Psychotropic medication continuation during pregnancy and risk of postpartum self-injurious thoughts and behaviors

Suicide remains a leading cause of maternal mortality. Among individuals with mental disorders, self-injurious thoughts and behaviors (SITBs) are strong predictors of postpartum suicide. Despite evidence for psychotropic safety in pregnancy, discontinuation is common. This study examined the association between continuation of psychotropic medication during pregnancy and postpartum SITBs risk.

This retrospective cohort study used Optum's Clinformatics® Data Mart Database (2007-2021). We included 7554 commercially insured females (aged 18-50) who delivered between 2010 and 2020, with at least one ICD-coded mental disorder within 180 days before conception, and who filled a psychotropic prescription both pre-conception and in the first trimester. Individuals with SITBs in the year before conception or during pregnancy were excluded. Exposure was measured using a continuity index (0-1), reflecting the proportion of days covered by psychotropic medication. Marginal structural Cox models estimated the associations between medication continuation and hazard of SITBs in the first postpartum year, adjusting for time-dependent confounding.

Of 7554 participants (mean age = 30.5, SD = 4.9), 116 (1.54 %) experienced postpartum SITBs. Higher medication continuation during pregnancy was associated with a significantly lower hazard of postpartum SITBs (adjusted HR = 0.06, 95 % CI = 0.02-0.19). Elevated hazards were observed among individuals with bipolar disorder and alcohol-related substance use disorders.

Because randomized trials are infeasible, modern causal inference methods were used to examine causal questions with observational data, though residual confounding may persist.

Continued psychotropic medication use during pregnancy was associated with significantly lower hazard of postpartum SITBs. Clinical interventions supporting sustained medication use may improve maternal mental health outcomes.