Enlarging the Treatment Lens for Postpartum Depression

The specter of postpartum depression (PPD) has haunted me from the time I was a little girl. When my baby-sister was born in 1959, my mother struggled to manage her life taking care of three young children along with a newborn. I was too young to remember what her struggles may have been, but my father’s records revealed a lot about her condition at the time. I found a very informative letter dated years after Mom’s hospitalization addressed to her new psychiatrist. Dad says her doctor prescribed the following drugs for her in a six-week period: Ritalin (stimulant), Nardil and Tofranil (antidepressants), Trilafon (antipsychotic), Nembutal (barbiturate), and Dexamyl (combination amphetamine and barbiturate). But the drugs failed to help my mother’s depression, and Dad told the doctor that “by the end of May ’59 she was so bad…I didn’t see how she could avoid hospitalization.”

My mother spent the next six months in a private psychiatric hospital in Baltimore where she endured numerous electroconvulsive therapy treatments (ECT), was prescribed even more drugs, and was finally discharged in December of 1959. Mom continued to struggle to overcome depression until her death in 2002.

I detail Mom’s full story in this blog post, and I relate both of our stories in my memoir Crash: A Memoir of Overmedication and Recovery.  Because Mom never recovered, I harbored the idea that once someone “got depressed,” the illness settled in like an unwelcome and troublesome guest. Even though I vowed very early to never be like my mother, I, too, succumbed to postpartum depression after the birth of my second child in 1982. I fought back shame over my condition and endured extreme pressure from my ex-husband to get off the antidepressant as soon as I felt better.

Neither my mother nor I had the benefit of a structured and caring system of support to help us adjust to our new roles. No one reassured us that what we were doing for the baby was all right. No one helped us to understand how the sleep disturbances we experienced could play havoc with our moods. And most importantly, no one stepped in and offered to be there for us on a continuing basis while we adjusted to our “new normal.” Instead, they told us that something was wrong with our minds or that we had a chemical imbalance and if we just took the right pills, we’d be fine.

But what’s happening today for new mothers? Surely things have changed for the better. Sadly, research tells us a different story, at least here in the United States, where between one in seven to one in ten women struggle with PPD. A StatPearls article lists a variety of likely causes, ranging from a risky or difficult pregnancy and a history of previous depression and anxiety to a myriad of social and lifestyle features which can include a lack of social support, spousal/partner abuse, eating habits, sleep cycles, and even a lack of certain vitamins. They are careful to state that the precise cause of PPD is unknown.

The article acknowledges the significant role of social and lifestyle causes and recommends psychotherapy as the first-line treatment for mild to moderate PPD. However, they recommend antidepressants for severe depression, followed by transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT) and a new drug specifically for treating PPD called brexanolone. Besides the significant risks of harm with these medical approaches, they fail to address the social and physical needs of a new mother by framing it as an individual problem. Additionally, the article omits descriptions of what mild, moderate, and severe depression look like. What seems mild for one person may feel like an unbearable weight for another.

The Office on Women’s Health emphasizes psychosocial causes as being significant in PPD. Some of the factors they name include hormonal changes that can occur quite quickly after birth, returning to pre-pregnancy levels in as little as 24 hours. They also cite low-thyroid levels as contributing to depression and recommend a check on those levels after birth. Lastly, they look at a variety of problems women may have experienced as being significant in developing PPD, including having a difficult birth, experiencing abuse or adversity as a child, having experiences of domestic violence, struggling with money problems, becoming a mother before age 20, breastfeeding difficulties, having a premature or special needs baby, and having an unplanned pregnancy. The Office on Women’s Health makes similar recommendations as in the StatPearls article, but they place an emphasis on therapy, support groups, self-care, social support before turning to medication. In addition to mentioning antidepressants, they provide information on two new drugs developed specifically to treat PPD, brexanolone (Zulresso) and zuranolone (Zurzuvae).

Are Drugs the Answer?

But new mothers would be wise to do some research before trying either of those drugs due to the significant downsides and possible risks to both mother and baby. Kelly Brogan, a holistic women’s health psychiatrist, reports significant concerns about brexanolone. The drug gained FDA approval despite an unknown mechanism of action, a very high price tag of between $20-50K, and unknown effects on breastfed infants. Additionally, since the mother must receive the drug under medical supervision for a period of 60 hours, she cannot function as the primary caregiver for her infant. Additionally, drugs.com warns that brexanolone can cause “excessive drowsiness or sudden loss of consciousness,” further impairing a mother’s caregiving ability.

