Transcript Non-Medication Approaches to Perinatal Mental Illness

Complimentary and
Alternative Approaches to
Perinatal Mental Illness
Dena Whitesell, MD
April 29, 2011
Importance of Treatment


Therapeutic relationship
Traditional medications
…but what about women
who want a different
approach, or for whom
the traditional approach
hasn’t worked?
Alternative Methods





Omega-3 fatty acids
St. John’s wort
Acupuncture
Massage
Light therapy
Omega-3 fatty acids


Best evidence of any alternative
treatment
Two types well studied:
EPA– eicosapentaenoic acid
 DHA—docosahexaenoic acid


Meta-analyses show benefit of
supplements over placebo as
ADJUNCTIVE therapy for both
unipolar and bipolar depression
(Parket et al., 2006; Freeman et al, 2006; Su et al., 2006; Nemets et
al., 2007)
Omega-3 fatty acids

Depletion is common during
pregnancy


Selectively transferred to the fetus for
brain and retinal development
Intake of omega-3 fatty acids by
pregnant and lactating women in
US is only 20-60% of the
recommended amounts
(Otto et al., 1997; Holman et al., 1991; Al et al., 1995; Hornstra et al., 1995, Min et al., 2000;
Benisek et al., 2000)
Omega-3 fatty acids

US FDA mercury advisories for pregnant women—2003



Avoid tilefish, swordfish, shark, king mackerel
Limit other fish intake to 12 oz/week
Main concern is CNS teratogenicity
 Women hear “Don’t eat fish!”
-
-
We know fish intake in pregnant women
has fallen significantly since this advisory
We also know higher fish intake during pregnancy has
been associated with better infant cognitive function
(Oken et al., 2005; Helland et al., 2003)
Omega-3 fatty acids
Freeman, et al., Omega-3 fatty acids and supportive
psychotherapy for perinatal depression: A randomized
placebo-controlled study. Journal of Affective Disorders,
2008.
 n = 59, 8 week trial
 Both pregnant and post-partum women
 Randomized to 1.9 g. of EPA/DHA or placebo
 All received manualized supportive psychotherapy
 Omega 3 fatty acids well tolerated
 BOTH groups had significant decrease in EPDS and HAMD scores (p < 0.0001) but no significant difference
between the groups
Omega-3 fatty acids
Study
Study design
N
Omega-3
dose
Length
Outcome
Freeman,
et al., 2008
Double-blind
59
Placebo-controlled
Pregnant and
post-partum
Supportive
psychotherapy
DHA/EPA
1.9 g
8 weeks
No significant differences
between omega-3 fatty
acids and placebo
Su, et al.,
2008
Double-blind
36
Placebo-controlled
Pregnant
DHA/EPA
3.6 g
8 weeks
Significantly higher
response and remission
rates in omega-3 group
Rees, et
al., 2008
Double-blind
26
Placebo-controlled
Pregnant and
post-partum
DHA/EPA
(much
higher
EPA)
2.1 g
6 weeks
No significant differences
between omega-3 fatty
acids and placebo
Omega-3 fatty acids
Fish Oil Use in Pregnancy Didn’t Make Babies Smart
Makrides et al., Effect of DHA Supplementation
During Pregnancy on Maternal Depression and
Neurodevelopment of Young Children. JAMA, Oct.
2010.
- DHA supplementation during pregnancy
- No clear cognitive benefit to babies
- No evidence that DHA can reduce postpartum
depression (maybe for women already at risk
for it)
Omega-3 fatty acids




Considerable evidence for use as
an add-on to more traditional
medications
Potentially beneficial as
monotherapy in
pregnancy/postpartum– maybe
more so at higher doses, higher
EPA: DHA ratios
May have cognitive benefit for
baby (combination EPA/DHA)
Low risk!
St. John’s wort




Hypericum perforatum
Conflicting evidence for use in treatment of mild
to moderate depression
N = 49, no increased rate of birth defects
N = 33, neonatal syndrome


