What is the safest antidepressant, such as selective serotonin reuptake inhibitor (SSRI), for use during pregnancy?

From the Guidelines

Sertraline (Zoloft) is generally considered the safest SSRI antidepressant for use during pregnancy, with the most extensive safety data and minimal placental transfer compared to other antidepressants. The typical starting dose is 25-50 mg daily, which can be gradually increased to 50-200 mg daily as needed 1. Fluoxetine (Prozac) and citalopram (Celexa) are reasonable alternatives if sertraline is not tolerated. When considering antidepressant use during pregnancy, it's essential to weigh the risks of untreated depression against potential medication risks. Untreated depression during pregnancy can lead to poor prenatal care, inadequate nutrition, increased substance use, and complications like preterm birth or low birth weight. While no medication is completely risk-free during pregnancy, the small potential risks associated with sertraline (slight increased risk of persistent pulmonary hypertension of the newborn and transient neonatal adaptation syndrome) are generally outweighed by the benefits of treating moderate to severe depression 1.

Some key points to consider when prescribing antidepressants during pregnancy include:

• The American Psychiatric Association and the American College of Obstetricians and Gynecologists recommend a stepped approach to treatment of depression during pregnancy, with women with mild depression being monitored and encouraged to exercise and seek social support, and women with moderate-to-severe depression seeking evidence-based treatment 1.
• The US Preventive Services Task Force recommends routine screening for depression in all adults, including pregnant women, using validated self-report screening measures 1.
• Antidepressant use during pregnancy has not been shown to improve outcomes such as premature birth and decreased initiation of breastfeeding, and may increase the risk of preterm delivery compared to untreated women with depression 1.
• SSRIs are the most commonly prescribed antidepressants for pregnant women, and sertraline is considered one of the safest options due to its extensive safety data and minimal placental transfer 1.

Any medication changes should be discussed with both a psychiatrist and obstetrician, and the lowest effective dose should be used. It's also crucial to consider the severity of current symptoms, previous mental health history, and patient treatment preferences when making decisions about antidepressant use during pregnancy 1.

From the FDA Drug Label

There are no adequate and well-controlled studies in pregnant women. Sertraline hydrochloride should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus Pregnancy-Nonteratogenic Effects Neonates exposed to sertraline and other SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs), late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. 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 safest antidepressant for pregnancy is not explicitly stated in the provided drug labels. Sertraline is mentioned as an option, but the labels emphasize that it should only be used during pregnancy if the potential benefit justifies the potential risk to the fetus 2. The decision to use sertraline or any other antidepressant during pregnancy should be made on a case-by-case basis, considering both the potential risks and benefits. Key points to consider include:

• Increased risk of complications in neonates exposed to SSRIs in the third trimester
• Potential risk of persistent pulmonary hypertension of the newborn (PPHN)
• Risk of relapse in women who discontinue antidepressant medication during pregnancy It is essential to carefully weigh these factors and consult with a healthcare professional to determine the best course of treatment for each individual case.

From the Research

Safest Antidepressant for Pregnancy

The safest antidepressant for use during pregnancy is a topic of ongoing debate and research. According to various studies, selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressant medications worldwide 3, 4, 5, 6, 7.

Risks Associated with SSRIs

• Exposure to SSRIs in pregnancy has been associated with miscarriage, premature delivery, neonatal complications, birth defects, and neurodevelopmental disorders in childhood 3, 5.
• Studies addressing the effect of individual SSRIs indicate a small but higher risk for birth defects with maternal fluoxetine and paroxetine use 3, 7.
• The risk of major congenital malformations could be prevented by observing guidelines that discourage the use of paroxetine and fluoxetine 5.

Recommended SSRIs for Pregnancy

• Sertraline and citalopram should be first-line drug treatments for anxiety and depression in pregnant women in the SSRI class 7.
• Sertraline can be continued in breast-feeding as the concentration found in breast milk is very low and has not been linked to infant complications 7.

Considerations for Antidepressant Use in Pregnancy

• Antenatal depression itself is associated with adverse perinatal outcomes, and discontinuing antidepressant treatment during pregnancy is associated with a high risk of relapse of depression 3, 6.
• Every pregnant woman being treated with an SSRI (or considering such treatment) should carefully weigh the risks of treatment against the risk of untreated depression for both herself and her child 3, 4, 6.
• Pregnant women exposed to any SSRI in early pregnancy should be offered options for prenatal diagnosis through ultrasound examinations and fetal echocardiography to detect the presence of birth defects 3.