Hello and welcome to this four-part webinar series on perinatal mental and substance use disorders. This webinar series is a result of the work conducted by a group of clinicians, researchers and clinical researchers from across various disciplines in mental and behavioral health. Before starting the webinar, we would like to acknowledge that this product would not be possible without the partial funding from the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services, grant number NU38OT000288. In addition, we would like to stress that the contents provided herein are solely the responsibility of the authors and do not necessarily represent the official views of, nor an endorsement by, HHS, CDC or the CDC Foundation. Similarly, the contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the American Psychiatric Association, the APA. We would like to draw your attention to terminologies used in the webinar series. Where possible, we have used inclusive language such as person or persons instead of woman or women. For example, we refer to pregnant persons instead of pregnant women. This has been done consistently throughout the webinar, except in instances where the research we cited specifically stated that there is inclusion of women only in their study population. Similarly, we use the inclusive term parental instead of maternal. In contrast, you will notice that we used the word breastfeeding throughout the webinar. This was done because the studies we reviewed talked about breastfeeding. However, we would like to acknowledge that breastfeeding is a more inclusive term. Other terms of interest include antenatal or antepartum, which refers to before birth. Postnatal refers to after birth. Perinatal covers the pregnancy and postpartum period. Peripartum covers the period shortly before, during, and immediately after giving birth. Postpartum refers to the postnatal period up to one year following given birth. We also use the acronym PANPBH, and this is used to refer to psychiatrists and non-physician behavioral health when referring to the practitioners who participated in the focus groups and surveys associated with this initiative. So, why is this topic and webinar series important? Well, studies have shown that mental and substance use disorders are associated with poor obstetrical outcomes, as well as poor outcomes for a fetus or child. Despite these findings, the rate of psychiatric treatment in the perinatal population Despite these findings, the rate of psychiatric treatment in the perinatal population remained low. Furthermore, there is limited research on best practices for the treatment of perinatal mental and substance use disorders. Compounding the issue of low rate of treatment and limited research on best practices are the findings that there is inadequate training of psychiatrists and non-physician behavioral health practitioners in the United States. Understanding the factors that contribute to the inadequate training of psychiatrists and non-physician behavioral health practitioners is important for the field of perinatal mental health care. Osborne and colleagues and their 2015 survey of psychiatry residency training directors found that only 36% of directors believe that their residents required competencies in this area. These directors cited lack of time to teach a topic as the primary barrier. These observations, plus the anecdotal reports by persons with mental and substance use disorders of having their clinical care dropped by their behavioral health practitioners once they become pregnant, was the impetus behind the project that resulted in this webinar series. The project aimed to investigate if the anecdotal report was supported and to try to identify potential causes and consequences as well as strategies to address this issue. A number of methods were utilized to address the issue with the goal of developing a perinatal psychiatric toolkit, which includes this webinar series as well as to formulate educational and training recommendations. Methods used included separate focus groups and surveys of pregnant persons and psychiatrists and non-physician behavioral health practitioners and their trainees. Similar to the 2015 survey of psychiatry residency training director conducted by Osborne and colleagues, we surveyed program chairs and training directors of mental and behavioral health training programs, but in addition to psychiatrists, our sample included clinical psychology, clinical social work, clinical mental health counseling, and advanced nurse practitioner programs. In addition, we conducted literature review on various topics in the broad areas of epidemiology, etiology, and adverse outcomes, clinical management of perinatal mental and substance use disorders, perinatal mental and substance use disorders in vulnerable and underserved populations, and training gaps in perinatal mental health care. The results of the literature review formed the basis for this webinar series, with supplemental information from the focus groups and, in some instances, the surveys conducted. The work was informed by an advisory panel of experts from across various disciplines in behavioral and mental health. This four-part webinar series aims to enhance your awareness and understanding of treatment and training gaps in perinatal mental and substance use disorders and their impact. The series highlights ways to address these gaps. The webinar series include webinar one, epidemiology, etiology, and adverse outcomes of perinatal mental and substance use disorders. Webinar two, which covers clinical management of perinatal mental and substance use disorders. Webinar three, which focuses on vulnerable and underserved populations with perinatal mental and substance use disorders. And the fourth webinar that covers behavioral health education and training in perinatal mental and substance use disorders with a focus on gaps and recommendations. We hope you find each session and the full webinar series informative. Welcome to webinar one. This webinar focuses on epidemiology, etiology, and adverse outcomes of perinatal mental and substance use disorders. This session sets the foundation for the other webinars in this four-part series. Each faculty member will introduce themselves at the start of their component of the webinar. I am Diana Clark, Principal