Evidence-Backed Benefits of Taking Antidepressants During Pregnancy

The U.S. Food and Drug Administration (FDA) recently convened a panel to discuss the use and safety of a class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). During the presentation, panel members mostly discussed concerns about the risks of using these medications in pregnancy, but did not touch much on the benefits.

Mental health professionals and reproductive experts are concerned that this approach presents the public with an unbalanced view of antidepressant use during pregnancy, especially because the group didn’t mention what could happen to pregnant people and the fetus if depression and other mood disorders are not treated.

“The discussion of a possible black box warning has already caused confusion and fear among pregnant individuals considering treatment,” says Sharon Batista, MD, DFAPA, FACLP, FAMWA, a multiple board-certified psychiatrist specializing in women’s mental health, including perinatal health. “This news made my heart sink with dread as I anticipate there will be many people who stand to suffer unnecessarily.”

Experts stress that there are benefits to taking antidepressants during pregnancy if a person needs them and counter misinformation.

What Do Experts Think About the Panel?

Nothing has changed in the data or guidance to prompt this meeting, says Emma Basch, PsyD, a licensed clinical psychologist who specializes in reproductive mental health. “This panel was composed primarily of non-specialists who are on the record against the use of SSRIs,” adds Dr. Basch.

Additionally, some of the studies the panel cited have methodological issues, such as failing to control for the severity of maternal mental health illness, according to Dr. Batista. “Without this context, any policy decision [by the FDA] risks doing more harm than good,” says Dr. Batista.

By contrast, one of the most robust studies on SSRI use in pregnancy found no significant increase in congenital heart defects or most other major malformations when SSRIs were used in the first trimester, adds Dr. Batista. Plus, researchers in this study reviewed nearly 1 million pregnancies.

Meanwhile, the American College of Obstetricians and Gynecologists (ACOG) publicly criticized the panel and its approach. It released a statement noting that it’s dangerous for the group to focus only on the purported risks of antidepressants in pregnancy without also discussing the effects of mental health, especially because mental health conditions are a frequent cause of pregnancy-related death. Doing so could “incite fear and cause patients to come to false conclusions that could prevent them from getting the treatment they need.”

What Are the Risks of Taking SSRIs in Pregnancy?

SSRIs are some of the most studied medications in pregnancy, says Ariadna Forray, MD, an associate professor of psychiatry and director of the Yale Center for Wellbeing of Women and Mothers. But Dr. Forray adds that some of “the data informing SSRI use in pregnancy are limited to retrospective, observational studies, which are prone to bias and confounding.”

Dr. Forray says many of the studies that point to adverse outcomes with SSRI exposure fail to adequately control for confounding by indication, such as the underlying mental health condition for which the medication was prescribed, or by other contributing factors like poor prenatal care, active substance use, smoking, and obesity, among others.

“Current data do not support a causal relationship between prenatal SSRI exposure and congenital malformations, miscarriage, or autism spectrum disorder,” says Dr. Forray. “Preterm birth and neonatal adaptation syndrome are the only consistent associations with prenatal SSRIs exposure.”

That said, she says these risks need to be put into context. The risk of preterm birth associated with untreated depression and anxiety is nearly double, she says.

Benefits of Taking SSRIs During Pregnancy

Mood and anxiety disorders are relatively common conditions, and pregnancy is not “protective” against their onset or recurrence, says Eleanor Curry, MD, a psychiatrist and women’s health specialist with Mindpath Health. But rather than being reassured that there are some benefits to continuing antidepressant use, some pregnant people are encouraged to stop taking them.

“In my clinical experience, women are much more likely to be ‘talked out of’ continuing their antidepressant than somehow ‘forced’ into taking it against their wishes,” says Dr. Curry.

Here are some benefits to continue taking an antidepressant during pregnancy or if you develop depression while pregnant.

Improves mental health and decreases risks

Antidepressants boost mood and improve day-to-day functioning. But, not taking them when needed may have a significant impact, says Amber Samuel, MD, a board-certified maternal-fetal medicine specialist and medical director at Pediatrix Medical Group in Houston.

“While we always advise using any medication only when necessary and only at the lowest effective dose, patients on these medications are on them for a reason,” says Dr. Samuel. “Untreated mood and other psychiatric disorders can lead to significant perinatal risks up to and including death.”

Lowers risk of preterm birth

One study found that taking antidepressants in pregnancy when needed reduces the risk of preterm birth by 16%. Meanwhile, the risk of very preterm birth is nearly 50% lower in people using SSRIs compared to those with a psychiatric diagnosis but no medication use.

Researchers also note that preterm birth is the most important single cause of neonatal and infant death and is associated with long-term neurological disabilities.

Combats postpartum depression

For someone with a history of postpartum depression (PPD), starting an antidepressant in pregnancy can reduce the risk of the condition, says Dr. Curry.

“Going into the postpartum period free of clinical depression can help mitigate the impact of other stressors of that time, like lack of sleep, challenges with breastfeeding, caring simultaneously for energetic older children, and partner stress,” she says.

What Happens if You Stop Antidepressants in Pregnancy?

Research shows that depression during pregnancy doesn’t resolve. Instead, it can persist or even worsen, putting both the pregnant person and their baby at risk.

For pregnant people with a history of severe depression, abruptly stopping medication can lead to relapse of symptoms, says Dr. Forray. In fact, up to 70% who discontinue medications relapse, she points out.

“This might lead to significant functional deterioration and increase the risk for suicide,” says Dr. Forray. “Having active psychiatric symptoms in pregnancy can also lead to poor nutrition, lack of prenatal care, and increased risk of substance use, all of which can increase the risk of adverse pregnancy and infant outcomes.”

Are There Alternatives to SSRIs?

SSRIs are just one part of comprehensive, evidence-based mental health care, says Dr. Forray.

“Cognitive behavioral therapy (CBT) and interpersonal psychotherapy are two evidence-based therapies for perinatal depression,” explains Dr. Forray. “They are first-line treatments for mild to moderate depression in this population.”

Being physically active, getting adequate sleep, and having social support or connections are additional interventions that are helpful for perinatal depression, she says. You and your health care team can determine what will work best in your situation.

How To Decide What’s Right for You

The most important aspect in choosing the correct approach for your situation is an open conversation with a qualified health care professional about your symptoms and health history, says Dr. Samuel.

You also should discuss the safety of the medication, the goals of the therapy, and the impact on your pregnancy and the fetus. Weighing these things against one another will help you make an informed decision that is right for you and your growing family. But if you decide to take or continue using SSRIs, experts say you should not feel guilty.

“SSRIs remain one of the most studied and widely used treatment options during pregnancy,” says Dr. Batista. “In my clinical work, they have been life-saving for many patients. Removing them from the treatment toolbox would restrict safe, effective care for individuals who need it most.”