24h-payday

Archive

Posts Tagged ‘postpartum depression’

A Functional Medicine Approach to Perinatal Mental Health – Part Two

February 20th, 2014 by avatar

In a two part post this week, regular contributor Kathy Morelli shares information about and an interview with Kelly Brogan, MD on her nontraditional approach to working with women who are dealing with perinatal mental health issues.  Today in part two, Dr. Brogan shares information on incorporating a whole body Functional Medicine approach alongside traditional Western medicine to help and support women dealing with postpartum mood and anxiety disorders. Part one of this short blog series ran on Tuesday. – Sharon Muza, Community Manager, Science & Sensibility.

Kathy Morelli (KM): In the news, there’s been a lot of information about the negative impact of a dairy-gluten-and- sugar based diet on the body. Can you tell us a bit about the impact of gluten and sugar on thyroid function after childbirth? Can you reference research on this?

Kelly Brogan, MD (KB): Yes, there’s an explosion of research implicating the immune-modulating and inflammatory effects of gluten and sugar (often co-occuring). Many individuals perceive that they are totally “fine” until that day when they’re not. In reality, there has been a long period of “incubation” of their symptoms.

Istock/GoldenKB

Istock/GoldenKB

When it comes to autoimmunity, we know that the postpartum population is very vulnerable to new onset autoimmune disorders, and we know that autoimmunity requires three ingredients: genetic susceptibility, environmental trigger, and intestinal permeability. This has been well-established by Dr. Alessio Fasano of The Center for Celiac Research.

We know that gluten causes an inflammatory response in all people, locally, in the intestine, and that in a subset of about 80% of people, it provokes intestinal wall changes that allow for compounds, food particles, and bacterial molecules called LPS or lipopolysaccharide into the blood stream. In animal models, LPS is used to induce “depression”. There is a large literature, since 1991, establishing the role of inflammation in depression, including in the postpartum depression population.

We also know of a process called molecular mimicry, whereby, immune responses to a food particle or pathogen can lead to attacks on our own body because of common amino acid structures.

We know how to modify inflammation through diet, and we know how to support appropriate immune response through nutrients such as Vitamin A, D, Alpha Lipoic Acid, probiotics and others. I have written about the research supporting these claims on my website if you are interested in the references, but suffice it to say that elimination of gluten, dairy, corn, soy, and sugar is my first step with patients and a primary reason that I no longer need to use medication. It’s quite powerful.

 KM: And can you elaborate on the impact of dairy products on brain health? Can you share a research article on this?

KB: I don’t think that dairy is an issue for every person with mental health symptoms, but I believe it is a compelling variable to control for.

But sure, I can talk about dairy and its impact on health. In schizophrenia and bipolar, in particular, there are papers discussing the role of casein antibodies in clinical presentations. Some of these papers are listed in the references at the end of this article. Some speculation about the reasons that casein, a protein, particularly from Holstein cows which we use in America, is stimulating to the immune system, relates to its being heavily processed – homogenized and pasteurized – so that the fats and nutrients are no longer in their natural state and are provocative to the immune system.

In a paper by Severance et al (2010), they found that new onset and long-term schizophrenics were 8 times more likely to have circulating antibodies to casein than controls and up to 16.5 times more likely in a subgroup of those with psychotic depression.

kelly brogan head shot

© Kelly Brogan MD

In a separate study, this team found similar results in the setting of Bipolar I diagnosis and found that medication treatment did not mitigate this immune response. In a study this year, Li et al (2012) found that new onset schizophrenia was associated with immune activation and a 34% increased risk of developing schizophrenia if their levels of antibody were 2 standard deviations elevated. Casein and gliadin (a component of gluten) interact with opiate receptors in the brain in an unpredictable way.

KM: Based on your research and clinical practice, looking at it as a public health issue, do you believe that the overall public incidence of postpartum depression and anxiety can be reduced by educating women about modifying their diets and lifestyles?

KB: Absolutely and unconditionally, yes. Conventional psychiatry has made no progress with regard to identifying markers for vulnerable populations. We are overly focused on serotonin and examination. Research by Oberland et al (2008) into serotonin transporter polymorphisms has been confusing and inconsistent.

We must look at the cumulative burden that pregnancy places on some women and how it exposes the dysfunction of their interrelated neuroendocrine systems resulting in depression, anxiety, and psychosis as non-specific indications that there is lifestyle imbalance and inflammation.

I have a detailed research article about the Neuro-inflammatory Models of Postpartum Depression published here for your further reference.

KM: Based on your research and clinical practice, do you believe that the personal incidence of postpartum depression and anxiety can be reduced for a woman modifying her diet and lifestyle?

KB: Yes. In my clinical practice, with the preventive cases that I work with, I have yet to have an incidence of a woman with postpartum onset symptoms, including those women with previous history.

KM: I’ve heard you lecture about the nutrient deficiencies and dietary factors that could feed into an occurrence of postpartum psychosis. Based on your research and clinical practice, do you believe that the incidence of postpartum psychosis can be reduced by a woman being aware of the risk factors and modifying her diet and lifestyle?

KB: I am very interested in research like that of Bergink et al (2012) that suggests a significant overlap between thyroid autoantibodies and postpartum psychosis.

We know that these antibodies portend endocrine dysfunction and we know that thyroid stimulation can result in psychosis. We also have precedent, in the literature of bipolar and schizophrenia being induced by nutrient deficiencies, even as simple as niacin.

It is myopic to abandon simple and potentially effective interventions in the interest of medicating these patients, particularly because of the established incidence of mania and violence toward self and others with SSRI treatment. I believe these medications, in the postpartum population account for incidences of violence that might have otherwise been avoided. Ssristories.com explores these cases.

KM: In the hierarchy of risk factors for perinatal mental illness, such as an individual’s previous history and family history, where do you think the role of lifestyle management and diet modifications fall?

KB: I think that it trumps all other risk factors, and this is because of what we have learned about the 98% of “junk DNA” that we found after the completion of the Human Genome Project.

