Antidepressant prescriptions for prenatal and postpartum women in Japan: A health administrative database study

Association of antidepressant use with obesity risk in pregnant women: a retrospective cohort study

OBJECTIVE

This study evaluated the relationship between treatment for depression and anxiety in pregnancy and the risk of obesity.

DESIGN

Multivariate logistic regression analysis, nested case control study design.

SETTING

Births occurring 2008-2022 at an outer-suburban, lower socioeconomic maternity hospital in Australia. Population: 75,308 eligible births. Main outcome measures: BMI ≥ 30 (obesity), BMI ≥ 35 (severe obesity/obesity class II and III).

RESULTS

In this analysis, we found an adjusted OR of 1.56 of BMI ≥ 30, p < .000 with CI (1.35-1.80) in women taking antidepressants in pregnancy, OR 1.56 of BMI ≥ 35, p < .000, CI (1.31-1.84). Within this dataset, a cohort of 7559 women with a history or current diagnosis of depression or anxiety were found; adjusted OR of 1.40 of BMI ≥ 30, p < .000, CI (1.22-1.60) in women within this group taking antidepressants. Rates of severe obesity were similar in this cohort, BMI ≥ 35; OR 1.39, p < .000; CI 1.18-1.62).

CONCLUSIONS

These results suggest an increase in rates of obesity in women taking antidepressants in pregnancy not accounted for by other risks for obesity which might accrue from current mental ill-health or other cohort effects such as genetic vulnerability or lifestyle factors. This outcome is important in relation to the care of pregnant women with depression and anxiety. In view of current high rates of prescribing of antidepressants in pregnancy and the postpartum, this research may help inform clinician decision-making for women at risk of obesity in pregnancy.

Inclination of antidepressant medication continuation during pregnancy between 2012 and 2023 in Japan: A cohort study

BACKGROUND

As multiple Japanese academic societies have recently issued treatment guidelines for perinatal antidepressant treatments, it is considered worthwhile to evaluate the latest trends and continuation of antidepressant medication during pregnancy to optimize antenatal prescriptions.

METHODS

The prevalence, trend, and continuation of antidepressant use during pregnancy in Japan from 2012 to 2023 were evaluated, using a large administrative claims database, in women whose pregnancies ended in live births. Annual changes were evaluated using a multivariate logistic regression model adjusted for maternal age at delivery.

RESULTS

Of 179,797 women with a mean maternal age at delivery of 32.5 years, 1870 (1.04%) were prescribed antidepressants during pregnancy. The prevalence significantly increased (P < 0.0001) from 0.63% in 2012 to 1.67% in 2023. Antidepressants were prescribed to 1730 women (0.96%) during the first trimester. Of these, 670 (38.7%) were antidepressant continuers throughout pregnancy, showing a significant increase (P < 0.0001) from 19.51% in 2012 to 50.70% in 2023. The most frequently prescribed class of antidepressants during pregnancy was serotonin reuptake inhibitors (0.74%), especially sertraline (0.33%) and escitalopram (0.23%), with a significant increase in their annual prevalence.

LIMITATIONS

Prescriptions for women whose pregnancies ended in abortion or stillbirth could not be evaluated.

CONCLUSIONS

Given that antidepressant use and its continuation during pregnancy have become more common, it is important to further disseminate knowledge of the guidelines to healthcare professionals and women of childbearing age, including the promotion of preconception care and shared decision-making.

Time trends in incidence of postpartum depression and depression in women of reproductive age

BACKGROUND

Little is known about the time trends of postpartum depression (PPD) and whether they differ from time trends of depression among women in general.

METHODS

Using Danish health registers, we identified a postpartum population from all women who had a liveborn child from 2000-2022. We sampled a background population by matching five women for each delivery on age and date of childbirth. Depression and PPD were measured as incident depression diagnosis or redeemed antidepressant prescription within 180 days from childbirth/matching. We described incidence rates from 2000-2022 using Poisson regression with a restricted cubic spline.

RESULTS

The study population included 1,133,947 postpartum women (669,101 unique), matched to 5,669,735 women (1,165,505 unique). Overall IR per 10,000 person-years of diagnoses was 34.3 (95% CI: 32.8-35.9) for PPD and 18.9 (95% CI: 18.3-19.4) for depression. Both IRs increased similarly over time in the main analyses, but more pronounced for PPD in primiparous and older mothers. Correspondingly, IR for prescriptions was 135.7 (95% CI: 132.7-138.8) for PPD and 209.8 (95% CI: 208.1-211.5) for depression, and both groups had fluctuating time trends.

LIMITATIONS

Depression measures were based on women who actively sought and received treatment, expectedly underestimating true disease incidence.

