrative health databases; using a validated algorithm, we identified 1103 non-institutionalised individuals with schizophrenia and 156 376 without schizophrenia. We examined the prevalence of eight CVD risk factors: smoking, diabetes, hypertension, obesity, physical inactivity, fruit/vegetables consumption, psychosocial stress and binge drinking. To examine temporal trends, we compared prevalence estimates from 2001-2005 to 2007-2010., Results: The prevalence of most CVD risk factors was significantly higher among those with schizophrenia than the general population. Obesity and diabetes prevalence increased by 39% and 71%, respectively, in the schizophrenia group vs 11% and 24%, respectively, in the non-schizophrenia group between the two time periods. Unlike the general population, smoking rates among those with schizophrenia did not decline. Almost 90% of individuals with schizophrenia had at least one CVD risk factor and almost 40% had ≥3 co-occurring risk factors., Conclusion: Individuals with schizophrenia had a greater prevalence of individual and multiple CVD risk factors compared with those without schizophrenia, which persisted over time. Our findings suggest that public health efforts to reduce the burden of CVD risk factors have not been as effective in the schizophrenia population, thus highlighting the need for more targeted interventions and prevention strategies., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Morbidity and mortality after deliberate self-harm (DSH) are high, so mental health care shortly after DSH is recommended. Using population-level health data we determined the association between a mental health visit and risk for repeat DSH with or without intensive care unit (ICU) admission or all-cause death. Over two years, 23,140 individuals had emergency department treatment for DSH. Within 30 days, 10.7% had a family physician mental health visit, 17.1% visited a psychiatrist, 3.6% visited both and 68.6% neither. Individuals who received mental health follow-up had more chronic and severe mental illness and higher acuity DSH. Over five years, repeat DSH occurred in 4792 (20.7%). Repeat DSH was more common in those who had a mental health visit within 30 days. Adjusting for baseline characteristics attenuated these differences. Similar results were found for DSH with ICU admission (5.0%) and death (7.6%). More frequent follow-up was not associated with better outcome. Timely access to mental health care after DSH was poor at 31%. Follow-up care had virtually no association with subsequent risk, so treatment as usual is insufficient. Post-DSH care augmented with evidence-based interventions is required., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To characterize youth who use the emergency department (ED) as a "first contact" for mental health (MH) problems., Method: This was a population-based cross-sectional cohort study using linked health and demographic administrative datasets of youth 10 to 24 years of age with an incident MH ED visit from April 1, 2010, to March 31, 2014, in Ontario, Canada. We modeled the association of demographic, clinical, and health service use characteristics with having no prior outpatient MH care in the preceding 2-year period ("first contact") using modified Poisson models., Results: Among 118,851 youth with an incident mental health ED visit, 14.0% were admitted. More than half (53.5%) had no prior outpatient MH care, and this was associated with younger age (14-17 versus 22-24 years old: risk ratio [RR] = 1.09, 95% CI = 1.07-1.10), rural residence (RR = 1.16, 95% CI = 1.14-1.18), lowest versus highest income quintile (RR = 1.04, 95% CI = 1.03-1.06), and refugee immigrants (RR = 1.17, 95% CI = 1.13-1.21) and other immigrants (RR = 1.10, 95% CI = 1.08-1.13) versus nonimmigrants. The 5.1% of the cohort without a usual provider of primary care had the highest risk of first contact (RR = 1.78, 95% CI = 1.77-1.80). A history of low-acuity ED use and individuals whose primary care physicians were in the lowest tertile for mental health visit volumes were associated with higher risk., Conclusion: More than half of youth requiring ED care had not previously sought outpatient MH care. Associations with multiple markers of primary care access characteristics suggest that timely primary care could prevent some of these visits., (Copyright © 2017 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Lone parenthood is associated with poorer health; however, the vast majority of previous studies have examined lone mothers and only a few have focused on lone fathers. We aimed to examine the self-rated health and mental health status among a large population-based cross-sectional sample of Canadian lone fathers compared with both partnered fathers and lone mothers., Methods: We investigated differences in self-rated health and mental health among 1058 lone fathers compared with 20 692 partnered fathers and 5725 lone mothers using the Ontario component of the Canadian Community Health Survey (2001-2013). Multivariable logistic regression was used to compare the odds of poor/fair self-rated health and mental health between the study groups while adjusting for a comprehensive list of sociodemographic factors, stressors and lifestyle factors., Results: Lone fathers and lone mothers showed similar prevalence of poor/fair self-rated health (11.6% and 12.5%, respectively) and mental health (6.2% and 8.4%, respectively); the odds were similar even after multivariable adjustment. Lone fathers showed higher odds of poor/fair self-rated health (OR 1.53, 95% CI 1.07 to 2.17) and mental health (OR 2.09, 95% CI 1.26 to 3.46) than partnered fathers after adjustment for sociodemographic factors; however, these differences were no longer significant after accounting for stressors, including low income and unemployment., Conclusions: In this large population-based study, lone fathers had worse self-rated health and mental health than partnered fathers and similarly poor self-rated health and mental health as lone mothers. Interventions, supports and social policies designed for single parents should also recognise the needs of lone fathers., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: Individuals with schizophrenia are more likely to develop diabetes than individuals without schizophrenia. The objective of this study was to determine the quality of diabetes care and diabetes-related health outcomes among individuals with and without schizophrenia., Method: We conducted a retrospective cohort study. As of April 1, 2011, we identified all individuals with diabetes in Ontario with and without a diagnosis of schizophrenia. The main outcomes were quality of diabetes care (guideline-concordant testing for HbA1c, lipid testing, eye exams) and diabetes-related Emergency Department (ED) visits and hospitalizations between April 1, 2011 and March 31, 2013. We compared quality of care and diabetes outcomes among those with and without schizophrenia, adjusting for demographic, illness severity, and health service utilization variables., Results: We identified 1,131,375 individuals with diabetes, among whom 25,628 (2.3%) had schizophrenia. Schizophrenia was associated with reduced likelihood of optimal diabetes care (all 3 of HbA1c, lipid testing, and eye exams) (adjusted OR (95% CI): 0.64 (0.61-0.67)) and increased likelihood of diabetes-related ED visits (adjusted OR (95% CI): 1.34 (1.28-1.41)) and hospitalizations (adjusted OR (95% CI): 1.36 (1.28-1.43))., Conclusion: Individuals with diabetes and schizophrenia have lower rates of recommended testing and higher rates of diabetes-related hospital visits than those with diabetes but without schizophrenia. Research is needed to understand patient, provider, and system factors underlying these disparities and test related interventions to close the gaps in quality of care., (Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.)

