BJGP Interviews

Today, we’re speaking to Flo Martin, an honorary research associate at the University of Bristol.Title of paper: First trimester antidepressant use and miscarriage: a comprehensive analysis in the Clinical Practice Research Datalink GOLDAvailable at: https://doi.org/10.3399/BJGP.2025.0092Antidepressant use during pregnancy is rising, with concerns from pregnant women that these medications may increase the risk of miscarriage if taken prenatally. Evidence is conflicting so we used the Clinical Practice Research Datalink, a large repository of UK-based primary care data, and a range of methods to investigate antidepressant use during trimester one and risk of miscarriage.TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.240 - 00:00:52.800Hello and welcome to BJJP Interviews. I'm Nada Khan and I'm one of the associate editors at the bjgp. Thanks for taking the time today to listen to this podcast.In today's episode, we're speaking to Dr. Flo Martin, an honorary research associate at the University of Bristol.We're here to look at the paper she's recently published here in the BJGP titled First Trimester Antidepressant Use and Miscarriage A Comprehensive Analysis in the Clinical Practice Research Data Link. Gold. So, hi, Flo, it's great to meet you and talk about this research.And I think this paper touches on an area that clinicians and women often approach with a bit of uncertainty, just in terms of prescribing safety, really, in pregnancy in general. But can you talk us through what we know already about prescribing for antidepressants and risk in pregnancy, just to frame what you've done here?Speaker B00:00:53.280 - 00:02:22.860Yeah, absolutely.So we actually did some work a couple of years ago doing a systematic review of the literature in this space, so looking at antidepressant use during pregnancy and the risk of miscarriage. And the work spanned the last kind of 30 years.And what we found was a 30% increase in risk of miscarriage following antidepressant use during pregnancy. And this was obviously kind of alarming to see this increase in risk. But the kind of key takeaway from the paper was not actually this finding.It was mostly the kind of variation in the literature that we observed when answering this question.We kind of were very cautious about interpreting this 30% increase in risk as a kind of true causal effect because we had observed these other things that might be driving the estimate kind of upwards and might not necessarily show the true effect that was happening in this population. So that was kind of the environment that we were existing in before we started the study.And it really informed the way that we wanted to do this study.So we thought it was really important to try and understand that baseline risk in both unexposed and exposed pregnancies, so that whatever we observed was contextualized against what the underlying risk was among those who hadn't been prescribed antidepressants.Speaker A00:02:23.500 - 00:02:58.120Yeah, fair enough.So this is a large analysis of the clinical practice research data link, and you looked at pregnancies between 1996 and 2016 and then followed up women who had been prescribed or not antidepressants and risk of miscarriage.And I think if people are specifically interested in how you did this, they can go back to the paper and look at some of the different methods you used. But I wanted to focus really on what you found here.And I think the first thing to point out is that it wasn't uncommon for women to have a prescription for an antidepressant in that first trimester of pregnancy. So talk us through that.Speaker B00:02:58.440 - 00:03:43.270Yeah, exactly. So I think we. We kind of report about 7% of the pregnancies in our study that had been prescribed antidepressants.And I think, as you say, this is, you know, potentially higher than what you would expect. I think there are kind of multiple things driving this.If we look outside of pregnancy and kind of zoom out and look at the prescribing rates of antidepressants in both men and women, we can see it's going up, you know, between the 1990s and the late sort of 20 teens. And.And I think, yeah, people will be maybe surprised to see, but it's very, you know, on trend with what we're seeing outside of pregnancy and then looking.Speaker A00:03:43.270 - 00:03:45.950Specifically at the risk of miscarriage here. What did you find?Speaker B00:03:47.150 - 00:04:59.060Yeah, so when we applied our kind of primary analysis where we were looking at pregnancies who had been prescribed antidepressants in trimester one, and comparing them to pregnancies who were not prescribed antidepressants in trimester one, we found a very, very small increase in relative risk. So I think we found about 4% increase in risk of miscarriage among the prescribed group than. Than the non prescribed.And what this translated to in terms of that baseline risk, we observed 13.1% of those not prescribed antidepressants, they experienced a miscarriage, and this increased to 13.6% among those who were prescribed. So I think that really puts into perspective when we