Suzanne Leigh, UC San Francisco
Baby blues occurs in most new mothers, but 1 in 6 will go on to develop the more crushing symptoms of postpartum depression, which in severe and rare cases can lead to psychosis, and, in offspring, insecure attachment, difficulty regulating emotions and poor attention.
The first pill for patients suffering from postpartum depression is expected to be available by the end of 2023. Zuranolone (Zurzuvae) is a synthetic form of a mood hormone that rises during pregnancy and plummets after delivery. In mimicking this hormone, it is believed that the more extreme symptoms of postpartum depression can be averted.
California is one of several states that requires health care providers to screen patients for depression during pregnancy. Those who screen positive at UCSF Health may find themselves connected to psychiatrist Margo Pumar, MD, medical director of perinatal psychiatry, and a self-described wife, mother, sister, daughter, friend, large-dog owner and mental health advocate. She discusses zuranolone’s potential, as well as other treatments for postpartum depression.
What characteristics are associated with a higher risk for postpartum depression?
Very young patients may be more overwhelmed and hence higher risk, but I also see those who may be older and view themselves as competent until they have their first baby and then they feel that they’re “not very good at this.” Also at higher risk: first-time parents, people with complex pregnancies or with babies who have special medical needs, as well as patients with previous or pre-existing depression or anxiety.
I’m concerned about patients with a shaky support system. Having grandparents living across the street who can hold a crying baby offers an opportunity to catch up on sleep. But here in the San Francisco Bay Area, I see many patients with no nearby family support.
Do you expect the new drug will be helpful for some patients?
Zuranolone is sedating so it should be taken at bedtime. This means refraining from driving for 12 hours, so it may be inconvenient for some patients.
The drug works on the same receptor as the benzodiazepines, medications like Xanax, Ativan and Valium, and it is possible patients will develop tolerance after a while, requiring them to take increased doses to achieve the same effects. But currently it is approved only for two-week usage. We don’t know if patients remained depression-free beyond four weeks.
Zuranolone may be very expensive, since approval to expand usage to patients with major depressive disorder was denied. It is possible insurers will require patients to show they have failed other treatments before providing coverage.
A major limitation is that we do not know how much of the drug is transferred into breastmilk or what the risks are, so it’s only recommended for those who don’t intend to breastfeed or who are willing to “pump and dump.” Overall, zuranolone may be helpful, but most likely only for a small subset of patients until we know more.
Are other postpartum depression drugs safe for breastfeeding patients?
We know that some SSRIs (selective serotonin reuptake inhibitors), like Zoloft and Celexa, have been used in lactating patients since the 1990s. Traces of these drugs have been detected in breastmilk and side effects are generally minimal. We have to weigh the risk of untreated postpartum depression against the risks and the benefits of these drugs. I can say that I have seen SSRIs make a big difference to my patients with postpartum depression.
What other measures can be taken to minimize the risk of postpartum depression?
Postpartum depression can be mild, so medication is not required in all cases. I advise all parents-to-be to start building their village if they don’t have one. Join a moms’ or dads’ group. Some cities have LGBTQ parents’ groups that welcome those who identify as nonbinary. Sleep will likely be an issue, so tag-team if you have a partner or consider a night doula if you can afford it. Exercise! This will ease anxiety and help you sleep. Some supplements may help. Magnesium is safe to take during lactation and may relieve some symptoms of anxiety.
I’m a big believer in therapy. Medication alone may not be enough to help new parents deal with the negative thinking that may accompany postpartum depression.