What is the safest antidepressant during pregnancy?

From the Guidelines

Selective serotonin reuptake inhibitors (SSRIs), particularly sertraline (Zoloft), are generally considered the safest antidepressants during pregnancy, with the most recent and highest quality study suggesting that sertraline has minimal transfer across the placenta and the most safety data 1.

Key Considerations

• Sertraline is often the first choice for treating depression during pregnancy due to its safety profile and minimal placental transfer.
• Typical starting doses for sertraline are 25-50mg daily, which can be adjusted as needed based on the patient's response and tolerance.
• The decision to use antidepressants during pregnancy should be made in consultation with healthcare providers, weighing the mother's mental health needs against potential risks to the developing baby.
• Untreated depression poses significant risks to both mother and baby, and the benefits of treating maternal depression with SSRIs generally outweigh the potential risks, which may include a slightly increased risk of persistent pulmonary hypertension in newborns 1.
• Some SSRIs, like paroxetine, are typically avoided due to a higher association with birth defects.

Clinical Recommendations

• Healthcare providers should work with pregnant women to consider the severity of current symptoms, previous mental health history, and patient treatment preferences when making decisions about antidepressant use during pregnancy 1.
• Women with a history of severe suicide attempts or severe depression who have previously experienced symptom reduction with antidepressant treatment may respond better to antidepressants than psychotherapy.
• The American Psychiatric Association and the American College of Obstetricians and Gynecologists recommend that antidepressants may be a superior treatment option to psychotherapy for some women, and that women who have tried psychotherapy but have not achieved adequate symptom reduction may also need antidepressant treatment during pregnancy 1.
• Services should be provided to women with depressive and anxiety disorders and their children to reduce the risk of offspring neurodevelopmental problems.

Safety and Efficacy

• The most recent and highest quality study suggests that intrauterine antidepressant exposure does not substantially increase the risk for neurodevelopmental problems, such as autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) 1.
• Observational studies have documented associations between prenatal antidepressant exposure and adverse offspring outcomes, but these findings may not reflect a causal effect of prenatal antidepressant exposure, and may be due to systematic differences between exposed and unexposed offspring 1.

From the FDA Drug Label

When treating a pregnant woman with sertraline, the physician should carefully consider both the potential risks of taking an SSRI, along with the established benefits of treating depression with an antidepressant. The decision can only be made on a case by case basis

When treating a pregnant woman with citalopram tablets, the physician should carefully consider both the potential risks of taking an SSRl, along with the established benefits of treating depression with an antidepressant. This decision can only be made on a case by case basis

Safest Antidepressant During Pregnancy: There is no clear answer to this question as both sertraline and citalopram have potential risks associated with their use during pregnancy.

• Sertraline: has been shown to have no evidence of teratogenicity, but may cause delayed ossification in fetuses and increase the risk of persistent pulmonary hypertension of the newborn (PPHN) 2.
• Citalopram: has been shown to have adverse effects on embryo/fetal and postnatal development, including teratogenic effects, when administered at doses greater than human therapeutic doses, and may also increase the risk of PPHN 3. It is essential to weigh the potential benefits and risks of each medication on a case-by-case basis, considering the individual patient's needs and medical history.

From the Research

Safety of Antidepressants During Pregnancy

The safety of antidepressants during pregnancy is a concern due to the potential risks to the developing fetus.

• Studies have shown that selective serotonin reuptake inhibitors (SSRIs) are associated with an increased risk of miscarriage, premature delivery, neonatal complications, birth defects, and neurodevelopmental disorders in childhood 4, 5, 6.
• However, the risk of untreated depression during pregnancy should also be considered, as it can lead to adverse perinatal outcomes 4, 5.

Comparison of SSRIs

• Different SSRIs have varying safety profiles during pregnancy.
• Paroxetine and fluoxetine have been associated with a higher risk of negative outcomes, such as birth defects and persistent pulmonary hypertension of the newborn 7, 6.
• Sertraline and citalopram are considered to be safer options, with a lower risk of adverse outcomes 7, 6.
• Escitalopram and fluvoxamine have limited data available, making it difficult to determine their safety during pregnancy 7.

Sertraline as a Safe Option

• Sertraline has been shown to have a low transfer rate to infants, with median concentrations in cord blood and infant plasma being 33% and 25% of maternal concentrations, respectively 8.
• The interindividual variation in maternal sertraline concentrations during pregnancy is significant, highlighting the potential need for therapeutic drug monitoring to ensure safe treatment 8.
• Sertraline can be considered a safe option for pregnant women, especially when the benefits of treatment outweigh the risks 7, 8.

Risk-Benefit Assessment

• The decision to use antidepressants during pregnancy should be made on a case-by-case basis, taking into account the individual woman's medical history, the severity of her depression, and the potential risks and benefits of treatment 4, 5.
• Pregnant women exposed to SSRIs in early pregnancy should be offered options for prenatal diagnosis and monitoring to detect potential birth defects 4.
• The importance of recognizing the potential risks and benefits of antidepressant use during pregnancy lies in the potential for surveillance and timely intervention to minimize adverse outcomes 4, 5.