July 2024

Postpartum Depression and Selective Serotonin Reuptake Inhibitor (SSRI) Use During Lactation

Written by: Rachel Dragovich, PharmD, BCPS, CLC

While feelings of unhappiness, worry, and fatigue, known as the “baby blues”, are common in postpartum women, they usually resolve on their own within two weeks of delivery. Postpartum depression (PPD) on the other hand, is a more serious condition. The feelings of unhappiness are intense and interfere with the performance of daily activities. The mother may have feelings of hopelessness, disinterest in previously enjoyed activities, and even thoughts of hurting herself or her baby. Postpartum depression most commonly manifests within 1-3 weeks after delivery, but symptoms can present up to 12 months postpartum. According to the CDC, 1 in 8 women report feelings of depression after giving birth.1 Studies have estimated that the prevalence of PPD in women is approximately 10-16%. 2-4  PPD often goes undiagnosed and the concerns about using antidepressants during lactation may lead to early-weaning or untreated depression. Unlike the feelings associated with the “baby blues” that resolve on their own, PPD often requires treatment. 

In all women with PPD, psychotherapy is recommended, and may be the only form of treatment needed for women with mild-moderate PPD. In women with moderate to severe PPD or those in which psychotherapy is not effective or unavailable, it is recommended to treat PPD with antidepressant medications. Selective serotonin reuptake inhibitors or SSRIs are the drugs of choice for depression and anxiety disorders during pregnancy and lactation. SSRI’s have been shown to be effective and well-tolerated in this population.5 The Academy of Breastfeeding Medicine (ABM), Clinical Protocol #18: Use of Antidepressants in Breastfeeding Mothers, highlights the fact that evidence has shown that untreated PPD can have significant and lasting effects on mothers and infants. The ABM states that “treatment is strongly preferred”.6

All antidepressant medications transfer into the breastmilk to some degree and have the capability to cause adverse effects in the mother and the infant. However, untreated depression can also cause severe adverse effects for the mother, baby, and surrounding family members. Therefore, in moderate to severe depression, the benefits of treatment with an antidepressant are likely to outweigh the risks of the medication causing adverse effects in the infant. Additionally, several studies are available to help guide our choice of drug treatment in this population. Looking at SSRI’s, the majority of them pass into the breastmilk at a dose that is less than 10% of the maternal level, which is generally considered safe when breastfeeding a healthy, full-term infant.7 The best choice of treatment should take into account the mother’s medical history and response to prior treatment, the risks of untreated depression, the benefits of breastfeeding, the benefits of treatment, the potential risks of treatment and exposure to the baby, and ultimately the mother’s wishes. Table 1 lists the SSRI’s currently available in the United States and their considerations for use in breastfeeding mothers.

It should be noted that breastfeeding and symptoms of depression may go together, if you are having concerns about milk-transfer, baby weight gain/loss, or other difficulties breastfeeding, you should contact a professional who specializes in lactation management. For some mothers, the stress of feeding a baby around-the-clock and lack of sleep can worsen depression symptoms. However, many mothers find that breastfeeding strengthens the bond with their baby and improves their mood. There is even evidence that breastfeeding may improve symptoms of depression.14  Another concern about using medications during lactation is maintaining an adequate milk supply. There are some studies that suggest antidepressant use during pregnancy may lead to poor breast-feeding outcomes, such as decreased initiation of breastfeeding, difficulty establishing supply, or reduced milk volume.15-17 However, this may be linked to depression itself, rather than the medications.18 A more recent study of over 3000 women concluded that the use of antidepressants late in pregnancy, was not associated with an increased risk of low milk supply.19  There are currently no studies that indicate SSRIs have a negative impact on breastfeeding duration when initiated postpartum. As with all clinical information and studies, the ones mentioned in this article should be evaluated and interpreted appropriately and may not be applicable to every patient. Healthcare providers are here to offer guidance and support based on the best information currently available. Ultimately, the decision to breastfeed and the decision for medication treatment should be the mother’s choice.