Best SSRI Alternative to Sertraline for Women Trying to Conceive
Citalopram is the best alternative SSRI for a woman trying to get pregnant who cannot tolerate sertraline. 1, 2
First-Line Recommendation
If sertraline is not tolerated, switch to citalopram as the next preferred SSRI. 1, 2 The American Academy of Pediatrics identifies citalopram as an acceptable first-line alternative alongside sertraline, though the evidence base is not quite as robust as for sertraline. 2
SSRIs to Avoid
Paroxetine should be avoided in women planning pregnancy or who are pregnant. 1, 3 The FDA assigned paroxetine pregnancy category D classification in 2005 due to concerns about cardiac malformations, and the American College of Obstetricians and Gynecologists specifically recommends avoiding paroxetine in this population. 1, 3
Fluoxetine deserves caution and should be avoided when possible. 4, 5 Fluoxetine has the strongest association with negative pregnancy outcomes including significant malformations, persistent pulmonary hypertension of the newborn (PPHN), and poor neonatal adaptation syndrome (PNAS). 4 Additionally, fluoxetine exposure is associated with 24% reduced fecundability and significantly lower live birth rates compared to other SSRIs. 5
Dosing Strategy
- Start citalopram at the lowest effective dose and maintain throughout pregnancy. 1, 2 The goal is to use the minimum dose that controls symptoms, as continuing SSRI treatment during pregnancy at low doses is safer than withdrawal, which may have harmful effects on the mother-infant dyad. 1, 2
Safety Profile of Citalopram
Citalopram has a mixed but generally favorable safety profile during pregnancy. 4 When studies showing associations with negative outcomes are controlled for maternal depression and associated confounding factors, the associations between citalopram and adverse outcomes remain unsubstantiated. 4
No increased risk of major cardiac malformations has been demonstrated with first-trimester citalopram use in large population-based studies. 1
Expected Neonatal Effects
Approximately one-third of infants exposed to any SSRI (including citalopram) in utero will experience neonatal adaptation syndrome. 6 Symptoms include irritability, jitteriness, tremors, feeding difficulty, sleep disturbance, and respiratory distress. 1, 6
These symptoms typically appear within hours to days after birth and usually resolve within 1-2 weeks without intervention. 1, 6
Infants should be monitored for at least 48 hours after birth with early follow-up arranged after hospital discharge. 6
Critical Pitfall to Avoid
Do not discontinue SSRI treatment altogether due to fear of medication risks. 1 Untreated depression during pregnancy carries substantial documented risks including premature birth, decreased breastfeeding initiation, harm to the mother-infant relationship, and in severe cases, suicide and infanticide. 2, 6
The risks of untreated psychiatric illness during pregnancy outweigh the medication exposure risks in most cases. 2