Drug of Choice for Postpartum Depression
Sertraline is the first-line antidepressant for postpartum depression in breastfeeding women, as it transfers into breast milk in the lowest concentrations and consistently produces undetectable infant plasma levels. 1
Primary Pharmacologic Recommendation
Sertraline and paroxetine are the preferred first-line agents for postpartum depression in breastfeeding mothers, based on American Academy of Family Physicians guidelines. 1 These medications have the most favorable safety profile during lactation:
- Sertraline transfers to breast milk in minimal concentrations and consistently produces undetectable infant plasma levels 1
- Paroxetine similarly transfers in lower concentrations than other antidepressants and produces undetectable infant plasma levels 1
- Both are the most commonly prescribed antidepressants during breastfeeding 1
- Sertraline demonstrated significantly greater response rates (59%) compared to placebo (26%) and more than doubled remission rates (53% vs 21%) in postpartum depression trials 2
Alternative Pharmacologic Options
Bupropion can be considered for postpartum depression, particularly with comorbid conditions, as it is present in human milk at very low or undetectable levels in infant serum. 1 This may be especially useful for women requiring treatment for co-occurring depression and other conditions. 1
Agents to Use with Caution
Certain SSRIs require more careful consideration due to higher infant exposure:
- Fluoxetine produces the highest infant plasma concentrations among SSRIs and has been associated with more frequent reports of suspected adverse effects in infants 1
- Citalopram produces higher infant plasma levels and has been associated with nonspecific adverse effects (irritability, decreased feeding) more often than sertraline or paroxetine 1
- Venlafaxine produces higher infant plasma concentrations compared to sertraline and paroxetine 1
Dosing and Administration
For sertraline in postpartum depression:
- Typical starting dose is 50 mg daily, with titration up to a maximum of 200 mg/day based on clinical response 2
- The FDA label notes sertraline should be used during pregnancy and postpartum only if the potential benefit justifies the potential risk 3
- Maintain therapeutic dose at the time of delivery and during breastfeeding for women already on sertraline 4
Infant Monitoring Requirements
All breastfed infants of mothers on antidepressants require systematic monitoring for the following: 1
- Irritability and excessive crying
- Poor feeding or decreased appetite
- Unusual drowsiness or sedation
- Sleep disturbances
- Adequate weight gain and developmental milestones
Most reported adverse effects in infants are nonspecific and resolve spontaneously. 1
Clinical Context and Safety Data
The recommendation for sertraline is supported by:
- Decades of safety data demonstrating minimal passage into breastmilk 5
- Studies showing little to no change in platelet serotonin levels in breastfed infants, suggesting minimal effects on peripheral and central serotonin transporter blockade 6
- All antidepressants transfer into breast milk in low concentrations, with little evidence supporting any causal link between antidepressant use in breastfeeding mothers and adverse effects in infants overall 1
Important Caveats
Untreated postpartum depression carries significant risks that must be weighed against medication concerns:
- Depression during pregnancy is associated with premature birth and decreased initiation of breastfeeding 7
- Untreated maternal depression has multiple potential negative effects on maternal-infant attachment and child development 8
- The decision to treat must weigh both the potential risks of taking an SSRI along with the established benefits of treating depression 3
For women with moderate-to-severe depression, the benefits of treatment typically outweigh the minimal risks of sertraline exposure through breastfeeding. 7, 5