Psychiatric Medications During Pregnancy: How to Weigh the Decision
Deciding about psychiatric medication in pregnancy is a choice between two sets of risks, not between risk and safety. Untreated depression in pregnancy is linked with preterm birth, preeclampsia, low birth weight, substance use and suicide, and the American College of Obstetricians and Gynecologists (ACOG) says discontinuing SSRIs because of pregnancy can itself carry risks. ACOG also states that robust evidence shows SSRIs are safe in pregnancy and that most do not increase the risk of birth defects.
A few medicines need very different handling. Valproate can cause major birth defects and lower IQ and should not be used in pregnancy for bipolar disorder unless other medicines have failed, and lithium needs close blood-level monitoring. The safest path is a plan made with your prescriber and obstetric clinician, ideally before conception. Never stop or change a psychiatric medicine on your own because you are pregnant or hoping to be.
If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.
Why stopping everything is not automatically the safe choice
Many people's first instinct on a positive pregnancy test is to stop every medication. For psychiatric medicines, that instinct can backfire. ACOG notes that mental health conditions are the most frequent cause of pregnancy-related death, and its 2025 update calls perinatal mental health conditions, including suicide and overdose, a leading cause of preventable maternal mortality.
Relapse is a concrete risk. The sertraline label describes a prospective study of 201 pregnant women with a history of major depression who were well on antidepressants at the start of pregnancy; those who stopped were more likely to relapse than those who continued. The label tells prescribers to consider the risks of untreated depression when stopping or changing antidepressants during pregnancy and postpartum.
Untreated illness can also affect pregnancy itself. ACOG lists limited engagement in medical care and self-care and impaired attachment with the infant among the risks, alongside the obstetric outcomes above. None of this means everyone should stay on medication. It means the decision deserves a real conversation, not a reflex.
What the main U.S. guideline covers
ACOG Clinical Practice Guideline No. 5, "Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum," was published in June 2023 and replaced an older practice bulletin from 2008. It reviews the safety and effectiveness of psychiatric medications in pregnancy and lactation for depression, anxiety disorders, bipolar disorder and acute psychosis, with recommendations graded by strength and evidence quality. The Society for Maternal-Fetal Medicine endorses it, and the American Psychiatric Association's Committee on Women's Mental Health reviewed it. ACOG issued a focused update on postpartum depression medicines in October 2025.
The public debate shifted in July 2025, when the FDA held an expert panel on SSRIs and pregnancy. ACOG called the panel "alarmingly unbalanced," restated its view that SSRIs are safe in pregnancy, and agreed with one point: randomized trials of SSRI safety in pregnancy have not been done and should be prioritized. Because labeling and guidance can change, ask your prescriber to check the current label and guidance at the time you are deciding.
Medication-by-medication overview
| Medicine | What the label or guidance says about pregnancy | Typical discussion points |
|---|---|---|
| Sertraline and most SSRIs | First-trimester sertraline studies suggest no difference in major birth defect risk compared with background rates | Newborn adaptation symptoms and PPHN with late-pregnancy exposure; postpartum bleeding |
| Paroxetine | Associated with a less than 2-fold increase in cardiovascular malformations with first-trimester use | Label says to start it in early pregnancy or when planning pregnancy only after considering other options |
| Lithium | May cause harm; early reports linked it to heart malformations including Ebstein's anomaly, though later studies suggest the increased risk is likely small | Frequent blood levels; dose changes near delivery; newborn monitoring |
| Valproate (divalproex) | Boxed warning: major malformations, especially neural tube defects, plus decreased IQ and neurodevelopmental disorders | Not for bipolar disorder in pregnancy unless other medicines have failed or are unacceptable |
| Zuranolone (Zurzuvae) | Approved for postpartum depression in adults; may cause fetal harm based on animal data and is not approved for use during pregnancy | Contraception during the 14-day course and for 1 week after |
| Brexanolone (Zulresso) | No longer available; FDA approval withdrawn as of April 14, 2025 | Not an option |
Other medicines, including lamotrigine, antipsychotics, stimulants and benzodiazepines, each have their own data and are beyond what this overview can cover responsibly. MotherToBaby fact sheets (below) and your prescriber are the right places for those questions.
SSRIs in more detail
For SSRIs, the questions usually shift from birth defects to late-pregnancy effects. Newborns exposed to SSRIs or SNRIs late in the third trimester have developed complications requiring prolonged hospitalization, breathing support and tube feeding, according to postmarketing reports in the sertraline label. Reported signs include breathing difficulty, feeding problems, jitteriness, irritability and constant crying, and the label says these may reflect a direct drug effect or a discontinuation syndrome. Late-pregnancy SSRI exposure may also increase the risk of persistent pulmonary hypertension of the newborn (PPHN).
