Photo courtesy of Flickr.com user Sabrina Campagna
The following article is a fantastic overview of alternative ways of treating depression by Kathleen Kendall-Tackett, Ph.D., IBCLC (AKA Uppity Science Chick- if women’s mental health interests you, you should DEFINITELY check out her EXCELLENT articles on her site). I especially appreciate how she provides such easy-to-follow instructions and dosages for these different techniques at the end of the article. Special thanks for JewishMOM SK for telling me about this site.
Non-Drug Treatments for Depression in Nursing and Post-Partum Women by Kathleen Kendall-Tackett, Ph.D., IBCLC
Sarah has had depression on and off throughout most of her adult life. She finally found an antidepressant that worked for her. But
now she’s pregnant and she’s been hearing all the awful things about
antidepressants during pregnancy. She’s talked with her doctor about
it, and he has assured her that the risk of problems is very small. But
he is willing to consider other approaches. He is simply worried that
she will get depressed again if she stops taking her medications, and
her depression would also be bad for the baby.
Michelle has never had a problem with depression. But she is 4
months postpartum and her mother died unexpectedly. Her mother’s
death has had a devastating effect and she is finding herself having
problems completing even the simplest of tasks. She is overwhelmed
with sorrow and grief, and her midwife is recommending an
antidepressant to help her through this time. She too is worried about
how antidepressants will affect her baby.
Depression during pregnancy and postpartum are fairly common,
affecting anywhere from 15% to 25% of women. Antidepressants
are an important part of the treatment arsenal for depression. But
clinicians, and women themselves, are increasingly concerned
about their use in pregnancy and while breastfeeding. Specifically,
do antidepressants taken during pregnancy cause birth defects?
Some studies have found that found a small, but statistically
significant, increase in problems, such as heart defects. Other
studies have found no harmful effects of antidepressants. Similarly,
are there hazards for infants if their mothers takes antidepressants
while breastfeeding? Health care providers often make treatment
decisions by balancing the risks and benefits of a medication. Is the
risk of using the medication less than the risk of the mother getting
depressed again? In most cases, the risk of using the medication is
less than the risk of possible depression, so clinicians will prescribe
it. But are antidepressants the only choice?
Curiously, while people debate about antidepressant use in both
research studies and the popular media, non-drug treatments for
depression are largely absent from the discussion. Fortunately,
antidepressants are not the only choice for treating depression
and may offer a safe “third choice” for treating depression during
pregnancy and breastfeeding. Physicians and other health care
providers may not consider these non-drug treatments, assuming
that they cannot address more severe depression. But recent
research paints a very different picture. There are a number of
non-drug treatments that are effective for even major depression.
Non-drug treatments include Omega-3s, exercise, bright light
therapy, psychotherapy, and St. John’s wort. Many of these can be
combined with each other, and are sometimes used in addition
to antidepressants (only St. John’s wort cannot be combined with
medications). I describe these treatment options below.
Omega-3 Fatty Acids
The long-chain Omega-3 fatty acids, EPA and DHA, have
been used successfully to both prevent and treat depression. Both
of these are found in fatty fish. EPA is the Omega-3 that actually
treats depression because it specifically addresses the physiologic
consequences of depression and lowers the stress response. It
has been used by itself or has been combined with medications.
When it is used with medications, it makes medications work
more effectively. The American Psychiatric Association recently
recognized EPA as a promising treatment for mood disorders.
DHA helps prevent depression, but studies so far have found that it
does not treat it by itself. It is usually combined with EPA. There is
a vegetarian source of DHA, but no vegetarian source of EPA; fish
oil is still the best source. (Vegetarian DHA is the same product
that is added to infant formula. Some mothers object to it because
of that connection, but it is a safe supplement for mothers to take.)
Sources and dosages are listed on the side bar. Even in relatively
large doses, EPA and DHA are safe for pregnant and breastfeeding
women, and provide a number of other health benefits for women,
including lower their risk of heart disease and making them less
vulnerable to stress.
