Introduction The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used instrument in perinatal clinical practice and research based on a belief that somatic symptoms during the perinatal period impact on depression measurement validity and reliability. The Montgomery Åsberg Depression Rating Scale – Self report (MADRS-S) may have better psychometric performance as a screening and outcome instrument for depression. Methods Self-referred pregnant women were screened (n = 650), diagnostically assessed (n = 390), treated with internet-based cognitive behavior therapy for depression (n = 270) and followed-up diagnostically (n = 169). EPDS and MADRS-S were assessed at screening and after treatment. Item level data from all patients were used in a series of psychometric tests including confirmatory factor analysis (CFA) and item response-theory tests (IRT). Results Both scales showed adequate reliability. Using depression as a unidimensional latent trait in CFA, MADRS-S fitted data better than EPDS. IRT revealed that the somatic items in MADRS-S contributed less than average rather than inflating the totals. For more depressed respondents, the EPDS scores’ validity decreased compared to MADRS-S. Conclusions MADRS-S and EPDS are reliable tools for assessing depressive symptoms in pregnant patients, but MADRS-S outperforms EPDS on several key psychometric indicators. Contrary to common belief, somatic items seem not to inflate scores, and MADRS-S retains better precision at higher symptom levels. These findings support the use of standard depression measures, such as the MADRS-S, in pregnant populations. Doing so may improve detection and treatment by integrating antenatal depression into general psychiatric care and research rather than isolating it within perinatal-specific frameworks.

Lithium is a first-line treatment option for preventing relapse in bipolar disorder but may be discontinued periconceptionally due to safety concerns. We aimed to examine the prevalence of lithium discontinuation among pregnant women with bipolar disorder in Sweden, using a novel method to identify daily dose, and to describe the characteristics of the discontinuers and continuers. Cohort study. Swedish population-based registers (2006–2019). Women with bipolar disorder and an ongoing lithium treatment episode 6 months prior to pregnancy were identified. Natural language processing (NLP) of the prescription free-text information was used to define the daily dose, and to construct treatment episodes. Not applicable. Lithium discontinuation was defined as the end of a continuous treatment episode between 6 months before the start of pregnancy and delivery. The performance of the NLP method was compared with manual review of the prescription texts. The characteristics of the discontinuers and the continuers were described, including psychiatric comorbidities and other medications used. In 662 pregnancies, 438 women (70%) discontinued lithium treatment, the majority in prepregnancy or first trimester. The NLP method showed high internal validity compared with manual review of prescription texts; however, the estimated date of discontinuation could not be validated against measures of actual drug use. Discontinuers, compared with continuers, had a higher prevalence of comorbid substance use disorder (7.8% vs 2.7%), personality disorder (11.4% vs 6.0%) and attention-deficit/hyperactivity disorder (13.5% vs 7.6%). After discontinuation, there was no increased use of other mood stabilisers, and 46% had a new dispensation of lithium within 6–12 months. The majority of lithium-treated women with bipolar disorder discontinued treatment around the start of pregnancy; however, lithium discontinuation is also common outside pregnancy, and the reason for discontinuation in our cohort remains unknown. Discontinuers had a higher rate of psychiatric comorbidity, and switches to other mood stabilising treatments did not appear to be common. Given that both the peripartum period and withdrawal of mood stabilising treatment may contribute to increased risk of relapse, the consequences of lithium discontinuation for maternal psychiatric health should be studied further.

