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What to Know About Antidepressants and Pregnancy

My prenatal depression shouldn’t have come as a surprise. I’d been diagnosed with depression at age 19 and spent the next 10 years in a cycle of trial and error: different medications, different therapies, different doctors.

By the time I was 32, I was accustomed to life with a mental illness. But I was still unprepared for the swift, severe low I hit early in my pregnancy with my second child. Only two weeks after crying happy tears over a positive pregnancy test, I was weeping silently under my duvet, unable to eat, sleep or talk about how I was feeling. The truth was, I couldn’t put it into words. I was numb and overwhelmed by sadness, during what should have been one of the happiest times of my life.  

At the doctor, blood pressure and prenatal vitamins weren’t the only items up for discussion. I’d weaned myself off antidepressants under medical supervision a few months before getting pregnant. As far as my doctor was concerned, the risks of staying off meds outweighed any risks of resuming them, given my history of severe depression.

I grappled with the pros and cons: Should I take medication that could harm my unborn child, or go against my doctor’s advice and risk harming everything else? Ultimately, it was my decision to make. And I made it — while sleep-deprived, unfocused and barely able to string together a sentence. Here’s what to know if you face the same decision.

What are the risks of taking meds during pregnancy?

If you take headlines at face value, antidepressant use during pregnancy can put an unborn child’s health at risk in numerous, terrifying ways, starting at birth and lasting into childhood.

Reported birth defects include cleft lip, spina bifida and heart defects. Reported withdrawal symptoms from medication include irritability, muscle spasms, poor muscle tone, fast heartbeat, restlessness, sleeplessness, breathing difficulties, fever, fits, low blood sugar, jitteriness, an inability to cry loudly and high blood pressure in the lungs.

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The Ongoing Quest to Figure Out SAD

Elisabeth Netherton, a psychiatrist and neurologist at The Menninger Clinic in Houston who specializes in the psychiatric treatment of women and men before, during and after childbirth, says the most common adverse effect on infant health attributable to antidepressants taken during pregnancy is neonatal adaptation syndrome. It’s a temporary and typically mild issue characterized by restlessness, elevated or decreased muscle tone, and feeding and sleep disturbances.

“Babies with this condition usually exhibit symptoms within the first 72 hours after delivery,” said Brett Galley, a neonatologist with Advocate Children’s Hospital in Oak Lawn, Illinois. “Since symptoms may be mild and nonspecific, and the condition is not always well recognized by medical staff, it is possible that babies with this condition are simply mislabeled as ‘fussy.’”

“Antidepressants are not the only tool in our toolbox, but they are frequently a necessary one.”  

If a baby is diagnosed with neonatal adaptation syndrome, the mother should follow the advice of the physician who’s caring for the infant. “The basis of treatment is primarily supportive and includes providing a quiet, soothing environment that promotes normal bonding and adequate nutrition,” Galley said. “Breastfeeding is generally encouraged, but should be discussed with the infant’s physician.”

Autism and ADHD have also been linked to maternal antidepressant use during pregnancy, but studies on the issue offer inconsistent findings: A 2017 study published in JAMA found no heightened chance of developing either condition, while another 2017 study, published in the British Medical Journal, found a slightly elevated risk of autism among children exposed to antidepressants during pregnancy. However, researchers noted the small absolute risk of autism and cautioned that their results “should not be considered alarming.”  

Across the board, research into the effects of antidepressants on unborn babies is contradictory or inconclusive more often than not. In recent years, doctors have paid much closer attention to the importance of the mother’s mental health and how it contributes to positive health outcomes for the baby. No healthcare provider wants a woman to take unnecessary medication during her pregnancy, but it’s crucial to weigh the risks of enduring pregnancy without antidepressants.

“We have to consider that the biggest risk to moms and their babies may not be the risk of medication, but the risk that a mom remains significantly depressed or struggles with other debilitating symptoms during pregnancy and the postpartum period,” said Netherton.

What are the risks of depression during pregnancy?

During pregnancy, depression can lead to neglected personal care, potentially manifesting in unhealthy eating, lack of exercise, failure to comply with medication, alcohol and drug use, and disregard for supportive relationships. Other major concerns include loss of appetite (depriving the baby of adequate nutrition, if the mother is breastfeeding), lack of sleep (associated with an increase in symptoms of depression and anxiety) and an increased risk of suicide. According to a 2017 study in the Canadian Medical Association Journal, suicide is statistically just as likely to cause death during pregnancy, and the first year postpartum, as a hemorrhage or high blood pressure.

“Depression affects not only the health of the baby’s intrauterine environment, but influences outcomes for the baby for years to come,” Netherton said, “including through infant and childhood development and formation of attachment with the mom.”

There’s evidence that depression during pregnancy can stunt children’s communication and social skills. This becomes possible if depression interferes with a mother’s ability to respond appropriately to her child in terms of physical attention, gestures or speech; connections in the child’s brain don’t form normally as a result.

Netherton also noted that maternal depression is closely associated with, and potentially contributes to, the father becoming depressed during the postpartum period. “This also negatively impacts the baby,” she said. “While there is much less in the literature about this dynamic in gay and lesbian couples, it is reasonable to suspect that the same might hold true.”

How do doctors decide when to medicate?

“In deciding how to treat the mom, we consider a number of factors, including the burden of symptoms that she has, how she is functioning and what her mental health history looks like,” Netherton said. “Antidepressants are not the only tool in our toolbox, but they are frequently a necessary one.”

