Pregnancy-related discontinuation of antidepressants and depression care visits among Medicaid recipients.
ABSTRACT This study examined whether pregnancy is associated with discontinuation of care for depression among low-income women.
Medicaid claims data from all 50 states were used in a matched cohort study design. The study included 3,237 women who gave birth between 1999 and 2000 and received depression treatment (antidepressant medications or a depression care visit) before initiating prenatal care. A control cohort of nonpregnant women receiving gynecologic care in the same period was matched by demographic and depression treatment characteristics.
Prepregnancy, the antidepressant use rate was 66%. During pregnancy, antidepressant use dropped to 27% in the pregnant cohort compared with 62% in the control group (rate ratio [RR] =.44, 95% confidence interval [CI]=.41-.46) and remained low postpartum compared with the control group (35% versus 48%, RR=.74, CI=.70-.78). Similarly, depression care visits during the pregnancy period were reduced to 31% among the pregnant cohort compared with 49% for the control group (RR=.65, CI=.61-.69) and remained lower postpartum relative to the control group (24% versus 31%, RR=.78, CI=.73-.85). Interactions with pregnancy status were found for race-ethnicity and receipt of cash assistance from Medicaid. White women in the pregnancy cohort had a greater reduction in depression care visits than nonwhite women during the pregnancy period but less reduction in antidepressant use postpartum relative to the control group. Cash assistance was associated with less discontinuation in depression care visits postpartum compared with the control group (p<.05).
Pregnancy was associated with discontinuation of any depression care among women receiving Medicaid; care did not resume postpartum. Race-ethnicity and Medicaid cash benefit status moderated this finding. Efforts are needed to mitigate these reductions.
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ABSTRACT: It is estimated that 14.5% of women suffer depression in pregnancy [Sit, D.K.Y., Flint, C., Svidergol, D., White, J., Wimer, M., Bish, B., & Wisner, K.L. (2009). An emerging best practice model for perinatal depression care. Psychiatric Services, 60, 1429–1431. Retrieved from http://ps.psychiatryonline.org/journal.aspx?journalid = 18], which has been linked to a number of negative outcomes such as higher levels of preterm delivery, reduced cognitive development and poor mother–baby connection [Judd, F., Stafford, L., Gibson, P., & Ahrens, J. (2011). The early motherhood service: An acceptable and accessible perinatal mental health service. Australasian Psychiatry, 19, 240–246. doi:10.3109/10398562.2011.562294]. The lack of clarity surrounding safety information has impacted treatment decisions with general practitioners (GPs) reportedly feeling hesitant to prescribe antidepressants [Bilszta, J.L., Tsuchiya, S., Han, K., Buist, A.E., & Einarson, A. (2011). Primary care physicians attitudes and practices regarding antidepressant use during pregnancy: A survey of two countries. Archive of Women's Mental Health, 14, 71–75. doi:10.1007/s00737-010-0197-8], yet the usage of perinatal depression guidelines among GPs is reportedly low [Kean, L.J., Hamilton, J., & Shah, P. (2011). Antidepressants for mothers: What are we prescribing? Scottish Medical Journal, 56, 94–97. doi:10.1258/smj.2011.011034]. Therefore, this study aimed to explore the opinions of GPs on how clinical guidelines for perinatal depression facilitated them to empower pregnant women to make an informed decision about the use of antidepressants in pregnancy. Using qualitative methodology, semi-structured interviews were conducted with one GP from eight practices in Derry City, Northern Ireland. The main areas explored in the interview schedule were guidelines on perinatal depression, GP understanding of ‘patient empowerment’, GP practice policy on patient decision making, constraints of treatment decisions and a discussion on which health promotion model was most reflective of their views on the provision of healthcare. Only some of the GPs were aware of the National Institute National Institute for Health and Clinical Excellence Clinical Excellence [NICE (2007). Antenatal and postnatal mental health: Clinical management and service guidance (Clinical Guideline No. CG45). Retrieved from http://www.nice.org.uk/nicemedia/live/11004/30433/30433.pdf] perinatal depression guidelines but acknowledged that they were generic and lacked utility, instead they relied on their own professional experience and patient knowledge to make decisions. Involving patients in treatment decision making was viewed as central to patient empowerment; however, its application in routine practice was often limited by complex clinical scenarios. Findings from this study suggested an identified need for a local specialist perinatal service to provide evidence-based information and timely support. An empowerment model for the improvement of perinatal depression has been developed from the study findings as a framework for women, their community and their GPs.02/2013; 15(1):3-28. DOI:10.1080/14623730.2013.781872
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ABSTRACT: This exploratory study completed interviews with 25 depressed pregnant women who had prior depression, and when becoming pregnant, were receiving depression medication or tried to get mental health care. Seventy one percent of women were more than 25 weeks gestation at the time of the interview. Thirty-five percent of women were not receiving treatment. While 94 % told their provider of their pregnancy, 36 % had no opportunity to discuss the risks and benefits of continued pharmacotherapy; 42 % had no opportunity to continue pharmacotherapy. Some providers may be reluctant to treat depressed pregnant women, creating a potential barrier to their receipt of needed care.Psychiatric Quarterly 03/2014; 85(3). DOI:10.1007/s11126-014-9293-7 · 1.26 Impact Factor
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ABSTRACT: Pharmacological treatment of any maternal illness during pregnancy warrants consideration of the consequences of the illness and/or medication for both the mother and unborn child. In the case of major depressive disorder, which affects up to 10-20% of pregnant women, the deleterious effects of untreated depression on the offspring can be profound and long lasting. Progress has been made in our understanding of the mechanism(s) of action of antidepressants, fetal exposure to these medications, and serotonin's role in development. New technologies and careful study designs have enabled the accurate sampling of maternal serum, breast milk, umbilical cord serum, and infant serum psychotropic medication concentrations to characterize the magnitude of placental transfer and exposure through human breast milk. Despite this progress, the extant clinical literature is largely composed of case series, population-based patient registry data that are reliant on nonobjective means and retrospective recall to determine both medication and maternal depression exposure, and limited inclusion of suitable control groups for maternal depression. Conclusions drawn from such studies often fail to incorporate embryology/neurotransmitter ontogeny, appropriate gestational windows, or a critical discussion of statistically versus clinically significant. Similarly, preclinical studies have predominantly relied on dosing models, leading to exposures that may not be clinically relevant. The elucidation of a defined teratological effect or mechanism, if any, has yet to be conclusively demonstrated. The extant literature indicates that, in many cases, the benefits of antidepressant use during pregnancy for a depressed pregnant woman may outweigh potential risks.Pharmacological reviews 02/2014; 66(2):435-65. DOI:10.1124/pr.111.005207 · 18.55 Impact Factor