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Friday, October 17, 2014

Depression in new mothers

“The message that a lot of moms hear from families and friends and even professionals who may not know much about perinatal depression is ‘be tough and fight your way through it’ — and they don’t seek help.” — Robert Ammerman, Cincinnati Children’s Hospital Medical Center

IN JULY I published a Hey Look post called Not All Unicorns and Rainbows that was really just a sharing of The New York Times article The Trauma of Parenthood which discussed the elevated rate of depression among new mothers — as high as 42%, according to a 2010 Journal of the American Medical Association, and I received some surprising push-back.

One respondent seemed to feel that the person who wrote the article was whiny, and my sharing of the piece enabling and indulgent. I felt chastised. 

Yesterday, however, one of my favorite authors, David Bornstein, of one of my favorite regular NYT periodic features called Fixes, weighed in on the same subject in a much longer and detailed form, and I feel validated and vindicated. 

It's a long read, but I encourage you to do so.






FIXES
Treating Depression Before It Becomes Postpartum
By David Bornstein
October 16, 2014 

Shortly after the birth of her daughter, Andrea became severely depressed. She was 17 at the time and she didn’t fully understand what she was going through; she just felt like a failure. “I felt like I didn’t want to be alive,” she recalls. “I felt like I didn’t deserve to be alive. I felt like a bad person and a bad mother, and I was never going to get any better.”

When her baby persisted in crying, she felt her frustration mount quickly. “I was hitting a boiling point,” she says. “I was at a point where I didn’t want to deal with anything. Sometimes I would just let her cry — but then I would feel very bad afterwards.”

Depression is the most common health problem women face. In the United States, outside of obstetrics, it is the leading cause of hospitalizations among women ages 15 to 44. It’s estimated that 20 percent to 25 percent of women will experience depression during their lifetimes, and about one in seven will experience postpartum depression. For low-income women, the rates are about twice as high. As my colleague Tina Rosenberg has reported, the World Health Organization ranks depression as the most burdensome of all health conditions affecting women (as measured by lost years of productive life).

Postpartum depressions are often assumed to be associated with hormonal changes in women. In fact, only a small fraction of them are hormonally based, said Cindy-Lee Dennis, a professor at the University of Toronto and a senior scientist at Women’s College Research Institute, who holds a Canada Research Chair in Perinatal Community Health.

The misconception is itself a major obstacle, she adds. Postpartum depression is often not an isolated form of depression; nor is it typical. “We now consider depression to be a chronic condition,” Dennis says. “It reoccurs in approximately 30 to 50 percent of individuals. And a significant proportion of postpartum depression starts during the pregnancy but is not detected or treated to remission. We need to identify symptoms as early as possible, ideally long before birth.”

The major predictors include previous incidents of depression, as well as a woman’s past and current life stresses, like childhood trauma or abuse, conflicts with a partner or family members, lack of social support or coping skills, and poverty.

Only about 20 percent to 30 percent of women who experience postpartum depression in the United States get proper treatment, and for low-income mothers, the rate is considerably lower, says Robert T. Ammerman, a professor of pediatrics at Cincinnati Children’s Hospital Medical Center who is the scientific director of Every Child Succeeds, a home visiting program for vulnerable first-time mothers.

The consequences for both mother and child can be devastating. If left untreated, postpartum depression can develop into severe clinical depression. In addition to feeling listless, anxious, guilty, lonely and frequently suicidal, mothers who are clinically depressed in pregnancy are three to four times more likely to have a premature delivery or deliver a low-birth-weight baby (both predictors of serious developmental and medical problems for the child) and, just as urgent, less likely to form healthy attachments with their children. Their children are more likely to have attention deficits, difficulties controlling their emotions and behavior, language delays and lower I.Q.s — and they are themselves at increased risk of becoming depressed later in life.

“We have this idea that during motherhood struggling with emotional issues is normal,” Ammerman says. “The message that a lot of moms hear from families and friends and even professionals who may not know much about perinatal depression is ‘be tough and fight your way through it’ — and they don’t seek help.”

Ammerman says that while it’s true that many mothers have or develop depression, it’s not a normal or typical response to the challenges of parenting. There are effective treatments. They include medication as well as a range of therapies – like cognitive behavioral therapy (C.B.T.), which helps people learn how to counter negative thoughts and their associated emotions, and interpersonal psychotherapy (I.P.T.), which focuses on improving the quality of personal relationships and the satisfaction that is gained from them. About a third of women who get treated for chronic or recurrent depression achieve remission, and more than half see an improvement in their symptoms.