Zurzuvae, another new drug designed specifically to treat PPD, is delivered in a pill which the mother takes for 14 days. The trial results of 196 participants reported statistically significant (results measured on a rating scale) improvement over placebo from days 3 to 45. There is no information on long-term effects, but noted short-term effects include sleepiness, dizziness, and sedation. Zurzuvae’s cost is estimated to be $16,000 for the 14 days and it is still not known if insurance will cover it. Dr. Kristina Deligiannidis, the primary investigator, was interviewed for a segment of CBS Sunday Morning and cautioned that due to unknown effects on the infant, women should not breastfeed if taking Zurzuvae. The Executive Director of the Policy Center of Maternal Mental Health, Joy Bukrhardt, concluded her interview on the segment on the same segment by saying “Don’t overlook that women still need support. We need pills, but we need much more.”

Dr. Vinay Prasad and David Allely published a critique of Deligiannidis’ Zurzuvae study in JAMA which includes the following points:

• The trials assessed the effects of Zurzuvae on severe depression, but the FDA only approved the drug for milder forms of depression
• Both trials pointed to a large placebo effect of about 75%
• Researchers raised concerns about misuse potential, impaired psychomotor function, and a lack of compatibility with breastfeeding
• Extremely high-cost estimates of between $10,000-$30,000 for two weeks.

Prasad and Allely conclude their critique by saying, “Patients with postpartum depression in this study tended to get better, regardless of treatment.”

Because many doctors continue to recommend antidepressants to treat PPD, it is worth considering their possible adverse effects on the breastfeeding infant. In 2011, a study published in Current Women’s Health Reviews recommended that breastfeeding mothers avoid using Prozac and Celexa due to higher infant plasma levels than other antidepressants and the possible adverse effects on infants.

More recently, in 2021, Dr. Corey Laskey published detailed recommendations regarding drug treatment for PPD in the magazine U.S. Pharmacist. He began the article by recommending that lower-risk women should use therapy and if sleep disruptions are contributing to feelings of depression, new mothers should consider pumping milk so that their partner can take over the nighttime feedings. Additionally, he explained that the infant’s liver is still developing at 3-6 months (when most women continue to breastfeed) and babies may be unable to metabolize drugs that they are exposed to in breast milk, which can result in elevated plasma levels of a drug. Lastly, he cautioned that pre-term infants may be taking their own drugs and the interaction between the infant’s drugs and the mother’s could be problematic.

Later on in the article he made recommendations about specific drugs citing Pamelor, Paxil, and Zoloft as least likely to cause elevated serum levels. While the author specifically cautioned against Celexa and Prozac because they could cause elevated serum levels, he noted that nearly all the commonly used antidepressants have adverse effects such as drowsiness, weight loss, restlessness, irritability, impaired infant weight gain, and uneasy sleep—all of which he labelled as “relatively mild” effects.

On the contrary, I think most new parents and pediatricians would consider that list of effects as being very problematic in an infant. I’ve included a list of resources at the end of this article that give parents more detailed information about the effects of most drugs on infants, children, and mothers.

The Power of Social Support

Mothers, fathers, and professional caregivers can learn a lot about helping women with PPD by considering some of the research that investigates practices in other countries. One thread that runs through most of the articles and studies I read pointed in the direction of new mothers benefitting the most from social support, mothers’ groups, and therapy, as well as some type of parental leave. In many other countries, government policies provide periods of paid leave for both parents so they can recover from childbirth, acclimate to the rigors of parenthood, and bond as a family.

The Washington Post published an article in 2021 and found that while the U.S. provides no days of paid parental leave, Britain, Sweden, Estonia, and Japan provide between 39 weeks and 82 weeks of paid parental leave. The National Partnership for Women and Families says that mothers who take paid leave reduce rehospitalization by over 50%, are almost twice as likely to have success in managing stress and getting regular exercise, and reduce infant rehospitalization by 47%. They recommend that Congress pass the Family and Medical Insurance Leave (FAMILY) Act and provide access to paid leave for women, caregivers, and their families. Additionally, paid leave for fathers improves engagement with the infant, decreases the severity of depressive symptoms in the mother, and improves the child’s overall development.

