What is postpartum depression? It depends who you ask. If you ask me, I’m likely to describe a number of potential contributors that can ultimately be tagged with the impressionist psychiatric descriptor of postpartum depression, anxiety, and psychosis. These terms tell us little to nothing about what's actually going on in a woman’s body, yet the gold standard of treatment is medications that may only be riding a placebo effect, and may put that woman — and even her family — at risk, all while neglecting to investigate underlying drivers. It’s time to demand a more personalized and biochemically updated perspective on this syndrome that afflicts 10-15% of women.
In my communication with perinatal psychiatrists, and in reading the updated literature that attempts to identify predictive factors and best treatments, I'm struck by how one-dimensional this research is. Here are my complaints:
Research on pregnancy-related mood disorders rarely controls for metabolic and inflammatory markers that we know to be derailed in the setting of most of what we call depression.
It rarely, if ever, controls for dietary and environmental exposures (filtered water, plastics, and pesticides).
When studying natural agents, studies fail to apply a multi-interventional approach that includes lifestyle changes and a number of synergistic nutrients. The more we think about natural supplements the way we do medication — one pill for one disease — the further we get from understanding and appreciating their true potential.
You can imagine my excitement when I read Homocysteine and serotonin: Association with Postpartum Depression one weekend. Here, researchers state what I've come to believe is the most promising gauge of risk to baby and mother: elevated inflammatory markers. They state, “One of the biological factors for PPD may be higher levels of homocysteine,” and go on to discuss the results of their study, which assessed Edinburgh-confirmed postpartum depression and found elevated homocysteine at both 1-2 days postpartum and 6 weeks after delivery.
The babies of these mothers also had lower APGAR scores. Unsurprisingly to me, serotonin played a less predictable role (because depression is not a serotonin deficiency!). Let’s understand why homocysteine is a good candidate marker for a complex inflammatory syndrome that likely involves diet- and environment-driven immune reactivity inside and outside the brain:
An amino acid pathway, the methionine-homocysteine pathway plays a critical role in widespread bodily functions including production of the body’s principal methyl-donor, SAMe, and the body’s primary antioxidant glutathione. Through these two responsibilities, recycling of homocysteine accomplishes the following (and more) brain-relevant tasks:
- Production of myelin around nerve sheaths
- Production of neurotransmitters such as dopamine, serotonin, and norepinephrine
- Support of nerve cell membranes through phospholipid production
- Management of oxidative stress
B12, B9, and B6, all of which have been fingered as important nutrients for mood and brain health, are directly involved in the “one-carbon cycle,” which recycles homocysteine. Hence, low intake of these nutrients can promote inflammation and mood destabilization.
- Individual genetic variants that determine how well we traffic and metabolize these nutrients are being elucidated. For instance, MTHFR genetic mutations can render you up to 70% less efficient at converting food or synthetic folic acid into a form that your brain can use to make DNA, RNA, neurotransmitters, and fatty acids.
- The “bioavailability” (the form in a given fortified “food” or supplement) of these vitamins may make the difference between a happy mama, healthy baby or the opposite.
Polyunsaturated fats, like fish oil, may have a sweet spot in terms of minimizing inflammation:
- There is precious little data to support using omega-3 fatty acids as a treatment for perinatal depression, but there are a number of correlative studies identifying deficiency as a risk factor. This paper suggests that DHA specifically, and at lower rather than higher doses, may perform antioxidant roles. The ability of omega-3s to oxidize is related to pro-oxidant factors like dietary sugar, trans fat, alcohol, pathogen exposure, and stress.
- Our fats and our cell membranes are happiest when they're in good dietary supply and in a nonhostile bodily environment.
Oxidative stress is the enemy of a mom looking for a happy pregnancy and healthy postpartum and also for her baby, and has been implicated in miscarriage, diabetes-related congenital malformations, spontaneous abortions, preterm birth, pre-eclampsia, fetal growth restriction and low birth weight, according to this review.
Maternal micronutrients and fatty acid intake can thus alter the genetic expression of the fetus — or the baby's “epigenetics.” We also know that environmental factors, like exposure to bisphenol A, can do the same, but that diet and stress management may be protective.
A number of studies have implicated the immune system (responsive to oxidative stress signals) in postpartum depression. Theories of immune response have evolved to account for the interplay between genetics, environmental triggers, and hormones in such a way that makes postpartum onset mood and anxiety disorders a perfect candidate for viewing through this complex lens. What we have here is an opportunity to resolve and prevent complex neuroendocrine phenomenon through diet, environmental exposure modification, and stress response, while also supporting a health pregnancy, birth, and postpartum recovery. This is the new face of postpartum depression, root-cause resolution and full-body risk rehabilitation rather than medication treatment that sidesteps the whole enterprise of healing.
Want to minimize your risks? Ask your doctor to check (at least) the following labs:
- Rbc folate
- B12, methylmalonic acid
Then consider lifestyle medicine (and working with an enlightened provider), which includes:
Exercise: Burst exercise is my primary recommendation. It is the most bang for your buck in terms of cardiovascular benefit and specifically enhancing mitochondrial health because it puts a special kind of stress on the body when you move to your max for 30 seconds, then recover for 90. I recommend 8 intervals 1-3 times per week.
Meditation: The effects of stimulating the relaxation nervous system, even through listening to a 20-minute guided meditation, can be far-reaching. Enhanced genomic expression of anti-inflammotry genes and suppression of inflammatory ones were demonstrated in this study.
Diet: I recommend a diet that controls for glycemic fluctuations through elimination of refined carbs and grains, and through high levels of natural fats to push the body to relearn how to use fats for fuel. This is the brain’s preferred source. I discuss some therapeutic foods here.
Strategic supplementation: Natural anti-inflammatories like polyunsaturated fats (evening primrose oil and fish oil), vitamin D, N-acetylcysteine, magnesium, curcumin (the active component of turmeric), and probiotics can help promote a synergy of beneficial effects from the above interventions.
I’d like to bring pregnant and postpartum women into the light of functional medicine, for their sake and the sake of their little ones.
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