Antidepressants in pregnancy and breastfeeding: how Singapore doctors weigh the risks, which medicines come up, and how to get a referral

Antidepressants in pregnancy are a decision you make with your doctor, not one you have to avoid. SingHealth says there are options for pregnant and breastfeeding women, and that depression left untreated tends to get worse and affect both mother and baby. The usual approach in Singapore is talking therapy and support first for milder depression, with medicine added when depression is moderate or severe, at the lowest dose that works. If you're already on an antidepressant and have just found out you're pregnant, don't stop it suddenly: SingHealth's medicine guide warns against stopping abruptly. Call your doctor or psychiatrist this week, and ask your GP, polyclinic or O&G for a referral to a perinatal mental health service such as KKH's or NUH's.

Why doctors weigh it both ways

There are two sets of risks on the table, and the conversation with your doctor is about which is smaller for you.

• The risk of untreated depression. SingHealth says depression left untreated in pregnancy worsens and leads to adverse effects for mother and baby. A KKH and NUHS study reported on HealthXchange found that babies of mothers who were severely stressed, anxious or depressed in pregnancy had less developed brain networks linked to memory and stress regulation. KKH also says untreated perinatal illness can affect a mother's ability to bond with her baby.
• The risk of the medicine. SingHealth's guide to perinatal depression notes that the first trimester is when the baby's organs form, and that some medicines taken in the last weeks of pregnancy can cause withdrawal symptoms in the newborn. That is why timing and dose matter.
• The risk of relapse. SingHealth says that if you had severe depression in a previous pregnancy, the chance of it coming back in the next one can be as high as 50%, which is why some women are advised to take a preventive antidepressant.

A good doctor will lay both out and let you decide together. It's fine to ask for time to think, and to bring your partner.

What SingHealth's perinatal guide says, stage by stage

This is a summary of the guide written by KKH's Women's Mental Wellness Service and published by SingHealth. Your own plan may differ, because it depends on how severe your depression is and what has worked before.

The medicines that usually come up

The class you'll hear about most is the selective serotonin reuptake inhibitors, or SSRIs. SingHealth's medicine leaflet lists them as treatments for depression, anxiety and obsessive-compulsive disorder, and names brands sold here such as Lexapro, Prozac, Seroxat, Zoloft and Faverin. KKH's postnatal depression page adds that, depending on symptoms, a doctor may also use a sedative or anti-anxiety medicine.

Which specific medicine and dose suits you is your psychiatrist's call, based on your history and whether you plan to breastfeed. This guide doesn't rank medicines, and no Singapore health service publishes a ranking for pregnancy. What SingHealth's SSRI leaflet does say applies to everyone:

• Tell your doctor if you are pregnant, breastfeeding or planning a pregnancy before you start
• An SSRI can take a few weeks to work fully, so don't judge it in the first days
• Don't stop it or change the dose on your own, because stopping suddenly can cause unpleasant side effects and your symptoms may return
• Common side effects such as nausea, poor appetite, headache or trouble sleeping often settle with time
• Get help quickly for new or worse thoughts of self-harm, or for agitation, confusion, fever and a racing heart, which can be signs of a rare reaction called serotonin syndrome

If you're already on an antidepressant and pregnant, or planning to be

1. Don't stop the medicine abruptly, even if you're worried about the baby.
2. Book an appointment with the doctor who prescribed it, or your GP, within the week. If you're planning a pregnancy, do this before you start trying.
3. Make a list of every medicine and supplement you take, with doses.
4. Tell your O&G at your first visit, so your pregnancy care and mental health care are joined up.
5. Ask for a referral to a perinatal mental health service if you don't already have one.
6. Agree a plan for the last weeks of pregnancy and for after the birth, including breastfeeding.

If you're planning a pregnancy, our guide to trying to conceive in Singapore covers the preconception check where this conversation fits.

Breastfeeding on antidepressants

Many mums keep breastfeeding while being treated. SingHealth says there are certain medicines that can be used if you wish to continue nursing, and KKH says the treatment can be selected to fit the needs of both mother and baby, because most mothers worry about exposing their baby to side effects. Tell the psychiatrist that you're breastfeeding or plan to, and ask how the medicine passes into milk and what to watch for in your baby. If you decide to combine breast milk and formula for a while, our guide to mixed feeding explains how to keep your supply going.

How to get a referral in Singapore, and what it costs

KKH lists a self-referred or walk-in patient, or one referred by a non-CHAS GP, as paying non-subsidised rates, so a polyclinic or CHAS GP letter is usually the cheaper route in.

Questions to take to your appointment

• How severe is my depression, and what happens if I don't take medicine?
• Which medicine do you suggest, and why this one for me?
• What dose will I start on, and how will we know it's working?
• What do we know about this medicine in pregnancy and in breast milk?
• Should anything change in the last weeks of pregnancy or after delivery?
• What therapy or counselling can I have alongside it?
• Who do I call if I feel worse between appointments?

For the signs and screening of depression after birth, see our guide to postnatal depression in Singapore, and for mood changes during pregnancy, mood swings during pregnancy.

Frequently asked questions

Can I take antidepressants while pregnant?

Yes, when your doctor judges the benefit to be greater than the risk. SingHealth says there are options for pregnant and breastfeeding women, and that untreated depression can harm both mother and baby.

Should I stop my antidepressant when I find out I'm pregnant?

Not on your own. SingHealth's medicine guide says not to stop suddenly or change the dose without your doctor, and its perinatal guide says some women with severe depression are safer staying on medicine. Call your doctor this week.

Are SSRIs used in the first trimester?

SingHealth's perinatal guide says starting antidepressants in the first trimester is avoided where possible, because the baby's organs are forming. Women already on long-term treatment for severe depression may be advised to continue.

Can my baby have withdrawal from my antidepressant?

SingHealth says some medicines taken in the last weeks of pregnancy can cause withdrawal symptoms in the newborn, which is why a gradual taper may be suggested. Ask your doctor what to expect and tell the delivery team what you take.

Can I breastfeed while taking antidepressants?

Often, yes. SingHealth and KKH both say there are medicines that can be used while breastfeeding, and the choice is tailored to you and your baby.

How do I see a perinatal psychiatrist in Singapore?

Ask a polyclinic, CHAS GP or your O&G for a referral to KKH's Women's Mental Wellness Service or NUH's Women's Emotional Health Service. For advice first, email KKH at pnd@kkh.com.sg.