Publications

PURPOSE: Cannabis is the most-used substance during pregnancy and has known associations with psychiatric disorders (e.g., psychosis, depression). No prospective studies, however, have investigated associations between prenatal cannabis use disorder (CUD) and psychiatric outcomes in perinatal populations.

METHODS: Annual cohorts of women with a live infant delivery in California from 2016 to 2021 were constructed using statewide linked hospital and emergency department (ED) discharge data. We examined temporal trends in prenatal CUD prevalence and compared risk of postpartum psychiatric ED visits between delivering women with prenatal CUD, prenatal alcohol use disorder (AUD; included as a benchmark exposure), and neither disorder.

RESULTS: The study sample included 2,036,016 delivering women. Between 2016 and 2021, prenatal CUD prevalence increased 1.0% to 1.4%. Postpartum psychiatric ED visits occurred in 10.4% of women diagnosed with CUD, 15.6% with AUD, and 2.7% with neither diagnosis. Relative to women with neither, those with CUD had  40% higher risk of any postpartum psychiatric ED visit (RRadj=1.39, 95% CI: 1.32-1.47), while AUD was associated with 80% increased risk (RRadj=1.80, 95% CI: 1.56-2.09).

CONCLUSION: Elevated risk of adverse psychiatric outcomes associated with CUD underscore the need for consistent screening, diagnosis, and treatment among perinatal women with CUD diagnoses.

OBJECTIVE: To evaluate changes in pregnancy-associated drug overdose mortality in the United States from 2018 to 2023 and compare this with drug overdose mortality among reproductive-aged nonpregnant female decedents. Secondarily, to assess types and combinations of drugs that contribute to overdose mortality, regional patterns, and overdose timing.

METHODS: This was a cross-sectional study that used 2018-2023 National Center for Health Statistics death certificate data. Drug overdose deaths were identified using International Classification of Diseases, Tenth Revision codes, and specific drugs involved were identified using T codes. Among all female decedents of reproductive age (15-44 years), pregnancy-associated drug overdose deaths were identified from the pregnancy checkbox. We calculated absolute and relative changes in drug overdose mortality rates for pregnancy-associated deaths and non-pregnancy-associated deaths among reproductive-aged female individuals. The annual pregnancy-associated drug mortality rates were also calculated by drug type and U.S. region (Northeast, Midwest, South, and West).

RESULTS: There were 2,573 pregnancy-associated drug overdose deaths identified. Pregnancy-associated overdose mortality increased from 8.0 per 100,000 live births to 13.0 deaths per 100,000 live births (relative increase: 62.2%). The drug overdose mortality rate among female individuals of reproductive age increased from 16.8 per 100,000 live births to 22.3 per 100,000 live births across the same period (relative increase: 33.0%). The fentanyl-involved pregnancy-associated overdose mortality rate was higher than other drugs. The psychostimulant-involved rate increased across time (from 2.9 deaths/100,000 live births to 7.5 deaths/100,000 live births). Drug overdose mortality rates were highest in the South. Polysubstance-involved overdose deaths were also common, with fentanyl and psychostimulants accounting for 24.8% of deaths.

CONCLUSION: The relative increase in the drug overdose mortality rate among pregnant and postpartum individuals was nearly double that of nonpregnant female individuals of reproductive age, driven by fentanyl, increasing psychostimulant, and polysubstance overdose deaths.

OBJECTIVE: Amid rising cannabis use, declining perceived harm, and policy liberalization over the past 15 years, we examined whether the association between cannabis use disorder (CUD) and past-year suicidal ideation among U.S. adults changed from 2014-2023 and varied by sex, age, and race/ethnicity.

METHOD: Using data from 415,861 adults in the 2014-2023 National Surveys on Drug Use and Health, we examined temporal association change between past-year suicidal ideation and CUD (≥2 of 9 harmonized DSM-5 criteria). Logistic regression models, adjusted for demographic, social, clinical, and geographic covariates, tested whether survey year moderated the CUD-suicidal ideation association overall and in strata by sex, age, and race/ethnicity.

RESULTS: Adults with cannabis use disorder had 57% higher odds of past-year suicidal ideation than those without (OR, 1.57; 95% CI, 1.44-1.72) across years. Joint Wald tests showed no evidence that the association changed over time overall (p = 0.12) nor within strata defined by sex or age. Although the joint interaction test suggested some variation among Hispanic respondents (p = 0.01), no individual year-specific interaction terms remained statistically significant after Bonferroni correction.

CONCLUSIONS: Adults with CUD had higher odds of suicidal ideation but, contrary to expectations, the strength of this association remained stable from 2014-2023 and did not differ significantly across sex, age, or racial/ethnic groups despite widespread legalization, increased potency, and shifting norms.

