Antidepressants in Breastfeeding Mothers
Screening for PPD
Clinical Approach to Treating PPD
Clinical Factors Affecting Antidepressant Choice
- Consider the primary symptoms that the medication will be targeting and its potential side effect profile.
- Choose psychotropic medications with an evidence base in lactating women. Older medications with available data are preferred over newer antidepressants with limited safety information.
Choosing an Antidepressant During Lactation
1. Route of drug administration and pharmacokinetics:
- absorption rate
- half-life and peak serum time
- dissociation constant
- volume of distribution
- molecular size
- degree of ionization
- pH of plasma (7.4) and milk (6.8)
- solubility of the drug in water and in lipids
- binding to plasma protein
- milk yield
- colostrum versus mature milk
- concentration of the drug in the milk
- how well the breast was emptied during the previous feeding
- the infant’s ability to absorb, detoxify, and excrete the drug.
Most antidepressant studies provide milk levels, or milk to mother’s plasma ratio, that are not constant and depend on factors such as dose, frequency, duration of dosing, maternal variation in drug disposition, drug interactions, and genetic background. Few studies provide infant serum levels, although they are the best measure of infant exposure.
Recommendations for Antidepressant Treatment in Lactating Women
- Women with moderate to severe symptoms may require only antidepressant drug treatment. In the setting of moderate to severe depression, the benefits of treatment likely outweigh the risks of the medication to the mother or infant.
- There is no widely accepted algorithm for antidepressant medication treatment of depression in lactating women. An individualized risk–benefit analysis must be conducted in each situation and take into account the mother’s clinical history and response to treatment, the risks of untreated depression, the risks and benefits of breastfeeding, the benefits of treatment, the known and unknown risks of the medication to the infant, and the mother’s wishes.
- If a mother has been successfully treated with a particular selective serotonin reuptake inhibitor, tricyclic antidepressant, or serotonin–norepinephrine uptake inhibitor in the past, the data regarding this particular antidepressant should be reviewed, and it should be considered as a firstline treatment if there are no contraindications.
- Mothers who were being treated with a selective serotonin reuptake inhibitor, tricyclic antidepressant, or serotonin– norepinephrine uptake inhibitor during pregnancy with good symptom control should continue on the same agent during breastfeeding. It is important to reassure the mother that exposure to the antidepressant in breastmilk is far less than exposure to the antidepressant during pregnancy. Moreover, ongoing treatment of the mood disorder is critical for the health of both mother and baby. Mothers should be provided information regarding the known and unknown risks and benefits of the treatment to make an informed decision.
- Mothers should be monitored carefully in the initial stages of treatment for changes in symptoms, including worsening of symptoms. Specifically, women with histories of bipolar disorder, which may be undiagnosed, are at increased risk of developing an episode of depression, mania, or psychosis in the postpartum period. Although this situation is rare, mothers and partners should be made aware of the symptoms to watch for such as increased insomnia, delusions, hallucinations, racing thoughts, and talking/moving fast. Women experiencing such symptoms should contact their mental health provider immediately.
- The mother’s provider should communicate with the infant’s provider to facilitate monitoring and follow-up. Infants should be monitored carefully by the physician/ healthcare worker, including carefully following growth. Serum levels are not indicated on a regular basis without a clinical indication or concern. In addition, in most cases, the serum level would not provide helpful information unless it is a psychotropic that has a documented therapeutic window and laboratory norms (i.e., tricyclic antidepressants).
Use of Antidepressants in Breastfeeding Mothers
July 23, 2015
External Publication Status
Country of Publication
Discuss the spectrum of depression disorders, emphasize the importance of screening, and provide evidence based information recommendations for treatment of PPD in breastfeeding mothers.
Target Patient Population
Mothers suffering from postpartum depression while breastfeeding
Health Care Settings
Ambulatory, Home health, Hospital, Outpatient
Psychologist, nurse midwife, dietician nutritionist, counselor, nurse, nurse practitioner, physician, physician assistant
Counseling, Assessment and screening, Management, Treatment
D001942 - Breast Feeding, D019052 - Depression, Postpartum, D003863 - Depression
lactation, Breastfeeding, Lactation, postpartum depression, antidepressants, Antidepressants, PPD
Natasha K. Sriraman, Kathryn Melvin, Samantha Meltzer-Brody, and the Academy of Breastfeeding Medicine.Breastfeeding Medicine.Jul 2015.290-299.http://doi.org/10.1089/bfm.2015.29002