Depression and anxiety are both common and potentially debilitating perinatal complications faced by pregnant individuals. While the experience of postpartum depression (PPD) is subjective and varies from person to person, women physicians face added complexities in their experience of and treatment challenges for PPD. High-pressure medical occupations that often have limited work-life balance and a lack of supportive policies contribute to the stress of pregnancy and motherhood. However, the recent approval of zuranolone — the first oral medication to treat PPD — provides hope for all women, but especially the high-risk population of women physicians.
Postpartum Depression Diagnosis
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), defines PPD as a major depressive episode with onset during pregnancy or within 4 weeks of delivery.1,2
At least 5 of the following 9 criteria must be observed most days for at least 2 weeks during the postpartum period to obtain a diagnosis of PPD. These 9 criteria include:2
- persistent depression
- anhedonia
- sleep disturbance
- feelings of worthlessness or guilt
- loss of energy or fatigue
- impaired concentration or indecisiveness
- change in weight or appetite
- agitation or mood swings
- suicidal ideation or attempt and recurrent thoughts of death
Additionally, relevant symptoms that may also indicate PPD include frequent tearfulness, low interest in or sense of bonding with the baby, feeling anxious about the baby, feelings of inadequate parenting, and fears of self-harm or harm to the baby.
Physicians typically assess the presence of these symptoms using screening tools, such as the Edinburgh Postnatal Depression Scale, Postpartum Depression Screening Scale, Patient Health Questionnaire 9, and Beck Depression Inventory. The most sensitive and specific measure for PPD is the Edinburgh Postnatal Depression Scale.1
PPD Risk Factors
In the United States (US), 1 in 8 women report persistent depression after childbirth, particularly those with a personal or family history of anxiety or depression.1 Additional risk factors for developing PPD include the following: 1,3,4
- a traumatic or instrument-assisted birth experience (including cesareans)
- preterm delivery
- multiple births (twins or higher order multiples) especially among women of advanced maternal age
- an insufficient support system
- a poor relationship with their partner
- unintended or teen pregnancy
- domestic violence
- gestational diabetes
- first-time pregnancy
Higher Rate of PPD Among Women Physicians
According to findings presented at the 2022 American College of Obstetricians and Gynecologists (ACOG) Annual Meeting, a survey of 637 women physicians and medical students in the United States indicated that 25% of these women experienced PPD; this rate is double that of the general population.5
An interview with Dr Kailey Caplan, a reproductive psychiatrist at the University of Texas (UT) Health Houston, Houston, Texas, shed some light on how PPD impacts women physicians differently from the general population.
Among the many factors that may contribute to the higher rates of PPD among women physicians, Dr Caplan stated, “It might be the kind of people in general that are attracted to the field of medicine. There are a lot of type A personalities and self-motivated individuals in medicine… Women physicians thrive on a sense of order and predictability and following the right way of doing things.” However, she urged women to rethink how they approach motherhood, stating “Babies don’t read the textbooks. It doesn’t matter how correctly you follow the formulas; you are not going to be able to control what happens to you after you give birth.” Additionally, “Feelings of competence come into play as well, making women physicians question why they can’t make it work when everyone else does it so well, which is simply not true,” Dr Caplan shared.
Another major factor that may heighten the risk of developing PPD among women physicians is the timing of pregnancy. “I think for women in medicine there are two options: have babies at a normal time and delay their training or residency, or have babies once they’ve finished training and are more financially stable in their careers, but then they have to deal with a geriatric pregnancy,” commented Dr Caplan.
Current evidence points to an increased risk for PPD at both ends of the maternal age spectrum. For example, a study conducted in 2017 found an increased risk for PPD among women between 15 and 24 years of age and those aged greater than 35 years, relative to women aged 25 to 29 years.3 A Canadian Community Health Survey also evaluated maternal age on PPD and found that women of advanced maternal age have significantly higher rates of depression than younger women.6 Additionally, findings published in the Journal of Affective Disorders indicate that mothers aged 40 and older who had twins were at particularly high risk, potentially reflective of pregnancies achieved with the aid of reproductive technologies due to the choice to delay motherhood.4
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In the long run, I think de-stigmatization and flexibility will play a large role in giving the individualized care women physicians with PPD need.
These time periods of heightened PPD risk often match the career trajectory for many women in medicine. If they choose to start families before medical training, their younger age may make them more prone to PPD. Yet, if they delay family planning to establish themselves professionally, an advanced maternal age (and potential use of reproductive aid) may also increase their PPD risk.
Dr Caplan added that “Women physicians who wait to start their families also know more about the risks of pregnancy at more advanced ages, so this may also factor into the risk for PPD.” She stated, “Guilt becomes more of a factor in this case if something does go wrong with the pregnancy or due to feelings of selfishness for waiting too long to start a family compounded by having to return to work so quickly.”
Difficulties Seeking Help
The altruism and genuine desire to help make other people’s lives better are the foundational motivations as to why individuals choose to practice medicine in the first place. However, this same sentiment can obstruct physicians from seeking care for themselves when needed.
