Psychiatric Pharmacy Essentials: Psychotropic Medications in Pregnancy

Many patients and providers can be hesitant to utilize medications during pregnancy due to concerns of harm to the fetus. However, medications in pregnancy cannot always be avoided, especially in patients where the benefit outweighs the risks. Exacerbations of mental health conditions can increase risks for both mother and fetus. For each medication and each individual pregnancy, the risks and benefits must be carefully weighed. The following questions address considerations for using psychotropic medications during pregnancy.

  • What should be considered when evaluating a psychotropic medication’s safety during pregnancy?1-3
  • Where can I find dependable resources for medications during pregnancy and lactation4-5, including patient friendly resources?6
  • Why are pregnancy categories (A, B, C, D, X) no longer used for medications?1,7
  • What non-pharmacological therapies are evidence-based recommendations for treating anxiety or depression during pregnancy?8-9
  • What is the evidence for safety and efficacy of antidepressant1,2,10-12 and antipsychotic medication use during pregnancy?1,2,13-15
  • How are postpartum depression16-18 and postpartum psychosis treated?19
  • How is opioid use disorder (OUD) managed during pregnancy?20-21
  • What is the evidence for treating insomnia during pregnancy?22
  • What are the recommendations for managing lithium during pregnancy and post-partum?1,19,23
  • What pharmacokinetic differences should pharmacists consider when managing patients during and after pregnancy?24

Reviewer 1: Claire Herbst, PharmD, BCPS, BCPP
Reviewer 2: Mackenzie Pierce, PharmD, BCPS, BCPP
Reviewer 3: Austin Smith, PharmD, BCPP
2023-2024 AAPP Resident and New Practitioner Committee

