February 19, 2014
A Functional Medicine Approach to Perinatal Mental Health - Part Two
By: Kathy Morelli | 0 Comments
In a two part post this week, regular contributor Kathy Morelli shares information about and an interview with Kelly Brogan, MD on her nontraditional approach to working with women who are dealing with perinatal mental health issues. Today in part two, Dr. Brogan shares information on incorporating a whole body Functional Medicine approach alongside traditional Western medicine to help and support women dealing with postpartum mood and anxiety disorders. Part one of this short blog series ran on Tuesday. - Sharon Muza, Community Manager, Science & Sensibility.
Kathy Morelli (KM): In the news, there's been a lot of information about the negative impact of a dairy-gluten-and- sugar based diet on the body. Can you tell us a bit about the impact of gluten and sugar on thyroid function after childbirth? Can you reference research on this?
Kelly Brogan, MD (KB): Yes, there's an explosion of research implicating the immune-modulating and inflammatory effects of gluten and sugar (often co-occuring). Many individuals perceive that they are totally "fine" until that day when they're not. In reality, there has been a long period of "incubation" of their symptoms.
When it comes to autoimmunity, we know that the postpartum population is very vulnerable to new onset autoimmune disorders, and we know that autoimmunity requires three ingredients: genetic susceptibility, environmental trigger, and intestinal permeability. This has been well-established by Dr. Alessio Fasano of The Center for Celiac Research.
We know that gluten causes an inflammatory response in all people, locally, in the intestine, and that in a subset of about 80% of people, it provokes intestinal wall changes that allow for compounds, food particles, and bacterial molecules called LPS or lipopolysaccharide into the blood stream. In animal models, LPS is used to induce "depression". There is a large literature, since 1991, establishing the role of inflammation in depression, including in the postpartum depression population.
We also know of a process called molecular mimicry, whereby, immune responses to a food particle or pathogen can lead to attacks on our own body because of common amino acid structures.
We know how to modify inflammation through diet, and we know how to support appropriate immune response through nutrients such as Vitamin A, D, Alpha Lipoic Acid, probiotics and others. I have written about the research supporting these claims on my website if you are interested in the references, but suffice it to say that elimination of gluten, dairy, corn, soy, and sugar is my first step with patients and a primary reason that I no longer need to use medication. It's quite powerful.
KM: And can you elaborate on the impact of dairy products on brain health? Can you share a research article on this?
KB: I don't think that dairy is an issue for every person with mental health symptoms, but I believe it is a compelling variable to control for.
But sure, I can talk about dairy and its impact on health. In schizophrenia and bipolar, in particular, there are papers discussing the role of casein antibodies in clinical presentations. Some of these papers are listed in the references at the end of this article. Some speculation about the reasons that casein, a protein, particularly from Holstein cows which we use in America, is stimulating to the immune system, relates to its being heavily processed - homogenized and pasteurized - so that the fats and nutrients are no longer in their natural state and are provocative to the immune system.
In a paper by Severance et al (2010), they found that new onset and long-term schizophrenics were 8 times more likely to have circulating antibodies to casein than controls and up to 16.5 times more likely in a subgroup of those with psychotic depression.
In a separate study, this team found similar results in the setting of Bipolar I diagnosis and found that medication treatment did not mitigate this immune response. In a study this year, Li et al (2012) found that new onset schizophrenia was associated with immune activation and a 34% increased risk of developing schizophrenia if their levels of antibody were 2 standard deviations elevated. Casein and gliadin (a component of gluten) interact with opiate receptors in the brain in an unpredictable way.
KM: Based on your research and clinical practice, looking at it as a public health issue, do you believe that the overall public incidence of postpartum depression and anxiety can be reduced by educating women about modifying their diets and lifestyles?
KB: Absolutely and unconditionally, yes. Conventional psychiatry has made no progress with regard to identifying markers for vulnerable populations. We are overly focused on serotonin and examination. Research by Oberland et al (2008) into serotonin transporter polymorphisms has been confusing and inconsistent.
