Study offers ‘some reassurance’ about prenatal antipsychotic use
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Researchers reported that prenatal use of antipsychotics was not associated with risks for adverse outcomes in children — specifically, ADHD, autism spectrum disorder, preterm birth or being born small for gestational age.
However, underlying maternal psychiatric disorders may be associated with ADHD and ASD in children, they said.
Kenneth K.C. Man, PhD, a fellow in the research department of practice and policy at the University College London School of Pharmacy, told Healio that there “is an increasing trend of antipsychotics prescribing for pregnant women,” but there are limited studies about the safety of the medications and long-term outcomes in children.
“Therefore, gaining knowledge on the safety of medication use during pregnancy is a public health priority,” he said.
The researchers examined the link between maternal antipsychotic use and an increased risk for ASD, preterm birth and small for gestational age in a cohort of 411,251 mother-child pairs, and they examined the link between antipsychotic use and ADHD in a cohort of 333,749 pairs. The data were collected through the Hong Kong Clinical Data Analysis and Reporting System. Women who were exposed to antidepressants and/or lithium while pregnant were not included in the analysis. The infants were born between January 2001 and January 2015, and they were followed up through December 2019.
Man and colleagues reported that among all children, 3.95% were eventually diagnosed with ADHD, 2.12% with ASD, 8.24% were preterm and 1.7% were small for gestational age. Comparing gestationally exposed with nonexposed individuals, the researchers found that the weighted hazard ratio (wHR) was 1.16 (95% CI, 0.83-1.61) for ADHD and 1.06 (95% CI, 0.7-1.6) for ASD, whereas the weighted odds ratio (wOR) was 1.4 (95% CI, 1.13-1.75) for preterm birth and 1.36 (95% CI, 0.86-2.14) for small for gestational age.
Although maternal antipsychotic use during pregnancy was associated with a small increased risk for preterm birth, additional analyses showed no such association when the researchers compared women with gestational exposure and those with past exposure (ADHD: wHR = 0.99; 95% CI, 0.6-1.61; ASD: wHR = 1.1; 95% CI, 0.58-2.08; preterm birth: wOR = 0.93; 95% CI, 0.7-1.24; and small for gestational age: wOR = 1.21; 95% CI, 0.66-2.2). A sibling-matched analysis also failed to show a link (ADHD: wHR = 0.41; 95% CI, 0.04-4.93; ASD: wHR = 0.9; 95% CI, 0.4-2.01; preterm birth: wOR = 1.25; 95% CI, 0.85-1.82; and small for gestational age: wOR = 0.86; 95% CI, 0.32-2.31).
“However, among pregnant women who were never exposed to antipsychotics, children born to mothers with psychiatric disorders had a higher risk of neurodevelopmental disorders (ASD and ADHD), but not negative birth outcomes (preterm birth and small for gestational age) compared with those with mothers without psychiatric disorders,” the researchers wrote.
According to Man and colleagues, the study did not include data from mother-child pairs who presented to private hospitals and medical practitioners, although they noted that in Hong Kong, children with neurodevelopmental disorders usually receive care from the public sector. Additionally, they could not confirm if the women had adhered to their antipsychotic medications, “which may affect the accuracy of the results,” they wrote. Information like the mothers’ BMI, alcohol consumption and smoking history also were not available, and because the data were collected in Hong Kong, “it is unclear whether the results are generalizable,” they said.
Notwithstanding the study’s limitations, Man said the results show a clear message: “Patients should not be fearful of antipsychotic medications causing harm to the future child. Instead, proper management of their existing condition should be prioritized.”
Amanda Yeaton-Massey, MD, medical director of outpatient obstetrics at the University of California, San Francisco, and colleagues wrote in an invited commentary that the study findings should “provide some reassurance” to both patients and clinicians.
“This study also highlights that pregnant patients with psychiatric diagnoses, whether or not they are prescribed medication, are at high risk of adverse maternal and child outcomes and need higher levels of medical and psychosocial support that extend well beyond delivery,” they wrote.
Wang Z, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.4571.
References:
Wang Z, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.4571.
Yeaton-Massey A, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.4562.
Perspective
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Mary C. Kimmel, MD
This study provides us more information for individuals who are taking or may need to take antipsychotics in pregnancy. We always, regardless of the medication and the cause for taking a medication, must weigh the risk of medication with the risk of the individual not taking medication. This study used a number of tools to try to understand what the risk may be from the medication vs. risk of the reason the mother is taking the antipsychotic (eg, psychosis, anxiety, mood stabilization).
In interpreting the results, it is important to understand that while there may look like an increased risk for the child (eg, ASD, small for gestational age, ADHD), these were not found to be true differences comparing those taking the medication those not taking the medication. While there was a slight increased risk for preterm birth this difference was not supported with further analyses to better understand the risk associated with medication use during pregnancy vs. other factors. In fact, a limitation of this study was the inability to also consider other factors such as smoking or stress. So, this study may show a slightly increased risk of preterm birth when in fact other factors are creating the increased risk.
In summary, this article continues to confirm that it is important to understand that these medications can be important components in mental wellness and that for individuals in whom these therapies are an important component, we should ensure they have access to these medications. Furthermore, future research is needed to understand treatments that may improve outcomes for mother and her child by improving her mental wellness.
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Wang Z, et al. JAMA Int Med. 2021;doi:10.1001/jamainternmed.2021.4571.
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