news item: “study finds genetic prediction of postpartum depression”

I don’t discuss it much, but I went through a Very Bad Time after my first son was born. When he was about 4 months old, my husband realized that I was no longer doing things like leaving the house, showering, eating, sleeping, etc. He took me to the emergency room. A psychiatrist, social worker, mental health nurse doing home visits, support groups, and months of medication later and I was semi-human again.

Postpartum depression is FOR REAL. It is not the “baby blues” nor is it “regular” depression, something I have struggled with as well. Without going into much detail (as this is something I still struggle greatly with sharing) I was not myself. And on top of it all, I was debilitated with guilt and shame. How could I feel this way when I just won the lottery?

In hindsight, I had many risk factors for PPD all lined up neatly in a row. A history of anxiety and depression, suffering back to back miscarriages, infertility, an extremely stressful pregnancy, traumatic birth experience, lack of support after birth, and so on. However something I had never considered was whether I was genetically predisposed to it. Yesterday on Twitter I came across an article (thanks KeAnne, you re-tweeter you) that has me thinking…

Study Finds Genetic Prediction of Postpartum Depression

It is not clear what causes postpartum depression, a condition marked by persistent feelings of sadness, hopelessness, exhaustion and anxiety that begins within four weeks of childbirth and can last weeks, several months or up to a year. An estimated 10 to 18 percent of all new mothers develop the condition, and the rate rises to 30 to 35 percent among women with previously diagnosed mood disorders.

The researchers later confirmed their findings in humans by looking for epigenetic changes to thousands of genes in blood samples from 52 pregnant women with mood disorders. The women were followed both during and after pregnancy to see who developed postpartum depression.

The researchers noticed that women who developed postpartum depression exhibited stronger epigenetic changes in those genes that are most responsive to estrogen, suggesting that these women are more sensitive to the hormone’s effects. Specifically, two genes were most highly correlated with the development of postpartum depression. TTC9B and HP1BP3 predicted with 85 percent certainty which women became ill.

“We were pretty surprised by how well the genes were correlated with postpartum depression,” Kaminsky says. “With more research, this could prove to be a powerful tool.”

Without going off on a tangent about study size, sample population, and commentary on methodology, I will say that this study is very interesting. It is general assumed (even by mental health professionals) that PPD can be attributed to “wacky hormones being all out of whack.”  More specifically, that a drop in estrogen levels affects mood significantly in some women, but not others. Although, that reason doesn’t answer the question of why this woman and not that one?

This study suggests that certain woman are more sensitive to changes in estrogen. What is interesting about this research is that it could potentially lead to a blood test performed in the third trimester to determine whether these changes are taking place and raise a potential red flag for the woman, her family, and her healthcare provider.  The lead researcher, Zachary Kaminsky, an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins, hopes that this could help HCPs and mothers make informed decisions about treatment for depression during and after pregnancy, including the appropriate use of medication when weighed against other risks. In other words, if you knew you higher risk, you could better prepare for the possibility that it might be more likely to happen.

I have been chewing on this all morning, and will likely continue to for a while. I felt that I had no choice but to go on medication or risk not being able to parent my child. Curiously, I have not remotely had the same experience after the birth of my second son, despite life (and life events) being more stressful now. I attribute this to a a different pregnancy, and empowering birth, and experience as a mother, but also to being on the lookout for The Very Bad Time – Part 2. I have written here before that I lied to my HCP about feeling depressed during pregnancy. So as I read this over and over this morning, I can’t help thinking that normalizing mental health issues before and after pregnancy is a good thing. Yes, a blood test like this raises moral and ethical questions and could be used for all sorts of nefarious purposes. But what if it is used for good?

I’m chewing on it.

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If you or someone you know is struggling with postpartum depression, an excellent resource is Postpartum Progress. Click on GET HELP for more information.

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What do you make of this research? Can you see this being added to the battery of available pregnancy testing?

If this test were available, would you choose to take it? Why or why not?

Prior to giving birth did you discuss mental health issues (relating to pregnancy and the postpartum period) with your healthcare provider? 

Did you have adequate emotional support (or access to resources) after bringing your child home? 

