For people who have managed anxiety or depression with antidepressants, pregnancy can seem like a terrifying choice between mental health and the well-being of a future child.

"Some providers and patients alike really come from the perspective that the use of psychiatric medication is not compatible with pregnancy," said Dr. Allison Deutch, the director of reproductive consultation-liaison psychiatry at NYU Langone Health and clinical associate professor of psychiatry at New York University Grossman School of Medicine.

"Battling that misconception, both from the patient perspective and the provider perspective, is one of the most challenging aspects of doing this work," Deutch said.

A patient, Blake, said she and her husband sat with Deutch for a long conversation weighing if she should stay on the medication she started during the pandemic to get back to equilibrium.

They talked through questions like "Would it affect the baby? Would the baby have withdrawal? Would the baby have any developmental issues? Would the baby have any physical issues? What could happen to the baby?" said Blake, who only wanted to be identified by her first name.

In the end, Blake decided to stay on her medication.

"I firmly believe it was best for me because in order to be the best mother you can be, you need to be your best self," she said.

In her 28 years as an obstetrician gynecologist, Dr. Maria Sophocles said one thing she had seen over and over is her patients' willingness to put others first — even to their own detriment.

The decision of how to treat a person's depression while they are pregnant isn't as simple as choosing the well-being of one over the other, said Sophocles, who is also the medical director of Women's Healthcare of Princeton in New Jersey.

And with all the shame around mental health and the pressure on expectant parents, it is important to talk about how much more nuanced the conversation around medication to treat anxiety and depression while pregnant is, Sophocles said.

"Treating mental illness is as important as treating any other condition in pregnancy," Deutch said. "When done properly with a careful degree of vigilance ... many women can go on to have very healthy successful pregnancies, while also on these medications, which are many times really essential to their well-being."

Risks versus risks

In many medical circumstances, people make decisions by weighing the risks and benefits. When deciding whether to stay on antidepressants during pregnancy, it's more like analyzing the risks versus the risks, Deutch said.

"We are weighing what is the risk of medication exposure to both mom and baby against what is the risk of untreated maternal mental illness to both mom and baby," she added.

When it comes to taking medication, concerns include risks of low birth weight, preterm birth, problems with development and birth defects, said Dr. Rubiahna Vaughn, director of consultation-liaison and emergency psychiatry at the Jack D. Weiler Hospital in Bronx, New York, that's part of the Montefiore Health System.

The most common medication to treat depression are selective serotonin reuptake inhibitors, also known as SSRIs, and the data is largely reassuring that they are safe to use while pregnant, Deutch added.

A 2022 study found antidepressant use during pregnancy was not associated with autism, attention-deficit hyperactivity disorder (ADHD), behavioral disorders, developmental speech, language, learning, and coordination disorders or intellectual disabilities.

And the risk of giving birth to a baby with birth defects while on SSRIs is lower than the baseline risk, Vaughn said.

Serotonin and norepinephrine reuptake inhibitors (SNRIs) are also considered an option during pregnancy, Sophocles added.

Some medications in the same categories might have less risk than others, so talk with your doctor to find the right one for you, she said.

The risk of complications on antidepressants during pregnancy is low, but nothing is completely without any risk when it comes to poor birth outcomes — not even acetaminophen, Sophocles said.

"We don't take treating pregnant women with medications lightly at all," Vaughn said. "But we also have to weigh that with the real risks of leaving depression untreated and how that can impact not only Mom but also the fetus and the baby as it develops."

Untreated depression during pregnancy has been associated with risk for lower birth weight and preterm birth, said Vaughn, who is also assistant professor of psychiatry and behavioral sciences and of obstetrics and gynecology and women's health at Albert Einstein College of Medicine in Bronx, New York.

Because people who had depression before pregnancy are at greater risk for postpartum depression, patients should also consider the risk of relapse with a newborn when talking with their doctor about whether to stay on their medication, Deutch said.

Taking care of Mom is taking care of baby

Some of the fear around antidepressants may come from stigma or misinformation, but much of it comes from caring for a future child, Deutch said.

"This is one place where women really feel like 'if I have an option to white-knuckle it, I would rather suffer than cause undue harm to my baby,'" she added. But toughing it out may not be the safest option either.

"I think we all intuitively know that in a family system where there is a mother, if the mom is not functioning well, the whole household is not functioning well," Vaughn said. "There are reams and reams of data to support that idea."

It would make sense that it would be harder to have a healthy pregnancy if the parents are struggling.

"You can imagine that if you're depressed and pregnant, it is pretty hard to make it to a doctor's appointment ... really hard to take that prenatal vitamin, it's really hard to make sure that you're getting good adequate nutrition to support your pregnancy," Vaughn added.

And there is risk for the baby after birth as well. What infants really need are responsive parents — and being engaged and connected is difficult when people are anxious and depressed, Deutch said.

"No parent wants to make a decision that is going to harm their baby, and we understand that. We are completely sympathetic to that perspective," she added. But "a healthy mom makes for a healthy baby."

Talking to your doctor

For those who are experiencing depression or anxiety for the first time during their pregnancy or in the postpartum period, it might be hard to recognize, Deutch said.

Many of her patients think it is normal to be worrying about their child's stages of development, not getting sleep or missing showers with a newborn, she said.

But when that worry starts to impede on your life or you feel a sense of hopelessness, helplessness or worthlessness, it may be time to speak to your doctor, Vaughn said.

"I think the question is, how much time are we spending during a day worrying? And to what extent is it impacting our ability to function," she added.

Sophocles recommends having conversations with your doctor regularly, and she hopes medical professionals are proactive in talking about mental health.

Just getting in the door and starting the conversation can help pave the way for a healthier pregnancy, she added.

And even if you are not yet pregnant but thinking about getting on antidepressants, it is never too early to talk with your doctor about the implications for pregnancy, Vaughn said.

"Most American women will have at least one pregnancy in their lifetime and close to 50% of pregnancies in the US are unplanned," she said. Ask: "Is this something that I can get pregnant on? Is this something I can breastfeed my baby? And if it's not what are the options that I have?"

But just like not every pregnancy is the same, not every case of anxiety and depression are the same. Some may benefit greatly from medication, some will do very well off medication and with other options such as psychotherapy and cognitive behavioral therapy, Vaughn said.

The primary advice is to talk with your doctor and give yourself permission to make choices that are best for you and your baby, she added.

"It's not the story for everyone," Vaughn said. "But I think for women who are really suffering from depression, you want to really set yourself up to have the best possible experience during pregnancy and the postpartum. And it's hard to do that if you're depressed."

Blake's advice is to "trust your doctor, and trust your instincts."