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Perinatal Mental Health and Childbirth Education: Professional Perspectives Part II

December 11th, 2012 by avatar

By, Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Recent press coverage of a British mother suffering from severe PMAD has made headlines and the topic is one that belongs in whatever childbirth class a woman chooses to take.  The first post in the series is here  Part III will appear on Dec 13th, 2012.– Sharon Muza, Community Manager.

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We have the opportunity to hear another expert perspective regarding the use of antidepressants, stigma, and the role childbirth education might play in the prevention of perinatal mood and anxiety disorders (PMAD). This installment features Nancy Byatt, D.O., MBA. Dr. Byatt is a perinatal psychiatrist and Assistant Professor of Psychiatry and Obstetrics & Gynecology at University of Massachusetts Medical School/UMass Memorial Medical Center.  Dr. Byatt’s research focuses on understanding and evaluating ways to improve depression outcomes for perinatal women and their children through health care system improvement.  Her current research aims to improve the uptake of evidence-based treatments for perinatal depression in obstetric settings.  I know I speak for Lamaze International in thanking Dr. Byatt for participating.

WK: What can we do to increase the understanding that a woman’s mental health is part of maternal health?  

Dr. Byatt: Providing psychoeducation to women and their partners about the importance of perinatal mental health is a good first step.   Psychoeducation should aim to destigmatize depression and other perinatal mental health concerns and encourage women to engage in treatment.  Providing psychiatric resource and referral source guides may also empower women to seek treatment.  Childbirth educators could also be trained in motivational enhancement interventions that may inspire women to address their mental health concerns.  For example, providing information about health risks, wellness interventions, support groups, psychotherapy, medication options, and other mental health resources can encourage women to engage in treatment.

WK: How might childbirth professionals integrate perinatal mood disorders in classes? 

Dr. Byatt: Childbirth education classes are an excellent opportunity to prepare women and their partner or primary support for the emotional transition to the postpartum period.  Ideally, women should be taught how to take care of themselves both physically and emotionally during this vulnerable time period.  Women and their partners or primary support could be given information about the signs and symptoms of depression so they can recognize depression if it occurs.  It would also be helpful to destigmatize depression and review mental health resources.  Psychoeducation could also be provided about what factors may put women at higher risk for a perinatal mood disorder.

WK: How would you describe the stigma of perinatal mental health disorders and its impact?

Dr. Byatt: Many studies have demonstrated that many women feel very ashamed of perinatal depression and as a result may be less likely to seek help.  More specifically, women may be afraid that they will lose parental or personal rights if they disclose psychiatric symptoms.  They may also fear feeling judged by perinatal health care professionals and/or friends and family.   Acknowledging depression symptoms can also negatively impact women’s view of themselves as a mother.   Unfortunately, these concerns may result is avoidance of mental health discussions.

WK: What do you see as the most significant barriers to treatment for women with PMADs?

Dr. Byatt: Women face many barriers to accessing and seeking help for perinatal depression. Stigma and shame have been consistently reported in numerous studies.  Studies also suggest that interactions with perinatal health care professionals may discourage help-seeking. Some women also report that their emotional needs are not addressed by perinatal health care professionals, perceiving them as unresponsive or unsupportive.  Women also perceive that perinatal health care professionals lack training in regards to perinatal mental health.  Available treatment resources are often limited for both perinatal women and obstetric providers and staff, creating both patient and provider barriers, respectively.

Some typical (but not all inclusive) symptoms of Postpartum Mood and Anxiety Disorders

  • Are you feeling sad or depressed?
  • Do you feel more irritable or angry with those around you?
  • Are you having difficulty bonding with your baby?
  • Do you feel anxious or panicky?
  • Are you having problems with eating or sleeping?
  • Are you having upsetting thoughts that you can’t get out
  • of your mind?
  • Do you feel as if you are “out of control” or “going crazy”?
  • Do you feel like you never should have become a mother?
  • Are you worried that you might hurt your baby or yourself?

Women note numerous factors that impede their ability access mental health treatment, including disconnected pathways to depression care.  Women’s interactions with mental health providers can also be perceived as a barrier to treatment. Women may find it hard to access mental health care due to long wait times or lack of available providers. Women may not know who to call or how to get help or have difficulty finding a mental health provider willing to see perinatal women.  