This is called “epigenetics” and refers to the role of lifestyle or the “exposome” to modify gene expression within one lifetime.

We outsource much of our bodily function to out bodily microbes, as well, which outnumber our human cells 10:1. This is exciting and empowering because it means that we are not condemned by our family histories or genes. We can change them with each bite off a fork, with each step, and with our home environments.

KM: In your work, you do a thorough assessment and then work carefully to support a woman to taper off their psychotropic medications, if possible. Do you advocate that a woman go off of her medications without supervision?

KB: I do not recommend that women go off their medications without supervision.

My initial consultation is 2 hours and I work intimately with patients during tapers. As I deal with some complicated cases, I require patients to optimize their health and wellness prior to initiating a taper to confer resilience and assure adrenal hormone reserves which are often highly perturbed during a taper (the impact of SSRIs on glucocorticoid functioning is well understood).

Then, we initiate a taper that can take 1-2 years.

This is the most responsible way to do it, and keep in mind it cannot always be done.

This is why I believe that true informed consent prior to beginning a medication must include disclosure of dependency. It is not the original symptoms returning, as I was taught to parrot in my training, it is drug-induced withdrawal and associated “relapse” that often looks like agitation and profound anxiety, often novel symptoms to the patient who has never experienced such autonomic nervous system disruption.

KM: Generally, how do you help a woman who is depressed preserve the breastfeeding relationship, if she states that she wished to do so?

KB: Great question. I believe that lactation support is non-optional and must be daily for the first week and perhaps even the first several weeks. Women need to be supported to nurture this skill and to protect it at all costs. They can’t do it alone (in my observation). Here is a link to more information I’ve published about how to help meet breastfeeding goals.

Once lactation is in place, and supply is established, breastfeeding becomes protective of depression. I will be publishing an article about studies supporting this in the coming weeks. I also encourage pumping early (beginning at 2 weeks) so that there is flexibility around night feedings with partner support.

Basically, we have a crisis of failed lactation that I believe relates to environmental toxins called endocrine disruption, undiagnosed thyroid conditions, and insulin resistance from high sugar diet. >Of course, in the end, it’s a woman’s decision to care for and feed her infant as she sees fit. Here’s a link to some very detailed information about finding safe organic formula products.

KM: What do you recommend as readily available methods a woman can do herself to help her heal postpartum depression and anxiety holistically?

KB: I certainly recommend consulting with a holistic provider such as a naturopath, acupuncturist, homeopath, or certified physician. That said, dietary modification, mild exercise, and 20 minutes daily or relaxation response is a great place to start.

KM: What are some of your other projects going on now?

KB: My cup runneth over! I am writing a book that I hope will be a resource to the women I cannot personally see in my busy practice. I maintain an active blog at www.kellybroganmd.com and am also on Huffington Post. I am directing a conference and participating in several in the coming year, and will be providing a course with Aviva Romm, MD to help educate women about holistic health. Fearless Parent will be very active throughout the year with events, blogs, and weekly radio shows to help parents navigate all of the information that comes at them in the realm of thoughtful parenting. Join us!

KM: Thank you for your valuable time & input!

KB: My absolute pleasure. Your interest and support mean a lot to me, as does the mission and educational dedication that Lamaze upholds. I’m an enormous fan!

How do you feel about the information that Dr. Brogan shared?  Have you or your clients had any experience with Functional Medicine?  Would you provide this information to women along with more traditional recommendations, for them to explore when they are being treated for perinatal mood disorders? – SM.

References

Bergink V. et al. Prevalence of autoimmune thyroid dysfunction in postpartum psychosis. British Journal of Psychiatry, 2011;198:264-8. Epub February 22, 2011.

Black, M.M. (2008). Effects of B12 and folate deficiency on brain development in children. Food and Nutrition Bulletin, June (29), 126-131.

Brogan K. (2013). Putting theory into preliminary practice: Neuroinflammatory models of postpartum depression. OA Alternative Medicine, May 01;1(2):12.

Dickerson F, Stallings C, Origoni A, Vaughan C, Khushalani S, Alaedini A, Yolken R. Markers of gluten sensitivity and celiac disease in bipolar disorder. Bipolar Disorder. 2011 Feb;13(1):52-8. doi: 10.1111/j.1399-5618.2011.00894.x.

Fasano, A. and colleagues at the Celiac Center, numerous medical research articles.

Jackson, J., Eaton, W., Cascella, N., Fasano, A., Kelly, D. (2012). Neurologic and Psychiatric Manifestations of Celiac Disease and Gluten Sensitivity.Psychiatric Quarterly, 83(1), 91-102, http://dx.doi.org/10.1007/s11126-011-9186-y

Li J, Harris RA, Cheung SW, Coarfa C, Jeong M, et al. (2012) Genomic Hypomethylation in the Human Germline Associates with Selective Structural Mutability in the Human Genome. PLoS Genet 8(5): e1002692. doi:10.1371/journal.pgen.1002692

Niebuhr DW, Li Y, Cowan DN, Weber NS, Fisher JA, Ford GM, Yolken R. Association between casein bovine antibody and new onset schizophrenia among US military personnel. Schizophrenia Research, 2011 May;128(1-3):51-5. doi: 10.1016/j.schres.2011.02.005. Epub 2011 Mar 4.

Oberland, TF, Weinberg, J, Papsdorf, M, Grunau, R, Misri, S, & Devlin, AM (2008). Prenatal exposure to maternal depression, neonatal methylation of human glucocorticoid receptor gene (NR3C1) and infant cortisol stress responses. Epigenetics, Mar-Apr,3(2), 97-106.

Severance EG, Dupont D, Dickerson FB, Stallings CR, Origoni AE, Krivogorsky B, Yang S, Haasnoot W, Yolken RH. Immune activation by casein dietary antigens in bipolar disorder. Bipolar Disorder. 2010 Dec;12(8):834-42. doi: 10.1111/j.1399-5618.2010.00879.x.

