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Lee S. Cohen, MD; Lori L. Altshuler, MD; Bernard L. Harlow, PhD; Ruta Nonacs, MD, PhD; D. Jeffrey Newport, MD; Adele C. Viguera, MD; Rita Suri, MD; Vivien K. Burt, MD, PhD; Victoria Hendrick, MD; Alison M. Reminick, BA; Ada Loughead, BA; Allison F. Vitonis, BA; Zachary N. Stowe, MD

JAMA. 2006;295:499-507.

Context  Pregnancy has historically been described as a time of emotional well-being, providing "protection" against psychiatric disorder. However, systematic delineation of risk of relapse in women who maintain or discontinue pharmacological treatment during pregnancy is necessary.

Objective  To describe risk of relapse in pregnant women who discontinued antidepressant medication proximate to conception compared with those who maintained treatment with these medications.

Design, Setting, and Patients  A prospective naturalistic investigation using longitudinal psychiatric assessments on a monthly basis across pregnancy; a survival analysis was conducted to determine time to relapse of depression during pregnancy. A total of 201 pregnant women were enrolled between March 1999 and April 2003 from 3 centers with specific expertise in the treatment of psychiatric illness during pregnancy. The cohort of women was recruited from (1) within the hospital clinics, (2) self-referral via advertisements and community outreach detailing the study, and (3) direct referrals from the community. Participants were considered eligible if they (1) had a history of major depression prior to pregnancy, (2) were less than 16 weeks' gestation, (3) were euthymic for at least 3 months prior to their last menstrual period, and (4) were currently or recently (<12 weeks prior to last menstrual period) receiving antidepressant treatment. Of the 201 participants, 13 miscarried, 5 electively terminated their pregnancy, 12 were lost to follow-up prior to completion of pregnancy, and 8 chose to discontinue participation in the study.

Main Outcome Measure  Relapse of major depression defined as fulfilling Structured Clinical Interview for DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] Diagnosis (SCID) criteria.

Results  Among the 201 women in the sample, 86 (43%) experienced a relapse of major depression during pregnancy. Among the 82 women who maintained their medication throughout their pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication. Women who discontinued medication relapsed significantly more frequently over the course of their pregnancy compared with women who maintained their medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P<.001).

Conclusions  Pregnancy is not "protective" with respect to risk of relapse of major depression. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation.

Author Affiliations: Perinatal and Reproductive Psychiatry Clinical Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (Drs Cohen, Nonacs, and Viguera, and Ms Reminick); Women's Mood Disorders Research Program, University of California Los Angeles School of Medicine (Drs Altshuler, Suri, Burt, and Hendrick); Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Boston, Mass (Dr Harlow and Ms Vitonis); and Women's Mental Health Program, Emory University School of Medicine, Atlanta, Ga (Drs Newport and Stowe, and Ms Loughead).

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