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. Every year, 1 in 7 pregnant women in the U.S. experiences a major depressive episode. For many, the weight of untreated illness-fatigue, hopelessness, panic attacks, even thoughts of self-harm-is heavier than the fear of medication. So what does the science actually say about SSRIs like sertraline, citalopram, or fluoxetine during pregnancy? Let’s cut through the noise.

Why SSRIs Are Commonly Used in Pregnancy

SSRIs, or selective serotonin reuptake inhibitors, were designed to help balance brain chemistry by increasing serotonin levels. They’re not just for severe depression. Many women take them for anxiety, OCD, or panic disorders that flare up during pregnancy. The first SSRI, fluoxetine (Prozac), hit the market in 1987. Since then, millions of pregnant women have used them-and the data has slowly caught up.

The real reason doctors recommend them isn’t because they’re perfect. It’s because untreated depression is far more dangerous. 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 preeclampsia. Untreated depression also increases the risk of preterm birth by more than double, and it’s the strongest predictor of postpartum depression. One study found that 14.5% of women with untreated antenatal depression develop postpartum depression-compared to just 4.8% of those who stayed on treatment.

The Biggest Risks: What the Data Shows

No medication is risk-free. But when we look at the numbers, the risks are small-and often misunderstood.

One concern is persistent pulmonary hypertension of the newborn (PPHN). This rare but serious lung condition affects about 1-2 in 1,000 babies overall. With SSRI use in the third trimester, that number rises to 3-6 in 1,000. That sounds scary, but let’s put it in perspective: even with increased exposure, the absolute risk is still under 1%. Most babies with PPHN recover fully with treatment.

Another issue is preterm birth. Some studies show a 1.4-fold increase in preterm delivery among women taking SSRIs. But here’s the key: when researchers adjust for how severe the depression was to begin with, that risk drops almost to zero. In other words, it’s not the medication-it’s the illness-that’s pushing labor early.

Low birth weight and low Apgar scores are also slightly more common, but again, these differences vanish when you compare women with depression who took SSRIs to those with depression who didn’t. The real difference? Between women with depression (treated or not) and women without depression at all.

Paroxetine Is the Exception

Not all SSRIs are created equal. Paroxetine (Paxil) is the only one with a clear, consistent link to birth defects-specifically heart septal defects. Studies show it increases the absolute risk from about 0.5% to 0.7-1.0%. That’s still low, but it’s enough for guidelines to say: avoid it in the first trimester if possible. If you’re on paroxetine and planning pregnancy, talk to your doctor about switching. Sertraline, citalopram, and escitalopram don’t carry that same risk.

Sertraline Is the First-Line Choice

Why is sertraline (Zoloft) recommended first? Because it crosses the placenta less than other SSRIs. Studies show cord blood levels are nearly equal to maternal levels-meaning less drug reaches the baby. It’s also the safest when it comes to PPHN risk among SSRIs. Dosing is straightforward: start at 25-50 mg daily, increase slowly if needed, up to 150-200 mg. Most women do well on the lower end.

Fluoxetine (Prozac) is a second-line option. It stays in the body longer, which can be helpful for women who miss doses-but it also means it lingers in the newborn. That’s why some doctors avoid it near delivery, especially if the baby might be sensitive to withdrawal symptoms.

What About Long-Term Effects on the Child?

This is where things get messy. Some studies suggest children exposed to SSRIs in utero might have slightly higher rates of anxiety or depression by age 15. One Columbia University study found 28% of exposed children developed depression by adolescence, compared to 12% of children whose mothers had depression but didn’t take SSRIs. But here’s the catch: those mothers were likely more severely ill. And when researchers compared exposed children to siblings who weren’t exposed, the difference disappeared.

A 2021 Lancet study looked at families with genetic risk for autism and found no increased risk from SSRIs. Other large studies-including one tracking 1.8 million births in Nordic countries-found no link between SSRIs and autism when they controlled for family history and maternal mental health severity.

The bottom line? There’s no smoking gun. The data doesn’t prove SSRIs cause long-term harm. But it also doesn’t prove they’re completely harmless. That’s why experts say: if you need them, use them. But if you don’t, don’t start them just because you can.

What Happens If You Stop?

Stopping SSRIs cold turkey during pregnancy is one of the riskiest choices you can make. A 2022 JAMA Psychiatry trial showed that 92% of women who stopped their medication relapsed into depression-compared to only 21% who stayed on it. Relapse isn’t just about feeling sad. It means skipping prenatal visits, not eating well, using alcohol or drugs, and even neglecting the baby after birth.

Abruptly quitting can also cause withdrawal symptoms: dizziness (42%), nausea (38%), and what patients call “brain zaps” (29%). These aren’t imaginary. They’re real, uncomfortable, and can last for weeks. If you’re thinking about stopping, work with your doctor on a slow taper over 4-6 weeks. Test your mood weekly with the PHQ-9 questionnaire. If your score climbs above 10, you’re likely relapsing.

What About Breastfeeding?

SSRIs are generally safe while breastfeeding. Sertraline passes into breast milk in the smallest amounts. Most babies show no signs of exposure. Fluoxetine is the worst offender here-it builds up in breast milk over time. If you’re breastfeeding, sertraline or citalopram are preferred.

A 2023 review found no evidence of developmental delays, sleep problems, or feeding issues in babies exposed to SSRIs through breast milk. The American Academy of Pediatrics lists SSRIs as compatible with breastfeeding. If your baby seems unusually fussy or sleepy, talk to your pediatrician-but don’t assume it’s the medication without checking.

What Should You Do?

There’s no one-size-fits-all answer. But here’s what the experts agree on:

• If you have moderate to severe depression or anxiety, continuing an SSRI is usually safer than stopping.
• Use sertraline as your first choice. Avoid paroxetine.
• Take the lowest effective dose. Don’t increase unless necessary.
• Don’t switch medications mid-pregnancy unless there’s a clear reason.
• Monitor your mood weekly. Use the PHQ-9. If your score goes above 10, reach out.
• If you’re breastfeeding, stick with sertraline or citalopram.

The Bigger Picture

The FDA’s labeling rules changed in 2015 to stop using vague categories like “Category C” and instead give clear, data-driven summaries. That’s why you now see phrases like “no substantial evidence of increased major birth defects” instead of “may be harmful.”

The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine both say the same thing: untreated mental illness poses a greater threat to mother and baby than SSRIs. In July 2025, ACOG publicly criticized an FDA panel for ignoring the benefits of SSRIs, calling their approach “alarmingly unbalanced.”

Meanwhile, the NIH is launching a $15 million study in 2025 to track 10,000 mother-child pairs over 15 years. We’ll know more in a decade. But right now, the evidence is clear enough to make a decision.

Final Thoughts

You’re not choosing between a perfect, risk-free option and a dangerous one. You’re choosing between two imperfect paths: managing your mental health with medication, or risking the consequences of untreated illness. For most women, the scale tips heavily toward continuing treatment.

If you’re scared, that’s normal. Talk to your OB, your psychiatrist, your therapist. Ask for the numbers. Ask for the studies. Don’t let fear or guilt make the decision for you. Your mental health matters. Your baby’s health matters. And sometimes, taking a pill is the most loving thing you can do-for yourself, and for them.