Antidepressants, Antipsychotics, Benzodiazepines, and the Breastfeeding Dyad

Perspectives in Psychiatric Care, Apr-Jun 2004 by Malone, Kirsten J, Papagni, Karla, Ramini, Sasha, Keltner, Norman L

Psychotropic Drugs

Selective Serotonin Reuptake Inhibitors

Based on the estimated percentage of women breastfeeding at the time of discharge from hospitals in the United States (68.4% [Ross, 20001), the estimated rate of postpartum depression (10% [Schmidt, Olesen, & Jensen, 2000]), and the U.S. birth rate of approximately 4 million per year (National Vital Statistics Report, 2000), it is estimated that each year in the United States more than a quarter of a million women may want to breastfeed while taking antidepressant medication (Epperson et al, 2001). That number is likely to increase, as the U.S. Department of Health and Human Services (USDHHS) steps up breastfeeding promotion initiatives to meet the goals outlined in Healthy People 2010 (USDHHS, 2000).

Selective serolonin reuptake inhibitors (SSRIa) are often the first choice for treatment of depression because of better side-effect profiles and fewer autonomie effects than from tricyclic antidepressants. The major concern about exposing infants to SSRIs through breast milk is how the infanf s serotonin levels will be affected, and how that might affect neurodevelopment and/or behavior. Research has found that the levels of SSRI and their metabolites in the infant's blood are often below the levels of assay detection. Even when SSRI levels are detectable, infant serotonin levels are often not affected at all (Burt et al., 2001; Epperson et al, 2001). Long-term neurobehavioral and developmental effects from exposure to SSRIs during infancy have not been studied. The AAP (2001) categorizes antidepressants as "drugs for which the effect on nursing infants is unknown, but may be of concern" (p. 776), largely because of lack of available data. Table 5 outlines selected available data for the SSRIs cited in this column.

Citalopram (Celexa). Citalopram is a relatively new SSRI and is similar to fluoxetine (Prozac) and sertraline (Zoloft), but has a shorter half -life (35 hours). It is 80% absorbed by the mother (Deglin & Vallerand, 2003) and is 80% protein bound (Hale, 2002). Reports of M/P ratios of citalopram are variable. One study found an M/P ratio of between 16 .16 and 1.88 (Hale, 2002). In a case study of one mother, an M/P ratio of 30 .0 0 was reported. Levels of citalopram in that mother's breast milk peaked at 3 to 9 hours following administration of 20 mg. It was estimated the infant received approximately 5% of the mother's dose, adjusted for weight. No adverse effects in the infant were noted (Jensen, Olesen, Berteisen, & Linnet, 1997). One study found low serum concentrations of citalopram (2 -2.3 �g/L) in three of seven infants (Hale, 2002). Outside of that study, Hale notes there have been two reports of excessive sleepiness, poor feeding, and weight loss in breastfed infants exposed to citalopram.

Fluoxetine (Prozac). Fluoxetine absorption in the mother is rapid and complete (100%), with rapid conversion to its active metabolite, norfluoxetine. Fluoxetine is 94.5% protein bound. Fluoxetine has a half-life of 48 to 72 hours; norfluoxetine has a half-life of 360 hours and is present both in breast milk and infant plasma after ingestion of breast milk (Hale, 2002).