Use of psychotropic medications in breastfeeding women: acute and prophylactic treatment

Objectives: The postnatal period is a time of increased onset and relapse of mental illness. It poses a clinical dilemma, as many mothers requiring medication acutely or prophylactically will also choose to breast feed. The present paper first reviews the safety of psychotropes in breast-fed infants and the usefulness of prophylaxis for women at risk of postpartum affective relapse and, second, provides guidelines in the use of psychotropic drugs in breast-feeding women. Methods: A Medline review was conducted reviewing all papers published during the period 1993-1998 (and their associated bibliographies) on the use of psychotropes in breast-feeding women and the prophylactic usefulness of medications in women at risk of affective postpartum relapse. Results: Findings are based on case reports and small, mostly uncontrolled studies. Both tricyclic antidepressants (TCA) and specific serotonin re-uptake inhibitors (SSRIs) appear to be relatively safe in breast feeding. Antidepressants commenced in the early postpartum period may reduce depressive relapse. While prophylactic lithium appears to significantly reduce relapse of affective psychosis in the puerperium, there have been no studies of the anticonvulsants in the puerperium. Finally, high dose antipsychotics should be avoided, as they may be associated with longterm adverse sequelae in the infant. Conclusions: On the basis of current knowledge, the use of SSRIs, TCA, carbamazepine, sodium valproate and short-acting benzodiazepines in breast feeding is relatively safe. If lithium is to be used, close collaboration with a paediatrician is essential. The long-term risks of antipsychotics, especially at high doses, remain to be clarified. Before a decision can be made, the risk-benefit ratio must be clearly outlined and discussed with the mother and her partner.