WK: How would you respond to media-based concerns regarding the safety of SSRI medication in pregnancy? 

Dr.  Byatt: It is imperative to consider risk of untreated depression when considering medication or non-medication treatment during pregnancy.  Multiple studies have demonstrated that perinatal depression can negatively impact mother, infant, child and family.   Maternal depression has been associated with emotional and functional disability in children of depressed mothers.  Although risks have been reported with SSRI use in pregnancy, the preponderance of data is reassuring.

The risks and benefits of treatment with antidepressants should be weighed against the risks of untreated illness.  Does exposure to the antidepressant or untreated illness pose a greater risk?    If treatment with an antidepressant is indicated, then a discussion of the risks and benefits should take place before medication is prescribed.  Pharmacotherapy should be used judiciously and treatment should aim to maximize evidence-based non-medication treatments, such as psychotherapy, in order to maintain or reach remission of the maternal symptoms.

WK: What are your thoughts regarding discontinuation of medication in pregnancy?

Dr. Byatt: Clinical decisions should be based on the risks, benefits and alternatives to medication treatment.  Untreated maternal illness and the potential risks of psychotropic medication must be considered.  It is vital to consider women’s treatment preferences, illness severity, and the risks of no treatment and under-treatment.  Discontinuation of an effective medication often poses more risk than continuation because it carries the risk of relapse and/or in utero exposure to a second antidepressant.

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice?

Dr. Byatt: A combination of staff training, structured screening programs, and community resource guides may help childbirth education organizations encompass perinatal mental health training into their curriculum and practice.  Training childbirth educators in mental health can allow them to feel more confident discussing perinatal mental health, which in turn may mitigate women’s fears and concerns and activate them to seek treatment.

Conclusion:

I wonder about the perception of lack of training in childbirth education courses as a part of the barrier to treatment noted by Dr. Byatt. Disconnected pathways to care seem a call to action for childbirth professionals. Where women and families find lack of education, empathy, and acceptance –childbirth professionals could provide pathways to better treatment merely through community resource lists.  Training, structured screening programs and community resource guides are good suggestions to not only optimize care for women, but to optimize practices for educators.

If you took inventory of the training and resources you have been given regarding perinatal mental health—what would you find? Do you know what resources are available from your certifying organization for you to use in your classes? Have you read Kathy McGrath’s article on the Lamaze.org website on Baby Blues? What are some of your favorite resources and activities that you use in class to cover these topics? How do you envision your childbirth organization creating or growing pathways in the future to support continued education on this topic?

Check

About Nancy Byatt, DO, MBA

Nancy Byatt, DO, MBA:  Dr. Byatt’s clinical, educational and research efforts have been led her numerous publications and awards including the Briscoli Award for Resident-Faculty Academic Collaboration and APA/APIRE Junior Investigators Award.   She recently submitted a Career Development Award Proposal to the NIH/NIMH (National Institute of Health/National Institute of Mental Health) in order to develop and evaluate a new low-cost program that aims to improve the delivery of depression care in outpatient obstetric settings.  Her recent publications include:

1. Byatt N, Biebel K, Lundquist R, Moore Simas T, Debourdes-Jackson G, Ziedonis D.  Patient, Provider and System-level Barriers and Facilitators to Addressing Perinatal Depression:  Perspective of Obstetric Providers and Support Staff. Journal of Reproductive and Infant Psychology.  Link to article:  http://dx.doi.org/10.1080/02646838.2012.743000

2. Byatt N, Biebel K, Debourdes-Jackson G, Lundquist R, Moore Simas T, Weinreb L, Ziedonis D.  Community Mental Health Provider Reluctance to Provide Pharmacotherapy May Be a Barrier to Addressing Perinatal Depression: A Preliminary Study. Psychiatric Quarterly, 2012; ePub ahead of print DOI: 10.1007/s11126-012-9236-0.

3.  Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012 Dec;33(4):143-61. doi: http://www.ncbi.nlm.nih.gov/pubmed/23194018

4. Byatt N, Deligiannidis K, Freeman M.  Antidepressant Use in Pregnancy:  A Critical Review Focusing on Controversies and Risks. Acta Psychiatrica Scandinavica. In Press.

