There have always been so many questions from mothers and professionals about the treatment of depression during breastfeeding. So many times mothers are TOLD to stop breastfeeding without discussion about what they want. We know that not reaching breastfeeding goals can increase the risk of depression. This factsheet is intended to dispel some of the myths about antidepressants taken whilst a mother is breastfeeding. As always I am happy to answer individual questions and provide more information.
“Specialist sources indicate that sertraline and paroxetine are the SSRIs of choice in breast-feeding based on passage into milk, half-life, and published evidence of safety. However, all SSRIs can be used in breast-feeding with caution, and since there are risks with switching an SSRI, it may be more clinically appropriate to continue treatment with an SSRI that has been effective, or restart treatment with an SSRI that has previously been effective. With all SSRIs, infants should be monitored for drowsiness, poor feeding, adequate weight gain, gastro-intestinal disturbances, irritability, and restlessness.”
Factsheet is available as a pdf :
Depression is said to affect up to 20% of women in the perinatal period. Incidence is higher where they have had symptoms prior to pregnancy particularly if they stopped medication when planning a pregnancy fearing that they may harm their unborn baby.
Information on pregnancy can be found below the breastfeeding data.
Choice of antidepressant in breastfeeding
Whichever drug a mother has taken during or prior to pregnancy is the best choice for her, knowing that it is effective and free from troublesome adverse effects for her. Individuals react differently to medication.
If the prescription is newly prescribed post-partum it is reasonable to choose sertraline because of the pharmacokinetics of the drug which restrict passage into breastmilk. For more information see https://breastfeeding-and-medication.co.uk/fact-sheet/sertraline-and-breastfeeding
Citalopram is also widely used during breastfeeding. Its half-life is slightly longer but does not seem to affect babies in doses < 40mg/day. There is one case of restless sleep in a baby exposed to 40mg citalopram which resolved when the dose was reduced. For more information see https://breastfeeding-and-medication.co.uk/fact-sheet/citalopram-and-breastfeeding
Paroxetine is often advocated as equally suitable as sertraline because of its shorter half-life and other pharmacokinetic properties. The difficulty with this drug is that when trying to stop there can be persistent discontinuation syndrome. It can be useful for individuals. Half-life 21 hours, Plasma protein binding 95%, Relative Infant Dose 1.2%-2.8%.
Fluoxetine is often regarded as contra-indicated in breastfeeding because of its greater transfer into breastmilk. It can also produce side effects in the baby as it withdraws from placental transfer. This can exhibit as jitteriness or excessive drowsiness but resolves in a few days. For more information see https://breastfeeding-and-medication.co.uk/fact-sheet/fluoxetine-and-breastfeeding
Monitoring of the baby exposed to SSRI through breastmilk.
Most babies do not react to the levels of SSRI in breastmilk although there are reports that mothers taking these medications may need additional support to establish breastfeeding. It is sensible to observe for growth and drowsiness but to observe these initially as breastfeeding issues needing support from a breastfeeding expert rather than an adverse effect of the medication.
SSRI medications do not cause drowsiness and there is no risk in co-sleeping according to evidence-based guidelines https://www.basisonline.org.uk/about-us/. Taking of SSRIs at night on the assumption that this precedes the longest sleep period may result in poor sleep and is ineffective due to the half lives of these drugs. For more information see https://breastfeeding-and-medication.co.uk/fact-sheet/timing-of-breastfeeds-if-taking-medication
Venlafaxine (Efexor™) is an SRNI– Infants receive venlafaxine and its active metabolite in breastmilk, and the metabolite of the drug can be found in the plasma of most breastfed infants; however, concurrent side effects have rarely been reported ( https://www.ncbi.nlm.nih.gov/books/NBK501192/). Various studies failed to show short or long-term side-effects among infants whose mothers were on Venlafaxine, both on physical or psychomotor development ( https://www.e-lactancia.org/breastfeeding/venlafaxine-hydrochloride/product/)
The dose transferred to the infant is relatively high although no adverse reports have been reported. As the drug is associated with discontinuation syndrome it would be difficult for the mother to stop abruptly. In neonates, monitoring for excessive sedation and lower than expected weight gain is advisable.