We must look at the cumulative burden that pregnancy places on some women and how it exposes the dysfunction of their interrelated neuroendocrine systems resulting in depression, anxiety, and psychosis as non-specific indications that there is lifestyle imbalance and inflammation.
I have a detailed research article about the Neuro-inflammatory Models of Postpartum Depression published here for your further reference.
KM: Based on your research and clinical practice, do you believe that the personal incidence of postpartum depression and anxiety can be reduced for a woman modifying her diet and lifestyle?
KB: Yes. In my clinical practice, with the preventive cases that I work with, I have yet to have an incidence of a woman with postpartum onset symptoms, including those women with previous history.
KM: I've heard you lecture about the nutrient deficiencies and dietary factors that could feed into an occurrence of postpartum psychosis. Based on your research and clinical practice, do you believe that the incidence of postpartum psychosis can be reduced by a woman being aware of the risk factors and modifying her diet and lifestyle?
KB: I am very interested in research like that of Bergink et al (2012) that suggests a significant overlap between thyroid autoantibodies and postpartum psychosis.
We know that these antibodies portend endocrine dysfunction and we know that thyroid stimulation can result in psychosis. We also have precedent, in the literature of bipolar and schizophrenia being induced by nutrient deficiencies, even as simple as niacin.
It is myopic to abandon simple and potentially effective interventions in the interest of medicating these patients, particularly because of the established incidence of mania and violence toward self and others with SSRI treatment. I believe these medications, in the postpartum population account for incidences of violence that might have otherwise been avoided. Ssristories.com explores these cases.
KM: In the hierarchy of risk factors for perinatal mental illness, such as an individual's previous history and family history, where do you think the role of lifestyle management and diet modifications fall?
KB: I think that it trumps all other risk factors, and this is because of what we have learned about the 98% of "junk DNA" that we found after the completion of the Human Genome Project.
This is called "epigenetics" and refers to the role of lifestyle or the "exposome" to modify gene expression within one lifetime.
We outsource much of our bodily function to out bodily microbes, as well, which outnumber our human cells 10:1. This is exciting and empowering because it means that we are not condemned by our family histories or genes. We can change them with each bite off a fork, with each step, and with our home environments.
KM: In your work, you do a thorough assessment and then work carefully to support a woman to taper off their psychotropic medications, if possible. Do you advocate that a woman go off of her medications without supervision?
KB: I do not recommend that women go off their medications without supervision.
My initial consultation is 2 hours and I work intimately with patients during tapers. As I deal with some complicated cases, I require patients to optimize their health and wellness prior to initiating a taper to confer resilience and assure adrenal hormone reserves which are often highly perturbed during a taper (the impact of SSRIs on glucocorticoid functioning is well understood).
Then, we initiate a taper that can take 1-2 years.
This is the most responsible way to do it, and keep in mind it cannot always be done.
This is why I believe that true informed consent prior to beginning a medication must include disclosure of dependency. It is not the original symptoms returning, as I was taught to parrot in my training, it is drug-induced withdrawal and associated "relapse" that often looks like agitation and profound anxiety, often novel symptoms to the patient who has never experienced such autonomic nervous system disruption.
KM: Generally, how do you help a woman who is depressed preserve the breastfeeding relationship, if she states that she wished to do so?
KB: Great question. I believe that lactation support is non-optional and must be daily for the first week and perhaps even the first several weeks. Women need to be supported to nurture this skill and to protect it at all costs. They can't do it alone (in my observation). Here is a link to more information I've published about how to help meet breastfeeding goals.
Once lactation is in place, and supply is established, breastfeeding becomes protective of depression. I will be publishing an article about studies supporting this in the coming weeks. I also encourage pumping early (beginning at 2 weeks) so that there is flexibility around night feedings with partner support.
Basically, we have a crisis of failed lactation that I believe relates to environmental toxins called endocrine disruption, undiagnosed thyroid conditions, and insulin resistance from high sugar diet. >Of course, in the end, it's a woman's decision to care for and feed her infant as she sees fit. Here's a link to some very detailed information about finding safe organic formula products.
