Women with attention-deficit/hyperactivity disorder (ADHD) often discontinue ADHD medications during pregnancy, especially if they have milder symptoms. 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.
A recent study from Sweden examines 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 between 2005 and 2013 in Sweden (n = 773,047). In this cohort, 0.5% (n = 3515) of the women carried a diagnosis of ADHD prior to pregnancy. Diagnoses of depression and anxiety disorders up to one year after delivery were collected from the national register.
Among the women with ADHD, 16.8% of the women were also diagnosed with depression during the postpartum period. The prevalence of 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).
A total of 24.92% of the women with an ADHD diagnosis were also diagnosed with anxiety disorders 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.
The findings of this study indicate that ADHD is an important risk factor for postpartum depression and postpartum anxiety disorders. While we routinely ask our patients about a history of mood and anxiety disorders when estimating risk for perinatal mood and anxiety disorders, we less often ask about ADHD, especially in women with milder illness or in those who are currently not using ADHD medications. Given the relatively low prevalence of ADHD documented in the medical record in this study, it is likely that the women at greatest risk are those with more severe ADHD symptoms or those requiring pharmacotherapy. From this study, we cannot determine whether women with milder symptoms are also at increased risk for mood and anxiety disorders.
Although women with ADHD were more likely to carry other risk factors for postpartum depression and anxiety, such as lower education level and lower socioeconomic status, ADHD was an independent risk factor for postpartum depression and anxiety.
The findings of this study are consistent with a research study from our program (Baker et al., 2022) that observed that women who stopped ADHD medications during pregnancy were more likely to experience higher levels of depressive symptoms. 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) despite making no changes in their antidepressant medications. In contrast, women who either maintained or adjusted ADHD medications during pregnancy experienced no significant change in depressive symptoms.
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.
Ruta Nonacs, MD PhD
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.