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Childhood Sexual Abuse as a Risk Factor for Postpartum Depression- Part 2: The Educator’s Role

June 5th, 2014 by avatar
© CC Smoochi: http://flickr.com/photos/smadars/4758708634

© CC Smoochi: http://flickr.com/photos/smadars/4758708634

Kathy Morelli, perinatal mental health expert and S&S contributor is sharing information about the impact of childhood sexual abuse on women during the childbearing year.  Tuesday, in Part 1,  Kathy discussed the brain changes that can occur as a result of such abuse and today, Kathy shares the impact during the childbearing year and the role of the childbirth educator.  - Sharon Muza, Community Manager, Science & Sensibility

How do these underlying biological changes affect a woman during the childbearing year?

Childhood sexual abuse (CSA) and a woman’s subsequent reproductive life, including menstruation, pregnancy, birth and ongoing sexuality, occur at different times, maybe even in different decades, in a woman’s life. Yet, in clinical practice and in the research, these issues are intertwined.

In general, the research indicates that women who experienced childhood sexual abuse have more emotional distress in pregnancy, which directly impacts their physical health, which then impacts their pregnancy and leads to more medical interventions (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009).

The somatic, body-based feelings in pregnancy can be re-triggering to a woman who has deep, non-verbal somatic memories of childhood sexual abuse. It’s important that women receive sensitive reproductive care, both physically and emotionally. An unaccepting attitude from her healthcare providers can trigger deeply held feelings of helplessness, fear, low self-worth and shame and actual flashbacks, symptoms of post-traumatic stress disorder (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009).

The obvious sexual themes resonate on multiple levels: body-based, emotional and psychological. Yet, there hasn’t been lot of research about how a history of childhood sexual abuse impacts a woman’s mental health during pregnancy and postpartum. However, what research exists, finds that women who suffered from childhood sexual abuse have an elevated risk of postpartum depression (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009).

There are a lot of body-based feelings in pregnancy that could be re-triggering to a woman who has deep, non-verbal somatic memories of childhood sexual abuse, even if she is being treated with respect and kindness in the present day.

Pregnancy

Prenatally, simple things such as the position of a woman’s body as she lays on her to be checked vaginally can bring back non-verbal emotional memories of past abuse. The baby moving inside her body might cause intense joy, but might also create an underlying, non-verbal uneasiness.

Birth

Childbirth is an intense experience; a time of hormonal, physical and emotional exertion. Due to the pre-existing priming of early trauma memory networks – an intense distressful emotion, a particular scent, or a body position – can trigger flashbacks to earlier traumatic experiences. Feeling powerless, not heard, or disregarded by healthcare providers during childbirth, can activate the symptoms of post-traumatic stress disorder. Her present day feelings of powerlessness and fear are amplified by pre-existing traumatic memories (Beck, Driscoll & Watson, 2013).

Remember the disregard by the medical professionals may just be due to the rush of the medical team as they attend professionally to a medical emergency. The medical protocol doesn’t have a person assigned to talking and listening to the mother during the event, so she feels disregarded (Beck, Driscoll & Watson, 2013).

However, even if she is being treated in a kind way, your client’s body positioning or a scent can recollect something from her past trauma. In an uncanny and timeless way, her body and mind remember the past and take her back to feelings of fear and helplessness. She may wordlessly freeze or panic, for what seems to be no present day reason.

Postpartum

Postpartum, there are physical, emotional and psychological factors feeding emotional health. As has been noted over and over again, a pre-existing personal depressive or anxiety disorder (PTSD is in the spectrum of anxiety disorders) will set up the body up for another episode postpartum. Drs. Deborah Sichel and Jeanne Driscoll (2000) say the brain chemistry “remembers” its previous old depressive pathway and finds its way back there. Plus, there’s a major swing in hormonal activity in your body as you adjust from high levels of pregnancy and birth hormones to pre-pregnancy levels. This adjustment is different for all women, depending on whether or not they are breastfeeding and on their individual differences in metabolism and individual sensitivity level to their own hormonal shifts (Sichel and Driscoll, 2000).

