Thursday, April 23, 2009

Melanie Blocker Stokes Act: Let’s Promote Therapy Over Meds For PPD

Blog on Melanie Blocker Stokes Act! Great!

I have a lot to say, but I am going to stick to one point. I may get readers who otherwise would never look at my blog, so I really want to get my point across. (Well, no one reads my blog anyway, so I might actually get some readers with this PPD MBS blog week 2009).

Here is my point: Because there are very serious, grave issues with psych drug treatment of depression, including postpartum depression, as we advocate for detection and treatment of postpartum depression, we should strongly consider psychotherapy, and other psychosocial interventions, as FIRST-LINE treatment for depression, before resorting to any psych meds.

OK, thanks for reading. If you are interested in the evidence base for my opinion, please read on.

I have personally looked at MOST of the published empirical evidence (that means actual published, peer-reviewed scientific evidence versus opinions from anyone, professional, patient, pharmaceutical company representative, political activists, legislators, etc.) regarding the actual treatment (not just detection, just demographics, natural history, consensus statements, clinical guidelines, etc.) of postpartum depression.

I have three conclusions, as of this point in time, subject to change (I try to base my opinions on actual evidence, which can change as new studies emerge, etc.). Here are my three conclusions:

1. The evidence overall is just as promising, if not more so, for psychotherapy and other psychosocial interventions (such as fitness walking AKA “pram-walking”);
Example of evidence, talk therapy for PPD: Published by Grote and colleagues, in "Psychintric Services," March 2009: "A randomized controlled trial of culturally relevant, brief interpersonal psychotherapy for perinatal depression;" "participants in enhanced IPT-B, compared with those in enhanced usual care, displayed significant reductions in depression diagnoses and depressive symptoms before childbirth (three months postbaseline) and at six months postpartum and showed significant improvements in social functioning at six months postpartum."

2. There is the risk of harm from medications to the developing fetus or the breast-feeding baby (and I don’t trust the pharmaceutical companies to be perfectly honest and forthcoming about these risks, since there is documented lawsuit evidence that they have hidden and suppressed side effect harm in antidepressant studies as well as other studies).
One example of bad outcomes associated with SSRI, simply to make the point that there is reason for concern, despite ALL the reassurance from the pharmaceutical companies and the researchers they bankroll: Risk for birth defects: Alwan and collegues, and the National Birth Defects Prevention Study, published in New England Journal of Medicine, June 28, 2007:
"Maternal SSRI use was associated with anencephaly (214 infants, 9 exposed; adjusted odds ratio, 2.4; 95% confidence interval [CI], 1.1 to 5.1), craniosynostosis (432 infants, 24 exposed; adjusted odds ratio, 2.5; 95% CI, 1.5 to 4.0), and omphalocele (181 infants, 11 exposed; adjusted odds ratio, 2.8; 95% CI, 1.3 to 5.7)." How to read these results? In plain English, if a fetus had anencephalopathy, the chances are three times as good that the mom was, versus was not, in the group of women taking antidepressants. You pay your money and you take your chances. You pick. Meds vs. therapy.

3. It is becoming increasingly apparent that for some people, antidepressants, or withdrawal from antidepressants, contribute to the person becoming impulsively violent, including murder, suicide, and murder/suicide. For more information, look at my other posts, or google “antidepressants” and “suicide”, or look at, just to begin, these websites:

Point 3, and Melanie Blocker Stokes: It is my opinion, based on limited information from her story on the web, that this phenomenon of antidepressant side effects, NOT postpartum depression itself, may have led to this mother’s suicide. This guess is limited, since Melanie Blocker Stokes’ problems were not typical depression, but also included psychosis, which is NOT typical of the majority of PPD cases. So, this is a limited guess. I recognize that for the family, this young mom’s death is a highly profound and painful issue. I don’t know any of these people, but I only mean to HELP anyone I might help by sharing evidence-based, well-reasoned ideas regarding how to MAXIMALLY help ANY person with problems such as depression, including PPD. By my OPINION, I do NOT mean to diminish the cause of the MBS Act, or say ANYTHING bad about MBS or her family. For them, I say: Philippians 4:8. And any other scripture that might bring comfort.

