Should Breastfeeding Moms Stay On Antidepressants? Why These Researchers Say Yes

New mothers who struggle with depression might feel hesitant to keep taking antidepressant medication while breastfeeding. But new research hints that there are benefits to staying on antidepressants, despite the reported short-term risks of drug exposure in babies.

An analysis from the Robinson Research Institute at the University of Adelaide, Australia suggests that rather than posing a risk to newborns, antidepressants could actually make it more likely that mothers will nurse their babies for the six-month period recommended by pediatricians.

"This is a really important message because we know that breastfeeding has immense benefits for the child and the mum herself, including a degree of protection against post-natal depression," said pharmacist and lead researcher Luke Grzeskowiak, PhD., in a press release.

Much debate exists over whether mothers should take antidepressants while breastfeeding. Opponents argue that there's very little research on the long-term effects that the medication can have on a nursing baby, while advocates say that it's better for both the mother and the child if the mother stays on her meds and doesn't risk a bout of depression.

The study examined a group of several hundred women in Denmark, with an emphasis on a particular category of antidepressants called SSRIs, or selective serotonin reuptake inhibitors. Grzeskowiak identified two groups of mothers -- those who were on SSRIs before they were pregnant and continued to take them while pregnant, and those with untreated depression who did not take SSRI medication before, during or after pregnancy.

The researchers found that a full two-thirds of women in the first group stopped their medication in order to breastfeed. Meanwhile, the remaining third in the first group continued their regimen uninterrupted as they transitioned from pregnancy to lactation. The study doesn't indicate why the women stopped taking antidepressants.

Seventy percent of those who never stopped their antidepressant medication managed to breastfeed until the six-month mark and beyond, while 57 percent of those who stopped taking medication quit before the pediatrician-recommended sixth month. Fifty-four percent of mothers with untreated depression who never took SSRIs also stopped breastfeeding before six months.

The research seems to suggest that mothers experiencing untreated depression will have a harder time successfully breastfeeding than mothers who stay on their prescribed medication. In the release, Grzeskowiak argued that the health benefits of breastfeeding far outweigh the potential risks from exposure to antidepressants. He also encouraged family members, friends and health care professionals to support a breastfeeding mother if she chooses to continue taking her medication.

Adam Urato, M.D., a maternal-fetal medicine specialist at Tufts Medical Center in Boston, took issue with Grzeskowiak's conclusions, calling them "misleading" and an "overreach."

"What concerns me about the press release that was issued from this research group is that it sends out such a strong pro-antidepressant message, which is not warranted from their relatively weak data," Urato told The Huffington Post.

Grzeskowiak is funded by the National Health and Medical Research Council of Australia, a federal organization that funds public health research.

Urato says the relatively small sample size in Grzeskowiak's study means it has weak statistical significance. More importantly, he said, Grzeskowiak's abstract has no information on the overall health of the mothers or babies after six months or more of breastfeeding.

The American Academy of Pediatrics released a report last year indicating that many medications are safe for women to take while nursing, including some antidepressants. There are also a number of studies showing that breastfeeding babies don't appear to be exposed to high levels of certain SSRI drugs through breast milk.

However, there are a handful of sobering case studies that have led doctors like Urato to warn that some babies, because of their still-developing bodies, are more vulnerable to SSRI compounds than others.

"No one is arguing that we should ignore depressed women, or depressed postpartum women," said Urato. "That's not the choice, and no one should be arguing for that."

But given the known risks for infants like sleep interruption and colic, as well as the unknown potential long-term risks, Urato advised mothers with mild depression to explore non-pharmaceutical treatment before resorting to SSRIs.

"The conclusion is common sense," he said. "Pregnant women and women of child-bearing age should, as a first-line approach to depression, be given non-drug approaches like psychotherapy and exercise."

While the long-term effects, if any, of antidepressants on nursing newborns is unknown, the long-term effects of being raised by a mother with untreated depression are well established, said Alison Stuebe, M.D., a maternal-fetal medicine physician and medical director of lactation services at the University of North Carolina at Chapel Hill.

Mothers with severe, untreated depression may not smile at their babies, make eye contact with their babies or respond to them when they cry, Stuebe told HuffPost. This puts babies at an increased risk of anxiety and depression later in life.

More urgently, suicide remains a leading cause of death among pregnant and postpartum women, and up to one in seven women suffer from postpartum depression at some point in their lives. Misinformation about SSRI exposure in the womb and in breast milk could put yet another barrier between a depressed woman and life-saving treatment.

"My big worry when I see moms affected by depression is that they're going to try to keep a stiff upper lip and not treat their depression," said Stuebe. "And that will make Mom miserable, which could affect how she engages with baby and thus affect baby's development."

