Depression is a common illness among women in the postpartum period; a prevalence of 10 to 15 % is often reported [1
]. During this period, challenges are related to caretaking of the newborn infant in addition to the potentially harmful effects of the depression on the mother. Depressed mothers may be intrusive or withdrawn and disengaged, and are less sensitively attuned to their infants than healthy women [4
]. In a study of 112 mother-infant pairs, chronic maternal depression in the first year postpartum was related to delayed psychomotor development in the infant at 15 months [5
]. Moreover, untreated maternal depression may also affect the cognitive and emotional development of the infant. Thus, the high prevalence of postpartum depression, causing functional impairment in the mother and potential disturbances of the mother-infant relationship, makes it important to initiate effective, rapid-onset therapies in women suffering from this disorder [4
Postpartum anxiety disorders are underemphasized and may be even more common than postpartum depression [6
]. The peak age of onset for anxiety disorders in women corresponds with their childbearing years, and particularly the rates of obsessive-convulsive disorder and generalized anxiety disorder are increased in postpartum women. Due to few studies only very limited data are available to guide clinical interventions for women with or at risk for having perinatal anxiety disorders [9
]. Medication with antidepressants, in particular selective serotonin reuptake inhibitors, may be indicated also in some of these women.
The benefits of breastfeeding are well documented, both for the infant and the mother [7
]. Human milk represents the ideal primary source of nutrients and provides better immunological and antioxidant protection than do milk substitutes [7
]. Therefore, women are strongly encouraged to breastfeed when possible [12
]. Both the American Academy of Pediatrics and the World Health Organisation recommend the exclusive use of breast milk for 6 months, with use of milk substitutes only for infants who cannot be breastfed [12
The dilemma in the treatment of breastfeeding mothers is weighing the potential risk to the infant of antidepressant exposure through breast milk against the disadvantage of not receiving mother’s milk. A third alternative, to discontinue or not commence drug treatment, might be even more harmful, taking into account the risk of not receiving adequate treatment for the mother and thereby indirectly also for the infant [5
]. Specific questions to be answered when deciding how to handle a woman with postpartum depression include: What are the risks for the mother and the infant if the maternal depression is not adequately treated? How strong is the mother’s desire to breastfeed her infant? What are the disadvantages of not receiving mother’s milk for the infant? What are the risks for the infant of being exposed to an antidepressant through breast milk? Is there any evidence to suggest that some antidepressants are more favorable than others to use during breastfeeding, and are there sufficient data to give conclusive advice for the most recently marketed antidepressants? Could any practical strategies be used to reduce the drug exposure to the infant? And finally, given that there is a (small) risk of adverse effects in the infant due to drug exposure and breastfeeding nevertheless is allowed, should the infant be monitored in any way?
In some cases, non-pharmacological treatment may be an option, and women with postpartum depression tend to prefer non-pharmacological treatment instead of using medicines [14
]. It has also been shown that women in the postpartum period receive fewer prescriptions of psychotropic drugs than do non-breastfeeding women, but although psychotherapy is effective in the treatment of postpartum depression [15
], it is not widely available. Thus, there is a risk that women not receiving antidepressant treatment would be inadequately treated for their illness. One major study showed that psychological intervention for post-partum depression improved maternal mood in the short term, but that this benefit was not superior to spontaneous remission in the long run [16
A few studies have specifically addressed the effect of antidepressants in the postpartum period. Recent case reports, case series and open trials suggest efficacy in women suffering from postpartum depression, although many of these trials excluded women who were breastfeeding [14
]. Several studies have shown improvements in postpartum depressive symptoms resulting from treatment with selective serotonin reuptake inhibitors (SSRIs), such as sertraline [17
], fluvoxamine [18
] and fluoxetine [19
], and the SSRIs are thus considered first-line therapy in postpartum depression [20
]. The SSRI group is also recommended in the treatment of postpartum dysthymia, panic disorder, and obsessive-compulsive disorder [21
]. In addition, the serotonin-noradrenaline reuptake inhibitor (SNRI) venlafaxine has been found to reduce the symptoms of postpartum depression [22
Women with a previous episode of postpartum depression comprise a high-risk group for subsequent episodes; a recurrence risk of about 25% has been reported [23
]. The findings from a small randomised study comparing sertraline and placebo in asymptomatic women with at least one prior episode of postpartum depression suggest that postpartum depression can be prevented [24
], although the result needs to be replicated in a larger scale. Psychosocial or psychological interventions have not been shown to significantly prevent the risk of developing postpartum depression [25
A Cochrane review of antidepressant prevention of postpartum depression from 2005 concluded that it is not possible to draw any clear conclusions about the effectiveness of antidepressants in preventing postpartum depression [26
]. The reason was the lack of conclusive evidence, and the authors stated that larger trials were needed.
In some cases, there is a question of whether an effective antidepressant treatment given during pregnancy could be continued or not when the mother wants to breastfeed. Discontinuing essential antidepressant treatment in the postpartum period should be avoided, and switching to another antidepressant might also be problematic in this vulnerable period. Thus, the issue of infant safety in the postpartum period should preferably be taken into consideration already when drug treatment is started in a woman, irrespective of whether it is before or during pregnancy.
Knowledge about infant effects of antidepressants transferred via
breast milk is mostly based upon case studies and small case series. A comprehensive review and pooled analysis of antidepressant levels in breast milk and nursing infants, including possible adverse effects in the infants, was published in 2004 [27
]. An update of this review, adding new information from the period 2004 - 2008, was published in 2009 [7
]. The aim of the present article is to take even newer data into account, providing aggregated background information and presenting practical advice and recommendations for the clinician dealing with the treatment of depression in the postpartum period. During the last decade, the use of tricyclic antidepressants has considerably decreased, mostly because they are no longer considered first-line therapy due to their adverse effect profile and toxicity. Therefore, this review focuses on the newer, non-tricyclic antidepressants, i.e. the SSRIs citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline, the SNRIs venlafaxine and duloxetine, and reboxetine, bupropion and mirtazapine. First, we present data on the levels of these antidepressants in breast milk and in infant plasma; thereafter we discuss the reported short-term and long-term adverse effects in infants. Finally, we suggest a number of practical recommendations.