SSRIs and Antidepressants During Pregnancy: What You Need to Know About Risks and Benefits

When you're pregnant and struggling with depression or anxiety, the question isn't just whether to take an SSRI - it's whether not taking one might be riskier. For many women, this isn't a theoretical debate. It's a daily decision that affects their survival, their baby's health, and their ability to bond with their newborn. The truth? The risks of untreated depression during pregnancy often outweigh the known risks of SSRIs - but only if you understand the real numbers, not the headlines.

What Are SSRIs, and Why Are They Used in Pregnancy?

SSRIs - selective serotonin reuptake inhibitors - are the most commonly prescribed antidepressants today. Drugs like sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac) work by increasing serotonin levels in the brain. Serotonin helps regulate mood, sleep, and appetite. For someone with moderate to severe depression, this isn't a luxury - it's a lifeline.

About 1 in 7 pregnant women experience depression or anxiety serious enough to need treatment. Left untreated, these conditions don't just make pregnancy harder - they can be deadly. According to CDC data from 2022, suicide accounts for 20% of all pregnancy-related deaths in the U.S. That’s more than hemorrhage or high blood pressure. And it’s not just about the mother. Untreated depression increases the risk of preterm birth by more than double, lowers birth weight, and makes postpartum depression far more likely.

The Real Risks: Numbers That Matter

When people talk about SSRI risks, they often cite scary percentages. But percentages without context are misleading. Let’s break it down with actual numbers.

Persistent Pulmonary Hypertension of the Newborn (PPHN) - a rare but serious lung condition - affects 1 to 2 out of every 1,000 babies in the general population. With SSRI use in the third trimester, that number rises to 3 to 6 per 1,000. That’s a relative increase of about 80%, but the absolute risk is still less than 1%. Compare that to untreated depression, which increases preterm birth risk by 120% - a much larger threat.

Preterm birth happens in about 9.5% of pregnant women with depression who aren’t on medication. For those taking SSRIs, it’s 12.5%. At first glance, that sounds bad. But when researchers adjust for how severe the depression was to begin with - the real driver of risk - the difference shrinks to almost nothing. In fact, women with severe depression who stop their meds have a higher chance of preterm birth than those who stay on them.

Birth defects are another big concern. Paroxetine (Paxil) is the only SSRI with a clear link to heart defects, increasing the risk from 0.5% to about 0.7-1%. That’s a small absolute increase. For all other SSRIs - including sertraline, the most commonly used - large studies of over 1.8 million births found no meaningful rise in major birth defects.

The Bigger Picture: What Happens When You Stop

The biggest mistake many women make is stopping their SSRI cold turkey because they’re afraid of the baby. That’s dangerous.

A 2022 JAMA Psychiatry study showed that women who stop SSRIs during pregnancy have a 4.3 times higher chance of their depression coming back. In fact, 92% of those who quit relapsed. Only 21% of those who kept taking their medication had a recurrence. Relapse doesn’t just mean feeling sad. It means inability to eat, sleep, care for yourself, or bond with your baby. It means higher risk of substance use - 25% of untreated depressed pregnant women use alcohol or drugs, compared to 8% of those on treatment.

And then there’s postpartum depression. If you had depression during pregnancy and didn’t treat it, your chance of postpartum depression jumps to 14.5%. If you were treated with an SSRI? That drops to 4.8%. That’s a 67% reduction in risk.

Which SSRI Is Safest?

Not all SSRIs are the same. Sertraline is the first-line choice for pregnancy because it has the lowest placental transfer rate - meaning less of the drug crosses to the baby. Studies show cord blood levels are nearly equal to the mother’s, which is actually better than drugs that build up in the fetus. It’s also the SSRI with the lowest risk of PPHN.

Citalopram and escitalopram are also considered safe. Fluoxetine stays in the body longer, so it’s often used when adherence is a concern, but it can accumulate in the baby, leading to more neonatal adaptation symptoms.

Paroxetine? Avoid it. The cardiac defect risk, though small, is real and consistent across studies. Even if you’re not in your first trimester, switching to sertraline is recommended if you’re still on paroxetine.

What About Long-Term Effects on the Child?

This is where things get murky. Some studies suggest children exposed to SSRIs in utero may have slightly higher rates of anxiety or depression by age 15. One Columbia University study found 28% of these children developed depression by adolescence, compared to 12% in children whose mothers had depression but didn’t take SSRIs.

But here’s the catch: those same children’s mothers had more severe depression. And genetics play a huge role. A 2021 Lancet study that controlled for family history - including whether the father had depression - found no link between SSRIs and autism or major developmental delays. The risk, if any, appears tied more to the mother’s mental illness than the medication.

The NIH’s 2023 review concluded: “The available data do not support a causal link between SSRI exposure and long-term neurodevelopmental harm.” That doesn’t mean we ignore the possibility - it means we weigh it against the known harm of untreated illness.

What Should You Do If You’re Pregnant and on an SSRI?

If you’re already taking an SSRI and find out you’re pregnant, do not stop. Talk to your doctor immediately. Here’s what to expect:

• Stick with your current medication if it’s working - switching can trigger relapse.
• If you’re on paroxetine, switch to sertraline as soon as possible.
• Use the lowest effective dose. Many women do fine on 50mg of sertraline daily.
• Monitor for gestational hypertension - it’s slightly more common with SSRIs (8.5% vs. 6.2% in non-users), so weekly blood pressure checks after 20 weeks are recommended.
• Don’t stop abruptly. Withdrawal symptoms - dizziness, nausea, “brain zaps” - happen in 73% of women who quit cold turkey.

What If You’re Not on Medication But Think You Need It?

If you’re pregnant, feeling hopeless, unable to sleep, or crying most days - you don’t have to suffer alone. Depression isn’t weakness. It’s a medical condition.

Talk to your OB-GYN or a perinatal psychiatrist. Therapy (like CBT) can help, but for moderate to severe cases, medication is often necessary. SSRIs are not a cure-all, but they’re one of the most effective tools we have.

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) both say: for women with moderate to severe depression, the benefits of SSRIs outweigh the risks. That’s not an opinion - it’s based on data from millions of pregnancies.

The Bottom Line

You’re not choosing between a safe drug and a dangerous one. You’re choosing between two risks: the risk of a medication with low, measurable side effects - and the risk of untreated depression, which carries far higher odds of harming you and your baby.

Sertraline is safe. Fluoxetine is safe. Paroxetine is not. Stopping your meds is riskier than staying on them. The data doesn’t lie. The fear does.

Your mental health matters as much as your baby’s physical health. Treating depression isn’t selfish - it’s the most protective thing you can do for your child.