complimentary and alternative approaches to perinatal mental illness dena whitesell, md april 29,...
TRANSCRIPT
Complimentary and Alternative Approaches to
Perinatal Mental Illness
Dena Whitesell, MDApril 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 HAM-D scores (p < 0.0001) but no significant difference between the groups
Omega-3 fatty acidsStudy Study design N Omega-3
doseLength Outcome
Freeman, et al., 2008
Double-blindPlacebo-controlledPregnant and post-partumSupportive psychotherapy
59 DHA/EPA1.9 g
8 weeks
No significant differences between omega-3 fatty acids and placebo
Su, et al., 2008
Double-blindPlacebo-controlledPregnant
36 DHA/EPA 3.6 g
8 weeks
Significantly higher response and remission rates in omega-3 group
Rees, et al., 2008
Double-blindPlacebo-controlledPregnant and post-partum
26 DHA/EPA(much higher EPA)2.1 g
6 weeks
No significant differences between omega-3 fatty acids and placebo
Omega-3 fatty acidsFish 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 TherapyManber 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 majordepressive disorder,
both seasonal andnon-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