Both postpartum support and the existence of motherhood rituals play a significant role in the health of new mothers around the globe. According to an article published on the website Healthline called “What Postpartum Care Looks Like Around the World, and Why the U.S. is Missing the Mark,” the Netherlands, Belgium, Spain, and Finland all offer extensive postpartum planning and in-home support for new mothers and babies. The article also cites a study from 2013 that “found that including a doula in prenatal care reduces adverse birth outcomes while benefiting mothers, babies, and the medical community as a whole.” A 2010 study cited in the same article looked at cross-cultural and historical aspects of postnatal care and had this to say: “The postnatal period seems to be universally defined as 40 days. Most cultures have special postnatal customs, including special diet, isolation, rest, and assistance for the mother.”

For example, in Mexico, new mothers observe a 30-day period of rest with family called cuarentena, while in China they refer to the 30 days after birth as “doing the month.” Other countries have similar practices, including Japan, Korea, Denmark, France, Sweden, and some Eastern European countries. One thing that researchers say we can take away for moms in the U.S. is to slow down and recognize that everything a new baby needs, a new mother needs, including soothing, nourishing meals, and contact with supportive family mothers.

The Healthline article adds that most research on PPD has been conducted in Western countries and has not taken into account the “range of psychosocial experiences involved in childbirth” and the myriad ways that other cultures care for new mothers with rituals and rites of passage. In most non-Western societies, “rituals, prohibitions, and proscriptions…provide guidance and social support while the mother adapts to her new role.” Because of such practices in other countries, anthropologists have found little evidence of what we call PPD and they suggest that our lack of formal rituals surrounding motherhood may be a contributing factor, saying that “…intact post-partum codes of behavior, high status of motherhood, and social support might protect against postnatal depression.”

Placenta Encapsulation

A cultural practice that is enjoying a resurgence in the United States is placenta encapsulation (“practiced in Traditional Chinese Medicine for centuries to treat postpartum hormonal imbalances, support mental health, and to aid in the relief of fatigue and lactation issues after giving birth”). It was fascinating for me to learn the process for being able to ingest the placenta.  The placenta can be used in its natural state or it can be steamed first. Then it is dehydrated, ground, and placed into pills. The pills are most commonly used in the six to eight weeks immediately following the birth.

I have one friend who used her placenta in this way and I asked if she found it helpful. “I actually found it too energizing and it made me a little shaky, but I know other people who have benefitted from taking the pills.” The Association of Placenta Preparation Arts has a training program for health professionals who want to learn how to process and use the placenta. For those that are interested, the Association’s resource page lists people all over the U.S. who will process your placenta as well as provide various other services for new mothers.

An article in the German journal Geburschilfe Frauenheilkd (Obstetrics and Gynecology), published on the National Library of Medicine website, discussed the pros and cons of placenta encapsulation as well as explaining the biology of the placenta itself. They authors point out that during pregnancy, the placenta is a rich source of both estrogen and progesterone, but both hormones decline swiftly after delivery, resulting in massive hormonal shifts which are often very difficult for the mother to manage. The placenta tissue also contains a variety of other hormones, including oxytocin (which can help mood and milk production) and human placental lactogens ACTH and CRH.

Women who are considering placenta encapsulation need to inform themselves of both the risks as well as the potential benefits that result from this practice. The authors don’t recommend the practice if either the mother or infant has a viral or bacterial infection, the mother had general anesthesia during delivery due to the possibility of opioids or other anesthetics in the placenta, the mother smoked during pregnancy which may result in cadmium in the placenta, or the mother suffers from either mastitis or blocked milk ducts because the placenta capsules can stimulate milk production. On the other hand, the authors say that in the case of spontaneous, non-interventionist deliveries where the mother has not had long-term drug use during pregnancy, even if the benefits can be attributed to the placebo effect, the practice poses little risk and may even be beneficial to both mother and baby.