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SRBSarah is a former high school teacher, turned medical writer, turned SAHM to two boys. She enjoys beer, knitting, gardening, and cheese, and is striving to raise boys who can will do their own laundry and cooking. This urban mama parents with an ever-evolving mix of natural, attachment and RIE principles with a dash of by-the-seat-of-her-pants for good measure. She blogs about her life at a sausage party at Little Chicken Nuggets.

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news item: “while you were puking…” (SSRI risky during pregnancy)

Today’s post ended up evolving into something of a guest post from Ms Future PharmD, with an assist from yours truly. It has been really interesting and illuminating getting to know the expertise that is out there on the blogroll this way. Every one of us has something unique to offer, from both personal and professional knowledge. So if you see something interesting in the news, on any relevant topic that interests you, please send it to us with your thoughts here. Similarly, if you have a site suggestion, don’t hesitate to drop us a line here.

In this post, we examine a recent blurb from Babble discussing the risk of SSRI during pregnancy. We recognize that within this community, the incidence of anxiety and depression related to infertility, loss, and pregnancy are likely higher than the general population of similar demographics. PAIL recommends that you always consult with your healthcare professional to choose a treatment path that is right for you, your child, and your circumstances – whatever that path is. Please take care of yourself, and understand that others are trying to do the same.  

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Last week, Ms Future PharmD emailed us about an “article” (it’s a paragraph at best – let’s call it a blurb) about SSRI (selective serotonin re-uptake inhibitor) use during pregnancy, complete with evidence trail leading back to the clinical study. To say this piqued my curiousity both personally and professionally is an understatement. I have mentioned before that I dealt with crippling anxiety during my pregnancy with HGB, but may not have confided that I subsequently went on an SSRI (an agonizing decision made while breastfeeding) to treat severe PPD afterwards. (Please feel free to email me if you would like to know more about this experience and the choices I had to make – I have not blogged about it to date). I have also mentioned that in my professional life, I use clinical drug trials to support brand messaging for pharmaceuticals (albeit for a different audience than the general public, 90% of the time). When I read the Babble blurb on SSRI use during pregnancy, I immediately saw the problem. Ms Future PharmD had this to say when she initially contacted us:

Here’s the trail of discovery: first I read it at a Babble article (yes, I should stop…) This is the article the Babble author references. Here’s the actual study (freely accessible) – via Human Reproduction It seems to have been addressed in a pile of regular newspapers as well as some TV news outlets.  Here’s one from a Boston TV news station.

I also saw it pop in my Twitter feed via Postpartum Progress here and again at Babble here (both pieces by Katherine Stone @ Postpartum Progress and both worthwhile reads in my opinion). So, what is causing all the stir? Here is the original blurb from Babble, in its entirity:

SSRI Risky During Pregnancy

According to a new study, “there is clear and concerning evidence of risk with the use of the SSRI antidepressants by pregnant women, [and] that these drugs lead to worsened pregnancy outcomes.” Additionally, there is no evidence at all of any benefits of using these antidepressants during pregnancy — not for the mother or the baby. Source; Medical Xpress
I have written here before about the actual importance and validity of  “a new study” and the perceived importance and validity of ” a new study” by the general public as reported to them in the mass media. To say that it is watered down, with the “key messages” distilled into a single soundbite i s putting it mildly, but right above this paragraph is a shining example (e.g. what are the definitions for “outcomes” and “benefits?”). Alarmism, with a dash of no actual imformation makes for a one-sided, and frankly potentially damaging blurb. To find out exactly what “the study” measured, one would have to click on the source (which is again, a study summary, and not the actual study). How many readers are likely to do this? (Which, to be clear, is not a statement on the intelligence of the average reader, but simply the amount of time available to flesh out the message that was just consumed.) As it turns out, the study is actually a meta-analysis of existing literature chosen by the researchers and examined for common themes. In other words, nothing was actually empirically measured in a clinical setting.  At this point, I begin to see red and have a hard time separating my professional distate from my personal outrage and experiences.

