Antidepressants and Breast-Feeding

OB/GYN News,  July 1, 2000  by Lee Cohen

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Women with postpartum depression are frequently counseled to defer treatment if they are going to breast-feed or they elect not to use antidepressants because they want to breast-feed. Usually the clinician provides this advice based on personal impressions, rather than on hard data.

As a result, these women continue to suffer from postpartum mood disturbances.

Until recently, there has been a dearth of information regarding the safety of breast-feeding while using antidepressants. But over the past few years, research on antidepressants during lactation has outpaced that on other drugs, such as anticonvulsants and antibiotics.

In particular, the literature on use of selective serotonin reuptake inhibitors (SSRIs) during lactation is reassuring.

All psychiatric medications, including antidepressants, are secreted into breast milk. When a highly sensitive assay is used, trace amounts of both older and newer antidepressants are detected in the plasma of breast-feeding infants. Fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) are among the most widely studied SSRIs. In several case series involving women whose infants were exposed to fluoxetine and sertraline while breast-feeding, trace amounts of the parent compounds and metabolites of fluoxetine and sertraline were detected in the plasma of nursing infants.

In another study, Dr. Zachary Stoewe of Emory University Atlanta, and I detected paroxetine in every sample of breast milk, but we could not find it in the plasma of the nursing infants using a sensitive assay (Am. J. Psychiatry 157[2]:185-89, 2000).

In the literature, there are anecdotal reports of irritability feeding difficulties, and functional ileus in breast-feeding babies whose mothers were taking an SSRI, but these were not specifically linked to the SSRI exposure, given the obvious lack of any control group in case reports.

In the studies on sertraline, paroxetine, and fluoxetine, however, there were no observed treatment-emergent side effects in infants whose mothers breast-fed while using these medications. While it's possible that sample sizes were too small to detect adverse effects in infants, it's clear that for mothers the incidence of acute treatment-emergent adverse effects in all probability is extremely low.

The long-term neurodevelopmental effects of exposure, even exposure to trace amounts of SSRIs, are unclear. Studies are being planned to follow infants who are exposed to SSRIs in breast milk.

Thus, we're left to weigh the risks against the benefits. Yes, there may be risks associated with even trace exposure, but there are even dearer risks associated with untreated mood disturbance in women and particularly in postpartum women.

There are no data to support a recommendation against antidepressant therapy in women who want to breast-feed and who suffer from postpartum psychiatric depression that requires treatment.

The key consideration in determining which drug to use is the woman's history. If a woman develops postpartum depression and has responded to a particular antidepressant in the past, then that is the best medication to prescribe. For a woman who has no history of depression and who presents with postpartum depression, prescribing one of the three most extensively studied SSRIs (paroxetine, fluoxetine, or sertraline) makes sense. There are few data on fluvoxamine (Luvox), ciralopram (Celexa), bupropion (Wellbutrin), or mirtazapine (Remeron).

DR. LEE COHEN is a psychiatrist and director of the perinatal psychiatry program at Massachusetts General Hospital, Boston. He receives research support, consulting and speaker fees from several manufacturers of antidepressant drugs.

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