talk about increases in risk, this is an incredibly modest one, an increase all the same.And it's important to not kind of trivialize that increase in risk.But I think it's also incredibly reassuring that when we kind of really place it within what the underlying risk is had someone not taken antidepressants, it's very, very small.Speaker A00:04:59.620 - 00:05:00.100Yeah.Speaker B00:05:00.180 - 00:06:32.630Yeah. I think this is a really important piece of the puzzle for risk communication.Being able to show relative increases in risk, which are incredibly useful alongside what that actually means in terms of the percentage, the proportion of people that experience an outcome, because it just reminds people that, you know, clinicians and patients alike, that this isn't something that you have complete control over. This isn't purely your behavior driven. It's not.So I think that can be really kind of reassuring for Individuals who feel that kind of burden of risk mitigation.We see it in Heather James's paper in BJDP last year, a beautiful qualitative study speaking to women who had experienced antidepressant use during pregnancy and talking through their decision making process and their fears and concerns.And a couple of the participants who were involved in that study cited miscarriage as one of a specific, one of their specific concerns when taking antidepressants during pregnancy and actually discontinued their antidepressants because they were worried about miscarriage.So these concerns are having direct impacts on individuals and their behaviour and, you know, their potential management of their depression and anxiety.Speaker A00:06:33.190 - 00:06:44.230So, yeah, I think it's important to balance these risks against the mental health risks for the woman who's taking or needing antidepressants. And I think, as you point out, that was demonstrated beautifully in that qualitative research as well.Speaker B00:06:44.310 - 00:06:45.030Definitely.Speaker A00:06:45.670 - 00:06:59.990I wanted to sort of just draw back to how we can use these results in practice, really.And I wonder what your thoughts are about how clinicians and women should use these findings to inform their decisions around using antidepressants in pregnancy.Speaker B00:07:00.950 - 00:08:34.090Absolutely, yeah. So while I'm hoping that these results, as a non clinician myself, I'm hoping that these results can be informative for decision making.This isn't the only piece of evidence out there and it shouldn't be considered as the kind of gold standard, because it isn't.We utilize a lot of methods and comparators, we use large data, we've thought carefully about all of the things that might be driving these effects and discuss them at length. But it's not the only piece of the puzzle.I'm hoping that these results can help to kind of illuminate what the truth might be and the factors that might be influencing our perception of the results.So understanding data, understanding methods that will make us kind of rightly critical and cautious and understanding of what these types of studies in general mean, and also the fact that we've tried to kind of get at this baseline risk where we can report these proportions in both prescribed and non prescribed pregnancies should really allow for easy access to what these results mean. Rather than kind of speaking generally about relative increases, we can speak objectively about proportions in these data in these patients.Speaker A00:08:35.130 - 00:09:09.040Yeah, and absolutely, as you mentioned, it's part of the picture in terms of the decision making process that doctors and women might want to take on in terms of information when informing their decisions. So I think this is really important work, as you say, looking at those absolute risks to help guide those conversations as well.But I think that's probably a great place to wrap things up.And I think it's been great to hear more about the research, and hopefully, as you mentioned, it's building up the evidence in this area and helping women and clinicians make those decisions together.Speaker B00:09:10.410 - 00:09:10.890Thank you.Speaker A00:09:11.290 - 00:09:26.730And thank you all very much for your time here and listening to this BJTP podcast.Flo's original research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] thanks again for listening and bye.

Today, we’re speaking to Dr Jo Burgin, a GP and a researcher based at the University of Bristol.Title of paper: Mental health consultations during the perimenopausal age range – Are GPs and patients on the same page?: A qualitative studyAvailable at: https://doi.org/10.3399/BJGP.2025.0069Mood changes are a recognised symptom of perimenopause, for which Hormone Replacement Therapy is considered a first line treatment. Recent studies have found mental health symptoms are overlooked in menopause care, which is mostly delivered in primary care. This study identifies some key barriers to identifying perimenopause in women presenting with mental health symptoms and suggests important changes clinicians could make to their consultations to address this.

