The Costs of Discontinuing Antidepressants During Pregnancy

Many women who are taking antidepressants discontinue therapy during pregnancy because of safety concerns. However, a study conducted in Canada demonstrates that the costs of discontinuing antidepressants are considerable. O’Brien and colleagues¹ analyzed the direct medical costs associated with the discontinuation of antidepressant therapy in pregnant women in Ontario. They estimated that a relapse of depression occurred annually in about 2953 pregnant women who discontinued antidepressant therapy.

After subtracting the estimated cost of the risks associated with continuing antidepressant therapy during pregnancy, the investigators found that about $20,546,982 is spent annually in Ontario on untreated depression in pregnant women. They concluded that safe treatment options for depression during pregnancy should be pursued because such treatment will translate into cost savings, as well as helping to reduce the risk of the adverse effects of depression.

What Concerns Are Expressed by Patients With Recently Diagnosed Bipolar Disorder?
Patients who have recently received a diagnosis of bipolar disorder understandably have many concerns. Among the most important, according to a study by Proudfoot and colleagues,² are reactions to their diagnosis, coping with symptoms, adverse effects of medication, loss of sense of self, uncertainty about the future, and stigma.

This study included 26 persons with recently diagnosed bipolar disorder. In an online educational program in a public health service setting, the participants communicated with expert patients who were trained to provide informed support. In addition to the concerns noted above, the participants mentioned that identifying warning signs and triggers of illness was of major importance. The investigators said that the concerns that arise after bipolar disorder is diagnosed can undermine the effectiveness of therapy, impede self-management efforts, and interfere with patients’ functioning. They suggested that clinicians take these factors into consid- eration when developing self-management plans with their patients.

Cognitive Impairment in Bipolar Disorder
The results of several recent studies suggest that subclinical depressive symptoms and certain forms of neurocognitive impairment are predictors of a worse long-term functional outcome in patients with bipolar disorder.

Bonnn and colleagues³ evaluated clinical and neurocognitive predictors of functional outcomes in 32 patients with bipolar disorder. After an average of 4 years’ follow-up, a regression analysis indicated that subclinical depressive symptoms and performance on a verbal memory task were predictors of psycho- social functioning. Subclinical depression and performance on a measure of executive function and a “digits backwards” task were predictors of occupational functioning.

Rosa and associates⁴ studied 71 patients with euthymic bipolar disorder and 61 healthy controls. On the basis of the results of the Functional Assessment Short Test, 60% of the patients had functional impairment, compared with 13% of the control group. Depressive symptoms, older age, number of previous mixed episodes, and number of previ-ous hospitalizations were associated with poor functioning.

Martinez-Aran and associates⁵ studied 103 patients with bipolar disorder and 35 healthy controls. Those with bipolar disorder were classified as having either a high level of treatment adherence (n = 61) or a low level of treatment adherence (n = 42).

Poor treatment adherence was associated with more hospitalizations. After controlling for age, gender, estimated IQ, and Young Mania Rating scale and 17-item Hamilton Rating Scale for Depression scores, the nonadherent patients performed less well on verbal learning and some executive functions. Nonadherent patients were more impaired in their ability to inhibit interferences and in spatial working memory than adherent patients. Poorer treatment adherence was also associated with more manic episodes and hospitalizations. The investigators acknowledged that it is not clear whether nonadherence leads to cognitive impairment or whether cognitive impairment contributes to nonadherence.

References
1. O’Brien L, Laporte A, Koren G. Estimating the economic costs of antidepressant discontinuation during pregnancy. Can J Psychiatry. 2009;54:399-408.
2. Proudfoot JG, Parker GB, Benoit M, et al. What happens after diagnosis? Understanding the experiences of patients with newly-diagnosed bipolar disorder. Health Expect. 2009;12:120-129.
3. Bonnn CM, Martnez-Arn A, Torrent C, et al. Clinical and neurocognitive predictors of functional outcome in bipolar euthymic patients: a long-term, follow-up study. J Affect Disord. 2009 Jun 6; [Epub ahead of print].
4. Rosa AR, Reinares M, Franco C, et al. Clinical predictors of functional outcome of bipolar patients in remission. Bipolar Disord. 2009;11:401-409.
5. Martinez-Aran A, Scott J, Colom F, et al. Treatment nonadherence and neurocognitive impairment in bipolar disorder. J Clin Psychiatry. 2009 Jun 2; [Epub ahead of print].