Pregnancy and the postpartum year are full-body, full-brain transitions. For many people, that includes clinically significant depression or anxiety, sometimes new, sometimes a relapse of a pre-existing condition. The hardest part for patients and OB/GYNs is often the same question: “Is medication safer than going untreated?”
Perinatal psychiatry is about answering that with evidence, not fear. At Advanced Psychiatry Associates across California, we provide medical evaluation and medication management for perinatal mood and anxiety disorders, with close coordination with obstetric teams. This article walks through the risk-balancing framework, the medication data, and what patients should expect from psychiatric care during pregnancy and breastfeeding.
The Clinical Reality: Untreated Illness vs. Medication Exposure
The instinct to “avoid all meds” during pregnancy is understandable, but untreated perinatal depression and anxiety carry real medical risks for both parent and baby.
Large clinical guidelines note that untreated or undertreated perinatal mental health conditions are linked to negative outcomes, including disrupted prenatal health behaviors, physiologic stress, impaired bonding, and elevated risk of relapse or crisis.
In practice, untreated illness can lead to:
Poor sleep, nutrition, and prenatal care can affect pregnancy course.
Higher risk of preterm birth and low birth weight in moderate-to-severe cases.
Postpartum relapse, especially in people with a prior history.
In the most serious situations, maternal suicide or overdose.
So the clinical question isn’t “meds vs. no meds.” It’s medication risk vs. illness risk, based on severity and history.
Pharmacotherapy Evidence: First-Line SSRI Protocols in Pregnancy
The strongest data for perinatal depression and anxiety support selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacotherapy when medication is indicated.
Key points we discuss with families:
SSRIs are among the most studied psychiatric medications in pregnancy. The overall risk of major congenital malformations with SSRIs is low, and for most agents, the data do not show a large causal increase when controlling for illness severity and confounders.
If there’s no prior medication history, ACOG identifies sertraline or escitalopram as reasonable first-line choices during pregnancy because of safety and tolerability data.
If a patient previously responded well to a specific SSRI, continuing that same medication often makes more sense than switching during pregnancy, unless there’s a clear risk reason to change.
Postpartum Pharmacology: SSRI Safety and Lactation Kinetics
Breastfeeding adds another layer of worry, but the evidence base is reassuring.
Sertraline is widely considered a preferred SSRI during breastfeeding because infant exposure through milk is very low.
Escitalopram/citalopram can be used with monitoring; infant effects are uncommon.
We advise pediatric monitoring for sleepiness, irritability, or feeding/weight-gain issues, especially early in lactation, but serious complications are rare.
Bottom line: when medication is clinically needed, breastfeeding is usually still possible with the right agent and monitoring.
Differential Prescribing: Avoiding High-Risk Agents and Managing Interactions
Perinatal psychiatry is not “SSRIs for everyone.” It’s a careful selection.
Examples of common adjustments:
Paroxetine is generally avoided as a first-line during pregnancy due to data suggesting a small increased risk of certain cardiac malformations with first-trimester exposure.
Fluoxetine has a long half-life; it’s not banned, but if starting new treatment in pregnancy or lactation, many clinicians prefer sertraline/escitalopram for a cleaner safety and dosing profile.
SNRIs (like venlafaxine or duloxetine) are reasonable alternatives when SSRIs fail or when prior response favors them.
We also review co-medications (anti-nausea meds, sleep aids, thyroid meds, stimulants) to avoid interactions and unnecessary fetal exposure.
The Prescribing Algorithm: ACOG Guidelines and Risk-Balancing
ACOG emphasizes that perinatal medication decisions should be individualized and made through shared decision-making, not blanket rules.
In APA clinics, that looks like:
Define severity & pattern. Is this mild but persistent anxiety? Recurrent major depression? A prior severe postpartum episode?
List illness risks. What happened in past untreated episodes? Any hospitalization, inability to function, or safety crisis?
Choose the lowest-effective, best-studied agent for the specific patient.
Plan pregnancy-stage dosing. Sometimes doses need adjustment as blood volume and metabolism change during pregnancy.
Build postpartum prevention. The postpartum window is high-risk for recurrence; we often plan medication continuity rather than stopping abruptly at delivery.
This approach is exactly why OB/GYNs refer to perinatal psychiatry: we do the medication management with you.
Interdisciplinary Care: Coordinating Psychiatry and Obstetrics
Your obstetric team is central. We routinely coordinate on:
Medication choice and timing within your prenatal plan
Any needed lab monitoring (thyroid, anemia, vitamin levels) to rule out contributors to mood symptoms
Blood pressure monitoring, especially if SNRIs or other agents are used
Delivery and postpartum plans, including continuation vs. adjustment
APA offers this care across APA California offices and through telehealth when clinically appropriate.
The APA Protocol: Evaluation, Titration, and Relapse Prevention
Perinatal psychiatric care at APA is medical and structured:
Comprehensive evaluation for depression and anxiety in pregnancy/postpartum
Evidence-based medication selection and titration through Medication Management
Ongoing coordination with your OB/GYN
A clear relapse-prevention plan for the postpartum year
If symptoms overlap with other conditions (sleep disorders, OCD, bipolar spectrum), we adjust accordingly using our service structure.
For condition context, see: Depression and Anxiety.
Ready to talk through risks with a psychiatrist?
If you’re pregnant or postpartum in California and struggling with depression or anxiety, you don’t have to choose between suffering in silence and fearful medication decisions. We’ll help you weigh risks clearly and build a plan that protects both you and your baby.
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