# #PPDChat Topic: Postpartum Therapy Q & A (And a Giveaway!) with @DrCHibbert

Tonight’s chat will cover a topic many of us have questions about – therapy.

Postpartum Mood & Anxiety disorders are complex to say the least. There is so much to consider when you’re facing diagnosis. One of the chief concerns is most definitely where to find help, how to tell if it’s good help, how to reach out for help, and how to talk with your family about finding good help.

I hope you’ll join me and Dr. Christina Hibbert, author of This is How We Grow and founder of the AZ Postpartum Wellness Coalition, as we discuss therapy and answer any questions you may have about it. Be sure to follow her on Twitter: @DrCHibbert

Also! We will be giving away a copy of Dr. Hibbert’s book to a lucky chat participant so you’ll want to be sure to join in! (No registration required and no money or product changed hands for this giveaway/chat.)

See you tonight on Twitter at 830pm ET, 530pm PT.

# 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.

# Enriching postpartum therapy through at-home activities

In addition to the different types of therapy we discussed yesterday, there are some at home activities you can do (provided your therapist has approved them) to enrich your professional care and journey toward wellness.

First, start a gratitude journal. But I don’t journal. I hate writing! Don’t worry – this isn’t having to write an entire page every day. It’s a simple two entries a day. In the morning, when you first wake up, grab your pen and journal. Write down three things for which you are grateful, no matter how small that thing may be. As your day progresses, focus on what has made you laugh or smile. Once you have retired to bed each night (even if it’s for two hours), write down at least three things which made you smile or laugh during the day. At the beginning, even just barely cracking a smile counts. This activity is two-fold. First, it forces your brain to refocus on the positive things in your life. Second, it provides physical evidence of the positive influences in your life you can look through on the particularly tough days.

Second, write down all five senses on a sheet of paper. Taste, touch, smell, sounds, and sight. Write down five of your favorite things for each sense. Chocolate, silk, a favorite perfume, a cd or song that makes you smile, favorite color or flower or art. Post the list on the fridge. Treat yourself to at least one thing from EACH SENSE every week. Rotate them out. Putting the list on the fridge helps family members and friends to know what to help keep around the house as well. (Sneaky, I know)

Third, take time for yourself. Schedule it if you have to. One thing I love to do is to dress up my lunch. It’s my quiet time of day and I have been known to make a frozen pizza and a coke look like it belongs on a table prepped by Gordon Ramsey. Lean Cuisine never looked so haute. I’ll also treat myself to the routine of making tea. The key is finding one thing you love and making sure you do it at least once a day. Without interruption.

Some other moms will put positive post-its throughout the house and even in the car to help give them a boost when they need it most.

A successful recovery relies heavily on your active participation. If you’re not participating, you’re not getting better. YOU are the most important quotient in the equation when it comes to journeying toward mental health wellness!

How did you actively participate in your recovery? Have any tips for currently struggling moms? We’d love to hear them!

Be sure to stop back tomorrow for the triumphant return of the Friday Soother, my weekly gift to you!

# Therapy Choices for the Postpartum Woman

Once diagnosed with a Postpartum Mood Disorder, you are then faced with a literal bevy of choices regarding your path to wellness.

Some doctors may toss pills at you. If that happens, run. Run very fast and very far away from any physician who shoves anti-depressants your way before you’ve even finished describing what’s wrong. A good prescribing doctor will sit down with you and hear you out before grabbing for his pen and pad (or these days, keyboard and internet connection). A good physician should also run a couple of simple blood tests first to rule out thyroid disorders or anemia which need completely different types of medication to show improvement.

Some doctors may suggest psychotherapy. And that is where things start to get a little sticky. What kind of talk therapy? Will there be a couch? Will it be comfy? Will I have to talk about how my Great Aunt Edna used to kiss me on the cheeks and leave funny lipstick stains? Will I have to talk about things not related at all to my current state of mind? Will I be hypnotized? Or any other strange mumbo jumbo I’ve seen happen on TV or in the movies or from my best friend who found this website and…

Hold the phone there.

Cognitive Behavioral Therapy proved to be the best option out there for me. There was a couch but I didn’t lay down on it. I sat cross-legged on it as I drank coffee and chatted with my therapist. She sat in a really cool rocking chair with a foot stool. I got along fabulously with my therapist. That’s not to say we were bestest of buds but she knew what she was doing, just let me talk and work a lot of my issues out. I did occasionally talk about things in my past but it wasn’t at all like “So, you were born… let’s start there.” She met me where I was and let things fall where they fell. Or at least she seemed to. She did ask questions to get me to think about issues and how I was reacting to them. I had not planned on staying in therapy for long but once I became pregnant again, I made the decision to stay in through my pregnancy. Therapy gradually stopped at about 6 months postpartum of that pregnancy as we scaled our sessions back.

While I will not be covering every single last type of therapy out there, my goal is to provide some basic information for the most common therapies  used with Postpartum women.

At the top of the list is Cognitive Behavioral Therapy which is actually a blanket term for several types of therapies with similar traits. Primarily Cognitive Behavior Therapy (CBT) promotes that WE have power over our moods through our thoughts. You can read more about it by clicking here. A great resource now available for women and clinicians alike when it comes to treating Postpartum Depression is Karen Kleiman’s Therapy and the Postpartum Woman. You can read more about it by clicking here. (In the interest of full disclosure now required by the FTC, I have not been compensated at all for including this link. I sincerely believe it’s a good resource.)

