Antidepressant discontinuation before or during pregnancy and risk of psychiatric emergency in Denmark: A population-based propensity score–matched cohort study

Abstract

Background Women prescribed antidepressants face the dilemma of whether or not to continue their treatment during pregnancy. Currently, limited evidence is available on the efficacy of continuing versus discontinuing antidepressant treatment during pregnancy to aid their decision. We aimed to estimate whether antidepressant discontinuation before or during pregnancy was associated with an increased risk of psychiatric emergency (ascertained by psychiatric admission or emergency room visit), a proxy measure of severe exacerbation of symptoms/mental health crisis. Methods and findings We carried out a propensity score–matched cohort study of women who gave birth to live-born singletons between January 1, 1997 and June 30, 2016 in Denmark and who redeemed an antidepressant prescription in the 90 days before the pregnancy, identified by Anatomical Therapeutic Chemical (ATC) code N06A. We constructed 2 matched cohorts, matching each woman who discontinued antidepressants before pregnancy (N = 2,669) or during pregnancy (N = 5,467) to one who continued antidepressants based on propensity scores. Maternal characteristics and variables related to disease severity were used to generate the propensity scores in logistic regression models. We estimated hazard ratios (HRs) of psychiatric emergency in the perinatal period (pregnancy and 6 months postpartum) using stratified Cox regression. Psychiatric emergencies were observed in 76 women who discontinued antidepressants before pregnancy and 91 women who continued. There was no evidence of higher risk of psychiatric emergency among women who discontinued antidepressants before pregnancy (cumulative incidence: 2.9%, 95% confidence interval [CI]: 2.3% to 3.6% for discontinuation versus 3.4%, 95% CI: 2.8% to 4.2% for continuation; HR = 0.84, 95% CI: 0.61 to 1.16, p = 0.298). Overall, 202 women who discontinued antidepressants during pregnancy and 156 who continued had psychiatric emergencies (cumulative incidence: 5.0%, 95% CI: 4.2% to 5.9% versus 3.7%, 95% CI: 3.1% to 4.5%). Antidepressant discontinuation during pregnancy was associated with increased risk of psychiatric emergency (HR = 1.25, 95% CI: 1.00 to 1.55, p = 0.048). Study limitations include lack of information on indications for antidepressant treatment and reasons for discontinuing antidepressants. Conclusions In this study, we found that discontinuing antidepressant medication during pregnancy (but not before) is associated with an apparent increased risk of psychiatric emergency compared to continuing treatment throughout pregnancy.

Antidepressant Fill and Dose Trajectories in Pregnant Women with Depression and/or Anxiety: A Norwegian Registry Linkage Study

“…Pregnant women are generally advised to discuss with their prescribing physician about pharmacological treatment options during pregnancy; however, many women experience high decisional conflict in the decision-making. [7][8][9][10][11] Most available studies investigating the effectiveness and safety of AD during pregnancy, however, have defined AD exposure in a simplistic way using a fixed time window and without taking into account the nature of long-term treatment and changes in dosage as well as indication. [12][13][14] A recent study using Danish registry linked data also highlighted the differences in psychiatric outcomes with regard to the timing of discontinuation during pregnancy.…”

“…[12][13][14] A recent study using Danish registry linked data also highlighted the differences in psychiatric outcomes with regard to the timing of discontinuation during pregnancy. 10 In addition, studies using register-based data usually rely on the simple assumptions of one defined daily dose (DDD) or one tablet per day to model duration of treatment. 15,16 Recently, a novel method generating drug use patterns from prescription dispensations (PRE2DUP) was developed and validated on the Finnish prescription register.…”

Timing of Antidepressant Discontinuation During Pregnancy and Postpartum Psychiatric Outcomes in Denmark and Norway

“…Initiation of psycholeptics was defined as filling a psycholeptic (ATC code N05) prescription, including antipsychotics, anxiolytics, hypnotics, and sedatives, post partum without psycholeptic prescriptions filled in the 6 months before and during pregnancy. A psychiatric emergency was defined as having emergency department visits or inpatient treatment for mental disorders ( ICD-10 F codes) . Self-harm was defined based on ICD-8 and ICD-10 codes derived from a validated coding algorithm (definition in the eMethods in Supplement 1).…”

“…The risk was more pronounced among women with severe and recurrent depression (risk ratio, 2.30; 95% CI, 1.58-3.35). A recent study in Denmark found that pregnant women who discontinued antidepressants during but not before pregnancy had an increased risk of psychiatric emergency during pregnancy compared with continuers . Of note, antidepressant use patterns before and during pregnancy are complex, especially the timing of discontinuation .…”

Psychiatric visits during the postpartum year in women with eating disorders who continue or discontinue antidepressant treatment in pregnancy

“…Limited evidence exists on the effectiveness of antidepressants in pregnancy or as a preventive treatment of postnatal mental illness in high‐risk patients (Bayrampour et al, 2020; Liu et al, 2022; Molyneaux et al, 2014; Sharma, 2017). The few available studies focus mainly on depression (Bayrampour et al, 2020).…”