Research on Postpartum Depression: a point-counterpoint discussion
From: LEAVEN, Vol. 44, No. 2, 2008, pp. 4-7
Editor's note: I'm excited to present a point-counterpoint piece in this issue of LEAVEN. As you may recall, in the Jul-Aug-Sept 2007 issue, we published an article by Kathleen Kendall-Tackett, PhD, IBCLC, titled "New Research on Postpartum Depression: The Central Role of Inflammation and How Breastfeeding and Anti-Inflammatory Treatments Protect Maternal Mental Health." The article inspired numerous comments in appreciation. One response came from psychotherapist Naomi Stadlen, an LLL Leader in Great Britain, taking issue with some of Kathleen's points within the article. Kathleen was invited to read Naomi's concerns and correspond with her. The following is the result of their discussion. It's always refreshing to read opposing viewpoints that are written intelligently and respectfully.
by Naomi Stadlen
I want to respond to Professor Kathleen Kendall-Tackett's contribution, "New Research on Postpartum Depression." I am a La Leche League Leader working in Central London. I am also an existential psychotherapist, specializing in seeing mothers. I have worked with several mothers who have been very depressed after giving birth. I learned a good deal from listening to them. This gives me a different perspective from the medical one. I haven't worked with large numbers of mothers, but I have worked in detail and in depth.
Professor Kendall-Tackett has performed a valuable service in simplifying a great deal of research. She writes that our immune systems respond to stress by releasing molecules, known as proinflammatory cytokines, which increase inflammation. She states that these molecules "have a causal role in depression….In depressed women, inflammation levels are too high."
Professor Kendall-Tackett has focused on a change that is physical and therefore quantifiable. It differs in this respect from those noted, for example, on the Edinburgh Postnatal Depression Scale, which are changes in a mother's thoughts and behavior. The research discussed by Professor Kendall-Tackett suggests that if a mother complains that she feels "different" there is physical evidence to validate her.
However, this medical approach, and also approaches such as that of the Edinburgh Postnatal Depression Scale, while they differ in some respects, nevertheless share a common use of language. For example, they both use the noun "depression." Once depression becomes a noun, it is easy to make it the subject of a sentence, such as "Depression can strike" or "Depression is a killer," as if it somehow acted independently. This suggests that the mother is its impotent victim.
A related problem arises over the use of the noun "stress." Professor Kendall-Tackett states that "stress of all types increases inflammation." So what is stress? The difficulty with using this kind of language is that, in order to be inclusive, it has to be general and non-specific. Three categories are offered: "sleep disturbance and fatigue," "pain," and "psychological trauma." This conveys very little. It is then easy to conclude that stress affects some mothers more than others—but it is impossible to know why.
If we focus on the mother, rather than on "stress" (or on "depression"), we change our whole perspective. If a mother feels stressed, it is not for general reasons. Her reasons are particular. If one questions her or simply listens to her talking, her account starts to justify the degree of her distress. There has been a television series in Britain called "Help Me Love My Baby" (3 and 10 December, 2007; Channel Four Television Corporation). Dr Amanda Jones, a psychoanalyst from the Anna Freud Centre in London, stated that she preferred the term "emotional breakdown" to "postnatal depression," believing it more accurately described the range of symptoms that a mother showing no affection to her child can experience, resulting, at worst, in harming him or her. Her therapeutic sessions examine the very personal causes of the mother's emotional breakdown. "We believe we help the majority of mothers who see us," she said.
Professor Kendall-Tackett cites research studies to indicate that cognitive therapy may reduce a mother's raised level of inflammation. She states: "Cognitive therapy helps clients recognize negative or untrue beliefs that they have about themselves or others, and to challenge those beliefs with the truth." This sounds logical. "Negative or untrue beliefs" sounds like two different kinds of beliefs, but Professor Kendall-Tackett speaks of "challenging" each of them with "the truth." A depressed mother may well mention some negative beliefs. But however negative they are, they may still be true. Self-evidently, not all truths can be positive.
"I think I'm the worst mother in the world," one mother confessed at a meeting that I recently attended. After she had given her reasons, another mother began to cry and stated that she was the worst mother in the world. I watched their interaction with interest. Both mothers seemed to mean what they had said, yet neither appeared to feel invalidated by the other one. Only one mother in the world could claim the ultimate distinction of being the "worst," yet there did not appear to be the slightest competition between them. Clearly each was describing the depths of her feelings, not a literal truth.
