Zuranolone offers hope for treating postpartum depression in new mothers

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In March 2023, Kristina Leos, a 39-year-old ICU nurse in the local Dallas hospital, gave birth to her third child, Victoria, via in vitro fertilization. Instead of feeling elated, she was consumed by feelings of detachment, guilt, and suicidal ideation.

“I felt so much guilt that I didn't enjoy her,” Leos told HCPLive. “I couldn't feel love or joy.”

After Victoria was born, Leos felt like she was stuck in a fog. Everything became overwhelming: cooking, cleaning, taking care of everyday things. Soon diagnosed with postpartum depression, Leos tried many medications—escitalopram, bupropion, sertraline—but only experienced temporary relief.

“It [was] basically a roller coaster for me,” Leos said. “Things just kept getting worse and worse. And then around December, my psychiatrist was like, ‘I really don't know what else to do with you, because all the traditional SSRIs were not working.’”

Her psychiatrist suggested ketamine infusions, shock therapy, or partial inpatient treatment. However, these options stressed Leos out, especially since it was around the holidays.

Leos inquired about going on zuranolone (Zurzuvae), a treatment she heard about from Facebook groups. Her psychiatrist agreed, and she was soon prescribed the oral medication.

On zuranolone, Leos started feeling like herself again.

“I felt like a fog was lifting,” she said. “I've heard people say that, and I never understood it until I actually went through that. I finally felt like I was actually present in my life.”

The US Food and Drug Administration (FDA) approved zuranolone for postpartum depression (PPD) in adult patients on August 4, 2023. A GABA-positive allosteric modulator, clinical research demostrated it reduced depression symptoms on day 3, with continued improvement over 45 days.

Zuranolone became available on December 14, 2023, just when Leos was desperate for a new treatment. Before this, only brexanolone (Zulresso) was approved for PPD, requiring a 60-hour intravenous infusion in a certified facility.

“[Zuranolone] could potentially replace brexanolone,” Anita Clayton, MD, of the University of Virginia School of Medicine, told HCPLive in December. “It’s much more preferable to be able to take a pill every night for 14 days.”

Despite zuranolone’s availability, many patients are unaware of it.

“It's probably different regionally, but out here in Arizona, it's really just been over the past probably 2 or 3 months that we've been able to really start having good discussions about it with patients,” Douglas Weber, MD, an OBGYN practicing in Arizona, told HCPLive.

Leos was concerned about being among the first to take zuranolone outside clinical trials.

“I think this is the first medicine I've ever taken in my entire life that I've read the entire sheet of all the interactions,” she said.

She worried about interactions, cost, and the medication’s presence in breast milk. She was pleasantly surprised to learn about the drug cards which helped reduce costs.

“I'm in postpartum support groups, and I think a lot of people don't know about the drug cost or the drug card and that people don’t have to actually pay $14,000 out of pocket,” Leos said.

Uncertainty about zuranolone’s long-term effectiveness also worried Leos since the studies only tracked participants for 45 days, but her concerns were alleviated as she continued the medication.

However, Leos’ concerns about zuranolone were hardly alleviated when it was first prescribed. She asked her psychiatrist many questions, but her psychiatrist was also new to the drug.

“She didn't tell me outright, but I'm almost positive I was her first patient to take it, and probably the first one at the clinic that she's at,” Leos said. “She didn't even know how to write the prescription.”

Zuranolone prescriptions need to go to special pharmacies, such as CVS care pharmacy, based on insurance. Thus, psychiatrists needed to learn how to properly word the prescriptions for these pharmacies.

Leos’ psychiatrist assured her that her that the benefits of zuranolone would outweigh the concerns. If necessary, she could give her baby formula for 2 weeks or deal with mild dizziness, which would be worth the advantage of zuranolone.

Rachel Dalthorp, MD, the executive medical director at LifeStance Health and a reproductive psychiatrist in Moore, Oklahoma, shares a similar sentiment. In an interview with HCPLive, she emphasized that mother’s depression causes significantly more harm to a baby than exposure to any of the medications used for postpartum depression.

“Moms have to know that deciding to treat their postpartum depression with medication is really the best option, not just for them, but for their baby,” Dalthorp said. “They're not putting their baby at risk by prioritizing their mental health. Risk for baby comes from not treating mental illness.”

Dalthorp noted many mothers view emotional concerns after childbirth as normal and believe they will get better on their own. However, statistics indicate about 1 in 5 women experience PPD.3 Some hold the misconception that they should try a traditional antidepressant before zuranolone, but this only delays effective treatment and prolongs illness.

Many patients, like Leos, also think zuranolone will be expensive. However, Dalthorp explained patients only have out-of-pocket cost of around $50.

Dalthorp takes a personalized patient with each patient she prescribes zuranolone to, discussing their risk factors for postpartum depression and their history of depression and anxiety. She works with moms in treatment planning and includes dads in the conversation.

“I've actually found dads to be really strong advocates for their wives and for treatment that helps to decrease mom's guilt and shame,” Dalthorp said.

Weber also emphasized the importance of involving partners and educating patients about what to expect with zuranolone.

Zuranolone has brought unexpected and positive outcomes, helping new mothers with postpartum depression and improving anxiety symptoms. Weber shared a case where a patient was consumed by visions of her baby dying. The visions stopped just after 3 days on zuranolone

“She still had some anxiety but was significantly like day and night differences how she described it,” Weber said.

Dalthorp was also surprised when a patient’s anxiety symptoms decreased dramatically and quickly after starting zuranolone.

“[The patient] and her husband had made the decision not to have any more children because her postpartum depression was so severe, and she didn't feel like she could go through it again,” Dalthorp said. “But after being treated with a medication for postpartum depression, they realized that there was an option that would work for her, and that made them open to having more children, so that's really a beautiful thing.”

This article was originally published by our sister publication HCPLive.

References

1. Kunzmann, K. FDA Approves Zuranolone for Postpartum Depression. HCPLive. August 4, 2023. https://www.hcplive.com/view/fda-approves-zuranolone-postpartum-depression. Accessed August 2, 2024.
2. Derman, C. Zuranolone Introduces Convenience to Postpartum Depression Care. HCPLive. December 20, 2023. https://www.hcplive.com/view/zuranolone-introduces-convenience-postpartum-depression-care. Accessed August 2, 2024.
3. Wang Z, Liu J, Shuai H, et al. Mapping global prevalence of depression among postpartum women [published correction appears in Transl Psychiatry. 2021 Dec 20;11(1):640. doi: 10.1038/s41398-021-01692-1]. Transl Psychiatry. 2021;11(1):543. Published 2021 Oct 20. doi:10.1038/s41398-021-01663-6