Investigator of the project and Managing Director of Research and Senior Epidemiologist and Research Statistician at the American Psychiatric Association. I am also an Adjunct Assistant Professor in Department of Mental Health at Johns Hopkins Bloomberg School of Public Health. It is important to know that all faculty members for this webinar report no financial conflicts to disclose. The learning objectives of this webinar are, to improve your understanding of the epidemiology of perinatal mental and substance use disorders, to improve your understanding of the etiology of perinatal mental and substance use disorders, to improve your understanding of the impact of untreated perinatal mental and substance use disorders on parental outcomes, and lastly, to improve your understanding of the impact of untreated perinatal mental and substance use disorders on outcomes for the fetus and child. As stated in the overview of this webinar series, perinatal mental and substance use disorders are vastly overlooked and undertreated as well as under-researched. Understanding the epidemiology of perinatal mental and substance use disorders is critical to informing prevention and treatment efforts for the perinatal population. Efforts can include screening and detection of perinatal mental and substance use disorders, risk reduction and prevention strategies, including emphasis on underserved and vulnerable populations, the development and implementation of formal treatments, and informal support and resource-based interventions. The results of epidemiologic studies can help to shape public health practice and policymaking, and help to enhance training for practitioners, thereby leading to enhanced improvement in quality of care for the perinatal population. First, what have we learned from pregnant persons who participated in our focus groups? What we learned was that getting pregnant placed a huge barrier on treatment that individuals receive for their mental health. Pregnant persons' report of mental health symptoms can sometimes be ignored by their healthcare practitioners and described as part of normal symptoms, resulting in a lack of treatment for perinatal mental and substance use disorders. Also, pregnant persons may experience different types of mental health symptoms during their pregnancy, which can lead to isolation. This warrants attention to perinatal mental and substance use disorders, both clinically and in research. Before introducing information on the epidemiology of perinatal mental and substance use disorders, it is important to know that studies varied in the disorders of interest examined. For example, studies focused on peripartum depression and anxiety disorders, bipolar disorders, eating disorders, post-traumatic stress disorders, attention deficit hyperactivity disorders, and OCD, obsessive compulsive disorder. With regards to substance use disorders or symptoms, studies focused on alcohol, nicotine, e-cigarette use, tobacco or cigarettes, cannabis, co-use of cannabis and other substances, such as opioid, cocaine, and methamphetamines, and this might vary even within and across studies. In addition, many studies focused on symptoms rather than clinical syndrome, which made it difficult to get a complete picture of the epidemiology of perinatal mental and substance use disorders. Despite these limitations, the existing data underscores the need for more attention to be paid to perinatal mental and substance use disorders in terms of clinical care, research, and training. Studies on the incidence of perinatal mental and substance use disorders are limited relative to studies on the prevalence of these conditions. That said, these limited studies indicate that mental and substance use disorders or symptoms can emerge or be exacerbated perinatally and warrant clinical attention. For instance, studies showed that among women who gave birth to their first child, the incidence of psychiatric hospitalization for postpartum psychosis among those without previous psychiatric hospitalization was 0.4% and 9.24% for those with any psychiatric hospitalization before delivery. With regards to major depressive episode, the incidence was 7.5 in the prenatal period and 6.5 in the postnatal period. Another study that looked at depressive symptoms rather than diagnosable depressive disorder or episode found the incidence of depressive symptoms to be 25.4% in the postpartum period. For anxiety symptoms and anxiety-related disorders, the incidence rate reported were 23% and 3 to 11% respectively. Similar, the incidence of PTSD was only 7.6% in postpartum women relative to 16.6% for post-traumatic stress symptoms meeting partial criteria. For perinatal obsessive-compulsive disorder, the incidence rate found in one systematic review was 4.7 new cases per 1,000 women per week postpartum. These findings showed that many more perinatal women experienced symptoms of mental disorders than those meeting criteria for the disorder. It is important to note, as stated by pregnant persons in our focus group, these symptoms can be distressing and impairing. Prevalence studies. Prevalence studies show that the prevalence of psychosis at delivery was 698.76 per 100,000 hospitalization. When broken down, this represents the prevalence of 649.69 per 100,000 hospitalization for effective psychosis compared to 60.09 per 100,000 hospitalization for schizophrenia and 10.15 per 100,000 hospitalization for other psychosis, indicating that effective psychosis is more prevalent than the other forms. For perinatal mood disorders, which include depressive and bipolar disorders, the prevalence estimate was about 13%, but variability was found depending on how the mood disorder was conceptualized. For example, it was estimated that antenatal depression affected approximately 17% of women, similar to minor depression, which was estimated at 16.6%. The prevalence of major depressive disorder, however, was much lower at 6.1%. Time series studies showed a sevenfold increase in recorded diagnosis or diagnoses of depressive disorders at the time of delivery, from 4.1 per 1,000 delivery hospitalization in 2000 to 28.7 per 1,000 hospitalization or delivery hospitalization in 2015. When prevalence estimates from across various studies on perinatal bipolar disorder was pooled, 2.6% of women with no