Today, we’re speaking to Dr Cini Bhanu, GP and Academic Clinical Lecturer in the Primary Care and Population Health Department at University College London. Title of paper: Antidepressants and risk of postural hypotension: a self-controlled case series study in UK primary careAvailable at: https://doi.org/10.3399/BJGP.2024.0429Antidepressants are associated with postural hypotension (PH). This is not widely recognised in general practice, where antihypertensives are considered the worst culprits. The present study examined >21 000 older adults and found a striking increased risk of PH with use of all antidepressants (over a four- fold risk with SSRIs) in the first 28 days of initiation. TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.480 - 00:00:56.990Hello and welcome to BJGP Interviews. My name is Nada Khan and I'm one of the associate editors of the bjgp. Thanks for listening to this podcast today.In today's episode, we're speaking to Dr. Cini Banu, who is a GP in an academic clinical lecturer based in the Department of Primary Care and Population Health at University College London.We're here to talk about her recent paper in the BJGP titled Antidepressants and Risk of Postural Hypertension, A Self Controlled Case Series Study in UK Primary Care. So, hi Cinny, it's really nice to meet you today.I guess this is an interesting area to cover, especially as the prescribing rates for some antidepressant medications are increasing.But I don't know what your feeling is, but I'm not sure if many GPs would actually know that antidepressants are associated with poison postural hypertension. So, yeah, talk us through that.Speaker B00:00:57.310 - 00:01:18.350Yeah, so I think that's one of the reasons this study is so important.So definitely from conversations that I've had with gps that I work with and it's not commonly recognized that postural hypotension is associated with antidepressants, though it is by geriatricians, for example, where it's very.Speaker A00:01:18.350 - 00:01:41.850Well recognized and in this study used a big database to look at the risk of new postural hypertension associated with the use of antidepressants in people aged over 60.I guess there's quite a lot of in depth stuff in the methods, but I guess just for a summary for people who are interested in what you did, do you mind just sort of going over it at sort of like a high level?Speaker B00:01:41.850 - 00:02:54.200Yeah, yeah. So we looked at a big database, what we call a routine primary care database called imrd.And essentially this captures data from software that gps use like EMIS and Vision System and captures a whole load of information like problems, symptoms and prescriptions. So we went into this database and identified everyone over the age of 60 that might be eligible during our study period.And for this we looked at people that were contributing at least one full year of data between 2010 and 2018. And then within that we identified people with a first diagnosis of postural hypotension.And then again we made subgroups according to people who had this diagnosis but also had a first prescription of a new antidepressant during that time.And what we were interested in, and the methodology is called a self controlled case series, we weren't interested in who got postural Hypotension, because everyone was a case, but rather when that diagnosis happened in relation to antidepressant exposure.Speaker A00:02:55.230 - 00:03:07.310And we'll talk about those different time points in a bit, but I wonder if you could just talk us through why that focus on people aged over 60 and why this is so important, especially in that age group.Speaker B00:03:07.710 - 00:04:22.710Yes, so two big reasons.So, postural hypotension is very, very common in people aged over 60 and we know that it affects around a third of people living out in the community. It's largely under recognized and under detected by gps and in prim care.And postural hypotension in older adults has significant risk of adverse complications and long term effects, including risk of being admitted to hospital, falls, fractures, but also later down the line it increases your risk of stroke and cognitive decline. So it's a really important common diagnosis. We're probably not managing as well as we can in primary care.Second is that antidepressants are actually used quite commonly in this group of patients.So we know that for people with late life depression, they're more likely to be given an antidepressant treatment for their depression rather than another therapy. So over 80% of people with depression in this age group are given an anti, are prescribed an antidepressant.So there's very high risk with both the exposure and the outcome.Speaker A00:04:23.510 - 00:04:50.610And I guess this comes back to the fact that, yes, a lot of GPs might not know about this as a risk. So it's really important that you've done this research.And so you looked at these different time points of people after starting their antidepressants and risk of postural hypertension. But talk us through what you found here.So in people who were taking