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4 General Approach toPsychopharmacological Treatment During thePerinatal Period
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4.2 Risks ofUntreated Mental Illnesses During
thePerinatal Period
Although the perinatal period has been usually considered as a period of “wellbeing and happiness” for women and a time of relative psychological stability,
depressive and/or anxiety disorders occurring in pregnancy and during the postpartum are much more frequent than those observed in the general population.
4.2.1 Risks ofAdverse Pregnancy andNeonatal Outcomes
Many studies, including original investigations, systematic reviews, and metaanalyses, well documented that an untreated severe psychiatric disorder can be
associated with some gestational and neonatal complications. Moreover, it should
be noted that, while most studies focused on patients with anxiety and/or depressive
disorders, less information is available for other severe psychopathological conditions, such as psychotic, obsessive-compulsive, eating, and personality disorders.
A severe maternal mental illness has been associated with adverse perinatal outcomes, including spontaneous abortion, newborns small for gestational age, low
birth weight, fetal distress, preterm delivery, adverse neurodevelopmental outcomes,
and changes in the fetus-mother attachment. Pregnant women with untreated mental
illness are also more likely to be engaged in high-risk behaviors and unhealthy lifestyles, such as smoking, alcohol drinking, drug abuse, inadequate nutrition, and use
of folic acid, and can be at risk for gestational diabetes and preeclampsia. Major
depression and general anxiety disorders have also been associated with higher rates
of neonatal admission to intensive care unit as compared to neonates of the general
population. In addition, it should not be underestimated that in the perinatal period
the risk of suicide and suicide attempts is not uncommon, since the prevalence rate
has been estimated from 5% to 20% of women (Orsolini etal. 2016).
An untreated severe antenatal depression and/or anxiety may also interfere with
childhood neuro-development; higher impulsivity, maladaptive social interactions,
behavioral and emotional difculties have been reported in infants of mothers with
untreated mental disorders. Women with untreated mental disorders during pregnancy should be considered even at higher risk during the puerperium for depressive
disorders, puerperal psychoses, as well as suicide attempt and infanticide. Recent
studies also documented that major depression in the perinatal period is associated
with relevant alterations in some biological systems, including the hypothalamicpituitary-adrenal (HPA) axis, immune system, metabolic, and endocrinological dysfunctions. Furthermore, being the pregnancy a phase in which communication
between mother and baby is essential, it is not surprising that biological changes,
such as high cortisol levels in the mother are transmitted to the developing fetus;
after delivery, such increase in neonatal cortisol levels have been also documented
up to 12months after birth (Stein etal. 2014).
In addition, a number of evidences from recent studies have stablished that the
intrauterine environment can have an impact on long-term offspring health, the
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so-called “fetal programming”. Among the several environmental stressors which
have been studied in humans, maternal mental stress especially if severe and persistent is of particular concern (Stevenson 2020). A systematic review including 13
original studies has supported these ndings suggesting that maternal antenatal
major depression can be a risk factor for some neuropsychiatric disorders in children (Robinson etal. 2019). Based on the scientic evidences available so far, it can
be concluded that there are nowadays enough clinical and biological data to conrm
that prenatal maternal major depression and most likely other severe psychiatric
illnesses can have signicant clinical implications on maternal and offspring’s mental health (Bind etal. 2022).
4.2.2 Risks DuetoDiscontinuation ofPsychotropic Drugs
Overall, it has been well established that to discontinue a psychotropic drug treatment before or during pregnancy as well as after delivery, for the fear of adverse
events for the fetus, the gestation and the newborn is a decision that needs to be
carefully evaluated and obviously adequately discussed with the mother, due to the
high risk of relapse/recurrence of a psychiatric disorder during the perinatal period.
The discussion should be adequately and comprehensively informed, and the clinician should adequately provide any supportive information to guarantee an informed
decision to the mother and her partner.
A large trial published many years ago clearly documented that patients with
major depression who discontinued their antidepressant therapy relapsed signicantly more frequently as compared to women who maintained their antidepressant
therapy during pregnancy. In this study, 68% of patients who discontinued their
medication had severe depressive relapse as compared with 26% of those who
maintained the drug treatment; moreover, patients who discontinued their medication were 3 times more likely to be hospitalized (Cohen etal. 2006).
