PPD Archives - Hormones Matter

Beyond Depression: Understanding Perinatal Mental Health

Published on December 4, 2014

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In part one of this series I noted that my approach to postpartum depression research was a little bit different than most others. Namely, I didn’t ascribe to either the nomenclature of the syndromes, whether defined by popular culture or by the DSM, the timing of the onset of the symptoms nor the explanation of the causes. I think the symptoms are largely hormone related, and as such, ought to be distinct entities diagnostically. That requires understanding, testing and then defining the spectrum of symptoms and their relationships with individual and hormone patterns. I’d like to discuss symptoms first, even though this particular research was conducted after finding hormone – symptom relationships and informed by the patient stories collected in conjunction with that research.

Postpartum Depression or Not?

Not, but with a caveat.

As I accumulated data for my hormone symptom study, those data along with participant stories led me to design a broad-based symptom study for postpartum women (this particular study did not include pregnant women, as some my other studies did). I wanted to test whether the typical designations of postpartum depression clustered statistically within discrete but consistent diagnostic categories. Did postpartum depression exist and if so, did the symptoms mirror those in the DSM or in the popular science? Or was depression just one among many types of symptoms that emerged and how would those symptoms fall together statistically? In other words, I wanted to test what the women were telling me about their experiences and against what my other data were showing. The study:

Dimensions of Postpartum Psychiatric Distress: Preliminary Evidence for Broadening Clinical Scope

Study Basics. The study was online with questions covering nine dimensions of postpartum mental health that I had found relevant in previous work: depression, anxiety, mania, psychosis, obsessive-compulsive behavior, self-image, social support, mental status and perceptions of motherhood. The questions were retrospective and the participants were asked to rate the frequency of symptoms experienced over the first 30 days following childbirth on the following scale: 1-never, 2-occassionally, 3-frequently, 4-most of the time. We had 215 women complete the survey. From those data we did an exploratory factor analysis (EFA) to see how the symptom data grouped itself statistically. Did the symptoms group by established psychiatric dimension e.g. depressive symptoms in a depression category, anxiety symptoms with the anxiety category, psychosis with psychosis, etc.? Or would the symptoms group in some other manner?

Results. As I expected, the standard categories were not statistically grouped. That is, there was no such thing as postpartum depression or postpartum anxiety or postpartum psychosis. Rather, there were unique clusters of symptoms that grouped together and contained aspects each traditional symptom category. The EFA data revealed 10 new and distinct factors or symptom groups. Most telling were the first three factors or groupings: mental status, psychoticism/morbid thoughts and a general anxiety. Notice, I didn’t find a depression grouping. Indeed, depressive symptoms were interspersed throughout the 10 categories, but most densely and the most severe within the psychoticism group. Let me explain. Here are the 10 symptom groups or factors, listed in order of importance or prominence (variance accounted for):

Mental status – This was the most prominent cluster of symptoms, with upwards of 40% of the women reporting difficulty with two primary areas of mental status: memory and attention, and motivation – or lack of motivation. Some of the symptoms ascribed to within this group included: difficulty completing simple tasks and staying focused, mind going blank, difficulty organizing thoughts, losing track of time, no motivation, difficulty expressing thoughts, fatigue and loneliness among others. From other research conducted, we know that measurable cognitive difficulties, especially those associated with attention and memory, are common problems amongst pregnant and postpartum women. That this was the highest ranked factor, meaning that it accounted for the most variance, was consistent with my previous work.

Psychoticism and morbid thoughts – This was the most striking category and accounted for what many would consider the most troubling symptoms. This factor grouping included everything from intrusive and morbid thoughts, to hallucinations and suicidality. It truly represented what would have been the most serious of psychiatric conditions but was not akin either to a strictly depressed state or psychosis in the most traditional sense or even to an obsessive compulsive disorder, emphasis on obsessive. Rather it had components of each, uniquely focused on the maternal state. Some of the symptoms ascribed too included: images of the baby being stabbed or thrown out of a window, fear of harming the infant, thoughts of violence, hearing voices to harm myself or others, inability to keep bad thoughts out head, afraid to be alone with baby, afraid of harming self, frightening dreams, the feeling that others want to harm me (the mother) or the baby, feelings of terror, no hope for the future, feel like someone is controlling one’s thoughts, worrying that the infant will suffocate.

