Today, Explained - A postpartum pill

Episode Date: August 14, 2023

The FDA’s approval of a new pill that treats postpartum depression could be yet another signal that we are living in a golden age of medicine. This episode was produced by Jon Ehrens, edited by Amina Al-Sadi, fact-checked by Laura Bullard, engineered by Patrick Boyd, and hosted by Sean Rameswaram. Transcript at vox.com/todayexplained Support Today, Explained by making a financial contribution to Vox! bit.ly/givepodcasts Learn more about your ad choices. Visit podcastchoices.com/adchoices

Hi, this is Karen Kurdoff calling from Salt Lake City, Utah. Having a baby is hard enough, but for a lot of people, things can get even tougher after birth. I had my first child back in January and experienced postpartum depression. My doctor was willing to prescribe me medication, but I didn't feel comfortable going on medication without having counseling or supervision. I was granted short-term disability, but it was really hard to get that extended. And on top of that, I was just isolated by myself. But now, for the first time ever, there's a pill to treat postpartum depression. I think a new medication to directly deal with postpartum effects would be awesome.

We're going to figure out if this pill is going to be a game changer on Today Explained. I think it's awesome you're doing a show about postpartum depression, and I just hope that it encourages anybody out there that's suffering. Get groceries delivered across the GTA from Real Canadian Superstore with PC Express. Shop online for super prices and super savings. Try it today and get up to $75 in PC Optimum Points. Visit superstore.ca to get started. Estar escuchando a Hoy Explicado. Today Explained. When you want to talk about postpartum depression, you want to talk to Dr. Nancy Byatt. I'm a professor with tenure of psychiatry at UMass Chan Medical School.

And? I'm a psychiatrist that focuses on working with pregnant and postpartum individuals. And? I direct a center here at UMass Chan Medical School called Lifeline for Families. And? There's an exciting new medication that was just approved by the FDA called Zoranolone. Zoranolone. Zoranolone is exciting because it works quickly.

Most of the medications that we have available, in fact, all of the medications we have available that someone can take by mouth take quite a lot of time to work. So typically, the available antidepressants that we have that we use for pregnant and postpartum individuals that people can take by mouth take several weeks to work, often four to six weeks. And Zoranilone is exciting because people get better within three days, that those improvement in depression symptoms are sustained at 15 days and then also at 45 days. And it's also the first medication that people can take by mouth that's specifically approved for postpartum depression. But presumably postpartum depression's been around for a minute.

What took so long? I think there's a few things as to why we're seeing this now. So one, there has been an evolution in the recognition of women's health care in general, where many of the research over the years and studies and evidence-based protocols were more based on men than on women historically. And so research that specifically includes women is more recent. And research focused on the perinatal time period. And when I use that term, I'm referring to pregnancy and the year postpartum is also more recent. So we've had an evolution and want to focus on general women's health. And specifically, we've had more focus on women's mental health. And also within that, we've had an increased focus on perinatal mental health,

so that pregnancy and the postpartum period. And then along with that, we've had novel treatments like this that, you know, are recognizing that women's physiology is different during pregnancy and the postpartum period, both for obstetric care, but also for mental health care. Mental health and substance use disorders that occur during pregnancy and the year postpartum are actually the leading cause of maternal mortality in the United States. They're the leading cause of pregnancy-related deaths. And that includes things beyond depression, but depression is including among those illnesses

that are of the leading causes of maternal mortality. 23% of deaths in the United States are due to mental health and substance use disorders during the perinatal time period. And we also know that these illnesses are very common. One in seven individuals will experience depression. And when we think about mood and cheese disorders during the perinatal time period. And we also know that these illnesses are very common. One in seven individuals will experience depression. And when we think about mood and anxiety disorders together, that's as many as one in five. So these illnesses are common. We know that women are dying. And we also know they have a negative impact on the individuals themselves that are experiencing this and also their families. They've been linked with negative

outcomes for the baby, negative outcomes for kids later on, and also negative obstetric outcomes. What do we know about postpartum depression in terms of how it differs from your regular run-of-the-mill depression? When we think about the perinatal time, so the few things that are happening that are different during this time period than other time periods in people's lives. So one, there's a physiological changes. So during pregnancy, we see a surge in hormones. They continue to increase throughout pregnancy and there's the quick drop in the postpartum period. So that's physiologically very different. And this is why we think that there is increased risk of mood anxiety disorders during this time period because many

women are sensitive to those hormonal fluctuations that can increase the risk of mood or anxiety disorders or symptoms. I also want to make a note that I'm saying women, sometimes I say perinatal individuals, not all people that are pregnant or postpartum identify as women. So I sort of use those terms interchangeably just to note that. And so that's one piece is that physiologically things are different. The other piece is that it's an extraordinarily challenging time period because of what's going on from a psychosocial perspective. So during the perinatal time period, transitioning to being a parent is a huge transition and it rocks a relationship, it rocks a family, and it can really cause a lot of challenges psychosocially.

