(211) Brexanolone Infusions and the Role of C-L Psychiatry: Interdisciplinary Care for Postpartum Women

Background/Significance: Approximately 1 in 7 individuals will experience postpartum depression (PPD), which has been associated with numerous negative outcomes including adverse effects on maternal-infant bonding, lower rates of breastfeeding, developmental delays in the infant, lower maternal quality of life, and mortality. Brexanolone, a positive allosteric modulator of the GABA-A receptor, was approved in 2019 by the Food and Drug Administration as an available intravenous treatment for PPD, and studies have shown benefit of the infusion within a week. Administered as a 60-hour treatment, this medication is largely provided in inpatient medical hospital settings, yet little is published on the role of consultation-liaison (CL) psychiatry in providing brexanolone (Howard 2022). Moreover, CL-administered brexanolone has not been discussed as a treatment option across a continuum of clinical care delivery. We present two cases of successful brexanolone infusions referred to CL from our institution’s peripartum intensive outpatient program (IOP) for a planned admission, utilizing a stepped-care approach.
Cases: Both patients were within 6 months postpartum and referred from our institution’s co-located perinatal psychiatry clinic to peripartum IOP with symptoms consistent with major depressive episodes defined by DSM-5 criteria. Initial PHQ-9 scores both indicated severe symptoms with scores of 18 and 21. After initial evaluations and medication management to maximize their regimens, patients met screening criteria for brexanolone, and a referral was placed electronically for evaluation for brexanolone treatment. Care coordination with inpatient CL psychiatry (who was ultimately responsible for the medication), maternal-fetal medicine, care management, and pharmacy teams preceded a planned admission to the hospital during their time in IOP to receive the infusion. Hospitalizations were uncomplicated and followed by significant clinical improvement over the following weeks, leading to early completion of IOP for both patients, and transfer to a lower level of care. PHQ-9 scores obtained at the end of IOP notable for a reduction in symptoms to mild and moderate severity with score reductions of 11 and 7 points, respectively.
Discussion/Implications: These two cases illustrate the clinical importance and potential benefit of utilizing Brexanolone infusion in the treatment of PPD for rapid improvement in depressive symptoms. They also highlight the critical role CL psychiatrists play in providing Brexanolone treatment. In our presentation, we will detail our cases, include relevant findings of their outpatient course over the next several months, assessed through chart review, and outline interdisciplinary approaches to care. We will describe the process of creating the integrated, interdisciplinary Brexanolone program pathway at our institution with an emphasis on the role of CL psychiatry as a critical stakeholder and leader of this program. Additionally, systems-based practices around stepped care (i.e., referral from a perinatal co-located program to IOP to hospital-based care) will be explored. Practical clinical pearls for the CL psychiatrist on Brexanolone as an interventional method will be provided.

References:
1. Howard, M. M., Diaz, Z., & Battle, C. L. (2022). Implementation of a hospital-based Brexanolone program. Journal of Psychiatric Practice, 28(5), 404–408. https://doi.org/10.1097/pra.0000000000000650