Alternative Treatments for Postpartum Depression

Following delivery, approximately 13% of new mothers experience a major depressive episode (Wisner et al., 2002). This rate translates to hundreds of thousands of women in the United States each year. This widespread condition affects not only the mother but also the child; numerous studies have documented an adverse effect on children's cognitive and social development from exposure to maternal depression in the first year of life (Hay et al., 2001). Women with a previous history of depression are at a particularly high risk for depression (Wisner et al., 2002). Additional risk factors include conflict with the baby's father, stressful life events and child care stresses. Many women benefit from individual or group psychotherapy (Appleby et al., 1997; O'Hara et al., 2000). Attending weekly therapy sessions, however, is frequently difficult for women who are looking after one or more small children at home. Further, many patients are unable to afford ongoing psychotherapy.

Antidepressants are an additional treatment option for postpartum depression, and several appear to be safe when used during breast-feeding (Burt et al., 2001; Hendrick et al., 2001; Stowe et al., 2000). Nevertheless, many new mothers are reluctant to take medications while nursing because they are concerned about the potential adverse effects on their infant. Further, antidepressants are not universally effective and often produce unacceptable side effects such as reduced libido. Many women look forward to a renewed intimacy with their partners after the pregnancy and prefer not to take medications with such a side effect. Therefore, alternative treatment approaches for postpartum depression merit consideration.

The use of alternative treatments, including acupuncture, homeopathy, herbs, dietary supplements, massage and relaxation techniques, for depression is becoming increasingly widespread (Figure) (Eisenberg et al., 1998; Gallagher et al., 2001; Habek et al., 2002). However, few studies have examined these alternative treatments for depression occurring in the postpartum period.

A recent case report described successful treatment of major depression during pregnancy and following delivery with omega-3 polyunsaturated fatty acids (4 g/day ethyl eicosapentaenoic acid and 2 g/day docosahexaenoic acid). Inadequate levels of omega-3 fatty acids have been associated with depression, including postpartum depression (Hibbeln, 1998; Horrobin and Bennett, 1999; Peet and Horrobin, 2002; Peet et al., 1998), and these fatty acids (e.g., 1 g/day to 4 g/day ethyl eicosapentaenoate) have been used to potentiate the effects of antidepressant medications (Nemets et al., 2002; Peet and Horrobin, 2002).

Omega-3 polyunsaturated fatty acids offer significant health benefits to pregnant and nursing women and their infants. An adequate supply of maternal docosahexanoic acid during pregnancy and nursing is necessary to support the optimal neurological development of the fetus and infant (Birch et al., 2000; Willatts and Forsyth, 2000). Underscoring the importance of maternal dietary supplementation of omega-3 fatty acids, the high fetal demand for these fatty acids can lead to a 50% reduction of the maternal levels (Hornstra, 2000). Research has demonstrated that the risk of preterm labor is reducedin women who consume omega-3 fatty acids during pregnancy (Olsen and Secher, 2002).

The health benefits of these fatty acids continue following delivery. For example, when supplied in infant formula at adequate doses, omega-3 fatty acids improve infant cognitive development and visual acuity (Birch et al., 2000; Willatts and Forsyth, 2000). If the preliminary data on omega-3 fatty acids' positive mood effects are corroborated in larger studies, they will become a safe and healthful treatment option for depression occurring during pregnancy and the postpartum period.

Herbal supplements offer an alternative treatment for depression. Nationwide, the most widely used herbal compound for depression is St. John's wort (Hypericum performatum) (Bilia et al., 2002). The hypericin in this herb is believed to produce its therapeutic effects. Meta-analyses and systematic reviews of clinical trials support the efficacy of St. John's wort in the treatment of depression (Bilia et al., 2002; Gaster and Holroyd, 2000; Kim et al., 1999; Linde et al., 1996). St. John's wort is generally well-tolerated, relatively inexpensive and widely accessible. It is important to keep in mind, however, that the purity and potency of commercially available preparations of St. John's wort may not be what the labels purport. As a result of the Dietary Supplement Health and Education Act of 1994, the U.S. Food and Drug Administration minimally regulates most herbal products sold in the United States.