In Netherton’s opinion, therapy is an important but frequently overlooked tool for treating perinatal depression and anxiety disorders. (The perinatal period refers to the weeks immediately before and after giving birth.)

“We know that for depression and anxiety, regardless of pregnancy status, people do well with therapy, they do well with medications and they do best when they have both,” Netherton said. “A psychiatrist would take into account symptom severity and history when recommending whether a trial of therapy prior to starting medication would be appropriate. It’s also crucial to marshal support around mom and ensure that she is getting enough sleep.”

“There are several types of therapy that treat depression, and a woman will need to decide which type feels best for her,” said Gail M. Saltz, a psychiatrist and associate professor at New York Presbyterian/Weill Cornell Medical Center. If a woman decides she doesn’t want to take antidepressants during pregnancy, other options include psychodynamic psychotherapy and cognitive behavioral therapy.

“Psychodynamic psychotherapy looks at unconscious conflicts in the mind and makes them conscious. Resolving conflict decreases depression,” Saltz said. “Cognitive behavioral therapy and its various offshoots look at the negative thoughts a person has and how they drive behaviors. By raising awareness of and replacing automatic negative thoughts, depression may be resolved. In addition, exercise helps reduce symptoms of depression.”

Depression isn’t a “one size fits all” scenario, so the severity of the condition needs to be assessed by the doctor, who might be the mother’s obstetrician, psychiatrist or both. For mild to moderate depression, Saltz recommends using therapy alone and not medication. However, for moderate to severe depression, medication may be prescribed to prevent serious effects on both the mother and the baby: “A doctor must weigh the severity of the depression with the possibility of any impact on a growing fetus.”

“One of the hard things about antidepressants is that we sometimes don’t have a sense of how much they’re helping until we discontinue them and symptoms return.”

Netherton also noted the importance of evaluating medication dosage for women who decide to start or resume antidepressants during pregnancy. “Antidepressants used to treat depression and anxiety frequently take four to six weeks to take effect, and need to be started at a low dose, then slowly increased to a therapeutic dose.” Given the time it takes for medication to kick in, she doesn’t recommend waiting to treat a clinically depressed or anxious mom until a specific point during pregnancy.

“Our goal is that the baby is exposed to as few potentially adverse factors as possible,” Netherton said. “We consider depression and anxiety to be an ‘exposure’ to the baby, just as we consider any medication mom may take during pregnancy to be an exposure.”

If a woman stops taking antidepressants during pregnancy and her depression relapses, Netherton explained, that leaves the baby exposed to risks associated with both medication and depression. “If we restart medications at that point,” she said, “there can be a significant lag time before we can get medications back to a therapeutic dose and they can start to take effect.”

If a woman decides to begin antidepressants during pregnancy and then later second-guesses that decision, her doctor may advise her to continue the course of treatment anyway, depending on her medical history and symptoms.

“One of the hard things about antidepressants is that we sometimes don’t have a sense of how much they’re helping until we discontinue them and symptoms return,” Netherton said. “There is significant data that women who have had recurrent depressive episodes and women who have bipolar disorder have a high rate of relapse during pregnancy, so we want to bear that in mind when making recommendations about stopping medication.”

If a pregnant woman still feels strongly about discontinuing medication after discussing the risks and benefits, Netherton recommends tapering off slowly and under the guidance of her physician.

For women who are already taking antidepressants when they become pregnant, then decide to stay on them during pregnancy, doctors will take into account medical history and symptom severity before advising them to maintain, reduce or increase their dosage.

Which antidepressants are recommended for pregnant women?

When it comes to which type of antidepressants to take during pregnancy, some are considered safer than others, although Netherton says the available data is imperfect at best. “If a drug company is developing a new medication for hypertension, they test the drug for safety and efficacy on people who have hypertension,” she said. “The same is not true for pregnancy — we don’t conduct double-blind randomized controlled trials of medications in pregnant women, as this would have serious ethical implications, so this ‘gold-standard’ level of evidence is not available to us.”

A recent, widely reported study found the effects of antidepressants to be modest at best. But Saltz points out that even a modest improvement, in the case of severe depression, can make a big difference.

According to Saltz, the safer antidepressant medications mostly belong to the selective serotonin reuptake inhibitors (SSRI) family, including Zoloft (sertraline), Prozac (fluoxetine) and Celexa (citalopram). However, the SSRI Paxil (paroxetine) is not recommended for use by pregnant women. A class of antidepressants known as monoamine oxidase inhibitors (MAOIs) are not considered safe for pregnancy. “No drug is entirely risk-free,” Saltz said. “In each case, risks must be weighed against the specific diagnosis and the risks posed by not taking the medication.”

In some cases, weaning off one type of antidepressant and switching to a safer one, like an SSRI, may be warranted, unless a patient is taking that type of antidepressant because SSRIs haven’t worked for them previously.

While anxiety and depression can be separate issues, they often overlap. The two conditions are sometimes, but not always, managed with the same treatments. “Long-term anxiety often leads to depression,” Saltz said. “Anxiety may respond better to CBT, and therapy is a good first-line treatment. There are other short-term meds that can be used if needed with anxiety, but SSRIs are still likely best. But for panic disorder, a short-acting benzodiazepine may be deemed appropriate.”

It was an SSRI that I began taking six weeks into my pregnancy. Though I grappled with the decision, it was without a doubt the right thing to do for both me and my now 8-year-old daughter. No matter how a woman decides to manage depression during pregnancy, she should make the choice on the basis of sound medical advice and without any feelings of guilt. 

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