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. Around 1 in 7 pregnant women experience depression or anxiety severe enough to need treatment. But the fear of harming the baby often leads to silence, or worse, stopping medication cold turkey. That’s not just risky-it’s dangerous.

What SSRIs Actually Do

SSRIs, or selective serotonin reuptake inhibitors, are the most common type of antidepressant used today. They work by helping your brain hold onto more serotonin, a chemical that affects mood, sleep, and appetite. Medications like sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac) have been used for decades. Fluoxetine was the first, approved in 1987. Since then, millions of pregnant women have taken them. And the data? It’s clearer now than ever.

These drugs cross the placenta, but not as much as you might think. Sertraline, for example, transfers at about 60-70% efficiency from mother to baby. That’s enough to help, but not so much that it floods the fetal system. The key is using the lowest dose that works. Most doctors start with 25-50 mg of sertraline daily and adjust slowly.

The Real Risk: Untreated Depression

The biggest danger isn’t the medication-it’s the illness itself. Untreated depression during pregnancy increases the risk of preterm birth by more than double. It raises the chance of low birth weight. It makes postpartum depression far more likely-nearly 15% of women with untreated antenatal depression develop it, compared to just 5% when treated.

And then there’s suicide. In the U.S., suicide accounts for 20% of all pregnancy-related deaths. That’s not a footnote. It’s the leading cause. Substance use also spikes: 25% of untreated depressed pregnant women turn to alcohol or drugs, compared to 8% of those on treatment. Bonding with your baby? That’s harder, too. Studies show mothers with untreated depression score 30% lower on attachment scales after birth.

When you stop your SSRI during pregnancy, the relapse rate is terrifying. One 2022 study found that 92% of women who stopped their medication had a full depressive relapse. Only 21% of those who kept taking it did. That’s not a small difference. That’s life or death.

What About Birth Defects?

You’ve probably heard that SSRIs cause heart defects. That’s mostly about paroxetine (Paxil). It’s the only SSRI with a clear, small increase in septal heart defects-rising from a baseline of 0.5% to about 0.7-1.0%. That’s still less than 1 in 100. For that reason, paroxetine is avoided entirely in the first trimester.

But the other SSRIs? Sertraline, citalopram, escitalopram, fluoxetine? Large studies of over 1.8 million births found no meaningful increase in major birth defects. The absolute risk difference between women taking SSRIs and those not taking them? Just 0.3%. That’s not a signal. That’s noise.

The FDA changed its labeling system in 2015 to stop using vague categories like “Category C.” Now, labels must say exactly what the data shows. Most SSRIs now carry a summary that reads: “No substantial evidence of increased major congenital malformations.”

What About PPHN and Preterm Birth?

Persistent Pulmonary Hypertension of the Newborn (PPHN) is a rare but serious lung condition. In the general population, it affects 1-2 in 1,000 babies. With SSRI use in the third trimester, that number goes up to 3-6 in 1,000. That sounds scary-but remember, it’s still less than 1% of exposed babies. And when you adjust for how severe the mother’s depression was, the link weakens. Severe depression itself increases PPHN risk.

Preterm birth (before 37 weeks) happens in about 12.5% of SSRI-exposed pregnancies versus 9.5% in depressed women not on meds. But here’s the catch: those not on meds often have worse depression. When researchers compared women with similar depression severity, the difference vanished. The real driver? Depression, not the drug.

Neurodevelopment: The Long-Term Question

This is where things get messy. Some studies suggest children exposed to SSRIs in utero might have slightly higher rates of autism or anxiety later in life. A 2022 JAMA Pediatrics paper reported a 1.3-fold increase in autism risk. But a 2021 Lancet study, which controlled for family history and genetics, found no link at all. The difference? One study compared babies of depressed moms on meds to babies of non-depressed moms. The other compared babies of depressed moms-with and without meds.

Columbia University researchers found that by age 15, 28% of children exposed to SSRIs in utero had depression, compared to 12% of children whose moms had depression but didn’t take meds. But here’s the flaw: those moms likely had more severe, chronic depression. And depression runs in families. The medication might not be the cause-the genetic risk is.

The NIH’s 2023 review put it bluntly: “Animal studies can’t replicate human complexity.” Mouse brains don’t have social stressors, parenting pressures, or access to therapy. Human outcomes are shaped by a thousand variables. SSRIs might be one of them-but not the biggest.

What About Breastfeeding?

If you’re planning to breastfeed, sertraline is still the top pick. It transfers in very low amounts into breast milk-so low that infant blood levels are often undetectable. Fluoxetine lingers longer and can build up, so it’s less ideal. Most experts agree: the benefits of breastfeeding almost always outweigh the tiny amount of medication passed along.

Infants exposed to SSRIs through breast milk rarely show side effects. If they do, it’s usually mild fussiness or sleep changes-and those usually fade within weeks. The American Academy of Pediatrics considers SSRIs compatible with breastfeeding.

What Should You Do?

If you’re pregnant and on an SSRI, don’t stop. Not without talking to your doctor. Abruptly quitting leads to withdrawal symptoms in 73% of cases: dizziness, nausea, brain zaps, even rebound anxiety. That’s not safe for you-or your baby.

Here’s what experts recommend:

1. Stick with sertraline if you’re on an SSRI already. It has the best safety profile.
2. Avoid paroxetine entirely during pregnancy.
3. Use the lowest effective dose. Don’t increase unless necessary.
4. Monitor for gestational hypertension-SSRIs slightly raise the risk (8.5% vs. 6.2% in controls).
5. Don’t switch medications unless you have to. Switching increases relapse risk.
6. If you’re considering stopping, do it slowly-over 4 to 6 weeks-with weekly depression checks.

And talk about your fears. Not just with your OB-GYN, but with a therapist or psychiatrist who specializes in perinatal care. You’re not weak for needing help. You’re not selfish for choosing to stay well. You’re doing the hardest thing a parent can do: putting your health first so you can be there for your child.

What’s Next?

In September 2025, the NIH launched a $15 million study tracking 10,000 mother-child pairs to see how SSRI exposure affects kids into adolescence. Results won’t come until 2030. But we already know enough to make smart choices.

The American Psychiatric Association now recommends matching SSRIs to symptom types: sertraline for anxiety-heavy depression, fluoxetine for low energy, citalopram for trouble sleeping. Personalized treatment isn’t a luxury-it’s the standard.

Future research is focused on two things: drugs that don’t cross the placenta as easily, and genetic tests that tell you how your body breaks down SSRIs. About 40% of people have genetic variants that make them slow or fast metabolizers. That affects dosing and side effects. We’re getting closer to precision medicine in pregnancy.

For now, the message is simple: untreated depression is far more dangerous than SSRIs. The risks of the medication are small, measurable, and manageable. The risks of silence? They’re not.