Duloxetine (Cymalta ™) is an SNRI- Little published information is available on the use of duloxetine during breastfeeding; however, the dose in milk is low and serum levels were low in two breastfed ( https://www.ncbi.nlm.nih.gov/books/NBK501470/). Because there is less experience published than with other antidepressants of the same pharmacological group, it should be preferred the use of an alternative drug that is known to be safer in the neonatal period or prematurity. However, it is excreted into breast milk in clinically non-significant amount with no side-effects being observed in breastfed infants from treated mothers ( https://www.e-lactancia.org/breastfeeding/duloxetine/product/)
Mirtazapine (Zispin™) – Mirtazapine maybe initiated if other antidepressants have proved ineffective or not been tolerated. It may also be invaluable when poor sleep and loss of appetite is the major symptom of depression. Limited information indicates that maternal doses of up to 120 mg daily produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months ( https://www.ncbi.nlm.nih.gov/books/NBK501188/). Mirtazapine produces fewer symptoms of sexual dysfunction that have been reported in SSRIs. It can initially cause drowsiness and abnormal dreams. Care should be taken with co sleeping as natural reactions will be lessened. In a study of 8 babies whose mothers were taking up to 120mg at night. Levels of mirtazapine were only identified at a low level in one baby and were undetectable after 12 hours.
It is excreted into breast milk in a clinically non-significant amount (https://www.e-lactancia.org/breastfeeding/mirtazapine/product/)
Plasma protein binding 85%, Oral bioavailability 50%, relative infant dose 1.6% – 6.3%%.
Tricyclic antidepressants are more rarely used due to their side effect profile. Care should be taken with co sleeping as they may cause drowsiness but also urine retention, constipation and dry mouth.
Amitriptyline Plasma protein binding 94.8%, Oral bioavailability 100%, relative infant dose 1.08%-2.8%
Clomipramine Plasma protein binding 96%, Oral bioavailability 100%, relative infant dose 2.8%
Imipramine Plasma protein binding 90%, Oral bioavailability 90%, relative infant dose 0.1%-4.4%
Lofepramine BNF : The amount secreted into breast milk is too small to be harmful.
Some mothers prefer to use herbal remedies, many of which we do not have research on. One option available is St Johns Wort. For more information see
What do women want healthcare professional to know about the needs of the perinatal mum with mental health challenges?
I asked the mothers who follow my Facebook Page Breastfeeding and Medication what message they wanted to pass on to professionals who see them when they have mental health challenges. I have included their responses here as I believe that their comments should be borne in mind by all who see mothers with depression and anxiety. https://breastfeeding-and-medication.co.uk/fact-sheet/what-do-women-want-healthcare-professional-to-know-about-the-needs-of-the-perinatal-mum-with-mental-health-challenges
I’m not going to include recommendations on the use of antidepressants in pregnancy but to point to the expert sites:
- Dubovicky M, Belovicova K, Csatlosova K, Bogi E. Risks of using SSRI / SNRI antidepressants during pregnancy and lactation. Interdiscip Toxicol. 2017 Sep;10(1):30-34. doi: 10.1515/intox-2017-0004. PMID: 30123033; PMCID: PMC6096863. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6096863/
- Sharifi F, Nouraei S, Shahverdi E. The Relation of Pre and Postnatal Depression and Anxiety with Exclusive Breastfeeding. Electron Physician. 2016 Nov 25;8(11):3234-3239. doi: 10.19082/3234. PMID: 28070257; PMCID: PMC5217816. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217816/
- RCGP Perinatal Mental Health Toolkiit https://www.rcgp.org.uk/representing-you/policy-areas/perinatal-mental-health
However, I will point out that many women continue to take medication throughout pregnancy to maintain their mental health during what can be a very stressful period.
SSRI drugs ( sertraline, citalopram, fluoxetine and paroxetine) re known to increase bleeding risks due to their effect on platelet function. Data from observational studies suggest that the use of SSRI/SNRI antidepressants during the month before delivery may result in a small increased risk of postpartum haemorrhage. This is something which midwives and the delivery team will be observant for during and after delivery.
- Palmsten K, HernÃ¡ndez-DÃaz S, Huybrechts K F, Williams P L, Michels K B, Achtyes E D et al. Use of antidepressants near delivery and risk of postpartum hemorrhage: cohort study of low income women in the United States BMJ 2013; 347 :f4877 doi:10.1136/bmj.f4877 https://www.bmj.com/content/347/bmj.f4877
Gestational diabetes is often associated with weight gain which occurs in some women who take anti-depressants but is most associated with venlafaxine(SNRI) and amitriptyline (tri-cyclic). Studies have often compared pregnant women on medication with healthy women without treatment. Depression in pregnancy itself can lead to insulin resistance. Nevertheless, as with routine antenatal monitoring a high BMI should be investigated for Gestational Diabetes.
