Why Depression is Not Like Diabetes

At the recent gubernatorial candidates forum on mental health, Martha Coakley repeated the oft-heard phrase that depression is like diabetes. Her motivation was good, the idea being to reduce the stigma of mental illness, and to offer "parity" or equal insurance coverage, for mental and physical illness. However, I am concerned that this phrase, and its companion, "ADHD is like diabetes," will, in fact, have the exact opposite effect.

A recent New York Times op ed, The Trouble with Brain Science, helped me to put my finger on what is troubling about these statements. Psychologist Gary Marcus identifies the need for a bridge between neuroscience and psychology that does not currently exist.

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. The above analogies disregard the intimate intertwining of brain and mind. For the pancreas, there is no corresponding "mind" that exists in the realm of feelings and relationships.

While there is some emerging evidence of the brain structures involved in the collection of symptoms named by the DSM (Diagnostic and Statistical Manual of Mental Disorders,) there are no known biological processes corresponding to depression, ADHD or any other diagnosis in the DSM. There is, however, a wealth of new evidence showing how brain structure and function changes in relationships.

These collections of symptoms, intimately intertwined with feelings and relationships, are problems of behavioral and emotional regulation. The capacity for emotional regulation develops in relationships.  If DSM diagnoses can only be legitimized by comparing them to diabetes-and food allergies, as was recently done by the director of the NIMH (National Institute for Mental Health)- this comparison may increase, rather than decrease the stigma by de-valuing relationships and our basic human need for meaningful connection.

The primary treatment for diabetes is a drug. This analogy works if we accept that the primary treatment for mental illness is drugs. The pharmaceutical industry must be pleased with this approach.

But, in fact, the primary treatment for problems of emotional well-being is time. What is needed is time and space for listening, where individuals can have the opportunity to have their feelings recognized and understood. In this time and space, people can make sense of, and find meaning in, their experience.

A model that compares depression to diabetes is an illness model. It promotes a kind of "there is something wrong with you and I will fix it" approach.   It is not simply a question of "therapy vs. medication" as many "evidence based" research studies suggest. It is a question of a completely different model, a resilience model. Such a model, that values time and space for listening and being heard, seeks to help people re-connect with their most competent selves.

But we will only get there if we stop comparing depression to diabetes.

Postpartum Depression Rx Links Mothers Day and Childrens Mental Health Month

On Sunday we celebrate mothers- bringing breakfast in bed, going out to dinner, buying flowers. In my personal experience, one of the greatest pleasures of Mother's Day, in addition to having the "day off," is to take joy in my beautiful children as they grow and develop and make their way out into the world.

D. W. Winnicott, pediatrician turned psychoanalyst, famously said, "There is no such thing as a baby." What he meant  is that one cannot fully understand a baby without considering the relationship with the mother. Equally true is that without a child, there is no such thing as a mother. In order to understand a mother's experience, it important to consider the child and what he or she brings to the relationship.

I have been thinking about this a lot as I participate in the important work of Representative Ellen Story's Postpartum Depression(PPD) commission. Rep. Story originally filed a bill that mandated universal PPD screening in multiple settings (OB and pediatric), but it was amended to a law that calls on the Department of Public Health to issue regulations on best practices for PPD screening. The law also created the Commission, whose  job is to help DPH in its work to come up with a proposal for what the state should do on PPD. 

I think this was a good plan. Universal screening is important. Liz Friedman, program director at MotherWoman, an Amherst based non-profit that was instrumental in he bill's passage, addresses the issue in a recent article.

Friedman continues to believe in the crucial importance of screening all new mothers, rather than screening only those whom doctors suspect might be struggling—a practice that runs the risk of "profiling" women who might seem distressed while overlooking others who are suffering but don't show it as obviously. 

However, without a carefully thought through way to provide treatment for women with PPD, universal screening is meaningless. One excellent model of care, the Community-based Perinatal Support Model, developed by MotherWoman, has been implemented in Franklin county with great success, is currently being implemented in Berkshire and Hampshire counties. It will likely be the basis of the recommendations to the DPH. 

The Community-based Perinatal Support Model (CPSM) has been developed to address the gap between screening and services for mothers. CPSM aims to prevent, identify and facilitate treatment of PMD (perinatal mood disorders) by creating a comprehensive, community-based, multi-disciplinary safety net for women.

Winnicott again is helpful in understanding why such a model would be effective. He coined the phrase 'the holding environment" to describe the way in which a mother, by being present both physically and emotionally with her baby, helps him to manage and contain intense feelings.  Quoting Winnicott: 

It will be observed that though at first we were talking about very simple things, we were also talking about matters that have vital importance, matters that concern the laying down of the foundations for mental health

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The phrase "holding environment" has been used to describe other caregiving relationships, such as a therapist-patient relationship. In the CPS model, a network of people, including nurses, primary care clinicians, mental health professionals, and other parents in the group setting, provides a "holding environment" for mothers who are struggling emotionally in these early months with their baby. 

