Mental health concerns can occur in the postpartum period, and depression is the most common mental health concern that is seen. Previous e-Weekly’s have discussed the effects of postpartum depression on a new mother and her bonding with her baby. It is not uncommon for a new mother to feel like she has to make a choice between treating her psychiatric condition with medication and breastfeeding. Therefore some new mothers stop their psychotropic medications in order to breastfeed and others decide not to breastfeed so that they can continue their medication.
The research has shown that newborn babies can have negative effects from exposure to antidepressant medications, including jitteriness, irritability, feeding problems, and excessive crying. Serious acute adverse effects from antidepressant medications in breast milk appear to be uncommon, and the highest risk is in the first two months of life when a baby’s liver is still immature. It is very important to be especially careful with premature infants because their livers would have a hard time metabolizing medications. Epidemiological studies looking at long terms effects of exposure during breastfeeding are lacking however.
There are some important factors that go into making a decision about medication while breastfeeding. These include the patient’s goals and beliefs, the severity of the illness and previous treatments and responses to previous treatments and the specific traits of the medication being considered. It is important for the primary care provider to ask the patient about her goals with breastfeeding (how long, how often, exclusive or with supplementing) because these choices might impact that decision.
In terms of pharmacokinetics, the ideal medication to use while breastfeeding has a short half-life, is highly protein bound, and has low oral bioavailability. Strategies to minimize exposure include: (1) administering medications right after breastfeeding immediately before the longest sleep period if possible; (2) picking medications that are approved for pediatrics use if possible as these are generally safe in the breastfeeding mother; (3) choosing drugs with published data over drugs without any published data.
In 2014 the Food and Drug Administration (FDA) published a final rule entitled Content and Format of Labeling for Human Prescription Drug and Biological Products: Requirements for Pregnancy and Lactation Labeling, which is also known simply as the “Pregnancy and Lactation Labeling Rule” (PLLR) as a new rule for categorizing medication during lactation. In summary,
L1: Compatible (many BF mothers have taken these medications without adverse effects)
L2: Probably Compatible – limited studies
L3: Probably Compatible – no controlled studies (all new medications are added to this category automatically)
L4: Possibly Hazardous (some demonstrated adverse effects, but benefits might outweigh risk, ex. serious illness)
L5: Hazardous (contraindicated)
Regarding treatment of postpartum depression and anxiety, sertraline is the most extensively studied SSRI in breastfeeding mothers. Most of the SSRIs are considered L2 although fluoxetine is not considered first line because of its long half-life. After sertraline, generally paroxetine (which is contraindicated in pregnancy) and escitalopram are considered next line agents. The SNRIs and other antidepressants have not been well studied so would not be considered first line treatment for depression in breastfeeding mothers. Most have an L3 categorization. Therapy is considered first line for mild-moderate depression and anxiety. Therapy and SSRI medication are considered first line for moderate-severe depression and anxiety. If a patient has a favorable response to a particular SSRI in the past, that should be considered, otherwise sertraline or paroxetine could be considered as the medication treatment.
Various meta-analyses support that the benefits of breastfeeding outweigh the risk of exposure via breast milk for most therapeutic agents. This should be considered when deciding whether or not to have medication be part of a patient’s treatment plan for her mental health disorder. There are apps (Infant Risk and LactMed), websites (LactMed and American Academy of Breastfeeding Medicine, which has a protocol on antidepressant medications), and books (Medications and Mother’s Milk) that are great resources for further information for those you are interested.