For new parents who grew up in an abusive home, there’s the added challenge of the emotional and psychological work required to examine and modify negative repetitive childhood patterns. It’s not an easy task for your client as she evaluates her past behavioral, emotional and psychological patterns and replaces them with new and more positive patterns about family life and parenting. This adds another level of complexity to parenting a newborn, itself a major lifestyle adjustment.

Adjusting to a new lifestyle with an infant and baby care is physically and emotionally challenging. Feelings of frustration emerge as your client adjusts her schedule yet again to accommodate her baby plus the endless touching and carrying may leave her feeling like her body isn’t her own anymore. Breastfeeding may feel triggering to some women if it invokes past experiences.

A Childbirth Educator Can Help

Childbirth educators can play a key role in helping a woman who has survived childhood sexual abuse to proactively manager her experience of pregnancy, birth and postpartum.The good news is that, even with all these challenges, it’s important to realize that your client’s childhood sexual abusive does NOT define her. There are many aspects of the self that compose her constellation of self-definition.

The human mind and body are plastic, so the past isn’t destiny. Remember to factor in the resiliency of human nature. With patience and perseverance, human beings can move beyond survivorship, learn to bloom and move into the “thriving” phase.

However, learning to thrive is not an easy task. There are no “five steps” here! Managing the effects of an abusive childhood is an ongoing, deeply personal experience. It’s honorable life work, and highly individualized. As your client moves along her healing path, she’ll choose what feels right for her.

She can work positively on herself and experience post-traumatic growth. Post-traumatic growth is inner growth through personal development. It’s possible for her to experience this growth arising from her painful experience, with her own inner work.

Below are some positive ideas you may want to keep in mind as you teach your childbirth education curriculum to a diverse set of families. Your raised consciousness will help create an inclusive space for women survivors CSA to enhance her experience of pregnancy, birth and postpartum.

Be sensitive to the emotional aspects of working with someone recovering from CSA.

Help her honor the importance of pregnancy, childbirth and motherhood

  • Encourage women to honor their experience of childbirth as the important developmental life passage it is. CSA survivors may tend to dissociate and dismiss their experiences
  • Encourage women to interview some providers. Have a list of referrals of gynecologists/obstetricians/midwives that you know are open to and sensitive to working with women recovering from CSA
  • Encourage women to give themselves the respect of investigating the hospital or birth center where her provider practices
  • Allow women to have the freedom to have a personally honorable birth experience, in any manner that birth happens
  • Allow women to feel that they are not less of a woman or a mother, however the birth experience happens. Each woman gets to choose her path in childbirth. Not other people or the unseen, but felt, social pressures.
  • People heal individually at their own pace.
  • Don’t pressure women to use her childbirth experience as a healing ritual. Childbirth is a life-changing experience, and each woman gets to choose how to experience this. If she wants to explore the idea of birth as healing, encourage her to be open to many options. But birth is unpredictable, don’t put this out there as the only way to define healing. There are many paths to healing.
  • Help her by doing what you’re best at: demystify childbirth while accepting her choices. Don’t impose your personal agenda about what is right and wrong for her birth experience
  • If she has alot of anxiety about childbirth, honor her by encouraging her to put in the emotional work with a mental health professional. Childbirth education, while important, may not be enough to manage anxiety, depression and post-traumatic stress symptoms. Prenatal fear of childbirth increases the likelihood of postpartum depression.
  • Encourage her to develop a daily, holistic relaxation practice to counteract the effects of stress imbalance

