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Symptoms Depressed mood most of the day.
Markedly diminished interest or pleasure in all, or almost all, activities, most of the day.
Marked decrease or increase in appetite, resulting in significant unintentional weight loss or weight gain (ie, >5% body weight in 1 month).
Insomnia or hypersomnia .
Psychomotor agitation or retardation .
Fatigue or loss of energy.
Feelings of worthlessness or inappropriate guilt.
Decreased ability to think or concentrate.
Recurrent thoughts of death, or recurrent suicidal thoughts (with or without a plan).
Diagnostic Criteria Five or more of the symptoms listed above, representing a change in baseline, present nearly every day for the same 2-week period, and producing clinically significant distress or change in functioning
Must include symptom 1 or 2.
Symptoms do not meet criteria for a mixed episode, and they are not due to drugs, another medical condition, or bereavement (unless prolonged; i.e., >2 months)
Adapted from Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.
- Table 2.
Antidepressant Drug Therapy in Breastfeeding Mothers: Infant Serum Drug Levels and Behavioral Outcomes
Study No. of Infants Maternal Dose Infant Age (weeks) Infant Serum Drug Levels (Lower Limit of Detection)* Adverse Infant-Related Clinical Outcomes Selective Serotonin Reuptake Inhibitors (SSRIs) Citalopram (Celexa) Jensen et al, 199723 1 20 mg/day 8 7 ng/mL None Schmidt et al, 200024 1 40 mg/day 6 12.7 ng/mL Uneasy sleep, normalized with dose reduction Rampono et al, 200025 7 0.36 mg/kg/day (median) Not detected; 2.3 ng/mL (1 ng/mL) None Spigset et al, 199726 3 20–40 mg/day 8–16 Not discussed None Fluoxetine (Prozac) Brent & Wisner, 199827 1 20 mg/day 2–3 61 ng/mL Limp, unresponsive, cyanotic (mother also taking carbamazepine and buspirone) Burch & Wells, 199228 1 20 mg/day 17 Not discussed None Chambers et al, 199929 64 Not given 2–24 Not discussed Lower growth curves (average deficit of 392 g) Hendrick et al, 200130 20 10–60 mg/day 0–31 Fluoxetine, <1–84 ng/mL; Norfluoxetine, <1 - 265 ng/mL (2 ng/mL) None Isenberg, 199031 1 20 mg/day 20 Not discussed Irritability Kristensen et al, 199932 14 0.24–0.94 mg/kg/day 0–60 Not detected; 252 ng/mL (10 ng/mL) Colic in 2 infants; irritability, crying, and poor feeding in 2 infants (one of these also had methadone exposure) Lester et al, 199333 1 20 mg/day 24 Fluoxetine, 340 ng/mL; Norfluoxetine, 208 ng/mL Crying, vomiting, diarrhea, and decreased sleep, problem reversed with formula feeding Taddio et al, 199634 11 0.17–0.85 mg/kg/day 3–107 Not detected in the one infant sampled (1 ng/mL) None Yoshida et al, 199835 4 20–40 mg/day 4–40 Fluoxetine and nonfluoxetine not detectable (2 ng/mL) None Fluvoxamine (Luvox) Hendrick et al, 200136 5 100–150 mg/day 6–13 Not detected (1 ng/mL) None Piontek, 200137 2 300 mg/day 2–8 Not detected (2.5 ng/mL) None, for up to 2–3 years after exposure Wright et al, 199138 1 200 mg/day 12 Not discussed None Yoshida et al, 199739 1 100–200 mg/day 17 Not discussed None Paroxetine (Paxil) Hendrick et al, 200136 16 5–30 mg/day 2–26 Not detected (1 ng/mL) None Misri et al, 200040 23 10–40 mg/day 4–42 Not detected (0.1 ng/mL) None Ohman et al, 199941 7 10–40 mg/day 6–30 Not discussed None Stowe et al, 200042 16 10–50 mg/day 4–55 Not detected (2 ng/mL) None Sertraline (Zoloft) Altshuler et al, 199543 1 100 mg/day 3–7 Not detected (0.5 ng/mL) None Dodd et al, 200144 10 50–150 mg/day Not detected (2 ng/mL) None Epperson et al, 200145 14 25–200 mg/day 17–26 Not detected (2.5 ng/mL) None Hendrick et al, 200136 33 25–200 mg/day 2–60 Not detected in 28; 2–8 ng/mL in 2 (1 ng/mL) None Holland, 200046 6 Not discussed 12–16 Not discussed Reduced breast milk supply Stowe et al, 199747 11 25–150 mg/day 4–141 Sertraline, undetectable or <3 ng/mL; desmethyl-sertraline, undetectable or <10 ng/mL (1 ng/mL) None Wisner et al, 199848 9 50–200 mg/day 0–22 Sertraline, not detected or <64 ng/mL; N-desmethyl-sertraline, not detected or <68 ng/mL (2 ng/mL) None Tricyclic Antidepressants (TCAs) Amitriptyline (Elavil) Bader & Newman, 198049 1 100 mg/day 7 Not detected (10 ng/mL) Not discussed Breyer-Pfaff et al, 199550 1 175 mg/day 0–4 Not detected (5 ng/mL) None Brixen-Rasmussen et al, 198251 1 75–100 mg/day 14–30 Not detected (5 ng/mL) None Erickson et al, 197952 1 150 mg/day 8–11 Not detected (28 ng/mL) Not discussed Pittard & O’Neal, 198653 1 100 mg/day 2–3 Not discussed Not discussed Yoshida et al, 199754 2 100–175 mg/day 4–34 Not detected in one, 7.5 ng/mL in one (0.1 ng/mL) Probably none (1 infant was hypotonic before and after exposure) Clomipramine (Anafranil) Schimmell et al, 199155 1 125 mg/day 1–5 9.8–45.4 (20 ng/mL) None Wisner et al, 199556 4 75–125 mg/day 2–19 Not detected or not quantifiable (10 ng/mL) None Yoshida et al, 199754 2 75–125 mg/day 20–56 Not detected in one; 3.2–5.5 ng/mL in one (0.1 ng/mL) None Desipramine (Norpramin) Stancer & Reed, 198657 1 300 mg/day 10–11 Not detected (1 ng/mL) None Doxepin (Sinequan) Frey et al, 199958 1 35 mg/day 1 Doxepin, 10 μg/L; N-desmethyldoxepin not detected (10 ng/mL) Poor suckling and swallowing, drowsiness, hypotonia, vomiting, weight loss Kemp et al, 198559 1 150 mg/day 6 Not detected (5 ng/mL) None Matheson et al, 198560 1 75 mg/day 8 Doxepin, 3 μg/L; N-desmethyldoxepin, 58–66 μg/L (7 ng/mL) Sedation, respiratory depression Imipramine (Tofranil) Erickson et al, 197952 1 150 mg/day 8 Not detected (28 ng/mL) Not discussed Sovner & Orsulak, 197961 1 200 mg/day 4 Not discussed None Yoshida et al, 199754 4 75–150 mg/day 2–25 Not detected in 2; 0.6–7.4 ng/mL in two (0.1 ng/mL) None Nortriptyline (Pamelor) Altshuler et al, 199543 1 125 mg/day 3–7 Not detected (10 ng/mL) None Mammen et al, 199762 2 Not discussed 16–31 Nortriptyline not detected; E-10-hydroxynortriptyline, <4 (2 ng/mL) None Matheson & Skjaeraasen, 198863 1 75–100 mg/day 1 Not discussed None Wisner & Perel, 199164 7 50–80 mg/day 0–24 Nortriptyline, not detectable; 10-hydroxynortriptyline, 5–11 ng/mL in 2 infants (4–5 ng/mL) None Wisner & Perel, 199665 5 75–110 mg/day 4–10 Not detected (<4 ng/mL) None Wisner et al, 199766 7 60–150 mg/day 4–6 0–10 ng/mL in 6 term infants; 16 ng/mL in the single preterm infant (4 ng/mL) None Other Antidepressants Buproprion (Wellbutrin) Briggs et al, 199367 1 100 mg/day 56 Not detected (25 ng/mL) None Nefazodone (Serzone) Yapp et al, 200068 1 300 mg/day 7–10 1270 ng/mL (lower limits of detection not given) Drowsiness, lethargy, hypothermia, and poor feeding (preterm infant) Venlafaxine (Effexor) Ilett et al, 199869 3 3–8 mg/kg/day 2–24 Venlafaxine, not detected (4 ng/mL); O-desmethyl-venlafaxine, 23–225 ng/mL (3 ng/mL) None Ilett et al, 200270 7 225–300 mg/day 11–41 Venlafaxine, not detected; 5 ng/mL; O-desmethyl-venlafaxine, 1.5–5.7 ng/mL (1 ng/mL) None * Lower limits of detection are shown in parentheses (in nanograms per milliliter) when the specified drug was not detected in the infant’s serum. Lower limits vary with the precision of the laboratory method. ‘Safe’ infant serum levels of antidepressants have not been established, in that safety profiles depend on the age of the infant (healthy term infants more than 10 weeks old have a lower risk of negative effects), the characteristics of the drug, and concentrations of its metabolites.13
