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Koldeweij C, Dibbets C, Franklin BD, Scheepers HCJ, de Wildt SN. A User-Driven Framework for Dose Selection in Pregnancy: Proof of Concept for Sertraline. Clin Pharmacol Ther 2024. [PMID: 39248386 DOI: 10.1002/cpt.3429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 08/07/2024] [Indexed: 09/10/2024]
Abstract
Despite growing knowledge of pregnancy-induced changes in physiology that may alter maternal and fetal pharmacokinetics, evidence-based antenatal doses are lacking for most drugs. Pharmacokinetic modeling and expanding clinical data in pregnancy may support antenatal doses. We aimed to develop and pilot a comprehensive and user-driven Framework for Dose Selection in Pregnancy to support the clinical implementation of a best-evidence antenatal dose for sertraline. After initial development and evaluation by experts, the framework prototype was piloted to formulate an antenatal dosing strategy for sertraline in depression and anxiety disorders. Next, the framework was reviewed and assessed for usability by a multidisciplinary working committee of end-users comprising healthcare practitioners, experts from other disciplines including pharmacometrics, reproductive toxicology and medical ethics, alongside pregnant women and a partner. The resulting framework encompasses the following: rationale for drug selection, a comprehensive analysis of pharmacokinetic and dose-related efficacy and safety data, and implementation aspects including feasibility and desirability of the recommended antenatal dose based on a structured maternal and fetal benefit-risk assessment. An antenatal dose recommendation for sertraline, as a case study, was formulated using this approach and endorsed for clinical use by the working committee. Future applications of the framework for other drugs can further demonstrate its suitability for developing best evidence, acceptable and clinically feasible antenatal doses.
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Affiliation(s)
- Charlotte Koldeweij
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Caroline Dibbets
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bryony D Franklin
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Grow, School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Saskia N de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pediatric and Neonatal Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Lupattelli A, Corrao G, Gatti C, Rea F, Trinh NTH, Cantarutti A. Antidepressant continuation and adherence in pregnancy, and risk of antenatal hospitalization for unipolar major depressive and/or anxiety disorders. J Affect Disord 2023; 339:502-510. [PMID: 37459974 DOI: 10.1016/j.jad.2023.07.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/18/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Knowledge about the effectiveness of antidepressants in pregnancy is limited. We aimed to evaluate the association of antidepressant continuation in pregnancy and adherence with the risk of antenatal hospitalization for depression/anxiety. METHODS In a population-based study based on the healthcare databases of the Lombardy region, Italy (2010-2020), we included 17,033 live-birth pregnancies within 16,091 women with antidepressant use before pregnancy. Antidepressant exposure was classified as continued in pregnancy versus discontinued proximal to pregnancy. Outcome measure was antenatal hospitalization for depression/anxiety. Propensity score matching analysis was performed to control for measured confounding. Stratification by pre-pregnancy antidepressant adherence based on the proportion of days covered (PDC) with antidepressants served to address confounding by disease severity. We applied 60 days lag-time for antidepressant exposure to minimize the risk of protopathic bias. RESULTS There were 362 (2.1 %) antenatal hospitalizations for depression/anxiety. Among the matched pairs, the cumulative incidence was 3.5 (continued antidepressant) versus 2.1 (discontinued antidepressant) per 1000 person-months, yielding a hazard ratio (HR) of 1.76 (95 % confidence interval (CI): 1.34-2.33)). The HR declined to the null (1.02, 95 % CI: 0.62-1.69) in the stratified analysis of pregnancies with moderate-high adherence pre-pregnancy. Moderate-high adherence in pregnancy was associated with 85 % greater risk of the antenatal outcome, but the HR decreased with the 60 days lag-time (HR: 1.40, 95 % CI: 0.79-2.50). LIMITATIONS Lack of information regarding antidepressant dosage. CONCLUSION We found no difference in risk for antenatal hospitalization for depression/anxiety with antidepressant continuation or higher adherence in pregnancy, relative to discontinuation or lower adherence.
