Evidence-Based Reviews

Postpartum depression: What to tell patients who breast-feed

Current Psychiatry. 2008 May;7(5):87-95

References

1. Munk-Olsen T, Laursen TM, Pedersen CB, et al. New parents and mental disorders: a population-based register study. JAMA 2006;296:2592-9.

2. Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ) 2005;(119):1-8.

3. Cox JL, Holden JM, Sagovsk R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6.

4. Beck CT, Gable RK. Comparative analysis of the performance of the Postpartum Depression Screening Scale with two other depression instruments. Nurs Res 2001;50:242-50.

5. Bloch M, Schmidt PJ, Danaceau M, et al. Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry 2000;157(6):924-30.

6. Mastorakos G, Ilias I. Maternal and fetal hypothalamic-pituitary-adrenal axes during pregnancy and postpartum. Ann N Y Acad Sci 2003;997:136-49.

7. Noltern WE, Lindheimer MD, Rueckert PA, et al. Diurnal patterns and regulation of cortisol secretion in pregnancy. J Clin Endocrinology Metab 1980;51:466-72.

8. Bloch M, Daly RC, Rubinow DR. Endocrine factors in the etiology of postpartum depression. Compr Psychiatry 2003;44(3):234-46.

9. Magiakou MA, Mastorakos G, Rabin D. Hypothalamic-cortico-releasing hormone suppression during the postpartum period: implications for the increase in psychiatric manifestations at this time. J Clin Endocrinol Metab 1996;81:1912-7.

10. Jolley SN, Elmore S, Barnard KE, Carr D. Dysregulation of the hypothalamic-pituitary-adrenal axis in postpartum depression. Biol Res Nurs 2007;8:210-22.

11. Gold PW, Gabry KE, Yasuda MR, Chrousos GP. Divergent endocrine abnormalities in melancholic and atypical depression: clinical and pathophysiologic implications. Endocrinol Metab Clin North Am 2002;31:37-62.

12. Bloch M, Rubinow DR, Schmidt PJ. Cortisol response to ovine corticotropin-releasing hormone in a model of pregnancy and parturition in euthymic women with and without a history of postpartum depression. J Clin Endocrinol Metab 2005;90(2):695-9.

13. Raison CL, Miller AH. When not enough is too much: the role of insufficient glucocorticoid signaling in the pathophysiology of stress-related disorders. Am J Psychiatry 2003;160:1554-65.

14. Pedersen CA, Johnson JL, Silva S, et al. Antenatal thyroid correlates of postpartum depression. Psychoneuroendocrinology 2007;32(3):235-45.

15. Yonkers KA. The treatment of women suffering from depression who are either pregnant or breastfeeding. Am J Psychiatry 2007;164(10):1457-9.

16. Ryan AS, Wenjun Z, Acosta A. Breastfeeding continues to increase into the new millennium. Pediatrics 2002;110:1103-9.

17. Payne J. Antidepressant use in the postpartum period: practical considerations. Am J Psychiatry 2007;164:1329-32.

18. Murray L, Sinclair D, Cooper PJ, et al. The socioemotional development of 5-year old children of postnatally depressed mothers. J Child Psychol Psychiatry 1999;40:1259-71.

19. Weissman AM, Levt BT, Hartz AJ, et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry 2004;161(6):1066-78.

20. Eberhard-Gran M, Eskild A, Opjordsmoen S. Use of psychotropic medications in treating mood disorders during lactation: practical recommendations. CNS Drugs 2006;20:187-98.

21. Rampono J, Hackett LP, Kristensen JH, et al. Transfer of escitalopram and its metabolite demethylescitalopram into breastmilk. Br J Clin Pharmacol 2006;62(3):316-22.

22. Wisner KL, Perel JM, Findling RL. Antidepressant treatment during breast-feeding. Am J Psychiatry 1996;153(9):1132-7.

