Race, PTSD and Urban Violence

"From elementary school through middle school, I can't remember how many times the White kids asked if they could touch my hair. I'm not kidding when I say it happened pretty much once a week at least. At first, it didn't bother me. But eventually I felt like an exhibit in a petting zoo. And I didn't have the vocabulary to explain to them that it was really weird that they kept asking to touch my hair all the time. See, I was a pretty shy kid. I was the only Black one, I was overweight, and I'd moved three times before I turned 10. So, rather than tell the White kids that no, they couldn't rummage through my hair, I just said yes and sat there quietly while they marveled at how my hair felt.", says Brian Crooks on his Chicago Tribune's essay "What it's like to be black in Naperville, America".
And he continues, "I've never had a Black boss. I played football from middle school through senior year of high school and only had one Black coach in that whole time. Not just head coaches, I'm talking about assistants and position coaches. I've had two Black teachers in my entire life. One was for my Harlem Renaissance class, and one was for my sign language class. I've never been to a Black doctor, or a Black dentist. I've never been pulled over by a Black police officer. What I'm trying to explain is that, in 31 years, I've seen three Black people in a position of authority.".

While the theme of racial discrimination is somewhat outside the scope of this blog, July is National Minority Mental Health Month and I think, more than ever, that it's crucial to talk about it. Racial attacks and protests have become routine on media vehicles. Being a white, green-eyed woman has always put me in a rather privileged condition and I can honestly say I never experienced racism first hand in America despite my Latino background. Having the letters "MD" after my name certainly helped. 
But, in my profession, I get to feel the pain of people who didn't have the same "luck" to receive fair, equal treatment; who didn't get to have the benefit of the doubt; who have to teach their children to protect themselves from the very ones who were supposed to protect them; who were denied opportunities simply because of the color of their skin. Day after day, I see the tears, struggles and challenges of those black women with mental illness-- a triple minority of an unjust society. 

"But what does one's complexion have to do with mental health?", you may ask.
Racial discrimination is closely related to trauma, and can even cause Post-Traumatic Stress Disorder (PTSD).

It is, indeed, one of the greatest misconceptions about PTSD, that it’s limited to wars and combat

zones or to a life-threatening event.  The reality is that one can have PTSD simply from witnessing a 

traumatic event of any nature or even if a loved one has suffered a traumatic event. (A 2014 

study  from the University of Miami showed that almost 50% of women had PTSD 

symptoms after Hurricane Katrina, for example).

The DSM- 5 even broadened the definition to include a person who learns about a traumatic event 

that happened to a close family member or a close friend, and also stress due to a prolonged 

exposure to an aversive situation.


Well, racism itself may be a traumatic experience!

Watching repeated acts of violence is a source of stress and trauma in Black people, particularly


black women. Research has shown that stress and trauma from racially motivated events create 

reactions that can be identical to PTSD.

If I am African American and I see this pattern on television I may identify myself with the entire 

situation. But trauma extends well beyond what we see on cable news and social media. It is an 

everyday challenge that people face with institutionalized racism leading to what some mental health

professionals call RACE-BASED TRAUMA. Racism continues to be a daily part of American

culture and to have an overwhelming impact on the oppressed.

 In the case of racial discrimination, we’re not talking about an issue that’s been around for

years or decades, but centuries. It’s people who were kidnapped and thrown in the bowels of slave 

ships and submitted to forced labor and torture. Later on, that was translated into exclusion from

educational, social and health resources causing disparities that are linked to mental health. 

It's important to have that in mind in order to understand one's perceptions and society's 

(mis)perceptions.


Victims can become distressed by things that are not typically worrisome to white people, for

example. "Microaggressions, or routine slights, can trigger stress reactions: it’s the black man 

followed by a security guard at the department store or the white woman clutching her purse when a 

black man enters the elevator", says Dr. Carl Bell, from the University of Illinois at Chicago.


What is PTSD?

It’s a severe and chronic condition that may occur in the aftermath of a traumatic event.

Symptoms usually develop within the first 3 months after the trauma and the diagnosis is made

if symptoms persist for over a month. Women are more affected than men.

Symptoms include depression, anxiety, flashbacks, fear, intrusive thoughts about the traumatic event, recurrent nightmares (leading to sleep difficulties), anger, apathy, inability to get pleasure, impaired concentration. It may also cause hypervigilance, hyperarousal and an exaggerated startle response (certain sounds or smells make the person relive the trauma) as well as avoidance behaviors leading to social isolation-- the person becomes more seclusive and uninterested, fears getting out of the house, or may change the route they normally take to avoid walking by a police officer or the street corner etc.

PTSD may have short-term or long-term impact. How long? The answer may be shocking:

Studies suggest that trauma is intergenerational and inherited, with memories passed along

through the DNA! That is shown, for example, in several interesting studies with families of

Holocaust survivors, or more recent studies with victims of the 9/11 attacks, that showed that

pregnant women who experienced the bombings passed on biological signs to their babies.

There is another study from Columbia University that revealed that one-third of NYC’s school

children suffered mental health disorders following the WTC attacks.

We must ensure black women have the ability and the right to raise their children in a healthy

environment. It is a matter of Reproductive Justice.



 African-Americans are 20 % more likely to report serious psychological distress than adult whites; 

they are also more likely to have feelings of sadness, hopelessness, worthlessness and more likely to 

attempt suicide (8% vs 6%).

The National Survey of American Life found that AA have a prevalence of PTSD around 9% (vs

6% for Non-Hispanic Whites). In certain populations, this number can get much higher. Inner city

studies in high crime zones of Detroit and Baltimore show something like 30%, which is

comparable to war zones in Vietnam, Iraq and Afghanistan.

