Seeing a Perinatal Psychiatrist: Medication Decisions During Pregnancy

The Question That Keeps You Up at Night

You are pregnant, or planning to become pregnant, and you take medication for a mental health condition. An antidepressant, a mood stabilizer, something for anxiety or ADHD. Whatever it is, you are now facing a question that can feel almost unbearable: is it safe to keep taking this?

Or perhaps you have never taken medication before, but you are struggling. Depression, anxiety, OCD, or something else has intensified during pregnancy, and you are wondering whether medication could help, and whether it is even an option while you are carrying a baby.

A perinatal psychiatrist is the person trained to sit with you in that uncertainty and walk through it carefully.

What Is a Perinatal Psychiatrist?

A perinatal psychiatrist is a medical doctor who focuses specifically on mental health during pregnancy, the postpartum period, and sometimes the wider reproductive lifespan. Their training covers:

• How psychiatric medications interact with pregnancy physiology
• The effects of medications on fetal development
• The risks of untreated mental illness during pregnancy
• Medication management during breastfeeding
• The hormonal and psychological changes of the perinatal period

This depth matters. The questions involved are genuinely complex, and a general psychiatrist or OB/GYN may not have the specialized knowledge to guide these decisions with the nuance they deserve.

The Risk-Benefit Conversation: It Is Never One-Sided

Here is the central truth about medication decisions during pregnancy: every option carries some form of risk. That includes the option of stopping your medication.

The Risk of Medication

Psychiatric medications cross the placenta. Depending on the specific drug, potential concerns include:

• Effects on fetal development, particularly organ formation in the first trimester
• Neonatal adaptation issues after birth, such as withdrawal-like symptoms in the newborn
• Potential long-term developmental effects, though for most medications the long-term data is limited but generally reassuring
• Specific medication-related risks that vary by drug class

The Risk of Untreated Mental Illness

Now consider the other side. Untreated or undertreated mental illness during pregnancy is not a neutral choice. Research has linked untreated perinatal depression, anxiety, and other conditions to:

• Preterm birth and low birth weight. Multiple studies have found associations between untreated maternal depression and adverse birth outcomes.
• Impaired prenatal care. People who are severely depressed or anxious may miss appointments, eat poorly, or struggle to follow other health recommendations.
• Substance use. Some people turn to alcohol, cannabis, or other substances to self-medicate when psychiatric symptoms go untreated. Those substances carry their own significant risks during pregnancy.
• Suicidal ideation. Maternal suicide is a leading cause of maternal mortality in the perinatal period. Undertreating severe depression can be life-threatening.
• Postpartum complications. Untreated prenatal mental illness is one of the strongest predictors of postpartum depression and anxiety.
• Attachment and bonding. Severe, untreated maternal mental illness can affect the early parent-infant relationship.

A perinatal psychiatrist holds both sides of this equation in view and helps you weigh them against your specific situation.

Common Medications and Their Safety Profiles

What follows is general information, not prescriptive guidance. Every medication decision should be made with your healthcare provider based on your individual circumstances. This overview reflects current research as of the time of writing.

SSRIs (Selective Serotonin Reuptake Inhibitors)

Examples: sertraline (Zoloft), fluoxetine (Prozac), escitalopram (Lexapro), citalopram (Celexa)

SSRIs are among the most studied medications in pregnancy. The overall evidence suggests:

• Most SSRIs do not appear to significantly increase the risk of major birth defects
• Sertraline is often considered a first-line choice during pregnancy due to its extensive safety data
• Some studies have found a small increased risk of persistent pulmonary hypertension of the newborn (PPHN) with SSRI use in the third trimester, though the absolute risk remains low
• Neonatal adaptation syndrome, including jitteriness, feeding difficulties, and respiratory changes, can occur in newborns exposed to SSRIs, typically resolving within days to two weeks

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

Examples: venlafaxine (Effexor), duloxetine (Cymbalta)

Less studied than SSRIs, but the evidence base is growing:

• Available data have not identified a consistent pattern of major birth defects
• Similar neonatal adaptation concerns as SSRIs
• Venlafaxine may be associated with slightly higher rates of neonatal symptoms, possibly due to its shorter half-life

Benzodiazepines

Examples: lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax)

