Are Antidepressants Safe in Pregnancy?

If you are taking an antidepressant, you might wonder if becoming pregnant might affect your treatment options. Deciding whether to start or continue taking an antidepressant if you become pregnant can be a difficult decision. Letting depression go untreated can negatively impact fetal development and your mental health.

Armed with the facts about each type of antidepressant, you can discuss the pros and cons of your choice with your doctor and mental healthcare provider. 

Depression During Pregnancy

Pregnancy was once believed to provide some protection against depression due to shifting hormones, but research has not supported this theory. In fact, the opposite may be true: Women with a history of anxiety or depression may be more at risk for depression when they are pregnant.

Depression during pregnancy (also called antepartum or prenatal depression) is one of the most common complications during pregnancy. According to the American College of Obstetricians and Gynecologists (ACOG), about 10% of women experience depression during pregnancy. For reference, around 10% of women in the U.S. have depression.

Pregnancy and Antidepressants

Blood volume nearly doubles in pregnancy and this impacts the efficacy of some medications. Some women also have changes in metabolism, which can impact how your body absorbs, distributes, breaks down, and eliminates antidepressant medications should you choose to take them. 

Between 6% and 8% of pregnant women in the U.S. report being prescribed or using an antidepressant. If you want to continue taking your antidepressant while pregnant, ask your doctor how you can reduce any risks. They may be able to adjust your dosage or start you on a different antidepressant.

Antidepressants and Birth Effects

The most commonly used antidepressants are SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs). Monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), and atypical antidepressants are also used, though less frequently.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are the most used class of antidepressants during pregnancy. Some of the most common SSRIs prescribed to treat depression during pregnancy include:

• Celexa (citalopram)
• Lexapro (escitalopram) 
• Luvox (fluvoxamine) 
• Paxil (paroxetine)
• Prozac (fluoxetine) 
• Zoloft (sertraline) 

Hundreds of studies have looked at SSRI exposure and congenital anomalies. Although findings have been mixed, the overall conclusion is that SSRIs are generally considered safe during pregnancy. But they are not without risk.

Specifically, Paxil use during the first trimester was associated with several birth defects, including heart defects, problems with brain and skull formation (anencephaly), and abdominal wall defects. The study also confirmed links between Prozac use and two types of congenital anomalies: heart wall defects and irregular skull shape (craniosynostosis).

The same 2015 study found no evidence of an association between the use of SSRIs like Celexa, Zoloft, and Lexapro and birth defects, even though other studies have.

Controversy also exists regarding the association between SSRI use during pregnancy and the risk of persistent pulmonary hypertension of the newborn (PPHN), a rare condition where the baby's lungs don't inflate well. A 2006 study linked SSRI use during late pregnancy with a 6-fold increased risk of PPHN. However, many researchers say the linkage is greatly exaggerated.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Serotonin-norepinephrine reuptake inhibitors (SNRIs) block the reuptake of both serotonin and another neurotransmitter called norepinephrine.

Common SNRIs include: 

• Cymbalta (duloxetine) 
• Effexor and Effexor XR (venlafaxine/venlafaxine XR) 
• Fetzima (levomilnacipran)
• Pristiq (desvenlafaxine) 

Research shows that using Effexor during early pregnancy may be linked to several congenital anomalies, including heart defects, defects of the brain and spine, cleft lip, and cleft palate. However, the risk for these anomalies remains below that of the general population risk.

Tricyclic Antidepressants (TCAs)

Tricyclic antidepressants (TCAs) are the oldest class of antidepressants. They work by blocking neurotransmitters and other receptors in the brain. Though they can be effective as SSRIs in treating depression, they cause more adverse effects.

The most commonly prescribed TCAs for use during pregnancy include: 

• Elavil (amitriptyline)   
• Norpramin (desipramine)
• Pamelor (nortriptyline)  
• Tofranil (imipramine) 

There is not enough research to determine whether TCA use during pregnancy has a negative effect on a developing fetus. However, a study published in 2017 indicated that TCAs may be associated with an increased risk of digestive defects as well as eye, ear, face, and neck defects.