Perlmutter, D. (2011). Grain brain: The surprising truth about wheat, carbs, and sugar – Your brain’s silent killers. New York: Little, Brown & Company

Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Perinatal Mood Disorders , , , , , , ,

A Functional Medicine Approach to Perinatal Mental Health – Part One

February 18th, 2014 by avatar

 In a two part post this week, regular contributor Kathy Morelli shares information about and an interview with Kelly Brogan, MD on her nontraditional approach to working with women who are dealing with perinatal mental health issues.  Dr. Brogan shares information on incorporating a whole body Functional Medicine approach alongside traditional Western medicine to help and support women dealing with postpartum mood and anxiety disorders. Part two of this short blog series runs on Thursday. – Sharon Muza, Community Manager, Science & Sensibility.

Creative Commons Image: Pamela Machado

Creative Commons Image: Pamela Machado

I’ve been interested in Integrative medicine for many years. I’ve gotten a lot of feedback from Science & Sensibility readers and my psychotherapy clients that they are very interested in holistic approaches to their health.

On a personal level, I struggled with depression at different times in my life. Nineteen years ago, I suffered a long postpartum depression. I didn’t want to take any psychotropic drugs as I was breastfeeding; there wasn’t much research available then about medication and breastfeeding. I looked for other ways to heal. In the short term, homeopathy is what healed my severe depression. On a longer term basis, I studied many forms of mindbody healing: diet, exercise, bodywork and professional counseling techniques have been my holistic program for mental and physical health. I’ve been fortunate that I haven’t had depression in 17 years.

On a professional level, in my clinical practice, I’ve seen the whole gamut of results in my clients’ levels of anxiety and depression when using psycho-trophic drugs: successful, lackluster and very poor results. So, I’m always searching for complementary and gentle therapies to add to my own toolbox and referral list to improve my clients’ mental health.

Disclosure: I want to clarify that I’m not a doctor and I’m not licensed to prescribe medication, but in my role as a licensed counselor, I often share clients with psychiatrists, who do prescribe medications.

Medication Taper: I want to clarify that this article does not suggest that women should discontinue their medication.

In some ways, what is old is new again! Conceptually, functional medicine (FM) mirrors the approach of Traditional Chinese Medicine (TCM), which approaches the patient from a holistic level. However, functional medicine is an evolutionary development in the practice of modern conventional medicine. FM is a systems biology approach. FM uses all the tools now available to the modern medical doctor: current assessment and diagnostic technology, cutting edge research into the interaction of the endocrine, gastrointestinal, and immune systems with our environment and treatment with a range of integrative and pharmaceutical medical therapies.

A doctor trained in this sophisticated approach performs a personal and careful assessment of an individual in order to find and then correct the underlying imbalances in the body, rather than treat separate symptoms. This is a departure from the conventional “organ based” practice of medicine, whereby the focus of diagnosis and treatment of a person is set up in silo-like medical specialties.

Dr. Kelly Brogan practices Holistic Women’s Psychiatry in this manner. She has impressive academic credentials, having studied cognitive neuroscience at the Massachusetts Institute of Technology and medicine at Cornell University Medical College. She is Board Certified in both Reproductive Psychiatry and Integrative Medicine and certified in Endocrinology. She is a leader in Functional Medicine. For her clinical work in Holistic Women’s Health Psychiatry, she analyzes and combines the research from the intersection of these three fields. She has appeared at many conferences, including the recent 2013 Postpartum Support International conference, the 2013 Lamaze International conference, is the Medical Director at Fearless Parent, blogs for Green Medical Information and has blogged for Postpartum Progress.

At her private practice in New York City, she offers a supervised lifestyle and food-based approach for women to manage perinatal mood disorders without psychotropic drugs.

This article is meant as an introduction to a different medical approach to women’s mental health. The functional medicine approach integrates the emergent research of the past three decades that suggests that a modern diet high in processed food, carbohydrates and sugar not only impacts the body with such chronic diseases as diabetes and heart disease, but also impacts brain health and contribute to the rising rates of mental illnesses such as depression and postpartum depression, postpartum psychosis and more severe mental illnesses such as schizophrenia.

Kathy Morelli (KM): Dr. Brogan, I was excited to discover your work via the Fearless Parent website, where you’re the Medical Director. You’re also active on the Green Medical Information website, where you regularly blog and present webinars. I admit, I was at first skeptical. However, after attending your webinar, and finding the information to be so very detailed and well-researched, I’m very intrigued. How did you become interested in your particular niche, Reproductive Psychiatry and Maternal Mental Health?

Dr. Kelly Brogan (KB): My post-residency fellowship training was in medical psychiatry, which is looking at how bodily problems like infection or liver disease can cause psychiatric symptoms. I specifically focused on reproductive psychiatry and the treatment of mood and anxiety disorders related to menses, pregnancy, and postpartum.

Despite my extensive training in helping women to navigate the risks and benefits of medication treatment during this vulnerable time period, I found that many women chose to discontinue medication.

Because of this and also because I wanted to help the women in my care optimize their health for anticipated or current pregnancy, I decided to investigate some common body-based drivers of psychiatric symptoms. I focused on these areas of the body: thyroid and adrenal dysfunction, food intolerances and gut infections, and sugar imbalances, rather than solely looking at the neurochemistry of the brain.

I also began to research what evidence there was to support mood-enhancing treatments that were also beneficial to the baby (given maternal deficiency) such as vitamin D, fatty acids, magnesium, and b vitamins.

Now I focus on inflammatory models of depression and anxiety and look at environmental exposures first and supporting the immune system and minimizing inflammation second. I haven’t started a patient on an antidepressant in some time.

KM: Dr. Brogan, as I understand it, you approach your work by focusing on the underlying human physiology of depression and anxiety, which is impacted by such factors as a sedentary lifestyle and a nutrient-poor diet which, in turn, causes inflammation. The inflammation in the body negatively impacts hormonal and neurotransmitter production and balance, which causes mindbody ailments, such as thyroid dysfunction and depression and anxiety. How would a woman coming to your office experience her visit with you differently than she would in a conventional psychiatric visit?

