From 15 to 20 percent of mothers experience postpartum depression, which is now called peripartum depression. Often they see themselves primarily as anxious, rather than depressed. Either way, antidepressants can help.
Let’s say you’ve already been seeing a therapist, but you’ve been feeling steadily worse since childbirth. You may feel continually sad and too numb to enjoy your baby. You’re plagued by self-critical thoughts and feelings of failure and guilt. Sometimes you can’t make the simplest decision. After night-time feedings, you’re awake full of worries that something awful will happen to you, your baby, or husband. You’re tired but can’t nap even when you have help with your baby.
Your first thought may be, “If I take antidepressants, can’t breastfeed.” That’s not true.
Although babies who are not breastfed can flourish, it’s a good idea to breastfeed if you can. The American Academy of Pediatrics and the World Health Organization recommend feeding babies breast milk exclusively for the first 6 months of life. Breastfed infants, as they grow up, have lower rates of asthma, inflammatory bowel disease, and obesity. Breastfeeding can also cut the mother’s risk of ovarian and breast cancer.
The American Academy of Breastfeeding Medicine, the American College of Obstetrics and Gynecology and the National Institute of Clinical Excellence have published practical recommendations to guide doctors advising breastfeeding women about taking antidepressants. Overall, the greatest risk is leaving your depression untreated. Some science, for example, indicates that the infants of mothers who have been depressed while breastfeeding for two months tend to gain less weight — but antidepressants don’t affect infant weight gain.
If you’ve responded well in the past to an antidepressant, talk to your doctor about taking it again. If this is your first time, your doctor might start with prescribing sertraline (Zoloft), followed by paroxetine (Paxil), if Zoloft doesn’t succeed. Babies feeding on breastmilk from mothers taking these drugs seem to have no detectable signs of them in their own blood. Also, no bad effects on the babies have been reported.
It is true that the studies on this question so far are small and short. Mothers could feel more confident if there were large studies following babies over many years. You can see an overview of the evidence on specific antidepressants and breastfeeding as of 2013 in this chart. Some do show up in the infant’s blood — though almost always without causing problems. Infant blood levels of citalopram (Celexa) and fluoxetine (Prozac) have been shown to exceed the recommended 10 percent of maternal level in some, but not all cases.
Your doctor may suggest a benzodiazepine like clonazepam (Klonopin) because it could relieve symptoms quickly. Many women get more anxious when they first start an antidepressant. You might take a benzodiazepine at the same time, and taper off within two to three weeks after an antidepressant takes effect. This is especially helpful if you haven’t been able to sleep. A doula or night nurse could be invaluable during this transition. Benzodiazepines do not tend to show up in a baby’s blood, but they are potentially addictive. In one small 2012 study, 2 of 124 infants exposed to a benzodiazepine through breast milk showed signs of being sedated.
Electroconvulsive therapy or repetitive transcranial magnetic stimulation are also possibilities for severe depression that doesn’t respond to medication and therapy.
If you’re a parent, sibling, or friend of a mother who may be suicidal and doesn’t live with you, be sure you have access to her home. People are most at risk for a suicide attempt if they have a personal or family history of suicide, a history of impulsive behavior, or have been hospitalized or involved in a violent incident within the last year. Drug abuse, legal problems, and big disruptions in relationships are all red flags. If you see an immediate risk, take the mother to an emergency room. Reassure her that she won’t necessarily be admitted to the hospital and the main risk to go to the ER is to avoid waiting for an appointment.
October 12, 2016
Christopher Nystuen, MD, MBA