Antidepressants and anxiolytics during lactation

The postnatal period may represent a critical phase for mothers, due to an increased risk for the onset/recrudescence of affective as well as anxiety disorders. In some cases, according to the severity and intensity of a psychiatric condition, an antidepressant and/or anxiolytic agent should be promptly administered. However, some mothers may wish to continue breastfeeding despite the psychotropic drug. Therefore, there is the need to obtain more reliable information regarding to the safety profile of such medications through maternal milk, in order to weight the potential neonatal risks. This chapter aims to provide a complete overview on the neonatal safety profile of anxiolytic agents (i.e., benzodiazepines, Z-drugs) and antidepressants (tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin noradrenergic reuptake inhibitors (SNRIs), reboxetine, mirtazapine, bupropion, trazodone, mianserin, and agomelatine) during breastfeeding. Clinical and pharmacological data are here provided. In particular, the chapter shows data on both neonatal outcomes and pharmacokinetic indices such as the relative infant dose (RID), milk drug concentration (MDC), neonatal plasma drug concentration (NPDC), milk-to-plasma ratio (M/P). There are still few reliable data on the neonatal safety of these psychotropic drugs. However, available evidence suggest that SSRIs should be considered as first-line agents (particularly, sertraline and paroxetine), among the antidepressants. Whilst nortriptyline may be preferred among the TCAs. Furthermore, shorter-acting benzodiazepines (i.e., alprazolam, lorazepam) are generally considered safe during breastfeeding whilst longeracting benzodiazepines (i.e., diazepam, clonazepam, etc.) are considered less safe and should not be preferred during the lactation period. More limited data are available for Z-drugs.