One-third of women at high risk experience a postpartum relapse. In women with bipolar disorder, continuation of prophylactic medication during pregnancy appears highly protective for maintaining mood stability postpartum. In women with a history of isolated postpartum psychosis, initiation of prophylaxis immediately after delivery offers the opportunity to minimize the risk of relapse while avoiding in utero medication exposure.

ECT is particularly effective in patients with depression with psychotic features and in elderly people with depression. More research on both biological and clinical predictors is needed to further evaluate the position of ECT in treatment protocols for major depression. Declaration of interest None.

BackgroundAlthough crime victimisation is as prevalent in psychiatric patients as crime perpetration (and possibly more so), few European figures for it are available. We therefore assessed its one-year prevalence and incident rates in Dutch severely mentally ill outpatients, and compared the results with victimisation rates in the general population.MethodThis multisite epidemiological survey included a random sample of 956 adult severely mentally ill outpatients. Data on victimisation were obtained using the victimisation scale of the Dutch Crime and Victimisation Survey, which assesses crime victimisation over the preceding 12 months. Comparison data were derived from the nationwide survey on safety and victimisation in the Netherlands. Prevalence and incident rates were weighted for sex, age, ethnicity and socioeconomic status, and compared with a general population sample matched by region (N = 38,227).ResultsIn the past year, almost half of the severely mentally ill outpatients (47%) had been victim of a crime. After control for demographic differences, prevalence rates of overall and specific victimisation measures were significantly higher in severely mentally ill outpatients than in the general population. The relative rates were especially high for personal crimes such as violent threats (RR = 2.12, 95% CI: 1.72–2.61), physical assaults (RR = 4.85, 95% CI: 3.69–6.39) and sexual harassment and assaults (RR = 3.94, 95% CI: 3.05–5.09). In concordance, severely mentally ill outpatients reported almost 14 times more personal crime incidents than persons from the general population (IRR = 13.68, 95% CI: 12.85–14.56).ConclusionCrime victimisation is a serious problem in Dutch severely mentally ill outpatients. Mental-healthcare institutions and clinicians should become aware of their patients’ victimisation risk, and should implement structural measures to detect and prevent (re-)victimisation.

The meta-analysis of the RCTs on advance statements showed a statistically significant and clinically relevant 23% reduction in compulsory admissions in adult psychiatric patients, whereas the meta-analyses of the RCTs on community treatment orders, compliance enhancement, and integrated treatment showed no evidence of such a reduction. To date, only 13 RCTs have used compulsory admissions as their primary or secondary outcome measure. This demonstrates the need for more research in this field.

BackgroundThis study took place to enable the measurement of the effects on mental health of a psychosocial intervention in Rwanda. It aimed to establish the capacities of the Self-Reporting Questionnaire (SRQ-20) to screen for mental disorder and to assess symptom change over time in a Rwandan community setting.MethodsThe SRQ-20 was translated into Kinyarwanda in a process of forward and back-translation. SRQ-20 data were collected in a Rwandan setting on 418 respondents; a random subsample of 230 respondents was assessed a second time with a three month time interval. Internal reliability was tested using Cronbach's alpha. The optimal cut-off point was determined by calculating Receiver Operating Curves, using semi-structured clinical interviews as standard in a random subsample of 99 respondents. Subsequently, predictive value, likelihood ratio, and interrater agreement were calculated. The factor structure of the SRQ-20 was determined through exploratory factor analysis. Factorial invariance over time was tested in a multigroup confirmatory factor analysis.ResultsThe reliability of the SRQ-20 in women (α = 0.85) and men (α = 0.81) could be considered good. The instrument performed moderately well in detecting common mental disorders, with an area under the curve (AUC) of 0.76 for women and 0.74 for men. Cut-off scores were different for women (10) and men (8). Factor analysis yielded five factors, explaining 38% of the total variance. The factor structure proved to be time invariant.ConclusionsThe SRQ-20 can be used as a screener to detect mental disorder in a Rwandan community setting, but cut-off scores need to be adjusted for women and men separately. The instrument also shows longitudinal factorial invariance, which is an important prerequisite for assessing changes in symptom severity. This is a significant finding as in non-western post-conflict settings the relevance of diagnostic categories is questionable. The use of the SRQ-20 can be considered an alternative option for measuring the effect of a psychosocial intervention on mental health.Trial registrationNederlands Trial Register NTR1120.

