Canadian

Psychiatric Association

Association des psychiatres

Original Research du Canada

The Canadian Journal of Psychiatry /

La Revue Canadienne de Psychiatrie
Psychotropic Drug Use before, during, and 2017, Vol. 62(8) 543-550
ª The Author(s) 2017
after Pregnancy: A Population-Based Study Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0706743717711168
in a Canadian Cohort (2001-2013) TheCJP.ca | LaRCP.ca

Christine Leong, BSc, BScPharm, PharmD1,

Colette Raymond, BScPharm, MSc, PharmD, ACPR, FCSHP2,
Dan Château, PhD2, Matthew Dahl, BSc2, Silvia Alessi-Severini, PhD1,
Jamie Falk, BScPharm, PharmD1, Shawn Bugden, BScPharm, MSc, PharmD1,
and Alan Katz, MBChB, MSc, CCFP2

Abstract
Objective: To describe the extent of increase in use and the rate of continuation versus discontinuation of psychotropic
agents before, during, and after pregnancy.
Methods: Rates of psychotropic use (antidepressants, anxiolytic/sedative-hypnotics, antiepileptics, antipsychotics, lithium,
stimulants) among women with a hospital-recorded pregnancy outcome were assessed using databases at the Manitoba
Centre for Health Policy. Rate of use was defined as 1 prescription over the total number of pregnancies in the 3-12 months
before pregnancy, 0-3 months before pregnancy, during pregnancy, or 3 months after pregnancy. Continued use was defined
as 2 prescriptions with gap 14 days. Poisson regression was used to analyze trends.
Results: Over the study period, a psychotropic drug was used before, during, or after pregnancy in 41,923 of 224,762
pregnancies. From 2001 to 2013, psychotropic use increased 1.5-fold from 11.1% to 16.2% (p < 0.0001) in the 3-12 months
before pregnancy, 1.6-fold from 6.4% to 10.5% (p < 0.0001) in the 3 months before pregnancy, 1.8-fold from 3.3% to 6.0% (p <
0.0001) during pregnancy, and 1.5-fold from 6.2% to 9.5% (p < 0.0001) in the 3 months postpartum. Among the 13,579 women
who received at least 1 psychotropic agent in the 3 months prior to pregnancy, 38.5% stopped the agent prior to pregnancy
and only 10.3% continued use throughout pregnancy. Continued use throughout pregnancy was higher (56.9%) among the
6693 women who received at least 2 prescriptions for a psychotropic agent and were at least 80% adherent in the 3 months
prior to pregnancy.
Conclusion: The use of psychotropic agents increased over 12 years. The safety of continuing versus discontinuing these
agents during pregnancy remains uncertain, but we observed a decrease in psychotropic drug use during the pregnancy period.

Keywords
drug use, pregnancy, pharmacoepidemiology, psychotropic drugs

As many as 10% of women of childbearing age experience
mental illness and may be exposed to a psychotropic medi-
cation prior to becoming pregnant.1-4 However, the relative
risk of continuing versus discontinuing drug therapy during
pregnancy on maternal and child health outcomes remains
uncertain.5 Although not treating mental illness in pregnant
women may pose a higher risk of maternal relapse, poor
obstetric care, and pregnancy complications,6 the perceived
risk of psychotropic drug use during pregnancy may contrib-
ute to nonadherence and discontinuation of these agents.5,7
Clinicians are provided with limited guidance on how to
best manage patients who are stable on medication during
the perinatal period, and this decision is controversial and
challenging for many clinicians. It is therefore important to
study the pattern of psychotropic exposure in order to
address the clinical implications associated with the use of
1
College of Pharmacy, Rady Faculty of Health Sciences, University
of Manitoba, Winnipeg, Manitoba
2
Manitoba Centre for Health Policy, Department of Community Health
Sciences, University of Manitoba, Winnipeg, Manitoba
Corresponding Author:
Christine Leong, BSc, BScPharm, PharmD, College of Pharmacy, Rady
Faculty of Health Sciences, University of Manitoba, 750 McDermot
Avenue, Winnipeg, MB, R3E 0T5, Canada.
Email: christine.leong@umanitoba.ca
544 The Canadian Journal of Psychiatry 62(8)

these drugs. To date, only a few observational studies have

(99.8)

