Following the FDA approval of the drug zuranolone (Zurzuvae) for treating postpartum depression (PPD), I analyzed some of the clinical trial data through a biopsychosocial and intersectionality lens. From a scientific, social, and ethical standpoint, I believe this medication is not the panacea to tackle the maternal mental health crisis in the U.S. and globally, particularly in minority populations.
Let me start by outlining the strengths of the research. The zuranolone trials included a diverse group of women; for example, one of the studies included 38.3% Hispanic/Latina and 21.9% Black/African American patients. This diversity could allow for more generalizability of the results across different racial and ethnic groups and recognizes the importance of considering how depression may manifest differently among women from various backgrounds.
This study also successfully demonstrates that zuranolone might offer a quick and effective short-course oral treatment for severe PPD. This could be particularly beneficial for women with severe PPD who face barriers to accessing long-term treatments, such as low-income women or those with limited healthcare access.
However, medications alone can’t address the underlying cause of PPD for many groups.
Medications shouldn’t be the first or only line of treatment for mental health conditions, particularly among women, children, and historically oppressed populations. PPD is not just a biological or an individual issue but a culmination of complex interactions between gender roles, societal expectations, and systemic inequalities. Social, cultural, and structural factors contribute to women’s overall health experiences, including PPD, and these factors influence the prevalence, diagnosis, presentation, management, and access to treatment for this condition.
Before prescribing zuranolone to a perinatal woman, the following biopsychosocial factors need to be addressed:
Lack of Long-Term Data
Currently, there is insufficient data on long-term potential side effects of zuranolone and the influence on the mother-child dynamic. The effect of zuranolone reported in clinical trials was measured only for 45 days among postpartum women with severe PPD who don’t breastfeed. We need further studies to assess the long-term impact of the medication, including among women with mild to moderate PPD, breastfeeding mothers, as well as the patient-child interaction.
Gender Roles and Expectations
Traditional gender roles and societal expectations can impact women’s mental health during the postpartum period. Expectations around motherhood, such as being the primary caregiver and maintaining the perfect “nurturing mother” image, can create immense pressure and stress for women. When these expectations clash with a woman’s reality or desires, it can lead to feelings of inadequacy and guilt, contributing to PPD.
Motherhood as a Social Construct
Motherhood is a socially constructed role that can be influenced by factors such as race, class, and cultural background. Intersectionality plays a crucial role here, as women from different backgrounds may face unique challenges and experiences related to motherhood and PPD, such as marital status, education, income, and social determinants of health.
Patriarchal Power Dynamics, Gender-Based Violence, Socioeconomic Status, Chronic and Traumatic Stress
Patriarchal power structures can contribute to women’s vulnerability to mental health issues like PPD. Gender-based violence, younger age, low education attainment, and inequalities in various spheres of life, including work, healthcare, and decision-making, can create stress and feelings of disempowerment for women, impacting their mental well-being.
We need to develop family-friendly social and public health policies, trauma-focused interventions, and sustainable coping strategies to patriarchy, economic strain, and racialization among perinatal women.
Lack of Social Support
Social support networks for women during the postpartum period are crucial. Isolation and lack of support from partners, family, and friends can exacerbate feelings of loneliness and distress, increasing the risk of PPD. Adequate social support is essential for women to navigate the challenges of motherhood effectively.
Healthcare Disparities and the Need for Multidisciplinary Care
Feminist perspectives draw attention to healthcare disparities affecting women, particularly women of color and marginalized communities. These disparities can lead to inadequate screening, misdiagnosis, or lack of appropriate support and treatment for PPD.
Maternal mortality review committees have previously reported that 80% of pregnancy-related deaths were preventable. The use of critical interventions — such as integrating multidisciplinary care for pregnant women, lessening the impact of social determinants of health, implementing hospital-wide safety training programs, and improving communication between providers and patients — can help reduce these needless deaths. While zuranolone may prove useful for some patients, I am not sure the drug is a suitable alternative to tackle the effects of social determinants of health on maternal mental health and morbidity among Black women and other women of color.
The etiology of PPD is multifaceted and goes beyond individual biology. It examines how gender roles, societal norms, power dynamics, and systemic inequalities intersect to influence women’s experiences of motherhood and mental health. Understanding and addressing these complex factors are crucial for providing comprehensive support and effective interventions for women with PPD.
Judite Blanc, PhD, is an assistant professor of psychiatry and behavioral sciences, and founding director of the Holistic Families Lab at the University of Miami Miller School of Medicine.
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