It is difficult to hear someone voicing a very negative belief about herself without wanting to ameliorate it in some way. I do this often, though I should know better. I say: "Well, I know you say you are a terrible mother, but I can see how tenderly you are holding your baby." This is positive, and I could probably demonstrate its truth. But I have imposed it over a different aspect of the truth that the mother is trying to establish. Usually she wants to acknowledge just how bad she feels, and how far she has fallen from her own mothering ideals. She is struggling to convey truth as well as she knows it, and if we oppose her with our positive beliefs we simply frustrate her.
Charles Dickens describes this kind of despair in Hard Times. In a dramatic scene, Louisa, the "perfect" daughter, tells her father that she has failed to be perfect.
He tightened [her father] his hold in time to prevent her sinking on the floor, but she cried out in a terrible voice: "I shall die if you hold me! Let me fall upon the ground!" And he laid her down there, and he saw the pride of his heart and the triumph of his system, lying, an insensible heap, at his feet.
How many mothers voice negative beliefs because, like Louisa, they long to abandon their huge efforts to be perfect, and seek the relief of falling to the ground? How many listeners, like Louisa's father, try to hold them up and stop them from falling?
Who are we to tell a depressed mother that her negative beliefs are not the truth? What criteria should we use to convince her that we know the truth better than she? I don't believe that such criteria exist. The mother often sounds in the midst of an existential crisis. Her desperate language serves to express it truthfully. It is not the final truth, as she may modify her words later, but it certainly does justice to the pain of the moment.
Seen like this, as a painful stage of a mother's existential life-journey, her experience makes sense. She has little energy for her baby. She is preoccupied with herself. Becoming a mother has brought up an unexpected dilemma that she needs to recognize. Her expressions of exhaustion, anger, self-hatred usually fall into place once she feels safe enough to discuss them.
Mothers who have more obvious reasons for being distressed do not seem to suffer this kind of crisis. They anticipate difficulties, and often express pleasure at how well they are coping. By contrast, "I've got a beautiful baby. I shouldn't be feeling like this," is the cry of many depressed mothers. Part of their anguish is that of feeling exhausted and unhappy for no obvious reason. However, mothers who have talked to psychotherapists, such as myself, describe very personal dilemmas about having a baby. Once we connect up some of the details of their lives, their dilemmas become part of a meaningful picture. This process enables a mother to shift from self-blame to self-understanding, and so to feeling more compassionate and gentle toward herself. She can then generate the energy she needs for compassion towards her baby.
In her response on page seven, Professor Kendall-Tackett states that "the source of stress is less important than recognizing the common effect." This assertion rests on being able to identify "the source of stress," before it can be pronounced to be "less important." However, the references given here are to general and obvious problems of mothers, rather than to the slow work of identifying "the source of stress" in individual cases. A broad survey of mothers' general problems is unlikely to reveal their individual "source of stress."
Clearly, there does not need to be a competition for importance. We have here two possible "roads." I have written this response to identify and describe a very different "road." Most mothers prefer one or other of the two "roads." Both options are available to mothers, and every mother should be free to choose the one which she prefers. I think it is important for La Leche League Leaders to be aware that mothers have this choice.
Professor Kendall-Tackett states that "what we can do is provide mothers with information on what they can do to heal." While this might suit some Leaders, I think this point ought to be qualified. Surely a La Leche League Leader does not have to offer her time for providing information on healing. It goes beyond her role of offering mother-to-mother breastfeeding support. It would be useful to put together an international list of well-informed health professionals and psychotherapists who, in addition to their usual qualifications, are as committed as we are to breastfeeding.
by Kathleen Kendall-Tackett, PhD, IBCLC
I want to thank Naomi Stadlen for her thoughtful questions regarding my article in LEAVEN, "New Research on Depression in New Mothers" (July-August-September 2007). I'd like to specifically address some of the questions and concerns that she raised.
First, Ms. Stadlen is correct that the version of this research I presented in LEAVEN was a simplification -- purposely so, given the limitations on length and the wide range of readership of LEAVEN. For readers who want more depth, I'd like to refer them to three of my current publications: my 2007 article in the International Breastfeeding Journal (www.InternationalBreastfeedingJournal.com); a recently released monograph, Non-Pharmacologic Treatments for Depression in New Mothers (Hale Publications 2008; Available from LLLI) and a forthcoming book, The Psychoneuroimmunology of Chronic Disease (in press, American Psychological Association). These publications go into a great deal of depth, from several lines of research, on the etiologic or causal role of inflammation in depression. I also have a number of primary source articles on my Web site (www.GraniteScientific.com). But let me provide some further clarification below.
The beauty of the psychoneuroimmunology (PNI) approach is that it is truly a bidirectional, mind-body approach. It's not simply a way to describe that something biological is happening that a woman has no control over. In fact, she has a great deal of control over her mental state. And once she knows that, she is empowered to do something about it. What she thinks, feels, and believes can actually trigger the inflammatory response. So the physiologic response is quite in line with a woman's responses to the Edinburgh Scale. I would fully expect them to be consistent -- not opposed.
