What the Data Really Says About ADHD in Pregnancy with Dr. Jonathan Zipursky
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What does the latest data say about ADHD and pregnancy, and how should those findings be understood without stigma or fear?
In this episode, Dr. Jonathan Zipursky discusses why supportive, personalized care and informed decision-making are key for people navigating pregnancy with ADHD. This episode is a shorter, refreshed take as we try out a new format that zooms in on a single study, giving us the chance to explore it in more depth while still delivering the key insights in a quick, focused way. Let us know what you think!
TRANSCRIPT
Misty Pratt
Welcome to In Our VoICES, the podcast that brings you the health data without the drama. I’m your host, Misty Pratt, and today’s episode looks at ADHD and pregnancy, what the research actually tells us, how to interpret the risks, and how to have these conversations without shame or blame. Joining me is Dr. Jonathan Zipursky, a physician and scientist with expertise in drug safety in pregnancy. Together, we’ll unpack a recent study that sparked a lot of discussion, clarify what it does and doesn’t tell us, and focus on what this information means for people with ADHD who are pregnant, planning a pregnancy, or caring for a newborn. Jonathan, welcome to In Our VoICES.
Jonathan Zipursky
Thanks for having me, Misty.
Misty Pratt
So, first, tell us why you felt it was important to undertake this study.
Jonathan Zipursky
So, it’s a great question. I think there are a few reasons. The first reason is our team really felt that, based on the prior literature, there wasn’t that much data out there on the potential risks associated with ADHD and pregnancy, and we felt that this was really an understudied area, and we wanted, we felt that we had the ability through our data ICES to really do a deep dive into the data surrounding ADHD and pregnancy. I think the second reason is that as time goes on, there’s been more interest in ADHD. We know over time there’s been more people who are diagnosed with ADHD, so in some of the clinical work that I do, I was starting to see more patients who suffer from ADHD and also are taking psychostimulant medications to treat their ADHD, with a lot of questions about their safety in pregnancy. So, those together, in collaboration with my co-investigators, we felt this was really an understudied area and a really important area to study,
Misty Pratt
And it’s been a really big rise in ADHD across the board, but particularly for females, right?
Jonathan Zipursky
There are sex and gender-based differences in how ADHD is diagnosed, and it’s actually quite common for females to be diagnosed a little bit later on in life. It’s more common for males to be diagnosed early, because the symptoms that females may experience with ADHD may be different and may only sort of manifest or come to attention a little bit later in life, so we’re seeing more people who are in their reproductive years who are now diagnosed with ADHD later in life.
Misty Pratt
And this was an observational study. So, for people listening who may not be familiar with different types of studies, can you explain what you set out to look at, and then what kinds of questions this type of study can and cannot answer?
Jonathan Zipursky
This is an observational study. We use all the data, all the data that we have access to in Ontario, and we aim to create a large cohort of people retrospectively, so the data is already there, but we go and look at it, and we have different algorithms to tell us who has ADHD, who has other diseases and comorbidities, and we go into the Ontario data, and we pull out a large cohort of people who are pregnant, some of whom have ADHD, some of whom do not, based on our diagnostic algorithm that we use, and then we look at a series of outcomes in the future. And those may be outcomes related to mom, and those may be outcomes related to baby.
In this study, we looked at both of those. What we’re really able to do in Ontario with some of the data that we have at ICES is that we’re able to connect mom to baby, which is quite unique and makes it very powerful for us to study a question like this. Now it’s really important to keep in mind the second part of your question is what can we study and what can’t we study, so we can look at associations, so we may be able to say that a diagnosis with ADHD in mom is associated with outcomes in the baby, or is associated with various outcomes in mom, but we can’t really establish causal inference, so we can’t say that a diagnosis of ADHD actually causes these outcomes. The gold standard to actually do a study where we’re looking at causality is really a randomized controlled trial, and this is not it.
Misty Pratt
And you talked about ICES and the data, and so it sounds like it’s different types of data than that was linked together, where it’s mom’s data and then baby’s data, potentially, and you’re looking at that across the board?
