What the Lindsay Clancy case can teach us about how we treat postpartum depression
The nation’s eyes were riveted last week on the trial of Lindsay Clancy, the killer of her three young children. It was rendered a mistrial after the jury deadlocked, as if the justice system itself were overmatched by the very monstrosity of the crime.
The trial highlighted the issue of postpartum syndrome, a pervasive and poorly understood condition. It comes in two shades: postpartum depression, which is exceedingly common, afflicting an estimated 13-19% of pregnancies in the U.S.—460,000 mothers annually.
Then there’s postpartum psychosis, which was invoked by the Clancy defense, that affects 0.1-0.2% of live births in the U.S.—only one or two in a thousand.
Symptoms of postpartum depression—crossing the line from mere so-called “baby blues” lasting a few days—include prolonged mood swings, crying spells, anxiety, difficulty sleeping, and a feeling of being overwhelmed. Frequently, new mothers who experience postpartum depression suffer intense irritability and anger, fear that they’re not a good mother, hopelessness, feelings of worthlessness, shame, guilt or inadequacy, and reduced ability to think clearly, concentrate, or make decisions.
This can exact a toll on spouses and family members and has been shown to have deleterious long-term consequences for the newborn. While it impedes maternal nurturing, it rarely results in actual physical harm to infants.
But psychosis is different. While profound depression is one of its hallmarks, it crosses over into extreme confusion and anxiety, delusions—sometimes of a paranoid nature—and auditory and visual hallucinations. Sufferers may manifest mania or delirium. Self-harm and suicide are common; postpartum psychosis accounted for 38% of maternal suicides in the UK.
Rarer still are instances where women with postpartum psychosis harm their kids, but the condition heightens the risk to offspring.
The antecedents of postpartum syndromes include a history of mental illness, but fully half of women with postpartum conditions have no prior history of depression or bipolar disorder. Social factors impact the risk: lack of familial support, having additional young children to care for, stress, and poverty. C-sections, delivery complications, and inability to breast feed make postpartum depression more likely.
Hormone hell!
The biological underpinnings of postpartum syndromes are beginning to be better understood. Chief among them are the enormous fluctuations in female hormones that accompany delivery: estrogen and progesterone which are sky-high during pregnancy, and often produce feelings of wellbeing, drop precipitously. These impact “feel-good” neurotransmitters like GABA (progesterone) and serotonin (estrogen).
The thyroid is also whip-sawed by the abrupt transition to motherhood. Up to 23% of new mothers experience postpartum thyroid changes, with thyroiditis contributing to anxiety, or hypothyroidism causing depression or fatigue. Hence the need for careful monitoring of thyroid status in the postpartum period.
Novel drug
A breakthrough in understanding postpartum syndromes has arrived with our new appreciation of how hormones act as neurosteroids, influencing brain function. Allopregnanolone, a byproduct of progesterone, acts as a potent buffer to stress. Until recently, it had to be administered via IV, limiting its practicality, but a new oral version (Zuranolone) has been approved by the FDA specifically for treatment of postpartum depression.
This comes closer to a “root cause” biological treatment of postpartum syndromes, which are traditionally managed with psychotherapy and a mix of antidepressants or bipolar medications—treatments which apparently fell tragically short in Lindsay Clancy’s case.
A witches’ brew?
It may also be the case—impossible to know without disclosure of the cocktail of psychiatric meds Clancy was given—that her very treatment triggered a psychotic break. Well-known to psychiatrists is the phenomenon of “manic switching”—what happens when a patient with underlying bipolar tendencies is inappropriately given an SSRI antidepressant, without a mood stabilizer like lithium or an antipsychotic, when they’re mistakenly thought to have just garden-variety depression.
That can flip them into full-blown mania, or rapid mood-cycling, with increased risk for impulsive behavior, self-harm or violence.
Natural treatments
But what of diet and supplements? Is there any evidence they can be deployed to treat or prevent postpartum syndromes?
