A Possible Prescription Treatment for D-MER
If there is concern from a care provider regarding the use of these drugs in a breastfeeding mother we suggest consulting Dr. Thomas Hale's book, "Medications and Mothers' Milk".
Bupropion, the active ingredient in Wellbutrin, is the treatment that looks the best at this point. Here's why it makes sense:
So far, it seems that anything that increases dopamine is likely to improve D-MER. There are a few things that increase dopamine that just aren't sustainable for use all day every day, however, and we'd all like something we can keep taking!
A Brief Course in Neurophysiology: By Novices, For Novices
Hormones are chemicals that are released by cells into the bloodstream, stimulating or blocking activity in other cells. Neurotransmitters are chemicals that are released by nerve cells (neurons), stimulating or blocking activity in other neurons. A signal travels electrically within the neuron, out to its very tip, releasing a neurotransmitter that now has to cross only the tiniest of gaps in order to stimulate the neighboring neuron. The neurotransmitter quickly fastens itself to receiving points, called receptors, on this neighboring neuron. Any "leftover" neurotransmitter is taken up again by the transmitting neuron. A drug that keeps a transmitting cell from taking back its released neurotransmitter is called a "reuptake inhibitor".
Neurotransmitters work faster than hormones, just as electricity travels faster than a river. That's probably why D-MER mothers feel the dysphoria before their milk starts to flow. The milk release reflex is triggered within their brains by neurotransmitters that have already done their job by the time their hormonal partners have reached the breast to release milk there.
The brain is fairly well protected from blood contaminants by the "blood-brain barrier". That means that raising the blood's level of a chemical doesn't necessarily raise the brain's level, so we sometimes have to be sneaky when the neurotransmitters we want to affect are inside the brain itself.
Dopamine is both a hormone and a neurotransmitter. It is probably its role as neurotransmitter within the brain that matters in D-MER. This is where the sneaky part comes in. Since we can't squirt extra dopamine into the bloodstream and have it cross the blood-brain barrier to reach the brain, if we want to increase brain dopamine levels we have to 1) make the brain increase its own output of dopamine, or 2) make the brain release a chemical that the receptors will accept as if it were dopamine, or 3) keep the transmitting cells from taking back left-over dopamine, so that there will be more available for the receptors to keep accepting, or 4) increase the number of receptors.
Bupropion (Wellbutrin) is a "dopamine reuptake inhibitor," which means it allows a woman's own dopamine to be used more completely, essentially increasing her dopamine levels. There are other dopamine reuptake inhibitors, and there are "dopamine agonists," which fool the receptors into behaving as if they've been given dopamine. However, at this point bupropion has the best track record as a medication for breastfeeding mothers. It's also familiar to physicians, who have probably prescribed to breastfeeding women before, so we think getting a prescription should be easier.
How Much Do You Need?
Probably not much.
A typical dose for depression is 150mg to 300 mg per day, often given in a once a day extended release pill. A 300 mg per day dose is sometimes used to help quit smoking. We suspect that these levels are unnecessarily high for many D-MER mothers.
Consider asking for 100 mg time release pills, and start with one pill per day. If that seems inadequate, you can work your way up slowly. Talk to your doctor about how and when to increase or decrease your dose; extended release pills must not be broken to change dosage. At a starting dose of 150 mg per day, one woman felt a small improvement once during the first day; by the end of the week her D-MER was essentially gone. However, she began to experience an annoying side effect, and will be backing her dosage down, to find a level that does nothing more than erase, or nearly erase, her D-MER. We'll keep you posted. Please understand, D-MER treatment is very much a work in progress!
Any Cautions, Besides What's in the Package Insert?
Any drug that raises dopamine levels will lower prolactin levels, so dopamine reuptake inhibitors and dopamine agonists are not generally advised for breastfeeding mothers. However, based on our very, very limited testing we think perhaps D-MER mothers may be resistant to the drop in supply that other mothers might experience. If D-MER mothers are starting with slightly less dopamine (and thus slightly more prolactin) than usual, a slight increase in dopamine should simply "level" them, the way thyroid medication just brings a mother's thyroid hormones back into her normal range. Our "test mother" took pseudoephedrine for a cold, not realizing that it can lower a supply, and had no unwanted decrease. She has had no unwanted decrease with bupropion. She began with a slight oversupply that the drugs may have helped normalized, but the change was very small.
We are suggesting a starting dose 2/3 the size of the usual starting dose, 100 mg per day instead of 150 mg per day. Nonetheless, please recognize that we're all feeling our way through this, and keep an eye on your supply if you use bupropion.
What About the Effect on Your Baby?
According to Thomas Hale's book, Medications and Mothers' Milk, Twelfth Edition (2006), the amount of bupropion that the baby gets is probably about 2 percent of the mother's dose. If your baby has started solids, the amount of drug he gets will be even lower. Blood levels of bupropion were undetectable in the babies' blood when 10 mothers took 150 mg per day for 2 days and then 300 mg for another 5 days. There were no side effects noted. There is a recent report of seizures in a 6-month-old whose mother had taken 150 mg per day for 4 days. She discontinued the drug and continued breastfeeding with no further effects. Those two outcomes, seizures in one baby and undetectable blood levels in others, don't fit together well, but that's all we have to go on.
Many breastfeeding mothers have taken bupropion at the usual antidepressant dose of 300mg, and we are suggesting something only 1/3 that high to start with, but it is still a prescription drug. Discuss its appropriateness for you with your doctor and pharmacist.
Would You Like to Help Build our Knowledge Base?
If you and your doctor decide bupropion or another dopamine-enhancing drug is a good choice for you, we'd love a report on:
- Your starting symptoms
- Your dosage
- Changes you experience, and after how many days
Why Won't Other Antidepressants Work?
Most of the antidepressants typically prescribed to breastfeeding mothers are SSRIs (Selective Serotonin Reuptake Inhibitors.) Now that you know what a reuptake inhibitor is, you can see why they don't work. Serotonin doesn't seem to be the neurotransmitter we need to target. The SSRIs may help any generalized or postpartum depression that you may have in addition to D-MER, but mothers report that they haven't helped with D-MER.
Who Shouldn't Try Bupropion?
If your baby is very young or your symptoms are mild, you might want to wait before seeking a prescription. But if are thinking of weaning, or have an older baby (you can define for yourself what "older" means), a low-dose prescription may be a good option. It's very early in the game for specific recommendations so talk with your pharmacist and doctor about it, and take into account the age of your baby and severity of your symptoms. Remember that a very low dose is probably all that is needed. Also look over the suggestions for natural treatments and lifestyle changes for further help.
And those of you who do try bupropion? Please let us know your experience with it! It works in theory, it has worked in practice, but we need more numbers. Thank you!