Background: Women with intellectual and developmental disabilities have high rates of pregnancy complications. However, their postpartum health is largely unknown. We compared risks for postpartum hospital admissions and emergency department visits among women with and without intellectual and developmental disabilities., Methods: We conducted a population-based study using linked Ontario (Canada) health and social services administrative data to identify singleton live births to women with (N = 3,803) and without intellectual and developmental disabilities (N = 378,313) (2002-2012). Outcomes were hospital admissions and emergency department visits in the 42 days following delivery discharge. We classified these as medical or psychiatric depending on the recorded primary discharge diagnosis., Results: Women with intellectual and developmental disabilities, compared to those without, had increased risk for postpartum hospital admissions overall (2.4% vs. 1.2%; adjusted hazard ratios [aHR]: 1.76, 95% confidence interval [CI]: 1.43-2.17) and for psychiatric reasons (0.8% vs. 0.1%; aHR: 10.46, 95% CI: 6.96-15.70), but not for medical reasons. They also had increased risk for postpartum emergency department visits overall (16.6% vs. 7.9%; aHR: 1.85, 95% CI: 1.71-2.01) and for both medical (15.8% vs. 7.8%; aHR: 1.80, 95% CI: 1.66-1.96) and psychiatric reasons (1.3% vs. 0.1%; aHR: 5.66, 95% CI: 4.17-7.69)., Conclusions: High rates of postpartum hospital admissions and emergency department visits among women with intellectual and developmental disabilities demonstrate that this group may be vulnerable to acute complications or inadequate preventive care after childbirth. Providing enhanced health services during the postpartum period, in the form of longer or more frequent visits or specialized supports, could optimize their outcomes following delivery.

Mental health conditions are one of the most common reasons for postpartum emergency department (ED) visits. Characteristics of women using the ED and their mental health service use before presentation are unknown. We characterized all women in Ontario, Canada (2006-2012), who delivered a live born infant and had a psychiatric ED visit within 1 year postpartum (n = 8728). We compared those whose ED visit was the first physician mental health contact since delivery to those who had accessed mental health services on specific indicators of marginalization hypothesized to be associated with lower likelihood of mental health contact prior to the ED visit. For 60.4 % of women, this was the first physician mental health contact since delivery. The majority were presenting with a mood or anxiety disorder, and only 13.6 % required hospital admission. These women were more likely to have material deprivation and residential instability than women with contact (Q5 vs. Q1 aORs 1.30, 95 % CI 1.12-1.50; 1.17, 95 % CI 1.01-1.36), to live in rural vs. urban areas (aOR 1.58, 95 % CI 1.38-1.80), and to be low vs. high income quintile (aOR 1.18, 95 % CI 1.01-1.38). The frequent use of ED services as the first point of contact for mental health concerns suggests that interventions to improve timely and equitable access to effective outpatient postpartum mental health care are needed. Marginalized women are at particularly high risk of not having accessed outpatient services prior to an ED visit, and therefore, future research and interventions will specifically need to consider the needs of this group.

Objective: Women with intellectual and developmental disabilities (IDD) have high rates of adverse perinatal outcomes. However, the perinatal health of women with co-occurring IDD and mental illness (dual diagnosis) is largely unknown. Our objectives were to 1) describe a cohort of women with dual diagnosis in terms of their social and health characteristics and 2) compare their risks for adverse maternal and neonatal outcomes to those of women with IDD only., Method: We conducted a population-based study using linked Ontario (Canada) health and social services administrative data to identify singleton obstetric deliveries to women with dual diagnosis (n = 2080) and women with IDD only (n = 1852; 2002-2012). Primary maternal outcomes were gestational diabetes, gestational hypertension, preeclampsia/eclampsia, and venous thromboembolism. Primary neonatal outcomes were preterm birth, small for gestational age, and large for gestational age. We also examined several secondary outcomes., Results: Women with dual diagnosis were more likely than women with IDD only to live in poor neighborhoods and to have prepregnancy health conditions; however, they had more frequent prenatal care. Infants born to women with dual diagnosis had increased risks for preterm birth (adjusted relative risk [aRR] 1.31, 95% confidence interval [CI] 1.08 to 1.59) and neonatal morbidity (aRR 1.35, 95% CI 1.03 to 1.76) compared with infants born to women with IDD only. All other primary and secondary outcomes were nonsignificant., Conclusions: Comorbid mental illness contributes little additional risk for adverse perinatal outcomes among women with IDD. Women with dual diagnosis and women with IDD alone require increased surveillance for maternal and neonatal complications., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Simone Vigod was awarded a one-time consulting honorarium from MDH Consulting for continuing medical education activities related to perinatal mental health., (© The Author(s) 2016.)

