Sometimes Perinatal mood disorders overlap, and it's hard to tell where one ends and the other begins. PTSD is caused by an event in which you feel threatened, violated, and feel as if you could die. By the way our brain has processed the memory of the event, is causes hightened anxiety, hypervigilence, flashbacks, nightmares, etc. Therefore it is an anxiety or stress reaction and it is different from Postpartum Depression (PPD). However, PPD can occur at the same time PTSD...

PPD is a mood disorder caused by an imbalance of neurotransmitters in the brain. First of all, estrogen is the primary female sex hormone produced primarily by the ovaries and the placenta. Results from a study published in the October-December, 2005, issue of Advances in Nursing Science, “indicate that sudden estrogen withdrawal, fluctuating estrogen, and sustained estrogen deficit are correlated with significant mood disturbance.” (Douma, S.L. et. al.) The reason is that estrogen, the primary female sex hormone produced primarily by the ovaries and the placenta, regulates Monoamine oxidase (MAO), an enzyme in the body that breaks down certain substances including the serotonin and norepinephrine, according to a study published in the 1983 issue of Neuroendocrinology, (Luine, V. N. et. al.) Too much MAO activity is thought to be associated with a number of neurological disorders including depression. Monoamine oxidase inhibitors (MAOI’s) are one of the major classes of drugs prescribed for the treatment of depression.

Serotonin is a chemical in the brain believed to play an important role in the regulation of mood, sleep, sexuality, and appetite. Serotonin has been thought to be a part of the biochemistry of depression, anxiety, bipolar disorder and migraines. Norepinephrine is another chemical in the brain that is a stress hormone, and it affects the part of the brain that controls attention and focus. Selective serotonin reuptake inhibitors (SSRI’s) treat depression by increasing the amount of serotonin available in the brain. Selective serotonin-norepinephrine reuptake inhibitors (SNRI’s) treat depression by increasing the amount of serotonin and norepinephrine available in the brain. (Wikipedia)

Higher levels of estrogen decrease the activity of MAO in the brain, therefore increasing the amount of serotonin and norepinephrine available. The more serotonin and norepinephrine in the brain, the better your mood is. Clinical Gynecologic Endocrinology and Infertility, 3rd Edition, states that during pregnancy, estrogen levels increase over 100 times because is it produced by the placenta while the baby is forming. When the placenta is removed at delivery, estrogen levels drop to what they were before pregnancy, by the fifth day postpartum. (Speroff, L. et. al. 1983) So when estrogen levels decrease, MAO activity increases, therefore decreasing the amount of serotonin and norepinephrine available in the brain. The less serotonin and norepinephrine in the brain, the more depressed we are.

According to the DSM IV, one must meet the following criteria in order to be diagnosed with Depression:

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do note include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
   
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
   
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
   
4. Insomnia or hypersomnia nearly every day
   
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
   
6. Fatigue or loss of energy nearly every day
   
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
   
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
   
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
   

B. The symptoms do not meet criteria for another condition.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Specify (for current or most recent episode):

• Severity/Psychotic/Remission Specifiers
  
• Chronic
  
• With Catatonic Features
  
• With Atypical Features
  
• With Postpartum Onset

Symptoms usually improve with treatment. According to The University of Maryland Medical Center, treatment options include:

Preventive Care

The following steps can help prevent depression or decrease the chances of relapse:

• Adequate sleep, regular exercise, and a balanced, healthy diet may help prevent depression and diminish symptoms of this mood disorder.
• Mind-body techniques, such as biofeedback, meditation, and tai chi, are effective ways to prevent or reduce symptoms associated with depression.
• Psychotherapy directed at coping skills generally helps prevent relapse.
• Family therapy may prevent children or teens of depressed parents from becoming depressed later in life.
• Compliance with the prescribed treatment regimen decreases the chance of relapse.

Treatment Approach

People with depression have several options for treatment, but a combination of psychotherapy and antidepressant medications is the regimen of choice, particularly for people with major depression. Cognitive-behavioral therapy appears to be the most effective type of psychotherapy, particularly for adolescents and people with atypical or postpartum depression. As many as 90% of people with depression improve from a combination of psychotherapy and antidepressants. However, adverse side effects from certain medications make it difficult for many to take their medications. Some complementary and alternative therapies may be helpful in reducing the side effects from such medications, while other complementary and alternative therapies may actually diminish the symptoms of depression.

