Antidepressants in Breastfeeding Mothers

Publication Date: July 23, 2015


Screening for PPD

Although definitive evidence of benefit is limited, the American College of Obstetricians and Gynecologists recommends that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. For the first time, a large U.S. multicenter study of screening and follow-up care for PPD in a family practice setting has shown improved maternal outcomes at 12 months. (I)

Screening instruments

The screening instrument that has been most studied throughout the world is the Edinburgh Postnatal Depression Scale (EPDS). The EPDS is free, considered to be in the public domain, and available in many languages and has crosscultural validity. It has 10 questions to be completed by the mother based on symptoms over the past 7 days and takes approximately 5 minutes to complete. There are multiple points of contact in which screening can occur. In wellchildcare visits, EPDS screening could occur during the 1-, 2-, 4-, and 6-month visits. The cesarean section incision check at 2 weeks and the postpartum visit at 4–8 weeks are also important screening opportunities. The EPDS can be readily administered and has demonstrated validity to detect postpartum mood disorders at as early as 4–8 weeks postpartum. (II-3)
Either a score of 10 or higher or a positive response to Question 10 about suicidal thoughts is considered positive and indicates that the mother may be suffering from a depressive illness of varying severity. (II-3)
Providers caring for the infant must refer a mother with a positive screen for appropriate care.

Clinical Approach to Treating PPD

Once a woman is identified as being at risk for PPD, treatment choices must be considered and offered to her. For mild to moderate depression in the breastfeeding mother, psychology/cognitive behavioral therapy, if available, should be considered as first-line therapy. (II-2)


Infant feeding considerations. Breastfeeding difficulties and perinatal depression symptoms often present together, and management of depression should include a discussion of the mother’s experience of breastfeeding. Some mothers with depression find that breastfeeding enhances bonding and improves their mood, whereas others find breastfeeding to be difficult. For dyads struggling with milk production and latch issues, efforts should be undertaken to simplify feeding plans to ensure that mother and infant have time to enjoy one another. The demands of nighttime breastfeeding can be challenging for mothers for whom interruption of sleep is a major trigger for mood symptoms. In these cases, it may be helpful to arrange for another caregiver to feed the infant once at night, allowing the mother to receive 5–6 hours of uninterrupted sleep. A caregiver may also bring the infant to the mother to feed at the breast and then assume responsibility for settling the baby back to sleep, thereby minimizing maternal sleep disruption. (III)


If psychological/cognitive behavioral therapy is unavailable, symptoms are severe, or mothers refuse this therapy, antidepressants are an effective option. Many factors must be considered when choosing an antidepressant during breastfeeding. All antidepressants are present in human milk to some extent. Data to inform clinical decisions are derived primarily from case reports or case series. Therefore, the initial treatment choice should be based on an informed clinical approach that takes into account the patient’s previous treatments for depression, especially use during the pregnancy, the targeted symptoms, family history of depression and their experiences with antidepressants, current and past medical disorders, current medications, allergies, side effects of the medications, and maternal wishes. (I)

Clinical Factors Affecting Antidepressant Choice

Obtain a psychiatric history with a focus on previous episodes of mood and anxiety disorders and effective treatment interventions. If psychotropic medications were used, determine what treatments were effective with a tolerable side effect profile. Past treatment response is often the best predictor of future response. (II-2)
Obtain a family history of psychiatric illness and treatment response. An immediate family member’s history may be indicative of the mother’s treatment response. (II-2)
  • 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

When considering the use of any medication in a lactating woman, providers must consider both maternal and infant safety factors. The medication must be both efficacious for the mother and safe for the infant. Although infant serum levels of psychotropic medication are the most accurate measure of infant exposure, it is often difficult to measure infant serum levels in routine clinical practice. However, factors affecting the passage of medication into human milk must be considered, including the following:
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
2. Amount of drug received by the infant in human milk:
  • 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.
Up-to-date information about medication use during lactation is easily available from the Internet on TOXNET LACTMED ( .htm) (available in English) and e-lactancia (http://e-lactan cia. org/) (available in both English and Spanish).
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.

Specific Antidepressants

Data from a recent meta-analysis indicated that all antidepressants were detected in milk but that not all were found in infant serum. Infant serum levels of nortriptyline, paroxetine, and sertraline were undetectable in most cases. Infant serum levels of citalopram and fluoxetine exceeded the recommended 10% maternal level in 17% and 22% of cases, respectively. Few adverse outcomes were reported for any of the antidepressants. Conclusions could not be drawn for other antidepressants due to an insufficient number of cases. There is little or no evidence that ethnic or regional ‘‘medicines’’ are safe or effective; thus their use by healthcare providers is strongly cautioned. (II-2)
Both psychological/cognitive behavioral therapy and antidepressant medication are recommended for women with moderate to severe symptoms or for whom there are current stressors or interpersonal issues that psychological therapy may help address. Maternal lactation status should not delay treatment. (II-2)

Recommendations for Antidepressant Treatment in Lactating Women

Current evidence suggests that untreated maternal depression can have serious and long-term effects on mothers and infants and that treatment may improve outcomes for mothers and infants. Therefore treatment is strongly preferred. (II-2)
However, it is important not to label mothers who are only suffering from mild cases of postpartum blues as ‘‘depressed.’’ We must make a distinction. For women with mild symptoms who are in the first 2 weeks postpartum, close follow-up, rather than initiation of antidepressant medication, is suggested. (II-2)
When available and when symptoms are in the mild to moderate range, psychological/cognitive behavioral therapy is the first line of treatment for lactating women as it carries no known risk for the infant. Mothers must be monitored and reevaluated. If they are not improving or their symptoms are worsening, antidepressant drug treatment should be considered. (II-2)
  • 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 no history of antidepressant treatment, an antidepressant such as sertraline that has evidence of lower levels in human milk and infant serum and few side effects is an appropriate first choice. (II-2)
Sertraline has the best safety profile during lactation. The recommended starting dose is 25 mg for 5–7 days to avoid side effects, which then can be increased to 50 mg/day.
  • 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).
A strategy that may be used to decrease infant exposure based on breastfeeding pharmacokinetic reports is medication administration immediately after feedings. (III)
There are several Web-based and book references available for professionals and mothers to assist in gaining knowledge and help regarding these issues.

Recommendation Grading




Use of Antidepressants in Breastfeeding Mothers

Authoring Organization

Publication Month/Year

July 23, 2015

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

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

Inclusion Criteria

Female, Adult

Health Care Settings

Ambulatory, Home health, Hospital, Outpatient

Intended Users

Psychologist, nurse midwife, dietician nutritionist, counselor, nurse, nurse practitioner, physician, physician assistant


Counseling, Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D001942 - Breast Feeding, D019052 - Depression, Postpartum, D003863 - Depression


lactation, Breastfeeding, Lactation, postpartum depression, antidepressants, Antidepressants, PPD

Source Citation

Natasha K. Sriraman, Kathryn Melvin, Samantha Meltzer-Brody, and the Academy of Breastfeeding Medicine.Breastfeeding Medicine.Jul 2015.290-299.