Mental Health Medications in Pregnancy: What You Need to Know About Shared Decision-Making

When you’re pregnant and managing a mental health condition, the question isn’t just whether to take medication-it’s how to decide, with confidence, in a world full of fear and conflicting advice.

Every year, thousands of pregnant people face this exact crossroads. They’ve been stable on antidepressants or mood stabilizers. Then comes the pregnancy test. Suddenly, every article, every well-meaning friend, every online forum screams: Stop now. It’s dangerous. But what if stopping means falling apart?

Here’s the truth no one tells you: There is no risk-free choice. Not taking medication carries real danger. So does taking it. The only way forward is shared decision-making-a process where you and your provider weigh real numbers, not myths, to find the path that protects both you and your baby.

Why Shared Decision-Making Isn’t Just a Buzzword

Shared decision-making isn’t about handing you a pamphlet and saying, ‘You decide.’ It’s a structured conversation built on facts, values, and trust. The British Association for Psychopharmacology and the American College of Obstetricians and Gynecologists both say this approach is the standard of care-not a suggestion, but a requirement.

Why? Because untreated depression, anxiety, or bipolar disorder during pregnancy increases the risk of preterm birth by 62%, and maternal suicide risk by 20%. These aren’t rare outcomes. They’re documented, measurable, and preventable.

Meanwhile, the fear of birth defects from medications often outweighs the actual risk. For example, paroxetine (Paxil) carries a slightly higher chance of heart defects-rising from about 8 in 1,000 births to 10 in 1,000. That’s a 25% increase, but the absolute risk is still low. Compare that to the 30-50% higher chance of preterm birth if depression goes untreated. Which risk are you really trying to avoid?

Which Medications Are Actually Safe?

Not all psychiatric medications are created equal. Some have decades of safety data. Others? Not so much.

SSRIs are the first-line choice for depression and anxiety during pregnancy. Sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac) are all considered low-risk options. Studies involving over 15,000 pregnant women show no consistent link to major birth defects-with one exception: paroxetine. That’s why most providers avoid it unless other options have failed.

For bipolar disorder, lamotrigine is the go-to. It’s been studied in thousands of pregnancies and shows no increased risk of major malformations. Lithium works too, but it needs careful monitoring. Pregnancy changes how your body processes it-your kidneys work faster, your blood volume increases-so your dose might need adjusting every few weeks. Regular blood tests are non-negotiable.

Now, the big red flag: valproic acid (Depakote). It increases the risk of neural tube defects from 0.1% to 1-2%. That’s a 10- to 20-fold jump. It’s also linked to lower IQ and autism risk in children. If you’re on this drug and planning pregnancy, switch before conception. No exceptions.

Bupropion (Wellbutrin) has a small association with miscarriage and heart defects. Tricyclics like nortriptyline are less studied but can be used if SSRIs don’t work. For psychosis, older antipsychotics like haloperidol and chlorpromazine have better safety data than newer ones like risperidone or olanzapine-because the newer ones just haven’t been studied enough in pregnancy.

The Real Danger: Stopping Medication Without a Plan

Here’s what the data doesn’t show you: 68% of pregnant people say they weren’t properly informed about their medication risks before getting pregnant. And 42% stopped taking their meds on their own-because they were scared.

The result? A 2022 survey by Postpartum Support International found that women who stopped medication without medical guidance were far more likely to be hospitalized after birth. One Reddit user wrote: ‘I went off my SSRI at 8 weeks. By 16 weeks, I couldn’t get out of bed. By 20 weeks, I was crying in the OB’s office, begging for help.’

Dr. Lee Cohen from Massachusetts General Hospital says it plainly: ‘If you stop treatment for severe depression during pregnancy, you have an 80% chance of relapse.’ That’s not a guess. That’s what the registry data shows.

Stopping medication doesn’t make you ‘brave.’ It makes you vulnerable. And the baby? They’re caught in the middle.

What Shared Decision-Making Actually Looks Like

This isn’t a one-time chat. It’s a process.

Step 1: Know your baseline. How many episodes have you had? How long were you stable before pregnancy? If you’ve had three major depressive episodes in the past five years, your relapse risk is over 70% if you stop meds. That’s not a number you ignore.

Step 2: Get the real numbers. Your provider should show you absolute risks, not percentages. ‘Paroxetine increases heart defect risk from 8 in 1,000 to 10 in 1,000’ is clearer than ‘slightly higher risk.’ ACOG’s free decision aid breaks this down for 24 medications-and it’s updated quarterly with new data.

Step 3: Plan for the worst. What if your anxiety spikes at 24 weeks? What if you can’t sleep, can’t eat, can’t get out of bed? Have a back-up plan: who to call, what dose to adjust, when to go to the ER. Most women who have this plan report feeling calmer, not more anxious.

And yes-document it. A 2021 AMA study found that when providers documented shared decision-making, malpractice claims dropped by 65%. It’s not about covering your back. It’s about making sure your voice is heard.

What’s New in 2026

The field is moving fast. The National Pregnancy Registry has tracked over 15,700 women since 2010. Now, they’re using that data to build predictive tools.

A pilot study from Massachusetts General Hospital used machine learning to predict individual responses to medication with 82% accuracy. That means in the near future, your provider won’t just say, ‘Most women tolerate sertraline.’ They’ll say, ‘Based on your age, weight, history of anxiety, and previous medication response, 8 out of 10 women like you stayed stable on 100mg of sertraline.’

By 2026, real-time data from the registry will be integrated into clinical tools. You’ll see your own risk profile-not a population average. That’s the future of care.

What You Can Do Right Now

If you’re pregnant or planning to be:

• Don’t wait until you’re 12 weeks along to talk about meds. Start the conversation before conception. Stability for at least 3 months before pregnancy cuts relapse risk by 40%.
• Ask for the ACOG Mental Health Medication Decision Aid. It’s free, evidence-based, and updated quarterly.
• If your OB doesn’t know about it, ask for a referral to a perinatal psychiatrist. 87% of ACOG members now consult them regularly-this isn’t rare anymore.
• Write down your fears. Write down your priorities. Is it avoiding any medication? Is it staying functional? Is it avoiding hospitalization? Bring that list to your appointment.

You’re not being selfish for wanting to stay well. You’re being responsible. A mother who is mentally stable is the best thing for her child-not a mother who’s medicated but terrified, or one who’s unmedicated but broken.

There’s no perfect choice. But there is a right choice-for you, right now. And it starts with a conversation, not a fear.

What Comes Next

If you’re reading this and feeling overwhelmed, that’s normal. But you’re not alone. You’re not failing. You’re doing the hard work of protecting your health-and your baby’s future.

Reach out to your provider. Ask for the decision aid. Bring a friend or partner to your appointment. Write down your questions. You deserve to make this choice with clarity, not fear.

The goal isn’t to be perfect. It’s to be present. And that starts with a conversation-yours, your provider’s, and your baby’s.