I’ve lived much of my life secretly following rules and compulsions. Some rules I made up as a child, like tapping my heels or counting down before I left the shower; others I picked up as a teenager, like not eating salt or standing up to do jumping jacks at specific times of day. And while the particular rules and rituals have shifted over the years, the panic and guilt that would follow if I didn’t comply were consistent and debilitating. As a teenager, I was diagnosed with anxiety and obsessive-compulsive disorder and have taken the selective serotonin reuptake inhibitor Prozac ever since. SSRIs are the most commonly prescribed antidepressants, typically used to treat anxiety disorders, depression, and OCD; more than 13 percent of adults in the U.S. take SSRIs. For decades, these pea-size pills, lighter than a quarter-teaspoon of water, have anchored me to the earth.
This past June, in the second month of my pregnancy, I was confronted with the possibility of suddenly being adrift. It was year two of COVID-19 in California — the weeks were blurs of mixed messaging on masks, unpredictable lockdowns, and wildfire warnings. Still, I’d wanted a child for years, and the knowledge that cells were multiplying inside my womb, building a tiny beating heart, was powerful enough to clear away the chaos and give me something to focus on. I knew I couldn’t control the environment around me, but, I thought, at least I could control what went into my body and this baby-to-be. Trivial decisions like which sunscreen to use and what position to sleep in suddenly felt momentous. I didn’t want to mess up. It was easy enough to limit caffeine, avoid uncooked fish, and say no to the occasional drink or hit of marijuana. But as I reviewed my medicine cabinet, I realized I had no idea whether my Prozac pills were safe to swallow.
Here’s where I suggest you never Google such things. And perhaps I wouldn’t have, but I was searching for a psychiatrist who accepted my insurance and I had no idea how long that might take. So I turned to that dark place many of us go when we’re alone with our medical fears: Dr. Internet. And it wasted no time pummeling me with scary headlines.
From WebMD and Scientific American, there were warnings about SSRIs and birth defects and autism: “Antidepressants Linked to Birth Defect,” “Antidepressants in Pregnancy Tied to Autism.” CNN featured a study linking SSRIs during pregnancy to language disorders like dyslexia. Yale and Reuters cautioned about preterm birth and children growing up with mood disorders: “Antidepressants — not depression — increase risk of preterm birth, study shows,” “Child psychiatric disorders tied to in utero antidepressant exposure.”
For weeks, I pored over the studies cited by these articles. I sank deeper into fear each time I read words like double the risk and severe and difficulty breathing. The abbreviations and numbers began to jump around the page, and I struggled to pin them down or interpret their meaning. Between work meetings, I would scroll through Ovia, the popular pregnancy-tracking app I’d downloaded onto my phone, to see if other people were as confused as I was. They were — and much like people’s opinions on COVID vaccines, their takes on SSRIs ranged from conspiracy theories to miracle cures.
Finally, one mid-July afternoon, after Googling how much Prozac a 14-week-old fetus absorbs in the womb, my husband, Paulo, came home to find me in a fetal position on the couch, face smeared with tears and mascara, shielding myself against what felt like the onset of a panic attack. (As in just about every other study, the authors here noted that “further research is needed” but also warned that there was reason to believe Prozac “not only crosses the placenta but also accumulates within fetal brain tissue within five hours after drug administration.”)
I was terrified that I had already harmed this tiny human growing inside me and certain that I needed to quit being selfish and quit taking the pills. Paulo was just as overwhelmed as I was — he had been laid off during the pandemic and was still coming to terms with the fact that I was pregnant. And now here I was wailing about how messed up our baby would be. “Just wait to speak with the psychiatrists,” he said, trying to calm me down. “They’ll know the answers.”
Three different virtual visits with three different psychiatrists clarified nothing. One psychiatrist suggested I taper off Prozac entirely in the third trimester. Another told me not to “worry” about it. A third said I might want to switch from Prozac to Zoloft. I know medical decisions are not always cut-and-dried; I spent four years as a health reporter covering the complexities of care. I understood why, for example, information about the new COVID vaccines was limited, but I couldn’t understand how, after decades of these pills being on the market, psychiatrists continued tossing around such varied information about an antidepressant like Prozac.
Prozac hit the market the year I was born, in 1988. It quickly became the most commonly prescribed antidepressant in the United States; today, nearly 8 percent of women in the U.S. use SSRIs like Prozac during pregnancy. Tens of millions of pregnant women have taken these medications while pregnant, and hundreds of published studies have evaluated their safety.