Background: Antenatal depression is common and often remains untreated. Few studies that have evaluated pregnancy-adapted internet-based cognitive behavioural therapy (ICBT). Although these studies indicate promising treatment effects, participants frequently report feelings of loneliness, being overwhelmed, and a desire for increased interaction. With the DANA-project, we attempt to address these needs by incorporating live support sessions to a pregnancy-adapted ICBT-treatment, providing increased support and contact with two clinicians. This study explores participants' experience of this treatment. Methods: We conducted a qualitative study using semi-structured interviews with participants (n=20) who had received a 10-week guided ICBT for antenatal depression, complemented with live support sessions delivered by a midwife over video or telephone. The data were analysed using reflexive thematic analysis. Results: One overarching theme was generated, named ‘ Feeling held over a distance – the interplay of Support and Obligation ’, comprising three themes representing the participants’ experiences of the treatment. Participants described the treatment as supportive and validating, with many elements perceived as helpful, indicating that the key elements of the treatment were well received. Participants emphasized the value of the therapeutic relationship, the relevance of the content, and the emotional resonance of the treatment. At the same time, they experienced the program as demanding, reporting a high level of burden, both related to the illness itself, the treatment, and other life circumstances. A strong wish for personal tailoring was evident. The support sessions were valued, offering opportunities for individualised guidance and contributing to a deeper therapeutic relationship. Conclusions: Participants in therapist-guided ICBT for antenatal depression with added live support sessions delivered by a counsellor, appreciated the treatment but reported substantial burdenthat may affect perceived feasibility. Personal tailoring of both structure and content was highly valued, and although this was described as present, participants expressed a desire for more. Feeling seen was repeatedly highlighted as a valued aspect of the intervention. These findings may informrefinement of perinatal digital interventions and guide future implementation efforts. Trial registration: The study was a sub-study in a prospectively registered randomized controlled trial conducted in Sweden, the DANA project. Trial registration: ClinicalTrials.gov, NCT05533138. Registered 9 September 2022.

Psychological symptoms tend to change over time, even in the absence of clinical intervention. For example, self-ratings are often higher at screening compared to start of treatment. A plausible hypothesis is that this is due to patients' self-referring when their gradually fluctuating symptoms are worse than usual. That hypothesis predicts that patients that wait longer will have had longer time to return to their average symptom level. On the other hand, other processes related to measurement reactivity, contact with a clinician, or regression towards the mean, do not predict a time-dependent relationship. Our aim was to estimate the extent of this hypothesized symptom reduction in depression, social anxiety disorder, panic disorder, health anxiety and insomnia (both total reduction and the relationship with time). The sample included adults (N = 8744) from an outpatient psychiatric clinic providing ICBT in Swedish routine care. Time-dependent effects were estimated with linear regression for both primary symptoms and secondary depressive symptoms. A simulation of symptom fluctuations was built to estimate power and further contextualize the effects. Patients improved on average from screening to the start of the intervention, but this varied substantially depending on diagnosis and questionnaire used. The waiting time weakly predicted the degree of improvement both for primary depressive symptoms and comorbid depressive symptoms. The estimate for primary depressive symptoms was sensitive to modeling choices, shrinking towards zero when modeled with fat-tailed residuals. The preponderance of "immediate" reductions in symptoms have implications for reporting standards of pre-treatment-measurements, especially in single-group intervention studies.

There has recently been an increased emphasis on patient empowerment and collaboration within their healthcare. However, there is widely a lack of clarity to the concept of empowerment and existing measurement tools lack uniformity, covering diverse domains and related concepts. This study aims to conduct a psychometric evaluation of the Swedish version of the Empowerment Scale– Making Decisions, focusing on its structural validity and reliability in assessing patient empowerment. This includes a detailed examination of the factor structure across two different contexts, psychiatric care (n = 211) and primary care (n = 210). We will compare several confirmatory factor analysis (CFA) models proposed in previous research to identify the best fit. If no models provide a good fit, we intend to suggest a new scale for further evaluation. The dimensionality of the scale was tested by comparing four CFA models, together with a one-factor solution, to identify the best fit for the two samples. Reliability measures were determined by coefficient Omega (ω) as well as Cronbach’s alpha (α). There was limited support for the one-factor solution in both samples, challenging the scale’s assumed unidimensionality (primary care sample: x2(350) = 1074, p <.001, CFI = 0.58, TLI = 0.54, RMSEA = 0.10 (90