AA usually have more serious traumatic events and are more likely to experience child abuse,

sexual trauma, and to witness domestic violence. An Emory study showed that almost 90% AA 

living in impoverished urban areas reported some form of trauma.

A UMichigan study from 2011 with 1600 women (~half AA) showed that the prevalence of PTSD

was 4 times higher among AA, but they were also less likely to get treatment. They also noted

the correlation of PTSD and pregnancy complications, including preterm birth (due to increased

cortisol levels causing placental abnormalities).

 AA are under-represented in outpatient settings but over-represented in inpatient treatment.

They are also over-represented in jails: AA and Hispanics comprise 30% of the US population but

account for almost 60% of the prison population. They’re also 14% of drug users but 37% of

drug arrests.

Police are also at an increased risk for violent behaviors as a consequence of stress. The uncertainty 

about whether they’ll come home alive to their families at the end of their shifts and the pressure 

from being at the front lines may cause depression, and anxiety, and burnout. Stigma is particularly 

significant in this population and a lot of them won’t disclose their feelings and struggles with fears 

of being perceived as weak, or even of losing their jobs.

As a consequence, lot of them will use alcohol or drugs to self-medicate their symptoms, making the

 symptoms much worse and more difficult to treat and contributing to poor judgement and 

inappropriate defenses.

This attitude is thankfully starting to change but the process is really slow: There’s still something 

between 120-140 documented suicides per year among police officers and a very high prevalence of 

PTSD (1 in 8).

What can be done?

We need to understand this phenomenon as a  Public Health Crisis: there are still a lot of underserved 

areas and significant lack of resources to treat mental illness. AA physicians are 5 times more likely 

to treat AA patients but the vast majority of mental health professionals are white. 

Some people have difficulty expressing their feelings and experiences thinking they won’t be fully 

understood.  It’s important to make mental health professionals aware and

teach them how to address this problem and how to actively screen specifically for racial-based

trauma when assessing the trauma or abuse history.

Despite the growing evidence that PTSD is related to racial discrimination, little is being done to

address this problem. Hospital trauma centers are well-equipped to treat the physical injuries

from the trauma, but not its emotional and psychological components.


 We have a number of evidence-based interventions and treatment models for trauma but not

specifically for racial trauma so more studies should be done and more attention should be paid

to this matter.

 Also it’s important to develop interventions to decrease violent crime and increase access to

mental health treatment and to work on decreasing the stigma that surrounds mental illness.

Below is a panel that aired last week on the morning news about the theme of Race, Trauma and Urban Violence:

Treating PMDD without Medications

In an earlier post, we defined PMS and PMDD, and briefly discussed their etiology. Here, we will look into the treatment of PMS/PMDD. While there are many pharmacologic treatments of PMDD, non-pharmacologic approaches may often be considered first. Indeed, just like mild to moderate hypertension is often first treated with lifestyle modifications like exercise and a low-sodium diet, PMS/PMDD is often improved with the following lifestyle modifications:

• regular aerobic exercise 4-5 times a week
• good sleep hygiene, i.e., establishing a consistent sleep schedule 
• dietary changes: limiting alcohol, caffeine, salt, chocolate, red meat, and eating smaller, more frequent meals with complex carbohydrates 
• avoiding stressful activities/ situations during the premenstrual period 

These interventions can often be started in the 2 months (or 2 menstrual cycles) during which a patient is completing the daily symptom ratings needed to confirm a diagnosis of PMDD, and for some women, they may be enough to control their symptoms. 

We have had patients ask us about whether certain vitamins and dietary supplements (like vitamin B6, calcium, magnesium, chasteberry, soy) are helpful for PMS/ PMDD symptoms. For most of these supplements, there is no consistent evidence from research showing that they are are better than placebo, and some may carry risks:   

• vitamin B6; at high doses may lead to peripheral neuropathy and there is only low-quality evidence that it may help with PMDD symptoms, so it is not recommended
• calcium supplementation has benefits beyond those on mood symptoms, but high doses may increase the risk of heart disease 
• soy was found to have reduced physical symptoms but not mood symptoms in women with PMS/ PMDD
• chasteberry (vitex agnus-castus) may also be more helpful for the physical symptoms rather than mood symptoms of PMDD

Some other therapeutic modalities that have been considered in the treatment of PMDD include group or individual psychotherapy, acupuncture, yoga, and bright light therapy. There is little research evidence available for most of these treatments, but bright light therapy in particular has shown some promise, and psychotherapy has shown promise but with small effect sizes. 

Can I take antidepressants while breastfeeding?

Given the high prevalence of postpartum depression in the US (often cited as between 10-15% of postpartum women), and the myriad benefits of breastfeeding for both baby and mother, it's not a surprise that women in our clinic often ask about the safety of breastfeeding while taking antidepressants.

To answer this question, it's important to note that concentrations of psychotropics in breast milk have been found to vary widely. The amount of a psychotropic medication that an infant is exposed to depends on multiple factors, including dosage of the drug, rate of maternal drug metabolism, and frequency and timing of feedings. In the past, a technique called "pumping and dumping" was recommended. However, that has been found to be unnecessary; you can read more about why it is not a good idea to pump and dump in this post.

One of the main ways researchers have investigated antidepressant safety in lactation has been to look at infant plasma (i.e., blood) concentrations. The chart below from Berle and Spigset (2011) shows that of the most commonly prescribed SSRIs, sertraline and paroxetine have the lowest infant plasma concentrations: 

click image to enlarge

Duloxetine (an SNRI) and bupropion (an NDRI) also had undetectable infant plasma levels, but there were fewer mother/ infant pairs studied. The SSRIs fluoxetine and citalopram had higher infant plasma concentrations; it's generally recommended that these be used with caution or avoided during breastfeeding. However, if a woman has been stable on these medications prior to and/ or during pregnancy, it may be fine to continue them during breastfeeding.

