January 27, 2014
December 2013, ObGyn News, Lee S. Cohen, M.D.
Over the last 2 decades, abundant data on the reproductive safety of medications used to treat psychiatric disorders have become available, filling in many gaps with respect to our knowledge about the safety of commonly used psychiatric medications during pregnancy. But the availability of such safety data with respect to the use of these agents during breastfeeding is less complete.
Because of fears of potential adverse effects on infants associated with psychotropic drug use during lactation, many women with a psychiatric disorder who are treated with a range of psychiatric medications are advised not to breastfeed; or if they choose to breastfeed, they are counseled to avoid taking the essential medication that has made them well. This has been a somewhat intuitive, cautious approach. However, in my 25 years of clinical experience taking care of pregnant and postpartum women with a range of psychiatric disorders, one sad scenario I have frequently witnessed is the woman who decides to defer pharmacologic treatment for severe postpartum psychiatric illness after being counseled to defer treatment given a wish to breastfeed. Those women often have been psychiatrically ill for months while breastfeeding after having decided to defer their own treatment because they do not want to expose the baby to even scant amounts of medication secreted into breast milk associated with use of a needed medicine during lactation.
In a recently published clinical report from the American Academy of Pediatrics committee on drugs, authors suggest that advice not to breastfeed or to uniformly avoid medications while nursing because of possible adverse effects in the infant is often not evidence based and may not be necessary in many cases. The committee states that most drugs do not pose a risk to the mother or infant who is nursing, and that “the benefits of breastfeeding outweigh the risks of exposure to most therapeutic agents via human breast milk” (Pediatrics 2013;132:e796-e809).
The report points out that for certain drugs, a careful risk-benefit analysis is needed, especially for drugs that are concentrated in human milk, those with unproven benefits, and those with long half-lives. Importantly, the report notes say that decisions about the use of medications during lactation have to be made on a case-by-case basis. A concrete example would be exercising appropriate vigilance about the use of these medicines in premature infants with immature metabolism.
The report, published on-line in Pediatrics in August 2013, includes a section on antidepressants, anxiolytics, and antipsychotics. As a resource for clinicians, the report highlights LactMed, part of the National Library of Medicine’s toxicology data network (TOXNET), which provides real-time updated scientific information on the excretion of drugs into breast milk.
The report makes the important distinction regarding the range of clinical decisions that get made in the context of different clinical situations. For example, at our center, patients frequently present with questions about whether to use psychiatric medications while breastfeeding when these women have already been taking the medication during pregnancy for treatment of underlying psychiatric disorder. Others make queries about introduction of pharmacologic therapy in the early postpartum period in the context, for example, of new-onset postpartum depression. Specifically, a woman with a history of psychiatric disorder who is treated with antidepressant during pregnancy may continue that medication across the postpartum period to attenuate risk for postpartum depression, particularly if she has a history of recurrent disease, or depressive relapse when medication has been discontinued. That is clinical scenario differs from that of a woman who develops new onset of depression during the postpartum period.
One part of the AAP report addresses use of certain psychiatric medications in the context of available information from the literature regarding extent of excretion of these medications into breast milk. This section states that many antianxiety drugs, antidepressants, and mood stabilizers are excreted in low concentrations into human milk, with the estimated infant doses under 2% of the weight-adjusted maternal dose. However, the authors also cite small series or case reports where infant plasma levels of some drugs were reported to exceed 10% of maternal plasma concentrations. They list 13 such drugs, which include selective serotonin reuptake inhibitors (SSRIs), antipsychotics, anxiolytics, and mood stabilizers. It is important to keep in mind that the number of these cases is small and represent a very small proportion of cases, when the total denominator of reports in the literature of psychotropic drug use during lactation is considered. For example, olanzapine, a second generation antipsychotic is highlighted as an agent of concern based on one case report (J. Psychopharmacol. 2010;24:121-3).
The take-home message for the clinician is that all psychotropics are excreted into breast milk, even if quantification of the agents in breast milk or infant plasma reveals relatively scant concentration (J. Clin. Psychiatry 2003;64:73-80). If mom takes the medicine coincident with lactation, baby is exposed. At our center, we are usually reluctant to discontinue a medication such as an atypical antipsychotic to treat bipolar disorder in the postpartum period even if the mom chooses to breastfeed considering the extent to which women with bipolar disorder are at a high risk for relapse during the puerperium.
Ironically, we probably have more information regarding the excretion of antidepressants and drugs such as lamotrigine, used as a mood stabilizer, into breast milk than most medicines women take during the postpartum period, with data over the past 15 years suggesting that these medications, like other medications, are excreted into breast milk and are present in infant plasma in extremely sparse concentrations. It is noteworthy that cases of frank newborn toxicity directly associated with mothers who breastfeed on psychiatric medications are extremely few and far between, and are anecdotal at best. For some context, the literature on the effects of SSRI use during pregnancy is vast and prevalence of use of these medications during pregnancy and the postpartum period is substantial; that being said, reports of adverse effects reported in the babies of women who breastfeed while taking an SSRI are scant and thus at least somewhat reassuring.
And yet, consistently, I have witnessed that psychiatric medications are highlighted in the literature as particular agents of concern when it comes to lactation, compared with other medicines, for which only sparse data are available. Whether this reflects a bias about the necessity of treating psychiatric disorders during the postpartum period is unknown. Certainly, the long-term implications for the infant of exposure to low concentrations of psychiatric and nonpsychiatric medications in the context of breastfeeding exposure have yet to be clarified.
Whether a woman treated with a psychiatric medication during the post partum should breastfeed is a prime example of a clinical scenario in which there is no perfect decision, and we need to make the best decision possible, taking into account the available data, and the mother’s psychiatric disorder and her wishes. Some women may be extremely committed to breastfeeding and may choose to breastfeed, acknowledging some of the unknowns regarding these medications during lactation, while other women consider some of the ambiguity associated with the long-term effects of exposure while lactating and may choose not to breastfeed.
It is noteworthy that the AAP committee on drugs concluded the benefits of breastfeeding outweigh the risk of exposure to most therapeutic agents via human milk. And those at our center would certainly suggest that this is the case for psychiatric medications, particularly those used to sustain postpartum maternal psychiatric well-being, which is so critical. As is the case with any clinical decision, and certainly with respect to the use of psychiatric medications during pregnancy and lactation, the decision to treat is contingent on a careful risk-benefit analysis, where the risks of exposure to a medicine is weighed against the risk of untreated psychiatric illness. Even with the well-documented benefits of breastfeeding, nothing should trump the treatment of postpartum psychiatric illness, even if the cost is deferring breastfeeding. Treatment cannot be deferred because of the impact of untreated maternal psychiatric illness on maternal morbidity and on the development of children.
Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information about reproductive mental health at www.womensmentalhealth.org. To comment, e-mail him at firstname.lastname@example.org. Dr. Cohen has been a consultant to manufacturers of antidepressants and antipsychotic medications.