General Anxiety – this grouping of symptoms is what I believe may represent milder forms of distress that to some degree all women feel as they enter into motherhood. Some of the symptoms include: ‘I believe others see me as a bad mother’,’ I think I am a bad mother’, confusion, no confidence, overwhelmed, mind racing, losing control, constantly being judged, no one understands me, among others.

The remaining seven factors or groupings were somewhat more specific to traditional psychiatric categories but also included psychosocial aspects relative to self-image, relationship and social support. They also accounted for far less statistical variance, indicating some degree of specificity to certain groups of women rather than being applicable to most postpartum women and/or were far less relevant to the overall distress. These groups included:

Panic – fear of large crowds, fear of leaving the house, feeling keyed up, restless, on edge, skin crawling

Guilt and emotionality – a range of guilt related feelings, but also, mood lability – switching from happy to sad, quickly and frequently

Compulsive behaviors – cleaning and checking

Hyper-vigilance – a sense that the new mom was the only one who could care for the child

Contentment – positive relationship, social support, and general well being

Negative self-image – range of negative self-image attributes, along with a sense that her body was shutting down –that something was wrong with her.

Mania – hyper excitable, excessive energy despite a lack of sleep, impulsive behavior

What Does This Mean?

The results from this study suggest that neither the current diagnostic categories nor the popular nomenclature appropriately categorize the types and severity of postpartum related mental health issues. Depressive symptoms were neither the most common symptoms nor contained within a defined category. Rather depressive symptoms were interspersed throughout each category with the most severe depression symptoms, loss of hope and suicidality loading to the psychosis/morbid thoughts category. Along with the more severe depression symptoms, this category contained hallmark psychosis symptoms like hearing voices, seeing things, but also what could only be described as violent, frightening intrusive thoughts.

What was particularly interesting is that mania, which has long been linked to postpartum psychosis, was neither present in the psychosis/morbid thoughts category nor accounted for much variance at all within this study. This could mean that mania is not a common component of the most serious forms postpartum distress for most women, but rather a distinct subset of the disorder. Instead, it may be the violent intrusive thoughts and the hallucinations that are associated with the most serious symptoms of depression – the suicidality. From these data, the postpartum spectrum is not from mild sadness (baby blues) to more intense sadness or postpartum depression to psychosis but rather based on the degree and severity of intrusive thoughts and hallucinations – the degree of psychotic symptoms may very well determine and drive the ‘depression.’ Additional research will tell if this is the case.

Addendum

Phase II of this study, a follow up confirmatory factor analysis was begun, some data collected (n=100), but not completed. When the economy tanked in 2008-9, I, and many other adjunct faculty were let go. I hope to resume this research soon through Hormones Matter.

Maternal Psychiatric Disturbances and Hormones

by Chandler Marrs, PhD

Published on March 4, 2014

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As a mom of young children, I was very much affected by the Andrea Yates case. If you recall she experienced successive bouts of psychosis and pursued multiple attempts at suicide following the delivery of each of her children. After her fifth child, she drowned her children, killing them all. The case was a heartbreaking, and I believe, a totally preventable tragedy had her psychosis been taken seriously by medical professionals, family and others in the community. In spite of her psychosis and suicide attempts she was sent home to care for her children, as if a woman with postpartum psychosis is somehow less ill than a man or than a woman whose psychosis develops unrelated to her pregnancies. Raising young children is difficult, even under the best of circumstances, but sending a severely depressed and psychotic woman home to care for young children is just downright negligent. Although there was blame to go around among the doctors, her family and community, I couldn’t but shake the feeling that this tragedy could have been averted if her illness had been taken more seriously.

