Pharmacotherapy of Postpartum Depression

Pharmacotherapy of Postpartum Depression

Unknown Girl in the Maternity Ward   by Anne Sexton

Child, the current of your breath is six days long.   

You lie, a small knuckle on my white bed;   

lie, fisted like a snail, so small and strong

at my breast. Your lips are animals; you are fed   

with love. At first hunger is not wrong.

The nurses nod their caps; you are shepherded   

down starch halls with the other unnested throng   

in wheeling baskets. You tip like a cup; your head   

moving to my touch. You sense the way we belong.   

But this is an institution bed.

You will not know me very long.

The doctors are enamel. They want to know

the facts. They guess about the man who left me,   

some pendulum soul, going the way men go   

and leave you full of child. But our case history   

stays blank. All I did was let you grow.   

Now we are here for all the ward to see.   

They thought I was strange, although   

I never spoke a word. I burst empty   

of you, letting you learn how the air is so.   

The doctors chart the riddle they ask of me   

and I turn my head away. I do not know.

Yours is the only face I recognize.

Bone at my bone, you drink my answers in.   

Six times a day I prize

your need, the animals of your lips, your skin   

growing warm and plump. I see your eyes

lifting their tents. They are blue stones, they begin   

to outgrow their moss. You blink in surprise

and I wonder what you can see, my funny kin,   

as you trouble my silence. I am a shelter of lies.   

Should I learn to speak again, or hopeless in   

such sanity will I touch some face I recognize?

Down the hall the baskets start back. My arms   

fit you like a sleeve, they hold

catkins of your willows, the wild bee farms   

of your nerves, each muscle and fold

of your first days. Your old man’s face disarms   

the nurses. But the doctors return to scold   

me. I speak. It is you my silence harms.   

I should have known; I should have told

them something to write down. My voice alarms   

my throat. “Name of father—none.” I hold   

you and name you bastard in my arms.

And now that’s that. There is nothing more   

that I can say or lose.

Others have traded life before

and could not speak. I tighten to refuse   

your owling eyes, my fragile visitor.

I touch your cheeks, like flowers. You bruise   

against me. We unlearn. I am a shore   

rocking you off. You break from me. I choose   

your only way, my small inheritor

and hand you off, trembling the selves we lose.   

Go child, who is my sin and nothing more.

___________________________________

No matter how many times I’ve read this, it wrenches my heart. The raw lyrical quality her suffering, which her child will also go on to later absorb this early abandonment. Sexton describes the anguish of recognizing she could not care for her baby. Published posthumously, with undiagnosed Postpartum Depression (PPD), Sexton wrote this after the birth of her first child in 1953. She also suffered with Bipolar disorder and committed suicide at the age of 45. Treatments were limited to electroshock therapy, tricyclic anti-depressants, psychoanalysis. How effective were these? Not.

Postpartum Depression (PPD), according to the CDC, the U.S. average is approx. 13% or 1 in 8 women will go through it, with varying degrees of severity and longevity. Globally, the incidence is 10 to 20%. These estimates are lower than the actual incidence due to unreported cases, self-reporting inaccuracies and mis-diagnoses. The good news? Most women fully recover. [This is not to be confused with Perinatal Depression, which can happen during pregnancy in both mothers and fathers, as well as gestational carriers/surrogates].

Distinguishing between PPD and “baby blues” is nuanced. After giving birth, almost all women go through “baby blues”—during the third trimester, estrogen and progesterone peak, but after delivery, they fall. With this abrupt drop, it’s normal for the body to re-calibrate and need time to adjust, e.g. feeling like you’re on edge, hypersensitive, emotions raw and on the surface … this is usual and within a few weeks, usually equilibrates to your new ‘normal.’

