Excellent and important question 🌱 — the choice of antidepressants in pregnancy requires balancing maternal mental health with fetal safety. Here’s what the evidence and guidelines (ACOG, APA, NICE) say:
✅ Antidepressants Generally Considered Safer in Pregnancy
SSRIs (Selective Serotonin Reuptake Inhibitors)
- Sertraline (Zoloft)
- Often considered first-line in pregnancy due to relatively favorable safety data.
- Lowest placental transfer among SSRIs.
- Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac)
- Large registry studies: no major increase in congenital malformations.
- Fluoxetine has the most long-term safety data, but slightly higher risk of neonatal adaptation syndrome (jitteriness, feeding issues).
- Paroxetine (Paxil)
- Avoid if possible in 1st trimester — associated with small ↑ risk of cardiac malformations. May still be continued if mother is stable and alternatives failed.
SNRIs (Serotonin–Norepinephrine Reuptake Inhibitors)
- Venlafaxine (Effexor), Duloxetine (Cymbalta)
- No major teratogenic risks found, but may increase risk of hypertension in pregnancy.
- Sometimes used when SSRIs fail.
Other Options
- Bupropion (Wellbutrin)
- Data suggest low risk for major malformations; sometimes used if smoking cessation is also a goal.
- Tricyclics (esp. nortriptyline, desipramine)
- Older but generally safe if SSRIs not tolerated.
- Mirtazapine
- Limited but reassuring data; useful if insomnia and poor appetite are severe.
⚠️ Considerations & Risks
- Persistent Pulmonary Hypertension of the Newborn (PPHN): Slight ↑ risk with late-pregnancy SSRI/SNRI use, but absolute risk is small.
- Neonatal Adaptation Syndrome: Transient jitteriness, irritability, or respiratory issues in ~20–30% of infants exposed to SSRIs late in pregnancy. Usually mild and self-limited.
- Untreated Depression Risks: Higher risks of preterm birth, low birthweight, impaired bonding, suicide risk. These often outweigh the modest medication risks.
🚫 Antidepressants Generally Avoided
- Paroxetine (esp. 1st trimester) → cardiac malformation risk.
- MAOIs (phenelzine, tranylcypromine) → dangerous in pregnancy due to hypertensive crises, dietary restrictions.
✅ Clinical Takeaway
- First-line choices: Sertraline, fluoxetine, citalopram, escitalopram.
- Second-line / when indicated: Venlafaxine, duloxetine, bupropion, mirtazapine, or certain TCAs.
- Avoid: Paroxetine in early pregnancy, MAOIs altogether.
👉 Would you like me to also prepare a table (drug-by-drug: safety rating, risks, special considerations) that could serve as a quick reference for pregnant patients with depression or anxiety?