Essential Questions and References

  1. Payne JL. Psychiatric Medication Use in Pregnancy and Breastfeeding. Obstet Gynecol Clin North Am. 2021 Mar;48(1):131-149. doi: 10.1016/j.ogc.2020.11.006. PMID: 33573783. [PubMed]
  2. Creeley CE, Denton LK. Use of Prescribed Psychotropics during Pregnancy: A Systematic Review of Pregnancy, Neonatal, and Childhood Outcomes. Brain Sci. 2019 Sep 14;9(9):235. doi: 10.3390/brainsci9090235. PMID: 31540060; PMCID: PMC6770670. [PubMed]
  3. Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N, Ramin S, Chaudron L, Lockwood C. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009 Sep;114(3):703-713. doi: 10.1097/AOG.0b013e3181ba0632. PMID: 19701065; PMCID: PMC3103063.[PubMed]
  4. Drugs and Lactation Database (LactMed®) Internet. Bethesda (MD): National Institute of Child Health and Human Development; 2006-.[Weblink]
  5. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. 10th ed. Wolters Kluwer Health: Lippincott Williams & Wilkins; 2015. [Print]
  6. MotherToBaby. The Organization of Teratology Information Specialists. Retrieved August 30, 2023. [Weblink]
  7. US Food and Drug Administration. Pregnancy and Lactation Labeling (Drugs) Final Rule. 2014 [Weblink]
  8. Evans, K, Spiby, H, & Morrell, JC. (2020). Non-pharmacological interventions to reduce the symptoms of mild to moderate anxiety in pregnant women. A systematic review and narrative synthesis of women's views on the acceptability of and satisfaction with interventions. Archives of women's mental health, 23(1), 11–28. doi: 10.1007/s00737-018-0936-9 [PubMed]
  9. van Ravesteyn, LM, Lambregtse-van den Berg, MP, Hoogendijk, WJ, & Kamperman, AM. (2017). Interventions to treat mental disorders during pregnancy: A systematic review and multiple treatment meta-analysis. PloS one, 12(3), e0173397. https://doi.org/10.1371/journal.pone.0173397 [PubMed]
  10. Alwan S., Reefhuis J., Rasmussen S., et al. (2007). Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med, 356(26):268402692. [PubMed]
  11. Bayrampour H, Kapoor A, Bunka M, Ryan D. The Risk of Relapse of Depression During Pregnancy After Discontinuation of Antidepressants: A Systematic Review and Meta-Analysis. J Clin Psychiatry. 2020 Jun 9;81(4):19r13134. doi: 10.4088/JCP.19r13134. PMID: 32558401. [PubMed]
  12. Dandjinou, M, Sheehy, O, & Bérard, A. (2019). Antidepressant use during pregnancy and the risk of gestational diabetes mellitus: a nested case-control study. BMJ open, 9(9), e025908. https://doi.org/10.1136/bmjopen-2018-025908 [PubMed]
  13. Huybrechts KF., Straub L., Karlsson P., et al. (2022) Association of In Utero Antipsychotic Medication Exposure with Risk of Congenital Malformations in Nordic Countries and the US. JAMA Psychiatry, 80(2):156-166. [JAMA].
  14. Wang Z., Chan A., Coghill D., et al. (2021). Association Between Prenatal Exposure Antipsychotics and Attention-Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, Preterm Birth, and Small for Gestational Age. Jama Internal Med, 181(10):1332-1340. [JAMA]
  15. Betcher, HK, Montiel, C, & Clark, CT. (2019). Use of Antipsychotic Drugs During Pregnancy. Current treatment options in psychiatry, 6(1), 17–31. https://doi.org/10.1007/s40501-019-0165-5 [PubMed]
  16. O’Hara, MW, & Engeldinger, J. (2018). Treatment of postpartum depression: Recommendations for the clinician. Clinical Obstetrics & Gynecology, 61(3), 604–614. [Weblink]
  17. Meltzer-Brody S, Colquhoun H, Riesenberg R, Epperson CN, Deligiannidis KM, Rubinow DR, Li H, Sankoh AJ, Clemson C, Schacterle A, Jonas J, Kanes S. Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. Lancet. 2018 Sep 22;392(10152):1058-1070. Epub 2018 Aug 31. Erratum in: Lancet. 2018 Sep 29;392(10153):1116. [PubMed]
  18. Deligiannidis KM, Meltzer-Brody S, Maximos B, Peeper EQ, Freeman M, Lasser R, Bullock A, Kotecha M, Li S, Forrestal F, Rana N, Garcia M, Leclair B, Doherty J. Zuranolone for the Treatment of Postpartum Depression. Am J Psychiatry. 2023 Jul 26:appiajp20220785. doi: 10.1176/appi.ajp.20220785. Epub ahead of print. PMID: 37491938. [PubMed]
  19. Jairaj C, Seneviratne G, Bergink V, Sommer IE, Dazzan P. Postpartum psychosis: A proposed treatment algorithm. J Psychopharmacol. 2023 Jul 29:2698811231181573. doi: 10.1177/02698811231181573. Epub ahead of print. PMID: 37515460. [PubMed]
  20. Substance Abuse and Mental Health Services Administration. Clinical guidance for treating pregnant and parenting women with opioid use disorder and their infants. SAMHSA publications and digital products. 2018. Retrieved August 30, 2023. [Weblink]
  21. American College of Obstetricians and Gynecologists.  Opioid use and opioid use disorder in pregnancy. May 2012, reaffirmed 2021. Retrieved August 30, 2023. [Weblink]
  22. Chaudhry SK, Susser LC. Considerations in Treating Insomnia During Pregnancy: A Literature Review. Psychosomatics. 2018 Jul-Aug;59(4):341-348. Epub 2018 Mar 21. PMID: 29706359.  [PubMed]
  23. Wesseloo R., Wierdsma AI., van Kamp IL., et al. (2017). Lithium dosing strategies during pregnancy and the postpartum period. British J of Psych, 211:31-36. [PubMed]
  24. Costantine MM. (2014). Physiologic and pharmacokinetic changes in pregnancy. Front Pharmacol, 3(5):65. [PubMed]