A Deeper Shade of Blue

Several recent studies have suggested that new fathers, not only mothers, can suffer from postpartum depression.  Fewer men are affected than women (about 3-5%), but it turns out that paternal depression can also have negative effects on the child. 

Good Morning America will be doing a story on male postpartum depression and is looking for men who are willing to talk on-camera about their struggle with depression after the birth of a child.

Some studies have suggested that in some cultures, where sons are more highly valued, women who give birth to daughters are more vulnerable to postpartum depression; however, a recent French study has reported that women who give birth to sons are more likely to suffer postpartum depression than those having daughters.

The study also found that women who had given birth to a son reported overall lower quality of life, regardless of whether they suffered from postpartum depression. In women who did not have depression, mothers of sons had lower quality of life scores in nine out of the 10 categories, including physical functioning, pain, emotional health, vitality and general health.

Why are the mothers of sons more vulnerable? The reasons are probably complex, but there are several theories:

The study, published in the February issue of Journal of Clinical Nursing, says psychoanalytical theories suggest a mother’s attitude towards her son may be shaped by her relationship with present and past male figures.

There was also the possibility that male babies are seen by presentday mothers as “more difficult”.

“Depressed mothers who are often in difficult marital relationships may respond more negatively to their sons,” the report says.

“This requires further research so as to better apprehend the ways in which the birth of a boy can have - on average - a more damaging effect on the mother’s quality of life than the birth of a girl.”

de Tychey C, Briançon S, Lighezzolo J, et al. Quality of life, post- natal depression and baby gender. J Clin Nurs. 2008; 17(3):312-322.

Although pregnancy has often been concerned a time of emotional well-being, several recent studies have indicated that women are vulnerable to depression during pregnancy. Analyzing data from the Kaiser Permanente Northwest HMO, researchers assessed the prevalence of depression before, during, and after pregnancy in a group of 4,398 women with pregnancies ending in a live birth. Women identified as being depressed were those with an ICD-9-CM diagnosis indicated in the medical record or those who received at least one prescription for an antidepressant medication. Depression treatment was defined as receiving antidepressant medication and/or attending at least one mental health visit.

This study indicated that about one in seven women was identified as being depressed in the period spanning 39 weeks prior to pregnancy to 39 weeks after pregnancy.

Among the 4,398 women assessed, 678 (15.4%) were depressed during at least one period; 8.7%, 6.9%, and 10.4% had depression diagnoses before, during, and/or after pregnancy, respectively.

Of the women who were identified as having depression during the 39 weeks before pregnancy, over half (56.4%) of those women also suffered from depression during pregnancy.

Of the women with a diagnosis of depression during the postpartum period, 54.2% were also identified as depressed either before or during pregnancy.

This study is consistent with previous reports, indicating a high prevalence of depressive disorders among child-bearing women. However, this type of study may actually underestimate the prevalence of depression. Previous studies have indicated that during pregnancy women are often reluctant to report depressive symptoms and that depression is often overlooked when stringent screening protocols are not employed. In a recent study using the Center for Epidemiological Studies-Depression scale (CES-D) to screen for depression, Drs. Heather Flynn and Sheila Marcus at the University of Michigan, observed higher rates of depression (about 20%) among pregnant women.

The authors stated that 93% of the women with depression received treatment. At face value, this finding is encouraging but unfortunately may be somewhat misleading, as “receiving treatment” in this study is defined as having at least one mental health visit or filling at least one prescription for an antidepressant. Whether these women received adequate treatment is not clear. In the previously mentioned study, overall rates of depression treatment were very low (about 20%) among pregnant women. Furthermore, this study indicated that when treatment was delivered, it was often inadequate. For example, only 43% of those taking antidepressant medications received adequate treatment - antidepressant used at the recommended dose for at least six weeks.

The study highlights the importance of screening women for mood disorders before and during pregnancy, indicating the depression before pregnancy is a significant risk factor for depression during pregnancy. Similarly, depression during pregnancy is a robust predictor of postpartum depression. By indentifying these women at risk for mood disorders early on, it may be possible to use interventions that limit the risk of depression either during pregnancy or after delivery.

According to multiple studies, it is estimated that about 10% to 15% of women suffer from depression during pregnancy. Given the concerns regarding the use of medications during pregnancy and the incomplete information regarding the reproductive safety of certain antidepressants, there is a need for effective non-pharmacologic options for the treatment of depression during pregnancy.