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Affiliation(s)
- Angela Lupattelli
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Norway.
| | - Giovanni Corrao
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, Laboratory of Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Chiara Gatti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, Laboratory of Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Federico Rea
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, Laboratory of Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Nhung T H Trinh
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Norway
| | - Anna Cantarutti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, Laboratory of Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
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Oddo VM, Moise C, Welke L, Bernabé BP, Maki P, Koenig MD, Pezley L, Xia Y, Tussing-Humphreys L. Mediterranean Diet Adherence and Depressive Symptoms among a Nationally Representative Sample of Pregnant Women in the United States. J Nutr 2023; 153:3041-3048. [PMID: 37598749 PMCID: PMC10613757 DOI: 10.1016/j.tjnut.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/29/2023] [Accepted: 08/16/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Prenatal depression affects ∼12% of pregnant women in the United States and is associated with an increased risk of adverse birth outcomes and maternal mortality. Adherence to a healthy dietary pattern may reduce and/or protect against depressive symptoms. OBJECTIVES To investigate the relationship between adherence to a Mediterranean diet and depressive symptoms among pregnant women in the United States. METHODS We used data from the National Health and Nutrition Examination Survey (2005-2018, N = 540) and included pregnant women aged 18-44 y with a positive urine pregnancy test. The Mediterranean diet score (aMED) was calculated from 1 24-h recall; aMED typically ranges from 0-9, but in these analyses, it ranged from 0-8 because alcohol was not included. The aMED score was dichotomized as high (>3) compared with low (≤3). The Patient Health Questionnaire-9 (PHQ-9), which measures depressive symptoms, was dichotomized as lower compared with higher (PHQ-9 score ≥10), based on the clinical cutoff for patient referral. Our primary model employed logistic regression to investigate the association between aMED adherence and high depressive symptoms when controlling for socio-demographics (age, racial/ethnicity, education, poverty, and relationship status), total calories, and prepregnancy body mass index (kg/m2). We also modeled the PHQ-9 score as a continuous variable using a random-effects model. RESULTS About 5% of pregnant women had moderate to severe depressive symptoms, and 45% were highly adherent to a Mediterranean diet. Higher adherence to a Mediterranean diet was associated with lower odds of depressive symptoms (odds ratio: 0.31, 95% confidence interval: 0.10, 0.98). Results were not significant for the continuous PHQ-9 score (β: -0.30; 95% confidence interval: -0.90, 0.30). CONCLUSIONS Adherence to a Mediterranean diet may have the potential to lower depressive symptoms among pregnant women; however, these results should be interpreted with caution. Nevertheless, considering the public health significance of promoting mental wellness among pregnant women, this relationship merits further examination using experimental designs.
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Affiliation(s)
- Vanessa M Oddo
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, United States.
| | - Crussie Moise
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, United States
| | | | - Beatriz Peñalver Bernabé
- Department of Biomedical Engineering, University of Illinois Chicago, Chicago, IL, United States
| | - Pauline Maki
- Department of Psychology, University of Illinois Chicago, Chicago, IL, United States; Department of Psychiatry, University of Illinois Chicago, Chicago, IL, United States
| | - Mary Dawn Koenig
- Department of Human Development Nursing Science, University of Illinois Chicago, Chicago, IL, United States
| | - Lacey Pezley
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, United States
| | - Yinglin Xia
- Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Lisa Tussing-Humphreys
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, United States; University of Illinois Cancer Center, University of Illinois Chicago, Chicago, IL United States
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Heuvelman H, Davies NM, Ben-Shlomo Y, Emond A, Evans J, Gunnell D, Liebling R, Morris R, Payne R, Storey C, Viner M, Rai D. Antidepressants in pregnancy: applying causal epidemiological methods to understand service-use outcomes in women and long-term neurodevelopmental outcomes in exposed children. Health Technol Assess 2023; 27:1-83. [PMID: 37842916 DOI: 10.3310/aqtf4490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Background Antidepressants are commonly prescribed during pregnancy, despite a lack of evidence from randomised trials on the benefits or risks. Some studies have reported associations of antidepressants during pregnancy with adverse offspring neurodevelopment, but whether or not such associations are causal is unclear. Objectives To study the associations of antidepressants for depression in pregnancy with outcomes using multiple methods to strengthen causal inference. Design This was an observational cohort design using multiple methods to strengthen causal inference, including multivariable regression, propensity score matching, instrumental variable analysis, negative control exposures, comparison across indications and exposure discordant pregnancies analysis. Setting This took place in UK general practice. Participants Participants were pregnant women with depression. Interventions The interventions were initiation of antidepressants in pregnancy compared with no initiation, and continuation of antidepressants in pregnancy compared with discontinuation. Main outcome measures