Understanding Postpartum Depression

But first, let’s first talk about postpartum depression…

Around 85% of all women experience some mood disturbance after childbirth. As well as being pregnant, the postpartum period is a mix of emotions. With this new role of motherhood, many new feelings could come about. Some women get excessively anxious and experience mood-changes. If this behavior starts interrupting your new life it may be a good idea to consider a medical evaluation to determine if you are experiencing a postpartum mood disorder.

Most women suffer postpartum blues, lovingly known as baby blues, which is a low mood and mild depressive period that is transient and limited. On the contrary, around 10 to 15% of women suffer from postpartum depression, a more delicate situation that could start before labor. The symptoms are the same as depression, including:

• Depression 
• Sad mood and tearfulness
• Loss of interest in usual activities
• Feelings of guilt, worthlessness, or incompetence
• Fatigue and sleep disturbance
• Change in appetite
• Poor concentration
• Suicidal thoughts

I also want to mention here that as rare as it is, postpartum psychosis affects 1 to 2 per 1000 women after childbirth. This extreme condition would trigger delusional beliefs and erratic behavior. 

When Should I Take an Antidepressant?

Are you feeling overwhelming feelings, mood changes, and getting anxious frequently. In that case, you may want to try therapy or perhaps meditation. Consider talking with your doctor!

If you are having symptoms of depression or anxiety -and maybe other treatments did not help- your doctor may recommend taking medication, antidepressant specifically. The drug must be safe to take while breastfeeding if you are, some of them are not, so talk to your doctor about possible side effects. Be aware that the risks of untreated mental health -severe anxiety and depression are types of mental health imbalance- problems have side effects and risks to you and your baby. 

So, I am Breastfeeding… What Types of Antidepressants are Available for Me?

If, for any reason, you have to start taking antidepressants, your doctor may suggest one or another -yes! Numerous drugs act as antidepressants. What is best for you will depend according to your personal medical history and symptoms. All antidepressants are chemical molecules working at your brain level, trying to return it to a balanced state. Think of them as high-qualified workers that assists with the imbalance in your brain, returning it to normal. These antidepressive molecules act primarily with neurotransmitters -the brain messengers- allowing their levels to grow in the brain, so the signaling pathway is restored, and your mood gets back into balance.

​​As I said before, there many types of antidepressants, so I will explain a little bit about how each of them (those that you could take while are breastfeeding) works.

• Cyclic antidepressants: this type of antidepressant works by blocking the reabsorption of neurotransmitters, so the neurotransmitters level increases within your brain to regulate your mood. There are many chemicals in this family of antidepressants, however, a few that are safe to be used during breastfeeding include: Imipramine and nortriptyline.
• Serotonin and noradrenaline-reuptake inhibitors (SNRI): as the name tells us, this antidepressant works by increasing the level of serotonin and noradrenaline within the brain, by blocking their reabsorption (or reuptake). The most common drugs in this family are venlafaxine and duloxetine. However, in 2020, a new drug was released: desmthylvenlafaxine, which results from the metabolism of venlafaxine. Due to the lack of data, the safety of using these antidepressants while breastfeeding (or even during pregnancy) is not proven.
• Selective serotonin-reuptake inhibitors (SSRI): despite the simple name, this family of medication act over many neurotransmitters. While specifically block serotonin reabsorption (thus increasing levels within the brain), many of these drugs act over other neurotransmitters pathways. The outstanding data of this family is that their effect on our mood changes are fast, so maybe your doctor initiates the treatment with half (or less) of the dose. It has been proven that women with postpartum depression who start a full-dose treatment could experience severe headaches. Added to a relative safety overdose of these drugs, place them as the first choice antidepressant. Paroxetine and sertraline are the SSRIs of choice during breastfeeding.
• Other lesser-known drugs, but used during breastfeeding are Mirtazapine and Bupropion. At this point, you are aware that one way or another, antidepressants work by increasing some important neurotransmitters -there are five types in total. These two drugs act slightly differently from the above-mentioned drug action. While the drug Mirtazapine (NaSSA antidepressant) allows the liberation of noradrenaline and serotonin, Bupropion acts as a norepinephrine and dopamine reabsorption blocker, increasing their levels, and blocking the effect of another neurotransmitter: acetylcholine.

In Simple Words, How Does Zoloft® Work?

Well… Zoloft^® is the brand name for sertraline and acts to increase serotonin levels by blocking its reabsorption. As discussed above, it is one of the preferred drugs to prescribe during pregnancy or after labor when depression or anxiety rises.

The increasing amounts of serotonin help maintain mental balance. The scientific community calls this natural substance as the “happiness regulator”. The explanation is that, beyond external factors, happiness depends on internal factors too. And this is the role of serotonin: regulate satisfaction, optimism, and happiness at the brain level. When serotonin levels falls, you may get depressed, and antidepressants, like Zoloft®, increase the amounts of serotonin in within the brain. 

I will take a moment to tell you one more thing: during uterine life, babies receive serotonin from their mothers via the placenta, so when mothers have a low serotonin level, serotonin does not reach the baby and may have consequences on the baby’s overall brain development. This is why, during pregnancy, you must be cognisant of depression or anxiety symptoms.

