Selective serotonin reuptake inhibitors (SSRIs) for postpartum depression

Examples

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Brand Name	Generic Name
Celexa	citalopram

Brand Name	Generic Name
Prozac	fluoxetine

Brand Name	Generic Name
Luvox	fluvoxamine

Brand Name	Generic Name
Paxil	paroxetine

Brand Name	Generic Name
Zoloft	sertraline

How It Works

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SSRIs improve your mood by increasing your brain's use of a chemical messenger (neurotransmitter) called serotonin. You may start to feel better within 1 to 3 weeks of taking antidepressant medicine. But it can take as many as 6 to 8 weeks to see more improvement. If you have questions or concerns about your medicines, or if you do not notice any improvement by 3 weeks, talk to your doctor.

Why It Is Used

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SSRIs are usually the first-choice medicine for treating postpartum depression (PPD). Sertraline and paroxetine are most often recommended for breast-feeding women.¹

SSRIs are also used to relieve severe anxiety and depression during pregnancy and to prevent PPD in high-risk women.

How Well It Works

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SSRIs have become the first line of treatment for depression because they have proved effective for most people and have few side effects.²

Side Effects

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Maternal side effects of SSRIs, which tend to improve over time, can include:

• Nausea, appetite changes, weight loss.
• Nervousness.
• Headache.
• Insomnia, fatigue.
• Loss of sexual desire or ability.
• Dizziness.
• Tremors.
• Rash (rare).
• Weight gain (rare) with long term use.

SSRI treatment is not recommended if you have a seizure disorder or a history of mania (including bipolar disorder). These conditions can be made worse by an SSRI.

Breast-feeding infant side effects

Breast-feeding babies whose mothers take an antidepressant usually do not have side effects. But they may. If you take an antidepressant while breast-feeding, talk to your doctor and your baby's doctor about what types of side effects to look for.

Experts cannot yet say that a mother's antidepressant treatment is completely safe for the breast-fed baby. But, research does show which SSRIs seem most safe. Sertraline (Zoloft) is generally the first choice for a breast-feeding mother. Side effects have only been seen in some breast-feeding babies exposed to fluoxetine (Prozac, Sarafem), paroxetine (Paxil), or citalopram (Celexa).^{3 1} Side effects include poor feeding and more crying and irritability.¹

Some SSRIs, such as fluoxetine and citalopram, are passed on to the breast-fed baby more than others. Also, every woman uses (metabolizes) and passes on medicine in different amounts. The level of medicine in your breast milk depends in part on when you take your daily dose. Talk to your doctor about when the level of medicine in your breast milk is lowest.

Researchers are studying children who breast-fed while their mothers took SSRIs. So far, they have seen no signs of problems in these children into their preschool years.⁴

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

FDA Advisories. The U.S. Food and Drug Administration (FDA) has issued:

• An advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. This is especially important at the beginning of treatment or when doses are changed.
• A warning about the antidepressants Paxil and Paxil CR and birth defects. Taking these medicines in the first 12 weeks of pregnancy may increase your chance of having a baby with a birth defect.
• A warning about taking triptans, used for headaches, with SSRIs (selective serotonin reuptake inhibitors) or SNRIs (selective serotonin/norepinephrine reuptake inhibitors). Taking these medicines together can cause a very rare but serious condition called serotonin syndrome.

What To Think About

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SSRIs are effective for treatment of PPD. Some experts recommend using an SSRI to prevent PPD in high-risk women. But studies have not yet proved that this works.³

Talk to your doctor about your postpartum depression symptoms and decide on what type of treatment is right for you. Antidepressant medicine and cognitive-behavioral counseling have proven to be equally effective for many women.⁵ Counseling and support are considered a first-line treatment for mild to severe PPD. Women with mild PPD are likely to benefit from counseling alone, and those with moderate to severe PPD are advised to combine counseling with antidepressant medicine.⁶

Do not suddenly stop taking an SSRI. Abruptly stopping an SSRI medicine can cause headaches, nervousness, anxiety, or insomnia. An SSRI must be gradually tapered off with supervision from your doctor.

SSRIs and breast-feeding

Treating postpartum depression is very important for both you and your baby. Untreated postpartum depression can have bad effects on your baby's development.⁷

Breast-feeding is also proved to be good for babies and mothers. This is why breast-feeding is recommended for the first year after childbirth.

• If your doctor thinks that you need an antidepressant to treat postpartum depression, you do not have to stop breast-feeding. Some SSRIs are barely detectable in breast milk.
• If you are breast-feeding and need treatment for postpartum depression, talk to your doctor. You can use an SSRI that is known to occur in low levels in breast milk. Also let your baby's doctor know about what medicine you're taking while breast-feeding.
• If the antidepressant that works best for you is one that has higher levels in breast milk, talk to your baby's doctor about whether formula feeding would be a good choice.

Complete the new medication information form (PDF) (What is a PDF document?) to help you understand this medication.

References

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Citations

1. Weissman AM, et al. (2004). Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. American Journal of Psychiatry, 161: 1066–1078.

2. Butler R, et al. (2007). Depression in adults (drug and other physical treatments), search date April 2006. Online version of Clinical Evidence. Also available online: http://www.clinicalevidence.com.

3. Brockingham I (2004). Postpartum psychiatric disorders. Lancet, 363(9405): 303–310.

4. Parry BL (2004). Management of depression and psychoses during pregnancy and the puerperium. In RK Creasy et al., eds., Maternal-Fetal Medicine: Principles and Practice, 5th ed., pp. 1193–1200. Philadelphia: Saunders.

5. Appleby L, et al. (1997). A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. BMJ, 314(7085): 932–936.

6. Altshuler LL, et al. (2001). The expert consensus guideline series: Treatment of depression in women. Postgraduate Medicine Special Report (March): 1–116.

7. Wisner KL, et al. (2002). Postpartum depression. New England Journal of Medicine, 347(3): 194–199.

Credits

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Author	Jeannette Curtis
Editor	Susan Van Houten, RN, BSN, MBA
Associate Editor	Pat Truman, MATC
Primary Medical Reviewer	Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer	Lisa S. Weinstock, MD - Psychiatry
Last Updated	June 24, 2008