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Ms Future Pharm D dissected the summary AND the clinical paper for us, adding in her thoughts:
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Preface: I’m not your doctor, or a doctor at all, so this doesn’t count as medical advice.  See your own doctor or get a referral to a specialist if you have questions about your own health.  SSRIs are a group of medications used to treat depression and anxiety that might do something to serotonin levels in your brain but we aren’t sure yet exactly how they work.  Popular ones are Proz.ac (fluoxetine) and Zo.loft (sertraline) although there are a whole bunch of diverse drugs in the class.

One of the things that makes me really mad about this article is the things it isn’t telling you.  It doesn’t really have anything new to say.  All of science says that SSRI antidepressants are helpful for some people and not for others (publication bias or not).  This isn’t new, yet this article gets all excited about it as if this is something new.  (Sidenote: publication bias means that if your study doesn’t find your drug beneficial, you don’t publish it, but it gets reported to the FDA. This article reviews all the studies, not just the published ones.  Having no access to unpublished articles, we don’t know if the only reason they weren’t published was that the findings weren’t positive.  There could be other problems too.)  All of our research says that CBT (cognitive behavioral therapy a.k.a. talk therapy) is as beneficial as or more beneficial than SSRIs alone.  That’s not new either.

The big things that are missing from the (second, summary) article are an explanation of the magnitude of effects seen, or how big a deal it is that the SSRI changes pregnancy outcomes.  There’s a higher risk of cardiac defects, yes.  The difference is 0.09% with no SSRI or 0.1% with it.  Is that fundamentally different? Probably not.  How much shorter are pregnancies when the mom takes an SSRI?  The article makes a big fuss about how gestation is shorter but never admits how much shorter (it’s less than a week shorter).  They mention an increased risk of miscarriage, but again skip mentioning how much higher.  In one of the studies they cite, the SSRI-taking women had a 13% miscarriage rate and those without had a rate of 8%.  The usually accepted miscarriage rate is 12-15% in the population, so that isn’t actually evidence that the SSRIs had a thing to do with it.

When we get to the section specifically on SSRIs and infertility, the authors conclude that we should study it more because the evidence is sparse and that sperm counts might be affected by SSRI usage.  Yes, there’s one study that showed that couples treated for depression while undergoing infertility treatment got pregnant at much higher rates, but it was published in a not-so-reputable journal (not a good sign of its credibility) and it only sampled 140 couples (hardly enough to conclude anything about every infertility patient everywhere, other than to say treating mental health is important).  All this fuss and the real conclusion is that we should study it more?  News media, read the article.

This article also spends a lot of time talking about how SSRI use is associated with negative outcomes in pregnancy (hypertension for example).  That tells us not much about whether the SSRI is being used because the pregnant person is otherwise at increased risk of hypertension (say due to anxiety or obesity or something else) or if the SSRI causes the hypertension, and since most studies are done after the pregnancy ends (retrospectively), there’s no way to really know.  Likewise, perhaps someone with a history of loss gets depressed and then an SSRI.  Does the next miscarriage really have to do with the SSRI?  It’s hard to know without a whole lot more study.

The biggest thing left out of this article is what happens in depressed women who get pregnant and aren’t treated at all for depression.  The outcomes are worse than those in women taking SSRIs and include more miscarriages and preterm births.

The thing that makes me the most upset reading this article is the focus on the fetus.  Yep, fetuses are important if you’re trying to have a baby (duh) but so are mothers.  Nowhere does the article talk about the incidence of postpartum depression or psychosis in mothers treated with SSRIs or CBT (it’s lower based on the research we have).  Nowhere does it talk about quality of life for depressed pregnant mothers who are untreated, or her support people.  Nowhere does it talk about the long-term consequences to relationships of women being untreated or possibly undertreated for depression/anxiety during pregnancy.  Untreated depression is not a pretty thing and that’s why we treat it.  Treatment of some sort is probably a really good idea if it was in place before pregnancy and stopping suddenly is not a great idea either (brains are slow to adapt to changing medications that alter their functioning so you have to taper down, and this doesn’t mean the medicine is horrible for you, it means your brain is good at adapting).