KB: The backbone of my clinical interventions is a sophisticated diagnostic assessment which includes a large battery of blood work, stool samples, salivary hormonal assessments, and urinary organic acids. In this way, I can personalize interventions rather than just empirically suppress symptoms. All of my patients require expert nutritional guidance, which I support them through, as well as personally tailored exercise and relaxation response interventions.

I’ve developed deep concern for the excessive, and what I believe to be irresponsible, use of medications to manage chronic disease. We have lost touch with our body’s native ability to heal itself and to correct, through elaborate checks and balances, any disturbances.

We’ve lost touch with this because we look to doctors when we should first be looking to our homes, our plates, and our minds to see how we can better facilitate that healing process, as you have done, Kathy. I believe that psychiatric medications, but also common medications prescribed for pain, acid reflux, and high cholesterol are wreaking havoc on the body’s ability to function optimally.

Here is an example of how I work with a simpler case: A lovely woman comes in to see me. She says she has debilitating melancholic depression, no energy and brain fog. I even note some instability when she walks. When I take her history, she tells me she was put on an acid blocking medication 2 years ago for her heartburn. I ask about her diet, which is high in sugar and fried foods, which is most likely causing her stomach discomfort. It’s well known clinically and in the research literature that long-term suppression of stomach acid blocks the absorption of the essential B12 vitamin.

Did you know B12 is one of the building blocks of life? A B12 deficiency is a silent condition that disrupts the myelination process, which leads to depression, confusion and eventually, to brain shrinkage. B12 protects your brain and nervous system, regulates rest and mood cycles and also keeps the immune system functioning properly. In fact, in persons over 65, B12 deficiency is linked to memory decline, brain shrinkage and a greater risk of age-related dementia, as the production of hydrochloric acid slows down with age.

In addition, because my patient is of childbearing age, it is very important to help her maintain her proper B12 levels, in order to help maintain her baby’s health. An infant born to a woman deficient in B12 is at serious risk for negative neurological symptoms, such as lethargy, developmental delays and delayed cognitive and motor development.

So, back to my patient. I’ll run a simple blood test to determine B12 levels to see if this lovely woman has either a suboptimal B12 level and/or a secondary marker of B12 deficiency. If so, I treat her with non-invasive B12, which can resolve all of her symptoms.

I do this because there are cases in the research literature describing patients receiving electroshock and antipsychotic medications before someone bothered to check their B12 levels and then successfully treat them to remission with this vitamin!

I work overtime to uncover what might be driving symptoms and driving inflammation. I don’t believe that the answer lies in a psychiatric medication, and I do believe that these medications can cause significant short and long-term side effects. Some have posited that, in addition to often containing synthetic preservatives, titanium, and gluten, medications such as Prozac contain fluoridated molecules which may impact the body as fluoride – a neuroendocrine toxin – does.

If they were seeing someone else, they might be started on an antidepressant after a 45 minute clinical contact. They can expect to take that antidepressant for the rest of their lives because few prescribers are experienced in medication discontinuation.

On Thursday, Kathy continues her interview with Dr. Brogan, sharing more information about the role of diet on the childbearing woman’s mental health and how the functional medicine approach can help to improve perinatal mental health and provide help to those who need it. – SM

References

Bergink V. et al. Prevalence of autoimmune thyroid dysfunction in postpartum psychosis. British Journal of Psychiatry, 2011;198:264-8. Epub February 22, 2011.

Black, M.M. (2008). Effects of B12 and folate deficiency on brain development in children. Food and Nutrition Bulletin, June (29), 126-131.

Brogan K. (2013). Putting theory into preliminary practice: Neuroinflammatory models of postpartum depression. OA Alternative Medicine, May 01;1(2):12.

Dickerson F, Stallings C, Origoni A, Vaughan C, Khushalani S, Alaedini A, Yolken R. Markers of gluten sensitivity and celiac disease in bipolar disorder. Bipolar Disorder. 2011 Feb;13(1):52-8. doi: 10.1111/j.1399-5618.2011.00894.x.

Fasano, A. and colleagues at the Celiac Center, numerous medical research articles.

Jackson, J., Eaton, W., Cascella, N., Fasano, A., Kelly, D. (2012). Neurologic and Psychiatric Manifestations of Celiac Disease and Gluten Sensitivity.Psychiatric Quarterly, 83(1), 91-102, http://dx.doi.org/10.1007/s11126-011-9186-y

Li J, Harris RA, Cheung SW, Coarfa C, Jeong M, et al. (2012) Genomic Hypomethylation in the Human Germline Associates with Selective Structural Mutability in the Human Genome. PLoS Genet 8(5): e1002692. doi:10.1371/journal.pgen.1002692

Niebuhr DW, Li Y, Cowan DN, Weber NS, Fisher JA, Ford GM, Yolken R. Association between casein bovine antibody and new onset schizophrenia among US military personnel. Schizophrenia Research, 2011 May;128(1-3):51-5. doi: 10.1016/j.schres.2011.02.005. Epub 2011 Mar 4.

Oberland, TF, Weinberg, J, Papsdorf, M, Grunau, R, Misri, S, & Devlin, AM (2008). Prenatal exposure to maternal depression, neonatal methylation of human glucocorticoid receptor gene (NR3C1) and infant cortisol stress responses. Epigenetics, Mar-Apr,3(2), 97-106.

Severance EG, Dupont D, Dickerson FB, Stallings CR, Origoni AE, Krivogorsky B, Yang S, Haasnoot W, Yolken RH. Immune activation by casein dietary antigens in bipolar disorder. Bipolar Disorder. 2010 Dec;12(8):834-42. doi: 10.1111/j.1399-5618.2010.00879.x.

Perlmutter, D. (2011). Grain brain: The surprising truth about wheat, carbs, and sugar – Your brain’s silent killers. New York: Little, Brown & Company.

