Fern had severe postpartum depression with her first child, a colicky baby that couldn’t sleep through the night.
“I had constant intrusive thoughts about how worthless I was as a mother and wife,” Fern, who asked to be identified only by her first name, told The Daily Beast. “I was convinced my husband and son would be better off without me and started fantasizing about killing myself.”
She knew something was wrong but “I didn't want to tell anyone because I was convinced that child protective services would take my son away.” It wasn’t until a year after giving birth that she finally told her husband what was going on, sought help, and got diagnosed with postpartum depression.
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On Tuesday, the FDA greenlit brexanolone, a brand new treatment for postpartum depression promising to virtually erase the symptoms mothers like Fern battle with. A joint FDA advisory panel voted unanimously on its efficacy based on randomized trial data, going so far as to laud it as a “breakthrough” and a “gamechanger.”
But there’s a catch: It costs between $20,000 to $35,000 and is administered intravenously for 60 continuous hours under close medical supervision, making it virtually inaccessible to lower income mothers.
Brexanolone (manufacturer Sage Therapeutics will market it under the name Zulresso) is a synthetic version of allopregnanolone, a hormone that drops following childbirth. Until now, treatments included talk therapy and antidepressant medications—also used to treat depression and anxiety disorders in the general population.
These drugs haven’t proven equally effective for all new moms with postpartum depression though, and they can take up to four to eight weeks to start working, which has posed an ongoing challenge for postnatal healthcare providers.
Postpartum depression is a severe mood disorder occurring in the days and weeks following birth that affects up to 1 in 7 women. It’s far more intense than just the “baby blues” —symptoms can include overwhelming fatigue, feelings of hopelessness and guilt, thoughts of suicide, and difficulty or even inability to care for a new baby. Left untreated, postpartum depression can be life threatening and last for months or longer.
Unfortunately, the cost and time commitment mean that the drug may not help those who need it most. Studies suggest that low-income women and minorities have higher rates of postpartum depression, and are also less likely to receive adequate care. Black and Latina women are about half as likely to get treatment, continue a regimen, and get a prescription refill for postpartum depression compared to white women, despite being slightly more likely to have postpartum depression. And poorer women are more likely to develop postpartum depression than their more affluent counterparts.
A treatment costing tens of thousands of dollars and 60 straight hours with an IV is not a luxury that is within access for many of these women.
Maria Muzik, medical director of the Perinatal Psychiatry Clinic at the University of Michigan, is hopeful about brenaxolone. She notes that, right now, the drug “is actually not going to be benefiting low income women at all” but that this is a moment of opportunity for Sage Therapeutics, policy makers, insurance companies, and medical institutions to “really negotiate an implementation model for this new treatment that is fair and benefits all.”
Clinical psychologist Nathilee Caldeira, the director of clinical services at Let’s Talk Psychological Wellness Center in New York City, notes that most of her clients are college-educated and work full time, and “based on their finances, that population would have a hard time accessing this drug" unless insurance covers it.
“It would be even more difficult for those who are earning a lot less,” she said.
Even if insurance companies decide to cover the drug, it’s unlikely that low income moms will be able to reap its benefits. Up to an estimated 1 in 4 women in the U.S. simply can’t afford to take extended maternity leave and are forced to return to work in as little as two weeks—long before the six or more weeks required to heal from giving birth and often well before postpartum depression can be diagnosed, let alone treated.
According to the American College of Obstetrics and Gynecology, racism and life stressors, being underinsured or uninsured, and stereotyping and implicit bias on the part of healthcare providers are among the myriad complex factors that could explain these disparities in maternal care.
And many economically-disadvantaged women have to travel long distances to access care during and after pregnancy. In fact, travel distances have increased in the last decade.
A promising oral medication that works similarly to brexanolone, made by the same manufacturer, might be much easier and less costly to access, and is making its way through clinical trials. The once-daily pill, SAGE-217, is no doubt an exciting possibility, but it won’t be a magic fix for helping moms suffering with postpartum depression.
Muzik points out that only half of those with antenatal or postpartum depression get screened, “This is a problem. So access is key with or without brexanolone.”
In addition to all of the logistical challenges that come with a 60-hour treatment, some women may avoid doing so even if they can. Fern said she would because “the stigma of being hospitalized for a mental health problem is pretty high.”
Despite the criticism, proponents say that brexanolone is worth the hassle. “For women suffering, you can say, ‘You can come in and be treated and in 2.5 days it can go away, and not come back,’” Samantha Meltzer-Brody, a psychiatrist at the University of North Carolina at Chapel Hill, who led the clinical trials for the drug, told the Washington Post.
