In postpartum depression, early treatment is key
The tragedy of Andrea Yates, the Texas mother convicted of drowning her 5 children, raises questions about the role of physicians in identifying and treating women at risk for severe postpartum depression. In most cases, Ob/Gyns are the first line of defense.
The literature on the use of SSRIs in lactating women has expanded rapidly in recent years (Table 3). But because these agents have been on the market a relatively short time, the long-term developmental effects of infants’ exposure to SSRIs through breast milk have yet to be evaluated.
Fluoxetine. Most of the published data on the use of SSRIs in breastfeeding women concern the drug fluoxetine. To date, 9 studies have reported the outcomes of a total of 57 infants exposed to fluoxetine during breastfeeding.13,14 Norfluoxetine, the drug’s potent metabolite, has a long half-life that may predispose to accumulation in the serum of nursing infants.
Adverse effects such as colic, fussiness, crying, seizure activity, and reduced weight gain were reported in 2 cases.15,16 The remaining studies on the use of fluoxetine by breastfeeding women reported low drug levels in both mothers and infants. No other adverse effects have been documented.
Sertraline. To date, 7 published reports of sertraline exposure have documented 46 infant outcomes. In all these reports, sertraline and its weak metabolite have been detected in low or trace amounts in the sera of nursing infants.13,14,17-19 A recent study of 19 breastfeeding mother-infant pairs found that platelet serotonin uptake in these infants was unaltered, despite the detection of low serum levels of sertraline and its metabolite.19
Paroxetine. Although this agent does not contain an active metabolite that could potentially accumulate in the serum of nursing infants, it is excreted into the breast milk. Five reports totaling 60 infant outcomes have been published regarding paroxetine exposure during breastfeeding. Low or undetectable serum levels were reported in all of the infants, and no adverse effects were noted.13,14,20
Fluvoxamine and citalopram. Two small case studies of fluvoxamine have each reported very low drug levels in breast milk and no adverse events in the exposed infants.21,22 Only 3 case studies involving 5 infants exposed to citalopram during breastfeeding have been published.13 Because information is limited regarding the effects of these medications on nursing infants, caution is advised when prescribing them to breastfeeding women.
TABLE 3
SSRI drug therapy for postpartum depression
| Medication | Starting daily dose (mg) | Maximum daily dose (mg) | Precautions |
|---|---|---|---|
| Fluoxetine | 10 | 80 | Very long half-life of active metabolite may lead to accumulation in infants. Inform parents of possible side effects. |
| Sertraline | 25 | 300 | Benign neonatal sleep myoclonus has been documented in 1 case of sertraline exposure during breastfeeding. Inform parents of possible side effects. |
| Paroxetine | 10 | 60 | No adverse effects reported. |
| Fluvoxamine | 50 | 300 | Data limited |
| Citalopram | 10 | 60 | Data limited |
Tricyclics and other antidepressants
Tricyclics are useful for treating PPD when the patient previously has responded well to them or SSRIs have failed. All tricyclic antidepressants are excreted into breast milk in low concentrations, and a wide range of infant serum levels has been reported.
No adverse effects have been documented for infant exposure to amitriptyline, clomipramine, desipramine, imipramine, or nortriptyline.13,14,23,24 The active metabolite of doxepin has the longest half-life (37 hours) among the tricyclics and may be potentially hazardous to nursing infants because of high serum accumulations. Because 2 reports have associated doxepin exposure with respiratory distress, poor sucking, drowsiness, and vomiting in infants, the use of medications with a shorter half-life and better-documented effects is recommended.13
Limited evidence is available on the use of newer antidepressants such as bupropion, trazodone, and nefazodone by breastfeeding women.25-27 When possible, patients should be prescribed an antidepressant that has been documented more closely in this population.
Venlafaxine is a newer antidepressant that inhibits reuptake of both serotonin and norepinephrine. The only case report published to date regarding venlafaxine levels in nursing infants found high drug levels in the sera of 3 exposed infants, but no adverse effects.28
When psychosis is present
Psychotic depression in the postpartum period is sometimes associated with chronic mood disorders, especially untreated depression. The most prevalent psychotic features include paranoid delusions that incorporate the newborn. Hallucinations are rare. Psychotic depression places the postpartum patient at a heightened risk for suicide and/or infanticide and is considered a medical emergency that requires immediate hospitalization and treatment to ensure the safety of the infant and the ill mother (see the sidebar on page 60 for an example of the dangers of missing these warning signs).
To distinguish psychotic depression from regular postpartum depression, it is critical that the Ob/Gyn inquire about the presence of perceptual disturbances and delusional thinking, both of which are markers of psychotic depression. Very few new mothers will volunteer this information if not specifically asked about these symptoms.
If a patient with psychotic PPD is experiencing delusions centered on harming her infant, a family member or members should assume responsibility for the child’s care, and the patient should not be left alone with the infant. When the mother is hospitalized, visitation between the mother and infant should be restricted, particularly if the infant’s presence precipitates anxiety in the mother. The goal of hospitalization is to achieve symptom remission and stability so that bonding and attachment can occur. Maternal-infant bonding is difficult, if not impossible, if the mother is out of touch with reality.
