Written by Aisha Saleem, Pharmacist & Health Writer at PharmaHealths.com
Last Updated: August 2026
One of the most common anxieties for people with mental health conditions is what happens to their medication when they become pregnant or are planning to conceive. The default assumption is often that all psychiatric medication must stop immediately to protect the baby. This assumption is not only clinically incorrect but can, in some situations, be dangerous. The decision about mental health medication in pregnancy is not medication versus no medication. It is a careful comparison of two real and important risks: the risks associated with specific medications, and the risks associated with untreated or undertreated mental illness. Both sides carry real clinical consequences.
Untreated Mental Illness in Pregnancy Carries Its Own Risks
This is the most important starting point and the piece of information most people are not given clearly enough. A review of perinatal mental health published in World Psychiatry by Howard and Khalifeh found that mental disorders are among the most common complications of pregnancy, affecting approximately 10 to 20% of women globally. The review identified that untreated perinatal depression and anxiety are associated with increased risks of preterm birth, low birth weight, impaired mother-infant attachment, and poorer infant developmental outcomes. Maternal suicide is consistently identified as one of the leading causes of maternal death across high income countries.
According to the National Institute of Mental Health, untreated perinatal depression also increases the likelihood of poor prenatal care, inadequate nutrition, substance use, and postpartum depression following delivery.
The World Health Organization identifies depression and anxiety as major contributors to the global burden of disease in women during their reproductive years, making perinatal mental health one of the most clinically significant yet undertreated areas of women’s health globally.
Stopping mental health medication in pregnancy is not automatically the safer choice. For many people, continuing or adjusting medication under specialist oversight is clinically safer than stopping. Decisions should never be made abruptly after a positive pregnancy test without medical guidance. This risk benefit conversation must always involve a clinician with expertise in perinatal mental health.
Antidepressants in Pregnancy
SSRIs are the most extensively studied class of psychiatric medication in pregnancy. Research examining the effects of SSRIs in pregnancy, including a study published in the BMJ by Vigod, Wilson, and Howard, consistently finds that the overall risk profile of SSRIs in pregnancy is considerably more favorable than the risk profile of untreated depression during pregnancy.
Within SSRIs, sertraline has the largest pregnancy safety dataset and is generally considered the preferred first line option when antidepressant treatment is needed during pregnancy. Escitalopram is also widely used with a reasonable safety profile.
Paroxetine is generally avoided in pregnancy. Evidence suggests a possible association with minor cardiac malformations in the first trimester, and it also carries a higher risk of neonatal adaptation syndrome due to its shorter half-life and more abrupt discontinuation effects in the newborn.
Venlafaxine, an SNRI, has less pregnancy data than SSRIs but is considered a reasonable option where SSRIs have not been effective. It carries a somewhat higher risk of neonatal adaptation syndrome and neonatal withdrawal symptoms.
NICE Clinical Guideline CG192 on Antenatal and Postnatal Mental Health states that prescribing decisions for antidepressants in pregnancy should account for the stage of pregnancy, the known reproductive safety data for the specific drug, the risk of discontinuation symptoms in the person, and the risk of neonatal adaptation syndrome in the baby, particularly with paroxetine and venlafaxine. The risk of relapse if medication is stopped must also be explicitly weighed in any decision.
Neonatal Adaptation Syndrome
Neonatal adaptation syndrome describes a cluster of mild, transient symptoms sometimes seen in newborns exposed to SSRIs, SNRIs, or tricyclic antidepressants in late pregnancy. Symptoms can include jitteriness, feeding difficulties, irritability, respiratory disturbances, and disturbed sleep. These symptoms typically resolve within a few days without active intervention and are monitored rather than treated in most cases. Importantly, these symptoms are usually short lived and manageable, and they are not equivalent to neonatal withdrawal syndrome, which carries more serious clinical implications. Their possibility alone should not be used as a reason to stop necessary antidepressant treatment.
Mood Stabilizers in Pregnancy
Valproate must not be used during pregnancy or in women of childbearing potential unless all other treatments have been ineffective or are not tolerated and a pregnancy prevention programmed is formally in place. NICE CG192 is unequivocal on this point, and it reflects strong evidence. Valproate is associated with a high rate of major congenital malformations and significant neurodevelopmental harm in children exposed in utero, including lower IQ and increased risk of autism spectrum disorder. This is a clear contraindication rather than a situation requiring routine risk balancing.