Existing research on barriers to breast and cervical cancer screening uptake has focused primarily on socio-demographic characteristics of individuals. However, contextual factors, such as service organization, as well as healthcare providers' training and practices, are more feasibly altered to increase health service use. The objective of the authors in this study was to perform a critical systematic review of the literature to identify contextual factors at the provider- and system-level that were associated with breast and cervical cancer screening uptake. Studies published from 2000 to 2013 were identified through PubMed and PsycInfo. Methodologic quality was assessed, and studies were examined for themes related to provider- and system-level factors associated with screening uptake. Thirteen studies met the inclusion criteria. Findings revealed a positive association between patients' receipt of provider recommendation and uptake of breast and cervical cancer screening. Uptake was also higher among patients of female providers. Facilities with flexible appointment times and reminders had higher mammography and Pap test uptake. Similarly, greater organizational commitment to quality and performance had higher breast and cervical cancer screening rates. Knowledge provided in this review could be used in future research to inform the development of public health policy and clinical programs to improve screening uptake.

Objective: Postpartum mental disorders are twice as common among immigrant women compared to nonimmigrant women in developed countries. Immigrant women may experience barriers to access and use of postpartum mental health services, but little is known about their service use on a population level. We described postpartum mental health service use of immigrant mothers living in Ontario, Canada, comparing to a referent group of mothers who were either born in Canada or had lived in Ontario or another Canadian province since 1985., Method: Among all women in Ontario, Canada, delivering a live infant from 2008 to 2012 (n = 450,622), we described mental health service use within 1 year postpartum, including mental health physician visits, psychiatric emergency department visits, and psychiatric hospitalization. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) comparing immigrant women to the referent group were adjusted for maternal age, parity, income, rurality, mental health services in prior 2 years, and maternal and newborn health., Results: Immigrant women (n = 123,231; 27%) were less likely to use mental health services than women in the referent group (14.1% vs. 21.4%; aOR, 0.59; 95% CI, 0.58 to 0.61), including for physician-based (13.9% vs. 21.1%; aOR, 0.59; 95% CI, 0.58 to 0.61) and emergency department (0.6% vs. 1.3%; aOR, 0.63; 95% CI, 0.57 to 0.68) services. Hospitalization risk was lower among immigrants (0.20% vs. 0.33%) but became similar after covariate adjustment (aOR, 0.92; 95% CI, 0.79 to 1.06)., Conclusions: Underuse of postpartum mental health services may be contributing to the high burden of postpartum mental disorders among immigrant women., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2016.)

The objective of this study was to detail the nature and correlates of mental health and non-mental health care contacts prior to suicide death. We conducted a systematic extraction of data from records at the Office of the Chief Coroner of Ontario of each person who died by suicide in the city of Toronto from 1998 to 2011. Data on 2,835 suicide deaths were linked with provincial health administrative data to identify health care contacts during the 12 months prior to suicide. Sub-populations of suicide decedents based on the presence and type of mental health care contact were described and compared across socio-demographic, clinical and suicide-specific variables. Time periods from last mental health contact to date of death were calculated and a Cox proportional hazards model examined covariates. Among suicide decedents, 91.7% had some type of past-year health care contact prior to death, 66.4% had a mental health care contact, and 25.3% had only non-mental health contacts. The most common type of mental health contact was an outpatient primary care visit (54.0%), followed by an outpatient psychiatric visit (39.8%), an emergency department visit (31.1%), and a psychiatric hospitalization (21.0%). The median time from last mental health contact to death was 18 days (interquartile range 5-63). Mental health contact was significantly associated with female gender, age 25-64, absence of a psychosocial stressor, diagnosis of schizophrenia or bipolar disorder, past suicide attempt, self-poisoning method and absence of a suicide note. Significant differences between sub-populations of suicide decedents based on the presence and nature of their health care contacts suggest the need for targeting of community and clinical-based suicide prevention strategies. The predominance of ambulatory mental health care contacts, often close to the time of death, reinforce the importance of concentrating efforts on embedding risk assessment and care pathways into all routine primary and specialty clinical care, and not only acute care settings., (© 2016 World Psychiatric Association.)

Dyadic interactions associated with maternal depression and anxiety may perpetuate maternal mental illness and impact infant attachment. Individual and maternal-dyadic therapies are effective but resource intensive. We assessed feasibility, acceptability, and preliminary efficacy of a newly developed maternal-infant dyadic group therapy intervention. This was an open-label pilot study targeting mothers with mood or anxiety disorders, and their infants aged 6 to 12 months. We conducted three 12-week groups combining evidence-based maternal and mother-infant dyadic strategies to enhance mood, insight, parenting, and mentalizing capacity. We measured recruitment and retention rates, reasons for nonparticipation, and missed sessions. Acceptability of the intervention was assessed via questionnaires and semi-structured interviews. Efficacy outcomes were the Parenting Stress Index (PSI), Edinburgh Postnatal Depression Scale (EDPS), and the Beck Anxiety Inventory (BAI), measured pretreatment and posttreatment. The feasibility and acceptability were excellent. There was a significant reduction in mean depressive symptom scores (t 3.31; p 0.008 sig) and a trend toward decreasing anxiety scores (t 1.96; p 0.08). The total PSI score decreased, approaching statistical significance (t 2.23; p 0.057). Enhanced insight, parenting capacity, affect regulation, and positive interaction with baby were supported with self-report surveys and interviews. This resource-efficient novel mother-baby dyadic group intervention shows excellent feasibility, acceptability, and has good preliminary efficacy results. It has the potential to improve depression, anxiety, affect regulation, parenting, and maternal mentalization.

