Treating depression in pregnancy comes first, and childhood adversity tops the modifiable risks for psychosis

The edition in brief

A JAMA Psychiatry review of SSRI treatment in pregnancy concludes that, once the effect of the drug is separated from that of depression itself, accumulated evidence suggests little or no risk of serious adverse outcomes, while stopping treatment in moderate to severe depression has documented harms. Major depression affects about 12% of pregnancies and psychiatric illness is a leading cause of maternal morbidity and mortality. An umbrella review of 69 meta-analyses covering 221 factors graded six risk factors for psychotic disorders as convincing, including birthweight under 2,000 g (OR 1.77) and South Asian ethnicity in England (OR 2.15). Among potentially modifiable factors, childhood adversity carried the largest population attributable fraction (about 41%), followed by Toxoplasma seropositivity (20%) and near-daily cannabis use (13%). A review of the RECOVER trial in 493 adults with markedly treatment-resistant depression reports that vagus nerve stimulation did not beat sham on the prespecified primary outcome, though several secondary measures of symptoms, function and quality of life favoured active stimulation and most responders kept their gains to 24 months. The pearl: ask how often, not whether, a young person uses cannabis.