CONCLUSIONS

Incidence rates of PPD and depression diagnoses increased over time, especially for PPD among primiparous and older mothers. These findings could suggest either increased vulnerability or increased awareness and detection over time in these groups. Fluctuating trends overserved from prescriptions could likely be driven by external factors and not a reflection of disease trends.

Combination of taking neuropsychiatric medications and psychological distress in pregnant women, with behavioral problems in children at 2 years of age: The Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study

Aim

To examine the association of the combination of taking neuropsychiatric medications from the onset of pregnancy to mid-pregnancy and maternal psychological distress at mid-pregnancy, with children's behavioral problems.

Methods

Neuropsychiatric medication use from the onset of pregnancy to mid-pregnancy was defined by the self-reported name of the neuropsychiatric medication in the questionnaire in early and mid-pregnancy. Maternal psychological distress was defined by the Kessler Psychological Distress Scale (K6) ≥13 on the questionnaire in mid-pregnancy. We classified the participants into four categories based on the combination of taking neuropsychiatric medications and psychological distress: "None," "Medications only," "K6 ≥ 13 only," and "Both." Children's behavioral problems were assessed using the Child Behavior Checklist for Ages 1½-5 (CBCL) at 2 years of age. The clinical ranges of the internalizing and externalizing scales of the CBCL were defined as behavioral problems. We conducted a multivariable logistic regression analysis to examine the associations between the four categories of maternal exposure and children's behavioral problems.

Results

Compared with the "None" category (n = 9873), the "K6 ≥ 13 only" category (n = 308) was statistically significantly associated with internalizing and externalizing problems. In contrast, the "Medications only" (n = 93) and "Both" (n = 22) categories were not statistically significantly associated with internalizing and externalizing problems, although the point estimates of the odds ratio in the "Both" category were relatively high (1.58 for the internalizing problem and 2.50 for the externalizing problem).

Conclusion

The category of mothers taking neuropsychiatric medications and having no psychological distress during pregnancy was not associated with children's behavioral problems in the present population.

Real-world prevalence, time of diagnosis, and co-occurrence patterns of birth defects in live-born infants, 2014-2020: A health administrative database study in Japan

BACKGROUND

A study evaluating the real-world prevalence of birth defects (BDs), including co-occurrence patterns, will provide the information required to estimate Japan's true BD prevalence and monitor it. Information such as when infants are diagnosed with BDs is crucial for defining the study population and data collection period in future administrative database studies.

METHODS

This study utilized the DeSC database, a large claims database comprising multiple health insurance schemes. The prevalence of major BDs, including structural congenital malformations (CMs) and chromosomal abnormalities, was determined in infants born between 2014 and 2020 and continuously insured for ≥1 year. The time of the first BD diagnosis and multiple BD patterns were also evaluated.

RESULTS

Among 43,147 infants, 3050 (7.07%) were diagnosed with major BDs, and 3002 (6.96%) with major CMs. The circulatory system (2.95%) was the most frequent organ system affected by CMs, followed by CMs and deformations of the musculoskeletal system (1.94%). The cumulative diagnostic rates of BDs and CMs at month 6 were 85.9% and 85.6%, respectively. The EUROCAT BD subgroups diagnosed in more than 1.0% of the infants were atrial septal defects (1.47%) and patent ductus arteriosus (1.07%). Among the 2997 infants with EUROCAT BDs, 241 (8.04%) were classified as having multiple BDs.

CONCLUSIONS

A large claims database is a valuable resource for evaluating and monitoring the prevalence of BDs, including multiple patterns. At least 1 year since birth should be considered in future administrative database studies evaluating BDs as outcomes.

Risk of major congenital malformations associated with first-trimester antihypertensives, including amlodipine and methyldopa: A large claims database study 2010-2019

OBJECTIVES

To evaluate the major congenital malformation (MCM) risk of first-trimester antihypertensive exposure, specifically of amlodipine and methyldopa.

STUDY DESIGN

A large administrative claims database was used.

MAIN OUTCOME MEASURES

The prevalence of antihypertensive prescriptions during pregnancy was described in 91,390 women giving birth between 2010 and 2019. The MCM risk of first-trimester antihypertensives was evaluated in 1,185 women diagnosed with hypertensive disorders in the first trimester. The MCM risk of first-trimester amlodipine and methyldopa was evaluated in 178 women who were prescribed antihypertensives in the first trimester.