EMDR or Eye movement desensitization and reprocessing is gaining popularity as an option. EMDR is most effective with Post Traumatic Stress Syndrome. You can read more about this approach by clicking here.

Peer Support/Group therapy is also an option. The primary benefit of this option is the realization it provides to women of not being alone. They really aren’t the only ones having a panic attack when they get in a car or experiencing frightening thoughts prancing through their mind at the most inopportune moments. Many times this option is a cost-effective option as well because many groups do not charge. A group led by a therapist may only charge a small fee such as \$10-15 for attending. While peer support should absolutely not replace professional medical care for Postpartum Mood Disorders, it is an important aspect to add to recovery. If your area does not have a local peer group, you can find help online. The Online PPD Support Page has a very active forum for postpartum women. You can also visit the iVillage Postpartum or the Pregnant & Depressed/Mental Illness Boards. (Shameless plug on the iVillage boards, I am the Community Leader for both.) Another bonus of peer support? It reduces the recovery time.

Pharmaceutical therapy is also an available option. Some women are against taking medication and that’s perfectly okay. No one should ever be forced to take medication. Typically, pharmaceutical therapy is paired with another type of therapy. In fact, combining pharmaceutical therapy with a type of Cognitive Behavioral Therapy has proven to be one of the most successful approaches for the Postpartum Woman. Sinead O’Connor really put it best during an appearance on Oprah in regards to the function of psychiatric medications. They are the scaffolding holding you up as you revamp yourself. There are risks involved with taking medications and you should absolutely educate yourself, talk with your doctor, and if you end up deciding to take medication, be sure to inform your child’s pediatrician if you are nursing so they can be involved in monitoring for any potential issues.You should also familiarize yourself with the symptoms of Serotonin Syndrome, a fast-acting reaction which occurs for some people when they do not metabolize medication quickly enough. The build up results in a severe toxic situation. You should also avoid stopping any pharmaceutical therapy without consulting with a physician. Stopping suddenly can cause very negative symptoms similar to Serotonin Syndrome. If you have any signs or symptoms of Serotonin Syndrome, get medical help immediately.

For more serious cases of Postpartum Depression that do not respond to medication, Electroconvulsive Therapy may be suggested. ECT has come a long way since the 50’s and is a viable choice for many women who do not respond to medication. Now, I am not saying that if you choose not to take medication, you’ll be given ECT. This is for women with severe depression who cannot metabolize or do not respond at all to medication. Choosing not to take medication does not buy you an ECT ticket at all.

For women who want to use a more natural approach, there are a lot of choices. Again though, I have to urge you to make sure you are seeing a professional during your recovery. Don’t take something because it worked well for Aunt Martha. Check with your doctor and make sure it’s applicable to your situation and okay for you to take in combination with any other medication you may already be taking. Be sure your naturalist or herbalist is licensed and trained. You’ll also want to make sure that any herbs/natural supplements you are taking are compatible with breastfeeding if you are doing so. You can visit the blog over at Rebuild from Depression for a food/diet based approach.

As you can see, there are a lot of options available if you are diagnosed with a Postpartum Mood Disorder. More and more practitioners are becoming familiar with these disorders. More help is available today than even 6 years ago when I was first diagnosed. Remember to ask questions when choosing a therapist, advocate for yourself and what best fits your personal lifestyle philosophy. Don’t settle just because you want to heal. You have the power to say no. It’s your body, your mind, your say.

# Just Talkin’ Tuesday 03.23.10: How did you find your therapist?

Original photo: "Everyday Use Items: a couch" by @foka_kytutr @ flickr.com

Congratulations!

You have broken through the fear to make the call for help.

But now what?

Unless you have a therapist tucked away with the burp cloths or shoved in a random diaper bag pocket, chances are you’ll be scrambling to find one after diagnosis with Postpartum Mood Disorder.

There are a lot of questions to be considered when searching for a therapist. Some are financial, some regarding training, and others regarding how experienced the therapist is with your specific diagnosis.

Just as you wouldn’t see an Oncologist for a Pulmonary Embolism, you wouldn’t visit a Substance abuse therapist for a Postpartum Mood Disorder.

But when you are in the throes of Postpartum Mood Disorder, you don’t necessarily have the wherewithal to be going down a checklist of requirements for a Therapist. (That is, unless you get lucky like me and develop Postpartum OCD. Then lists and keeping certain things in a very particular order becomes very very important to you.)

So how can you tell your therapist is going to be a good match or is trained in dealing with Postpartum Mood Disorders?

The first thing you need to know is what degrees to look for when ensuring the therapist you are considering is professionally and properly trained. A therapist will primarily hold a Masters level degree and be either a Licensed Social Worker or Counselor/Therapist depending on your state’s licensing office. A solid counselor should not hesitate to provide evidence of his/her training and current license status if requested. You may also see a Psychologist, who will hold either a Ph.D (research) or a Psy.D (Professional) for therapy.

