Participants with a history of depression before WAFACS randomization (n=1,111) were excluded from this analysis, leaving 4,331 women (Fig. 1 ). History of depression at baseline was determined by: 1) self-report of ever having physician-diagnosed depression; 2) self-reported use of select antidepressants (described further below), along with an appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) depressive disorder code (i.e., 296.2x, 296.3x, 300.4, 309.0, 309.1, 309.28, 311), as entered by trained data coders. Women who had ICD-9-CM codes for bipolar disorder or nonaffective psychosis were also excluded. ICD-9-CM codes could be generated because participants specified physician diagnoses for which they were prescribed medications; participants did so by either writing down the diagnosis or verbally relaying this information to trained research staff over the phone.
The above exclusion process provided reassurance for assembling a baseline sample that was at risk for true incident depression. Regarding the requirement that antidepressant use be accompanied by a relevant ICD-9-CM code, this procedure was driven by clear evidence in our data of varying susceptibility to misclassification by class/type of antidepressant. For example, among all participants reporting use of selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs, excluding low-dose [5 mg daily] selegiline), tri- or tetracyclics widely-known for mood indications (e.g., nortriptyline, desipramine, imipramine, maprotiline) or newer/atypical antidepressants (e.g., bupropion, nefazodone), over 70% had a depression code and nearly 80% had a mood, anxiety or other mental health-related code. By contrast, only ~25% of participants reporting use of certain tricyclic antidepressants (TCAs) (e.g., sinequan, amytriptyline) or trazodone had any mental health-related code – depression or otherwise; these women were frequently prescribed for sleep or pain conditions. Thus, our data suggested that antidepressant use alone could not function as a reliable proxy of depression and likely reflected the shift away from TCAs in favor of newer agents during the post-1990s period of the WAFACS trial(17 (link)).
The above exclusion process provided reassurance for assembling a baseline sample that was at risk for true incident depression. Regarding the requirement that antidepressant use be accompanied by a relevant ICD-9-CM code, this procedure was driven by clear evidence in our data of varying susceptibility to misclassification by class/type of antidepressant. For example, among all participants reporting use of selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs, excluding low-dose [5 mg daily] selegiline), tri- or tetracyclics widely-known for mood indications (e.g., nortriptyline, desipramine, imipramine, maprotiline) or newer/atypical antidepressants (e.g., bupropion, nefazodone), over 70% had a depression code and nearly 80% had a mood, anxiety or other mental health-related code. By contrast, only ~25% of participants reporting use of certain tricyclic antidepressants (TCAs) (e.g., sinequan, amytriptyline) or trazodone had any mental health-related code – depression or otherwise; these women were frequently prescribed for sleep or pain conditions. Thus, our data suggested that antidepressant use alone could not function as a reliable proxy of depression and likely reflected the shift away from TCAs in favor of newer agents during the post-1990s period of the WAFACS trial(17 (link)).