In part 1 I looked at the ‘three degrees’ of postnatal mental disturbance; the mild, common and short-lived ‘baby blues’; the much less common but more severe and prolonged postnatal depression, or PND; and the rarer still but very serious post-natal (puerperal) psychosis. I touched on the implications of these conditions for mothers, families, carers and for the newborn babies themselves.
So, given the importance of these illnesses in the postnatal period, what are the best forms of prevention and treatment?
In reviewing the research literature and talking to key workers in this field, I was reminded of one of the many folk tales from the middle-East and Asia featuring Mullah (or Sheikh) Nasruddin, a simple soul who in fact represents ‘Everyman’, and illustrates all the foibles of human nature:
Sheikh Nasruddin was pacing slowly up and down, his eyes fixed on the dusty ground under a single street lamp, thirty yards down the road from his home, when a friend walked by.
“What are you looking for, O Nasruddin?” he asked.
“I have lost my most precious gold medallion” said the Sheikh.
“Then I shall help you search” said the friend.
20 minutes later and still there was no sign.
“It really doesn’t seem to be here” said the friend. “Just where exactly did you drop it, Nasruddin?”
“Oh, back there in my house” said the Sheikh.
“Then why on earth are you looking for it here” said the friend, astonished.
“Because it’s dark in there” replied Nasruddin, – “I can see much better out here under the street light!”
Of course, WE wouldn’t be like this, would we? Especially not researchers? And yet……
It turns out that our subject perfectly illustrates the difficulty of establishing ‘the truth’ in a particular area of Medicine. If we apply the three approaches of analogy (what others say about a thing); analysis (trying to understand how it works); and personal experience, what do we find?
What others say: Talking to key workers in the field of postnatal illness and reviewing relevant research papers, I found disagreement not only between psychiatrists and gynaecologists, but also different views within each discipline.
For instance, the Psychiatric Research Trust says that ‘at the present time treatments are conventional drug therapy; but we urgently need to develop and test specific hormone therapies’.
One eminent psychiatrist said there were ‘some positive small sample studies on the use of hormones; but as many, if not more, negative ones’.
Another quoted a double-blind placebo-controlled trial that concluded that ‘progesterone was of no value in PND and could even make depression worse’; only for me to discover that the paper was, in fact, referring to the use of synthetic progestogens, – very different in their action from progesterone. This misunderstanding crops up again and again (most recently in an article in ‘The Independent’ on the menopause) causing confusion and undermining the use of a very effective and trouble-free hormone, bio-identical progesterone.
Professor John Studd at the Chelsea and Westminster Hospital, who may see the world through oestrogen-coated specs (as opposed to my progesterone-tinted ones) has written that the essential cause of PND is the sudden decrease of hormones, particularly oestrogen, following delivery; and that moderately high doses of oestrogen have been shown to be effective even in patients where prolonged anti-depressants have failed.
Vis-a-vis psychiatrists he says ‘it is much easier for them to use a whole gamut of treatments ranging from mother and child units, SSRI anti-depressants or even ECT rather than prescribe oestrogens which are the logical and proven treatment, producing a rapid improvement in symptoms’. He confirms synthetic progestogens are a definite no-no; but consideration of progesterone itself is notable by its absence.
Set against all the above is the compelling work of two doctors – Katherina Dalton in the UK and John Lee in the USA, who both extensively studied the roles of bio-identical progesterone, the former in post-partum illness and PMS, the latter more in the menopause and pre-menopause. Dr Dalton’s excellent work seems to have been forgotten by the medical mainstream, possibly because of her ‘larger than life’ personality and lack of ‘rigorous’ research methods. Her book ‘Depression After Childbirth’ is, however, a classic and happily still in print.
If we also take into account the personal experience in the use of progesterone of the relatively small number of doctors in the UK, the contributors on this website included, a broader perspective emerges.
So how can we make coherent sense of this? The answer lies in the precipitous drop in progesterone, and to a lesser extent oestrogen, after birth. This has a destabilising effect on the emotional resilience and resistance to stress of the majority of mothers (70-80%). If they are psychologically and emotionally stable, however, the effects are short lived. Hence the ‘baby blues’.
If the mother is more vulnerable, such as having a previous history of depression or PMS, then depression is the result. If she is more severely vulnerable, with a more defined previous mental/emotional instability, then psychosis is the result.
Thus the abrupt hormonal change is the ‘trigger’, acting on the stability or otherwise of the mother and altering the threshold at which these symptoms appear. As regards the differing views of doctors and researchers, well, as the sages say, “The World is as you See it”.
Each discipline, – psychiatrists, gynaecologists and family doctors – all see the problem through the glasses or filters of their own training, conditioning and experience. Each leans towards the interpretation with which she is most comfortable. Neither should we forget that there are different groups of patients who will be subtly drawn to the doctors that are in alignment with their own beliefs and symptoms.
That said, my own experience is mainly of women who are relatively ‘oestrogen dominant’ in relation to progesterone and whose symptoms worsen if prescribed oestrogen. I believe this problem is likely to become increasingly prevalent with the passage of time.
As regards prevention and treatment, I believe the best option in postnatal illness to be a combination of the appropriate therapy for the depression or psychosis (which may have to be drugs or ECT if severe but for which I would prefer to find alternatives in milder cases) and bio-identical progesterone in cream or pessary form to reduce the likelihood of the postpartum fall in hormones triggering symptoms.
I regret that it seems unlikely that large ‘gold standard’ double-blind trials will be funded to clarify the situation as unfortunately there are also only a small number of doctors in the UK specialising in this field. I do not have first-hand information on how established the hormonal approach is in General Practice, but anecdotal evidence suggests it is very patchy.
But with the advent of bio-identical progesterone creams, self-administration is now possible. I see no reason why this should not become routine if guided by a doctor familiar with its use, if a mother with depression does not find her own doctor conversant with or sympathetic to this approach. If the latter does apply then co-operation between doctors would be a very positive step.
In the meantime, if any of you have experiences either the positive or negative use of either oestrogens or progesterone in post-natal depression or psychosis, I would like to hear from you; it’s all helpful information so please contact me at: