# Medication or Therapy?

In a very insightful piece at the NY Times in the Well section, “To Treat Depression, Drugs or Therapy“,  Dr. Richard Friedman, M.D., explores recent research which examined the manner in which people respond to either medication, therapy, or both.

It’s a question we hear a lot as we support women fighting their way through a Perinatal Mood & Anxiety Disorder. The concern is valid, for a variety of reasons. Breastfeeding mothers worry about what the medicine will do to their children. All mothers worry about the stigma about being on a medication. Therapy provides its own challenges with childcare and financial being the two primary ones.

So how do you choose? Why is it that what works for one doesn’t work for another?

Turns out, according to the research Dr. Friedman examined, it comes down to our brains. The research, led by Dr. Helen Mayburg of Emory University, holds great potential for successful treatment of those of us who struggle with mental health issues.

“Dr. Helen Mayberg, a professor of psychiatry at Emory University, recently published a study in JAMA Psychiatry that identified a potential biomarker in the brain that could predict whether a depressed patient would respond better to psychotherapy or antidepressant medication.”

Read that again. A biomarker. In the brain. This vein of research, which involves imaging the brain, may one day allow us to side step the arduous task of finding the right medication for our own situations.

Go read the article, which also touches briefly toward the end on Dr. Charles Nemeroff’s research regarding the treatment response of those who endured childhood trauma. (This is also very enlightening).

Mental health will always be a challenge. How our brain works affects everything we do, everything we are, everything we hope to be. It’s a fight to get it all done. But it’s a fight worth every single breath.

# What Does Kurt Gödel’s Incompleteness Theorem Have to Do With Mental Health?

In 1931, Kurt Gödel, a brilliant mathematician, gained quite a bit of fame with his “Incompleteness Theorem.” What Gödel stated was the following (in non-technical terms thanks to a Wikipedia article):

Any effectively generated theory capable of expressing elementary arithmetic cannot be both consistent and complete. In particular, for any consistent, effectively generated formal theory that proves certain basic arithmetic truths, there is an arithmetical statement that is true,[1] but not provable in the theory (Kleene 1967, p. 250).

Reading this, although directly applicable to mathematics, hit home as an analogy for mental health care and the quest for successful treatment of our conditions as patients.

The equation in our case, at its simplest expression is expressed as such: $\frac{P+D}{C}= T$

whereas P = patient, D = Doctor, C = condition, and T = treatment. But we know all too well that it is not this simple, don’t we? No treatments for mental health are fully consistent nor are they anywhere near complete.

There are too many factors involved to arrive at a simple treatment for the more complex mental health problems. Too many unknowns or additional variables. These variables come in the form of emotional/situational issues with the patient, education/knowledge of the presenting symptoms by the doctor, the symptoms presented by the patient, and the available known data regarding the various symptom sets related to the potential condition diagnoses which is again, limited by the presenting patient and comprehension of said presentation by the attending physician. Therefore, with this equation, we have an infinite amount of possibilities which is essentially what Gödel’s theorem states – that there is an infinite amount of true possible answers but none of them are absolutely provable.

If we take this theory, this Gödel theorem of Incompleteness, we significantly address the reasoning behind the continuing stigma of treatment for mental health in the world today. For instance, let’s address cancer. Most cancers respond to radiation and various forms of chemotherapy, right? Granted, we still lose people to cancer but there is an accepted manner of treatment and no one seems to question that course. It is assumed if one is diagnosed with cancer, he or she will receive some form of radiation or chemotherapy to combat the disease within.

If one is struggling mentally, we hear everything from “suck it up” to “take the natural approach” to “go exercise more” to “take a pill” to “every kind of therapy under the sun” to “eat more chocolate” to “happy light” to “color therapy” to “hospitalization” to…. you get my point. I could keep going for quite some time. There is a sea of possibilities to treat the many various forms of mental health issues which have plagued mankind since the dawn of time.

Even the ancient Greek scholars studied these disorders of the mind and out of these studies, they developed equations which helped them further gain insight into the functioning of the brain we have today. Now, they may have referred to mental imbalance as “black bile” but they were aware that when the mind and body were not connected and in balance, there was something very awry in the state of man. For the Greeks, mental well-being was very closely associated with the health of the body which is why good health was important. As a group of voracious scholars, to be off balance was to fail to be the essence of what their very society represented.

Back to the equation at hand, however. While scholars today struggle to continue to understand the inner workings of the human mind and thereby the issues which cause mental disharmony, we are left with this Incomplete Theorem of care to combat the imbalance inside us.

Gödel’s Theorem in the application of mental health may seem hopeless in the face of stigma because it does not narrow down the understanding of the range of issues so many of us face but there is a silver lining. With the infinite possibilities available for care and those possibilities increasing in effectiveness every day, we are able to fine-tune the available treatments for each patient, thereby increasing the potential for a successful outcome, even if it is just one case at a time.