known psychiatric illness prior to becoming pregnant experienced bipolar disorder or symptoms. Similar to the incidence data, the prevalence data showed higher estimates of broader categories of symptoms of mental disorders compared to specific or clinically diagnosable or diagnosed mental disorders. For example, the prevalence of any anxiety disorder was 15.2%, whereas the prevalence for a generalized anxiety disorder was only 4.1%. The prevalence of bipolar disorder was only 4.1%. The pool prevalence of PTSD and post-traumatic stress was 4.7% relative to 12.3%, and that's for mothers, and then 1.2% and 1.3% respectively for fathers. Approximately 6% of pregnant women and 11% to 14% of postpartum women experience clinical levels of obsessive-compulsive disorders. When we look at perinatal suicidal ideation or suicide-related behaviors such as self-harm and suicide attempts during pregnancy and postpartum, we found higher prevalence of suicidal ideation relative to suicidal behavior, which differs in the pregnancy and postpartum periods. For example, the prevalence of suicidal ideation was 7% to 12% during pregnancy and 4% to 9% during the postpartum period. In contrast, another study showed that the prevalence of suicidal ideation and or intentional self-harm defined collectively as suicidality in pregnant or postpartum women was less than 1%, but rose from 0.2% to 0.6% per 100 individuals from 2006 to 2017. The prevalence of suicide attempts during pregnancy was 680 per 100,000 women or 0.68%, but 210 per 100,000 or 0.2% during the first year postpartum. So the prevalence of suicide attempt was higher during the pregnancy period. When we look at substance use disorder, we noted a lack of studies on the incidence of substance use and substance use disorders in the perinatal period. This is likely related to the stigma associated with substance use disorder in general and substance use while pregnant and breastfeeding. In fact, during our focus group, participants who indicated substance use during pregnancy asked to stay off camera. Despite the lack of incidence studies, time series data showed increased trends in the use of substances such as tobacco, marijuana, opioids, and alcohol during the perinatal period. Also, studies showed variations in the rates of substances used based on stages of pregnancy. For example, the number of mothers using or dependent on opiates increased from 1.19 to 5.63 per 1,000 hospital births per year between 2000 and 2009. Other studies show that the proportion of women reporting several binge episodes of opiate use peaked in week three of their pregnancy to 17.8% and declined to 1.7% in week seven. With respect to marijuana use, use in pregnancy increased from 3.4% to 7.7% between 2015 and 2021. However, marijuana use declined with advance in gestation from 37% in the first trimester, 26% in the second trimester, to 18% in the third trimester. With regards to tobacco use, use decreased from 13.9% to 10.8% between 2015 and 2001 in pregnant women. However, use of smokeless tobacco increased from 0.2% to 1.1% in the same time period. For alcohol use, use increased slightly in pregnant women between 9.3% to 9.8% between 2015 and 2021. However, heavy alcohol use increased from 0.8% to 1.2% in the same time period. Perinatal substance use disorder was found to occur in 5.5% of deliveries. Among currently pregnant persons, 22% reported using one or more substances in the previous month. Of those, 35% reported using alcohol only, 10% reported using cannabis only, and 46% reported using tobacco only. Among those who reported using more than one substances, 5% reported using tobacco and opioids, and 5% reported using polysubstances or multiple substances. The literature to date has reported prevalence rate primarily rather than incidence rates, making it harder to assess the onset of new cases of perinatal mental and substance use disorders. Efforts are needed to better understand causes of perinatal mental and substance use disorders, as well as to further scrutinize prevalence data to ensure their representativeness, especially for vulnerable populations that typically lack access to treatment and less likely to participate in surveys, which make them less likely to be accurately represented in datasets used to estimate prevalence rates. The literature on perinatal substance use disorders is limited by the fact that studies of perinatal addictions typically report on patterns of use and misuse rather than based on clinically diagnosable disorders, except in the case of opioid use disorders. In conclusion, perinatal mental and substance use disorders are not uncommon. Common conditions or symptoms, such as anxiety, alcohol use, cannabis use, tobacco use, demonstrate relatively higher incidence and or prevalence rates than others, such as psychosis, bipolarity, and opioid misuse. The prevalence of suicidal thoughts and related behaviors during pregnancy and postpartum are not trivial and need to be better measured, understood, and addressed. More epidemiologic research are needed to understand the incidence of perinatal mental and substance use disorders and symptoms. Likewise, future epidemiologic studies need to have greater representation of underserved and vulnerable populations who are more likely to not participate in surveys or access care that results in the data used to estimate prevalence rates. We will now turn our attention to the etiology or potential causes of perinatal mental and substance use disorders. The etiologies or causes behind most perinatal mental or substance use disorders are not well studied. Although there are studies aiming to identify the relationship between various aspects, such as genetics, biological, environmental, reproductive, and or social risk factors, there's a scarcity of articles that report strong associations. That said, there are a number of risk factors that practitioners should be aware of in their assessment and care of pregnant persons and those who are postpartum who may experience new onset or exacerbation of their mental and or substance use disorders if these conditions go un- or undertreated. Few studies examine the association between various genes or epigenetic alterations and mental and substance use disorders. The majority of studies that examine genetic risk and perinatal mental and