Today, several states, including Illinois, New Jersey, West Virginia and Washington, have initiated mandatory screening for perinatal depression (something that is done nationally in Australia). But inadequate screening is only part of the problem. Cost and access barriers and stigmatization – and an overall lack of awareness among health professionals – are what prevent most mothers who need help from getting it. Many primary care doctors fail to recognize when their patients are depressed. And when they do, they often don’t know how to provide the most effective treatments. They also can’t ensure that patients will follow up with mental health professionals (many of whom do not accept Medicaid). And communication between doctors is notoriously problematic.

“When people are referred to mental health professionals from primary care settings, the vast majority of the referral slips go into the garbage,” says Katherine L. Wisner, director of the Asher Center for the Study and Treatment of Depressive Disorders at Northwestern University.

Given the scope of the problem, new outreach and treatment models are urgently needed. The three that I’m highlighting today are in early stages of development, but they are noteworthy because they demonstrate promise and illustrate pathways for potentially broader system changes.

The first is a collaborative care model called DAWN being pioneered at two urban obstetrics and gynecology (ob-gyn) clinics that are part of the University of Washington system. The innovation here is that mental health care is being integrated directly into ob-gyn care. Why is this such an important idea? About a third of women in the country see their ob-gyn physicians for their primary care, explains Wayne Katon, vice chair of the department of psychiatry and behavioral sciences at the University of Washington School of Medicine. When depression screening and treatment are handled in the same place as primary care, it’s more likely that women will get effective help.

Through the DAWN program, when a woman comes in for care, she is screened for depression using a standard questionnaire known as PHQ-9. If her score indicates a likelihood of major depression, she is assigned a care manager who is trained to educate her about depression, explore real or perceived barriers in her life and motivate her to pursue treatment.

It’s important that treatments are designed to fit with a patient’s preferences. “They’re given the choice to start with a form of therapy or an antidepressant,” Katon says. “Some say, ‘I’m pregnant, I’d rather not be on medication.’ Some want to take medication.” They can also choose in-person visits or telephone consultations. Physician-supervised care managers follow up regularly for a year, tracking patients’ progress. If their symptoms persist, they adjust or increase the intensity of treatment.

In two studies published this year, women experienced significant improvements in depressive symptoms. The gains were particularly notable among women who were uninsured or received public insurance, such as Medicaid. “The women were more satisfied with the care they got and the ob-gyn doctors were more satisfied because their patients got better,” Katon adds.

The second model was developed by Every Child Succeeds, a home visiting program for vulnerable first-time mothers based out of the Cincinnati Children’s Hospital Medical Center. In recent years, as I have reported in this column, home visiting programs have spread across the country as a result of a $1.5 billion appropriation in the Affordable Care Act. This summer, a study of families served by the Nurse-Family Partnership found, remarkably, that the mothers and children assisted by the program had significantly lower death rates over a 20-year period.

But home visiting programs have one notable limitation. As recent research indicates, when mothers are clinically depressed, they don’t benefit as much from the visits. “A mother who is depressed has very little to give her child,” said Judith B. Van Ginkel, the founder of Every Child Succeeds, which has worked with 22,000 families. “We found that half of the mothers we were working with were depressed, and three-quarters had witnessed or been victims of violence.”

With the leadership of Robert Ammerman and others, Every Child Succeeds has developed a program called Moving Beyond Depression, to train therapists to deliver C.B.T. in conjunction with home visitation.


This is how Andrea was able to receive treatment. Shortly after her home visits started, Andrea, who lives just north of Cincinnati and works in a call center, was asked to fill out a questionnaire. (I have changed her name.) She learned that she was depressed. “I had been in denial,” she said. For months, conflicts with her mother had been getting worse. Her mother suffered from mental illness and depression, had used drugs, and had long counted on, and expected, Andrea to take care of her.

But now Andrea needed every ounce of her strength to care for her baby, and her mother reacted angrily. Over 15 sessions, the therapist helped Andrea develop strategies to manage her feelings and interact with her mother — rather than being thrown repeatedly to anger, negative thoughts and guilt.

Last year, results from a clinical trial funded by the National Institute of Mental Health showed that mothers receiving Moving Beyond Depression’s in-home C.B.T. model experienced subtantial improvements in depressive symptoms and decreased diagnosis of major depressive disorder following treatment relative to a control group. The model has spread to several states, including Connecticut, Massachusetts, Kentucky and Kansas, and has been used to assist 600 mothers.

The third model grows out of Cindy-Lee Dennis’s research in Canada, and is important because it illustrates the potential of treating women through interventions over the phone. It thus reduces one of the biggest barriers low-income or rural women face in accessing treatment: transportation to and from treatment and scheduling appointments.

