Can I take an antidepressant while I am nursing?

Data regarding use of many medications during breastfeeding are scarce. The FDA gives a category classification for most medications as to whether they are safe during pregnancy or nursing, but this information is not always reliably based on available data. When some medications, such as benzodiazepines, are consumed, they are known to be present in large quantities in breast milk and thus are presumed to be unsafe. In general, all antidepressants are excreted into breast milk. Although differences may exist between antidepressants as to quantities found in breast milk, data are insufficient to make definitive statements about these differences. A case report on paroxetine found no evidence of it in breast milk, thought possibly because of its half-life, but more studies are needed. Both TCAs and SSRIs are generally undetectable in nursing infant blood. Nortriptyline has been the most studied TCA in breast-feeding women. Children exposed to TCAs have been followed through preschool, and no developmental differences have been found compared with children not exposed to TCAs. TCAs, however, are not typically the first-line treatment for depression because of their side effects.

Increasing research has been conducted into the use of SSRIs during breast-feeding because of their relatively safe side-effect profiles. Data are available on the use of fluoxetine, sertraline, paroxetine, citalopram, and fluvoxamine, with sertraline being studied most over the past few years. Although the medication has not usually been detectable in most studies, there have been infrequent reports of detectable serum levels of sertraline, citalopram, and fluoxetine in exposed infants. No adverse developmental or behavioral effects have been detected to date in nursing infants, but no long-term studies exist. Sertraline is generally considered a relatively low-risk medication choice, whereas fluoxetine may have some level of risk associated with it, possibly because of its long half-life. Three cases of colic have been reported in infants with detectable levels of fluoxetine, and some evidence exists for reduced weight gain after birth.

Although for the most part levels of SSRIs are not usually detectable in infant serum, this does not exclude the possibility of the drug having entered the central nervous system. Therefore until further studies are done the use of an SSRI needs to be balanced against the risk of untreated depression in a nursing mother, with strong consideration of the benefits of breast-feeding. Four possible choices are as follows:

1. Nurse infant-no medication

2. Nurse infant-take medication

3. Formula feed infant-no medication

4. Formula feed infant-take medication

Clearly, choice number 3 would be the least desirable, because the infant is exposed to maternal depression and not getting the benefits of breast milk. Choice number 1 would offer the infant the benefits of breast milk, but the risk from exposure to maternal depression would likely be greater than the benefits of breastfeeding can offset. Infant exposure to maternal depression for extended periods has been associated with reduced weight gain as well as other complications described in Question 82. Thus the decision to balance will likely be between choices 2 and 4. Based on the current literature the benefits of breast-feeding likely exceed the risk of SSRI exposure, but you will need to go over the choice more thoroughly with your doctor so you feel comfortable with your decision.

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