Broken Medicine

New Clues Reveal How to Treat Postpartum Depression

Postpartum depression affects up to 20 percent of people. A universal treatment could be the key to preventing it.

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Five weeks after her baby was born, Tara started seeking support groups for new mothers. She sensed that the anguish she was experiencing was more complicated than the “baby blues” and wondered whether she was suffering from postpartum depression.

Tara felt there was a dissonance between the emotions she thought she was supposed to be experiencing—joy, triumph, contentment—and the physical and emotional suffering she was actually enduring.

“You start to feel like, What’s wrong with me? Why are people congratulating me? I’m in the worst pain I’ve ever experienced,” recalls Tara, who asked that her name be changed for privacy. “I’m having the wrong experience completely.”

Looking back, Tara questions whether she received enough information about mental health during her pregnancy. During that time, Tara learned there are certain risk factors linked to postpartum depression—high stress, a lack of support, and pre-existing depression, among others. She felt relieved then, knowing she couldn’t check any of those boxes. But now after having her baby, she wonders how much of her current situation was preventable.

Perinatal depression, a collective term for depression during or after pregnancy (e.g., postpartum depression), affects 10-20 percent of people during pregnancy. Around one in seven women develops postpartum depression after giving birth. Trans men who give birth also experience postpartum depression; though rates of this medical condition among this group are unknown, research and lived experience show it happens. In one study, trans men expressed that they wished their care providers prioritized talking about postpartum depression with them and that they felt ill-equipped to navigate the experience.

Research led by Dr. Jennifer Payne, M.D., a professor at the University of Virginia Health, found national rates of postpartum depression increased during the first year of the COVID pandemic. While a follow-up study hasn’t been conducted yet, Payne says it’s likely that those levels are still elevated.

Depression can be challenging to recognize, and patients can be reluctant to reveal their symptoms due to the expectations of parenthood and stigmas attached to mental health issues. According to the Centers for Disease Control and Prevention (CDC), approximately 60 percent of women with depressive symptoms do not receive a clinical diagnosis, and 50 percent of women with a diagnosis do not receive any treatment. What’s more, since 1990, maternal mortality has more than doubled in the U.S., and suicide is a leading cause of death. As a result, pediatricians describe maternal depression as a public health crisis.

At this precarious juncture, preventative care has emerged as an effective path forward. Researchers are creating new ways of identifying those most in need of help so that they can get aid before their baby is born. In addition, a critical reassessment is underway of how pregnant people generally receive care—broadening who gets help could be even more effective in preventing postpartum depression.

“I think in my lifetime, it will be easier to predict who’s at elevated risk and prevent postpartum depression,” says Payne.

The answer is in our genes

Payne has identified two biomarkers of postpartum depression that are around 80 percent accurate in predicting who’s at risk. She’s currently developing a test that doctors could order to detect these biomarkers. In October 2022, Payne and colleagues made another discovery: a pattern of decreased autophagy before women develop depressive symptoms. Autophagy is when cells clean out old proteins and debris. Other studies have found a connection between decreased autophagy and depression, but this is the first time it’s been observed before the onset of illness.

Because decreased autophagy can be treated with some existing antidepressants—Payne uses Prozac as an example—the finding could mean pregnant people who display this pattern should be given these medications before they give birth. The discovery is a foundational clue to an ongoing endeavor: How to spot who is vulnerable to postpartum depression and provide corresponding preventative care.

In 2019, the U.S. Preventive Services Task Force issued a recommendation saying that because there’s now enough convincing evidence that counseling interventions can help, women at risk for perinatal depression should receive these preventative services.

It was a step in the right direction and reflective of the current state of evidence, says Jennifer Johnson, Ph.D., a professor at Michigan State University. But critically, Johnson observes, the current evidence doesn’t answer an important question.

“We think the right question is: Should postpartum depression prevention [only] be given to moms at risk, or should it be given to everyone?” Johnson says.

The potential of universal treatment

The ROSE Scale-Up Study, which received a $6.2 million National Institutes of Health research grant in September, is likely to address this. The study is a continuation of research on the ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program, an empirically validated prevention intervention for postpartum depression developed by Caron Zlotnik, Ph.D., a professor at Brown University. It’s an educational class rooted in interpersonal psychotherapy that can be facilitated by anyone who works with pregnant people.

Work on ROSE began around 2001. Since then, its benefits and efficiency have been tested in various settings. So far, findings indicate that ROSE prevents half the cases of postpartum depression when given to at-risk women.

