SSRIs and Antidepressants During Pregnancy: What the Evidence Really Shows

When you're pregnant and struggling with depression or anxiety, the question isn't just should I take medication? It's: What happens if I don't? For many women, this isn't a theoretical debate-it's a daily, high-stakes choice between managing their mental health and fearing harm to their baby. The truth? The risks of untreated depression during pregnancy are often far greater than the risks of taking certain antidepressants.

Why Untreated Depression Is Dangerous in Pregnancy

Depression during pregnancy isn't just feeling sad. It can lead to poor nutrition, missed prenatal visits, substance use, and even suicide. In the U.S., suicide is the leading cause of pregnancy-related death, accounting for 20% of all maternal deaths, according to CDC data from 2022. Women with untreated depression are 2.2 times more likely to give birth prematurely. Their babies are more likely to have low birth weight and struggle with bonding after birth.

Postpartum depression is also far more likely if depression isn't treated during pregnancy. About 14.5% of women with untreated antenatal depression develop postpartum depression, compared to just 4.8% of those who receive treatment. That’s a threefold difference. And it’s not just emotional-it affects feeding, sleep, and the baby’s development. Studies show mothers with untreated depression score 30% lower on attachment scales, which predict long-term emotional and cognitive outcomes for the child.

What Are SSRIs, and Which Ones Are Used in Pregnancy?

SSRIs-Selective Serotonin Reuptake Inhibitors-are the most commonly prescribed antidepressants during pregnancy. They work by increasing serotonin levels in the brain, which helps regulate mood. The first SSRI, fluoxetine (Prozac), was approved in 1987. Since then, several others have become standard options.

Not all SSRIs are the same when it comes to pregnancy. Sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac) are considered first-line choices. They’ve been studied in hundreds of thousands of pregnancies and show no clear link to major birth defects. Paroxetine (Paxil), however, is avoided. It carries a slightly higher risk-about 1.5 to 2 times greater-of causing heart defects in the baby when taken during the first trimester. The absolute risk is still low: rising from 0.5% in the general population to 0.7-1.0% with paroxetine use.

Sertraline is often the go-to because it crosses the placenta less than others, with cord blood levels close to maternal levels (0.9-1.1 ratio). That means less fetal exposure. It’s also the SSRI with the lowest reported risk for persistent pulmonary hypertension of the newborn (PPHN), a rare but serious lung condition.

The Real Risks: What the Data Actually Says

The biggest fear? Birth defects. But large studies of 1.8 million births in Nordic countries and the U.S. found no meaningful increase in major congenital malformations with SSRI use. The rate was 2.8% in exposed pregnancies versus 2.5% in unexposed-essentially the same.

Another concern is PPHN. In the general population, it affects 1-2 out of every 1,000 newborns. With SSRI use in the third trimester, that number rises to 3-6 per 1,000. That sounds alarming, but it’s still rare. For comparison, smoking during pregnancy increases PPHN risk by 4 times. The key is knowing the absolute risk, not just the relative increase.

Preterm birth and low birth weight are also slightly more common in women taking SSRIs. But here’s the catch: women who take SSRIs often have more severe depression-and depression itself increases these risks. When researchers adjusted for depression severity, the link to preterm birth disappeared. The same goes for Apgar scores and neonatal complications. The medication isn’t the main driver; the illness is.

The Bigger Picture: Benefits Outweigh Risks

If you stop your SSRI during pregnancy, your chance of relapse is over 90%. In one 2022 JAMA Psychiatry trial, 92% of women who stopped their medication had a depressive episode return. Only 21% of those who kept taking it did. That’s not just feeling down-it’s risking hospitalization, self-harm, or inability to care for yourself or your baby.

Continuing treatment cuts the risk of preterm birth in half compared to stopping. It reduces postpartum depression by more than two-thirds. It lowers the chance of substance use during pregnancy-from 25% in untreated women to 8% in those receiving treatment. And it improves mother-infant bonding, which is critical for brain development in the first year of life.

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) both say clearly: for women with moderate to severe depression, the benefits of continuing SSRIs outweigh the risks. The FDA’s 2025 advisory panel agreed, noting that absolute risks remain low and shouldn’t be overstated.

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 adolescence. One Columbia University study found 28% of these children developed depression by age 15, compared to 12% in children whose mothers had depression but didn’t take SSRIs. But here’s the problem: those mothers likely had more severe illness.

Other studies, including a 2021 Lancet analysis, looked at siblings-one exposed, one not-and found no difference in autism or depression rates. That suggests genetics and environment, not the medication, may be the real factor. The NIH review in 2023 concluded: “Mixed evidence exists, but no clear causal link has been established.”

Animal studies sometimes get cited to scare people, but they don’t reflect human complexity. As SMFM put it in 2024: “Animal models can’t replicate the interplay of genetics, environment, and maternal mental health.”

What Should You Do? A Practical Guide

If you’re on an SSRI and planning pregnancy-or already pregnant-don’t stop abruptly. Withdrawal can cause dizziness, nausea, brain zaps, and worsen depression. A 2023 study found 73% of women who quit cold turkey had withdrawal symptoms.

Here’s what experts recommend:

1. Stick with your current SSRI if it’s working. Switching meds adds unnecessary risk.
2. Use sertraline as your first choice if starting now. It has the best safety profile.
3. Avoid paroxetine in the first trimester.
4. Use the lowest effective dose. More isn’t better.
5. Monitor for gestational hypertension-SSRI users have a slightly higher risk (8.5% vs. 6.2%). Weekly blood pressure checks after 20 weeks are advised.
6. If you want to stop, taper slowly over 4-6 weeks with weekly depression screenings (PHQ-9).

Don’t be swayed by scary headlines. The real danger isn’t sertraline-it’s untreated depression. A 2023 ACOG statement called out FDA panels for being “alarmingly unbalanced,” focusing only on risks while ignoring the consequences of doing nothing.

What’s Next? Research on the Horizon

In September 2025, the NIH launched a $15 million study tracking 10,000 mother-child pairs to see how SSRI exposure affects brain development into adolescence. Results won’t come until 2030, but they’ll help personalize care.

Future tools may include genetic testing. About 40% of people have variations in CYP2D6 or CYP2C19 genes that affect how they metabolize SSRIs. That could help doctors pick the right drug and dose before pregnancy even begins.

There’s also work on new SSRIs designed to cross the placenta less. And better protocols for managing neonatal adaptation syndrome-a temporary condition affecting 30% of exposed newborns, with jitteriness, irritability, or mild breathing issues that resolve in 1-2 weeks.

Final Thoughts: It’s About Balance, Not Fear

There’s no perfect choice. But the evidence is clear: for women with moderate to severe depression, staying on an SSRI is safer than stopping. The risks of the medication are small, measurable, and often overstated. The risks of depression are large, real, and life-threatening.

Work with your doctor. Use sertraline if you can. Don’t quit without a plan. And remember: taking care of your mental health isn’t selfish-it’s the best thing you can do for your baby.