Can I take antidepressants while breastfeeding?

Given the high prevalence of postpartum depression in the US (often cited as between 10-15% of postpartum women), and the myriad benefits of breastfeeding for both baby and mother, it's not a surprise that women in our clinic often ask about the safety of breastfeeding while taking antidepressants.

To answer this question, it's important to note that concentrations of psychotropics in breast milk have been found to vary widely. The amount of a psychotropic medication that an infant is exposed to depends on multiple factors, including dosage of the drug, rate of maternal drug metabolism, and frequency and timing of feedings. In the past, a technique called "pumping and dumping" was recommended. However, that has been found to be unnecessary; you can read more about why it is not a good idea to pump and dump in this post.

One of the main ways researchers have investigated antidepressant safety in lactation has been to look at infant plasma (i.e., blood) concentrations. The chart below from Berle and Spigset (2011) shows that of the most commonly prescribed SSRIs, sertraline and paroxetine have the lowest infant plasma concentrations: 

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Duloxetine (an SNRI) and bupropion (an NDRI) also had undetectable infant plasma levels, but there were fewer mother/ infant pairs studied. The SSRIs fluoxetine and citalopram had higher infant plasma concentrations; it's generally recommended that these be used with caution or avoided during breastfeeding. However, if a woman has been stable on these medications prior to and/ or during pregnancy, it may be fine to continue them during breastfeeding.

Another way to evaluate the safety of medications in lactation has been to look at adverse events. Scalia and Wisner did an extensive literature search to create clinical guidelines for antidepressant use during breastfeeding. They found that sertraline, paroxetine, and nortriptyline are the most evidence-based antidepressants in lactation, because levels are usually undetectable in infants, there have been no reports of short term adverse effects, and findings about them have been consistent among different laboratories. They also created the following decision-tree:

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As you can see, sertraline and paroxetine are generally considered to be the first-line agents if pharmacological treatment is necessary in lactation. Sertraline is often preferred over paroxetine because of paroxetine's greater anticholinergic side effects (including dry mouth, blurred vision, sedation, constipation, and memory impairment) and its shorter half life/ more significant discontinuation syndrome (marked by flu-like symptoms, insomnia, nausea, imbalance, and anxiety).