Another way to evaluate the safety of medications in lactation has been to look at adverse events. Scalia and Wisner did an extensive literature search to create clinical guidelines for antidepressant use during breastfeeding. They found that sertraline, paroxetine, and nortriptyline are the most evidence-based antidepressants in lactation, because levels are usually undetectable in infants, there have been no reports of short term adverse effects, and findings about them have been consistent among different laboratories. They also created the following decision-tree:

click image to enlarge

As you can see, sertraline and paroxetine are generally considered to be the first-line agents if pharmacological treatment is necessary in lactation. Sertraline is often preferred over paroxetine because of paroxetine's greater anticholinergic side effects (including dry mouth, blurred vision, sedation, constipation, and memory impairment) and its shorter half life/ more significant discontinuation syndrome (marked by flu-like symptoms, insomnia, nausea, imbalance, and anxiety).

Happy Mother's Day.

I've always thought that Mother's Day should be celebrated by ALL women!
For all who haven't had children-- whether by choice or circumstances-- this one's for you:

"Even if she has never birthed a child,
Even if she never comes to do so
Every woman is a mother!
First, of her dolls; then, of her little siblings;
Getting married, she's her husband's mother
before mothering their children.

If childless, she will become an adoptive mother and will give someone else's spawn all her love: nieces and nephews, children of friends, students, animals, a good cause.

How many women weren't chosen to mother
their own children but ended up mothering their own mothers? Or fathers? Grandparents?

Motherhood cannot be suppressed.
Just like a water flow that gets blocked by a stone, it will surely find its way out.

During war, they care for the injured,
even if they wave a different flag
or wear a different uniform.

Motherhood has no borders, colors or preferences.
It's one of those few things that are
sufficient in themselves.

Every woman is a mother!"

On Antipsychotics in Pregnancy and the Problem of Confounding

Second-generation antipsychotics, also known as atypical antipsychotics, are frequently used in psychiatry, prescribed not just for psychotic disorders, but also for treatment of bipolar disorder, and for augmentation of depression or OCD treatment. Studies have shown that there is a very high risk of relapse of psychiatric disorders in pregnancy--for example, women with a history of bipolar disorder who discontinue their medications while pregnant have an 85% chance of recurrence of a mood episode while pregnant, compared to a 37% chance of recurrence when continuing to take their medications. Thus, it's important for women who are taking antipsychotics prior to pregnancy to know about the risks and benefits of continuing these medications while pregnant. Here we will focus on a recent article which looked at how taking antipsychotics in pregnancy may affect maternal and perinatal outcomes.

A large population-based cohort study looked at the question of whether or not antipsychotics affected certain maternal and perinatal health outcomes. It looked at all women who had delivered between April 2003 and December 2012 in Ontario, Canada. Data were collected from multiple linked healthcare administrative databases, which included information about medications women were taking, inpatient and outpatient claims, and demographic information. Antipsychotic exposure was defined as at least 2 consecutive filled prescriptions for an antipsychotic between conception and delivery. There were a total of 41,523 women in the study. Of these women, 1,209 were prescribed an antipsychotic, and 40,314 were not. The women were compared in 2 ways--there was an unmatched cohort, and a matched cohort. In the unmatched cohort, maternal and perinatal outcomes between women who were prescribed an antipsychotic and those who were not were compared directly. In the matched cohort, 1,021 women who were prescribed antipsychotics were matched with 1,021 women who were not, using something called a high dimensional propensity score (HDPS) algorithm.

What is a high dimensional propensity score (HDPS), you ask? It's a method commonly used in pharmaco-epidemiological studies to create less biased estimates of treatment effects. In other words, these epidemiological studies are subject to many confounders--things like age, ethnicity, multiple gestations, multi-parity, pre-existing medical problems like hypertension, diabetes, renal disease, smoking, drug use, other medications, and number of healthcare visits. Many of these confounders are observed, or known (e.g., it's easy to determine age from the databases). Researchers sometimes create a propensity score, which is a summary confounding score. The HDPS algorithm attempts to further minimize residual confounding by also incorporating proxy variables (healthcare diagnoses, procedures, and drug claims), which, when combined, can account for important confounders that are unobserved. This is extremely important, because without controlling for the unobserved confounders, we cannot know if a certain maternal or perinatal outcome is due to medication exposure, or to something else. In fact, women who take medications during pregnancy are often very different from women who do not; they tend to have more severe illness with higher risk of relapse...without controlling for this, we won't know if an outcome is related to a woman's underlying illness (severity), or to the medication she took. And this is how the HDPS is very useful.

Back to the study: the researchers looked at the following maternal medical outcomes: gestational diabetes, hypertensive disorders of pregnancy (gestational hypertension, pre-eclampsia, eclampsia), and venous thromboembolism (VTE), and the following perinatal outcomes: preterm birth (<37 weeks gestation), and extremes of newborn weight (a birth weight <3rd percentile or >97th percentile for the same sex and gestational age). What the researchers found illustrates not only the possible effects of antipsychotics on pregnancy outcomes, but also the importance of controlling for confounding. In terms of maternal outcomes in the matched cohort (where HDPS was used), there were no differences in terms of gestational diabetes, hypertensive disorders of pregnancy, and VTE between women who took antipsychotics in pregnancy and those who did not. However, in the unmatched cohort, there was an increased risk of gestational diabetes and hypertensive disorders in the antipsychotic group. In terms of perinatal outcomes, there were similar differences between the matched and unmatched cohorts. In the matched cohort, the 2 groups had no differences in preterm birth, and extremes of newborn weight. However, in the unmatched cohort without HDPS, the infants exposed to antipsychotics had an increased risk of preterm birth and weight >97th percentile. The study thus shows that when these antipsychotic users were matched with non-users who had similar pre-pregnancy morbidity (e.g., weight,  other medical conditions, diagnoses, and other variables), then the risk was about the same for both groups. Here is an illustration of the potential magnitude of bias that is created by not controlling for confounding variables. However, it also showed that the absolute rates of adverse maternal and perinatal outcomes in antipsychotic users were higher than those in the general population. Thus, for women who require antipsychotics during pregnancy, it's imperative to closely monitor their health before and during pregnancy, paying close attention to diabetes, hypertension, preterm birth and fetal growth.