Stuebe agreed with Urato that regular therapy can be effective in treating mild depression, but access to mental health services is limited for many -- and can be more difficult than getting a prescription for an antidepressant. Last year, a study showed that of the 45.6 million Americans who suffer from a mental illness, 50 percent could not afford the cost of mental health services.

Stuebe, who has done her own studies on depression and breastfeeding, says the important thing is to strengthen the mother-baby bond. If breastfeeding is important to a mom, then physicians should help find an antidepressant that won't affect a baby's serotonin level. On the other hand, if a mom absolutely hates breastfeeding, then forcing herself to do it could harm her relationship with her child.

Because of the documented risks in a handful of cases, and perhaps because of the stigma still attached to mental illness, there doesn't appear to be a standardized approach among OB-GYNs for discussing antidepressant use with their patients. Stuebe said she found several of her lactation patients had been given erroneous information about antidepressants and breastfeeding, while Grzeskowiak has encountered many women in Australia whose doctors never brought up the subject.

Both said there needs to be a consistent message, across the board, about the proper use of antidepressants during pregnancy and lactation. Stuebe added that lactation specialists need to learn how to screen new mothers for depression, while psychiatrists should ask their clients about breastfeeding problems.

When expectant mothers are given the wrong information about antidepressants, said Stuebe, "a lot of [them] will say, 'The hell with that, I'm not going to breastfeed' or 'I'm not going to take the medicine.'"

Stuebe said she couldn't agree with Grzeskowiak's conclusion that antidepressants help women breastfeed better. But, she added, his study does "support the notion that untreated depression is just one of many things that make it difficult for women to breastfeed."

Grzeskowiak defended the small sample size of his study in an interview with HuffPost, saying that he factored in things like the women's ages, weights and levels of education to make sure those variables weren't affecting the results. He also defended the quality of the data, noting that the women self-reported their medication but were asked so many other things to be part of the dataset that they likely had no idea their answers would be used for a study on antidepressants and breastfeeding.

Grzeskowiak, who plans to conduct follow-up research on the mothers and children in his study, said that he got the idea for the project after reading a 2012 Lancet medical journal editorial about a mother who had stopped taking her prescribed antidepressants for fear the drugs would contaminate in her breast milk. She ended up suffocating her 14-month-old and 10-week-old children and was sentenced to inpatient psychiatric treatment.

CORRECTION: A previous version of this article misspelled Dr. Alison Stuebe's last name. We regret the error.

