(from: http://www.kellymom.com/health/meds/antidepressants-hale10-02.html)

Dr. Hale provided an insightful and fact filled presentation on treating depression in nursing moms. For reference on items contained below, see Medications & Mothers’ Milk, 2004 by Thomas Hale. Notes are arranged as follows:

• Highlights
• SSRI improvements over older drugs
• SSRI sequence of effects
• Specific drugs
  • Prozac
  • Zoloft
  • Paxil
  • Celexa
  • Effexor
  • St. Johns Wort
  • Bupropion
  • Lithium
  • Valium
  • Tricyclics
• Drug Hierarchy
• Concluding remarks

Highlights were that:

• The effects of an untreated depressed mom on the infant are significant and hazardous; but the marginal effects of any medication usually are less hazardous than those effects. Treating a mom with postpartum depression (PPD) is much preferable to not treating, since a baby has a better outcome generally (as measured by Bayley scores, measuring interaction skills and speech and language development) when being cared for by a non-depressed parent.
• PPD is significantly more dangerous compared to depression outside of postpartum; PPD patients are sometimes more likely to commit suicide, and need to be treated with due haste. Waiting to wean before starting medication is not a sound option. Also, weaning in order to treat is not a good choice due to the loss of the positive effects of breastfeeding. The rate of depression in the general population in an individual’s lifetime is between 3% and 17%. However, in the postpartum population depression is about 15%, and is often more severe. For example, it moves to psychosis more frequently.
• In all studies thus far, any negative effects of medication usually occur in the first 30-60 days postpartum, so breastfeeding beyond that and taking medication is usually fine.
• Babies exposed in utero can suffer “discontinuation syndrome” (a.k.a. withdrawal effects) but sometimes this is misdiagnosed as a reaction to the continued medications in mom’s milk, when really the milk transfer rate for many of the SSRIs is negligible.

The SSRI family of antidepressants is significantly improved over older antidepressants as follows:

• Not addictive
• No associated buzz
• Mild withdrawal or “discontinuation syndrome” in some patients
• More rapid onset as compared to older tricyclics
• Side effects generally wane over time
• Reported 60%-70% response rate in patients.

The sequence of effects for SSRIs is as follows:

• Sleep and anxiety normalize within the 1st week
• Motivation, interest, hopefulness and appetite return within 2nd and 3rd week
• Mood and libido may improve after (libido may worsen)

Specific drugs discussed:

• Prozac is the only drug “cleared by the FDA” for use during pregnancy. A mother on Prozac during pregnancy may wish to change drugs before birth or immediately after, or titrate the dose down in the last trimester since the existing blood plasma level in the newborn fetus plus the drug transfer through milk may lead to toxicity. Its effects on the breastfed infant have been reported in infants 2 months old or less.
• Zoloft is the “best drug choice so far”. It has a low, low transfer rate to breastmilk (17-173 ug/liter) in mothers taking up to 150 mg/day. In one excellent study of 11 mother/infant pairs, the zoloft was undetectable in 7 of the 11 breastfeeding infants’ serum and minimal in the other infants. In two other studies of one and three mother/infant pairs respectively, zoloft was undetectable in the plasma of all 4 infants. A theoretical concern with Zoloft is that some babies may not gain weight as rapidly or as well when breastfed by moms on Zoloft; so weight gain should be monitored and dosage tweaked as necessary.
• Paxil has low blood plasma levels in the mother, and a low transfer rate to human milk. It was undetected in the blood plasma of 7 of 8 breastfed infants in one study, all 16 of the infants in a second study, and all 24 of the infants in a third study. For babies exposed to paxil in utero, there is evidence that withdrawal may occur 24-48 hours after birth.
• Celexa has a 4.3-16 nanogram/kg blood plasma level, but transfer rate is higher via milk. Use with caution and watch infant for side effects (per Hale, “There have been two cases of excessive somnolence, decreased feeding, and weight loss in breastfed infants.”).
• Effexor is a popular drug for treating depression in Australia. It is less popular here in the USA due to reported side effects. Effexor can also be used in breastfeeding mothers if it is efficacious. It may be effective against hyperactivity. It is an SSRI and NRI.
• St. John’s Wort is a weak SSRI. It also stimulates liver enzymes and may enhance the metabolism of other drugs. German varieties are found to be the most pure in independent testing; other brands may have contaminates and not be very pure. Documented drug-drug interactions have been found; the action of St. John’s Wort on the liver can accentuate the metabolism of many drugs. For example, St. John’s Wort may reduce the efficacy of birth control pill regimens, although this has not been documented.
• Bupropion has a high milk to plasma ratio, and is excellent for use in smoking cessation programs. It may reduce the milk supply but as yet this is undocumented.
• Lithium use by the breastfeeding mother is dangerous to the breastfed infant.
• Valium use by the breastfeeding mother entails a greater risk of infant sedation, and may perhaps increase the risk of SIDS.
• Tricyclics – many have significant side effects in mothers including dry mouth, constipation and other anticholinergic symptoms. Thus they are not overly popular with patients. Generally, tricyclics have a poor transfer to milk with the exception of Doxepin, which has a higher transfer rate. Long-term effects are unknown.

