The moment two lines appear on the test, joy often comes with a quiet panic, especially for women already taking medication. In my clinic, one of the first thoughts many of them voice is, "I need to stop my pills right away." The instinct makes sense. It feels like the protective thing to do for the baby. But the question of antidepressants during pregnancy is rarely that simple.
Stopping or continuing affects more than the baby. It also shapes whether your own condition stays stable through one of the most demanding seasons of your life. This article is meant to help you see both sides clearly, so you can bring a calmer, better-informed conversation to your doctor.
Why depression during pregnancy should not be ignored
Pregnancy is often pictured as a glowing, joyful time. In reality, sharp hormonal shifts, physical changes, and uncertainty about the future can leave the mood fragile. Depression during pregnancy is not rare, and it is not a matter of "thinking too much" or lacking willpower. It is a medical condition that deserves to be taken seriously.
The trouble is that it is easily mistaken for the normal emotional ups and downs of pregnancy, which means it often goes unnoticed and untreated. Persistent low mood, loss of interest, disrupted sleep and appetite, or thoughts of self-harm are not things to simply "wait out."
The real dilemma is this. Medication carries considerations, but leaving depression untreated carries its own cost. To decide well, you have to lay both sets of risks side by side.
Should you stop antidepressants during pregnancy? What ACOG recommends
Here is the bottom line first. This was never a clean either-or between stopping and continuing.
In its 2023 clinical practice guideline, the American College of Obstetricians and Gynecologists (ACOG) notes that if you are already on medication and stable, or if you have a history of severe or recurrent depression, the benefits of continuing usually outweigh the risk of relapse after abruptly stopping[1][2]. In other words, for some people, suddenly quitting is the riskier move.
Why? Because a relapse is rarely a simple return to baseline. Pregnancy itself is a high-risk window for relapse, and stopping medication on your own can leave your condition harder to manage than it was before conception, which serves neither mother nor baby.
This does not mean everyone must continue. Those with mild illness, or who remain stable after tapering, may reduce or stop under a doctor's supervision. What matters is who makes that call and on what basis, a point we return to at the end.
Choosing an antidepressant in pregnancy: SSRIs as first-line treatment
If medication is needed during pregnancy, which one you choose matters a great deal.
Selective serotonin reuptake inhibitors (SSRIs, a common class of antidepressant) are the preferred option in pregnancy. Among them, sertraline and escitalopram are frequently listed as first-line, and escitalopram carries the lowest association with birth defects in current data[1][3].
Safety does vary between SSRIs. Clinically, I weigh which medication you have responded well to in the past, how you tolerated it, and its pregnancy safety profile together, rather than automatically switching everyone to whichever drug "sounds safest." A medication you have taken before, found effective, and is reasonably safe is often a steadier choice than an unfamiliar new one.
The table below summarizes where several common SSRIs sit in pregnancy, to give you and your doctor a starting point for discussion.
[Table 1] Where common SSRIs sit in pregnancy
| Medication | Class | Position in pregnancy | Safety note |
|---|---|---|---|
| Sertraline | SSRI | First-line | No clear increase in birth defects observed |
| Escitalopram | SSRI | First-line | Lowest association with birth defects |
| Fluoxetine | SSRI | Second choice, individualized | Relatively higher cardiac risk |
| Paroxetine | SSRI | Generally avoided | Relatively higher risk of heart defects |
A reminder: this table is a starting point for conversation, not a basis for changing or stopping medication on your own. Any adjustment should be assessed by your prescribing doctor.
The truth about the risk: the absolute risk is usually small
When it comes to medication in pregnancy, what most people fear is "will the drug harm my baby?" Honestly, the risk is not zero, but the absolute risk is usually small, and these two things are easily confused.
Take the most frequently raised concern, newborn heart problems. Studies show only a small association between early SSRI use and infant heart defects, with a relative risk of about 1.24[2][4][5]. That sounds like a 24 percent increase, but a relative risk applied to an already low baseline translates into a very small change in actual probability.
The risk also differs by drug. Paroxetine and fluoxetine carry comparatively higher risk, while sertraline has shown no clear increase[2][4][5]. This is exactly why drug choice is so important. Rather than rejecting SSRIs outright because "they carry risk," it makes more sense to choose a lower-risk option.
[Table 2] Risk comparison across SSRIs in pregnancy
| Risk item | Associated drug | Risk level | Clinical meaning |
|---|---|---|---|
| Newborn heart defect | Early SSRI (overall) | Small association, RR ~1.24 | Absolute risk still low |
| Heart defect | Paroxetine, fluoxetine | Relatively higher | Usually not first choice |
| Heart defect | Sertraline | No clear increase | Reasonable first-line option |
| Birth defects (overall) | Escitalopram | Lowest association | Reasonable first-line option |
Seeing the numbers clearly often halves the anxiety. The risk deserves caution, but it should not be magnified to the point of ignoring the more concrete danger on the other side.
Do not forget the other side: the risks of untreated depression
Many people focus entirely on "the risk of taking medication" and forget the other end of the scale, the risk of not treating, and that side is often underestimated.