Discuss postpartum planning in your curriculum

  • Have a babymoon/postpartum plan in place
  • Encourage women to practice self-love by allowing time to rest
  • Encourage women to gentle with themselves – pregnancy and childbirth puts body and mind through a lot of hormonal changes!
  • Educate her about hormonal changes. Hormonal balance takes at least three months to come back to pre-pregnancy levels. The hormonal adjustments are individualized; it also depends on if the mother is breastfeeding or not.
  • Educate women to protect her fourth trimester, and help her body shift to-wards balance:
    • Rest; develop the mindset of being, not doing
    • Practice good nutrition with whole foods and good supplements
    • Get help: If she can afford it, time with a postpartum doula or a baby nurse will help her achieve balance and rest
    • Don’t underestimate the power of sleep; discuss sleep planning
    • Practice mindfulness and relaxation to counteract the inevitable chal-lenges of caring for a new born and the emotional change of identity in motherhood
  • Complementary care is nurturing, safe touch helps rebalance the body and mind
  • Social support is important. Have resources available. Women who “Tend and Befriend” in real life and online help mothers feel supported, Women and birth circles are important resources.
  • Expect emotional ups and downs
  • De-stigmatize professional help; there’s a lot of professional help available. If she feels very sad or anxious, it’s ok to seek help.

As a childbirth professional, you can positively affect your clients and their families. Know that childhood sexual abuse,  though prevalent, doesn’t define people, they can work through it to experience positive personal growth, through resilience and post-traumatic growth.

References

Beck, C. Driscoll, J., and S. Watson (2013). Traumatic childbirth. New York: Routledge Press.

Lev-Weisel, R., Daphna- Tekoah, S., Hallak, M. (2009). Childhood sexual abuse as a predictor of birth-related posttraumatic stress and postpartum posttraumatic stress. Child Abuse and Neglect, 33, 877-887.
Perez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S. & Blanco, C., (2013). Prevalence and correlates of child sexual abuse: a national study. Comprehensive Psychiatry, 5(1), 16-27. http://www.ncbi.nlm.nih.gov/pubmed/22854279

Plaza, A., Garcia-Estave, L., Ascaso, C., Navarro, P, et al. (2010). Childhood sex-ual abuse and hypothalamus-pituitary-thyroid axis in postpartum major depression. Journal of Affective Disorders, 122, 159-163.

Sichel, D. & Driscoll, J. (2000).Women’s Moods. New York: Harper Paperbacka.

Yampolsky, L., Lev-Wiesel, R., & Ben-Zion, I. Z. (2010). Child sexual abuse: is it a risk factor for pregnancy?. Journal of Advanced Nursing, 66(9), 2025-2037. doi:10.1111/j.1365-2648.2010.05387.x

Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression , , , , , , , ,

Childhood Sexual Abuse as a Risk Factor for Postpartum Depression – Part 1

June 3rd, 2014 by avatar

Childhood sexual abuse can play a key role as a risk factor for postpartum depression.  Kathy Morelli takes a look at the impact of this horrible childhood event on a woman during her childbearing year.  Today, in Part 1 – we learn how the brain actually undergoes changes as a result of the trauma experienced.  On Thursday, Kathy Morelli will discuss how the woman who has experienced childhood sexual abuse (CSA) and what affect that has on her during the childbearing year,(pregnancy, birth and postpartum)  along with information and tips  for what childbirth educators can do.  Join us on Thursday for Childhood Sexual Abuse as a Risk Factor for Postpartum Depression – Part 2. – Sharon Muza, Community Manager, Science & Sensibility.

© CC Michelle Brea: http://flickr.com/photos/itsallaboutmich/451493421

© CC Michelle Brea: http://flickr.com/photos/itsallaboutmich/451493421

Woman to Woman Support

As I’ve said in my previous articles about Perinatal Mental Health, Lamaze childbirth professionals are very often the first point of contact for pregnant and new mothers. You’re an important resource in your community about pregnancy and childbirth, so becoming educated about the signs of perinatal mood/anxiety disorders and having an awareness about the prevalence of childhood sexual abuse (12% -20% of women) is an important aspect of your knowledge base. This article is meant to:

  • Increase awareness about the emotional aspects of surviving childhood sexual abuse (CSA)
  • Present a broad overview about the research regarding CSA
  • Present how CSA impacts a woman holistically, over her lifespan
  • Present how CSA impacts a woman specifically during childbearing
  • Discuss the complex recovery process from CSA
  • Generate ideas about whom to add to your community resource and referral list
  • Encourage being effective and supportive while preserving your own personal, certification and/or licensure boundaries

Remember, you may be the first person with whom she feels safe enough to discuss her personal history, even before her healthcare provider and sometimes even before her family. You can help out by being positively aware, being appropriately supportive and providing a list of contacts in the community and online.