one of the most commonly prescribed antidepressant classes, SSRIs, what did you find here about the risks?Speaker B00:04:50.770 - 00:06:05.480Yeah, so we actually found some really interesting time variable trends with the risk of postural hypotension associated with ssri. So we looked at two specific time periods.And that was initiating the drug, which was between a short period, days 1 to 28, and then days 29 to 56, which we treated as initiation, and then a continuation period, day 57 onwards.And what we've seen in SSRIs, but also all of the antidepressant drugs, is this peak in your risk of developing a new diagnosis of postural hypotension within that acute day 1 to 28 period.And so that was mimicked across SSRIs, tricyclic antidepressants and the other antidepressant group for SSRIs in particular, we noticed a fourfold increase in that day 1 to 28 peak that gradually declined as time went on.And tricyclic antidepressants and other antidepressants had a similarly increased peak, not to the same extent, but about twofold that declined with time.Speaker A00:06:05.960 - 00:06:17.240And we know that tricyclic drugs are often prescribed for other things as well, like pain. So do we need to be careful when prescribing it at lower doses for things like neuropathic pain?Speaker B00:06:17.240 - 00:06:51.460We didn't look into dosing, but it's certainly likely that the majority of these prescriptions were prescribed in low doses for other indications, like neuropathic pain, as you. You've said, and insomnia. And we've already seen a twofold increased risk in that acute initiation period, likely for low doses.So there is certainly a risk to be aware of in older patients that we're prescribing tricyclic antidepressants to. And it's likely that as the dose increases, that this risk increases.Speaker A00:06:51.620 - 00:07:04.400And I think one thing that's really important here is that the effect sizes are actually pretty significant. So this could represent a fairly significant risk for patients, especially in that initial peak time that you mentioned.Speaker B00:07:04.960 - 00:07:38.380Absolutely, yes.And I think there's certainly a striking risk associated with SSRIs in this group, and a lot of it depends on the context of the person you're prescribing this medication to.So whilst we know there's a fourfold increased risk in this study, you may be more cautious with someone who is at greater risk of postural hypotension at their baseline anyway, either related to advancing age or other chronic conditions like diabetes or Parkinson's, for example.Speaker A00:07:38.700 - 00:07:53.740And I think what's really interesting is you point out in the paper that actually postural hypertension isn't highlighted as a common side effect in the BNF for these drugs. So it seems with such a significant effect that probably that's something that should be highlighted.Speaker B00:07:54.300 - 00:08:19.640Yes, that's something I think is really, really important.So you'll often see hypotension cited as a side, but they are quite different and the assessment is different and how you might manage it would be different too. So I think it's definitely really important that that increased risk of postural changes in blood pressure is documented for these medications.Speaker A00:08:20.760 - 00:08:46.019I think it's interesting because often when people start these medications, they might have an early review with a GP about how they're getting on with it. And often that that initial review really focuses on mood and how they're coping and may touch on side effects.But I'm not sure that at the moment that sort of initial review would include a check for postural hypertension, for instance.Speaker B00:08:46.179 - 00:09:28.160I think it's unlikely.And whilst many of us may be very good at asking about side effects more broadly, I think one of the barriers here is that a lot of patients may not recognize the symptoms of postural hypotension, or if they experience dizziness on standing and it's transient, they may not think it's important to report to their gp. And that's something that we've gauged from our PPI group that are involved in this study.So really, it does need for a clinician to ask directly about postural symptoms and maybe even check their lying and standing blood pressure.Speaker A00:09:28.320 - 00:09:39.500I guess that overlaps with what I was going to ask next, really, which was really, what should we be telling people starting these medications? And is there anything that GP should be doing differently in practice as a result?Speaker B00:09:40.060 - 00:10:32.290Yeah.So I think some really simple things about just warning patients that they might experience these side effects and symptoms to report, like dizziness on standing or other symptoms like blurred vision or feeling light headed on standing upright, are important to make note of and to report to report back in itself will make a huge difference. But just also some general advice around reducing falls risk during this period.Once you've initiated an antidepressant, which will look different from person