Hope for Postpartum Depression, Blocked by the System

In August 2023, the FDA approved Zuranolone–the first oral medication developed specifically to treat postpartum depression. It was a milestone that researchers, clinicians, and advocates had pushed toward for years. It was also, for many of the women who needed it the most, immediately out of reach. 

What to Know About Postpartum Depression 

Postpartum depression (PPD) is not the baby blues. The baby blues is a very common feeling of sadness or moodiness a few days after giving birth [1]. Up to 80% of new mothers experience the baby blues, marked by mood swings, tearfulness, and fatigue [2]. While the baby blues tend to go away on their own within two weeks after birth, PPD persists with more severe symptoms, making it an entirely different phenomenon [1]. PPD is a clinical condition marked by persistent sadness, hopelessness, difficulty bonding with a newborn, and in severe cases, thoughts of self-harm [3]. It can begin within the first few weeks after birth or develop up to a year later. If left untreated, it can  last for months or years [4]. Approximately 500,000 people in the United States are diagnosed with PPD each year [5].

The difference between the two conditions matters because PPD has long been under-treated, underfunded, and too often dismissed as a normal part of new motherhood. That dismissal is not accidental–social stigma frames PPD as an individual failure rather than a medical condition, shifting blame onto women rather than pressure onto the systems responsible for treating them. Women’s mental health issues have been systematically excluded from research and policy in ways that negatively impact how well and how quickly the healthcare system responds [6]. 

What Zuranolone Is and Why It Matters 

Before Zuranolone, the only medication approved specifically for PPD was Brexanolone, which had to be administered intravenously in a certified healthcare facility over the span of 60 hours [7,8,9] . The logistical barriers alone put it out of reach for most women.  Zuranolone changed this barrier to care. It is taken orally, at home, over a 14-day course, and clinical trials showed it produced meaningful symptom relief faster than traditional antidepressants [10]. In December 2024, Sage Therapeutics announced it would discontinue Brexanolone, making Zuranolone the only targeted treatment for postpartum depression available in the United States [11]. This makes what happens next–whether women can actually access the medication–a particularly high-stakes question. 

The Insurance Problem

FDA approval does not guarantee insurance coverage, and insurance coverage does not guarantee access. Both of those gaps are currently on display with Zuranolone. 

In the year following approval, major insurance companies eventually published coverage guidelines for the drug, but the conditions attached to that coverage created new barriers. Of the insurers with published guidelines, five required patients to try a different antidepressant before Zuranolone would be covered, three did not permit OB/GYNs to prescribe it, three required a comprehensive psychological evaluation before coverage would apply, and one required a diagnosis of severe postpartum depression [12]. These requirements delay treatment for a condition that worsens the longer it goes untreated. They also shift the burden onto patients–many of whom are weeks postpartum, sleep-deprived, and navigating a newborn–to fight through a prior authorization process before receiving care. 

The high cost of the drug also adds to the problem. Without coverage, Zuranolone is extremely expensive with an official list price of $15,900 for a complete two-week treatment [13]. This high-price means that women without adequate insurance or financial resources to cover out-of-pocket costs  effectively do not have access to the treatment [14].

Who Gets Left Out 

The access gap does not fall evenly. Black women are two to three times more likely to experience and be diagnosed with PPD compared to white women. While PPD affects about 10-20% of all women, around 40% of Black mothers report depressive symptoms after giving birth [15]. One study found that Black women were half as likely as White women to initiate postpartum mental health treatment and had a longer gap between delivery and the start of care [16]. Black women are also more likely to be misdiagnosed–standard screening tools were developed and validated primarily with white research participants. Clinicians have also documented that Black women experiencing depression are less likely to use the term

“depression,” and more likely to describe their symptoms in physical terms. They are also more likely to be referred away from counseling than their White counterparts [15,16]. 

The result is a compounding set of barriers: higher rates of the condition, lower rates of diagnosis, lower rates of treatment initiation, and now a new drug whose coverage requirements create additional hurdles before it can be prescribed. For low-income women the issue is even worse. A 2023 study found that Zuranolone's cost and insurance uncertainty had the potential to widen, rather than narrow, existing socioeconomic disparities in postpartum depression care [17].

What Policy Would Need to Change

State-level action has been uneven and limited. California capped prescription drug copays at $250 for a 30-day supply, which limits out-of-pocket exposure for covered patients [18]. But state-level action is uneven, and it addresses cost without addressing the prior authorization requirements, prescriber restrictions, and diagnostic thresholds that insurers have imposed as conditions of coverage. 

