Discontinuation of antipsychotic medication in pregnancy: A cohort study

Petersen, Irene; McCrea, Rachel L; Osborn, David; Evans, Stephen; Pinfold, Vanessa; Cowen, Philip J.; Gilbert, Ruth; Nazareth, Irwin

doi:10.1016/j.schres.2014.07.034

Cited by 52 publications

(40 citation statements)

References 18 publications

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“…The discontinuation patterns observed in this study were similar to the results from previous studies in the UK in which close to 50% of women had discontinued atypical antipsychotics by six weeks of pregnancy and 62% to 72.3% by the third trimester (19, 22). Interestingly, a greater number of women filled a prescription for a typical antipsychotic after LMP compared to the baseline period; a similar trend was not seen for atypical antipsychotics.…”

Section: Discussionsupporting

confidence: 88%

“…The prevalence of women on antipsychotic treatment during pregnancy in our study is higher than that found in European cohorts (range .1% to .3%) or privately insured women in the US (.7% for atypical antipsychotics) during partly overlapping periods (18–22). This is not surprising, because the prevalence of mental illness is known to be higher for the Medicaid insured population, due partly to the lower socioeconomic status and higher proportion of minority groups (23).…”

Section: Discussioncontrasting

confidence: 79%

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Antipsychotic Medication Use Among Publicly Insured Pregnant Women in the United States

Park

Huybrechts

Cohen

et al. 2017

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Objective Given the increasing use and broadening of indications for antipsychotic medications in the general population, as well as the paucity of information on the safety of this drug class during pregnancy, the study aim was to document patterns of antipsychotic medication use in pregnant women. Method Medicaid Analytic eXtract data (2001–2010) from pregnant women who delivered live-born infants was used. Antipsychotic use at both the class and individual drug level was defined based on dispensed outpatient prescriptions. Users’ characteristics, including mental disorder diagnoses, were described. Temporal trends in use, as well as discontinuation patterns and polytherapy with other psychotropic medications during pregnancy were evaluated. Results Among 1,522,247 pregnancies, the prevalence of atypical antipsychotic use at any time during pregnancy increased three-fold, from .4% to 1.3%, over the 10-year period while the use of typical antipsychotics remained stable around .1%. The increase in atypical use was largely driven by more frequent use in patients with bipolar disorder. Quetiapine and aripiprazole were the most frequently dispensed drugs, and polytherapy with antidepressants (65.2%), benzodiazepines (24.9%), and/or other mood stabilizers (22.0%) was common among women using antipsychotics during pregnancy. More than 50% of women receiving an antipsychotic in the 3 months prior to pregnancy discontinued during pregnancy. Conclusions A growing number of pregnant women in Medicaid are exposed to atypical antipsychotics, frequently in combination with other psychotropic medications. This study highlights the importance of documenting the use and safety of these drugs during pregnancy to inform therapeutic decision making for pregnant women with psychiatric disorders.

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Section: Discussionsupporting

confidence: 88%

Section: Discussioncontrasting

confidence: 79%

Antipsychotic Medication Use Among Publicly Insured Pregnant Women in the United States

Park

Huybrechts

Cohen

et al. 2017

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“…Parts of this work have been published elsewhere. 46,47 Prevalence of psychotropic treatment before, during and after delivery…”

Section: Resultsmentioning

confidence: 99%

“…12,18,20 In this project we demonstrated that the majority of these women discontinue psychotropic medication either before or in early pregnancy. 46,47 For each individual woman this is likely to result from an informal 'risk-benefit' evaluation, which may include a range of factors such as previous medical history, current state of illness, likelihood of relapse in pregnancy and postpartum, family circumstances, known teratogenic risks and fear of doing harm to the unborn child. 4,14,20 For some women the answer to this evaluation is 'clear-cut' with the benefits of continuing treatment in pregnancy noticeably outweighing the potential risks.…”

Section: Risks and Benefits Of Psychotropic Medication In Pregnancymentioning

confidence: 99%

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Risks and benefits of psychotropic medication in pregnancy: cohort studies based on UK electronic primary care health records

