Judicious antidepressant use in pregnancy

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Goodfellow Gems

"Judicious antidepressant use in pregnancy"

Drug intervention threshold is higher during pregnancy due to foetal safety concerns.1 For women with current (or former) moderate or severe depression (many of whom are taking antidepressants before pregnancy) antidepressants will usually be necessary with continued psychological therapy. SSRIs are first line drugs in pregnancy for unipolar depression, but SNRI, bupropion, and mirtazapine are all OK with an historical response or non-response to SSRIs. Complicated depression may require referral. For women with no previous antidepressant use, any SSRI is a reasonable first choice, with the possible exception of paroxetine owing to its higher risk of neonatal adaptation syndrome (NAS). Reducing the dose before delivery does not reduces the risk of NAS. Antidepressants can prevent relapse of depression in pregnancy. The greatest prophylactic effect is in severe or recurrent depression. SSRIs are considered compatible with breast feeding. Switching antidepressants during pregnancy/lactation is not recommended (even with paroxetine). Sertraline has the lowest passage to breast milk.

This GEM has been checked by Dr Rob Shieff Private Psychiatrist 25 Vermont St, Ponsonby, Auckland 1011 Ph 9-360 0360.


  1. Vigod SN, et al Depression in pregnancy. BMJ 2016;352:i1547 doi: 10.1136/bmj.i1547 (Published 24 March 2016)
  2. BMJ talk medicine podcast on this topic doi: 10.1136/bmj.i1547

Gems are chosen by the Goodfellow director Dr. Bruce Arroll to be either practice changing or practice maintaining. The information is educational and not clinical advice.

As published in NZ Doctor 25/05/2016