The maternal outcome measures were the use of primary care and secondary mental health services during pregnancy, and during four 6-month follow-up periods up to 24 months after pregnancy, and antidepressant prescription status 24 months following pregnancy. The child outcome measures were diagnosis of autism, diagnosis of attention deficit hyperactivity disorder and intellectual disability. Data sources UK Clinical Practice Research Datalink. Results Data on 80,103 pregnancies were used to study maternal primary care outcomes and were linked to 34,274 children with at least 4-year follow-up for neurodevelopmental outcomes. Women who initiated or continued antidepressants during pregnancy were more likely to have contact with primary and secondary health-care services during and after pregnancy and more likely to be prescribed an antidepressant 2 years following the end of pregnancy than women who did not initiate or continue antidepressants during pregnancy (odds ratioinitiation 2.16, 95% confidence interval 1.95 to 2.39; odds ratiocontinuation 2.40, 95% confidence interval 2.27 to 2.53). There was little evidence for any substantial association with autism (odds ratiomultivariableregression 1.10, 95% confidence interval 0.90 to 1.35; odds ratiopropensityscore 1.06, 95% confidence interval 0.84 to 1.32), attention deficit hyperactivity disorder (odds ratiomultivariableregression 1.02, 95% confidence interval 0.80 to 1.29; odds ratiopropensityscore 0.97, 95% confidence interval 0.75 to 1.25) or intellectual disability (odds ratiomultivariableregression 0.81, 95% confidence interval 0.55 to 1.19; odds ratiopropensityscore 0.89, 95% confidence interval 0.61 to 1.31) in children of women who continued antidepressants compared with those who discontinued antidepressants. There was inconsistent evidence of an association between initiation of antidepressants in pregnancy and diagnosis of autism in offspring (odds ratiomultivariableregression 1.23, 95% confidence interval 0.85 to 1.78; odds ratiopropensityscore 1.64, 95% confidence interval 1.01 to 2.66) but not attention deficit hyperactivity disorder or intellectual disability; however, but results were imprecise owing to smaller numbers. Limitations Several causal-inference analyses lacked precision owing to limited numbers. In addition, adherence to the prescribed treatment was not measured. Conclusions Women prescribed antidepressants during pregnancy had greater service use during and after pregnancy than those not prescribed antidepressants. The evidence against any substantial association with autism, attention deficit hyperactivity disorder or intellectual disability in the children of women who continued compared with those who discontinued antidepressants in pregnancy is reassuring. Potential association of initiation of antidepressants during pregnancy with offspring autism needs further investigation. Future work Further research on larger samples could increase the robustness and precision of these findings. These methods applied could be a template for future pharmaco-epidemiological investigation of other pregnancy-related prescribing safety concerns. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (15/80/19) and will be published in full in Health Technology Assessment; Vol. 27, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hein Heuvelman
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Neil M Davies
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Yoav Ben-Shlomo
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Alan Emond
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan Evans
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - David Gunnell
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Rachel Liebling
- Fetal Medicine Unit, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Richard Morris
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Rupert Payne
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | | | | | - Dheeraj Rai
- Department of Population Health Sciences, University of Bristol, Bristol, UK
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5
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Abstract
Many (> 40%) women discontinue antidepressants during pregnancy because of concerns about effects on the foetus, based on information from inadequately-controlled studies. The sibling-control study design provides the best control for confounding factors, notably maternal depression. The purpose of this review was to investigate the evidence from sibling-control analyses for adverse outcomes in offspring associated with antidepressant exposure during pregnancy. Fourteen sibling-control studies were identified through searches of PubMed and Embase. Outcomes included preterm birth, small for gestational age, neonatal size, birth defects, autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), behavioural problems, neurodevelopmental deficits, and scholastic attainment. For the majority of these outcomes, no statistically significant associations were found when comparing exposed and unexposed siblings. Single studies reported associations with preterm birth, reduced gestational age, ADHD, anxiety at 36 months, and lower mathematics test scores, which persisted in the sibling-control analyses. However, differences were small and possibly not clinically significant. Moreover, effects of residual confounding could not be excluded. These findings provide evidence that many of the previously reported associations between prenatal antidepressant exposure and adverse outcomes in offspring are no longer statistically significant when exposed offspring are compared with unexposed siblings. The few statistically significant differences in sibling-control analyses were generally small with doubtful clinical significance. Decisions on antidepressant treatment during pregnancy should be made individually, based on evidence from properly controlled studies, not on misleading information based on studies that have not controlled adequately for confounding factors.
