What medications are safe for a breastfeeding mother with bipolar disorder and anxiety to take?

Medications for Bipolar Disorder and Anxiety During Breastfeeding

For bipolar disorder during breastfeeding, quetiapine or olanzapine should be considered first-line treatment options, with sertraline as the preferred agent for comorbid anxiety. 1

Mood Stabilizers for Bipolar Disorder

First-Line Options

• Quetiapine and olanzapine are the preferred antipsychotics for treating bipolar disorder while breastfeeding, based on the most comprehensive systematic review of mood stabilizers and antipsychotics during lactation 1

• Lithium can be used as a possible treatment option during breastfeeding, though it requires close monitoring 1, 2

  • Two cases have reported symptoms consistent with lithium toxicity in breastfed infants 2
  • Close collaboration with a pediatrician is essential if lithium is chosen 3
  • Infant serum levels should be monitored 2

Alternative Mood Stabilizers

• Carbamazepine and valproic acid are considered relatively safe during breastfeeding 1, 2

  • Carbamazepine: 50 cases reported during breastfeeding, with 2 infants experiencing hepatic dysfunction 2
  • Valproate: 39 cases reported, with 1 case of thrombocytopenia and anemia in an infant 2
  • Both anticonvulsants are compatible with breastfeeding 4, 3

• Lamotrigine can be used but only at the lowest effective doses and should be considered on an individual basis 1

Medications to Avoid

• Clozapine and amisulpiride are currently contraindicated during breastfeeding 1

Treatment for Comorbid Anxiety

First-Line SSRI

• Sertraline is the preferred first-line treatment for anxiety in breastfeeding mothers with bipolar disorder 5, 6

  • Transfers to breast milk in the lowest concentrations among antidepressants 6
  • Produces undetectable infant plasma levels consistently 5, 6
  • Starting dose: 50 mg daily, with titration up to 200 mg/day based on response 5

• Paroxetine is the second-line SSRI option if sertraline is ineffective or not tolerated 5, 6

  • Also produces undetectable infant plasma levels 6
  • Lower breast milk transfer compared to other SSRIs 6

Alternative for Anxiety

• Bupropion can be considered for comorbid anxiety and depression, particularly when treating multiple conditions simultaneously 7, 6
  • Present in human milk at very low or undetectable levels in infant serum 6
  • Monitor infant for vomiting, diarrhea, jitteriness, sedation, and/or seizures 6

SSRIs to Use with Caution

• Fluoxetine produces the highest infant plasma concentrations among SSRIs and has more frequent reports of suspected adverse effects 6
• Citalopram produces higher infant plasma levels and has been associated with irritability and decreased feeding more often than sertraline or paroxetine 6

Infant Monitoring Protocol

All breastfed infants exposed to psychotropic medications require systematic monitoring:

• Watch for irritability, excessive crying, or agitation 5, 6
• Monitor for poor feeding, decreased appetite, or feeding difficulties 5, 6
• Assess for unusual drowsiness, sedation, or sleep disturbances 5, 6
• Track adequate weight gain and developmental milestones 6
• Most reported adverse effects are nonspecific and resolve spontaneously 6

Clinical Decision-Making Framework

The choice of medication should prioritize the mother's historical response to treatment rather than strict categorical safety assignments 2

• Untreated maternal bipolar disorder poses significant risks to both mother and infant 4
• The postpartum period represents an exceptionally high-risk time for recurrence of depression, mania, or psychosis in women with bipolar disorder 2
• Maintain therapeutic doses during breastfeeding rather than reducing below clinically effective levels 5

Common Pitfalls to Avoid

• Do not discontinue effective treatment solely due to breastfeeding, as the risks of untreated bipolar disorder typically outweigh medication risks 1, 4
• Avoid high-dose antipsychotics, as they may be associated with long-term adverse sequelae in infants 3
• Do not use clozapine or amisulpiride during breastfeeding under any circumstances 1
• Avoid polypharmacy when possible, as data on combination therapy during breastfeeding is limited and confounded 2