How to treat postpartum depression
By Dana G. Smith
In recent years, mental health struggles have become the leading cause of maternal mortality in the United States, primarily due to suicides and drug overdoses. It is estimated that 1 in 8 new moms experience postpartum depression, and some research has suggested that the prevalence climbed to as high as 1 in 3 during the early days of the pandemic.
Yet roughly half of the women who are struggling with their mental health after pregnancy don’t receive treatment. Barriers to care include a lack of awareness about symptoms and treatments, an inability to access resources and stigma.
Postpartum depression has historically been underdiagnosed and underresearched, but recognition of the condition is finally growing. As a result, there are more treatment options available than ever, including innovative therapeutic models and at least one new medication.
Diagnosing postpartum depression
Many women experience mood swings in the days and weeks following birth because of dramatic hormonal shifts. Sometimes called the “baby blues,” symptoms include feelings of sadness, anxiety, tearfulness or overwhelm; they typically subside within a week or two.
New mothers “feel like they’re on a hormonal ride because they are,” said Dr. Samantha Meltzer-Brody, chair of the psychiatry department at the University of North Carolina at Chapel Hill, who helped found the university’s perinatal psychiatry inpatient unit — the first in the country. “That happens to every single person that gives birth, and that’s considered a normal part of the transition from pregnancy to the postpartum period.”
Postpartum depression is different. It is defined as a major depressive episode that lasts at least two weeks and starts during the year after birth, usually emerging in the first few weeks.
“To meet criteria for a postpartum depressive episode, you must meet criteria for a major depressive episode,” Meltzer-Brody said. Those include persistent low mood, low energy, feelings of worthlessness or guilt, suicidal thoughts and a loss of interest in things that were previously enjoyable.
The condition is typically screened for using a questionnaire known as the Edinburgh Postnatal Depression Scale, which is ideally (but not always) administered at the six-week postpartum visit to the obstetrician’s office. Pediatricians are also encouraged to ask about postpartum depression because they see the family more frequently in the year after birth. Risk factors include a history of depression, a traumatic birth experience and lack of social support, said Latoya Frolov, a perinatal psychiatrist at the University of Texas Southwestern Medical Center.
Treatment options
The treatment a woman receives should depend on her score on the Edinburgh Scale, but all too often there is no follow-up care, either because adequate mental health resources aren’t available or because she can’t access them.
It’s hard to make it to an appointment when you’re overwhelmed, exhausted and depressed, especially if you don’t have easy transportation or child care, Frolov said. “When I see someone make it to an appointment with me, I am overjoyed, honestly, to see them in my office, because I know that often there’s a lot that went into it.”
Therapy
If a woman is found to have mild to moderate depression, she should quickly be referred to some sort of therapy.
Group therapy is often recommended for new moms who are struggling, and it can be one of the most powerful interventions, said Paige Bellenbaum, a licensed clinical social worker and the founding director of The Motherhood Center, a clinic in New York City that offers intensive outpatient care for women with postpartum depression. “It’s the support that women provide to one another,” she said, “that helps them to feel so much less alone in this really, really challenging journey.”
Medication
For women who have moderate to severe postpartum depression, experts often recommend medication — most commonly selective serotonin reuptake inhibitors, or SSRIs. There is limited research specifically testing SSRIs for postpartum depression, but one meta-analysis assessing six studies indicated that a little less than half of the women who take them see an improvement.
Traditionally, doctors have worried that these medications are unsafe for women who are pregnant or breastfeeding, but Frolov said the risks are small, especially compared to those associated with postpartum depression. She said Zoloft, in particular, is frequently prescribed because less medication is secreted into breast milk than with other SSRIs.
Frolov is trying to empower physicians who work with pregnant and postpartum women to feel more comfortable prescribing SSRIs, especially to women who are struggling but aren’t able to see a mental health professional. “I always encourage OBs to treat,” she said. “It’s not enough to screen.”
New options
For women who don’t respond to these therapies, more intensive treatment options are starting to become available, including full-day outpatient and inpatient facilities dedicated to maternal mental health, such as The Motherhood Center and UNC’s perinatal psychiatry unit.
The first medication specifically for postpartum depression also now exists, and it works differently than SSRIs. Treatment with the drug, called Brexanolone, causes a significant reduction in depression scores for about 70% of women who receive it, said Meltzer-Brody, who ran the clinical trials at UNC. Most notably, it works within 24 hours, compared with the weeks or months it takes to see a benefit from therapy or SSRIs.
While Brexanolone’s efficacy is promising, it must be delivered in a hospital vwia an IV for 60 hours straight, which makes it extremely difficult to access. As a result, only a few hundred women, usually the most severe cases, have been treated with the drug since it was approved in 2019.
Experts are optimistic that a related fast-acting medication that can be delivered in a pill form may soon become available. The drug, called Zuranolone, is under review by the Food and Drug Administration, both for postpartum depression and major depressive disorder; a ruling could come as soon as Labor Day.
Perhaps even more important than the new medications, Bellenbaum said, is the fact that the medical and scientific community is investing in research into postpartum depression. “The field of maternal mental health is finally starting to matter,” she said.