The incidence of depression during pregnancy and the postpartum period is unclear—sadly, many cases are unrecognized and untreated—but a report by the (U.S.) Agency for Healthcare Research and Quality (AHRQ) suggests that as many as 5.5 to 33.1 percent of women will suffer symptoms of depression during pregnancy or while breastfeeding.
Medication is a typical treatment option for depression, often (but not always) in combination with talk therapy. Currently, antidepressants are among the most prescribed drugs in the U.S.—perhaps due to calls for increased screening of the general adult population as well as for perinatal and postpartum screening. While medication can transfer to your baby through your breast milk, the levels are generally low, much less than would cross the placenta during pregnancy. However, it is important that you and your health care provider carefully consider the benefits and the risks associated with taking antidepressants while breastfeeding.
What are SSRIs?
Selective serotonin reuptake inhibitors (SSRIs) are among the most commonly prescribed antidepressants. The first drug in this class, fluoxetine (a.k.a. Prozac), was released in 1987 followed by Paxil, Zoloft, and others. SSRIs are designed to boost serotonin levels. Serotonin is a hormone produced in the brain that helps transmit signals from one part of the brain to another. Serotonin can affect a wide range of body functions including mood, memory, appetite, temperature, sleep, and social behavior. It is widely believed that serotonin plays a role in depression and that people suffering from depression typically have low levels of serotonin. It’s unclear whether low levels of serotonin cause depression or if depression brings about low serotonin levels. Recent data suggest that serotonin may also play a role in milk production.
Do SSRIs affect milk production?
Data suggest that serotonin may affect mother's milk production. A 2010 study examined the effects of SSRI drugs on lactation using laboratory studies of human and animal cell lines and lactating mice. Since the ability to secrete milk is related to the body’s production and regulation of serotonin, the researchers hypothesized that women taking an SSRI drug might experience a delay in the onset of abundant milk production (a phenomenon known as lactogenesis) that typically occurs in the early days after birth.
“I was able to examine this hypothesis using data from an observational study of 431 breastfeeding, first-time mothers. Only eight of the women were taking an SSRI medication, but it is notable that seven of the eight did experience delayed onset of lactogenesis (defined as occurring after 72 hours postpartum) and the eighth woman experienced onset right at 72 hours. Median onset of lactation was 85.8 hours postpartum for the SSRI-treated mothers and 69.1 hours for mothers not treated with SSRI drugs,” said Nommsen-Rivers.
“Perhaps the most alarming finding is the timing of lactogenesis for the entire sample of women (69.1 hours),” said Nommsen-Rivers. “Evidence is mounting that the timing of lactogenesis is occurring much later in mothers here in the U.S. as compared to other countries, and this broader issue deserves our attention.”
Given the small number of SSRI users in the study, these results must be interpreted cautiously. Even though 7 of the 8 women experienced a delay in the onset of abundant milk production, all went on to breastfeed successfully. More human studies are needed before any type of clinical recommendation can be made regarding the use of SSRI medications. In the meantime, women taking SSRIs should be encouraged to breastfeed, but should be made aware that the onset of abundant milk production may be delayed. Also, health care providers should be prepared to provide additional support if needed.
Are SSRIs safe for breastfeeding mothers and babies?
The effect of SSRIs on breastfeeding babies depends on a number of factors such as the gestational and chronological age of the baby, the health of the baby, the dose of the drug, and the drug’s characteristics (bioavailability, molecular weight, half-life etc.) According to Thomas Hale, Doctor of Pharmacology and Toxicology, and author of Medications and Mothers’ Milk, available data suggest that Zoloft (sertraline) and Paxil (paroxetine) are far less likely to transfer into mothers’ milk and therefore babies compared to Prozac (fluoxetine). If women taking Prozac are unable to switch to another SSRI, Dr. Hale suggests that these women still be encouraged to breastfeed, given the many benefits of breastfeeding, but be cautioned to watch their babies for possible side effects such as irritability, excessive crying, colic, and seizures.
Women who are pregnant or breastfeeding should check with their doctor or their baby’s doctor before taking any medication, including drugs available over-the-counter. As with all medications, consideration must be given to the benefits and the risks. The U.S. Preventive Services Task Force (USPSTF) reports finding “evidence of potential serious fetal harms from pharmacologic treatment of depression in pregnant women,” especially with “second-generation antidepressants (mostly SSRIs).” For pregnant women suffering from depression, USPSTF encourages counseling to be considered as a first line of treatment, but given that the risks of untreated depression are serious, women and physicians should consider a range of treatment options. Untreated depression can be far more dangerous for mothers and babies.
To learn about the safety of antidepressant use during pregnancy, read this.