A Mother's Love- Infertility and Pregnancy Loss

(photo: Sher Institutes)

One could argue that there's nothing more intense than a mother's love, long before her child is even born.

This week we celebrate the National Infertility Awareness Week, a movement that started in 1989.  My interest in Women’s Mental Health and Reproductive Psychiatry began a little less than two decades later, when my husband and I were diagnosed with infertility. Suddenly, this two-physician couple assumed the patient role, with all its emotional and physical pains, challenges and distress. Denial, anger, shock, grief and disbelief, depression and anxiety all followed. A terrifying sense of loss of control marked that turbulent, draining road.

Relationships suffer- marital discord arises, friendships get affected, one’s social life may vanish. Diminished quality of life, complicated grief, major depressive disorder, anxiety disorders, and post-traumatic stress disorder may develop.

Infertility is the inability to achieve pregnancy for one year (or six months if over 35) or being unable to carry a pregnancy to live birth. It is quite common, affecting approximately 1 in 8 couples. One third of infertility is attributed to the female partner, 1/3 attributed to the male partner and 1/3 is unexplained or results from a combination of problems in both partners 

According to Dr. John Rapisarda, Reproductive Endocrinologist and Vice President of Fertility Centers of Illinois, “The most common causes of infertility in women are Polycystic Ovarian Syndrome (PCOS) and other ovulation disorders, blockage of the Fallopian tubes and diminished ovarian reserve while the most common causes of infertility in men are hormonal imbalances, low sperm count, abnormal sperm shape, and poor sperm movement (motility)”.

The frustration, pressure and uncertainty that surround infertility have been shown to cause significant mental stress, particularly anxiety and depression. In addition to that, fertility treatment often involves invasive, time-consuming tests and procedures, and complicated medication schedules that further add to the stress of the diagnosis. That is commonly accompanied by feelings of grief, failure, and guilt. 

The prevalence of depressive symptoms among infertile women has been reported as being twiceas high as that of fertile women. Further, levels of distress and anxiety in infertile women persist over extended periods of time, tending to increase as treatment intensifies and the duration of treatment lengthens. Several factors are involved: 

·         The drugs and hormones that are commonly used to treat infertility often cause a myriad of psychological side effects. Clomiphene citrate (Clomid, Serophene), frequently prescribed because it improves ovulation and increases sperm production, may cause anxiety, sleep interruptions, mood swings, and irritability; Oral contraceptives, often part of the treatment protocols, have higher doses of progesterone, which has been associated with increased depression. GnRH Agonists (Leuprolide/Lupron) are associated with depression, emotional lability, and changes in libido; Steroids and immunosuppresants may also cause depression, mania, anxiety and psychosis. 

·         Financial Difficulties: insurance coverage varies widely, and infertility treatments can be financially draining while still offering disappointing success rates in a lot of cases;

·         Religious ambivalence: fertility treatment goes against several religious doctrines, further adding to feelings of guilt and anxiety or social criticism.

·         Social aspects: patients may find it very distressing to socialize with their friends who are pregnant or have children. They may feel guilty for not being able to fully rejoice with them and end up opting to exclude them from their lives, becoming increasingly withdrawn and seclusive, with fewer support systems at a time when social support could be so helpful.

   

 While it is clear that infertility can affect mental health, researchers are not sure if mental health can affect fertility. Some studies have proposed that high levels of depression, anxiety, and stress can affect some of the hormones that regulate ovulation. The hormonal impact on mood and its correlation with pre-menstrual syndrome, pre-menstrual dysphoric disorder, pregnancy and postpartum depression, and menopause are well-established. The psychological impact of the hormones used in fertility treatments, however, hasn’t been as widely studied.

A Japanese study with 83 women undergoing fertility treatment showed that the rates of anxiety and depression were higher as the age increased. They also found that patients who underwent infertility treatment were more likely to have higher depression scores compared to patients who had not undergone treatment. Additionally, patients whose husbands were infertile had significantly lower total mood and anxiety scores than those whose husbands were not infertile.

“Eliminating psychological stress may be necessary for successful infertility treatment.

Women appear to have a higher rate of infertility-related stress than men. Studies have also found that greater than half of the women receiving infertility treatment feel that infertility is the most stressful experience of their lives", they conclude.

One study of 200 couples seen at a fertility clinic, for example, found that half of the women and 15% of the men said that infertility was "the most upsetting experience" of their lives. Another study of 488 American women who filled out a standard psychological questionnaire before undergoing a stress reduction program concluded that women with infertility felt as anxious or depressed as those diagnosed with cancer, hypertension, or recovering from a heart attack.

Despite the evidence that infertility has a profound impact on mood and anxiety, mental health care during this treatment is often neglected. A couple dealing with infertility may benefit from several treatment approaches observing the biopsychosocial model. Those include counseling and psychotherapy, relaxation techniques, yoga, meditation and exercises (see our post about that here) and psychiatric medications that may alleviate mood and anxiety symptoms. The prevalence of antidepressant use has been reported to comprise as much as 4 and 11% of women undergoing infertility treatment according to some studies.

But is there any evidence that antidepressants increase the fertility rates? 

