What are the recommended treatments for anxiety during pregnancy, specifically regarding the use of selective serotonin reuptake inhibitors (SSRIs) like sertraline (Zoloft) and fluoxetine (Prozac)?

Treatment of Anxiety During Pregnancy

For pregnant women with anxiety, begin with non-pharmacological interventions such as cognitive behavioral therapy (CBT) and mindfulness therapy; if pharmacotherapy is necessary, sertraline and citalopram are the preferred first-line SSRIs based on their more favorable reproductive safety profiles compared to paroxetine and fluoxetine. 1

Initial Assessment and Screening

• Screen all pregnant women for anxiety using validated instruments including the Generalized Anxiety Disorder Scale, State-Trait Anxiety Inventory, or Edinburgh Postnatal Depression Scale, which demonstrate moderate to high accuracy in identifying anxiety symptoms during pregnancy 2
• Distinguish between normal pregnancy-related worry and pathological anxiety by assessing whether the anxiety is persistent (typically lasting 6 months or more), causes clinically significant distress or functional impairment, and is disproportionate to actual circumstances 2, 3
• Evaluate severity (mild, moderate, or severe) and assess for comorbid depression, as this combination changes illness course and treatment outcomes 4, 3

Treatment Algorithm Based on Severity

Mild Anxiety

• Start with non-pharmacological interventions as first-line treatment 4, 5
• Implement evidence-based psychotherapies: cognitive behavioral therapy, mindfulness therapy, or interpersonal therapy 4, 6
• Consider additional interventions including relaxation techniques, mind-body exercises (such as yoga), music therapy, and behavioral activation 7, 6
• Mindfulness therapy shows the strongest evidence for reducing both depressive and anxiety symptoms in pregnant women (SUCRA = 80% for depression) 6
• Monitor closely for symptom progression or lack of improvement within 2 weeks 4

Moderate to Severe Anxiety

• Consider combination therapy with both psychotherapy and pharmacotherapy 4, 3
• Base medication selection on previous treatment response and history of severe symptoms or suicide attempts 4, 5

Pharmacological Management

First-Line SSRI Selection

• Sertraline and citalopram are the preferred first-line SSRIs due to mixed and generally unsubstantiated associations with negative outcomes when controlled for maternal depression 1
• Avoid paroxetine and fluoxetine as they have the strongest associations with significant malformations, persistent pulmonary hypertension of the newborn (PPHN), and poor neonatal adaptation syndrome (PNAS) 1
• Paroxetine is classified as FDA pregnancy category D due to concerns about congenital cardiac malformations 2

Sertraline-Specific Considerations

• The FDA label states sertraline should be used during pregnancy only if potential benefit justifies potential risk to the fetus 8
• Neonates exposed to sertraline in late third trimester may develop complications including respiratory distress, jitteriness, irritability, feeding difficulty, hypoglycemia, and tremors, typically resolving within 1-2 weeks 2, 8
• Sertraline can be safely continued during breastfeeding as concentrations in breast milk are very low and not linked to infant complications 2, 1
• Ensure adequate dosing (therapeutic doses for at least 4-6 weeks) before determining efficacy 5

Important Safety Considerations

• The risk of untreated severe anxiety generally outweighs the minimal risks associated with SSRI use during pregnancy 5
• Women who discontinue antidepressants during pregnancy show significantly increased relapse rates compared to those who continue treatment 8
• SSRIs may increase risk of preterm delivery, though depression itself is also associated with premature birth 2
• Conflicting evidence exists regarding SSRI use after 20 weeks gestation and PPHN risk; the FDA revised its 2006 advisory in 2011 stating findings are unclear 2

Monitoring and Follow-Up

• Schedule follow-up within 1-2 weeks after initiating or changing treatment to assess symptom improvement 5
• Monitor for pregnancy complications including blood pressure (preeclampsia screening), appropriate weight gain, and fetal growth 5
• Watch for signs of serotonin syndrome if combining serotonergic medications: tremor, diarrhea, delirium, neuromuscular rigidity, and hyperthermia 2

Common Pitfalls to Avoid

• Do not underdiagnose anxiety due to difficulty distinguishing normal pregnancy worry from pathological anxiety; use validated screening tools 3
• Do not overlook comorbid conditions such as depression or ADHD that may complicate treatment response 4, 5
• Do not fail to provide psychoeducation about illness course, warning signs, and treatment options to overcome denial and stigma 4, 3
• Do not prescribe benzodiazepines as first-line treatment; they are only appropriate for short-term use in severe cases 3
• Do not discontinue effective antidepressants without careful consideration of the significantly increased relapse risk 8