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Risks with or without treatment

PPD has potentially serious adverse consequences and needs to be aggressively treated. Ethical and practical challenges have hindered PPD research, however, and evidence to guide treatment is limited.¹⁵

Approximately 70% of mothers in the United States breast-feed their infants at least for the first 3 months.¹⁶ With any patient with PPD who is breast-feeding, carefully discuss the risk of antidepressant side effects for the mother and child.¹⁷

Also discuss potential risks and benefits of treatment vs no treatment.¹⁷ Potential risks of untreated depression include:

impaired mother/child bonding because of ongoing maternal depressive illness
impaired cognitive, emotional, and social development in the child.¹⁸

Clinical Point

Most studies of antidepressant use in lactating women found low rates of adverse events in infants

A collaborative, multidisciplinary treatment approach that includes the patient’s psychiatrist, obstetrician, and pediatrician is important to:

educate the patient about potential antidepressant side effects for mother and baby
avoid communicating “mixed messages” to the patient about the risk and benefits of treatment
ensure the health of mother and baby.¹⁷

Advise mothers who take antidepressants that they can minimize their babies’ exposure to peak drug concentrations by taking the antidepressant immediately after breast-feeding and before the infant sleeps.¹⁷ Also discuss strategies for balancing the need for sleep with the demands of breast-feeding. Reassure patients that although this is not easy, it can be accomplished with thoughtful planning and good partner support.

Antidepressants. In general, women with PPD respond well to antidepressant therapy. They may be hesitant to take any medication while breast-feeding because of possible harmful effects to their babies, but most studies examining antidepressant use by lactating women found low rates of adverse events in infants exposed to antidepressants (Table).^19-24 Potential adverse effects include:

sedation
changes in sleep or feeding
irritability.¹⁷

Clinical Point

Use fluoxetine or citalopram only in women who responded to them during a previous pregnancy or depressive episode

Selective serotonin reuptake inhibitors (SSRIs) and tricyclics (except doxepin) are commonly used to treat PPD.²⁵ Neither class has been proven superior.¹⁷ Monoamine oxidase inhibitors are not recommended because they can exacerbate hypertension and interact with food and other medications.²⁵

SSRIs. Few adverse events have been reported with sertraline, paroxetine, and fluvoxamine during lactation.²⁰ However, paroxetine may be associated with increased risk of cardiac abnormalities in infants exposed during the first trimester of pregnancy.²⁶ Two agents in this class may be less desirable:

fluoxetine, because it has a long half-life
citalopram, because of potentially high breast milk concentration.²⁰

Use fluoxetine or citalopram only in patients who had a good response to them during pregnancy or a previous depressive episode. For women who took an antidepressant during pregnancy, continue the same medication postpartum to prevent exposing the infant to another drug.

Clinical Point

Avoid doxepin because adverse effects have been reported in infants exposed to it via breast milk

Tricyclics might be indicated for patients who responded to them previously or who have not responded to SSRIs. No adverse effects have been reported in breast-feeding infants receiving amitriptyline, clomipramine, desipramine, imipramine, or nortriptyline.²⁵ Avoid doxepin, however, because it has the longest half-life among tricyclics, and adverse effects in infants—including respiratory distress, drowsiness, and vomiting—have been reported.

Other antidepressants. Venlafaxine and duloxetine are not recommended because of limited data about use of these agents during lactation. Bupropion poses a small increased risk of seizures in newborns but is not absolutely contraindicated.²⁴ Trazodone also has limited data, but in clinical practice it has been used safely at low doses for many years.²⁰

Psychotherapeutic techniques—including individual or group therapy—also can effectively reduce depressive symptoms in women with PPD.²⁷

Table

Antidepressants for postpartum depression

Medication	Starting dosage	Maximum dosage during lactation	Potential adverse event(s)
Selective serotonin reuptake inhibitors
Citalopram	10 mg	60 mg	High milk/plasma concentration at higher doses²⁰
Escitalopram	10 mg	20 mg	Very limited data to date show lower milk/plasma concentrations compared with citalopram²¹
Fluoxetine	10 mg	60 mg	Long half-life can increase the potential for accumulation²⁰
Sertraline	25 mg	150 to 200 mg	Minimal detection of drug in infants’ serum^19,20
Paroxetine	10 mg	50 mg	Minimal detection of drug in infants’ serum^19,20
Tricyclics
Desipramine	25 mg	200 mg	Minimal detection of drug in infants’ serum^19,22
Imipramine	25 mg	200 mg	Minimal detection of drug in infants’ serum^19,22
Nortriptyline	25 mg	125 to 150 mg	Minimal detection of drug in infants’ serum^19,22
Others
Bupropion	75 to 150 mg	300 mg	Limited data available. Small increased risk of infant seizure (case report)²⁴
Mirtazapine	7.5 mg	45 mg	Limited data available. Well tolerated in a small study.²³ Always monitor for changes in sleep (sedation and activation) and eating behaviors
Note: Clinical monitoring of the infant for adverse effects—including sedation, changes in sleep or feeding, and irritability—should be part of routine care