Psychoactive Drug Patterns Before, During and Just After Pregnancy

Fewer than one-fourth of women who had prescriptions for depression or anxiety medications before becoming pregnant maintained those prescriptions throughout pregnancy and at discharge.

That was among findings of a recent retrospective cohort study led by Adina Kern-Goldberger, MD, a Cleveland Clinic maternal-fetal medicine specialist. The researchers reviewed records of 52,778 patients who gave birth at Cleveland Clinic between Jan. 1, 2021, and June 30, 2025. They found that 6,421 of those (12.2%) had antidepressant or anxiolytic prescription in the six months before pregnancy. Of these, 1,499 (22.9%) continued those prescriptions.

The study also found that 5,048 patients (9.6% of the cohort) started medication during pregnancy or immediately postpartum.

Lulu Zhao, MD, Co-Director of Women's Behavioral Health at the Cleveland Clinic, specializes in the treatment of mood disorders during key reproductive transitions such as puberty, pregnancy and menopause. Having medication-use data for this patient group supports clinicians in understanding trend trajectories and can inform clinical conversations.

A message-filled environment

Right now, media and social media are filled with messaging of all kinds regarding the use of medications in pregnancy. Further confounding the environment is the relative paucity of pregnancy-related safety data behind some of the newer drugs for treating mood disorders.

Concerned patients often decide to quit their medication when they become pregnant even if that means the return of symptoms from a chronic mental health condition. This can have poor outcomes for patient and fetus.

“The established data convincingly support the fact that when people with mood disorders stop their medications in pregnancy, their chance of having a recurrent mood episode is upwards of 50%,” she says.

It is important for clinicians to understand current best practices and be familiar with the context behind pregnancy-related medication starts and stops.

“If only 23% of people continue their medications, what does that mean for the other women who have discontinued? What can they expect?” she says.

What the numbers suggest

The patients who continued their prescriptions throughout pregnancy tended to be older, more likely to be privately insured and to have started prenatal care earlier and be more likely to have multiple children. This group likely benefits from better healthcare access, prior experience with psychiatric illness, and stronger physician rapport with more in-depth counseling, while those who discontinue might have fewer such opportunities.

A planned or new pregnancy is an opportunity to review patient history and participate in shared decision making so that patients can be comfortable with their plan going forward.

“Sometimes, de-prescribing is appropriate and completely aligned with the patient’s intentions during the pregnancy," says Dr. Zhao. "Having a conversation about medications enables clinicians and patients to be on the same page about pros and cons, and it is a great opportunity to discuss what surveillance of mood symptoms in the perinatal period should look like. That way, if symptoms do change, there is already a plan for what the next steps will be.”

Risks on both sides

Although some clinicians still relay outdated information (such as there being only one safe antidepressant to use while pregnant), the mental health needs of pregnant women are better understood today.

There is growing recognition that both treatment and untreated mental health conditions carry potential risks during pregnancy, says Dr. Zhao. Psychiatric decompensation is a very real risk for patients with untreated mood disorders, and poor maternal mental health is itself linked to risks of preterm birth, hypertensive disease and other poor obstetrical outcomes. Meanwhile, mothers who are depressed or anxious suffer not only long-term adverse sequelae, but multiple downstream negative effects at home, at work, and with parenting.

“Women who are clinically depressed or anxious need to pursue treatment,” says Dr. Zhao. “It doesn't necessarily have to be medication, though medication is warranted for moderate to severe cases. For milder cases, women can do very well with psychotherapy alone, and they just weren't aware that was an option, or they don't know where to go.”

Counseling matters

Clinicians treating women of reproductive age on antidepressants should be proactive about talking about medications and pregnancy, says Dr. Zhao. Those who do not want to become pregnant on antidepressants will benefit from contraception counseling; others may benefit from a deeper conversation about the risks of taking – and not taking – certain medications while pregnant.

It’s also important for providers to understand and to convey to their patients that mood disorders can be chronic relapsing conditions, says Dr. Zhao, and that symptoms often return when medication is stopped.

Meanwhile, data on the most commonly used class of medications in pregnancy, SSRIs, is overall reassuring in pregnancy and lactation. Even for medications with less data, it is important to recognize that there are risks to both continuing and discontinuing medications.

“There is still a lot of clinical conservatism when it comes to medications during pregnancy, a mistaken belief that women must choose themselves or their baby. In reality, the mother-baby dyad is intimately linked, and what affects one affects the other,” says Dr. Zhao.

Women often hear the message that medications can be dangerous, without the corollary that depression is also dangerous.

“Mental health disorders, including overdose, are the number one cause of pregnancy-associated death in the first year postpartum, more than hemorrhage or hypertension,” notes Dr. Zhao. “Women are trying to do the best thing for themselves and their children. If the message they hear is, ‘You shouldn’t take medication because it isn’t safe,’ what are the chances they will be willing to resume or continue their meds when they feel more depressed?”

At Cleveland Clinic’s Women's Behavioral Health program, clinicians provide expert, in-depth counseling that can empower patients to make informed, rather than reactive, decisions.

“We provide anticipatory guidance and evidence-based recommendations,” says Dr Zhao. “What are the absolute risks of sequelae like congenital defects and neonatal abstinence syndrome? What is the expectation that mood symptoms may get worse? If the patient decides to stop her medication, what benchmarks will we use to decide if she needs a different approach? We believe that with the right team by her side, all women are capable of having the healthiest possible pregnancy.”