When you're pregnant or breastfeeding and managing a mental health condition, the stakes feel higher than ever. One doctor tells you to stay on your medication. Another says to stop. You’re caught in the middle, scared of harming your baby but also terrified of falling apart. This isn’t just confusing-it’s dangerous. The truth is, coordinating care between your OB/GYN and psychiatrist isn’t optional. It’s the difference between a safe pregnancy and a preventable crisis.
Why Coordination Isn’t Just Helpful-It’s Essential
About 1 in 5 women experience depression or anxiety during pregnancy or after giving birth. Left untreated, these conditions raise the risk of preterm birth, low birth weight, and even long-term developmental delays in children. But switching or stopping medication without expert guidance can trigger relapse-and that’s just as risky. A 2022 study of over 8,700 pregnant women found that those with coordinated care were more than twice as likely to stay on necessary medications and had 37% fewer postpartum depressive symptoms. The problem? Most OB/GYNs aren’t trained to manage psychiatric meds. And most psychiatrists don’t understand how pregnancy changes your body’s chemistry. That’s why you need both talking to each other-not just you repeating what each one said.What Medications Are Safe? The Evidence-Based Shortlist
Not all antidepressants or mood stabilizers are created equal when you’re pregnant or nursing. The safest choices aren’t based on opinion-they’re backed by data from over 15,000 pregnancies tracked by the National Pregnancy Registry for Psychiatric Medications.- Sertraline (Zoloft): First-line choice. Only a 0.5% absolute risk increase for heart defects-lower than the 1% baseline risk in the general population. It passes into breast milk in tiny amounts, and studies show no impact on infant development.
- Escitalopram (Lexapro): Nearly as safe as sertraline. Lower risk of neonatal adaptation syndrome compared to other SSRIs.
- Fluoxetine (Prozac): Avoid during late pregnancy and breastfeeding. It lingers in the body longer and can build up in babies.
- Paroxetine (Paxil): Not recommended. Linked to higher rates of heart defects. Even small doses carry more risk.
- Lithium: Used for bipolar disorder. Safe with careful monitoring. Blood levels must be checked weekly in the third trimester because your body clears it faster.
- Valproate (Depakote): Absolutely avoid during pregnancy. Raises the risk of major birth defects to over 10%.
The 5-Step Coordination Protocol (What Actually Works)
This isn’t theory. It’s a proven system used by top hospitals and now required by Medicaid for reimbursement.- Preconception planning (3-6 months before trying): Schedule a joint visit-or at least a detailed handoff. Your OB/GYN and psychiatrist should review your current meds, family history, past episodes, and whether you’ve had side effects before. This is the best time to switch to safer options if needed.
- First-trimester check-in (by 8-10 weeks): Your body changes fast. Blood volume increases by 40-50%. Kidneys filter meds faster. Doses that worked before may not be enough now. This is when your psychiatrist adjusts your dose, not your OB/GYN guessing.
- Monthly communication (every 4 weeks): Your OB/GYN should send a standardized note to your psychiatrist every month. It should include: medication name, dose, recent mood symptoms, sleep patterns, and any side effects. No vague messages like “she’s doing okay.” Specifics matter.
- Third-trimester dose review: Around week 20, your liver starts processing meds faster. Sertraline’s clearance increases by 40-60%. Your psychiatrist needs to know this so they don’t let your levels drop too low.
- Postpartum and breastfeeding plan: The first 3 weeks after birth are the highest-risk time for relapse. Your psychiatrist should be involved in the discharge plan. Breastfeeding? Sertraline and escitalopram are safest. Avoid benzodiazepines unless absolutely necessary-and even then, only for 5-7 days max.
How to Make Sure They Talk to Each Other
Here’s the hard truth: 67% of providers say their electronic records don’t talk to each other. Your OB/GYN’s system won’t notify your psychiatrist when they prescribe an antidepressant. That’s why you have to be the bridge.- Ask your OB/GYN to send a formal referral with your diagnosis, current meds, and reason for coordination. Don’t just say “she needs help.”
- Bring a printed copy of your medication list to every appointment. Highlight the names, doses, and when you started each one.
- Use the ACOG Reproductive Safety Checklist (available online). It rates risks on a 1-10 scale for both relapse and medication exposure. Show it to both providers.
- If your psychiatrist won’t talk to your OB/GYN, ask for a warm handoff: a video call where both doctors speak together while you’re present. This is now covered by most insurance.
What to Do If They Don’t Agree
You might hear: “My OB says stop. My psychiatrist says don’t.” That’s a red flag. Neither should be making decisions alone.- Insist on a joint consultation. You have the right to one.
- Ask for a second opinion from a maternal-fetal medicine specialist who works with psychiatrists. These are high-risk pregnancy doctors trained in mental health coordination.
- Call the National Pregnancy Registry for Psychiatric Medications (1-877-311-8972). They’ll give you free, evidence-based guidance on your specific meds.
Insurance, Costs, and Real Barriers
You might be told, “We can’t coordinate because of insurance.” That’s changing.- Medicaid now requires documented coordination for reimbursement. If your OB/GYN won’t refer you, ask why.