The second thing to consider is specialized training in Postpartum Mood Disorders. If the therapist is truly focused/familiar with Postpartum Mood Disorder patients, he or she will be aware of Postpartum Support International, Karen Kleiman’s Clinician Training at the Postpartum Stress Center, or Pec Indman’s two day training via Postpartum Support International. If your therapist claims to be intimately involved with treating Postpartum Mood Disorder clients yet has no earthly idea who these people or organizations are, be wary. Ask what specialized training they have completed in the area of Postpartum Mood Disorders (if any) and how long they’ve been treating patients with similar diagnoses to yours.

Third, while your therapist is not meant to be your best friend, you should feel somewhat at ease during the appointment. If you feel uncomfortable or on edge during therapy, you’ll be less likely to disclose as much and therefore hinder your own journey toward wellness. It’s worth the search to find a therapist with philosophies similar to yours.

Do not be afraid to ask what their policy is on admitting to Intrusive thoughts. Many many women worry that if they admit they have thoughts of doing horrible things to their children, the children will be taken away from them. I faced this very same issue and asked my therapist this question before I admitted some pretty dark thoughts to her. Her response was that yes, she was required to report situations which indicated imminent harm to oneself or others but that she understood intrusive thoughts and their involvement in my particular diagnosis. This particular concern goes back to finding out what experience the therapist you are considering has with Postpartum Mood Disorders.

Dr. John Grohol over at PsychCentral has some good advice on how to tell a good therapist from a bad one. I would highly recommend you read it and keep these tips in mind.

Another great link to keep tucked away is “Tips for talking with your doctor” by Karen Kleiman over at the Postpartum Stress Center. She suggests starting with the doctor you feel most at ease with even if it’s your primary care physician. He or she can always refer you to specialists once a consensus is made that further help is indeed needed.

I now hand this post over to you, the reader.

What did you do to find your Postpartum Therapist? Any tips? Suggestions? What to look for? What to avoid?

Let’s get to just talking here!

(Tomorrow we’ll be discussing different types of therapy available for the Postpartum Woman. Stay tuned!)

# Tips on Identifying Reliable Health Information on the Internet

If you’ve landed here as a result of a Google, Yahoo,  Bing, or other search engine, you already know how many results you can get in mere seconds and even sometimes nano-seconds. Thousands! So you wade through the results hoping for reliable and trustworthy information. Unfortunately, not everything out there is reliable and trustworthy. And even if it is reliable and trustworthy, you should ALWAYS check with a professional prior to implementing or stopping any treatment.

Here are some general tips to help you tell the good from the bad (source: Medical Library Association):

• Can you easily identify the site sponsor? Sponsorship is important because it helps establish the site as respected and dependable. Does the site list advisory board members or consultants? This may give you further insights on the credibility of information published on the site.
• A government agency has .gov in the address.
• An educational institution is indicated by .edu in the address.
• A professional organization such as a scientific or research society will be identified as .org. For example, the American Cancer Society’s website is http://www.cancer.org/.
• Commercial sites identified by .com will most often identify the sponsor as a company, for example Merck & Co., the pharmaceutical firm.
• What should you know about .com health sites? Commercial sites may represent a specific company or be sponsored by a company using the web for commercial reasons—to sell products. At the same time, many commercial websites have valuable and credible information. Many hospitals have .com in their address. The site should fully disclose the sponsor of the site, including the identities of commercial and noncommercial organizations that have contributed funding, services, or material to the site.
##### 2. Currency
• The site should be updated frequently. Health information changes constantly as new information is learned about diseases and treatments through research and patient care. websites should reflect the most up-to-date information.
• The website should be consistently available, with the date of the latest revision clearly posted. This usually appears at the bottom of the page.
##### 3. Factual information
• Information should be presented in a clear manner. It should be factual (not opinion) and capable of being verified from a primary information source such as the professional literature, abstracts, or links to other web pages.
• Information represented as an opinion should be clearly stated and the source should be identified as a qualified professional or organization.
##### 4. Audience
• The website should clearly state whether the information is intended for the consumer or the health professional.
• Many health information websites have two different areas – one for consumers, one for professionals. The design of the site should make selection of one area over the other clear to the user.

MLA’s guidelines are an excellent starting point and should be used by anyone searching for Medical information on the internet. Many caregivers will also tell you to not search the web for information, especially if you have a Postpartum Mood Disorder. If you have a question and feel overwhelmed with doing research on your own, get in touch with a Postpartum Support International Coordinator, your midwife, or your doctor, and ask for help in doing research. Sometimes you may come across research or news stories that are not applicable to your situation that may cause triggering thoughts or increase your fear and anxiety without justification.

Another great way to check the reliability of a website is to do so through HONcode. HONcode, Health on the Net certifies websites with healthcare information. Their standards are pretty high and they certify on a random basis once a website has been accepted. (I’m currently working on acheiving this certification for this blog myself). Through HONcode, as a patient/consumer, you can download a toolbar or search directly from their site and will only be given websites that have been approved by them. Click here to learn more about the safety process at HONcode.

As a Postpartum Support International Coordinator myself, I work very hard to support the journey the mother is on and the treatment route that best fits with her personal philosophy. I encourage the involvement of professionals – including her OB or midwife, a psychiatrist, and a therapist. I also encourage Mom to take time for herself, something we all forget to do from time to time, but is very important for our mental well-being.

Thoroughly check the source of the information you are reading online using the above guidelines from the Medical Library Association as well as searching via HONcode for your information.

Double-check any information regarding starting treatment or stopping treatment with your professional caregiver prior to implementation.

