An Integrative Approach To The Prevention And Treatment Of Postpartum Depression (ppd)
Dean Raffelock, D.C., L
Dean Raffelock, D.C., L. Ac, CCN, DACBN, DIBAKHyla Cass, M.D.
Postpartum depression (PPD) Postpartum Anxiety (PPA) have become a national epidemic in the United States, affecting 15%-20% of all new mothers, or about 600,000-800,000 women annually. (1) It is now estimated that over 30 million Americans are on antidepressant or anti-anxiety medications. (2) The majority of this 30 million are women who have one or more children. The chance of suffering from PPD increases with each successive child. (3)
The most common medical treatment for postpartum depression is SSRI (selective serotonin reuptake inhibitors) antidepressant drugs. Postpartum Anxiety Disorder is most commonly treated by the benzodiazepine family of drugs like Valium, Ativan, Xanax, and Klonopin. Combination reuptake inhibitors for both serotonin and norepinephrine (SNRIs) are also commonly used in postpartum depression. In the case of postpartum psychosis, antipsychotic drugs are used and are immediately necessary. Many women are now given samples of SSRIs as they are leaving the maternity ward. Most medical sources believe that PPD is caused by an imbalance of brain chemistry and that pharmaceutical intervention is the treatment of choice. While a certain percentage of women suffering from PPD do need pharmaceutical assistance, these are far fewer than are actually receiving them. Recent Meta-studies show this to be true. While it is clear that some women with PPD do need and benefit from pharmaceutical intervention, it is our experience that an integrative approach yields the best results.
Postpartum Anxiety Disorder is mostly treated
The most common Postpartum Depression symptoms include the following:
1. Persistent feelings of despair and/or anxiety;
2. Loss of energy and low levels of daily functioning;
3. Sleep and eating disturbances;
4. Inability to focus, concentrate or make decisions;
5. Feelings of worthlessness, shame and guilt;
6. Feelings of indifference and/or resentment towards the baby;
7. Intrusive negative thoughts and/or obsessive worries""in the most serious cases, this includes thoughts of harming oneself or the baby;
8. Reduced sex drive;
9. Loss of joy and appreciation for life;
10. Irritability or excessive anger.
The literature generally outlines several types of postpartum disorders that have special features beyond the typical symptoms of depression. These include:
1. Postpartum Anxiety Disorder (PPA). Here, the primary symptoms are excessive nervousness, hyper-vigilance, racing thoughts and in some cases outright panic. Panic attacks are especially frightening""sufferers often believe they are dying, as they experience shortness of breath, dizziness and a pounding chest.
2. Postpartum Obsessive-Compulsive Disorder. Most often, this takes the form of obsessive thoughts or worries about the baby and may be accompanied by compulsive behaviors such as constantly checking if the baby is breathing, constantly washing to protect the baby from germs, etc. The most disturbing type of obsessive thoughts are those in which the mother envisions harming her baby in some way. These thoughts are unwanted, intrusive and terrifying to the mother. It is important to emphasize that, except in extremely rare instance of psychosis (see below), these thoughts are not accompanied by any actions. Nonetheless, the mother may be so frightened by her own thoughts that she avoids the baby and consequently neglects her. It is terribly difficult for new mothers to acknowledge having such thoughts, and as a result, many suffer in isolation.
3. Post-traumatic Stress Disorder. PTSD can occur in response to a real or perceived traumatic childbirth or because of unresolved past trauma""sometimes sexual in nature""triggered during childbirth. A woman who experiences PTSD is likely to have recurring, memories, dreams or even flashbacks of the traumatic labor/birth. She will be hyper-vigilant and startle easily, and will likely suffer from sleeplessness, irritability, poor concentration and apathy. Women who have experienced a particularly traumatic childbirth often show symptoms of both PTSD and PPD.
4. Postpartum Psychosis. This is the most extreme and rarest of all postpartum disorders. When it occurs, the mother loses touch with reality and her symptoms may include extreme disorientation (e.g., not knowing who she is), delusional or paranoid thinking, and visual or auditory hallucinations. The few, tragic cases where mothers have harmed their children while in a psychotic state have received enormous media attention. As a result, many people inaccurately associate PPD with psychotic symptoms and dangerous behavior. This constitutes yet another reason why women fail to get help""they want to avoid being labeled with such a stigmatized disorder.
