What antidepressant medications are safe for use during pregnancy?

From the Guidelines

Selective serotonin reuptake inhibitors (SSRIs) are considered relatively safe for treating depression during pregnancy, with sertraline (Zoloft) often being the first choice, as it has a relatively low risk of neonatal drug withdrawal and is effective in managing depression 1. When considering antidepressant use during pregnancy, it's essential to weigh the potential risks and benefits, including the risk of untreated depression, which can lead to poor prenatal care, inadequate nutrition, and increased substance use 1. The decision to use medication should be individualized based on depression severity, prior response to medications, and patient preference, with regular monitoring throughout pregnancy and dosage adjustments as needed due to physiological changes affecting drug metabolism. Some key points to consider when prescribing SSRIs during pregnancy include:

• Starting with a low dose, such as 25-50mg daily, and gradually increasing as needed
• Considering the risk of neonatal drug withdrawal, which can manifest as continuous crying, irritability, and jitteriness, and arranging for early follow-up after hospital discharge
• Counseling women on the risks and benefits of breastfeeding while taking SSRIs, as some SSRIs, such as paroxetine, have a lower ratio of infant to maternal plasma concentrations
• Providing services to women with depressive and anxiety disorders and their children to reduce the risk of offspring neurodevelopmental problems, such as autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) 1. Women should never discontinue antidepressants abruptly without medical consultation, as this can lead to harmful effects on the mother-infant dyad 1. In terms of specific medications, fluoxetine (Prozac) and citalopram (Celexa) are also reasonable options, while bupropion (Wellbutrin) and venlafaxine (Effexor) may be considered in certain cases, such as when a woman has responded well to them previously 1. Ultimately, the goal is to balance the risks and benefits of medication use during pregnancy and provide individualized care to support the health and well-being of both mother and baby.

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 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 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.

Drugs safe in pregnancy for depression:

• Sertraline may be used during pregnancy if the potential benefit justifies the potential risk to the fetus 2.
• The decision to use sertraline during pregnancy should be made on a case-by-case basis, considering the potential risks and benefits of treating depression with an antidepressant.
• Key considerations:
  • Potential risks to the fetus
  • Established benefits of treating depression with an antidepressant
  • Increased risk of relapse of major depression if antidepressant medication is discontinued during pregnancy

From the Research

Drugs Safe in Pregnancy for Depression

The following SSRIs are considered to be relatively safe for use in pregnancy:

• Sertraline: This medication has been shown to have a low risk of negative outcomes, such as significant malformations, PPHN, and PNAS, when used during pregnancy 3.
• Citalopram: Similar to sertraline, citalopram has been found to have a mixed association with negative outcomes, but the risks are generally unsubstantiated when controlled for maternal depression and associated factors 3.

Comparison of SSRIs

A literature review comparing the reproductive safety profiles of different SSRIs found that:

• Paroxetine and fluoxetine have the strongest association with negative outcomes, such as significant malformations, PPHN, and PNAS 3.
• Escitalopram and fluvoxamine have limited studies, making it difficult to draw definite conclusions regarding their safety during pregnancy 3.

Treatment of Depression in Pregnant Women

Optimal treatment of perinatal depression includes:

• Close symptom monitoring and medication adjustments to maintain symptom remission 4.
• A balanced discussion of the risks of both drug exposure and untreated depression 4.
• Consideration of cognitive-behavioral therapy (CBT) as an alternative or adjunct to medication 5, 6.

Breastfeeding Considerations

• Sertraline can be continued during breastfeeding, as the concentration found in breast milk is very low and has not been linked to infant complications 3.