Objective: To test the hypothesis of an increased incidence of antiparkinson drug prescribing or Parkinson disease (PD) diagnostic codes after chronic lithium treatment compared with chronic valproic acid or antidepressant treatment among older adults., Methods: A retrospective cohort study using healthcare administrative databases in Ontario, Canada included 1,749 lithium users, 1,787 valproic acid users, and 285,154 other antidepressant users ≥ 66 years old having used the drug continuously in monotherapy for at least 1 year. Outcome measures were start of (1) a dopaminergic medication (levodopa or a dopamine agonist), (2) any antiparkinson drug (levodopa, dopamine agonists, anticholinergic medication, amantadine, monoamine oxidase B inhibitors), (3) any antiparkinson drug or a diagnostic code for PD, and (4) any antiparkinson drug in the absence of a diagnostic code for PD., Results: For patients with no previous antipsychotic use, lithium monotherapy was associated with an increased incidence of dopaminergic drug use (adjusted HR: 1.87; 95% CI: 1.06-3.30) and an increased incidence of antiparkinson drug use or a PD diagnosis (adjusted HR: 1. 68; 95% CI: 1.13-2.48) compared with antidepressant monotherapy., Conclusion: Chronic lithium use is associated with an increased incidence of dopaminergic drug use compared with antidepressants, identifying a prescribing cascade related to lithium use in the elderly. Whether this reflects inappropriate treatment of action tremor or treatment of drug-induced parkinsonism should be addressed by a close examination of prescribing practices., (Copyright © 2016 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Many women with depression experience significant difficulty making a decision about whether or not to use antidepressant medication in pregnancy. Patient decision aids (PDAs) are tools that assist patients in making complex health decisions. PDAs can reduce decision-making difficulty and lead to better treatment outcomes. We describe the methods for a pilot randomized controlled trial of an interactive web-based PDA for women who are having difficulty deciding about antidepressant drug use in pregnancy., Methods/design: This is a pilot randomized controlled trial that aims to assess the feasibility of a larger, multi-center efficacy study. The PDA aims to help a woman: (1) understand why an antidepressant is being recommended, (2) be knowledgeable about potential benefits and risks of treatment and non-treatment with antidepressants, and (3) be clear about which benefits and risks are most important to her, with the goal of improving confidence in her decision-making. We include women aged 18 years or older who are: (1) planning a pregnancy or are pregnant (gestational age less than 30 weeks), (2) diagnosed with major depressive disorder, (3) deciding whether or not to use a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) antidepressant in pregnancy, and (4) having at least moderate decision-making difficulty as per a Decisional Conflict Scale (DCS) Score ≥25. Participants are randomized to receive the PDA or an informational resource sheet via a secure website, and have access to the stated allocation until their final study follow-up. The primary outcomes of the pilot study are feasibility of recruitment and retention, acceptability of the intervention, and adherence to the trial protocol. The primary efficacy outcome is DCS score at 4 weeks post randomization, with secondary outcomes including depressive and anxiety symptoms., Discussion: Our PDA represents a key opportunity to optimize the decision-making process for women around antidepressants in pregnancy, leading to effective decision-making and optimizing improved maternal and child outcomes related to depression in pregnancy. The electronic nature of the PDA will facilitate keeping it up-to-date, and allow for widespread dissemination after efficacy is demonstrated., Trial Registration: This trial is registered on ClinicalTrials.Gov under the identifier NCT02308592 (first registered: 2 December 2014).

Intimate partner violence (IPV) is a global public health and human rights problem that causes physical, sexual and psychological harms to men and women. IPV includes physical aggression, sexual coercion, psychological abuse and/or controlling behaviours perpetrated by a current or previous intimate partner in a heterosexual or same-sex relationship. IPV affects both men and women, but women are disproportionately affected with nearly one third reporting IPV during their lifetime. Physical and sexual harms from IPV include injury, increased risk for sexually transmitted diseases, pregnancy complications and sometimes death. Psychological consequences include depression, anxiety, posttraumatic stress disorder, substance abuse, impulsivity and suicidality and non-specific physical complaints thought to be related to the traumatic nature and chronic stress of IPV. Children who witness IPV are also negatively impacted in the short and long term. This paper reviews prevalence, risk factors, adverse effects and current evidence-based mental health treatment advice for IPV victims.

