In Postpartum Depression, Effective Care Is Often Out of Reach

Darby E. Saxbe, PhD

Disclosures

August 08, 2019

"Everything just seemed like a complete and utter unmitigated disaster," says Amanda, a biology professor in Georgia, as she looks back on the time surrounding her son's birth.

"Our son was a wonderful surprise," she says, but she wasn't prepared to be pregnant. She battled pre-eclampsia and hyperemesis throughout the pregnancy, becoming so sick that she lost 35 pounds in her first 3 months. "I spent more time under my desk with a garbage can than actually sitting at my desk," she remembers. "It was pretty brutal." She'd also had a longstanding history of depression, which worsened following her pregnancy.

Before pregnancy, Amanda took both venlafaxine (Effexor) and aripiprazole (Abilify) to manage her mood disorder; during pregnancy, she continued on the venlafaxine but stopped the aripiprazole given that its pregnancy outcomes were largely unknown. Reflecting back, Amanda believes that her pregnancy "was not well managed emotionally or medically."

After her son was born via an emergency C-section at 36 weeks, she knew within a week that she was experiencing postpartum depression. Amanda resumed the aripiprazole, but her depressive symptoms and anxiety only intensified. Worse, Amanda's milk supply plummeted after she started the medication. She struggled to breastfeed for several weeks, soon discovering that lactation problems are a known side effect of aripiprazole. "I had this wonderful plan to breastfeed, and then that fell apart," she says. "It was a rough transition."

Balancing the Health of Mothers and Infants

Providing mental health care to perinatal women like Amanda is complex. The transition to parenthood is a period of renegotiating identities and social roles, as well as a perfect storm of hormonal changes. Moreover, mothers and infants may have divergent health needs. Antidepressant medications cross the placental barrier,[1] and some studies have suggested that they compromise fetal neurodevelopment.[2] Taken postpartum, the drugs may interfere with breastfeeding, as Amanda discovered.

Most seriously, self-harm and suicidality are a leading cause of morbidity and death for women in the first year postpartum.

Though the reluctance to include pregnant women in clinical trials is waning, traditionally it was considered unethical to experiment on pregnant or lactating women. As a result, conclusive evidence on peripartum psychiatric drug therapies is hard to find. Many women thus avoid or discontinue antidepressants during pregnancy, which may introduce additional risks and complications.

Depression affects "not only the health of the mother, but the health of the fetus or nursing infant, the marriage or partner relationship, and the new role of parenting," says Emily Dossett, a psychiatrist who directs the Women's Mental Health Program at the Keck School of Medicine at the University of Southern California. In the perinatal period, she says, "you're more aware of treating not just the individual but her family, [both] present and future."

Vivian Burt, a psychiatrist who directs the Women's Life Center at UCLA, concurs. "Treating perinatally depressed patients means addressing the needs of women, while at the same time taking into consideration the well-being of their babies. Often there are other family members (other children and spouses) who are impacted as well by perinatally depressed mothers (or mothers-to-be), and so it is important to assess and address issues in the family that have a bearing on treatment decisions."

The DSM-V refers to pregnancy-related depression as "major depressive disorder with peripartum onset," a definition that includes the "most recent episode occurring during pregnancy as well as in the 4 weeks following delivery." Many women with post- or peripartum depression have had depression at other points in life. A recent study found that nearly 70% of women with a history of depression who discontinued their antidepressant going into pregnancy experienced a relapse, compared with just 26% of those who continued on antidepressant therapy.[3] A survey published in 2008 in the Archives of General Psychiatry found that women who had been pregnant in the previous year who also had a mood disorder diagnosis were significantly less likely to seek out any mental health care in the first place.[4]

There is also evidence that women with depression and other psychiatric diagnoses have a more than threefold risk of inadequately using available perinatal care.[5] This is especially troubling given that rates of postpartum depression are as high as 15%, and that mood-related maladies such as depression are risk factors for substance abuse and self-harm.