Moreover, a higher relapse rate in bipolar women who discontinued their mood
stabilizers before or during pregnancy was documented by an original study published several years ago (Viguera etal. 2007). In this study, bipolar patients who
discontinued versus those who continued the mood stabilizers, the risk of recurrence was two-fold greater, median time to rst recurrence was more than four-fold
shorter, and the proportion of weeks ill during pregnancy was ve-fold greater.
More recently, a systematic review of six studies conrmed that recurrence rate in
bipolar women who discontinued their drug treatment during pregnancy was higher
(71%) as compared to those who maintained the treatment (24%) (Anya etal. 2019).
The risk of relapse following a drug discontinuation has also been reported in other
psychopathological conditions, such as schizophrenia, obsessive-compulsive disorder, generalized anxiety, and panic disorders. Therefore, according to the amount of
evidence-based data and guidelines, it is strongly recommended that women affected
by severe and persistent psychiatric illnesses maintain their drug treatment during
pregnancy and postpartum to prevent the risk of relapse.
4 General Approach toPsychopharmacological Treatment During thePerinatal Period
69
4.3 Critical Issues intheEvaluation ofSafety ofPDs During
thePerinatal Period
4.3.1 The Evaluation ofSafety ofPDs During Pregnancy
Despite many studies focusing on the safety of PDs during pregnancy have been
published in the last 50 years, the data do not always report univocal results. The
reasons are mainly due to the different methodology used in these clinical investigations, such as the kind of experimental design adopted, the sample size, the source
of information, the analysis of confounding factors, and the statistical analysis.
A critical issue in this eld is that PDs could simply represent an important
“marker” and not the cause of an adverse event associated with drug exposure during pregnancy. For example, it has been recently suggested that the exposure to
antidepressant treatment during pregnancy should be considered not the cause of
some neurodevelopment disorders, such as adult decit and hyperactivity disorder
(ADHD) and/or autism spectrum disorder (ASD), but rather a relevant marker for
early screening and intervention in children of mother affected by depressive disorders. (Suarez etal. 2022). Moreover, it should be considered that several risk factors, such as obesity, diabetes, smoking, alcohol, and illicit drugs use, are not
uncommon in pregnant women with mental illness and could represent risk factors
for congenital birth defects and other adverse pregnancy and neonatal outcomes.
Furthermore, it is not surprising that many of the associations lose their statistical
signicance when “confounders”, particularly maternal depression, genetic susceptibility, and other risk factors, are adequately controlled for. Therefore, we must be
aware that studies that do not adjust or control for these relevant confounding factors are likely to result in misleading conclusions. Indeed, the biomedical international literature is full of examples of “indication bias”, wherein the use of PDs is
believed to be associated with a gestational/neonatal adverse event, even though
such event is likely to be caused by the clinical condition for which a woman was
treated (Smith and Payne 2024). Furthermore, most data concerning the assessment
of PDs risks in pregnancy comes from retrospective studies, with associated biases
that this entails; so, it is more likely to be reported the occurrence of a congenital
birth defect following drug exposure among women taking PDs, as they are usually
more often monitored by clinicians (recall bias).
Moreover, it is worthwhile to remember that the Relative Risk (RR/odds ratio) of
specic malformation needs to be evaluated along with data of its Absolute Risk
(AR), so that the specialist and her patient can better evaluate and also quantify the
overall risk of drug exposure in the light of its clinical and epidemiological relevance. This way of communication between doctor and patient can certainly facilitate the decision-making process in taking or not taking a certain drug during
pregnancy.
For example, exposure to sertraline during the rst trimester of pregnancy was
found in a paper published several years ago to be associated with a higher risk
(RR=4,4) of anal atresia. If we consider that anal atresia is a rare defect in general
population (5 infants out of 10,000 births, i.e., 0.06%), the AR for a pregnant woman
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who takes sertraline would be 0.2% of newborns exposed in utero to such drug. This
risk, however, has never been highlighted again in other studies (Louik etal. 2007).
As well, a meta-analytic study published more than 10 years ago reported a statistically signicant risk of cardiac septal anomalies (RR=1,5) for infants of women
treated with paroxetine. Considering that the rate of cardiac anomalies in the general population is on average 1.1% (from 0.8% to 1.4%), the AR for the newborns
exposed in utero to paroxetine would be approximately 1.6% (Grigoriadis etal.