substance use disorders have focused on the development of peripartum depression. The influence of genetic factors, such as the onset of depressive symptoms, was found to vary by trimester, highlighting potential hormonal and environmental influences. However, the association between several genetic, several candidate genes, and various conditions such as postpartum depression, smoking, and or alcohol use were not conclusive. Studies that examine biological risk factors included those that investigated the effects of nutrients such as vitamins, trace minerals, micronutrients, and fat, and reported possible association between lower pregnancy folate levels and increased prenatal depression, and that low circulating levels of vitamin D were associated with a higher risk of peripartum depression. In addition, hormonal factors have been assessed as a risk for mental and substance use disorder in the perinatal period, but with inconclusive evidence. Poor sleep scores and fatigue were among factors associated with increased risk for depressive symptoms. Other studies reported that medical conditions such as anemia, chronic disorders such as diabetes and hypertension, infections such as HIV or TB were found to be associated with a higher risk of perinatal depression, anxiety, and substance use disorders. There are limited studies at date that examined the effect of COVID-19 on perinatal mental and substance use disorders. There are environmental factors that increase the risk of perinatal mental and substance use disorders. For instance, studies have shown that the season of delivery is potentially related to postpartum depression. For example, women who gave birth in the winter were found to be more likely to have postpartum depression when compared to those who did not give birth in the winter. In addition, higher levels of air pollutants have been found to be associated with an increased risk of postpartum depression. Likewise, exposure to metals such as barium, cadmium, chromium in the environment was associated with higher risk of anxiety symptoms during pregnancy. Endocrine-disrupting chemicals such as bisphenols and phthalates may influence hormonal shifts during pregnancy and contribute to postpartum depression. On the other hand, physical activity was found to be associated with a reduced risk of peripartum depression. There are a number of psychological factors that have been found to be related with perinatal mental and substance use disorders. For example, studies have shown that personality traits or style, for example, being neurotic, anxious, obsessive-compulsive, or having a vulnerable personality style are associated with a higher risk of postpartum depression and anxiety. Also, having a personal or family history of mental or substance use disorder is associated with perinatal mental or substance use disorders. For example, having a history of psychiatric conditions such as depression, bipolar disorder, panic disorder, anxiety disorder have been found to be associated with an increased risk of postpartum depression. With respect to having a family history of mental or substance use disorder, a meta-analysis published in 2022 reported a two-fold increase in the risk of developing postpartum depression among mothers who have a family history of any psychiatric disorder compared to those without. Exposure to stressful life events prior to conception are associated with tobacco use both before as well as alcohol and substance use disorder during pregnancy. Also, studies show that women who reported analgesic opioid use were more likely than non-users to report using illicit drugs during pregnancy and were three times more likely to report smoking cigarettes in the second or third trimester of their pregnancy. Pregnant depression or anxiety were related to greater likelihood of smoking before and during pregnancy and lowered the likelihood of quitting smoking during the prenatal period. Mental health symptoms, substance use, intimate partner violence, and recent stressors were found to be associated with suicides during pregnancy and postpartum. In fact, the rates of suicidal ideation during pregnancy ranged from 4.6% to 12%, which is important to note given that suicide ideation is a risk factor for both suicide and suicide attempts. There are a number of reproductive factors that are associated with increased risk of perinatal mental and substance use disorders or symptoms. For instance, experiencing obstetric complications such as having a C-section or emergency delivery was associated with diagnosis of PTSD or depression after giving birth. Also, infant complications including low support during labor and delivery or psychological difficulties in pregnancies were risk factors for developing PTSD after giving birth. In addition, the prevalence rates for anxiety and post-traumatic stress were higher among parents of infants admitted to neonatal units compared to those who did not. Anxiety prevalence was 41.9% and for post-traumatic stress, it was 39.9%. Additional evidence of the association between reproductive factors and perinatal mental and substance use disorder included the finding that among women with multiple births, the risk of postpartum depressive symptoms was 55% higher in those with preterm births in both deliveries and 74% higher in those with preterm birth in the index delivery only when compared to women who had multiple births but with full-term deliveries. Reproductive factors in combination with other risk factors impact perinatal mental health. For example, women with unintended or mistimed pregnancies were more likely to report severe or moderate perinatal depressive symptoms. First-time mothers, as well as mothers of twins, especially older mothers, reported higher rates of postpartum depression symptoms and symptom burden. Younger maternal age and multi-parity, along with non-reproductive risk factors such as low education, unemployment, criminal history, and so on, were associated with higher rates of maternal smoking during pregnancy. Unintended pregnancies and miscarriages were independently associated with an increase in later suicide attempts. In fact, miscarriage was associated with a two-fold increase in the likelihood of suicide attempts. According to the CDC, social determinants of health are the conditions in the environment