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The Problem of Postpartum Depression

During your pregnancy, you knew from your reading to expect emotional changes, but now you may be overwhelmed by worry and sadness. Where is the happiness you know you should be feeling? The fact that it seems beyond your grasp makes you feel even worse.

Despite being exhausted from the responsibilities of new motherhood, you lie awake at night worrying about your baby's health and your ability to mother him or her. During the day, you are constantly anxious about harm befalling your baby. You can barely think clearly enough to decide what to have for lunch, and the idea of making any kind of important decision about how to deal with issues that come up for your baby is more than you can stand. You realize that you must be suffering from postpartum depression.

Nearly every book on pregnancy and childbirth warns new mothers of the possibility of postpartum depression (PPD). In order to be diagnosed with PPD, you must suffer from depression, or lack interest in life, for most of the day, every day, for two weeks or more following the birth of a child. An estimated one new mother in ten experiences PPD. The level of depression may be constant, or it may be mild on some days and severe on others.

A diagnosis of PPD is not made unless at least four of the following symptoms are present:

While it seems likely that many of these symptoms would be commonplace in sleep-deprived women with new babies and bodies on the mend, they can become debilitating in a mother with PPD.

Postpartum depression is often confused with a milder, more fleeting, and more common form of depression known as the "baby blues." From half to three-quarters of all new moms get the blues in the first few days after giving birth. They may burst into tears for no apparent reason or be restless, irritable, and impatient (not so uncalled-for if you are dealing with a crying newborn and stitches in your most sensitive areas). This usually goes away on its own and is often attributed to the psychological letdown after the emotional high of giving birth. However, in many instances, the baby blues or a mild form of depression called dysthymia can be prolonged for months or even years postpartum if nutrient reserves are not replenished.

About one in every thousand women experiences postpartum psychosis, complete with hallucinations, delusions, severe insomnia, agitation, and bizarre behaviors. Rarely, women suffer from postpartum anxiety/panic disorder, which shows up as intense fear, rapid breathing and heart rate, hot or cold flashes, trembling, dizziness, and even chest pain. Postpartum obsessive-compulsive disorder (OCD) can also occur, although it too is rare. It is more likely to occur in women who have had OCD in the past.

A study of more than 35,000 women showed a sevenfold increase in the likelihood of being hospitalized with a psychiatric illness during the first three months postpartum. Of the approximately 11.4 million women who give birth each year in the United States, it is thought that about 40 percent have to work their way through some sort of mood disorder after giving birth.

Psychiatrists make distinctions among numerous forms of depression. Unipolar or major depression is a very serious form of depression, as is bipolar disorder, which is characterized by severe mood swings. We do not at all suggest that those with these more serious forms of depression depend solely on the nutrients suggested. It is absolutely essential a person with a serious form of depression be under the care of a competent psychiatrist. We do look forward to the day that many more physicians will be educated in the use of the nutritional precursors to the brain neurotransmitters to help support such people nutritionally in addition to using pharmaceutical antidepressants.

Dysthymia, the more mild form of depression mentioned above, affects tens of millions of people, most of them women. Many of those who suffer from dysthymia can be helped by using nutraceuticals (nutrients taken in therapeutic dosages), either alone or as an adjunct to antidepressant drugs. The key here is to know that antidepressant drugs actually deplete the nutritional precursors the brain needs to make its own neurotransmitters and to find a physician experienced in the use of both nutritional and pharmaceutical protocols.

What causes postpartum depression?
Women who have been depressed in the past are more likely to end up with PPD, and women who have had PPD with previous pregnancies have a 70 percent chance of having it again. Those with marital problems, abusive spouses, substance abuse problems, or a lack of social support are more likely to have PPD. Many experts feel that these factors are enough to explain the PPD phenomenon.