Lifestyle

Exercise

Studies have consistently shown that regular exercise (either aerobic or strength and flexibility training) significantly reduces depressive symptoms in people with mild to moderate depression and improves the mood of people with major depression. Some even suggest that exercise may be as effective as psychotherapy for people with mild-to-moderate depression, although additional research is needed. In the meantime, exercise can be used safely in conjunction with medication for those with depression.

Medications

Antidepressant medications are very effective; reports indicate that they are 90% successful in treating depression. In general, medications are taken for at least 4 - 6 months to assure complete and effective treatment. However, antidepressants often cause adverse side effects, making it difficult for some people to comply with taking their medications. Medications must not be stopped before first talking with a physician. Most antidepressants cause withdrawal symptoms if they are not discontinued slowly over time with guidance from a physician.

There are several classes of antidepressant medications, including:

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs increase the activity of a chemical in the brain called serotonin. Most health care providers will prescribe SSRIs before any other antidepressant medication for depression, in part because the side effects associated with SSRIs are generally fewer than for other classes of antidepressants. Typical side effects caused by SSRIs include stomach upset, weight gain or loss, drowsiness, sexual dysfunction (such as impotence, decreased libido, and diminished orgasm), headache, jaw grinding, and apathy. Very unusual side effects from this class of prescription drugs include extreme agitation, impulsivity, tremors, and insomnia. People who discontinue taking SSRIs due to side effects usually attribute their discontent to sexual dysfunction.

Drugs classified as SSRIs include:

• Fluoxetine
• Sertraline
• Paroxetine -- most likely in this class to cause sexual dysfunction
• Fluvoxamine
• Citalopram -- least likely in this class to cause sexual dysfunction

Another group of antidepressant medications (which are similar to SSRIs, but target other brain chemicals in addition to serotonin) may cause fewer negative sexual side effects. These include:

• Bupropion -- should not be used if there is history of or risk for seizure
• Nefazodone -- no sexual dysfunction reported. It begins to work very quickly and may cause a decrease in blood pressure when going from lying or sitting to standing.
• Venlafaxine -- may impair sexual function and is not recommended in the elderly. It may improve quality of life more effectively than other antidepressants, but can cause irregular heart rhythm. Withdrawal from the medication is difficult.
• Mirtazapine -- may be particularly effective if feelings of anxiety are also present. It helps with insomnia but may cause drowsiness, blurred vision, weight gain, and damage to production of cells in the bone marrow (very rare).
• Maprotiline -- may cause dry mouth, drowsiness, sensitivity to the sun, and seizures

Tricyclic Antidepressants

Tricyclics increase the activity of the brain chemicals serotonin and norepinephrine. They are as effective as SSRIs, but are usually prescribed only to those who do not respond well to SSRIs because side effects are quite common and are usually less tolerable. Tricyclic antidepressants include:

• Amitriptyline
• Amoxapine -- increases risk of seizure in those who are prone to have a seizure
• Clomipramine -- used for obsessive-compulsive disorder
• Desipramine
• Doxepin -- may help with insomnia
• Imipramine -- may cause a rare lung disorder called idiopathic pulmonary fibrosis
• Nortriptyline -- less risk of irregular heart rhythm than others in this class
• Protriptyline -- less drowsiness than others in this class and may even cause weight loss and sun sensitivity
• Trimipramine -- high risk for irregular heart rhythm

Side effects of tricyclics may include:

• Dry mouth
• Blurred vision
• Constipation
• Sexual dysfunction
• Weight gain
• Dizziness
• Drowsiness
• Urinary urgency (a sense that one has to urinate even when the bladder is empty)
• Drop in blood pressure when going from lying or sitting to standing (causes dizziness and lightheadedness)
• Irregular heart rhythm

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs boost levels of norepinephrine, dopamine, and serotonin in the brain. MAOIs are generally prescribed only when other antidepressants have not been effective, which may occur in people with atypical depression. People who take MAOIs may experience a sharp increase in blood pressure after consuming food or drink containing the amino acid tyramine (found in such foods as aged cheeses and red wine). MAOIs also negatively interact with other medications, including Ritalin (used for attention deficit hyperactivity disorder) and pseudoephedrine (decongestant in many over-the-counter and prescription medications), and should not be taken with other classes of antidepressants.

