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PAPERS: Cindy-Lee Dennis Psychosocial and psychological interventions for prevention of postnatal depression: systematic review BMJ 2005; 331: 15 [Abstract] [Full text]

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Postpartum Depression May Be Related to Unresolved Prior Pregnancy Losses

David Reardon   (7 July 2005)

Multifactorial aetiology of Postpartum Depression

James Paul Pandarakalam, jpandarak@hotmail.com   (12 July 2005)

Prevention of Postnatal Depression or Distress

Stephen Matthey   (21 October 2005)

Managment of post natal response

Dr E D M Tod   (20 August 2008)

Postnatal depression and low zinc and high copper levels

Ellen CG Grant   (21 August 2008)

Copper in post-natal depression

Edmond V O`Flaherty, Co Dublin   (29 August 2008)

Postpartum Depression May Be Related to Unresolved Prior Pregnancy Losses 7 July 2005
David Reardon, Director Elliot Institute 62791-7348 Send response to journal: Re: Postpartum Depression May Be Related to Unresolved Prior Pregnancy Losses	Dear Editor, Self-reports and clinical experience suggest that unresolved feelings about a prior pregnancy loss, involuntary or voluntary, may play an important role postpartum depression.(1) The explanation offered is that feelings and conflicts about the prior loss that were once successfully repressed are aroused by the birth of a subsequent child. If prior pregnancy loss is a risk factor for postpartum depression, it could be a very useful tool for screening higher risk patients may provide helpful directions for more useful interventions. It does not appear, however, that this possible association has ever been statistically tested. Perhaps Professor Lee could review the studies she examined to verify or correct this observation. The possible connection between pregnancy loss and postpartum depression is indirectly supported by numerous studies linking pregnancy loss with higher risk of subsequent adverse psychological problems. For example, women with a history of abortion are more likely to use emotional altering substances during subsequent pregnancies(2,3) and depression(4) and general anxiety disorder.(5) Both miscarriage and abortion are associated with a significant increased risk of suicide.(6) Also, a small record based study in Denmark,(7) and a larger study in California, have also shown significantly elevated rates of psychiatric admissions(8) and outpatient psychiatric treatment(9) following induced abortion. The latter also found that patterns of pregnancy outcomes effected subsequent admission rates. Sincerely, David C. Reardon, Ph.D. Elliot Institute (1) Burke T, Reardon DC. Forbidden grief: the unspoken pain of abortion. Springfield (IL): Acorn Books, 2002. (2) Coleman PK, Reardon DC, Cougle J. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Br J Health Psychol. 2005; 10:255-68. (3) Coleman PK, Reardon DC, Rue VM, Cougle J. A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. Am J Obstet Gynecol. 2002;187(6):1673-8. (4) Cougle JR, Reardon DC, Coleman PK. Depression associated with abortion and childbirth: a long-term analysis of the NLSY cohort. Med Sci Monit. 2003 Apr;9(4):CR105-12. (5) Cougle JR, Reardon DC, Coleman PK. Generalized anxiety following unintended pregnancies resolved through childbirth and abortion: a cohort study of the 1995 National Survey of Family Growth. J Anxiety Disord. 2005;19(1):137-42. (6) Gissler G, Hemminki E, Lonnqvist J. Suicides after pregnancy in Finland: 1987-94: register linkage study. BMJ. 1996; 313:1431-4. (7) David H, Rasmussen N, Holst E. (1981). Post-abortion and postpartum psychotic reactions. Fam Plann Perspect. 1981 Jan-Feb; 13(1): 32-4. (8) Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low income women following abortion and childbirth. Can Med Assoc J. 2003; 168(10):1253-7. (9) Coleman PK, Reardon DC, Rue VM, Cougle J. State-funded abortions versus deliveries: a comparison of outpatient mental health claims over 4 years. Am J Orthopsychiatry. 2002 Jan;72(1):141-52. Competing interests: The Elliot Institute's mission includes researching the impact of abortion and raising public awareness of abortion's risks.
Multifactorial aetiology of Postpartum Depression 12 July 2005
James Paul Pandarakalam, consultant psychiatrist, 5 Borough Partnership NHS Trust St Helens North CMHT, Peasley Cross Resource Centre, St Helens, Merseyside WA 9 3DA, jpandarak@hotmail.com Send response to journal: Re: Multifactorial aetiology of Postpartum Depression	Cindy- Lee Dennis appears to have indirectly favoured the biological aetiology of postpartum depression by portraying the failure or deficiencies of diverse psychological and psychosocial intervention in preventing postnatal depression although the author finds intense, professional postpartum support targeted at risk women are beneficial.1 The aetiology of postpartum depression is still a moot point and is multifactorial. Debate continues about its cause, definition, diagnostic criteria and even its very existence as a separate disease entity. Contributing factors may be physiological, psychological and genetic. Biological factors are of paramount importance. Depression is twice as common in woman as it is in men and a link between reproductive status and the illness is further substantiated by its frequency during pre- menstrual phase, the perimenopausal period and in the immediate postpartum period 2.There is a large drop in circulating hormonal level between pregnancy and puerperium. Thyroxin and progesterone require special mention. The thyroid gland shows increased activity during pregnancy, but the amount of circulating