With the impetus of Digital Mental Health Interventions (DMHIs), complex data can be leveraged to improve and personalize mental health care. However, most approaches rely on a very limited number of often costly features. Computer mouse trajectories can be unobtrusively and cost-efficiently gathered and seamlessly integrated into current baseline processes. Empirical evidence suggests that mouse movements hold information on user motivation and attention, both valuable aspects otherwise difficult to measure at scale. Further, mouse trajectories can already be collected on pre-treatment questionnaires, making them a promising candidate for early predictions informing treatment allocation. Therefore, this paper discusses how to collect and process mouse trajectory data on questionnaires in DMHIs. Covering different complexity levels, we combine hand-crafted features with non-sequential machine learning models, as well as spatiotemporal raw mouse data with state-of-the-art sequential neural networks. The data processing pipeline for the latter includes task-specific pre-processing to convert the variable length trajectories into a single prediction per user. As a feasibility study, we collected mouse trajectory data from 183 patients filling out a pre-intervention depression questionnaire. While the hand-crafted features slightly improve baseline predictions, the spatiotemporal models underperform. However, considering our small data set size, we propose more research to investigate the potential value of this novel and promising data type and provide the necessary steps and open-source code to do so.

OBJECTIVES:Previous research has suggested antiviral properties for lithium, including potential effectiveness against COVID-19 in vitro. This study aimed to investigate the impact of lithium and other psychotropic drugs on the risks of mortality, hospitalization, and ICU admission due to COVID-19 among individuals with bipolar disorder. The primary objective was to assess whether lithium was beneficial in COVID-19-infection in a real-world population. METHODS:Retrospective register study using data from multiple Swedish patient registers, including 39,063 individuals in Sweden with bipolar disorder and prescribed mood stabilizers. Outcomes included COVID-19-associated death, hospitalization, and ICU admission between 11 March 2020 and 10 March 2021. Multivariate logistic regression adjusted for age, sex, and somatic comorbidities was conducted. RESULTS:Lithium were prescribed to 44.2 % of patients, either as mono- or combination therapy; other mood stabilizers were prescribed to 55.8 %. There were no significant associations between lithium and COVID-19-associated death, hospitalization, or ICU admission. Atypical antipsychotics were associated with increased odds ratios for COVID-19-associated death (OR 1.58 [95 % CI 1.01-2.47]), hospitalization (OR 1.80 [95 % CI 1.49-2.18]), and ICU admission (OR 2.25 [95 % CI 1.33-3.80]). Benzodiazepines were associated with a significant increase in COVID-19-associated death (OR 1.54 [95 % CI 1.01-2.35]) and hospitalization OR 1.26 [95 % CI 1.03-1.53]). In an ad hoc analysis, lithium monotherapy was, however, associated with reduced hospitalizations and ICU admissions. CONCLUSIONS:Our findings weaken the hypothesis that lithium reduces the risk of severe events associated with COVID-19 infection in bipolar disorder.

ImportanceIn pregnancy, the benefits of lithium treatment for relapse prevention in psychiatric conditions must be weighed against potential teratogenic effects. Currently, there is a paucity of information on how and when lithium is used by pregnant women.ObjectiveTo examine lithium use in the perinatal period.Design, Setting, and ParticipantsThis cohort study used individual-level data of pregnancies from January 1, 2000, to December 31, 2021, in Australia, Denmark, Finland, Germany, Hong Kong, Iceland, Israel, New Zealand, Norway, South Korea, Sweden, Taiwan, the UK, and 2 cohorts in the US. Analyses were performed from September 1 to November 30, 2023.ExposuresThe prevalence of lithium use as the proportion of pregnancies with at least 1 prescription fill or prescription within 3 months before pregnancy until childbirth was estimated using a common protocol. Lithium use during pregnancy by trimester and in the 3 months before and after pregnancy was examined.Main Outcomes and MeasuresComparison of prevalence between the first and last 3-year periods of available data.ResultsAmong 21 659 454 pregnancies from all collaborating sites, the prevalence of lithium use ranged from 0.07 per 1000 pregnancies in Hong Kong to 1.56 per 1000 in the US publicly insured population. Lithium use increased per 1000 pregnancies in 10 populations (Australia [0.60 to 0.74], Denmark [0.09 to 0.51], Finland [0.10 to 0.29], Iceland [0.24 to 0.99], Israel [0.25 to 0.37], Norway [0.24 to 0.47], South Korea [0.30 to 0.44], Sweden [0.42 to 1.07], the UK [0.07 to 0.10], and Taiwan [0.15 to 0.19]), remained stable in 4 populations (Germany [0.17 to 0.16], Hong Kong [0.06 to 0.06], and the publicly [1.50 to 1.34] and commercially [0.38 to 0.36] insured US populations), and decreased in 1 population (New Zealand [0.54 to 0.39]). Use of lithium decreased with each trimester of pregnancy, while prevalence of postpartum use was similar to prepregnancy levels. The proportion of lithium use in the second trimester compared with the prepregnancy period ranged from 2% in South Korea to 80% in Denmark.Conclusions and RelevancePrevalence of lithium use in pregnant women over the past 2 decades varied markedly between populations. Patterns of use before, during, and after pregnancy suggest that many women discontinued lithium use during pregnancy and reinitiated treatment after childbirth, with large variations between countries. These findings underscore the need for internationally harmonized guidelines, specifically for psychiatric conditions among pregnant women that may benefit from lithium treatment.

