Treating Perinatal Mood and Anxiety Disorders: A Call to Action

This editorial is reprinted without references from the Cleveland Clinic Journal of Medicine (April 2026, 93(4) 207-209 doi.org/10.3949/ccjm.93a.26002). The open-access and fully referenced original article is available at https://www.ccjm.org/content/93/4/207.

By Lulu Zhao, MD

When Cohen et al published their 2006 landmark study on the relapse of depression during pregnancy, they stated, “There has been a common belief that characteristic hormonal changes associated with pregnancy are inherently ‘protective’ with respect to … depression … and that discontinuation of psychiatric medications should be almost uniformly pursued given concerns regarding prenatal exposure to these agents.”

We now know that pregnancy confers no such protection. One in 5 individuals giving birth in the United States experiences a mood disorder during the perinatal period (during pregnancy or up to 1 year postpartum). Anxiety is the most common (20.7%), followed by depression (12.1%). Other conditions such as mania, postpartum psychosis, and post-traumatic stress disorder are less common but can create an outsized effect on the health and life trajectories of those affected.

Various factors drive the high incidence of perinatal mood and anxiety disorders. During pregnancy, a massive influx of estrogen and progesterone —both sex hormones and neuroactive steroids — promote neuroplasticity. Accordingly, the brain undergoes significant neuroanatomic remodeling during the perinatal period. [These shifts] invite parents to imagine new ways of relating to the world around them. For individuals with biologic and psychosocial vulnerabilities, however, these new thought patterns may be maladaptive.

Consequences of untreated illness

Untreated perinatal mood and anxiety disorders create an environment of psychosocial toxicity that devolves into longitudinal adversity. Studies show that depressed parents are less able to engage in productive relationships, including with their newborn children.

Maternal depression in the postpartum year is also strongly associated with an increased unemployment risk for up to 15 years after childbirth, with an estimated societal cost of nearly $31,800 per affected mother-child dyad over the first 6 years. Meanwhile, the leading cause of death for mothers in the first year postpartum is untreated mental health disorders, outranking serious conditions like hemorrhage and hypertensive disease.

Currently, perinatal mood and anxiety disorders remain untreated in 3 of 4 affected individuals giving birth, and the discrepancy between needing care and receiving care is highest in our most vulnerable populations: the marginalized, the socioeconomically disadvantaged, the isolated and the inadequately insured.

Prioritizing mental healthcare

Where does that leave our patients who struggle with their mental health while juggling the responsibilities of a growing family? Many will rely on the knowledge and judgment of non–mental health specialists (e.g., obstetricians and primary care clinicians). It is noteworthy that more than half of women discontinue antidepressant medications during pregnancy. Yet, 53% of these women will end up back on antidepressants in the postpartum period, as the risk of symptom recurrence is 50% to 70% even in those who were euthymic at the time of discontinuation.

Treatment decisions during pregnancy should therefore be framed as a risk-risk discussion. Lack of treatment is not neutral — untreated perinatal mood and anxiety disorders themselves are associated with adverse obstetrical and neurodevelopmental outcomes. Decades of quality, peer-reviewed research have demonstrated the favorable safety profile of selective serotonin reuptake inhibitors (SSRIs), the most commonly prescribed class of medications for depression and anxiety.

Women with depression who are treated with SSRIs during pregnancy exhibit no clinically significant increased risk of miscarriage, fetal growth restriction, preterm birth, cesarean birth, or adverse neurodevelopmental outcomes compared with those with untreated depression. SSRIs are also widely considered compatible with breastfeeding because low amounts of these medications pass into breast milk.

Meanwhile, risks that do exist should be put into proper context. The baseline risk of birth defects in all pregnancies is about 3%. Exposure to an SSRI during pregnancy, including paroxetine, increases the risk of birth defects by less than 1%.

Traditional vs. novel agents

Timing is another consideration that significantly impacts a patient’s quality of life. Traditional antidepressants like SSRIs must be used for 4 to 6 weeks at a therapeutic dose to yield significant clinical benefit. Today, postpartum patients have access to a new medication class that mimics the action of progesterone metabolites at the gamma-aminobutyric acid receptor.

The rapid onset of these medications can produce reductions in depression scores within days. While more research is needed on which populations benefit most from traditional antidepressants vs novel ones, patients and clinicians alike now have more options to treat these serious mental health conditions.

It is imperative that obstetricians and primary care clinicians achieve basic competency in managing psychiatric disorders during the perinatal period. If we hope to see improved mental wellness for our mothers, families, and communities, we must all play an active role.