A study published this year on the Journal of Psychosomatics Research by a Canadian group did a systematic review of databases from January 1950 to November 2015 and did not find that antidepressant use by women receiving fertility therapy impacted gamete quality or pregnancy success. “Collectively, the findings of the four studies meeting inclusion criteria reflect no differences between antidepressant users and comparators in assisted reproductive outcomes (i.e., peak serum FSH or estradiol levels, oocyte retrieval, or embryo maturation, transfer and implantation rates). This is consistent with Worly and Gur's findings that clinical studies have yet to demonstrate a deleterious effect of psychotropic medications on oocyte quality or reproductive success”.

A Swedish nation-wide study including 23,557 nulliparous women undergoing their first IVF cycle between January 1, 2007 and December 31, 2012 found no statistically significant associations between SSRI treatment and IVF outcomes. Conversely, women treated with non-SSRI antidepressants had reduced odds of pregnancy (Adjusted Odds Ratio (AOR): 0.41; 95% CI: 0.21, 0.80) and live birth (AOR: 0.27; 95% CI: 0.11, 0.68) and an increased likelihood of miscarriage (AOR: 3.56; 95% CI: 1.06, 11.9). These risks were also significant for untreated individuals in pregnancy (AOR: 0.58; 95% CI: 0.41, 0.82) and live birth (AOR: 0.60; 95% CI: 0.41, 0.89) but not miscarriage (AOR = 1.28; 95% CI: 0.49, 3.39).

It is crucial to note, however, that each patient should be treated according to the severity of her symptoms and medications are often required to ensure safety and well-being. In fact, a recent study on suicidal risk among infertile women undergoing in-vitro fertilization found that being "childless, depressive and non-positive reappraisal predict suicide risk" and stressed that suicidal risk is recommended for women in the course of IVF.

“The incidence of suicide risk was 9.4%. Suicidal women were more likely to be childless or had fewer children and experienced higher levels of depressive symptoms. In addition, they reported more frequently on denial, social withdrawal and self-blame coping strategies compared to participants without suicidal risk”. 

Perinatal loss (miscarriage, stillbirth) is another major risk factor for depression and other psychiatric issues. A recently-published study entitled “Infertility and Perinatal Loss: When the Bough Breaks” does a comprehensive review on the correlation between pregnancy loss, depression, suicidality and trauma:

"Young women, who lack social supports, have experienced recurrent pregnancy loss or a history of trauma and / or preexisting psychiatric illness are at a higher risk of experiencing psychiatric illnesses or symptoms after a perinatal loss or during infertility.

Perinatal loss is the non-voluntary end of pregnancy or death of the baby from conception until 28 days into a newborns life. The term perinatal loss includes miscarriage, stillbirth, and neonatal death.

Psychological Aspects of Perinatal Loss Understanding and addressing psychological aspects of perinatal loss is critical because of the psychological reactions of women (grief, depression, anxiety, PTSD, suicide) and the impact on subsequent pregnancies and relationships with partners and surviving siblings. The grief that follows miscarriage often declines significantly by 6 months for both men and women, yet sometimes persists for up to 2 years. Perinatal loss leads to complicated grief more frequently than other losses. Several factors may contribute to this. Pregnancy loss is often sudden and unexpected. The grief that parents experience after early pregnancy loss is often not openly acknowledged or socially supported. Perinatal loss is associated with guilt or self-blame, and women may feel that their bodies have failed. Predictors of complicated grief following perinatal loss include lack of social support, previous loss, major depression, ambivalence about pregnancy, and termination of pregnancy for fetal anomaly. Termination of pregnancy for fetal anomaly is associated with higher levels of self-blame, guilt, and social isolation. Other factors that have been reported as predictive in some, but not all studies include older maternal age, having viewed an ultrasound, having experienced quickening (fetal movement), having named the baby or bought things for the baby, and length of gestation.  Whether miscarriage is managed medically or surgically does not have a bearing on the intensity or duration of grief. The presence of living children is protective against grief after perinatal loss. The perinatal loss of a co-twin or a higher order pregnancy is associated with unique challenges such as enduring the trauma of prolonged hospitalization for the surviving twin. Grief following perinatal loss is a normal phenomenon. Nonetheless, women, especially those with risk factors, should be monitored for prolonged or complicated grief and persistence of depression, anxiety, or posttraumatic symptoms. Women who experience a perinatal loss have fourfold higher odds than women with a live birth of screening positive for depression. Risk factors for persisting depression/ psychological distress after miscarriage are infertility treatment, recurrent pregnancy loss, prior history of depression, prior PTSD, intimate partner violence (IPV), and high levels of distress immediately after miscarriage. There is also a higher risk of inpatient or outpatient psychiatric treatment 12 months after fetal death. The highest risk is for women with a loss occurring after 20 weeks of gestation, and the most commonly reported psychiatric disorder is adjustment disorder. However, 5 to 18 years after intrauterine fetal death (IUFD), there are no significant increases in depression scores. Thus, while women with recurrent miscarriages and a past history of depression and fetal death after 20 weeks of gestation are at a high risk of depression/ adjustment disorder in the year following perinatal loss, this risk declines subsequently.

Post-Traumatic Stress Disorder (PTSD) rates are increased after all types of perinatal loss—miscarriage, termination of pregnancy, stillbirth, and neonatal death. Risk factors for PTSD include younger age, lower education, previous trauma, and mental health problems. Longer gestational ages are associated with greater severity of PTSD. Even 9 months after a stillbirth or neonatal death, women have a sevenfold higher rate for screen positive PTSD when compared with women with live births. It is important to encourage the use of available social support because having a support network is associated with less depression and PTSD. The mean annual suicide rate is higher (18.1 per 100,000) in the first year after miscarriage than after live birth (5.9) or in the general population (11.3)”.