A small proportion of health care users, called high-cost patients, account for a disproportionately large share of health care costs. Most literature on these patients has focused on the entire population. However, high-cost patients whose use of mental health care services is substantial are likely to differ from other members of the population. We defined a mental health high-cost patient as someone for whom mental health-related services accounted for at least 50 percent of total health care costs. We examined these patients' health care utilization and costs in Ontario, Canada. We found that their average cost for health care, in 2012 Canadian dollars, was $31,611. In contrast, the cost was $23,681 for other high-cost patients. Mental health high-cost patients were younger, lived in poorer neighborhoods, and had different health care utilization patterns, compared to other high-cost patients. These findings should be considered when implementing policies or interventions to address quality of care for mental health patients so as to ensure that mental health high-cost patients receive appropriate care in a cost-effective manner. Furthermore, efforts to manage mental health patients' health care use should address their complex profile through integrated multidisciplinary health care delivery., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: A significant proportion of patients with depression fail to respond to psychotherapy and standard pharmacotherapy, leading to treatment-resistant depression (TRD). Due to the significant prevalence of TRD, alternative therapies for depression have emerged as viable treatments in the armamentarium for this disorder. Repetitive transcranial magnetic stimulation (rTMS) is now being offered in clinical practice in broader numbers. Many studies have investigated various different neurobiological predictors of response of rTMS. However, a synthesis of this literature and an understanding of what biological targets predict response is lacking. This review aims to systematically synthesize the literature on the neurobiological predictors of rTMS in patients with depression., Methods: Medline (1996-2014), Embase (1980-2014), and PsycINFO (1806-2014) were searched under set terms. Two authors reviewed each article and came to consensus on the inclusion and exclusion criteria. All eligible studies were reviewed, duplicates were removed, and data were extracted individually., Results: The search identified 1,673 articles, 41 of which met both inclusion and exclusion criteria. Various biological factors at baseline appear to predict response to rTMS, including levels of certain molecular factors, blood flow in brain regions implicated in depression, electrophysiological findings, and specific genetic polymorphisms., Conclusions: Significant methodological variability in rTMS treatment protocols limits the ability to generalize conclusions. However, response to treatment may be predicted by baseline frontal lobe blood flow, and presence of polymorphisms of the 5-hydroxytryptamine (5-HT) -1a gene, the LL genotype of the serotonin transporter linked polymorphic region (5-HTTLPR) gene, and Val/Val homozygotes of the brain-derived neurotrophic factor (BDNF) gene., (© 2015 Wiley Periodicals, Inc.)

The aims of this systematic review and meta-analysis were threefold: to estimate the prevalence of postpartum depressive symptoms in immigrant women, compare this prevalence to non-immigrant women, and determine risk factors for postpartum depressive symptoms in immigrant women. Literature searches were conducted in PubMed, Embase, PsycINFO, Web of Science, Scopus, ResearchGate and Google Scholar databases from 1950 until October 2014. Twenty-four studies met the inclusion criteria of which 22 (12 cross-sectional and 10 prospective cohort) contributed data for meta-analyses. Heterogeneity and publication bias were assessed. The prevalence of postpartum depressive symptoms in immigrant women was 20% (95% confidence interval [CI] 17-23%, 18 studies, N = 13,749 women). Immigrant women were twice more likely to experience depressive symptoms in the postpartum period than non-immigrant women (pooled unadjusted odds ratio [OR] = 2.10 [95% CI 1.62-2.73, 15 studies, N = 50,519 women] and adjusted OR = 2.18 [95% CI 1.60-2.96, 7 studies, N = 35,557 women]). There was, however, evidence of publication bias with the pooled adjusted OR reduced to 1.63 (95% CI 1.22-2.17) after adjustment for bias. Risk factors associated with postpartum depressive symptoms among immigrant women included shorter length of residence in the destination country, lower levels of social support, poorer marital adjustment, and perceived insufficient household income. This study suggests that postpartum depression is a common condition among immigrant women. Moreover, immigrant women are at higher risk of postpartum depression than non-immigrant women. Further prospective studies on the risk factors of postpartum depression among immigrant women verified by a clinical diagnosis are needed., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Studies of the diagnostic accuracy of depression screening tools often used data-driven methods to select optimal cut-offs. Typically, these studies report results from a small range of cut-off points around whatever cut-off score is identified as most accurate. When published data are combined in meta-analyses, estimates of accuracy for different cut-off points may be based on data from different studies, rather than data from all studies for each cut-off point. Thus, traditional meta-analyses may exaggerate accuracy estimates. Individual patient data (IPD) meta-analyses synthesise data from all studies for each cut-off score to obtain accuracy estimates. The 10-item Edinburgh Postnatal Depression Scale (EPDS) is commonly recommended for depression screening in the perinatal period. The primary objective of this IPD meta-analysis is to determine the diagnostic accuracy of the EPDS to detect major depression among women during pregnancy and in the postpartum period across all potentially relevant cut-off scores, accounting for patient factors that may influence accuracy (age, pregnancy vs postpartum)., Methods and Analysis: Data sources will include Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science. Studies that include a diagnosis of major depression based on a validated structured or semistructured clinical interview administered within 2 weeks of (before or after) the administration of the EPDS will be included. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cut-off values. Analyses will evaluate data from pregnancy and the postpartum period separately, as well as combining data from all women in a single model., Ethics and Dissemination: This study does not require ethics approval. Dissemination will include journal articles and presentations to policymakers, healthcare providers and researchers., Systematic Review Registration: PROSPERO 2015:CRD42015024785., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Mental health and/or substance use issues are associated with significant disparities in morbidity and mortality. The aim of this study was to identify the mechanisms underlying poor primary care access for this population., Method: This was a community-based participatory action qualitative study, in which 85 adults who self-identified as having a serious mental health and/or substance use issue and 17 service providers from various disciplines who worked with this population participated in a semi-structured interview., Results: Client, service provider and health system barriers to access were identified. Client factors, including socioeconomic and psychological barriers, make it difficult for clients to access primary care, keep appointments, and/or prioritize their own health care. Provider factors, including knowledge and personal values related to mental health and substance use, determine the extent to which clients report their specific needs are met in the primary care setting. Health system factors, such as models of primary care delivery, determine the context within which both client and service provider factors operate., Conclusions: This study helps elucidate the mechanisms behind poor primary health care access among people with substance use and/or mental health issues. The results suggest that interdisciplinary, collaborative models of primary healthcare may improve accessibility and quality of care for this population, and that more education about mental health and substance use issues may be needed to support service providers in providing adequate care for their clients.