Article Premise: Fully Replenishing a New Mother"s Postpartum Nutritional Reserves Has Been Largely Ignored and Should be An Integral Part of Treating Postpartum Depression.
Foundations of A Nutritional Approach to PPD
The human body is entirely formed from nutrients. Every muscle, organ, gland, bone, cell, and fluid is composed entirely of nutrients (environmental toxins notwithstanding). All of the neurotransmitters, hormones, biochemical structures, and metabolic pathways are formed from nutrients.
No other normal physiological process uses up and drains more vital nutrients from a postnatal woman"s body than the process of being pregnant, giving birth, and caring for a new infant which may include breastfeeding. The fact that a mother"s body donates all the nutrients required to form her baby"s body is too often overlooked when it comes to the medical treatment of PPD. Not only does the placenta literally rob the mother"s body of all the key nutrients required to make a baby"s body, but the placenta itself is formed from nutrients taken from the mother"s body. This is the main reason that many postpartum women become nutritional drained and this nutrient depletion syndrome can lead to postpartum depression and anxiety disorder.
Other factors that may contribute to a drain of a new mother"s nutrient reserves are loss of blood during the birth process, sleep deprivation, breastfeeding, returning to work too soon, and the immense extra energy required to take care of a new infant with intense needs. If a pregnant woman"s or new mother"s nutrient reserves are too low, she is much more vulnerable to experiencing PPD and PPA because all of the body"s normal metabolic processes are entirely dependent upon nutrients. The preponderance of extremely poor quality pharmaceutical prenatal vitamins significantly adds to the tendency of nutrient depletion.
Rarely is there is any mention that the body"s production of neurotransmitters is completely dependent upon their nutritional precursors. (4) Nor are the causes of these nutritional precursor deficiencies discussed. Additionally, the interdependent relationship between hormones and neurotransmitters is rarely taken into consideration by most physicians when considering treatment for PPD and PPA. The nutritional requirements of mitochondrial function, the importance of liver function from Western and Eastern perspectives, and some individual nutrients like Omega 3 fish oils, pharmaGABA, L-theanine, SAMe, inositol, magnesium, and the herb St. John"s Wort can also be of great assistance in treating PPD and PPA. These will be briefly discussed.
An integrative approach to treating PPD may include nutritional therapies, bio-identical hormone replacement, moderate exercise, a nutrient dense diet, proper rest, psychological counseling/support, stress reduction techniques, elimination of caffeine, alcohol and other addictive drugs, and if needed, pharmaceutical intervention.
Neurotransmitter Nutritional Precursors
Serotonin and Tryptophan
The amino acid L-Tryptophan is required for the body to produce serotonin. Ninety-five percent of the serotonin in the human body is produced in the intestinal tract. Approximately five percent is produced in the brain. The serotonin produced in the intestinal tract is unavailable to the brain because serotonin cannot pass through the blood- brain barrier. L-Tryptophan also does not easily pass through the blood-brain barrier and requires a carrier protein to ferry it into the brain. The consumption of simple sugars changes brain neuron cell membrane amino acid selectivity, allowing tryptophan to enter the brain more easily. Hence, the craving of sweets is often a sign of serotonin deficiency.
Serotonin has been referred to as the brain"s mood elevating and tranquilizing chemical. Inadequate serotonin levels are linked with depression, anxiety, insomnia, irritability, and weight gain. Serotonin mediated depression usually contains an element of anxiety. Serotonin is considered an inhibitory neurotransmitter. Its functions include:
- Inhibiting Glutamate excitability over diverse regions of the CNS
-Stimulating its own receptors on GABA neurons prompting GABA to perform its inhibitory function
- Inhibiting the release of the Catecholamines: Dopamine, Norepinephrine, and Epinephrine.