They proceed to commenting on the guidelines for the management of psychological responses after stillbirth, which remain controversial, “especially surrounding the parent’s decision to hold the baby. Although there is a dearth of randomized controlled trials of bereavement counseling or specialized psychotherapy for mothers, fathers, and families after perinatal death, there is evidence from studies using other study designs. Some studies have found that holding the baby may increase the risk of depression, anxiety, and PTSD in the mother, sometimes up to 7 years after stillbirth. However, other studies have found that parents appreciate time and contact with their deceased infant, and that parents who see and hold their baby report fewer poor mental health outcomes. Encouragement of parents to see and hold their deceased baby may be best done under guidance from experienced staff , always emphasizing the importance of respecting culturally diverse approaches to neonatal death. In the case of termination of pregnancy for fetal anomaly, observing a deformed baby can be traumatic, but it may also help to reduce guilt if observing the baby convinces the mother that she made the right decision. Other approaches to supporting parents grieving after a stillbirth have included supportive DVDs, internet-based cognitive behavior therapy and mindfulness-based therapy. Physical activity may help as shown in a recent study, which found that in women within a year of stillbirth, those who reported higher levels of physical activity reported lower levels of depressive symptoms. There is a dearth of studies or reviews specifically examining the use of SSRIs or other psychotropics in the aftermath of perinatal loss. However, it is worth noting that the association between SSRI use and miscarriage is controversial, and there is no association between SSRI use and stillbirth. Although all women may not need preventive psychosocial interventions after miscarriage, stillbirth, or neonatal death, it is important that they be monitored, especially if they have established risk factors. Given the lack of evidence for any specific approach, we recommend a customized treatment plan based on the individual’s preferences.

Couples dealing with infertility and pregnancy loss eventually come to some form of resolution achieved through biological children, adopted children, surrogacy, embryo/egg/sperm donation, or a decision to have a life without children. Whatever the outcome is, the experience will change some of the most important aspects of who you are- you may reframe your self-identity and self-perception, strengths and weaknesses, relationships, and even your global view of existence.

Eating Disorders and Infertility

Twenty million American women (compared to 10 million men), will experience an eating disorder at some point in their lifetimes. Eating disorders come with a slew of medical complications, including infertility. In this post, we will discuss how fertility is affected by 3 common eating disorders--anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

Anorexia nervosa
In past editions of the DSM, amenorrhea was listed as a criterion for AN. While it is not included in the DSM-5, the absence of menstruation for >3 months affects about 66-84% of women with AN, while an additional 6-11% of women report light or infrequent menses (oligomenorrhea). Low BMI, high levels of exercise, and low caloric intake are the strongest predictors of amenorrhea. Amenorrhea occurs because food deprivation inhibits the hypothalamic-pituitary-gonadal (HPG) axis, decreasing the release of gonadotropin-releasing hormone (GnRH) from the hypothalamus, which subsequently decreases the release of follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland, which in turn, decreases the synthesis of estrogen and progesterone. A functioning HPG axis is imperative for ovulation and, thus, fertility. 

Recent research has found that estrogen receptor alpha (ERα), a nuclear receptor activated by estrogen, is also involved in the nutritional regulation of reproduction. Caloric restriction has been shown to decrease liver ERα activity, which disrupts the estrous cycle. However, dietary amino acids prevent this from occurring by promoting hepatic ERα activity. Finally, increased physical activity (over-exercise) is sometimes seen in patients with AN. It's been found that moderate exercise leads to increased fertility; however, exercising to exhaustion leads to a 2.3- to 3-fold increased risk of infertility. This effect of exercise is thought to be independent of body fat stores.

What is the upshot of this? According to a survey by Hassan and Killick, it takes underweight women (BMI <19 kg/m²) 4 times longer to conceive than it does for women with a normal BMI. Specifically, they found that underweight women took an average of 29 months to become pregnant, compared to 6.8 months for women of normal weight.

Bulimia nervosa

About 7-40% of women with BN report amenorrhea and 36-64% report oligomenorrhea. Research has found that women with BN have increased odds of receiving fertility treatments. This is thought to be possibly related to increased rates of polycystic ovarian syndrome (PCOS) in women with BN. The pathophysiology of infertility in PCOS is complex, but strongly associated with insulin resistance, which will be discussed in more detail below. 

Binge eating disorder 

While amenorrhea and oligomenorrhea may not be surprising consequences for patients with AN or BN, patients with BED have also been found to have light, infrequent, or absent menses, even after controlling for conditions like PCOS, or compensatory behaviors like purging. Obesity has been shown to increase the risk of infertility, miscarriage, poor pregnancy outcomes, and impaired fetal well-being. In fact, it's been found that with each unit increase in BMI above 29 kg/m^2, the chance of spontaneous conception decreases by 5%. Studies have found that obesity impairs the HPG axis, and also affects oocyte quality and uterine receptivity.

This decreased fertility in obese women is thought to be multifactorial. Elevated serum free cholesterol concentrations have been associated with reduced fecundity, and dyslipidemia is common in obese patients. Further, abnormal levels of insulin, leptin, and adiponectin in obese patients have been shown reduce fertility.

In obese patients with BED, insulin levels rise, leading to insulin resistance. This insulin resistance is highly correlated with PCOS. High levels of insulin inhibit synthesis of sex hormone-binding globulin (SHBG), leading to increased free testosterone levels, and also increase ovarian androgen synthesis. Insulin resistance has been shown to lead to abnormally high levels of LH. This combination results in a hyperandrogenic state that suppresses ovulation and thus reduces fertility.