- Private insurers often delay prior authorization for psychiatrists by 14+ days. Call your insurer and ask for a medical necessity review. Cite ACOG’s 2023 guidelines.
- Many hospitals now use Epic’s Perinatal Mental Health Module. It auto-notifies psychiatrists when an OB/GYN prescribes an antidepressant. Ask if your practice uses it.
What You Need to Know About Breastfeeding
Many women stop meds because they’re told breastfeeding and antidepressants don’t mix. That’s outdated.- Sertraline and escitalopram have the lowest levels in breast milk-often less than 1% of the mother’s dose.
- Infants exposed to these meds show no difference in weight gain, sleep, or development at 6 months.
- Never stop cold turkey. Tapering under psychiatric supervision reduces withdrawal risk in the baby.
- Watch for signs of infant sedation: excessive sleepiness, poor feeding, or limpness. If you see this, call your pediatrician and psychiatrist immediately.
What Happens If You Don’t Coordinate?
A case from Project TEACH NY tells the story: A woman stopped sertraline after her OB/GYN told her it was “unsafe.” Her psychiatrist wasn’t informed. Two weeks after birth, she was hospitalized for severe postpartum depression. Her baby spent three days in the NICU due to feeding issues linked to maternal stress. She later said, “I didn’t know I had to make them talk.” Untreated depression increases preterm birth risk by 40%. Low birth weight risk by 30%. The real danger isn’t the medication-it’s the silence between doctors.Where to Start Today
You don’t need to fix everything tomorrow. Start here:- Write down your current meds, doses, and when you started them.
- Call your OB/GYN and say: “I need a referral to a psychiatrist who coordinates with OB/GYNs for perinatal care.”
- Ask both providers if they use the ACOG Reproductive Safety Checklist.
- Bookmark the National Pregnancy Registry website-call them if you’re unsure.
Coordinating care isn’t about bureaucracy. It’s about keeping you alive, your baby safe, and your mind steady. You’re not asking for special treatment-you’re asking for the standard of care that’s already proven to work.
Can I stay on my antidepressant during pregnancy?
Yes, if it’s the right one. Sertraline and escitalopram are considered safest. Stopping abruptly increases your risk of severe depression, which is more dangerous to your baby than the medication. Never stop without talking to both your OB/GYN and psychiatrist.
Is it safe to breastfeed while taking psychiatric meds?
Most are. Sertraline and escitalopram pass into breast milk in very small amounts and have no proven negative effects on infant development. Avoid fluoxetine and paroxetine if possible. Always monitor your baby for unusual sleepiness or feeding issues.
What if my OB/GYN and psychiatrist give me different advice?
Insist on a joint consultation. Neither provider should be making decisions alone. Use the ACOG Reproductive Safety Checklist to give them a shared framework. If they still disagree, ask for a referral to a maternal-fetal medicine specialist who works with psychiatrists.
Do I need to switch meds if I’m trying to get pregnant?
It depends. If you’re on paroxetine or valproate, yes-switch before conception. For sertraline or escitalopram, you can usually stay on them. The goal is to avoid starting new meds during pregnancy. Plan ahead: talk to both doctors 3-6 months before trying to conceive.
How often should my OB/GYN and psychiatrist communicate?
At least every 4 weeks during pregnancy. If your condition is unstable or you’re adjusting doses, weekly communication is needed. The communication should be documented-no vague notes. Use a standardized form that includes dose, symptoms, and risk-benefit analysis.
What if my insurance won’t cover a psychiatrist visit?
Call your insurer and request a medical necessity review. Cite ACOG’s 2023 guidelines, which state that coordinated care is standard of care. Medicaid now requires it for reimbursement. If you’re denied, contact the National Pregnancy Registry-they can provide free guidance and sometimes help connect you with low-cost providers.
Are there any medications I should avoid completely during pregnancy?
Yes. Valproate (Depakote) has a 10.7% risk of major birth defects and must be avoided. Paroxetine increases heart defect risk and should not be used. Benzodiazepines like Xanax or Klonopin should be avoided unless absolutely necessary and only for short-term use under strict supervision.
Can my OB/GYN prescribe antidepressants on their own?
Yes, they can start treatment for mild to moderate depression or anxiety. But for bipolar disorder, treatment-resistant depression, or complex cases, they are expected to refer you to a psychiatrist. ACOG guidelines say OB/GYNs alone manage 58% of cases-but only achieve good outcomes when they coordinate with psychiatrists.
If you're reading this while pregnant or breastfeeding, you're already doing the right thing by seeking answers. Now take one step: call your OB/GYN and ask if they coordinate with a psychiatrist. If they don’t, ask why-and insist they start.
11 Comments
Elan Ricarte
Let’s be real - this post is basically the gospel according to ACOG. I’ve seen so many women get gaslit by OBs who think SSRIs are ‘toxic’ while ignoring the fact that untreated depression kills more moms than lithium ever could. Sertraline? Safe as milk. Paroxetine? Avoid like the plague. And don’t even get me started on valproate - that shit’s a birth defect lottery ticket. The real tragedy isn’t the meds, it’s the system that lets doctors operate in silos. If your OB won’t talk to your shrink, find a new one. Period.
