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Postpartum Depression Treatment and Breastfeeding

Marlene P. Freeman, MD

Center for Women’s Mental Health, Massachusetts General Hospital, Boston

Prevalence and Onset of Postpartum Depression

Postpartum depression is experienced by 10% to 20% of women who bear children.1 Postpartum depression is usually defined as a major depressive episode that starts within 1 month after delivery. Some women experience symptoms during pregnancy that worsen after delivery, but others experience a more sudden onset of postpartum depressive symptoms.2 Anxiety is often a prominent component of postpartum depression, as are depressed mood, guilt, anhedonia, and low energy.2 The Edinburgh Postnatal Depression Scale3 can be a useful tool to assess postpartum depression.

When clinicians and mothers select treatment, the risks of untreated maternal depression have to be balanced against the risks of infant exposure to medication via breast milk.4 Nonpharmacologic treatments are available and should be considered. However, it is crucial that health care providers and mothers consider the serious risks of untreated maternal mood disorders as paramount to the discussion. It is reasonable for women to consider formula feeding rather than breastfeeding, especially if the demands of breastfeeding are contributing to distress in the context of postpartum depression. Antidepressants in general are considered reasonable for use during breastfeeding and are in fact one of the best studied classes of medications used during breastfeeding. Excellent and thorough reviews on the topic of antidepressants and breastfeeding have been published.5,6

Risks to Baby of Untreated Maternal Depression

For babies, a broad range of well-established short-term risks and long-term consequences are associated with having a depressed mother.7 Babies are sensitive to the emotional state of their mothers who, if depressed, may be disengaged when parenting. Risks of untreated maternal depression to the baby include insecure maternal-infant attachment that may be related to behavioral and relationship problems later in life. These children may also be at greater risk of other childhood psychiatric problems.

Compared with mothers without depression, depressed mothers may be less likely to heed preventative health care advice. Individuals with psychiatric disorders that are untreated may be more likely to drink alcohol and smoke, posing possible risks to babies,8 and they may be less likely to take preventative child safety measures.9 Depressed mothers are also more likely to think of harming their children, often a manifestation of postpartum obsessive thoughts, although postpartum psychosis must be considered when such thoughts are assessed (AV 1AV 1).10

Breastfeeding and Depression

Breastfeeding has broad health benefits for the baby and for the mother, and is also inexpensive compared with formula (AV 2AV 2).11,12 However, breastfeeding can be more challenging than many mothers expect. Depressed women in particular may find breastfeeding difficult to establish and maintain, and clinicians should monitor patients with postpartum depression for breastfeeding problems. Some mothers with depression may also feel conflicted about using antidepressant medications while breastfeeding.

Nonpharmacologic Treatments

For women with mild depression, nonpharmacologic treatments may be a reasonable alternative to medication during breastfeeding. For women with moderate or severe depression, nonpharmacologic therapies can be used so that medication exposure can be minimized.

Several nonpharmacologic treatments are available. Interpersonal psychotherapy13 may be especially effective in postpartum depression to help women transition to their new roles as mothers. Cognitive-behavioral therapy has also received a small amount of specific study in the postpartum period.14 Bright light therapy might be useful for postpartum depression, but more research is needed specifically for this depressive type.15 Omega-3 fatty acids, which have health benefits for mothers and babies, may be useful as adjunctive therapy, but results in small trials have been inconsistent.16 Women with severe depression may benefit from ECT.17

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Risks to Baby of Antidepressant Exposure Via Breastfeeding

Although no major trials have investigated the long-term safety of antidepressants during breastfeeding, evidence about exposure via breastfeeding is available from studies that have assessed quantities of medication in breast milk and infant serum or plasma, and several small trials and case reports inform the short-term safety profile.

Data for infant exposure to antidepressants via breast milk are difficult to compare because concentrations of the drug in breast milk can vary both from feeding to feeding and from the foremilk of early feeding to the hindmilk of later feeding.6 Time since dose of medication also affects drug transfer from maternal serum to milk.1 Exposure may be more relevant in newborn babies due to small size and immature metabolic system, and these babies may require greater vigilance in monitoring side effects than older infants, who may also be eating other foods.

A few reports of adverse effects in infants exposed to maternal antidepressants exist,1,5,6 but most have been case reports in which cause and effect are difficult to ascertain or other methodological problems existed, making them difficult to interpret. In general, few adverse clinical effects of TCA exposure in breastfed infants have been reported, and reports of adverse drug reactions in infants exposed to SSRIs during breastfeeding are rare.1,5,6

Among SSRIs, adverse events were reported in infants whose mothers were treated with citalopram or fluoxetine.1,5 Sleep disturbance was reported in 1 infant exposed to citalopram and was resolved after reducing the maternal dose5,6; it is important to note that sleep disturbance in a single infant is almost impossible to interpret clinically. Fluoxetine is the antidepressant with the longest half-life and therefore may be more likely than other agents to accumulate in infant serum, particularly if the infant was exposed to the drug in utero; however, fluoxetine is still considered compatible with breastfeeding and should be considered if a mother has responded well to it in the past.5,6 In case series of paroxetine use during breastfeeding, levels of paroxetine in infant serum were not detectable or were low,1 and adverse events have been rare in infants exposed to paroxetine in breast milk.6,12 Sertraline use in breastfeeding has received a relatively high amount of study; low concentrations have generally been found in both breast milk and infant serum, and only rare adverse events have been reported for infants exposed to sertraline during breastfeeding.1,5,6,12

An 8-week, randomized study18 compared sertraline and nortriptyline in breast-feeding women, and both drugs produced levels in infant serum that were near or below the quantifiable limit without adverse events. One suspected seizure was reported in an infant exposed to bupropion through maternal breast milk, although other case reports have indicated low levels of bupropion exposure through breast milk.19 No clinical effects or developmental problems have been reported in infants breastfed during maternal use of venlafaxine.19

If maternal doses of antidepressants are high, infants should be monitored especially carefully for side effects. Reducing the maternal antidepressant dose or supplementing breast milk with infant formula may be reasonable strategies.

Summary

Postpartum depression is common, but many new mothers do not receive treatment. Because untreated depression can have unhealthy effects on both mothers and infants, new mothers should be treated for depression. Although antidepressants may be present in breast milk and in infant blood in low levels, most of the commonly used antidepressants are considered compatible with breastfeeding and are not contraindicated for this purpose. The effects of postpartum depression impact a woman, her baby, and the entire family, and while breastfeeding is important from a nutritional standpoint, some women may opt to stop in order to take necessary medications. When developing an individual treatment plan, concerns about infant exposure to medication via breast milk should be balanced against the benefits of breastfeeding and the risks of untreated depression.

Drug Names

bupropion (Aplenzin, Wellbutrin, and others), citalopram (Celexa and others), fluoxetine (Prozac and others), nortriptyline (Pamelor and others), paroxetine (Paxil, Pexeva, and others), sertraline (Zoloft and others), venlafaxine (Effexor and others)

Abbreviations

ECT=electroconvulsive therapy
SSRI=selective serotonin reuptake inhibitor
TCA=tricyclic antidepressant

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References

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