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 should I take medication? It's what happens if I don't? For many women, this isn't a theoretical choice-it's a matter of survival, stability, and the ability to bond with their baby. The truth is, untreated depression during pregnancy carries serious risks, and so do some medications. But the data now shows that for most women, continuing an SSRI like sertraline is safer than stopping it.

Why SSRIs Are Commonly Used in Pregnancy

Selective Serotonin Reuptake Inhibitors, or SSRIs, are the most prescribed antidepressants for pregnant women. They include sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac). These drugs work by increasing serotonin, a brain chemical tied to mood, sleep, and emotional regulation. About 1 in 7 pregnant women experience depression or anxiety severe enough to need treatment. Left alone, these conditions can lead to preterm birth, low birth weight, poor bonding, and even suicide-the leading cause of maternal death in the U.S., responsible for 20% of pregnancy-related fatalities, according to CDC 2022 data.

SSRIs aren't perfect, but they're often the best tool available. Unlike older antidepressants, they have more predictable effects during pregnancy and don't cause dangerous interactions with other common medications. They're also the most studied class of antidepressants in pregnant women, with millions of data points from Nordic registries, U.S. birth records, and long-term child follow-ups.

The Real Risks: What the Numbers Actually Show

It's easy to get scared by headlines like "SSRIs cause birth defects." But numbers don't lie when they're looked at clearly. Let’s break it down.

Major birth defects occur in about 2.5% of all pregnancies. In pregnancies where the mother took SSRIs, the rate is 2.8%. That’s a 0.3% absolute increase. For perspective: a 0.3% increase means 3 extra cases per 1,000 births-not a dramatic spike. The only SSRI with a clear, consistent risk is paroxetine (Paxil). It's linked to a 1.5 to 2 times higher chance of heart septal defects, so it's avoided entirely in the first trimester.

Another concern is Persistent Pulmonary Hypertension of the Newborn (PPHN), a rare but serious lung condition. In the general population, it affects 1-2 out of every 1,000 babies. With SSRI exposure in the third trimester, that number rises to 3-6 per 1,000. That sounds scary, but it still means over 99% of babies exposed to SSRIs don’t develop PPHN. And here's the key: the risk is highest with fluoxetine and escitalopram, lowest with sertraline.

Preterm birth (before 37 weeks) is more common in women taking SSRIs-12.5% versus 9.5% in depressed women not on medication. But when researchers controlled for how severe the depression was, the difference shrank to almost nothing. In fact, women with severe depression who didn’t take SSRIs had a 2.2 times higher risk of preterm birth than those who did. The medication isn't the main driver-the illness is.

The Bigger Risk: What Happens When You Stop Taking SSRIs

This is where most people miss the point. Stopping an SSRI during pregnancy doesn’t make things safer-it often makes them worse.

A 2022 JAMA Psychiatry trial followed 300 pregnant women who were stable on SSRIs. Half continued their medication; half stopped. The results were stark: 92% of women who stopped had a full relapse of depression. Only 21% of those who stayed on their medication did. That’s not a small difference-it’s catastrophic for many families.

Untreated depression leads to:

• 2.2 times higher risk of preterm birth
• 25% chance of using alcohol or drugs during pregnancy (vs. 8% in treated women)
• 14.5% chance of developing postpartum depression (vs. 4.8% in treated women)
• 30% lower maternal bonding scores on the Maternal Postpartum Attachment Scale

And here’s the quiet truth: women who stop SSRIs because they’re afraid of risks often end up in the ER, in therapy, or worse. Suicide attempts during pregnancy are rare-but they’re almost always linked to untreated depression.

Which SSRI Is Safest? Sertraline Leads the Pack

Not all SSRIs are created equal. Based on current data from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM), sertraline is the first-line choice for pregnancy.

Why?

• Lowest risk of PPHN
• Minimal placental transfer-only about 60-70% of the mother’s dose reaches the baby
• Lowest risk of cardiac defects
• Best-studied safety profile in over 1.8 million births

Fluoxetine is second-line, especially if anxiety or low energy are the main symptoms. Citalopram and escitalopram are also options, but escitalopram carries slightly higher PPHN risk. Paroxetine? Avoid it. The cardiac risk is real and avoidable.

Doctors now use a simple rule: if you were stable on an SSRI before pregnancy, stay on it. Switching medications mid-pregnancy is more dangerous than staying put. A 2023 study in Obstetrics & Gynecology found that 73% of women who abruptly stopped SSRIs had withdrawal symptoms like dizziness, nausea, and "brain zaps." That’s not a minor side effect-it’s destabilizing.

What About Long-Term Effects on the Child?

This is the question that keeps parents up at night. Will my child be different? Will they have autism? Will they be more prone to depression?

Some studies say yes. Columbia University researchers found that children exposed to SSRIs in utero had a 28% rate of depression by age 15, compared to 12% in children whose mothers had depression but didn’t take medication. That sounds alarming. But here’s the catch: those same children had mothers with the most severe depression. And when researchers compared them to siblings who weren’t exposed to SSRIs, the difference vanished. Genetics, environment, maternal stress-all of it plays a role.

Meanwhile, a 2021 study in The Lancet looked at over 500,000 children and found no increased autism risk when controlling for family history. A 2022 JAMA Pediatrics study did find a small increase, but it was weakened by poor control of maternal mental health severity. The NIH’s 2023 review concluded: "The evidence for long-term neurodevelopmental harm is mixed and likely confounded by the underlying illness."

The bottom line? The biggest risk to a child’s mental health isn’t an SSRI in utero-it’s an untreated, severely depressed mother.

What Should You Do? A Practical Guide

If you're pregnant and taking an SSRI, here’s what you need to know:

1. Don’t stop cold turkey. Withdrawal can cause dizziness, nausea, anxiety, and even suicidal thoughts. Taper slowly over 4-6 weeks under medical supervision.
2. Stick with sertraline if possible. It’s the safest option. If you’re on another SSRI and doing well, don’t switch unless your doctor recommends it.
3. Avoid paroxetine. It’s the only SSRI with clear, avoidable risks.
4. Monitor your mood. Use the PHQ-9 depression screening tool every 4-6 weeks. Your mood matters more than your pill count.
5. Get support. Therapy, support groups, sleep help, and partner involvement reduce the need for higher doses.
6. Don’t be shamed. Choosing to take medication isn’t weakness-it’s responsibility.

For women considering pregnancy, talk to your doctor before conceiving. If you’re on an SSRI, it’s often better to stay on it than to risk relapse during the first trimester, when many women don’t even know they’re pregnant.

The Bottom Line: Safety Is Relative

The FDA, ACOG, SMFM, and NIH all agree on one thing: the risks of SSRIs during pregnancy are low. The risks of not treating depression? They’re not low. They’re life-threatening.

When you weigh the numbers:

• PPHN risk: 3-6 per 1,000 (SSRI) vs. 1-2 per 1,000 (general population)
• Preterm birth risk: 12.5% (SSRI) vs. 18% (untreated depression)
• Relapse risk: 92% (stopped) vs. 21% (continued)
• Suicide risk: 20% of maternal deaths linked to untreated depression

It’s not a close call. For women with moderate to severe depression, continuing an SSRI-especially sertraline-is the safer, more responsible choice. The goal isn’t to eliminate all risk. It’s to minimize the biggest risks: your life, your baby’s health, and your ability to care for them.

There’s no perfect answer. But there is a clear one: if you need an SSRI to survive pregnancy, take it. You’re not harming your baby-you’re protecting them.