New mothers can get emotional support from therapy, drugs, their community

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

The Food and Drug Administration recently approved a pill to treat postpartum depression, and today we'll hear how medication is already helping new moms in Central New York who are struggling.

My guest is Dr. Seetha Ramanathan. She's an associate professor of psychiatry and behavioral sciences and the director of the Women's Mental Health Program at Upstate.

Welcome to "The Informed Patient," Dr. Ramanathan.

Seetha Ramanathan, MD: Thank you, Amber.

Host Amber Smith: Before you tell us about this new oral medication, I'd like to first ask you about postpartum depression.

How common is this?

Seetha Ramanathan, MD: Well, unfortunately it is very common. One in eight women experience postpartum depression. Sometimes these numbers are higher, but in general, the CDC (Centers for Disease Control and Prevention) notes it as one in eight.

Host Amber Smith: How is PPD -- postpartum depression -- how is that defined, and how does it get diagnosed?

Seetha Ramanathan, MD: There is a medical definition of PPD. It's essentially onset of depressive symptoms in the last trimester or within the first postpartum month. But we know that depressive symptoms can last beyond four weeks, so there is a debate there as to whether it should be just the first four weeks, or it should be the first year postpartum.

And most experts will say we should look at it in the first year postpartum. We also talk about depressive symptoms in the postpartum period being a little different. For majority of depressive symptoms, we talk about exhaustion, sleep disturbance and low energy levels.

This is very common. When you had a baby, you are going to be waking up every two hours. You are going to be exhausted. You have a new baby. You just gave birth, and you are going to have some low energy levels. So that's pretty common, and it makes it a little tricky to diagnose postpartum depression.

But we also see additional symptoms in the postpartum period, which includesthe mom is just not able to bond with the baby, or she's a little bit more irritable. She just doesn't have any interest in doing things and does not feel joy.

Another thing that happens in the postpartum period is postpartum blues, which is actually even more common. Around 75% of mothers will actually experience postpartum blues. The difference between blues and depression is that blues will fade away in four weeks, but depression does not go away; it becomes more severe and more intense. The good thing is, postpartum individuals are scheduled to go for follow-ups with their OBs (obstetricians) and the pediatricians, and everyone now screens mothers, using a specific depression-screening tool. And we can now attempt to differentiate and identify mothers with postpartum depression.

Host Amber Smith: Is it the first-time moms that are most at risk for this, or do you see it in second or third, or subsequent births?

Seetha Ramanathan, MD: Well, we can see it across all births, but studies have shown that first-time mothers do have a higher risk of postpartum depression. But then once you've had postpartum depression after the first pregnancy, the risk remains for later pregnancies as well. But that being said, just because you don't have it with your first birth does not necessarily mean you won't have it with the second or third birth, because it's not just hormonal and chemical. There's a lot of environmental factors that also play a role in postpartum depression.

Host Amber Smith: I was going to ask if we know what actually causes it. Because if it's one in eight women, that means seven of the eight women are not dealing with this, so what's the differing factor between them?

Seetha Ramanathan, MD: Well, perhaps, what differentiates postpartum depression with all of the forms of depression is clearly hormonal changes. There are theories that suggest that for some women, their neurochemicals, their brain structure, may be a little bit more susceptible to hormonal changes. In fact, there is one potential association with premenstrual symptoms and postpartum depression, that these women may be more susceptible, more at risk for postpartum depression.

Now we do have to be mindful that the research in postpartum depression and generally in women's mental health is pretty limited, and we need more data. So these are all associations, but there are a number of other factors that actually increase the risk of postpartum depression. And this includes, say, family issues, like single mothers, conflicts with your significant other, poor social support. There are also risk factors. for example, socioeconomic risk factors like poverty can increase, the risk of postpartum depression. Violence, neighborhood violence, can increase the risk of postpartum depression. In fact, there is data coming from some areas that in some countries which have environmental risk factors, the risk of postpartum depression is actually as high as 39% -- that is, one in three mothers can struggle with postpartum depression. So there are all these other factors that play a role in increasing the risk. There's the hormones and the biology, but there's also psychosocial elements.

Another thing that's a risk factor is actually if the mother has already struggled with depression in the past, depression, anxiety, post-traumatic stress disorder, that increases the risk of postpartum depression as well.

Host Amber Smith: Do dads ever grapple with postpartum depression?

