Hala Salah

Lecturer of psychiatry
 Prenatal Classes

 Newspaper articles

 Community lectures

 Family involvement in the educational process

 Routine prenatal screening

-Exercise
-Diet:
Omega 3 Protein
Hydration Vit. (B)
-Plan
-For women with histories of postpartum depression
consider prophylactic antidepressants
- For those who were treated during pregnancy
◦ Rest

◦ Proper nutrition

◦ Help with infant and household responsibilities

◦ Family and friends support systems

◦ Avoidance of isolation
 Type of illness (bipolar)

 Severity

 Medications needed

 Infant issues
Individual patient approach is needed

Quality of Risks of drug-induced

mother’s life toxicity in breast-fed
infant
Benefits of breast
feeding

Precious baby
 Psychotropics

Social Support
Psychotherapy

ECT
 Psychosocial therapies

◦ First choice for those with mild to moderate symptoms of PPD

◦ Cognitive-behavioral therapy

◦ Interpersonal psychotherapy- focuses on patient’s interpersonal

relationship and changing roles
 Group therapy
◦ Helps to increase support network

 Family and marital therapy

◦ More rapid recovery
◦ More appreciative of partner’s contribution

 Peer-support groups
 Four factors are needed in order to understand
problems related to breast-feeding by mothers taking
psychotropic medication:

 the prescribed dose;

 the level of the drug in the mother’s blood plasma;
 the level in the breast milk;
 and the levels in the infant’s serum.
 Medication’s diffusion across membranes,
Molecular weight and its lipophilicity.

 The timing of the dose in relation to the

infant’s feeding patterns.

 Drug’s dosage and frequency, its

pharmacodynamics and pharmacokinetics.
Maternal / Infant / Drug
Maternal:
• Drug dosage and duration of therapy

• Route and frequency of administration

• Metabolism

• Renal clearance

• Blood flow to the breasts

• Milk pH and composition

Maternal / Infant / Drug
Infant:
• Age of the infant
-preterm
- full term 3w
8-12w
• Feeding pattern

• Amount of breast milk consumed

• Drug absorption, distribution, metabolism and elimination

 Most drugs are transferred into milk by the passive
diffusion processes and hence maternal drug .

 Active or carrier-mediated transport occurs for some.

 Drugs must pass from the maternal plasma, through the

capillary walls, into the alveolar cells lining milk duct.

 During the first few days of life there are large gaps
between these alveolar cells, which allow most
molecules to cross through easily.
 For psychotropics the arbitrary concentration in the
infant’s plasma of 10% of the established therapeutic
maternal dose is used as the upper threshold where the
risks of a particular drug’s side-effects are low and
treatment is accepted as safe
 The newborn’s health should be taken into
consideration when planning breast-feeding

 Preterm immature infants should not be exposed to

psychotropics

 Infants’ hepatic, renal and cardiac functions should be

checked before they are breast-fed by mothers on
psychotropic medication
 Infants older than 10 weeks are at a lower risk for
adverse effects of tricyclics and there is no evidence of
accumulation in the infant

 The newborn should be examined regularly for any

possible adverse events of medication

 All professionals involved in the care of the infant

should be informed of psychotropic medication usage
 Increase risk of suicide after initiation of medication

 If significant anxiety or insomnia present, consider

adding benzodiazepine

 Close follow-up
 SSRI
 SSRI preferred initially.
 Drug levels are low to undetectable.
 All effective in open trials (Moretti, 2009).
 SSRIs such as fluoxetine, sertraline, paroxetine and
citalopram are safe during breast-feeding (Berle, 2004).
 Sertraline is considered as first line in USA (Altshuler
et al. (2001).
 Tricyclics have a less favorable side effect profile and a
much higher risk of morbidity and mortality from
overdose.
 However, it is relatively safer and low levels of drugs
are secreted for most tricyclics.
 Tricyclics such as amitryptyline, imipramine,
nortriptyline and clomipramine are safe during breast-
feeding (Becker, 2009).
 Doxepin is contraindicated (respiratory depression).
 Trazodone appears to be of lower risk because only 1%
passes into the milk, although drowsiness and poor
feeding have been reported. Data are limited to a few
cases and caution is advised in use of the drug.
- It has been mentioned in certain studies that
Mirtazapine can be used as first-line treatment and,
because of its action on histamine H1 receptors, may be
preferred in some patients with postnatal depression,
when night-time sedation is required (Snellen, 2007)
 Venlafaxine is considered safe (Snellen, 2007).

 Bupropion: Few studies found no adverse effects (in

one case, it lead to occurance of seizure in the new
born) (Becker, 2009).
 Conventional antipsychotics have been used for
decades and the accumulated data show that they are
safe during breast-feeding (Phenothiazines may
increase risk of SIDS).

 New information is starting to emerge about some

atypical antipsychotics such as olanzapine and
risperidone but their safety has yet to be established
(Moreeti,2009)
 There is currently no information on quetiapine and
amisulpride and therefore it is not safe to expose
newborns to these medications

 Clozapine accumulates in breast milk and is

contraindicated during breast-feeding
 Lithium is contraindicated during breast-feeding (high
serum level, but 3 studies recommended its use with
caution if no other options available. (Hale , 2004)

 There is little evidence of adverse events in infants

breast-fed by mothers taking carbamazepine or sodium
valproate, although transient hepatic toxicity is possible
with the former (Moretti, 2009)

 Lamotrigine is considered moderately safe in practice

(But with high serum level in infant-be careful of risk
of Steven Johnson syndrome) (Becker, 2009).
 It is unsafe to expose infants to repeated doses of long-
acting benzodiazepines

 Shorter acting agents such as oxazepam, alprazolam

and lorazepam are preferred by most authors (Becker,
2009). It must be used for short term.

 Buspirone, zaleplon and zopiclone are better avoided

because of limited safety data on their use.
 Psychiatric emergency! Inpatient treatment
 Mood stabilizers
 Antipsychotics
 Benzodiazepines
 Lithium prophylaxis
 Electroconvulsive therapy
 The decision to prescribe antipsychotics to breast-feeding
women should depend on individual risk/benefit analysis

 The current available research does not allow any absolute

and clear recommendation because much of the work on
psychotropic medication in breast-feeding is limited to
single case reports, small series and naturalistic data
collection

 Causes and consequences of different adverse events are not

yet widely studied
 Berle J.O. The challenges of motherhood and mental
health. World Psychiatry. 2004;3(2):p101–102.

 Becker M.A, Mayor G.F, Elisabeth J.S. Psychotropic

Medications and Breastfeeding. Primary Psychiatry.
2009;16(3):p42–51
 -Hale T.W. Drug Therapy and Breastfeeding:
Antidepressants, Antipsychotics, Antimanics, and
Sedatives. Neo Reviews. 2004;5(10):e451.

-Moretti M.E. Psychotropic Drugs in Lactation. Can J

Clin Pharmacol. 2009;16(1):p e49–e57.

-Snellen M, Galbally M, Udechuku A, Spalding G,

Munro C, Drinkwater P. Psychotropic Medication in
Pregnancy/Lactation. Revised 2nd Edition. Mercy
Health & Aged Care: Melbourne; 2007. Pharmacy
Department Mercy Hospital for Women. October 2007
Thank you