"Depression in Breastfeeding Mothers" - A Day With Kathleen Kendall-Tackett

Last Thursday I had the pleasure of travelling to Buellton to attend an all day course titled “Perinatal Depression – Options for the Breastfeeding Mother,” presented by Kathleen Kendall-Tackett. I attended both of the sessions she presented at last year’s La Leche League of Southern California/Nevada conference and enjoyed both very much, so I was really looking forward to the course.

Kathleen presented four sessions over the course of the day, and each one was really informative. Kathleen is a talented speaker. Even in a room with 60 other participants, it’s as if she is chatting with you. She is very animated and entertaining and her research is fascinating.

The first session of the day was “A New Paradigm for Depression in New Mothers.” We learned that stress, pain, a history of depression, a history of trauma, fatigue and inflammation have all been found in the past to be risk factors for depression. New research is showing that in fact inflammation is the risk factor for depression. Physiologically it both causes and is caused by depression. The other risk factors are important too, but inflammation seems to always be present, no matter what the ultimate cause or causes of the depression are, and all therapies for depression counter inflammation one way or another. Inflammation also causes or contributes to many physical diseases including diabetes, cardiovascular disease, metabolic syndrome and more.

Catacholamine, HPA axis, and proinflammatory cytokines are all important hormones released by the body under stressful situations. The catacholamines are the fight or flight hormones, the HPA axis includes cortisol, which suppresses the immune system and speeds up metabolism, and the proinflammatory cytokines prepare the body to fight infection and heal wounds. These hormones are very important and useful, but they are not designed to be in our bloodstreams at high levels long term, and when they are, as during prolonged stress or depression, they can negatively impact our health.

Proinflammotory cytokine levels rise in the last trimester of pregnancy. This seems logical, because the body is preparing for the birth, and the mother’s immune system needs to be ready to respond. However, these rising hormones put women at risk for depression, and in fact, the highest risk for depression in pregnancy is during the third trimester.

Both depression and anxiety in pregnancy can trigger preterm labor in various ways related to many of the biochemical functions of the hormones mentioned above. After the baby is born, other factors can contribute to depression. The levels of proinflammatory cytokines remain at higher levels for months, probably to protect both mom and baby from infection. Many women experience nipple pain with breastfeeding, and nipple pain had been found to contribute to postpartum depression. Most new mothers get very little sleep for the first few months, and sleep deprivation and depression tend to reinforce each other strongly. Any history of trauma or adverse childhood events can also contribute to risk for depression at any time, but particularly postpartum when women are already vulnerable for so many other reasons.

The good news is, now that we know the major risk factors for depression, hopefully we can help women who are at risk of depression prevent it or treat it early on. Also, almost all treatments for depression are compatible with pregnancy and breastfeeding. Breastfeeding, if it is going well, reduces stress and increases sleep for mothers. If it’s not going well, then it can contribute to depression.

Kathleen’s second talk was “Treatment Options for Depressed Breastfeeding Mothers.” I would add that these are also applicable to mothers who are not breastfeeding.

Much of this session was devoted to new research about Omega 3s, in particular EPA and DHA, and their roles in preventing and treating depression. EPA seems to be the one that really treats depression, but DHA certainly has a positive role as well, we just don’t understand yet what it is. Many people are finding that when pharmaceutical antidepressants aren’t helping, adding EPA can often get them to work. The recommended dosages were 200-400 mg of DHA for prevention of depression, and 1 gram of EPA for treatment of depression.

Other effective therapies for depression include bright light therapy and dawn simulation. These are sometimes used alone and sometimes in conjunction with antidepressant medication. One really useful aspect of both is that people tend to respond within one week, whereas medications tend to take at least 4-6 weeks to reach full effectiveness.

Exercise can also be effective for treating postpartum depression. It seems to have several therapeutic effects including lowering levels of those stress hormones I mentioned earlier. Even strenuous exercise seems to have no impact on breastfeeding duration. Kathleen mentioned that moderate exercise does not cause lactic acid to build up in the breastmilk, but that strenuous exercise can. Research has found however, that babies don’t seem to mind having some lactic acid in the milk if their moms exercise strenuously, and it isn’t harmful to them. For mild-to-moderate depression the recommendation is moderate intensity exercise 2-3 times a week for 20-30 minutes. For major depression the recommendation is to exercise at 60% to 85% of maximal capacity 3-5 times a week for 45-60 minutes.