2013). Even in this case, it should be noted that other original well-designed studies
and meta-analyses no longer reported such risk of heart defect (Huybrechts
etal. 2014).
As general approach, we must be aware that the results of so many studies conducted to assess the risks of PDs exposure in pregnancy, need a careful clinical,
statistical and epidemiological evaluation, knowing that in this wide and complex
literature, fetal and gestational risks have been found in some investigations but not
in many others.
The international literature concerning the perinatal psychopharmacology, which
dates back about 50years, could be considered a sort of “jungle of papers” in which
one must critically analyze the methodology adopted in each study and how the
results are presented and carefully discussed in term of relative and absolute risk, as
well as in the light of their clinical and epidemiological relevance. Many expert
clinical researchers have in fact suggested that not all data we found as “statistically
signicant” are of clinical and/or epidemiological relevance, particularly in the eld
of perinatal psychopharmacotherapy (Andrade 2020).
4.3.2 The Evaluation ofSafety ofPDs During Breastfeeding
During the postpartum period, breastfeeding is one of the major problems in women
who need to be treated with PDs. It has also been well established by the WHO
Guideline that breastmilk is an essential source of nutrition for the baby and that the
infant should be exclusively breastfed for at least the rst 6months to achieve optimal growth, development, and health (WHO 2017).
It is common practice that many mothers in maintenance therapy with PDs would
like to breastfeed their baby; however, these mothers are rightfully concerned about
the transfer of PDs into breast milk and about the potential adverse effects that such
medications can induce to breastfed infant. Therefore, information on the safety
prole of these drugs during lactation is of great clinical relevance to assist clinicians in the management of such women.
A useful guide to obtain information on the safety of drugs (including PDs) during breastfeeding can be found in Drugs and Lactation Database—LactMed
(LactMed 2023). However, even in this large database, limited information exists
for some drugs, particularly for drugs recently marketed. Moreover, some safety
information can be found from case reports or case series. In addition, the majority
of such data generally apply to term and healthy infants, while very limited information is available in breastfed premature or sick infants.
4 General Approach toPsychopharmacological Treatment During thePerinatal Period
An update on Consensus Panel Recommendations for the Pharmacological
Management of Breastfeeding Women with Postpartum Depression has been
recently published (Eleftheriou etal. 2024). In this paper, a panel of 16 Italian clinical research experts, representing eight scientic societies with a keen interest in
postpartum depression, has been involved. An extensive review, including 373 studies, was performed to assess the risks associated with untreated maternal depression
during breastfeeding and the risk of adverse effects in breastfed infants after the use
of antidepressant and anxiolytic drugs during breastfeeding.
The authors strongly suggested, on the basis of the evidence on the safety of
these drugs during lactation, to discuss with the patient the risks of untreated illness,
as well as the risks and benets of treatment for the nursed infant. A misleading
information can have a signicant inuence on the woman’s decision not to breastfeed their baby, even in the case of drugs considered absolutely safe during breastfeeding. For example, among antidepressants and benzodiazepines, sertraline,
paroxetine, lorazepam, and other benzodiazepines oxazepam-like are considered
rst-line options during lactation as documented by their safety index, particularly
the milk to plasma ratio (M/P) and the relative infant dose (RID).
However, it is clear that further studies are needed to better improve our knowledge on the safety of PDs, particularly of those more recently introduced into the
market and for those where the information is still lacking.
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4.4 General Approach andRecommendations inPDs
Prescription During thePerinatal Period
Planning the drug treatment for women affected by a severe psychopathological
condition should be always made before the woman becomes pregnant, that is in the
“preconception period”. Therefore, it is appropriate that all women affected by psychiatric disorders should be in a good mental health condition for at least 6–8months
before trying to get pregnant. The priority should be to keep the women in a good
psychological condition during pregnancy and postpartum period.
Considering that about 50% of pregnancies are unplanned, clinicians often need
to make treatment decisions for patients who are already pregnant. Every case
should be considered individually, with a careful evaluation on the risks and benets
concerning the prescription of a PDs treatment. The patient’s psychiatric history, the
severity of symptoms, and the response to treatment all play an important role in
planning a course of clinical care during the perinatal period.
Nowadays, there is still a need in routine clinical practice to improve the overall
management of women with mental disorders in pregnancy and postpartum.
Furthermore, we also need to counteract the stigma still surrounding these women,
often considered psychologically inadequate for childbearing and parenting and
sometimes even improperly advised to not seek pregnancy.