(0.04)

(0.01)

(0.02)
(0.1)

(0.1)
Stimulant
examined the impact of continuing versus discontinuing psy-

(n,%)
chotropic agents during pregnancy, and findings on the risk

288
82
104
25
<6*
<6*
45
224,197
of continuing drug therapy during pregnancy are conflict-
ing.8-11 Surveys have reported that up to 60% of women had
poor adherence to chronic medication therapy during preg-

(99.0)

(0.03)
Antiepileptic

(0.4)
(0.1)
(0.3)
(0.1)

(0.1)
(0.1)
nancy.5,7 Previous studies have examined the extent of psy-

(n,%)
chotropic medication use and discontinuation during

880
246
666
232
73
121
125
222,419
pregnancy11-24; however, few studies have used large admin-
istrative databases that distinguished between regular and
intermittent users of these agents, and even fewer studies

224,540 (99.9)

20 (0.01)
48 (0.02)
24 (0.01)

13 (0.01)
examined these trends in a Canadian population. We also

106 (0.1)
Lithium
have limited knowledge about the intentional use of certain

(n,%)

<6*
<6*
psychotropic classes, such as stimulants, anxiolytics, and
mood stabilizers, from a population perspective. Manitoba
has one of the most comprehensive databases with which to
study psychotropic drug use from a population perspective.

221,747 (98.7)

75 (0.03)
Antipsychotic

1,284 (0.6)
273 (0.1)
494 (0.2)
395 (0.2)

361 (0.2)
133 (0.1)
We aimed to describe the extent of increase in use of select

(n,%)
psychotropic agents before, during, and after pregnancy and

Table 1. Overall psychotropic use (receipt of at least 1 prescription) before, during, and after pregnancy (N ¼ 224,762).

Drug

Note: Before pregnancy exposure is defined as 12 months before pregnancy; Post-partum exposure is defined 3 months after delivery.
to examine the rate of continued and discontinued use of
these agents during pregnancy between 2001 and 2013.

Antidepressant

197,494 (87.9)
11,417 (5.2)
2,817 (1.3)
5,424 (2.4)
3,556 (1.6)
706 (0.3)
1,371 (0.6)
1,977 (0.9)
*Values <6 could not be reported due to restrictions on reporting small cell counts by the health information privacy laws.
(n,%)
Methods
Data Sources
This was a retrospective, population-based, cohort study to Sedative-Hypnotic
examine the frequency of psychotropic prescriptions dis-
196,391 (87.4)
12,795 (5.7)
2,466 (1.1)
4,210 (1.9)
3,819 (1.7)
701 (0.3)
2,839 (1.3)
1,541 (0.7)
pensed before, during, and after pregnancy between April
Anxiolytic/

(n,%)

1, 2001, and March 31, 2013. Data were obtained from the
administrative database of the Population Health Research
Data Repository located at the Manitoba Centre for Health
Policy (MCHP), which includes administrative data for 1.2
million individuals living in Manitoba.
All Psychotropics

182,839 (81.4)

The Drug Program Information Network (DPIN) database

16,913 (7.5)
4,132 (1.8)
9,084 (4.0)
4,798 (2.1)
1,012 (0.5)
2,871 (1.3)
was used to provide the outpatient prescription drug use of 3113 (1.4)
(n,%)

individuals living in Manitoba. DPIN captures the outpatient

prescription dispensing record (this includes the name and
strength of the medication, date of dispensing, days of supply,
and quantity dispensed) from community pharmacies of all
Pattern of Drug Use by Time Period Peri-Pregnancy

Manitobans regardless of drug coverage. Diagnoses were

identified by ICD-9-CM or ICD-10-CA equivalent codes
Use During Pregnancy and Post Partum Only

from hospitalization (hospital abstracts) files. Prescription

data are linked to individuals with specific diagnoses from
Use Before and During Pregnancy Only