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Affiliation(s)
- Frank M C Besag
- East London NHS Foundation Trust, 9 Rush Court, Bedford, MK40 3JT, UK.
- University College London, London, UK.
- King's College London, London, UK.
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6
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Trinh NTH, Nordeng HME, Bandoli G, Palmsten K, Eberhard-Gran M, Lupattelli A. Antidepressant Fill and Dose Trajectories in Pregnant Women with Depression and/or Anxiety: A Norwegian Registry Linkage Study. Clin Epidemiol 2022; 14:1439-1451. [PMID: 36506004 PMCID: PMC9733444 DOI: 10.2147/clep.s379370] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/18/2022] [Indexed: 12/08/2022] Open
Abstract
Background Few studies investigated longitudinal antidepressant exposure during pregnancy and included dosage in the assessment. Methods We conducted a nationwide, registry-linkage study in Norway using data on antidepressant prescription fills in pregnancies lasting ≥32 weeks in women with a delivery between 2009 and 2018 who had a depression/anxiety diagnosis and antidepressant fills prior to pregnancy. Information on antidepressant exposure by week (measured by filled prescriptions) and prescribed average daily dose was used in longitudinal k-means trajectory modelling for a 108-week time window from six months prior to pregnancy to one year after delivery. Factors associated with trajectory group membership were examined using multinomial logistic regression models. Results We included 8,460 pregnancies in 8,092 women. Four antidepressant fill trajectories were identified based on filled antidepressant prescriptions: two distinct discontinuing patterns, one at around the start of pregnancy (30.4%) and one around the end of pregnancy (33.8%); one continuing pattern (20.6%); and one interrupting pattern (15.2%). Using average usual daily dose, we identified low dose discontinuing (60.3%), medium dose reducing (20.6%) and high dose continuing (15.2%) patterns. The multinomial logistic regressions showed that the fill trajectory group membership was strongly associated with: antidepressant type and dose prior to pregnancy and co-medication prior to pregnancy, maternal age, marital status, parity, previous pregnancy loss, and pregnancy planning. Conclusion Longitudinal trajectory modelling revealed distinct antidepressant fill and dosage patterns in the period around pregnancy. Knowledge about factors associated with utilization trajectories might be useful for health-care personnel counselling women about antidepressant use in pregnancy.
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Affiliation(s)
- Nhung T H Trinh
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway,Correspondence: Nhung TH Trinh, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Post box 1068 Blindern, Oslo, 0316, Norway, Email
| | - Hedvig M E Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway,Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | - Gretchen Bandoli
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
| | | | - Malin Eberhard-Gran
- Norwegian Research Centre for Women’s Health, Women’s and Children’s Division, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Angela Lupattelli
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
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7
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Copeland LA, Kinney RL, Kroll-Desrosiers AR, Shivakumar G, Mattocks KM. Medications with Potential for Fetal Risk Prescribed to Veterans. J Womens Health (Larchmt) 2022; 31:1450-1458. [PMID: 35352967 DOI: 10.1089/jwh.2021.0529] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Women service members of the past 20 years experienced high rates of traumatizing events resulting in pharmacological treatment. Post-military lives may include having children. Typically, Veterans Health Administration (VHA) patients' pregnancies are managed outside the VHA. This study examined medication exposures during pregnancy. Materials and Methods: The Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study collected primary survey data and linked secondary health care data from the VHA from 2015 to 2021. Medication fills and covariates were extracted for three 9-month periods: preconception, pregnancy, and postpartum. Multiple regression assessed factors associated with use during pregnancy of selective serotonin reuptake inhibitor (SSRI)/serotonin norepinephrine reuptake inhibitor (SNRI) or of non-recommended, potentially risky drugs, and of discontinuation of those medications from prepregnancy to pregnancy. Results: The cohort comprised 501 women-29% Black, 65% White, and 6% other races, of whom 63% had 50%-100% service-connected disability. During pregnancy, 36% had a pain-related disorder, 19% major depression, and 18% post-traumatic stress disorder. The median number of drug classes prescribed during pregnancy was 5. The use of SSRI/SNRI antidepressants dropped from 36% preconception to 26% during pregnancy including new starts; 15% discontinued SSRI/SNRI. Comorbidity predicted medication use. Depression predicted discontinuing SSRI/SNRI during pregnancy; no predictors of discontinuing potentially risky drugs were identified. Conclusions: Based on prescriptions filled within the VHA only-ignoring potential community-based fills-women veterans were prescribed numerous medications during pregnancy and discontinued antidepressants alarmingly. Veterans of childbearing potential should receive counseling about medication use before pregnancy occurs. Their non-VHA obstetricians and VHA providers should share information to optimize outcomes, reviewing medications as soon as pregnancy is detected as well as after pregnancy concludes.
