Guest Author Series: Dr. Dean Raffelock and Dr. Hyla Cass

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An Integrative Approach to the Prevention and Treatment of Postpartum Depression
Dean Raffelock, D.C., Dipl.Ac./L.Ac, CCN, DIBAK
Hyla Cass, M.D.

Dean Raffelock D.C., Dipl. Ac./ L.Ac, CCN, DIBAK is a doctor of chiropractic and has earned board certifications in acupuncture, clinical nutrition, and applied kinesiology. He is the lead author of the book A Natural Guide to Pregnancy and Postpartum Health (Avery, 2003). Dr. Raffelock has a holistic practice in Boulder, Colorado. He is Vice President of Research and Development for Sound Formulas, LLC, a nutritional company dedicated to helping pregnant and new mothers receive optimal nutrition before, during, and after giving birth. For more information, see his website: http://www.soundformulas.com/.

 

 Hyla Cass, M.D. is a board-certified psychiatrist, former Assistant Clinical Professor of Psychiatry at UCLA School of Medicine, and author of several books, including Natural Highs, 8 Weeks to Vibrant Health, and Supplement Your Prescription. A member of the Medical Advisory Board of the Health Sciences Institute and Taste for Life Magazine, she is also Associate Editor of Total Health and served on the board of California Citizens for Health. Dr. Cass has also served as president of Vitamin Relief USA (www.vrusa.org). She has a clinical practice of integrative medicine and psychiatry in Pacific Palisades, CA. For more information, see her website: http://www.drcass.com.

Postpartum depression (PPD) has 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 PPD is SSRI (selective serotonin reuptake inhibitors) antidepressant drugs.

Combination reuptake inhibitors for both serotonin and norepinephrine (SNRIs) are also commonly used. In the case of postpartum psychosis, antipsychotic drugs are used and are 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 may need pharmaceutical assistance, these are far fewer than are actually receiving them.

The most common symptoms of PPD 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. 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 Overview: 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.

There is no other normal physiological process that drains more nutrients than pregnancy, 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 another human being, but the placenta itself is formed from nutrients taken from the mother’s body.
Other factors that may contribute to a drain of a new mother’s nutrient reserves are sleep deprivation, breastfeeding, returning to work, and the extra energy required to take care of an infant and integrate a new baby into her family. If a pregnant woman’s or new mother’s nutrient reserves are too low, she is much more vulnerable to experiencing PPD because all of the body’s normal metabolic processes are entirely dependent upon nutrients.

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 reciprocal relationship between hormone and neurotransmitter production is rarely taken into consideration by most physicians when considering treatment for PPD. 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, L-theanine, SAMe, inositol, and the herb St. John’s Wort can also be of great assistance in treating PPD. 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 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)

from Dr. Marty Hinz neurotransmitter seminar

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