Question:
I have a 32-year-old patient with ADHD who stopped her stimulant medication (Concerta 54 mg) during pregnancy. She is now at 34 weeks of gestation, and she is wondering if she can resume treatment with the stimulant. She feels that without it, she is mostly OK and able to function relatively well; however, she does not feel that she is at her best and is struggling a bit to keep up with life at work and at home. She feels less confident and is concerned about her risk for postpartum depression. She has no history of depression.
Answer:
Women with attention-deficit/hyperactivity disorder (ADHD) often discontinue ADHD medications during pregnancy, especially if they have milder symptoms. During the postpartum period, we might conclude that most women with ADHD do not “need” their ADHD medications while they are on maternity leave because they do not have to deal with the demands of work or school.
While this approach makes sense in terms of limiting unnecessary exposures in women with milder illness, we have often been surprised by clinical outcomes in this population, specifically when women who were previously high functioning experience significant psychiatric morbidity during pregnancy and the postpartum period after discontinuation of ADHD medications.
In a research study from our program (Baker et al, 2022), we observed that women who stopped ADHD medications during pregnancy were more likely to experience higher levels of depressive symptoms during pregnancy. Although ADHD symptoms remained relatively stable across pregnancy for women who discontinued psychostimulants, this group of women experienced a clinically significant increase in depressive symptoms compared to women who either maintained or adjusted ADHD medications during pregnancy.
In addition, women who discontinued psychostimulant treatment during pregnancy experienced significant impairment in family functioning. Specifically, they were more likely to experience conflict within the family, had greater difficulty in having fun as a family, rated parenting as more difficult, and described being more isolated from their family.
Another study from Sweden examined the risk of postpartum depression and anxiety in women diagnosed with ADHD. In this study, researchers used register-based data to identify women who gave birth to their first and/or second child (n = 773,047). The prevalence of postpartum depression in women with ADHD was about fivefold higher than observed in women with no ADHD diagnosis (prevalence ratio 5.09; 95% confidence interval, 4.68-5.54). In addition, about 25% of the women with an ADHD diagnosis were also diagnosed with anxiety disorder in the postpartum period. The prevalence of anxiety in women with ADHD was about fivefold higher than observed in women with no ADHD diagnosis (prevalence ratio 5.41; CI 5.06-5.78).
Although a total of 59% of the women diagnosed with ADHD carried additional psychiatric diagnoses (compared to only 5% of the women without ADHD), they observed that ADHD was an independent risk factor for postpartum depression and anxiety.
What these studies tell us is that ADHD is an important risk factor for mood and anxiety disorders during pregnancy and the postpartum period. While it may make sense to discontinue ADHD medications in patients with milder illness, we must be alert to the emergence of depressive symptoms and anxiety during pregnancy and the postpartum period. We have a growing body of literature to support the reproductive safety of stimulants in pregnant women, and these studies suggest that not treating may have negative consequences for the mother and her child.
Ruta Nonacs, MD PhD
References
Baker AS, Wales R, Noe O, Gaccione P, Freeman MP, Cohen LS. The Course of ADHD during Pregnancy. J Atten Disord. 2022 Jan;26(2):143-148.
Andersson A, Garcia-Argibay M, Viktorin A, Ghirardi L, Butwicka A, Skoglund C, Madsen KB, D’onofrio BM, Lichtenstein P, Tuvblad C, Larsson H. Depression and anxiety disorders during the postpartum period in women diagnosed with attention deficit hyperactivity disorder. J Affect Disord. 2023 Jan 18: S0165-0327(23)00085-X.
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