The association between antidepressant use and assisted reproductive technology (ART) treatment in Danish women: A national registry-based cohort study

OBJECTIVE

To investigate (1) if antidepressant use among women in assisted reproductive technology (ART) treatment and among women without ART treatment influences cumulative live birth rates (CLBR) and number of initiated treatment cycles per woman, (2) whether women undergoing ART treatment are at higher risk of initiating use of antidepressants compared to women not having undergone ART, (3) if mothers after ART treatment have higher risk for postpartum use of antidepressants after ART treatment compared to mothers not having used ART treatment.

STUDY DESIGN

A Danish nation-wide register-based cohort study including all women in ART treatment between 1995 through 2009 and an age-matched comparison group of women not having initiated ART treatment. In both groups, women had no previous children before study entry. The women were followed from time of initiating first ART treatment until time of permanent emigration (> 6 months), date of death, or end of follow-up by 31st of December 2009. Chi-square test was used to assess whether observed differences in CLBR between groups were significant. Adjusted incidence rates (IR) and incidence rate ratio (IRR) with 95 % confidence interval (CI) were calculated using Poisson regression analysis. The main outcome measures were: CLBR, number of initiated ART treatment cycles and IRR of initiating antidepressant use.

RESULTS

Women using antidepressants before, during or after ART treatment were significantly older, had a lower CLBR and a lower mean number of initiated ART treatment cycles compared to women in ART treatment with no use of antidepressants. No significant difference was found in the incidence of initiating antidepressant use between women in ART treatment and the comparison group. However, when comparing only women with a live birth, significantly more women in ART treatment initiated antidepressant use in the postpartum period (adjusted incidence rate ratio (IRR) = 2.56 (95 % CI 1.98-3.30; p < 0.001)).

CONCLUSION

Generally, women undergoing ART treatment are not at higher risk of initiating use of antidepressants compared with an age-matched comparison group not treated with ART. However, women with antidepressant medication use prior to ART initiate fewer ART treatments and have lower CLBR. Even though it has not been possible to adjust for all relevant confounders and our follow-up period only runs until the end of 2009, we still believe the results of this study to be highly relevant. According to our study, clinicians should be aware that women conceiving after ART treatment might experience an increased level of psychological strain during the postpartum period compared to mothers who conceived without ART.

Early labor force exits in patients with treatment-resistant depression: an assessment of work years lost in a Danish nationwide register-based cohort study

BACKGROUND

Depression is one of the leading causes of premature workforce exit in many Western countries, but little is known about the extent to which treatment-resistance reduces number of work-years. We compared the risk of premature workforce exit among patients with treatment-resistant depression (TRD) relative to non-TRD patients and estimated work years lost (WYL) before scheduled retirement age.

METHODS

The study population, identified in the Danish National Prescription Registry, included all individuals born and living in Denmark who redeemed their first antidepressant (AD) prescription for depression at age 18-60 years between 2005 and 2012. TRD was defined as failure to respond to at least two different treatment trials. Premature workforce exit was measured using disability pension records. We used Cox regression to estimate the hazard ratio (HR) for premature workforce exit in TRD relative to non-TRD patients, adjusting for calendar year, psychiatric and somatic comorbidity, and educational level. Differences in WYL in patients with TRD and all depression patients were estimated through a competing risks model.

RESULTS

Out of the total sample of patients with depression (N = 129,945), 7478 (5.75%) were classified as having TRD. During follow up, 17% of patients with TRD and 8% of non-TRD patients received disability pension, resulting in a greater than three-fold larger risk of premature workforce exit [adjusted HR (aHR) 3.23 95% confidence interval (CI) 3.05-3.43]. The TRD group lost on average six work-years (95% CI 5.64-6.47) more than the total sample due to early labor force exit. The association between TRD and age at premature workforce exit was inversely U-shaped; the hazard rate of premature workforce exit for patients with TRD compared with non-TRD patients was highest in the age groups 31-35, 36-40, and 41-45 years.

CONCLUSION

Patients with TRD constitute a small group within depression patients, but contribute disproportionally to societal costs due to premature workforce exit at a young age.

Socio-demographic and clinical risk factors of treatment-resistant depression: A Danish population-based cohort study

BACKGROUND

Knowledge of risk factors of treatment-resistant depression (TRD) contributes to understand the underlying mechanisms and to identify patients at risk. However, there is still a lack of studies on how different risk factors associate with TRD. The objective of this study was to determine the independent association of several socio-demographic and clinical risk factors with TRD.