where people are born, where they live, learn, work, worship, and play, and these factors can affect their health, mental health, functioning, and quality of life. These factors can impact the individual over their life course. In the perinatal period, the social determinants of health factors not only impact pregnant persons during and after their pregnancy, but can also impact their offspring. Increase in adverse childhood events was found to increase the risk of depression, anxiety, smoking, and alcohol use during pregnancy, especially among low-income persons. For instance, having a history of childhood sexual abuse was found to be a significant risk factor for opioid misuse in pregnancy, PTSD, depression, and anxiety. There's also some evidence that points to a possible relationship between severe abuse or multiple viscinimization and the risk of developing postpartum psychosis. Exposure to abuse or domestic violence and alcohol consumption behaviors of partners and family members were strong predictors of risky alcohol consumption, depression, sexual ideation, attempts, or death by suicide during pregnancy. Working pregnant persons of all ethno-racial groups reported work-related predictors of mental health state during the postpartum period. For instance, work-to-family conflict and total hours of workload were significantly related to worse mental health state during the postpartum period. Multiple social determinants of health risk factors, such as exposure to discrimination, toxic stress, teen pregnancy, low income, low education, history of substance abuse, and living in high-crime areas, increased the risk of smoking during pregnancy. For example, individual reporting experience of emotional upset due to racism found higher prevalence of smoking in the postpartum period, especially for people of color. A partner's involvement in childcare was found to be helpful in reducing mother's parenting stress and promoting maternal psychological adjustment in whites, Latinx, and Black women. In conclusion, in general, and similarly in the perinatal period, mental and substance use disorders are complex conditions that often co-occur and have multiple ideologies. There are a wide range of precipitating and predisposing factors for perinatal mental and substance use disorders, including genetic, biologic, psychological, environmental, reproductive, and social determinants of health factors. These factors can operate independently and jointly, as well as differently for each pregnant person. As such, better understanding of personal susceptibility to perinatal mental and substance use disorders can help inform more individualized approaches to prevention, treatment, and supportive intervention for perinatal populations, thereby giving patients and their offspring the best chance possible at achieving health and wellness. Hello, my name is Ludmila De Faria. I am an associate professor at the University of Florida in Gainesville, and I am also the chair for the Committee on Women's Mental Health for the American Psychiatric Association. Today, I'm going to talk about the impact of perinatal mental health and substance use disorders on parental outcomes. So the perinatal period is marked by significant psychological and physiological changes that impact the pregnant patient, their relationship, and the infant. Mental and substance use disorders can significantly affect pregnant person's health, self-efficacy, and the ability to engage in good prenatal care, self-care, resulting in poor outcomes. On the other hand, the data on the impact of mental health and substance use disorder on maternal outcome is limited, and more research is definitely required, and some of the limitations include paucity of studies, especially prospective studies with good data collection, a lot of heterogeneity among studies where the diagnosis that are used or some of the prior-to-conception data don't match, so it's very hard to figure out what the results mean. More data on pre-pregnancy history of mental health and substance use disorder, especially on the diagnosis other than depression. So some of the obstetric and gynecological outcomes that we know about include that starting in the prenatal period, mental disorder symptoms and substance use can shape obstetric outcomes by influencing prenatal health behaviors and consequently pregnancy and birth outcomes. Stress response, diet and exercise impact gestational weight gain and pregnancy outcomes, including postpartum depression. It is important to discuss family planning with women with psychiatric vulnerabilities. Any women that has been diagnosed with mood anxiety, psychotic substance use, conduct, or eating disorder, usually there is a lack of poor planning capacity, especially in disorders that include poor impulse control, lack of compliance with contraceptives, and risky sexual behavior, and that can lead to unintended pregnancies which can contribute to poor maternal and offspring outcomes. About 20% of women experience perinatal mood and anxiety disorders, which is an umbrella term often used by OB-GYN doctors that include both anxiety, a spectrum of anxiety and depressive disorders, up to and including postpartum depression. Out of this 20% of women with perinatal mood and anxiety disorders, 10% meet criteria for postpartum depression, and that's only among the ones that are screened, and the experts estimate that about 50% of women that may have perinatal mood and anxiety disorders are not identified because screening for anxiety and depression are not widespread. Depression and anxiety during pregnancy increase unhealthy health behaviors like tobacco use or poor maternal weight gain, rates of preterm delivery, risk of postpartum depression and postpartum suicide, the probability of a primary c-section, even in women that do not have obstetric risks, and perception of obstetric pain, leading to prolonged hospitalizations. Universal screening for perinatal mood and anxiety disorders is necessary, just like any other well-established risk factors for perinatal complications. So let's now focus on some of these perinatal complications that have been mentioned a little bit and dwelt more into it. First and foremost, gestational diabetes. There is a very well established bidirectional association between gestational diabetes