FEATURE
AMELLIA KAPA COMMUNICATIONS ADVISOR
perinatal mental health in aotearoa part II: medications and implications Part I of the perinatal mental health series provided an overview of the current landscape in Aotearoa, discussing the midwife’s role, including screening. Part II focuses on commonly prescribed psychotropic medications and considerations for midwives when discussing their potential implications with wāhine/whānau. BACKGROUND He Ara Oranga, the 2018 report on the Government inquiry into Mental Health and Addiction Services in New Zealand, states that the number of general prescriptions for mental health-related medications increased by 50% over the previous 10 years, and was continuing to rise at a rate of around 5% each year at the time of the report’s publication (Government Inquiry into Mental Health and Addiction, 2018). In the same vein, a University of Otago study published this year which aimed to describe and compare antidepressant dispensing patterns before, during and after pregnancy in New Zealand between 20052014, reveals an antidepressant was dispensed in 3.1% of pregnancies in 2005, rising to 4.9% by 2014 (Donald et al., 2021). The study, which linked antidepressant dispensing records with 805,990 pregnancies over the nine-year period, also demonstrated a clear pattern; dispensing during the first trimester dropped to below pre-pregnancy and post-pregnancy levels, and the number
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fell even further in the second and third trimesters. This data would indicate women in Aotearoa who have been taking antidepressants prior to pregnancy are stopping, or significantly reducing their use of the medication during pregnancy. This finding is consistent with international data, including a Danish retrospective cohort study which showed that despite an overall increase of exposure to antidepressants in pregnancy in Denmark from 0.2% in 1997 to 3.2% in 2010, rate of exposure halved during the first trimester (Jimenez-Solem et al., 2013). A UK study mirrored these findings, revealing 79.57% of 19,774 women who were taking a psychiatric medication pre-conception, discontinued it in pregnancy (Margulis, Kang & Hammad, 2014). It is thought that hesitancy from both the practitioner to prescribe, and the woman to accept psychotropic medications in pregnancy, may be responsible for the sharp drop off, but both the Danish and New Zealand studies acknowledged the need for further research into the possible contributing factors (Jimenez-Solem et al., 2013).
Donald et al.’s (2021) analysis also showed that younger women, and those of Māori, Pacific, or Asian ethnicity were less likely to continue therapy during pregnancy if they were taking an antidepressant preconception. In their discussion, it was noted that whilst the prevalence of depression and anxiety in European and Māori women is similar, Māori women in the study were only dispensed an antidepressant around half as often as their European counterparts. Furthermore, Pacific and Asian women were only one-fifth as likely as European women to be dispensed an antidepressant, despite the fact that a longitudinal study has found that depressive symptoms during pregnancy were twice as likely to be experienced by the same group when compared with European women (Waldie et al., 2015). Donald et al. (2021) acknowledge that one possible explanation for the disparity in figures could be the potential for use of non-pharmacological therapies being higher in non-European ethnic groups, but do not discount the well-documented disparities in health service accessibility as possible contributing factors, nor the differences in cultural values regarding mental illness. Ethnicity aside, given that evidence has shown fetal antidepressant exposure may carry a small increased risk of preterm birth, congenital cardiac abnormalities, and persistent pulmonary hypertension of the newborn, hesitancy from a woman’s perspective is hardly surprising, and midwives may find themselves facing this situation in practice (Donald et al., 2021). COMMONLY PRESCRIBED MEDICATIONS Around 80% of dispensings in the Otago University study were for selective serotonin reuptake inhibitors (SSRIs) (Donald et al., 2021). Consultant psychiatrist and Clinical Head of the Mother and Babies Service at Canterbury District Health Board, Dr Liz MacDonald, has been working in the field of perinatal psychiatry for 20 years and corroborates this, naming SSRIs as the most commonly prescribed class in her experience. She cites sertraline and escitalopram as two well-known examples midwives will be familiar with.
