Shift in Perspective on SSRI Use During Pregnancy: Experts Advocate for Individualized Care

The debate surrounding the use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy is evolving, with new evidence suggesting that serious adverse outcomes are unlikely when the drug's effects are disentangled from the impact of maternal depression. This shift in perspective is challenging long-held fears that have influenced clinical recommendations for pregnant women with major depressive disorder (MDD). ## The Changing Landscape of SSRI Use in Pregnancy For decades, the specter of thalidomide-a drug that caused severe congenital malformations in the 1950s and 1960s-has loomed over discussions about medication use during pregnancy. This historical context has led to a cautious approach to prescribing SSRIs, despite their effectiveness in treating MDD. However, recent research indicates that when the effects of SSRIs are carefully separated from those of the underlying depression and other confounding factors, the drugs appear to carry minimal risk for serious adverse outcomes. Katherine L. Wisner, MD, of the Developing Brain Institute at Children's National Hospital in Washington, D.C., and her colleagues argue that the focus should shift toward prioritizing the treatment of MDD to optimize maternal health. In a special communication in *JAMA Psychiatry*, they highlight that psychiatric disorders are among the leading causes of maternal morbidity and mortality. Women with MDD face higher rates of pregnancy complications, including preterm birth, low birth weight, and preeclampsia, as well as increased risks of hypertension and other medical issues. ## Risks of Discontinuing SSRIs Despite these findings, many pregnant women still discontinue or avoid SSRIs due to concerns about fetal harm. A cross-sectional study found that only 17.6% of women who delivered babies in 2023 or 2024 continued their antidepressants without gaps, while 64.6% had a gap of 60 days or more. This discontinuance carries its own risks: a systematic review and meta-analysis showed that women with severe or recurrent depression who stopped antidepressants during pregnancy relapsed significantly more often than those who continued treatment. Additionally, a Danish cohort study suggested that pregnant women who discontinued antidepressants experienced an increased risk of psychiatric emergencies. Kay Roussos-Ross, MD, of the University of Florida, emphasizes the need to move away from counseling that treats discontinuing medication as the 'safe' choice. She points out that discontinuation can have serious consequences for both maternal and offspring health. Similarly, Sonia Hernandez-Diaz, MD, DrPH, of the Harvard T.H. Chan School of Public Health, acknowledges that while the evidence is not definitive, SSRIs are not strong teratogens. The discussion around potential risks, such as preterm delivery, remains ongoing. ## The Importance of Shared Decision-Making Given the complexities of the research, Wisner and her colleagues advocate for a structured decision-making process that involves patients in the discussion. This approach includes using visual aids to help patients understand the research and quantify the risks and benefits of treatment. Roussos-Ross supports this idea, arguing against blanket recommendations for or against antidepressants in pregnancy. The experts stress the importance of supporting patients' values and preferences, as well as providing clear, evidence-based information. By doing so, clinicians can help pregnant women with MDD make informed decisions about their treatment, balancing the potential risks of SSRIs with the well-documented dangers of untreated depression.