Use Before Pregnancy and Post-Partum

their contacts with the healthcare system (e.g., hospitaliza-

tions, prescriptions dispensed) through scrambled personal
health numbers. Emergency data are available from April 1,
1999, to March 31, 2013, and were used to capture emergency
Use During Pregnancy Only
Use Before Pregnancy Only

visit encounters in Winnipeg for pregnancies that occurred

No Use in All 3 Periods

Use Post-Partum Only

between April 1, 2000, and December 31, 2012, to allow

Use in All 3 Periods

observation of emergency visits in the full year prior to preg-

nancy and 3 months after pregnancy. The Manitoba Health
Insurance Registry provided demographic information at the
beginning of each interval. Statistics Canada census data pro-
vided the average household income and income quintiles at
the beginning of each index interval.
La Revue Canadienne de Psychiatrie 62(8)
Figure 1. Weighted percentage of pregnant women who filled at least 1 prescription for a psychotropic medication (2001-2013).
Cohort
Pregnant women were identified based on date of pregnancy
outcome (index date) using ICD-9-CM (or corresponding
ICD-10-CA) codes for livebirth, stillbirth (ICD-9-CM
656.4 or ICD-10-CA O36.4), and in-province specific hos-
pitalization or healthcare database (ICD-9-CM V27 or ICD-
10-CA Z37); terminations, molar, or ectopic abortions; and
molar and ectopic pregnancies. Women with more than 1
pregnancy during the study period were included as multiple
pregnancy observations. Date of conception was determined
by subtracting gestational age at delivery from the date of
birth. Out-of-hospital births, midwife care, and nurse practi-
tioner care were not included in the analysis. Only those
women registered with Manitoba Health for 365 days pre-
ceding the date of conception, through to at least 3 months
following the index date (delivery or termination), were
included (approximately 6.2% of all pregnancies during the
study period were excluded for not meeting this criterion).
Psychotropic Medication Exposure
Psychotropic agents in this study included all available for-
mulations of antidepressants (ATC N06A and N06CA),
anxiolytic/sedative-hypnotics (N05B, N05C, and
N03AE01), antiepileptic agents (N03A except N03AE01),
antipsychotic agents (N05A except N05AN), lithium
(N05AN), and stimulant agents (N06B). The annual rate of
psychotropic use (among women with a hospital-recorded
pregnancy outcome [2001-2013]) was assessed. Rate of use
was defined as 1 prescription received by the total number
of pregnancies in the 3 to 12 months before pregnancy, 3
months before pregnancy, during pregnancy (overall and
separated by each trimester of pregnancy), and 3 months
after pregnancy.
545
Among those with a livebirth, stillbirth, or intrauterine
death pregnancy outcome, we identified those with at least
2 consecutive prescriptions for a psychotropic agent with a
gap of 14 days or less between prescription fills in the 3
months prior to pregnancy and identified patients based on
their pattern of continued or discontinued use based on 4
categories: (1) patients who did not receive a subsequent
psychotropic medication in the first trimester; (2) patients
who did not receive a subsequent psychotropic medication in
the second trimester; (3) patients who received a subsequent
psychotropic medication throughout their entire pregnancy
(no gap of >14 days received in every trimester); and (4)
patients who filled a subsequent psychotropic medication
intermittently throughout pregnancy (may have gap >14
days). The gap of 14 days between prescription fills that was
used to formulate the categories was established by estimat-
ing the end-date of each prescription using the supply (num-
ber of days) that was dispensed. As a secondary analysis, the
average medication possession ratio (MPR) and the propor-
tion of women who received a psychotropic agent with an
MPR of 80% or more in the 3 months prior to pregnancy,
during pregnancy, and for each category of use (discontinued
before first trimester, discontinued before second trimester,
continued use, intermittent use) were also determined to
assess a change in adherence to medication. MPR was cal-
culated using the days-supply received divided by the num-
ber of days in the observation period.
Statistical Analysis
SAS software for Windows, version 9.3, was used for all
analyses. Summary statistics (mean and standard deviation
for normally distributed data; median and interquartile range
for skewed data) were used to describe prescription data.
Poisson regression using a generalized estimating equation
546 The Canadian Journal of Psychiatry 62(8)

Table 2. Baseline demographic and clinical characteristics of pregnant women (birth outcome of livebirth, stillbirth, or intrauterine death
only) who had 1 psychotropic drug prescription dispensed in the 3 months prior to start of pregnancy.