Seetha Ramanathan, MD: This is a very interesting question, and I am the director of Women's Mental Health, but dads do struggle with postpartum depression.

Now, the research on women is low. The research on dads is even lower, but it's actually up to 25%, like one in four dads can actually struggle with postpartum depression. The risk is higher if the mother has postpartum depression. In the postpartum period, there's also a role change. There is this dream of a baby, which now becomes a reality, and now you are responsible for one more, if I can say, this tiny thing that cannot talk about anything, cannot say anything and pretty much conveys in crying. And there's a role transition to becoming a parent. Dads struggle with that as well, and so up to one in four, it's usually 10%, but up to one in four dads can also struggle with postpartum depression. It's a family dynamic.

Host Amber Smith: Well, what have the treatment options been up until now for postpartum depression for women?

Seetha Ramanathan, MD: We have a lot of treatment options. The most common ones have always been antidepressants. The most common one is Zoloft. Everyone's heard of Zoloft. A lot of our antidepressants have been found to be safe. Remember that postpartum depression can actually begin in the perinatal period, during the pregnancy itself, and a lot of mothers struggle with taking medications during pregnancy: "What if it's going to harm my baby?"

A lot of these medications have been found to be safe. Antidepressants have been used in pregnancy and in the postpartum period. There's also psychotherapy. And of course now the two new ones. One is not so new. One is brexanolone, which is very specific for postpartum depression. And the second one is the newest medication, the newest pill that's been approved, zuranolone, which is essentially a pill form of brexanolone, makes it easier for access, for mothers to get the pill. But we have a lot of medication options and treatment options for perinatal depression.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Seetha Ramanathan. She's an associate professor of psychiatry and behavioral sciences at Upstate, and she also directs the Women's Mental Health Program at Upstate.

So tell us a little bit more about this new medication that's available.

What did you call it?

It's zuranolone, also called Zurzuvae.

Host Amber Smith: So how does it work?

Seetha Ramanathan, MD: The two medications, brexanolone and zuranolone, work on neurosteroids. Essentially, if I put it very simply, during pregnancy and the postpartum period, there are some hormonal changes that happen, which are very dramatic in nature, and these two medications in some ways correct those hormonal changes. And that is the mechanism of action in this, progesterone, estrogen and progesterone. and there's pregnenolone, which is similar to progesterone. And these two medications work on that system of hormones, so they correct that, and that's what's used in the postpartum period to address postpartum depression.

Host Amber Smith: Are there any side effects of these medications?

Seetha Ramanathan, MD: Both of them have the the side effect that the FDA (Food and Drug Administration) has listed, for example, for zuranolone, is sedation. And the warning is: Don't drive. It was the same thing for brexanolone as well. We would monitor for drowsiness and a very small population would have a drop in oxygen saturation, so we would monitor for that. Now, that has not been given as a warning for zuranolone, which is great. The primary one, the main one, is somnolence, or sleepiness.

Host Amber Smith: Is it safe to take if you're breastfeeding?

Seetha Ramanathan, MD: As of now, there is no data on that. Now we know for brexanolone, we would ask the mothers to stop breastfeeding, and that is the same thing for zuranolone as well: no breastfeeding for the 14 days of the duration of the pill.

Host Amber Smith: And when a woman is prescribed these medications, is she also recommended psychotherapy? Do they happen at the same time? Or does the medicine take the place?

Seetha Ramanathan, MD: No, absolutely. psychotherapy plays a huge role and should be a part of all treatment for postpartum depression.

Psychotherapy cannot be replaced by pills.

Host Amber Smith: Well, let me ask you, in terms of resolving postpartum depression: After the birth of the baby, once the woman's cycle returns to normal, and the hormones are sort of tapered out, does it sort of naturally resolve?

Seetha Ramanathan, MD: Well, unfortunately, most studies have shown no. It can last for up to a year and sometimes longer. In fact, one of the greatest risk factors of anybody struggling with depression is suicide,and the risk of suicide in postpartum period is actually in the ninth to 12th month. So you can see it can actually last quite long and sometimes even longer.

Now, again, we don't know how long it lasts, but unfortunately, it does not resolve with the resumption of the cycle.

Host Amber Smith: Well, I'm assuming that postpartum depression is one of the conditions that you're commonly treating through the Women's Mental Health Program.

What are the other conditions that you might see in that program?

