Can I continue taking Celexa (citalopram) and buspirone if I discover I am pregnant?

Continuing Celexa and Buspirone in Pregnancy

If you discover you are pregnant while taking Celexa (citalopram) and buspirone, you should have an urgent discussion with your physician about the risks and benefits of continuing these medications, as untreated depression and anxiety during pregnancy carry their own significant risks to both you and your baby.

Understanding the Evidence

Celexa (Citalopram) in Pregnancy

The FDA drug label for Celexa indicates that animal studies showed fetal abnormalities at high doses, but there are no adequate well-controlled studies in pregnant women 1. The label states citalopram should only be used during pregnancy if the potential benefit justifies the potential risk to the fetus 1.

However, the clinical evidence is more reassuring:

• First-trimester exposure does not appear to cause major birth defects. A large population-based cohort study of nearly 1 million pregnant women found no link between first-trimester antidepressant use and cardiac malformations 2. A prospective study of 125 women taking citalopram in the first trimester found only 1 major malformation (0.9%), which is not significantly elevated 3.

• Late pregnancy exposure (after 20 weeks) carries specific risks: The FDA issued advisories about persistent pulmonary hypertension of the newborn (PPHN), though the evidence remains conflicting. A meta-analysis suggested a link with a number needed to harm of 286-351 2. More commonly, neonates exposed late in pregnancy may experience poor neonatal adaptation syndrome—requiring prolonged hospitalization with symptoms including respiratory distress, feeding difficulties, jitteriness, and irritability 1, 3.

• The risk of untreated depression is substantial: Depression during pregnancy is associated with premature birth and decreased breastfeeding initiation 2. Women who discontinue antidepressants during pregnancy are significantly more likely to relapse into major depression 1.

Buspirone in Pregnancy

The evidence for buspirone is much more limited:

• The FDA drug label advises informing your physician if you become pregnant but does not provide specific pregnancy category information 4.

• The most rigorous prospective data available comes from a 2022 study: Among 68 evaluable women who took buspirone during the first trimester (resulting in 72 infants including twins), there were zero major malformations observed 5. While this is a small sample, it represents the only prospectively ascertained data on buspirone pregnancy outcomes.

• No other significant adverse outcomes have been reported in the limited available literature 5.

Clinical Decision-Making Algorithm

Step 1: Assess Your Depression/Anxiety Severity

If you have severe depression with:

• History of severe suicide attempts
• Previous severe depression that responded only to medication
• Previous relapse when stopping antidepressants
• Symptoms not adequately controlled with psychotherapy alone

→ Continuing medication is likely warranted 6

If you have mild-to-moderate depression:

• Consider whether evidence-based psychotherapy (cognitive therapy) could be an alternative
• Evaluate whether you've tried non-pharmacologic approaches
• Discuss with your physician whether a trial off medication is reasonable

→ Shared decision-making is essential 6

Step 2: Medication-Specific Considerations

For Celexa (citalopram):

• Can be continued if clinically necessary, particularly in first and second trimesters
• If continuing into third trimester: Be aware of increased risk of poor neonatal adaptation syndrome (4-6 fold increased risk of special-care nursery admission) 3
• Your baby will need close monitoring at birth for withdrawal symptoms or adaptation issues
• Consider whether switching to sertraline or paroxetine might be preferable, as these have more extensive safety data 2

For Buspirone:

• Very limited data, but no safety signals identified 5
• The absence of observed malformations in the only prospective study is reassuring
• Given the lack of robust data, consider whether this medication is essential or if alternatives exist

Step 3: Timing Considerations

First Trimester (Weeks 1-13):

• Critical period for organ formation
• Citalopram: No clear evidence of major malformations 2, 3
• Buspirone: No malformations in limited data 5

Second Trimester (Weeks 14-27):

• Generally considered lower risk period
• Continue monitoring for maternal mental health

Third Trimester (Weeks 28-40):

• Highest risk for neonatal adaptation problems with citalopram 1, 3
• Inform your obstetric team so they can prepare for potential neonatal monitoring
• Do NOT abruptly discontinue—this increases relapse risk and may cause maternal withdrawal

Critical Pitfalls to Avoid

1. Never abruptly stop antidepressants upon discovering pregnancy—this dramatically increases relapse risk and may cause withdrawal syndrome 1

2. Don't assume "no medication is safest"—untreated maternal depression carries real risks including preterm birth 2

3. Ensure your obstetric team knows about third-trimester SSRI exposure—your baby may need special monitoring at birth for adaptation issues 1

4. Plan for postpartum period now—postpartum is highest risk time for depression relapse; have medication continuation plan in place 1

Practical Recommendations

Most appropriate approach:

• Continue both medications if your depression/anxiety is moderate-to-severe and you've had good response to this regimen
• Inform your obstetrician immediately about your medications
• Ensure pediatric team is aware at delivery to monitor for neonatal adaptation syndrome
• Consider therapeutic drug monitoring for citalopram, as pregnancy may alter drug levels 7
• Plan for breastfeeding: Both citalopram and buspirone are present in breast milk, but citalopram appears relatively safe during breastfeeding with mostly undetectable infant levels 8; buspirone data during breastfeeding is extremely limited 4

The decision to continue or discontinue should prioritize: your history of depression severity, previous response to treatment, previous relapse history, and current symptom severity—balanced against the relatively modest fetal risks identified in the literature 6.