Intermittent use No use after Stopped before Continuous use

throughout first trimester pregnancy throughout entire Overall
Characteristic pregnancy (n ¼ 3642) (n ¼ 2519) (n ¼ 4781) pregnancy (n ¼ 1211) (n ¼ 12,153)

Age (y), mean (SD) 28.4 (5.6) 27.5 (5.8) 27.0 (5.8) 29.7 (5.1) 27.8 (5.8)
Age group, n (%)
20 years 311 (8.5) 303 (12.0) 721 (15.1) 45 (3.7) 1380 (11.4)
21-29 years 1801 (49.5) 1260 (50.0) 2434 (50.9) 547 (45.2) 6042 (49.7)
30-39 years 1449 (39.8) 915 (36.3) 1551 (32.4) 584 (48.2) 4499 (37.0)
40 years 81 (2.2) 41 (1.6) 75 (1.6) 35 (2.9) 232 (1.9)
Year of start of pregnancy, n (%)
2000 125 (3.4) 121 (4.8) 281 (5.9) 27 (2.2) 554 (4.6)
2001 174 (4.8) 140 (5.6) 371 (7.8) 50 (4.1) 735 (6.0)
2002 211 (5.8) 175 (6.9) 371 (7.8) 67 (5.5) 824 (6.8)
2003 260 (7.1) 201 (8.0) 373 (7.8) 84 (6.9) 918 (7.6)
2004 280 (7.7) 200 (7.9) 376 (7.9) 75 (6.2) 931 (7.7)
2005 326 (9.0) 205 (8.1) 405 (8.5) 84 (6.9) 1020 (8.4)
2006 282 (7.7) 192 (7.6) 409 (8.6) 87 (7.2) 970 (8.0)
2007 320 (8.8) 211 (8.4) 424 (8.9) 98 (8.1) 1053 (8.7)
2008 346 (9.5) 220 (8.7) 407 (8.5) 122 (10.1) 1095 (9.0)
2009 367 (10.1) 245 (9.7) 381 (8.0) 143 (11.8) 1136 (9.3)
2010 392 (10.8) 262 (10.4) 408 (8.5) 158 (13.0) 1220 (10.0)
2011 432 (11.9) 272 (10.8) 461 (9.6) 174 (14.4) 1339 (11.0)
2012a 127 (3.5) 75 (3.0) 114 (2.4) 42 (3.5) 358 (2.9)
Income quintile, n (%)
Quintile 1 1272 (34.9) 879 (34.9) 1487 (31.1) 375 (31.0) 4013 (33.0)
Quintile 2 717 (19.7) 508 (20.2) 946 (19.8) 247 (20.4) 2418 (19.9)
Quintile 3 590 (16.2) 460 (18.3) 879 (18.4) 213 (17.6) 2142 (17.6)
Quintile 4 531 (14.6) 376 (14.9) 772 (16.1) 200 (16.5) 1879 (15.5)
Quintile 5 507 (13.9) 280 (11.1) 664 (13.9) 168 (13.9) 1619 (13.3)
Not found 25 (0.7) 16 (0.6) 33 (0.7) 8 (0.7) 82 (0.7)
Rural, n (%) 1397 (38.4) 1085 (43.1) 1912 (40.0) 405 (33.4) 4799 (39.5)
Primiparous, n (%) 1041 (28.6) 823 (32.7) 1654 (34.6) 378 (31.2) 3896 (32.1)
Health care utilization in year prior to
start of pregnancy, n (%)
Psychiatric services hospitalization 218 (6.0) 120 (4.8) 156 (3.3) 77 (6.4) 571 (4.7)
Inpatient hospitalization 870 (23.9) 561 (22.3) 1009 (21.1) 279 (23.0) 2719 (22.4)
Emergency visitb 1124 (30.9) 657 (26.1) 1179 (24.7) 401 (33.1) 3361 (27.7)
Co-medication in 3 months prior to start
of pregnancy, n (%)
Anxiolytic/sedative 1057 (29.0) 650 (25.8) 386 (8.1) 428 (35.3) 2521 (20.7)
Antipsychotic 194 (5.3) 75 (3.0) 42 (0.9) 98 (8.1) 409 (3.4)
Antidepressant 1702 (46.7) 1114 (44.2) 937 (19.6) 753 (62.2) 4506 (37.1)
Lithium 14 (0.4) 11 (0.4) s (s) s (s) 38 (0.3)
Antiepileptic 202 (5.5) 44 (1.7) 44 (0.9) 156 (12.9) 446 (3.7)
Stimulant 19 (0.5) 37 (1.5) 20 (0.4) 13 (1.1) 89 (0.7)
Opioid 768 (21.1) 439 (17.4) 333 (7.0) 271 (22.4) 1811 (14.9)
Psychiatric diagnosis in 3 yearsc prior to
start of pregnancy, n (%)
Mood/anxiety 3184 (87.4) 2130 (84.6) 3288 (68.8) 1062 (87.7) 9664 (79.5)
Schizophrenia 95 (2.6) 37 (1.5) 33 (0.7) 41 (3.4) 206 (1.7)
Substance use disorder 669 (18.4) 444 (17.6) 656 (13.7) 234 (19.3) 2003 (16.5)
Self-harm 81 (2.2) 50 (2.0) 68 (1.4) 35 (2.9) 234 (1.9)
Nonpsychiatric comorbidities in 3 yearsc
prior to start of pregnancy, n (%)
Cancer 21 (0.6) 23 (0.9) 36 (0.8) 17 (1.4) 97 (0.8)
Diabetes 190 (5.2) 110 (4.4) 167 (3.5) 43 (3.6) 510 (4.2)
Headache 530 (14.6) 352 (14.0) 543 (11.4) 156 (12.9) 1581 (13.0)
Epilepsy 181 (5.0) 29 (1.2) 34 (0.7) 121 (10.0) 365 (3.0)
a
2012 includes data only up to March 31, 2012.
b
Emergency department database only for Winnipeg emergency department visits from April 1, 1999, to March 31, 2013. Population for characteristics was
limited to those whose start of pregnancy was on or after April 1, 2000, and end of pregnancy was on or before December 31, 2012.
c
There are 4.3% (523 pregnancies) with less than 3 years of coverage prior to start of pregnancy.
La Revue Canadienne de Psychiatrie 62(8) 547

