Antidepressants and Breastfeeding: Are They Compatible?

Any woman who has recently given birth is susceptible to post-partum depression. There are also some mothers who suffer from depression during pregnancy and some mothers that have been on long-term treatment for depression. When it comes to nursing their newborns, they are given the choice to try prescription antidepressants. A great deal of misinformation and simple lack of knowledge on the mothers' and the doctors' part has led to confusion and reluctance to use medications. However, experts consider a number of antidepressants to be relatively safe for mother and baby.

Dr. Thomas Hale, Ph.D. is the leading expert on medications and nursing. He is the author of Medications and Mother's Milk: A Manual of Lactational Pharmacology, the go-to source for pediatricians, obstetricians and lactation consultants. His website has a forum for medical professionals to ask him questions, but anyone can search it and read the posts. He writes about all categories of medications, not just antidepressants. The American Academy of Pediatrics also maintains lists of medications and their effects on nursing infants. They have a separate list for psychotropic drugs. The United States National Library of Medicine has a searchable database of medications, LactMed. The scope of this article does not include an in-depth discussion of the different categories of antidepressants. A solid introduction to them can easily be found online.

Similar to the FDA pregnancy risk categories, there are lactational risk categories. As defined in Dr. Hale's book and referenced from Kellymom.com, there are five categories: L1 through L5. Medications in the L1 category are considered to be the "safest;" there have been adequate studies in humans and a large number of breastfeeding mothers have taken the medication with no demonstrable negative effects in the infant. Medications in the L2 category are considered to be "safer;" there have been limited studies of nursing mothers but in those studies, no negative effects on the infant was observed. L3 medications are "moderately safe;" there have been no controlled studies in nursing women or the controlled studies have shown a slightly increased risk of negative effects in the infant. These medications are recommended only if the potential benefits outweigh the potential risks. Medications in the L4 category are considered to be "possibly hazardous;" negative effects on the infant have been demonstrated but these medications could be considered if the benefits to the mother outweigh the possible risks if there are no alternatives available. The final risk category is L5 and these medications are "contraindicated;" studies have shown a definite and well-documented risk of serious negative effects on the infant and the benefits to the mother do not outweigh the risks to the infant. Nursing mothers should not take these.

In Dr. Hale's article "Evaluating Medications for the Lactating Woman," published in Breastfeeding Abstracts, November 2004, Vol. 24, No. 1, pp. 3 & 4, and posted on The La Leche League International's website, he says that "Fortunately the average transfer of most medications into human milk is exceedingly low." An average of 1-4% of the maternal dose of a medication is transferred to the infant. He does caution that antidepressants exceed this level, but are under the 10% transfer rate that is the threshold for relative safety.

The antidepressant section of Dr. Hale's forum has a wealth of information on most antidepressants, and particularly the most popular ones. According to the LactMed database, the SSRIs Paxil, Zoloft, and Lexapro are considered relatively safe and are the medications of choice in nursing mothers. Prozac and Celexa have shown a slightly higher tendency to cause negative effects in the infant, but the effects are still relatively small. The other SSRIs are preferred, but both Dr. Hale's and LactMed's entries on Prozac and Celexa note that they are not a reason to discontinue breasfeeding.

The drug Effexor is the preferred SNRI for nursing mothers. There have been no adverse effects reported, according to LactMed and Dr. Hale. Cymbalta has not been adequately studied but LactMed says it is not a reason to stop breastfeeding. The newest SNRI, Pristiq, has also not been adequately studied, but since it is the metabolite of Effexor, Dr. Hale thinks it is "probably safe" to use.

The older class of tricyclic antidepressants have been more extensively studied. Amitriptyline, Imipramine, Nortriptyline, and Desipramine are the preferred tricyclics according to LactMed. Protriptyline, Trimipramine, and Clomipramine are not considered to be reasons to stop breastfeeding, but the previous four medications are preferred. LactMed considers Doxepin to be a "poor choice."

The monoamine oxidase inhibitors (MAOIs) Nardil, Parnate, Emsam and Marplan should be avoided during breastfeeding because there is a definite lack of data, according to LactMed.

There are newer drugs that do not fit into any of the other categories. These include Wellbutrin, Trazodone, Serzone and Remeron. Both Dr. Hale and LactMed agree that there is limited evidence, but what does exist suggests these are relatively safe.

Nursing mothers no longer need to suffer with depression and related mental health issues. They now have many options for antidepressants, and with the wide variety of choices available, most can find relief. The more information a woman can arm herself with, the better her outcome can be.

Sources:
Dr. Thomas Hale, Ph.D, "Index", (Breastfeeding Pharmacology). Texas Tech University Health Sciences Center School of Medicine at Amarillo.
American Academy of Pediatrics, "The Transfer of Drugs and Other Chemicals Into Human Milk." AAP Policy.
Drugs and Lactation Database (LactMed), "LactMed Search." United State National Library of Medicine.
SafeFetus.com, "Drugs in Pregnancy." SafeFetus.org.
Dr. Thomas Hale, Ph.D, "Lactation Risk Categories." Kellymom.com.
Dr. Thomas Hale, Ph.D., "Evaluating Medications for Lactating Women." La Leche League, International.
Dr. Thomas Hale, Ph.D, "Index", (Medication Forums). Texas Tech University Health Sciences Center School of Medicine at Amarillo.