Breastfeeding and Psychiatric Medications

Information on the safety of antidepressants and mood stablizers during breastfeeding.

Bupropion and Breastfeeding (December 2002)

Q. I'm looking for further information regarding postpartum depression and the use of Wellbutrin (bupropion). Prior to my pregnancy I was taking Wellbutrin for depression and had relief of my symptoms. (I had also tried Celexa and Paxil with no success). When I became pregnant, I discontinued all medications but still felt really good and had a healthy pregnancy. I delivered my son about 6 weeks ago; I'm breastfeeding but I'm really starting to feel pretty down and overwhelmed. I'm wondering if I can go back on Wellbutrin and still continue breastfeeding?

A. Data have accumulated over the last few years on the use of antidepressants in nursing mothers. It appears that all antidepressants are secreted into the breast milk; however, the amount of medication to which the nursing child is exposed appears to be relatively small. We have the most information is available for fluoxetine (Prozac), , paroxetine (Paxil), and the tricyclic antidepressants. In general, one should try to choose an antidepressant for which there are data to support its safety during breastfeeding. However, there are often situations where one may choose another antidepressant that has not been as well characterized. For instance, if a woman has not responded well to any of the above medications.

To date, there has been only one report on the use of bupropion in two breastfeeding mothers. Serum levels of bupropion and its metabolite were undetectable in the infants, and there were no observed adverse events in the nursing infants. While this information is reassuring, further study is needed to fully determine the effects of bupropion in nursing infants.

In general, the risk of adverse events in the nursing infant appears to be low. The child should be monitored for any changes in behavior, level of alertness, or sleep and feeding patterns. In this setting, collaboration with the child's pediatrician is essential.

Source: Baab SW, Peindl KS, Piontek CM, Wisner KL. 2002. Serum bupropion levels in two breastfeeding mother-infant pairs. J Clin Psychiatry 63: 910-1.

Paxil and Breastfeeding (August 2002)

Q. I am trying to get more information about the effects of Paxil (Paroxetine) and breastfeeding. How safe is it? Any side effects for the baby? My daughter is 7 months old and is down to 2-3 feedings a day. I plan to start Paxil and would like to continue with two feedings a day if it is safe to do so. If I take the Paxil at bedtime, is there a time of day when the level is lower in my body and less of the drug would be passed on to the baby, or is the level constant so the time of feeding and time of taking the Paxil do not matter? I would appreciate any information. My daughter had a very hard first five months and I don't want to pass along the Paxil to her if it is not safe or if it may cause her any side effects. Thanks.

A. All medications are secreted into the breast milk, although concentrations appear to vary. There is a fair amount of information on the use of Paxil in nursing women. While Paxil may be detected in the breast milk, there have been no reports of adverse events in the nursing infant. The only situation where one may want to avoid breastfeeding is when the baby is premature or has signs of hepatic immaturity, which may make it more difficult for the infant to metabolize the medication to which he or she is exposed. Premature babies are also probably more vulnerable to the toxic effects of these medications.

There may be some ways to minimize the amount of medication to which the nursing infant is exposed. First, the lowest dose of medication that is effective should be used. Second, in older infants, it may be possible to time the feedings so as to minimize exposure. The levels of Paxil in the breast milk peak about 8 hours after ingestion of medication and decline thereafter, reaching the lowest levels immediately before the next dose of medication is to be taken. Theoretically, the amount of medication to which the infant is exposed could be reduced by avoiding nursing during times at which the medication concentration in the breast milk would be the highest (i.e., 8 hours after taking the medication). Studies with indicate that this approach leads to a 20% reduction in the amount of medication to which the infant is exposed.

Sources: Burt VK, Suri R, Altshuler L, Stowe Z, Hendrick VC, Muntean E. The use of psychotropic medications during breast-feeding. Am J Psychiatry 2001; 158(7): 1001-9.
Newport DJ, Hostetter A, Arnold A, Stowe ZN. The treatment of postpartum depression: minimizing infant exposures. J Clin Psychiatry 2002; 63(7): 31-44.

Breastfeeding and Bipolar Disorder (June 2002)

Q. I was diagnosed with bipolar disorder (manic depression) in July of 2001. In January, I became pregnant and immediately stopped my Lithium. I am now 18 weeks along and my psychiatrist would like me to start on Lithium again. I do not want to, as I would like to breastfeed. It seems that the biggest concern is that I will experience postpartum depression. One suggestion was to start an antidepressant at 8 months and to continue it through breastfeeding. What is a safe antidepressant to use while breastfeeding? Also are there any safe mood stabilizers to use while breastfeeding?