Holistic View of a Woman’s Emotional History

Whenever a woman comes into my office for help for feelings of emotional and somatic distress during her pregnancy, childbirth experience and postpartum, I look at her life holistically, across her lifespan. I don’t assume, but I wonder, if she might be in that estimated 12% – 20% of women who have been sexually abused in their lifetime.

Is there a likelihood that past abuse affects how a woman feels about herself during pregnancy and childbirth and can be an underlying causative factor for antenatal depression or anxiety?

The research literature about the link between a woman’s past childhood sexual abuse and distress during pregnancy is scarce, but emergent research does show a connection.

How does a history of childhood sexual abuse (CSA) intersect with postpartum depression? This is a complicated question, but I’ll try to list some influential factors.

The HPA Axis is Modified: Fear and panic of CSA alters internal stress response

In general, research shows us that people who suffered from childhood sexual abuse (CSA) have a higher incidence of emotional, psychological and social distress, in addition to post-traumatic and physical, or somatic, symptoms. Specifically, research shows us that adult survivors of CSA suffer from higher rates of diabetes and cardiovascular symptoms (Plaza et al, 2010).

Women who have suffered past childhood sexual abuse suffer more unexplained gynecological symptoms, such as recurrent pelvic pain and more painful periods and sexual dysfunction than women who don’t have a traumatic sexual history (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009). The stress and fear from childhood abuse manifests later on in adult life on all levels: body, mind and spirit.

What are some of the physical processes underlying this distress on the body and mind levels?

Researchers believe that long-term negative emotions, such as fear, panic and pain, cause an over-activation of the neural pathways in the brain associated with these strong emotions. The internal production of neurotransmitters, which affect mood, is affected. So chronic emotional stress impacts brain health.

The brain communicates with the pituitary and adrenal glands via the feedback loop called the Hypothalamus-Pituitary-Adrenal Cortex Axis (HPA Axis). The pituitary and adrenal glands are responsible for hormone production, which, in turn, affects the brain and our emotional state (Plaza et al, 2010).

During long-term childhood sexual abuse, the HPA Axis is continually activated and, with overactivation, the stress response becomes chronic, persisting throughout a lifetime. Thus, the chronic over-activation of the fear and pain response underlies anxiety disorders and chronic pain syndromes across the lifespan (Plaza et al, 2010).

During pregnancy and postpartum, hormonal changes are very dramatic, so there’s an additional adjustment for the mind and body to cope with. Thus, the hormonal changes during pregnancy also impact brain health via the pituitary and adrenal glands feedback loop.

Brain Development is Modified: Fear and panic of CSA can inhibit encoding of memories

Research shows that chronic fear and stress in childhood can actually inhibit the growth of some brain structures. In fact, some parts of the brain, such as the hippocampus, which is in charge of memory, are smaller in CSA survivors than people who were not abused in childhood. So, recollection of childhood memories is impaired.

In addition, brain imaging shows brain development is hindered in that there are less robust connections between the emotional part of the brain and the upper part of the brain (Plaza et al, 2010).

How do these underlying biological changes affect a person’s emotional health?

Survivors of childhood sexual abuse survivors are known to suffer from post-traumatic stress disorder, which has a constellation of symptoms on many levels: depression, anxiety, panic attacks, somatic pain, flashbacks and dissociative episodes.

