What is the treatment for postpartum anxiety using Abilify (aripiprazole)?

Abilify (Aripiprazole) for Postpartum Anxiety

Aripiprazole is not a recommended treatment for postpartum anxiety and should be avoided in breastfeeding mothers due to significant safety concerns, including reports of poor weight gain in infants and inadequate milk supply in lactating women. 1

Why Aripiprazole Is Not Appropriate

The FDA drug label for aripiprazole explicitly warns about breastfeeding risks that directly contradict its use for postpartum anxiety:

• Aripiprazole is present in breast milk at relative infant doses ranging from 0.7% to 8.3% of the maternal weight-adjusted dosage 1
• There are documented reports of poor weight gain in breastfed infants exposed to aripiprazole 1
• Reports exist of inadequate milk supply in lactating women taking aripiprazole 1
• Neonates exposed to antipsychotics including aripiprazole during the third trimester may experience extrapyramidal and/or withdrawal symptoms, including agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorders 1

Appropriate First-Line Treatments for Postpartum Anxiety

Pharmacological Options

For postpartum anxiety requiring medication, selective serotonin reuptake inhibitors (SSRIs) are the evidence-based first-line treatment, with sertraline being the preferred agent due to minimal passage into breastmilk and decades of safety data. 2

• Sertraline and paroxetine should be considered first-line medications in women who need antidepressant treatment during the postpartum period and wish to continue breastfeeding 3
• Most antidepressant drugs are considered compatible with breastfeeding, unlike antipsychotics 2
• SSRIs have established efficacy for anxiety disorders and are the standard of care in the postpartum period 2, 4

Non-Pharmacological Approaches

Psychological treatments are effective and preferred by many perinatal patients over medications 2:

• Cognitive-behavioral therapy (CBT) has shown the most effectiveness among non-pharmacological treatments for postpartum mood and anxiety disorders 5
• Other evidence-based options include psychoeducation, self-management strategies, mindfulness-based interventions, and dialectical behavior therapy 5

Clinical Decision Algorithm

1. Assess severity of postpartum anxiety symptoms and functional impairment
2. For mild-to-moderate symptoms: Initiate psychological treatment (CBT preferred) 5, 2
3. For moderate-to-severe symptoms or inadequate response to therapy: Add pharmacotherapy with sertraline as first-line SSRI 2, 3
4. If sertraline is ineffective or not tolerated: Consider paroxetine as second-line SSRI 3
5. Monitor breastfed infants for any behavioral changes, feeding difficulties, or developmental concerns 4

Critical Pitfalls to Avoid

• Do not prescribe aripiprazole or other antipsychotics for postpartum anxiety unless treating psychotic symptoms or bipolar disorder 1, 6
• Do not assume antipsychotics are safe alternatives to antidepressants in breastfeeding—the opposite is true 1, 6
• Aripiprazole, haloperidol, perphenazine, and trifluoperazine demonstrate no known developmental dangers only when used for appropriate psychiatric indications (psychosis, bipolar disorder), not anxiety 6
• The fear of medication exposure should not prevent treatment, as untreated maternal anxiety has detrimental effects on maternal and infant well-being 2, 4

When Antipsychotics May Be Appropriate

Aripiprazole would only be considered in the postpartum period for:

• Postpartum psychosis 1
• Bipolar disorder with manic or mixed episodes 1
• Treatment-resistant depression as augmentation (not monotherapy for anxiety) 1

Even in these scenarios, the risks to the breastfed infant must be carefully weighed, and alternative feeding options may need to be discussed 1.