Safe Antidepressants for Breastfeeding

Primary Recommendations

The American Academy of Family Physicians recommends sertraline and paroxetine as the preferred first-line antidepressants for breastfeeding mothers, as they transfer into breast milk in the lowest concentrations and produce undetectable or very low infant plasma levels 1, 2
Sertraline is one of the safest antidepressants during breastfeeding, transferring to breast milk in low concentrations and consistently producing undetectable infant plasma levels 1, 2
Paroxetine similarly transfers in lower concentrations than other antidepressants and produces undetectable infant plasma levels 1, 2
Both medications are the most commonly prescribed antidepressants during breastfeeding and should be considered first-line agents 1, 3

Fluoxetine produces the highest infant plasma concentrations among SSRIs and has been associated with more frequent reports of suspected adverse effects in infants 4
Citalopram also produces higher infant plasma levels and has been associated with nonspecific adverse effects (irritability, decreased feeding) more often than sertraline or paroxetine 4
Venlafaxine produces higher infant plasma concentrations compared to sertraline and paroxetine 4

Bupropion is present in human milk at very low or sometimes undetectable levels in infant serum 5
The American Academy of Pediatrics recommends maintaining therapeutic dose of bupropion while breastfeeding if needed, with careful monitoring for vomiting, diarrhea, jitteriness, sedation, and/or seizures 5

All antidepressants transfer into breast milk in low concentrations 1, 3
There is little evidence supporting any causal link between antidepressant use in breastfeeding mothers and adverse effects in infants overall 4
Potential adverse effects documented in case reports are nonspecific (irritability, decreased feeding) and occur more frequently with fluoxetine and citalopram 4
No long-term neurodevelopmental data exist for most antidepressants used during lactation 4

Bupropion can be considered for individuals with postpartum depression, particularly with comorbid conditions, as it is present in human milk at very low or undetectable levels in infant serum, and is useful for individuals requiring treatment for co-occurring depression and other conditions, according to the American College of Obstetricians and Gynecologists 6

All breastfed infants should be monitored for irritability and excessive crying, poor feeding or decreased appetite, unusual drowsiness or sedation, sleep disturbances, and adequate weight gain and developmental milestones, as recommended by the American Academy of Pediatrics 7
Infants should also be monitored for adequate weight gain and developmental milestones, as suggested by the American College of Obstetricians and Gynecologists 6

Most reported adverse effects in infants are nonspecific and resolve spontaneously, according to the American Academy of Pediatrics 7

The American Academy of Family Physicians recommends sertraline as a first-line treatment for postpartum depression in breastfeeding women, with a typical starting dose of 50 mg daily and a maximum dose of 200 mg/day, based on clinical response 8

The American College of Obstetricians and Gynecologists supports maintaining a therapeutic dose of sertraline at the time of delivery and during breastfeeding for women already on sertraline 8

Sertraline remains the preferred first-line antidepressant for breastfeeding mothers across all therapeutic doses because it transfers into breast milk in the lowest concentrations and produces undetectable infant plasma levels, as recommended by the American Academy of Family Physicians 9

The American Academy of Family Physicians was not found to have any relevant information in this article, however the article does mention that sertraline at doses up to 200mg daily produced significantly greater response rates, but no specific citation was provided for this information, however the safety of sertraline during breastfeeding at this dose is supported by 9