Camille Hall
I’m a nurse practitioner in maternal health, and I can’t tell you how many times I’ve had to mediate between an OB and a psychiatrist because the patient didn’t know who to trust. This guide? Perfect. I print it out for every patient who’s pregnant and on meds. Sertraline and escitalopram are the gold standard - no debate. And yes, breastfeeding while on them? Totally fine. I’ve seen babies grow up healthy, alert, and thriving. The fear is real, but the data is clearer. You’re not choosing between your mental health and your baby - you’re choosing the best version of both.
Ritteka Goyal
OMG I LOVE THIS POST!! I am from India and my friend just had baby and she was on zoloft and her doctor said stop but she kept it and baby is fine!! Indian doctors are so old school like ‘no medicine during preg’ but science says different!! I told her to call this National Registry and she did and they helped her so much!! Now her baby is 6 months and super happy and she is also happy!! Everyone should read this!! We need more awareness in India!! My cousin also had bipolar and they gave her depakote and she lost baby 😭 but now she is on lithium with monitoring and doing great!! So happy this exists!!
THANGAVEL PARASAKTHI
Been there. Had to switch from fluoxetine to sertraline before trying to conceive because my psychiatrist warned me about the half-life. OB didn’t know what I was talking about. Took me bringing printed NIH guidelines to get them to listen. Once they did? Smooth sailing. Monthly notes, joint calls, the whole nine yards. My kid’s 2 now - no developmental delays, no weird sleep issues. Just a happy baby and a mom who didn’t crash. Bottom line: if your docs aren’t talking, you’re the only one who can make them. Don’t be shy. Print the checklist. Send the email. Demand the handoff. You’re not being difficult - you’re being smart.
Chelsea Deflyss
Ugh. I can’t believe people still think it’s ‘safe’ to stay on meds during pregnancy. What about the long-term effects? We don’t even know what 20 years down the line looks like. And breastfeeding? Please. Babies are tiny sponges. Why risk it? I know it’s ‘popular’ to say ‘sertraline is fine’ but what about the ones who had issues? You don’t hear about them. You only hear the success stories. I’m just saying… maybe just try therapy? Or yoga? Or meditation? There are natural ways.
Scott Conner
Quick question - if someone’s on lithium and their levels are stable at 0.8, but they’re in the third trimester and clearance goes up 60%, do you just bump the dose 60%? Or is there a better way to adjust? I’m trying to help a friend and I want to get this right.
Sam Dickison
As someone who works in perinatal psychiatry, I can confirm: the 5-step protocol outlined here is textbook. We use it in our clinic. Monthly standardized notes? Non-negotiable. Warm handoffs? Required. The real win is when OBs and psychs actually share a chart - Epic’s Perinatal Module is a game-changer. But here’s the kicker: most patients don’t know to ask for it. This post? It’s not just informative - it’s a tool for empowerment. If you’re reading this and your providers aren’t coordinating? You’re not being ‘difficult.’ You’re being the advocate your life depends on.
Karianne Jackson
I stopped everything when I got pregnant. I thought I was being ‘strong.’ Two weeks postpartum? I was crying in the shower because I couldn’t hold my baby. I didn’t want to live. My husband had to call 911. I didn’t know meds could be safe. I didn’t know I had to make them talk. Now I’m on sertraline and breastfeeding and I’m not dead. If you’re scared - I get it. But please, don’t be scared into silence.
Tom Forwood
Just moved from the US to Canada and holy hell, the difference in care is insane. Here, OBs automatically refer you to a perinatal psych team. No begging. No paperwork. Just… done. We have integrated clinics. I wish I’d known this was possible. To anyone reading this: don’t accept ‘we don’t do that here.’ Push. Ask for the ACOG checklist. Call the registry. You deserve coordinated care. It’s not a luxury - it’s basic human care. And if your provider doesn’t get it? Find someone who does.
Jacob den Hollander
My sister was on paroxetine during her first pregnancy - her OB said ‘it’s fine.’ She had a baby with severe NICU issues. Then she got pregnant again, read this exact guide, switched to sertraline, coordinated with her psych, and now her second kid is thriving. I cried reading this. I didn’t know what to do. Now I’m sharing it with everyone I know. If you’re pregnant and on meds - don’t wait. Print this. Bring it. Demand it. You’re not asking for a favor. You’re asking for the standard of care. And it’s yours.
Andrew Jackson
While I appreciate the empirical data presented herein, I must respectfully contend that the very premise of pharmacological intervention during gestation reflects a profound epistemological failure of modern medicine. The human body, when left to its natural equilibrium, possesses an innate capacity for homeostasis. To artificially modulate neurochemistry - even with ostensibly ‘safe’ agents - constitutes a violation of the ontological sanctity of gestation. One might argue that the statistical outcomes are favorable; yet, we must interrogate the foundational ethics of substituting algorithmic probability for the moral imperative of biological purity. Is not the greater danger not in the medication, but in the cultural surrender to chemical solutions? I submit that true maternal health is cultivated through mindfulness, fasting, and ancestral wisdom - not through electronic referrals and Epic modules.