Many of you have asked what type of effective complementary or alternative treatments exist for postpartum depression. I asked Kelly Brogan, MD, to help educate us all and she was kind enough to share her expertise with the following post. Dr. Brogan is an integrative reproductive psychiatrist with her own practice in New York City.
Navigating the ever-evolving risks and benefits of psychiatric treatment during pregnancy and postpartum remains a challenging endeavor. Perhaps it is in response to this complexity that many women express an interest in alternative or complementary treatments. Treating an expecting or new mother is treating an entire family, and the decisions involved require consideration of the woman as a whole, her preferences, history and the nature of her current symptoms. Given the prevalence of significant mood symptoms during pregnancy and postpartum, and the risks of untreated maternal mental illness (low birth weight, prematurity, pre-eclampsia, childhood psychiatric pathology, etc.) women must be proactive about management of emerging symptoms.
For moderate to severe symptoms of postpartum depression, a careful discussion of risks and benefits of medication treatment must be explored with an expert psychiatrist. Many complementary interventions enhance standard treatment, and may even limit the dosages required to treat to remission, and for mild symptoms they may even be considered as first-line interventions.
Per Dr. Marlene Freeman, the American Psychiatric Association is poised to release results of a taskforce on integrative treatment approaches, and future research is likely to further substantiate complementary and alternative medicine (CAM) interventions which may hold special appeal for a population concerned about the risks of medication exposures. Currently, there are several interventions with a significant evidence base despite the fact that CAM studies are often limited by challenges to controls (exercise, acupuncture), as well as limited in terms of funding for large-scale, placebo-controlled trials. In my practice, I routinely recommend omega-3 fatty acids, SAMe, light therapy, folic acid, exercise and cranial electrical stimulation, and refer to qualified acupuncturists for management of antepartum and postpartum illness.
At a recent Integrative Mental Health conference, Dr. Freeman discussed the available evidence on this subject. Meta-analysis of Omega-3 fatty acids (EPA and DHA from fish sources) have demonstrated benefit over placebo for mood support, although some outcome heterogeneity can be attributed to insufficiently powered studies (Su, Parker, Freeman, Nemets). [This means that some studies show it works, and some studies show it doesn’t, but that may be because the trials weren’t big enough.] Because of depletion of maternal fatty acids by the fetus during pregnancy and lactation, in addition to insufficient dietary consumption, Omega-3 used at therapeutic doses represents a potential benefit to both the mother and the infant.
Sam-E (S-adenosyl methionine) is a natively occurring molecule involved in the biosynthesis of neurotransmitters, with a long history of use in Europe for treatment of depression, and FDA-approval for over-the-counter use in the US based on more than 40 controlled trials encompassing 24,000 patients. It is well-tolerated without weight gain and sexual side effects, and has some precedent for treatment in pregnant women with liver problems. One study of postpartum depression showed promising treatment effect (Cerutti) and no reports of adverse effects in breastfed infants.
Folic acid (vitamin B9) supplementation is based on data demonstrating that deficiency is associated with poor treatment response while augmentation is associated with more rapid and robust effect (Papakostas, Coppen and Bailey). While it has not been studied for monotherapy [standalone use]in perinatal depression, it is recommended to women of reproductive age for prevention of birth defects, and is a reasonable augmentation consideration.
Bright light therapy has been substantiated through meta-analysis as a treatment for seasonal and non-seasonal depression, and has been studied in antenatal and postpartum depression with significant benefit in antenatal studies and limited power to detect benefit in a postpartum study (Oren, Epperson, Corrall). This treatment is typically used for 30-60 minutes daily with a 10,000 lux light source, and would not be appropriate for patients with a personal or family history of Bipolar disorder.
With regard to acupuncture, an important study was recently published demonstrating a 63% response rate in pregnant women with major depression, although postpartum data is lacking (Manber).
Cranial electrical stimulation is a home-use device which acts to modify electrical activity in the brain to support neurotransmitter production and alpha wave activity. Although there are no perinatal studies, this modality has been supported by randomized placebo-controlled trials (approximately 20 adequate quality trials) for the treatment of anxiety, insomnia and depression, and represents a low-risk consideration or augmentation strategy for women concerned about the risks of medication exposure.
Finally, exercise is often an important “prescription” for pregnant and postpartum women experiencing mood symptoms as it is formally recommended by the American College of Obstetrics and Gynecology (30 minutes of exercise on most days for pregnant women), and two studies have demonstrated benefit in pregnant and postpartum patients with depression (Koltyn and Schultes, Heh). As part of a complete treatment plan, relaxation exercises/meditation, breathwork and diet are also essential considerations.