Depression, Guest Posts, Infant Attachment, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression , , , , , , , ,

Postpartum Psychosis: Review and Resources Plus Additional PPMAD Resources

October 8th, 2013 by avatar

We are just a few days past the sad events that occurred in Washington DC, right near the capital, when Miriam Carey, a mother of a year old child slammed her car into security barricades and led law enforcement officials on a high speed car chase, injured federal officials and was shot and killed, all while having her baby in the car.

It is not clear at this time, what exactly led Miriam Carey to behave the way she did, but it has been suggested that she was suffering from postpartum depression.  Postpartum mood and anxiety disorders (PPMAD) affect approximately 20 percent of all new mothers.  While not every circumstance of PPMAD escalates into a situation like what we saw last week, we do know that many women and their families are not aware of the signs and symptoms of PPMAD, most women do not seek help and are not provided information and resources for proper treatment.  Left untreated PPMADs can become a situation where the mother may harm herself or others.

As childbirth educators and professionals who work with birthing women, it is imperative that we speak and share, both prenatally and in the postpartum period. about PPMAD illnesses, and provide resources for help.  Here is some previously provided information on Postpartum Psychosis along with great resources provided by regular contributor, Walker Karraa, PhD.  Click to see previous Science & Sensibility posts on postpartum mood and anxiety disorder topics, for even more resources for professionals to share with parents. – Sharon Muza, Science & Sensibility Community Manager.

_____________________________________________

http://flic.kr/p/7U4sW

Despite mounting credible medical evidence of the realty of postpartum issues and their effect on the mindset of the new mother, we as a country still remain the only civilized society that refuses to legally acknowledge the existence of this illness.—George Parnham, Attorney for Andrea Pia Yates

I wrote an OP/ED recently titled, “Who is at Stake? Andrea Yates, CNN and the Call for Revolution” at Katherine Stone’s Postpartum Progress. Given the airing of the CNN Crimes of the Century featuring Andrea Yates, I compiled a brief review of the facts and resources that might be helpful in approaching the topic in childbirth education. Thanks to Sharon Muza for supporting this piece.

Postpartum psychosis (PPP) is a psychiatric emergency that requires immediate medical attention.

It has been acknowledged in medical literature since Hippocrates 4th Century (Brockington, Cernick, Schofield, Downing, Francis, Keelan, 1981; Healy, 2013). In a comparative study of epidemiological data regarding perinatal melancholia from 1875-1924 and then 1995-2005, Healy (2013) concluded:

History shows that complaints can be readily tailored to fashionable remedies, whereas disease has a relative invariance. The disease may wax and wane in virulence, treatments and associated conditions may modify its course, but the disease has a continuity that underpins a commonality of clinical presentations across time. (p. 190)

Women experience PPP. Women have experienced PPP. And women in the future could avoid this tragedy by recognizing this mental illness. PPP is frequently confused with postpartum depression in public and professional nomenclature. It is extremely important to emphasize the difference in discussion of perinatal mental health with clients and students, as the word “postpartum” means different things to different students and providers.

Postpartum psychosis is not postpartum depression, lack of sleep, or postpartum anxiety, or post-traumatic stress disorder. PPP is a psychiatric emergency, tantamount to a medical emergency that requires immediate medical attention.

Prevalence

Postpartum psychosis affects 1-2 women per 1,000 births globally, and while rare, it is an extremely severe postpartum mood disorder (Kendell, Chalmers, & Platz, 1987; Munk-Olsen, Laursen, Pedersen, Mors, & Mortensen, 2006). Postpartum psychosis (PPP) occurs in all cultures, affecting mothers across socioeconomic, ethnic, and religious communities (Kumar, 1994).

Symptoms

Symptoms of postpartum psychosis are sudden in onset, usually occurring within 48 hours to 2 weeks following birth. Postpartum psychosis represents “psychiatric emergency and warrants hospitalization” (Beck & Driscoll, 2009, p. 47).

  • Waxing and waning delirium and amnesia (Spinelli, 2009)
  • “Cognitive Disorganization/Psychosis”
    • Wisner, Peindl, and Hanusa (1994) discovered that disturbances of sensory perceptions were a feature of the cognitive disruption experienced in postpartum psychosis. These include auditory, tactile, visual, and olfactory hallucinations.
    • Memory and cognitive impairment such as confusion and amnesia (Wisner et al., 1994).
    • Agitation, irritability
    • Paranoid delusions
    • Confusion
    • Bizarre and changing delusions
    • Suicidal or infanticidal intrusive thoughts with ego syntonic feature (Spinelli, 2009; Wisner et al., 1994)

In other perinatal mood or anxiety disorders, intrusive thoughts of self-harm or harming the baby are known as ego-dystonic and are common (41%-57%; Brandes, Soares, Cohen, 2004). Ego dystonic cognitions are thoughts experienced by the woman as abhorrent, and she recognizes that they inconsistent with her personality and fundamental beliefs (see: Kleiman & Wenzel, 2010 Dropping the Baby and Other Scary Thoughts).

In contrast, for a woman experiencing postpartum psychosis, the intrusive thoughts or ideations, of harming self or other are ego-syntonic—intrusive thoughts experienced as reasonable, appropriate and are “associated with psychotic beliefs and loss of reality testing, with a compulsion to act on them and without the ability to assess the consequences of their actions” (Spinelli, 2009, p. 405).

If left untreated, some dire potential outcomes include: 

  • 5% of women who experience PPP commit suicide (Appleby, Mortensen, & Faragher, 1998; Knopps, 1993).
  • 2%-4% are at risk of harming their infants (Knopps, 1993; Spinelli, 2004).
  • As high as a 90% recurrence rate (Kendell et al., 1987)

Risk Factors

  • Women with history of bipolar disorder or previous postpartum psychosis

“A personal history of bipolar disorder is the most significant risk factor for developing PP.” (Dorfman, Meisner, & Frank, 2012, p. 257)

  • Having a first-degree relative who has bipolar disorder, or experienced an episode of postpartum psychosis
  • Current research demonstrates that contrary to popular beliefs, PPP is often the result of either bipolar disorder or major depressive disorder with psychotic features, and there is little frequency of PPP caused by reactive psychosis or schizophrenia (McGorry & Connell, 1990).