Identifying the Biological Underpinnings of Maternal Psychiatric Disturbances

The Andrea Yates tragedy inspired me to research and identify the clinical and biological components of perinatal mental illness. My goal was to identify early warning markers; biological tests, that would give women, their physicians and family members a way to predict the possibility of illness and confirm that illness once it had arrived. I thought that if we could predict and identify the risk for this illness, then the families could prepare and maybe even lessen the severity the disease process. At the very least, tragedies like the Andrea Yates case could be prevented.

I knew hormones would be key to the onset and maintenance of perinatal psychiatric symptoms. What I didn’t know is which hormones, when, and related to which symptoms. It seems that no one else did either. Despite years of research and a clear temporal association between the onset of psychiatric distress and childbirth, only tenuous connections between maternal hormone concentrations and varying degrees of postpartum depression had ever been established. This was primarily because the research was focused so narrowly upon the relationships among what are often referred to as the female hormones, progesterone and estradiol, and depressive symptoms. Very little research had examined associations between a broader range of steroid hormones and the full spectrum of potential psychiatric symptoms. This didn’t make sense to me. Certainly, other hormones affected by pregnancy, might also impact brain chemistry; certainly, the range of clinical symptoms that women might experience would go beyond the blues and depression. Even when psychosis appeared, I wasn’t convinced that the psychosis of pregnancy and postpartum was clinically similar to the psychoses that developed irrespective of the vast biochemical changes that took place across pregnancy, parturition and in the weeks and months that followed. If the biochemistry was different, as it most necessarily had to be, wouldn’t everything else about maternal psychiatric disturbances be different as well?

Looking Beyond the Boundaries

And so began my research. For the first study: Beyond Progesterone and Estrogen: Maternal Psychiatric Disturbances Linked to Adrenal Androgens, I recruited healthy, medication free, first time moms, with no previous history of mental illness. This was no easy feat. I soon realized that many women, even pregnant women, were using antidepressants and anxiolytics and many other medications. It seems the old adage that pregnant women should not take medications lest it cross the placental barrier and affect the developing fetus, had fallen by the wayside.

To assess the psychiatric distress, I abandoned the singular blues, depression and anxiety scales used so often in this research and found a broad-based, standardized assessment of psychiatric distress called the Symptom Check List 90R (SCL90R). SCL-90R is a 90-item psychiatric self-report inventory designed to measure the severity and intensity of psychiatric symptoms in both inpatient and outpatient populations. Participants rate the severity of distress experienced during the prior seven-day period using a 0-4 Likert-type scale (0=no distress-“not at all” to 4=extreme). Symptoms measured included: anxiety, hostility (aggression, irritability, etc.) phobic anxiety, paranoid ideation, psychoticism, somatization (perceptions of pain or other physical disturbances), obsessive-compulsive behavior, interpersonal sensitivity (feelings of personal inadequacy), depression and the global severity index (GSI), which reflects the overall symptom severity.

Along with the clinical symptoms, I measured five hormones, progesterone, DHEAS, testosterone, estrone, estradiol and estradiol, using saliva based testing. Symptoms and hormones were assessed twice, first in late pregnancy at 37 weeks (n =32) and again within 10 days following the delivery of their children (n=28, four were lost to attrition). I also conducted a year long follow up of those same participants and will report those data soon.

It’s Not Just Depression and It’s Not Just Postpartum

As I suspected, symptoms were present in late pregnancy and in some cases, increased in severity postpartum, but in other cases, decreased in severity. For some women, pregnancy was more problematic than postpartum, especially those with obsessive compulsive symptoms.

Fully 50% of the women tested experienced symptoms during pregnancy and 57% postpartum. This means maternal psychiatric distress is far more common than generally ascribed. As a group the anxiety related symptom scales, particularly the anxiety and obsessive compulsive scales, had the highest individual scores at each test time and when combined with hostility, phobia and psychoticism contributed the largest increase in symptom severity from pregnancy to postpartum. So it wasn’t the blues and depressive type symptoms that were most troubling, but the agitated, anxiety and even psychotic type symptoms that were the most severe.

