Antidepressants and Breastfeeding

The headline

For most antidepressants, treatment and breastfeeding are compatible, and the untreated illness is itself a risk. NICE CG192 states: "Encourage women with a mental health problem to breastfeed, unless they are taking carbamazepine, clozapine or lithium." It adds that valproate is not recommended to treat a mental health problem in women or girls of childbearing potential, and points to the MHRA safety advice on valproate.

The same recommendation ends with a line worth holding onto: "However, support each woman in the choice of feeding method that best suits her and her family." Stopping breastfeeding is a legitimate choice too, and choosing it does not mean you failed at something.

This page names medicines as options. It gives no doses. Dosing is a decision for the person prescribing, and it depends on the drug, the preparation and you.

How the decision is actually made

NICE CG192 sets out the reasoning clinicians are told to use: "When assessing the risks and benefits of TCAs, SSRIs or (S)NRIs for women who are breastfeeding, take into account: the limited data about the safety of these drugs and the risks associated with switching from a previously effective medication."

That second clause is the one most people are never told. If a particular antidepressant has worked for you in the past, switching to a theoretically "safer" one you have never responded to is not automatically the better decision. NICE weighs the risk of the switch itself.

CG192 adds: "Seek advice from a specialist (preferably from a specialist perinatal mental health service) if needed for specific drugs," and points to the UK Drugs in Lactation Advisory Service. You can ask your GP to do exactly that.

What is known about the common options

The Breastfeeding Network's antidepressants factsheet is written for exactly this question. Its summary line on the SSRIs: "Sertraline has the lowest passage of SSRI drugs into breastmilk. Citalopram also passes into breastmilk in low levels. If you have found an antidepressant you were previously prescribed of benefit, that may influence the choice of drug prescribed."

On sertraline specifically, the factsheet says: "It is normally seen as the SSRI of choice for a breastfeeding mother if she has not had a previous antidepressant which was effective for her — this would then be the drug of choice."

The factsheet also notes something practical about the first weeks on any of them: side effects can include nausea, headache, insomnia and agitation, and "It may be difficult to differentiate the side effects of the drugs from the symptoms of depression so it may seem that the drugs are not being effective in the early weeks of therapy."

And on expectations: "Most anti-depressants take three to four weeks to exert maximal efficacy and it is important that the woman is informed of this. Many patients stop taking anti-depressant medication within the first four weeks having found no benefit."

That is the single most useful sentence on this page. If you stop at day ten because nothing has changed, you will have taken the side effects and none of the benefit.

Monitoring the baby

NICE CG192 is brief and clear: "If a woman is taking psychotropic medication while breastfeeding, monitor the baby for adverse effects." In practice that means telling your health visitor or GP what you are on, and mentioning it if your baby becomes unusually sleepy, feeds poorly or is not gaining weight as expected. Those are things to report and discuss, not reasons to stop the medicine on your own.

The Breastfeeding Network notes that with the more sedating options, care should be taken with co-sleeping "as natural reactions will be lessened." That applies to any sedating medicine, and it is a genuinely important safety point.

Antipsychotics and other medicines

CG192 gives the same framework for antipsychotics: take into account "the limited data on the safety of these drugs" and the fact that "the level of antipsychotic medication in breast milk depends on the drug." Carbamazepine, clozapine and lithium are the three named exceptions to the encouragement to breastfeed.

If you are on any of those, that is a conversation with a specialist perinatal mental health service rather than a decision to make from a website.

Where to get an answer about your specific drug

• The Breastfeeding Network's Drugs in Breastmilk service, which publishes factsheets on individual medicines and answers questions by email.
• Your GP or prescriber, who can contact the UK Drugs in Lactation Advisory Service, as NICE directs.
• The specialist perinatal mental health service, which NICE names as the preferred source of advice for specific drugs. Your GP, midwife or health visitor can refer you.
• The National Breastfeeding Helpline, 0300 100 0212, which its own site says is "open 24 hours a day, 365 days a year," with support also available in Welsh, Polish, Bengali and Sylheti.

What not to do

Do not stop an antidepressant abruptly to breastfeed. Several, including paroxetine and venlafaxine, are associated with discontinuation effects, and relapse is a real risk at a point where you are least able to absorb it.

Do not rely on the leaflet in the box. The Breastfeeding Network explains why it says what it says: most manufacturers "have not conducted clinical trials on the use in lactation and in the Summary of Product characteristics recommend that they are not used by breastfeeding mothers. Their use is therefore off-licence and at the discretion and responsibility of the prescribing physician." Off-licence here means insufficient commercial trial data, not evidence of harm.

The point of treating it

The Breastfeeding Network puts it directly: "It is important that post-natal depression is recognised and treated effectively as it may impair bonding between mother and child and enjoyment of an important period in the relationship." Treating the illness is the thing that protects the relationship. The feeding method is a separate decision, and one you get to make.