Evidence-Based Reviews

Postpartum depression: Help patients find the right treatment

Current Psychiatry. 2012 November;11(11):14-21

References

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Study	Design and size	Medication	Results
Appleby et al, 1997²⁰	12-week, placebo-controlled, N = 87	Fluoxetine	Patients taking fluoxetine showed greater improvement than those taking placebo
Yonkers et al, 2008²¹	8-week, placebo-controlled, N = 70	Paroxetine	Both groups improved over time, but patients taking paroxetine had greater improvement in overall clinical severity
Wisner et al, 2006²²	8-week, RCT, N = 109	Sertraline vs nortriptyline	Proportion of women who responded or remitted did not differ between those taking sertraline or nortriptyline
Misri et al, 2004²³	12-week, RCT, N = 35	Paroxetine monotherapy vs paroxetine + CBT	Both groups showed significant improvement in mood and anxiety symptoms
Stowe et al, 1995²⁴	8-week, open-label, N = 21	Sertraline	20 patients experienced >50% reduction in SIGH-D score
Cohen et al, 1997²⁵	Open-label, N = 15	Venlafaxine	12 patients achieved remission
Suri et al, 2001²⁶	8-week, open-label, N = 6	Fluvoxamine	4 patients became euthymic, with HDRS scores ranging from 2 to 5
Nonacs et al, 2005²⁷	8-week, open-label, N = 8	Bupropion	6 patients had ≥50% decrease in HDRS score from baseline; 3 achieved remission
CBT: cognitive-behavioral therapy; HDRS: Hamilton Depression Rating Scale; PPD: postpartum depression; RCT: randomized controlled trial; SIGH-D: Structured Interview Guide for the Hamilton Depression Rating Scale

Breast-feeding considerations

From a nutritional standpoint, breast-feeding is optimal for a newborn. However, for some women, breast-feeding is difficult and stressful, and new mothers may experience this difficulty as failure. Some women prefer not to breast-feed, and others may prefer to formula feed if they require pharmacotherapy, particularly if the medication has not been well studied in breast-feeding patients. Some women may decline to take medications if they are breast-feeding out of concern for the baby’s exposure via breast milk and prefer to try nonpharmacologic approaches first. Many mothers with PPD need to be reassured that stopping breast-feeding may be exactly what is needed if the experience is contributing to their PPD or making them uncomfortable accepting pharmacotherapy when indicated. Maternal mental health is more important than breast-feeding to the health and wellness of the mother-baby dyad.

Clinical Point

Rigorous studies generally have found low levels of exposure to antidepressants in breast milk

Breast-feeding and antidepressants. Any medication used during lactation should be assumed to pass into breast milk, although rigorous studies quantifying amounts of antidepressants in breast milk and infant serum generally have demonstrated low levels of exposure among the better studied antidepressants.^28,29 Studies that inform extent of drug exposure during lactation have included mothers who have provided serial samples of breast milk and allowed their infant’s blood levels to be checked for the drug. See Table 2^29-31 for details regarding specific antidepressants and breast-feeding.

Table 2

Considerations for antidepressant use during breast-feeding

Drug(s)	Comments
Fluoxetine	Because of long half-life, may be more likely to be detected in infant serum, especially at higher doses. Reasonable for use during breast-feeding if a woman has had a good previous response to the drug or used it during pregnancy
Sertraline	Reports of low levels of exposure. Relatively large amount of data available
Citalopram, escitalopram	Less systematic study of mother-infant pairs compared with sertraline and paroxetine. Low levels of exposure to infant via breast-feeding observed
Paroxetine	Consistent reports of low levels of exposure and has been relatively well studied without reported adverse events. Use limited by commonly experienced withdrawal symptoms; may be more sedating than other SSRIs
Bupropion	Paucity of systematic study in newborns of nursing mothers; a few case reports in older infants demonstrated low levels of exposure via breast-feeding. May help women who smoke to quit or to maintain abstinence from smoking. Reasonable to use if a woman had good previous response. One case report of possible infant seizure; no other reported adverse events
Venlafaxine, desvenlafaxine	Higher levels of desvenlafaxine than venlafaxine found in breast milk. No adverse events reported. Patients may experience withdrawal with discontinuation or missed doses
Tricyclic antidepressants	Considered reasonable for breast-feeding mothers if use is clinically warranted; few adverse effects in babies and generally low levels of exposure reported
Mirtazapine, nefazodone, MAOIs, duloxetine	Systematic human data not available for breast-feeding patients. May be reasonable if a woman previously has responded best to 1 of these; advise patients that data are not available to guide decisions
MAOIs: monoamine oxidase inhibitors; SSRIs: selective serotonin reuptake inhibitors Source: References 29-31

Lactation exposure to paroxetine and sertraline has been most studied, and both have been nondetectable or found in low amounts in infant drug assays. Because fluoxetine has a longer half-life than other antidepressants, it may be more likely to be detected in infant blood sampling, with higher doses more likely to be detected than lower doses.³² Decisions to breast-feed while taking medication must take into account unknown long-term effects of antidepressant exposure. There are a few case reports of suspected adverse events associated with antidepressant use during lactation.