MAOIs include:

• Phenelzine -- should be avoided by people with a history of seizures or bipolar disorder (manic-depression)
• Isocarboxazid -- side effects include drowsiness, sexual dysfunction, weakness, trembling, and blurred vision.
• Tranylcypromine -- should not be used if there is any history of kidney disease or bipolar disorder

Surgery and Other Procedures

• Electroconvulsive Therapy (ECT) for depression is usually reserved for when all other therapies have been unsuccessful. In this procedure, a small electrical current induces a seizure lasting approximately 40 seconds. A muscle relaxant and mild sedative are administered prior to the procedure. ECT is generally repeated every 2 - 5 days for a total of six treatments. It may cause temporary confusion, memory impairment, headache, muscle aches, irregular heart rhythm, or nausea.
• Magnetic Resonance Imaging (MRI)-Guided Cingulotomy involves the application of an electrical current to a specific part of the brain. The MRI is used as a guide for an exact placement. Long-term improvement has been reported using this technique in over 50% of people with depression who have not responded to other treatment methods.

Nutrition and Dietary Supplements

A comprehensive treatment plan for depression may include a range of complementary and alternative therapies. Preliminary studies suggest that nutritional supplements may reduce the symptoms of some depression. Ask your team of health care providers about the best ways to incorporate these therapies into your overall treatment plan. Always tell your health care provider about the herbs and supplements you are using or considering using.

Following these nutritional tips may help reduce symptoms:

• Try to eliminate potential food allergens, including dairy, wheat (gluten), corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
• Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
• Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables such as kelp and dulce.
• Avoid refined foods, such as white breads, pastas, and especially sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein.
• Use healthy oils for cooking, such as olive oil or vegetable oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

You my address nutritional deficiencies with the following supplements:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
• Omega-3 fatty acids, such as fish oil, one to two capsules or one tablespoonful oil one to three times daily, to help decrease inflammation and help with mental balance.
• Vitamin C, 500 - 1000 mg one to three times daily, as an antioxidant and for immune support.
• Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
• 5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for mood stabilization. Ask your health care provider about potential prescription interactions.
• Probiotic supplement (containing Lactobacillus acidophilus and other species), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. You should refrigerate your probiotic supplements for best results.
• SAMe (s-adenosyl-L-methionine), 100 - 200 mg before breakfast daily, for mood improvement.
• Dihydroepiandosterone (DHEA), start at 5 mg three times a day and work up to 100 mg per day for 7 - 12 months. It is recommended to use DHEA under the supervision of a qualified health care provider. If adverse effects develop, discontinue use.
• L-theanine, 200 mg one to three times daily, for nervous system support.
• Melatonin, 2 - 5 mg one hour before bedtime, for sleep and immune protection. Ask your health care provider about potential prescription interactions.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

• St. John's wort ( Hypericum perforatum ) standardized extract, 300 mg two to three times per day, for depression. Check with your health care provider if you are taking prescription medications.
• Kava kava ( Piper methysticum ) standardized extract, 100 - 250 mg one to three times daily, as needed for symptoms of stress and anxiety. Talk with your health care provider before taking kava kava if you have an unhealthy liver.
• Ginkgo ( Ginkgo biloba ) standardized extract, 40 - 80 mg three times daily, for blood flow and depression.
• Green tea ( Camellia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant and general health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Rhodiola ( Rhodiola rosea ) standardized extract, 100 - 600 mg daily, for antioxidant and anti-stress activity.

Acupuncture

Two randomized, controlled, clinical trials suggest that electroacupuncture may reduce symptoms of depression as effectively as amitriptyline, a tricyclic antidepressant medication. Electroacupuncture involves the application of a small electrical current through acupuncture needles. Other studies suggest that acupuncture may be effective for people with mild depression and for those with depression related to a chronic medical illness. Further research is warranted in this area.

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies to alleviate the symptoms of depression based on their knowledge and experience.

Before prescribing a remedy, homeopaths take into account a person’s constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual. A few homeopathic remedies that may work for depression include:

• Ignatia -- for a sudden sense of grief or disappointment following the death of a loved one, the end of a romantic relationship, or an unexpected loss of one's job
• Natrum muriaticum -- for grief following the death of a loved one or sadness from the end of a romantic relationship

Massage and Physical Therapy

Studies of formerly depressed adolescent mothers, children hospitalized for depression, and women with eating disorders, suggest that massage decreases stress hormone levels, feelings of anxiety, and symptoms of depression. Giving massage may also be beneficial for people who are depressed. Elderly volunteers with depression showed notable improvement in their symptoms when they massaged infants.