Researchers have also recently found that all of the effective treatments for depression are also anti-inflammatory. And this could explain why such a wide range of treatments work. Effective treatments include exercise, EPA (a long-chain omega-3 fatty acid), social support, psychotherapy, the herbal antidepressant St. John's wort, and standard antidepressants. For example, in a study of women who had coronary bypass surgery (Doering, Cross, Vredevoe et al. 2007), depressed women had significantly higher rates of postoperative infection because depression was compromising their immune systems by increasing inflammation and decreasing natural killer cell cytotoxicity -- two important markers of immune system function. After randomly assigning depressed women to eight weeks of cognitive therapy versus standard care, women who received cognitive therapy had fewer infections, increased natural killer cell cytotoxicity, and decreased inflammation (specifically, IL-6 [intereukin-6]). Antidepressants, such as Zoloft and Paxil, have been used to treat inflammatory conditions, including septic shock (shock caused by severe allergic reaction) and allergic asthma, and they boost the anti-inflammatory effects of drugs that lower inflammation, such as steroids or Cox-2 inhibitors. Finally, St. John's wort's antidepressant constituent hyperforin lowers inflammation, and specifically lowers levels of proinflammatory cytokines. (All these studies are described in detail in Non-pharmacologic Treatments for Depression in New Mothers.)
With regard to stress, again the article in LEAVEN was limited in depth because of page restrictions. The purpose of that article was to provide a brief overview and refer readers interested in more detail to the full-length article. But let me elaborate a bit more here. What I tried to demonstrate is that PNI researchers have discovered that "stress" can be used more generally than previously thought because the physiological response is the same, regardless of the source of stress. Researchers first discovered this when studying women who were taking care of husbands with Alzheimer's disease (Kiecolt-Glaser, Preacher, MacCallum et al. 2003). These women were dying at higher than expected rates and researchers wanted to know why. They discovered substantially elevated levels of inflammation (specifically, IL-6) that persisted even after the husbands had died -- and that was increasing the women's risk of diseases, such as heart disease and cancer, and increasing their rate of premature mortality. It was a breakthrough study because it showed that a psychological stress could lead to a specifically physical result.
When speaking of stressors common to new mothers, I included sleep disturbance, pain, and psychological trauma. All of these increase inflammation, but do so in different ways. For example, tired mothers have higher levels of proinflammatory cytokines, and depression results in several measurable sleep abnormalities, such as reduced-REM latency (the point in the night where REM [rapid eye movement] sleep becomes the predominant state). Studies published within the last couple of years have demonstrated that people with altered sleep architecture have more inflammation. With regard to pain, Substance P (a neuropeptide that is elevated when there is pain) increases inflammation. In fact, we already know this since one of the most common types of pain relievers are the NSAIDs (non-steroidal anti-inflammatory drugs). Finally, we know that traumatic events prime the inflammatory response, so there is more inflammation produced in the wake of a subsequent stressful event. Further, cortisol (a steroid hormone) levels are often abnormally low in patients with post-traumatic stress disorder, and thus it fails to restrain the inflammatory response. So what we can conclude from these studies is that the source of stress is less important than recognizing the common effect. In short, different types of stressors, the same net result: increased inflammation.
As for individual reactions, stress is in the eye of the beholder. How a mother frames the world -- or her current situation -- has everything to do with whether her stress response will be triggered, kicking off the inflammatory response. Prior trauma can also explain why one mother might be more troubled by a current stress than another mother. We also need to recognize that social support attenuates stress by halting, or at least lessening, the inflammatory response.
To summarize, the PNI approach does not describe depression as a medical condition. The PNI approach incorporates a woman's body and mind. Yes, there may be things outside her immediate control. But there is much she can do to heal, including exercise, social support, talking with someone, taking omega-3s (especially EPA), and taking St. John's wort or antidepressants. The most effective treatments for depression will empower her and involve her in every step of her treatment.
La Leche League Leaders are not there to provide psychotherapy. What we can do is provide mothers with information on what they can do to heal, while respecting and preserving the breastfeeding relationship.
Doering, L.V., Cross, R., Vredevoe, D. et al. Infection, depression and immunity in women after coronary artery bypass: A pilot study of cognitive behavioral therapy. Alternative Therapy, Health & Medicine 2007; 13:18-21.
Kiecolt-Glaser, J.K., Preacher, K.J., MacCallum, R.C. et al. Chronic stress and age-related increases in the proinflammatory cytokine IL-6. Proc Natl Acad Sci USA 2003 Jul 22; 100(15):9090-95.