Postpartum Depression Screening: Prevention or Problem?

Kelly Brogan, MD, ABIHM
15
116

Medicine, in its truest form is a beautiful testament to the human condition. We are in this together. When one struggles, others support. We are fundamentally compassionate, loving beings, deeply invested in the welfare of our fellow planet-dwellers.

Today’s medicine is undergoing a process of metamorphosis, however. We are moving from a warring posture of “Anti” pharmacology – from antihypertensives, antibiotics, and antidepressants, to a deeper understanding that we have to work with the body and recognize its connection to nature and its own evolutionary imperatives. In short, the microbiome has sent us all back to the drawing board.

If we see disease and disorder as something to “fight” and symptoms as something to suppress, then having someone up in the watchtower looking out for intruders is a wonderful idea, right?  Screening and conventional preventive efforts seem to fit the bill. The sooner we can “catch” it, the sooner we can treat it, and the more likely we are to beat it.

What does screening mean, in the ever more prevalent field of Psychiatry, though? Psychiatric screening is not a biological metric that can be assumed to predict the future in a linear manner. It’s a series of subjective questions. It is, in short, a survey.

Psychiatry is one of the only fields to use such an impressionistic diagnostic system. The field’s Diagnostic and Statistical Manual has come under great scrutiny in the past several years. As exposed by a former chair of the DSM Task Force, conflicts of interest are the norm and the dictionary of pathological labels highly subject to influence.

Screening implies that we have arrived at a state of diagnostic validity and that our interventions have been proven over time and across statistical methodologies to improve outcomes. It has taken years for the dangers of overdiagnosis and over-treatment to emerge, for example, in the cancer arena.

The United States Preventive Services Task Force seems to feel that we have this necessary science under our belt in recommending universal screening for depression in pregnant and postpartum women.

As a fellowship-trained reproductive psychiatrist, I used to believe that “access to care” was of paramount importance. Care most typically implied medication management and exploration, with a given patient, of the known (and unknown) risks of fetal and infant medication exposure.

What I have learned in the intervening 8 years has raised grave concerns around this fantasy-like desire to help women through better access to mental health services. Here are some of my considerations:

  • With such an impressionist diagnostic system, depression can be a wastebasket term for many physiologic processes including thyroid dysfunctionautoimmune and inflammatory flares, and micronutrientdeficiency. Depression is often a symptom of reversible bodily imbalance.
  • When it’s not physiologic in origin, what if it is cultural in origin? What if women are departing too radically from what their evolutionary expectations demand? Community and family support and nurturing. If women are feeling isolated and disconnected, alone and hopeless, is medication or therapy getting at the root of this larger societal issue, or is it blaming the victim?
  • At my last review, there were 3 randomized, placebo-controlled trials of antidepressants in the postpartum population. At a time of immense complexity with regard to psychoneuroendocrine and immunologic shifts, introduction of a poorly studied medication that has known side effects of agitation and impulsivity seems premature at best. Where is the data that demonstrates better outcomes with treatment?

Perhaps we are hoping and wishing to help this growing cohort of women so desperately that we are offering to use medication to turn off their “smoke alarm,” without putting out the fire raging in their life experience.

There is a story about Psychiatry that conflicts significantly with the story I was told through my 9 years of medical training. The naturalistic and longitudinal data raises a signal of harm for long-term treatment, emergent risks for short-term treatment, and a profoundly disappointing picture of inefficacy over active placebo.

There is another way to help women thrive and embrace this next chapter in their lives, and it has to do with listening to depression’s message. It requires that we view this symptom as a sign of “evolutionary mismatch” and give the body back what it expects – sound nutritiona non-toxic/immunostimulatory environmentmovementphysiologic birthbreastfeedingstress response support, and community engagement.

Sometimes doing something proactively appears defensible and logical, when at its root lies hubris that we may soon come to regret.

* * * * *

(Adapted from KellyBroganMD.com)

15 COMMENTS

    • Good question, since there does seem to be a problem of “medical kidnaps” on the rise.

      Thank you, Kelly, for pointing out, “Sometimes doing something proactively appears defensible and logical, when at its root lies hubris that we may soon come to regret.”

      Especially since the medical community does not yet seem to know how to properly use the antidepressants, if they should be used at all. And they are commonly misdiagnosing, now “appropriately” diagnosing, the common adverse effects, and withdrawal effects, of the antidepressants as “bipolar.”

      Resulting in millions of destroyed lives, via a completely iatrogenically created illness. Especially, given the reality that today’s “bipolar” drug cocktail recommendations are actually a recipe for how to create “psychosis,” via anticholinergic toxidrome.

      • Oh, there’s a probable illness due to imbalances of one sort or another but the accepted treatments would indeed be a joke if they didn’t induce suicide in a number of patients. Were I still into sorcery- sorry, no masks or rattles, songs or dances around the campfire- I’d use B6, zinc (Ma’s high in copper at this time), B100’s and C(3g+/day) and get Ma to take an HOD test to see if there were any special disperceptions or mood problems to fear, which might require further action (remember I have no access to drugs).

      • Step 1: Depression label.