Background: Antidepressant use during pregnancy has increased over the last decades, while safety has been under debate. Our aim was to measure the international prevalence of antidepressant use before, during, and after pregnancy and examine timing, type of prescriptions and geographic variability. Methods: We searched Embase, Medline Ovid, Web of Science, Cochrane Central and Google Scholar from their inception until February 19, 2019. We determined pooled prevalence estimates of antidepressants before, during, and after pregnancy, as well as stratified according to substantive variables. Results: We identified 40 cohorts from 15 countries, together reporting on 14,072,251 pregnancies. Included studies had a low risk of bias, often reporting on large representative cohorts. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly used antidepressants during pregnancy, with an international prevalence estimate of 3.0% (95%CI 2.3;3.7). While Europe and Australasia had pooled prevalence estimates of 1.6% and 1.3% respectively, Northern America had a prevalence estimate of 5.5% (Q-value = 126.19; df = 2; p-value<0.01). Highest SSRI prevalence rates were found for sertraline (1.10%), followed by citalopram and fluoxetine (0.77% and 0.76% respectively) (Q-value = 121.25; df = 5; p-value<0.01). Qualitative analysis indicated an increase in antidepressant use over subsequent calendar years. Limitations: Substantial heterogeneity remained unaccounted for throughout the analyses, even after accounting for hypothetical contributors. Conclusions: This meta-analysis revealed substantial regional differences in antidepressant use around pregnancy, which could be due to variability in prescription behavior, healthcare seeking behavior and organization of healthcare. There is an urgent need for evidence on effectiveness, benefit, and harm of antidepressants during pregnancy to guide clinical practice. greatly contribute to this increase (Andrade et al., 2016;Charlton et al., 2015;Cooper et al., 2007). In the general population, antidepressants are now among the top three most commonly prescribed therapeutic drug classes in the United States (Pratt et al., 2017). Antidepressants showed the largest increase in prescriptions during pregnancy over time, compared to other drugs associated with potential harmful neonatal effects (van Gelder et al., 2014).

Objective:Several countries have developed Clinical Practice Guidelines regarding treatment of perinatal depressive symptoms and perinatal use of antidepressant. We aimed to compare guidelines to guide clinicians in best clinical practice.Methods:An extensive search in guideline databases, MEDLINE and PsycINFO was performed. When no guidelines were (publicly) available online, we contacted psychiatric-, obstetric-, perinatal- and mood disorder societies of all first world countries and the five largest second world countries. Only Clinical Practice Guidelines adhering to quality criteria of the Appraisal of Guidelines for Research and Evaluation instrument and including a systematic review of evidence were included. Data extraction focussed on recommendations regarding continuation or withdrawal of antidepressants and preferred treatment in newly depressed patients.Results:Our initial search resulted in 1094 articles. After first screening, 40 full-text articles were screened. Of these, 24 were excluded for not being an official Clinical Practice Guidelines. In total, 16 Clinical Practice Guidelines were included originating from 12 countries. Eight guidelines were perinatal specific and eight were general guidelines.Conclusion:During pregnancy, four guidelines advise to continue antidepressants, while there is a lack of evidence supporting this recommendation. Five guidelines do not specifically advise or discourage continuation. For new episodes, guidelines agree on psychotherapy (especially cognitive behavioural therapy) as initial treatment for mild to moderate depression and antidepressants for severe depression, with a preference for sertraline. Paroxetine is not preferred treatment for new episodes but switching antidepressants for ongoing treatment is discouraged (three guidelines). If mothers use antidepressants, observation of the neonate is generally recommended and breastfeeding encouraged.

Postpartum psychosis is a severe disorder that warrants acute clinical intervention. Little is known, however, about what interventions are most effective. The authors present treatment response and remission outcomes at 9 months postpartum using a four-step algorithm in patients with first-onset psychosis or mania in the postpartum period. Treatment involved the structured sequential administration of benzodiazepines, antipsychotics, lithium, and ECT. The outcome of clinical remission was examined in 64 women consecutively admitted for postpartum psychosis. Remission was defined as the absence of psychotic, manic, and severe depressive symptoms for at least 1 week. Women who remitted on antipsychotic monotherapy were advised to continue this treatment as maintenance therapy, and women who required both antipsychotics and lithium to achieve remission were maintained on lithium monotherapy. Relapse was defined as the occurrence of any mood or psychotic episode fulfilling DSM-IV-TR criteria. Using this treatment algorithm, the authors observed that nearly all patients (98.4%) achieved complete remission within the first three steps. None of the patients required ECT. At 9 months postpartum, sustained remission was observed in 79.7%. Patients treated with lithium had a significantly lower rate of relapse compared with those treated with antipsychotic monotherapy. Multiparity and nonaffective psychosis were identified as risk factors for relapse. The authors conclude that a structured treatment algorithm with the sequential addition of benzodiazepines, antipsychotics, and lithium may result in high rates of remission in patients with first-onset postpartum psychosis and that lithium maintenance may be most beneficial for relapse prevention.