Increased rates of colic, drowsiness, lethargy in exposed
infants
Breastfeeding case reports


Low levels in breastmilk
Undetectable levels in infant plasma
(Lee et al., 2003; Klein et al., 2002; Klein et al., 2006 Dugoua et al., 2006)
St. John’s wort

Animal studies:



Increased uterine muscle tone, ?
Implications
Increased rates of miscarriage
Overall:


Potential risks, drug-drug
interactions
Natural does not mean
better/safer– antidepressants have
been much better studied
(Dugoua, et al., 2006; Moretti et al., 2009)
Acupuncture
Mixed results as a treatment
for depression in the general population
 Difficult to study because difficult to
control

Acupuncture
Studies by Manber et al., 2004 and 2010
 Both studies had three groups:




acupuncture for depression
“sham” acupuncture, needles in different places
massage therapy
2004 study, n = 61




Acupuncture for depression response 69%
“sham” acupuncture response 47%
Massage response 32%
2010 study, n = 150, more rigorous, defined response as
> 50% reduction in HAM-D score



Acupuncture for depression response 63%
Massage response 50%
“sham” acupuncture response 37.5%
Massage Therapy


Very limited data in the literature specifically for mental
health treatment
Depressive symptoms, when measured, often decrease
in studies using massage for other indications



Meta-analysis of 17 studies showed significant improvement in
depressive symptoms compared to control conditions
Studies vary regarding number of sessions
Studies vary in terms of controls, including no control, relaxation
exercises, treatment as usual
(Hou et al., 2010)
Massage Therapy
Field et al., Journal of Bodywork and
Movement Therapies. 2009
Randomized study, n = 112
Pregnant women with diagnosis of depression
Compared interpersonal therapy (group format) to interpersonal
therapy plus massage
Depressive symptoms measured by Center for Epidemiological
Studies Depression Scale (CES-D)
Women in massage group:
-
Had significantly greater improvements on depression AND anxiety
measures
Had more study completers
Attended more sessions of the interpersonal therapy
Massage Therapy
Field et al., Infant Behavior and
Development, 2009.
Pregnant women with depression, n = 88
Randomized to receive 2x week massage from
partner (after training) vs. treatment as usual,
weeks 20-32 of pregnancy
-
Massage group had:
-
Greater decrease in depression scores
Lower rates of low birth weight and prematurity
Infants had lower saliva cortisol levels
Infants scored higher on Brazelton Neonatal behavioral
Assessment Scales
Massage Therapy
Manber et al., 2010
-
Strong study:
-
-
Verified diagnosis of major depression, minimum HAM-D score
Blinded raters
Standardized Swedish massage
Response rate (> 50% reduction of HAM-D) = 50%
Remission rate (HAM-D < 7) 31%
Unclear mechanism of action
-
-
Increased parasympathetic activity 
decreased stress hormones, BP, HR
Increasing serotonin availability
Increasing oxytocin production
Light Therapy



Has benefit in major
depressive disorder,
both seasonal and
non-seasonal
Risk of switching into hypomania or mania
Very few, small, open trials for treatment
of depression in therapy with light therapy

Though promising
Light Therapy
Wirz-Justice et al., 2011
 Randomized, double-blind,
placebo-controlled study for pregnant
women
 7000 lux fluorescent bright white light
vs. 70 lux dim red light


Depressive symptoms measured via Structured Interview
Guide for the Hamilton Depression Rating Scale, with
Atypical Depression Supplement
Response rates:


Bright light: 81%
Placebo light 45%
Take Home Messages


Continue antidepressants when you can
When you can’t, or the patient needs
adjunctive therapy, consider:
Omega-3 fatty acids
 Acupuncture
 Massage therapy
 Light therapy


Have a “menu of reasonable options” for
your patients
MAPP PPD Project




Provider education
Consumer
education
Collaboration
Consultation
www.mainepsych.org