Antidepressants, Antipsychotics, Benzodiazepines, and the Breastfeeding Dyad

In Hamlet, Shakespeare's protagonist utters words that have echoed throughout history: "To be or not to be, that is the question." We borrow from him when we paraphrase with "To breastfeed or not to breastfeed, that is the question"--and an important one at that. For mothers taking or in need of psychotropic medication, the question becomes more complex. If a mother asked your advice, how would you respond? It is tempting to present the questioner with an either/or decision: either stop the medications or do not breastfeed. While that approach seems less complicated in some ways, it is not necessarily the best answer, and certainly is not without risks. This column is a review of existing scientific literature intended to help the nurse to better understand this controversial topic. There are compelling reasons to treat some new mothers with psychotropic medication directly after childbirth. The World Health Organization (WHO) estimates depression will become one of the two major illness burdens in developed countries by the year 2020. The incidence of depression in women is twice as high as in men, and the average age of onset is 25 years. It has also been noted that psychiatric illnesses increase markedly in the postpartum period (Buist, 2001). Postpartum depression and postpartum psychosis have made headlines in the last few years, yet many non-headline-making families have suffered in relative silence. Simply refusing to consider treatment of the mother is not a viable option. On the other hand, not breastfeeding forfeits a number of significant health protections for mother and baby. It must be emphasized that breastfeeding is the biological norm for the mother-infant dyad, and disruption of that norm should not be taken lightly. Issues Surrounding Psychotropic Drug Use and Breastfeeding Breastfeeding Benefits and Formula-Feeding Risks: Two Sides of the Same Coin Infants who are formula fed are at risk for more short-and long-term health problems than are their breastfed peers (Table 1). The American Academy of Pediatrics (AAP, 1997) recommends exclusive breastfeeding for approximately the first 6 months of life, and continued breastfeeding to at least 1 year or beyond. Formula-fed infants have more allergies and incidents of asthma and wheezing (Burr et al., 1993), more episodes of diarrhea (Clemens et al., 1999), more ear infections (Duffy, Faden, Wasielewski, Wolf, & Krystofik, 1997), and are more likely to be overweight or obese entering kindergarten (Armstrong & Reilly, 2001). Children who were not breastfed as infants are at increased risk for developing childhood cancers (Davis, 1998) and type 1 insulin-dependent diabetes (Virtanen et al., 1991). If a mother chooses (or is advised) to formula-feed, her health is at risk, too, both in the postpartum period and in the long term. Not breastfeeding increases the risk of postpartum bleeding, and women who do not breastfeed also have a greater incidence of obesity and osteoporosis later in life (Lawrence & Lawrence, 1999). Mothers who do not breastfeed significantly increase their risk of ovarian cancer (Lawrence & Lawrence), and a recent large-scale reanalysis of data from 47 different studies (including more than 50,000 women) found that mothers decreased their risk of breast cancer by 4.3% for every 12 months they breastfed (Collaborative Group, 2002). Mothers who do not breastfeed miss out on important mother-infant bonding and the empowerment many mothers find in being able to provide something positive and special for their babies (Lawrence & Lawrence). In other words, not only is "breast best," breast is normal. Breastfeeding and Psychotropic Drugs: General Considerations in the Healthy Full-Term Infant Many healthcare providers know little about the effects on the infant of drugs in breast milk, and fear possible harmful effects if a drug is known to have an unfavorable pregnancy category rating. …