“People walk out of the hospital, wanting to be with their child, wanting to return home,” said Dr. Riah Patterson, who has been treating women with brexanolone at the University of North Carolina-Chapel Hill since it became available in summer 2019. “There is a hopefulness, a brightness. You can really see that transformation in the hospital room over those 60 hours. It’s pretty miraculous.”
McDonald wanted to try it.
But when she asked her doctor for brexanolone, she was told no. In an email, the doctor wrote that the existing studies were “not very impressive.” She added that McDonald did not meet Kaiser Permanente’s criteria for the drug: She would first have to try — and fail to improve with — four medications and electroconvulsive therapy (ECT) before she could try brexanolone. And she had to be six months or less postpartum to try it at all. For Miriam, the clock had run out. She wondered, How could anyone qualify?
“This is crazy. By the time you even try one drug, that’s like four weeks out,” she said, noting that traditional antidepressants take weeks to become effective and weeks to taper off from. “There’s just no way.”
‘Unacceptable burden’ on new moms
Kaiser Permanente’s guidance is an outlier. An analysis of guidelines from a dozen health plans revealed that three of them require women to fail treatment with at least one other medication before trying brexanolone. One plan, California’s Medicaid program for low-income women, requires two fails. But KP is the only system analyzed that recommends women first fail four drugs, as well as ECT.
“That’s absurd. So I’m assuming no woman will ever have the opportunity to try brexanolone?” said UNC’s Patterson, one of several experts on postpartum depression who questioned KP’s guidance.
“Asking someone to fail four oral antidepressants is an unacceptable burden that will undoubtedly create more harm than good,” said Bethany Sasaki, who runs the Midtown Birth Center in Sacramento, California, and is licensed to administer brexanolone.
Psychiatrist Dr. Shannon Clark, who’s been administering brexanolone at UC Davis Medical Center for the past two years, seeing positive results, said there are a lot of reasons new moms may not be candidates for one medication, let alone four: taking pills while breastfeeding could be too anxiety-provoking; some women may not be able to adhere to a daily pill regimen; or they may have a liver condition that contraindicates those medications. Clark called Kaiser Permanente’s guidance “terrible.”
It could also be illegal, according to some California lawmakers and mental health advocates. Under a California state law that took effect this January, health plans must conform to generally accepted standards of care, including scientific literature and expert consensus, when making decisions about mental health treatment.