Mood stabilizers during breastfeeding: A review

Background: The postpartum period is an exceptionally high-risk time for re currence of depression, mania, or psychosis for women with bipolar disorder . Puerperal prophylaxis with mood stabilizers decreases this risk. To allow patients and clinicians to make informed decisions about mood-stabilizer u se during breastfeeding, there is a need for a critical review and analysis of the data. Data Sources: A search of MEDLINE (1966-1998) and the Lithium Database, Mad ison Institute of Medicine, was conducted to obtain articles about lithium, valproate, carbamazepine, gabapentin, or lamotrigine use during lactation. Search terms used were pregnancy, teratogenesis, breastfeeding, lactation, breast milk levels and lithium, anticonvulsants, mood stabilizers. No othe r search restrictions were used. Unpublished data on gabapentin and lamotri gine were provided by the manufacturers. Results: The search revealed ii cases of Lithium use during breastfeeding, 8 of which reported infant serum levels. Two cases reported symptoms consis tent with lithium toxicity in the infants. Thirty-nine cases of valproate u se during breastfeeding were found, 8 of which reported infant serum levels . There was 1 report of thrombocytopenia and anemia in an infant. Fifty cas es of carbamazepine use during breastfeeding were found, 10 of which report ed infant serum levels. Two infants experienced hepatic dysfunction. One un published study of gabapentin in breast milk was found. Three reports of la motrigine use during breastfeeding were found. Discussion: Available information remains limited to uncontrolled studies a nd case reports. Carbamazepine and valproate, but not lithium, have general ly been considered compatible with breastfeeding. The overall paucity of da ta, data confounded by polypharmacy and infant age differences, and adverse reactions reported with all established mood stabilizers dictate a reasses sment of these recommendations. We propose that a woman's historical respon se to medication and the clinical circumstances be the primary consideratio ns when choosing a mood stabilizer during breastfeeding, rather than strict adherence to categorical assignments.