In one clinical trial, 700 women in the first two weeks after giving birth, who had been identified as being at a high risk of postpartum depression, were given telephone-based peer support from other mothers — volunteers from the community who had previously experienced and recovered from self-reported postpartum depression (and received four hours of training).

“We created a support network for the mothers early in the postpartum period,” Dennis explains. “It cut the risk of depression by 50 percent.” On average, each mother received just eight contacts — calls or messages, and the calls averaged 14 minutes. Over 80 percent of the mothers said they would recommend this support to a friend.

In another clinical trial conducted by Dennis, trained nurses provided interpersonal psychotherapy (I.P.T.) over the phone to 240 clinically depressed mothers across Canada. The calls were scheduled at the mothers’ convenience. The results have not been published yet, but Dennis says the treatment was highly effective. Treatment compliance rates were greater than 85 percent. Dennis is currently working with health officials to pilot test the model in New York City.

“We underestimate very simple interventions,” she says. “We have this huge bias that face to face is the most effective way to provide care. But we have to be innovative about how we offer help to women.”

Andrea, who is now 19, remains grateful for the help she received. “I can actually focus on my daughter and be with her the way I want to be with her, and teach her things,” she says. “I feel like now that I’ve been through the program — and distanced myself from people I needed to — I can focus on what I need to focus on rather than ever

Wednesday, October 15, 2014

Cat in the hat

“Women and cats will do as they please, and men and dogs should relax and get used to the idea.” ― Robert A. Heinlein

I CAN'T help it! I have to post this 25-second video. It's just that incredibly adorable and . . . skilled. I think Paul has a harder time getting into his clothes than this furry-purry!

Monday, October 13, 2014

Why indeed

“I believe that it is better to tell the truth than a lie. I believe it is better to be free than to be a slave. And I believe it is better to know than to be ignorant.” — H. L. Mencken

LAST YEAR one of my Hey Look readers was miffed at me for suggesting that we ditch Columbus Day and replace it with International Nelson Mandela Day. My friend said, "Why insult all those of Italian descent in our country?" 

Okay. I like Italians. One of my most favorite people in all the world was first generation 100% Italian. So I amend my suggestion thusly: change the designation from Columbus Day to Italian Heritage Day (it would have to be downgraded from being a national holiday of course, but then neither is Saint Patrick's Day, and I don't grouse about that) and add International Nelson Mandela Day to the calendar as a national holiday.

There. Problem solved. We no longer celebrate the decimation of the original inhabitants of the Americas, we have the same number of days off (well, the banks, post offices and governmental workers do; the rest of us don't), and we have one additional day to drink to excess: beer on St. Patty's Day and vino on Italian Heritage Day. I expect my call from the State Department with an ambassadorial offer at any moment.

PS: This video is courtesy of my pal, Dale Bert. We don't get whatever channel John Oliver is on (more's the pity), so thanks, Dale, for sharing it with me.


Sunday, October 12, 2014

Non-celiac gluten sensitivity

“Diets, like clothes, should be tailored to you.” — Joan Rivers

I'VE ALLUDED a few times to Paul's gluten intolerance and mentioned that I'd say more about it in the future. I've just come across an excellent explanatory article in The New York Times that has finally prompted me to fulfill my promise.

The morning of what was to be our first day back at work eight years ago after the Christmas and New Year's holiday break, Paul was giving little indication of willingness to get out of bed. When I made sympathetic noises about how hard it always is to go back to work after a nice break, he almost burst into tears and said, "That's not it. I'm just tired of being in pain every day."

I knew that the joints in Paul's feet hurt with increasing frequency, but we both believed it was his genetic legacy since both his mom and sister have had to have joint surgery on their big toes, and Paul had already been to a foot specialist who told him that yes, he'd have to have the same surgery at some point. But the fact that all of his joints hurt so much came as a shock. 

I adore my husband, and I like to at least imagine that I'm attentive to his well-being. How could I not know this? 

Because Paul is not a complainer. He tends to ignore aches and pains and soldier on, and that can be a very double-edged sword. For Paul to reach a point where he was almost in tears meant that he was in tremendous pain. 

I had been suggesting for a couple of years that he fly to Las Vegas to visit a particular clinic that had been highly recommended by a trusted friend who'd had his health rescued there, but Paul demurred over and over again. On this morning, however, he volunteered, "I think I want to go to that clinic you've been telling me about."

And a couple of weeks later he was there. It was the start of a somewhat circuitous process of getting Paul on a path to recovery.

The clinic ran lots of tests and concluded that Paul was allergic to wheat among other things. Although now that we know more, we don't believe he has a wheat allergy, it was a clue that, although seemingly so unrelated, his diet might be the cause of his joint pain.