And when we think about, you know, this from a trauma perspective, many of us have experienced trauma and experienced adversity. And a lot of times that's related to the relationships that we've had. When we've experienced adversity and trauma, those things tend to come up more so when we are all of a sudden a parent. Because now we have a baby we have to take care of. And any of our own unmet needs when we're younger tend to come more to the surface during the parental time period. So when we think about it from that perspective, that's one of the big differences. And I'd say the other big difference is that the process of becoming pregnant, delivering, and having a baby is challenging from a perspective of if someone has a history of trauma, you know, the delivery itself can often be traumatic for people. Interactions with the healthcare system can

be traumatic. So those other pieces and physiologically, depending on what kind of birth somebody has, there can be physical injuries from that. And so those pieces that are happening too, that sort of culminate in this being a really challenging time period for people that is often more challenging than other times in people's lives. So prior to this, what sounds like game-changing pill, Zoran alone, how was a professional like yourself typically treating someone with postpartum depression? The mainstay of treatment for mild to moderate depression, first-line treatment is psychotherapy. So we have evidence-based psychotherapies that work. We'll continue to use those. We also have an evidence base for psychosocial treatments. So those are

often a mainstay of treatment. If someone has more severe depression or depression that medications indicated, we were typically using antidepressants. The challenge with those, as I noted earlier, is that they often take weeks to work. They typically take four to six weeks to work. And when someone's pregnant or postpartum, time is of the essence. And four to six weeks is a really long time to wait when someone's postpartum, when they have a baby, and they're already in this extraordinarily challenging time period. There is a medication called brexanilone that was recently became available and FDA approved that is similar to ziranilone. The difference is

brexanilone is an IV medication that requires an IV infusion and also requires monitoring. And so while it works really quickly, similar to the way Zoranolone does, implementing that was challenging because one needs to be, you know, monitored for a few days, often in a hospital setting, which is challenging. And then, you know, they're separated from their baby and so forth. So the great thing about Zoranolone is it's a by-mouth medication that is going to be, I think, much easier to access from a logistical perspective than Brixanolone was. What's different about this treatment, this pill, other than the fact that it's a pill? What exactly is it doing to the brain of someone with postpartum that's a game changer?

The way it works is that when people are pregnant or postpartum, you know, we have an increase in hormone start pregnancy and then a decrease postpartum. One of those hormones is allopregnenolone. Allopregnenolone. Allopregnenolone increases in pregnancy, decreases in postpartum. So ranolone is a neuroactive steroid that really aims to balance out those levels in the system. So we know that allopregnenolone. Allopregnenolone interacts with pathways in our brain that

regulate our emotions. They can regulate our mood. They can regulate whether we're experiencing anxiety symptoms. And what ziranolone does is it interacts with those pathways in the brain to balance that out, really balancing out that decrease in hormones that we see in the postpartum period. How available will Zoranolone be? So that is a major question and an excellent question. I hope it's going to be available. One of the big challenges and what tempers my enthusiasm for Zoranolone is that it will be effective and helpful to the extent that people can access it. It's great. We're going to have a medication that decreases symptoms within a few days. However, to give our state as an example, in Massachusetts, if someone has public health insurance, it can take three to six months

to see a psychiatrist. So it's great if we have medication that works quickly. Along with that, we need to have access to available treatment. And also some of our work, we found that without a system in place, even if somebody screens positive for depression in the perinatal time period, less than a quarter of those individuals will get even to an initial mental health appointment. Great, we have a new medication, but if only a quarter of people are able to get to an initial appointment, then its impact becomes much more limited. I would also add that when we think about, you know, the perinatal time period, there's multiple barriers to care that people experience. So I mentioned that, you know, less than a quarter of people get to an appointment

even if they screen positive. And we see that there are major inequities by race, by socioeconomic situation, by what insurance people have. And, you know, when we think about the increase in maternal mortality rates we have in America, much of the reasons that many of us believe that those are there is because of these challenges with access. And, you know, we know that there's disparities in the rates of maternal mortality. So great, we have a game-changing pill. We have to be paralleling these novel, really exciting, rapid-acting treatments with work that focuses on increasing access to these treatments and that also focuses on doing that in a way that's

equitable and doing that in a way that people can actually access these treatments that we have available, because right now that's not the case. And so whenever I'm thinking about Zoranolone, it's not a panacea because we need to accompany it by all these other things. And also medication treatment is one piece. You know, when we think about paranormal to healthcare, we have a lot of evidence-based treatment options and medications are one of them. So there's very clear evidence that the treatment for depression is best when it's, you know, medication treatment combined with psychotherapy and other psychosocial treatments. So along with having rapid acting treatments like Zoranilone, we also need to be focusing on increasing access to other treatments that