At the federal level, there are no requirements specifically governing how insurers must cover postpartum depression medications. The Mental Health Parity and Addiction Equity Act requires that mental health benefits be comparable to medical and surgical benefits, but its application to specific coverage conditions for postpartum treatments has not been tested. So, no court or federal regulator has yet ruled on whether the law’s parity¹ standard applies to conditions like prior authorization, prescriber restrictions, or diagnostic thresholds specifically. Advocates have called for coverage requirements that prohibit step therapy mandates for PPD medications, allow OB/GYNs and midwives to prescribe them without specialist referral, and eliminate prior authorization requirements that delay care for a time-sensitive condition [11].

Approving a drug and making it accessible are not the same policy decision. For the 500,000 women diagnosed with postpartum depression in the United States each year, the distance between approval and feasible accessibility is still being measured in delayed care, denied claims, and untreated illness.

References

1. March of Dimes. Baby blues after pregnancy. 2021. Available from: www.marchofdimes.org/find-support/topics/postpartum/baby-blues-after-pregnancy

2. UPMC HealthBeat. Postpartum depression vs. baby blues: understanding the key difference. 2025. Available from: share.upmc.com/2025/05/postpartum-vs-baby-blues/

3. Carlson K, et al. Perinatal Depression. StatPearls Publishing; 2025. Available from: www.ncbi.nlm.nih.gov/books/NBK519070/

4. Mayo Clinic. Postpartum depression - symptoms and causes. 2022. Available from: www.mayoclinic.org/diseases-conditions/postpartum-depression/symptoms-causes/syc-20376617

5. Guintivano J, et al. Predictors of postpartum depression: a comprehensive review of the last decade of evidence. Clin Obstet Gynecol. 2018;61(3):1. https://doi.org/10.1097/grf.0000000000000368

6. Paolo Fusar-Poli, et al. The lived experience of postpartum depression and psychosis in women: a bottom-up review co-written by experts by experience and academics. World Psychiatry. 2025;24(1):32–45. https://doi.org/10.1002/wps.21264

7. Cornett EM, et al. Brexanolone to treat postpartum depression in adult women. Psychopharmacology Bulletin. 2021;51(2):115. Available from: pmc.ncbi.nlm.nih.gov/articles/PMC8146562/

8. Grant A. FDA approves first oral treatment for postpartum depression. FDA; 2023. Available from:www.fda.gov/news-events/press-announcements/fda-approves-first-oral-treatment-postpartum-depression

9. University of Illinois Chicago Drug Information Group. How do Brexanolone and Zuranolone compare in patients with postpartum depression? 2024. Available from: dig.pharmacy.uic.edu/faqs/2024-2/april-2024-faqs/how-do-brexanolone-and-zuranolone-compare-in-patients-with-postpartum-depression/

10. Meshkat S, et al. Clinical efficacy and safety of Zuranolone (SAGE-217) in individuals with major depressive disorder. J Affect Disord. 2023;340:893–898. https://doi.org/10.1016/j.jad.2023.08.027

11. Yang C, et al. Justice delayed: the case of Zuranolone and barriers to advancing perinatal mental health. Psychiatr Serv. 2025;76(8):764–766. https://doi.org/10.1176/appi.ps.20250025

12. MGH Center for Women's Mental Health. New oral drug Zuranolone (Zurzuvae) for postpartum depression is now available. 2023. Available from: womensmentalhealth.org/posts/new-oral-postpartum-drug-zuranolone-available/

13. Lusk V. Zurzuvae cost: insurance coverage, discounts, and more. GoodRx; 2024. Available from: www.goodrx.com/zurzuvae/cost

14. eBioMedicine. Therapeutic advances and open questions in postpartum-depression research. EBioMedicine. 2023;98:104925. Available from: https://doi.org/10.1016/j.ebiom.2023.104925

15. Policy Center for Maternal Mental Health. Fact sheet: maternal mental health. 2023. Available from: policycentermmh.org/maternal-mental-health-fact-sheet/

16. Britt R. Black Maternal Mental Health Issue Brief. Policy Center for Maternal Mental Health; 2023. Available from: policycentermmh.org/black-maternal-mental-health-issue-brief/

17. Lasair O'Callaghan, et al. The cost-effectiveness of Zuranolone versus selective serotonin reuptake inhibitors for the treatment of postpartum depression in the United States. J Med Econ. 2024;1–40. https://doi.org/10.1080/13696998.2024.2327946

18. Connecticut General Assembly. State laws limiting prescription drug cost sharing. 2017. Available from: www.cga.ct.gov/2016/rpt/2016-R-0134.htm

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¹Parity means mental health coverage must be no more restrictive than coverage for physical health conditions.