Other researchers believe that there is a biological mechanism at work. Fluctuations in hormones, including thyroid hormone, cortisol, prolactin, progesterone, and estrogen, can strongly influence a woman's emotional state. There is nothing like the transition from late-term pregnancy to new motherhood to toss one's hormones into complete disarray. Changes in brain levels of the neurotransmitters serotonin and norepinephrine also take place soon after a woman gives birth, and these changes are thought to be very important contributors to PPD as well. Deficiencies of the amino acids, vitamins, and minerals that form these neurotransmitters can severely limit the ability of the brain and nervous system to make them.

The scientific consensus is that PPD is multifactorial, which means that all of the above variables – hormonal, psychological, and neurochemical – come into play. We believe that all of these factors share one important and commonly overlooked characteristic: The balance of each of these systems relies upon proper nutrition. If the nutritional building blocks that the body needs to make hormones, neurotransmitters, and other mood-altering body chemicals are not present in adequate amounts, mood and physical health can both be compromised.

Medical treatment for postpartum depression
As is the case with depression unrelated to pregnancy, mood-altering drugs and psychotherapy are conventional medicine's treatments of choice for PPD. While talking to a trusted friend or psychotherapist is often helpful, the usefulness of the drugs most often prescribed for women with PPD has not yet been proven. Most physicians treat PPD with various psychiatric drugs that, in effect, trick the brain into thinking it has more neurotransmitters than it actually does – specifically, that levels of one or both of two very important brain neurotransmitters, serotonin and norepinephrine, have been increased. Serotonin and norepinephrine are fundamental to a healthy body because they carry nerve signals and messages throughout the brain and the rest of the nervous system. They have a profound effect on mood and self-esteem, as well as on many other important functions within the body. A deficiency of these neurotransmitters can lead to depression, anxiety, insomnia, anger, obesity, and a host of other serious ailments.

In the vast majority of cases of PPD, the real cause of low levels of serotonin or norepinephrine in the brain is a deficiency of the nutritional precursors that the body needs to make these neurotransmitters. Interestingly, not only do the psychiatric drugs most commonly prescribed for PPD not increase serotonin and neroepinephrine levels, but they actually cause the body's reserves of the nutritional precursors needed to produce them to be used up more rapidly, worsening the state of nutritional deficiency. This is probably why it is so difficult for so many people to go off these drugs. It is not unusual for doctors to hear that a person had a very good initial experience with one of these drugs but that, as time passed, the good feelings wore off and higher doses and/or different medications were needed.

The most common class of drugs physicians prescribe for PPD is known as selective serotonin reuptake inhibitors, or SSRIs, the best-known of which is fluoxetine (Prozac). Other medications in this category include citalopram (Celexa), paroxetine (Paxil), and sertraline (Zoloft). These agents act by keeping serotonin in the brain's synapses (the spaces between nerve cells) for a longer period of time. They also pull serotonin out of the "serotonin stores" in the brain cells and pull it into the synapses. However, as we learn so tragically from time to time when we hear of mothers on medication for PPD who harm or even kill their children, these drugs don't always work. In fact, they fail to work over the long term at least one-third of the time. SSRIs speed up the rate at which serotonin is used up in the brain. If you drive a car at a high rate of speed, it uses up more gas and you have to fill up the tank more often. Similarly, if you speed up the rate at which the brain uses up serotonin by taking SSRIs you will need to replace the nutritional precursors more rapidly.

Why are so many people apparently suffering the effects of low serotonin levels? There are a number of reasons. Serotonin and a group of neurotransmitters called the catecholamines – adrenaline (epinephrine), noradrenaline (norepinephrine), and dopamine – which are predominantly made by the adrenal glands, work together and need to be in balance within the nervous system. As the general level of stress with which we live has gone up, our adrenal glands have been induced to make more catecholamines. The brain then is faced with the need to make more serotonin to maintain a proper balance. It is estimated that the level of stress most of us face on a daily basis is 100 times higher than that faced by our grandparents. The world keeps getting more complicated, and our nervous systems keep trying to adapt. We have reached a point at which many people's brains are having trouble making enough serotonin to match the levels of adrenal catecholamines required to cope with life.