For many women with severe psychiatric conditions who do not receive adequate
social, psychological, and pharmacological support, the motherhood can become a
kind of nightmare.
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In the following sections, the most relevant clinical recommendations concerning the prescription of PDs before and during the perinatal period have been provided (Orsolini and Bellantuono 2022).
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4.4.1 Recommendations inPrescribing PDs
inthePreconception Period
• Recent guidelines and the expert opinions recommend that in women of child-
bearing age the possibility of becoming pregnant should always be taken into
account when a psychotropic treatment is prescribed. It is well established that
severe psychopathological disorders, such as major depression, bipolar disorder,
and general anxiety, could arise at the rst onset of pregnancy or can be exacer-
bated as a result of signicant physiologic and psychosocial changes occurring
during the gestational period.
• Contraception and optimization of physical and mental health in potential future
pregnancies should therefore be discussed at all stages of care, not just when a
woman discovers she is pregnant.
• Women affected by mental illness in their reproductive age should therefore
receive updated information from her specialist on the safety prole of drugs
they are taking, particularly concerning the fetus development and any gesta-
tional and neonatal complications.
• It is documented that about 50% of pregnancies have not been planned.
• Women already taking psychotropic medications for a maintenance therapy
should also be adequately informed (before pregnancy) about the high risk of
relapse if the drug treatment is discontinued before pregnancy or when they real-
ize they are pregnant, which usually occurs around the 5th/6th week of gestation.
This is clinically relevant when the drug prescribed is at risk of teratogenicity, as
in case of valproate, whose severe adverse effects (e.g., neural tube defects) can
occur precociously, within the rst 4th/5th weeks of gestation. In this case could
be appropriate to change the drug at risk with an alternative and safe drug treat-
ment, if possible; of course, the new therapeutic option should be evaluated for
several months before starting the pregnancy.
4.4.2 Recommendations inPrescribing PDs During Pregnancy
• The prescription of a psychopharmacological treatment during the pregnancy
should be reserved to women suffering from a severe mental disorder. The com-
bination of drug treatment, with an effective psychotherapy, such as the cogni-
tive-behavioral therapy CBT), is recommended in patients requiring a
psychotherapeutic intervention.
• The management of mental disorders in pregnancy always requires an adequate
clinical monitoring of fetal development and maternal mental state, with close
liaison among the perinatal mental health professionals (i.e., obstetricians, pedia-
4 General Approach toPsychopharmacological Treatment During thePerinatal Period
73
tricians, and midwives). It is also recommended that women treated with PDs
should give birth in a general hospital in which there is a neonatal intensive care
unit, to provide a timely and effective management of potential neonatal compli-
cations, like the “neonatal adaptation syndrome” (NAS); a not severe adverse
reaction reported in neonates exposed to SSRI late in pregnancy. It was sug-
gested that the discontinuation of drug treatment 2 or 3 weeks before delivery
could avoid or attenuate the NAS.Unfortunately, despite the drug discontinua-
tion, such complication can still occur in most newborns, particularly if preterm;
in any case the symptoms resolve spontaneously from 1 to 3 weeks. In addition,
it should be considered that discontinuing the treatment could pose the mother at
risk of an early relapse in a critical period of gestation.
• It is established that formula-fed infants were more likely to develop the NAS
than infants who were breastfed; therefore, breastfeeding should always be con-
sidered the rst-line option, particularly among preterm newborns.
• It is not recommended to stop the medications suddenly after the discovery of
pregnancy, because of the risk of relapse or severe maternal withdrawal reaction.
It would be much better if the decision to maintain or stop the drug treatment is
taken after consulting a specialist in perinatal psychiatry, so that the mother and
her partner can share the decision after having updated information about the
neonatal possible risks due to drug exposure, as well as about the risks of early
relapse in case of drug discontinuation. A written informed consent, in which all
available information concerning risks and benets of drug treatment and non-
treatment during pregnancy and postpartum, is strongly suggested.
• During gestation, the prescription of monotherapy is always preferred and the
dosage must be individualized, in order to accurately nd the “lowest effective
dosage” for each patient; hence, polypharmacy should be avoided, if possible. It
is also not appropriate to prescribe sub-therapeutic dosages, as this strategy
expose in any case the fetus to the risks of a drug and the pregnant to the risk of
relapse.
