Postpartum depression: current care and an emerging option

Anna is a 32-year-old female, four weeks postpartum after the birth of her first child. She presents to her community pharmacy to pick up prenatal vitamins and hesitantly mentions she has been feeling persistently low, tearful and emotionally disconnected. She reports poor sleep despite opportunities to rest, difficulty concentrating, and a sense of guilt that she is “not enjoying motherhood the way she expected.” When asked directly, Anna acknowledges passive thoughts of self-harm, but denies intent or a plan. A brief Patient Health Questionairre-9 (PHQ-9) administered in the pharmacy scores 18, consistent with moderately severe depression. Anna asks, “What do you think I should do?”.Postpartum depression: scope and impactPostpartum depression (PPD) is a serious mood disorder that can occur within the first year after childbirth.1 In Canada, approximately 20% of individuals experience PPD following delivery.2 PPD is associated with significant functional impairment and can negatively affect maternal health, infant development and family relationships if left untreated.1-3 PPD is characterized by persistent symptoms such as depressed mood, inability to experience pleasure, sleep disturbance, impaired concentration, excessive guilt, and in some cases, suicidal ideation.1,2How is PPD typically managed?Management is multimodal and individualized, guided by symptom severity, functional impairment, patient preference, comorbidities and chestfeeding considerations.1-31. Identification and assessmentPharmacists are often among the first healthcare professionals patients with PPD encounter. We are well positioned to initiate conversations about mood, identify red flags and facilitate timely referral. Tools such as the PHQ-9 or Edinburgh Postnatal Depression Scale can support assessment.1,22. Psychotherapy and psychosocial supportsFor mild to moderate PPD, psychotherapy is foundational. Cognitive behavioural therapy and interpersonal therapy are first-line interventions.1,3 Addressing sleep deprivation, social isolation and psychosocial stressors is essential and often requires coordination with primary care and community supports.1,3 Maintaining an updated list of local mental health and parenting resources can help pharmacists support system navigation.3. Pharmacologic treatmentFor moderate to severe PPD, pharmacotherapy is frequently indicated, often alongside psychotherapy.1,3 Selective serotonin reuptake inhibitors (SSRIs) remain the most commonly used medications, with sertraline, escitalopram and citalopram supported by guideline recommendations.1,3 Sertraline has the lowest passage into breastmilk and is generally preferred when initiating treatment in individuals who are chestfeeding.1While onset of effect may begin within one to two weeks, meaningful improvement in mood often requires four to six weeks.3 Setting this expectation is critical to prevent premature discontinuation. Meta-analysis suggests SSRIs may improve response (55% vs. 43%; pooled risk ratio [RR] 1.27, 95% confidence interval [CI] 0.97–1.66), remission (42% vs 27%; RR 1.54, 95% CI 0.99–2.41) and depressive symptom scores (standardized mean difference −0.30, 95% CI −0.55 to −0.05) compared with placebo at five to 12 weeks.4Once remission is achieved, antidepressant therapy should generally be continued for at least six to 12 months to reduce relapse risk.3 Longer durations may be warranted in individuals with recurrent or severe episodes. Tapering should be gradual and during a period of clinical stability.When counselling patients, pharmacists should review expected timelines, common early adverse effects (e.g., gastrointestinal upset, headache, mild activation) and safety monitoring. Patients should be advised that early side effects are often transient and worsening mood or emergent suicidal ideation requires urgent assessment. Shared decision-making remains central, especially when balancing symptom severity with concerns about medication exposure during lactation.Zuranolone: an emerging optionIn December 2025, Health Canada approved zuranolone for moderate to severe PPD in adults following childbirth.5 Market availability is expected in the first half of 2026.6 Zuranolone is an oral synthetic neuroactive steroid that positively modulates gamma-aminobutyric acid (GABA)-A receptors.5Zuranolone: key features3,5• A 14-day, 50 mg once-daily oral treatment course, taken in the evening with fat-containing food (e.g., nuts, avocado, eggs)• Rapid onset of effect, with symptom improvement observed within days in clinical trials• Intended