At the end of March, Sage Therapeutics announced FDA approval for the intravenous and hospital-supervised use of their new postpartum depression (PPD) drug, Zulresso (brexanlone). The possibility of a new way to help women who are struggling with depression after childbirth is an exciting and important development, especially with claims that around 11% of new mothers experience PPD. However, treatment with the drug is anticipated to cost about $34,000 ($7,450 per vial), and Sage does not expect to offer much in the way of discounts. Various articles and opinion pieces have described frustration with the obscene price tag.
In addition to the $34,000 cost, it also requires 60 hours of in-hospital treatment, since the FDA deemed the side effects (somewhat high rates of women losing consciousness) too dangerous for home delivery. The hospitalization will add thousands to the price tag and an additional burden in terms of women’s availability and childcare needs. In this state the drug would, at best, perpetuate class-based inequalities in the treatment of postpartum depression. The reality, though, is that Sage has other versions of PPD drugs in the approval pipeline, drugs that will be expensive — but probably not as obscenely expensive. Given the likelihood of more drugs, including oral options, specifically marketed for PPD in the coming year or two, the $34,000 price tag is not the whole story.
While Zulresso will be too expensive for almost anyone to use right away, it is still likely to have an impact on the way we think about, define, and discuss PPD. It has the potential to legitimize the diagnosis of postpartum depression. In other words, in the teleological thinking common with psychiatric drugs, the existence of an FDA-approved treatment promises us the disease is “real” — i.e. the problem is biomedical, not just “in a woman’s head.” Legitimization is important, both because as a culture we often treat mental illness as less legitimate than other illnesses, and because the medical profession has not always taken women’s suffering seriously.
The desire to recognize and treat women’s suffering, especially in extreme cases of severe depression and even suicide, is a laudable goal. But popular discourses rely too heavily on biomedical etiologies and biomedical solutions to ground that legitimacy. Postpartum depression should not need to be 100% caused by hormonal fluctuations or neurotransmitters to be treated seriously. A new mother’s suffering simply is a serious problem, whether the cause is a hormonal imbalance or any of the dozens of social reasons that women are considered to be at higher risk.
As a reflection of our problem of discussing postpartum depression, it is quite difficult to pinpoint both the causes and the distinctiveness of the ailment. While the obstetric literature currently emphasizes that extreme drops in progesterone and estrogen following childbirth are a causal factor, most women experience these hormonal drops without developing clinical depression. Moreover, hormone therapy alone has not proven a cure. Likewise, psychiatrists and obstetricians have long been uncertain whether postpartum depression is medically distinct from other depressions, or whether it is a variation of them. The Diagnostic and Statistical Manual of Mental Disorders – 5 describes it as depression with a unique onset specifier, while the International Classification of Diseases – 10 recently added a code specific to postpartum depression. Some women’s health activists have vigorously opposed the way PPD is treated in the DSM, but the manual’s authors maintain there is not adequate evidence that it is a distinct mental illness. Sage Therapeutics is currently testing its postpartum depression-specific drug for Major Depressive Disorder, Bipolar Disorder, and insomnia, highlighting the speciousness of claims of a specifically postpartum depression drug. This is not unusual in pharmaceuticals, but it undermines claims of any clear-cut cause — or clear-cut solution — to postpartum depression.
The difficulty in pinning down a cause of PPD is reflected in the ways various institutions describe risk factors. The National Institute of Mental Health, for instance, notes hormonal changes are a likely cause of postpartum depression. They also note that women’s risk of PPD is raised by stressful life events, medical complications for themselves or their babies, a lack of emotional support, and fatigue. Even Sage Therapeutics, which has a deep investment in a biochemical explanation for PPD, describes limited support, domestic conflict, stressful life events, and, ironically, financial difficulties, as major risk factors for PPD on its website. In other words, we know that a solely biomedical explanation is not the whole story, and that a solely biomedical solution is not the whole answer.
So many of the publicized risk factors are social and cultural, not simply biochemical. As others have described, structural problems ranging from a lack of paid parental leave to infrequent medical attention for women after birth to the isolated structure of the modern American family can all play a role in women developing mental health problems in the postpartum period. Yet those of us concerned with women’s health also walk a dangerous line when we want to emphasize these factors, as if considering them somehow undermines the legitimacy or “realness” of the diagnosis. This is because the context in which we discuss mental health can be so black and white, and because the tendency to blame women for not instantly adjusting to motherhood is so great. Hormonal explanations become a shorthand for telling women it is not their fault. In a context in which women experiencing depressive symptoms postpartum often report shame and embarrassment at their depression, there is a major need to emphasize the legitimacy of their suffering. A solely biochemical explanation can do this, and can provide individual women relief from a debilitating self-blame. It can also make it extremely hard to address the social and cultural causes of postpartum depression.
The legitimizing story offered by a drug like Zulresso is at first glance exciting, not just for pharmaceutical stocks but also for women’s health advocates. Certainly fighting postpartum depression needs to include a range of individual solutions, which might include psychotherapy and support groups and both new pharmaceuticals alongside the currently available antidepressants that already help many women. We should not run from new approaches to treatment, but we must proceed cautiously. We must proceed with an understanding that a fight against postpartum depression must also be a fight for structural improvements like paid family leave policies, health care that includes psychiatric services, affordable childcare, and accessible support networks for women. We must think through how limited support for new mothers in the US might contribute to the high rates of the PPD diagnosis in the country today. We must pursue women’s health in its full context, and work toward postpartum mental health in such a way that pharmaceutical innovation is not our only path to believing in and addressing women’s suffering.