Knowledgeable pharmacists can positively influence mothers who are depressed as well as women who want to breast-feed but do not because of medication use.
Knowledgeable pharmacists can positively influence not only mothers who are depressed, but also women who want to breast-feed but do not because of medication use.
Major depression is considered a common and treatable mental disorder. Nine percent of the US population is affected by depression, with 6.7% being adults. Women are significantly more likely than men to be depressed (4% versus 2.7%).1 At least 10% of women report postpartum depression.2 In 2006, approximately 1 million mothers stated that “[they] had to take medicine and didn’t want [their] baby to get it” as the reason for discontinuing breast-feeding.3 Therefore, approximately 100,000 women every year apparently do not breast-feed if they have to take a medication to treat their depression. The implications for positive interventions by knowledgeable pharmacists are immense, not only for mothers who are depressed, but for all women who want to breast-feed but do not because of medication use. The potential positive benefits of breast-feeding for the mother and her baby are lost entirely.
In any breast-feeding situation, the pharmacist and mother need to weigh the benefits of medication use and breast-feeding against the risks of medication use and formula use (not breast-feeding). The benefits and risks of medication use can be readily determined from drug labeling and available literature. Pharmacists may not be knowledgeable about the benefits of breast-feeding and may be even less knowledgeable about the risks of not breast-feeding.4-6 Table 1 lists the benefits of breast-feeding and the risks of not breast-feeding.
Prescription Antidepressant Medication
Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for mothers experiencing postpartum depression or experiencing depression before giving birth. When counseling breast-feeding mothers experiencing and/or being treated for depression, pharmacists should recognize the following:
High protein binding, high volumes of distribution (Vd), and high molecular weights/mass (MW) limit the passage of drugs into human milk. Low milk concentrations usually result in a low relative infant dose (RID), which is the ratio of the weight-adjusted dose in mg/ kg/d of drug that the infant receives divided by the weight-adjusted dose in mg/kg/d of drug that the mother receives. If this ratio is 10% or less, the drug is considered usually compatible with breast-feeding. The following SSRIs are commonly used antidepressants that are preferred during breast-feeding12:
Sertraline: High protein binding (98%), high Vd (20), and high MW (306) result in very low milk concentrations. One study assessed the effect on an infant’s own serotonin reuptake and found that the infant blood serum level did not change significantly. The RID is 0.4% to 2.2%.
Paroxetine: High protein binding (95%), high Vd (3-28), and high MW (329) result in very low concentrations with minimal amounts in milk. No or minimal infant adverse effects have been shown in numerous studies. The drug is contraindicated in the first trimester of pregnancy (to prevent cardiac defects), but this is not related to compatibility during breast-feeding. The RID is 1.2% to 2.8%.Fluoxetine: High protein binding (95%), high Vd (2.6), and high MW (309) probably result in very low concentrations in milk. A case of severe colic, fussiness, and crying has been reported. Among all SSRIs, the drug has the most extensive use in breast-feeding women. The drug is contraindicated in the first trimester of pregnancy (to prevent cardiac defects), but this is not related to compatibility during breast-feeding. The RID is 7.7%.
Fluoxetine: High protein binding (95%), high Vd (2.6), and high MW (309) probably result in very low concentrations in milk. A case of severe colic, fussiness, and crying has been reported. Among all SSRIs, the drug has the most extensive use in breast-feeding women. The drug is contraindicated in the first trimester of pregnancy (to prevent cardiac defects), but this is not related to compatibility during breast-feeding. The RID is 7.7%.
Escitalopram: High Vd (12) and high MW (414) lead to very low concentrations in milk. Breast-fed infants have very low levels in their blood. Infants should be observed for possible drowsiness. The RID is 5.2% to 7.9%.
Venlafaxine: High Vd (4—12) and high MW (313) probably result in very low concentrations in milk. Although studies are limited, no adverse effects have been reported during breast-feeding. The RID is 6.8% to 8.1%.
Fluvoxamine: Moderately high protein binding (80%) and high MW (318) result in very low concentrations in milk. There is low drug exposure to infants; no infant adverse effects have been reported in several studies. The RID is 0.3% to 1.4%.
Citalopram: Moderately high protein binding (80%), high Vd (12), and high MW (405) probably result in very low concentrations in milk. In 2 cases, breast-fed infants experienced excessive sleepiness, decreased feeding, and weight loss. Most studies have shown no or limited infant adverse effects. The RID is 3.6%.
Breast-feeding mothers also try herbal treatment for depression. The herbal most often used is St. John’s Wort. A study conducted by the National Institutes of Health showed that St. John’s Wort was not effective for the treatment of moderate to severe depression but probably effective for minor to moderate depression.13,14 Herbalists, scientists, and trade organizations have criticized the study because it looked mainly at moderate to severe depression, only 1 dose range was used, and study sensitivity and accuracy were lacking. In addition, European data suggest that the herbal is a safe and effective remedy for mild to moderate depression.15 In response to these criticisms, a new study is now being conducted.
Much supporting documentation and studies show that antidepressants are appropriate and reasonable treatment for breast-feeding women and are compatible with breast-fed infants. Two resources that provide supportive information are Tom Hale’s Medications and Mother’s Milk, 14th edition,12 and my Nonprescription Drugs for the Breastfeeding Mother, 2nd edition.16 A depressed mother who is being treated with medication can successfully bond with her baby and lower her risk for suicide.
The lack of provision of human milk to infants costs the health care system over $13 billion each year and results in over 900 unnecessary infant deaths annually.17 One of the major medical obstacles to breast-feeding is the lack of encouragement for it by health care professionals who fear potential infant toxicosis due to maternal medication. Alternative approaches and tools and techniques for counseling not only depressed but all breast-feeding women can be found in a comprehensive article covering current concepts on the use of medications while breast-feeding.18 Use of this type of objective information enables health care providers and mothers to make the most educated choices regarding drug therapy and breast-feeding.
Dr. Nice is a pharmacist project manager for the FDA in Rockville, Maryland, and is the author of Nonprescription Drugs for the Breastfeeding Mother, which was published in 2011.