RESULTS

Antihypertensives were prescribed to 278 (0.30%) women during their first trimester. The prescription prevalence in the first trimester was highest for methyldopa (115, 0.13%), followed by amlodipine (55, 0.06%). Antihypertensives were prescribed to 2,955 (3.23%) women during pregnancy. Nifedipine (903, 0.99%) and nicardipine (758, 0.83%) were the most frequently prescribed oral and injectable antihypertensives during pregnancy, both with a significant increase in annual prevalence. Of the 1,185 women diagnosed with hypertensive disorders in the first trimester, antihypertensives were prescribed to 178 women. The adjusted odds ratio (aOR) of MCMs in the first-trimester prescription of any antihypertensive medication was 1.124 (95% confidence interval [CI], 0.618-2.045). Amlodipine and methyldopa were prescribed to 44 and 93 of the 178 women, respectively. The aORs of MCMs in the first-trimester prescription of amlodipine and methyldopa were 1.219 (95% CI, 0.400-3.721) and 0.921 (0.331-2.564), respectively.

CONCLUSIONS

The MCM risk of first-trimester exposure to antihypertensives, including amlodipine and methyldopa, was not suggested.

Benefits and Risks of Antidepressant Drugs During Pregnancy: A Systematic Review of Meta-analyses

BACKGROUND

The prescription of antidepressant drugs during pregnancy has been steadily increasing for several decades. Meta-analyses (MAs), which increase the statistical power and precision of results, have gained interest for assessing the safety of antidepressant drugs during pregnancy.

OBJECTIVE

We aimed to provide a meta-review of MAs assessing the benefits and risks of antidepressant drug use during pregnancy.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search on PubMed and Web of Science databases was conducted on 25 October, 2021, on MAs assessing the association between antidepressant drug use during pregnancy and health outcomes for the pregnant women, embryo, fetus, newborn, and developing child. Study selection and data extraction were carried out independently and in duplicate by two authors. The methodological quality of included studies was evaluated with the AMSTAR-2 tool. Overlap among MAs was assessed by calculating the corrected covered area. Data were presented in a narrative synthesis, using four levels of evidence.

RESULTS

Fifty-one MAs were included, all but one assessing risks. These provided evidence for a significant increase in the risks for major congenital malformations (selective serotonin reuptake inhibitors, paroxetine, fluoxetine, no evidence for sertraline; eight MAs), congenital heart defects (paroxetine, fluoxetine, sertraline; 11 MAs), preterm birth (eight MAs), neonatal adaptation symptoms (eight MAs), and persistent pulmonary hypertension of the newborn (three MAs). There was limited evidence (only one MA for each outcome) for a significant increase in the risks for postpartum hemorrhage, and with a high risk of bias, for stillbirth, impaired motor development, and intellectual disability. There was inconclusive evidence, i.e., discrepant results, for an increase in the risks for spontaneous abortion, small for gestational age and low birthweight, respiratory distress, convulsions, feeding problems, and for a subsequent risk for autism with an early antidepressant drug exposure. Finally, MAs provided no evidence for an increase in the risks for gestational hypertension, preeclampsia, and for a subsequent risk for attention-deficit/hyperactivity disorder. Only one MA assessed benefits, providing limited evidence for preventing relapse in severe or recurrent depression. Effect sizes were small, except for neonatal symptoms (small to large). Results were based on MAs in which overall methodological quality was low (AMSTAR-2 score = 54.8% ± 12.9%, [19-81%]), with a high risk of bias, notably indication bias. The corrected covered area was 3.27%, which corresponds to a slight overlap.

CONCLUSIONS

This meta-review has implications for clinical practice and future research. First, these results suggest that antidepressant drugs should be used as a second-line treatment during pregnancy (after first-line psychotherapy, according to the guidelines). The risk of major congenital malformations could be prevented by observing guidelines that discourage the use of paroxetine and fluoxetine. Second, to decrease heterogeneity and bias, future MAs should adjust for maternal psychiatric disorders and antidepressant drug dosage, and perform analyses by timing of exposure.

Risk Factors Associated With Peripartum Suicide Attempts in Japan

IMPORTANCE

Peripartum suicide attempt is a major psychiatric complication associated with pregnancy, but the risk factors remain largely uncertain.

OBJECTIVE

To identify the demographic characteristics and predisposing risks for peripartum suicide attempts and postpartum depression.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used retrospective data on pregnant women who delivered children between April 1, 2016, and March 31, 2021, at 712 hospitals in Japan. The nationwide Diagnosis Procedure Combination database was used.

EXPOSURES

Psychiatric and nonpsychiatric medical history, age, alcohol and tobacco use, and obstetric complications and procedures.

MAIN OUTCOMES AND MEASURES

Data on admissions for prepartum suicide attempt and delivery during the same hospital stay and readmissions for depression or suicide attempt within 1 year post partum were collected. Comparisons of prevalence of each study variable were performed, and multivariable logistic regression analyses were used to determine risk factors.