Leptin is a hormone produced by adipose tissue that normally works to maintain energy homeostasis by inhibiting hunger/ reducing food intake and regulating pancreatic islet cells. Levels are low in women with AN, but markedly increased in obese patients, who develop a leptin resistance. Leptin affects reproduction by facilitating GnRH secretion in the HPG axis. Leptin-deficient female mice produce low levels of gonadotropins like LH and FSH,  and, consequently, sex steroids, which partly explains the hypogonadotropic hypogonadism in patients with AN. However, high concentrations of leptin, like those seen in obese patients with BED, have been demonstrated to directly interfere with estradiol production and oocyte maturation, which also decreases fertility.

Under physiologic conditions, leptin reduces hunger and food intake. The mouse on the left was leptin-deficient. 

Levels of adiponectin, another hormone secreted by adipose tissue, are low in obese patients. Adiponectin has insulin-sensitizing, anti-atherosclerosis and anti-inflammatory effects, but affects female fertility by stimulating granulosa cell steroidogeneis, and by possibly playing a role in uterine receptivity and embryo development.

(Un)safety of Marijuana in Pregnancy

Over 180 million people use cannabis for recreational or medical purposes globally, which is becoming a worsening public health issue in light of its recent legalization battles for both medicinal and recreational purposes and its ubiquitous use among adolescents and young adults, several of whom continue using it during pregnancy. Cannabis is, in fact, the most commonly illicit drug used during pregnancy with a self-reported prevalence ranging from 2% to 5% in most studies but increases to 15–28% among young, urban, socioeconomically disadvantaged women.

It is estimated that 48–60% of marijuana users continue use during pregnancy, with many women believing that it is relatively safe to use during pregnancy and less expensive than tobacco. In reality, though, we’ve been learning that cannabis in pregnancy isn’t benign and it has been reported that healthcare providers don’t routinely counsel their patients on the potential risks.

Tetrahydrocannabinol (THC), one of the psychoactive substances found in marijuana, is distributed rapidly to the brain and fat. It is known to cross the placenta, producing fetal plasma levels that were approximately 10% of maternal levels after acute exposure.

Marijuana has been associated with several adverse pregnancy outcomes, including:

•  Central Nervous System Effects: It has been shown to disrupt normal brain development and function. Animal models demonstrate that endocannabinoids play key roles in normal fetal brain development, including in neurotransmitter systems, and neuronal proliferation, migration, differentiation, and survival. Human fetuses exhibit central nervous system cannabinoid receptor type 1 as early as 14 weeks of gestation, with increasing receptor density with advancing gestational age, which suggests a role for endocannabinoids in normal human brain development;
• A Hungarian study just published this month on Biological Psychiatry points out to the correlation of prenatal marijuana exposure and the neuropsychiatric outcome in the offspring. They reviewed data from human and experimental studies to show that long-term and heavy cannabis use during pregnancy can impair brain maturation and predispose the offspring to neurodevelopmental disorders.  “Endocannabinoids regulate brain development via modulating neural proliferation, migration, and the differentiation of lineage-committed cells. In the fetal nervous system, endocannabinoid-sensing receptors and the enzymatic machinery of endocannabinoid metabolism exhibit a cellular distribution map different from that in the adult, implying distinct functions”.
•  This Dutch study emphasizes that, “Besides its well-known involvement in specific brain functions, such as control of movement, memory and emotions, the endocannabinoid system plays an important role in fundamental developmental processes such as cell proliferation, migration and differentiation. For this reason, changes in its activity during stages of high neuronal plasticity, such as the perinatal and the adolescent period, can have long-lasting neurobehavioral consequences”.
• It has repeatedly been correlated with impaired cognition and increased sensitivity to drugs of abuse; (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3988557/)
• The National Institute on Drug Abuse emphasizes that “human studies have shown that some babies born to women who used marijuana during their pregnancies respond differently to visual stimuli, tremble more, and have a high-pitched cry, which could indicate problems with neurological development. In school, children prenatally exposed to marijuana are more likely to show gaps in problem-solving skills, memory, and the ability to remain attentive. Establishing marijuana’s effects on prenatal development is important, because roughly half of U.S. pregnancies are unplanned, with the rate considerably higher for teens and young adults, so many women may use marijuana without knowing they are pregnant. Furthermore, breastfeeding mothers are cautioned that some research suggests that THC is excreted into breast milk in moderate amounts. Researchers do not yet know what this means for the baby developing brains”.
• Women who use cannabis are more likely to experience intimate partner violence; (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3686908/)
• Children who were exposed to marijuana in utero had lower scores on tests of visual problem solving, visual-motor coordination, and visual analysis than children who were not exposed to marijuana in utero (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2975798/ and http://www.ncbi.nlm.nih.gov/pubmed/8727237);
• It is associated with decreased attention span and behavioral problems and is an independent predictor of marijuana use by age 14 years (http://www.ncbi.nlm.nih.gov/pubmed/16911731, http://www.ncbi.nlm.nih.gov/pubmed/10840176, http://www.ncbi.nlm.nih.gov/pubmed/1469105); and
•  Poorer reading and spelling scores and lower teacher-perceived school performance (http://www.ncbi.nlm.nih.gov/pubmed/15203174).
• At least one study showed that THC was significantly associated with stillbirth (odds ratio 2.34, 95% CI, 1.13–4.81), though this finding was somewhat confounded by the effect of cigarette smoking. It has also been shown to increase the risk of intrauterine growth restriction and low birth weight.

In light of all the evidence above, The American College of Obstetricians and Gynecologists (ACOG) issued an official recommendation in 2015 advising ob-gyns to urge their patients who are pregnant or contemplating pregnancy to discontinue marijuana use.