Overall I’d say that this article is sensational and doesn’t include literature that is important to the decision on how to treat a woman who’s depressed and is/may become pregnant.  The guidance from the leading medical folks is still “consider the risks and benefits carefully before treating or changing treatment.”  This article doesn’t change that at all, so if this might be you, be sure you get the treatment you need to be healthy and have a doctor you know is an expert in depression treatment during pregnancy supervising your care.  The article does make a good point that it’s important to have a qualified specialist treating pregnant women, especially those with infertility to cope with.

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Did/do you struggle with anxiety/depression related to your ALI journey? Pregnancy? Postpartum period?

Have you previously written about these experiences, and would you be willing to share them again by linking in the comments?

What is your impression of the Babble blurb? Would you have clicked the “source” link to find out more?

Have you taken (or decided not to take) an SSRI during pregnancy or while breastfeeding? What factors went into your decision?

Do you feel that there is enough accessible information about these issues made easily available to the average woman?

What questions would you ask your doctor (or have asked) if faced with this decision?

**Please be mindful of your comments in this discussion. The choice to take medication or not is extremely personal and sometimes difficult. Thank you.**

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featured post: “Wanted for Robbery” by No Baby Ruth

I am generally not into blogging about blogging about blogging. There are as many reasons for blogging as there are blogs, and then some. However, within the ALI corner of the blogosphere an over-arching theme presents itself: community. And again, there are as many definitions for what that means as there are bloggers and then some more. Deep down, I think we all just like to know that somebody is listening to us.

When I first read “Wanted for Robbery” by No Baby Ruth, I was doing a lot of thinking about blogging. Should I just close up shop? Should I just go balls out? Her first paragraph took those “All or Nothing” blinders off for me:

I came to the realization this weekend that I’ve not been using this space to its full potential. The point of blogging is connecting, communicating, interacting. Otherwise we’d all just journal. And, yet, I’ve not been writing about some of my most prevalent emotions and thoughts of late, things I could surely use some help with. I’ve been updating, but not saying much. I’ve been thinking, but not writing. And that’s silly. This space is here for me. I need to use it.

Point taken. And truly, I needed to read this. I need to write in my space, however I define that, or I am not communicating. Not even with myself. I am just updating. And only sort of. Kick in the pants, received.

But that is not why I kept going back to this post – why I kept thinking about it for the last few weeks.

The rest of this post hit me at a much deeper level. I go through bouts when I struggle with what I could have been, had I been as driven as I was at X point in time. I never did become what I thought, what everyone thought, I would. And then I wonder when I lost “it” and begin to panic that that was a long time ago and I have done nothing since. Obviously, that isn’t true – I have done a lot of living since then. Maybe living isn’t the right word – existing.

The worst part is that I can no longer look around, see what I want, and go for it. Why? Because I can’t see how to get what I want. Where do people put their passion? Where do they invest their drive? Their work. Their spare time. Themselves. None of those are working for me.

I’m not that good at the “fun” side of life. I don’t have any hobbies. I flit in and out of a regular yoga practice. I love to read and yet I lie on the couch watching terrible reality TV. I love tennis and yet I haven’t played since before I was pregnant with Sofia.

I’m just okay at everything. I do fine work, but it’s not my best. I don’t eat terribly poorly, but nor do I eat as healthily as I could. I go for a run occasionally, but I’m certainly no runner.

No Baby Ruth echos me wondering “Where Did I Go?” and suddenly, while I still feel lost, I don’t feel so alone out there in the fog. Something stole the clearly lit path away, and it is difficult to pinpoint who did it. For her, maybe it’s PCOS. For me, maybe it was my second loss. These wounds, they cut us deeply, and healing is a non-linear process. Perhaps figuring out what was stolen is the first step to getting it back.

I’m being held hostage by infertility. Won’t someone pay the ransom, please?

Please head over to No Baby Ruth and check out “Wanted for Robbery” – an honest look for the things that have gone missing. Comments on this thread will be closed in an effort for you to connect directly and share your thoughts with her.

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If you have a post of any kind (old or new!), on any topic that you would like share, please fill out the form on the main Featured Posts page here. You are welcome to submit your a post of your own! 