Figure 2. Comparison of discontinued (before first trimester and before second trimester), intermittent, and continued users among
pregnant patients (birth outcome of livebirth, stillbirth, intrauterine death only) who had 1 psychotropic drug prescription dispensed in the
3 months prior to start of pregnancy. Denominator is population who received at least 1 prescription for each class of drug in 3 months prior
to conception (shown in parentheses). Continuous use was defined as no gap greater than 14 days.

to account for repeated observations was used to analyze Results

trends in rates of psychotropic drug use. Poisson regression
During the study period, there were 41,923 of 224,762 preg-
models were used to compare the percentage of weighted
nancies in which at least 1 psychotropic drug was used in the
pregnancies from 2001 to 2013 with at least 1 psychotropic
12 months before pregnancy, during the pregnancy, or 3
medication for the 3-month prior period, for the during-
months after pregnancy. The rate of psychotropic use in the
pregnancy period, and for the 3-month postpartum period.
12 months before pregnancy was higher (7.5%) than use in
Weighted number of pregnancies was used since not all
the other periods (Table 1). Anxiolytic/sedative-hypnotics
women complete all trimesters. The weighted value was cal-
and antidepressants were the most common psychotropic
culated by summing the actual number of days each woman
drugs used among these women. From 2001 to 2013, the
contributed during a time period for all pregnancies, and the
weighted percentage of pregnant women who received at
total number of days all pregnancies contributed to a time
least 1 psychotropic medication prescription increased 1.5-
period was then divided by the possible number of days in
fold from 11.1% to 16.2% (p < 0.0001) in the 3 to 12 months
that time period as the denominator (e.g., 91 days for each
before pregnancy, 1.6-fold from 6.4% to 10.5% (p < 0.0001)
trimester). Patient characteristics of psychotropic medication
in the 3 months before pregnancy, 1.8-fold from 3.3% to 6.0%
users overall and by category of continued and discontinued
(p < 0.0001) during pregnancy, and 1.5-fold from 6.2% to
use were described with descriptive statistics. Characteristics
9.5% (p < 0.0001) in the 3 months postpartum (Figure 1).
included maternal age (mean and proportion per age group
While an increase in the use of psychotropic agents was
[20, 21-29, 30-39, and 40 years]), income quintile, rural or
observed from 2001 to 2013, the rate of use was always high-
urban residence, primiparous versus multiparous, healthcare
est in the 3- to 12-month period before pregnancy and lowest
use in the year prior to start of pregnancy (psychiatric, inpa-
in the second and third trimester of pregnancy (Figure 1). For
tient hospitalization, emergency visit), co-medications in the 3
further information on the trend in use peripregnancy by drug
months prior to pregnancy (anxiolytic/sedatives, antipsycho-
class over time, see the online supplement.
tics, antidepressants, lithium, antiepileptics, stimulants,
The study identified 12,153 pregnant women with a birth
opioids), psychiatric diagnosis in 3 years prior to pregnancy
outcome of livebirth, stillbirth, or intrauterine death who had
(mood/anxiety, schizophrenia, substance use disorder, self-
at least 1 prescription for a psychotropic agent dispensed in
harm), and nonpsychiatric comorbidities in 3 years prior to
the 3 months prior to the start of pregnancy. Mean age was
pregnancy (cancer, diabetes, headache, epilepsy).
28 years (SD, 5.8 years). Baseline characteristics for patients
overall, and for those who were categorized as discontinued,
intermittent, and continued users of psychotropic agents, are
Ethics described in Table 2.
This study was conducted in compliance with the Privacy of Among those who filled at least 1 prescription for a psy-
Health Information Act of Manitoba and was approved by chotropic drug in the 3 months prior to pregnancy, 10.3%
the Research Ethics Board of the University of Manitoba and (n ¼ 1401) of pregnant patients continued their psychotropic
the Manitoba Health Information Privacy Committee. agent throughout pregnancy, and 38.5% (n ¼ 5226) and
548 The Canadian Journal of Psychiatry 62(8)