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Recommendations

The American College of Obstetricians and Gynecologists recommends the following:

• Before pregnancy and in early pregnancy, all women should be asked about their use of tobacco, alcohol, and other drugs, including marijuana and other medications used for nonmedical reasons.
• Women reporting marijuana use should be counseled about concerns regarding potential adverse health consequences of continued use during pregnancy.
• Women who are pregnant or contemplating pregnancy should be encouraged to discontinue marijuana use.
• Pregnant women or women contemplating pregnancy should be encouraged to discontinue use of marijuana for medicinal purposes in favor of an alternative therapy for which there are better pregnancy-specific safety data.
• There are insufficient data to evaluate the effects of marijuana use on infants during lactation and breastfeeding, and in the absence of such data, marijuana use is discouraged.

“It is important to emphasize that the purpose of screening is to allow treatment of the woman’s substance use, not to punish or prosecute her. Seeking obstetric–gynecologic care should not expose a woman to criminal or civil penalties for marijuana use, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing. Addiction is a chronic, relapsing biological and behavioral disorder with genetic components, and marijuana use is addictive in some individuals. Drug enforcement policies that deter women from seeking prenatal care are contrary to the welfare of the mother and fetus”, ACOG concludes.

DON'T Pump and Dump!

Few things can be more painful for a mother than to discard her precious liquid gold. Successful breastfeeding often requires a great level of commitment and dedication, and seeing a woman throw away the product of that effort after a drink or two is really disturbing given the evidence that, in the great majority of cases, she wouldn’t need to do it. Current research says that occasional use of alcohol (1-2 drinks) does not appear to be harmful to the nursing baby. As long as the mother feels neurologically normal, the concentration of alcohol in breast milk is negligible. “That means if you are sober enough to drive, you are sober enough to breastfeed”, according to this article.

Sometimes a new mother finds herself in a situation where she may want to drink: it can be a date night (they’re so common in the postpartum period, right?), a wedding, or just to see how beer or wine tastes after 40 weeks of abstinence. While the harmful consequences of alcohol in pregnancy are well-established (the current recommendation is to completely avoid alcohol during pregnancy), its consumption in lactation remains unclear and women continue to receive very conflicting advice on it.

The American Academy of Pediatrics places emphasis on increasing breastfeeding in the United States and their Committee on Drugs considers alcohol compatible with breastfeeding.

The concentration of alcohol in the breast milk equilibrates with the mother’s blood concentration; it does not accumulate (it is not "trapped") in the milk. Pumping and dumping breast milk doesn't speed the elimination of alcohol from your body.

It is wise to avoid breast-feeding until alcohol has completely cleared your breast milk, which typically takes two to three hours for 12 ounces (355 milliliters) of 5 percent beer, 5 ounces (148 milliliters) of 11 percent wine or 1.5 ounces (44 milliliters) of 40 percent liquor, depending on your body weight.

The American Academy of Pediatrics Section on Breastfeeding notes: “ingestion of alcoholic beverages should be minimized and limited to an occasional intake but no more than 0.5 g alcohol per kg body weight, which for a 60 kg mother is approximately 2 oz liquor, 8 oz wine, or 2 beers. Nursing should take place 2 hours or longer after the alcohol intake to minimize its concentration in the ingested milk.”

Factors that influence alcohol metabolism and its concentration in the milk are:

• Your baby's age
• A newborn has an immature liver, and will be more affected by alcohol
• Up until around 3 months of age, infants metabolize alcohol at about half the rate of adults
• An older baby can metabolize alcohol more quickly than a young infant
• Your weight
• A person's size has an impact on how quickly they metabolize alcohol
• A heavier person can metabolize alcohol more quickly than a lighter person
• Amount of alcohol
• The effect of alcohol on the baby is directly related to the amount of alcohol that is consumed
• The more alcohol consumed, the longer it takes to clear the mother's body
• Will you be eating
• An alcoholic drink consumed with food decreases absorption

(source: http://www.llli.org/faq/alcohol.html)

Note that we’re talking about the occasional social drinker (i.e., 1-2 drinks on special occasions). Chronic and heavy consumption of alcohol has been shown to cause impairment on motor and cognitive development, weight gain/failure to thrive and sleep patterns. References here. 

Substantial consume may cause drowsiness, sleep irregularities, weakness and decreased growth in the infant. Very importantly, the effects of alcohol may impair judgement and affect the ability of the mother care for her child and to be aware of her baby’s needs, whether she is breastfeeding or not. If you drink heavily, it is safest to arrange for extra supervision for your baby and it may be best not to breastfeed.

Also, the popular idea that alcohol improves milk production is a myth. Studies show that alcohol actually decreases milk production and that the presence of alcohol in breast milk causes babies to drink about 20 percent less breast milk (Mennella & Beauchamp 1991, 1993; Mennella 1997, 1999) or inhibit let-down (Coiro et al 1992; Cobo 1974). 

(For a complete of the amount of drugs that are transferred into human milk please read: http://pediatrics.aappublications.org/content/pediatrics/108/3/776.full.pdf)

Dr. Jack Newman, member of the LLLI Health Advisory Council, says this in his handout "More Breastfeeding Myths":

“Reasonable alcohol intake should not be discouraged at all. As is the case with most drugs, very little alcohol comes out in the milk. The mother can take some alcohol and continue breastfeeding as she normally does. Prohibiting alcohol is another way we make life unnecessarily restrictive for nursing mothers.”

In summary: "As alcohol leaves the bloodstream, it leaves the breast milk. Pumping and dumping will not remove it. Pumping and dumping, drinking a lot of water, resting, or drinking coffee will not speed up the rate of the elimination of alcohol from your body".

Mothers who are intoxicated should not breastfeed until they are completely sober, at which time most of the alcohol will have left the mother's blood (which may take up to three hours). Drinking to the point of intoxication,binge drinking, or drinking daily has not been adequately studied and is not advised in concurrence with breast feeding.