- Lupattelli A, Barone-Adesi F, Nordeng H. Association between antidepressant use in pregnancy and gestational diabetes mellitus: Results from the Norwegian Mother, Father and Child Cohort Study. Pharmacoepidemiol Drug Saf. 2021 Nov 24.
- Wartko PD, Weiss NS, Enquobahrie DA, Chan KCG, Stephenson-Famy A, Mueller BA, Dublin S. Antidepressant continuation in pregnancy and risk of gestational diabetes. Pharmacoepidemiol Drug Saf. 2019 Sep;28(9):1194-1203. doi: 10.1002/pds.4799. Epub 2019 Jul 12. PMID: 31298445; PMCID: PMC6728166. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6728166/
- Antidepressants linked to heightened pregnancy related diabetes risk BMJOpen https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2018-025908
Pulmonary hypertension of the new-born
“Rarely, SSRI use in pregnancy can cause a problem in the baby, where blood flow to the lungs is too high. This is called persistent pulmonary hypertension of the new-born (PPHN). Around one in every 300 babies whose mother takes an SSRI may develop PPHN” (BUMPS https://www.medicinesinpregnancy.org/Medicine–pregnancy/Sertraline/)
- Kieler H, Artama M, Engeland A, Ericsson /span>, Furu K, Gissler M et al. Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the new-born: population based cohort study from the five Nordic countries BMJ 2012; 344 :d8012 doi:10.1136/bmj.d8012 https://www.bmj.com/content/344/bmj.d8012#:~:text=Exposure%20to%20SSRIs%20in%20late,confidence%20interval%201.5%20to%203.0).
- Ng QX, Venkatanarayanan N, Ho CYX, Sim WS, Lim DY, Yeo WS. Selective Serotonin Reuptake Inhibitors and Persistent Pulmonary Hypertension of the Newborn: An Update Meta-Analysis. J Womens Health (Larchmt). 2019 Mar;28(3):331-338. doi: 10.1089/jwh.2018.7319. Epub 2018 Nov 8. PMID: 30407100. https://pubmed.ncbi.nlm.nih.gov/30407100/
- Bérard A, Sheehy O, Zhao JP, Vinet É, Bernatsky S, Abrahamowicz M. SSRI and SNRI use during pregnancy and the risk of persistent pulmonary hypertension of the newborn. Br J Clin Pharmacol. 2017 May;83(5):1126-1133. doi: 10.1111/bcp.13194. Epub 2017 Jan 18. PMID: 27874994; PMCID: PMC5401975. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5401975/
Autism after exposure in pregnancy
“Some studies have suggested that up to three out of every 100 children born to women taking an SSRI may develop autism spectrum disorder (ASD). In comparison, around one in every 100 children in the background population is diagnosed with ASD. Other studies have found no links between SSRI exposure and ASD.” (BUMPS https://www.medicinesinpregnancy.org/Medicine–pregnancy/Sertraline/)
- Morales, D.R., Slattery, J., Evans, S. et al. Antidepressant use during pregnancy and risk of autism spectrum disorder and attention deficit hyperactivity disorder: systematic review of observational studies and methodological considerations. BMC Med 16, 6 (2018). https://doi.org/10.1186/s12916-017-0993-3 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0993-3#Sec6
- Rai D, Lee B K, Dalman C, Newschaffer C, Lewis G, Magnusson C et al. Antidepressants during pregnancy and autism in offspring: population based cohort study BMJ 2017; 358 :j2811 doi:10.1136/bmj.j2811 https://www.bmj.com/content/358/bmj.j2811
- Morales DR, Slattery J, Evans S, Kurz X. Antidepressant use during pregnancy and risk of autism spectrum disorder and attention deficit hyperactivity disorder: systematic review of observational studies and methodological considerations. BMC Med. 2018 Jan 15;16(1):6. doi: 10.1186/s12916-017-0993-3. PMID: 29332605; PMCID: PMC5767968. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5767968/
- Maloney SE, Rogers CE, Constantino JN Antidepressants, Pregnancy, and Autism: Setting the Record(s) Straight Published Online:1 Jun 2020https://doi.org/10.1176/appi.ajp.2020.20040418 https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2020.20040418
Some withdrawal from placental transfer occurs with the longer acting SSRIs (particularly fluoxetine) and the SNRI quetiapine. The resolves within a few days without treatment in most cases. The mother may be supported to initiate hand expression to stimulate her supply and to feed the expressed milk to the baby if it is too drowsy to feed effectively. It does not mean that commercial formula needs to be substituted for breastmilk.