Talk Therapy: A Low-Cost, High Impact Treatment Option

In March 2019, the US Food and Drug Administration (FDA) approved the first drug for postpartum depression, brexanolone (Zulresso). Though hailed as a game-changer by its manufacturer for its nontraditional mechanism of action (it targets the brain's gamma aminobutyric acid network and can take effect within hours), brexanolone has been called out for its high price tag—$34,000 for a single course of treatment—and its intensive mode of delivery. The drug is given as a single 60-hour infusion, during which new mothers must be monitored and accompanied during interactions with their newborn(s).

Dossett is excited that a medication approach with a novel mechanism of action is now available and hopes that it can become more accessible clinically and financially in the very near future. But so far, she hasn't prescribed brexanolone  much because she works in the safety net system and the cost is "currently prohibitive." Plus, the prolonged monitoring period would mean hospitalization and finding an appropriate place to administer the drug. For many mothers, brexanolone may simply be out of reach, not just because of its high cost but also because of the logistical challenge of spending multiple days away from a new baby.

A lower-tech treatment option for women at less acute risk—talk therapy—also offers promise. Just a month before brexanolone received its FDA approval, the US Preventive Services Task Force (USPSTF), a nonpartisan body that makes preventive healthcare recommendations, published a systematic review paper in JAMA[6] evaluating interventions to prevent postpartum depression. USPSTF reviewed 50 studies that it considered to be of reasonably good quality: 49 randomized clinical trials and one nonrandomized controlled intervention study. These studies tested a variety of interventions, ranging from pharmacologic and dietary treatments (such as sertraline, nortriptyline, and omega-3 fatty acid supplementation) to counseling or talk therapy interventions.

The strongest support emerged for talk therapy. After pooling effects of the 20 studies included in the review (reflecting a total of 4107 participants), USPSTF concluded that counseling interventions reduced the likelihood of perinatal depression by 39%.

A few specific interventions showed particularly compelling risk reduction rates of over 50%. For example, "Mothers and Babies," which comprises 6-12 weekly group sessions and a handful of postpartum booster sessions, uses a cognitive-behavioral therapy approach with modules on topics like stress, cognitive distortions, and automatic thoughts. The "Reach Out, Stay Strong" program uses an interpersonal therapy framework, with four to five prenatal group sessions and an individual postpartum follow-up session. The course includes psychoeducation on role transitions, social support, and role-play exercises to help women resolve interpersonal conflicts.

For women who may not need medication or who wish to combine medication with talk therapy, the data suggest that these programs can be effective and fairly low-cost, given that they can be facilitated in a group format with master's-level paraprofessionals.

Moreover, these interventions were deemed as low-risk; USPSTF reported zero  side effects of talk therapy, in contrast to pharmacologic treatments. Dossett concurs that most women do not need medication. The integrated obstetrics and mental health clinic where she practices has a "stepwise" approach to care. All women receive depression and anxiety screening at their first prenatal visit, and a community health worker delivers psychoeducation regarding mental health.

If the woman screens positive or requests more mental health support, she is referred to a social worker. The social worker then conducts a more thorough behavioral health assessment and can engage the patient in ongoing psychotherapy. Only the women who have severe, complex, or historic symptoms of psychiatric illness come to Dossett for psychiatric care. Even then, she doesn't start all women on medication but instead focuses on a thorough discussion of the risks of untreated illness versus the risks of medication, and what seems to be more appropriate for the patient and her preferences.

Sometimes it takes several visits to properly assess and educate the patient before making a decision about whether to start a medication. "What I try to emphasize is that the baby's best chance at health comes from having a mother who is healthy and well, even if it takes medication to achieve that," Dossett says. 

