Antidepressants During Pregnancy and Breastfeeding

When managing depression pre- and post-pregnancy, the question of whether to stay on antidepressants or discontinue them is very common. Staying on antidepressants may lead to adverse side effects for mom and baby, but discontinuing antidepressants comes with a high risk of depression recurrence. It is important to discuss with your provider on which option is best for you.

SSRIs and Pregnancy

SSRIs are some of the most commonly prescribed medications for depression. These include medications such as Zoloft, Prozac, Paxil, Celexa, and Lexapro. The use of SSRIs during pregnancy has been widely studied. Generally speaking, research shows that the risk of untreated moderate to severe depression is greater than the risk of antidepressants. In general, SSRIs have a low risk of congenital defects when taken during the first trimester of pregnancy. Previously, it was believed that Paxil may be associated with a small increase in risk of congenital heart defects; however, many studies since have found no association. SSRIs have also not been found to be clinically associated with higher risk of miscarriage, hypertensive disorders of pregnancy, preterm birth, low birth weight, or perinatal death. Some evidence was found that SSRIs may be associated with postpartum hemorrhage, but higher quality studies need to be conducted to confirm this. In rare cases, symptoms of withdrawal may occur post-delivery. These include jitteriness, difficulty feeding, and low blood sugar. An option to reduce this risk is to slowly taper the SSRI dose during the last month of pregnancy and return to the full dose following deliver. This method reduces risk of withdrawal for baby and risk of post-partum depression for mom.

Other Antidepressants and Pregnancy

          There are many other medications that women may be on for depression management. The use of SNRIs (Effexor, Pristiq, Cymbalta) in pregnancy has not been associated with congenital malformations. Research has not shown a clear association with SRNIs and spontaneous abortion or preterm birth. There is some concern for increased risk of hypertensive disorders with Effexor, and there is association risk for postpartum hemorrhage similar to SSRIs. Bupropion has not been associated with increased risk for preterm birth, low birth weight, postpartum hemorrhage, congenital malformations, or hypertensive disorders of pregnancy. However, there may be some association with spontaneous abortion. Mirtazapine has limited data on its use in pregnancy. The studies that have been conducted show no association with risk for spontaneous abortion, preeclampsia, postpartum hemorrhage, low birth weight, or preterm birth. Tricyclic antidepressants (TCAs) are not associated with risk of spontaneous abortion, preterm birth, or abnormal development post-delivery. They are associated with hypertensive disorders of pregnancy and possibly post-partum hemorrhage. Generally, TCAs are considered to have low risk for congenital defects, but Clomipramine has been associated with elevated rate of severe malformations, including cardiovascular defects.

Antidepressants and Breastfeeding

          After delivery, many moms with depression may wish to breastfeed. All psychotropic medications are transferred to baby via breastmilk in different amounts. In general, untreated maternal depression has higher risks to baby than psychotropic medication exposure. SSRIs have been used very successfully during breastfeeding with low risk for baby. SNRIs have also been associated with low risk during breastfeeding, but infant exposure may be higher than other antidepressants. There is little research on the use of atypical antidepressants during breastfeeding, but mirtazapine may be compatible. Nortriptyline has the highest safety profile of the tricyclics and doxepin should be avoided. Benzodiazepine use during breastfeeding should be limited to those with short half-lives and no active metabolites. Diazepam should not be used due to its long half-life. Adverse effects to baby include sedation and withdrawal. If mom decides to stay on antidepressants during breastfeeding, start at the lowest effective dose and titrate up. Use medications that were effective for mom in the past, if possible. Try to use medications with short half-lives and avoid multi-drug regimens to reduce exposure to baby. Additionally, consider using formula if baby was born premature, sick, or with a low birthweight.

Words of Advice

          When it is time to decide whether to continue or discontinue pharmacologic management during pregnancy and breastfeeding, seek advice from your provider. Ask about effects and side effects of the medications that you are taking. Make sure to disclose any alternative therapies or over the counter medications that you may be using, as well. If you decide to continue or initiate an antidepressant during pregnancy or breastfeeding, work with your provider to choose the right medication at the right dose. If you decide to stop taking your antidepressant, ask your provider how the medication should be stopped. Many antidepressants require a taper in order to safely discontinue without inducing withdrawal. Remember that some of these medications only work if they are taken regularly and that symptoms of depression may come back if treatment is stopped. Following these guidelines will help ensure the safety for both you and your baby during pregnancy and after delivery.

Resources:

Kimmel M, Meltzer-Brody S. Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding. UpToDate.

Roca C. Depression. Office on Women's Health. OASH.

Stewart D, Vigod S. Antenatal use of antidepressants and risk of teratogenicity and adverse pregnancy outcomes: Selective serotonin reuptake inhibitors (SSRIs). UpToDate.

Stewart D, Vigod S. Antenatal use of antidepressants and risks of teratogenicity and adverse pregnancy outcomes: Drugs other than selective serotonin reuptake inhibitors. UpToDate.