Pregnancy and breastfeeding come with two competing fears: like, if I stay on my meds, will I hurt the baby? Or if I stop my meds, will I fall apart, and is that worse for the baby?
At Advanced Psychiatry Associates offices in California, we don’t answer that with guesswork or guilt. We use perinatal psychiatry medication principles and current guidelines to weigh: Risk of untreated illness vs. risk of medication exposure for your diagnosis, your history, and this pregnancy.
This article focuses only on psychiatric medication during pregnancy and breastfeeding, so you can understand how a psychiatrist thinks about antidepressants in pregnancy, anxiety medication during pregnancy, bipolar medications, and antipsychotics, and how we coordinate with OB/GYNs.
Why doing “nothing” is not zero-risk
ACOG’s 2023 clinical guideline on treating mental health conditions during pregnancy and postpartum is very clear: untreated depression, anxiety, bipolar disorder, and psychosis carry real risks for both parent and baby.
Untreated or abruptly stopped psychiatric medication can be associated with:
Worsening depression or anxiety and a higher risk of suicide
Poor prenatal care, nutrition, and sleep
Higher risk of preterm birth and low birth weight in significant mood disorders
High relapse risk in bipolar disorder, especially postpartum
So when we talk about antidepressants while pregnant or bipolar medication during pregnancy, the comparison is not “risk vs no risk.” It’s medication risk vs. illness risk.
That’s the frame we use at APA across our California offices
Antidepressants & anxiety medication in pregnancy: SSRIs, SNRIs, and “safe” options
For many patients, the main question is, Are there safe antidepressants in pregnancy?
The honest answer is: there’s no zero-risk drug, but SSRIs are among the best studied medications in pregnancy and are considered first-line when treatment is indicated.
SSRIs (sertraline, escitalopram, fluoxetine, etc.)
Key points from ACOG and other major reviews:
SSRIs are first-line for depression and anxiety in pregnancy when medication is needed.
Data overall suggest low absolute risk of major malformations; some agents, like paroxetine, have historically been linked to a small increase in certain cardiac malformations, so we usually avoid them as first-line in new starts.
Sertraline and escitalopram are commonly recommended as reasonable first choices if there’s no prior strong response to another agent.
We talk patients through:
Possible risks like transient neonatal adaptation issues.
Serious risks of untreated depression or anxiety, suicidality, poor prenatal care, and preterm birth.
For many patients, staying on or starting an SSRI is the safer path than remaining severely ill. This is exactly the kind of risk–benefit decision perinatal psychiatrists are trained to make.
You can see how we treat these conditions more broadly here:
SNRIs (venlafaxine, duloxetine)
SNRIs are sometimes used when SSRIs failed or weren’t tolerated. They have less pregnancy data than SSRIs, but are still widely used with careful blood pressure and symptom monitoring. ACOG considers them reasonable options in the right clinical context.
Antidepressants while breastfeeding: what we know
The breastfeeding question is usually, Can I keep taking antidepressants while breastfeeding, or do I have to choose between meds and milk?
Good news: multiple authoritative sources like LactMed support that certain SSRIs, especially sertraline and paroxetine, produce very low infant exposure and are compatible with breastfeeding.
Sertraline: often considered the first choice SSRI in breastfeeding because infant serum levels are usually undetectable.
Escitalopram, Paroxetine, citalopram: also generally acceptable with monitoring, particularly when they were effective pre-pregnancy.
At APA, breastfeeding decisions happen in three-way coordination:
The patient
Their OB/pediatric team
Our psychiatrist is doing perinatal mental health medication management
Bipolar medication during pregnancy: lithium, lamotrigine, and what we avoid
For bipolar disorder, the stakes are high: postpartum relapse risk is very high without pharmacologic prophylaxis, and severe episodes can be dangerous for both parent and infant.
Lithium
Lithium remains a viable and often life-saving option in pregnancy for some patients with bipolar disorder, especially those with a strong past lithium response or severe mania history.
There is a small increased risk of cardiac malformations, but the absolute risk is relatively low, and for many women, the benefits outweigh the risks.
Requires close monitoring of:
Lithium levels
Kidney and thyroid function
Dose adjustments in late pregnancy and postpartum
Lamotrigine
Lamotrigine is often favored as a mood stabilizer in pregnancy for bipolar depression or bipolar II:
Pregnancy data are relatively reassuring compared to other anticonvulsants.
Doses often need to be increased during pregnancy due to higher clearance, then reduced postpartum.
Valproate (valproic acid) and carbamazepine
Current guidance is blunt: Avoid valproate in women who are pregnant or may become pregnant, due to the high risk of major congenital malformations and long-term neurodevelopmental problems. Carbamazepine carries teratogenic risk as well and is generally avoided when safer alternatives exist.
Atypical antipsychotics
Second-generation antipsychotics, like quetiapine, olanzapine, sometimes lurasidone, or others, are often used:
As alternatives or adjuncts in bipolar disorder during pregnancy
Generally considered relatively safe, though they may increase risk for gestational diabetes and large-for-gestational-age infants, requiring metabolic monitoring.
Our Bipolar Disorder care explains our broader approach outside pregnancy
Perinatal, we individualize based on:
Prior episodes and severity
Past medication response
Other medical risks
The patient’s values and preferences
How we actually make decisions: shared risk-balancing
At APA, perinatal medication decisions follow a structure aligned with ACOG’s guidance on Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum
Clarify the diagnosis
Depression? Anxiety? Bipolar disorder? Psychosis? Mixed? We use your existing history and a fresh evaluation.
Review prior response
If you did really well on sertraline or lithium before pregnancy, that matters. Starting from scratch is not always safer.
Estimate illness risk if untreated or undertreated
History of suicide attempts? psychosis? postpartum episodes?
Need for hospitalization in prior relapses?
Choose the lowest-risk, evidence-supported medication
For antidepressants in pregnancy: usually an SSRI with good data
For bipolar medication in pregnancy: lithium or lamotrigine ± atypical antipsychotics, while avoiding valproate where possible
Coordinate closely with OB and pediatrics
Labs, ultrasounds, fetal growth, glucose screening, and postpartum monitoring are shared across teams.
Plan for postpartum and breastfeeding
Postpartum is often higher risk for relapse than pregnancy itself, especially in bipolar disorder.
We make a plan for continuation, dose changes, and breastfeeding in advance.
This is exactly what we mean by perinatal mental health medication management; it’s not just antidepressants while pregnant, it’s an ongoing strategy.
What to expect at Advanced Psychiatry Associates (California)
If you’re searching for an insomnia and mental health or perinatal psychiatrist in California and land on APA, here’s what care usually includes:
A detailed psychiatric evaluation focused on pregnancy/postpartum
Review of all current and past psychiatric medications
Discussion of illness risks vs. pregnancy and antidepressant risks
Selection or adjustment of psychiatric medication during pregnancy with OB coordination
Planning for breastfeeding while on antidepressants or mood stabilizers, using up-to-date resources like LactMed and ACOG
Ongoing Medication Management visits to track mood, side effects, labs, and baby outcomes
You shouldn’t have to choose between your mental health and your baby’s safety in the dark. With a perinatal-focused psychiatrist and an informed OB team, you can make evidence-based decisions that protect both.
