Teratogenic mood stabilizers (valproate, and carbamazepine treated the same way) do not belong in women who may become pregnant, so do not start a drug you will later have to taper. Haloperidol, olanzapine and quetiapine are generally accepted, paroxetine is the worst SSRI for pregnancy, lamotrigine levels drop by about half, and ECT is a fast, effective option when the illness puts mother and fetus at risk.
Medications to avoid
Valproate's teratogenicity means women absolutely should not be using it. If a woman on it is talking about pregnancy planning, you pretty much have to taper it off.
“The valproate, the The teratogenicity makes it so that women absolutely should not be using it, period. And if you have a woman who's on the medication, you pretty much have to taper it off if they're talking about pregnancy planning”
40:21Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026 Why start a patient on a medication you know you will have to taper in the next five or ten years?
“Why would you start a patient on a medication that in the next five years, next 10 years, you know that you're going to have to taper them off”
40:14Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026 Carbamazepine can cause Stevens-Johnson syndrome and is a teratogen, so using it in reproductive-age women is a whole different ballgame. Start thinking of it more like valproate.
“Yes, it can cause Stevens-Johnson syndrome. Yes, it is a teratogen. So using it in reproductive age women is a whole different ballgame. So we should start thinking of it a little bit more like valproid”
55:12Dr. Jim Phelps’ Bipolar Treatment Tier List: Lessons from 30+ Years in PsychiatryJul 2026Guest episode Paroxetine is the worst SSRI for pregnancy, on top of its anticholinergic effects and weight gain.
“I don't like the anticholinergic effects. I don't like, um, there's weight gain. Uh, it's not good. It's got the worst, I think it's the worst SSRI for pregnancy”
25:59Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026
Safer options
Antipsychotics generally accepted in pregnancy include haloperidol, olanzapine and quetiapine.
“there's at least one study showing relative safety in pregnancy. So that's a nice thing to have with trazodone. While we're on it, I believe other ones that are generally accepted in pregnancy that you can see here on the board include Haldol, Olanzapine, and Quetiapine”
47:56Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 When mania, psychosis or depression is putting the life of a pregnant woman and her fetus at risk, ECT is effective and rapidly acting.
“pregnancy, especially if a pregnant female is experiencing mania or psychosis or depression that is putting her life and the life of her fetus at risk, ECT is effective and it is rapidly acting”
45:14ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode
Monitoring
Pregnancy reduces serum lamotrigine levels by about half, likely an effect of estrogen.
“pregnancy will reduce the serum levels of lamotrigine by about half. I believe it's estrogen that does this”
49:45Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026
From these episodes
- Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 · 1 point
- Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026 · 3 points
- Dr. Jim Phelps’ Bipolar Treatment Tier List: Lessons from 30+ Years in PsychiatryJul 2026 · 1 point
- Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 · 1 point
- ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.