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Antidepressants in Pregnancy and Lactation

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ANTIDEPRESSANTS in Pregnancy & Lactation

Antidepressants	Dose Range (mg/day)	Initial Suggested Dose	Characteristics & Administration Schedule
Selective Serotonin Reuptake Inhibitors (SSRIs)
Fluoxetine (Prozac)	10 – 40	20 mg q AM with food (10 mg if anxiety)	*Activating: not first choice in pts with anxiety; can be beneficial for fatigue. Increase in 10 mg increments at intervals of 7 days. Maintain 20 mg for 4-6 weeks before dose increase. Monitor weight gain and decrease dose in week prior to delivery to aide in neonatal clearance. (Pregnancy Class C)
Sertraline (Zoloft)	50 - 150	50 mg q d, with food (25 mg if anxiety)	Increase in 25-50 mg increments at intervals of 7 days as tolerated. Maintain 100 mg for 4 weeks before dose increase. This medication has been extensively studied for use in breast feeding as well. Minimal amounts transfer into breast milk, but if a mother wishes to minimizethe exposure even further (by 66%), she can pump and discard her breast milk 8 hours after her oral dose. (Pregnancy Category C)
Paroxetine (Paxil)	10 - 50	20 mg q d, with food (10 mg if anxiety q AM)	More sedating: appropriate for anxiety. Increase in 10 mg increments at intervals of 7 days up to a maximum of 40 mg/day. Maintain 20 mg for 4 weeks before dose increase. This* medication has the most anticholinergic side effects of the SSRIs and may be associated with an increased risk of congenital malformation if used in the first trimester and may precipitate mild withdrawal in the neonate following delivery. Inform the pediatrician to supportively monitor the infant. It passes the least into the breast milk of the SSRIs and is virtually undetectable in breast milk. (*Class D)*
Citalopram (Celexa)	10 - 40	20 mg q AM with food (10 mg if anxiety)	Increase in 10 mg increments every 7 days as tolerated. Maintain 20 mg for 4 weeks before dose increase. This edication has been widely prescribed in Europe during pregnancy and lactation. (Class C)[U1]

Tricyclic Antidepressants (TCAs)

Nortriptyline
(Pamelor)

50 - 100

50 mg at bedtime
(10 - 25 mg if anxiety)

Increase in 25 mg increments every 7 days as tolerated
to full therapeutic dose over period of several weeks.
Once daily dosing at bedtime often minimizes side effects.
Adequate trial considered to be 100 mg/day for at least
4 weeks. Therapeutic blood levels can be monitored.
Do not prescribe tricyclic antidepressants to patients
prone to take impulsive overdoses. Do not utilize TCAs
if left bundle branch block is present.
(Pregnancy Category D)

Desipramine
(Norpramin)

75 - 300

50 mg at bedtime
(25 mg if anxiety)

Increase in 25 mg increments every 7 days as tolerated
to full therapeutic dose over period of several weeks.
Once daily dosing at bedtime often minimizes side effects.
Adequate trial considered to be 150 mg/day for at least
4 weeks. Do not prescribe tricyclic antidepressants to
patients prone to take impulsive overdoses. Do not
utilize TCAs if left bundle branch block is present.
(Class C)

Rule out underlying hypothyroidism, nicotine withdrawal, alcohol or substance use, and/or abusive relationships as etiology of depression.

For mild depression (score on EPDS of >12) with minimal impairment recommend:
• Support group
• Interpersonal psychotherapy (with a counselor such as LCSW or a PhD psychologist)
• Bright-Light therapy (read in front of a broad spectrum light each morning for approximately 15 - 45 minutes)
• Social support, regular low impact exercise, and good nutrition
For moderate to severe depression (score on EPDS of >23) with impairment in role functioning:
• Consider adding medication to the above treatment approaches

Treatment Tips
• In the presence of significant co-morbid anxiety, initiate the antidepressant at half the usual starting dose, and slowly increase the dose as the patient tolerates

• For a recurrent depression following cessation of an antidepressant, resume the medication that was previously effective (providing safety data regarding its use in pregnancy and lactation exist)

• Do not change a medication between pregnancy exposure and lactation exposure

• Only expose the fetus / infant to a single antidepressant whenever possible. Data does not exist regarding risks associated with exposure to multiple antidepressants

• Before initiating an antidepressant, be certain to rule out a history of bipolar disorder (e.g. episodes of having high energy, little need for sleep for an extended period of time, elated or irritable mood, and grandiosity). If bipolar disorder is present, consult a psychiatrist to assist with management.

• Treatment duration: Once a single episode of depression is in remission, continue treatment for a full 10 to 12 months. Then very gradually taper and discontinue the medication over 4 – 8 weeks during a non-stressful time, observing for any re-emergence of symptoms. If depression is recurrent or if high levels of stress are present, continue the medication and refer for continued supportive psychotherapy. If marital discord exists, refer for couples counseling prior to the discontinuation of an antidepressant.

ANGELS DREAM Consultation Service for OB providers

• Telephone ANGELS Call Center (866) 273-3835 for access to consultation with mental health experts in perinatal depression.

• ANGELS DREAM Web Site: http://www.uams.edu/angels

Treatment of Depression During Pregnancy

Chronological list of references
http://www.pregnancyanddepression.com

Antidepression in Pregnancy and Lactation    Interested in an Educational Program?    Local Resources

Media Information / Patient Brochures   Overview of Perinatal Depression   Provider Information

Protocols and Guidelines   Screening Tools For Use With Patients & Additional Resources

ANGELS
University of Arkansas for Medical Sciences
Department of Obstetrics and Gynecology
4301 W. Markham St. #518
Little Rock, AR 72205

ANGELS Call Center
(866) 273-3835 or 501-526-7425