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Affiliation(s)
- Laurel A Copeland
- Research Service, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Rebecca L Kinney
- Research Service, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Aimee R Kroll-Desrosiers
- Research Service, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Geetha Shivakumar
- Research Service, VA North Texas Health Care System, Dallas, Texas, USA
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kristin M Mattocks
- Research Service, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Kan ACO, Chan JKN, Wong CSM, Chen EYH, Chang WC. Psychotropic drug utilization patterns in pregnant women with bipolar disorder: A 16-year population-based cohort study. Eur Neuropsychopharmacol 2022; 57:75-85. [PMID: 35151952 DOI: 10.1016/j.euroneuro.2022.01.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 12/15/2022]
Abstract
Despite growing concern about reproductive safety of psychotropic drugs, there is a paucity of research assessing prenatal prescribing practices for bipolar disorder (BD). This population-based cohort study identified women aged 15-50 years with BD diagnosis, who delivered their first and singleton child between 2003 and 2018 in Hong Kong, with an aim to examine temporal trends and predictors of prenatal psychotropic drug use as well as drug utilization patterns before and during pregnancy were evaluated. Data were retrieved from territory-wide medical-record database of public healthcare services. Of 302 identified women, 202 (66.9%) and 180 (59.6%) redeemed at least 1 prescription for psychotropic drugs in 12 months pre-pregnancy and during pregnancy, respectively. Psychotropic drug treatment (OR = 16.14 [95% CI: 8.79-29.65]) and psychiatric admission (OR = 4.12 [95% CI: 1.66-10.24]) within 12 months pre-pregnancy were associated with prenatal drug use. Second-generation antipsychotic use during pregnancy increased over time, while prenatal use of lithium, anti-epileptics and first-generation-antipsychotics showed declining trend. Use of psychotropic drugs progressively decreased across pre-pregnancy and trimesters of pregnancy. Forty-two (23.3%) women received polypharmacy during pregnancy. Antidepressant use accounted for 17% of all monotherapy episodes. A significant proportion of women exposed to valproate in 12 months pre-pregnancy (27.2%) and first-trimester (16%). In conclusion, our results generally indicate trajectories of reduced psychotropic drug use across pregnancy. Deviations between real-world prescribing patterns and treatment guidelines underscore the need for comprehensive review of current clinical practices. Further research clarifying relationships of prenatal psychotropic drug exposure with maternal and fetal outcomes is warranted.
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Affiliation(s)
- Anson Chi On Kan
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Joe Kwun Nam Chan
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Corine Sau Man Wong
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Eric Yu Hai Chen
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong; State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong
| | - Wing Chung Chang
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong; State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong.
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9
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The COVID-19 Pandemic Impacted Maternal Mental Health Differently Depending on Pregnancy Status and Trimester of Gestation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052926. [PMID: 35270623 PMCID: PMC8910614 DOI: 10.3390/ijerph19052926] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 01/27/2023]
Abstract
Introduction: We aimed to measure the impact of the COVID-19 pandemic on maternal mental health, stratifying on pregnancy status, trimester of gestation, and pandemic period/wave. Methods: Pregnant persons and persons who delivered in Canada during the pandemic, >18 years, were recruited, and data were collected using a web-based strategy. The current analysis includes data on persons enrolled between 06/2020−08/2021. Maternal sociodemographic indicators, mental health measures (Edinburgh Perinatal Depression Scale (EPDS), Generalized Anxiety Disorders (GAD-7), stress) were self-reported. Maternal mental health in pregnant women (stratified by trimester, and pandemic period/wave at recruitment) was compared with the mental health of women who had delivered; determinants of severe depression were identified with multivariate logistic regression models. Results: 2574 persons were pregnant and 626 had already delivered at recruitment. Participants who had delivered had significantly higher mean depressive symptom scores compared to those pregnant at recruitment (9.1 (SD, 5.7) vs. 8.4 (SD, 5.3), p = 0.009). Maternal anxiety (aOR 1.51; 95%CI 1.44−1.59) and stress (aOR 1.35; 95%CI 1.24−1.48) were the most significant predictors of severe maternal depression (EDPS ˃ 13) in pregnancy. Conclusion: The COVID-19 pandemic had a significant impact on maternal depression during pregnancy and in the post-partum period. Given that gestational depression/anxiety/stress has been associated with preterm birth and childhood cognitive problems, it is essential to continue following women/children, and develop strategies to reduce COVID-19′s longer-term impact.