20.7% (n ¼ 2812) stopped their psychotropic medication

Restricted to women who filled at least 2 consecutive prescriptions for the psychotropic agent in the 3 months prior to pregnancy with a medication possession ratio of at least 80% based on the additive day
Stimulant,

22 (24.4)

35 (38.9)

29 (32.2)
n (%)
prior to their first and second trimesters, respectively.
Approximately 30.5% (n ¼ 4140) of patients were consid-

<6
ered intermittent users of these agents throughout pregnancy.
Antidepressant, Antipsychotic, Lithium, n Antiepileptic, The proportions of patients who continued, discontinued,

51 (11.1)

66 (14.4)

293 (63.7)
50 (10.9)
n (%) and intermittently used their agents by psychotropic drug
class are shown in Figure 2. When the population was
restricted to only those who filled at least 2 consecutive
Table 3. Pattern of continued and discontinued psychotropic use among pregnant women resulting in a livebirth, stillbirth, or intrauterine death (n ¼ 6693)a.

prescriptions (gap 14 days apart) in the 3 months prior to

12 (36.36)
10 (30.3)
pregnancy who were at least 80% adherent (80% MPR) (n ¼
(%)

6693), a higher proportion of women continued use through

<6

<6 the entire pregnancy (56.9%, n ¼ 3808), and only 16.5% (n

¼ 1105) and 15.2% (n ¼ 1020) stopped their psychotropic
54 (16.4)

59 (17.9)

159 (48.3)
57 (17.3)

medication prior to the first and second trimesters, respec-

n (%)

tively. Only 11.4% (n ¼ 760) were considered intermittent

users of these agents throughout pregnancy (Table 3). Anti-
epileptic drugs were among the psychotropic agents that
Drug

were most likely to be continued throughout pregnancy.

821 (20.1)

820 (20.1)

1837 (44.9)
610 (14.9)

Among the 460 women who received at least 2 prescriptions

n (%)

for an antiepileptic drug and were 80% adherent in the 3

months prior to pregnancy, 63.7% continued their treatment
throughout pregnancy (Table 3).
Anxiolytic/sedative-

Discussion
hypnotic, n (%)

201 (11.3)

448 (25.2)

745 (41.9)
384 (21.6)

This study presents population-based, real-world patterns of

psychotropic medication use before, during, and after preg-
nancy. While an increasing trend in the use of psychotropic
drugs was observed in all periods from 2001 to 2013, the use
of these agents decreased considerably during the pregnancy
period. However, the majority of women who were more
All psychotro-

1105 (16.5)

1020 (15.2)