Suggestions for Educators:

Reflect/Remind/Review/Refer

Given the stigma, misinformation and confusion regarding postpartum mental illness and particularly postpartum psychosis– it is important to clearly, and objectively identify and differentiate the full spectrum of perinatal mood and anxiety disorders. From the most prevalent and benign ‘baby blues’ to the most rare and severe postpartum psychosis, women and partners need accurate, accessible information to dispel myths, and give resources. See your education organization for their handouts, citations and referrals regarding PMADs in your curriculum.

Reflect back that you hear their concern. Repeat the question out loud so that others hear it. Chances are everyone in the room has a question around the topic of mental health, and as we know, 1 in 7 of the general population of childbearing women will develop a postpartum mood or anxiety disorder. Acknowledging the topic non-judgmentally by restating the question brings the topic into the room, reflects that you have heard the concerns expressed and not expressed, and that you are capable of holding the space for a quick, accurate review. 

Remind: PPP is Rare but Real

Remind class/clients that the incidence of PPP is extremely rare. Only 1-2 per 1,000 women develop postpartum psychosis. Secondly, with medical attention and treatment, PPP is preventable, and treatable. It is different than postpartum blues, depression, PTSD, or anxiety. Symptoms of PPP require immediate medical attention. 

Review the Facts

  • Rates: Only occurs in 1-2 per 1,000
  • Risk: Women with history of bipolar disorder or previous postpartum psychosis, and women with family history of bipolar disorder or first degree relative with history of postpartum psychosis are at higher risk.
  • PPP is preventable
  • PPP is treatable
  • PPP prevention and treatment require medical evaluation, intervention and care

Refer to Resources

What makes a good resource? Referring to accurate and accessible resources is an essential response to questions and concerns regarding postpartum psychosis (PPP).  Avoid any anecdotal advice regarding complimentary alternative medicine. The onset of PPP is tantamount to a medical emergency and requires immediate medical attention.

Have resources available in several formats and languages just as you would for other resources regarding childbirth education. Make sure your links, telephone numbers, and local resources are working and up to date.

Resources for Women and Partners Postpartum Progress

 Postpartum Psychosis Symptoms (in Plain Mama English)

Postpartum Support International 1-800-944-4PPD

 National Suicide Prevention Lifeline 1-800-273-TALK

Mother to Baby (formerly OTIS)

Medications & More During Pregnancy & Breastfeeding.

(866) 626-6847

Text-4-Baby Health Info Links

References

Appleby, L., Mortensen, P., & Faragher, E. (1998). Suicide and other causes of mortality after post-partum psychiatric admission. British Journal of Psychiatry, 173, 209-211.

Beck, C. & Driscoll, J. (2006). Postpartum mood and anxiety disorders: A clinician’s guide. Sudbury, MA: Jones and Bartlett.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi:10.191/1478088706qp063oa

Brockington, I. F., Cernik, K. F., Schofield, E.M., Downing, A.R., Francis, A.F., & Keelan, C. (1981). Puerperal psychosis: phenomena and diagnosis. Archives of General Psychiatry, 38, 829-833.

Dorfman, J., Meisner, R., & Frank, J.B. (2012). Prevention and diagnosis of postpartum psychosis. Psychiatric Annals, 42(7), 257-261. doi:10.3928/00485713-20120705-05.

Doucet, S., Letourneau, N., & Blackmore, E. R. (2012). Support needs of mothers who experience postpartum psychosis and their partners. Journal of Obstetric, Gynecological & Neonatal Nursing, 41(2), 236-245.

Healey, D. (2013). Melancholia: Past and present. Canadian Journal of Psychiatry, 58(4), 190-194.

Kendell, R., Chalmers, J., & Platz, C. (1987). Epidemiology of puerperal psychosis. British Journal of Psychiatry, 150, 662-673.

Knopps, G. (1993). Postpartum mood disorders: A startling contrast to the joy of birth. Postgraduate Medicine, 93, 103-116.

Kumar, R. (1994). Postnatal mental illness: A transcultural perspective. Social Psychiatry and Psychiatric Epidemiology, 29, 250-264. doi:10.1007/BF00802048

McGorry, P., & Connell, S. (1990). The nosology and prognosis of puerperal psychosis: A review. Comprehensive Psychiatry, 31, 519-534.

Munk-Olsen, T., Laursen, T., Pederson, C., Mors, O., & Mortensen, P. (2006). New parents and mental disorders: A population-based register study. Journal of the American Medical Association, 296(21), 2582-2589. doi:10.1001/jama.296.21.2582

Spinelli, M. (2004). Maternal infanticide associated with mental illness: Prevention and promise of saved lives. American Journal of Psychiatry, 161(9), 1548-1557.

 

Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Parenting an Infant, Perinatal Mood Disorders, Postpartum Depression, PTSD , , , , , , ,

Perception of Social Support and Increased Risk of PPD in Cities: Research Review

August 27th, 2013 by avatar

Today, regular Science & Sensibility contributor Walker Karraa shares a study that came out earlier this summer examining the incidence of postpartum depression and place of residence (rural vs urban.)  Women living in urban areas were more likely to suffer from PPD.  Are you surprised?  Why do you think that might be?  Take a look at the information Walker shares and join the conversation in the comments section.  If you work in an urban setting, are you doing everything you can to help mothers with this increased risk? Let us know. – Sharon Muza, Community Manager

______________________

A new Canadian study has examined the relationship between place of residence and risk of developing postpartum depression (PPD) based on population-based sample. Vigod, Tarasoff, Bryja, Dennis, Yudin, & Ross (2013) presented Relation between place of residence and postpartum depression in the early release at Canadian Medical Association. The study is a comprehensive and complex analysis of the statistical indicators related between where women live and the risk for developing postpartum depression (PPD.) For childbirth professionals who practice in urban settings, the findings here underscore the need for heightened awareness of the issues of support and awareness regarding maternal mental health in pregnancy and postpartum.

source: futurity.org

An overview of the study objectives, design, methods, and results has been compiled. Finally, a brief discussion as to the role of childbirth professionals is offered, and resources are provided.

