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Traumatic events are relatively common in the lives of pregnant and breastfeeding women. According to the National Center for PTSD, the most common traumatic experiences for women are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse (National Center for PTSD, www.ncptsd.va.gov). Trauma in the perinatal period can also be caused by previous pregnancy loss, preterm birth, neonatal death, or a life-threatening birth experience. Some trauma-exposed women will develop posttraumatic symptoms and others will meet full criteria for PTSD.
Comprehensive trauma treatment involves a wide range of activities including patient education, peer support, EMDR, and trauma-focused psychotherapy. Clinicians treating women trauma survivors may also treat them while they are either pregnant or breastfeeding. Most of the standard treatments for PTSD are non-pharmacologic and therefore quite safe for both. But medications are also commonly used to treat PTSD and trauma symptoms. According to Friedman et al. (2009), medications have three potential benefits for patients: 1) they ameliorate PTSD symptoms, 2) they treat comorbid disorders, and 3) they reduce symptoms that can negatively affect both psychotherapy and daily living.
Two recent articles have outlined the state of the art in terms of medication choices for trauma symptoms and trauma symptoms and PTSD (Alderman et al., 2009; Friedman et al., 2009). The classes of medications used to treat PTSD include SSRIs, SNRIs, mirtazapine, SARIs, adrenergic agents, and atypical antipsychotics. Benzodiazepines, anticonvulsants, cyproheptadine, and buspirone cannot be recommended at this time (Friedman et al., 2009).
In each of these classes of medications, there are safer choices for pregnant and breastfeeding women. In perinatal health, the standard reference regarding medication use in this population is Medications and Mothers’ Milk (Hale, 201-). Above is a summary of current medications recommended for trauma symptoms/PTSD, with their pregnancy and lactation risk categories. The pregnancy risk categories are based on U.S. F.D.A. guidelines.
From Hale, T. (2010). "Medications and Mothers’ Milk, 14th Edition." Amarillo, TX: Hale Publishing. Used with permission.
SSRIs address all three symptom clusters of PTSD: re-experiencing, avoidance and numbing, and hyperarousal (Friedman, 2001; Friedman et al., 2009). In the U.S., sertraline (Zoloft) was the first SSRI that was FDA-approved as a treatment for PTSD. Paroxetine (Paxil) is the treatment of choice in the U.K, and the only drug listed with a current U.K. product license for PTSD (National Institute for Clinical Excellence, 2005). Zoloft is also the preferred SSRIs for breastfeeding mothers because its inert metabolites mean that babies are exposed to less than one percent of the mothers’ dose (Hale, 2010). Paxil also results in low levels of exposure for breastfeeding infants, but there is currently a black-box warning against using it during pregnancy. Lexapro (escitalopram) is another good choice for breastfeeding mothers.
Other SSRIs, including fluoxetine (Prozac) and citalopram (Celexa), can also be used to treat PTSD, but result in higher levels of exposure for infants. None of these are contraindicated for breastfeeding mothers, but sertraline, paroxetine and escitalopram are better choices whenever possible (Hale, 2010).
Some newer types of antidepressants can also be used (Friedman et al., 2009). These include venlafaxine (Effexor) and mirtazapine (Remeron). Venlafaxine is a selective norepinephrine reuptake inhibitor (SNRI) and is a frontline treatment for PTSD. Mirtazapine is also showing promise (Friedman et al., 2009). Both have a rating of L3 (“moderately safe”), and should be prescribed only if the benefit outweighs the potential risk to the infant (Hale, 2010).
Trazodone (Desyrel) is a SARI with modest efficacy, but can be a useful adjunctive treatment to promote sleep (Friedman et al., 2009). Trazodone suppresses REM sleep, which reduces the number of nightmares patients experience (Lange et al., 2000). Because trazodone is sedative, breastfeeding women should not share a bed with their babies while taking it. (Nefazodone, the other medication in this class, has been removed from the U.S. market due to liver toxicity.)