 

Babies, Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Perinatal Mood Disorders, Postpartum Depression , , , , , , , , , , ,

Beating the Winter Blues: Bright Light Therapy for Seasonal and Non-Seasonal Depression

October 3rd, 2010 by avatar

Some people dread the change of seasons. Shorter, darker days mean fatigue, oversleeping, too many carbs, and having a general sense of malaise: a pattern known as seasonal affective disorder (SAD). Seasonal affective disorder is depression that occurs during late fall and winter months, as darkness occurs earlier in the day.  Symptoms include depression, lethargy, difficulty waking, and craving carbohydrates, which often leads to weight gain (NAMI, 2007). With winter approaching, it’s important that we recognize that seasonal depression may be an issue for some of the women we see. Fortunately, safe treatments for pregnant and breastfeeding women are available.

For more than 20 years, clinicians have used bright light therapy to successfully treat seasonal affective disorder. Light therapy has far fewer side effects than medications and can provide relief within days (NAMI, 2007). In a recent clinical trial, light therapy was as effective as fluoxetine in relieving symptoms, and patients who received light therapy had an earlier response to treatment with fewer side effects (Lam et al., 2006).

Researchers have recently discovered that light therapy is also helpful for other affective disorders, including non-seasonal depression, antenatal and postpartum depression, bipolar disorder, some eating disorders, and certain sleep disorders (Oren et al., 2002; Terman & Terman, 2005).  In a 2005 meta-analysis, the American Psychiatric Association indicated that bright light therapy was an effective treatment for both seasonal and non-seasonal depression, “with effect sizes equivalent to those in most antidepressant pharmacotherapy trials” (Golden et al., 2005, p. 656).

Light therapy can also be safely combined with medications in most cases, and can boost the activity of medications in patients who are either not responding or who have had a partial response. Terman and Terman (2005) summarized the results of several recent clinical trials where patients were given either bright light therapy (10,000 lux) or dim light (2,500 lux) in addition to their medications. They noted that in all of these studies, bright light improved both remission rate and speed of improvement.

Light Intensity, Duration, and Timing of Light Exposure

Although a number of light intensities have been investigated, lights with intensities of 10,000 lux, with 30 to 40 minutes of exposure, appear most effective (Terman & Terman, 2005).  Two studies with light exposures of 30-40 minutes at 10,000 lux achieved a 75% remission rate. It took 2 hours to achieve similar remission rates with 2,500 lux. And in some cases, even with longer exposure, lower-intensity lights are not as effective (Terman & Terman, 2005). Also, when longer exposure times are necessary, patients are less likely to comply. This may particularly be true for mothers of young children who probably won’t find it practical to sit for two to three hours in front of a light box.

Timing of light exposure also makes a difference. Exposure to bright light is generally much more successful in achieving remission if it occurs in the morning.  Terman and Terman (2005) cited one analysis of 332 patients, across 25 different studies, that compared administration of light in the morning, mid-day and evening. They noted remission rates after one week of treatment, with significantly higher rates in the morning (53%), compared with mid-day (32%) and evening (38%) exposures.  According to their analysis, morning light should be administered 8.5 hours after a patient’s melatonin onset. Melatonin onset can be difficult, or impractical, to assess directly. However, the Center for Environmental Therapeutics (www.cet.org) has a free online questionnaire that will help patients estimate this and calculate individual treatment time.

Because of the effectiveness of morning light exposure, a variant to standard light therapy has recently been added to the repertoire of possible treatments: dawn simulation. As the name implies, dawn simulation refers to a light that comes on before a patient is awake, and gradually increases in intensity over a period of 15 to 90 minutes (the length of the sunrise can be tailored to individual preference). The advantage to this treatment is that it does not require sitting in front of a light box for an extended time, making it a more practical alternative for new mothers or mothers of young children. Although a relatively new technique, it is showing promise as a treatment for SAD (Golden et al., 2005). Some newer lighting devices are both light boxes and dawn simulators.

Why Light is Effective?

