Many women experience an even greater vulnerability to psychiatric crisis in the postpartum period than during pregnancy, requiring a careful balancing of needs that should prioritize the mother's health, Marlene Freeman, MD, said in a session at Psych Congress 2020.
Dr. Freeman, associate director of the Center for Women's Health at Harvard Medical School, Boston, Massachusetts, expressed great hope over new medication options for treating postpartum depression, including the injectable brexanolone approved by the US Food and Drug Administration in 2019. She also discussed critical challenges around diagnosing and treating postpartum psychosis, which occurs in only an estimated 1 to 2 per 1000 pregnancies but is significantly associated with risk of maternal suicide or infant harm.
Addressing the constellation of symptoms that can affect many women postpartum requires a collaborative relationship between physician and patient, and often coordination of care as a new mother transitions from obstetric care to seeing another provider, Dr. Freeman said in her virtual session.
Medication remains first-line treatment for moderate to severe postpartum depression, but undertreatment can pose a major concern, in part because many women hesitate to use an antidepressant when they're breastfeeding. Dr. Freeman recommends that for women with no history of antidepressant use, sertraline offers a good first option, given that it is generally well tolerated and has significant research suggesting it is largely undetectable in infant serum. “But if a woman has done best on fluoxetine, then it would still generally be our go-to medication,” she said, even though some physicians hesitate to prescribe fluoxetine to a woman who is breastfeeding because of its longer half-life.
Promise of New Medications
Brexanolone, an intravenously delivered analogue of allopregnanolone, last year became the first drug approved specifically for treatment of postpartum depression. Dr. Freeman's clinic at Massachusetts General Hospital served as a study site for placebo-controlled trials that showed the injectable formulation to be fast-acting, with durable efficacy to 30 days.
“It's exciting as a field right now to see some treatments that work more quickly,” she said.
However, she said the need to admit women to an inpatient unit or infusion center in order to monitor for effects such as sedation risk limits the potential of the injectable drug. Dr. Freeman and colleagues are optimistic about the potential of a related oral compound that her clinic and others will be testing.
Postpartum psychosis, Dr. Freeman explained, is a highly dangerous disorder that almost always requires hospitalization to protect the safety of mother and baby. Research suggests that just under half of women who are hospitalized for a psychotic episode during pregnancy will develop postpartum psychosis.
Mood stabilizers are considered the primary therapy for postpartum psychosis. Anecdotal evidence supports a combination of lithium and an atypical antipsychotic for yielding the fastest improvement, and an atypical alone doesn't usually produce an effect until lithium is added, Dr. Freeman said.
“Breastfeeding is by far the topic that I've seen more tears about in my office than any other topic in my entire career,” Dr. Freeman said.
While she said it is unequivocally the healthiest choice from a nutritional standpoint, intense pressure socially and from health providers can create undue stress for some new mothers. This sometimes results in the need for a woman who is doing poorly to be supported in her decision not to breastfeed, Dr. Freeman said.
“In the long run, the mother's mental health is more important than whether the baby is breastfed or gets formula,” she said.
In essence, that type of approach proves critical in any effort to treat maternal psychiatric illness. While any risks to the child must of course be considered, it is clear that undertreated maternal illness carries huge consequences for the new baby and the family, Dr. Freeman suggested.
“Treatment of Postpartum Mood and Anxiety Disorders.” Presented at Psych Congress 2020: Virtual; September 11, 2020.