The next piece of the puzzle came by accident. I was chatting with a friend who mentioned celiac disease in passing. I'd never heard of it, but based on Paul's symptoms — in addition to severe joint pain, he'd also had ongoing diarrhea for about two years — it sounded like celiac might be the explanation.

After reading up on celiac disease, I convinced Paul to go on a gluten-free diet, and his joint pain and diarrhea eased up, but we wanted to make sure we were doing the right thing, so Paul went in for  the celiac disease blood test. 

It came back negative; now we were really confused. 

A more definitive test would have been a biopsy, but in order for it to be accurate, he would have had to start eating wheat and gluten again and continue for at least two weeks, and he didn't want to put himself through that misery. Instead he continued on his more or less gluten-free diet.

After awhile, though, Paul fell off the wagon for an extended period of time. After all, the blood test had come back negative, and maintaining an entirely gluten-free diet involves a lot of discipline, not to mention considerable inconvenience. 

His body had something to say about that, however. The joint pain and the diarrhea were back. 

Paul wisely decided to listen to his body instead of the blood test, and we adopted a rigid gluten-free diet which he continues to maintain.

The reward is that the surgery he thought he was destined to have on his big toes, now seems unnecessary, the intestinal distress is gone and so are the nosebleeds he used to get on a regular basis, and after adhering to a strict diet for some years now, the restless legs problem that used to cause him so much misery has also disappeared.

Despite our success, because our methodology was trial and error, from time to time we've both wondered if we'd cobbled together the right answer. Recent research, however, has proven that there's much more to the whole gluten issue than a simple yes or no to celiac disease.

This article from The New York Times has clarified much to us and validated our decisions. It's the second of two articles. I'll share the first one in a few days and yet another article I've found a few days after that because I believe understanding celiac disease and non-celiac gluten sensitivity may help many people be healthier. Maybe you.





When Gluten Sensitivity Isn’t Celiac Disease
By Jane E. Brody  
OctoberR 6, 2014

My nephew, sister-in-law and several others I know are on gluten-free diets, helping to support a market for these foods that is expected to reach $15 billion in annual sales by 2016.

Supermarket shelves are now packed with foods labeled gluten-free (including some, like peanut and almond butter, that naturally lack gluten). Chefs, too, have joined the cause: Many high-end restaurants and even pizza parlors now offer gluten-free dishes.

Those who say they react to gluten, a protein in wheat and other grains, report symptoms like abdominal pain; bloating; gas; diarrhea; headache; fatigue; joint pain; foggy mind; numbness in the legs, arms or fingers; and balance problems after eating a gluten-rich food.

I suspected at first that the gluten-free craze was an attempt by some to find a physical explanation for emotional problems, similar to the “epidemic” of hypoglycemia in decades past. But a growing body of research indicates that many may be suffering a real condition called non-celiac gluten sensitivity, or NCGS.

It is not celiac disease, a far less common autoimmune condition that can destroy the small intestine. Indeed, no one has conclusively identified a physical explanation for gluten sensitivity and its array of symptoms.

Recent studies have strongly suggested that many, and possibly most, people who react badly to gluten may have a more challenging problem: sensitivity to a long list of foods containing certain carbohydrates.

In 2011, Dr. Peter Gibson, a gastroenterologist at Monash University in Victoria, Australia, and his colleagues studied 34 people with irritable bowel syndrome who did not have celiac disease but reacted badly to wheat, a gluten-rich grain. The researchers concluded that non-celiac gluten sensitivity “may exist.”

Many of their subjects still had symptoms on a gluten-free diet, however, which prompted a second study of 37 patients with irritable bowel syndrome and non-celiac gluten sensitivity who were randomly assigned to a two-week diet low in certain carbohydrates, collectively called Fodmaps.

All patients on the special diet improved, but got significantly worse when fed gluten or whey protein. Only 8 percent of the participants reacted specifically to gluten, prompting the researchers to conclude that Fodmaps, not gluten, accounted for most of the distress.

Fodmaps is an acronym for fermentable oligosaccharides, disaccharides, monosaccharides and polyols, sugars that draw water into the intestinal tract. They may be poorly digested or absorbed, and become fodder for colonic bacteria that produce gas and can cause abdominal distress. They are:

■ Fructose: A sugar prominent in apples, pears, watermelon, mangoes, grapes, blueberries, tomatoes and tomato concentrate, and all dried fruits; vegetables like sugar-snap peas, sweet peppers and pickles; honey; agave; and jams, dressings and drinks made with high-fructose corn syrup.

■ Lactose: The sugar in milk from cows, goats and sheep, present in ice cream, soft cheeses, sour cream and custard.

