For The Treatment of postpartum Depression
Post-partum depression affects up to 15% of mothers (7). The negative effects on child development are well-established. Previously, the only two treatment options were psychotherapy and anti-depressants. Neither option was very effective and took weeks to take effect. Families were also faced with exposing the infant to anti-depressants through breastmilk.
THANKFULLY, there are now two available treatment options! Unlike conventional anti-depressants that take weeks to take effect, brexanolone and ketamine are RAPID ACTING. And since they work so fast, breastfeeding can be held temporarily. So what do we know?
Ketamine has been FDA approved as an anesthetic since 1970. Until recently it wasn't approved in depression. That changed recently (2019) with the approval of Spravato (esketamine). That is certainly exciting, but esketamine is only the left-isomer of ketamine. That means it is only one-half of the drug with a less than optimal delivery system (nasal). The studies have shown response, but when you really dig, Spravato really doesn't have the results that ketamine infusion clinics all over the country have been reporting.
For many years, off-label low-dose ketamine infusions have been available in outpatient clinics throughout the country. These infusions are given in-office and monitored. There is a short recovery period and you are then discharged home (with another adult to drive). Although most patients are able to resume limited activities as tolerated. It would be recommended that the Mother have help with her infant until the following morning.
Ketamine has shown a high-rate of success in treating postpartum depression. For treatment resistant depression, low-dose ketamine infusions are repeated six times within a two week period. HOWEVER, post-partum depression typically responds in 1-3 infusions spaced 2-3days apart. That's 1-6days instead of the weeks it takes a conventional anti-depressant to work! And UNLIKE treatment resistant depression, ketamine can be used FIRST-LINE with post-partum depression.
Studies continue to be published supporting the use of ketamine in depression, PTSD and anxiety. As of 2019, only one study specifically looked at ketamine and post-partum depression (8). This well-designed study gave a one-time sub-anesthetic dose to the ketamine group, but not the control group. The researchers that conducted the follow up were blind to which patients received ketamine and which did not. This further validates the study because the researchers were not swayed during their assessments. The RESULTS showed a significantly lower incidence of post-partum depression in the ketamine group versus the control group. In addition, the prevalence of post-partum blues was also significantly lower in the ketamine group.
Breastfeeding? The levels of ketamine in breastmilk have not been measured. The limited data available suggests that ketamine does not affect the infant, nor does it affect lactation (2,7). Despite this most clinics recommend that the mother "pump and dump" her breastmilk for 24hours following an infusion. It is important to keep in mind that ketamine is a preferred anesthetic for painful pediatric procedures. This is due to its excellent safety profile. So thousands of infants and pediatrics have been given ketamine over many years without any known adverse effects.
Have you heard about Zulresso (brexanolone)? This recently FDA approved drug (March 19, 2019) is indicated for post-partum depression. While that is great news, there are some major hurdles.
First! The infusion is 60 hours. Yes SIXTY HOURS! That is 2.5days. A major drawback to the infusion is sudden loss of consciousness and excessive sedation. Therefore, the patient has to be monitored continuously during the entire infusion. Someone else will have to care for the infant during that time. During the drug trials, the women ceased breastfeeding during the infusion and resumed after the infusion. Therefore, there is zero data whether breastfeeding is safe.
Second! Due to the length of the infusion and requirement for continuous monitoring, the mother will likely have to be readmitted to the hospital. Hospitals have age limitations for visitors and they really don't like an infant being exposed to hospital germs.
Finally, the cost. You might want to sit down for this part. The drug cost will be around $34,000! (5) If you haven't already fainted, that cost doesn't include the hospital bill for 2.5days. So let's do the math. The average cost per hospital day in the United States is about $1,900 (1). Multiply that by 2.5days and your hospital stay is $4,750. So the total estimated cost is $38,750!
But you have insurance? Since it is FDA approved, it might….MIGHT be "covered" by your insurance. So let's say you have "good" insurance. You just had a baby, so you have likely met your deductible for the year…if the year hasn't rolled over. Many have plans that have an 80%-20% split. You are then only responsible for 20% of the cost. That comes out to $7,750 out of pocket…in addition to the thousands that you just paid to meet your deductible! So much for insurance "coverage". Yikes!
SO NOW WHAT?
It is clear that the risks of untreated post-partum depression is unacceptable short-term and long-term on both the infant and the mother.
Conventional antidepressants don't work fast enough. Until recently, they were the only option and something was better than nothing.
Zulresso (brexanolone) is an exciting new treatment with some major limitations.
Low-dose ketamine is an off-label use of an FDA approved medication. Costs vary between areas of the country and between clinics. The range is $400-800 per infusion (4). Calculating the cost of four infusions would total about $1,600-$3,200. That's three infusions and a booster. That is less than the $7,750 estimated out of pocket for those with so-called good insurance. And you can go home after each infusion! And you can breastfeed between infusions!
Its great news that there are now options for post-partum depression. If you (and your family) are suffering with postpartum depression, do not delay getting treatment. Research your options and choose what is best for your situation.
The Injection and Infusion Clinic of ABQ, hopes to hear from you. But if we don't, we wish you happy days ahead, free from the crippling effects of depression.
Rappleye, E. (2015, May 19). Becker Hospital Review. Retrieved from 1. https://www.beckershospitalreview.com/finance/average-cost-per-inpatient-day-across-50-states.html
Drugs and Lactation Database. (2018, December 3). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK500566/
(n.d.). Retrieved from Ketamine Advocacy Network: www.ketamineadvocacynetwork.org/cost/
Loftus, P. (2019, March 19). age Therapeutics’ Drug for Postpartum Depression Gets FDA Nod. Wall Street Journal. Retrieved from www.wsj.com/articles/fda-approves-sage-therapeutics-zulresso-for-postpartum-depression-11553035954
Ortega D, Viviand X, Lorec AM et al. Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery. Acta Anaesthesiol Scand. 1999;43:394-7. [PubMed]
Pearlstein, T., Howard, M., Salisbury, A., & Zlotnick, C. (2009). Postpartum depression. American journal of obstetrics and gynecology, 200(4), 357–364. doi:10.1016/j.ajog.2008.11.033
Suppa E, Valente A, Catarci S et al. A study of low-dose S-ketamine infusion as "preventive" pain treatment for cesarean section with spinal anesthesia: benefits and side effects. Minerva Anestesiol. 2012;78:774-81
Ma, J. H., Wang, S. Y., Yu, H. Y., Li, D. Y., Luo, S. C., Zheng, S. S., ... & Duan, K. M. (2019). Prophylactic use of ketamine reduces postpartum depression in Chinese women undergoing cesarean section✰. Psychiatry research