Poorly treated depression during pregnancy is linked to preterm birth and low birth weight[2]. When a mother stays in a prolonged low mood, her sleep, appetite, and self-care all suffer, and these in turn affect the environment in which the baby develops.
There is also a common misconception that delaying and stopping later is safer. In fact, waiting until the third trimester to stop does not undo the neonatal complications that may already be in play[2]. Stopping later is not more protective. It may simply strip away support at the very stage a mother most needs stability.
[Table 3] Possible risks of untreated depression in pregnancy
| Untreated effect | Possible link | Affects | Risk level |
|---|---|---|---|
| Preterm birth | Stress response, reduced self-care | Fetus | Clear association |
| Low birth weight | Disrupted sleep and nutrition | Newborn | Clear association |
| Stopping in third trimester | Cannot reverse existing risk | Newborn | No protective effect |
| Worsening illness | Loss of medication support | Mother | Needs close monitoring |
So the real choice was never as simple as "medication harms the baby" versus "stopping keeps things safe." Both sides carry risk. The question is which risk is more worth avoiding in your particular situation.
Frequently Asked Questions
Q1: Can I just stop my antidepressants once I find out I'm pregnant?
Stopping on your own is not advised. Abruptly quitting can trigger discontinuation symptoms and raises the chance of relapse, and pregnancy is itself a high-risk window for relapse. If you are thinking about stopping, talk to your doctor first so they can assess whether to continue, taper, or stop, and decide the safest path with you.
Q2: Will taking an SSRI in pregnancy harm my baby's heart?
Overall, early SSRI use carries only a small association with newborn heart defects (relative risk about 1.24), which translates into a very low actual probability[2][4][5]. Sertraline in particular has shown no clear increase, making it a relatively reassuring option. The key is discussing drug choice with your doctor, not avoiding treatment out of fear.
Q3: Which antidepressant is safest in pregnancy?
In current data, sertraline and escitalopram are commonly listed as first-line in pregnancy, with escitalopram carrying the lowest association with birth defects[1][3]. That said, the "best drug for you" also depends on how you have responded to medication in the past, so there is no one-size-fits-all answer.
Q4: Does paroxetine have to be avoided completely in pregnancy?
Paroxetine carries a comparatively higher risk of heart defects and is usually not the first choice in pregnancy[2][4][5]. But that does not mean someone already taking it should stop immediately, as the risk of quitting on your own may be greater. The right approach is to discuss with your doctor whether to switch to a lower-risk option.
Q5: I'm already in my third trimester. Is it too late to stop now?
Waiting until the third trimester to stop does not reverse the neonatal complications that may already be present[2]. In other words, stopping late is not safer, and it may leave you without support right when you most need stability around delivery. Any adjustment at this stage should be weighed especially carefully with your doctor.
Q6: What happens if I leave depression untreated during pregnancy?
Untreated depression during pregnancy is linked to preterm birth and low birth weight[2], and it also affects a mother's sleep, appetite, and self-care. Leaving depression unmanaged is not the "more natural" choice. It is a real risk in its own right and deserves to be taken seriously.
Further reading:
- Maternal Depression: Symptoms, Causes, Treatment and How Families Can Help
- EPDS Edinburgh Postnatal Depression Scale Self-Assessment
Dr. Tam's clinical perspective
The core principle of medication decisions in pregnancy is individualization. There is no single answer that fits everyone. Your history, the severity of your illness, and how you have responded to medication in the past all shape what the right choice looks like.
- If you are on medication and stable, do not rush to stop. Bring that thought into the clinic and discuss it with your doctor
- When medication is genuinely needed, prioritize lower-risk first-line SSRIs such as sertraline or escitalopram
- Weigh "the risk of taking medication" and "the risk of not treating" on the same scale, rather than looking at only one side
- Let your prescribing doctor be part of any decision to stop, reduce, or switch. Do not make that call alone
This was never an either-or between stopping and continuing. It is a decision you and your doctor reach together, based on your situation. If this is weighing on you, please do not carry it alone. Setting aside time for an honest conversation with your doctor will feel far steadier than turning it over by yourself.
Want to book an appointment with Dr. Tam?
Psychiatrist at Ten-Chan & Ten-Hsiang General Hospital, Zhongli. Consultations in English, Mandarin and Cantonese.
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- Committee on Clinical Practice Guidelines—Obstetrics. Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 5. Obstetrics and Gynecology. 2023;141(6):1262-1288. DOI · PubMed
- Kovich H, Kim W, Quaste AM. Pharmacologic Treatment of Depression. American Family Physician. 2023;107(2):173-181. PubMed
- Anderson KN, Lind JN, Simeone RM, et al. Maternal Use of Specific Antidepressant Medications During Early Pregnancy and the Risk of Selected Birth Defects. JAMA Psychiatry. 2020;77(12):1246-1255. DOI · PubMed
- O'Connor E, Rossom RC, Henninger M, et al. Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;315(4):388-406. DOI · PubMed
- Desaunay P, Eude LG, Dreyfus M, et al. Benefits and Risks of Antidepressant Drugs During Pregnancy: A Systematic Review of Meta-analyses. Paediatric Drugs. 2023;25(3):247-265. DOI · PubMed