Researchers are pushing for a focus on shared structured decision-making processes when it comes to pregnant women and the treatment prescription of selective serotonin reuptake inhibitors (SSRI), saying optimising maternal health is a priority, reports Medpage Today.
In the United States, at least 5% to 6% of pregnant women are treated with SSRIs, mostly for major depressive disorder (MDD).
Despite some opinions, evidence suggests that serious adverse outcomes are unlikely with the use of SSRIs in pregnancy, once the effects of the drug are separated from confounders such as the impact of underlying psychiatric illness, and researchers, in a special communication in JAMA Psychiatry, emphasised the importance of structured decision-making processes, including the use of visual aids to help patients understand the research.
“After thalidomide used for morning sickness led to congenital malformations in more than 10 000 children decades ago, fear of another drug-associated devastating foetal effect has overshadowed concern about the impact of maternal disorders on maternal-foetal health,” wrote Katherine Wisner, MD, of the Developing Brain Institute at Children's National Hospital in Washington and co-authors in JAMA.
However, there’s been a change in recent years.
“Once the impact of the drug is disentangled from that of MDD and its sequelae, accumulated evidence suggests that SSRIs carry little or no risk for serious adverse outcomes,” noted the authors. “The thrust of the field has shifted to prioritise treatment of MDD to optimise maternal health.”
Wisner told MedPage Today that “the knee-jerk reaction of advising women to stop medication during pregnancy ignores the impact of the underlying illness on maternal-foetal health and increases the risk for depression relapse, maternal medical complications, and loss of function and resources (like employment and personal relationships)”.
Kay Roussos-Ross, MD, of the University of Florida in Gainesville who was not involved in the report, said there needs to be a “move away from counselling that implicitly treats discontinuing medication as the ‘safe’ choice”.
Discontinuation carries its own risks for pregnancy and offspring outcomes, she added.
Psychiatric disorders are among the leading causes of maternal morbidity and mortality. Women with MDD have higher rates of pregnancy complications, including preterm birth, low birth weight, Caesarean delivery, and hyperemesis gravidarum, as well as greater risks of hypertension and pre-eclampsia, Wisner and co-authors said.
A recent cross-sectional study showed that just 17.6% of women who delivered babies in 2023 or 2024 continued their antidepressants in pregnancy without gaps, while 17.8% had no fills during pregnancy and 64.6% had a gap of 60 days or more.
In a systematic review and meta-analysis, women with severe or recurrent depression who discontinued antidepressants during pregnancy relapsed significantly more often than those who continued treatment (risk ratio 2.30, 95% CI 1.58-3.35).
Additionally, a Danish cohort study suggested that pregnant women who discontinued antidepressants experienced an increased risk of psychiatric emergencies compared with a propensity score-matched group that remained on treatment (HR 1.25, 95% CI 1.00-1.55).
Assessing the safety of SSRI use in pregnancy is made more difficult by the potential for confounding in observational studies from the underlying condition itself and from other associated factors, like smoking, substance use, obesity, and socio-economic adversity, Wisner and team pointed out.
For example, a recent meta-analysis showed that children exposed to prenatal antidepressants had an increased risk of autism or attention deficit-hyperactivity disorder, which was no longer significant after adjusting for confounding factors.
HHS Secretary Robert F. Kennedy Jr has expressed concern about the use of SSRIs in pregnancy, stating, without evidence backing up his claims, that the drugs could be linked to autism or other foetal harms. Earlier this year, he launched a deprescribing initiative for antidepressants.
“Unlike for most other drugs, there are many studies published on SSRIs in pregnancy, including in vitro, animal, and human studies,” Sonia Hernandez-Diaz, MD, DrPH, of the Harvard TH Chan School of Public Health, who also wasn’t involved in the report, told MedPage Today.
However, in addition to the heterogeneity of results, many studies were small or had “important flaws in design or interpretation”, and some meta-analyses “that superficially evaluated the literature may have simply created more noise”, she argued.
“Although it is not totally satisfying for decision makers – we all prefer yes/no answers – what everybody would agree is that these drugs are not strong teratogens. The discussion on whether they might increase … the risk of preterm delivery and other outcomes is still ongoing,’ Hernandez-Diaz said.
There are also grey areas around the threshold for what is considered “an acceptable 'small risk’,” she added. “But there is consensus that those with severe depression who might experience ‘terrible consequences’ without antidepressants should continue treatment, as the benefits are likely to outweigh any potential risks.”
Deciding when to use antidepressants for more moderate depression requires understanding the nuances of the literature, quantifying the risks and benefits for individual patients, and balancing both, all of which is very difficult, she acknowledged.
Ultimately, Wisner and colleagues pushed for a focus on shared structured decision-making processes, an idea Roussos-Ross said she wholly supports in place of blanket recommendations for or against antidepressants in pregnancy.
Wisner and team stressed the importance of supporting patients’ values and preferences, as well as the value of visual aids that summarise absolute risks and help patients interpret the research.
Study details
Depression and SSRI treatment during pregnancy – prioritising maternal mental health
Published in JAMA Psychiatry on 12 August 2026
Key Points
Question How can the effects of exposure to major depressive disorder (MDD) and selective serotonin reuptake inhibitors (SSRI) treatment be balanced during pregnancy?
Findings The goal of this Special Communication is to synthesise accumulated evidence, which suggests that when the impact of the drug is disentangled from that of MDD and its sequelae, SSRI alone carry little or no risk for the most serious averse outcomes for mothers and their offspring.
Meaning Treatment of maternal depression must be prioritised, and SSRI are an essential component of perinatal mental healthcare.
Abstract
Importance
In the US, 5% to 6% of pregnant patients are treated with selective serotonin reuptake inhibitors (SSRI), primarily for major depressive disorder (MDD), which has a prevalence of about 12%. Psychiatric conditions are a leading cause of maternal morbidity and mortality. MDD is a common disorder that must be treated during pregnancy to improve outcomes for the mother, infant, family, and community.
Observations
MDD is a complex, multifactorial brain disease arising from genetic, environmental, and epigenetic factors. Factors unique to the perinatal period are associated with additional pathophysiologic changes specific to MDD. Maternal stress and psychiatric illnesses adversely affect foetal and infant outcomes. SSRI are an essential component of perinatal mental health care. Studies that define the benefits of SSRI treatment in pregnancy are fewer than those defining risks; however, several describe adverse effects with drug discontinuation in women with moderate to severe MDD. Evaluating the safety of SSRI treatment during pregnancy has been challenging due to the potential for confounding in observational studies by the underlying indication and associated factors. Once the impact of the drug is disentangled from that of MDD and its sequelae, accumulated evidence suggests that SSRI carry little or no risk for serious adverse outcomes. The thrust of the field has shifted to prioritise treatment of MDD to optimise maternal health.
Conclusions and Relevance
Meaningful advances in the treatment of perinatal MDD require co-ordinated attention to multiple aspects of clinical care delivery and research, informed by a perspective accounting for the health needs of two generations. Expanding access to care – particularly in maternity, child health, and psychiatric care deserts – is a public health imperative. A structured decision-making process facilitates the provision of balanced information on the potential maternal and foetal risks of untreated or undertreated illness, the benefits of treatment, and the risks associated with SSRI exposure.
MedPage Today article – Debate on Use of SSRIs in Pregnancy Shifting, Experts Say (Open access)
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