• Earlier studies raised concerns about cleft palate risk, but more recent research has not consistently confirmed this association
• Use in the third trimester can cause neonatal sedation and withdrawal
• Generally used sparingly during pregnancy, with preference for shorter-acting formulations when needed
• A perinatal psychiatrist may help explore alternatives while keeping these available for acute situations

Mood Stabilizers

Examples: lithium, lamotrigine (Lamictal), valproic acid (Depakote)

• Valproic acid carries significant risks during pregnancy, including neural tube defects and developmental effects. Most guidelines strongly recommend against its use during pregnancy when alternatives exist.
• Lithium was historically considered highly risky, but more recent research suggests the risk of the cardiac defect Ebstein's anomaly is lower than originally thought, though still elevated. Lithium remains an important option for severe bipolar disorder when the benefits outweigh the risks.
• Lamotrigine has one of the more favorable safety profiles among mood stabilizers in pregnancy and is often a preferred option.

Antipsychotics

Examples: quetiapine (Seroquel), aripiprazole (Abilify), olanzapine (Zyprexa)

• Growing body of reassuring data, particularly for quetiapine and olanzapine
• Some association with metabolic effects, including gestational diabetes and larger birth weight, that require monitoring
• Generally considered when the condition being treated, such as severe depression, bipolar disorder, or psychotic symptoms, carries significant risk if untreated

What a Perinatal Psychiatrist Appointment Looks Like

If this is your first time seeing a perinatal psychiatrist, knowing what to expect can ease some of the nervousness around that first visit.

The Initial Assessment

A thorough first appointment typically runs 60 to 90 minutes and covers:

• Complete psychiatric history. Your diagnoses, previous episodes, hospitalizations, medication history (what has worked, what has not), and family psychiatric history.
• Pregnancy history. Current pregnancy status, obstetric history, any previous postpartum mental health experiences.
• Current medication review. Dose, duration, effectiveness, side effects.
• Symptom assessment. Current mental health symptoms and severity.
• Risk assessment. Evaluating the risks of continuing, changing, or stopping your current treatment.
• Collaborative discussion. This is not a conversation where someone tells you what to do. A good perinatal psychiatrist presents the evidence, discusses the options, and helps you make the decision that aligns with your values and circumstances.

Ongoing Care

If you continue with a perinatal psychiatrist, follow-up appointments typically happen every 2 to 6 weeks during pregnancy, with frequency adjusted based on symptom severity, medication changes, and where you are in your pregnancy.

Medication doses may need adjustment as blood volume increases and metabolism shifts. Your psychiatrist will keep an eye on that.

The Danger of "Just Stop Taking Everything"

One of the most common and most risky things people do upon learning they are pregnant is stop all psychiatric medication abruptly. It makes sense, driven by fear and a fierce desire to protect the baby. But it can be dangerous for several reasons:

• Abrupt discontinuation of certain medications, particularly SSRIs, SNRIs, benzodiazepines, and mood stabilizers, can cause withdrawal symptoms that are physically distressing and can be medically serious.
• Relapse risk is high when effective medication is suddenly stopped, especially during the hormonal changes of pregnancy.
• The first trimester, when many people stop medication, is often when mood and anxiety symptoms are most likely to worsen due to hormonal shifts.

If you are pregnant and want to reconsider your medication, please do so with professional guidance rather than stopping cold turkey. A perinatal psychiatrist can help you taper safely if that is the right decision, or reassure you about continuing if the evidence supports it.

Finding a Perinatal Psychiatrist

Perinatal psychiatry is a growing but still relatively small subspecialty. Finding a provider may take some effort. Resources include:

• Postpartum Support International (PSI) maintains a provider directory
• Your OB/GYN or midwife may have referral relationships with perinatal psychiatrists
• Maternal mental health organizations in your state or region
• Academic medical centers often have perinatal psychiatry programs
• Telehealth options have expanded access significantly, particularly for people in areas without local perinatal psychiatrists

You Deserve Both: A Healthy Pregnancy and a Healthy Mind

The conversation about medication during pregnancy is not about choosing between your health and your baby's health. It is about finding the approach that gives you both the best chance of thriving. Sometimes that includes medication. Sometimes it does not. And sometimes the answer shifts as your pregnancy progresses.

A perinatal psychiatrist is the specialist best equipped to guide you through this nuanced, deeply personal decision.

If you are looking for a perinatal psychiatrist or other mental health support during pregnancy, BAABY can help you find qualified providers in your area.