as a single course of therapy, with limited evidence for retreatment• Studied in females aged 18–45 years, up to six months postpartum, with a nonpsychotic major depressive episode that began in the third trimester or within four weeks of delivery, and baseline moderate to severe symptoms (Table 1).3,7-9 Most patients received zuranolone monotherapy, but some continued background antidepressants.7,8Zuranolone’s placement within treatment algorithms currently remains unclear. The 2024 Canadian Network for Mood and Anxiety Treatments guidelines do not specify its positioning.3 Based on trial data, zuranolone may be used as monotherapy or adjunctively. It is unlikely to replace SSRIs as first-line therapy, but may have a role in carefully selected patients with severe symptom burden (e.g., HAM-D ≥ 20), marked functional impairment, or need for rapid improvement, including those with partial or nonresponse to SSRIs. However, reimbursement decisions and cost may influence real-world uptake.Safety considerationsThe Canadian product monograph for zuranolone highlights central nervous system depressant effects, including somnolence (28%) and dizziness (13%).5 Patients must avoid driving or activities requiring full alertness for at least 12 hours after each dose.5 Patients caring for infants should be counselled to arrange support until individual response is known.5 Concomitant use with alcohol, opioids and benzodiazepines should be avoided or may require dose adjustment.5 Due to the potential for misuse and physical dependence, Health Canada issued a Notice of Intent to add zuranolone to Schedule IV of the Controlled Drugs and Substances Act.10Zuranolone is metabolized by CYP3A4 and requires drug interaction screening.4 It is contraindicated during pregnancy; highly effective contraception is required during zuranolone treatment and for seven days following discontinuation.5 Chestfeeding is not recommended during treatment.5Returning to AnnaFollowing your discussion, Anna contacts her primary care provider and is started on sertraline 25 mg po daily and referred for psychotherapy. You counsel her on expected timelines for improvement, side effects and safety monitoring. At follow-up several weeks later, she reports gradual improvement. When she asks about a new treatment she has read about, you explain the potential role of zuranolone and discuss that it may be an option to consider.SummaryPPD is a common treatable condition that requires coordinated patient-centred care. Pharmacists are uniquely positioned to support early identification, evidence-based treatment and thoughtful integration of emerging therapies as the PPD treatment landscape continues to evolve.Katelyn Halpape is a clinical pharmacist at the Dube Centre for Mental Health in Saskatoon, SK, and an associate professor in the College of Pharmacy and Nutrition at the University of Saskatchewan.References:Stewart DE, Vigod SN. Postpartum depression: pathophysiology, treatment, and emerging therapeutics. Annu Rev Med 2019;70(1):183-96.Society of Obstetricians and Gynaecologists of Canada. Perinatal mental health for health care providers. (accessed January 24, 2026).Vigod SN, Frey BN, Clark CT, et al. Canadian Network for Mood and Anxiety Treatments 2024 clinical practice guideline for the management of perinatal mood, anxiety, and related disorders. Can J Psychiatry 2025;70(6):429-89.Brown JVE, Wilson CA, Ayre K, et al. Antidepressant treatment for postnatal depression. Cochrane Database Syst Rev 2021;2(2):CD013560. doi:10.1002/14651858.CD013560.pub2.Biogen Canada Inc. Zurzuvae (zuranolone capsules) product monograph. Toronto, ON; December 5, 2025. (accessed January 27, 2026).Zafar A. Medication to treat postpartum depression approved by Health Canada. CBC News; December 10, 2025. (accessed January 27, 2026).Deligiannidis KM, Meltzer-Brody S, Gunduz-Bruce H, et al. Effect of zuranolone vs placebo in postpartum depression: a randomized clinical trial. JAMA Psychiatry 2021;78(9):951-9. doi:10.1001/jamapsychiatry.2021.155.Deligiannidis KM, Meltzer-Brody S, Maximos B, et al. Zuranolone for the treatment of postpartum depression. Am J Psychiatry 2023;180(9):668-75. doi: 10.1176/appi.ajp.20220785.Hengartner MP, Plöderl M. Estimates of the minimal important difference to evaluate the clinical significance of antidepressants in the acute treatment of moderate-to-severe depression. BMJ Evidence-Based Medicine 2022;27:69-73.Government of Canada. Consultation: Notice of intent to control zuranolone under the Controlled Drugs and Substances Act. Health Product InfoWatch: February 2026. (accessed February 27, 2026).