we know are really important and are often the first line when we're thinking about, you know, mild to moderate depression. Dr. Nancy Byatt is a professor of psychiatry with tenure at UMass Chan Medical School. I'm Sean Ramos-Firm, and when we're back on Today Explained, we're going to hear an argument that you and I are currently living in a golden age of medicine. Support for Today Explained comes from Ramp. Ramp is the corporate card and spend management software designed to help you save time and put money back in your pocket. Ramp says they give finance teams unprecedented control and insight into company spend. With Ramp, you're able to issue cards to every employee with limits and restrictions and automate expense reporting so you can stop wasting time at the end of every month. And now you can get $250 when you join Ramp.

You can go to ramp.com slash explained, ramp.com slash explained, r-a-m-p.com slash explained. Cards issued by Sutton Bank, member FDIC, terms and conditions apply. Sportsbook born in Vegas. That's a feeling you can only get with BetMGM. And no matter your team, your favorite player, or your style, there's something every NBA fan will love about BetMGM. Download the app today and discover why BetMGM is your basketball home for the season. Raise your game to the next level this year with BetMGM, a sportsbook worth a slam dunk, An authorized gaming partner of the NBA. BetMGM.com for terms and conditions. Must be 19 years of age or older to wager.

Ontario only. Please play responsibly. If you have any questions or concerns about your gambling or someone close to you, please contact Connex Ontario at 1-866-531-2600 to speak to an advisor free of charge. BetMGM operates pursuant to an operating agreement with iGaming Ontario. I'm David Wallace-Wells. I'm a writer for the New York Times Opinion Section and a columnist for the New York Times Magazine. And David, we just got news about the first ever pill to treat

postpartum depression. And you recently wrote for the New York Times that we might be living in a golden age of medicine. Why did you write that? Well, just over the last couple of years, especially in the aftermath of the pandemic and the incredible, I think, miraculous development of the COVID vaccines, we've seen a huge wave of new treatments and therapies either come online or begin clinical trials. Twelve countries in Africa are to receive 18 million doses of the malaria vaccine over the next two years. The CRISPR technology allows scientists to make changes to the DNA in cells that could allow us to cure genetic disease. Altogether, they don't represent like the end of disease or

anything like that, but it seemed to me like a watershed sort of phase shift moment in a lot of different areas of medicine. And each drug, each therapy on its own seemed impressive and exciting, but altogether it felt like a whole new horizon of treatment possibility was opening up that most Americans, I think, just haven't yet begun to appreciate. I do think it's worth pausing for a second on just how incredible the COVID vaccines are. I think in part because we experienced them in such a time of panic and desperation, in part because the uptake was so politicized, the rollout was politicized. I think most Americans don't appreciate just how completely unprecedented a biomedical innovation this really was. Today, our nation has achieved a medical miracle. We have delivered a safe and effective

vaccine in just nine months. So within two days of the time that the virus's genome was posted publicly, within two days, Moderna had designed an mRNA vaccine to fight it. And that is the mRNA vaccine that we, most of us, got in America within two days. I didn't realize it was two days. Designed it in two days, had it manufactured in the space of a couple of months. You know, most vaccines, as we were told at the beginning of the pandemic, take at least a decade to produce. Even the most impressive drug development stories of the last few decades are on that sort of five to ten year timescale. And this was, we're talking about literally just a few months before it was going into people's arms.

So we're talking about an astonishing medical miracle that most of us treated as like the workaday development of public health and medicine. We were just like, okay, the vaccines are here, now we'll take it. But one of the incredible side effects of mRNA COVID vaccines is that because they worked so effectively, they then brought

into the sphere of possibility all of these other potential mRNA applications. So now we're testing it to treat a whole raft of other diseases, which are whole new potential applications for this platform. Thinking about using Ozempic not just to treat weight loss, but to treat cardiac events, which it seems that they're reducing that by 20%. Or we're talking about immunotherapy in cancer. This is not something we're just using in one area, but really across the board. And that's what's so exciting is that we're not just dealing with individual drugs, we're dealing with a whole new toolbox, each of which may ultimately be used in not just one application, but in many, many applications. With stuff like a potential cancer vaccine, though,

who will realistically have access to those treatments and technologies first? Well, you know, when I think about the sort of equity and justice aspects of these new drug developments, I think primarily in terms of the global picture, which is to say, I worry a lot more about the billions of people in the global South, almost none of whom will have access to these drugs, than I do about Americans. Because while we live in a quite imperfect public health system, not every American is insured. American insurance companies can be quite rapacious and skimpy when it comes to approving especially new expensive drugs.