Make sure your caregiver respects your opinion regarding your body. (You are of course, your #1 expert in this area!) If he/she fails to respect you, although it may be difficult, find another caregiver who DOES respect you!

Take time for yourself as you heal.

# Thoughts on exploring a “Pregnant Pause”

An article in May’s issue of Vogue entitled “Pregnant Pause” by Alexis Jetter attempts to provide insight into the very confusing world of the pharmacological treatment of depression or mental illness during pregnancy. Ms. Jetter seems to have done her homework. She brings up some very valid points, includes supportive research, referring to specific studies all framed within a heart-tugging story of a boy born with a heart defect as a result of his Mom taking Paxil during her pregnancy. Yet Ms. Jetter forgets to tell both sides of the story. Here’s my take on the article.

In no way am I belittling this Mom’s experience by rebutting some of Ms. Jetter’s claims. As a Mom of a special needs child, I know first-hand how difficult life becomes as you work with and around your child’s needs. I also understand the enveloping guilt which rages inside you every time you see your child suffer or struggle and wonder “Did I do that? Was it my fault?”

You see, I didn’t take my pre-natal vitamins during my second pregnancy. At first it was because of the wretched morning sickness. Then I just didn’t want to take them. I even pondered what would happen if I didn’t take them, thinking it would be a neat little “experiment” to find out.

When my daughter was born with Pierre Robin Sequence which included a complete and bilateral cleft of her hard and soft palate, I felt a guilt that cannot begin to be described by any words known to mankind. It took me nearly two years to admit this to anyone. I lied at the hospital when I was asked if I had taken my prenatal vitamins. Why? Because I knew from my mom’s quick research about PRS that lack of folic acid in the maternal diet increases the risk for this particular condition. The last thing I needed was for the doctors to also blame me for my monumentally bad judgment. Looking back, I’m pretty sure this erratic behavior was directly related to my untreated issues with Postpartum OCD/Depression after the birth of our first daughter.

To this day as my daughter struggles with speech, socialization, and a myriad of other challenges, I still blame myself somewhat. Intellectually I know her problems are not my fault. I have accepted this on that level. But a small part of me will always wonder if she would have these problems if I had just taken my vitamins. So I get it. I get the guilt, I get the hind-sight. I get the anger and outrage. And I definitely get the need for education and informed consent.

What I don’t get is the desire to limit treatment options for other people. Instead of limiting, let’s encourage the development and shared knowledge of non-pharmacological therapies for mild cases of depression during pregnancy such as altering your diet, increasing exercise, natural supplements, psychotherapy, to name a few. Instead of judging, let’s allow women to make their own decisions regarding their mental health treatment. (you can read more on my thoughts regarding the ante-partum medication conundrum here)

Just as with those who are passionate for home-birth and those who are passionate for breastfeeding, there is a caution to be heeded here. We cannot convince a woman who is determined to have a caesarean section to have home-birth just as we cannot convince a woman who is convinced that a pill will solve her problems to try other therapies. All we can do is provide the education, statistics, and support. Then we need to step out of the way and let the woman make the decision with her medical professional team.

We can only fix ourselves, not those around us.

Now, onto the meat of the article, if you will.

After we meet Gina Fromm and hear of her difficult experience as a result of taking Paxil during her pregnancy, we are introduced to Dr. Anick Berard, PhD and Professor of Pharmacy at the University of Montreal. He discusses his study on Paxil, concluding that “..now other people have done the studies, too. And I’m much more comfortable saying that Paxil is a bad drug to take during pregnancy.”

Really, Dr. Berard?

I found a more recent study undertaken by none other than Dr. Anick Berard which concludes that unless the dose of Paxil is above 25mg during the first trimester, Paxil usage is not associated with an increase in congenital cardiac malformations when compared with non-SSRI usage. (Typical therapeutic dosage for Paxil can range anywhere from 10mg to 40mg.) When researching it’s not difficult to find studies to contradict one another but when you find them from the same researcher it’s a bit odd.

Next we meet Carol Louik, Sc.D, author of one of the two studies released in June of 2007 extolling the small risk SSRI’s posed to the human fetus. Turns out Carol’s study was partially funded by GlaxoSmithKline, Sanofi Aventis, and another Pharmaceutical Company. However, at the same time Carol’s study was published in the New England Journal of Medicine, another study was also published. This study was coordinated by the CDC out of Atlanta and did not have any financial disclosures to the Pharmaceutical Companies. Sura Alwan, MSc, and Jennita Reefhuis, RN, were first and senior authors respectively. Their study concluded the absolute risk of exposure vs. non-exposure not to be much different than the standard baseline risk for defects in any healthy pregnancy.

But the Alwan/Reffhuis study results are not present in the Vogue article.

Then we’re tossed this golden nugget – “….SSRI usage dramatically increases the chances that a baby may be miscarried, born prematurely or too small, suffer erratic heartbeats, and have trouble breathing.” The author further states that “Taken together the NEW research caught many experts by surprise.” Yet most of the research articles I located by the researchers quoted were from 2006 or earlier. This is hardly NEW research. In fact, the NEW research contradicts many of the studies referenced in the Vogue Article.

