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 acidsFreeman, 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

AcupunctureStudies 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 TherapyField 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 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 TherapyWirz-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