Objectives

The objectives of this study were as follows:

  1. To compare the risk of PPD among Canadian women living in rural and urban areas
  2. To identify factors that could explain any associations between place of residence and risk of postpartum depression (Vigod, et al., 2013, p. 1)

Design

Sample: Women who had recently given birth and responded to the 2006 Canadian Maternity Experiences Survey through the Public Health Agency of Canada and the Canadian Perinatal Surveillance System were contacted. The study is a comprehensive and complex analysis of the statistical indicators related between where women live and the risk for developing PPD.

Stratified sampling by province or territory ensured sample size and a simple random sample without replacement was pulled from each stratum.  Inclusion consisted of women age over 15 who had singleton birth and were living with their child at the time of the interview. Response rate of 78% were collected via telephone and computer assisted interview resulting in 6421 of 8244 women contacted, representing 76, 500 Canadian women nationally. The final sample was 6126.

Outcome Measure: All women were administered the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, Sagovsky, 1987). Risk of PPD was operationalized as anyone with a score of < 13 points.

Definitions of populations. The authors defined the types of populations as follows:

  • Rural: populations outside the settlements of 1000 or more people or outside areas with a population density of 400 more inhabitants per square kilometer (p. 2)
  • Semi-rural: population <30,000
  • Semi-urban: population 30,000-499,999
  • Urban: > 500,000

Additionally, the authors implemented a metropolitan-influence component in defining and compartmentalizing different populations:

To separate the women with the most potential for social isolation from those with less potential for isolation, we further divided women living in rural and small town areas by ‘metropolitan-influenced zone’. These zones indicate the percentage of residents who commute to urban centers. The zones are designated as strong (> 30% residents commute to urban core), moderate (5%-29% commute), weak (> 0%, but <5%) or no (0%) metropolitan influence. (Vigod, et al., 2013, p. 2)

Methods

A thorough panel of covariates was administered to data analysis, including: age, parity, marital status, SES, educational status, and country of birth, recent immigration (within 5 years), and distance travelled to birth. In addition, history of depression, substance/alcohol use and life stressors such as interpersonal violence, abuse, and social support during pregnancy and postpartum period were factored.  Medical covariates of complications during perinatal period included preterm birth, birth weight, NICU, and cesarean section. All data were analyzed through SAS version 9.3.

Findings

We found that Canadian women who lived in large urban areas (i.e., population > 500,000 inhabitants) were at higher risk of postpartum depression than women living in other areas. The risk factors for postpartum depression (including history of depression, social support and immigration status) that were unequally distributed across geographic regions accounted for most of the variance in the rates of postpartum depression. (Vigod et al., 2013, p. 5)

The authors noted that immigration status, interpersonal violence, and self-perceived health and social support were responsible for the variance. For example, in the area of perceived social support in pregnancy and postpartum, the following findings were noted in the table below. 

 Conclusions

The authors noted that modifiable risk factors included social support in pregnancy and postpartum. Childbirth professionals working in cities can provide invaluable social connectivity and access to key resources targeting this issue.  Issues of dislocation, immigration status, and domestic violence are risk factors for higher incidence of PPD that need to be addressed in education, training and curriculum. Resources for domestic violence and legal advocacy have been provided.  Each professional can create ways to offer the material to students and clients that remains within a scope of practice as defined by their certifying organization, and that resonates with h/her personal style and community needs. Please feel free to add to the list of resources!

 Resources

Postpartum Support International (resources in Spanish as well)

Interpersonal violence resources

National Domestic Violence Hotline: Staffed 24 hours a day by trained counselors who can provide crisis assistance and information about shelters, legal advocacy, health care centers, and counseling.

1-800-799-SAFE (7233); 1-800-787-3224 (TDD)

Domestic Violence Fact Sheets

Domestic Violence State Hotlines

Learn more for your own continuing education at the Department of Justice Office of Violence Against Women.

References

Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British journal of psychiatry, 150(6), 782-786.

Vigod, S. N., Tarasoff, L. A., Bryja, B., Dennis, C. L., Yudin, M. H., & Ross, L.E. (2013).  Relation between place of residence and postpartum depression. Journal of Canadian Medical Association. doi:10.1503/cmaj.122028.

 

Childbirth Education, Guest Posts, Infant Attachment, Maternal Mental Health, Postpartum Depression, Research, Uncategorized , , , , , ,

Placentophagy: A Pop-Culture Phenomenon or an Evidence Based Practice?

June 11th, 2013 by avatar

© Robin Gray-Reed, RN, IBCLC
mindfulmidwife.com

“Do women really eat their placentas?” I am asked this question in every Lamaze class I teach. This question is often accompanied by a raised eyebrow and a giggle. Many times, at least one mother will sheepishly avert her eyes and mention that she’s thinking about doing it because she’s heard of the amazing benefits that can be achieved by consuming her placenta. Our class discussion commences with differing opinions, theories, vague and distorted facts and many grunts of “ugh, gross!” It then becomes my job as the childbirth educator to sort this out and offer my students evidence based information with regards to placentophagy.

There’s been quite a bit in the news this last week or so about placenta eating.  Recently, Kim Kardashian, on her show, “Keeping up with the Kardashians,” queried her doctor about consuming her placenta after birth. She wanted to know if he thought that by consuming it, it would help keep her looking younger – a veritable fountain of youth. Don’t you think it makes you look younger?” Kim asks her doctor during the episode. “Some people believe in that,” her doctor replies. “There are cookbooks on placentas.”

In 2012, Mad Men star, January Jones let it be known that she consumed her encapsulated placenta after her baby was born, per her doula’s suggestion.  ”Jones’s secret to staying high energy through the grueling shooting schedule? ‘I have a great doula who makes sure I’m eating well, with vitamins and teas, and with placenta capsulation.’ “

Hollywood seems to have picked up on the trend. Locally, in Pittsburgh, were I practice, there are at least three placenta encapsulation specialists and a few others who dabble in it. Talking to one recently, she mentioned that she was busy enough that she needed to bring in a partner to help her. It would appear that the trend is indeed on the rise.

