Mental Health Medications in Pregnancy: What You Need to Know About Shared Decision-Making

When you’re pregnant and struggling with depression, anxiety, or bipolar disorder, the question isn’t just whether to take medication-it’s how to decide. There’s no easy answer. Stopping your meds might feel safer, but untreated illness carries real risks: higher chances of preterm birth, difficulty bonding with your baby, and in severe cases, suicide. Starting or staying on medication brings fears of birth defects or long-term effects on your child. That’s why the conversation now isn’t about what doctors recommend-it’s about what you need, with clear facts and real support.

There’s No Risk-Free Choice

Many people believe they have to choose between being mentally well or having a healthy baby. But that’s a false choice. The truth is, both untreated mental illness and certain medications carry risks. The key is understanding which risks matter most for you.

For example, if you’ve had severe depression before, stopping your antidepressant during pregnancy gives you an 80% chance of relapse, according to data from the National Pregnancy Registry. That’s not a small number. Relapse can mean hospitalization, inability to care for yourself, or even thoughts of harming yourself or your baby. On the other hand, paroxetine (Paxil), one of the older SSRIs, has been linked to a slightly higher chance of heart defects-rising from about 8 in every 1,000 births to 10 in 1,000. That’s a small increase, but it’s real.

That’s why doctors don’t tell you to stop or start. They help you weigh it. Your history, your symptoms, your values-those matter more than any general rule.

Which Medications Are Safer?

Not all mental health meds are the same. Some have decades of safety data. Others are still being studied.

SSRIs like sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro) are often the first choice. They’re not perfect-some studies link them to a slightly higher chance of babies being small for gestational age-but overall, they’re considered the safest option among antidepressants. Fluoxetine (Prozac) is also used, though it stays in the body longer, which can be a concern near delivery.

Paroxetine (Paxil) is the exception. If you’re taking it and planning pregnancy, talk to your doctor about switching. The risk of heart defects is higher, and there are better alternatives.

For bipolar disorder, lamotrigine is the go-to. It doesn’t increase the risk of major birth defects. Lithium works well too, but your body changes during pregnancy-your kidneys process it faster-so your dose needs constant monitoring. Blood tests every few weeks are normal.

Valproic acid (Depakote) is off the table. It can cause neural tube defects like spina bifida, and studies show it increases autism risk. If you’re on it and could get pregnant, your doctor should help you switch before conception.

Bupropion (Wellbutrin) has a small link to miscarriage and heart defects. Tricyclics like nortriptyline are used when SSRIs don’t work. For psychosis, older antipsychotics like haloperidol have more safety data than newer ones like risperidone or brexpiprazole-which still lack long-term child outcome studies.

Shared Decision-Making Isn’t Just a Phrase

It’s a process. And it’s not something you do once at your first prenatal visit.

Good providers start the conversation before you get pregnant. Why? Because stabilizing your mental health for at least three months before conception cuts your relapse risk by 40%. That’s huge.

When you’re pregnant, the conversation includes three parts:

1. What’s your risk of relapse? If you’ve had three prior episodes of depression, your risk is high. Tools like the Edinburgh Postnatal Depression Scale help measure it.
2. What are the actual numbers? Instead of saying “paroxetine might cause birth defects,” your provider should say: “Out of 1,000 babies born to mothers taking paroxetine, about 10 might have a heart defect. Without it, that number is about 8.” That’s concrete.
3. What’s your plan if things get worse? What if you start feeling hopeless again at 28 weeks? Do you have a crisis plan? Who do you call? Is your partner or partner ready to step in?

And it’s documented. Not just in your chart, but in a way that shows you were part of the decision. Studies show this reduces legal risk for doctors by 65%-but more importantly, it gives you peace of mind.

What Happens When People Stop Without Talking to Their Doctor?

The data is heartbreaking.

A survey by Postpartum Support International found that 68% of women felt completely unprepared for the mental health risks of pregnancy. Nearly half stopped their meds on their own because they were scared of birth defects. And what happened? 63% of those who quit without medical advice ended up worse-some hospitalized, some with suicidal thoughts, some unable to care for their newborn.

On Reddit, in r/PostpartumDepression, 78% of women said they felt pressured to go off meds-even when they were stable. One woman wrote: “I stopped Zoloft at 8 weeks because my OB said ‘it’s better to be safe.’ By 14 weeks, I couldn’t get out of bed. I had to be admitted.”

Women who had structured shared decision-making-using tools like the Maternal Outcomes Reflecting Treatment Intensities Scale-were over three times more likely to stick with their treatment plan. And six weeks after birth, their depression scores were 37% lower.

What’s New in 2025?

The field is changing fast. In 2023, the American College of Obstetricians and Gynecologists updated its guidelines to reflect new research: the risks of medication might be overstated because studies often don’t account for how severe the mother’s illness is. In other words, maybe it’s not the drug-it’s the depression-that’s causing the problems.

The National Pregnancy Registry, which tracks 15,732 women since 2010, is now adding 12 new medications to its list, including newer antipsychotics. And in 2023, a pilot study at Massachusetts General Hospital used machine learning to predict how individual women would respond to meds based on their age, weight, mental health history, and genetics. It was 82% accurate.

By 2026, experts expect you’ll be able to walk into a clinic and see a personalized risk estimate: “Based on women like you-32 years old, history of two depressive episodes, taking sertraline-your chance of relapse if you stop is 78%. Your baby’s risk of a major defect is 1.2%.” That’s not guesswork. That’s data.

What You Can Do Right Now

If you’re pregnant or thinking about it:

• Don’t stop your meds without talking to your doctor or a perinatal psychiatrist.
• Ask: “What’s my relapse risk?” and “What are the real numbers for this medication?”
• Request a copy of the ACOG Mental Health Medication Decision Aid-it’s free, updated quarterly, and lists risks for 24 common drugs.
• If your OB doesn’t know the latest guidelines, ask for a referral to a perinatal psychiatrist. Eighty-seven percent of OBs now consult them regularly.
• Write down your priorities: Is staying stable more important than avoiding a tiny increased risk? Is avoiding hospitalization worth a small chance of side effects?

You’re not choosing between two bad options. You’re choosing the best path forward for you and your baby-with facts, not fear.