Bright light therapy may be an attractive option, and in a preliminary study it was shown to be effective for women suffering from depression during pregnancy. In this pilot study, 16 pregnant women with major depression received treatment with morning light therapy. After 3 weeks, mean depression ratings on the Hamilton Depression Rating Scale improved by 49%, with half of the women experiencing a complete remission.

Researchers at Yale University and the University of Pittsburgh are now conducting a clinical trial in order to better evaluate the effectiveness of light therapy for women suffering from depression during pregnancy.

The New York Times recently had a very helpful article on the use of light therapy for those who suffer from seasonal depression. Some important points:

• The incidence of seasonal affective disorder (SAD) rises with increasing latitude, ranging from 1.4 percent among the residents of Florida to as high as 9.7 percent among those who live in New Hampshire.

• January and February are the worst months for people with SAD.

• Many patients get good results from only half an hour of light therapy each day.

• Full spectrum light is not necessary; ordinary fluorescent light bulbs with an intensity of 10,000 lux (about 10 to 20 times as bright as ordinary indoor light) are effective.

This article also includes information on where to get a good light box.

First Thursday is a program from MedEdPPD.org. On the first Thursday of every month, registered users can participate in live teleconferences on various PPD topics and have the opportunity to address their questions to PPD experts like Katherine Wisner and Margaret Spinelli.

In addition, downloadable PowerPoint slides for each teleconference will be available in advance. After the teleconference is completed, the recording will be archived on the site.

On February 7, 2008, Dr. Margaret Spinelli will be talking about “Postpartum Psychosis and Infanticide”.

Here are the topics of some previous teleconferences:

• Bipolar Disorder: Pharmacology During Pregnancy and Breastfeeding (Katherine L. Wisner, MD, MS)
• SSRIs and Pregnancy (Shari Lusskin, MD)
• Appropriate Screening Techniques for PPD (Linda H. Chaudron, MD, MS)
• Postpartum Psychosis (Katherine L. Wisner, MD, MS)

After delivery, women experience a dramatic drop in estrogen hormone levels. Many have hypothesized that this decline in estrogen levels may precipitate postpartum depression (PPD) in susceptible individuals, and several studies have explored the use of estrogen for the treatment of depression after delivery.

In a double blind, placebo-controlled study including 61 women with PPD, Gregoire and colleagues demonstrated that transdermal estrogen therapy may be beneficial. Although this study was small and was confounded by the inclusion of patients who were simultaneously treated with antidepressant medications, it is the first to demonstrate that estrogen alone or when used in conjunction with an antidepressant may be useful in women with PPD.

More recently, Ahokas and colleagues have shown that estrogen was effective in women with PPD who had low estrogen levels. In this open trial, 23 women with PPD were treated with sulingual estradiol. Within two weeks of treatment, 19 of the 23 women experienced a remission of their depressive symptoms. It is unclear if these findings can be generalized to all women with PPD, as most of the women had very low estrogen levels. (In 16 of the 23 participants, estrogen concentrations were even lower than the threshold value for gonadal failure.)

Although these studies suggest a role for estrogen in the treatment of women with postpartum depression, hormonal treatments remain experimental. Estrogen delivered in the acute postpartum period is not without risk and has been associated with changes in breast milk production, as well as an increased risk of significant thrombo-embolic events, including stroke and deep vein thrombosis.

Antidepressants are safe, well tolerated and highly effective and remain the first choice for women with PPD. Estrogen augmentation is typically reserved for cases where there is evidence of estrogen deficiency or when the depression appears particularly refractory to treatment.

Gregoire AJP, Kumar R, Everitt B, et al. Transdermal oestrogen for treatment of severe postnatal depression. Lancet 1996; 347: 930-933.

Ahokas A. Kaukoranta J. Wahlbeck K. Aito M. Estrogen deficiency in severe postpartum depression: successful treatment with sublingual physiologic 17beta-estradiol: a preliminary study. Journal of Clinical Psychiatry 2001; 62: 332-336.

BlogHer, Postpartum Support International (PSI), and Postpartum Progress are joining forces and asking that you take action to help the MOTHERS Act advance to the Senate floor with the support of as many Senators as possible.