Get To Class
Dr. Ann Borders, an OB-GYN who works with NorthShore University HealthSystem, recommends that her patients and their partners go to a breastfeeding class before Baby is born. In class, they don't just focus on why breastfeeding matters, but what you can actually expect in those daunting first few days. And Borders doesn't just recommend this for newbie families, but also moms who may have tried breastfeeding before and found it difficult. "You're not going to know everything from taking the class, but it gives you a groundwork that you can build on at the hospital once you have the nurses helping you," Borders said. Most OB-GYNs will be able to give you a referral to a breastfeeding class nearby, but if for some reason yours doesn't have any suggestions, a quick online search should bring up options in your area.
Don't Leave Until You Get Help
When you're in the hospital or birthing center, or while you've still got your midwife with you after a home birth, make sure you speak up and ask for help getting started. "Every health care person should know the basic mechanics of breastfeeding," said Mary Ryngaert, a board certified lactation consultant with the University of Florida's Center for Breastfeeding and Newborns. "I joke that the person who empties the trash [in labor and delivery] should be able to help someone latch on." Even Borders, whose professional life and research centers around breastfeeding, said that when her first baby was born, she had to ask for guidance. Women should feel 100 percent empowered to ask their care provider to help them start breastfeeding within the first hour after a vaginal birth or two hours after a C-section if the circumstances allow for it, she said. Don't leave the hospital until you've gotten the help you need.
When In Doubt, Think Skin-To-Skin
There's a reason why hospitals hoping to earn the coveted "baby friendly" designation for breastfeeding support stress the importance of skin-to-skin: It works. Research shows that essential contact helps relax both the mom and baby, stimulates feeding behaviors and triggers the release of certain hormones that spur breastfeeding. Experts say it's important to do it both early -- ideally right after birth -- and often. "Keeping the baby skin-to-skin as much as possible in the early days after birth is very important," Ryngaert said. "If the mother is 'touched out,' then the partner can hold the baby skin-to-skin. It still helps the baby move instinctually to what [he or she] is supposed to do." If you're not in a "baby friendly" hospital with policies in place to promote skin-to-skin, don't be discouraged. Tell your doctors and nurses that it's important to you, Borders said. As long as your baby is stable, there's no reason why they shouldn't let you hold him or her close.
Be Prepared For Engorgement
Engorgement, or a feeling of heavy fullness in the breasts that can be very painful, is common several days after delivery, but Borders said a lot of women don't know to expect it because no one talks to them about it. Having a game plan in place can help curb the pain and keep women from throwing in the towel when they're sore and freaked out. She suggests an over-the-counter pain medication, like Motrin, and ice. Two bags of frozen peas can also work, Borders said, and -- bonus! -- they tend to fit nicely into nursing bras. Some women may also want to take a hot shower to express some of their milk.
Lean Back And Put Your Feet Up!
Susan Burger, president of the New York Lactation Consultant Association, finds few things as irksome as telling women that they need to try specific holds. Moms hear those tips and get "all twisted up with finding the perfect position," she said. What matters most in her book is that breastfeeding mothers get comfortable, which often means leaning back a bit and putting their feet up. "If she's comfortable, it's so much easier to get the baby into a comfortable position," Burger explained. This is one area where partners can really step in, looking at moms to spot any ways in which they might be uncomfortable, then helping by giving them a pillow, a shoulder rub ... whatever.
Ask Your Partner To Sit With You
Your partner, or your mom or friend can also help by agreeing to sit with you while you breastfeed. Why? Since moms are often extremely relaxed and drowsy while they're breast-feeding, your partner can agree to be on "alert" -- maybe quietly reading a book or checking e-mails -- while you get some sleep. "Invite her to take a cat nap while breast-feeding," Ryngaert said. It may sound like a simple trick, but Ryngaert said it's such an easy, often-overlooked way for women to fully relax while breast-feeding, which only increases bonding and enjoyment, and also, possibly, catch up on some much-needed sleep.
Tilt Back, Open Wide
Drop your mouth down to your chest, then open your mouth. A bit tricky, no? Now tilt your head back slightly and open it again. See how much easier that is? Burger said that one of the biggest ways to help babies drink is to make sure their heads are tilted back a bit. You can help support them in that position by putting a forearm under the baby's neck, or even a rolled-up receiving blanket. "There are a lot of different ways to achieve it," she said.
Think Close, Close, Close
While experts may not poo-poo specific holds, at least ones a professional hasn't personally recommended for you and your baby, they do offer broader positioning advice: "I like to see the baby and mother have almost no space between them," Ryngaert said. "You're not just putting your breast in their mouth, you're really bringing your bodies together," she said. That helps babies bring a big, wide open mouth to the breast, giving them the deep attachment that they need. If you're not sure what that means, a good first place to look is the internet: There are videos online that demonstrate the concept, Ryngaert said, and places like La Leche League have helpful illustrations as well.
Pump In Short, Frequent Bursts
Burger said that one of the mistakes women can make is to focus too much on duration and not enough on the frequency of pumping. Often they're too hard on themselves, sitting there for long stretches and pumping away in an attempt to produce more milk, when really, they'd be better served by just a few minutes here and there throughout the day. Burger likened it to training for a marathon: "You wouldn't just go out and run 13 miles," she said. "If you're just starting out, you'd try a mile or two and do that three or four times a week. That's a much better approach." In the same vein, if you can work it into your schedule, frequent, brief bouts of pumping help build milk supply better than sitting there, rather helplessly, and pumping for one long stretch.
Don't Just Deal With Sore Nipples
Borders said that women shouldn't just write off sore nipples -- which can sometimes become so bad they don't want to breast-feed at all. She recommends something called Newman's all-purpose ointment, which your pharmacist can mix for you. For women who don't have thrush (a generally harmless yeast infection) La Leche League also recommends applying freshly expressed breast milk to your nipples, which can help them heal. The bottom line? If your nipples hurt, don't just accept it. Talk to your doctor about what might be causing it and what you can do.
Know When To Call
"Make sure you leave the hospital with the number for someone you can call with questions," Borders said. Many pediatricians offices now have lactation consultants on staff, which makes it easier for women to find someone who can offer guidance when you're they're in for one of those many new baby visits that happen after birth. In many cases, lactation consultants are covered by insurance, Ryngaert said, but places like La Leche League also have a call system where you can speak to someone for free. Many nurses and pediatricians are also board certified lactation consultants, which can help with insurance coverage. Women shouldn't feel pressure to figure everything out in the first week, Ryngaert said. "If a baby needs to go on formula for a time while the mother's milk supply is being established, that doesn't mean the baby's not going to be breastfed," she added. "I've seen babies that didn't latch on until eight weeks." But new moms should never, ever hesitate to ask for help. "If a mother is having more than a little tenderness, she should not just tough it out. She should get some help" Burger said. "And if that person says, 'Oh, it's normal, suck it up,' that's not a good person to get help from, and they should see someone else."