Anorexia nervosa (AN), a psychiatric condition defined by low body weight for age and height, is associated with numerous dermatological conditions. Yet, clinical observations report that patients with AN do not suffer from infectious skin diseases like those associated with primary malnutrition. Cell-mediated immunity appears to be amplified in AN; however, this proinflammatory state does not sufficiently explain the lower incidence of infections. Antimicrobial peptides (AMPs) are important components of the innate immune system protecting from pathogens and shaping the microbiota. In Drosophila melanogaster starvation precedes increased AMP gene expression. Here, we analyzed skin microbiota in patients with AN and age-matched, healthy-weight controls and investigated the influence of weight gain on microbial community structure. We then correlated features of the skin microbial community with psoriasin and RNase 7, two highly abundant AMPs in human skin, to clarify whether an association between AMPs and skin microbiota exists and whether such a relationship might contribute to the resistance to cutaneous infections observed in AN. We find significant statistical correlations between Shannon diversity and the highly abundant skin AMP psoriasin and bacterial load, respectively. Moreover, we reveal psoriasin significantly associates with Abiotrophia, an indicator for the healthy-weight control group. Additionally, we observe a significant correlation between an individual's body mass index and Lactobacillus, a microbial indicator of health. Future investigation may help clarify physiological mechanisms that link nutritional intake with skin physiology.

Background: Individuals with severe mental disorder (SMD) have a higher risk of somatic comorbidity and mortality than the rest of the population. We set up a population-based study to assess whether individuals with SMD had a higher risk of death associated with a COVID-19 infection (COVID-19 associated death) than individuals without SMD. Methods: Exploratory analysis with a cross-sectional design in the framework of a population-based register study covering the entire Swedish population. The Swedish Board for Health and Welfare (Socialstyrelsen) provided anonymized tabulated summary data for further analysis. We compared numbers of COVID-19 associated death in individuals with SMD (cases) and without SMD (controls). We calculated the odds ratio (OR) for the whole sample and by age group and four comorbidities, namely diabetes, cardiovascular disease, hypertension, chronic lung disease. Results: The sample comprised of 7,923,859 individuals, 103,999 with SMD and 7,819,860 controls. There were 130 (0.1%) COVID-19 associated deaths in the SMD group and 4,945 (0.06%) in the control group, corresponding to an OR of 1.98 (CI 1.66-2.35; p < 0.001). The odds were 4-fold for the age groups between 60 and 79 years and 1.5-fold for cardiovascular diseases. Individuals with SMD without any of the risk factors under study had 3-fold odds of COVID-19 associated death. Conclusion: Our preliminary results identify individuals with SMD as a further group at increased risk of COVID-19 associated death. In regard to comorbidities, future studies should explore the potential confounding or mediation role in the relationship between SMD and COVID-19 associated deaths.