Seetha Ramanathan, MD: Well, I'm just going to start off with, broadly, we know that women have a different biological status as compared to men, and they respond to medications and environmental situations very differently. So that's one area we do work in, that we recognize that women may respond differently to medications.

They have different physiological states. So that's No. 1. The second one, of course, we have premenstrual dysphoric disorder. Thankfully, people have started talking about it, that premenstrual dysphoria is a real condition, and it can really affect your functioning. So that's a common condition we work with, and the final one is menopause. Menopause is also associated with all these hormonal changes and is associated with depressive states, anxiety states, and even sometimes cognitive changes, changes in attention. We work with women who are struggling with menopause as well.

A lot of women with menopause also talk about hot flashes, night sweats, and there's an association with this condition with these states and depressive states. So again, we have to remember, we have to be mindful that we have to do a lot of work to understand these states. I'm just thankful to see everyone talking about premenstrual dysphoria, athletes talking about not working during this premenstrual state, just thankful that everyone's paying attention to the unique mental health needs of women.

Host Amber Smith: Is substance use tied to any of this? Do you see that often?

Seetha Ramanathan, MD: Substance use is definitely tied across the board. We do work with women with substance use, but there are some conditions, some substance use disorders that we don't work with, but we collaborate with Crouse (Hospital), which has a great program, especially (for) women struggling with opioid use disorder. Crouse has some special programs for pregnant and postpartum mothers, and we collaborate with them to help mothers who struggle with opioid use disorder, but we can work with women struggling with alcohol use disorder, tobacco use disorder and others.

Host Amber Smith: Can you go over the services that this program provides and what sorts of research trials are underway?

Seetha Ramanathan, MD: Well, our main, service over here, our focus is, we do medication management, and we do psychotherapy. we are trying to expand to do group psychotherapy. One of our biggest research trials is essentially to address barriers to care.

So although we have these great medications, we know medications are saved (not taken) during pregnancy and postpartum period -- (by) mothers who do not want to take medications during breastfeeding. But before zuranolone, we still had medications.

What we were seeing is that mothers were still not coming for treatment. They were not acknowledging -- I mean, it's hard to acknowledge "I'm depressed" in the postpartum period. "This was a happy time of my life. How can I be depressed? Something must been wrong with me." It's a lot of stigma associated with postpartum depression, acknowledging and seeking help. So we've been working with some community agencies to address that stigma.

A lot of it is psychotherapy and psychoeducation, so that's our No. 1 area of work.

The second one is, we have been doing a lot of work in ADHD in women, attention-deficit/hyperactivity disorder. Again, unfortunately, females don't often get diagnosed with ADHD. It seems to be, if we look at the data, it's younger boys who get diagnosed more than females, but during adulthood the prevalence becomes almost similar, so clearly something is changing. And studies have also shown that women come to ask for help for ADHD when they notice that their child is being diagnosed with ADHD, and they're start seeing similarities. So, we've been working in ADHD in women.

But another one that we are actually involved in at Upstate is something called Project TEACH. It's a great initiative across the state, seven institutions across the state that offer consultations to OBs and primary care physicians who are struggling with figuring out what medication to prescribe to this pregnant woman or the postpartum mothers. So that's another thing we've been doing. It's a 9-to-5 service, and a reproductive psychiatrist gets on the phone with the person asking the question and tries to work with the physician to help the mother get the appropriate treatment.

So a lot of work in barriers to accessing care in pregnant and postpartum mothers.

Host Amber Smith: How does someone who's listening to this interview reach the Women's Health Program? Do they need a referral from their primary care doctor?

Seetha Ramanathan, MD: Oh, that would be fantastic if we can get one. That's definitely one way of getting here.

But the second way is to just call the front desk at 315-464-3265 and ask for Women's Mental Health. We usually try to reach the woman back in 24 to 48 hours, do a quick triage, and then try to get them in for a first appointment. Depending on the need, they'll definitely try to get them in within four weeks; but if it's a more urgent need, because of all these different connections, we'll try to get them help as soon as possible.

Host Amber Smith: Well, getting back to postpartum depression, can you go over the signs and symptoms?

Because becoming a mother is such a huge transition. It may include some sadness and some anxiety. So how do you tell if what you're feeling is normal or something more to be concerned about?