• Drugs with the largest up-to-date evidence of safety for the fetus (e.g., risk of
malformations) should be preferred as rst-line option; the previous response to
drug treatment needs also to be considered in the choice of a psychotropic treat-
ment. For example, agents belonging to SRI (SSRI SNRI) should be preferred as
rst-line option in depressive and anxiety disorders, because their safety prole
has been more investigated during pregnancy than that of other antidepres-
sant drugs.
• All change between psychotropic drugs should be carried out before pregnancy
(preconception period); it is better to avoid switching medications during preg-
nancy, unless the benets are likely to outweigh the risk; changing the drug once
women are pregnant increase also the number of fetal exposures.
• It is recommended not to prescribe PDs which have been recently introduced in
the pharmaceutical market, because the data available on their safety prole in
pregnancy and breastfeeding is most likely poor.
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4.4.3 Recommendations inPrescribing PDs
During Breastfeeding
• It is strongly recommended that neonates should be exclusively breastfed during
at least the rst 6 months of life to achieve optimal growth and development.
Thus, clinicians should avoid (if possible) using formula feeding immediately
after delivery in infants of women taking PDs, for the fear that these medications
can be at risk for the infant. In fact, most drugs are not contraindicated during
breastfeeding as their concentration in breast milk is very low or undetectable,
such as some SSRIs (e.g., paroxetine or sertraline), some benzodiazepine (e.g.,
lorazepam, lormetazepam), and some antipsychotic and mood stabilizers (like
olanzapine and quetiapine).
• An updated guide for clinicians to get information about the neonatal safety of
drugs, including PDs, during breastfeeding can be found in the US above-
mentioned database. The LactMed database contains information on drugs to
which breastfeeding mothers may be exposed. It includes many data on the levels
of such substances in breast milk and infant blood, and the possible adverse
effects reported in the nursing infants. Suggested therapeutic alternatives to those
drugs are also provided, where appropriate. All data are come from the recent
scientic literature and fully referenced. A peer review panel reviews the data to
assure scientic validity and currency.
• LactMed database is updated monthly and is free of charge.
• It is strongly recommended that breastfed infants whose mothers have been
treated with PDs should be monitored for potential adverse reactions, such the
above-mentioned NAS and in case of respiratory distress; this is a are adverse
events but particularly frequent in premature or sick newborns and in mothers
taking more than one psychotropic medication or taking high dose of these medi-
cations in late pregnancy.
4.5 Conclusions
Mental disorders, particularly if severe and persistent, are among the commonest
morbidities during the perinatal period and make an important contribution to
maternal morbidity and mortality, as well as to adverse neonatal, infant, and child
outcomes. Mental health services will always care for women of childbearing age,
many of whom will become pregnant, sometimes planned and sometimes unplanned,
and have children. Therefore, psychiatrists and other mental health professionals
need to be trained to “think family”, so that they can deliver care having in mind
together pregnancies and families.
It is well established that women with severe mental illness have an increased
risk for adverse obstetric and pregnancy outcomes, including preterm births and
fetal growth impairments; these women are also at high risk of developing preeclampsia, antepartum and postpartum hemorrhage, placental abruption, and
stillbirths.
4 General Approach toPsychopharmacological Treatment During thePerinatal Period
75
There is a general agreement among psychiatrists that during the antenatal period
the prescription of PDs should be always considered in case of women affected by
severe psychiatric illness. However, it is also reasonable to prescribe these drugs, as
an add-on therapy, in case of women with psychopathological conditions that have
only partially responded to non-pharmacological treatments.
The decision to prescribe PDs during the perinatal period is in many cases complex, particularly in early pregnancy and therefore needs a careful assessment of the
risks concerning the drug fetal exposure and those concerning the untreated psychiatric illness.
It has been documented by clinical investigations that mental disorders, such as
major depression, bipolar disorders, psychotic conditions, have been associated
during pregnancy with biological adverse events involving the immune, endocrine,
metabolic, and inammatory system that could signicantly interfere in the process
of organogenesis and later with child neurodevelopment.
A number of studies focusing on the risks of children of untreated mothers
affected by psychopathological condition have reported adverse outcomes including lower IQ, slower language development, increased risk of the ADHD and ASD.
These relevant ndings however often seem to get lost in the debate of whether
to use or not psychotropic medications during pregnancy (Wang etal. 2022).