There are a number of other factors that make it more difficult for our brains to produce enough serotonin. The brain needs a steady supply of the amino acid tryptophan and vitamin B6 to make serotonin. Proteins in foods contain a very small percentage of tryptophan as compared with other amino acids. Only about 3 percent of the tryptophan in food is actually converted into serotonin in the brain. This is partly due to the fact that about 95 percent of the serotonin in the body is needed and used in the intestinal tract. Further, to reach the brain, tryptophan must be ferried across the blood-brain barrier (a protective mechanism in the brain that keeps certain substances from easily entering the inner sanctum of the brain) by means of a carrier protein. Tryptophan has to compete with other amino acids for these carrier proteins, and this limits the amount of tryptophan that can enter the brain at any given time. Further, the adrenal hormone cortisol, which is produced in response to stress, converts tryptophan into a chemical called kynurenine, which cannot be converted into serotonin. If you drink coffee, smoke cigarettes, drink alcohol, eat chocolate, take diet pills, or just have a lot of stress in your life – and what mother doesn't? – your body will produce too much cortisol, increasing the amount of tryptophan that is converted to kynurenine and limiting the amount available to produce serotonin.

To make matters even a bit more difficult, the production of serotonin does not take place in a single step, but is a complicated biochemical process, and each of the steps along the way requires specific nutrients. Your body must have enough iron and vitamin B3 (niacin) to convert tryptophan into a compound known as 5-hydroxy-L-tryptophan (5-HTP) and enough other B vitamins plus the mineral magnesium to convert vitamin B6 to pyridoxal-5-phosphate (P5P), the form necessary for serotonin production. Without enough 5-HTP and P5P available in the brain, serotonin cannot be made at adequate levels. Doctors cannot simply give their patients serotonin orally or intravenously because serotonin is fat soluble and does not pass through the blood-brain barrier. The only way that the brain can get serotonin is to make it from the specific nutritional precursors available to it at the time. (Fortunately, 5-HTP and P5P are available in supplement form.)

All of these factors can lead to an individual having an inadequate supply of serotonin for optimal health, and in turn may explain the startling statistic that an estimated one in ten Americans – and one in four women! – is now on SSRI drugs.

The safety of SSRIs for the babies of nursing mothers also has not been proven. Some studies have linked the maternal use of Prozac to colic in nursing infants. A baby with colic can push the most even-tempered mother over the edge. For this reason alone, giving such a drug to a mom with PPD doesn't seem like the best way to support her recovery. Further, Prozac and similar drugs pass into a nursing mother's milk and, thus, into her baby's body. While studies have shown that little or no drug circulates in a baby's bloodstream, others that have looked at the concentrations of the drug in babies' brain tissue have found much higher levels. Nothing is known about the possible harm this can do to a newborn.

Some mothers choose to take the drugs and not to nurse. This deprives their babies of the most perfect food they can be given, and deprives both mother and child of the important bonding that comes with breastfeeding. Mothers with PPD who miss out on the bonding experience of breastfeeding may end up feeling even more distant from their babies. Most of the mothers we have consulted with who chose to take SSRIs over breastfeeding would have chosen to nurse if they had felt there was any other way to heal PPD. Unfortunately, mainstream medicine routinely tells new mothers with PPD that these drugs are the only way out.

The dangers of SSRIs go beyond their dangers to the baby. One potential side effect of these drugs is a feeling of numbness, of separateness from others. Feeling numb does tend to blunt depression, but it may do so at the expense of a new mother's feelings of intimacy with her baby and her partner at this crucial time. The most common side effects of SSRIs include nausea, sleepiness, insomnia, sexual dysfunction, headaches, trembling, indigestion, abdominal pain, and nervousness. SSRI drugs also seem to lift normal inhibitions against violence and suicide in some people. Prozac has been linked with violence toward others, suicide, and self-mutilation, and thus may even play a part in enabling an overwrought woman to commit one of the worst crimes imaginable – causing serious harm to her child. Many experts, including Harvard University psychiatrist and author Joseph Glenmullen, M.D., and Peter R. Breggin, M.D., psychiatrist, author, and director of the nonprofit International Center for the Study of Psychiatry and Psychology (ICSPP), warn that SSRIs are overprescribed and that their dangers are drastically underplayed.