3808 (56.9)
760 (11.4)

likely to be adherent to their psychotropic medication prior

pic, n (%)

to becoming pregnant were observed to continue their treat-

ment with good adherence throughout pregnancy. This
reflects current practice guidelines that recommend women
who are stable on needed treatment to continue their therapy
trimester
Pattern of drug use by time period before and during pregnancy

if the benefit of continuing outweighs the risk of discontinu-

Third

N/A

N/A

ing that agent.25-27 This pattern of use could also be an

indication that women with more severe disorders or better
controlled disorders are more likely to continue their
trimester
Second

medications.
N/A

N/A

Our findings were consistent with previous studies that

Continuous use throughout entire pregnancy

examined the extent of psychotropic drug use and the rates of

continuation and discontinuation of these agents during
0-3 months before pregnancy trimester

pregnancy.11-24 While antidepressants,20,23,24 antipsycho-

First

N/A

tics,15,20,21 lithium,18,23 and anticonvulsants16,17,20,23 are

Stopped before second trimester

commonly received before and during early pregnancy in

Use before and intermittently
Stopped before first trimester

the United Kingdom, Quebec (Canada), and the United

States, a similar decrease in use was observed in late preg-
throughout pregnancy

nancy in these studies. However, it is not known whether the

N/A ¼ not applicable.

women in these studies, whose use was based on the receipt

of pregnancy

of pregnancy

of at least 1 antidepressant prescription, were adherent users

of these agents prior to pregnancy. Moreover, our findings
will build on the limited detailed data on the pattern of
supply.

sedative-hypnotic and stimulant medication during

pregnancy.
a
La Revue Canadienne de Psychiatrie 62(8)
Our study had a number of strengths, including a large
sample size and comprehensive database not restricted to
income or age, which adds to the existing literature on psy-
chotropic use during pregnancy. We also made a distinction
between those who filled only 1 prescription prior to preg-
nancy and those who had good adherence to medication
prior to pregnancy. There were a few limitations worth not-
ing. We were unable to determine whether the decision to
stop medication was based on the decision of the physician,
patient, or both. We also did not identify the indication for
the psychotropic agent. The number of patients who received
lithium and stimulant medication in our sample was small.
We also did not look at specific agents within each class of
psychotropic agents, which warrants further investigation
due to some inherent differences within each class. Data
from these administrative databases do not capture those
who do not use medical services during pregnancy or who
deliver outside a hospital setting. We are only able to calcu-
late the rate of use based on the dispensing of medications
captured within these databases, which may not reflect
actual drug consumption. However, the use of administrative
databases is not prone to recall bias and encompasses pre-
scription use for the entire population. Moreover, we did
attempt to determine the rates of use based on patients who
received at least 2 prescriptions with an MPR of at least 80%
to capture those more likely to have consumed these agents.
Further investigation is warranted to examine the impact of
continuing versus discontinuing psychotropic agents during
pregnancy on maternal mental health.
In conclusion, while the use of psychotropic agents
increased over 12 years, we observed a decrease in use dur-
ing the pregnancy period among women in a Canadian pop-
ulation; this is similar to the patterns of use observed in other
countries. Continued use of psychotropic drug treatment was
more likely in those who had good adherence to medication
before pregnancy. These findings will provide the basis for
future research examining the clinical implications of con-
tinuing versus discontinuing these agents during pregnancy.
Acknowledgements
The authors acknowledge the Manitoba Centre for Health Policy,
University of Manitoba, for the use of data contained in the Popu-
lation Health Research Data Repository (Health Information Pri-
vacy Committee [HIPC] No. 2013/2014-35). The results and
conclusions are those of the authors, and no official endorsement
by the Manitoba Centre for Health Policy, Manitoba Health,
Seniors and Active Living, or other data providers is intended or
should be inferred. Data used in this study are from the Population
Health Research Data Repository housed at the Manitoba Centre
for Health Policy, University of Manitoba, and were derived from
data provided by Manitoba Health, Seniors and Active Living.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
549
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: Fund-
ing for this study was provided by the Canadian Network for Obser-
vational Drug Effects Studies (CNODES), a collaborating centre of
the Drug Safety and Effectiveness Network funded by the Canadian
Institutes of Health Research.
Supplemental Material
See the supplemental figures and tables at http://journals.sagepub.
com/doi/full/10.1177/0706743717711168.
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