Original studies, systematic reviews and meta-analyses have documented that
most PDs can be considered safe during early and late pregnancy, as well as during
breastfeeding. Therefore, the decision to start, to continue or to stop such drugs,
particularly during the antepartum period, need to be taken by the mother and her
partner, only after having updated information on the infant risks due to PDs exposure, as well as on the risks of relapse in case of PDs discontinuation.
In women affected by psychiatric illness and being treatment with PDs who wish
to have a baby, it would be strongly recommended to consult a specialist in perinatal
psychiatry in order to take an evidence-based decision, particularly in the cases
concerning drugs at risk.
An excellent overview has been recently published, focusing both on the impact
of biological, clinical, and psychosocial effects of mental disorders during the perinatal period and on the safety of the available psychopharmacological treatments
(Percudani etal. 2022).
Time has come to consider the perinatal psychiatry not simply an “emerging
specialty”, but a key issue that should be of interest to all those professional roles
working in the eld of women’s mental health. The question remains, however, if
the amount of so many data published is adequately disseminated and understood to
support more broadly the treatment of women in the perinatal period (Freeman 2014).
This is particularly relevant in the eld of perinatal clinical psychopharmacology
where the results of so many studies published do not always report reliable information about the risks of PDs in pregnancy.
Until now it is not feasible to carry out randomized controlled clinical trials
(RCTs) of PDs during pregnancy, due to concerns of the ethics and medico-legal
issues related to such trials; nevertheless, it has been suggested, that a challenge
might be in the near future, to reach a consensus among researchers, specialists and
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patients on the group of women for whom there is clinical equipoise that would
justify such trials (Howard and Khalifeh 2020).
In addition, it must be observed that the plethora of clinical investigations on PDs
use in pregnancy have placed a greater emphasis on the safety of the exposed newborns rather than on their therapeutic efcacy for the mentally unwell new mothers.
This focus on risk of harm to child is well documented in the high rates of psychotropic drug discontinuation in early pregnancy in women with psychiatric disorder, as well documented by several studies in women affected by depressive, anxiety,
and bipolar disorders.
A recent investigation was performed to explore the experiences of women living
with severe mental illnesses in making decisions concerning psychotropic medication use in pregnancy and breastfeeding and what helped or hindered the decisionmaking process (Frayne etal. 2023).
The results of this study recommend that the perinatal psychiatrist should provide clear and updated information, giving space for a woman’s voice to be heard
and guide them from a state of uncertainty and anxiety to one of reassurance and
clarication. Collaboration within a multidisciplinary team and external care providers, combined with consistency of care assists this process. A desirable goal
would be that the perinatal psychiatry becomes of common interest, not only for
psychiatrists and psychologists but also for other clinicians, such as general practitioners, gynecologists, and pediatricians who often deal in their routine clinical
practice with problems regarding the motherhood and the children mental health.
It is also worthwhile to remember, according to Viguera, that a proportion of
patients during pregnancy are prescribed multiple psychotropic drugs; this practice
(polypharmacotherapy) appears to be the norm rather than exception (Viguera
2024). A recent systematic review including 14 studies found that the prevalence of
women being prescribed two or more medications during pregnancy ranged from
4.9% to 62.4%, with a median of 22.5% (Anand etal. 2023).
Therefore, reproductive safety data reecting this clinical practice are crucial,
even though remain still inadequate. Closing this research gap is clinically relevant
and needs to be addressed in the future studies to enhance maternal and child outcome. This is especially relevant for women with multiple and long-term psychiatric disorders who are most likely to need more than one psychotropic drug.
Finally, it must also be reiterated that the risk of suicide in the perinatal period is
not negligible.
It was reported in a large cohort study conducted in Ontario that a high proportion of the pregnant and postpartum women who committed suicide had received
mental health care within the last year, predominantly within a primary care setting.
The perinatal suicide rate was 2.58 per 100,000 live births, with suicide accounting
for 51 (5.3%) of 966 perinatal deaths (Grigoriadis etal. 2017).
For these reasons, it would be important to know more about the type of care
provided, particularly what proportion of these women were taking psychotropic
drugs when they committed suicide (e.g., antidepressants and/or other drugs?) versus obtaining psychotherapy or other non-drug treatments, and for which psychopathological condition? Even in this case, data are still missing.