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Ask the Mental Health Expert Archives 2001-2004

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Nursing with OCD

Q. I would appreciate your opinion in the pharmacological treatment for nursing mothers with severe cases of OCD.

A. The pharmacological issues of treating nursing mothers with obsessive-compulsive disorder (OCD) are essentially the same as those involving nursing mothers being treated for major depression. The chief concern, of course, is the effect of medication in breast milk, upon the developing infant. Most of the research in OCD nursing mothers seems to have involved older antidepressant agents, such as the tricyclic compound, clomipramine (See Chelmow & Halfin, J Matern Fetal Med 1997;6:31-34).

In one study of serum clomipramine in four nursing mother-infant pairs, Wisner et al (J Clin Psychiatry 1995;56:17-20) found that the parent drug and metabolites were either non-detectable or below the quantifiable limit in the blood of all four infants. No adverse clinical effects were observed in these infants. Most of the research on newer SSRI type medications in breast milk have involved women with depression. While the studies vary in design and outcome, the overall conclusion I reach is that SSRIs appear to pose little threat to the nursing infant.

For example, in one study by Misri et al (J Clin Psychiatry 2000;61:828-32), paroxetine [Paxil] concentrations were barely detectable in the infants' blood, and no unusual adverse effects were reported in any of the infants. Similar findings have been reported with citalopram [Celexa] (Rampono et al, 2000) and sertraline [Zoloft]. However, there is one case of lethargy, low body temperature, and poor feeding in a breast-fed infant whose mother was taking nefazodone [Serzone] (Yapp et al, Ann Pharmacolther 2000;34:1269-72).

While its hard to generalize from the small numbers of infants examined in these studies of depressed mothers-and while no head-to-head comparison studies have been done-I think its likely that the use of antidepressants during breast-feeding poses little risk to most nursing infants, at least with the SSRIs or clomipramine. Since these agents are the ones normally used for OCD, I would assume that this also holds true for nursing mothers with OCD, and their infants. Of course, no psychotropic agent has been proved absolutely safe for nursing infants, and we do not have long-term follow-up studies (>2 years), so far as I know. For less severe cases of OCD, supportive and cognitive-behavioral therapy may suffice (Chelmow & Halfin, 1997), and eliminate the risk of medication to the neonate. For more severe cases, the benefits to the mother's overall well-being probably outweigh the slight risks to the nursing infant.

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June 2001

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