Perinatal Mental Health Conference
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Perinatal Mental Health Conference Fairmont Hot Springs, Montana October 2018 Connecting Pathways and Building Bridges An Integrative Approach for Treating Perinatal Mood and Anxiety Disorders Christine White Deeble, ND Psycho-Gastro-Neuro-Endo- Immuno Putting it all together. • This isn’t about who I work for or what I profit from. I work for myself and I’m not selling anything or profiting from this other than I have received some payment for my time. • I believe in the body’s inherent capacity to heal itself. My • I do not believe that illness, of any kind, manifests without clues being present. My job, our job as Disclaimers: health care providers, is to identify those clues. • I believe people have a basic right to be offered all their options, and that our jobs are to facilitate their process in making those choices, and to help them re-evaluate along their journey towards their own optimal health. • I am a full-time clinician, not a researcher. I am not regularly on the lecture circuit. Which means I do not have hours to search the archives of medicine for multitudes of studies to cite. • I do rely on those who have the time to condense information and my sources will be sources that you Who am I? can learn from beyond today. • I don’t mean to be disrespectful to any profession of type of treatment, but I do expect I will say some things that some of you might be uncomfortable with because it will challenge your paradigm. • Participants will be able to identify and understand the relevance of several clinical signs and symptoms, through testing and intake, which can guide treatment decisions for women experiencing a PMAD to allow for a more Objectives comprehensive care plan. • Participants will leave with an understanding of treatment plan options that include a range of integrative medicine options such as diet, lifestyle, nutrients, and herbal medicine. • Women, by nature, are built to be resilient and strong, healthy, in harmony while fluctuations occur, and to have balance. We are built to carry and raise children. We are complex systems with natural synchronization. Homeostasis, • Pregnancy and birth are fundamentally understood to be huge shift in the physiology and biochemistry. Seeking These are understood to have significant impact on how the brain functions and our moods. It touches Balance women at the deepest of all levels. • When balance is lost, the results can be devastating. Helping correct that balance in a manner that doesn’t respect all the pathways involved will result in an unstable condition that will have a tendency to want to fall out of balance. • Bridges must be built with solid footings and anchored on a firm foundation. Connecting • Pathways are routes we follow to get from one place to another. pathways and building • Let’s build bridges between disciplines and make obvious the pathways that are bridges responsible for the underlying or root causes of PMAD. • Psycho—life and relationship changes, stress, trauma • Neuro—brain chemistry changes • Endo—rapid hormone fluctuations, steroid and Multi-factoral thyroid…and age and stress levels play a huge role in this element. • Immuno—inflammatory • “In recent years various neuroendocrine and psycho neuro immunological involvements in the onset of postpartum depression have been reported. The leading idea behind this is that labor, delivery, and postpartum periods induce multiple inflammatory responses in women, which, in a subset of women could be intensified by genetic predisposition, preexisting inflammatory status, and specific vulnerability The leading to depressive symptomatology. Additionally, nutritional status is essential for proper functioning of the hypothalamic- pituitary-adrenal (HPA) axis and adequate immune reactions in Interconnected the body. During pregnancy due to higher demands for certain nutrients, deficiencies are more likely to occur, leading to Pathways dysregulation of immune mechanisms, deprivation of regular cellular mechanisms, and consequently, depressive symptomatology.” • “Reduced monoamine levels (serotonin, dopamine, and norepinephrine) in the brain have been proposed as factors contributing to the neurotransmitter insufficiency responsible for the onset of depressive disorders.” • Changes in the HPA axis are well documented with depression; elevated cortisol is linked with depression; stress results in HPA axis changes; and stress impacts gut immunity and gut barrier integrity. • It is well understood and documented that commensal gut microbes produce serotonin, melatonin, GABA, catecholamines, histamine and acetylcholine. These NTs don’t necessarily cross the BBB to a large degree, the Cont’d likely impact visceral reactions that impact the CNS. And for