Current research suggests that for only 1-2 per 1000 pregnancies psychosis will develop. What I found with this research and from another study, is that psychotic symptoms were far more prevalent than recognized and may be the symptoms that drive the depression. In this study, we found sub-threshold, but clinically relevant, psychotic symptoms present in several of the women postpartum. Their symptoms were absent concurrent elevations in paranoia (paranoia and psychosis often go hand in hand). The most frequently ascribed to symptoms within this cluster included fears of serious illness (n=8), loss of mind (n=7) and isolation (n=12). Surprisingly, three women showed mild to moderate distress about thought insertion and thought broadcasting, two were concerned about thought control and one woman indicated distress about auditory hallucinations. Interestingly, it was these very same women who had the most dysregulated hormone profiles.

In speaking with the women who indicated these symptoms, the visual hallucinations, involved their children suffering; usually graphic intrusive thoughts, seeing images of their children being burned, thrown out windows, cut with a butcher knife, strangled with the breast pump tubing and the like. When auditory hallucinations were present they berated the women for their weakness, bad mothering etc., inducing guilt and one can only assume, depression. We confirmed the prevalence of these types of symptoms in two subsequent studies, the first published here: Dimensions of postpartum psychiatric distress: preliminary evidence for broadening clinical scope, the second unpublished as of yet.

Aberrant Androgen Metabolism may be to Blame for Maternal Psychiatric Symptoms

As I suspected and as much research had shown, no symptom clusters were correlated with progesterone, estrone or estriol either pre- or postpartum. While expected to be a close correlate of postpartum psychiatric symptoms, estradiol was associated with very few symptom clusters in the present study. Instead, it was the androgens that were linked to the symptoms at both time periods and not in a way that might be expected.

Low late pregnancy testosterone was not only related to late pregnancy psychiatric symptoms, but significantly predicted postpartum symptom severity. In conjunction, and this is where the endocrinology gets interesting, elevated late pregnancy DHEAS and supra-elevated postpartum DHEAS were associated with pre – and postpartum symptoms, respectively. This was exciting, because in theory these two hormones should not be aligned. That is, high DHEAS should correlate with high testosterone and it didn’t. So somewhere between DHEAS>DHEA>androstenedione> testosterone there was a problem and I had pretty good idea where.

For now though, we had a pilot study that ripped open the notions that maternal psychiatric distress occurred only during postpartum, was depressive in nature, was rare and was related to the normal or expected hormone changes of pregnancy. It was none of these things. The psychiatric distress was present at both test points, was more agitated, included a spectrum of symptoms, and most importantly, was related to aberrant changes in hormones that were likely exacerbated by the normal or expected hormone disruptions of pregnancy. I was very excited. If we could identify the problem, then we could fix it right?

Not so fast. I could never get the research published and though I carried on with research I could do without funding, including a long term follow-up of the same participants (to be self-published soon) and an online study of the symptoms of psychiatric distress, the hormone work was routinely and summarily rejected. I learned very quickly how controversial studying hormones in women’s health was. So there it stands, the work was good, it pointed to a biomarker that could be used to identify and then treat a group of women who suffer horribly, but the study needs to be replicated with a much larger and more diverse population of women. It is likely that this is but one of many potential markers along this hormone pathway that could be used to predict and prevent perinatal psychiatric distress. It is also likely that this pattern of metabolism is linked to a host of other mental health and physical health issues. It was because of this research that I began Hormones Matter and have worked so arduously to increase awareness about the need for more research in women’s health. Hormones ought to be measured consistently across a woman’s life span, they aren’t and we need to change that.

Here are the full study details and the article, now officially self-published: Beyond Progesterone and Estrogen: Maternal Psychiatric Disturbances Linked to Adrenal Androgens.

Another portion of this study included assessing cognitive changes: Mommy Brain: Pregnancy and Postpartum Memory Deficits.

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