■ Fructans: Soluble fiber found in bananas, garlic, onions, leeks, artichokes, asparagus, beets, wheat and rye.

■ Galactans: Complex sugars prominent in dried peas and beans, soybeans, soy milk, broccoli, cabbage and brussels sprouts.

■ Polyols: The sugar alcohols (sweeteners) isomalt, mannitol, sorbitol and xylitol, present in stone fruits like avocado, cherries, peaches, plums and apricots.

People with irritable bowel syndrome often find that their symptoms lessen or disappear when avoiding foods rich in Fodmaps; however, it can take six to eight weeks on a low-Fodmap diet to see a significant improvement.

Experts advise those patients to eliminate all foods rich in Fodmaps at the start. (You can find a list of foods low in these carbohydrates at stanfordhealthcare.org.) Once symptoms resolve, individual foods are returned to the diet one by one to identify those to which patients react.

So what about patients who think they are sensitive only to gluten?

Dr. Joseph A. Murray, gastroenterologist at the Mayo Clinic and an expert on celiac disease, urges that they first be tested for celiac disease, a condition that has become dramatically more prevalent in recent decades. The signs of gluten sensitivity often mimic those of celiac disease, as well as irritable bowel syndrome.

Tests for celiac disease are less accurate if the diet does not currently include gluten. “Test first, test right,” Dr. Murray said in an interview. “We’re seeing people with symptoms who go on a gluten-free diet, and then we can’t make a correct diagnosis.”

With non-celiac gluten sensitivity, there is no damage to the small intestine, meaning many people may consume small amounts of gluten without incident. A forthcoming book edited by Dr. Murray, “Mayo Clinic Going Gluten Free,” lists the essential requirements for diagnosis of non-celiac gluten sensitivity:

■ Negative blood tests for celiac disease and no sign of damage on an intestinal biopsy.

■ Symptom improvement when gluten is removed from the diet.

■ Recurrence of symptoms when gluten is reintroduced.

■ No other explanation for the symptoms.

It is not yet known if the condition results from an immunological reaction similar to that seen in celiac disease, or whether gluten exerts a chemical or other negative effect on digestion.

Gluten sensitivity is not the same as a wheat allergy, a far less common problem with symptoms like swelling, itching, skin rash, tingling or burning of the mouth, and nasal congestion.

The best way to test for non-celiac gluten sensitivity (after ruling out celiac disease) is to remove all sources of gluten from one’s diet for several weeks. If the symptoms disappear, reintroduce gluten to see if they recur. Another option is to keep a food diary for a few weeks, recording everything you eat and drink and any symptoms that follow.

In addition to the inconvenience and added expense, a gluten-free diet can result in a poor intake of fiber and certain essential nutrients. It may be wise to consult a registered dietitian if you plan to go gluten-free.

Saturday, October 11, 2014

Jenga cat

"If animals could speak, the dog would be a blundering outspoken fellow; but the cat would have the rare grace of never saying a word too much." — Mark Twain

HONESTLY, you have to watch this to believe it.

Wednesday, October 8, 2014

Against-the-odds love story

“Where there is love there is life.” — Mahatma Gandhi

THE STORY of Lori Sousa and Peter Maxmean meeting and a marrying is so heartwarming, that I can't help but share it with you. 

Sunday, October 5, 2014

Hickies

“Women need food, water, and compliments. That's right. And an occasional pair of shoes.” ― Chris Rock

I CAME ACROSS this video for innovative shoe closures called Hickies that I've been meaning to share with you for many months. I'm not shilling for this company. I just think they're really creative and practical, and I mean to get some for Paul because he can never keep his shoes tied. (There's a video at the bottom.)

FYI: I'm not sure about Anaya, but the other three cats all snore. 

(Paul read this after I'd posted it and said, "What does snoring cats have to do with Hickies shoe fasteners?" The answer is "Nothing." A) This blog is, after all, called Hey Look Something Shiny. Does he really expect me to stay on topic? B) I was writing it in bed surrounded by three cats who were all taking turns snoring.)

HICKIES
Elastic Lacing System

Laces Out

Hickies replaces your traditional shoelaces, and turns any pair of lace-up shoes into comfortable slip-ons while keeping them secure on your feet.




As long as your shoe has eyelets, Hickies will fit; each set is adjustable to any shoe size, from kids to adults. Made of a flexible elastic that loosens and contracts with your foot, Hickies have a bit of memory so they keep their shape. They're perfect for just about anyone -- from everyday athletes, business travelers, the elderly and kids who can't yet tie their shoes to style-conscious folks who like their kicks to match their style.