A Professional’s View

I wanted to get a professional’s viewpoint on what therapists think about the most effective ways to help women with PPD. One of my friends recommended a Baltimore-based psychotherapist and the two of us spoke for about an hour on a frosty January morning in a Google-meet conversation. Emily Souder, a licensed clinical social worker specializing in perinatal mental health, provides her clients with a balanced and integrative approach to managing feelings of postpartum depression. She offers pre-conception, pregnancy, and post-partum support through her practice as well as workshops in birth-story processing for new parents and for therapists. We discussed the services she provides, the support of doulas, and even touched on the revival of placenta encapsulation.

I really like to begin my therapy relationships by sharing the slogan from Postpartum Support International: “With help, you will get well.” I take an eclectic approach to working with my clients and am well-versed in a variety of modalities, including psychotherapy, Reiki, and mindfulness, as well as perinatal or reproductive health. I always encourage my clients to look into any possible physical causes for how they are feeling, such as problems with their thyroid levels which can be affected by pregnancy. I help them to understand how the drastic drop in pregnancy hormones back to pre-pregnancy levels can affect their moods. Some of my clients benefit from a short period of medication (antidepressants), which I like to frame as offering a little extra boost to practice the skills they are learning in therapy. Clients need to weigh the risk of having feelings of being on high-alert or having thoughts of harming yourself or the baby and how that can affect a baby, for example, versus the effects of an antidepressant. I never recommend medication alone, and I find that some people are just way more sensitive to physical changes. I find that by providing information, it often has a calming effect on my clients.

One of the first set of tools I offer my clients comes from my training with Postpartum Support International and involves five areas of care that new mothers need to attend to. The first area is hydration, which is especially important for breastfeeding mothers. The second area is rest—and I use rest rather than sleep because sleep can feel like a pressure for some people. Instead, I encourage clients to look at ways they can relax, maybe with meditation. The third area is movement, as cleared by your health provider. I use the word movement as opposed to exercise because exercise is often linked to fitness and weight control, and I want my clients to get their bodies moving with provider-approved stretching, and maybe some gentle walking as opposed to focusing on changing their bodies. The fourth area is nourishment because good nutrition and an adequate amount of food is essential for both recovery and the new demands of motherhood. Lastly, I encourage my clients to get some fresh air whenever they can—walk outside and fill their lungs or at the very least, get some sunlight which helps with melatonin production.

I also encourage clients to journal and note how well they are doing in each of the five basic areas. It can be very disorienting to be in the postpartum space, so it’s important to have all hands on deck—support from friends as well as local and out-of-town parents, perhaps even staying with a parent for a while especially if a woman has thoughts of harming herself or the baby. That way, there are numerous people who can be informally assessing the new mother for any problems. And I reiterate, with enough support, you can get well.

Unlike many cultures around the world, we in the United States have stripped our culture of rituals surrounding the birth of a new baby. The systems we live in don’t support staying home and many women and their partners are forced back into the workforce way too early. One group of people who are working to support women throughout the pregnancy, birth, and postpartum period is doulas—”trained professional who provides continuous physical, emotional and informational support to their client before, during and shortly after childbirth to help them achieve the healthiest, most satisfying experience possible.” For more information regarding the work of doulas, becoming a doula, and finding a doula to work with, check out the website DonaInternational.org.

I always tell my clients that It’s vitally important for them to work with psychiatrists and therapists who specialize in perinatal mental health or reproductive health. My vision for the future is a that we’ll have (in the United States) a more compassionate, caring, holistic, and slower experience for new parents. I hope my kids will be able to experience a better world around birth and postpartum issues.

If you or someone you know is struggling with PPD, please encourage them to seek support, whether in the form of a new mothers’ support group, therapy, household help, or enlisting friends and extended family to form a nurturing network for the mother and baby. Hopefully, the expanded vision of care I’ve presented along with some of the resources mentioned in this article will be useful and reassuring to readers. As Emily Souder reminds us, “With help, you will get well.”

Resources for Drug Information Related to Pregnant and Breastfeeding Women

LactMed: Maintained by the National Library of Medicine, includes information on medication concentrations in breast milk, summaries of AEs [adverse effects] and any effects on milk production.

MotherToBaby: Organization of Teratology Information Specialists provides a telephone and Web-based service for patients and healthcare providers.

The InfantRisk Center: A Texas Tech University Health Sciences Center School of Medicine call center dedicated to offering providers and patients information to help evaluate the risk of multiple drug exposure to the infant.