Monoamine Oxidase Inhibitors (MAOIs)

Monoamine oxidase inhibitors (MAOIs) work by breaking down neurotransmitters like dopamine and serotonin. Like TCAs, MAOIs class tend to have more side effects than SSRIs and SNRIs.

Popular MAOIs include: 

• Nardil (phenelzine) 
• Emsam (selegiline) 
• Marplan (isocarboxazid) 
• Parnate (tranylcypromine) 

A 2017 case report published in the journal Reproductive Toxicology noted fetal malformations in the two pregnancies of a woman taking high doses of MAOIs. Both pregnancies resulted in fetal abnormalities, one of which was severe enough to result in stillbirth. The second infant was born with severe physical and neurological disabilities.

Research on the potential risk of Nardil (one of the more commonly prescribed MAOIs) on a developing fetus is limited. The FDA label states that healthcare providers need to weigh the potential risks of Nardil against the benefits when prescribing the medication for people who are pregnant. This recommendation is consistent with the other MAOI antidepressants as well as medications in other classes.  

Atypical Antidepressants

Atypical antidepressants are antidepressants that don't fall under any of the other four classes of antidepressants. They're often prescribed when other antidepressants aren't working.

Common medications in this group include:  

• Oleptro (trazodone)  
• Remeron (mirtazapine) 
• Serzone (nefazodone)
• Trintellix (vortioxetine)
• Wellbutrin (bupropion) 

Like SSRIs, the atypical antidepressants tend to cause fewer side effects than other antidepressants. However, like other medications, there are potential risks when used during pregnancy.

Natural Treatments for Depression 

There are also non-prescription or alternative treatments for depression such as St. John’s wort. Rigorous, formal research does not exist regarding the risk of exposure to supplements like St. John’s wart in pregnancy.

However, anyone planning to use St. John's wort needs to be aware of potential interactions. For example, taking St. John's wort with medications, supplements, or foods containing 5-hydroxytryptophan (5-HTP), L-tryptophan, or SAMe, can increase your risk for developing serotonin syndrome.

As with medications, ask your doctor about taking a nutritional supplement or herbal remedy if you are pregnant or breastfeeding.

Antidepressant Use While Breastfeeding

Antidepressants can be passed to your baby through your breast milk. However, the amount that is secreted into breast milk is less than that which crosses the placenta.

The following selective serotonin reuptake inhibitors (SSRIs) are some of the best-studied medications for use during breastfeeding:

• Paxil (paroxetine)
• Prozac (fluoxetine)
• Zoloft (sertraline)

According to multiple studies, the serum antidepressant levels in nursing infants are either low or undetectable, and there have been no reports of short-term adverse effects. For these reasons, they are considered relatively safe for use during breastfeeding.

The Risk of Untreated Depression 

It's important to remember that untreated depression also carries risks. Many studies have demonstrated that maternal stress during pregnancy can negatively affect fetal development and may influence the later behavior and emotional well-being of the child.

The physical and emotional stressors of pregnancy can contribute to or worsen feelings of depression. These symptoms of depression can also affect how well a person can take care of their needs—practicing overall self-care to pregnancy-specific care such as prenatal appointments.  

People with depression may also be more likely to use substances to cope with their symptoms. The risks associated with drinking alcohol and using illicit drugs during pregnancy are well-established. Substance use during pregnancy can have serious long-term consequences for parents and children.  

Takeaways

Each class of antidepressant medication carries its own set of risks. If you are trying to decide whether to stop taking your antidepressant during pregnancy, talk to your doctor. They can help you weigh the benefits of taking antidepressants during pregnancy against the potential consequences associated with letting your depression go untreated.

Being on an antidepressant should not keep you from having a healthy pregnancy. Your doctor can help you find a medication that can treat your depressive symptoms and is safe for you and your baby. If you decide to stop taking your antidepressant medication while you are pregnant, you should have a solid support system in place and strategies to help you cope with depression symptoms.