ALA, the Omega-3 in flax seed and other plant sources, such as
walnuts and canola oil, does not prevent or treat depression. ALA is
not harmful and can be helpful in other ways. But it is metabolically
too far removed from EPA to aid in lessening depression.
Bright Light Therapy
Bright light is another treatment for depression that is as effective
as medications in alleviating seasonal, or winter, depression. More
recently, light therapy has been used to successfully treat nonseasonal depression. It has also been used to treat depression in
pregnant and breastfeeding women, although the study sizes are
still small. An illumination level of 10,000 lux for 30 to 40 minutes
is the most commonly used dosage. But lower light intensities
have also been effective. To get the recommended amount of light,
you will need a special light box (see sidebar for names of some
reputable vendors). Regular home lighting is not sufficiently bright
to alleviate depression. Light therapy first thing in the morning is
more effective than light therapy later in the day.
Dawn simulation is an alternative to standard light therapy. With
dawn simulation, a light box is on a timer and comes on before
women awaken, which may prove more practical for mothers
of infants or young children. Light therapy is safe to use during
pregnancy and breastfeeding. Health care providers have also
added it as a treatment when antidepressants were not working.
Exercise
The most important studies on exercise as a treatment for depression
were two randomized trials from Duke University Medical Center
that directly compared exercise to Zoloft. In both studies, exercise was as effective Zoloft in treating major depression. The strongest effects are for aerobic exercise, but weight lifting and stretching/yoga are also helpful. If you exercise at a moderate level, exercise is safe during pregnancy or breastfeeding. The guidelines for treating mild-to-moderate and major depression with exercise are listed [below].
The recommended exercise regimen for treating major depression
requires more effort than the regimen for mild-to-moderate
depression. But it is a viable alternative to medications and many
women find that it is worth the effort. In the second Duke study,
the researchers found that the group that came to the lab to
exercise had a lower rate of depression than the group that followed
a home exercise program. The fact that they needed to come to
the laboratory probably meant that they received social support
from study staff and fellow participants in addition to benefits of
exercise. They were also probably more likely to exercise regularly
when they knew that they were expected to be someplace to do it.
You might find that exercise in a group setting works well for you
too.
Psychotherapy
Don’t let anyone tell you that “talking therapy” is not effective
for serious depression. That simply is not true. Two types of
psychotherapy are effective for perinatal depression, even if severe:
cognitive-behavioral therapy and interpersonal psychotherapy.
Both have proven as effective as medications in treating major
depression.
Cognitive therapy’s premise is that depression is due to distortions
in people’s beliefs about themselves and the world. By addressing
these beliefs, depression diminishes. This type of therapy is also
effective in treating anxiety, obsessive-compulsive disorder and even
chronic pain. If you are interested in learning more, I’d recommend
the book, Feeling Good: The New Mood Therapy by David Burns.
It is a do-it-yourself guide to cognitive therapy. The organizations
listed in the sidebar can also provide further information.
Interpersonal psychotherapy (IPT), the newer modality, is
quickly becoming the psychotherapy of choice for pregnant and
postpartum women. IPT specifically addresses women’s key
relationships, the support they receive from those relationships and
how the relationships have changed since having a baby. It teaches
mothers to identify sources of support and increase the amount
of support they receive from existing relationships. It’s been used
with many high-risk mothers to both prevent and treat depression
during pregnancy and postpartum. For more information on either
modality, refer to the organizations listed [below].
St. John’s wort
The herbal antidepressant St. John’s wort is the most widely
prescribed antidepressant in the world, and it is highly effective
in treating depression. Its standard uses are for mild-to-moderate
depression, but it has been used for major depression as well.
When researchers have compared St. John’s wort to Zoloft and
Paxil, St. John’s wort was as effective as medications and patients
reported fewer side effects. It is safe for breastfeeding, but some
have expressed caution about its use during pregnancy.
