Title: Prenatal opioid use as a predictor of postpartum suicide attempts among reproductive-age
women enrolled in Oregon Medicaid
Version: 2 Date: 21 Dec 2023
Reviewer's report:
This article addresses a very high priority area in need of much urgent investigation. I appreciate
the authors addressing this topic!
Given the importance, findings from this article would enhance the existing literature on mental
health in the postpartum period. However, revisions in how the methods and findings are framed
are necessary before publication in order to ensure that its findings are applicable to real life –
from a public health and clinical perspective, especially.
The most important point under this umbrella is the handling of “prenatal” vs. “postpartum”
OUD. OUD is a chronic disease, that does not just pop up during pregnancy nor go away
postpartum. Especially when utilizing administrative databases, what determines if a person
has ‘prenatal’ vs ‘postpartum’ OUD is mainly determined by if they accessed healthcare and
generated a Medicaid claim related to OUD in that specific time period of the lifecourse. Thus,
the focus of mediation of prenatal OUD by postpartum OUD on the outcome of suicide just
does not make clinical sense. I would recommend the authors reframe their findings, and/or
their methods, to better address the research question of interest within a clinical context. To tell
you the truth, “simply” focusing on association of OUD (captured prenatally by Medicaid +/-
during the year postpartum) with suicide in the year postpartum is the big take home finding,
and is more than adequate to justify adding to the scientific literature. So I would recommend
the authors first reframe this concept – perhaps not including the mediation analysis or changing
the exposure OUD variable to encompass ‘prenatal’ +/- ‘postpartum OUD’.
On a side note, if the authors really want to still include a mediation analysis, perhaps consider
one that actually could be an intervention target, like receipt of MOUD prenatally/postpartum –
does that moderate or mediate the risk of postpartum suicide among people with OUD?
Additionally, and related, I think that having multiple outcomes distracts from the main finding
focused on above. The authors have a lovely discussion of the significance of their main prenatal
OUD -> postpartum suicide risk in their discussion, and I don’t think that having MDD, SUD,
postpartum OUD as OUTCOMES adds much to the paper (and if anything, can distract the
reader and call into question the power of the study to do all these analyses when the N for
the suicide outcome is quantitatively small). Thus, I would ask the authors either to move all
those models with non-suicide postpartum outcomes to supplemental material (eg the figures,
tables, methods, etc) or provide a better justification (and address the sample size with multiple
comparisons) for these analyses.
Very important terminology point for the entire manuscript: Please focus on OUD and not
“opioid use”. OUD and opioid use are two very distinct clinical presentations. This study focuses
on OUD, and not receipt of prescription opioids, for example. So please replace the terminology
‘opioid use’ throughout the manuscript with OUD.
Other comments
Intro: “…quantify the impact of perinaal opioid use on maternal suicidality”: first, see OUD
vs opioid use comment above. Second, I would not say ‘impact’ as this study is really taking
the first, very important step, to identify the overlaps bw OUD and postpartum suicide, not
necessarily testing like in a trial or intervention observational trial the ‘impact’ of OUD on an
outcome.
Methods: The methods are pretty hard to follow right now. I would recommend clearly stating
what the primary exposure and outcome variables are, following the same order as the aims
stated clearly at the end of the intro.
Results: please address the ‘prenatal’ vs ‘postpartum’ ‘OUD diagnoses’ within the chronic
disease context as mentioned above. Really, what I want to know – how many people have OUD
in your sample (first)? Then second how many of those OUD dx were first identified prenatally
vs 1 year postpartum?
Discussion: First paragraph “…elevated risk of OUD…” compared to whom/what? The last 2
sentences of the paragraph on page 2 should be deleted, as stating them within a full context
can exacerbate stigma of OUD during pregnancy (“It is also worthwhile to note….” To “…
congenital heart disease”).