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10
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Anderson KN, Lind JN, Simeone RM, Bobo WV, Mitchell AA, Riehle-Colarusso T, Polen KN, Reefhuis J. Maternal Use of Specific Antidepressant Medications During Early Pregnancy and the Risk of Selected Birth Defects. JAMA Psychiatry 2020; 77:1246-1255. [PMID: 32777011 PMCID: PMC7407327 DOI: 10.1001/jamapsychiatry.2020.2453] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/29/2020] [Indexed: 01/31/2023]
Abstract
Importance Antidepressants are commonly used during pregnancy, but limited information is available about individual antidepressants and specific birth defect risks. Objective To examine associations between individual antidepressants and specific birth defects with and without attempts to partially account for potential confounding by underlying conditions. Design, Setting, and Participants The population-based, multicenter case-control National Birth Defects Prevention Study (October 1997-December 2011) included cases with selected birth defects who were identified from surveillance systems; controls were randomly sampled live-born infants without major birth defects. Mothers of cases and controls participated in an interview after the expected delivery date. The data were analyzed after the completion of the National Birth Defects Prevent Study's data collection. Exposures Self-reported antidepressant exposure was coded to indicate monotherapy exposure to antidepressants. Main Outcomes and Measures We used multivariable logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals for associations between maternal antidepressant use and birth defects. We compared early pregnancy antidepressant-exposed women with those without antidepressant exposure and, to partially account for confounding by underlying maternal conditions, those exposed to antidepressants outside of the birth defect development critical period. Results This study included 30 630 case mothers of infants with birth defects and 11 478 control mothers (aged 12-53 years). Early pregnancy antidepressant use was reported by 1562 case mothers (5.1%) and 467 control mothers (4.1%), for whom elevated aORs were observed for individual selective serotonin reuptake inhibitors (SSRIs) and selected congenital heart defects (CHD) (eg, fluoxetine and anomalous pulmonary venous return: aOR, 2.56; 95% CI, 1.10-5.93; this association was attenuated after partially accounting for underlying conditions: aOR, 1.89; 95% CI, 0.56-6.42). This pattern was observed for many SSRI-CHD combinations. Associations between SSRIs and non-CHD birth defects often persisted or strengthened after partially accounting for underlying conditions (eg, citalopram and diaphragmatic hernia: aOR, 5.11; 95% CI, 1.29-20.24). Venlafaxine had elevated associations with multiple defects that persisted after partially accounting for underlying conditions (eg, anencephaly and craniorachischisis: aOR, 9.14; 95% CI, 1.91-43.83). Conclusions and Relevance We found some associations between maternal antidepressant use and specific birth defects. Venlafaxine was associated with the highest number of defects, which needs confirmation given the limited literature on venlafaxine use during pregnancy and risk for birth defects. Our results suggest confounding by underlying conditions should be considered when assessing risk. Fully informed treatment decision-making requires balancing the risks and benefits of proposed interventions against those of untreated depression or anxiety.