However, I believe that as WE believers in postpartum depression, who believe ALSO that more needs to be done, we have to be careful that we are not promoting something that seems good but is actually bad: we should be wary of promoting, directly or indirectly, the increased prescription of antidepressants **when a perfectly acceptable, empirically supported, well-recognized alternative exists.**

There are MANY unanswered questions in the topic of PPD. We do need more research. What we DON’T need is more research of this pill versus that pill. Any such research needs to be done WELL: blinded, and against placebo, and also against psychotherapeutic interventions.

Well, that is what I have to say about peripartum depression, on this blog-about-peripartum-depression week 2009. Let’s avoid pills, and look to psychosocial treatments.

The rest of this blog post is technical details regarding how to evaluate pill studies for PPD. You have to become familiar with how the drug companies shape studies to make the benefits look better than they truly are, and to minimize the side effects.

So, if you have read this far, and have heard my points above, I greatly appreciate the attention. Wish me luck in my endeavors to understand and improve care for peripartum depression.

If you are interested in those technical details, which are important in the question of “meds versus therapy” (hence the blog name), read on. (Or, if you have insomnia, read on). -MVT

Here is an important technical detail to examine in any studies testing pills to treat peripartum depression: Was there a “control group”?

To get a group of 10 women with postpartum depression, and give them antidepressants, and to find at some follow-up point that depression scores were, on average, lower, is NOT sufficient to establish that medication as being effective for postpartum depression.

1. Because we don’t know where the scores would have gone without the medication being given. For example, what all of us know from our familiarity with anyone experiencing peripartum depression, it can last for months, or it can wax and wane across a few weeks. So, the overall change could have happened because of the med, or some other things, such as the “naturalistic” ebb and flow of the depressive symptoms.

2. Because the delivery of meds includes other aspects that can help, such as the increased activity, social involvement, and the “installation of hope.”

There are two pre-eminent psychologists who have defined the ways that psychotherapy works. There is a great deal of subsequent research supporting these principals of how psychotherapy works. We are talking back to the 1950s up to the present day, LONG before Prozac ever made it to the market. I believe these factors are worth looking at, since you can then begin to see how the process of seeing a physician and staff, being assessed and diagnosed, being prescribed a med, and being monitored as you start the med, can deliver, along with the med, some curative psychosocial factors.

Here are these factors, or principles.
Irwin Yalom: how does group psychotherapy work, for depression as well as other problems:
Installation of Hope; Universality; Imparting Information; Altruism; The Corrective Recapitulation of the Primary Family Group; Development of Socializing Techniques; Imitative Behavior; Interpersonal Learning; Group Cohesiveness; Catharsis; Existential Factors.

Carl Rogers: what are the "necessary and sufficient" ingredients of change in psychotherapy:
1. Two persons are in psychological contact.
2. The first, whom we shall term the client, is in a state of incongruence, being
vulnerable and anxious.
3. The second person, whom we shall term the therapist, is congruent or
integrated in the relationship.
4. The therapist experiences unconditional positive regard for the client.
5. The therapist experiences an empathic understanding of the client’s internal
frame of reference and endeavors to communicate this experience to the client.
6. The communication to the client of the therapist’s empathic understanding and
unconditional positive regard is to a minimal degree achieved.

To review these principals, you can begin to see that when you go through the process of getting assessed and receiving pill treatment, you are also probably receiving these curative factors as well.

Therefore, to determine if a medication works for peripartum depression, you need to have a placebo group who gets all of the social experience, but none of the pill's active ingredient. And, the researchers/pill providers have to be "blinded;" they can't know who is getting the true pill and who is getting the dummy pill, or they can bias the study. And the patient has to not-know, since the belief that you are getting the "real" pill could give "installation of hope," and lead to some benefit simply by this bias.

Psychotherapy studies don't have to "control" for these alternate effects because these are part-and-parcel of what psychotherapy is. Psychotherapy is partly the specific techniques, questions explored, skills taught, etc., but it is also curative through this special type of relationship. A relationship ultimately described as "unconditional positive regard." Sure you can get this from your Grandmother. And you probably should. If you don't, then I think that says something.

The pharmaceutical companies have dollar signs in their eyes, so they can really influence the design of a study to make their pill look good. So, we need to be wary of them.

On review, the medication studies overall are not at a very high quality level. The evidence for psychotherapy, and other things such as social support, is at a minimum just as promising for pre- and postpartum depression. Plus, there is a frightening aspect of birth defect risk with meds, but not with psychotherapy. So, what do you prefer? MedsVsTherapy.

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