Dr Caplan reflected on why it may be so difficult for women physicians to seek help for their PPD. “In general, mental health problems are a taboo for healthcare providers. It is something you have to report to maintain your licensing,” she stated. Dr Caplan expressed, “The stress of competence and the idealism of superwomen capabilities with which women can do everything are big parts of why women physicians don’t want to admit that they need help for PPD, particularly among a group of women who are already so high achieving.”
To make matters worse, Dr Caplan pointed out that “Most cases of PPD self-resolve if given the time and support, but often time and support are the things that are lacking.” Given that many women only have about 6 weeks of maternity leave, “they are barely physically healed, let alone mentally, emotionally, and hormonally healed. Postpartum symptoms can last for up to a year after birth.”
In 2021, researchers interviewed healthcare professionals who provided mental health services to moms with PPD to examine mental health service barriers. These interviews revealed that insufficient knowledge of how to diagnose PPD among other healthcare providers, the difficulty in recognizing the hidden nature of PPD symptoms, stigma of depression especially in certain cultures, limited human or financial resources, and insufficient policymaking all impose obstacles to sufficient care.7
Dr Caplan described how the medical community itself contributes to some of these barriers to care that all women with PPD face, as well as efforts within the medical community that are currently being implemented that could help overcome these barriers. She said:
I think a part of the problem is lack of provider knowledge. There are a lot of providers who tell pregnant women they need to come off of all of their medications, which isn’t necessarily the case. Another barrier in the medical system is this emphasis on productivity. Having 15- or 20-minute visits with a patient may not be enough time to adequately recognize PPD symptoms or cover what you need to in order to diagnose it. One thing the medical community is doing to address this is that pediatricians now are screening new mothers for PPD by administering the Edinburgh Postnatal Depression Scale whenever they bring their newborns in for the first pediatrician visit. But the question then becomes, now that this new mom has met the criteria for PPD, what can be done and to whom can she be referred? Reproductive psychiatry is a growing field to meet a growing demand, but it still might be difficult finding enough providers in this niche. I would love to say we can offer much longer parental leave or a more flexible and gradual return to work. In the long run, I think de-stigmatization and flexibility will play a large role in giving the individualized care women physicians with PPD need.
Zuranolone — A Source of Hope
In August 2023, the US Food and Drug Administration (FDA) approved zuranolone as the first oral medication to treat PPD.8 In Phase 3 clinical trials, zuranolone demonstrated rapid efficacy, improving symptoms of PPD within 15 days of initiating treatment. Symptoms also significantly improved on days 3, 28, and 45 compared with baseline measurements. These treatment effects were sustained through day 45 — at least 4 weeks after the last administered dose.9
Dr Caplan remarked:
I think the approval and accessibility of zuranolone is really exciting for women in medicine with PPD. Antidepressants are often quite effective, especially in PPD, which typically responds really well to them. But antidepressant treatment is not an instant gratification process. It takes 2 weeks to begin to see any effect and usually 6 to 8 weeks to see the full effect – if the antidepressants even help. This doesn’t cut it when you have 6 weeks total of maternity leave.
The concept of a quick turnaround for PPD is very exciting. However, it’s not without risks. Part of the reason it is only a 2-week course of treatment is not only because it works so quickly, but because it is potentially addictive. Researchers also still need to establish whether or not new moms can breastfeed while on zuranolone.
The fact that zuranolone can only be prescribed for women with PPD will affect accessibility because it will cost a lot more due to the limited patient population for whom it can be prescribed. Brexanolone, the standard PPD treatment prior to zuranolone’s approval, is a similar compound that needed to be administered intravenously during an inpatient infusion, costing tens of thousands of dollars. Often with new medications, it takes a while for insurance to cover it at all, and then, as the medication proves effective, insurance might only cover the generic form or cover it only after two other medications have failed. At the beginning, accessibility might be a problem, but eventually, zuranolone will be an amazing treatment option for women physicians or any women with PPD.
A Systemic Issue Needs Systemic Support
While zuranolone offers an ideal modality for the busy lives of women physicians and demonstrates rapid efficacy, Dr Caplan emphasizes that PPD is an incredibly complex issue that requires systematic support to help women function.
Dr Caplan gave these parting words:
A lot of the issues with PPD and anxiety have to do with postpartum overwhelm. It can be very isolating thinking that women have been doing this for thousands of years, yet I am the only one struggling or not good at it – which is not true. We have unrealistic expectations of ourselves, especially with social media feeding us false images and notions of what ‘perfect moms’ should be like. It can be encouraging for women to share their personal stories of doubt, which can be very community-building and therapeutic. Nobody can do it on their own. Med[ical] school might be something you can do on your own, but child-rearing is not. It truly takes a village. And in the case of women physicians, better self-care directly translates into better patient care.
Resources for Physicians
Editor’s note: Dr Caplan’s interview was edited for clarity and length.
This article originally appeared on Psychiatry Advisor