METHODS

194.074 patients with a first-time hospital contact for depression identified in the Danish National Patient Registry (DNPR) from 1996 through 2014 were followed for TRD for 12 months after diagnosis. Socio-demographic and clinical risk factors were identified in nation-wide registries. Data were analyzed using Cox Proportional Hazard Regression and Fine-Gray model for competing mortality risk.

RESULTS

Indicators of disease severity (recurrent depression (adjusted HR (aHR) 1.17 (1.14-1.20)), severity of depression (aHR 2.01 (1.95-2.08)), admission to a psychiatric ward (aHR 2.03 (1.96, 2.10)) were strong risk factors. Aged 65-84 (aHR 1.96 (1.83-2.10)), lost labor market affiliation ((aHR 1.12 (1.08, 1.16)), cohabiting (aHR 1.27 (1.23, 1.30)), comorbid anxiety (aHR 1.18 (1.10-1.27)), insomnia (aHR 1.27 (1.06-1.51)), migraine (aHR 1.42 (1.16-1.73)) and use of psychotropic drugs was also associated with higher rates of TRD.

LIMITATIONS

Information on drug use during hospitalization was not available. Information on rating scales could have provided a more precise assessment of symptom severity and treatment response.

CONCLUSIONS

Besides indicators of disease severity, other important risk factors associated with TRD are age, lost labor market affiliation, cohabiting with a partner as well as anxiety, insomnia, migraine and the use of psychotropic medications.

Incidence of suicidal behaviour and violent crime following antidepressant medication: a Danish cohort study

OBJECTIVE

To examine the incidence of suicidal and violent behaviour following initiation of antidepressant medication.

METHOD

Cohorts of 997 911 conscripts and 95 794 patients with a first-time affective disorder were followed for purchase of antidepressant medication, suicide, suicide attempts and conviction for violent crime in Danish registries between 1997 through 2015. Incidence of outcomes was estimated for the first 28 days, 28-365 days or later after initiation of antidepressants or study entry.

RESULTS

Of 16.5% of conscripts and 73.7% of patients with affective disorders initiated antidepressant medication. Incidence of suicide was 3-4 times higher during the first 28 days after initiation compared to the rates in the following year in both cohorts. A similar trend was seen among the untreated patients with affective disorders, whereas suicide incidence was stable at a low level among conscripts not treated with antidepressants. Incidence of attempted suicide was highest during the 28 days before and after initiation of antidepressants, while rates of violent crime were similar before and after initiation. These trends in incidence were independent of class of antidepressant.

CONCLUSION

Higher rates of suicidal behaviour in the weeks following initiation of antidepressant medication probably reflect disease severity and a delay in mood response.

Incidence of, Risk Factors for, and Changes Over Time in Treatment-Resistant Depression in Denmark: A Register-Based Cohort Study

OBJECTIVE

Varying definitions of treatment-resistant depression (TRD) across studies make it difficult to estimate the size of the problem and to identify patients at increased risk. The aim of this cohort study was to examine the incidence of TRD, disease-related risk factors, and changes over time using different definitions of TRD.

METHODS

From 1996 through 2014, all patients with a first-time hospital contact for depression (ICD-10 codes F32 and F33) were identified in Danish National Patient Registries. A total of 211,689 patients were followed for shifts in antidepressant treatment in the Danish Patient and Prescription Registries. TRD was defined at the second shift in treatment during the first 12 months after diagnosis. The associations of year and type of hospital contact, depression subtype, and severity of TRD were analyzed using Cox proportional hazard regression.

RESULTS

A total of 14.0% of patients experienced a second shift in antidepressant treatment during the first year after admission. When applying 3 other common TRD definitions, the proportion varied from 13% to 31%. Psychiatric inpatients and patients with recurrent or severe depression had the highest incidence of TRD. The incidence of TRD was also slightly higher in patients diagnosed after 2001. All associations were replicated when data were reanalyzed using the alternative definitions of TRD.

CONCLUSIONS

About 14% of patients with depression developed TRD during the first year after first hospital contact. The incidence was highest in patients with severe depression and was relatively stable over time. Various definitions of TRD provided different estimates of the frequency of TRD but were all associated with disease severity.