RESULTS

From a total of 39 908 649 hospitalization episodes, 804 617 cumulative pregnant women (median [IQR] age at childbirth, 33 [29-36] years) who delivered at the enrolled hospitals were identified, including 1202 who were admitted for suicide attempt and delivery during the same hospital stay and 111 readmitted for suicide attempt within 1 year post partum. Risk factors associated with prepartum suicide attempts included younger age (adjusted odds ratio [aOR], 0.99; 95% CI, 0.98-1.00) and histories of personality disorder (aOR, 10.81; 95% CI, 5.70-20.49), depression (aOR, 3.97; 95% CI, 2.35-6.70), schizophrenia (aOR, 2.89; 95% CI, 1.52-5.50), and adjustment disorder (aOR, 2.66; 95% CI, 1.07-6.58). Risk factors associated with postpartum suicide attempts included younger age (aOR, 0.96; 95% CI, 0.93-1.00), heavy tobacco use (aOR, 23.09; 95% CI, 5.46-97.62), and histories of alcohol use disorder (aOR, 163.54; 95% CI, 28.30-944.95), personality disorder (aOR, 10.28; 95% CI, 3.29-32.10), anxiety disorders (aOR, 8.13; 95% CI, 2.88-22.98), depression (aOR, 7.27; 95% CI, 2.95-17.91), schizophrenia (aOR, 5.77; 95% CI, 2.17-15.38), bipolar disorder (aOR, 3.98; 95% CI, 1.36-11.67), and insomnia (aOR, 3.17; 95% CI, 1.30-7.78). On sensitivity analysis, risk factors associated with postpartum depression after excluding those with prenatal depression included histories of personality disorder, adjustment disorder, bipolar disorder, insomnia, and anxiety disorders.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that histories of smoking and prenatal psychiatric disorders are potential risk factors for peripartum suicide attempts and may require additional treatment and prevention interventions.

Safety evaluation of the use of calcineurin inhibitor to prenatal and postpartum women in Japan from a health administrative database

BACKGROUND

To investigate the use of calcineurin inhibitors (CNIs) in pregnant Japanese women and to evaluate their safety in infants.

METHODS

Data were extracted from the claims database of the Japan Medical Data Center. The prevalence of CNIs was evaluated 180 days before pregnancy onset, during pregnancy, and within180-days post partum. We investigated the characteristics of the infants, including the presence of major malformations and their diagnoses, for 1 year after birth.

RESULTS

A total of 91,865 pregnancies in 80,049 women were included. Fifty-three women were prescribed CNIs between 180-day before pregnancy onset and 180-day postpartum; 35 of the 53 women were prescribed the drugs during pregnancy, and 10 of their infants were born preterm. Three were diagnosed with major congenital malformations, such as patent ductus arteriosus. Six preterm infants presented with infant respiratory distress syndrome.

CONCLUSIONS

No congenital anomalies were clearly attributable to the use of CNIs during pregnancy.

No association between major congenital malformations and exposure to Kampo medicines containing rhubarb rhizome: A Japanese database study

Traditional Japanese (Kampo) medicines containing rhubarb rhizome are prescribed for constipation during pregnancy; however, detailed safety information of their use for pregnant women is lacking. The aim of current study was to clarify the association between prescription Kampo-containing rhubarb rhizome (KRR) in the first trimester of pregnancy and congenital malformations in newborns. Using a large Japanese health insurance claims database, we included pregnant women who enrolled the same health insurance society from 3 months before pregnancy to the delivery date, who gave birth between 2010 and 2019, and those with data related to their infants. Pregnant women who were prescribed magnesium oxide (MgO), commonly used for constipation, during the first trimester of pregnancy and their infants were extracted as controls. Associations between KRR prescribed in the first pregnancy trimester and major congenital malformations (MCM) in the infants were examined using multivariate logistic regression analysis. Of 75,398 infants, 4,607 (6.1%) were diagnosed with MCMs within the first year after birth. Furthermore, 9,852 infants were born to women prescribed MgO, among whom 680 (6.9%) had MCMs; 450 infants were born to women prescribed KRR, among whom 28 (6.2%) had MCMs. Multivariate logistic regression analysis identified no difference in MCM risk between the two types of prescriptions [crude odds ratio (OR) 0.895, 95% confidence interval (CI) 0.606-1.322, adjusted OR 0.889, 95% CI 0.599-1.320]. In conclusion, the risk of MCMs did not differ between those prescribed KRR or MgO in the first trimester of pregnancy.

