Editor’s note: ‘Baby blues’ affects about 75% of all pregnant women, starting on the fourth or fifth day after giving birth. Women who suffer more severe symptoms are more likely to develop post-partum depression. I saw an interesting study that looked at providing nutritional supplements during those days to see if these changes in mood could be lessened. Although the study was small and it didn’t include a placebo, women taking the supplements had much better mood scores when checked 5 days after delivery. This study prompted me to ask my colleague, Dr. Harrison, about other interventions for post-partum depression.
Depression, both during pregnancy and postpartum, is a common, serious condition that can have devastating consequences. It has been linked to poor pregnancy outcomes, impaired maternal wellbeing and bonding with the infant, and potential developmental problems in the child.
There are many effective pharmacological treatments for depression. Researchers are currently exploring whether alternative therapies – such as omega-3 fatty acids or exercise – can work in tandem with medications to improve outcomes or be used to prevent postpartum depression in women with no history of the illness.
I want to be clear that if women need medication to treat depression there is no question that they should start or continue with antidepressant medications during pregnancy. Many of these medications have been shown to have low risk for harm to the developing baby.
But are there other ways to help manage depression for pregnant women and new mothers? Are there therapies we can use to help prevent the onset of postpartum depression? Let’s explore the possibilities.
Complementary and Alternative Medicine (CAM)
Complementary and Alternative Medicine (CAM) refers to treatments and therapies outside of mainstream medical care. The National Center for Complementary and Integrative Health defines complementary health approaches in two categories: natural products and mind/body practices.
Recent studies have examined whether some of these practices actually have an impact on patients. Of the CAM therapies thought to impact depression, the most studied include omega-3 fatty acids, folic acid, S-adenosyl 1-methionine (SAMe), St. John’s wort, bright light therapy, exercise, acupuncture, and mindfulness-based psychotherapies.
Other nutraceuticals (pharmaceutical-grade and standardized nutrients) like amino acids (tryptophan and tyrosine), Vitamins (C and D3), inositol, zinc, and creatine also have received some attention because of their roles in neurobiological mechanisms that could counteract or prevent the development of depression.
Approaching CAM with caution
While some of these therapies are promising, almost all require more research to determine whether they are truly beneficial and to understand any potential drawbacks.
For example, in the study Dr. Horsager-Boehrer mentioned, women started taking a dietary supplement consisting of tryptophan, tyrosine, and blueberry juice/extract on the third post-partum day. The intent was to make up for lowered levels of serotonin, norepinephrine, and tryptophan seen with elevated MAO-A levels in the early post-partum period. Researchers found that this combination robustly decreased the vulnerability to depressed mood during the peak period of postpartum blues.
While the results of this study seem exciting and promising, a critical review of the literature on the efficacy of these CAM therapies urges caution. Pursuing these relatively unstudied therapies in lieu of standard evaluation and treatment could prolong illness as patients engage in a trial-and-error process with CAM approaches. These practices may also result in unforeseen effects, as their impacts are not fully understood.
With appropriate consideration of risks and benefits, however, some of the better-studied CAM therapies can expand the list of treatment options available to patients and help support standard treatments. Below are descriptions of a few of them.
Common CAM therapies for treating postpartum depression
Omega-3 fatty acids
Omega-3 fatty acids found in fish oil – eicosapentaenoic acid (EPA) and docosahexaenoic (DHA) – are essential nutrients with well-established health benefits.
Meta-analyses of many randomized controlled trials found a statistically significant antidepressant benefit of omega-3 fatty acids in mood disorders overall. In general, these studies also found omega-3 fatty acids to be significantly effective when used as an augmentation treatment alongside more traditional treatment methods instead of as a sole therapy.
The American Heart Association recommends adults consume omega-3 rich fish twice a week. This can be a challenging recommendation for pregnant women to follow given concerns over mercury-contaminated fish.
St. John’s wort
St. John’s wort (Hypericum perforatum) is a wild plant that has long been used for medicinal purposes. In Europe the plant is commonly prescribed as a treatment for depression and studies have shown it may in fact be effective for some types of depression. However, the evidence is not definitive and the safety of this plant has not been established.
What’s more, St. John’s wort has also been shown to have severe drug-drug interactions that could reduce the efficacy of prescription medications or even be life threatening.