Objective: To validate algorithms to detect people with chronic psychotic illness in population-based health administrative databases., Method: We developed 8 algorithms to detect chronic psychotic illness using hospitalization and physician service claims data from administrative health databases in Ontario to identify cases of chronic psychotic illness between 2002 and 2007. Diagnostic data abstracted from the records of 281 randomly selected psychiatric patients from 2 hospitals in Toronto were linked to the administrative data cohort to test sensitivity, specificity, and positive predictive values (PPV) and negative predictive values., Results: Using only hospitalization data to capture chronic psychotic illness yielded the highest specificity (range 69.9% to 84.7%) and the highest PPV (range 55.2% to 80.8%). Using physician service claims in addition to hospitalization data to capture cases increased sensitivity (range 90.1% to 98.8%) but decreased specificity (range 31.1% to 68.0%) and PPV (range 38.4% to 71.1%)., Conclusion: Using health administrative data to study population-based outcomes for people with chronic psychotic illness is feasible and valid. Researchers can select case identification methods based on whether a more sensitive or more specific definition of chronic psychotic illness is desired.

Objective: Rehospitalization affects quality of life and health system efficiency. Although this outcome is a common quality indicator, there are few applications for linking evaluation to risk mitigation at the person level. This study examined risk factors for rehospitalization to develop an application for supporting care planning based on the interRAI Mental Health (MH), a commonly available assessment system., Method: A retrospective analysis was performed of 53,538 psychiatric inpatients assessed with the interRAI MH in Ontario, Canada, between January 2010 and May 2014. The interRAI MH is a clinical system for assessing demographic variables, service utilization, functional status, and clinical needs. Logistic regression models and survival analysis were used to develop the Rehospitalization Clinical Assessment Protocol by predicting 90-day rehospitalization to any inpatient mental health bed., Results: Variables found to significantly predict rehospitalization included 6 or more lifetime hospitalizations (odds ratio [OR] = 1.40), positive symptoms of psychosis (OR = 1.23), a secondary substance use disorder (OR = 1.13), and being at risk of harm to self (OR = 1.11). Using these variables, the Rehospitalization Clinical Assessment Protocol was derived whereby those at level 2 (highest) were 74% more likely to be rehospitalized within 90 days than those at level 0. By 1-year postdischarge, 30% at level 2 and 18% at level 0 were rehospitalized., Conclusions: The Rehospitalization Clinical Assessment Protocol is an application supporting care planning for targeting risk of rehospitalization whenever a person is assessed with the interRAI MH. Further exploration is needed to understand how the use of this Clinical Assessment Protocol, service processes, and health system structures further mediate or moderate psychiatric rehospitalization risk.

The purpose of this study was to examine decision-making among women considering antidepressant medication use in pregnancy. Decisional conflict was assessed using the Decisional Conflict Scale (DCS) among pregnant women considering antidepressant medication treatment (N = 40). Overall DCS and subscale scores were compared between women who were antidepressant users and non-users. Semi-structured interviews (N = 10) explored barriers and facilitators of decision-making. Twenty-one women (52 %) had moderate or high decisional conflict (DCS ≥ 25). Overall DCS scores did not differ between groups, but antidepressant use was associated with feeling more adequately informed (subscale mean 17.5, SD 17.9 vs. 42.1, SD 23.8, p = 0.001) and clear about values (subscale mean 16.7, SD 15.1 vs. 29.8, SD 24.0, p = 0.043). Barriers to decision-making were (1) difficulty weighing maternal versus infant health, (2) lack of high quality information, (3) negative external influences, and (4) emotional reactions to decision-making. Facilitators were (1) interpersonal supports, (2) accessible subspecialty care, and (3) severe depressive symptoms. Many pregnant women facing decisions regarding antidepressant medication use experience decisional conflict. Interventions that provide accurate information, assistance with weighing risks and benefits of treatment, management of problematic external influences, and emotional support may reduce decisional conflict and facilitate the decision-making process.

Background: Women with depression in pregnancy are faced with difficult treatment decisions. Untreated, antenatal depression has serious negative implications for mothers and children. While antidepressant drug treatment is likely to improve depressive symptoms, it crosses the placenta and may pose risks to the unborn child. Transcranial direct current stimulation is a focal brain stimulation treatment that improves depressive symptoms within 3 weeks of treatment by inducing changes to brain areas involved in depression, without impacting any other brain areas, and without inducing changes to heart rate, blood pressure or core body temperature. The localized nature of transcranial direct current stimulation makes it an ideal therapeutic approach for treating depression during pregnancy, although it has never previously been evaluated in this population., Methods/design: We describe a pilot randomized controlled trial of transcranial direct current stimulation among women with depression in pregnancy to assess the feasibility of a larger, multicentre efficacy study. Women over 18 years of age and between 14 and 32 weeks gestation can be enrolled in the study provided they meet diagnostic criteria for a major depressive episode of at least moderate severity and have been offered but refused antidepressant medication. Participants are randomized to receive active transcranial direct current stimulation or a sham condition that is administered in 15 30-minute treatments over three weeks. Women sit upright during treatment and receive obstetrical monitoring prior to, during and after each treatment session. Depressive symptoms, treatment acceptability, and pregnancy outcomes are assessed at baseline (prior to randomization), at the end of each treatment week, every four weeks post-treatment until delivery, and at 4 and 12 weeks postpartum., Discussion: Transcranial direct current stimulation is a novel therapeutic option for treating depression during pregnancy. This protocol allows for assessment of the feasibility of, acceptability of and adherence with a clinical trial protocol to administer this treatment to pregnant women with moderate to severe depression. Results from this pilot study will guide the development of a larger multicentre trial to definitively test the efficacy and safety of transcranial direct current stimulation for pregnant women with depression., Trial Registration: Clinical Trials Gov NCT02116127.

