Medication Management

Psychiatric Medication During Pregnancy and Breastfeeding

By Dr. Stacey Forbes, DNP, APRN, PMHNP-BC · Updated October 12, 2026

If you take psychiatric medication and are pregnant, planning a pregnancy or breastfeeding, the instinct to stop everything is understandable. The evidence suggests it is often the wrong move. The American College of Obstetricians and Gynecologists (ACOG) recommends against withholding or discontinuing mental health medication because of pregnancy or lactation alone, because untreated depression, anxiety and bipolar disorder carry their own risks for parent and baby. This guide explains how that balance is weighed, medication by medication.

Two sets of risks, not one

ACOG’s Clinical Practice Guideline No. 5, published in June 2023, asks clinicians to treat untreated or inadequately treated mental illness as an exposure in its own right. Its counseling table lists risks of under-treated depression in pregnancy that include less engagement with prenatal care, substance use, preterm birth, low birth weight, preeclampsia, postpartum depression, impaired bonding with the baby and suicide, which the guideline notes is a leading preventable contributor to maternal deaths in the United States.

On the other side sit the medication risks, which vary widely by drug. The comparison that matters is not “medication versus a perfectly healthy pregnancy.” It is medication versus the same illness without treatment. Many older studies compared medicated mothers with mothers who had no depression at all, and ACOG points out that this approach can produce misleading conclusions.

Antidepressants: what the evidence shows

ACOG recommends psychotherapy as a first-line treatment for mild-to-moderate perinatal depression, and SSRIs as the first-line medication for perinatal depression and anxiety, with SNRIs as reasonable alternatives. If someone has done well on a particular medication before, that history guides the choice. For someone with no medication history, sertraline or escitalopram are named as reasonable starting options.

Persistent pulmonary hypertension of the newborn (PPHN)

PPHN is a rare but serious breathing problem in newborns. After reviewing studies that accounted for the underlying illness, ACOG concludes there may be an increased risk with SSRI exposure, but that the absolute risk is low, approximately 1 to 2 additional cases per 1,000, and should be balanced against the significant risks of untreated depression. The FDA likewise advised clinicians not to change their practice of treating depression in pregnancy because of PPHN concerns.

Neonatal adaptation syndrome

Some babies exposed to SSRIs or SNRIs late in pregnancy are jittery, irritable or have feeding or sleep difficulty in the first days of life. ACOG notes these symptoms typically emerge within the first few days and resolve within two weeks. Letting the pediatric team know about the medication ahead of time means they can watch for it and reassure you.

Choosing among antidepressants follows the same principles as at any other time, with pregnancy data added in; see our guide to how a prescriber chooses a first antidepressant.

Mood stabilizers: valproate, lithium and lamotrigine

For bipolar disorder the stakes of stopping are high. ACOG recommends against discontinuing mood stabilizers during pregnancy, with one exception, because of the risk of relapse. Our overview of mood stabilizers explains how these medications work in general.

Valproate: the exception

Valproate (divalproex) carries a boxed warning on its U.S. label that it can cause major birth defects, particularly neural tube defects such as spina bifida, as well as decreased IQ scores and neurodevelopmental disorders after exposure in the womb. The label says it should not be used to treat bipolar disorder in people who are pregnant or planning pregnancy unless other medications have failed or are otherwise unacceptable. The European Medicines Agency went further in 2018, banning its use for bipolar disorder during pregnancy and requiring a pregnancy prevention programme for anyone able to become pregnant. ACOG recommends against valproate as a first-line treatment for bipolar disorder for this reason. Anyone of childbearing potential taking valproate should talk with their prescriber about contraception and alternatives before a pregnancy, not after.

Lithium: more nuanced than its reputation

Early reports linked first-trimester lithium to a heart defect called Ebstein anomaly at alarming rates. ACOG summarizes more recent data showing a much smaller increase in risk and calls lithium a reasonable treatment option, particularly for people with a history of mania or who have done well on it. The guideline recommends a detailed ultrasound in the second trimester for those exposed in the first, and stresses that lithium levels need close monitoring during pregnancy and after delivery, when dosing often has to be readjusted.