example, Lactobacilli alters tryptophan metabolism. The SCFAs in the gut produced by commensal microbes and this is likely one of the communication pathways. Research has shown that Butyrate, a SCFA, can produce impact on the frontal cortex and result in an antidepressant effect. • We are in an age of medicine where we can no longer chose to ignore epigenetics, the gut brain axis, the impact of food quality on health, and the relationship of stress and disease • We are the sum total of our experiences, pregnancy and postpartum aren’t some sort of reset button which negates who women were before they became pregnant, gave birth, or transitioned into motherhood. And when we do consider pre-pregnancy health, we aren’t just talking about Paradigm Shift diagnosed mental health issues or frank physical pathology. • This is the heart of naturopathic or functional medicine. Understanding whole health, understanding that we can be well based upon conventional standards but ill if we consider a functional perspective. • We don’t necessarily need new treatments that haven’t been invented, we need to use what we know already and apply it in the appropriate way to this population. We need to honor the obvious pathways at play. Regarding previous slide The predisposing, pregnancy and CUMS factors that contribute to PPD, both directly and via “baby blues” induce TDO and IDO, increasing TRYCATs, including KYNA and QUIN, as well as increasing PiCs and O&NS. Notes: Such increased immuno-inflammation drives down serotonin, melatonin, and á7nAChr, whilst increasing autoimmunity, somatization, and relative amygdalae–cortex activity. Along with decreased omega-3 polyunsaturated fatty acids, this increases PPD. Treatments include psychotherapy and antidepressants. Estrogen can enhance the efficacy of SSRIs, whilst melatonin may provide a safer treatment for both mother and child. Some antidepressants are not recommended if breastfeeding, including those where no relevant data exist. Abbreviations: á7nAChr, alpha 7 nicotinic acetylcholine receptor; CUMS, chronic unpredictable mild stress; E2, estradiol; EDO, indoleamine 2,3-dioxygenase; kyn, kynurenine; KYNA, kynurenic acid; MDD, major depressive disorder; O&NS, oxidative and nitrosative stress; PIC, proinflammatory cytokine; PPD, postpartum depression; QUIN, quinolinic acid; SES, socioeconomic status; SSI, selective serotonin reuptake inhibitor; T3, thyroid hormone; TDO, tryptophan 2,3-dioxygenase; TRYCAT, tryptophan catabolite. Anderson G, Maes M. Postpartum depression: psychoneuroimmunological underpinnings and treatment. Neuropsychiatric Disease and Treatment. 2013;9:277-287. doi:10.2147/NDT.S25320. • Progesterone is produced in the ovaries, adrenals and CNS and has many metabolites. • It can induce anxiety (anxiogenic), it can reduce anxiety (anxiolytic) and can enhance sleep. • In the CNS the majority of the effects of Progesterone progesterone are by the metabolites and Brain Allopregnanolone and Pregnenolone. • Allopregnanolone is the most neuro-active and is a major GABA agonist. This results in action on GABA Chemistry receptors that are important in regulating stress, anxiety, vigilance, alertness and seizures. The result can be calming and supportive of sleep, it can also result in anxiety and depressive moods. • When allopregnanolone interacts with the GABA receptor, it changes it and makes it less reactive to further stimulation and this can then result in decreased GABA-mediated inhibition centrally. This can then translate into anxiety and depression (the Allopregnenolone, theory being if GABA levels are innately to low). GABA and • Additionally, progesterone results in reduced serotonin action by deceasing platelet uptake of Serotonin serotonin and thus mood impact or increased anxiety. • Additionally, progesterone also lowers serotonin levels by increasing MAO which is the enzyme that breaks down serotonin. Brexanolone “Pregnancy causes a dramatic rise in the reproductive hormones estrogen and progesterone. It also produces a spike in brain levels of a steroid called allopregnanolone, which normally activates receptors for GABA—a neurochemical that signals brain cells to stop firing. GABA receptors go dormant during pregnancy to avoid overactivation by allopregnanolone; otherwise a pregnant woman would become virtually anesthetized. Immediately following birth, estrogen, progesterone and allopregnanolone drop back to normal levels, after which GABA receptor levels rebound quickly. But in some new mothers, this rebound takes longer, which may result in postpartum depression. The new drug, developed by Sage Therapeutics, works by elevating allopregnanolone. Doing so activates GABA receptors and keeps the neurochemical at a healthy level. In one of Meltzer-Brody’s studies, a phase II clinical trial of 21 severely