There certainly will be shortfalls. There will certainly be Americans who will not have access to these drugs who could benefit from them. But I think in the grand scheme of things, the greater tragedy is that they're going to be relatively commonplace and available to most Americans with insurance in relatively short order. And we might be talking about maybe even more years to come before they're available in, say, parts of sub-Saharan Africa or South Asia. That's not to say that none of these drugs have applications elsewhere. I mean, when you talk about some of the new, say, malaria vaccines, dengue vaccines, there are large-scale trials underway in other parts of the world. And in

theory, those could be quite effective and useful there. What do you think our blind spots are in this possible golden age? I mean, do we know? Well, you know, when you look at the list of leading causes of death in the U.S., we have made large improvements in number of heart disease deaths, but that's still a huge killer and we're very far from eliminating it as a problem. Diabetes is another one where we're still essentially using generation old treatments. There are also a whole lot of things which we consider

sort of currently treatable. I mean, I think about the whole range of mental health. We have people with depression taking drugs that are not very effective. And while there may be piecemeal improvements here and there, I don't think we're expecting a major step change in those areas. And that's unfortunate. Where do you think this golden age ends? I mean, we're only beginning to see the potential of CRISPR. The Mississippi woman was the first person with sickle cell disease to be treated with a gene editing technique known as CRISPR. And AI in medicine?

More than 350 gigabytes of information per patient goes into a central computer where artificial intelligence then processes the data. We can look at the patient and go, they're moving a lot. There's something going on there. Or their face has a certain grimace to it that they normally don't have. Is it possible that it could tell you before I even know that I'm having problems? Yes, 100%. But if this is maybe a golden age right now, does it just continue on and on and on? I think there's some real potential for quite dramatic transformative growth.

So just to take CRISPR for a second, I think people have probably read some headlines about CRISPR when it was first announced. but this is an absolutely astonishing technology. It allows the editing of DNA in your body while you are alive. It's not like you have to be editing the DNA of a baby as it's an embryo and only then can help cure the rare congenital disease that that baby will get. You can make those changes in later life too. In theory, CRISPR is an absolutely radically revolutionary medical technology, which would allow for a huge range of applications well beyond, I think, what the average person not working on it really appreciates. Since so much of our lives and our health is based on genetics, there's almost nothing that couldn't be affected by or helped by CRISPR therapy

once we sort of fine-tune and calibrate the particular approaches to particular problems. And with AI, we're able to unlock and solve the problem of protein folding using AI tools. How do proteins fold up? How do proteins go from a string of amino acids to a compact shape that acts as a machine and drives life? There are probably many more medical applications in terms of drug discovery just like that, where artificial intelligence working at a really high level, scanning huge bodies of data, will be able to highlight potentially new applications for existing drugs and potentially new exciting pathways of research for the development of new drugs. And I think we are very far from appreciating just how profoundly and dramatically that could change the landscape going forward. But even so, the U.S. is falling way behind our peer countries elsewhere in the world in terms of life expectancy and mortality outcomes. I wrote a piece this week showing that compared to our peer countries, every single year before

the pandemic, more than 500,000 more Americans were dying than would have died if our mortality rates matched the mortality rates of our peers. So every single year, there were half a million additional American deaths than would be expected if Americans were dying at the rate of other rich countries in the world. And that's despite some pretty impressive medical breakthroughs over the last couple of decades. I think when we talk about this frontier, it's easy to get pulled into a sort of a sci-fi futurist vision where like diseases, if not entirely defeated, then really push back, not just for, you know, the well-to-do, but for almost everybody. And I think there is going to be real progress across the board in America, particularly over the next decade or two. But I think the mortality statistics tell us also that there's a lot more going on

contributing to and shaping human well-being, biological health, mental health, and human flourishing than whether you can expect to live 12 years when you get diagnosed with stage four lung cancer or two years when you get diagnosed with stage four lung cancer. And there's a little bit of a losing the forest for the trees here. And I want to like emphasize if I can, that we really need to take seriously the fact that many Americans are suffering, many more Americans are dying and living less healthy, less comfortable, less happy lives than we might hope, even as we are rushing headlong into a pretty exciting time for biomedicine. David Wallace-Wells writes for the New York Times,

back in June he wrote that suddenly it looks like we're in a golden age for medicine. I used to struggle with a brain that was constantly empty and hurting, but then I asked my doctor about Today Explained. Ask your doctor about Today Explained. Ask your doctor about Today Explained. The program was produced by John Ahrens, edited by Amina Alsadi, fact-checked by Laura Bullard and Serena Solon, and mixed by Patrick Boyd.

The host was Sean Ramiswaran. This is Today Explained. This is Today Explained. Today Explained. This is Today Explained. Today Explained.