PhD Student UNC Chapel Hill Gillings School of Global Public Health, United States
Background: Use of antidepressants (AD) during pregnancy tends to decline across trimesters. The decision to continue or discontinue AD in pregnancy may occur following healthcare encounters, such as initiation of prenatal care (PNC).
Objectives: To describe the pattern of AD use before and after PNC initiation among commercially insured pregnant people.
Methods: Using healthcare claims data from Merative MarketScan, we constructed a cohort of pregnant women aged 12-55, who had pregnancies ending in live or still births between 2004 and 2015. Women were required to have continuous insurance plan enrollment including prescription drug coverage, from 180 days before estimated last menstrual period (LMP) through 1 month postpartum. Diagnosis codes from the International Classification of Diseases – 9th edition and procedure codes were used to define mental health conditions, comorbidities, and healthcare utilization variables. We estimated the prevalence of AD use overall and by drug class before pregnancy (defined as – 90 days to – 1 days before LMP) and during all trimesters. We evaluated treatment strategies (i.e., initiation and continuation/discontinuation) before pregnancy and following PNC initiation.
Results: Between 2004 and 2015, we identified 1,584,424 pregnancies, of which 69,668 (4.4%) were AD continuers, 35,899 (2.3%) discontinued after LMP, and 29,625 (1.9%) initiated during pregnancy. 7% of the pregnancies (n=104,094) had a diagnosis for depression or anxiety prior to pregnancy and 2% had diagnosis codes recorded for other mental health conditions (e.g., schizophrenia, psychotic disorders). The prevalence of any AD use decreased across trimesters with 7% filling a prescription before pregnancy and 3.4% in the 3rd trimester. At any time during pregnancy, selective serotonin reuptake inhibitors (SSRIs) were the most commonly filled prescriptions. Of the 105,567 women with AD prescription fills before pregnancy, 60% filled a prescription in the 1st trimester, while 37% and 36% filled a prescription in the 2nd and 3rd trimesters respectively. Among the 7% of pregnancies with pre-pregnancy depression or anxiety 42% initiated PNC by gestational week 8 and 77% by gestational week 12, regardless of pre-pregnancy AD prescription fills. Among individuals who used AD pre-pregnancy and initiated PNC within 8 weeks of pregnancy, 26% continued AD use. Pre-pregnancy AD users with earlier PNC initiation more often continued AD use than those with later PNC initiation (29.5% vs 23.7% for PNC initiations 0-4 vs > 12 weeks post-LMP).
Conclusions: The decline in the prescription of AD across trimesters coupled with increased discontinuation following PNC suggests shared decision-making between healthcare providers and patients on AD treatment plans during pregnancy.