What makes postpartum depression different from other forms of depression is that it occurs in the setting of responsibility for a new life-with a person who is completely dependent, and brings his or her unique qualities to the relationship.  To fully hold the mother's experience, it is important to recognize the baby's contribution. For example, when a baby is born with difficulties settling to sleep, or  is not naturally cuddly, it will have significant impact on the mother's emotional experience. Sleep deprivation and feelings of inadequacy may compound an existing depression. In turn, the mother's state of mind, particularly if she is preoccupied with her own distress, may impair her ability to help the baby to contain and manage his experience. A recent study showing that mother's struggling with anxiety and depression often wake their babies at night offers an example of how a mother's emotional state may affect her child's development. 

How fitting that Mother's Day occurs in the middle of Children's Mental Health Awareness Month. The work of Representative Story and the PPD commission is a tribute to both.  When we as a society attend to the emotional needs of new mothers, we help them to emerge from pain and suffering to take joy in their children.  This not only promotes their children's healthy development, but it makes for a really great Mother's Day!!

Pregnancy Loss and Postpartum Depression

Lately, following conversations with colleagues and patients, I have been doing a lot of thinking about pregnancy loss. In particular I've been wondering about its effect on subsequent term pregnancies, and relationships between parents and these children. In researching this subject, I came upon a study from 2011 in the British Journal of Psychiatry showing that depression and anxiety following a miscarriage may last for almost three years, even after the birth of a healthy baby. Researcher Emma Robertson Blackmore, PhD, an assistant professor of psychiatry at the University of Rochester Medical Center said of the study:

Health providers and women themselves think that once they have a healthy baby after a loss, all would be fine and that any anxiety, fears, or depression would go away, but that is simply not the case. I honestly thought that once a woman had a baby or had gone past the stage of her previous loss, the anxiety and depression would go away, but these feelings persist.

As a culture we often do not recognize the deep significance and impact of pregnancy loss. I still vividly recall my own family's well meaning reassurances of "don't worry you'll get pregnant again," that seemed so remote from the pain I felt following an early miscarriage.

In my work as a behavioral pediatrician, I frequently hear stories (identifying details, as always, have been changed to protect privacy) from mothers who have not had the opportunity to mourn the loss of a pregnancy. One mother told me about of having lost a baby at term and then suffering with severe postpartum depression (PPD) when her healthy child was born a year later. A five-year-old girl I saw struggled with severe separation anxiety. At first the focus of our work was on what to do to get her to sleep in her own room. But as we got to know each other, her mother, for the first time, spoke openly about her grief over a miscarriage when her daughter, an only child, was three. The little girl, it turned out, was worried about her mother. At the root of her separation anxiety was a wish to to protect her mother from feeling sad.

Mental health professionals who work with adults describe the phenomenon of the "replacement baby." These are adults who were born following the death of a previous child. When parents have not spoken of this child, or have not been able to fully grieve this loss, it may have significant long-term effects on the mental health of subsequent children. These effects may, in fact, persist for generations. One mother I worked with was such a "replacement baby." Her older brother had died at birth several years before she was born. When I saw this family, her son was 8 years old and the whole family was struggling. Separation anxiety was again the presenting problem. The marriage was strained because this mother had such an intensely close relationship with her son that her husband felt excluded. I learned that this son was named after her dead brother.

Interestingly, when I googled "pregnancy loss and postpartum depression" most of what I found asked if women could have postpartum depression following pregnancy loss. I think that both in terms of how we understand and how we treatment of these problems, it is important to think of them as two distinct and different phenomena.

Certainly a woman may slide from grief into depression following the loss of a baby. This may occur if the loss triggers memories of other losses, if she does not have an adequate support system, or there are other significant stressors in her life. But postpartum depression, as I describe in my previous post, is specifically a problem in a relationship. Untreated PPD often has significant long-term sequelae for the baby. Treatment of pregnancy loss focuses on the mother, while treatment of PPD needs to include the baby from the beginning.

What can we learn from these stories? As Massachusetts is currently working to address the issue of postpartum depession via the PPD commission, one very concrete we can do is to identify mothers who have had previous pregnancy loss, and especially those with multiple pregnancy losses and/or a stillbirth, as being at high risk for developing PPD. We can make sure that these mothers do not "fall through the cracks." One mother poignantly told me that because of a change in health insurance plans when her child was an infant, she was forced to give up the relationships with her health care providers that were very important to her, just at a time when she was most vulnerable.

Even before that, friends, family members, religious organizations and health care providers can be attuned to the nature of the trauma of pregnancy loss. Women themselves need to feel the right, and be given the space, to grieve a pregnancy loss. While the effects of such a loss can linger in any circumstances, it is unacknowledged and unprocessed grief that has to potential to have the tightest grip on people for years to come.