How to Treat Postpartum Depression

The New York Times

By Dana G. Smith

May 12, 2023

Mental health issues are the leading cause of maternal mortality. Group therapy, S.S.R.I.s and a new medication can help.

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 one in eight new moms experience postpartum depression, and some research has suggested that the prevalence climbed to as high as one in three 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 under-researched, but recognition of the condition is finally growing. As a result, there are more treatment options available than ever before, 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 the dramatic hormonal shifts that occur. 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, the 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,” Dr. 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 Dr. Latoya Frolov, a perinatal psychiatrist at the University of Texas Southwestern Medical Center.

Postpartum depression can affect not only the mother’s health but also that of her baby. Some research has shown that infants born to depressed mothers gain less weight and have more illnesses and developmental delays (though some other studies have not). As a result, timely treatment is important.

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 childcare, Dr. 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.”

In one-on-one therapy, counselors often use approaches like cognitive behavioral therapy, dialectical behavioral therapy and interpersonal therapy, which provide women with skills to help them manage their emotions, avoid or reframe negative thoughts and improve communication with their partner.

Medication

For women who have moderate to severe postpartum depression, experts often recommend medication — most commonly selective serotonin reuptake inhibitors, or S.S.R.I.s. There is limited research specifically testing S.S.R.I.s 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 Dr. 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 S.S.R.I.s.

Dr. Frolov is trying to empower physicians who work with pregnant and postpartum women to feel more comfortable prescribing S.S.R.I.s, 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, like The Motherhood Center and U.N.C.’s perinatal psychiatry unit.

The first medication specifically for postpartum depression also now exists, and it works differently than S.S.R.I.s. Treatment with the drug, called Brexanolone, causes a significant reduction in depression scores for about 70 percent of the women who receive it, said Dr. Meltzer-Brody, who ran the clinical trials at U.N.C. Most notably, it works within 24 hours, compared with the weeks or months it takes to see a benefit from therapy or S.S.R.I.s.

While Brexanolone’s efficacy is promising, it must be delivered in a hospital via an I.V. 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 currently 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 themselves, Ms. 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.