Objective: More women with schizophrenia are becoming pregnant, such that contemporary data are needed about maternal and newborn outcomes in this potentially vulnerable group. We aimed to quantify maternal and newborn health outcomes among women with schizophrenia., Design: Retrospective cohort study., Setting: Population based in Ontario, Canada, from 2002 to 2011., Population: Ontario women aged 15-49 years who gave birth to a liveborn or stillborn singleton infant., Methods: Women with schizophrenia (n = 1391) were identified based on either an inpatient diagnosis or two or more outpatient physician service claims for schizophrenia within 5 years prior to conception. The reference group comprised 432 358 women without diagnosed mental illness within the 5 years preceding conception in the index pregnancy., Main Outcome Measures: The primary maternal outcomes were gestational diabetes mellitus, gestational hypertension, pre-eclampsia/eclampsia, and venous thromboembolism. The primary neonatal outcomes were preterm birth, and small and large birthweight for gestational age (SGA and LGA). Secondary outcomes included additional key perinatal health indicators., Results: Schizophrenia was associated with a higher risk of pre-eclampsia (adjusted odds ratio, aOR 1.84; 95% confidence interval, 95% CI 1.28-2.66), venous thromboembolism (aOR 1.72, 95% CI 1.04-2.85), preterm birth (aOR 1.75, 95% CI 1.46-2.08), SGA (aOR 1.49, 95% CI 1.19-1.86), and LGA (aOR 1.53, 95% CI 1.17-1.99). Women with schizophrenia also required more intensive hospital resources, including operative delivery and admission to a maternal intensive care unit, paralleled by higher neonatal morbidity., Conclusions: Women with schizophrenia are at higher risk of multiple adverse pregnancy outcomes, paralleled by higher neonatal morbidity. Attention should focus on interventions to reduce the identified health disparities., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Background: Fewer than half of individuals with a mental disorder seek formal care in a given year. Much research has been conducted on the factors that influence service use in this population, but the methods generally used cannot easily identify the complex interactions that are thought to exist. In this paper, we examine predictors of subsequent service use among respondents to a population health survey who met criteria for a past-year mood, anxiety or substance-related disorder., Methods: To determine service use, we use an administrative database including all physician consultations in the period of interest. To identify predictors, we use classification tree (CART) analysis, a data mining technique with the ability to identify unsuspected interactions. We compare results to those from logistic regression models., Results: We identify 1213 individuals with past-year disorder. In the year after the survey, 24% (n=312) of these had a mental health-related physician consultation. Logistic regression revealed that age, sex and marital status predicted service use. CART analysis yielded a set of rules based on age, sex, marital status and income adequacy, with marital status playing a role among men and by income adequacy important among women. CART analysis proved moderately effective overall, with agreement of 60%, sensitivity of 82% and specificity of 53%., Conclusion: Results highlight the potential of data-mining techniques to uncover complex interactions, and offer support to the view that the intersection of multiple statuses influence health and behaviour in ways that are difficult to identify with conventional statistics. The disadvantages of these methods are also discussed.

Background: This study assessed the stability of maternal anxiety and concordance between State-Trait Anxiety Inventory (STAI) scores in the immediate postpartum period to 8 weeks postpartum., Methods: A population-based sample of 522 mothers completed the STAI at 1, 4, and 8 weeks postpartum. Sensitivity, specificity, and predictive power of the 1-week STAI in relation to identifying mothers with elevated STAI scores at 4 and 8 weeks was determined. Predictive power of the STAI was further assessed using odds ratios and receiver operator characteristic (ROC) curves., Results: At 1 week postpartum, 22.6% of mothers scored >40 on the STAI, decreasing to 17.2% at 4 weeks and 14.8% at 8 weeks. Using the cut-off score of >40, the 1-week STAI accurately classified 84.0% mothers at 4 weeks and 83.6% at 8 weeks with or without anxiety symptomatology. The 1-week STAI was significantly correlated to the 4-week (r=0.68, p<0.001) and 8-week (r=0.64, p<0.001) STAI. Mothers with a 1-week STAI score >40 were 15.2 times more likely at 4 weeks (95% CI=8.9-26.1) and 14.0 times more likely at 8 weeks (95% CI=7.9-24.8) to exhibit postpartum anxiety symptomatology., Limitations: Psychiatric interviews were not completed in collaboration with the STAI and specific types of anxiety disorders were not identified., Conclusions: A cut-off score of >40 on the STAI administered early in the postpartum period is recommended in a 2-phase identification program in order to not miss mothers with postpartum anxiety., (© 2013 Elsevier B.V. All rights reserved.)

The objective of this study was to determine the contribution of interpersonal violence and substance use to the prediction of postpartum depressive symptomatology. A community-based sample of 634 women in British Columbia, Canada was screened for interpersonal violence and substance use using the Antenatal Psychosocial Health Assessment (ALPHA) form. Of these women, 497 (78%) subsequently completed questionnaires at 8 weeks postpartum to assess for depressive symptomatology using the Edinburgh Postnatal Depression Scale (EPDS). A predictive model for postpartum depressive symptomatology (EPDS > 9) was developed using regression analysis. Findings suggest that women who experience past or current interpersonal violence or personal or partner substance use problems should be considered for targeted screening for postpartum depression (PPD).

