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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