Individuals with severe mental disorders (SMDs) such as psychotic disorders, bipolar disorders, and single manic episodes have increased mortality associated with COVID-19 infection. We set up a population-based study to examine whether individuals with SMD also had a higher risk of hospitalization and death from other infectious conditions. Anonymized and summarized data from multiple Swedish patient registers covering the entire Swedish population were supplied by the Swedish National Board of Health and Welfare. The frequencies of hospitalizations and deaths associated with influenza/pneumonia and sepsis in individuals with SMD were compared with the rest of the population during 2018–2019. Possible contributing comorbidities were also examined, of which diabetes, cardiovascular disease, chronic lung disease, and hypertension were chosen. A total of 7,780,727 individuals were included in the study; 97,034 (1.2%) cases with SMD and 7,683,693 (98.8%) controls. Individuals with SMD had increased risk of death associated with influenza/pneumonia (OR = 2.06, 95% CI [1.87–2.27]) and sepsis (OR = 1.61, 95% CI [1.38–1.89]). They also had an increased risk of hospitalization associated with influenza/pneumonia (OR = 2.12, 95% CI [2.03–2.20]) and sepsis (OR = 1.89, 95% CI [1.75–2.03]). Our results identify a need for further evaluation of whether these individuals should be included in prioritized risk groups for vaccination against infectious diseases other than COVID-19.

Introduction Individuals with severe mental disorder (SMD) have a higher risk of somatic comorbidity and mortality than the rest of the population. Objectives To assess whether individuals with SMD had a higher risk of death associated with a COVID-19 infection (COVID-19 associated death) than individuals without SMD. Methods Exploratory analysis with a cross-sectional design in the framework of a population-based register study covering the entire Swedish population. The Swedish Board for Health and Welfare (Socialstyrelsen) provided anonymised tabulated summary data for further analysis. We compared numbers of COVID-19 associated death in individuals with SMD (cases) and without SMD (controls). We calculated the odds ratio (OR) for the whole sample and by age group and four potential risk factors, namely diabetes, cardiovascular disease, hypertension, chronic lung disease. Results The sample comprised of 7,923,859 individuals, 103,999 with SMD and 7,819,860 controls. There were 130 (0.1%) COVID-19 associated deaths in the SMD group and 4945 (0.06%) in the control group, corresponding to an OR of 1.98 (CI 1.66-2.35; p < 0.001). The odds were fourfold in the age group between 60 and 79 years. Cardiovascular diseases increased the odds by 50%. Individuals with SMD without any of the risk factors under study had three-folds odds of COVID-19 associated death. Conclusions Our preliminary results suggest that individuals with SMD are a further group at increased risk of COVID-19 associated death. The factors contributing to this increased mortality risk require clarification. Disclosure Ursula Werneke has received funding for educational activities on behalf of Norrbotten Region (Masterclass Psychiatry Programme 2014-2018 and EAPM 2016, Luleå, Sweden): Astra Zeneca, Eli Lilly, Janssen, Novartis, Otsuka/Lundbeck, Servier, Shire and Sunovi

Clinical observations show that patients with anorexia nervosa (AN) are surprisingly free from infectious diseases. There is evidence from studies in Drosophila melanogaster that starvation leads to an increased expression of antimicrobial peptides (AMPs). AMPs are part of the innate immune system and protect human surfaces from colonization with pathogenic bacteria, viruses and fungi. We compared the expression of AMPs between patients with AN and healthy controls (HC) and investigated the influence of weight gain. Using a standardized skin rinsing method, quantitative determination of the AMPs psoriasin and RNase 7 was carried out by ELISA. Even though non-significant, effect sizes revealed slightly higher AMP concentrations in HC. After a mean weight gain of 2.0 body mass index points, the concentration of psoriasin on the forehead of patients with AN increased significantly. We could not confirm our hypotheses of higher AMP concentrations in patients with AN that decrease after weight gain. On the contrary, weight gain seems to be associated with increasing AMP concentrations.

Allopregnanolone and progesterone in estradiol treated severe postpartum affective disorder

BackgroundPostpartum affective disorders may be associated with dysregulation of gonadal steroids. We investigated peripheral levels of allopregnanolone and progesterone in a combined group of wome ...

•Allopregnanolone decreased during estradiol treatment in postpartum depression and psychosis.•The Allopregnanolone/Progesterone ratio was lower in patients compared with controls.•Change in neurosteroid metabolism may be risk factor for postnatal affective dysregulation.

A Swedish example of integrated perinatal mental health careMental disorders are common during the perinatal period and expose mother and child to major risks. Almost all women in Sweden attend mat ...

Corrigendum to Insulin and glucagon in plasma and cerebrospinal fluid in suicide attempters and healthy controls [Psychoneuroendocrinology 81 (2017) 1-7]