Used by itself, St. John’s wort has an excellent safety record. But
there are two important cautions. First, it can interact with other
medications, so should not be combined with antidepressants, birth
control pills, cyclosporins, and several other classes of medications.
If you decide to take St. John’s wort, be sure to tell your doctor,
midwife or other health care provider. Second, brands of herbal
products vary widely in quality, and it’s not always possible to tell
which product is good quality. Seek the advice of a naturopath or
licensed herbalist to find a good product, or visit ConsumerLabs.
com for information on specific brands.
In summary, there is a wide array of evidence-based treatments
for depression that can be safely used during pregnancy and
breastfeeding. Antidepressants can also be used. The only unwise
choice is not treating depression because it can have serious
consequences for both you and your baby.
Does the Benefit Outweigh the Risk?
Before prescribing antidepressants to pregnant or breastfeeding women, clinicians consider the risks and benefits. Does the benefit of using a medication outweigh the risk? With antidepressants, it’s not an idle question. For example, in one recent study, 20% of women who took antidepressants throughout their pregnancies had preterm babies. But 20% of the pregnant women with untreated depression also had preterm babies. Four to nine percent of the women who were either not depressed, or who had taken antidepressants only some of the time, had preterm babies. The researchers noted that there are substantial risks associated with NOT treating depression, and these need to be considered in any risk-benefit equation.
For More Information about Non-Drug Treatments for Depression
Omega-3 Fatty Acids (EPA & DHA)
Fish oil is still the best source of EPA and DHA (although a vegetarian DHA is available.) The U.S. Pharmacoepia specifically tests fish-oil products for contaminants. Visit USP.org for information about specific brands. Recommended dosages are as follows:
• 200-400 mg is the current recommended dosage of DHA for prevention of depression, but dosages of up to 800-1000 mg may soon be recommended
• 1,000 mg EPA for treatment of depression (can be combined with medication and/or DHA)
• U.S. Food and Drug Administration GRAS (generally recognized as safe) Levels:
– 1,500 mg DHA
– 3,000 mg DHA/EPA
Light Therapy
Rosenthal, N.E. (2006). Winter blues: Everything you need to know to beat seasonal affective disorder, Revised Ed. New York: Guilford.
Sources for Light Boxes
These are two companies I’ve found to be reputable.
• The Sunbox Company
http://www.sunbox.com
• TrueSun.com
http://www.truesun.com
Exercise
For mild-to-moderate depression
• Frequency: 2 to 3 times a week
• Intensity: moderate
• Duration: 20 to 30 minutes
For major depression
• Frequency: 3 to 5 times a week
• Intensity: 60% to 85% maximum capacity
• Duration: 45 to 60 minutes
Psychotherapy…
[this is Chana Jenny Weisberg’s addition, a great resource for mental health referrals in the Orthodox community is: http://www.reliefhelp.org/]
St. John’s wort
Dosage: 300 mg, three times a day
Standardized to: 0.3% hypericin or 2% to 4% hyperforin
http://www.ConsumerLab.com (rates quality of nutritional products through independent testing)
Humphrey, S. (2003) Nursing mothers’ herbal. Minneapolis: Fairview Press.
The Complete German Commission E Monographs available online and for purchase from the American Botanical Council, http://www.herbalgram.org
For More Information on Treatment of Postpartum Depression
Kendall-Tackett, K.A. (2010). Depression in new mothers, 2nd Edition. London: Routledge.
Kendall-Tackett, K.A. (2008). Non-pharmacologic treatments for depression in new mothers. Amarillo, TX: Hale Publishing.
Kathleen Kendall-Tackett, Ph.D., IBCLC is a health psychologist, board-certified lactation consultant, and La Leche League Leader. She is clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. For more information, visit her Web sites: UppityScienceChick.com and BreastfeedingMadeSimple.com.
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