Can Zoloft ® Pass Through Breast Milk??

Indeed it can! All antidepressants pass through breast milk in different proportions. Antidepressant molecules are lipid soluble, which means they can easily mix with fatty liquids like milk. But you also have to know that this passage depends on multiple factors related to the mammary gland, milk production, the mom´s drug metabolism ability, and/or health status (for example, if you are going through mastitis). 

Zoloft® is a safe medication. Although there are side effects (every medication taken has its risk), it is the most authoritative antidepressant for the breastfeeding period if you are suffering from depression or anxiety. The main reason is that sertraline, or its metabolites, are present at very low levels in breast milk, and the amount that the child could ingest is small, and usually not detected in the blood serum of the baby.

If I Have to Take Zoloft®, Are There Any Long-Term Effects?

I will start by telling you that there is no proof of any long-term side effects to the child or the mother from taking Zoloft®. Studies are inconclusive since the samples are too small and the sertraline levels are low in breast milk and children’s blood.

The last revision in the Drug and Lactation database (May 2022) shows a list of case reports and cohort studies where moms suffering from depression were taking sertraline while breastfeeding. Their babies were followed during different periods of their growth and development and conducted studies showed minor effects on the children, such as benign neonatal sleep myoclonus (sudden brief involuntary twitching or jerking), agitation, or blunted responses to pain. However, I have to point out that many studies lack a control group, so the conclusions were limited to observation and description.

Even more compiled data from 930 surveys revealed that 10% of children showed symptoms like irritability, uncontrolled crying, and eating and sleeping disorders, when their mothers cut the antidepressant treatment. 

Zoloft® is the favorite option for addressing postpartum depression, and numerous factors contribute to this preference, as we named a few of them. Still, adhering to your doctor’s directives is crucial when taking medication during breastfeeding. Ultimately, the main goal remains to sustain breastfeeding, as it confers advantages to you and your infant.

When Should I Expect the Highest Peak of Zoloft® in My Breast Milk?

It is hard to know when Zoloft® reaches the highest amount in breast milk. And the explanation depends on the mother and her course of treatment:

• Regarding the mother: the age, health status, and the mother´s metabolic performance all are factors to the amount of Zoloft in her breast milk. We also should not forget (of course!) to consider if breastfeeding is exclusively or partial.
• Regarding the treatment: the treatment duration, beginning, and dose are also important. While most women could start the treatment during pregnancy, plenty of others started it only after labor.

The medical and scientific communities have studied sertraline for a long time -to this day- and by far it is still the first choice to treat postpartum depression. The most important reason for this is that only slight amounts of sertraline passes into the breast milk. While the exact amount of Zoloft® in the breast milk is linked to the dose of the drug, the health status of the mother, and the duration of treatment, most studies show that the peak concentration of sertraline and its metabolites appear 8-9 hrs after the dose. 

Do I Have Alternatives Options to Treat Postpartum Depression?

Of course, there are! 

Once your doctor diagnosis you with postpartum depression, they may run some tests to elucidate if you have another health problem that may have lead to postpartum depression. Then, they will propose different options according to their findings:

• Therapy: could be cognitive behavioral therapy (CBT) or interpersonal therapy (IPT)
• Support groups: people who are in the same situation as you. In meetings, they share their experiences, fears, hopes, and feeling in this stressful situation.
• And, of course, medication. All of which are discussed in this article.

You may choose to take medication, but you can also combine this with other therapies: this could help to lower the dose of antidepressants or the duration of the treatment. The sooner you see your doctor, the better. You will have more options for your treatment and more time to enjoy motherhood.

When Should You Talk with Your Doctor?

It is hard to say, but I would say: as soon as you start to feel strange, such as a lack of interest in doing things or the feelings of guilt and shame buzzing in your head… Only you can see these symptoms because most of them are just a feeling. I leave you here a list of possible symptoms from the website of March of Dimes:

Changes in your feelings

• Feeling depressed most of the day every day
• Feeling shame, guilt, or like a failure
• Feeling panicked or scared a lot of the time
• Having severe mood swings

Changes in your everyday life

• Having little interest in things you normally like to do
• Feeling tired all the time
• Eating a lot more or a lot less than is normal for you
• Gaining or losing weight
• Having trouble sleeping or sleeping too much
• Having trouble concentrating or making decisions

Changes in how you think about yourself or your baby

• Having trouble bonding with your baby
• Thinking about hurting yourself or your baby
• Thinking about suicide

Final Thoughts 

Postpartum depression is an actual mental health diagnosis, despite what most people think. This new role can trigger emotions and feelings that sometimes turn into daily anxiety and depression. If you are struggling with these emotions call your doctor. It is better to be proactive than wait until you are really struggling. You can enjoy motherhood and breastfeeding (in case you decide it) with the correct depression treatment.

Having postpartum depression is not your fault or a sign of weakness. Your hormones are playing games in your brain. At last, let me remind you that you have tools to diminish the risk of suffering postpartum depression. Staying healthy and fit, reducing stress, practicing mindfulness, and a lot of other effective alternative therapies can work together to decrease your overall risks. 

Ask for help. Your friends and family are there and want to support you. And at the very least get professional help, Get in touch.