How to Coordinate Care Between OB/GYN and Psychiatrist for Medications During Pregnancy and Breastfeeding

When you're pregnant or breastfeeding and need psychiatric medication, you're not just managing your mental health-you're managing two lives. The decision isn't simple. Stopping your meds might bring back depression or anxiety. Keeping them might raise concerns about your baby's safety. The truth? The biggest risk isn't the medication-it's no coordination between your OB/GYN and psychiatrist.

Why Coordination Isn't Optional

One in five women experience depression or anxiety during pregnancy or after birth. Left untreated, these conditions increase the risk of preterm birth by 40%, low birth weight by 30%, and even developmental delays later in childhood. But many women stop their medications out of fear, often because no one clearly explained the risks of stopping versus staying on them.

A 2022 study of nearly 9,000 pregnant women found that when OB/GYNs and psychiatrists worked together, medication discontinuation dropped from 42% to just 18%. Postpartum depression symptoms fell by 37%. That’s not a small gain-it’s life-changing.

The American College of Obstetricians and Gynecologists (ACOG) made this clear in 2023: coordinated care isn’t a luxury. It’s the standard. And it’s backed by data from over 147 studies.

Which Medications Are Safe?

Not all antidepressants are created equal during pregnancy. Sertraline and escitalopram are the two most recommended SSRIs. Why? Because decades of data show they cross the placenta minimally and have the lowest risk of birth defects.

Sertraline, for example, increases the risk of heart defects by only 0.5%-compared to a 1% baseline risk in the general population. That’s a tiny increase. Paroxetine, on the other hand, carries a higher risk and is no longer first-line.

For bipolar disorder, mood stabilizers like lithium or lamotrigine are often continued. Valproate is avoided-it’s linked to a 10.7% risk of major birth defects. That’s why your psychiatrist needs to know you’re pregnant before making any changes.

During breastfeeding, these same medications are often preferred. Sertraline appears in breast milk at very low levels-lower than most other SSRIs. The National Pregnancy Registry, which tracks over 15,000 pregnancies, confirms this safety profile.

When Should Coordination Start?

Waiting until you’re 20 weeks pregnant is too late. The best time to start is before you conceive.

Ideally, you should have a 45- to 60-minute planning session with both your OB/GYN and psychiatrist 3 to 6 months before trying to get pregnant. This isn’t just a chat-it’s a documented plan. You’ll review your current meds, discuss dose adjustments needed for pregnancy (like higher doses in the third trimester due to increased blood volume), and set up a monitoring schedule.

If you’re already pregnant, don’t wait. The first coordinated meeting should happen by 8 to 10 weeks. That’s when the baby’s organs are forming, and it’s critical to lock in safe medication choices.

How Do They Actually Talk to Each Other?

Many women think their doctors just “talk.” In reality, most still use fax machines, unsecured emails, or no communication at all. That’s why 67% of providers say electronic health records don’t talk to each other.

Good coordination uses a standardized template. It includes:

• Current medication name and dose
• Protein binding percentage (e.g., sertraline is 98% bound)
• Placental transfer rate
• Lactation risk category (L1 or L2 is safest)
• Maternal relapse risk if stopped
• Estimated fetal risk from exposure

For example, a note might say: “Sertraline 75mg daily-maternal relapse risk 65% without treatment; 0.5% absolute increase in cardiac defects with treatment.” This isn’t jargon-it’s a decision tool.

Some clinics now use integrated systems like Epic’s Perinatal Mental Health Module. When an OB/GYN prescribes an antidepressant, the system automatically alerts the psychiatrist. That’s the future-and it’s already here in many hospitals.

What About Benzodiazepines and Sleep Aids?

Benzodiazepines like lorazepam or alprazolam are not recommended during pregnancy. They’re linked to cleft palate and withdrawal in newborns. But sometimes, acute anxiety or panic attacks require short-term use.

In those cases, ACOG recommends:

• Only use for 7 to 10 days max
• Prescribe the lowest effective dose
• Require weekly follow-up with a psychiatrist
• Never use long-term or as a sleep aid

Many women ask about melatonin or herbal supplements. There’s no solid safety data for these during pregnancy. Stick to proven, monitored options.

What If Your Doctors Don’t Talk?

You’re not powerless. If your OB/GYN says, “Just take your meds,” and your psychiatrist says, “Stop everything,” you have a problem.

Here’s what to do:

1. Ask your OB/GYN: “Can you refer me to a psychiatrist who works with pregnant patients?”
2. Ask your psychiatrist: “Do you have a protocol for coordinating with OB/GYNs?”
3. Request a joint visit-either in person or via video. Many clinics now offer this.
4. Bring a printed copy of ACOG’s Reproductive Safety Checklist (available online) to your next appointment.
5. If you’re denied care, contact your insurance. Medicaid and many private plans now require coordination for reimbursement.

One woman in New York stopped sertraline after her OB/GYN told her it was unsafe. Her psychiatrist had said it was fine. She developed severe postpartum depression and ended up hospitalized. That’s what happens when communication breaks down.

Insurance and Access Barriers

Even when you want coordination, it’s not always easy. In 2023, 57% of privately insured women reported waiting more than 14 days for prior authorization just to see a psychiatrist.

Medicaid programs now require documentation of OB/GYN-psychiatrist coordination to pay for services. That’s pushing clinics to adopt better systems. But in private practices, it’s still hit or miss.

If you’re struggling to get a referral:

• Ask your OB/GYN for a list of psychiatrists who specialize in perinatal care.
• Use the National Pregnancy Registry’s provider directory-it lists specialists who participate in research and coordinated care.
• Telehealth is now accepted for coordination. Many psychiatrists offer virtual consults with your OB/GYN in the room.

What About After Baby?

The postpartum period is when most relapses happen. Your body’s chemistry changes fast. Hormones crash. Sleep disappears. Your meds might need adjusting.

A coordinated plan should include:

• Follow-up with your psychiatrist within 2 weeks of delivery
• Monitoring for breastfeeding medication levels (especially if you’re on lithium)
• Plan for dose changes if you’re pumping or nursing
• Screening for postpartum psychosis (rare but serious)

Your OB/GYN can screen for depression at your 6-week checkup, but they can’t adjust psychiatric meds unless they’re trained. That’s why the psychiatrist stays involved.

Real Stories, Real Outcomes

Kaiser Permanente’s integrated mental health program-where OB/GYNs and psychiatrists sit in the same building-reported 89% patient satisfaction. Patients said they felt heard, safe, and supported.

One woman, 32, with a history of bipolar disorder, planned her pregnancy with both specialists. She stayed on lamotrigine, had weekly check-ins, and breastfed without issue. Her baby was born at 39 weeks, healthy, with no signs of withdrawal.

Another woman, 28, with severe anxiety, was told by her OB/GYN to stop her meds. She did-and spiraled into panic attacks. Her psychiatrist had to admit her to a perinatal unit. She later said: “I wish I’d asked them to talk to each other.”

What’s Next?

The future is getting better. The NIH is launching a major trial in late 2024 called PACT, which will use genetic testing to predict which antidepressants work best for each woman during pregnancy. ACOG is also testing AI tools that can predict relapse risk with 89% accuracy.

Medicare and Medicaid are now tying reimbursement to coordination quality. If your doctor’s office doesn’t have a system in place, they’ll lose money. That’s forcing change.

You don’t have to wait for the system to catch up. Start the conversation today. Ask your OB/GYN and psychiatrist to work together. Bring the checklist. Demand a plan. Your mental health and your baby’s health depend on it.