When I get really depressed, I shut down and don't want to get out of bed. Had I sought help sooner, I would have been a much better parent…

UCLA's Burt (who is a stockholder in Sage Therapeutics Inc, the company that developed brexanolone) takes a similar approach. "Because the use of antidepressants and other medications during pregnancy and breastfeeding is not without some risk, nonpharmacologic strategies such as psychotherapy, bright light therapy, and mindful meditation are reasonable modalities to try first," she says. "However, if a woman is experiencing severe, debilitating depression, or if she has a history of chronic depression with severe relapses following medication discontinuation, antidepressants and other medications should be considered, often in conjunction with psychotherapy."

Another consideration, according to Burt, is whether psychotherapy has worked in the past, and if so, which modality has been most beneficial (cognitive-behavioral, supportive, or interpersonal therapy), as well as what degree of support the patient has. Depending on the patient, she may recommend new mother support groups, parenting groups, and couples therapy if relationship issues are implicated in perinatal depression.

What's Still Needed?

Will women make the time to participate in preventive mental health care during pregnancy? For Amanda, the answer is an emphatic yes. "When I get really depressed, I shut down and don't want to get out of bed. Had I sought help sooner, I would have been a much better parent," she says.

Devon (last name withheld by request), a pediatric researcher in Indiana, agrees. Although her first child's birth had been uneventful, she found that after becoming pregnant with her second child through in vitro fertilization (IVF), "it was an unexpectedly much more difficult experience." Devon had been through six  rounds of IVF and says she "was on a hefty dose of IVF meds, so I had a lot of ups and downs in my moods." Devon felt "blue" throughout her pregnancy and worse after her baby arrived.

"It was absolutely terrible," she says. "My son was a really crappy sleeper. We worked so long to get him, and the mismatch of that with how hard it was to have him home… One day I woke up and felt like the weight of the world was sitting on my shoulders. It was very dark, like a blackness over me." After eventually seeking help, Devon's depression lifted, but she felt that she had lost weeks of her new son's life. "This can be a really isolating experience. If I had a place where I could have read and learned about it, I could have realized… You think you are alone, but it's not a failure on your part."

After Amanda's depression reached a low point in which she spent 6 weeks in bed, she finally found a treatment approach that worked for her: a combination of medication and therapy. "I found someone who is patient, kind, and is willing to explore different things with me…putting feelings into words and making them less scary and overwhelming, and coming up with a plan to better change my mindset and overcome some challenges."

Wanting to warn other mothers about her breastfeeding experience with aripiprazole, she also collaborated on a case study that was published in the journal Clinical Lactation in 2019.[7] Devon is also doing much better, although she still fears a recurrence of her depression: "I spent a long time waiting for the other shoe to drop."

Dossett sees perinatal mental health care as a microcosm of our larger mental health landscape. "The needs we have in maternal mental health reflect what we need in our healthcare system overall," she says. First, she sees a need for integrated care that decreases stigma and improves the delivery of services. Second, a need for language, culture, and socioeconomic sensitivity for how each woman experiences perinatal mood disorders. Third, a recognition that postpartum depression is a spectrum illness without a "one size fits all" approach.

She would also like to see more parity in care so that perinatal mental health problems are screened for and treated just like any other diagnosis in pregnancy or the postpartum period. Similarly, Burt notes that "it is important for public and private facilities to offer expanded perinatal psychiatric programs, staffed by trained clinicians in multidisciplinary settings." Although she hails the increase in awareness and recognition that perinatal depression and anxiety have gotten over the past decade, she emphasizes that an increase in awareness parallels an "increased need for provision of services for this patient population… The need for these patients is great and growing."

Dossett adds, "We also need to recognize that perinatal mental health is a moment in time for many women, and that their mental health needs preceded and may very well extend beyond the 2 years of pregnancy and postpartum."

Devon agrees, cautioning that "postpartum depression doesn't unfold according to a timetable. It can come and go. It doesn't always look the way you talk about it in the classroom or in a textbook." For women like Devon and Amanda, greater access to screening, resources, and treatment options during the perinatal period could have transformed their transition to parenthood and prevented the "complete and utter unmitigated disaster" of postpartum depression.

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