Antidepressants During Pregnancy: What to Know
Are depression and anxiety meds safe for pregnant women? Here’s why we need a lot more data to answer that question.
Out of the tens of millions of people with depression in America, there’s a subset of new and expecting moms that experience a unique form of the chronic mental health condition called perinatal depression. We often hear about mental health symptoms postpartum (in the months after you have your baby), but it’s almost just as common to struggle with symptoms during your pregnancy, too.
“As many as a quarter of pregnant women may have mental health or substance use disorders, and an estimated one in 10 may be on psychotropic drugs,” explains Meera Viswanathan, Ph.D., director of the RTI-UNC Evidence-based Practice Center at RTI International, a nonprofit research institute in Chapel Hill, NC. These drugs include antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers, all of which are lifesaving medications for people who need them.
But unfortunately, medications like these are not well-studied during pregnancy, which poses a challenge for pregnant women and their doctors trying to navigate mental health care. Viswanathan’s new report in Psychiatric Research & Clinical Practice illustrates this: She and her colleagues found that more studies have examined the harms of antidepressant medications during pregnancy than have explored the potential benefits of these drugs.
“Despite the relatively common occurrence of mental health disorders in pregnancy, the evidence and guidance has been inconsistent or unclear,” Viswanathan says. This is largely due to the ethical challenges of studying medication during pregnancy. It has left a huge gap in scientific research, leaving women to make these decisions largely on their own.
Pregnancy & Medication Use: Why It’s So Hard to Study
Clinical trials are the standard way to test the safety and efficacy of new drugs, and they’re used for everything from new birth control methods to vaccines. Case in point: the COVID vaccines went through months of clinical trials before becoming available to the general population. In the scheme of things, this was a short trial period—many drugs are in trials for years before hitting the market.
But pregnant women are a particularly tricky population to study. “Studying the effect of medications on a pregnancy has always been difficult because pregnant and lactating women are almost always excluded from medication trials due to ethical concerns,” says Noelia Zork, M.D., assistant clinical professor of medicine at Columbia University Vagelos College of Physicians and Surgeons in New York City. There is more at stake when balancing potential risk to the mother and the fetus, and oftentimes it’s easier for researchers not to take that gamble.
Unfortunately, that leaves women and their doctors to make the call on a case-by-case basis, with little to no data to help guide them. “For most medications, we find out if they are safe or not after pregnant women have started to use them in regular life,” Dr. Zork says. Studies are done retroactively, using pharmacy records or patient recollection to assess whether the medication was safe throughout pregnancy and delivery.
It’s a controversial system—one 2019 review in Philosophy, Ethics, and Humanities in Medicine called for better inclusion of consenting pregnant women in clinical trials, arguing that the potential benefits of greater knowledge outweigh the risks. Prominent organizations such as the American College of Obstetricians and Gynecologists (ACOG) have also advocated for thoughtful inclusion of pregnant women in medical research. ACOG’s opinion paper contended that the exclusion of pregnant women also puts the health of women and their fetuses at risk, and that there really is no zero-risk scenario. “It's a very imperfect system, but it's the best we have right now,” Dr. Zork explains.
What We Do Know About Safety
These decisions can be challenging for OB/GYNs and stressful for their pregnant patients. “Some providers are nervous to use these medications in pregnancy because there aren’t specific studies done with pregnant patients,” says Jennifer Meyers, certified nurse midwife with the Mayo Clinic Health System in La Crosse, WI. “It is very important that obstetric providers be up-to-date [on] current information regarding safety, because effective treatment of mental health concerns during pregnancy is incredibly important.”
While the research remains limited, there are some generally agreed upon recommendations for medication use during pregnancy:
Untreated mental health conditions can increase pregnancy complications. Going off your mental health medications during pregnancy is not necessarily a good idea. “We are learning more and more that untreated psychiatric illnesses like depression, anxiety, bipolar disorder, or schizophrenia increase the chances of complications in pregnancy, like a very small baby or preterm birth, and have long-term developmental implications for the child,” Dr. Zork says. “Some women will overall have a better pregnancy with a healthier baby by staying on their psychiatric medications rather than coming off them.” In fact, she says, she worries more about her patients who quit their medications cold turkey than the ones who stay on them under the guidance of a doctor.