hormone rapidly falls after childbirth. A normal level may not be regained for several months. Thyroxin is helpful in treating frigidity following childbirth. Normally levels of oestrogen, progesterone and cortisole fall dramatically within 48 hours after childbirth. The fact may be that women who are going to develop PPD may be more physically sensitive to the parturition related hormonal shirks. The mechanism underlying such differential sensitivities remains undetermined. Many psychological factors may operate. A child may be unwanted for a variety of reasons. Fear of child birth, resentment of loss of freedom or of added responsibilities, hostility to the husband, symbolic sex connotations, recollection of one’s own sibling rivalry and added financial stress may be some of them. Lack of emotional maturity is generally a cause for postpartum reactions. Disorders of psychosexual development in childhood may have a bearing in adult life. For example, unresolved oedipal complex may lead woman to reject her baby. The risk of major depression after miscarriage is high for women who are childless. Infant temperamental problems and high level of child care stress could lead to PPD. Feelings of loss of an old identity after the first child birth, feeling overwhelmed with responsibilities of motherhood, feeling less attractive physically and sexually, frustrations of not able to loose weight are contributing psychological factors. There are suggestions that PPD is an evolutionary adaptation by way of expressing negative emotions of helplessness in order to get greater level of investment from others.3 Evolutionary psychologists propose that humans and non-humans will not invest in their offspring when the cost outweigh benefits. Reduced care, abandonment, and killing of offspring have been documented in a wide range of species. In many bird species, both pre and post hatch abandonment of brood is common. Unlike non-human offspring, human infant demands extraordinary parent care. These etiological factors are only clues, straws in the wind. In the ancient cultures, there is a time-honoured practice of 40 days of “confinement”, and the family and relatives relieve her of her household chores so the new mother get enough rest for revitalising before she resumes her normal activities. Consequently there is less incidence of PPD in traditional cultures. Does this finding point towards a prominent psychosocial aetiology of postpartum depression? 1.Cindy- Lee Dennis. Psychosocial and psychological intervention for prevention of postnatal depression: systematic review. BMJ. 2005; 331:15. 2. Yonker KA, Chantilis SJ. Recognition of depression in Obstetrics/Gynaecological practice. American Journal of Obstetrics & Gynaecology. 1995; 173(2): 632-638. 3.Trivers R L. Parental investment and sexual selection. In B Campbell(Ed) Sexual Selction and the Descent of man. 1972;p136-179. London: Heinemann. Competing interests: None declared
Prevention of Postnatal Depression or Distress 21 October 2005
Stephen Matthey, Research Director, Infant, Child & Adolescent Mental Health Service Sydney South West Area Health Service, ICAMHS, Liverpool 2170. NSW. Australia. Send response to journal: Re: Prevention of Postnatal Depression or Distress	21 October 2005 Dear Editor, In a recent article in the BMJ a systematic review of psychological and psychosocial strategies to prevent postnatal depression was reported (Dennis, 2005). One of the conclusions was that “this systematic review shows that there is no clear evidence to recommend the implementation of antenatal and postnatal classes…” (p. 18). Unfortunately this review did not include a Randomised Controlled Trial (RCT) by myself and colleagues (Matthey et al., 2004), cited in both Medline and PsycINFO (this latter database was not included in the systematic review), and published within the timeframe of the systematic review. This study found a specific psychological strategy, introduced at antenatal classes with some postnatal components, was effective at reducing the level of depressive symptomatolgy for women previously assessed as having low self-esteem. There are many reasons why other psychosocial interventions may not have been effective, whereas ours was. These include the obvious one that the interventions in these other studies were inherently ineffective (which may be due in some cases to the lack of involvement of mental health professionals, as suggested by Lumley, 2005); or as often occurs the lack of involvement in the intervention by the participants (often due to low attendance at multi-session programs). In addition, we discussed how most prevention programmes only analyse the data for main effects, rather than interaction effects (that is, is the intervention more effective for particular sub-groups of participants? – in our case, women with low self-esteem). It is therefore important that clinicians realise that, contrary to the review’s conclusion about the lack of usefulness of antenatal classes, one rigorous RCT, using a strategy package not previously tested, has found significant benefits for women in the early postnatal period. These benefits led Ogrodniczuk (2004), in an independent review of the study, to conclude “The intervention appears to be feasible in any context that involves parenthood classes. It seems to offer a cost efficient approach to reducing maternal distress. The findings should change clinical practice.” (p. 116). I, and my colleagues, certainly hope that this last statement is the case! References Dennis C-L. Psychosocial and psychological interventions for prevention of postnatal depression: systematic review. BMJ 2005; 331:15- 18. Lumley J. Attempts to prevent postnatal depression. BMJ 2005; 331: 5- 6. Matthey S, Kavanagh D J, Howie P, Barnett B, Charles M. Prevention of Postnatal Distress or Depression: an evaluation of an intervention at Preparation for Parenthood classes. J Affect Disord 2004;79:113-126. Ogrodniczuk, JS (commentator). Increasing a partner’s understanding of motherhood significantly reduces postnatal distress and depression in first time mothers with low self esteem. Evid Based Ment Health 2004; 7: 116. Yours sincerely, Stephen Matthey, Ph.D. Research Director: ICAMHS , Sydney South West Area Health Service, NSW Australia. E: stephen.matthey@swsahs.nsw.gov.au Competing interests: None declared
