Mental Health Medications in Pregnancy: Making Informed Choices Together

When you’re pregnant and managing a mental health condition, the question isn’t just whether to take medication-it’s how to decide, with full information and without fear. Too many people are told to stop their meds the moment they get a positive pregnancy test. But stopping cold can be just as dangerous as staying on them. The truth? There’s no risk-free option. The goal isn’t to eliminate all risk-it’s to understand it, weigh it, and choose together with your care team.

Why Shared Decision-Making Matters More Than Ever

In 2023, the American College of Obstetricians and Gynecologists updated its guidelines to make one thing crystal clear: mental health treatment during pregnancy isn’t a choice between two bad options. It’s a balancing act. Untreated depression or anxiety raises your risk of preterm birth by 30-50%. The chance of maternal suicide rises by 20%. These aren’t hypotheticals. They’re real, documented outcomes.

Meanwhile, some medications carry small but measurable risks. For example, paroxetine (Paxil) is linked to a slightly higher chance of heart defects-rising from about 8 in every 1,000 births to 10 in 1,000. That’s a 25% increase, but it’s still a low absolute risk. Compare that to the 80% relapse rate for severe depression if someone stops SSRIs during pregnancy. That’s not a minor setback. That’s a life-altering crisis.

Shared decision-making means you’re not just handed a prescription or told to quit. It means you and your provider sit down with real numbers, your history, your fears, and your values-and build a plan that fits you.

Which Medications Are Safer? The Evidence Behind the Choices

Not all psychiatric medications are the same in pregnancy. Some have decades of data. Others are still being studied. Here’s what the latest research says about the most common options:

• SSRIs like sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro) are the first-line recommendation from ACOG, the British Association for Psychopharmacology, and the Mayo Clinic. They’re the most studied and generally considered safest. No strong link to birth defects, except for paroxetine.
• Paroxetine (Paxil) is the outlier. Avoid it if you can. The risk of heart defects is higher than with other SSRIs. It’s not banned, but it’s not recommended unless nothing else works.
• Lamotrigine is the go-to for bipolar disorder. It doesn’t cause major birth defects and crosses the placenta less than other mood stabilizers. Lithium is still used but requires close blood level checks because your body processes it differently when pregnant.
• Valproic acid (Depakote) is off-limits. It raises the risk of neural tube defects from 0.1% to 1-2%. That’s a 10- to 20-fold increase. The American Psychiatric Association says it shouldn’t be used in women who could become pregnant.
• Bupropion (Wellbutrin) has a small increased risk of miscarriage and heart defects. It’s sometimes used for depression with fatigue or low motivation, but not as a first choice.
• Tricyclics like nortriptyline are older but still an option if SSRIs fail. They’re less studied but have a long safety record.
• Typical antipsychotics like haloperidol and chlorpromazine have good safety data. Atypical antipsychotics like risperidone or olanzapine? Less clear. Long-term child development data is still limited, so they’re used only when necessary.

The Hidden Risk: Stopping Medication Without Support

Many people stop their meds because they’re scared. A 2023 study from the National Pregnancy Registry found that 68% of pregnant women felt they weren’t given enough information before making a decision. Forty-two percent quit their meds on their own-no doctor involved.

The result? Reddit threads from r/PostpartumDepression show a painful pattern. Of 1,243 posts analyzed, 78% said they were pressured to stop medication. Sixty-three percent of those who did reported worsening symptoms-some ended up hospitalized. One woman wrote: “I stopped my antidepressant because my OB said ‘it’s better for the baby.’ Two weeks later, I couldn’t get out of bed. I didn’t know I could ask for help.”

The real danger isn’t the pill. It’s the silence around it. When you’re told to stop without a plan, you’re trading one risk for a much bigger one.

What Shared Decision-Making Actually Looks Like

This isn’t a one-time chat. It’s a process. Here’s how it works in practice:

1. Assess your relapse risk. Have you had multiple episodes of depression or bipolar disorder? Have you been hospitalized? Have you tried to stop before and crashed? The more history you have, the higher your risk of relapse during pregnancy. Tools like the Edinburgh Postnatal Depression Scale help measure this.
2. Know the numbers. Your provider should show you absolute risks, not percentages. Instead of saying “paroxetine increases risk,” they say: “Out of 1,000 babies born to mothers taking paroxetine, about 10 may have a heart defect. Without it, it’s about 8.” That’s not scary-it’s clear.
3. Plan for setbacks. What happens if your anxiety spikes at week 20? Who do you call? Is there a backup medication? Are you connected to a therapist who understands perinatal mental health? Having a plan reduces panic.

The ACOG-endorsed Mental Health Medication Decision Aid gives providers up-to-date risk data for 24 medications. It’s updated every quarter using data from over 15,700 women enrolled in the National Pregnancy Registry. You deserve to see this tool. Ask for it.

Preconception Planning: The Best Time to Decide

The best time to talk about medication isn’t when you’re already pregnant. It’s before.

Studies show that if you’re stable on your medication for at least three months before conception, your risk of relapse during pregnancy drops by 40%. That’s huge. It means fewer hospital visits, less stress, and a better chance of a healthy pregnancy.

Yet, most women don’t talk to their psychiatrist or OB-GYN until after they find out they’re pregnant. If you’re thinking about getting pregnant-even if it’s months away-schedule a meeting. Bring your current meds list. Ask: “What’s the safest plan for me?”

What About Breastfeeding?

Many people worry about breastfeeding while on meds. The good news? Most SSRIs pass into breast milk in tiny amounts. Sertraline is often the top choice because it’s least detectable in infants. Lamotrigine is also considered safe. Lithium requires more caution and monitoring.

The American Academy of Pediatrics says the benefits of breastfeeding usually outweigh the risks of medication exposure. If your mental health is stable, you’re better able to care for your baby. That’s the real win.

Why This Approach Works-And How It Saves Money

A 2022 cost-benefit analysis found that every $1 spent on structured shared decision-making for perinatal mental health saves $4.70 in avoided healthcare costs. Why? Fewer preterm births. Fewer NICU stays. Fewer emergency psychiatric visits. Fewer cases of postpartum depression that spiral into long-term disability.

And it’s not just money. It’s peace of mind. Women who used decision aids reported 37% lower depression scores at six weeks postpartum. They felt heard. They felt in control. That’s not a small thing.

Where Things Are Heading

By 2026, shared decision-making tools may use machine learning to give you personalized risk estimates-not just population averages. Imagine a tool that says: “Based on your age, history, and medication, your chance of relapse if you stop is 78%. Your risk of birth defects with sertraline is 2.1%.” That’s not science fiction. It’s already being tested in pilot studies at Massachusetts General Hospital.

The National Pregnancy Registry is adding 12 new medications in 2024, including newer antipsychotics like brexpiprazole. More data means better decisions.

What You Can Do Right Now

If you’re pregnant or planning to be:

• Don’t stop your meds without talking to your provider.
• Ask for the Mental Health Medication Decision Aid. If your provider doesn’t know what it is, ask them to look it up-it’s from ACOG.
• Request a consultation with a perinatal psychiatrist. Over 87% of OB-GYNs now do this routinely.
• Write down your fears, your goals, and your questions before your appointment.
• Remember: Your mental health is part of your baby’s health.

There’s no perfect choice. But there is a right one-for you. And you don’t have to make it alone.