SSRIs and other mental health medications can be (and often are) prescribed during pregnancy. “There are a number of mental health medications that appear to be safe in pregnancy,” Meyers says. “These include most SSRI medications such as Zoloft (sertraline) and Prozac (fluoxetine), SNRI medications [like] Effexor (venlafaxine) and Cymbalta (duloxetine), and a few others such as Buspar (buspirone).”
Viswanathan and her research team found the strongest evidence for positive benefit from three medications: sertraline and Zulresso (brexanolone) for pregnant women with depression, and mood stabilizers for pregnant women with bipolar disorder. While they also found studies that suggested the potential for harm, “the results were not consistent,” she explains, “and we could not clearly establish whether it was the drug or the underlying condition that caused the outcome.” This once again suggests that mental health conditions can pose a risk to the fetus—a risk potentially greater than that posed by taking medication.
A medication being “safe” does not mean it comes with zero risk. We’ve said it before, but it is worth stating again: There is no zero-risk scenario here. Meyers explains that while these mental health medications do come with risks—the biggest being the risk of withdrawal symptoms in the newborn—she always explains this to her pregnant patients in context with the risk of discontinuing their medication.
“The term ‘safe’ doesn’t necessarily mean without any risk but means that these medications can be used when needed, even if a patient is pregnant,” she says. “Just like any category of medication, knowledge is gained over the years as we receive more evidence on safety.” The longer a medication is on the market and the more intensively it is studied, the more we learn about how it works in different populations.
Every woman, every medication, and every pregnancy is different. It is impossible to provide cut-and-dry guidance for a situation this complex. “I can't stress enough how important it is to talk to a trusted medical provider about this,” Dr. Zork urges. “A lot of the information on the internet can make medications sound a lot more dangerous than they really are, so this is a discussion that needs to happen with a medical professional.”
In some instances—when mental health symptoms are mild, and the mother has been feeling stable for years—it may make sense to wean off the medication. In other cases, it’s best to remain on your prescription to protect your mental health. This depends on many external factors in your life and can’t be decided through a simple internet search. (If only life were that simple!)
Proactivity is always a smart idea. It is worth starting this conversation with your doctor if you’re even considering getting pregnant in the next few years. “It's always a good idea to talk about the safety of your medications and your body's overall preparedness for pregnancy with your doctor even if you aren't planning on becoming pregnant any time soon,” Dr. Zork says. This can help you feel more prepared when the time comes to think through that decision.
In the meantime, we can all hope for future research that puts pregnant women at the forefront in a responsible way. “I hope this study is a wake-up call to conduct better studies in pregnant women,” Viswanathan says of her recent research. “When you take a step back and think about how common it is for pregnant women to have mental health conditions that may require medications, it’s shocking how poor the evidence is.”
After all, the health of the mother and fetus are inherently linked, and helping women have safer pregnancies is always a goal worth striving for. Meyers says it best: “Unfortunately, sometimes there becomes a struggle with balancing the needs of the fetus with the needs of the mother. What we need to realize, however, is that these two things are not mutually exclusive.” A woman’s mental health is critical to her ability to provide for herself and her child, and it should be a top priority before, during, and after her pregnancy.
Depression Statistics: National Institute of Mental Health. (n.d.) “Major Depression.” https://www.nimh.nih.gov/health/statistics/major-depression
Perinatal Depression: National Institute of Mental Health. (n.d.) “Perinatal Depression.” https://www.nimh.nih.gov/health/publications/perinatal-depression/
Research Review on Mental Health Medications During Pregnancy: Psychiatric Research & Clinical Practice. (2021.) “Maternal, Fetal, and Child Outcomes of Mental Health Treatments in Women: A Meta‐Analysis of Pharmacotherapy.” https://prcp.psychiatryonline.org/doi/10.1176/appi.prcp.20210001
Ethics of Clinical Trials During Pregnancy: Philosophy, Ethics, and Humanities in Medicine. (2019.) “The moral imperative to approve pregnant women’s participation in randomized clinical trials for pregnancy and newborn complications.” https://peh-med.biomedcentral.com/articles/10.1186/s13010-019-0081-8
ACOG Committee Opinion: American College of Obstetricians and Gynecologists. (2015.) “Ethical Considerations for Including Women as Research Participants.” https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/11/ethical-considerations-for-including-women-as-research-participants