and other glucose dysregulation and perinatal depression, meaning women with perinatal depression are more likely to develop gestational diabetes, and women with gestational diabetes are more likely to develop perinatal depression. The prevalence of depression among women with gestational diabetes ranges from 4 to 80 percent, and this is where you see the discrepancy among several studies. So depending on how they screen for depression among women with gestational diabetes, you have this wide range of prevalence. Women with prenatal depressive symptoms were more likely to have higher glucose tolerance tests, glucose level, and an abnormal gestational glucose tolerance. Having both gestational diabetes and depression is associated with higher perinatal complications because the combined burden of the gestational diabetes and depression results in significantly higher rates of preeclampsia, gestational hypertension, and preterm delivery, and difficulty achieving and maintaining glycemic control throughout pregnancy. Other complications, including depressive symptoms during pregnancy, are significantly associated with longer pre-delivery stays, meaning the time from admission to delivery. There is an association between depression and increased risk of preterm birth, stillbirth, neonatal death, and hypertensive disorders of pregnancy, and women with pre-existing and women with pre-existing depression and anxiety request more elective C-sections. Other complications, women with pre-existing mental health diagnosis and perinatal complications are at higher risk for suicide. Pregnant persons with suicidal behavior are more likely to have non-psychotic depression, psychosis, and substance or alcohol-related abuse. Those with suicidal behavior are at risk for antepartum hemorrhage, placental abruption, postpartum hemorrhage, premature delivery and poor fetal outcomes that will be covered in a different session. Women of color may be at higher risk for suicide because of the impact of social determinants of health and lack of environmental support. Perinatal anxiety and trauma-related disorders also increase the risk for obstetric and gynecological outcomes. They are negative. Anxiety disorders are often overlooked during the peripartum period, even though about a quarter of women who never had a live delivery might experience that. Again, the lack of actual numbers reflects the idea that more often than not, there is no screening for either anxiety or depression. Untreated perinatal anxiety is associated with preterm birth, small for gestational age infants, placental abruption and hypertensive disorders of pregnancy. Emerging evidence suggests that PTSD can increase the risk of cardiovascular morbidity in pregnancy. An estimated 30% had an increased risk of preeclampsia and an increased risk of hypertensive disorders of pregnancy. Perinatal psychotic disorders, such as schizophrenia, can elevate the risk for several adverse obstetric outcomes. Gestational hypertension, preeclampsia or eclampsia, C-section delivery, induced labor, antepartum and postpartum hemorrhage, placental abruption, preterm birth, stillbirth and premature rupture of membranes. Pregnant people with a diagnosis of schizophrenia need a patient-centered intensive care program or wraparound services with integrated multidisciplinary interventions in order to improve the delivery outcomes. Efforts to identify and manage pregnancies complicated by psychosis and the establishment of mother-baby units may significantly improve outcomes. Perinatal substance use disorders, prenatal alcohol exposure was associated with higher likelihood of placental abruption, decreased placental weight and altered placental vasculature, DNA methylation and molecular pathways. The use of cannabis prior to pregnancy is associated with infertility and during pregnancy with preterm births and pregnancy loss. Cigarettes and smoking increase the risk of miscarriage, spontaneous abortion, preterm and premature birth, premature rupture of membranes, placental abruption, premature descent of placenta, placenta accreta spectrum, and a 150% increase in overall perinatal mortality. Other substances such as opioids, opioids, opioid use disorder is associated with increased odds of maternal death during hospitalization, cardiac arrest, uterine growth restriction, placental abruption, longer stay at the hospital, preterm labor, oligohydrabnios transfusion, stillbirth and premature birth. Premature rupture of membranes and cesarean delivery. Methamphetamines are associated with higher odds of gestational hypertension, preeclampsia, severe preeclampsia and eclampsia, preterm birth, very preterm birth, intrauterine fetal demise, and abruption. And cocaine use is associated with increased odds of placental abruption, placenta infarction, and preeclampsia. Despite declines in use, cocaine remains the leading cause of undeparted hospitalizations for substance use among pregnant women. Although methamphetamines are approaching the numbers and it's fairly common, especially in urban areas. Other medical outcomes. Women with underlying anxiety and depression use the emergency department during the postpartum period for psychiatric and obstetric reasons more frequently. Women with underlying mental disorder were more likely to visit the emergency department for hypertension as well as psychiatric symptoms. Patients with schizophrenia and schizoaffective disorders have significantly higher rates of chronic diseases such as hypertension, diabetes, and urinary tract infections. They tend to be older, have more frequent smoking, alcohol, and substance use disorders, suffer from obesity, diabetes, and chronic obstructive pulmonary disease, and are more likely to be hospitalized in tertiary maternity hospitals. Several maternal and obstetric morbidity have been linked to the onset of psychiatric illnesses. Childbirth trauma by c-section or excessive blood loss in vaginal delivery or preterm birth increase the risk for postpartum depression and PTSD. Experiencing severe maternal morbidity was associated with an elevated risk of postpartum psychiatric morbidity as well, including elevated risk of hospitalization with a new psychiatric diagnosis. Poor pre-pregnancy and antepartum mental health can independently increase the odds of having postpartum mental