Petersen

McCrea

Sammon

et al. 2016

Health Technol Assess

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133

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BackgroundAlthough many women treated with psychotropic medication become pregnant, no psychotropic medication has been licensed for use in pregnancy. This leaves women and their health-care professionals in a treatment dilemma, as they need to balance the health of the woman with that of the unborn child. The aim of this project was to investigate the risks and benefits of psychotropic medication in women treated for psychosis who become pregnant.Objective(s)(1) To provide a descriptive account of psychotropic medication prescribed before pregnancy, during pregnancy and up to 15 months after delivery in UK primary care from 1995 to 2012; (2) to identify risk factors predictive of discontinuation and restarting of lithium (multiple manufacturers), anticonvulsant mood stabilisers and antipsychotic medication; (3) to examine the extent to which pregnancy is a determinant for discontinuation of psychotropic medication; (4) to examine prevalence of records suggestive of adverse mental health, deterioration or relapse 18 months before and during pregnancy, and up to 15 months after delivery; and (5) to estimate absolute and relative risks of adverse maternal and child outcomes of psychotropic treatment in pregnancy.DesignRetrospective cohort studies.SettingPrimary care.ParticipantsWomen treated for psychosis who became pregnant, and their children.InterventionsTreatment with antipsychotics, lithium or anticonvulsant mood stabilisers.Main outcome measuresDiscontinuation and restarting of treatment; worsening of mental health; acute pre-eclampsia/gestational hypertension; gestational diabetes; caesarean section; perinatal death; major congenital malformations; poor birth outcome (low birthweight, preterm birth, small for gestational age, low Apgar score); transient poor birth outcomes (tremor, agitation, breathing and muscle tone problems); and neurodevelopmental and behavioural disorders.Data sourcesClinical Practice Research Datalink database and The Health Improvement Network primary care database.ResultsPrescribing of psychotropic medication was relatively constant before pregnancy, decreased sharply in early pregnancy and peaked after delivery. Antipsychotic and anticonvulsant treatment increased over the study period. The recording of markers of worsening mental health peaked after delivery. Pregnancy was a strong determinant for discontinuation of psychotropic medication. However, between 40% and 76% of women who discontinued psychotropic medication before or in early pregnancy restarted treatment by 15 months after delivery. The risk of major congenital malformations, and neurodevelopmental and behavioural outcomes in valproate (multiple manufacturers) users was twice that in users of other anticonvulsants. The risks of adverse maternal and child outcomes in women who continued antipsychotic use in pregnancy were not greater than in those who discontinued treatment before pregnancy.LimitationsA few women would have received parts of their care outside primary care, which may not be captured in this analysis. Likewise, the analyses were based on prescribing data, which may differ from usage.ConclusionsPsychotropic medication is prescribed before, during and after pregnancy. Many women discontinue treatment before or during early pregnancy and then restart again in late pregnancy or after delivery. Our results support previous associations between valproate and adverse child outcomes but we found no evidence of such an association for antipsychotics.Future workFuture research should focus on (1) curtailing the use of sodium valproate; (2) estimating the benefits of psychotropic drug use in pregnancy; and (3) investigating the risks associated with lifestyle choices that are more prevalent among women using psychotropic drugs.Funding detailsThe National Institute for Health Research Health Technology Assessment programme.

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Perinatal Depression and Risk of Suicidal Behavior

Yu,

Shen,

Bränn

et al. 2024

JAMA Netw Open

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ImportanceSuicidal ideation is common among women with perinatal depression (PND). However, prospective data are limited on the risk, particularly long-term risk, of suicidal behavior (suicide attempt and completed suicide) among women with perinatal depression.ObjectiveTo examine the association between PND and risk of short- and long-term suicidal behavior.Design, Setting, and ParticipantsA nationwide population-matched cohort study was conducted in Sweden including 86 551 women with PND from 2001 to 2017 and 865 510 unaffected women individually matched on age and calendar year at delivery. Sibling comparison was used to account for familial confounding. Data were analyzed from January 2022 to November 2023.ExposurePND was identified through depression diagnosis or filled prescriptions of antidepressants from pregnancy to 1 year post partum in registers.Main Outcomes and MeasuresAll women were followed up for the first event of suicidal behavior recorded in registers. Hazard ratios (HR) of suicidal behavior were estimated using time-to-event analysis.ResultsWomen with PND (86 551 participants) received a diagnosis at a mean (SD) age of 30.67 (5.23) years. During a median (IQR) follow-up of 6.91 (3.62-10.88) years, 3604 events of suicidal behavior (incidence rate [IR], 5.62 per 1000 person-years) were identified among women with PND and 6445 (IR, 1.01 per 1000 person-years) among population-unaffected women. Women with PND had an elevated risk of suicidal behavior when compared with matched unaffected women (HR, 3.15; 95% CI, 2.97-3.35). Comparable, albeit somewhat attenuated, associations were yielded when comparing PND women with their PND-free sisters (HR, 2.75; 95% CI, 2.10-3.61). In the population-matched cohort, the association was greater for postnatal depression and among women without a history of psychiatric disorders. The excess risk was pronounced during the first year after diagnosis (HR, 7.20; 95% CI, 6.07-8.54), yet remained statistically significant during 5 to 18 years of follow-up (HR, 2.34; 95% CI, 2.12-2.57).Conclusions and RelevanceIn this nationwide cohort study, women with PND were at an increased risk of suicidal behavior, particularly within the first year after diagnosis with persistent risk elevations throughout the 18 years of follow-up, highlighting the need for vigilant clinical monitoring of this vulnerable group.

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Discontinuation of antipsychotic medication in pregnancy: A cohort study

Cited by 52 publications

References 18 publications

Antipsychotic Medication Use Among Publicly Insured Pregnant Women in the United States

Antipsychotic Medication Use Among Publicly Insured Pregnant Women in the United States

Risks and benefits of psychotropic medication in pregnancy: cohort studies based on UK electronic primary care health records

Perinatal Depression and Risk of Suicidal Behavior

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