In order to be formally diagnosed with PPD, a depressed mood (defined below) plus four of the other symptoms need to be present for most of the day, daily, for at least two weeks. They must be a change from the person’s previous functioning, cause distress, and not be caused by a substance/medical condition:

—Depressed mood: sadness, emptiness, or hopelessness most of the day

—Loss of interest: diminished interest in activities

—Sleep disturbances: Insomnia or hypersomnia

—Psychomotor agitation or retardation: Restlessness or slowing down

—Fatigue: exhaustion or loss of energy

—Weight change: significant change in weight, e.g. 5% change in a month

—Appetite change: eating much more or less than usual

—Suicidal ideation: Thoughts of death, plan/attempt to commit suicide

Research suggests that though the symptoms are similar, the biology of postpartum depression is different from major depression. Before 2019, what was the treatment for PPD? The usual anti-depressants, which though better than nothing, takes weeks to begin working and which often requires a trial and error approach. In 2019, drum roll … a new gold standard for treating PPD entered the space: Brexanolone (Zulresso), an FDA approved infusion GABA-A modulator that mimics a natural hormone and works by regulating hormone levels after childbirth! It often works within days, women report a cloud lifting and feeling like themselves again, they could “see” their baby for the first time without being mired in a haze.

As of Jan. 2025, Brexanolone is no longer available in the U.S. Instead, Sage Therapeutics (in partnership with Biogen)—who also released Brexanolone, according to the Journal Annals of Pharmacotherapy—focused on Zuranolone (Zurzuvae), a synthetic form of allopregnanolone, a naturally occurring neurosteroid which the body makes from the hormone progesterone. Zurzuvae is an oral pill taken once daily for two weeks. It works remarkably fast, often within three days—Allopregnanolone helps the GABA-A receptors, which regulate mood and behavior. This can also be combined with another antidepressant, which hopefully, pre-pregnancy, the woman had has a positive response to.

The American Journal of Psychiatry reports that because zuranolone passes into a woman’s breast milk and it’s not yet known if it can harm a baby, women in the study did not breastfeed while taking the medication. The Physicians Desk Reference (PDR) states: “There are no data on the effects of zuranolone on a breastfed infant and limited data on the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Zurzavae and any potential adverse effects on the breastfed child or from the underlying maternal condition.” As researchers collect more lactation data, what would be ideal if mothers could nurse, not only for the optimal nutrition but also for the intense psychological maternal-infant bonding experience, many have described as surreal, oceanic bliss.

According to The National Library of Medicine, Though Sage Therapeutics sought FDA approval to use zuranolone for major depressive disorder, they did not get it because clinical trials did not support efficacy. This lends further credibility to the hypothesis that the biology/etiology of Major Depressive Disorder (MDD) and PPD are distinct. Who develops PPD and why? We don’t know. But as with most things, the answer has multi-facets: biological/genetic, psychosocial, environmental, obstetric factors all play a role.

We’ve come a long way, e.g. until the mid-20th century, postpartum depression wasn’t seen as a distinct medical condition, dismissed as a “normal” part of childbirth, and sometimes seen as a “moral” failing of the mother. Imagine the trauma of giving birth with hormonal swings, healing from the labor, care-giving, nursing, wrestling with sleep deprivation … and being blamed for not being and doing ”enough?” Wow. Boggles the mind. With limited medication options, women were told to “rest,” “pray,” given social support. Though the gamut of antidepressants were also prescribed, if they worked, it would take weeks or months, especially because most of the time, it would be a trial and error approach to find one or a combo that worked. It’s exhausting for anyone, much less a depressed person, and even more so a new mother.

The Archives of Women’s Mental Health reports an aggregate of neuropsychological test deficits, e.g. when gripped by PPD, thought patterns become distorted and impaired, even basic solutions feel out of reach. With Zurzuvae and our emerging neurobiological understanding of the etiology of PPD, we’re in an awesome position to offer new mothers (and by extension, new fathers :-), the support they should get. I don’t mean to present this as a panacea, but it is an exciting treatment boon!

Due to the cognitive difficulties of PPD, new mothers aren’t always able to think through a solution. I’ll offer some coping strategies: ask for help within your nuclear and extended family, seek out a psychotherapist. If finances permit, hire help. I’ve had clients do everything from having full time live-in nannies to hiring someone to come in for two hours a day to do basic chores, e.g. laundry and cooking, meal prep, etc. Even when someone is stretched for money, people can often afford to hire someone for an hour a day, which though it sounds like it’s not enough, affords a Mom some much needed down time to simply shower or take a nap. Don’t compare yourself to other new moms, be kind and patient with yourself, attune to your needs your inner harsh dialogue, take a breath or two, enjoy your baby. This is a profound transitional phase in your life—give yourself what might seem like a luxury, but what is essential: time to settle into a new rhythm of life.

Dr. Ranjan Patel Marriage Family Therapist 1 (650) 692-5235