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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Martin L, Steber WA, Lupton TL, Mahler M, Fitch CM, McMillan JD, Schmidt DR, Fritzler MJ. Clinical and serological analysis of patients with positive anticyclic citrullinated Peptide antibodies referred through a Rheumatology Central Triage System. J Rheumatol 2015; 42:771-7. [PMID: 25641884 DOI: 10.3899/jrheum.141054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2014] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Anticitrullinated protein antibodies (ACPA) are a highly specific and sensitive biomarker for the diagnosis of rheumatoid arthritis (RA). Some patients who were found to have a positive ACPA test were referred to our Rheumatology Central Triage (CT; Calgary, Alberta, Canada) for assessment by a rheumatologist. The objectives of our study were to determine the clinical accuracy of ACPA in establishing a diagnosis of RA in a real-time clinical setting. METHODS Cases that met 3 criteria were included in the study: (1) referred to the CT over 3 calendar years (n = 20,389), (2) reason for referral was a positive ACPA test (n = 568), and (3) evaluated by a certified rheumatologist (n = 314). An administrative serological database was used to retrieve specific ACPA results. RESULTS Of patients referred through our CT for evaluation of a positive ACPA test, 57.6% received a diagnosis of RA; the remainder had a variety of other diagnoses, some of which might be considered early RA (9%). The predictive values of ACPA for the diagnosis of RA were increased when rheumatoid factor (RF) results were included in the analysis. When definite and possible RA were combined and the prevalence of moderate/high ACPA was compared to all other individuals, the positive and negative predictive values for moderate/high ACPA for RA were 74.3% and 68.4%, respectively. CONCLUSION About 58% of patients with a positive ACPA referred through a triage system for a rheumatologist opinion received a diagnosis of RA at their first visit. RF provides additional useful information to guide the diagnosis and urgency of referral.
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Affiliation(s)
- Liam Martin
- From the Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; and Inova Diagnostics Inc., San Diego, California, USA.L. Martin, MB, MRCPI, FRCPC, Professor of Medicine; W.A. Steber, BPE, BSc, Clinical Research Manager; T.L. Lupton, RN, Clinical Coordinator; C.M. Fitch, RN; J.D. McMillan, Research Assistant; D.R. Schmidt, Research Assistant; M.J. Fritzler, PhD, MD, FRCPC, Professor of Medicine, Faculty of Medicine, University of Calgary; M. Mahler, PhD, Vice-President, Research and Development, Inova Diagnostics Inc
| | - Whitney A Steber
- From the Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; and Inova Diagnostics Inc., San Diego, California, USA.L. Martin, MB, MRCPI, FRCPC, Professor of Medicine; W.A. Steber, BPE, BSc, Clinical Research Manager; T.L. Lupton, RN, Clinical Coordinator; C.M. Fitch, RN; J.D. McMillan, Research Assistant; D.R. Schmidt, Research Assistant; M.J. Fritzler, PhD, MD, FRCPC, Professor of Medicine, Faculty of Medicine, University of Calgary; M. Mahler, PhD, Vice-President, Research and Development, Inova Diagnostics Inc
| | - Terri L Lupton
- From the Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; and Inova Diagnostics Inc., San Diego, California, USA.L. Martin, MB, MRCPI, FRCPC, Professor of Medicine; W.A. Steber, BPE, BSc, Clinical Research Manager; T.L. Lupton, RN, Clinical Coordinator; C.M. Fitch, RN; J.D. McMillan, Research Assistant; D.R. Schmidt, Research Assistant; M.J. Fritzler, PhD, MD, FRCPC, Professor of Medicine, Faculty of Medicine, University of Calgary; M. Mahler, PhD, Vice-President, Research and Development, Inova Diagnostics Inc
| | - Michael Mahler
- From the Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; and Inova Diagnostics Inc., San Diego, California, USA.L. Martin, MB, MRCPI, FRCPC, Professor of Medicine; W.A. Steber, BPE, BSc, Clinical Research Manager; T.L. Lupton, RN, Clinical Coordinator; C.M. Fitch, RN; J.D. McMillan, Research Assistant; D.R. Schmidt, Research Assistant; M.J. Fritzler, PhD, MD, FRCPC, Professor of Medicine, Faculty of Medicine, University of Calgary; M. Mahler, PhD, Vice-President, Research and Development, Inova Diagnostics Inc
| | - Christie M Fitch
- From the Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; and Inova Diagnostics Inc., San Diego, California, USA.L. Martin, MB, MRCPI, FRCPC, Professor of Medicine; W.A. Steber, BPE, BSc, Clinical Research Manager; T.L. Lupton, RN, Clinical Coordinator; C.M. Fitch, RN; J.D. McMillan, Research Assistant; D.R. Schmidt, Research Assistant; M.J. Fritzler, PhD, MD, FRCPC, Professor of Medicine, Faculty of Medicine, University of Calgary; M. Mahler, PhD, Vice-President, Research and Development, Inova Diagnostics Inc
| | - Jacob D McMillan
- From the Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; and Inova Diagnostics Inc., San Diego, California, USA.L. Martin, MB, MRCPI, FRCPC, Professor of Medicine; W.A. Steber, BPE, BSc, Clinical Research Manager; T.L. Lupton, RN, Clinical Coordinator; C.M. Fitch, RN; J.D. McMillan, Research Assistant; D.R. Schmidt, Research Assistant; M.J. Fritzler, PhD, MD, FRCPC, Professor of Medicine, Faculty of Medicine, University of Calgary; M. Mahler, PhD, Vice-President, Research and Development, Inova Diagnostics Inc
| | - Danielle R Schmidt
- From the Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; and Inova Diagnostics Inc., San Diego, California, USA.L. Martin, MB, MRCPI, FRCPC, Professor of Medicine; W.A. Steber, BPE, BSc, Clinical Research Manager; T.L. Lupton, RN, Clinical Coordinator; C.M. Fitch, RN; J.D. McMillan, Research Assistant; D.R. Schmidt, Research Assistant; M.J. Fritzler, PhD, MD, FRCPC, Professor of Medicine, Faculty of Medicine, University of Calgary; M. Mahler, PhD, Vice-President, Research and Development, Inova Diagnostics Inc
| | - Marvin J Fritzler
- From the Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; and Inova Diagnostics Inc., San Diego, California, USA.L. Martin, MB, MRCPI, FRCPC, Professor of Medicine; W.A. Steber, BPE, BSc, Clinical Research Manager; T.L. Lupton, RN, Clinical Coordinator; C.M. Fitch, RN; J.D. McMillan, Research Assistant; D.R. Schmidt, Research Assistant; M.J. Fritzler, PhD, MD, FRCPC, Professor of Medicine, Faculty of Medicine, University of Calgary; M. Mahler, PhD, Vice-President, Research and Development, Inova Diagnostics Inc.
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