SAN FRANCISCO — All psychotropic medications are excreted into breast milk, but the benefits of breast-feeding generally outweigh the relatively small risks to the baby from antidepressants, Dr. Andrea J. Singer said.
The nutritional advantages and the bonding that occurs between mother and child during breast-feeding outweigh concerns about antidepressant effects on the infant, she said at the Perspectives in Women's Health conference sponsored by OB.GYN. NEWS.
The dose of antidepressant that the infant receives from the mother during breast-feeding is much lower than the dose received in utero because the drug crosses the placenta. If a mother and fetus have done well on an antidepressant during pregnancy, stick with that therapy after delivery. “The decision is easy—just continue,” said Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington.
SSRIs are first-line therapy for lactating women with depression because they have the most data supporting safe use during breast-feeding and efficacy in treating postpartum depression.
The aminoketone drug bupropion is a “not unreasonable alternative,” but the amount of data on it is far more limited, she said.
Combining an SSRI with other supportive services is recommended for severe postpartum depression. There is no consensus for treatment of mild postpartum depression, Dr. Singer added. Consider psychotherapy either alone or with an SSRI for mild depression in lactating women.
Dr. Singer is on the speakers' bureau of Pfizer, which makes the SSRI sertraline.
Generally, sertraline is the treatment of choice for depressed lactating women because of the amount of data available on its use. The SSRIs paroxetine or fluvoxamine are first-line alternatives. Second-line treatment choices include citalopram and fluoxetine. Start with monotherapy when possible, she advised.
The long-term impact of trace levels of antidepressants in infants is unknown. Most SSRIs and bupropion are rated Pregnancy Category C by the Food and Drug Administration. Tricyclic antidepressants fall in Category C or D.
“Most of my psychiatric colleagues don't look at labels so much as the amount of clinical trial data. There is far more experience with the SSRIs, particularly sertraline,” she said.