I am reminded at this time of the story of the hare and the turtle. The hare zooms off past the great oak tree at the top of the hill the beginning of the race while the turtle meanders along the dusty road because well, that’s what turtles do. The hare, winded halfway through the race, stopped to nestle himself among some clover for a quick rest, only to discover the turtle crossed the finish line while he slept. As those around us continue to sleep through the reality that is the challenge of mental health issues, unaware of the battle we fight every second of the day, it is up to those of us who are awake and trudging forward to bring them to the finish line and show them that we are capable of getting there too.

An infinite but unprovable amount of solutions is not a bad thing for us – in fact, it is a rainbow of hope shining across an otherwise dark and stormy sky. Don’t let it go.

# Johns Hopkins Study Says Moms with Depression have Shorter Kids

A friend of mine on FB commented on an article at MSN Now this morning. The title of the article? “Study links mother’s depression with shorter kids.”

Um. ‘Scuse me?

Apparently, researchers at Johns Hopkins, clearly with nothing better to do, filled their time  reviewing up to 6500 mother/child dyads to discover that children of mothers with depression of the postpartum variety were 40% more likely to have children of shorter stature. Their grand conclusion? “We don’t know why the hell this happens, it clears up by the time the kid’s 5, and well, moms with Postpartum Depression need support.”

Can we just file this under “Shit I didn’t need to worry about and well, DUH?”

Because.

Sighs.

Dear Researchers – if you’re going to bother to study something associated with Postpartum Mood & Anxiety Disorders? PLEASE make sure it matters and serves a purpose other than to make us worry about something that, well, frankly, isn’t worrisome. There’s absolutely nothing wrong with kids of a shorter stature and to blame it on depression is just an anxiety attack waiting to happen because yanno what? When you have Postpartum Mood Disorders, you worry about the stupid stuff like this. So thanks. No, really, thanks.

# Research Request: Quick Survey for Emory Grad Student

Hi y’all!

From time to time, I’m contacted by Graduate students and researchers asking me to share their work in the realm of Postpartum Mood & Anxiety Disorders.

If you have given birth within the past two years and feel up to completely a relatively painless survey (I’m told 10 minutes or less), I know the researcher would really appreciate it. She’s part of a class project at Emory University in Atlanta.

A quick note from the grad student:  “All information is anonymous and will be kept confidentially. We really appreciate your help in learning more about postpartum.”

You can complete the survey by clicking here.

Thank you for sharing your experience!

(Also – please pass this on to anyone you think may be willing to also complete the survey or knows someone who would be willing to do so!)

# The Great Divide: Researchers, Clinicians, Medical Professionals, Peer Support Advocates, Struggling Patients

All across the globe, there are Researchers dedicating their lives to exploring all aspects of Postpartum Mood Disorders. Many of these researchers work in clinics, some are purely academic, and others review the research of others and present a compilation to conclude results.

Clinicians (for our purposes here) are trained in a variety of professions from therapists to psychiatrists to psychologists. These are the professionals on the front line. Some may be trained specifically in Postpartum Mood & Anxiety Disorders while others may be largely unware of the nuances of these conditions.

Medical Professionals often see Postpartum Women prior to a Clinician is involved. These are General Pracitioners, Family Practice doctors, Pediatricians, Obstetricians, Midwives in some areas, ER doctors, nurses, etc. These professionals again, may or may not have additional specific training in Postpartum Mood & Anxiety Disorders yet it is highly unlikely they are familiar at all with the nuances involved.

Peer Support Advocates are in the trenches. These may be made up of survivors, passionate and informed Clinicians, nurses, pediatricians, IBCLC’s, doulas, and a number of other people various walks of life. They become Peer Support Advocates for various reasons but largely due to personal experience from either a lived experience or the experience of a loved one.

Struggling Patients are in the thick of a Postpartum Mood & Anxiety Disorder, often navigating the system for the very first time. Many of them have never had a mental illness before giving birth or pregnancy. They are not familiar with their rights, the issue of medication, diagnosis, follow-through, or where to turn for help. They are filled with guilt, shame, and fear. These families and patients are often afraid to speak up and reach out for help. But their voices are increasing. Yet they are still echoing into an empty cavern as they scream out for the help they so desperately need.

Peer Support Advocates often are the first to hear the cry of the struggling patients. We work with them to find knowledgeable support in their locale. While the possibility of connecting these patients with knowledgeable or compassionate care is increasing, often times, we find ourselves up against a brick wall riddled with barriers to treatment. The biggest barrier is lack of knowledgeable local referrals. Primary referral in many areas is often to an uninformed or untrained Medical Professional.

