Providing Timely, Appropriate Treatment of Postpartum Depression

CONFERENCE REPORTER

"It is critical that we screen all patients," said Patricia Junquera, MD, "I say all because some women feel a lot of pressure to be happy when they are pregnant."
In their presentation on addressing postpartum depression (PPD), Junquera; Erin Crown, MHS, PA-C, Psych-CAQ; and Shulamit Bossewitch, NP, discussed how best to provide timely psychiatric care to new mothers.

Ideally, decisions about psychiatric medication use during after pregnancy should be made before conception. The use of a single medication at a higher dose is preferred over multiple medications. Medications that are used should have fewer metabolites, higher protein binding, and fewer interactions with other medications.¹

Women with bipolar disorder have significantly higher risk of postpartum hospitalization, a rate 20 to 30 times higher than the general population. Additionally, the postpartum period is a high-risk time for the first onset or relapse of bipolar disorder.² Mothers diagnosed with postpartum psychosis may actually have bipolar spectrum disorder, shared Junquera.

In the postpartum and peripartum period, women face increased stigma around body image and weight. This weight stigma is associated with elevated depressive symptoms, stress, and unhealthy behaviors. Approximately 12.7% of women are diagnosed with major depressive disorder during pregnancy; body dissatisfaction is one of the leading causes. This poor body image can be an early predictor of postpartum depression.³

In terms of evidence-based solutions, Junquera recommended the following:

• Promoting body appreciation and acceptance
• Identifying and mitigating weight stigma
• Implementing emotion regulation interventions like cognitive reapproval
• Supporting realistic postpartum narrative that value function over form

"Words do matter," stressed Crown. Encouraging the healthiest choices possible is important for mothers, but it must be done without shaming, and thus leading to increased guilt, fear, and anxiety in mothers.

Bossewitch highlighted nonpharmacologic interventions. These include:

• Psychotherapy like cognitive behavioral therapy, interpersonal therapy, and supportive counseling.
• Peer support and group therapy, which can help prevent mothers from feeling isolated.
• Exercise, as regular physical activity can improve mood by boosting endorphins.
• Mindfulness-based interventions, such as breathwork. While there are only limited direct studies, anecdotal and clinical reports highlight benefits.
• Sleep, which can be especially difficult. Sleeping when the baby sleeps, establishing a nighttime routine, and avoiding screen time can help improve sleep hygiene for new mothers.
• Nutrition and supplements, as a balanced diet rich in omega-3 fatty acids, vitamins, and minerals can support mood regulation. Limiting caffeine and alcohol and staying hydrated can help stabilize energy and mood.
• Environmental interventions can maintain structure for new mothers. Building quiet time, reducing noise and clutter, and reminding her that she has interests outside of just the baby can help mothers feel normal.
• Engage with the partner and family. Educating partners and family encourages emotional and practical support.
• Bright light therapy can help stabilize mood, improve sleep, and reduce fatigue.
• Electroconvulsive therapy, while not FDA approved for PPD, is particularly effective for PPD with psychotic features or catatonia.
• rTMS, also not FDA approved for PPD, shows some evidence of reducing PPD symptoms in small studies.

"There are many effective nondrug options for these moms. They often work best in combination. There is no one size fits all for PPD, as in all mental health," said Bossewitch.

Crown shared more information on pharmacologic options. In terms of antidepressant selection for PPD, the typical antidepressants, SSRIs and SNRIs, are limited by slow onset of action and may not address pathophysiologic mechanisms in PPD. Suicide risk is important to screen for in this patient population.

Brexanolone is the first drug specifically approved for the treatment of PPD. It has a novel treatment approach as a neurosteroid and analogue of allopregnanolone. However, brexanolone was discontinued in 2025 and FDA approval was withdrawn.

Zuranolone is now the first and only oral medication FDA-approved for the treatment of PPD in adults. It is a neuroactive steroid GABA-A receptor. For dosing, appropriate absorption requires 50 mg taken orally once daily alongside a high fat meal in the evening. If the evening dose is missed, patients should take the next dose at the regular time the following evening. It is important not to take extra capsules on the same day to make up for the missed dose. Their are no contraindications per the FDA label. However, new m others should note impaired ability to drive or engage with other potentially hazardous activities. It should also not be used during pregnancy, only after.

"Now, I have a friend who was trained in forensic psychiatry, and he once taught me that we have a moral and legal responsibility to inform all of our patients about all of their treatment options, regardless of what we think about them, as long as they are appropriate treatment options and to allow them an opportunity to make informed choices. So this piece of patient preference is particularly important to consider when we're talking about postpartum depression," shared Crown.

References

1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 87 November 2007: use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2007;110(5):1179-1198.

2. Masters GA, Brenckle L, Sankaran P, et al. Positive screening rates for bipolar disorder in pregnant and postpartum women and associated risk factors. Gen Hosp Psychiatry. 2019:61:53-59.

3. Riesco-González FJ, Antúnez-Calvente I, Vázquez-Lara JM, et al. Body image dissatisfaction as a risk factor for postpartum depression. Medicina (Kaunas). 2022;58(6):752.