Aromatherapy, or the use of essential oils in massage therapy, may also be of value as a supplemental treatment for depression. Theoretically, the smells of the oils elicit positive emotions through the limbic system (the area of the brain responsible for memories and emotions). However, the benefits of aromatherapy appear to be related to the relaxation effects of the treatment as well as to the recipient's belief that the treatment will be beneficial. Essential oils used during massage for depression are quite varied and include:

• Lavender ( Lavandula officinalis)
• Basil ( Ocimum basilicum )
• Orange ( Citrus aurantium )
• Sandalwood ( Santalum album )
• Lemon ( Citrus limonis )
• Jasmine ( Jasminum spp . )
• Sage ( Salvia officinalis )
• Chamomile ( Chamaemelum nobile )
• Peppermint ( Mentha piperita )
• Rosemary ( Rosmarinus officinalis )

Mind-Body Medicine

Mind-body therapies and techniques that may be useful as a part of an overall treatment regimen for depression include:

Psychotherapy

Cognitive-behavioral therapy is a type of psychotherapy in which individuals learn to identify and change distorted perceptions about themselves and adapt new behaviors to better cope with the world around them. This therapy is frequently considered the treatment of choice for people with mild-to-moderate depression, but it may not be recommended for those with severe depression. Studies of people with depression indicate that cognitive-behavioral therapy is at least as effective as tricyclic antidepressants. Compared to those treated with antidepressants, people treated with cognitive-behavioral therapy demonstrated similar, or better, results and lower relapse rates.

Other therapeutic approaches that may be applied by a psychiatrist, psychologist, or social worker include:

• Psychodynamic psychotherapy -- based on Freud's theories about unresolved conflicts in childhood and depression as a grief process
• Interpersonal therapy -- acknowledges childhood roots of depression, but focuses on current problems contributing to depression and is considered very effective treatment for depression
• Supportive psychotherapy -- nonjudgmental advice, attention, and sympathy, and this approach may improve compliance with taking medication

Relaxation

One study suggests that relaxation techniques, such as yoga and tai chi, may improve symptoms of depression in people with mild depression.

Meditation

Some researchers believe that mindfulness meditation may prevent depression from recurring in people who once had the condition.

Other Considerations

Pregnancy

• Postpartum depression is experienced by 8 - 20% of women following delivery.
• The safety of SSRIs and tricyclic antidepressant medications during pregnancy remains uncertain. The physician will provide guidance regarding use or avoidance of antidepressants during pregnancy. The risks and benefits to the mother and the fetus must be weighed in each individual case in order to determine the most appropriate regimen during pregnancy. MAOIs cause birth defects and should be avoided during pregnancy.
• Many of the dietary supplements and herbs mentioned here have not been tested for safety during pregnancy. Talk with your doctor or pharmacist.

References:

• Estrogen. http://en.wikipedia.org/wiki/Estrogen, 2006.
• Neurotransmitter. http://en.wikipedia.org/wiki/Neurotransmitter, 2006.
• Monoamine oxidase. http://en.wikipedia.org/wiki/Monoamine_oxidase, 2006.
• Serotonin. http://en.wikipedia/wiki/Serotonin, 2006.
• Norepinephrine. http://en.wikipedia/wiki/Norepinephrine, 2006.
• Douma, S.L., Husband, C., O'Donnell, M.E., Barwin, B.N., Woodend, A.K. Estrogen-related mood disorders: reproductive life cycle. Advances in Nursing Science, 2005 Oct-Dec; 28(4):364-75.
• Luine, V.N., Rhodes, J.C. Gonadal hormone regulation of MAO and other enzymes in hypothalamic areas. Neuroendocrinology, 1983; (3): 235-41.
• Speroff, L., Glass, R.H., Kase, N.G.: Clinical Gynecologic Endocrinology and Infertility, 3rd Edition. Baltimore, MD, Williams & Wilkins, 1983.
• O’Hara, M.W., Swain, A.M. Rates and risk of postpartum depression: a meta-analysis. International Review of Psychiatry, 1996; (8):37-54.
• DSM IV
• Bennett, S.S., Indman, P.: Beyond the Blues: A Guide to Understanding and Treating Prenatal and Postpartum Depression. San Hose, CA, Moodswing Press, 2003.
• Alternative Treatment Options for Depression from The University of Maryland Medical Center (UMMC)