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news item: “Not Just the Baby Blues”

The article and topic for today’s discussion was submitted to us by mandski of Chhoto Pakhi (formerly AS of Mira’s Mama):

It seems that a lot of PAIL members have experienced prenatal or postpartum depression and/or anxiety, usually unexpectedly. I was lucky enough to have support (regular meetings with a psychotherapist and a prenatal psychiatrist available), and I still ended up afraid to get on the subway when I was pregnant (among other anxiety-related fears). In some ways, perhaps infertility exacerbates this experience. This article in Slate doesn’t talk about infertility, but I thought it was interesting since it’s a common topic of conversation here, and it’s not so commonly talked about in the mass media. The author talks about her mother saying that her doctor brushed off her concerns about depression, saying this should be the happiest time of her life. How many of us heard that?

*Raises hand*

In the last few days, I have been thinking a lot about pregnancy after IF/loss. Specifically, the unrelenting anxiety I felt during my pregnancy with HGB and how this was compounded by platitudes (variations of “just relax” continue after the BFP too!) or a general lack of support and understanding. And, in my case, some pretty blatant invalidation of my feelings. The situation surrounding my pregnancy left me very depressed, and I experienced a terrible bout of PPD after our son was born. Recently, I was asked for my advice and some resources to help someone with this very issue (prenatal anxiety), and it really struck me how differently I feel this time. How much clearer I am able to think about not only this pregnancy, but to really shine a light on my last one. It was a very bad time, and I did not begin to enjoy it until the very end. And I still feel guilty about that.

In her article for Slate, writer Jessica Grose details her struggle with prenatal depression, finding support, and coming to terms with it:

Neither the psychologist nor the psychiatrist mentioned prenatal depression. In fact, I had never heard the term before I started plunging into a clinical melancholy so deep that my Google history from that period is a darkly hilarious trail of cries for help. I entered many permutations of the terms “pregnancy depression” and “pregnancy can’t stop crying” and discovered that prenatal depression is just as common as postpartum depression—it affects between 10 and 15 percent of women. Despite these stats, prenatal depression is still relatively under the radar, and many obstetricians are not well-trained in its complexities

Speaking from my own experience, my doctor did ask about this a few times, and I lied. What if they knew how I was feeling and decided I was a terrible mother? What if they tell me all the horrible ways my feelings are harming my child in utero and confirm all the crazy shit Dr. Google has told me about? I’ll just hide it and feel even worse. Not my best logic.

Grose goes on to talk about the guilt that inevitably arises from these feels of anxiety and depression, and perhaps ever so slightly touches on the experience of pregnancy after infertility and loss (emphasis mine):

Compounding the obsessive thoughts was an overwhelming sense of guilt. We had wanted and planned for this child. I was supposed to be thrilled, cooing at strange babies in the street and gleefully learning how to knit tiny hats. This should have been something that brought my husband and me closer together. Instead, I was scared and sick and sloppy, and my husband was increasingly terrified.

Taking all the information and statistics provided in the article (and part two) with a grain of salt, I wish I read this 2 years ago. We all know that being in the ALI spectrum can cause significant stress and anxiety, often resulting in bouts of depression. I know that *I* hoped, nay, expected that to all go away when I got pregnant. Instead, it got worse. And I was extremely reluctant to talk about that people after being essentially ordered to “just be happy.”  It took me a long, long time and a lot of hard work to get to where I am today.

But here is the kicker: I went through this time without blogging – without seeing my experience mirrored anywhere. I wonder if it would have been different if I had been writing about this. I wonder if it would have helped me or hurt me to discuss those feelings here. Would commenters have been supportive? From reading blogs, I have come across very few in this community that discuss these feelings (particularly with respect to prenatal depression) openly and honestly. And I wonder, is it not happening, am I not reading the right blogs, or are we not talking about it?

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Did you experience (or are you now experiencing) anxiety and/or depression during your pregnancy? If you have adopted your child, did you experience similar emotions while waiting for your child to come home?

If so, did you blog about these experiences? What was that like for you? 

Do you think there is a reluctance to discuss this issue in the ALI community? Why or why not?

How can we encourage each other to seek out support if this happens to us or someone in the community we care about?

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