health problems. People giving birth to preterm versus full-term infants had increased risk of being hospitalized with a mental health diagnosis within three months and up to a year after delivery. Maternal prenatal depression and PTSD were associated with problematic parenting. Maternal depression was positively associated with not working for pay after delivery. Maternal depression also had a significant positive association with household poverty. Postpartum depressive symptoms may negatively influence maternal health practices, attending postpartum checkup or postpartum dental visits post after delivery in women after birth. Physicians and behavioral health professionals should make it a priority to encourage positive maternal health practices and to discuss the importance of regular physician and dentist visits before, during, and after pregnancy. Another issue that is affected by maternal mental health is breastfeeding. There is a complex relationship between breastfeeding and maternal mental health. Breastfeeding is often associated with fewer maternal mental health symptoms unless there are breastfeeding difficulties or a discordance between maternal role expectations and the actual experience. If there is enough support and the mother wants to breastfeed, there is a protective factor for mental health. Exclusive breastfeeding rates at hospital discharge were heavily influenced by mother's perceived stress, anxiety, and depression without a direct relationship to cortisol levels. And antepartum depression negatively correlated to continue exclusive breastfeeding for longer than three months. The odds of breastfeeding initiation and continuation are definitely lower among individuals with both prenatal tobacco and illicit substance use. Women who report opioid use had significantly shorter duration of breastfeeding and women with negative early breastfeeding experiences are more likely to have depressive symptoms at two months postpartum. In summary, mental and substance use disorders or symptoms, whether they occur before or during pregnancies, can significantly compromise a pregnant person's ability to engage in prenatal care. And it leads to high risk pregnancy and complications such as preterm birth, hypertension, and gestational diabetes, and also an increased risk and exacerbation or even the development of new mental or substance use disorder or symptoms. Such as postpartum depression, increased risk of suicide or overdose, and social withdrawal and isolation, which can heavily impact the bonding between the parent and the child. My name is Jonathan Alpert. I'm chair of the Department of Psychiatry and Behavioral Sciences at Montefiore Medical Center and Albert Einstein College of Medicine. I'm also a member and current chair of the APA Council on Research. I'll be focusing on the impact of perinatal mental and substance use disorders on the developing fetus and child. A growing body of literature supports an association between perinatal mental illness and substance use disorders and adverse impacts on offspring. The mechanisms underlying this association remain largely unknown and are likely to be multifactorial. In addition, although we know that untreated mental illness and substance use disorders appear to have a deleterious impact on the fetus and developing child, the impact of adequate treatment and or response or remission of perinatal mental and substance use disorders on offspring represents a vitally important area for future research. The mechanisms underlying the association between perinatal mental illness and substance use disorders and offspring outcomes are likely to include biological factors, psychological and behavioral factors, environmental factors, and social determinants of health factors. The mechanisms that underlie the association between mental and substance use disorders and adverse impacts on the fetus and developing child are likely to include biological factors, psychological and behavioral factors, environmental factors, and social determinants of health factors. We know that some substances, particularly alcohol, have direct teratogenic effects on the fetus. In addition, we know that disorders that have moderate to high hereditability, such as depression, anxiety, attention deficit hyperactivity disorder, and substance use disorders are likely to confer genetic risk on offspring. In addition, the direct or indirect consequences of mental illness and substance use disorders are likely to affect the intrauterine environment, as well as parental behavior postpartum, including parental bonding and parental feeding behavior. Adverse outcomes for offspring associated with perinatal mental and substance use disorders are far ranging, including greater risks of stillbirth and infant mortality, prematurity, impaired growth, neonatal abstinence syndromes, neonatal intensive care unit or hospital admissions, and enduring cognitive, behavioral, and emotional problems. Serious mental illnesses, including severe major depressive disorder, as well as bipolar disorder or schizophrenia, have been associated with fetal malformations. However, those fetal malformations are not specific to individual disorders and do not define a specific syndrome. In contrast, fetal malformations associated with antenatal alcohol use do comprise a specific syndrome known as the fetal alcohol spectrum disorder, which is associated with a range of craniofacial, cardiovascular, and musculoskeletal defects, along with subsequent learning and behavioral problems. This is associated even with low or moderate amounts of alcohol, and indeed, no safe amount of alcohol during pregnancy has been established. Tobacco smoking has also been associated with a discrete syndrome of congenital malformations, particularly including urogenital defects, such as hypospadias and kidney malformations. Most major mental health conditions have been associated with an elevated risk of preterm birth, which is defined as birth before 37 weeks gestational age. The incidence of preterm delivery appears to be higher among women with perinatal mood and anxiety disorders and serious mental illnesses compared with pregnant persons who are delivering who have not had those conditions. In addition, PTSD and OCD are also associated with an increased risk of preterm birth. Psychiatric