In the realm of reproductive psychiatry, the individualization of treatment is paramount, and integrative approaches are often the best way to achieve this goal. Regardless of postpartum depression treatment preference, it is essential that women consult with professional providers to determine the appropriateness of different treatment interventions for their particular symptoms.
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I would recommend folic acid and St. John's Wort as a preliminary effort. Of course, see a doctor if symptoms are more serious.
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As an acupuncturist who specializes in treating women, I have been impressed with how well women with postpartum depression respond to regular acupuncture and a specially tailored Chinese herbal formula. A well trained herbalist can prescribe herbs that are safe for breast feeding Moms and can add herbs to address a variety or symptoms from anxiety to obsessive thoughts or irritability. My patients find that weekly acupuncture helps elevate their mood and makes it easier to cope with the inevitable stresses of adjusting to looking after a newborn.
Great article. Thank you Katherine and Dr. Brogan.
A key takeaway from this article is this: find a qualified practitioner who is experienced in perinatal mental health.
A woman in crisis should not trust comments from blog readers to help her find her way. Making an appointment with a practitioner is enrolling in care.
Using these measures as self-help is not a substitute for a relationship that provides thorough assessment and case management.
Postpartum Support International (www.postpartum.net) offers support in much of the world through caring, trained peer counselors. These women can help locate local resources.
It is absolutely appropriate to trust comments..or essays..or dissertations.. of women who have been there. More so than trusting a male with a white coat or without one. Those who are not indoctrinated with academic medicine are more reliable and the longer healthcare staff ignore that, the more embarrassing of a case they will become.
Hi again Katherine!! I'm expecting again (yeah!!) and was wondering if you've ever heard of placental encapsulation? There's a local doula here that offers this service and says that it can really help with post partum depression. Here's the link — let me know what you think and if you've ever heard of this before!
I tried placenta encapsulation hoping it would help me avoid ppa for my second child. It didn’t work.
I had severe ppd with my first. Hoping to avoid it with my 2nd i did the placenta encapsulation. I was ok while taking them but as soon as they were empty the ppd came back 🙁
Hi Katherine and Dr. Brogan,
Thank you for this excellent article. It is critical to get this information out to physicians and others who are screening and identifying women with postpartum emotional complications and give them this information so that they can provide women with all the possible treatment options. In our region of Western Massachusetts, we have created a Resource and Referral Guide for women and have included many alternative therapies in it. You can see our guide at http://www.motherwoman.org.
This was a very informative review of alternative therapies that could be useful for expecting women who are considering their options.
In my experience, cranial electrotherapy stimulation (CES) is too often overlooked and mistakenly thought of as experimental and understudied. But over the last two decades, research has found CES to be extremely effective. The biggest hurdle with CES has always been the invasive procedure. However, the current hand-held devices you mention, such as the Fisher Wallace stimulator (www.fisherwallace.com), are noninvasive and can be used by patients at home with minimal to no supervision. Given its proven effectiveness and safety, I firmly believe it deserves more recognition as an excellent option for women with postpartum depression.
Cornell University '08
I really was happy to read your blog.. I prefer natural remedies and herbs..
Good article Kat! And the natural health 'advocates' say you play for the pharmaceutical companies.
I try to share all the options that research shows can work for women.
I would recommend Reiki. I had tried almost all conventional and alternative methods with little improvement. I have now fully recovered and I'm so thankful that I discovered Reiki!
Don’t forget talk therapy! I swear by it…before my depression and anxiety needed meds it’s all I used for years to manage anxiety.
These are all positive steps towards preventing and relieving PND, and I for one am glad to hear it. It felt like there was nothing out there for me and no one to guide me.
I have one thing I’d like to throw out for discussion. Exercise is supposed to be one of the best things to help depression. Those of us who have suffered know how hard it is to motivate yourself into doing anything no matter how good we know it could be. I’d like to hear some thoughts on getting that much needed boost, inspiration and motivation, the first step to getting those trainers on, or yoga pants, or swim suit.
For me it’s music. Some inspiring, feel good music, but I only discovered that recently. I’d love to create a playlist and take a few mums for a walk plugged into my playlist.
Any other ideas?
I have found diet (paleo) and nature to be the most helpful. Getting outside once a day, a walk around the block, hear the birds, feel the breeze and sun on your face, connect with mother nature is any way shape or form. It’s an instant mood lifter. And being grateful for all the good things in your life. I find when I am being grateful, it’s impossible to be sad.