KM: What do you recommend as readily available methods a woman can do herself to help her heal postpartum depression and anxiety holistically?
KB: I certainly recommend consulting with a holistic provider such as a naturopath, acupuncturist, homeopath, or certified physician. That said, dietary modification, mild exercise, and 20 minutes daily or relaxation response is a great place to start.
KM: What are some of your other projects going on now?
KB: My cup runneth over! I am writing a book that I hope will be a resource to the women I cannot personally see in my busy practice. I maintain an active blog at www.kellybroganmd.com and am also on Huffington Post. I am directing a conference and participating in several in the coming year, and will be providing a course with Aviva Romm, MD to help educate women about holistic health. Fearless Parent will be very active throughout the year with events, blogs, and weekly radio shows to help parents navigate all of the information that comes at them in the realm of thoughtful parenting. Join us!
KM: Thank you for your valuable time & input!
KB: My absolute pleasure. Your interest and support mean a lot to me, as does the mission and educational dedication that Lamaze upholds. I'm an enormous fan!
How do you feel about the information that Dr. Brogan shared? Have you or your clients had any experience with Functional Medicine? Would you provide this information to women along with more traditional recommendations, for them to explore when they are being treated for perinatal mood disorders? - SM.
Bergink V. et al. Prevalence of autoimmune thyroid dysfunction in postpartum psychosis. British Journal of Psychiatry, 2011;198:264-8. Epub February 22, 2011.
Black, M.M. (2008). Effects of B12 and folate deficiency on brain development in children. Food and Nutrition Bulletin, June (29), 126-131.
Brogan K. (2013). Putting theory into preliminary practice: Neuroinflammatory models of postpartum depression. OA Alternative Medicine, May 01;1(2):12.
Dickerson F, Stallings C, Origoni A, Vaughan C, Khushalani S, Alaedini A, Yolken R. Markers of gluten sensitivity and celiac disease in bipolar disorder. Bipolar Disorder. 2011 Feb;13(1):52-8. doi: 10.1111/j.1399-5618.2011.00894.x.
Fasano, A. and colleagues at the Celiac Center, numerous medical research articles.
Jackson, J., Eaton, W., Cascella, N., Fasano, A., Kelly, D. (2012). Neurologic and Psychiatric Manifestations of Celiac Disease and Gluten Sensitivity.Psychiatric Quarterly, 83(1), 91-102, http://dx.doi.org/10.1007/s11126-011-9186-y
Li J, Harris RA, Cheung SW, Coarfa C, Jeong M, et al. (2012) Genomic Hypomethylation in the Human Germline Associates with Selective Structural Mutability in the Human Genome. PLoS Genet 8(5): e1002692. doi:10.1371/journal.pgen.1002692
Niebuhr DW, Li Y, Cowan DN, Weber NS, Fisher JA, Ford GM, Yolken R. Association between casein bovine antibody and new onset schizophrenia among US military personnel. Schizophrenia Research, 2011 May;128(1-3):51-5. doi: 10.1016/j.schres.2011.02.005. Epub 2011 Mar 4.
Oberland, TF, Weinberg, J, Papsdorf, M, Grunau, R, Misri, S, & Devlin, AM (2008). Prenatal exposure to maternal depression, neonatal methylation of human glucocorticoid receptor gene (NR3C1) and infant cortisol stress responses. Epigenetics, Mar-Apr,3(2), 97-106.
Severance EG, Dupont D, Dickerson FB, Stallings CR, Origoni AE, Krivogorsky B, Yang S, Haasnoot W, Yolken RH. Immune activation by casein dietary antigens in bipolar disorder. Bipolar Disorder. 2010 Dec;12(8):834-42. doi: 10.1111/j.1399-5618.2010.00879.x.
Perlmutter, D. (2011). Grain brain: The surprising truth about wheat, carbs, and sugar - Your brain's silent killers. New York: Little, Brown & Company
TagsPostpartum depression Postpartum Postpartum Anxiety PPMAD Guest Posts Kathy Morelli depression Kelly Brogan perinatal mental health