What is the safest antidepressant medication in pregnancy?

From the Guidelines

Sertraline (Zoloft) is generally considered the safest antidepressant medication during pregnancy, due to its extensive study in pregnant women and minimal risk to the developing fetus compared to the risks of untreated depression 1. When considering the safest depression medication during pregnancy, several factors must be taken into account, including the potential risks and benefits of treatment, as well as the severity of the mother's depression.

• The risks of untreated depression during pregnancy can include preterm birth, low birth weight, and maternal complications, making treatment a crucial consideration for many women.
• Selective serotonin reuptake inhibitors (SSRIs), such as sertraline and citalopram, are commonly used to treat depression during pregnancy due to their relatively safe profile compared to other antidepressant medications.
• According to recent research, sertraline is often the first choice for treating depression during pregnancy, typically starting at 25-50mg daily and gradually increasing as needed up to 200mg daily 1.
• It is essential to work closely with both an obstetrician and psychiatrist to monitor medication effectiveness and adjust dosing as needed throughout pregnancy, as well as consider non-medication approaches like cognitive behavioral therapy as complementary treatments.
• The decision to use antidepressants during pregnancy should be individualized based on the severity of depression and the woman's medical history, taking into account the potential benefits and risks of treatment 1. Some SSRIs may be associated with a slight increase in certain complications, such as persistent pulmonary hypertension of the newborn, but this risk is very small (about 1 in 1000) 1.
• Ultimately, the goal of treatment is to minimize the risks associated with depression during pregnancy while also ensuring the best possible outcome for both the mother and the developing fetus.

From the FDA Drug Label

These doses correspond to approximately 4 times the maximum recommended human dose (MRHD) on a mg/m2 basis. There was no evidence of teratogenicity at any dose level. When pregnant rats and rabbits were given sertraline during the period of organogenesis, delayed ossification was observed in fetuses at doses of 10 mg/kg (0. 5 times the MRHD on a mg/m2 basis) in rats and 40 mg/kg (4 times the MRHD on a mg/m2 basis) in rabbits. Infants exposed to SSRIs in pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN). Physicians should also note the results of a prospective longitudinal study of 201 pregnant women with a history of major depression, who were either on antidepressants or had received antidepressants less than 12 weeks prior to their last menstrual period, and were in remission Women who discontinued antidepressant medication during pregnancy showed a significant increase in relapse of their major depression compared to those women who remained on antidepressant medication throughout pregnancy The decision can only be made on a case by case basis (see DOSAGE AND ADMINISTRATION).

The safest depression medication in pregnancy is not explicitly stated in the provided drug labels. However, based on the available information:

• Sertraline does not show evidence of teratogenicity, but it may cause delayed ossification in fetuses and increase the risk of persistent pulmonary hypertension of the newborn (PPHN) 2.
• Paroxetine has been associated with an increased risk of congenital malformations, particularly cardiovascular malformations, and should be used with caution in pregnancy 3. It is essential to weigh the potential benefits and risks of each medication on a case-by-case basis, considering the severity of the depression and the potential harm to the fetus. Sertraline may be considered a safer option due to the lack of evidence of teratogenicity, but the decision should be made under the guidance of a healthcare professional.

From the Research

Safest Depression Medication in Pregnancy

• The safest depression medication in pregnancy is a topic of ongoing research and debate 4, 5.
• According to a 2017 literature review, sertraline and citalopram are considered first-line treatments for anxiety and depression in pregnant women due to their relatively low risk of negative outcomes 4.
• A 2021 study found that sertraline concentrations in pregnant women are steady and the drug transfer to their infants is low, with only mild and transient adverse effects seen in infants 6.
• Another study published in 2024 found that sertraline is present in low levels in breast milk and is considered a preferred agent for treating depression during lactation 5.
• The following factors should be considered when choosing an antidepressant for pregnant women:
  • The risk of negative outcomes associated with the medication
  • The severity of the woman's depression
  • The potential benefits of treatment
  • The woman's medical history and other health conditions
• It is essential to consult with a healthcare provider to determine the best course of treatment for depression during pregnancy, as the risks and benefits of each medication can vary depending on individual circumstances 4, 5.