For instance, we’re informed through a quote from Dr. Adam Urato, M.D. That “these antidepressants are portrayed almost like prenatal vitamins that will level out their mood and lead to a healthier baby. But antidepressants have not been shown to decrease rates of miscarriage or birth defects or low birth weight. On the contrary, they’ve been shown to increase those problems.” Then directly after this quote, Ms. Jetters states pregnant women are routinely excluded from clinical tests of new drugs. But she fails to ask a very important question.

Why?

A solid answer can be found in the February 2009 Carlat Psychiatry Report, an unbiased report regarding all things psychiatry related, including medication. According to an article entitled “Psychotropics and Pregnancy: An Update,” the Carlat Psychiatry Report states “the gold standard study will never occur. It will never be ethically permissible to enroll pregnant women into a randomized, placebo controlled trial designed to determine if a drug causes birth defects. For this reason, we are left with less than ideal methods of determining risk.”

To seemingly substantiate Dr. Urato’s quote regarding miscarriage, birth defects, or low birth weight, a study performed by Developmental Pediatrician Tim Oberlander, M.D. At the University of British Columbia is briefly examined. This study concluded after tracking the birth outcomes of 120,000 women that infants exposed to SSRI’s prenatally were born too small and have trouble breathing. Oberlander’s quoted conclusion for the article? “It’s not the mother’s mood,” Oberlander says. “It’s the medication.”

Yet Oberlander’s study is negated by Einarson’s study, “Evaluation of the Risk of Congenital Cardiovascular Defects Associated With Use of Paroxetine During Pregnancy” Einarson also writes a letter to the American Journal of Psychiatry, (located in Vol. 64, No. 7, July 2007) which states the conclusions made by Oberlander and others is not supported by the data presented. Einarson points out that low birth weight was not stated as an investigated outcome and that only average weight of newborns and proportion falling lower than the 10th percentile (ie, small for gestational age but NOT low birth weight. Low birth weight is technically defined as >2500g2.

Einarson’s study combined both prospective and retrospective methodology to examine a large number of women specifically on Paxil. Their conclusion? “Paroxetine does not appear to be associated with an increased risk of cardiovascular defects following use in early pregnancy, as the incidence in more than 3,000 infants was well within the population incidence of approximately 1%.”

Just in case you’re wondering, no, their study was not funded by GlaxoSmithKline. The Carlat Psychiatry Report is quick to point out that seven of the nine authors received no funding from GSK or any other drug company but two have received funding for drug research from other drug companies but not GSK.

The Carlat Report also address what one should do with conflicting information regarding medicating during pregnancy. The best one can do from a “medico-legal perspective is to avoid paroxetine. But the data does suggest that paroxetine – and perhaps by extension, all SSRI’s – may be safer than what has been suggested by other smaller studies.”

Going back to the issue of pre-term delivery as well as low birth weight and their relation to mood or medication, a recent study released by Dr. Katherine Wisner examines this very topic. The study looked at 238 women with no, partial, or continuous exposure to either SSRI treatment or depression and compared infant outcomes. Dr. Wisner’s study found that exposure to SSRI’s did not increase birth defects or affect infant birth weight but the importance of this study lies within the finding that the pre-term delivery rates were the same with depression exclusive of SSRI treatment, leading the researchers to state that it is “possible that underlying depressive disorder is a factor in pre-term birth among women taking SSRI’s.” Dr. Wisner also encourages further research into this topic even though her study was just released this year. You can read more about this study by clicking here.

Rita Suri, M.D. from UCLA also studied this very situation, publishing her research in August 2007 in the American Journal of Psychiatry. Not surprisingly, Suri’s study is quoted in the Vogue article. Her results found that infants born to women taking SSRI’s were three times more likely to be born prematurely (although most were only 1 week early) She also found that the higher the antidepressant dose, the higher the risk of early delivery. However, her results did not show that untreated mild depression had an effect on prematurity. I’d like to add a personal digression here. My second daughter was born at 36 weeks. While not officially diagnosed, I would say that I suffered from untreated depression during that pregnancy. Sure it’s not an official research study but it’s very hard to discount personal experience especially when it agrees with current research.

At this point in the article, we’re introduced to one of the more well-known disorders associated with paroxetine usage, Persistent Pulmonary Hypertension of the newborn. Tina Chambers, Ph.d, a birth-defects researcher from University of California at San Diego is the chosen expert for this topic. She states that this condition normally strikes only one or two infants in 1,000. But Chambers found that rates jumped between six and twelve per 1,000 for mothers who take SSRI’s. In contrast, a recent prospective study by Susan Andrade, ScD, concluded no relationship between SSRI usage and PPHN but did admit that given limitations of the study and small number of confirmed cases, further study in this area may be warranted. In Andrade’s study, 1104 mothers were followed with only 5 confirmed cases of PPHN reported.

Alexis McLaughlin’s story about her daughter’s struggle with PPHN is striking, especially for me, because I’ve seen my daughter struggle for breath immediately after birth. Her quote, “It’s difficult because you need good mental health and a healthy baby,” is very reminiscent. You do indeed need good mental health and a healthy baby. When I was pregnant with Charlotte, we told people we didn’t care about gender, all we cared about was health. But if that doesn’t happen? You do your best to get through it because there is nothing you can do to go back and change what was done in the past. We can only move forward, changing what we can, and if we can’t change it, we change the way we think about it. Even with a normal pregnancy given no SSRI exposure or depressive exposure, a mother faces a 3% risk of giving birth to a child with a birth defect of some kind.

