SSRIs and Pregnancy: An Overview of the Debate

By Elizabeth Curley

The FDA recently hosted an expert panel about SSRIs and pregnancy (now uploaded on Youtube for anyone to watch) and though this might have gone unnoticed by some, the American College of Obstetricians & Gynecologists, the Society for Maternal Fetal Medicine, and the Massachusetts General Hospital for Women’s Mental Health and many other maternal health organizations (with over one hundred cosigners) posted statements in direct response.

Their largest critiques were that the panel did not properly acknowledge the risks of untreated (or undertreated) perinatal depression and anxiety. The debate, although that word carries stronger connotations that this misalignment may warrant, is between:

1) those who are advocating for stronger research, more detailed informed consent processes, and potential medication bottle warnings of documented risks (to support those informed consent procedures) 

and 

2) groups which advocate that informed consent is already in place to cover risks, and that the risk of not treating anxiety and depression also poses potential risks to fetuses by virtue of high risk of self-neglect and possible discontinuation risks of stopping SSRIs. 

The complication in these discussions seems to be the accumulation of multiple long-standing, complex discussions into one point of SSRIs and pregnancy: the research is flawed. Ultimately, research cannot ethically find direct causality between SRRIs while pregnant and adverse outcomes, because we cannot assign people to receive or not receive these medications. 

Our research, then, becomes observational - and cannot fully account for extra contextual details, such as parsing out what outcomes are from the mental health symptoms that already existed versus the medication’s adverse effects. This fact alone halts a specific, objective discussion. We’re left with the estimation that sometimes we see these things happen. 

It is important to note that SSRIs, even alongside other antidepressants and psychotropic medications, are not the only possible treatment for anxiety and depression. Antidepressants (with whatever risks we have possible signals for) are recommended for moderate to severe cases of depression and anxiety. However, non-medication treatments such as mindfulness-based therapies, cognitive behavioral therapy, interpersonal therapy, mind-body exercise, and enhanced support (and psychosocial care) or parenting-focused therapy have all shown effectiveness for depression and anxiety during pregnancy as well. 

The research is complicated given the limits of how strong the claims can be based on the design of the studies. An updated review from 2023 of the evidence on prenatal exposure and SSRIS found possible risks of maternal and birth outcomes of:

Mental health condition alone: possibly heart defects; long-term rates of ADHD or Autism
Medication alone: possibly diaphragmatic hernia (with citalopram); pulmonary hypertension of the newborn; 
Both mental health condition and medication: Post-partum hemorrhage; pre-eclampsia; preterm birth; low birth weight; NICU admissions; c-sections; low Apgar scores; respiratory distress; affective (mood) disorders; cognitive outcomes of children over time.

What is notable here is that the list of what could be either (or both) mental health condition and medication effects, is longer than any one list. 

This topic grows more complex when these discussions are broad-brushed across every stage pre-birth. The discussion of risks of SSRIs, possible discontinuation symptoms (or withdrawal), and the informed consent process to understand those risks is a large topic outside of pregnancy. 

There are risks to both beginning and the cessation of SSRIs. There are risks of self-neglect and risky behaviors of substance use for pregnant women with mental health struggles, whether medicated or not. None of these things are mutually exclusive. 

Additionally, SSRI usage and pregnancy have staged-differences. There is a difference between beginning SSRIs for the first time once you become pregnant and continuing medication you have been on for 5 years while you are pregnant. These variables, along with others, become more complicated when you bring in extra complications such as 1) polypharmacology (multiple medications), 2) severity of mental health symptomology and history, 3) socioeconomic factors, 4) experience of pregnancy, 5) existing risk factors for child birth, 6) access to medical care, 7) informed consent process at onset of SSRIs and at point of pregnancy. 

A study of women’s (UK) qualitative experience of decision-making around their mental health medications for severe mental health diagnoses (treated with antipsychotics or mood stabilizers prior to becoming pregnant) found that women felt that their healthcare professionals had limited information and left them to make their own decisions and explorations of limited evidence without guidance. 

Another, in the US, found that for pregnant women with substance use treatment needs, access to non-medication treatment was limited by factors such as time and transportation. The study noted that, “[w]omen expressed a desire for treatment that was tailored to their unique needs, whatever these might be.”

It is important that we continue our discussions of concern for mental wellbeing during pregnancy. The bundle of included topics for mental health and pregnancy is so much larger than just SSRIs - it includes abuse experiences, poverty, long-term histories of mental health snapshots and their various treatments, and so much more. 

In lieu of a perfect petri-dish for research and science, we need to be informing and listening to the patients that are actually facing pregnancy. We need a net of mental health support pre- and post-birth. We cannot pull out simple answers to hard questions. 

The consensus on one side says that whatever the medication risk that does exist, is worth trying to avoid the risks of having mental health issues that are not treated by medication. The real consideration here is is it worth it for you? Were YOU properly informed of the risks? Is your mental health medication still helping? Were you given the option to go off of it or receive non-drug treatment alongside it? 

It is much simpler to say let everyone decide for themselves than to work toward the protections and information access that allow everyone to truly decide for themselves.