        Step 2: Drugs

        Step 3: Label the side effects “danger to self and child”

        Step 4: CPS

        Step 5: Mandatory psychiatric treatment

        Step 6: More Drugs

        Step 7: Label mothers reaction to this growing nightmare “the illness”.

        Step 8: More Drugs “Find the right meds”

        Step 9: Goto step 3

        • For me it was a “safe smoking cessation med” to “bipolar” label. And, thankfully, my kids were better than most, I was an active volunteer in the schools, so DCFS left us alone. Husband didn’t survive though, talk about how to destroy lives and families, psychiatry’s got the ticket.

          • They have the ticket alright.

            If there was only a way to really describe to the public how it happens.

            Anyone that has lived it gets my step list describing the take that first pill and spiral down as they make it worse scenario but what about people that haven’t ?

            The label say’s may cause suicidal thoughts but like everyone thinks it won’t happen to me.

            I don’t know I am taking a break from computer for a wile.

  1. Psychiatrists are only able to “determine” whether or not someone “has Major Depression” little better than chance:

    https://www.madinamerica.com/2013/03/the-dsm-5-field-trials-inter-rater-reliability-ratings-take-a-nose-dive/

    The screening process for Major Depression, rather than being anything scientific, is therefore more like flipping a coin. Heads you have Major Depression, Tails you have some other disorder.

    This effort to screen people should be seen as what it is: An effort to expand the pool of sheep that can be drugged to increase profits of drug companies and maintain high incomes for psychiatrists. Period.

  2. Good reasons to be depressed postpartum:

    1) Sleep deprivation
    2) Complete change of daily routines and expectations to accommodate new, helpless infant
    3) Breastfeeding problems
    4) Shift of focus from pregnant mom to new baby
    5) Difficulties with body image resulting from pregnancy/birth changes, which are often not entirely reversible
    6) Loss of income
    7) Loss of connections with fellow employees
    8) Loss of sense of purpose provided by work environment
    9) Changes in relationships with friends who don’t have a baby
    10) Birth brings up own childhood issues
    11) Mythological social expectations fail to meet with reality of new baby
    12) Sex life essentially non-existent
    13) Potential contact with abusive/disrespectful family members
    14) Domestic abuse frequently starts or escalates during or after pregnancy
    15) Increasing sense of dependence or “trapped” feeling
    16) Challenges of dealing with unwanted pregnancy
    17) Baby presents medical challenges or other difficulties that violate expectations and prevent good bonding

    I could go on. Feel free to add to the list.

    Note that not one of the above even mentions the mother’s physiology or hormone changes, which of course can contribute in other ways, such as malnutrition or low blood sugar due to dieting to regain pre-pregnancy weight, or low iron resulting from difficulties with appetite during pregnancy. Being a new mom in today’s society is extremely difficult and often isolating, and also leaves new moms vulnerable to abuse or mistreatment by family members, including their spouse in too many cases. To suggest that “PPD” is some kind of a biological disorder of the brain in all or even most cases is laughable in the extreme. This is especially highlighted when we look at cross-cultural studies, which show that there are some cultures where PPD essentially never occurs.

    While it is always worthwhile to explore physiological factors like diet, sleep, and illness, the vast majority of depression following birth is an entirely normal response to a rather abnormal society’s lack of support for new motherhood. Normalizing feelings and helping the mom identify the reasons and some actions she can take to get more in control of her new life situation is much more effective than trying to dismiss these feelings as a “mental disorder” and drug the sufferer into numbness and increased disconnection from her emotions.

    —- Steve

    • Bravo, Steve. Your list makes so much sense. I especially appreciate that sleep deprivation is Number 1. YES! And how does drugging the new mom and telling her she’s “disordered” help with any of the challenges/problems on your list? It doesn’t help! What new mom needs is lots of empathy and support. And naps.

      The only thing I might add to your list is the temptation to feel guilty having a struggle at all with new motherhood – about not measuring up (Maybe #11 covers that). Oh, and having a new baby can put a strain on the relationship with the current child/children.

      • I was thinking of a first baby, but of course, sibling rivalry and confusion and attendant behavioral issues are very common responses to a new baby, which often leads to feeling even more overwhelmed. My mom had three of us under three, and four under 5. I’m amazed she didn’t beat one or more of us to death, or slit her wrists!

        Not only does telling a mom she is “disordered” for having these reactions not helpful, it my experience, it is the exact OPPOSITE of what should be done, and does overt and lasting harm. The mom is already feeling inadequate and overwhelmed. Now you tell her that her brain isn’t working right because she should be happy and shiny about all of these wonderful changes? I think if a psychiatrist had told even me that after our first, very challenging child was born, I’d have wanted to knock his teeth in. I can only imagine how invalidative that would be to a new mom!

        —- Steve

      • Right, ’cause everyone is SUPPOSED to be thrilled and happy 24-7 about their new baby, and if you’re not, well, have we got a drug for you! It’d be more honest if they prescribed vodka tonics three times a day. But, of course, there’s no way to patent a vodka tonic, so we have to go more esoteric to make the big bucks.

        —- Steve