Exposure to SSRIs, particularly in the month before delivery, has been associated with a less than 2-fold increase in postpartum hemorrhage. These are reasons to tell your obstetric team and your baby's pediatric team about the medication, not automatic reasons to stop it. The label tells prescribers to weigh both the potential risks and benefits of treatment in the third trimester.
Paroxetine is the SSRI singled out for early pregnancy, because of the cardiovascular malformation signal described above. If you already respond well to a particular antidepressant, switching for pregnancy has its own risks, including the chance that the new medicine works less well; our article on switching antidepressants explains what a switch involves, and sertraline vs escitalopram compares two commonly used SSRIs.
Bipolar disorder: lithium and valproate
Bipolar disorder raises the stakes in both directions, because relapse can be severe and two of its main medicines have specific pregnancy concerns. The valproate boxed warning says it can cause major congenital malformations, particularly neural tube defects such as spina bifida, along with decreased IQ scores and neurodevelopmental disorders after exposure in the womb. It should not be used for bipolar disorder in pregnant women or women planning pregnancy unless other medications have failed or are otherwise unacceptable, and women of childbearing potential who take it should use effective contraception.
The lithium label says lithium may cause harm in pregnancy and describes early registry reports of cardiovascular malformations, especially Ebstein's anomaly, while noting that later studies suggest the increased risk is likely small. If lithium is continued, blood levels are monitored and the dose adjusted during pregnancy, and the label describes lowering or pausing the dose 2 to 3 days before delivery to reduce toxicity risk for parent and baby. Newborns exposed late in pregnancy can show signs of lithium toxicity, so the pediatric team needs to know.
For more on the tradeoffs between mood stabilizers, see lithium vs lamotrigine and bipolar disorder medications compared.
What the evidence cannot tell you yet
It helps to know how the evidence was gathered, because that shapes how certain anyone can be. Randomized trials of SSRI safety in pregnancy have not been conducted, a gap ACOG says should be prioritized. Most of what is known comes from observational studies, which compare people who chose to take a medicine with people who did not. Those groups can differ in ways beyond the medicine, including how ill they were.
- For sertraline, some studies have reported increases in specific birth defects, but the label calls those results inconclusive.
- For lithium, the label says the data are insufficient to establish a drug-associated risk of heart malformations, even though the increased risk is likely small.
- For newborn complications after late-pregnancy SSRI exposure, much of the information comes from postmarketing reports rather than controlled studies.
- The background risk of birth defects and miscarriage for people with these psychiatric conditions is described in the labels as unknown.
Honest uncertainty cuts both ways. It is a reason not to dismiss concerns, and also a reason not to let alarming headlines push someone off a medicine that is keeping them well. A prescriber who walks you through what is known, what is not, and how they would monitor is giving you what you need to decide.
Planning before conception
The best time to make these decisions is before pregnancy, when there is time to adjust a regimen carefully, confirm stability and avoid an unplanned first-trimester exposure to a high-risk drug. A preconception visit with your prescriber can cover:
- Which of your current medicines have pregnancy-specific warnings, such as valproate or paroxetine.
- How stable you are now, and what happened in past attempts to stop or lower medication.
- Whether a change should happen before conception rather than during pregnancy.
- Contraception until the plan is in place, especially with valproate.
- Non-medication supports, such as psychotherapy, that can be started now.
- Who will coordinate with your obstetric clinician, and how.
Plans also need a fallback. Not every pregnancy is planned, so if you take a medicine with a serious pregnancy warning, ask now what you should do on the day of a positive test. The usual answer is to call your prescriber promptly rather than stopping on your own.
Weighing the decision
| Factor | Questions that shape the decision |
|---|---|
| Severity and history | How severe were past episodes? Has there been a relapse after stopping before? Any history of suicidal thoughts, mania or psychosis? |
| Response to medicine | Which medicines have worked? Would a switch risk losing a response that took months to find? |
| The specific drug | Is it one with a pregnancy-specific warning, or one with more reassuring data? |
| Timing | Is this before conception, early pregnancy, or late pregnancy, when newborn adaptation becomes the main question? |
| Other supports | Is psychotherapy available now? Is there help at home with sleep and stress? |
| Your values | How do you weigh small, uncertain medication risks against the risk of illness returning? |
There is rarely a risk-free option, and reasonable people choose differently with the same facts. A good decision is one made with accurate information, a plan for monitoring, and agreement about what will trigger a change.
After delivery: planning for postpartum
The postpartum period is part of the same plan. Zuranolone is FDA-approved for postpartum depression in adults and is taken by mouth for 14 days. ACOG's 2025 update recommends considering it after delivery (within 12 months) for severe depression that began in the third trimester or within 4 weeks after delivery. Its label carries a boxed warning about impaired driving, and patients should not drive for at least 12 hours after each dose. Brexanolone, the earlier intravenous option, is no longer available in the United States.