Prescription medicines that could be impacted, include:
- Birth control pills
- Cyclosporine (immunosuppressive)
- Digoxin (heart)
- Some HIV drugs (such as indinavir)
- Some cancer drugs (such as irinotecan)
- Warfarin and similar medications (blood thinners)
The National Institutes of Health website includes this warning on the subject: “St. John’s wort is not a proven therapy for depression. Do not use St. John’s wort to replace conventional care or to postpone seeing your health care provider.”
So while St. John’s wort may help treat depression, the plant should be approached with caution and discussed with your doctor before taking.
Lower levels of folic acid have been observed in some patients with depression, and reduced folic acid has been associated with slower responses to SSRIs, a type of antidepressant medication. This has led to speculation that increased levels of folic acid may help combat the effects of depression, but there is currently no evidence for its effectiveness as a stand-alone therapy.
Apart from addressing depression, taking folic acid supplements before and during pregnancy has other significant benefits for the mother and child. It has been shown to help prevent neural tube defects (birth defects of the brain and spine) and anemia.
Because many women are encouraged to take these supplements during pregnancy anyway, it does not seem unreasonable to suggest they continue taking the supplement in the postpartum period to help combat depression.
Talk with your doctor to make sure you are taking the correct amount of folic acid before, during, and after pregnancy. While it has benefits at the right dosage, you do not want to take too much of this supplement. In extreme cases, excessive long-term folic acid supplementation has been associated with some cancers.
S-Adenosyl-L-Methionine, or SAMe, is a chemical that occurs naturally in the body and is sold in the U.S. as a dietary supplement. SAMe has been found to regulate important functions in living cells and abnormal SAMe levels has been associated with certain illnesses, such as liver diseases and depression. It has also been used to treat cholestasis in pregnant women, although its safety during pregnancy has not been definitively established.
Overall, SAMe has been found to be perhaps one of the most effective and fast acting of the CAM treatments for depression. However, it is expensive and may be associated with mild gastrointestinal symptoms, sweating, dizziness, and anxiety. It also may trigger mania in patients with bipolar spectrum illness.
As with the therapies listed above, the evidence is not entirely conclusive that SAMe can safely and effectively reduce depressive symptoms.
A couple of studies have shown some effectiveness of acupuncture, a traditional Asian medical treatment, in treating depression during pregnancy.
It is difficult to study acupuncture within the context of Western medicine, particularly because it’s often used in the context of other cultural practices. Study design also poses a challenge. As such, existing research has come to varying conclusions about the practice. In the future, it could serve as part of an overall treatment plan but is not at this time considered a leading treatment for depression.
Massage may also have some antidepressant effects but has not been fully studied. Massage during pregnancy, when performed appropriately and by someone experienced with pregnant massage, can help reduce pregnancy aches and pains.
Existing research has shown massage therapy may help reduce both antenatal and postnatal depression, as indicated by lower levels of the stress hormone cortisol and increased levels of serotonin and dopamine. Massage certainly needs to be studied further and one day may prove to be part of a comprehensive treatment plan.
Exercise and yoga
Exercise has been shown to have antidepressant effects and is recommended as part of an overall treatment plan. In any event, women could integrate exercise during pregnancy due to its many benefits.
It is difficult to design studies that rigorously study exercise and its effects on the brain, so the underlying reasons it affects mood disorders is not entirely understood. But a recent study suggests that postpartum depression scores were better in women enrolled in physical activity programs and that appropriate exercise can safely be included in any treatment plan. Exercise also provides additional benefits of preventing conditions such as heart disease, obesity, diabetes, and more.
There is also evidence that yoga has modest effects on depression, anxiety disorders, and PTSD. This may be due to the fact that it has both an exercise and mindfulness component. I think yoga makes sense as an additional treatment within an overall plan.
Treatment recommendations for postpartum depression
Whatever the benefits of complementary and alternative medicines, here are three things that definitely should be included in addressing postpartum depression in your life:
1. Good social support and adequate sleep
These are the two most important factors for the prevention of postpartum mood disorders.
2. Good nutrition, both pre- and postnatal
Nutrition is incredibly important. Diets high in processed foods are associated with higher later rates of depression. Diets rich in naturally grown foods that have been minimally processed, such as fruits and vegetables, lower risk of depression and may protect against mood disorders.
3. Talk with your doctor
As health care providers, we should inquire about and encourage discussion regarding CAM use. Patients should keep in mind that “natural” does not always mean safe and evidence of the effectiveness of CAM treatments has oftentimes been inflated by the internet. If you are thinking about pursuing CAM therapies, I encourage you to talk with your physician about it beforehand.
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