The Fibrinolytic System in Peripartum Depression

The relationship between depression and reduced fibrinolytic activity reflects the role of tissue plasminogen activator and plasmin in brain remodeling underlying resilience, depression remission, and reward processing, rather than the dissolution of fibrin clots. Individuals who experience depression demonstrate hippocampal and prefrontal cortex atrophy, as well as impaired neuronal connectivity. Brain-derived neurotrophic factor (BDNF), synthesized as a precursor that is activated through cleavage by tissue plasminogen activator and plasmin, influences adult neurogenesis and neuronal plasticity in the hippocampus and prefrontal cortex. Depression is associated with decreased brain levels of BDNF, due to reduced activity of tissue plasminogen activator and plasmin. Tissue plasminogen activator and plasmin also mediate the release of dopamine, a neurotransmitter implicated in motivation and reward. Peripartum depression defines a depressive episode that occurs during pregnancy or in the first month after delivery, reinforcing the concept that postpartum depression may be a continuum of antenatal depression. This article describes the fibrinolytic status in the healthy brain, in stress and depression, emphasizing the links between biological markers of depression and defective fibrinolysis. It also discusses the association between hypofibrinolysis and risk factors for perinatal depression, including polycystic ovary syndrome, early miscarriage, preeclampsia, stressful life events, sedentariness, eating habits, gestational and type 2 diabetes, and antithyroid peroxidase antibodies. In addition, it reviews the evidence that antidepressant medications and interventions as diverse as placebo, psychotherapy, massage, video game playing, regular exercise, dietary modifications, omega 3 fatty acid supplementation, neurohormones, and cigarette smoking may reduce depression by restoring the fibrinolytic activity. Last, it suggests new directions for research.

Association between prenatal exposure to antidepressants and neonatal morbidity: An analysis of real-world data from a nationwide claims database in Japan

BACKGROUND

Depression during pregnancy is relatively undertreated; however, the relationship between prenatal exposure to antidepressants and neonatal outcomes remains controversial.

METHODS

This retrospective cohort study used a Japanese nationwide claims database. Data of 114,359 singletons born between January 2005 and November 2019 were used to evaluate the relationship between prenatal exposure to antidepressants and neonatal morbidity.

RESULTS

Of 2892 mothers with a history of depression before delivery, 352 (12.1%) received prescriptions within three months before delivery (MP3), and 2540 did not (non-MP3). The participants were propensity score matched (PSM) in a ratio of 1:3 using logistic regression (MP3_PSM [n = 351] vs non-MP3_PSM [n = 1052]), and maternal prescriptions of antidepressants within three months before delivery were associated with neonatal morbidity indicators, including admission to the neonatal intensive care unit (NICU) (15.7 vs. 9.1%, odds ratio (OR) 1.9 [95% confidence interval (CI): 1.3-2.6]), poor neonatal adaptation syndrome (6.0 vs 1.0%, OR 6.6 [95% CI: 3.1-14.2]), transient tachycardia (15.7 vs. 6.7%, OR 2.6 [95% CI: 1.8-3.8]), and meconium aspiration syndrome (3.1 vs 0.7%, OR 4.8 [95% CI, 1.9-12.5]). There were no significant differences in the long-term duration of stay at the NICU (>15 days).

LIMITATIONS

Confounding factors may remain even after the propensity matching.

CONCLUSION

Maternal prescription of antidepressants within three months before delivery was associated with increased admission to the NICU. However, the absolute risk of severe neonatal morbidity was low. Therefore, collaborative care for prenatal depression and the neonatal intensive care is warranted.

Antidepressant utilization patterns and predictors of treatment continuation in pregnant women: A 16-year population-based cohort

OBJECTIVE

Existing data on prenatal antidepressant prescribing patterns are mostly derived from Western countries, with limited research assessing antidepressant continuation and reinitiation during pregnancy. This study aimed to examine antidepressant prescribing practice among Chinese pregnant women in Hong Kong.

METHODS

This population-based study identified women aged 15-50 years who delivered their first and singleton child, and had redeemed at least one antidepressant prescription within 3 months pre-pregnancy and/or during pregnancy between 2003 and 2018, using data from the health-record database of Hong Kong public healthcare services. Antidepressant utilization patterns before and during pregnancy, and factors associated with antidepressant continuation and reinitiation following medication discontinuation were evaluated.