We are then moved into the science behind the affect of an anti-depressant on the human fetus. It’s hypothesized that serotonin is responsible for sending “crucial developmental signals to the fetal heart, lung, and brain….[and that]…SSRI’s, which prevent the body’s natural absorption of serotonin, could be tampering with essential cell growth.” A study by Francine Cote concludes that maternal serotonin is indeed involved in fetal development, precedes the appearance of sertogenic neurons, and is critical for development. The latter hypothesis regarding the interference of SSRI with essential cell growth has been and I’m sure will be studied for quite some time.

Shortly after this, the article winds down by warning of the “small coterie of influential doctors who…underplay the dangers of antidepressants,” again, a quote from Dr. Adam Urato. I do agree whole-heartedly with the latter part of his quote: “We want and need expert opinion that’s free from industry influence and from the appearance of bias,” Urato says. “It’s just outrageous that doctors have to work with that.”

Any of the several women I’ve come across who work with the Perinatal Population will be some of the first to admit that yes, there are risks to taking medications while pregnant or nursing. We even inform women we support to not only weigh the benefits against the risks by researching their options but let the professionals determine if the situation is severe enough to warrant medication.

Dr. Katherine Wisner examined this Risk-Benefit relationship in a study back in 2000. In this study, Dr. Wisner encourages physician and patient communication through the use of informed consent, provided the patient meets the legal definition of competent. She also recommends a family member or friend of the patient be present to help alleviate any anxiety and to ask questions the patient may not think of asking regarding any medication decision.

Many of the recommendations Dr. Wisner sets forth should be commonly used by a competent physician. Unfortunately there are physicians who do not follow informed consent and instead pay attention to the perks offered by Pharmaceutical Companies. However; these perks are slowly disappearing as the medical community awakens to the ethical dangers they pose as a result of increased consumer advocacy for fair and informed treatment when it comes to mental illness. If you should find yourself with a physician who prescribes SSRI’s like m&m’s or refuses to listen to your situation, it is time to find a new doctor for your care. A good doctor will listen, research, and collaborate with you.

I want to close with a quote directly from the Vogue article by Gina Fromm, Mother to Mark Fromm, the little boy with the heart defect as a result of his mother’s usage of Paxil. I couldn’t say it any better than this.

“It is easier to take a pill,” Gina says. “But over the long run, that’s not the best solution. It certainly hasn’t been for my life.”

I agree Gina, I agree whole-heartedly.

In my opinion, society today has gotten in the habit of quick fixes instead of sustaining solutions. I personally think it’s time we change that. But let’s do so in a logical, evidence based, and bias-free manner. Otherwise we’ll all just end up stuck right where we are screaming at each other so loud we can no longer hear ourselves think.

# The Confusion of Ante-Partum Depression: To Medicate or Not?

Finding yourself faced with depression during pregnancy is a confusing prospect indeed. How do you treat it? Do you tough it out and hope there is no effect on your pregnancy? Or do you risk medication and the potential effects that course may have on your baby as well? In addition, many care-givers are hesitant to medicate a pregnant mother for depression or even worse, are not familiar with ante-partum depression and negate the mother’s concerns over her mental health. If your caregiver brushes aside your concerns as normal pregnancy ups and downs yet you know in your gut it’s more, get a second opinion or ask for a referral to a therapist at the very least.

A recent study by Dr. Katherine Wisner, M.D., M.S., found that continuous exposure to either SSRI or Depression during pregnancy results in pre-term delivery rates in excess of twenty percent while mothers with no exposure to either depression or SSRI over the course of their pregnancy experienced rates of pre-term delivery at six percent or lower. The study looked at 238 women with no, partial, or continuous exposure to either SSRI treatment or depression and compared infant outcomes. They found that exposure to SSRI’s did not increase birth defects or affect infant birth weight but the importance of this study lies within the finding that the pre-term delivery rates were the same with depression exclusive of SSRI treatment, leading the researchers to state that it is “possible that underlying depressive disorder is a factor in preterm birth among women taking SSRIs.” You can read more about this study by clicking here.

“This study adds evidence that depression in pregnancy can negatively affect birth outcome. Although women treated with SSRI’s throughout the pregnancy may experience pre-term birth, the factor causing the problem may in fact be the depression and not the SSRI. More research is needed to tease out what is causing the changes in the uterine environment. As research comes forth, what continues to be clear is that treatment for depression in pregnancy is important. ‘Treatment’ doesn’t necessarily mean medication, but for everyone’s sake the pregnant woman needs to receive a plan for wellness.” Dr. Shoshana Bennett shares when asked about her take on Dr. Wisner’s research.

You may recall a recent study posted also regarding birth weight of infants. The study concluded that Prenatal Depression restricted the fetal growth rate. This study concluded that depressed women had a 13% rate of pre-term delivery as well as a 15% greater incidence of lower birth weight. This study’s results examined cortisol levels to determine risk of pre-term delivery and birth weight prediction, which leads us to another study examining the reliability of cortisol to predict short gestation and low birth weights. The study concluded cortisol levels were indeed a reliable manner in which to predict both.

So what’s a pregnant depressed mama to do?

Throw her hands up in the air?

Scream?

Cry?

Tough it out?

