Better Tolerance of Citalopram in a Breastfed Infant Who Could Not Tolerate Sertraline and Paroxetine

Introduction

Depression is the most common psychiatric disorder emerging after childbirth. Although depressive disorders in the postpartum period affect >10% of women in general,^1–3 the incidence of major depression that needs to be treated with antidepressant drugs in most postpartum women is 5–7%.^4–6 Selective serotonin reuptake inhibitors (SSRIs) are widely used in anxiety and depressive disorders. Similar to all psychotropic drugs, these antidepressants can be excreted into breast milk. In contrast, many mothers would like to breastfeed due to many benefits of breastfeeding both for the mother and the infant.^7,8 Therefore, mothers and their relatives frequently worry about the health of infants when the mother is treated with antidepressants.

A growing body of reports on the safety of antidepressants in breastfed infants has been published in the literature. Owing to good safety profiles such as relative infant dose (RID), which represents the weight-adjusted infant dose relative to the weight-adjusted maternal dose, ⁹ paroxetine and sertraline are the first-line antidepressants recommended for breastfeeding women when the mother requires antidepressant treatment.^10,11 However, fluoxetine and citalopram/escitalopram are also well tolerated by breastfed infants despite higher RID values than sertraline and paroxetine. ¹⁰ This report presents a breastfed infant who could tolerate maternal use of citalopram after adverse events to exposure to sertraline and paroxetine through breast milk.

Case

A 25-year-old breastfeeding woman with a 2-month-old baby was admitted to the psychiatry outpatient clinic of a university hospital with depressive symptoms such as insomnia, depressed mood, anhedonia, loss of appetite, and decrease in psychomotor activity. She had no history of psychiatric disorders before or during the pregnancy. The patient described that the symptoms occurred in the third week pospartum with a subsequent gradual increase in their severity. After a psychiatric interview performed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, ¹² the patient was diagnosed with major depressive disorder. The Hamilton Rating Scale for Depression (HAM-D) ¹³ score was 25.

After psychiatric assessment, sertraline at 50 mg/day was initiated in the patient. Six days later, a dramatic decrease in the duration of sleep and restlessness in the baby was reported. Sertraline treatment was stopped, and the symptoms completely resolved within 3 days. After that, paroxetine at 20 mg/day was administered to the patient. It was reported by the patient that the baby had severe constipation. When paroxetine was discontinued, constipation in the baby completely improved without any specific treatment within 2 days. In addition, the clinical examination of the baby by a pediatrician and laboratory tests including hemogram, biochemistry parameters, and thyroid function tests suggested that the baby did not have any illnesses that could have resulted in the symptoms developed during maternal usage of sertraline and paroxetine. Moreover, weight gain of the infant was within normal limits, and the baby was solely breastfed. Owing to the continuation of depressive symptoms, citalopram at 20 mg/day was prescribed to the patient. The mother reported that depressive symptoms were significantly ameliorated; moreover, the baby did not experience any side effects due to citalopram. At the end of 1 and 2 months of treatment with citalopram, the HAM-D scores in the patient were 11 and 6, respectively.

Discussion

The available scientific data do not suggest any contraindication for the use of SSRIs during breastfeeding. A recent systematic review ¹⁰ has suggested that the prevalence rates of adverse events in infants exposed to sertraline and paroxetine were <1%. However, more recently, some authors ¹⁴ have reported that 72 infants exposed to sertraline or paroxetine had higher frequency of adverse events (12.5%). The most widely reported side effects in babies exposed to antidepressants through breastfeeding are irritability, constant crying, feeding and sleep disturbances, agitation, and sedation.^12,14 In this report, sertraline and paroxetine were stopped due to sleep disturbances, restlessness, and constipation in the baby. Similar to previous reports, ¹⁴ the adverse effects recovered within days after discontinuation of sertraline and paroxetine.

Strategies to cope with the side effects of antidepressants in breastfed infants have not been adequately addressed in the literature. A switch between antidepressants may be useful in coping with adverse events observed in infants of at least some of the patients. ¹⁴ In the current case, a switch from sertraline to paroxetine was carried out, since these two antidepressants have better safety profiles and lower prevalence of side effects in breastfed infants. ¹⁰ When the infant could not tolerate either of these two antidepressants, citalopram was administered to the patient. During the follow-up period, no adverse events were observed in the infant. This finding suggests that continuing a switch between SSRI antidepressants even if the first two drugs show adverse events in breastfed infants may be a useful pharmacological option. However, in this case, a standard rating scale to assess side effects due to the medications was not used. This is a limitation for the current case.

In conclusion, if further studies confirm this case report, citalopram may be an appropriate choice for breastfeeding women even when exposed infants develop adverse events to other antidepressants such as sertraline and paroxetine.