Managment of post natal response 20 August 2008
Dr E D M Tod, physician tn12 0rs Send response to journal: Re: Managment of post natal response	Dear Sir In 1964 and 1971 I noted severe anaemia and/or folic acid deficiency as a precursor of severe post natal depression. Similiarly persistant anxiety--not always evident unless psychological profiling was undertaken during the pregnancy. This underlines the value of prospective epidemiological study. Pural depression, a prospective epidemiological study. Lancet 2. 1264-66 1964 Tod EDM pyschomatic medicine. Gynaecology 3rd International congress. 1974 338-340 (Kagr,basl1972) Yours sincerely Dr E David Macrae Tod OBE FRCGPE Competing interests: None declared
Postnatal depression and low zinc and high copper levels 21 August 2008
Ellen CG Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU Send response to journal: Re: Postnatal depression and low zinc and high copper levels	An obvious easily treatable cause of postnatal depression, common nutritional deficiencies especially of zinc and fish oils, has not been mentioned in the responses to the article on psychosocial and psychological interventions by Cindy- Lee Dennis.1 In contrast, Bodnar and Wisner write that child bearing-aged women are particularly vulnerable to the adverse effects of poor nutrition on mood because pregnancy and lactation are major nutritional stressors to the body.2 They believe that depletion of nutrient reserves throughout pregnancy and a lack of recovery postpartum may increase a woman's risk of depression. They also write that greater attention to nutritional factors in mental health is warranted given that nutrition interventions can be inexpensive, safe, easy to administer, and generally acceptable to patients. Wojcik and others demonstrated a relationship between the severity of depressive symptoms and decreased serum zinc concentrations in postpartum depression.3 Following observations of a possible association between elevated serum copper levels and post-partum depression, Crayton and Walsh found copper levels were significantly higher in women with a history of post- partum depression compared both to non-depressed women and to depressed women without a history of post-partum depression. The mean serum copper level of 78 women with a history of post-partum depression was 131+/- 39microg/dL compared with 111+/-25microg/dL in 148 women without such a history, and 106+/-20microg/dL in non-depressed controls (p<0.001). Increases in progesterone and oestrogen levels during pregnancy raise copper and lower zinc concentrations and I do not know why this is usually ignored. I have seen patients with high copper (up to 263 microg/L) and low zinc concentrations who have postnatal depression and premenstrual psychotic feelings. I am concerned that many pregnant women take nutritional supplements containing 1mg or more of copper daily and continue to take these high doses after childbirth. High doses of copper are common in several multivitamin and mineral supplement combinations recommended for use in pregnancy by companies selling such products. 1 Cindy- Lee Dennis. Psychosocial and psychological intervention for prevention of postnatal depression: systematic review. BMJ 2005; 331:15. 2 Bodnar LM, Wisner KL. Nutrition and depression: implications for improving mental health among childbearing-aged women. Biol Psychiatry. 2005;58:679-85. 3 Crayton JW, Walsh WJ. Elevated serum copper levels in women with a history of post-partum depression. J Trace Elem Med Biol. 2007;21:17-21. 4 Wójcik J, Dudek D, Schlegel-Zawadzka M, Grabowska M, et al. Antepartum/postpartum depressive symptoms and serum zinc and magnesium levels. Pharmacol Rep. 2006;58: 571-6. Competing interests: None declared
Copper in post-natal depression 29 August 2008
Edmond V O`Flaherty, GP Gleneagle,Greygates,Mount Merrion,, Co Dublin Send response to journal: Re: Copper in post-natal depression	I would be supportive of Dr Ellen Grant`s contribution to these rapid replys. Most doctors have little or no interest in nutritional psychiatry so a whole range of psychiatric problems are being treated indequately using medication only where the biochemistry should be sorted out too. Copper levels double during pregnancy, probably because it appears to be required for the formation of blood vessels in the foetus. If the copper level does not drop quickly after delivery depression appears to be likely.It seems then that giving zinc after delivery should protect against post-natal depression.Further research is needed to prove that definitively but as zinc competes with copper in passing through the gut wall it seems entirely logical. There is a whole world of biochemical treatments available for such varied conditions as autism and Alzheimers too but nobody seems to care as no drug company can make money out of natural nutrients-amino acids,vitamins,minerals and essential fatty acids. Competing interests: None declared