Antidepressant Medications in Pregnancy and the Postpartum: How to Weigh the Risks and
Benefits
Lindsay Lebin, MD
For many, antidepressant medication can be an essential part of maintaining mental health and
emotional well-being. However, the moment you become pregnant, more complex feelings and
questions about antidepressants may come up.
You may wonder:
Is this medication safe for my pregnancy?
Could this medication cause harm to the baby?
Is it safe to breastfeed on this medication?
Should I stop my medication?
It is very important to avoid abruptly stopping your medication and to first discuss these
questions with a mental health provider or your prenatal care provider. Discontinuing a
medication without medical supervision can potentially cause bothersome withdrawal
symptoms and may lead to return of depression and/or anxiety.
When weighing the decision over whether to start or continue antidepressant medication in
pregnancy/postpartum, there are a few factors to consider:
How severe are your current mood/anxiety symptoms? Antidepressants can be
especially helpful for moderate to severe symptoms.
Have you benefitted significantly from taking medication? For those who have had an
excellent response to medication, it may make sense to continue it in pregnancy.
If you’ve ever stopped medication before, did your symptoms noticeably worsen? If
you’ve had a symptom relapse off medication previously, it may make sense to continue
it in pregnancy.
Are you able to access other treatment, such as psychotherapy? Many are not able to
access psychotherapy due to resource limitations or insurance challenges, so medication
may be the only accessible form of treatment.
Are you symptoms worsening or causing problems in your ability to function at work,
home, or in your relationships? You may consider taking medication if your symptoms
are causing functional impairment and a decline in your quality of life.
Though patients tend to focus primarily on the risks of medication in pregnancy or during
breastfeeding, it is important to recognize that untreated mood and anxiety disorders in
pregnancy and postpartum can have significant risks as well. Untreated perinatal mood and
anxiety disorders leads to changes in the body’s stress hormones, which increases risk of
pregnancy complications such as preterm delivery, gestational hypertension, preeclampsia, and
postpartum hemorrhage (Jahan, Went, et al 2021). The heightened stress hormones can also
decrease placental blood flow and lead to decreased growth and weight gain for the baby
during the pregnancy. If symptoms remain untreated in the postpartum, this may impact your ability to bond with or take care of the baby. This can lead to risks for the child as they grow up. Studies show that untreated postpartum depression or anxiety increases a child’s risk of cognitive and motor delays as well as emotional/behavioral problems (Deave et al 2008).
In considering risks of medication, selective serotonin reuptake inhibitors (SSRI) antidepressants
are the most commonly prescribed and well-studied psychiatric medications in pregnancy.
There have been some studies showing harmful effects from SSRIs, but these studies did not
account for the impact of underlying depression or anxiety in pregnancy. Typically, these
studies compared a group of women with depression taking SSRIs to a group of healthy women
without depression not taking SSRIs. This is not a fair comparison and does not allow us to draw
conclusions about whether the harmful effects are due to the underlying mental illness or the
medication. When looking at well-designed studies that accounted for the impact of depression or anxiety, SSRIs have been shown to be generally safe to use in pregnancy with either no increased risk of adverse effects or small increased risk compared to untreated mental illness.
Based on evidence from high quality studies, we can conclude that SSRIs don’t increase risk of
birth defects with exposure in the first trimester (Huybrechts et al 2014). They also don’t
increase risk of miscarriage (Ross et al 2013). SSRIs may increase risk of preterm labor, though the risk is low and similar to the risk associated with untreated depression or anxiety. The most common adverse effect of SSRI exposure is neonatal adaptation syndrome (NAS), which occurs in 20-30% of infants exposed to SSRIs in utero (Levinson-Castiel et al 2006). NAS occurs shortly after birth, typically lasting hours to days. Common symptoms include fussiness, jitteriness, difficulty feeding, or difficulty sleeping. Most cases of NAS are mild and resolve without
treatment. Finally, SSRI exposure during pregnancy does not increase a child’s risk of autism,
developmental delay, or other neurodevelopmental disorders (Ames et al 2021).
Many mothers and parents may decide to start a medication in the postpartum while
breastfeeding. The good news is that nearly all antidepressants are compatible with breastfeeding. The American Academy of Pediatrics recommends that no more than 10% of
mom’s medication dose transmit into breastmilk in order to reduce risks to the infant. All SSRIs
are either at or below that 10% threshold, with sertraline having the lowest transmission into
breastmilk.
When weighing the risks of medication exposure in pregnancy and during breastfeeding, it may
make sense for you to start or continue antidepressant medication. This is an individualized
decision, so should be discussed in detail with your provider. Though stigma around taking
medication in pregnancy still exists, it is important to recognize that antidepressant use in
pregnancy is generally considered to be safe and low risk, especially when compared with the risks of untreated perinatal mood or anxiety disorders.
For more information on medication safety during pregnancy or postpartum, please see the
following resources for more information:
MGH Center for Women’s Mental Health
MotherToBaby