Mental health conditions are associated with an increased risk of chronic physical diseases, but their implications for other physical health outcomes, including injuries, are less established. In this prospective cohort study, we tested whether mental health conditions antedate unintentional as well as self-harm and assault injuries, using administrative data from Norway (N = 2,753,646) and New Zealand (N = 2,238,813). In Norway, after accounting for pre-existing injuries, individuals with a primary care encounter for a mental health condition had an elevated risk of subsequent primary care-recorded injury. In New Zealand, as expected, individuals with a mental health-related inpatient hospital admission had an elevated risk of subsequent inpatient hospital-recorded self-harm injury, as well as assault injury. However, they also had an elevated risk of unintentional injuries. Associations extended to injury insurance claims. Associations were evident across mental health conditions, sex, age and after accounting for indicators of socioeconomic status. Risk was particularly increased for brain and head injuries. Patients with mental health conditions are an important group for injury prevention.

BACKGROUND: In 2024, approximately 84,100 adolescents and young adults (AYAs) between 15 and 39 years old received a cancer diagnosis.

AIMS: Given their unique psychosocial, economic, and clinical stressors, we examined whether AYA cancer patients living in deprived neighborhoods have a higher risk of suicide when compared to those in the least deprived neighborhoods.

MATERIALS & METHODS: Our sample comprised 486,374 AYA cancer patients from the Surveillance, Epidemiology, and End Results (SEER) dataset between 2006 and 2020. We use Cox proportional hazard models to test the relation between quintiles of neighborhood deprivation, from Q1 (most deprived) to Q5 (least deprived), and survival months until suicide mortality from the time of cancer diagnosis.

RESULTS: We find that AYA cancer patients living in more deprived neighborhoods (Q1, Q2, Q4) have a higher risk of suicide when compared to those in the least deprived neighborhoods (Q5) (Q1: HR-1.82 [1.14-2.90]; Q2: HR-1.95 [1.35-2.81]; Q4: HR-1.48 [1.05-2.07]).

DISCUSSION: Mental health services and monitoring from treatment through survivorship may support suicide prevention efforts for young cancer patients.

CONCLUSION: Early identification of high-risk AYA cancer patients living in deprived areas may help target suicide prevention interventions.

INTRODUCTION: Opioid-related deaths among perinatal populations have increased sharply in the United States. Whether the recent ascendence of illicit fentanyl and other synthetic opioids in the drug supply translates to increasing prenatal opioid use disorder (OUD) remains unknown. This study tested whether California's comparatively late fentanyl influx, in 2019, was associated with a subsequent increase in OUD among pregnant people.

METHODS: This ecologic, repeated retrospective cohort study examined annual cohorts of individuals with an index live-birth delivery in California, 2010-2022. Analyses used statewide, all-payer linked hospitalization and emergency department (ED) records. Overall and subgroup-specific trends in prevalence of prenatal OUD, assessed using ICD-9/10-CM diagnoses recorded at delivery hospitalization and during prenatal ED visits, were examined using joinpoint and logistic regression analyses. Data analysis was conducted in 2025.

RESULTS: The study included 4,381,064 index deliveries. Between 2010 and 2022, prevalence of prenatal OUD doubled (as assessed at delivery: 0.15% to 0.30%; as assessed via prenatal OUD ED visits: 0.04% to 0.08%). Joinpoint analysis indicated that most of this increase occurred prior to 2018; annual percentage changes (APC) after 2018 were largely flat (at-delivery prevalence APC: 2.4%, 95% CI, -2.2% to 7.3%; ED prevalence APC: 1.4%, 95% CI, -7.0% to 3.8%). Differences in 2019-2022 vs. 2010-2018 prevalence of prenatal OUD were larger among non-Hispanic White and other/multiple-race individuals, and those covered by Medicaid.

CONCLUSIONS: The recent introduction of fentanyl to California was associated with only incremental increases in prevalence of prenatal OUD. Continued tracking of these trends is important for perinatal health.

Background: In the United States, suicide accounts for 1 out of every 20 deaths that occur during pregnancy and the first 12 months postpartum. Although nonfatal suicide attempts are the strongest known predictor of death by suicide, there are no prior population based estimates of the incidence of and clinical risk factors for pregnancy associated suicide attempts. Methods: This retrospective cohort study used statewide, all-payer, longitudinally linked hospital and emergency department (ED) patient records from California. Participants included all California residents with an index hospital delivery of a live infant between 2010 and 2020. Outcomes included ED presentation for nonfatal suicide attempt during pregnancy or up to 12 months postpartum. Clinical risk factors of interest included healthcare utilization patterns during pregnancy and behavioral health diagnoses recorded at index delivery. Results: Among delivering patients with an index delivery (N = 3,737,792), 0.13% (n = 4,968) had a suicide attempt during pregnancy or the postpartum period. After adjusting for background demographic characteristics, risks of a postpartum suicide attempt were increased 4- to 30-fold by several clinical factors, including prenatal suicide attempt ED visits, psychiatric ED visits, and assault ED visits, and by psychotic disorders, bipolar disorder, alcohol use disorder, recurrent and single-episode major depressive disorder, and anxiety disorders recorded at delivery. Conclusions: Risks of postpartum suicide attempt were substantially elevated for patients who had behavioral health related ED visits during pregnancy and by several psychiatric disorders at delivery. Clinical consideration should be given to monitoring these patients for suicide attempt risk.