A comparison of the effects of optimal serotonin levels to low serotonin levels to reveals the following contrasts:
1) Hopeful/optimistic""""""""""-Depressed
2) Calm""""""""""""""""""Anxious
3) Good-natured""""""""""""""Irritable
4) Patient""""""""""""""""""Impatient
5) Reflective/ thoughtful""""""""""Impulsive/Reactive
6) Loving /Caring""""""""""""""Abusive
7) Able to concentrate""""""""""-Short attention span
Creative/focused""""""""""""Blocked/scattered
9) Moderate carbohydrate intake""""""Excessive carbohydrate intake
10) Good sleep and dream recall""""""Insomnia and poor dream recall
Tryptophan is converted to its metabolite, 5- Hydroxy-Tryptophan (5-HTP) which is then converted to serotonin. Niacin, iron, and folic acid are required for L-Tryptophan to be converted into 5-HTP. The body also requires pyridoxal-5-phosphate along with 5-HTP in order to produce serotonin. Magnesium and riboflavin (B2) are required for the conversion of pyridoxine (B6) into pyridoxal-5-phosphate. Deficiencies in any of these nutrients can limit the production of serotonin. Numerous double-blind studies have shown 5-HTP to be as effective as antidepressant drugs with fewer and milder side effects and most times better tolerated. (5-11)
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From Martin Hintz, M.D. ""Neuro Research
A number of significant factors contribute to low L-Tryptophan levels in many people, especially postpartum women whose bodies are providing the proteins needed to form another human body, these include excessive levels of cortisol, epinephrine, norepinephrine, and dopamine. The ratio of L-tryptophan to other amino acids available in most foods is quite low.
An overabundance of the adrenal gland hormone cortisol (a very common occurrence in stressful psychological and physiologic states) adversely affects serotonin production and sensitivity in four different ways:
1. Excess cortisol significantly decreases the number of serotonin (5-HT1A) receptor sites. (12)
2. Excess cortisol suppresses serotonin receptors. (13, 14)
3. Excess cortisol increases serotonin reuptake. (15)
4. Excess cortisol, causes tryptophan oxygenase (TO) to metabolize tryptophan into kynurenine, leaving less tryptophan to become serotonin. (15,16)
If cortisol levels are too low in the amygdala, serotonin no longer has an Inhibitory effect on Glutamatergic activity, suggesting that cortisol plays a key role in maintaining Serotonergic-mediated modulation. (16,17) This may be another factor involving insomnia in PPD.
Added to the reasons that serotonin deficiencies are growing more common and contributing to PPD is a stress-related overabundance of the catecholamines. Epinephrine, norepinephrine, and dopamine also deplete serotonin because the inhibitory monoamine neurotransmitter serotonin is supposed to balance these three excitatory monoamine neurotransmitters. The more stress a person experiences, the more the body increases the production of the catecholamines in an attempt to respond to this stress. This requires a postpartum body to produce even more serotonin "" though deficiencies in nutrient precursors may interfere with its production.
The use of 5-HTP as a nutritional precursor to serotonin has significant advantages over tryptophan. 5-HTP easily passes directly through the blood-brain barrier without the need for a carrier protein, allowing for an easier conversion into serotonin in the brain. Sublingual forms of 5-HTP work more quickly. Dosage varies from 25 mg per day to 300 mg per day or more.
A deficiency of vitamin B6 (pyridoxine), which is required for serotonin synthesis, is often found in premenopausal female patients with depression. (18) Replacing B6 in cases of deficiency is an important aspect of PPD treatment that may enhance serotonin production in the brain. (19) The use of the vitamin B6 metabolite, pyridoxal-5-phosphate, instead of B6 is suggested especially when magnesium and/or riboflavin deficiencies are suspected or confirmed. There is some controversy whether it is best to supplement 5-HTP and pyridoxal-5-phosphate together or take them separately, adhering to a two-hour wait period. Our clinical experience indicates that it fine to supplement them together. Many products including a combination of 5-HTP and P-5-P are available.