Events that occured long ago in a woman’s life can still play a large role in her mental and physical health when she is pregnant, birthing and in the postpartum period. Join us on Thursday for Childhood Sexual Abuse as a Risk Factor for Postpartum Depression- Part 2: The Childbirth Educator’s Role.- SM

References

Beck, C. Driscoll, J., and S. Watson (2013). Traumatic childbirth. New York: Routledge Press.

Lev-Weisel, R., Daphna- Tekoah, S., Hallak, M. (2009). Childhood sexual abuse as a predictor of birth-related posttraumatic stress and postpartum posttraumatic stress. Child Abuse and Neglect, 33, 877-887.
Perez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S. & Blanco, C., (2013). Prevalence and correlates of child sexual abuse: a national study. Comprehensive Psychiatry, 5(1), 16-27. http://www.ncbi.nlm.nih.gov/pubmed/22854279

Plaza, A., Garcia-Estave, L., Ascaso, C., Navarro, P, et al. (2010). Childhood sex-ual abuse and hypothalamus-pituitary-thyroid axis in postpartum major depression. Journal of Affective Disorders, 122, 159-163.

Sichel, D. & Driscoll, J. (2000).Women’s Moods. New York: Harper Paperbacka.

Yampolsky, L., Lev-Wiesel, R., & Ben-Zion, I. Z. (2010). Child sexual abuse: is it a risk factor for pregnancy?. Journal of Advanced Nursing, 66(9), 2025-2037. doi:10.1111/j.1365-2648.2010.05387.x

Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Uncategorized , , , , , , ,

Every Day Should Be Maternal Mental Health Awareness Day! What Educators Need To Know!

May 27th, 2014 by avatar

Friday_may_campaignMay is Maternal Mental Health Awareness month, when agencies on the local, state and federal level along with private and public organizations promote campaigns designed to increase awareness of perinatal mood disorders.   While it is good to increase awareness of the symptoms, sources of help, treatment options and impact of perinatal mood disorders on parents, families and communities during the month of May, the focus really needs to be 365 days a year!  Over 4 million babies are born every year in the USA.  Pregnancy and birth happen every single day to women and families.  Perinatal mood disorders affect women and their families every single day!

Recently, the tragic death of three young children in Torrence, CA was in the news and the children’s mother was arrested on suspicion of murdering her three daughters.  While many details have yet to be made public, this was a new mother  whose youngest child was just two months old.  This woman may have been experiencing a crisis as a result of a postpartum mood or anxiety disorder (PPMAD).

Take this quick ten question quiz and test your knowledge of perinatal mood disorders.  Then read on to find out more and what you can do to help the families that you work with.

While PPMAD can affect a mother during pregnancy or the first year postpartum, there are some risk factors that may increase the likelihood of a woman experiencing this complication:

The above list is from the resource: Postpartum Progress

There is a wonderful three minute video from the 2020 Mom Project that explains more about why so many women are not receiving the help they need. This video was released by the National Coalition for Maternal Mental Health. We do not have the infrastructure in place that screens every woman or enough skilled providers who can recognize the symptoms and provide or refer to suitable treatment options.

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?

Childbirth educators and others who work with women during the childbearing year have a responsibility to discuss, share, educate and provide resources to all the families they work with.  Ignorance is not bliss, and the more we discuss the symptoms, risk factors and resources that are available to help families in need with those we have contact with, the fewer women will suffer in silence and go without the help they need.

Resources for Women and PartnersPostpartum 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

How do you talk about perinatal mood and anxiety disorders in your classes?  What activities do you do to convey this information effectively?  Do you bring up this topic again at the childbirth class reunions you attend?  Can you share what works well for you so that we can all learn?  What have your experiences been in helping women and their partners to be knowledgeable and informed? What do you do to be sure that every day is Maternal Mental Health Awareness Day?

 

Babies, Birth Trauma, Breastfeeding, Childbirth Education, Depression, Infant Attachment, Maternal Mental Health, Paternal Postnatal Depression, Perinatal Mood Disorders, 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 , , , , , , , ,