RESULTS

Of 466,358 pregnancies, 3019 (0.67%) received antidepressants within 3 months of pre-pregnancy and/or during pregnancy, and 2700 (0.58%) had prenatal antidepressant use. There was a significant rising trend of prenatal antidepressant use over time (0.6% in 2003 to 1.3% in 2018; odds ratio: 1.09, 95% confidence interval = [1.08, 1.10], p < 0.001). A consistent pattern of decreasing overall antidepressant use from 3 months pre-pregnancy to the second trimester was observed, followed by a slight increase in the third trimester. Almost half (n = 949, 49.5%) of 1918 women on antidepressants in 3 months pre-pregnancy continued treatment beyond the first trimester. A total of 8.2% that discontinued antidepressants in 3 months pre-pregnancy or in the first trimester reinitiated treatment in the later stage of pregnancy. Older age at conception (⩾35 years), recent calendar year of delivery (2015-2018), pre-existing depression/anxiety disorders, longer-term pre-pregnancy antidepressant treatment and pre-pregnancy prescription of other psychotropics were significantly associated with antidepressant continuation. Antidepressant reinitiation was predicted by pre-existing depression/anxiety disorders.

CONCLUSIONS

Our results that prenatal antidepressant use is increasingly prevalent and half of pregnant women discontinued antidepressants 3 months before or after conception underscore the need for future research to clarify the risk and benefit of antidepressant continuation versus discontinuation to facilitate development of evidence-based guidelines, so as to optimize maternal and fetal outcomes.

Discontinuation and re-initiation of antidepressants during pregnancy: A nationwide cohort study

BACKGROUND

Women tend to discontinue antidepressants during pregnancy. We examined the rate of and factors associated with antidepressant discontinuation and re-initiation during pregnancy.

METHODS

We conducted a nationwide cohort study using Korea's healthcare database. The study cohort included women who were aged 15-50 years, gave birth during 2013-2017, had ≥1 depression diagnosis, ≥2 antidepressant prescriptions within 6 months (one within one month of preconception). Cox proportional hazards model was used to evaluate factors associated with antidepressant discontinuation and re-initiation during pregnancy.

RESULTS

Among 5207 pregnancies, 4954 (95.1%) discontinued antidepressants during pregnancy, which included 4657 (89.4%) in the first trimester, 1810 (38.9%) of whom re-initiated them during pregnancy or postpartum period. The risk of antidepressant discontinuation increased in women with substance-related disorders (HR 1.17, 95% CI 1.01-1.35), but decreased in women receiving medical aid (0.53, 0.46-0.62) and patients suggestive of severe depression, such as psychiatric comorbidities and long-term antidepressant use before pregnancy. Antidepressant re-initiation occurred frequently in medical aid recipients (1.25, 1.06-1.47), nulliparous women (1.11, 1.01-1.22), and women with severe symptoms.

CONCLUSIONS

We found high rates of antidepressant discontinuation and re-initiation during pregnancy. Although women suggestive of severe symptoms were less likely to discontinue antidepressants during pregnancy, they were more likely to re-initiate them during their perinatal period, which warrants more detailed guidelines on perinatal depression.

Prescription of Kampo Formulations for Pre-natal and Post-partum Women in Japan: Data From an Administrative Health Database

Introduction: Traditional Japanese (Kampo) medicines are often prescribed for women in Japan before, during, and after pregnancy. However, detailed information on the actual frequency of use and safety of Kampo preparations during pregnancy is lacking. Aim: To investigate the frequency of prescription of Kampo medicines for pregnant women in Japan. Methods: Information on Kampo medicines prescribed during outpatient care and hospitalization of selected mothers from January 2005 to August 2016 were extracted from the Japan Medical Data Center (Tokyo, Japan), which is a large claims database. Results: Of the 33,941 subscribers identified from the database, 16,294 (48%) received at least one prescription of a Kampo medicine. Kakkonto was the formula most prescribed during the study period, followed by shoseiryuto and tokishakuyakusan. In the 180 days before pregnancy, the most prescribed medicine was tokishakuyakusan, followed by kakkonto and shoseiryuto. Shoseiryuto, tokishakuyakusan, and kakkonnto were the formulae most prescribed during pregnancy. The most prescribed medicines during the 180 days postpartum were kakkonto, shoseiryuto, and saireito. Conclusions: Information in the Japanese insurance system shows that Kampo medicines are often prescribed during pregnancy. Most of these prescriptions are generally used for the treatment of common cold. Tokishakuyakusan in particular is usually used in the treatment of various symptoms of pregnancy. Further research is needed to clarify the relationship between the use of Kampo medicines during pregnancy and adverse events in infants in Japan.

Risk of major congenital malformations associated with first-trimester exposure to propulsives: A health administrative database study in Japan

PURPOSE

To evaluate the risk of major congenital malformations (MCMs) associated with first-trimester exposure to propulsives with a special focus on domperidone using a large administrative database in Japan.