to person, things like keeping well hydrated and reducing alcohol intake are all conservative measures that can reduce your risk of postural hypotension and its adverse outcomes.Speaker A00:10:32.530 - 00:11:03.330And we know that for some medications, side effect profiles might only last in that first initial period.So often for SSRIs, for instance, I might mention to a patient, you may experience some gastrointestinal type symptoms for the first couple of weeks, but they may ease. So do you think your findings would support that of maybe being a bit more cautious in that first month?But then how would you recommend we monitor that? Or do you think it's really that initial peak that people need to be looking out for?Speaker B00:11:03.650 - 00:12:06.680Yeah, it's an interesting question.And certainly the results in this study where we looked at the three antidepressants, that's what the consistent trends seem to show, that it's the early acute period that's of greatest risk and your risk subsides over time.And it probably does align in the way that different adverse effects like you've mentioned GI adverse effects and the pharmacodynamics and pharmacokinetics of a drug lead to this initial period being the highest risk.So what I would say is I think that period is definitely a key time where it seems that giving this type of preventative advice and potentially even monitoring people who are at high risk is of greatest importance. But whether or not they're completely risk free later down the line, I think that's a difficult question to answer.And again, it will be different based on who you have in front of you and what their underlying risk of developing postural hypotension is at baseline.Speaker A00:12:07.320 - 00:12:30.480Yeah.And I think this study is really important in highlighting that risk because I think there are some drug classes where you may be, as you say, quite cautious about prescribing because of a risk of postural hypertension. So you may be very cautious with the beta blocker in an elderly patient.But it's important, I think, to highlight these other drug classes as potential culprits because we. You don't want people falling over and.Speaker B00:12:30.800 - 00:13:00.760Absolutely, absolutely. Yeah. And I think traditionally we associate these antihypertensive and cardiovascular drugs as the ones to have the greatest effects.But a lot of studies show that this group of drugs, but also antidepressants and alpha blockers used for urinary symptoms all have very, very high risk of drug induced postural hypotension. So yeah, hopefully it highlights that range of risk.Speaker A00:13:01.720 - 00:13:32.300Yeah.And as you've mentioned, with some of these other drugs, for instance alpha blockers or antihypertensives, often they will be co prescribed, especially in a more elderly population. So it's really great to highlight the risk of additional drug classes as well.But yeah, I think that's been a really interesting discussion with a lot of really key take home messages for practitioners to take back to their work and to their patients. So yeah, I just wanted to say thanks very much for joining me to talk about this.Speaker B00:13:32.540 - 00:13:36.860Great. Thank you so much. Thanks for having me and thank you.Speaker A00:13:36.860 - 00:14:00.550All very much for your time and for listening to this BJGP podcast.Cini's original research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] and Cindy has told me that she will be presenting this work at the Society for Academic Primary Care Conference which is happening in Cardiff this year. Thanks again for listening and bye.

Today, we’re going to do something a bit different and take a look back at the recent BJGP Research Conference, which was held on the 21st of March 2025 in Manchester. I’m going to discuss some of the highlights and really focus on what the conference is about and how to get involved in the future.Here are some of the links I discussed in the podcast:Linkshttps://journals.sagepub.com/doi/full/10.1177/1609406918797475https://bjgplife.com/write-for-bjgp-life/

Today, we’re speaking to Dr Louise Clarke, a GP and researcher based at the University of Nottingham.Title of paper: Barriers to diagnosing and treating vulval lichen sclerosus: a survey studyAvailable at: https://doi.org/10.3399/BJGP.2024.0360Previous research has identified a significant diagnostic delay and misdiagnosis of vulval lichen sclerosus (VLS), a condition most commonly presenting to primary care. Health care professionals (HCPs) in primary care share the concerns of women with VLS citing frequent misdiagnosis, embarrassment and lack of knowledge as barriers to diagnosis. In this survey, 92.6% of HCPs felt further education would be useful with 37.7% never having participated in learning on vulval skin disease, self-directed or otherwise. Key enablers identified to facilitate timely VLS diagnosis and treatment include: a comprehensive education programme for HCPs, implementation of standardised pathways of care and development of a VLS diagnostic criteria to be implemented in primary care workflow.