The answer appears to be yes. The first clue comes from research linking diets replete with ultra-processed foods (UPF) to greater likelihood of postpartum depression. In the first study of its kind, Greek researchers concluded that a higher prevalence of depressive symptoms was observed among women in the highest UPF intake quartile (40.0%) compared with lower quartiles (25.7-28.1%).
The correlation could be due to the pro-inflammatory effects of UPFs, thought to increase brain inflammation, deleterious impacts on the microbiome which affect the gut-brain axis, disruption of blood sugar control by an onslaught of refined carbohydrates, and/or inadequacy of crucial nutrients—or simply the acknowledged toll of metabolic dysfunction on brain energetics.
Indeed, in an article entitled “Depression as a disease of modernity: explanations for increasing prevalence”, researchers asserted:
“Mental and physical well-being are intimately related. The growing burden of chronic diseases, which arise from an evolutionary mismatch between past human environments and modern-day living, may be central to rising rates of depression . . . Modern populations are increasingly overfed, malnourished, sedentary, sunlight-deficient, sleep-deprived, and socially-isolated. These changes in lifestyle each contribute to poor physical health and affect the incidence and treatment of depression.”
The vitamin D connection
Other studies have looked at the roles played by specific nutrients in preventing postpartum syndromes. Chief among them is vitamin D.
In a review exploring the association between vitamin D levels and postpartum depression, researchers found that a majority of studies confirmed a link with vitamin D deficiency.
They explain that the connection to vitamin D is biologically plausible:
“Neurotransmitters involved in the process of depression are mainly dopamine and norepinephrine. The synthesis of dopamine and norepinephrine is influenced by the role of the essential enzyme Tyrosine Hydroxylase in their gene expression, which is influenced by vitamin D. Vitamin D stimulates receptors in the limbic system, cortex, and cerebellum, which are associated with emotion and behavior regulation . . . vitamin D is a powerful modulator of the expression of neurotrophic agents such as nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and neurotrophin (NT)-3 . . . It is underlined that neurogenesis and neurons that release neurotransmitters play crucial roles in depression and that vitamin D is crucial for supporting the health of neurons.”
Despite this promising association, it’s worth noting that to date no clinical trials of vitamin D administration have been undertaken in postpartum syndromes.
Omega-3s
A recent review article examined the premise that “Mechanistically, omega-3 polyunsaturated fatty acids (PUFAs) exert anti-inflammatory, neuroprotective, and mood-regulating effects, potentially mitigating PPD risk factors.”
It references previous studies and, while conceding more research with better designed trials is required, concludes that:
“Omega-3 PUFAs have emerged as a promising adjunctive therapy for PPD, with evidence suggesting a potential role in reducing depression risk and improving maternal mental health outcomes. Mechanistically, omega-3 PUFAs modulate inflammation, neurotransmitter function, brain structure, oxidative stress, and gene expression pathways implicated in depression pathophysiology.”
B vitamins
There’s also tantalizing evidence that B vitamins may play a role in ameliorating symptoms of postpartum depression. One randomized controlled trial found that 80 milligrams of B6 given daily during pregnancy improved mood during and after pregnancy.
Some comparative studies have shown that supplementation with riboflavin (B2) can reduce the risk of postpartum depression; undeniably, insufficiency of folate or B12 can undermine mood because these B vitamins are essential for neurotransmitter synthesis. Methylated folate (Cerefolin) is even sometimes used to boost the efficacy of antidepressants.
Lifestyle factors
Of course, poor sleep quality and lack of exercise, too, are among modifiable risk factors for postpartum depression. One study found that pregnant individuals who met physical activity guidelines during pregnancy had up to 45% lower odds of depression at six months postpartum than individuals who never met physical activity guidelines during pregnancy.
One can only hope . . .
If any good comes out of the sordid media feeding frenzy around the Lindsay Clancy tragedy, hopefully it will focus our attention on finding better ways to prevent and treat her debilitating affliction.