When you’re pregnant and struggling with depression, anxiety, or bipolar disorder, the question isn’t just whether to take medication-it’s how to make the safest choice for you and your baby. Too many women are told to stop their meds cold turkey because "it’s better for the baby." But the truth is, untreated mental illness carries real, measurable risks-risks that often outweigh the potential dangers of medication.

There’s No Risk-Free Option

Let’s be clear: no psychiatric medication is 100% safe during pregnancy. But neither is untreated depression, anxiety, or psychosis. Studies show that women with unmanaged mental health conditions during pregnancy face a 20% higher risk of suicide and a 30-50% increased chance of preterm birth. The baby’s development can also be affected-poor nutrition, lack of prenatal care, and high stress levels all impact fetal growth.

The goal isn’t to eliminate all risk. It’s to reduce the biggest risks. That’s where shared decision-making comes in. It’s not about a doctor telling you what to do. It’s about you and your provider sitting down with real data, talking through your history, your fears, and your goals-and making a plan together.

Which Medications Are Actually Safe?

Not all psychiatric drugs are created equal. Some have decades of safety data. Others? Not so much.

For depression and anxiety, SSRIs are the first-line choice. Sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac) are the most studied and generally considered the safest options. Most large studies show no increased risk of major birth defects with these medications. The one exception is paroxetine (Paxil). If you’re taking it and planning pregnancy, talk to your provider about switching. Paroxetine is linked to a slightly higher risk of heart defects-rising from about 8 in 1,000 births to 10 in 1,000.

For bipolar disorder, lamotrigine is often preferred. It doesn’t appear to cause major birth defects and works well for mood stabilization. Lithium is still used, but it needs careful monitoring because pregnancy changes how your body processes it. Your doctor will check your blood levels more often.

Avoid valproic acid (Depakote) at all costs if you’re pregnant or planning to be. It increases the risk of neural tube defects-from 0.1% in the general population to 1-2%. That’s a 10-20 times higher risk. It’s also linked to lower IQ and autism in children. The American Psychiatric Association recommends it shouldn’t be prescribed to women of childbearing age unless there’s absolutely no alternative.

Bupropion (Wellbutrin) carries a small risk of miscarriage or heart defects. Tricyclics like nortriptyline are less commonly used but can be an option if SSRIs don’t work. For psychosis, older antipsychotics like haloperidol and chlorpromazine have better safety data than newer ones. Atypicals like risperidone or olanzapine? We just don’t know enough about long-term effects on children yet.

Why Stopping Medication Can Be More Dangerous

Many women stop their meds the moment they find out they’re pregnant. Fear of birth defects is real-and understandable. But here’s what often happens next: relapse.

If you’ve had depression before, stopping your medication during pregnancy gives you an 80% chance of a major depressive episode. That’s not a guess. That’s from data collected by the National Pregnancy Registry for Psychiatric Medications. For women with bipolar disorder, the risk of mania or severe depression jumps even higher.

One mother I spoke with stopped her sertraline after her first positive pregnancy test. Within six weeks, she was hospitalized for severe depression. Her baby was born at 34 weeks. She didn’t need to go through that. Her doctor had offered to adjust her dose, not stop it entirely.

The risk isn’t just to you. Untreated depression increases the chance of low birth weight, developmental delays, and even postpartum psychosis. Your mental health isn’t separate from your baby’s health. It’s part of it.

How Shared Decision-Making Actually Works

This isn’t a one-time conversation. It’s a process. Good providers use tools like the Mental Health Medication Decision Aid from ACOG. It breaks down the risks for 24 different medications using real numbers-not vague warnings.

Here’s what a good shared decision-making session looks like:

1. Assess your personal risk. Have you had multiple episodes of depression? Were you hospitalized? How long have you been stable on your current meds? Tools like the Edinburgh Postnatal Depression Scale help measure this.
2. Present the facts clearly. Instead of saying "paroxetine might cause heart defects," say: "Out of 1,000 babies born to mothers taking paroxetine, about 10 might have a heart defect. Without it, that number is about 8. But if you stop your medication, your chance of severe depression goes up by 80%."
3. Plan for what happens if symptoms return. What’s your backup plan? Who will you call? When will you re-evaluate? Having a plan reduces panic.

Documentation matters too. If your provider writes down what you discussed, what risks you understood, and what you decided-this reduces legal risk for them and gives you peace of mind.

What Women Are Really Saying

A 2022 survey by Postpartum Support International found that women who had structured shared decision-making were 3.2 times more likely to stick with their treatment plan. At six weeks postpartum, their depression scores were 37% lower than women who were told to just stop their meds.

On Reddit’s r/PostpartumDepression, over 1,200 women shared their stories. Nearly 80% said they were pressured to stop medication. More than half ended up hospitalized, in crisis, or with severe postpartum depression after quitting.

Meanwhile, the National Pregnancy Registry has tracked over 15,700 women since 2010. Of those, 68% said they weren’t properly informed about risks before getting pregnant. That’s a system failure. No one should be left guessing.

What’s Changing in 2025

The field is evolving fast. The FDA stopped using the old A, B, C, D, X categories years ago. Now, labels give detailed summaries of risks, benefits, and data-based on real human outcomes.

The National Pregnancy Registry is adding 12 new medications in 2024, including newer antipsychotics like brexpiprazole. Researchers are also building machine learning tools that predict your personal risk based on your age, medical history, and medication type. Early models are 82% accurate.

By 2026, your doctor might be able to say: "Of the 42 women in our registry who are 31, have bipolar disorder, and took lamotrigine during pregnancy, 93% had healthy babies and stayed stable postpartum. Here’s what their outcomes looked like." That’s personalized care.

What You Can Do Now

If you’re pregnant or thinking about it:

• Don’t stop your meds without talking to your provider.
• Ask for a referral to a perinatal psychiatrist. Most OB-GYNs now work with them regularly.
• Request the ACOG Mental Health Medication Decision Aid. It’s free and easy to understand.
• Write down your concerns: "I’m scared of birth defects," or "I don’t want to feel numb again." Bring it to your appointment.
• Track your mood. Use a simple journal or app. It helps your provider see patterns.

Final Thought

This isn’t about choosing between a healthy baby and a healthy mom. It’s about making sure both of you stay healthy. The best outcome isn’t a pill-free pregnancy. It’s a supported, stable, informed pregnancy.

You deserve care that respects your experience, your data, and your right to make choices-not just follow orders. The tools are here. The evidence is clear. Now it’s about making sure every woman gets the conversation she needs.

Every pregnancy is different. Your mental health matters. Your choices matter. And you don’t have to make them alone.