Study Study design; n Intervention Outcome Individual Therapy Appleby et al, 199721 Randomized controlled trial; n = 87 women with PPD 4 treatment groups: fluoxetine or placebo, plus 1 or 6 sessions of counseling provided by trained health visitors and derived from cognitive behavioral therapy (included reassurance and practical advice about feelings of not coping, child care, and lack of enjoyable activities and practical support) Six sessions of counseling were better than 1 (clinical interview schedule score difference = 38.7% at 12 weeks), and fluoxetine was better than placebo (score difference = 40.7% at 12 weeks). There was no advantage in combining fluoxetine and counseling Cooper & Murray, 199780 Randomized controlled trial; n = 194 primiparous women with PPD 4 treatment groups: nondirective counseling (n = 48), cognitive-behavioral therapy (n = 42), dynamic psychotherapy (n = 48), and a control group (n = 54); therapy sessions occurred 1 hour/week for 10 weeks Over the initial 10-week period, the 3 treatment groups showed greater improvement than the control group; however, by 9 months postpartum, there was no significant difference between groups Holden et al, 198981 Randomized controlled trial; n = 55 women with PPD 8 weekly counseling visits by health visitors trained to provide nondirective counseling (listening to clients’ feelings, and encouraging them to make decisions based on their own judgment) 69% of women in the counseling group versus 38% in the control group had recovered after 3 months. O’Hara et al, 200082 Randomized controlled trial; n = 120 women with PPD 12 weekly individual counseling sessions led by experienced psychotherapists (discussed losses & and interpersonal conflicts and affirmed clients’ competence) 43.8% of women in the counseling group versus 13.7% controls had recovered after 3 months. Group Therapy Chen et al, 200083 Randomized controlled trial; n = 60 women with PPD 4 weekly supportive group sessions comprising discussions about transition to motherhood, postpartum stress management, communication skills, life planning, and strategies for change Intervention group members experienced significant declines in depression scores, whereas control group members did not (Beck Depression Inventory change: −6.14 versus −0.92, P < .01). Fleming et al, 199284 Non-randomized controlled trial; n = 76 depressed & 76 non-depressed mothers 8 weekly unstructured support groups, facilitated by psychologists; mothers discussed childbirth experiences, mood, motherhood, changing spousal relationships, and returning to work versus staying home While the entire sample showed an improvement in mood from 2 weeks to 5 months postpartum, there was no significant intervention effect. Meager & Milgrom, 199685 Randomized controlled trial; n = 20 mothers with PPD 10-week group treatment program, included education (about PPD), cognitive-behavioral therapy, and homework for reinforcement Depression scores dropped significantly in the experimental group (Edinburgh Postnatal Depression Scale difference: −9.0), but not in the control group (difference, 0.5).