Jonathan Zipursky
Yeah, so we start with a database at ICES called Mom-Baby, which allows us to connect mom to the infant, and so we can look at mom’s health, like diagnoses of ADHD in mom or drugs that are prescribed to mom, and then we can look at mom’s outcomes, but this database is quite powerful, and because of its ability to connect to the baby, we can actually look at babies’ outcomes as it relates to mom’s exposure or mom’s underlying illnesses, which is really neat.
Misty Pratt
And you talked about the algorithm, is that something that your team developed, or is that something developed at ICES?
Jonathan Zipursky
So that’s been developed previously. So, we used a validated diagnostic algorithm for ADHD, and it’s not perfect. So, it uses diagnostic codes mainly from the inpatient and outpatient setting and also combines prescriptions for medications that are used to treat ADHD. So, it’s not a perfect algorithm, but it gives us a pretty good sense of who has ADHD and who does not. But we sort of recognize that when we use a sort of administrative data algorithm like this, we may misidentify people, or we may not be able to identify people that actually have ADHD, because they might be diagnosed by a psychologist, for example. We’re only looking at physician claims data.
Misty Pratt
And so, what did you find with the study in terms of ADHD in pregnancy and newborn health?
Jonathan Zipursky
Our two main primary outcomes were a maternal outcome and an infant outcome. The maternal outcome was severe maternal morbidity, which is a combination of codes associated with morbidity at the time of birth for the mom, and then we have sort of an analogous outcome called severe neonatal morbidity, which is a series of sort of diagnostic codes associated with morbidity in the infant, and we found that a diagnosis of maternal ADHD, so ADHD in the mom, was associated with a small increased risk of both severe neonatal morbidity and severe maternal morbidity, and we examined a whole sort of host of other exploratory specific outcomes, and most of those exploratory outcomes, we found there was a small increased risk again of those outcomes, like premature birth, gestational hypertension, or hypertensive disorders of pregnancy, for example, with a diagnosis of maternal ADHD.
Misty Pratt
And morbidity, is it too simplistic to say that would mean just bad outcomes?
Jonathan Zipursky
We consider this sort of a composite outcome, where we look at a host of sort of adverse, maybe not bad, but adverse outcomes that may occur at the time of birth, or in the infant’s case, shortly after birth as well.
Misty Pratt
And you also split the ADHD group up by looking at those who filled a psychostimulant prescription during pregnancy, and then those who didn’t. And what did that analysis show?
Jonathan Zipursky
so we felt that it was an important analysis to be one of the questions that we’re always asked with respect to this topic is, is it the diagnosis of ADHD that may be associated with some of these outcomes, or not, or is it the medication that people are taking, and that’s really hard to tease out, we call it confounding by drug indication, the medication is used because a patient has an indication for it, and that can be really challenging to tease out. So, the purpose of that subgroup analysis was to attempt, in one sense, to remove any influence that we might have thought medications might exert on some of these outcomes, and even in that subgroup analysis, where we removed anybody who had been prescribed a psychostimulant in pregnancy, we again saw a small increased association with a maternal diagnosis of ADHD, and some of these adverse outcomes in mom and baby.
Misty Pratt
And recent research, so other studies coming out of ICES have shown a significant rise in prescriptions for these kinds of medications, particularly among young women. So, do you feel like this offers some reassurance to people who are maybe taking or considering taking medications to treat their ADHD?
Jonathan Zipursky
The study that we sought out to perform here, or conduct here, really wasn’t answering that question about what are the adverse potential adverse events, or what are the risks associated with taking psychostimulant drugs in pregnancy? It’s an important question, and that’s actually the next step of what we’re working on now with our team, is that we’re going to use the narcotic monitoring system database, which has, you know, 13 or 14 year’s worth of psychostimulant prescriptions for the entire Ontario population, really ask those questions and hopefully get some answers to provide guidance and reassurance to Ontarians and others who are thinking of using psychostimulants in pregnancy.
Misty Pratt
And my next question does go outside of your study too, but I do wonder if you know based on other research what could explain then these worse outcomes for people with ADHD?