Objectives: The primary objective of this study was to compare mortality following incident acute myocardial infarction (AMI) among individuals with and without schizophrenia. A secondary objective was to compare the likelihood to receive cardiac procedures and cardiologist visits., Methods: This retrospective cohort study took place in Ontario, Canada. We studied incident AMI patients who were alive at hospitalization discharge from January 1, 2002 to December 31, 2006. 71,668 subjects were included in the study (402 subjects were excluded because of missing data). The main exposure was a diagnosis of schizophrenia. The main outcome measure was 30-day mortality post-discharge. Secondary outcomes included receipt of cardiac procedures and cardiologist visits within 30 days post-discharge., Results: After risk adjustment, individuals with schizophrenia were 56% more likely to die within 30 days of discharge (OR 1.56, 95% CI 1.08-2.23; p=0.02), but approximately 50% less likely to receive cardiac procedures (OR 0.48, 95% CI 0.40-0.56; p<0.001) or to see a cardiologist within 30 days of discharge (OR 0.53, 95% CI 0.43-0.65; p<0.001)., Conclusions: Individuals with schizophrenia have a significant risk of dying following incident AMI. Despite the elevated mortality risk, individuals with schizophrenia are less likely to receive specialist care and cardiac procedures. Inequities in access to AMI care may be an important point of intervention for individuals with schizophrenia., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objectives: To describe national and regional prevalence rates for significant depressive symptoms in women after 12 weeks during the postpartum period, and to identify predictors of postpartum depressive symptoms during this later time period., Methods: Data from the Maternity Experiences Survey of the Canadian Perinatal Surveillance System were analyzed. Participants completed a computer-assisted telephone interview between 5 and 14 months during the postpartum period (n = 6421). Depressive symptomatology was measured using the Edinburgh Postnatal Depression Scale (EPDS ≥ 13). Proportions and odds ratios with 95% confidence intervals were calculated using bootstrap methods to account for sample design and weighting adjustments., Results: About 8% of Canadian women exhibited depressive symptoms past 12 weeks during the postpartum period. Prevalence rates varied between regions. In multivariable analysis, previous history of depression (OR 1.87; 95% CI 1.43 to 2.45, P < 0.001), low household income (OR 1.64; 95% CI 1.27 to 2.11, P < 0.001), low postpartum social support (OR 3.95; 95% CI 2.77 to 5.62, P < 0.001), stressful life events (OR 2.43; 95% CI 1.88 to 3.15, P < 0.001), interpersonal violence (OR 1.40; 95% CI 1.04 to 1.87, P = 0.02), and poor self-perceived maternal health (OR 4.48; 95% CI 3.15 to 6.38, P < 0.001) were independently associated with postpartum depressive symptoms. Regional differences in correlates of postpartum depressive symptoms were found., Conclusions: The finding that depression rates are elevated throughout the first postpartum year is important because of the known negative impact of postpartum depression (PPD). Targeted public health interventions may be needed to reduce the prevalence of PPD and its associated impact.

Mood disorders disproportionately affect women across the lifespan. Mood disorders in pregnancy and the postpartum period are common and have profound implications for women and their children. These include obstetric and neonatal complications, impaired mother-infant interactions, and, at the extreme, maternal suicide and infanticide. Because obstetrician-gynecologists are often the first (and sometimes the only) point of contact for young women in the health care system, familiarity with the presentation and treatment of depressive illness in the perinatal period is imperative. The goal of this review is to synthesize essential information on depressive illness in the perinatal period with a focus on its most common and severe presentations, major depressive disorder and bipolar disorder. Accurate diagnosis of unipolar major depressive disorder from bipolar disorder can facilitate the selection of the best possible treatment alternatives. Counseling may be sufficient for perinatal women who have mild to moderate depression, but women who are severely depressed are likely to require antidepressant treatment. Women with bipolar disorder are at high risk for relapse if mood stabilizer medication is discontinued, and they are vulnerable to relapse near the time of delivery. Comanagement of their care with psychiatrists will increase their chances of avoiding a recurrence of illness.

Background: It has been hypothesized that certain obstetrical populations, including women who conceive using assisted reproductive technologies (ART) and women with multiple births, may be at increased risk for postpartum depression. In this systematic literature review, we examine the published evidence for this hypothesis., Methods: The databases Medline, CINAHL, EMBASE, PsycINFO and the Cochrane Library were searched from their start dates through to April 1, 2009 using relevant keywords. All published, peer-reviewed articles in English, Spanish or French including a standardized assessment of depression administered between 2 and 52 weeks postpartum were considered for inclusion. Two independent reviewers abstracted and critically appraised a total of 13 eligible articles., Results: The data indicate little or no increased risk for postpartum depression among women who use ART to conceive. In contrast, most studies of adequate quality indicate that mothers of multiples may be at elevated risk for symptoms of depression. However, existing data do not permit differentiation between transient maternal distress and clinically significant postpartum depression., Conclusions: Studies included in this review were often limited by small samples and lack of appropriate comparison groups, making further research in this area essential. In particular, lack of control for maternal psychiatric history and other important sociodemographic predictors of depression is a serious limitation of existing research on this topic. Further, the use of reproductive technologies and multiple births often co-occur, and few study designs enabled separation of the effects of these two variables. However, evidence of increased risk for symptoms of postpartum depression among women with multiple births, if confirmed, may warrant targeted interventions for this population.