Share on Facebook
Share on Twitter
Share on LinkedIn
Share by Email
Print
What are some key recommendations for clinicians regarding screening, diagnosis, and treatment for PPD?
Dr Payne: Do the screening, make the diagnosis, and treat the patient. Most women with PPD go undiagnosed and untreated, which affects the exposed children as well as the mother. Most doctors assume that you can’t take psychiatric medications in pregnancy and that it’s better to discontinue them for the safety of the baby. This is simply not true. In fact, if you review the entirety of the literature, most psychiatric medications can be taken in pregnancy, though there are a few that should not be, especially since maternal psychiatric illness is associated with multiple negative outcomes for the pregnancy and baby, including preterm birth, low birth weight, pre-eclampsia, C-section.
In addition, postpartum maternal depression is associated with lower IQ, slower language development, and behavioral and psychological disturbance in exposed children, so not treating maternal depression is the exact wrong thing to do for the baby.
Dr Patterson: One in 7 women will experience depression in the postpartum period, making this the most common complication of childbirth.1 Women should be screened for depression, anxiety, and suicidal thoughts prior to pregnancy and throughout the perinatal time period. There are prevention screeners, birth trauma screeners, social determinants of health screeners, suicide screeners, and a variety of other tools, but having these implemented in a systematic way has been challenging.
It continues to be troublesome that if a patient is at high risk, there may be very limited resources in place to help. The pandemic has certainly made access to treatment even more challenging as so many people are struggling. The California Task Force on the Status of Maternal Mental Health Care developed a set of core competencies for a variety of health care providers.12 These core competencies start with recognition of and familiarity with evidence-based treatment options and are really helpful for any clinicians working with reproductive-aged women.
Dr Novick: Some of the most important things a mental health clinician can do for PPD happens before the postpartum period, and even before pregnancy. This means discussing an individual’s reproductive status and plans in advance. A big risk factor for depression during pregnancy and the postpartum period is unintended pregnancy. Therefore, if an individual is not currently interested in getting pregnant, it is within the scope of the mental health clinician to discuss birth control.
When medications are prescribed to individuals who have the capacity to become pregnant, their safety in pregnancy and breastfeeding should be considered and discussed. The best medication for PPD is often the medication that has previously worked for an individual, so it’s great if this is one that was originally chosen with reproduction in mind. For individuals who do express plans for pregnancy in the near future or are currently pregnant, it’s appropriate to evaluate their risk for perinatal/postpartum depression and think about plans, medication strategies, initiating or increasing intensity of psychotherapy, etc., in case significant symptoms emerge.
One doesn’t need to look far in the literature for resources and reviews to help guide management. The American Psychiatric Association actually just released the Textbook of Women’s Reproductive Mental Health which is a fantastic resource not just for PPD, but for caring for women across the reproductive lifespan.13
What are some of the most critical remaining needs in the area of PPD treatment?
Dr Patterson: I am the medical director of UNC’s perinatal psychiatry inpatient unit, and so I treat women who are acutely ill and in need of a high level of care. We desperately need more dedicated inpatient units for those with severe symptoms. To date, there are only 3 inpatient psychiatry units dedicated to women who are pregnant or postpartum in the United States. Suicide remains the leading cause of maternal death in the first year following childbirth — and yet where are the resources?
We absolutely need continued research, education, and advocacy for maternal mental health.
Dr Novick: While the approval of brexanolone is a game changer for PPD treatment in many ways, it has yet to take off as a widely accessible first-line option, so we still have a pressing need to make effective, rapidly acting treatments available to patients. A rapidly acting agent has the most impact if we can initiate it right away, therefore it needs to be covered by payers without requiring the patient to have failed multiple treatments. It also needs to be logistically feasible for the depressed parent of a newborn. Researchers are working on this, so I’m hopeful we are going to see solutions, but the solutions can’t get here soon enough.
Disclosures: Dr Payne reported research funding from Sage Therapeutics and a consulting role for Sage Therapeutics and Janssen Pharmaceuticals.
References
1. Patterson R, Krohn H, Richardson E, Kimmel M, Meltzer-Brody S. A brexanolone treatment program at an academic medical center: patient selection, 90-day post-treatment outcomes, and lessons learned. J Acad Consult Liaison Psychiatry. 2022;63(1):14-22. doi:10.1016/j.jaclp.2021.08.001
2. Yu Y, Liang HF, Chen J, et al. Postpartum depression: current status and possible identification using biomarkers. Front Psychiatry. 2021;12:620371. doi:10.3389/fpsyt.2021.620371
3. Meltzer-Brody S, Kanes SJ. Allopregnanolone in postpartum depression: role in pathophysiology and treatment. Neurobiol Stress. 2020;12:100212. doi:10.1016/j.ynstr.2020.100212
4. Kanes S, Colquhoun H, Gunduz-Bruce H, et al. Brexanolone (SAGE-547 injection) in post-partum depression: a randomised controlled trial. Lancet. 2017;390(10093):480-489. doi:10.1016/S0140-6736(17)31264-3
5. Meltzer-Brody S, Colquhoun H, Riesenberg R, et al. Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. Lancet. 2018;392(10152):1058-1070. doi:10.1016/S0140-6736(18)31551-4
6. Edinoff AN, Odisho AS, Lewis K, et al. Brexanolone, a GABAA modulator, in the treatment of postpartum depression in adults: a comprehensive review. Front Psychiatry. 2021;12:699740. doi:10.3389/fpsyt.2021.699740
7. Walkery A, Leader LD, Cooke E, VandenBerg A. Review of allopregnanolone agonist therapy for the treatment of depressive disorders. Drug Des Devel Ther. 2021;15:3017-3026. doi:10.2147/DDDT.S240856
8. Payne JL. Evaluating brexanolone for the treatment of postpartum depression. Expert Opin Pharmacother. 2021;22(8):959-964. doi:10.1080/14656566.2021.1897105
9. Batt MM, Duffy KA, Novick AM, Metcalf CA, Epperson CN. Is postpartum depression different from depression occurring outside of the perinatal period? A review of the evidence. Focus (Am Psychiatr Publ). 2020;18(2):106-119. doi:10.1176/appi.focus.20190045
10. Huddle MM, Costello SC, Barton DA. A systematic review of the efficacy of repetitive transcranial magnetic stimulation treatment for women with postpartum depression. Psychiatry International. 2021; 2(3):265-276. doi:10.3390/psychiatryint2030020
11. Crowley SK, Youngstedt SD. Efficacy of light therapy for perinatal depression: a review. J Physiol Anthropol. 2012;31(1):15. doi:10.1186/1880-6805-31-15
12. A report from the California Task Force on the status of maternal mental health care. California Task Force on the Status of Maternal Mental Health Care. Published April 2017. Accessed online March 26, 2022. https://static1.squarespace.com/static/56d5ca187da24ffed7378b40/t/5b40f84503ce641f98dbd329/1530984521889/Report-CATaskForce-7.18.pdf
13. Hutner LA, Catapano, LA, Nagle-Yang SM, Williams KE, Osborne LM. Textbook of Women’s Reproductive Mental Health. American Psychiatric Association. 2022.
