Fertility

Caveat on this rating: Small correlations, considerable heterogeneity, and a fail-safe number below criterion in every analysis; no link with live birth. The authors call the influence 'somewhat limited'. Boivin 2011 found no link. Read from the abstract only.

Caveat on this rating: Definitions do the heavy lifting here and are stated rather than assumed. 'Pregnancy-related' means causally related to the pregnancy and within one year of its end - a wider window than the 42-day definition used in international comparisons, which is why UK figures for suicide as a direct cause within 42 days (0.80 per 100,000) look nothing like the 6-week-to-1-year figures quoted. The MMRC category bundles suicide with overdose and poisoning related to substance use disorder, so it is not a suicide count. The 2020 US figure covers 38 states, not the nation, and a 2020 coding change moved substance-use-related overdose deaths into this category, which is part of why 22.5% is not comparable with the 11% from 2008-17. A separate CDC report gives 26% for mental health conditions as a CONTRIBUTING circumstance rather than an underlying cause; that figure answers a different question and is not used. None of these numbers say anything about the risk facing any individual reader.

Caveat on this rating: Every study in this row is observational and self-selected, and that cuts against the row's own direction as much as for it. Cohen 2006 recruited at three specialist perinatal psychiatry centres, so its population is women with severe recurrent illness rather than a general one, and its hazard ratio of 5.0 cannot be read as the causal effect of stopping. Grote 2010 measured antenatal depression rather than treatment status, and its effect sizes swing with the measurement instrument and the country. Jarde 2016's own conflict-of-interest subgroup nearly doubles the preterm-birth odds ratio, which is a warning about the literature and is printed here for that reason. No randomised trial of continuation versus discontinuation exists, so 'stopping is riskier' and 'continuing is riskier' rest on the same grade of evidence - which is the point of the stop, and why it closes on a conversation rather than a conclusion.

Caveat on this rating: What this row does not claim: that SSRIs in pregnancy are risk-free. Adjustment is not randomisation, and the propensity-score models can only correct for what was measured in claims data - smoking, alcohol, illness severity and body-mass index are poorly captured in Medicaid records, and residual confounding runs in both directions. The primary-PPHN result still clears one after adjustment. Brown 2017's sibling analysis has wide intervals rather than a null, and its authors wrote that a causal relationship cannot be ruled out. Sujan 2017's surviving preterm-birth association may itself reflect illness severity within a family rather than the drug. Levinson-Castiel is a single centre with 60 exposed infants. The defensible reading is that the large early relative risks shrank substantially under better designs, that the absolute excess risks are small where they persist, and that neither 'proven harmful' nor 'proven safe' is what the evidence supports.

Caveat on this rating: The uncertainty here is real and is printed rather than resolved. Patorno's adjusted risk ratio for cardiac malformations is 1.65 with a lower bound of 1.02, and the right ventricular outflow tract estimate is 2.66 with a lower bound of exactly 1.00 - both only just clear chance, and the lithium numerator for that outcome is suppressed under the Medicaid data-use agreement, so this row makes no claim about how many Ebstein cases the study did or did not observe. Patorno excluded Ebstein anomaly as a named outcome on purpose, because clinicians may be likelier to code a defect as Ebstein in an infant known to have been lithium-exposed. Munk-Olsen 2018's first-trimester malformation result is significant while its any-time and cardiac-specific results are not. Fornaro 2020's meta-analysis and Diav-Citrin 2014 point the same direction with wide intervals. The honest summary is a small absolute increase, dose-related, on a very small base - not the register's 400-fold, and not nothing.

Caveat on this rating: Named limits. EURAP is a prospective registry of women in epilepsy care, not a randomised comparison, and women prescribed valproate differ from women prescribed lamotrigine in ways registries cannot fully adjust away - the strongest single caution on every figure here. NEAD is observational and its age-6 arm retained 224 of 311 children. Christensen's whole-cohort autism estimate (4.42% vs 1.53%) is confounded by indication and the epilepsy-restricted hazard ratio of 1.7 (0.9-3.2) is NOT statistically significant; both are printed so the reader can see the difference the comparison group makes. The North American registry's 9.3% valproate figure is consistent with EURAP but its published abstract carries no confidence interval, so it is not quoted here. What is not in dispute across registries, cohorts and three regulators is the direction, the dose-dependence and the rough size.

Caveat on this rating: What is NOT established: that the narrative PLLR labels are better understood by clinicians in practice. No study shows that, and the Namazy survey points the other way - 68% of respondents did not find the narrative concise, and 95% still used the letters. This row asserts the documented change and the documented reasons the agency gave for it, not that the replacement works. The Namazy survey is also a 12% response rate (184/1500) among allergy/immunology clinicians, not a general prescriber sample. The Addis comparison is from 2000 and concerns three systems, two of which still exist.

Caveat on this rating: Dated: the search closed 31 December 2011 and the review has not been updated, so it predates the trauma-focused work of the last decade. Its conclusion applies to brief generic counselling as trialled up to 2011 and should not be read as evidence against structured psychological treatment for post-loss PTSD, depression, or complicated grief.

Caveat on this rating: These are screening-instrument prevalences drawn largely from cross-sectional studies with substantial heterogeneity, so they measure symptom burden rather than diagnosed disorder, and the pooled percentages are sensitive to which scales and cut-offs the contributing studies used.

Caveat on this rating: The control groups were not uniform — they mixed live births, difficult live births, and non-pregnant community samples — and "perinatal loss" spans early miscarriage through stillbirth, so the pooled risk ratios blur real differences between very different experiences.

Caveat on this rating: Only psychiatric conditions severe enough to require hospitalisation were captured, so ordinary depression and anxiety treated in primary care are invisible here — the absolute risks are small and the affective-disorder result should not be read as evidence that unsuccessful treatment protects against depression.

Caveat on this rating: The pregnancy-rate result is the weak half of this paper: the pooled studies were heterogeneous, not all randomised, and the finding directly contradicts the larger and better-controlled Boivin 2011 BMJ meta-analysis showing distress does not affect cycle outcome. Read this study as evidence that psychological support reduces distress, not as evidence that it makes you pregnant.

Caveat on this rating: Attrition was substantial and grew over follow-up: 67% of the loss cohort completed the one-month questionnaire, 58% at three months, and 46% at nine months, so the later percentages rest on a shrinking and possibly non-representative subgroup. These are validated screening thresholds, not clinical diagnoses.

Caveat on this rating: Partner response rates were low and fell over time (60%, 48%, and 39% at 1, 3, and 9 months), and all partners in the study were male, so nothing here speaks to same-sex-partner or non-birthing-mother grief. Men may also under-report distress on these instruments, which would bias the gap wider than it truly is.

Caveat on this rating: The authors themselves report evidence of moderate publication bias (contour-enhanced funnel plot, significant Egger's test, and a significant subgroup analysis on timing of the pregnancy test). Separately, the first author disclosed speaker fees from EMD Serono and Merck and a research grant from Merck Serono in the three years before publication, though the paper itself received no organisational support.

Caveat on this rating: These are screening-questionnaire symptom rates, not diagnosed major depressive disorder, and heterogeneity between the pooled studies was high. The published confidence interval for the HADS estimate (21.01%, 95% CI 15.61-34.42) is asymmetric around the point estimate as printed in the paper.