METHODS

A large claims database was used from January 2005 to August 2016. The dates of pregnancy onset and delivery were estimated using the developed algorithms. MCMs were defined according to the International Classification of Diseases, 10th revision codes. We compared the infants' risk of overall MCMs between women with or without first-trimester prescriptions of propulsives and estimated the odds ratios (ORs) with unadjusted and adjusted analyses. We also compared the risk of overall MCMs between women with domperidone prescriptions and those with other propulsive prescriptions during the first trimester.

RESULTS

Among 38 270 women, propulsives were prescribed to 3197 women (8.4%) in the first trimester, including domperidone to 371 women (1.0%). Propulsive prescriptions in the first trimester were not significantly associated with an increased risk of overall MCMs (adjusted OR [aOR] 1.030, 95% confidence interval [CI] 0.843-1.257). Compared to the prescription of other propulsives in the first trimester, the prescription of domperidone in the first trimester was not associated with an increased risk of overall MCMs (aOR 0.724, 95% CI 0.363-1.447).

CONCLUSIONS

The first-trimester prescription of propulsives, including domperidone, was not associated with an increased risk of overall MCMs.

[Study on the Safety of Perinatal Medication]

We have been conducting research with the aim of generating evidence for the safety of perinatal drugs. As a result of reviewing the records of inquiries to the Drug Information Office of our hospital, we found a large discrepancy between the description of perinatal drugs in package inserts in Japan and the description of the Pregnancy Risk Category according to the U.S. Food and Drug Administration. In the Japan Environment and Children's Study (JECS), we determined the proportion of drug and supplement use among 97464 pregnant women. We clarified that prescriptions of antihypertensive drugs for pregnant women increased during the second half of pregnancy, while prescriptions of anti-epileptic and anti-anxiety drugs decreased after pregnancy using a claims database. A survey of pharmacists and pharmacy students revealed a lack of awareness of effective folic acid intake to reduce the risk of neural tube defects in infants. The percentage of pre-pregnancy folic acid supplementation among pregnant women participating in the Babies and their Parents' Longitudinal Observation in Suzuki Memorial Hospital on Intrauterine Period (BOSHI) study, the JECS, and the Tohoku Medical Megabank (TMM) Birth and Three-Generation (BirThree) cohort study was 6.3-18.0%. As a result of close examination of the records of inquiries to the Drug Information Office of our hospital, and of cases in which our lactation plan sheet was applied, it was found that there were discrepancies between the information on the drug package insert and the information on Medications & Mother's Milk, etc. in Japan. The results obtained have been clinically applied in daily practice and we are continuing our research while taking measures.

Validity of congenital malformation diagnoses in healthcare claims from a university hospital in Japan

PURPOSE

This study aimed to assess the validity of diagnoses of congenital malformations (CMs) recorded in claims of a university hospital in Japan.

METHODS

Congenital malformations were identified according to Code Q00-Q89 of the International Classification of Diseases, 10th revision. All the children who had been diagnosed with CMs based on their claims in 2015 and within 1 year from their birth month were selected for this study. The infants' medical records were considered as a gold standard. Positive predictive values (PPVs) for CMs were calculated.

RESULTS

This study included 227 infants who had a CM diagnosis in their claims. Based on the algorithms established by the Quebec Pregnancy Cohort study group, the PPV for any CM was 90.7% and that for major CMs (MCMs) was 91.5%. Concerning MCMs of specific organ systems, those of the circulatory system (PPV 85.1%) were the most frequent, followed by cleft lip and cleft palate (PPV 100.0%), and other CMs of the digestive system (PPV 96.4%). Based on the EUROCAT classification, the PPV for any MCM was 88.5%. Specific MCMs reported in ≥20 infants were ventricular septal defect (PPV 96.0%), patent ductus arteriosus (PPV 72.7%) and cleft lip with or without cleft palate (PPV 100.0%).

CONCLUSIONS

The PPVs for CMs in the Japanese administrative data were high enough to suggest that these data could be utilized for perinatal pharmacoepidemiological evaluations. The results were from a single center, and further validation studies are needed.

