Are antidepressants safe to take during pregnancy?

Approximately 1 in 10 pregnant people experience depression, according to the American College of Obstetricians and Gynecologists (ACOG). And that number only counts those who seek treatment.

Research indicates that 7.4 percent of people experience depression in the first trimester and 12 to 12.8 percent experience it in their second and third trimester. Those rates climb even higher in the first year after delivery.

Hormonal changes during pregnancy can affect the brain, leading to symptoms of depression and anxiety, while lack of quality sleep can also be a contributing factor. Many pregnant people try therapy or mindfulness techniques like meditation and yoga to help ease depression symptoms. Medications are also available.

But because pregnancy is a delicate time for both pregnant person and a developing fetus, many may be concerned about the effect that antidepressants may have on their babies.

Although experts recommend avoiding certain types of antidepressants, many medications for depression are considered low risk for pregnant people when compared to the alternative of not adequately treating depression. In other words, depending on the circumstances of one’s condition—including severity, duration, and history of depression—the dangers of untreated depression may outweigh the potential risks posed by the drugs.

Amy Motamed, DO, a psychiatrist at Medical City Green Oaks Hospital in Dallas, Texas, has treated many pregnant people with severe depression. Her opinion is that the first priority should be to treat their mental illness—for their own sake and for that of their babies.

Getting an accurate diagnosis

The first step to treating depression is to get a sound diagnosis, but it can be challenging for patients to understand the overlapping symptoms of pregnancy and depression.

“A lot of symptoms of depression—like low appetite, fatigue, change in sleep habits—can also be consistent with a normal pregnancy, particularly in the first trimester,” Dr. Motamed says.

In order to diagnose depression, Motamed makes a point of getting to know her patients and speaking to family members and others involved with the pregnancy. She’ll ask her pregnant patients a series of questions to try to tease out the specific issues, including:

• Have you been pregnant before?
• Was there a time when you weren't depressed?
• How does this feeling compare to how you felt during a previous pregnancy?

Understanding the need for treatment

Before reviewing a patient’s treatment options, Motamed says it’s critical to help a patient understand the risks of not treating depression. For example, many pregnant people with untreated depression don’t receive adequate prenatal care—they don't eat well and may not get enough sleep.

Pregnant people with untreated depression may also be more likely to smoke, drink, or use drugs. “They’re often self-medicating,” Motamed notes. For reasons such as these, depression during pregnancy has been linked to premature birth, low birth weight, and complications after birth. Pregnant women with untreated depression may also be at increased risk of suicide.

What treatments are recommended

Treatment for pregnant people will depend on numerous factors including the severity of the depression, the strength of a patient’s support network, and their comfort level with different kinds of therapies.

For mild to moderate depression, especially for first-time episodes, the first line treatment in an outpatient setting is typically psychotherapy, Motamed says. “That usually means either cognitive behavioral therapy or interpersonal therapy.”

There are also situations where antidepressants are recommended for patients with mild to moderate depression. These include cases where talk therapy hasn’t helped or is unavailable to patients, when patients have a previous history of severe depression or have had multiple past relapses of depression, or when patients prefer antidepressants because they’ve helped them in the past.

Research into risks is not definitive

Because antidepressant medication crosses the placenta and circulates in the amniotic fluid, Motamed says, the substance can potentially have effects on the developing fetus. This can cause worry.

It’s difficult, though, to pin down exact an link between antidepressants and fetal issues because pregnant people are often excluded from clinical trials.

“The gold standard to assess whether or not a medication has side effects is a randomized control trial,” Motamed says. “But you can't do those trials in pregnant women because it's not considered ethical.”

As a result, she explains, the data available on antidepressants and pregnant women is typically based on reports that patients provide to researchers after pregnancy. What’s more, those studies that have been done can yield only associations—not cause-and-effect relationships—between the use of antidepressants and fetal issues.

When studies look backwards on self-reported habits, rather than isolating specific medications, other health factors—such as a person’s diet or their use of alcohol, tobacco, and other prescription medications—may influence the results. Some studies may also compare pregnant people with mental illness who took antidepressants with otherwise healthy pregnant people, which can muddy a clear comparison between pregnant people with depression who took antidepressants and those who did not.

Some antidepressants present concerns

For certain antidepressants, some of the concerns raised by research have persisted across multiple studies and may be worth taking into account when you consult with your healthcare provider (HCP) about treatment for depression.

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants for pregnant people, just as they are in the population at large. But one SSRI in particular, paroxetine, poses some concerns for pregnant people.

A 2015 analysis by the Centers for Disease Control and Prevention that looked at previous studies described associations between paroxetine and defects of the brain, skull, heart and abdomen. Twenty-nine studies including 9 million births concluded that use of SSRIs was associated with a small but increased risk of overall major birth defects, including heart defects.

Although the data linking first trimester use of paroxetine with heart defects are not generally deemed strong, the link was significant enough to lead the U.S. Food and Drug Administration to require a warning that pregnant people taking paroxetine should be advised of potential harm to the fetus.

Most HCPs prefer not to prescribe paroxetine to pregnant people. But in some cases, the benefits of effectively treating depression may outweigh potential risks to the baby.

“We try to avoid paroxetine if we can,” says Motamed. “But if a patient tells me she’s taken three other medications and the only time they've had any response was to paroxetine, it may make more sense to stay on it.” The key, she says, is to give the patient full access to the information available and help them make the best decision for their situation.

“If you have a patient who's moderately depressed and they've had a previous severe depressive episode or psychotic symptoms,” Motamed says, “I would be hesitant to advocate for changing their medication, even if that drug is paroxetine.”

If a patient is already taking paroxetine and switches to another medication, the fetus has now been exposed to two drugs. “And if that patient doesn’t respond to the new drug,” Motamed explains, “they may end up needing to go back to paroxetine anyway.”

Other classes of antidepressants—such as tricyclic antidepressants (TCAs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs)—are less commonly used in pregnant people than are SSRIs, but they still may be prescribed if your HCP determines that the benefits of treating your depression outweigh any risks potentially posed by those drugs.

“No two people are the same,” says Motamed. “If you're severely depressed, if you've had multiple episodes of depression, I would advocate for therapy and medication as needed.”