Seetha Ramanathan, MD: Oh, that's such a great question. Amber, in all our community work, we have actually heard exactly this, that everyone tells us this is normal.

Well, you know, there is some normalcy to being a new mother, the anxiety of the new mother and some sadness because roles are changing.

But postpartum depression is more intense. It is "sadness, which is taking away my joy." "I used to enjoy (say) cooking. I'm too tired to cook right now."

That's different from, "I just don't get any joy from cooking. I just don't feel like doing anything." I mean, "I don't have the energy to meet anybody" is different from, "I don't have the interest in meeting anybody." But the biggest red flag for us is, "I look at my baby, I just don't feel like I'm bonding with the baby."

So that's the biggest red flag for us. "I'm a little bit more irritable than usual," and one can understand irritability because you haven't slept well, you are taking on a new role. But this is, "I am more irritable than usual, and it's affecting my relationships." So that's what we are looking at.

But I also tell everyone, when in doubt, ask for help. Your OB is going to screen, in fact, ACOG has changed the screening protocols and now they get screened at three months and then three weeks and six weeks. Your pediatrician, when you go for your first week follow-up, is going to screen for depression.

The recommendation would be, just be honest and tell them. It's not uncommon. There are a lot of mothers struggling, so you are not alone.

Host Amber Smith: And ACOG: the () American College of OB/gyn's.

Seetha Ramanathan, MD: That's right.

Host Amber Smith: They're the ones that sort of set the standard for that.

Seetha Ramanathan, MD: They did say that they have actually changed a lot of standards because we are actually seeing, I mentioned the worst case is death by suicide ... we are actually seeing a lot of, that worst-case scenario. If the tip of the iceberg is getting larger, we know the iceberg is getting bigger. So, in fact, there's something called as a Maternal Mortality Review Committee, which looks at mothers who have died in the first year of postpartum. The most recent MMRC has actually shown that the No. 1 preventable cause of maternal mortality is, unfortunately, mental health and substance use disorders. And sadly, the United States has a very high maternal mortality rate. So when we look at the tip of the iceberg, and that's expanding, it's no longer postpartum hemorrhage and other conditions, but actually mental health, we know that we have a lot of work to do in perinatal mental health.

Host Amber Smith: Are there things that you recommend the partner or loved ones, neighbors, friends, are there things they can do that would help out a new mother so that this doesn't become a problem?

Seetha Ramanathan, MD: That's such a lovely question. Again, we've been doing a lot of interviews with our mothers, and the one thing they talk about is, "Where is my village?"

So, more recently I came across this concept called "matrescence" (the process of becoming a mother), and we talk about it takes a village to raise a child, but that one talks about it takes a village to raise a mother. So what we can talk about is prevention of postpartum depression and perinatal mood and anxiety disorders.

The first one is: Build your community, increasing awareness in the community about perinatal mood and anxiety disorders or postpartum depression, for example. We call it perinatal mood and anxiety disorders, or PMAT. And bring increasing awareness, stepping away from saying it's OK, it's normal, you'll struggle through it, we all have done it, but saying yes, some sadness can happen, but we are here, you are not alone, we are your village, is very helpful. Another thing we've been working on is actually trying to figure out preventive models, focusing on mother's wellness, focusing on mother-child interactions, focusing on building your village. In fact, the United States Preventive Services Task Force -- USPSTF -- has actually recommended that, women who are at high risk for depression, assistance should start offering them some preventive tools. Usually it's psychotherapeutic tools, and that's what we've been trying to build as well. Can we help mothers build preventive tools into their tool kit? And one of the most important things is community building, increasing awareness and supporting the mother and helping her address the stigma. A lot of the stigma comes from the community: "You should not be feeling sad. This is a time for you to be happy."

Brooke Shields (the actress) has a very nice narrative on it, and I won't go into that right now, but she talks about how she was expected to be happy in the postpartum period, but she was actually feeling sad, and that made her feel really bad as a mother. I mean, "I should be enjoying this little girl. I've always wanted this girl." And that is something we have to really come together as a community and tell the mother it's OK. Sometimes it can happen. We are here to help you.

Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Ramanathan.

Seetha Ramanathan, MD: Thank you, Amber, for having me, and it was my pleasure.

Host Amber Smith: My guest has been Dr. Seetha Ramanathan, an associate professor of psychiatry and behavioral sciences at Upstate and also the director of the Women's Mental Health Program.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

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