Yet, somehow, more data has made the decision-making process even more complicated. If you were to map out all the possible risks and recommendations for pregnant women, you would have something as impossible to understand as the New York City MTA map is to Midwesterners. Forget which train to take — I wasn’t even sure if I was at the right station. I needed to find a guide, someone with perspective.
For the past decade, Dr. Simone Vigod, a women’s-health psychiatrist and clinical researcher in pregnancy and postpartum mental health at Women’s College Hospital and a professor of psychiatry at the University of Toronto, has been working with and researching women struggling to navigate this medication maze. “For women who either have been on antidepressant medications prior to pregnancy or who are symptomatic in pregnancy, this is one of the biggest issues,” she told me. “The stakes are high, and you don’t have months and months to make up your mind.”
And we get such mixed messages, Dr. Vigod says, for a few reasons. The first complication is that the decision to either continue SSRI treatment or stop suddenly while pregnant each comes with potential risks.
Untreated depression during pregnancy, according to a clinical review published in The BMJ in 2016, has been associated with risks like preterm birth and childhood emotional difficulties as well as risks for the mother. Pregnant women with depression are more likely to develop postpartum depression and to engage in high-risk health behaviors like smoking and illicit-substance use. While reproductive psychiatrists generally agree that SSRIs do not pose a major risk to the developing fetus, there may be a risk of a short-term adaptation syndrome for the newborn as well as a very small risk of preterm birth, low birth weight and persistent pulmonary hypertension of the newborn. Vigod says interpreting the results of the many existing research studies and communicating to patients and providers how the results might apply to their individual situations are where things can get messy.
I was shocked to learn there has not been a single randomized controlled trial — the gold standard for scientific research — investigating the effects of SSRIs during pregnancy. In randomized controlled trials, like those done for Pfizer’s and Moderna’s COVID vaccines, participants are randomly assigned to receive either the treatment being investigated or a placebo. This makes it easier for researchers to determine whether there really is a cause-and-effect relationship between the treatment and the outcome. The studies of pregnant women taking SSRIs, like the ones that have led to headlines about autism, birth defects, and preterm birth, were all observational studies — meaning researchers collected data from health and prescription records (the women might or might not have taken the medication) or relied on patients themselves to accurately remember and report their own data. There was no randomization of who received medication, and there were no control groups. Vigod says in observational studies, researchers often compare the outcomes of women who have taken SSRIs while pregnant with the outcomes of women who haven’t taken such medications and don’t need to.
It’s obvious, but I’ll say it anyway: This is problematic because people like me take antidepressants for a reason.
Women who take antidepressants are more likely to have severe depression, Vigod notes, and they may also have more stressful life circumstances (e.g., financial issues, domestic violence), all of which may contribute to poor pregnancy outcomes. “So unless observational studies account for all of the ways that women who take and don’t take medication are different,” Vigod says, “someone could conclude that medications are the reason for a certain infant outcome — when really it was one of the other factors.”
In other words, many published studies essentially compare women like me (pregnant women with a history of anxiety and OCD on antidepressants) with my friends who have no histories of anxiety and OCD and don’t take medication. Of course, those women are more likely to have various better outcomes, and of course I wish I were like them. But … I’m not. Vigod says if you want to isolate the effects of SSRIs, you really need to run more rigorous trials that compare women like me with other women like me who are not given SSRIs. But that’s unlikely to happen because pregnant women are generally excluded from such research.
Despite decades of pushback from scientists and pregnant women themselves, ethical concerns about harming the fetus or the pregnant woman have kept us out of clinical trials — like the ones testing COVID vaccines.
While randomized controlled trials of pregnant women remain out of reach, better-designed observational studies have found some ways to disentangle the effects of a woman’s mental illness from the effects of antidepressant medications. I found the results to be quite reassuring. For example, whereas earlier studies had determined that a pregnant woman’s antidepressant use seemed to increase the risk of autism in her child, when researchers, including Vigod, conducted a study that accounted for potential confounding factors — including the mother’s mental-health diagnoses, age at delivery, and other medications taken, the association disappeared.