disorders are also associated with an elevated risk of low birth weight, which is defined as less than 2,500 grams or approximately five and a half pounds, or small for gestational age, which is defined as less than 10 percentile or less than two standard deviations below the expected size of a fetus or infant for their gestational age, or intrauterine growth restriction and fetal distress. Fetal or neonatal growth impairment and distress have also been associated with antenatal substance use during pregnancy. Marijuana, tobacco, opioids, and methamphetamine are all risk factors for preterm birth, low birth weight, small for gestational age, intrauterine growth restriction, and fetal distress. Perinatal mental disorders or symptoms have also been associated with an increased risk of admission to the neonatal intensive care unit or NICU. In one study, infants of mothers with anxiety disorders had a higher risk of being admitted to the NICU, but those mothers who were treated for their anxiety had a reduced risk of neonatal admissions to the NICU. Antenatal substance use, including opioid use, nicotine use, and use of benzodiazepines, has also been associated with the so-called neonatal abstinence syndrome, which is characterized by fetal and newborn irritability, autonomic instability, and increased reflexes. Infants born to mothers with mental and substance use disorders have a variety of adverse consequences, both during gestation and at birth, that appear to continue into early life. Follow-up studies of individuals who have had perinatal mental or substance use disorders and have peripartum depression have an increased risk of infant mortality, a greater likelihood of disrupted or discontinued breastfeeding, poor sleep patterns, delays in cognitive, language, and motor development, and impairment on some measures of mother-infant attachment. A rare but highly tragic and preventable association is known between postpartum mental illness and infanticide. Risk factors for infanticide include early life trauma, domestic violence, and substance abuse. Most importantly, infanticide is closely linked with postpartum psychotic disorders, including depressive, manic, or mixed episodes with psychotic features or psychosis not otherwise specified. Infanticide can also coincide with maternal suicidal thoughts or acts. It should be noted that the ego-dystonic intrusive thoughts of harm to an infant that sometimes occur in the setting of OCD and occur without hallucinations or impairment in reality testing do not appear to increase risk of harm to infants and do not appear to be associated with increased risk of infanticide. In terms of childhood outcomes, long-term consequences of antenatal alcohol use are particularly well documented. Fetal alcohol syndrome disorder is associated with facial dysmorphism and other congenital abnormalities as well as growth retardation, which may persist throughout adolescence. Fetal alcohol spectrum disorder can also be associated with intellectual deficits, problems with social skills, adaptive function, and executive function, as well as psychiatric comorbidities such as depression, anxiety, conduct disorder, and substance use disorder. Prenatal opioid use has been associated with an elevated risk of attention deficit hyperactivity disorder among offspring, as is the combination of opioids and cannabis use or opioids and tobacco smoking. Antenatal mental health conditions appear to have an impact on health problems beyond mental health problems, such as an increased risk of asthma of offspring who are born to individuals with perinatal mental or substance use disorders. In summary, the health of offspring is inextricably intertwined with the pregnant and birthing parents' mental and substance use disorders. Outcomes can include birth defects, premature birth, and associated effects including developmental and feeding delays, low birth weight, growth delays, fetal alcohol spectrum disorder, and the neonatal abstinence syndrome. Also, an increased risk of emotional and behavioral problems including anxiety, depression, and attention deficit disorder, which persist into childhood and adolescence. These almost certainly reflect the combination of genes, environment, and gene and environment effects. Impaired emotional and social development has also been noted among offspring of individuals, particularly with untreated or poorly controlled mental and substance use disorders. The overall conclusion of this webinar is that available data suggests that mental and substance use disorders have a significant impact on maternal health, relationships, economic trajectories, and offspring health. Most studies point in the direction, therefore, of universal screening for depression, anxiety, substance use, and early interventions such as education and counseling and referral for appropriate care. Healthcare providers need to be trained on screening and early intervention. Vulnerable and underserved populations need personalized programs to address specific concerns. For example, pregnant persons with schizophrenia are likely to benefit from a closely coordinated multidisciplinary approach that offers maximum support. So too, individuals from historically minoritized and underserved communities will likely benefit from culturally sensitive care to overcome stigma and navigate systemic inequalities. It is our pleasure to acknowledge the many people who have contributed to this webinar and to the APA and CDC Foundation project it represents. This includes the APA research team and the principal investigator of this project, Dr. Diana Clark, as well as the CDC Foundation team, our science writer, and the panel members of the physician and non-physician behavioral health advisory panel drawn from the disciplines of psychiatry, psychology, counseling, nursing, and social work. Those of you who would like to learn more about this initiative can go to this website, www.psychiatry.org, backslash maternal, hashtag section four. In addition, for those of you who wish to see the references cited in this webinar series, those are listed in the following slides. Thank you.

perinatal mental disorders

substance use disorders

psychiatric treatment

best practices

inclusive language

terminologies

obstetrical outcomes

fetus or child outcomes

epidemiology

etiology