“It will shed light on postpartum depression but it will not revolutionize our clinical practices in the coming months.” Romain Dugravier, child psychiatrist at the perinatal psychotherapy center of Sainte-Anne hospital in Paris, prefers to be cautious about Zurzuvae for the moment. This drug against postnatal depression, the first oral, has received the green light from the American Medicines Agency (FDA), and should be marketed and sold in the United States from the end of 2023. “An option beneficial for many of these women who face extreme feelings, and even sometimes life threatening”, specifies the American agency in its press release, while a treatment already existed across the Atlantic, but only under infusion, greatly limiting its access.
Even if there is still little data on the effectiveness of this longer-term treatment, the American agency specifies that patients who received Zurzuvae “showed much better improvements in their symptoms than those in the placebo group”. In France too, the scientific community scrutinizes this drug with particular attention. In France, postpartum depression affects between 15 and 20% of women who give birth each year, or more than 100,000 patients.
Long ignored, often trivialized, still taboo, postnatal depression remains unrecognized even in its description. “We can define this disease as any depressive episode occurring until the first year following the birth of a child, explains Romain Dugravier. It is characterized by difficulties in the relationship with his baby, such as the feeling of not taking any pleasure with him when we wanted and carried him, or even a feeling of guilt or incompetence. It is also very pathological unlike the baby blues, “a very common and very brief emotional upheaval”, continues the child psychiatrist, “which does not necessarily presage the establishment of something structural and a depressive state .”
“The consequences of this disease can be dramatic”, insists Lucie Joly, specialized in perinatal psychiatry at Saint-Antoine hospital in Paris, while suicide is the second cause of maternal mortality after cardiovascular disease, according to Public Health France and Inserm. “We are also talking about loss of contact with reality, possible violent acts against the infant. This can profoundly alter the early relationship between mother and child, and lead to a delay in its development”, details the psychiatrist.
An approach now more scientific than psychoanalytical
If the Zurzuvae constitutes a step forward, it is because it is based on precise scientific foundations, with an identified hormone: allopregnanolone. “It is produced through progesterone. During pregnancy, the latter will gradually increase until it reaches a peak, then will drop very quickly after delivery. Allopregnanolone follows the same dynamic. However, several studies show that its fall is directly linked to postpartum depressive symptoms”, explains Lucie Joly.
It is on this point that zuranolone (the molecule of Zurzuvae) intervenes: it mimics the effects of allopregnanolone on the brain, in order to attenuate the consequences of strong hormonal variations. This drug also has the advantage of coming into action quickly, from the third day, where conventional antidepressants sometimes take several weeks to act. For Lucie Joly, who also headed a joint perinatal psychiatry unit at the Pitié Salpêtrière, Tenon and Armand-Trousseau AP-HP hospitals, this drug demonstrates a better awareness of the issues specific to postpartum women. “For years, we focused a lot on the development of the newborn, with a very psychoanalytic approach. But today, we adopt a more scientific approach, which focuses on what happens in the body. and in the brains of mothers.”
A victory for science, believes Lucie Joly, who claims to have been “almost the only one in Paris to work on these questions” of perinatal psychiatry when she started eight years ago. “What is innovative with this drug is that we finally have a personified vision of medical treatment according to gender. For too long, we have imagined medicine as unisex. However, pathologies can be different if you are a man or woman. We are finally interested in better care for women”, welcomes the psychiatrist, who is fighting for better recognition of her medical discipline.
Only half of postpartum depression detected
There remains a major problem: “Only half of postpartum depressions are currently screened”, underlines Romain Dugravier, also co-author of the first 1000 days report, published by the Ministry of Health in 2020 to better support parents, from pregnancy until the child is two years old. “One of the reasons is that people who go through this kind of emotion still have a lot of difficulty talking about it. There is a fear of the gaze of the other. that you don’t take pleasure in taking care of your child. So talk to caregivers about it, even more so. Even if this taboo is gradually being lifted.”
Marie-Élise Launay, midwife in Brest and author of the book Postpartum SOS, confirms this: “There is a certain injunction to the happiness of having a baby. Women are very prepared for childbirth, but are helpless in relation to the changes that arise afterwards, in their body, their couple, their life. They don’t understand why they are in bad shape, when they are supposed to have everything to be happy.”
“We are not here to stuff people with drugs”
Added to this is a lack of awareness in the medical world, which is not always prepared to deal with this problem. “Many midwives experience dramatic situations, with babies who die, malformations, mothers who are left by their partner during their pregnancy, continues Marie-Elise Launay. There, we say to ourselves that it is normal that You don’t expect the woman for whom everything went well, who has no risk factors, to have postpartum depression. Especially when you have to really dig for that they manage to tell us about it.”
However, support for women affected by this disease is improving. Since September 2022, a postnatal consultation has been instituted 6 to 8 weeks after delivery. The extension of paternity leave has also made it possible to reduce cases of postpartum depression in fathers. They are in fact nearly 10% to be affected by this pathology, according to a Inserm study beginning of 2023, even if they present risk factors and symptoms different from women (anger, tension, toxic consumption).
“What patients are often looking for is a therapeutic relationship, treatment by talking. Not just drug treatment”, nuance Romain Dugravier. “Personally, I never prescribe antidepressants during the first interview. We’re not here to stuff people with drugs, shares Lucie Joly. But you have to be aware that this problem often takes time to be recognized. So when the symptoms are already severe, you shouldn’t drag it out too much either.”