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Affiliation(s)
- Kayla N. Anderson
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jennifer N. Lind
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
- United States Public Health Service, Atlanta, Georgia
| | - Regina M. Simeone
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - William V. Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida
| | - Allen A. Mitchell
- Slone Epidemiology Center at Boston University, Boston, Massachusetts
| | - Tiffany Riehle-Colarusso
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kara N. Polen
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jennita Reefhuis
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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11
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Bénard-Laribière A, Pambrun E, Sutter-Dallay AL, Gautier S, Hurault-Delarue C, Damase-Michel C, Lacroix I, Pariente A. Impact of pregnancy on antidepressant treatment course: a population-based comparative cohort study in France. Arch Womens Ment Health 2020; 23:699-707. [PMID: 32394399 DOI: 10.1007/s00737-020-01033-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 04/07/2020] [Indexed: 11/28/2022]
Abstract
The prevention of relapses and the treatment of depression during pregnancy are difficult challenges. The maintenance of antidepressants in pregnancy with its concomitant risks to mother and child needs to be weighed against those associated with not treating the disease. This study aimed at quantifying the impact of the occurrence of pregnancy on the course of antidepressant treatment among newly treated women (< 6 months). We performed a comparative observational cohort study using the nationwide French reimbursement healthcare system database. Women who conceived in 2014 and initiated an antidepressant at any time in the 6 months before pregnancy were compared with nonpregnant women newly exposed to antidepressants with matching on age, antidepressant exposure, history of psychiatric disorders, and area of residence. The primary outcome was a composite of antidepressant discontinuation, switch to another antidepressant, and concomitant use of antidepressants. The secondary outcome was the resumption of antidepressant during follow-up. We used Cox marginal proportional hazards models to compare time to outcomes between pregnant and nonpregnant women. The pregnant cohort included 6593 women, and the comparison cohort 29,347 nonpregnant women. In the period following the first month of treatment, pregnant women were more likely to experience treatment modification, and especially to stop receiving it, compared with nonpregnant women (adjusted hazard ratio (aHR) 1.58; 95%CI, 1.51-1.62). Pregnant women who discontinued treatment had a 41% decreased incidence of antidepressant resumption compared with nonpregnant women (aHR 0.59; 95%CI, 0.56-0.62). Pregnancy was a determinant of antidepressant treatment modification, and especially of discontinuation.
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Affiliation(s)
- Anne Bénard-Laribière
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team PHARMACOEPIDEMIOLOGY, UMR 1219, F-33000, Bordeaux, France.
| | - Elodie Pambrun
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team PHARMACOEPIDEMIOLOGY, UMR 1219, F-33000, Bordeaux, France
| | - Anne-Laure Sutter-Dallay
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team PHARMACOEPIDEMIOLOGY, UMR 1219, F-33000, Bordeaux, France
- Charles Perrens Hospital, F-33000, Bordeaux, France
| | - Sophie Gautier
- Clinical Pharmacology Department, U 1171 University Hospital of Lille, University of Lille, F-59000, Lille, France
| | - Caroline Hurault-Delarue
- Clinical Pharmacology Department, INSERM UMR 1027, CIC INSERM 1436, Faculty of Medicine, University Hospital of Toulouse, F-31000, Toulouse, France
| | - Christine Damase-Michel
- Clinical Pharmacology Department, INSERM UMR 1027, CIC INSERM 1436, Faculty of Medicine, University Hospital of Toulouse, F-31000, Toulouse, France
| | - Isabelle Lacroix
- Clinical Pharmacology Department, INSERM UMR 1027, CIC INSERM 1436, Faculty of Medicine, University Hospital of Toulouse, F-31000, Toulouse, France
| | - Antoine Pariente
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team PHARMACOEPIDEMIOLOGY, UMR 1219, F-33000, Bordeaux, France
- Clinical Pharmacology, University Hospital of Bordeaux, F-33000, Bordeaux, France
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12
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Maloney SE, Rogers CE, Constantino JN. Antidepressants, Pregnancy, and Autism: Setting the Record(s) Straight. Am J Psychiatry 2020; 177:479-481. [PMID: 32475141 DOI: 10.1176/appi.ajp.2020.20040418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Susan E Maloney
- Department of Psychiatry, Intellectual and Developmental Disabilities Research Center (Maloney, Rogers, Constantino), and Department of Pediatrics (Rogers, Constantino), Washington University School of Medicine, Saint Louis
| | - Cynthia E Rogers
- Department of Psychiatry, Intellectual and Developmental Disabilities Research Center (Maloney, Rogers, Constantino), and Department of Pediatrics (Rogers, Constantino), Washington University School of Medicine, Saint Louis
| | - John N Constantino
- Department of Psychiatry, Intellectual and Developmental Disabilities Research Center (Maloney, Rogers, Constantino), and Department of Pediatrics (Rogers, Constantino), Washington University School of Medicine, Saint Louis
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