Lamotrigine is generally considered the preferred mood stabilizer in pregnancy for people with bipolar disorder where valproate would otherwise be considered. It carries a more favorable risk profile, though dose requirements often increase during pregnancy due to enhanced lamotrigine clearance, which means blood level monitoring is needed throughout.
Lithium requires careful management during pregnancy. Its use is associated with a small increased risk of cardiac malformations in the fetus, including rare conditions such as Ebstein’s anomaly, though the absolute risk is lower than earlier estimates suggested. Lithium levels fluctuate significantly during pregnancy and in the postnatal period, requiring regular monitoring to avoid toxicity or subtherapeutic levels. Stopping lithium suddenly can significantly increase the risk of relapse, particularly in people with bipolar disorder. This is one of the clearest clinical examples of why stopping medication in pregnancy without specialist guidance can be more dangerous than continuing it with appropriate monitoring.
Antipsychotics in Pregnancy
Antipsychotics are sometimes necessary during pregnancy for people with schizophrenia, bipolar disorder, or treatment resistant depression. NICE CG192 advises against depot antipsychotics during pregnancy unless the person is responding well to a depot and has a documented history of non-adherence with oral medication. Oral atypical antipsychotics are preferred where continued treatment is needed. Quetiapine and olanzapine have the most pregnancy data among atypical, though metabolic monitoring remains clinically important throughout.
Benzodiazepines in Pregnancy
NICE CG192 recommends that benzodiazepines should not be offered during pregnancy or the postnatal period except for short term management of severe anxiety or agitation. In people planning pregnancy, a gradual taper from benzodiazepines is recommended where clinically feasible. Benzodiazepine use during pregnancy is associated with neonatal withdrawal symptoms and in some studies with increased risk of preterm birth. They are generally not recommended for long-term management due to dependence and neonatal risks.
Breastfeeding and Mental Health Medication
NICE CG192 actively encourages breastfeeding for women taking mental health medication, with specific exceptions. Women taking carbamazepine, clozapine, or lithium are advised not to breastfeed because of meaningful infant exposure through breast milk. Valproate is not recommended for mental health conditions in women of childbearing potential regardless of feeding method.
SSRIs transfer into breast milk in very small amounts. Sertraline and paroxetine have the lowest rates of infant exposure through breast milk among commonly used SSRIs and are preferred where a choice exists. Any breastfeeding decision should be made in collaboration with the prescriber and ideally with input from a specialist perinatal pharmacist or service.
Specialist Perinatal Mental Health Services
NICE CG192 recommends that any woman with a current or past severe mental illness who is planning a pregnancy should be referred to a specialist perinatal mental health service for preconception counselling. This is a clinical recommendation based on the genuine complexity of managing psychiatric medication across the perinatal period, not an administrative formality. Specialist perinatal services have the expertise to plan medication management proactively across all three trimesters and the postnatal period, helping reduce the risk of last-minute or crisis decisions.
If you have a significant mental health history and are pregnant or planning to conceive, asking your clinician whether a specialist perinatal referral is appropriate is one of the most useful steps you can take.
Conclusion
Mental health medication in pregnancy is one of the most emotionally complex areas of prescribing and also one of the most important to approach with accurate information. The evidence is clear on the central point: untreated mental illness in pregnancy is not the safe default. Every decision about continuing, adjusting, or stopping medication must weigh the risks of the medication against the risks of the condition it is treating. Sertraline has a well-established pregnancy safety profile. Valproate is contraindicated. Lithium and lamotrigine require specialist management and monitoring. Benzodiazepines are not appropriate for ongoing use in pregnancy. Specialist perinatal mental health services exist precisely because of this clinical complexity, and using these services can make treatment decisions safer and more structured.
Disclaimer
This article is for informational purposes only and does not constitute medical advice. Decisions about psychiatric medication during pregnancy must always be made with a qualified healthcare professional. Do not stop, start, or change any medication without medical guidance. If you are experiencing a mental health crisis during pregnancy, please contact a mental health service or emergency service in your area immediately.
References
• World Health Organization. Mental Health of Women. https://www.who.int/news-room/fact-sheets/detail/mental-health-of-women
• Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313-327. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491607/
• National Institute of Mental Health. Perinatal Depression. https://www.nimh.nih.gov/health/publications/perinatal-depression
• Vigod SN, Wilson CA, Howard LM. Depression in pregnancy. BMJ. 2016;352:i1547. https://www.bmj.com/content/352/bmj.i1547
• National Institute for Health and Care Excellence. Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. NICE Clinical Guideline CG192. 2014, updated 2020. https://www.nice.org.uk/guidance/cg192