Some controversy exists regarding the simultaneous use of SSRIs and serotonin nutritional precursors. The pharmaceutical companies seem adamant about avoiding this and often mention the possibility of Serotonin Syndrome, a dangerous condition generally brought about by combining serotonin enhancing medications, especially MAO inhibitors, with medications, herbs, or nutritional precursors that also enhance serotonin activity. Symptoms of serotonin syndrome may include nausea, headache, agitation, diaphoresis, hypertension, tachycardia, and hyperthermia that can go over 104 F. This appears a remote possibility at best when just using 5-HTP or using 5-HTP in combination with one SSRI medication. (20)
SSRIs appear to not only keep serotonin in the neuron synapses longer by inhibiting reuptake, but also by pulling the nutritional precursors for serotonin from the storage vesicles and reuptake ports. In fact, in our clinical experience, many women with PPD do better when taking 5-HTP and P-5-P along with their SSRIs than taking SSRIs alone. Serotonin precursor deficiencies may be the reason that SSRIs don"t work for some, work and then stop working for others, and why it is not unusual for a woman with PPD to have been prescribed two or more different SSRIs over time. The SSRIs do not give a net increase of serotonin so they need enough available serotonin in order to have enough to re-uptake.
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Dr. Dean Raffelock- catacholamine chart
The catecholamines are predominantly energizing and mood elevating when produced at appropriate levels. Synthesis of the catecholamines occurs in the CNS, adrenal medulla, and peripheral sympathetic neurons. Norepinephrine and dopamine act primarily as neurotransmitters in the CNS. Epinephrine acts primarily as an adrenal hormone to mobilize energy.
The catecholamines influence most organ systems. When levels are excessive they are catabolic and can lead to the body metabolizing its own nerve, muscle and bone tissue. Low levels can lead to depression, fatigue, and weight gain.
Dopamine: Dopamine is the catecholamine precursor for norepinephrine and is found both in the CNS and adrenal medulla. Its functions include motor function and posture, cognitive function (attention, focus, working memory and problem solving), and pleasure sensations. Dopamine can act either as an inhibitory or excitatory neurotransmitter in response to incoming afferent signals.
Norepinephrine (noradrenaline): CNS norepinephrine mediates mood regulation, drive, ambition, learning and memory, alertness, arousal and focus. Clinically, there is often an inverse relationship between norepinephrine (excitatory) and serotonin (inhibitory). When serotonin is low, norephinephrine may be over-upregulated, resulting in "fight or flight" responses leading to anxiety and/or panic attacks. Over-expression of CNS norepinephrine is clinically associated with anxiety, aggression, irritability, mania or bipolar disease, immune suppression, and hypertension; low norepinephrine is associated with atypical depression, with symptoms of fatigue, hypersomnia, hyperphagia, lethargy and apathy.
(21,22)
Epinephrine (adrenaline): Epinephrine synthesis is dependent upon norepinephrine being converted into epinephrine by methylation.
Hans Selye (1974) described the three phase s of the "General Adaptation Syndrome" to stress (23):
Phase I: Alarm reaction: high epinephrine/high cortisol
Phase II: Resistance: high cortisol/low DHEA, variable epinephrine
Phase III: Exhaustion: depletion of cortisol, epinephrine and DHEA
Adrenal exhaustion is a major factor in depression related to chronic or severe stress.
A woman suffering from PPD should be closely questioned about her symptoms; SSRIs are routinely given to women who have functional hypoadrenia involving the adrenal cortex and/or medulla, or low thyroid function (discussed below). Low glucocorticoid and/or catecholamine levels can cause the symptoms of fatigue, malaise, and depression. (24,25)
Many women with PPD require pharmaceuticals and/or nutriceuticals that address deficiencies in both serotonin and the catecholamines. Nutritional therapies for catecholamine balance include:
DL-phenylalanine and L-tyrosine, the amino acid precursors for epinephrine, norepinephrine, and dopamine. DL-phenylalanine also helps to increase endorphins, which are mood-elevating. Many PP women diagnosed with bipolar disorder will respond well to high dose DL-phenylalanine therapy (26), along with serotonin precursors and high-dose (6 grams per day) omega-3 fatty acids in the form of fish oils. (27)
L-cysteine, sulfur, iron, and folate, required for conversion of L-tyrosine into L-dopa.
Pyridoxal-5-phosphate, required for the conversion of L-dopa into dopamine. Copper and vitamin C are required to convert dopamine into norepinephrine. Pridoxal-5-phosphate, B12, and folic acid are required to convert norepinephrine into epinephrine.
Gamma-Aminobutyric Acid (GABA)
GABA is the most important and widespread inhibitory neur
by: Dr. Dean Raffelock