Seeing the whole picture of postpartum depression

This past May, the American Psychiatric Association (APA) convened for its annual meeting, with the theme “Disrupt, Include, Engage & Innovate”. During the 4-day event, no fewer than 28 sessions were dedicated to collaborative care models for mental health, making it a clear stand-out topic of the conference. Although several mental health conditions would benefit from a collaborative care approach, arguably postpartum depression should be high up on any physician's list. Physical and mental health care for mothers and babies in the USA is disjointed to say the least, despite the overwhelming evidence that a baby's health is directly linked to the mother's health after delivery: a period that is sometimes referred to as the fourth trimester. Given that one in nine mothers will experience postpartum depression in some form, there could hardly be a better opportunity for psychiatry to tackle a major mental health burden, engage and include a large population of historically underserved patients, and use the many tools at our disposal to initiate new ways to improve care. With the obvious enthusiasm shown at the APA meeting for collaborative care, one would expect this model to be a leading choice for conditions such as postpartum depression. Instead, the latest treatment for postpartum depression is an injectable drug called brexanolone that has a price of about US$35 000 and requires inpatient care for 60 h for drug infusion (with the hospital stay, naturally, adding to the costs). For mothers suffering from severe postpartum depression, brexanolone could provide an important new treatment option to rapidly reduce symptoms. Innovative treatments in psychiatry are rare enough that any new development is to be applauded. However, given what we know about the epidemiology of postpartum depression, it seems unlikely that brexanolone alone, even if delivered at scale, will be able to make even a slight dent in reducing the overall burden. An infusion of brexanolone will not address important psychosocial factors that drive postpartum depression, including intimate partner violence, lack of family support, low socioeconomic status, the stressful and uncertain US job environment that many economically disadvantaged women find themselves in, and, of course, lack of sufficient health insurance. Likewise, these factors will not dissipate after 1 month, the longest duration shown for mood improvement in women treated with brexanolone. A fourth-trimester collaborative care model that involves access to a night nurse after delivery, case management, temporary safe housing, family education, and a team-based approach to regular physical and behavioural health checks for both mother and baby could all go a long way to improving outcomes—and for substantially less cost than brexanolone. The most recent randomised controlled trial for brexanolone showed something very important besides the drug's pharmacological efficacy: mothers who received placebo infusions, but also had the attention and care of trained health professionals, as well as supportive care for their babies while staying in the hospital, also showed clinically significant improvements in their mood. One of the major benefits being touted for brexanolone is its speed of response, but there is nothing faster than prevention. Behavioural health screening throughout pregnancy to identify and help soon-to-be mothers most at risk for depression has been recommended for years, but rarely happens owing to a lack of resources, time, training, and integration of care across specialties. Given that many mothers are not diagnosed with postpartum depression until 6–12 weeks after giving birth—although they most likely have symptoms well before then—brexanolone is unlikely to fill the cracks in the system that depressed mothers consistently fall through. Before leaving his role as Director of the Division of Psychiatry Products at the US Food and Drug Administation, Mitchell V Mathis presented information on brexanolone to an advisory committee. In the memorandum, there was only one mention of public health, written as an agency comment: “If brexanolone were approved, it would be in the best interest of Public Health to have it widely available to the relevant patient population.” However, if we can afford the resources to make brexanolone widely accessible despite its disadvantages, surely we can afford to develop and align new prevention and treatment methods, such as collaborative care, with the everyday realities of what most mothers will face when struggling with postpartum depression.