“Every time we got positive findings, we thought, Okay, what’s the next logical step?” says Zlotnik. “It just sort of snowballed.”

Zlotnik and Johnson are the Scale-Up Study’s principal investigators. The study will last for about four years, and the program will be distributed through Henry Ford Health, a healthcare system based in Detroit, Michigan. The researchers will start to get a sense of the results about six months after its completion, but Johnson anticipates their hypothesis will prove correct.

“Right now, there’s no evidence that ROSE will help moms not at risk,” Johnson says. “But we think it will be more effective, more equitable, and more scalable if it’s given to everyone.”

The reasons why are several. One is its ease and low cost; previous ROSE studies suggest it’s often easier for healthcare systems to provide ROSE to everyone.

They’ve also found that the more at-risk or marginalized a person is, the less likely they are to want to participate in the program. For example, an undocumented person might worry that being put on a list for the program would make them vulnerable to deportation. On the other hand, providing all pregnant people with ROSE doesn’t single anyone out and is less stigmatizing. Ideally, it would be seen as something similar to a pap smear or a flu shot, says Johnson. It’s a routine, preventative health measure.

Too often, new parents blame themselves for feeling anything less than happy, Zlotnik says. One of the aims of ROSE is to help them understand that depression happens to many new parents—and to provide this understanding before the baby is born. ROSE is divided into four sessions, each with a different aim—pregnant people go over elements like the symptoms of postpartum depression, how to identify positive supportive systems, how to resolve interpersonal conflicts, and the importance of setting goals. After birth, a “postpartum booster” session reflects on the earlier lessons, problem-solving, and available resources. “This important information can allow new parents to reduce their self-criticism and be more willing to seek treatment,” Zlotnik says.

Breaking through systemic health barriers

Being around other new parents experiencing postpartum depression and anxiety has been helpful for Tara, who completed her participation in the Afterglow therapeutic support group in November. Afterglow, founded by Karen Kindig, a licensed therapist, is part of the Womb Room—a perinatal health and wellness center in Baltimore, Maryland, that started offering the services in 2019. Kindig was introduced to the Womb Room as a client and is now its owner.

Tara’s postpartum mental health issues were overwhelming yet so hard to articulate that it was immensely liberating to meet with others sharing the same experience. “The group really helped me let go of any sense that I was particularly weak,” Tara says. “I didn’t have to explain why delivering and parenting a newborn is traumatic. They already knew.”

Some people sign up for Afterglow as a proactive measure during their pregnancy, typically when they have a history of depression and anxiety, Kindig says. However, the majority join after they have their babies. Ever since it was put on the schedule, demand for the group has been high.

Kindig’s goal is to normalize postpartum depression, help people feel less alone, and gain resources that ease the experience. Its founding was also, in part, a response to her own experience with postpartum depression. Too often, she says, people have a certain idea of what postpartum depression looks like and when it can hit. If reality doesn’t match this, people may feel like they don’t meet the criteria for getting help.

“Many people suffer in silence, either because they’re ashamed, in denial, or just want to appear that they have it all together,” Kindig says.

But if a person wants to use their insurance to pay for the support group, they need to have a diagnosis (though the Womb Room offers sliding scale rates if the price is out of reach). This has less to do with any particulars of the center and more to do with the design of insurance and American health care. To bill insurance, you need to have a diagnostic code. Yet, the point of prevention is for a person not to have a diagnosis. Many who seek help prior to developing symptoms as an act of preparedness have to be prepared to cope with the financial burden.

At the same time, new mothers on Medicaid—the joint federal and state public insurance program intended to provide coverage to people with low income and limited resources—have almost twice the rates of postpartum depression as other moms, Johnson says. The cost of preventative care doesn’t always match their financial reality.

While there’s been a huge shift in recognizing the need to provide postpartum depression care, the United States is still “lagging behind in terms of infrastructure, programming, and reimbursement for prevention services,” Zlotnik says.

Further evaluation of the ROSE program, and work done by scientists like Payne, could open the door to a new understanding of how we provide preventative care to people who become pregnant. Community-focused efforts like Afterglow are a part of the equation, and their success reflects core elements of quality postpartum care. Science can guide top-level directives, and community opinion shows how much people want them, but a remaining question is whether what proves to be helpful is actually easy to access.

“I really wonder how much of my suffering was due to systemic barriers and how society values women and children,” Tara says. “It feels like we are set up to fail.”

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