July 6, 2001 -- Thirty weeks into her pregnancy with her second child, Dede Adams of Atlanta, Ga., knew something was wrong.
"I became very anxious, and I'm not an anxious person," she said. "I had an overwhelming fear that something was wrong."
Adams was fortunate. She was referred by a friend to the pregnancy and postpartum mood disorders clinic at Emory University. There, psychiatrist Zachary Stowe, MD, an associate professor of psychiatry and obstetrics-gynecology, informed Adams that her anxiety could be a symptom of an underlying depression and possible early evidence of postpartum depression.
Postpartum depression involves moderate to severe depression beginning slowly and sometimes undetectably during the second to third week after delivery, and afflicts an estimated 10% of pregnant women.
On Stowe's recommendation, Adams began to take the antidepressant Paxil. The results were profound: Within weeks she was back to normal. She continued using the medication after her son William was born, and -- against the recommendation of her pediatrician -- throughout the year and a half she was breastfeeding William.
Today, both Adams and William, now 4 years old, are healthy, with no discernible ill effects from exposure to medication through breast milk. But the dilemma faced by Adams is one that confronts many thousands of moms being treated with depression: Treat the depression and forgo breastfeeding, or decline treatment in favor of the nurturing and nutritional benefits of breastfeeding.
Yet some psychiatrists, including Stowe, say that in most cases there should be no dilemma.
"We know more about antidepressants and breast milk than we know about any other class of medication in the world," Stowe tells WebMD. "We have studied them extensively because we were afraid of them, but we have not found any pattern of consistent adverse problems associated with antidepressant use and breastfeeding."
Stowe says that exposure to medication that crosses the placenta prior to delivery is liable to be greater than any exposure through breast milk. "We see a lot of people taking antidepressant medication during pregnancy and being told they can't breastfeed," Stowe tells WebMD. "It's the dumbest thing I've ever heard of."
Nevertheless, "trace elements" of medication can be found in the blood of breastfed infants, and may vary according to the medication and the disorder that is being treated. And because there have been isolated reports of adverse events in breastfed infants that may be related to maternal antidepressant use, the decision remains clouded by a degree of scientific ambiguity.
A recent report in the American Journal of Psychiatry -- of which Stowe was a co-author -- suggests that decisions about using psychiatric medications while breastfeeding should be made on a case-by-case basis. And that decision should be made in the context of a range of factors, including not only information about possible side effects, but also consideration of the mother's commitment to breastfeeding.
"There are clear benefits to breastfeeding," Stowe tells WebMD. "If it's important to the woman, it should be their decision."
The study involved an extensive search of medical literature for reports on a wide range of medications used during breastfeeding. That search yielded none of the preferred controlled trials on the subject -- the kind of trials comparing adverse events in infants among mothers who used psychiatric medications during breastfeeding, and those who did not. What exists, instead, is a substantial body of smaller "case series" studies; these are published reports of patients who have used medication during breastfeeding.
Among the findings from the literature review was one showing 11 published reports of mothers using Prozac, involving 190 breastfed infants. Measurements of trace elements in infant blood varied, and no negative effects were noted in 180 of the 190 infants.
One case of an infant was reported in which blood levels of medication in the child were comparable to those in the mother. Negative effects included excessive crying, decreased sleep, vomiting, and diarrhea, which dissipated after discontinuation of breastfeeding.
Because of such reports, the authors of the study recommend that infants being breastfed by moms on antidepressant medication be actively monitored by a pediatrician.
But on that point, not all experts agree.
Psychiatrist Nada Stotland, MD, says that while trace elements are sometimes found, it would be all but impossible for a doctor to determine if they are related to any adverse events. And though she supports the authors' conclusions that decisions should be made on a case-by-case basis involving a host of factors, she is critical of the recommendation that pediatricians actively monitor infants.
"That suggestion is very likely to intensify the anxiety and guilt that many of these mothers experience as a part of their depression," she tells WebMD. Stotland is a professor of psychiatry and obstetrics and gynecology at Rush Medical College in Chicago.
Resolution of the ambiguity around breastfeeding while on psychiatric medication would appear to await greater scientific understanding of the importance of trace elements and their connection to infant behavior.
But for Dede Adams, there was little ambiguity about her determination to breastfeed while she was still taking medication to treat her depression. "I feel very strongly about breastfeeding," Adams tells WebMD. "It was something I wanted to do. Breastfeeding is such an incredible bond. It's a sit-still time when you can just focus on your baby."