When choosing a medication SSRIs are generally the preferred choice for a breastfeeding mother. Side effects from SSRIs are most common in the first 3 months postpartum; so with an older baby, there is little concern. Hale’s “choice hierarchy” is as follows:

• Zoloft
• Paxil
• Celexa
• Effexor
• Prozac

Finally, Dr. Hale concluded his talk by saying that breastfeeding should be supported fully and not interrupted by mom’s needs for medication; and that treatment of postpartum depression can be accomplished relatively safely in breastfeeding mothers. So, in his consideration, moms should continue breastfeeding and should get drug treatment as needed for depression.

I told my doctor as such, and must have been convincing–I mean, those *are* real issues and they were enough to make anyone depressed.  We spent most of my visit talking about my situation, though, and not how breastfeeding was going or how long I bled.  My doctor was genuinely concerned about me.  Even now it makes me emotional to think about.

Two days ago BabyCenter sent me the Month Three: Week One newsletter regarding my baby.  I clicked the link to “read more” and stumbled across this:

Your life: When the baby blues don’t pass

Do you feel anxious and moody a lot but chalk it up to new-mom nerves? As the weeks go by, has your partner or a friend wondered if your “baby blues” may be more serious? Don’t let embarrassment or pride keep you from talking with your doctor. As many as 10 to 20 percent of new mothers develop postpartum depression, which can last from two weeks to as long as a year. It’s a real and treatable illness.

If you’re still not feeling like yourself three months after giving birth, ask yourself the following questions, which were developed by the Postpartum Stress Center: in Rosemont, Pennsylvania. Do you:

• have trouble sleeping?
• feel exhausted most of the time?
• have less of an appetite?
• worry about little things that never used to bother you?
• wonder whether you’ll ever have time to yourself again?
• think your children would be better off without you?
• worry your partner will get tired of you feeling this way?
• snap at your partner and children frequently?
• think other moms are better mothers than you are?
• cry over small things?
• no longer enjoy the things you used to enjoy?
• isolate yourself from your friends and neighbors?
• fear leaving the house or being alone?
• have anxiety attacks?
• have unexplained anger?
• have difficulty concentrating?
• think something is wrong with you?
• feel like you’ll always feel this way and never get better?

If you answered yes to three or more questions, the Postpartum Stress Center recommends that you seek advice and treatment.

Three or more?  Try *most* on for size.  This is my life.

I have a rich, troubled history of mental illness, depression, anxiety and that was–ahem–complimented with a bit of self-mutilation.  It’s been passed down through the generations of my family and definitely didn’t skip mine.  I bounced around on anti-depressants, anti-anxiety medications and mood stabilizers in my teenage years and endured a few misdiagnoses as well.  All of that was enough for me to say goodbye to pills and deal with it myself.

And since I have been relatively successful in my dealings over the last few years, I figured that I could just push through this depressive, anxious, snappy, agitated thing I’m going through now.  I mean, I’m not happy, but I am used to that–I can deal with that.  But should my husband and son have to?  And really, just because I *can* deal with being miserable doesn’t mean that I *should*.

The night before last, after my son was tucked in and I was getting settled in for the night, I started talking to myself.  Normally such dialogues take place in my head, but not this time.  I found myself saying, “Why shouldn’t I just kill myself?  I’m going to kill myself.  I wish I could just chop my head off right now and be done with it.”  This may sound scary, but the idea is nothing new to me.  And even with all of these thoughts that swim through my mind, I am never actually suicidal.  I never think about *really* killing myself.  All of my frustrations build up to the point where I just feel like I can’t cope anymore, though, and wind up manifesting themselves as the idea of escaping it all.  The only way to not have to deal with anything is to die.  But I don’t want to die and I’m not going to.  Nor am I going to do anything to harm myself.

If for no other reason, I live because my kids need me.

And let’s be honest, here.  My kids need a GOOD me.  They need a HAPPY me.  They need a mother who isn’t so anxious and reactionary that she can’t enjoy all of the little things that used to light up her life.  And my husband deserves to have his wife back.

But does this mean that I have to go on anti-depressants again?  In my googling, I found that Zoloft is the most common SSRI prescribed to treat PPD and that it has the lowest instance of side-effects in breastfed babies.  I’ve taken Zoloft before–it didn’t work for me ten years ago, will it work now?  Do I want to risk exposing my baby to drugs?  No.  Am I willing to quit breastfeeding?  No.  So what do I do?

Another article I read said that if you are choosing between treatment and breastfeeding, choose the treatment.  But I don’t feel ready to make that choice–and I am not willing to put my three-month-old on formula.

Additionally, I have zero sex-drive, and Zoloft is known to reduce sex-drive and cause sexual dysfunction (in women, too).  I already feel huge amounts of guilt for not providing in that department, and fear that drugs would just make it worse.

I just don’t know *what* to do.