A number of possible mechanisms for light’s effectiveness have been proposed. Most explanations have to do with modifying the internal circadian clock.  Our circadian rhythms, or daily patterns of sleep and arousal, are regulated by the pineal gland, which secretes melatonin. The pineal gland responds to light via light receptors in the retina. Exposure to light in dark winter months appears to reset the internal clock. The antidepressant effect is stronger when patients are exposed to morning, rather than evening light. This is likely due to the diurnal variations in retinal photoreceptor sensitivity, with greater sensitivity to morning light. Indeed, exposure to evening light can lead to insomnia and hyperactivation in some people (NAMI, 2007; Terman & Terman, 2005). One exception to the use of morning light is in patients with bipolar disorder. Morning light exposure can increase risk of a manic episode. This problem can be addressed by timing light exposure later in the day and having them continue on their medications during light treatment (NAMI, 2007; Terman & Terman, 2005).

Safety Issues

Because light boxes can be relatively expensive (about $100 U.S.), and appear to be simple, patients often consider assembling a unit themselves. Just because they can, doesn’t mean they should. Clinicians generally recommend that patients don’t use homemade devices for several reasons. First, it is difficult for consumers to find lights that are of sufficient brightness to generate a therapeutic effect (despite advertising to the contrary). Second, some patients have experienced excessive irradiation, and corneal or eyelid burns with homemade devices. Finally, homemade devices often use incandescent lights. Some of these have been marketed for bright light therapy but are not recommended because approximately 90% of light output from incandescent bulbs is on the infrared end of the spectrum. Infrared exposure at high intensity can cause damage to the lens, cornea, and retina (Terman & Terman, 2005).

Light boxes with high levels of exposure to UV can also cause eye damage, and there is some controversy about the safety of blue lights. Safe light boxes are those encased in a box with a diffusing lens that filters out UV radiation (NAMI, 2007). “Full spectrum” bulbs are not necessarily advantageous and are often expensive. The National Alliance on Mental Illness (NAMI, 2007) recommends bulbs with a color temperature between 3000 and 6500 degrees Kelvin. These have not been shown to cause any harm to patients’ eyes. Patients wanting to try light therapy should only use a lighting apparatus from a reputable dealer (see Resources for a listing of possible sources). Since price may be an issue, many hospitals, and some manufacturers, have loaner programs that allow patients to try the lighting device in their homes before buying them.

Summary

Bright light therapy is a generally safe, well-tolerated treatment option for seasonal depression. It may relieve non-seasonal depression as well. Bright light therapy is also breastfeeding friendly and can be used during pregnancy. Although therapeutic light boxes can be costly at first, a single purchase will last for years. For patients who dread winter, this investment is often well worth the cost.

References

Golden, R.N., Gaynes, B.N., Ekstrom, R.D., Hamer, R.M., Jacobsen, F.M., Suppes, T., Wisner, K.L., & Nemeroff, C.B. (2005). The efficacy of light therapy in the treatment of mood disorders: A review and meta-analysis of the evidence. American Journal of Psychiatry, 162, 656-662.

Lam, R.W., Levitt, A.J., Levitan, R.D., Enns, M.W., Morehouse, R., Michalak, E.E., & Tam, E.M. (2006). The CAN-SAD Study: A randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder. American Journal of Psychiatry, 163, 805-812.

National Alliance on Mental Illness (2007). Seasonal affective disorder. www.nami.org, downloaded 10/5/2007.

Oren, D.A., Wisner, K.L., Spinelli, M., Epperson, C.N., Peindl, K.S., Terman, J.S., & Terman, M. (2002). An open trial on morning light therapy for treatment of antenatal depression. American Journal of Psychiatry, 159, 666-669.

Terman, M., & Terman, J.S. (2005). Light therapy for seasonal and nonseasonal depression: Efficacy, protocol, safety, and side effects. CNS Spectrums, 10, 647-663.

Resources

Rosenthal, N.E. (2006). Winter blues: Everything you need to know to beat seasonal affective disorder, Revised Ed. New York: Guilford.

This book is the “bible” of self-help guides on SAD, written by the physician who first documented the phenomenon.

I’ve dealt with both of these companies and have found them to be reputable.

The Sunbox Company

www.sunbox.com

TrueSun.com

www.truesun.com

Kathleen Kendall-Tackett, Ph.D., IBCLC is a health psychologist, board-certified lactation consultant, and La Leche League Leader. She is clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. For more information, visit her Web sites: UppityScienceChick.com and BreastfeedingMadeSimple.com.

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