None of the above – she should work in partnership with her doctors to weigh the risks. There are other treatments available for depression and anxiety during pregnancy besides SSRI’s. Therapy is always an option. (Yes, more studies to be quoted ahead) A study examining the effectiveness of a Mindfulness based intervention for pregnant mothers found women receiving the intervention experienced less stress and anxiety during their third trimester and postpartum period. There was no data collected regarding pre-term delivery or birth weight in relation to this particular study.

There’s also a wonderful article at wellpostpartum.com that discusses how cortisol impacts mothers. Included in this article are some terrific (and natural) suggestions on how to keep cortisol at bay.

Alrighty now. You’ve shared your precious studies with us. What about some real life advice? What did YOU do when faced with the Hamlet conundrum of medicating during pregnancy?

Voraciously.

The two biggest sources of help for me were Karen Kleiman’s What Am I Thinking? Having a Baby After Postpartum Depression and Kornstein/Clayton’s Women’s Mental Health. Karen’s book allowed me to realize my emotions were right on target for a woman facing pregnancy (expected or not) after surviving a PMD episode while Women’s Mental Health laid out the risk factors in a no-nonsense manner. I was convinced to stay on medication after I read my risk for relapse went up by 50% if I discontinued my medication during pregnancy. With my risk factor already 50% higher than women having never experienced a PMD, there was no way I was giving myself a 100% risk of traveling down that road.

I stayed on my medication. I stayed in therapy. I talked to my family and developed a postpartum action plan, spending more time on preparing for my possible fall than for my son’s arrival. And you know what, it paid off big time. I did not experience a PMD the third time around, even though (yes, more studies) having a boy may put you at a higher risk for developing a PMD and the risk for experiencing a PMD after two episodes is almost 100%. I beat the odds and don’t think a day doesn’t go by that I don’t give thanks to God for carrying me through.

I always encourage women I come in contact with to weigh their options with their caregivers. To educate themselves and make the best decision possible with the information at hand. Your doctor is on your team and should be willing to listen to your plan and at least consider your requests. If he/she does not respect your wishes, it may be time to find another physician for care during the prenatal period.

I would also encourage you to get a couple of books, the first being Dr. Shosh’s Pregnant on Prozac, in which she examines the relationship of psychiatric medications to pregnancy. It’s a must have resource for mothers facing the decision of psychiatric medication for an existing condition or a newly diagnosed condition. Also pick up a copy of Karen Kleiman’s Therapy & The Postpartum Woman. While this book is ultimately aimed at clinicians and the postpartum woman, pregnant women facing a mood disorder would glean quite a bit from this book as well and may consider gifting it to their caregiver as well, a paying it forward action if you will.

And if you’re interested in complementary or alternative treatment methods that don’t include SSRI’s, a great place to start researching is over at Well Postpartum. Run by Cheryl Jazzar, this blog has just about everything you could ever want to know about alternative care during the Perinatal Period.

The final thought on all of this? Do your homework. Don’t be afraid to ask questions or stand up for yourself (and your child). Above all, make the decision and agree not to second guess yourself or blame any outcome on yourself. As long as you make the best decision with the best information at your fingertips at the time, there is no blame. (And hey, the fact that you’re reading this article right now speaks pretty highly of your motivation to educate yourself!)

No matter how alone you may feel in that dark pit of depression during pregnancy or postpartum, you’re not. There are plenty of other women there with you and there are lots of us reaching our hands down to help you out. All you have to do is reach out and grab.

# New PPD Help for Middle TN

SAINT THOMAS HEALTH SERVICES PARTNERS WITH HOPE CLINIC FOR WOMEN TO PROVIDE POSTPARTUM DEPRESSION COUNSELING AND EDUCATION

NASHVILLE, Tenn. – Jan. 23, 2009 – Saint Thomas Health Services has developed a partnership with Hope Clinic for Women to provide better counseling and educational resources for Middle Tennessee women suffering postpartum depression.

Baptist Hospital in Nashville and Middle Tennessee Medical Center (MTMC) in Murfreesboro, Tenn., which are part of Saint Thomas Health Services, make follow up calls to new moms once they return home. Some of the questions asked are related to postpartum depression and the women can be connected to the Hope Clinic for Women for a full phone assessment or to set up counseling, if necessary. In addition, physicians at Baptist Hospital and MTMC can refer patients who might benefit from the treatment services offered and the program is open to any women in the Middle Tennessee community who may be experiencing postpartum depression.

Resources available from Hope Clinic for Women include screening and diagnostic assessment, individual or couples therapy, support groups, support services for fathers or referral for psychiatric  evaluation and follow up. Services are offered on a sliding scale, based on the ability to pay.

“Our hospitals deliver nearly 10,000 babies combined per year and based on input from our obstetricians, mental health – especially postpartum depression – is very under-served in Middle Tennessee,” said Amanda Cecconi, women’s health service line executive for Saint Thomas Health Services. “Part of the patient experience we provide is to ensure new moms have what they need when they return home. Unfortunately, postpartum depression is often a ‘silent topic.’ We want to be proactive by helping identify women who may be suffering from it and to offer additional resources. Hope Clinic for Women, also a faith-based organization, was a natural fit to develop a partnership.”

As many as 80 percent of women experience some mood disturbances after pregnancy. Many suffer the “baby blues,” which can last from several days up to two weeks after delivery and are characterized by mood swings, crying, feelings of doubt or being overwhelmed. These feelings subside as hormone levels begin to stabilize.