The adrenergic agents are another class of medications used to treat trauma symptoms/PTSD. Adrenergic agents work by blocking norepinephrine receptors and include clonidine (Catapres) and guanfacine (Tenex). [Propranolol (Inderal) is also used, but not when a patient has comorbid depression (Friedman, 2001).] Adrenergic agents are frequently prescribed to control hypertension, but in patients with PTSD, they also control symptoms of intrusive memories and hyperarousal. Prazosin (Minipress), an alpha blocker, can be helpful in reducing PTSD-related nightmares (Friedman et al., 2009), but has a rating of L4 (“possibly hazardous”), and should be used with extreme caution in breastfeeding women.
Clonidine is excreted into human milk, with the baby receiving about 6.8% of the mother’s dose. It may also reduce prolactin, which can influence milk production (Hale, 2010). Guanfacine has not been studied with regard to human milk. However, since this medication has low molecular weight, a high volume of distribution, and penetrates the central nervous system at high levels, it is likely to penetrate the milk, so caution is advised (Hale, 2010).
Atypical anti-psychotics may also be added to the treatment regimen as an adjunct therapy for partial responders. These medications may help lessen anxiety responses. The medications within this class include risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa). Olanzapine and quetiapine are rated L2. Risperidone has a risk category of L3. All have a C rating for use during pregnancy.
Although medications are not the central treatment modality for PTSD, they can be helpful in women’s recovery. Medications can be used safely in pregnant and breastfeeding women with trauma symptoms and there are safer choices within each medication category. Medications can also be used in addition to traditional trauma treatments, such as EMDR, psychotherapy, peer support, and psychoeducation.
Alderman, C.P., McCarthy, L.C., & Marwood, A.C. (2009). Pharmacotherapy for posttraumatic stress disorder. Expert Review in Clinical Pharmacology, 2, 77-86.
Freeman, M (2008). Perinatal psychiatry: Risk factors, treatment data, and specific challenges for clinical researchers. Journal of Clinical Psychiatry, 69, 633-634.
Friedman, M.J. (2001). Posttraumatic stress disorder: The latest assessment and treatment strategies. Kansas City, MO: Compact Clinicals.
Friedman, M.J., Davidson, J.R.T., & Stein, D.J. (2009). Psychopharmacotherapy for adults. In E.B. Foa, T.M. Keane, M.J. Friedman, & J.A. Cohen (Eds). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 245-268). New York: Guilford.
Hale, T. (2008). Medications and mothers’ milk, 13th Edition. Amarillo, TX: Hale Publishing.
Lange, J.T., Lange, C.L., & Cabaltica, R.B.G. (2000). Primary care treatment of posttraumatic stress disorder. American Family Physician, 62, 1035-1040, 1046.
Misri, S., Reebye, P., Kendrick, K., Carter, D., Ryan, D., Grunau, R.E., et al. (2006). Internalizing behaviors in 4-year-old children exposed in utero to psychotropic medications. American Journal of Psychiatry, 163, 1026-1031.
National Institute for Clinical Excellence. (2005). Posttraumatic stress disorder: The management of PTSD in adults and children in primary and secondary care. London: Author (available at www.nice.org.uk).
Wisner, K.L., Sit, D.K.Y., Hanusa, B.H., Moses-Kolko, E.L., Bogen, D.L., Hunker, D.F., et al. (2009). Major depression and antidepressant treatment: Impact on pregnancy and neonatal outcomes. American Journal of Psychiatry, published March 16, 2009 in advance (doi: 10.1176/appi.ajp.2008.08081170).
Kathleen Kendall-Tackett, Ph.D., IBCLC is a health psychologist, board-certified lactation consultant, and La Leche League Leader. She is clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. For more information, visit her Web sites: UppityScienceChick.com and BreastfeedingMadeSimple.com.
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