Dr. Glenmullen's most recent book, Prozac Backlash (Simon & Schuster, 2000), warns that SSRIs can cause symptoms similar to those of Parkinson's disease – including facial and body tics and muscle spasms that may persist even after the drug is discontinued – in at least 10 percent of those who use them. This finding implies that SSRIs may create dangerously low levels of the neurotransmitter dopamine in some people. Moreover, the long-term effects of Prozac and similar drugs are not known, but some studies indicate that permanent brain damage could occur because the constant artificial elevation of the neurotransmitter serotonin eventually burns out the serotonin receptor sites in the brain and makes them unable to respond.

The manufacturer of Prozac insists that no link between the drug and suicide has been proven. Interestingly, however, they will be marketing a newer version of the antidepressant, which, according to published reports, they will advertise as less likely to cause suicide and violent behavior in those who use it – raising the question of why they would use this issue as a selling point. The "new Prozac," R-fluoxetine, is set to hit the market just as the patent for the current version, which has had sales in excess of $2 billion a year, runs out. Incidentally, Sarafem, an antidepressant that is being marketed heavily for a form of premenstrual syndrome (PMS), is chemically identical to Prozac – with a different, female consumer-savvy name.

Serotonin does seem to play a role in depression, and that is why SSRIs can provide relief. Keep in mind, however, that no one has shown that a chemical imbalance – in this case, low serotonin levels – is the sole cause of depression. Boosting serotonin will improve most people's moods, but this symptomatic relief at best because the nutritional precursors the brain needs to produce its own serotonin remain depleted unless deliberately replenished. As Dr. Breggin says in his book Talking Back to Prozac (St. Martin's Press, 1994), depression is not caused by a Prozac deficiency any more than a headache is caused by an aspirin deficiency.

Fortunately for those who wish to avoid SSRIs, there are ways to elevate serotonin levels naturally with foods and supplements. We believe that taking SSRIs can make things worse for many women who suffer from PPD, and we do not recommend using them, especially over the long term, unless you have one of the more serious forms of depression. If you do need them for the short term, you should enlist your doctor's assistance to help you wean yourself off them as soon as possible. Never stop using SSRIs abruptly, however, as this can cause serious withdrawal symptoms. Taper off gradually with the guidance of a knowledgeable physician, preferably one who is experienced in prescribing increasing amounts of the nutritional precursors you need as you wean off the drugs.

Many women suffer from a kind of depression that results not at all from low brain serotonin levels but from low levels of another brain neurotransmitter, norepinephrine. Increasing serotonin levels with drugs does not help this kind of depression. On the contrary, it often makes people even more tired and depressed. Women with low serotonin levels tend to have a great deal of anxiety, while women with low norepinephrine levels feel like they fell into a deep, dark hole and just cannot muster the energy to get out of it, or elicit more than one positive thought in a row. People with low norepinephrine levels are often dramatically helped by restoring normal thyroid and adrenal gland function. The amino acid tyrosine, along with P5P, copper, iron, and vitamin C, is necessary to make norepinephrine. Tyrosine, along with the mineral iodine, is also the main nutritional precursor for all the thyroid hormones.

As you will discover, we believe that the vast majority of cases of PPD can be prevented and/or treated very successfully without resorting to drugs that may harm you and your baby. The natural strategies presented can help to restore serotonin levels and replenish key nutrients and other biochemicals that are likely to be depleted as a result of bringing a child into the world. We will see how a woman's nutritional status is affected by pregnancy and birth, how this can determine her overall state of health, and, most important, what she can do to regain a state of balance and well-being.

From A Natural Guide to Pregnancy and Postpartum Health by Dean Raffelock, Robert Rountree, and Virginia Hopkins with Melissa Block. Copyright © 2002 by Dr. Dean Raffelock. Used by arrangement with Avery, a member of Penguin Group (USA) Inc.

To order this book visit www.penguin.com. Get a 15% discount with the coupon code FENPARENT.

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