Is it safe for women to breastfeed while taking antidepressants? According to a CDC report from 2020, ~10.3% of women ages 18-39 take antidepressants, and the number of people diagnosed with depression and taking antidepressants continues to rise. In this article, we will look at the use of SSRIs in lactation.

All antidepressants pass into the breast milk to some degree, but antidepressants are generally safe for use while breastfeeding when clinically necessary. Studies have shown that SSRIs have been found to have minimal levels detectable in breast milk and limited adverse effects, and thus the infant has a low risk of exposure in general. It should be noted that there are some differences between the various SSRIs in lactation and if we have the option, which one should we select?

Sertraline and Paroxetine are the preferred SSRIs for breastfeeding mothers (great example of a board exam question!). Both of these antidepressants show low levels found in breast milk (<10%) and have favorable drug properties. Notably, use of paroxetine use in pregnancy is not preferred due to a small risk for fetal cardiac concerns so many women would not be taking paroxetine prior to delivery of the baby. On the other hand, sertraline is highly recommended in both pregnancy and lactation, making it a preferred medication for women of childbearing age. We have covered SSRIs in pregnancy in a previous post.

Citalopram, escitalopram, and fluvoxamine can be used with caution during breastfeeding. These medications are found in higher concentration in breast milk than sertraline and paroxetine on average, however, in certain situations, the benefits of continuing these therapies may outweigh the risks.

Fluoxetine has been found to have the highest levels in breast milk compared to other SSRIs, however this is still a very small amount. It is also long-acting and remains in both the mother’s and the infant’s system longer than other SSRIs. This being said, with appropriate monitoring, it can still be taken while breastfeeding but most prescribers will avoid using it if other options exist.

Table adapted from “Antidepressant Use During Breastfeeding” Berle, Spigset

Order of recommendation (most to least recommended):

1. Most preferred: Sertraline (Zoloft) and Paroxetine (Paxil)
2. Generally safe but not preferred: Citalopram (Celexa), Escitalopram (Lexapro), and Fluvoxamine (Luvox)
3. Least preferred: Fluoxetine (Prozac)

Another complication from medications is breast milk production. Mothers who take SSRIs while breastfeeding may have a harder time breastfeeding and possibly lower levels of breast milk. However, this can also be true for depression in general. This again demonstrates the inappropriateness of a one-size-fits-all approach.

As with all medications taken while breastfeeding, it is important to closely monitor the baby for signs and symptoms indicating excess levels of medication. Among the SSRIs in lactation, sertraline appears to provide the greatest level of safety and also carries a reasonable safety profile in pregnancy as well.

This article was written by Sara Hoag, PharmD Candidate in collaboration with Eric Christianson, PharmD, BCPS, BCGP

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Resources

1. Products – Data Briefs – Number 377 – September 2020. www.cdc.gov. Published September 8, 2020. Accessed April 25, 2024. https://www.cdc.gov/nchs/products/databriefs/db377.htm#:~:text=(figure%201).- 
2. Health MC for WM. Breastfeeding & Psychiatric Medications. MGH Center for Women’s Mental Health. https://womensmentalhealth.org/specialty-clinics-2/breastfeeding-and-psychiatric-medication-2/
3. Using SSRI antidepressants during breastfeeding. SPS – Specialist Pharmacy Service. Published January 13, 2023. https://www.sps.nhs.uk/articles/using-ssri-antidepressants-during-breastfeeding/#:~:text=Paroxetine%20and%20sertraline%20are%20the%20SSRIs%20of%20choice%20during%20breastfeeding
4. ‌Drugs and Lactation Database (LactMed®) [Internet]. Bethesda (MD): National Institute of Child Health and Human Development; 2006-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK501922/
5. Berle JO, Spigset O. Antidepressant Use During Breastfeeding. Curr Womens Health Rev. 2011 Feb;7(1):28-34. doi: 10.2174/157340411794474784. PMID: 22299006; PMCID: PMC3267169.