Our article on postpartum depression treatment options compares these choices, and psychiatric medications while breastfeeding covers what changes once you are nursing.
Reliable places to get information
- MotherToBaby, a free service of the nonprofit Organization of Teratology Information Specialists, answers questions about medications in pregnancy and breastfeeding by phone at 866-626-6847 or by text at 855-999-3525.
- The National Maternal Mental Health Hotline offers free, confidential support 24/7 by call or text at 1-833-852-6262 (1-833-TLC-MAMA), in English and Spanish with interpreters for other languages. It is not a crisis line; for a crisis, use 988.
- The National Pregnancy Registry for Antidepressants collects outcome data from people who took antidepressants in pregnancy; enrollment is at 1-866-961-2388.
Questions to ask your prescriber
- What are the known risks of this medicine in pregnancy, and how good is that evidence?
- What are my personal risks if I stop or lower it?
- Should anything change before I try to conceive?
- How will you coordinate with my obstetric clinician and my baby's pediatrician?
- What should I do if I find out I am pregnant before we have a plan?
- What is the plan for the weeks after delivery, including sleep and breastfeeding?
How Dr. Lewis's practice can help
The practice's team includes psychiatrists, psychiatric nurse practitioners and psychotherapists, and its ongoing care includes psychiatric evaluation, medication management and psychotherapy. If you are pregnant or planning a pregnancy, ask on the free discovery call whether the practice is the right fit for your situation. The drlewis.com article on pregnancy and depression offers background, and medication management explains how prescribing visits work. If you want a clinician who focuses on this period specifically, our guide to what a reproductive psychiatrist does explains that specialty. More comparisons are in the Choosing Psychiatric Care guide.
Frequently asked questions
Should I stop my antidepressant as soon as I find out I'm pregnant?
Do not stop on your own. Call your prescriber promptly. Stopping can lead to relapse, and ACOG notes that discontinuing SSRIs because of pregnancy can carry risks.
Do SSRIs cause birth defects?
ACOG states that most SSRIs do not increase the risk of birth defects, and sertraline studies suggest no difference from background rates. Paroxetine is the exception with a cardiovascular malformation signal.
What is the background risk of birth defects in any pregnancy?
FDA labels cite an estimated background risk of 2% to 4% for major birth defects and 15% to 20% for miscarriage in clinically recognized U.S. pregnancies. Medication risks are measured against that baseline.
Can I take lithium while pregnant?
Sometimes, with close monitoring. The label describes a likely small increase in heart malformation risk, frequent blood levels during pregnancy, and dose changes before delivery. This is a decision for you and your prescriber.
Is zuranolone safe to take during pregnancy?
No. It is approved for postpartum depression and is not approved for use during pregnancy; contraception is advised during treatment and for 1 week after.
Is therapy alone an option during pregnancy?
For some people, yes, especially with milder symptoms. The decision depends on severity, history and how well therapy has worked before. Our medication, therapy or both guide covers that choice.
Where can I get free, expert answers about a specific medicine?
MotherToBaby offers free information about medications in pregnancy and breastfeeding at 866-626-6847 or by text at 855-999-3525.
Sources
- Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum (Clinical Practice Guideline No. 5). American College of Obstetricians and Gynecologists, 2023. acog.org
- ACOG Statement on the Benefit of Access to SSRIs During Pregnancy. American College of Obstetricians and Gynecologists, 2025. acog.org
- ACOG Clinical Practice Update: Zuranolone and Brexanolone for the Treatment of Postpartum Depression. Obstetrics & Gynecology (ACOG), 2025. doi.org
- Zoloft (sertraline) prescribing information. DailyMed / U.S. FDA label, 2023. dailymed.nlm.nih.gov
- Paroxetine tablets prescribing information. DailyMed / U.S. FDA label, 2026. dailymed.nlm.nih.gov
- Lithium carbonate prescribing information. DailyMed / U.S. FDA label, 2026. dailymed.nlm.nih.gov
- Depakote (divalproex sodium) prescribing information. DailyMed / U.S. FDA label, 2026. dailymed.nlm.nih.gov
- About Us. MotherToBaby (Organization of Teratology Information Specialists), 2026. mothertobaby.org
- Zurzuvae (zuranolone) prescribing information. DailyMed / U.S. FDA label, 2026. dailymed.nlm.nih.gov
- National Maternal Mental Health Hotline: Frequently Asked Questions. Health Resources and Services Administration (HHS), 2026. mchb.hrsa.gov
Educational information, not medical, tax or legal advice. Decisions about diagnosis, medication and treatment belong with a clinician who knows your history.
The information provided on this blog is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
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