Antidepressants during pregnancy

Is it safe to take antidepressants while pregnant?

Around 20% of mothers experience depression during or after pregnancy, with many being prescribed antidepressant drugs to treat their condition ^[1]. Due to this, there has been a great deal of research into the safety of mother and baby during antidepressant use, during and after pregnancy.

Prior research indicated that antidepressant use while pregnant increases the risk of several issues, including premature birth, low birth weight, cardiac defects, growth and development issues, miscarriage, and stillborn, due to the passing of the medication to the fetus through the blood-brain barrier and the placental barrier ^[2][3].

Because of these risks, many who were prescribed an antidepressant choose to discontinue their treatment during pregnancy ^[2]. However, it is now believed that antidepressant medications usually cause very little harm to fetal development and health, and that untreated depression typically poses a greater risk to the health of mother and baby than the use of antidepressants in pregnancy ^[1][4].

Newer studies have found that, when results are adjusted to account for previously unconsidered variables, such as the severity of the mother’s mental health prior to pregnancy, dose, duration, and type of treatment, these risks are significantly lowered or are equal to those found in newborns who were not exposed to antidepressants during pregnancy ^[2][5].

Untreated depression during pregnancy can increase the risk of preeclampsia and eclampsia, postnatal depression, low birth weight, premature birth, impaired mother and baby relationships, and suicide risk in mothers. Furthermore, depression can increase the possibility of cigarette, alcohol, and substance use, thus impacting the health of the fetus ^[1][2][4].

Some antidepressants are considered safer than others, with certain risks still being considered significant barriers to treatment in some cases. For example, persistent pulmonary hypertension, which can cause breathing difficulties in newborns, has been found to occur in some babies exposed to antidepressants during pregnancy at equal or slightly higher rates than those who are not exposed ^[3][4][6].

Similarly, neonatal adaptive syndrome, which can cause irritability, excessive crying, and sleep issues in newborns, is believed to occur due to withdrawal or early exposure to antidepressants. However, the symptoms are generally considered to be mild and can typically be managed safely and with no further consequences to the health of the baby ^[1][5].

Is breastfeeding safe while on antidepressants?

Antidepressants can enter breast milk in varying levels, although these levels are typically considered minimal and harmless to newborns during breastfeeding ^[7].

Similar to antidepressant use during pregnancy, exposure to antidepressants during breastfeeding does carry some risk and should be considered on an individual basis, depending on the mother’s treatment requirements ^[1][3].

Some antidepressants are believed to be excreted in breast milk at higher levels and are therefore not considered as safe for breastfeeding as others. Due to this, it is advised for prospective mothers to begin antidepressant treatment that is considered safe for pregnancy and breastfeeding prior to conception. Then, if appropriate, the medication can be continued throughout, or during pregnancy ^[4].

However, if an antidepressant that is not considered as safe for breastfeeding has been part of a longstanding treatment plan, it may be safer to continue with this prescription during breastfeeding than making changes to treatment. This should be considered on an individualized basis and with proper professional advice ^[3].

It is generally recommended that, if the mother is already prescribed and using an antidepressant prior to childbirth, that she continues to take this medication during breastfeeding and not discontinue or change the medication at this time. Changes to medication can cause problems for the health of both mother and baby ^[4][7].

As breastfeeding is beneficial to newborns, in terms of health, development and maternal relationships, mothers taking antidepressants are typically not advised to avoid breastfeeding because of antidepressant treatment. The benefit of this treatment often outweighs the risk of exposure to antidepressants faced by the newborn ^[7].

Safest antidepressants to take while pregnant

Generally, selective serotonin reuptake inhibitors (SSRIs) are considered the safest antidepressants to take while pregnant or breastfeeding, due to their low risk of side effects and high tolerability. However, some SSRIs are not recommended as first-line treatment for mothers, due to increased risk of birth defects or high breast milk levels ^[1][5].

The safest antidepressant for both pregnancy and breastfeeding is considered to be sertraline. This medication carries little risk of birth defects and is excreted in breast milk in very small amounts ^[5][6][7].

Other SSRIs that may be safe include ^[1][5][6][7]:

• Fluoxetine: Low risk of birth defects but may be excreted in breast milk in high levels.
• Paroxetine: May cause cardiac defects if taken in the first trimester but is excreted in breast milk in low levels.
• Citalopram: Low risk of birth defects but may be excreted in breast milk in high levels with high doses.
• Escitalopram: Believed to cause low risk of birth defects but research is limited.

Tricyclic antidepressants (TCAs) are an older type of antidepressant, with more extensive research into their use during pregnancy. They are generally not tolerated as well as SSRIs and may cause adverse effects, but some are considered safe for use during pregnancy and breastfeeding, such as ^[5][6]:

• Desipramine
• Imipramine
• Nortriptyline

There is limited research about the use of other types of antidepressants, so they are generally not prescribed as a first-line treatment for those who are pregnant or breastfeeding. Although there is currently no evidence to suggest high risks of defects when used during pregnancy or high breast milk levels. This includes ^[5][6]:

• Mirtazapine
• Bupropion

When prescribing antidepressants or considering ongoing treatment for pregnancy or breastfeeding, doctors will consider these risks and likely prescribe the safest antidepressant for treatment. However, treatments will depend on the individual, their past response to medication, the severity of their condition, and any other relevant health information. Medication may not always be appropriate ^[3].

Alternative depression treatment for pregnancy and breastfeeding

If a pregnant or breastfeeding mother is not currently prescribed an antidepressant, treatment will depend on the severity of their condition. For some, psychotherapy or other non-medicinal treatments may be enough to manage symptoms. But for those with moderate to severe depression, an antidepressant may be required to ensure the wellbeing of both mother and baby ^[4][7].

In all cases, the benefit of treatment must outweigh the risks to the fetus or newborn. Medication will be prescribed with caution and only if required. If treatment does include medication, mother and baby will be closely monitored throughout pregnancy and breastfeeding, to mitigate any potential risks ^[2][3].

If an antidepressant is already prescribed, discontinuing or changing the medication could cause a relapse. A relapse can cause a significant impact on mother and baby, so the medication will typically be continued. Other medications that are sometimes used in the treatment of depression or mood disorders, such as benzodiazepines and valproic acid, will likely be discontinued during pregnancy, due to the risks they can cause ^[2][4].

Treatment plans will always be developed on an individualized basis, with the wishes of the mother and other caregivers in consideration. Treatment plans will work to ensure that all the benefits and risks are clearly explained to allow for informed decision-making about whether to proceed forward with or without medication ^[3][5].

Psychotherapy and group therapy may be recommended to help with managing symptoms of depression while pregnant or breastfeeding. Therapy can provide support in managing emotional distress and teach helpful coping strategies ^[2][7].

Similarly, alternative treatments such as acupuncture and prenatal yoga may be useful in managing distress and improving mood ^[4].