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

When you’re pregnant and managing a mental health condition, the question isn’t just whether to take medication-it’s how to decide, with your provider, what’s best for you and your baby. There’s no easy answer. Stopping your meds might feel safer, but untreated depression, anxiety, or bipolar disorder carries real risks too. The truth? There is no risk-free option. The goal isn’t to avoid all medication. It’s to make a clear, informed choice-based on your life, your history, and the latest science.

Why Shared Decision-Making Matters

For years, pregnant people were told to stop their psychiatric meds “just in case.” Many did. And many paid the price. Studies show that when women with depression stop their SSRIs during pregnancy, up to 80% relapse. That’s not just feeling down-it’s hospitalizations, suicidal thoughts, and babies born too early. One large review found that untreated mental illness increases the chance of preterm birth by 30-50%. That’s higher than the risk tied to most medications.

Shared decision-making flips the script. Instead of a doctor telling you what to do, you and your provider sit down with facts, numbers, and your values. You talk about your past episodes, how bad your symptoms get, what you’re scared of, and what you’re willing to risk. This isn’t a one-time chat. It’s an ongoing conversation that starts before conception if possible, and keeps going through pregnancy and after birth.

What Medications Are Actually Safe?

Not all psychiatric drugs are created equal in pregnancy. Some have decades of data behind them. Others? We’re still learning.

SSRIs are the go-to for depression and anxiety. Sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac) are the most studied. Most show no clear link to birth defects. The one exception? Paroxetine (Paxil). It’s linked to a slightly higher chance of heart defects-about 10 in every 1,000 births instead of the usual 8. That’s a small increase, but enough that most providers avoid it in early pregnancy.

For bipolar disorder, lamotrigine is often the first choice. It doesn’t raise the risk of major birth defects. Lithium works too, but your body changes during pregnancy-your kidneys process it differently. That means your dose needs constant checking. Blood levels must be monitored every few weeks. Valproic acid (Depakote)? Avoid it. It can cause neural tube defects in 1-2% of babies. That’s 10 to 20 times higher than normal. The American Psychiatric Association says it shouldn’t be used in women who could get pregnant.

Bupropion (Wellbutrin) has a small but real link to miscarriage and heart issues. Tricyclics like nortriptyline are older but still used when SSRIs don’t work. For psychosis, older antipsychotics like haloperidol and chlorpromazine have better safety data than newer ones. Atypicals like risperidone or quetiapine? We don’t know enough about long-term child development. So they’re not first-line unless absolutely needed.

Risks Are Often Overstated-Here’s Why

A big problem in this field? Confounding by indication. That’s a fancy way of saying: when researchers compare pregnant women on meds to those not on meds, they forget to account for how sick the women were to begin with.

A 2024 umbrella review in Nature looked at 78 studies and found that when they adjusted for the severity of the underlying mental illness, many of the supposed risks from medications disappeared. The real danger wasn’t the drug-it was the untreated illness.

Think of it this way: a woman with severe depression who stops her meds might not eat well, skip prenatal visits, smoke, or use alcohol. Those things raise risks too. But if you only look at the medication, you blame the pill instead of the illness.

That’s why experts say: don’t assume meds are the problem. Ask: what’s the risk of not treating this?

What the Data Really Says

Numbers matter. Vague warnings like “may cause birth defects” aren’t helpful. You need real numbers.

• SSRIs and small for gestational age (SGA): 1.5 times higher odds. That means if 8 out of 100 babies are usually small, it might go up to 12 out of 100.
• Paroxetine and heart defects: 8 per 1,000 births normally → 10 per 1,000 with exposure. That’s a 2-in-1,000 increase.
• Valproic acid and neural tube defects: 0.1% baseline → 1-2% with exposure. That’s a 10-20x jump.
• Relapse risk after stopping SSRIs: up to 80% during pregnancy.
• Untreated depression and preterm birth: 30-50% higher risk.

These aren’t scary odds. They’re manageable. And they’re better understood than ever thanks to the National Pregnancy Registry for Psychiatric Medications, which has tracked over 15,700 pregnancies since 2010. That data is updated quarterly and now powers the ACOG-endorsed Mental Health Medication Decision Aid-a tool providers use to show patients exact risks based on their medication.

What You Should Do Before and During Pregnancy

If you’re planning to get pregnant, don’t wait until you’re pregnant to talk about meds. Start now.

• Get stable first. If you can stay symptom-free for at least 3 months before conception, your relapse risk drops by 40%.
• Ask for the decision aid. Request the ACOG tool. It breaks down risks for 24 medications in plain language.
• Track your symptoms. Use the Edinburgh Postnatal Depression Scale (EPDS) to measure your mood before and during pregnancy. It’s simple, free, and widely used.
• Plan for setbacks. What if your anxiety spikes at week 20? What if you can’t sleep? Have a backup plan: therapy, support groups, a crisis line, or a quick med adjustment.

And if you’re already pregnant and thinking of stopping? Don’t. Call your provider first. The Perinatal Clinical Liaison service at the University of Washington has a simple rule: “If you’re thinking of stopping your patient’s meds because they’re pregnant-call us first.” Why? Because stopping often trades one risk for a bigger one.

What Real Women Are Saying

Surveys and online communities tell a clear story: many women feel unheard.

• 68% of women in the National Pregnancy Registry say they weren’t properly informed about risks before getting pregnant.
• 42% stopped their meds on their own because they were scared of birth defects.
• On Reddit’s r/PostpartumDepression, 78% of 1,243 posts said they felt pressured to quit meds-even when they were barely holding on.
• Women who had structured shared decision-making were 3.2 times more likely to stick with treatment and had 37% lower depression scores at 6 weeks postpartum.

This isn’t about being “strong” or “brave.” It’s about having the facts, feeling respected, and knowing you’re not alone. You’re not choosing between you and your baby. You’re choosing how to care for both.

The Bigger Picture

More providers are catching on. In 2015, only 42% of OB-GYNs consulted a perinatal psychiatrist. Now, 87% do. That’s progress.

The FDA got rid of the old A-B-C-D-X letter categories in 2015 because they were misleading. Now, labels give real data: “Risk of neural tube defects increased with valproic acid.” No more vague warnings.

And soon, it’ll get even better. A 2023 pilot study at Massachusetts General Hospital used machine learning to predict individual responses to meds with 82% accuracy. By 2026, your provider might be able to say: “Based on women like you-32, first pregnancy, history of two depressive episodes, on sertraline-your relapse risk if you stop is 76%. The risk of a heart defect with paroxetine is 1%. Here’s what we know.”

Final Thoughts

You don’t have to choose between being a good mom and taking care of yourself. You can be both. But it takes the right conversation. The right data. The right support.

If you’re pregnant and on mental health meds, ask:

• What’s my risk of relapse if I stop?
• What’s the actual risk of this medication-not just “maybe harmful”?
• Do I have a plan if things get worse?
• Can I see a perinatal psychiatrist?

You deserve to feel safe, stable, and heard. That’s what shared decision-making is for. Not to scare you. Not to push pills. But to give you the power to choose-with clarity, confidence, and care.

If you’re currently pregnant and managing mental health meds, remember: you’re not alone. Thousands of women have walked this path. With the right support, the right data, and the right conversation, you can protect your mental health-and your baby’s future.