Examples

Generic Name	Brand Name
citalopram	Celexa
fluvoxamine	Luvox
paroxetine	Paxil
sertraline	Zoloft

How It Works

SSRIs improve your mood by increasing your brain's use of a chemical messenger (neurotransmitter) called serotonin. SSRIs usually take 4 to 8 weeks to improve depression, but postpartum women may improve much sooner.

Why It Is Used

SSRIs are usually the first-choice medication 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.

Breast-feeding

• Of the various SSRIs, sertraline (Zoloft) is the first-choice medication. It is most studied and generally does not seem to affect breast-feeding babies.²
• There have been reports of side effects in babies exposed to paroxetine (Paxil), fluoxetine (Prozac), and citalopram (Celexa).^{3, 1}
• Fluvoxamine (Luvox) has not been well studied.

How Well It Works

SSRIs have become the first line of treatment for depression because they have proven effective for most people and have few side effects.⁴

Side Effects

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 worsened 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 increased crying and irritability, and poor feeding.¹

Some SSRIs, such as fluoxetine, are passed on to the breast-fed baby more than others. Also, every woman uses (metabolizes) and passes on medicine in different amounts. Overall, your milk has the lowest possible level of medicine just before you take a daily dose. Each SSRI is different, but in general the medicine is highest in your breast milk several hours after taking a daily dose.

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.⁵

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 migraines, with SSRIs (selective serotonin reuptake inhibitors) or SNRIs (selective serotonin/norepinephrine reuptake inhibitors). Taking these medicines together can cause a serious condition called serotonin syndrome.

What To Think About

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 proven that this works.³

Talk to your health professional about your postpartum depression symptoms and decide on what type of treatment is right for you. Antidepressant medication and cognitive-behavioral counseling have proven to be equally effective for many women.⁶ 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 medication.⁷

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

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.^{8, 9}

Breast-feeding is also proven 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 have no known infant side effects and 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 what formula feeding would be a good choice.

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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. Whitby DH, Smith KM (2005). The use of tricyclic antidepressants and selective serotonin reuptake inhibitors in women who are breastfeeding. Pharmacotherapy, 25(3): 411–425.

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

4. Butler R, et al. (2006). Depression in adults, search date September 2004. Online version of Clinical Evidence (15): 1–38.

5. 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.

6. 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.

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

8. Kaplan PS, et al. (1999). Child-directed speech produced by mothers with symptoms of depression fails to promote associative learning in 4-month-old infants. Child Development, 70: 560–570.

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