Nursing women may mistakenly assume that since St. John's wort and other herbs are "natural," they are safe. While case reports have described no adverse effects on pregnancy (Grush et al., 1998) or on infants exposed to St. John's wort through breast milk (Klier et al., 2002), data are too limited to recommend these herbs for use by pregnant or nursing women. An additional consideration among women of reproductive age is that St. John's wort induces the 3A4 isoenzyme of the cytochrome P450 system (Markowitz and DeVane, 2001). This enzyme metabolizes reproductive steroids and its induction can result in substantially lower efficacy of hormonal contraception. Women using hormonal contraceptives should be informed of this possibility and advised to use an alternative form of birth control.

Estrogen has been used to treat postpartum depression in two studies. In a double-blind study of 61 women with major depression that began three months postpartum, transdermal estrogen (as 17 ß-estradiol 200 µg/day) led to a rapid improvement in mood (Gregoire et al., 1996). The mean score on the depression rating scale (Edinburgh Postnatal Depression Scale) remained elevated among the women on estrogen, however, suggesting that the antidepressant effect was not robust.

In a second study, 23 women with major depression that occurred in the six months following delivery took sublingual estrogen (as micronized 17 ß-estradiol, mean dose=4.8 mg/day after the first week) (Ahokas et al., 2001). After two weeks of treatment, 19 of the women experienced a clinical recovery as defined by a score <7 on the Montgomery-Asberg Depression Rating Scale (MADRS).

Estrogen may appeal to patients because it is a naturally occurring substance. Also, since estrogen levels precipitously decline following delivery, some women may believe that estrogen deficiency underlies postpartum depression. However, postpartum depression has not been conclusively linked to low levels of estrogen or any other hormone (Hendrick et al., 1998). Patients should be warned that the use of estrogen is associated with several risks, including endometrial hyperplasia and thromboembolism. It also diminishes the production of breast milk in nursing mothers. Given these considerations, estrogen does not appear to have a primary role in the treatment of postpartum depression at this time.

The treatment of postpartum depression with natural progesterone has yet to be evaluated in a clinical trial. Natural progesterone is metabolized into allopregnanolone, a neuroactive steroid that enhances

-aminobutyric acid (GABA) in the central nervous system, producing anxiolytic and hypnotic effects (Rupprecht and Holsboer, 1999). Natural progesterone may therefore have a role in the treatment of postpartum depression with comorbid anxiety. This possibility should be explored in future treatment studies of postpartum depression.

Synthetic progestogens do not help postpartum depression and may, on the contrary, exacerbate the symptoms (Lawrie et al., 2000). Unlike natural progesterone, synthetic progestogens (e.g., medroxyprogesterone) are not metabolized into GABA-ergic neuroactive steroids.

Sleep deprivation improves depressive symptoms in approximately 40% to 60% of patients suffering from depression and has the advantage of very quick onset (Giedke and Schwarzler, 2002; Riemann et al., 2001). It may present a quick, easy and free treatment intervention for women with postpartum depression. On the other hand, sleep deprivation has been reported to exacerbate mood in new mothers, and improvement of children's disrupted sleep is associated with significant improvement in maternal mood (Armstrong et al., 1998). Sleep deprivation resulting from multiple, erratic awakenings may produce a very different effect compared to controlled and predictable sleep deprivation. Further research on sleep deprivation would be useful, including strategies to prolong its benefits. Sleep deprivation is probably not a reasonable intervention for new mothers who are generally trying to sleep whenever the baby sleeps, but it may benefit mothers of older infants who are able to sleep through the night.

Bright light therapy produced antidepressant effects in a small study of 16 pregnant patients with major depression (Oren et al., 2002) and in two women with postpartum-onset major depression (Corral et al., 2000). Since it is well-tolerated and does not produce medication exposure to the nursing infant, it may become a promising treatment for postpartum depression.

Massage therapy and relaxation training for mothers who are depressed have been reported to improve mood and produce more positive mother-infant interactions and better growth and health in the infants (Field et al., 2000). Infant massage classes also appear to improve mood in new mothers with depression and contribute to more rewarding mother-infant interactions (Onozawa et al., 2001).

In summary, women suffering from postpartum depression may benefit from several interventions other than medications and psychotherapy. More research is necessary to determine the efficacy of alternative treatments. Many alternative treatments have the advantages of being inexpensive, accessible, and generally safe and well-tolerated, thereby presenting attractive options to traditional treatments for postpartum depression.

References:

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