A. Women with bipolar disorder are particularly vulnerable during the postpartum period. Studies indicate at least 50% of women with bipolar disorder relapse during the first few months after childbirth. While most women present with depressive symptoms, there is also a significant risk of hypomania or mania. Prophylactic treatment with a mood stabilizer, initiated either towards the end of pregnancy or at the time of delivery, significantly reduces the risk of postpartum illness. Thus far we have no data on the use of antidepressants in this setting. Although antidepressants may help reduce the risk of recurrent illness in women with unipolar depression, there is evidence that using antidepressants without a mood stabilizer in patients with bipolar disorder may increase the likelihood of having a hypomanic or manic episode.

We often recommend that women with bipolar disorder remain on a mood stabilizer during the postpartum period; however, the use of medications during the postpartum period is complicated by the issue of breastfeeding. All medications are secreted into the breast milk, although their concentrations appear to vary. Lithium is found in the breast milk at relatively high concentrations, and there have been reports of toxicity in nursing infants exposed to lithium in the breast milk. Symptoms of toxicity in these infants include lethargy, poor muscle tone, and changes on the electrocardiogram. While there are risks associated with breastfeeding on lithium, it is probably the safest mood stabilizer to use in this setting. Other mood stabilizers, like valproic acid and carbamazepine, may cause liver damage in the nursing infant, which is a serious and potentially life-threatening complication.

For women with bipolar disorder, breastfeeding raises concerns for another reason. For a young infant, breastfeeding entails multiple feedings during the night. Sleep deprivation is destabilizing for those with bipolar disorder and may help to precipitate a relapse during this vulnerable time. For women with bipolar disorder, we recommend that somebody else take over the nighttime feedings in order to protect the mother's sleep and to increase her chances of staying well.

Sources: Cohen LS, Sichel DA, Roberston LM, et al: Postpartum prophylaxis for women with bipolar disoder. Am J Psychiatry 1995; 152: 1641-1645.
Viguera AC, Nonacs R, Cohen LS, Tondo L, Murray A, Baldessarni RJ: Risk of Recurrence of Bipolar Disorder in Pregnant and Nonpregnant Women After Discontinuing Lithium Maintenance. Am J Psychiatry 2000; 157: 179-184.

Breastfeeding and Antidepressants (January 2002)

Q. For women who are breastfeeding, it appears that certain antidepressants are safer than others. Researching the American Journal of Psychiatry and the New England Journal of Medicine, data point to as the drug of choice. What is your recommendation for breastfeeding women? Should any blood tests be conducted on mother and nursing infant?

A. When discussing the use of antidepressant medications by breastfeeding women, It is somewhat misleading to say that certain medications are "safer" than others. All medications taken by the mother are secreted into the breast milk. The amount of drug to which the infant is exposed depends on many factors, including the medication dosage, as well as the infant's age and feeding schedule. To date, we have not found that certain medications are found at lower levels in the breast milk and may therefore pose less of a risk to the nursing infant. Nor have we found that any antidepressant medication has been associated with serious adverse events in the baby.

In general, one should try to choose an antidepressant for which there are data to support its safety during breastfeeding. The most information is available on fluoxetine (Prozac), followed by , paroxetine (Paxil), and the tricyclic antidepressants. Other antidepressant medications have not been studied as well.

We do not regularly measure drug levels in the breastfeeding mother or baby; however, there may be certain situations where information on exposure to drug in the child may help make decisions regarding treatment. If there is a significant change in the child's behavior (e.g., irritability, sedation, feeding problems, or sleep disturbance) an infant serum drug level may be obtained. If levels are high, breastfeeding may be suspended. Similarly if the mother is taking a particularly high dosage of medication, it may be helpful to measure drug levels in the infant to determine the degree of exposure.

Source: Burt VK, Suri R, Altshuler L, Stowe Z, Hendrick VC, Muntean E. The use of psychotropic medications during breast-feeding. Am J Psychiatry 2001; 158: 1001-9.

About the author: Ruta M Nonacs, MD, PhD, is Associate Director of the Perinatal Psychiatry Clinical Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School.

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