Both cognitive-behavioral therapy and interpersonal psychotherapy have been shown to be effective, and they also reduce the rates of relapse. On this topic, Kathleen recommended a book called “Feeling Good, The New Mood Therapy” by David Burns.

Another option for treating depression is St. John’s Wort. It is considered lactation category 2, probably safe. It should not be taken with other antidepressants.

The most common antidepressants are all compatible with breastfeeding. Lexapro, Zoloft and Prozac seem to be the most common, with Lexapro and Zoloft often being preferred because lower amounts get into the breastmilk compared with Prozac. The MAOI antidepressants such as Nardil and Parnate are contraindicated for breastfeeding mothers, but it sounds like they are also not that commonly used, and only when other antidepressants and treatments are not working.

Kathleen’s conclusions were, depression is treatable and should be treated. Almost all treatments are compatible with breastfeeding, and if a mother wants to continue breastfeeding, she should be strongly supported.

The next talk was “Sexual Trauma in the Lives of Childbearing Women.” Kathleen’s research has found that women who reported experiencing childhood sexual abuse and/or rape were more likely to come from dysfunctional families with other types of physical or emotional abuse, alcoholism, drug use, violence, depressed parents, divorced parents or a parent in prison. These survivors were also more likely to have experienced depression, anxiety, or PTSD. In addition, they were more likely to be taking antidepressants, Omega 3s, and/or St. John’s Wort, and were more likely to be getting psychotherapy, and more exercise. The survivors’ overall physical health and energy level was lower, but they were equally likely to be breastfeeding! There was no significant difference between the groups in birth experiences, except that survivors were less likely to have an episiotomy.

Kathleen’s conclusions were that sexual trauma is common among new mothers, survivors have breastfeeding rates similar to non-abused women, survivors have a high risk of depression and PTSD, sleep disorders may also be a problem, and their partner tended to be the strongest source of support for the majority of women.

Kathleen’s last talk was on infant sleep and SIDS. I had heard her talk about sleep at the La Leche League conference, and really enjoyed that talk. This one was quite a bit different, and my notes from this talk are not nearly as detailed.

She talked about some of the recent media campaigns designed to teach parents not to bed share with their babies. Then she used information from her study to talk about where babies sleep. If you ask American parents if they co-sleep, the majority say no. If you ask where their babies begin the night, most say in a crib, but if you ask where their babies end the night, the majority of parents in the US are bed-sharing for at least part of the night. Most say it is either out of necessity, or that it is the right thing to do. Kathleen’s main point about this was that parents in America have gotten the message that public health officials think they shouldn’t sleep with their babies, but the majority do it anyway. What parents need is information about how to bed share safely since it is still happening and will continue.

She then showed us studies of statistics of infant deaths considered to be SIDS deaths in various areas and showed that the majority of SIDS deaths actually happen in cribs, not in adult beds. Of the infant deaths that happened when a baby was sleeping with an adult, the majority were on a dangerous sleep surface such as a sofa, recliner or chair. In most cases there was also alcohol or drugs involved. Research has been finding that breastfeeding has a strong protective effect against SIDS.

The thing that was confusing about this talk, and Kathleen did address this, is that my understanding of SIDS is that these deaths are sudden and unexplained. The thing is, infant deaths where an intoxicated parent fell asleep on a sofa with a baby get counted as the same thing, and then used as ammunition to tell parents that any kind of sleep sharing is dangerous. Kathleen said that it depends on the area, but in many places any kind of sleep related death like this is counted as SIDS, and in other places they are counted as other things so the statistics are difficult to tease apart. So really, I may not have understood all the statistics or implications properly, but the take-away messages for me were: in reality, most parents end up sharing their beds with their babies at least some of the time, so it is worth making sure those beds are set up to be a safe place for the baby to be, and if you think you might fall asleep with your baby, make sure you do it somewhere safe, and not on a sofa, recliner or chair.

It was a very full day, as you can see! I hope this information is useful for you - it certainly was for me! You can find out more about Kathleen Kendall-Tackett by checking out Uppity Science Chick, www.kathleenkendall-tackett.com, or follow her on Facebook.