One in seven women will experience postpartum depression, which usually occurs within a few months of delivery and should be treated by a health professional. It is more serious and a major form of depression that usually occurs within a few months of delivery and can last up to a year. Its peak onset usually occurs between two and 12 weeks postpartum. Symptoms can include drastic changes in motivation, appetite or mood, severe disruptions in sleep, excessive crying without cause or provocation and difficulty concentration.

“Postpartum struggles are common and the symptoms are treatable,” said Kristi Marshall, director of client programs for Hope Clinic for Women and a counselor for the program. “Our hope is that new moms won’t let feelings of shame or embarrassment get in the way. Seeking treatment doesn’t mean admitting failure; it is the first step in the road to relief. We’re here to help answer questions or provide treatment. We’re proud to be partnered with these hospitals.”

Saint Thomas Health Services assisted Hope Clinic for Women in obtaining postpartum depression training for two of its staff members.

Hope Clinic for Women has locations in Nashville at 1810 Hayes Street and in Spring Hill at The Garden, 2620 Thompson Station Road East. Another location in Rutherford County will be added in the near future.

For more information, call Saint Thomas Health Services at (615) 284-PINK (7465) or Hope Clinic for Women at (615) 321-0005 or visit www.hopeclinicforwomen.org.

Saint Thomas Health Services is a faith-based ministry with more than 8,000 associates serving Middle Tennessee. Saint Thomas Health Services’ regional health system consists of four hospitals – Baptist and Saint Thomas in Nashville, Middle Tennessee Medical Center in Murfreesboro and Hickman Community Hospital in Centerville – and a comprehensive network of affiliated joint ventures in diagnostics, cardiac services and ambulatory surgery as well as medical practices, the Center for Spinal Surgery, clinics and rehabilitation facilities. STHS is a member of Ascension Health, a Catholic organization that is the largest not-for-profit health system in the United States. For more information, visit http://www.sths.com.

# Blogs as Peer Support for PPD

With the recent release of the study regarding how helpful peer support is for women with Postpartum Depression, I thought it would be interesting to take a look at blogging as a form of peer support. The source of inspiration for this piece? An article by Kristin Schorsch over at the South Town Star about blogging and PPD in which yours truly is featured along with Natalie Dombrowski.

Many of the women I know who have blogs and have recovered from Postpartum Depression have found their blogging habit to be a powerful source of support. Those who read them undoubtedly feel the same way, finding strength and hope in the words that part ways with those of us who have been through the very dark in which they now find themselves enrobed.

For me, there was relief in knowing I had my blog to lean on and that through my blog I was potentially helping other families survive the very same thing I struggled against. I credit my blogging as a tremendous part of not experiencing PPD the third time around. After all, I had numerous risk factors according to several different studies and statistics.

My first risk factor lied within being a two time survivor. A third episode lies in a nearly 100% risk range. Studies have also shown that women who give birth to boys are more likely to experience Postpartum Depression than mothers who give birth to girls. My third child? A boy. I also had extenuating stressors – a marriage that was dashed onto the rocks at just 3 months postpartum after giving birth to Cameron and financial stressors to boot. Last but not least, women who experience severe pelvic pain during pregnancy are also more likely to suffer from Postpartum Depression. And guess what? I had severe pelvic pain with all three but it was the worst with Cameron. Relying solely on numbers, I should have suffered from Postpartum Depression with Cameron. Yet I didn’t.

Why?

I had peer support, social support, medication, education, blogging, meetings, advocacy, and preparation on my side.

But hey, I had all that too you say. And I still ended up suffering. Unfortunately this is where it gets tricky. What works for one woman in one situation may not work for another woman in her situation.

Why? We don’t necessarily know. What we do know is that communication with other women and TRAINED medical professionals is key to recovery. This is where I get on my soapbox.

The MOTHER’S Act would allow for research funding so we might be able to find these things out. It would also allow funding for additional social and community support programs to be implemented across the country so that no family would have to suffer silently. It would allow for women to speak up without fear about their intrusive thoughts, to admit they are not happy at a time when they feel they should be. It would educate caregivers so no more women would have to be fear being dismissed when they do speak up, as I was. It would decrease potentially lethal cases of untreated Postpartum Depression and catch episodes of Postpartum Psychosis before they reached the breaking point.

The MOTHER’S Act would finally allow for the recognition of Postpartum Mood Disorders as a true illness, allowing for the flow of ideas and treatment options between patients and clinicians to open up. It would allow us to finally create treatment networks between Pediatricians, OB’s, Therapist, Psychologists, and Psychiatrists, keeping women from slipping through the cracks and confused about which medical professional to talk with regarding their emotions.

The passage of the MOTHER’S Act would allow those of us who have survived and those of us who are still struggling to finally begin to live over the rainbow, where we deserve to live. Where there is finally acceptance, happiness, and true hope instead of disapproval, sadness, and despair that permeates the lives of so many women and families fighting to rid themselves of the beast of Postpartum Depression.

Off the soapbox now.

I blog to provide the land over the rainbow for myself and for others. We’ve fought hard enough against the rain on our own. Nothing more, nothing less. Providing hope to those who struggle behind me, those deserving of a helping hand as they claw furiously against the muddy wall of the hole they now find themselves lost inside.

We all deserve the rainbow.