Let’s take an in-depth look into the modern practice of placentophagy and the evidence behind it.

 How can placenta be consumed?

  • Eaten raw
  • Cooked in a stew or stir fry, or other recipes
  • Made into a tincture
  • Dehydrated and put into smoothies
  • Dehydrated and encapsulated in pill form

Most modern mothers will choose to encapsulate their placenta. Taking it in a pill form seems to be most palatable for many women interested in consuming their placenta. The placenta is washed, steamed (sometime with other ingredients such as jalapeño, ginger and lemon), sliced, dehydrated, pulverized and encapsulated. Within 24-48 hours after birth, the mother has her placenta back in pill form and will ingest a certain number of pills each day.

Why would a woman want to take placenta capsules?

There are many claims made about the benefits of consuming placenta. The list below is from Placenta Benefits.info

The baby’s placenta, contained in capsule form, is believed to:

  • contain the mother’s own natural hormones
  • be perfectly made for that mother
  • balance the mother’s system
  • replenish depleted iron
  • give the mother more energy
  • lessen bleeding postnatally
  • been shown to increase milk production
  • help the mother to have a happier postpartum period
  • hasten return of uterus to pre-pregnancy state
  • be helpful during menopause

This is a rather amazing list. It would appear that consuming placenta postpartum is a bit of a magic bullet. This, in and of itself, makes me wary of the claims. There are a number of oft cited studies to back these claims up. However, my research turns up only studies in animals, anthropological studies and a recent survey of mothers who consume placenta.

© Bjorna Hoen Photography
bjornahoen.com

Animal studies are good preliminary research and may provide indication for further study in humans. In and of themselves, they provide insufficient information to recommend placentophagy in human mothers.

Anthropological studies are a fascinating peek into human evolution, history and practice. They may provide clues as to why humans, as a rule, do not consume placenta. Or for those limited cultures that did/do consume it, the rationale behind doing so may be revealed. However, as with animal studies, anthropology alone does not give us cause to say that we should or should not be participating in placentophagy.

There is ongoing research out of Buffalo, NY by Mark Kristal, as well as from the University of Nevada, Las Vegas by Daniel Benyshek and Sharon Young on placentophagy. I look forward to their further contributions and hope their work provides impetus for additional hard science.

To date, there is not one double-blind placebo controlled study on human placentophagy.

Although advocates claim that these nutrients and hormones assumed to be present in both the prepared and unprepared forms of placenta are responsible for many benefits to postpartum mothers, exceedingly little research has been conducted to assess these claims and no systematic analysis has been performed to evaluate the experiences of women who engage in this behavior. (Selander et al. 2013)

 A note on Selander, et al: Jodi Selander is the owner of Placenta Benefits LTD. Her financial conflict of interest is noted in the survey.

What we have is anecdotal evidence from mothers who have consumed placenta (Selander 2013). Care providers who witness the effects of placentophagy in the mothers have been noted as well. There are a number of studies in animals, both with regards to behavioral and, chemical and nutritional benefits.  There are a number of anthropological studies, as well as a recent survey (Selander 2013).

What we truly lack is a double-blind, placebo controlled human study of the affects of placentophagy.

“While women in our sample reported various effects which were attributed to placentophagy, the basis of those subjective experiences and the mechanisms by which those reported effects occur are currently unknown. Future research focusing on the analysis of placental tissue is needed in order to identify and quantify any potentially harmful or beneficial substances contained in human placenta… ultimately, a more comprehensive understanding of maternal physiological responses to placentophagy and its effects on maternal mood must await studies employing a placebo-controlled double blind clinical trial research design.” (Selander 2013)

 This leaves us with a few unanswered questions. 

  1. Is the benefit we see in the human mother after consuming placenta because she has consumed it, or is this placebo effect?
  2. Are their benefits or risks to consuming amniotic fluid after birth?
  3. If there is no biological imperative for human mothers to consume placenta, is there a reason for that? Is this a reason suggesting harm from eating placenta, a social norm, or something larger with regards to our need for bonding with our community of women during and after birth?

“This need for greater sociality during delivery then, in combination with the consequent pressure to conform to cultural norms, led to a strengthening of socials bonds and a reduction in the likelihood of placentophagia.” (Kristal 2012)

Coming full circle; how do we approach the topic of placentophagy in our Lamaze classes? Keep it simple. As of today, consuming placenta is not an evidence-based practice. Therefore, we cannot directly recommend it to our students.

However, to support our students’ autonomny, I believe a mother should be able to take her placenta home and do with it as she will. If your students wish to engage in this practice, I’d encourage them to speak to their care providers prenatally, to ensure safe handling of the placenta and to set appropriate expectations at birth.

References:

Kristal, M. B. (1980). Placentophagia: A biobehavioral enigma (or< i> De gustibus non disputandum est</i>). Neuroscience & Biobehavioral Reviews,4(2), 141-150.

Kristal, M. B., DiPirro, J. M., & Thompson, A. C. (2012). Placentophagia in humans and nonhuman mammals: Causes and consequences. Ecology of Food and Nutrition51(3), 177-197.

Selander, J. (2013), Placenta Benefits, placentabenefits.info. Retrieved June 09, 2013, from http://placentabenefits.info/index.asp.

Selander, J., Cantor, A., Young, S. M., & Benyshek, D. C. (2013). Human Maternal Placentophagy: A Survey of Self-Reported Motivations and Experiences Associated with Placenta Consumption. Ecology of food and nutrition52(2), 93-115.

Soykova-Pachnerova E, et. al. (1954)  “Placenta as Lactagagen” Gynaecologia 138(6):617-627

Young, S. M., Benyshek, D. C., & Lienard, P. (2012). The conspicuous absence of placenta consumption in human postpartum females: The fire hypothesis. Ecology of Food and Nutrition51(3), 198-217.

 

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Uncategorized , , , , , , ,