An uninformed Medical Professional may do more harm than good with a Postpartum patient. He or she may erroneously take the DSM guidelines to heart, refusing to acknowledge a Postpartum Mood Disorder if the patient had her baby more than four weeks prior to presenting with symptoms. Nevermind that the APA itself admonishes the usage of the DSM in such a manner. If the non-mental health trained Medical Professional is informed, then the patient may find herself ushered higher up the ladder into the office of a professional Clinician trained to deal with psychiatric illness and disorders.

Clinicians are not always trained in Postpartum Mood & Anxiety Disorders. Therefore, it’s important for the patient to know what questions to ask when making an appointment with a specialist in the psychiatric field when seeking help for a PMAD. Questions like “Have you been trained in Perinatal Mood Disorders?” or “By whom have you been trained?” or “How long has it been since you were trained?” or “What is your approach to treating PMADs?” are all excellent questions someone who has been trained in Perinatal Mood Disorders would be comfortable in answering. A good clinician will answer honestly that he/she has not been trained but is willing to learn. He/She should offer her viewpoint on treatment and not force you into accepting their way or the highway. A good (and informed) clinician will also keep up with the latest research regarding PMADs.

Researchers are often not in the field with patients. On rare occasion they are clinicians themselves. Many are academic researchers. These researchers study everything from epidmeology to treatment to type of Perintal Mood Disorder, to risk factors, to contributing factors, birth trauma, etc. The issue with Researchers comes in when their research is manipulated, funded by Pharmaceutical companies, involves retro-data, a small data group, or a limited field in which some factors are not viable simply because the size of the group or source of the group is inherently flawed or for some other various reason. This is not to say that all research should be thrown out the window. It shouldn’t be at all. BUT it is important to be able to distill the research with a keen eye and apply some common sense to the outcome.

In light of the new guidelines in the DSM-5 which will keep the Postpartun Depression Identifier at 4 weeks, we need to work to get those involved in care for Postpartum Women struggling with disorders talking with each other instead of at each other or indirectly with each other via research, peer support survivors, and trainers, etc. But how do we do this?

How do we get the researcher to share with the Clinician their goals, interests, and conclusions? How do we then get the Clincian to spark interest in the Medical non-specialist Practioner to learn about Perinatal Mood & Anxiety Disorders? Then how do we plug in the Peer Advocate and the patient? How do we open the discussion between Professional, Peer Advocate, and patient? How do we keep the communication going once it’s started? What will it take? How many more tragedies must we endure before everyone involved is ready to talk and on the same page?

Enough is enough. We need to stop talking at each other, around each other, to each other and instead talk WITH each other. Until we do, innocent women, children, and families will continue to struggle, suffer, and possibly even die. I am not willing to let that happen. Are you?

Speak up. Say something. EVERY Word makes a difference. Every.Word.

# Oxytocin nasal spray may help moms bond with baby

An interesting article in the Sydney Morning Herald details a new study by Australian researchers.

This new study involves Mom getting a dose of a synthetic nasal spray version of the hormone Oxytocin, also known as the “cuddle hormone.”  Mom then participates in a few structured therapy sessions with baby to measure eye contact, affection, and if there is any improvement in bonding between mother and baby.

# CAMH researchers uncover possible biological link for Postpartum Mood Disorders

Researchers at the Centre for Addictions and Mental Health, or CAMH, have recently published an intriguing study regarding a biological link to Postpartum Mood Disorders.

The study involved 30 women; 15 of whom were immediately postpartum and 15 who were not at all postpartum. All women underwent PET scans to measure MAO-A binding.

The findings are stunning.

Normal women who have just delivered a baby had 43% higher MAO-A levels than women who had not given birth.

Why is this stunning?

Well, it has to do with the role of MAO-A in the body. MAO-A is a protein which helps to remove chemicals from your body like serotonin which help you maintain a good mood. Elevated levels of MAO-A means that more serotonin is being cleaned out of your body, thus making you sadder. Wait, there’s a kicker. The highest MAO-A levels were recorded on Day 5 post-delivery, the most severe day of the baby blues.

Interestingly enough, MAO-A is also located in the placenta, in the  Syncytiotrophoblast layer where moms and babies exchange nutrients.

While social struggles and lack of support may exacerbate the symptoms and increase the recovery from a Postpartum Mood Disorder, researchers like Dr. Jeffrey Meyer and Dr. Michael Silverman are peeling back more and more layers each and every day. They’re exploring deeper than ever before into a neurobiological basis of Postpartum Mood Disorders which may one day allow us to successfully avoid the experience all together. What a day that will be! Until then, we need to continue to provide non-judgmental and compassionate support for moms and families struggling with a Postpartum Mood Disorder. It’s through the careful marriage of research, social support and medical support that we will best reach recovery.

A New Biological Explanation for Sadness in early Postpartum, CAMH Press Release, retrieved 05/04/2010

# Canadian Researcher seeks young moms for research study

I received the following via email this morning. Passing it along. If you would do the same, I know Dr. Gina Wong-Wylie would be deeply appreciative. Thank you!

SEEKING RESEARCH PARTICIPANTS

April, May, and June 2010

Qualitative Research Study:

“Young Moms Can Soar”

Close to half of women under the age of 19 years who become young mothers are estimated to develop Postpartum Depression (PPD). Researchers with the Centre for Disease Control have indeed confirmed that young mothers are at an elevated risk for developing PPD. Nevertheless, the experience of depression for young moms does not necessitate negative long-term consequence and lifelong disadvantage. In this study, the researcher explores experiences of young moms who moved through PPD to a place of empowerment.

Participants:

• If you had a baby at, or before, the age of 19 years not more than 15 years ago
• If you experienced depression following the birth of the baby
• If you moved or are moving through the depression and are experiencing life more positively
• And you are willing to speak about the experience of maternal depression as a young mother and share stories of growth from that experience and positive outcome for the purposes of research.

Dr. Gina Wong-Wylie, Registered Psychologist

Email: ginaw@athabascau.ca

Toll Free in Canada: 1-866-442-3089

# Postpartum Depression formal screening not worth the cost, BMJ study says

According to a recently published study in the British Medical Journal (BMJ), Postpartum Depression Screening is not…. brace yourselves. Worth the cost.

That’s right.

NOT.WORTH.THE.COST.

The conclusion was that overall not using a formal screening method was much more cost effective as it eliminated false positives.

So the mental health of a woman which will then affect her child, her family, her community, the world at large, are just not worth it to the National Health System of the UK. The EPDS scored out at about \$67,000 per quality adjusted life years while no screening method scored at a price tag of just \$20 – \$30,000. No value for the money was found to exist when using the formal identification methods.

Did these researchers not read Murray & Cooper’s Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression which explores the effects of postpartum depression treatments on children?

There is SO much more at stake here than the dollar value to the National Health System.

There’s the potential for broken families. The potential for children growing into their own mental health issues, the potential for continued need for mental health treatment due to an undiagnosed episode of postpartum depression, potential for increased incarcerations due to untreated mental illness, continued sadness, the continued stigma, continued and perpetuated lack of education on the part of physicians in regards to Postpartum Mood Disorders.

The most interesting aspect of this study is that it focused on screening for Postpartum Depression in the Primary Care setting. Primary care physicians are not always comfortable or knowledgeable in screening for mental health issues. If a patient were to screen positive, that physician is then morally responsible for referring them to a specialist. Often times, at least here in the states, a Primary Care physician is unaware of where to refer a patient for help with a Postpartum Depression Disorder. Therefore, they become afraid of screening because they fear what will happen if a positive were to occur. What would they do with the patient? Where would they send them? How would they respond? Are they familiar enough with Postpartum Mood Disorders to recognize a false positive?

I think the key to the results of this study is not so much in blaming the high percentage of false positives but in urging that Primary Care physicians receive more training to enable them to recognize a false positive through more in depth questions after a positive is scored via the Edinburgh Postnatal Depression Scale.

original photo/graphic "Hand holding necklace" by K.Sawyer @flickr

A stronger safety net involving a stronger communication between midwives, Obstetricians, Pediatricians, and General Practitioners is so desperately needed to keep women from falling through the very big cracks which currently exist in the system.

A woman gets pregnant. She sees a medical physician to get the pregnancy confirmed. Most mothers seek OB or midwife care for their entire pregnancy. Unless they’re depressed – depressed and mentally ill mothers are less likely to take good care of themselves during a pregnancy, making specialized care even more important even when baby is still in utero. Once mothers give birth, they are then shuttled off to the pediatrician’s office for the bulk of their medical contact. One six week or eight week visit to the midwife or OB to ensure mom is healing properly then an annual PAP visit unless something arises in between. Many Pediatricians focus on babies and not mother. But the tide is changing as more and more Pediatricians are taking into account the family lifestyle and well-being. My own Pediatrician does this and I absolutely adore her for it.

But overall, there is typically no continuity of care, no communication between physicians throughout the birth process. There should be. There needs to be. A woman deserves a team of support. She deserves to thrive. So do her children.

No matter what the cost.

Because once you fail woman and her children, you fail society.

Fail society and we fail to exist.

If we fail to exist….

# Validation of the EPDS in Mainland China for antenatal women

Through research, the Mainland Chinese version of the Edinburgh Postnatal Depression Scale has been validated.

What does this mean?

It means the EPDS is now a valid tool practitioners available for use in the Chengdu region of China to identify pregnant mothers struggling with depression.

More research is needed to validate it for postnatal women. The overall prevalence of antenatal depression was at about 4.7%. Two studies were conducted: One to measure stability, the other to measure sensitivity. Both passed with flying colours.