Similarly, while several earlier studies had found a link between certain cardiac malformations in children exposed to Paxil, another SSRI, before birth, a large study that took into account other factors — like the mother’s history of alcohol or illicit-substance use, higher BMI, and diabetes — showed no increase in the risk of cardiac malformations attributable to antidepressant use during the first trimester of pregnancy.
Like I said, reassuring … but also completely exhausting to digest. Absorbing so much conflicting, ever-changing information is frustrating for pregnant women desperate for immediate and definite answers, and for the psychiatrists who are supposed to counsel them.
“It’s hard to acknowledge that we don’t have all the information,” says Dr. Nirmaljit Dhami, a reproductive psychiatrist at El Camino Hospital in Mountain View, California. Still, she emphasized that the aforementioned risks of taking SSRIs must be weighed against the risk of untreated mental-health disorders. In that equation, the balance often favors treatment, though each pregnant woman’s situation is unique.
There is a movement among primary-care doctors and OB-GYNs, Dr. Dhami explains, to pay closer attention to the mental health of pregnant women and new moms. This shift is partially due to updated guidance from the United States Preventive Services Task Force, the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics, as well as recent laws in more than a dozen states like California, Illinois, and New York, that encourage or require doctors to screen pregnant and postpartum women for depression.
“Doctors are referring patients faster to psychiatrists and writing prescriptions for SSRIs quicker,” Dhami says. “Now I’m mostly hearing patients tell me their doctors have said that mental health comes first, and that’s music to my ears.”
The intention is good, but the challenge of connecting women who screen positive with specialized care can be daunting. Both Dhami and Vigod point out that compared with the number of women who need help, there are few programs, therapists, or psychiatrists available who accept health insurance. It’s estimated that, on average, only one in five women who are identified as being depressed end up having at least one mental-health visit, due to factors like cost, stigma, and availability.
For pregnant women, access to mental-health care has become even more critical because of COVID. There has been a documented increase in maternal anxiety and depression since the pandemic began. “People have lost jobs, child care, and relationships, so it’s critical to help the patients now,” Dhami says. “The amount of anxiety and depression is much higher than what we were seeing before, and that’s why it’s really important to have these conversations.”
Until I had these conversations with psychiatrists who specialize in treating women during pregnancy, I was stuck in doomscroll mode, falling for headlines like “Antidepressant Use in Pregnancy Linked to Worse Math Test Scores in Kids.” I’m not the only one. Vigod researched Twitter activity and found that lower-quality studies and those showing harmful effects from antidepressant use during pregnancy were shared far more often than those providing reassurance. It’s no wonder women often overestimate the risks of medications.
It took me five months into my pregnancy to make a decision about whether to change my medication. Learning that the absolute risks of any complications were low was comforting, but ultimately the piece of advice that tipped the scale had nothing to do with statistics or new research. It was a suggestion from the medical director of perinatal mental health at UCSF, Dr. Amanda Yeaton-Massey.
Dr. Yeaton-Massey told me to ask myself the following question: What would allow me to have the best possible relationship with myself and my baby? If the answer is staying on medication, she said, then that is absolutely the right thing to do.
As someone used to relying on numbers and rules, taking a moment to touch base with my gut was awkward. But that area of my body had been speaking to me lately — granted, in a cryptic language of flutters and kicks and a drumbeat of hiccups. Nevertheless, I knew the answer. I would feel most connected to my baby and best able to care for her if I cared for myself. And for me, that meant staying on antidepressants.
To help manage my medication, I found a group of psychiatrists who specialize in perinatal health — and accept insurance. (It wasn’t easy, by the way. I spent weeks reaching out and scheduling phone calls only to learn that most of the perinatal psychiatrists I spoke with didn’t accept insurance at all and charged between $400 and $600 just for an initial appointment. Sources I spoke with confirmed this was the industry standard.) My new psychiatrist has since reassured me that I’m making the right choice for me and my future family.
My due date is fast approaching, and the cells growing inside of me have formed a heart, a brain, and plenty of fingers to suck and point and poke. With my decision to stay on Prozac out of the way, I have more space to feel excited about what this child may be like and how Paulo and I will be as parents. That’s not to say the anxiety is gone — and, of course, I’ll monitor my symptoms after birth, too — but I no longer feel so lost. I know I’m on the right train; now I just need to grab a handrail and let the wild ride begin.
Navigating medication decisions during pregnancy or postpartum? Here are some reliable (non–Dr. Internet prescribed) resources to help guide you: