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

Sertraline (Zoloft). Sertraline is 98% protein bound and has a half-life of 26 hours (Deglin & Vallerand, 2003). Absorption in the mother is complete. As with fluoxetine, the metabolite of sertraline (desmethylsertraline) has a long half-life, but unlike norfluoxetine, the metabolite of sertraline is only minimally active (Hale, 2002).

No adverse infant effects were reported in 9 49 infants whose mothers were taking sertraline (Burt et al., 2001 ). It was concluded that at typical clinical doses (250-150 mg/day), sertraline administered to mothers had negligible effects on serotonin transport even in young, exclusively breastfed infants (Epperson et al, 2001)

In a study of 12 mother-infant pairs, sertraline levels peaked in breast milk between 7 and 10 hours after maternal dosing, with highest levels in the fatty hind milk. Increasing the dose of maternal sertraline increased both the sertraline and desmethylsertraline levels in breast milk. Infant serum levels were ascertained 2 to 4 hours after nursing, and detectable concentrations of sertraline were found in three infants, and detectable concentrations of desmethylsertraline in six infants. No adverse effects were reported in any of the 12 infants (Stowe et al., 1997).

Venlafaxine (Effexor). Venlafaxine is a novel antidepressant. It is well absorbed in the mother (-90%) and is only 27% protein bound (Hale, 2002). It differs from other SSRIs in that it inhibits reuptake of both serotonin and norepinephrine, and it has a very short half-life (3-5 hr) (Deglin & Vallerand, 2003; Ilett et al, 2002). Research concerning venlafaxine and breastfeeding is limited. One study of seven infants indicated M/P ratios of venlafaxine and its metabolite, O-desmethyl venlafaxine, are 2.5 and 2.7, respectively.

Although no adverse effects were reported, the authors advised careful monitoring of infants exposed to venlafaxine through breast milk following detection of its metabolite in the plasma of four of the seven infants (Ilett et al, 2002).

Antipsychotics

Many antipsychotics are prescribed for psychoses connected in time to the postpartum period. Some of these psychoses linger from an existing diagnosis, while some emerge related to the postpartum period itself. Since psychosis must be treated and since all antipsychotics enter breast milk to some degree, a difficult treatment decision must be made. all the physiological variables associated with infancy contribute to potential problems with antipsychotics (Table 6); therefore, benefits and risks must be discussed with the mother prior to the administration of antipsychotics during breastfeeding (Trixler & Tenvi, 1997).

Haloperidol (Haldol). Haloperidol is a high-potency, traditional antipsychotic. Only a few traditional antipsychotics are even considered today for administration during lactation, and haloperidol is the most studied. It is 90% protein bound, so limited amounts are available for absorption into mother's milk (Deglin & Vallerand, 2003). Absorption following oral administration is 60%, and half-life is 12 to 38 hours (Hale, 2002).