Can Estrogen Be Used to Treat Posptartum Depression?

After delivery there is a dramatic drop in levels of estrogens and progesterone. Many have hypothesized that this decline in estrogen levels may precipitate postpartum depression (PPD) in susceptible individuals, and several studies have explored the use of estrogen for the treatment of depression after delivery. Gregoire and colleagues have shown a beneficial effect of estrogen therapy in a double blind, placebo-controlled study of women with PPD. Although this study was small and was confounded by the inclusion of patients who were simultaneously treated with antidepressant medications, it is the first to demonstrate that estrogen alone or when used in conjunction with an antidepressant may be useful in women with PPD.

More recently, Ahokas and colleagues have shown that estrogen alone was effective in women with PPD.

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

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

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

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

Support the MOTHERS Act by Calling Your Senator

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

What is the MOTHERS Act? 

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

Specifically, the MOTHERS Act will help new mothers by:

• Providing important education and screening on postpartum depression (PPD) that can lead to early identification and treatment.  The legislation includes two grants to help better educate healthcare providers to identify and treat PPD.
• Expanding important research to improve and discover new treatments, diagnostic tools and educational materials for PPD.  Since the exact cause of PPD isn’t known, research continues to be the key to unlocking the mystery of this condition.

What can you do?

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

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

Why do you have to contact your senator?

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

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

A Deeper Shade of Blue Now Available in Paperback

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

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

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

Available through Amazon and many other online retailers.

SSRIs and Pregnancy: Putting the Risks into Perspective

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

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

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

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

National Depression Screening Day

October 11th is National Depression Screening Day. To find a screening site in your community, look here.

For women who are pregnant or postpartum the Edinburgh Postnatal Depression Scale (EPDS) is a good screening tool. You may find a copy of the EPDS here. An online version of the EPDS may be found here.

Perinatal Programs in US and Canada

It can often be difficult to find good psychiatric care in your area.  Katherine Stone at Postpartum Progress has put together a list of programs in the United States and Canada offering care for women who suffer from mood and anxiety disorders during pregnancy and the postpartum period. 

Antenatal Depression and Anxiety May Affect Infant Sleep Patterns

About 15% of women suffer from depression during pregnancy, and many reports have suggested that depression during pregnancy may have negative effects on the fetus   A new study has discovered a link between depression and anxiety during pregnancy and infant sleep problems after childbirth.

Dr. Thomas O’Connor and his colleagues evaluated data from a large study in England called the Avon Longitudinal Study of Parents and Children (ALSPAC).  They analyzed data from  over 14,000 women giving birth.  Maternal mood and anxiety levels were assessed during pregnancy and the postpartum period, and infant sleep was assessed at 6, 18, and 30 months.  Higher levels of prenatal maternal anxiety and depression predicted more sleep problems at 18 and 30 months.

For instance, O’Connor tells WebMD, "Mothers with elevated anxiety at 18 weeks were 39% more likely to have children with sleep problems at 30 months. Mothers depressed at 32 weeks were about 40% more likely to have a child with sleep problems at 30 months. That’s true even after controlling for smoking, alcohol intake, and postnatal mood."

O’Connor and his colleagues speculate that the stress hormone cortisol is behind the pregnancy mood and sleep problems link. "We know moms who are anxious in pregnancy have higher levels of the stress hormone cortisol," he says. "There is an association between a pregnant woman’s level of stress hormone and stress hormone in the amniotic fluid. The placenta has an enzyme that breaks down the stress hormone. But evidently some still gets through.

This is yet another study that points to the importance of screening women for depression and anxiety during pregnancy.  Initiating treatment early on may have important beneficial effects for both the mother and her baby.

O’Connor TG, et al.  Prenatal mood disturbance predicts sleep problems in infancy and toddlerhood.  Early Human Dev 2007; 83: 451-8.

Antenatal Depression: Navigating the Treatment Dilemmas

About 10% to 15% of women suffer from depression during pregnancy.  Literature accumulated over the last decade supports the use of certain selective serotonin reuptake inhibitors (SSRIs) and the older tricyclic antidepressants during pregnancy, indicating no overall increase in the risk of congenital malformation in children exposed to these medications during the first trimester of pregnancy. Still, questions remain regarding the reproductive safety of SSRIs, including one report suggesting an association between exposure to SSRIs late in pregnancy and persistent pulmonary hypertension of the newborn (PPHN) and several other reports suggesting that paroxetine use may be associated with an increased risk of cardiovascular malformation.

In a very thorough and thoughtful article published in the American Journal of Psychiatry, Dr. Marlene Freeman discusses various options for treatment.  In summary:

Sorting out the risks and benefits of treatment for depression, particularly those of antidepressant medications, is complicated in pregnancy. The selection of treatment should be based on the severity of symptoms, the patient’s depression history (including past response to medication), and the patient’s preferences. In women with mild depression, nonpharmacological approaches may be useful first-choice treatments. In women with moderate to severe depression or a history of previous postpartum depression or recurrent major depression, antidepressants should be strongly considered, alone or in combination with nonpharmacological treatment.

And here’s another good review of the topic from Dr. Claudio Soares:

Journal Watch Psychiatry

Antenatal Depression: Navigating the Treatment Dilemmas

About 10% to 15% of women suffer from depression during pregnancy. Literature accumulated over the last decade supports the use of certain selective serotonin reuptake inhibitors (SSRIs) and the older tricyclic antidepressants during pregnancy, indicating no overall increase in the risk of congenital malformation in children exposed to these medications during the first trimester of pregnancy. Still, questions remain regarding the reproductive safety of SSRIs, including one report suggesting an association between exposure to SSRIs late in pregnancy and persistent pulmonary hypertension of the newborn (PPHN) and several other reports suggesting that paroxetine use may be be associated with an increased risk of cardiovascular malformation.

In a very thorough and thoughtful article published in the American Journal of Psychiatry, Dr. Marlene Freeman discusses various options for treatment. In summary:

Sorting out the risks and benefits of treatment for depression, particularly those of antidepressant medications, is complicated in pregnancy. The selection of treatment should be based on the severity of symptoms, the patient’s depression history (including past response to medication), and the patient’s preferences. In women with mild depression, nonpharmacological approaches may be useful first-choice treatments. In women with moderate to severe depression or a history of previous postpartum depression or recurrent major depression, antidepressants should be strongly considered, alone or in combination with nonpharmacological treatment.

Postpartum Support International Offers Free Open Forum

PSI is now offering free Postpartum Open Forum via it’s 800 teleconference line. Limited to the first 15 callers, these sessions, which are informational only, will offer participants an opportunity to ask questions and obtain information from PSI healthcare professionals. The sessions are opened to women who feel they may be suffering from a pregnancy related mood disorders as well as concerned family members and friends.

Participants must call 1-800-944-8766 five minutes before the call begins.