Patterns of ADHD Medication Usage During Pregnancy and the Postpartum Period

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder affecting a significant number of women of reproductive age. As we see more women receiving the diagnosis of and treatment for ADHD, the question of medication management during pregnancy and the postpartum period becomes increasingly relevant. A recent study from Bang Madsen and colleagues explores the patterns of ADHD medication use across pregnancy and the postpartum period.

Patterns of ADHD Medication Use

This population-based cohort study from Denmark examined patterns of ADHD medication use among 4,717 pregnancies in 4,052 mothers who filled at least one prescription for ADHD medication between one year before pregnancy to one year after delivery. The study identified four distinct treatment trajectories:

1. Continuers (23.3%): Women who continued their ADHD medication throughout pregnancy and the postpartum period.
2. Discontinuers (41.8%): Women who discontinued ADHD medications during pregnancy and the postpartum period.
3. Interrupters (17.2%): Women who stopped filling prescriptions during pregnancy but resumed after delivery.
4. Postpartum Initiators (17.7%): Women who initiated ADHD medication after giving birth.

While almost 60% of the women discontinued ADHD medication use, only 17% of them re-initiated treatment (interrupters) after giving birth. 

Which Women Elected to Continue or Initiate Treatment During the Perinatal Period?

The study found that women who continued their ADHD medication during pregnancy and postpartum (continuers) differed in several sociodemographic and clinical factors from those who discontinued or interrupted treatment.  Continuers were older at the time of conception, gave birth more recently, were more likely to smoke during pregnancy, and used other psychotropic medications during pregnancy. Additionally, a large proportion of continuers (89.1%) used the stimulant methylphenidate, compared to 75.9 – 84.1% in the other groups.  Continuers were also more likely to have switched ADHD medication types during the study period (16.4% vs. 7.4-14.8%).  These finding suggest that continuers may have more severe or difficult-to-treat illness or may have greater psychiatric morbidity.

Somewhat surprisingly, about 18% of the women with ADHD were not using medications prior to pregnancy but elected to initiate treatment with an ADHD medication after delivery (initiators).   The authors speculate that while this group of women did not “need” ADHD medications pror to pregnancy, the challenges associated with pregnancy and the transition to motherhood might have increased the need for treatment.  They also noted that almost half of the initiators had filled an antidepressant prescription in the period before, during, or after pregnancy, suggesting that this gorup of women may have greater psychiatric comorbidity.  

Clinical Implications

Treatment decisions regarding the use of ADHD medications during pregnancy and the postpartum period should consider the severity of ADHD symptoms, the presence of comorbid disorders, and the degree of impairment in daily functioning.  Factors such as driving safety, occupational role, and the ability to manage the demands of work and home life should also be taken into account.

For women with milder ADHD symptoms, discontinuing medication during pregnancy may be a reasonable option, but close monitoring for the emergence of depressive symptoms and anxiety is crucial.  Women with more severe ADHD or those who require medication to function optimally may benefit from continuing treatment, as the risks of untreated ADHD may outweigh the potential risks of medication exposure.

This study indicates that about 60% of women with ADHD elect to discontinue ADHD medications during pregnancy.  While discontinuation of medication is reasonable in many situations, we must also take into consideration the risks of discontinuing medications during pregnancy and the postpartum period. Women with ADHD who stop their medication during pregnancy are at an increased risk of experiencing higher levels of depressive symptoms and impaired family functioning, including increased conflict, difficulty in having fun as a family, and feeling isolated.  Additionally, a study from Sweden found that women with ADHD had a fivefold higher prevalence of postpartum depression and anxiety disorders compared to women without ADHD, regardless of other psychiatric diagnoses.

Ruta Nonacs, MD PhD

References
Bang Madsen K, Bliddal M, Skoglund CB, Larsson H, Munk-Olsen T, Madsen MG, Hove Thomsen P, Bergink V, Srinivas C, Cohen JM, Brikell I, Liu X. Attention-Deficit Hyperactivity Disorder (ADHD) Medication Use Trajectories Among Women in the Perinatal Period. CNS Drugs. 2024 Apr;38(4):303-314.