Association between antidepressant use during pregnancy and congenital anomalies in children: A retrospective cohort study based on Japanese claims data

Certain studies previously pointed out that treating pregnant women with antidepressants may increase risks of congenital anomalies in their children. However, to date, the study results are not conclusive. Furthermore, most studies have been performed using data from Western countries; therefore, we examined this association using Japanese data. This retrospective cohort study was based on claims data of mothers and their children from January 2005 to July 2014, obtained from the JMDC Inc. Information on antidepressant prescriptions was extracted from the database. Children were followed up from birth through July 2014 or until their withdrawal from the database and were identified for obtaining information on their congenital anomalies. We used logistic regression analysis to evaluate the association between maternal antidepressant use during pregnancy and the children's congenital anomalies. Of 53 864 eligible pairs of mothers and children, 53 697 pairs met the study criteria. No increased risk of total congenital anomalies in children whose mothers used antidepressants of any type during the first trimester of pregnancy was found in the analysis (adjusted analysis with confounders, odds ratio: 0.86; 95% confidence interval: 0.52, 1.42). In addition, there was no increased risk of organ specific anomalies in the analysis by type of antidepressant. We found no increased risk of congenital anomalies in children whose mothers used antidepressants during the first trimester of pregnancy compared to that of non-users based on the Japanese claims data. Additional studies are necessary to further clarify the association between antidepressant use during pregnancy and congenital anomalies in children.

Selective serotonin reuptake inhibitors and the risk of congenital anomalies: a systematic review of current meta-analyses

Objective: A review of current meta-analyses examining the relationship between maternal use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy and congenital anomalies. Methods: PubMed was searched for meta-analyses published in English language between January 2010 and April 2020 by using the following combinations of key words: meta-analysis, pregnancy, antidepressant, SSRI, citalopram, escitalopram, fuloxetine, paroxetine, sertraline, fluvoxamine, neonatal outcome, birth outcome, congenital malformation, congenital anomaly, birth defect, cardiac malformation and heart defect. Results: A total of 15 meta-analyses met the search criteria. These meta-analyses consistently suggested a significant positive association between the use of SSRIs in general and paroxetine and fluoxetine in particular and the risk of major congenital anomalies. The data also showed a consistency in increased cardiovascular defects in infants due to maternal use of paroxetine. The risk of cardiovascular defects in infants of women using SSRIs in general and fluoxetine and sertraline in particular was controversial. Conclusion: Further large-scale prospective observational studies and meta-analyses on the effects of individual SSRIs other than paroxetine, especially escitalopram and fluvoxamine, are required to reach definitive conclusions.

Use of Psychotropic Medication During Lactation in Postpartum Psychiatric Patients: Results from an 8-Year Clinical Sample

Objective: The aim of this study was to examine the lactation status and prevalence of use of psychotropic medications in perinatal psychiatric patients. Methods: Clinical data collated for a period of 8 years were retrospectively retrieved from patient registers. The sample included a total of 263 postpartum patients who were followed up for at least 4 weeks. Psychiatric diagnoses were ascertained by a structured clinical interview. Results: The most commonly administered psychotropic medications were paroxetine (43.3%), sertraline (31.9%), olanzapine (12.2%), and quetiapine (6.1%). Of the 242 patients who received psychotropic medication, 41 (16.9%) discontinued breastfeeding. The discontinuation in most cases was not due to psychiatrist's recommendation or adverse events due to medications. Conclusion: Paroxetine and sertraline are frequently used by postpartum psychiatric patients in our clinical sample. In addition, the results suggesting that most psychiatric patients included in this study can continue breastfeeding during pharmacotherapy should be confirmed by data derived from further clinical samples.

Folic acid prescribed to prenatal and postpartum women who are also prescribed antiepileptic drugs in Japan: Data from a health administrative database

BACKGROUND

The aim of this study was to evaluate the prevalence of folic acid (FA) prescription to prenatal and postpartum women who have also been prescribed antiepileptic drugs (AED) in Japan.

METHODS

The data set used in this study included women covered by health insurance between 2005 and 2016. The prevalence of FA prescriptions between 180 days before pregnancy and 180 days postpartum was determined from a large administrative database, with the FA prescription classified according to dose and timing.

RESULTS

For 33,941 women meeting our eligibility criteria, the mean maternal age at delivery was 32.3 years. At least one AED was prescribed to 225 of 33,941 women between 180 days before pregnancy and 180 days postpartum. FA was prescribed to 32 of 225 women (14.2%) during the same period. FA was prescribed to 8.8% of women with AED within 90 days before pregnancy and to 19.8% during the first trimester. FA was prescribed to 10.9% during the first 30 days after conception, all of whom were prescribed FA before the pregnancy. The maximum FA dose prescribed within 90 days before pregnancy was 5 mg/day for 5 of 12 women (41.7%) and >5 mg/day for 4 of 12 women (33.3%). The maximum FA dose prescribed during the first trimester was 5 mg/day for 14 of 22 women (63.6%) and >5 mg/day for 8 of 22 women (36.4%).

CONCLUSIONS

The concurrent prescription of FA with AEDs in Japan was an uncommon therapeutic approach both before and during pregnancy.