Jonathan Zipursky
So this is part of the work we’re seeking out to do as part of the grant that we have in some of the future studies, so a really important message here is not necessarily that ADHD is associated with poor outcomes, we’re not really sure the driver behind it. Is it some of the psychosocial effects surrounding ADHD? Is it some of the comorbidities associated with ADHD? Is it the medications associated with ADHD? And the messaging really that we want people to understand is it’s not that we’re trying to suggest that ADHD leads to adverse pregnancy outcomes, it’s that people who have ADHD need appropriate care, need appropriate support, need appropriate connections in pregnancy, because some of our work and others has identified that those who have ADHD may have some higher risks of these outcomes.
Misty Pratt
And if you were advising other physicians, then how would you suggest having conversations about this for someone who’s planning a pregnancy in a way that is honest, but also supportive?
Jonathan Zipursky
It’s really important to whether it’s a screen or inquire about ADHD and associated comorbidities. I think it’s important to talk about the symptoms they’re experiencing, and whether they’re taking medications, and whether those symptoms have been successfully treated with medications. It’s really, I think, a shared decision-making approach between patients and clinicians about how to pursue treatment in pregnancy, but I think it’s also this recognition that if clinicians, healthcare providers identify that their patients do have ADHD, like pre-morbid ADHD, prior to entering pregnancy, that they’re connected with the appropriate supports, counseling as they enter pregnancy, again, because of some of these risks that we’ve identified, we, we know that this may be a slightly higher risk group for some of these outcomes, and they need the appropriate care and connection to care in pregnancy.
Misty Pratt
And for people with ADHD who are pregnant, trying to conceive, or parenting an infant. What would you say is the most important message that you hope they take away from this research?
Jonathan Zipursky
The important message for me is that it’s really important to speak to your healthcare providers and figure out how, how you best can be treated, whether it’s prior to pregnancy, during pregnancy or postpartum, like it’s really important to seek appropriate care and care that works for you. And it may mean being on psychostimulant medications or other treatments for ADHD and pregnancy to help manage your symptoms, to make you as healthy as you possibly can, to make your mental health as best as it can be during what is a high risk time, we know that pregnancy, and especially postpartum, is a high risk time for mental health. So that’s really the message we want to put forth here, is that people who have ADHD and may have some concerns about pregnancy or the postpartum period really should seek out help and get the appropriate help that they need to be as healthy and successful as they can in the peripartum period.
Misty Pratt
I’m sure that message will be really well received and appreciated by people who have ADHD. You know, you talked a bit about what’s next, and is there anything in particular you want to touch on for, like, next steps?
Jonathan Zipursky
Yeah, so I think, Misty, the next steps really are to tease out some of these associations to really understand the association between ADHD and some of these adverse outcomes, and what are some of those mediators between a diagnosis of ADHD and some of these small risks that we’ve identified. I think that’s one of the big things. The second big thing is I think we need, and one that I’m really excited about, because of, you know, my interests in pharmacology and pharmacoepidemiology, is looking at the drugs specifically, and as you sort of highlighted, it’s very difficult to tease out from many of these outcomes, is this a an effect of the underlying illness, or some of the psychosocial factors surrounding the illness, or among those who are treated, is this an effect of the drug? And some of our future studies that are ongoing right now, we’re hoping to really take a deeper dive into the effects of some of these psychostimulant medications, and that’s to be honest, that’s the question I get most often in the clinic that I work in at Sunnybrook, is are these drugs safe in pregnancy? Can I continue them? Can I continue them postpartum while I’m breastfeeding? So that’s my hope. Is some of this future work will be able to answer some of those questions, and we certainly have the data here, the observational data here, to do it. We’re very lucky that we have a very robust database here that allows us to look at psychostimulant prescriptions for the entire Ontario population, including those who are pregnant and postpartum.
Misty Pratt
Thank you so much for being here, and for sharing this really important study.
Jonathan Zipursky
Thanks for having me. I appreciate it.
Misty Pratt
Thanks for joining me for this episode of In Our VoICES. Check out the show notes for links to research and any other information that we’ve referenced in this episode, a reminder that the opinions expressed in this podcast are not necessarily those of ICES. Please be sure to follow and rate us on your favorite podcast app. If you have feedback or questions about anything you’ve heard on In Our VoICES, please email us at [email protected] and we will get back to you. All of us at ICES wish you strong data and good health.