Lamotrigine

ACOG describes lamotrigine as a preferred option for bipolar II disorder in people of reproductive age because of its low risk of birth defects. Pregnancy speeds up its clearance, so doses often need adjusting during pregnancy and then bringing back down after delivery, which should be planned before the birth.

Antipsychotics and benzodiazepines

Antipsychotics are used in pregnancy for bipolar disorder, psychosis and sometimes severe depression. ACOG recommends that people taking them be screened for gestational diabetes as part of standard prenatal care, since several carry metabolic risks.

For anxiety, ACOG recommends that benzodiazepines be avoided or prescribed sparingly. For someone already taking one regularly, stopping abruptly carries its own dangers, so any change should be planned with the prescriber; our page on a supported benzodiazepine taper describes the general approach.

Planning before conception

The single most helpful step is a conversation before pregnancy. Because pregnancies are not always planned, it is worth having whenever pregnancy is possible, not only when you are actively trying. A pre-conception visit can cover:

• whether the current medication is the one you would want to be on if pregnancy happened, and if not, making the switch while you are well rather than in the first trimester
• how stable you have been, and what happened in the past when medication was stopped
• whether valproate or another high-risk medication is on the list, and what contraception and alternatives make sense
• baseline labs such as thyroid function, iron and vitamin D, which affect mood and energy in pregnancy and after birth
• who is on the team: your mental health prescriber, OB or midwife, and later the pediatrician

Hormonal transitions affect mood well beyond pregnancy; our guide to hormones and mental health covers thyroid and sex-hormone effects in more depth.

After birth: postpartum and breastfeeding

The weeks after delivery are a high-risk period for depression, anxiety and, for people with bipolar disorder, mood episodes and postpartum psychosis. Sleep loss is a powerful trigger. A plan made before delivery, including who will cover night feeds and when the first postpartum check-in will be, is part of treatment.

On breastfeeding, ACOG states that people with mental health conditions should not be discouraged from breastfeeding if that is how they want to feed their baby. If a medication was stable throughout pregnancy, it generally should not be changed after birth, because the baby’s exposure in the womb was greater than exposure through breast milk. When starting a new medication while breastfeeding, how much passes into milk is considered alongside how well it works. Two free resources are worth knowing:

• LactMed, the National Library of Medicine’s Drugs and Lactation Database, summarizes published data on medications in breast milk.
• MotherToBaby, a service of the Organization of Teratology Information Specialists, lets parents and clinicians ask experts about medications in pregnancy and breastfeeding by phone, text, chat or email.

Zuranolone for postpartum depression

On August 4, 2023, the FDA approved zuranolone (Zurzuvae) as the first oral medication specifically for postpartum depression in adults. It is taken once daily for 14 days. Its boxed warning says it impairs driving, so people should not drive or do other hazardous activities for at least 12 hours after each dose. The FDA also notes it may cause fetal harm, so effective contraception is advised during treatment and for a week afterward. Its prescribing information reports low levels in breast milk in a small study and no data yet on effects in breastfed infants. For more on recognizing and treating postpartum depression, see our postpartum depression treatment page.

Coordinating care

Medication decisions in pregnancy work best when everyone is reading from the same plan. At Willow & Stone, decisions about psychiatric medication in pregnancy or breastfeeding are made together with your OB or midwife and, after birth, your baby’s pediatrician, so the prenatal team knows what you take and the pediatric team knows what to watch for. ACOG also points clinicians toward perinatal psychiatry access programs, which offer consultation when a situation is complex. Our integrative medication management approach adds attention to sleep, iron, thyroid and nutrition, which matter even more in this season.

Common Questions

Sources & Further Reading

• ACOG — Clinical Practice Guideline No. 5: Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum (2023)
• FDA — FDA Approves First Oral Treatment for Postpartum Depression (2023)
• DailyMed — Depakote (divalproex sodium) prescribing information, Fetal Risk boxed warning
• European Medicines Agency — Valproate and related substances referral (2018)
• National Library of Medicine — Drugs and Lactation Database (LactMed)
• MotherToBaby (Organization of Teratology Information Specialists)

This article is general education, not advice for your situation. Do not start, stop, or change a medication or supplement without talking to the clinician who prescribes it.