What is the MOTHERS Act?

The Moms Opportunity to Access Help, Education, Research and Support for Postpartum Depression Act, or MOTHERS Act (S. 3529), will ensure that new mothers and their families are educated about postpartum depression, screened for symptoms and provided with essential services. In addition, it will increase research into the causes, diagnoses and treatments for postpartum depression. The legislation is sponsored by U.S. Senators Robert Menendez, D-N.J., and Richard Durbin D-Ill.

Specifically, the MOTHERS Act will help new mothers by:

Providing important education and screening on postpartum depression (PPD) that can lead to early identification and treatment. The legislation includes two grants to help better educate healthcare providers to identify and treat PPD.

Expanding important research to improve and discover new treatments, diagnostic tools and educational materials for PPD. Since the exact cause of PPD isn’t known, research continues to be the key to unlocking the mystery of this condition.

What can you do?

Most Senators rarely hear from mothers (and others!), and phone calls from you, your family members, and your friends will cause them to take notice of this important issue.

If you would like to see this legislation passed,call your Senators today to voice your support for the MOTHERS Act. Writing or sending emails has much less impact. Postpartum Support International has a list of Senators’ phone numbers and a suggested script for those of us who are not quite sure what to say. If your Senator is already a co-sponsor of the bill, PSI recommends that you call anyway to express your thanks. With your support, the MOTHERS Act can become a reality.

Why do you have to contact your senator?

All new mothers are at risk for postpartum depression. This is a serious and disabling condition that affects about 15 percent of new mothers. If you do the math, that’s about 800,000 American women each year that suffer from PPD. Yet most of those women never receive any type of treatment or support. And this is a tragedy that we cannot afford.

Because of the central role a mother occupies within the family, her depression may have a significant impact on her children and others who are close to her. One study after another has demonstrated that depression in the mother may lead to a constellation of problems in her child: sleep and feeding problems, developmental delays, and other behavioral problems.

A Deeper Shade of Blue is now out in paperback. Here are some of the latest reviews:

“Timely and critical. A lot has been written about postpartum depression but very little about depression as it pertains to the entire spectrum of childbearing, and rearing, and Dr. Nonacs has done a fantastic job of illuminating and elucidating this condition in prose that is at once authorial and empathic. I am thankful for her book in particular and her work in general.” — Lauren Slater, author of Prozac Diary

“This book is unique because it discusses depression within the context of women’s health needs, but it will be useful for anyone seeking in-depth information about the disease. Highly recommended….” –Library Journal

Available through Amazon and many other online retailers.

Depression is common during pregnancy, affecting 10% to 15% of women.  While psychotherapy is an attractive option for the treatment of depression during pregnancy, all women do not respond to this intervention and many require pharmacotherapy.  Thus far, no antidepressants have yet been approved by the FDA for use during pregnancy. Although data accumulated over the past 30 years suggest that certain medications, including the serotonin reuptake inhibitors (SSRIs), may be used safely during pregnancy, several new studies have raised concerns regarding the use of these medications during pregnancy.   

A recent article published in the Psychiatric Times reviews the risks of antidepressant use in pregnant women. 

In choosing an antidepressant for use during pregnancy, the clinician should attempt to select a medication that has a well-characterized reproductive safety profile. Fluoxetine, with the most extensive literature supporting its reproductive safety, is a first-line choice. There is growing literature on the reproductive safety of the newer SSRIs. Although SSRIs are the antidepressants most commonly used in this setting, there are data that support the use of tricyclic antidepressants (TCAs). While several studies outlined here suggest that there may be a small increase in the risk of certain malformations, it is felt that the absolute risk is low and that treatment is warranted when the risks of depression are thought to outweigh the risks associated with drug exposure.

In a recent editorial, Michael F. Greene, MD, of the division of maternal and fetal medicine at Massachusetts General Hospital in Boston, noted that these newer—and often conflicting—studies clearly have made it more difficult to make decisions regarding the treatment of depression during pregnancy. He noted further that “patients and physicians alike would prefer it if there were clear lines separating risk and no risk and if all studies gave consistent results pointing in the same direction.”  While these more recent reports have raised concerns, the data, taken as a whole, are reassuring and indicate that the risks associated with SSRI exposure during pregnancy are low.