Alprazolam Use Disorder
Helll-ooo people! I hope everyone had a great holiday weekend, maybe bit the head off a big bunny- a chocolate one of course. We’ve been talking about alprazolam, trade name Xanax. Last week I warned you about the dangers of buying it off of the street. If you’ve forgotten why it’s dangerous, it’s because it’s nearly always counterfeit crap made in some moron’s basement with fentanyl and heaven knows what else, and you don’t want that. If you think I have a pretty clear opinion on fake Xanax, or any fake pharmaceutical for that matter, Captain Obvious says you’d be right.
If you read the first blog in this series a couple of weeks ago, you already know that Xanax, generic name alprazolam, is a member of the class of anxiolytic drugs called benzodiazepines, and very commonly prescribed for anxiety and panic disorders- mainly because it’s very effective and works quickly. But it also has serious addiction potential and is a common drug of abuse, and this is something that patients and their families must be aware of up front. With that in mind, this week’s blog will focus on the signs and symptoms of Xanax abuse, and how that progresses to the diagnosis of sedative use disorder, or more specifically Xanax use disorder.
Some people who are prescribed Xanax for anxiety or panic disorders can take their prescribed dose twice a day for years and never experience an issue, unless or until they stop taking it. They become dependent upon it, but only in that their body becomes used to having the drug in their system- it’s not a pathological dependence. Upon stopping it, they’ll still experience withdrawal symptoms, but they don’t develop Xanax use disorder, because their use is quite literally not disordered. Incidentally, I’ll be focusing on withdrawal from Xanax next week. In contrast, far too many people develop a pathological dependence upon Xanax. Even if they have a genuine anxiety disorder and start out taking it only as prescribed, they begin to abuse it by taking too much and/ or too often, and they develop a use disorder, which progresses to what we colloquially call an addiction.
This is a process that generally starts because they begin to develop a tolerance to the drug and require more of it to achieve the desired effect, whether that is to quell their symptoms of anxiety, or to get high. Tolerance is a phenomenon that occurs with many drugs, but it is especially dangerous in a drug like Xanax, as it’s a closed circuit- the more you need, the more you take, and the more you take, the more you need. Ideally, a patient informs their prescribing physician if they feel that their current dose is no longer adequate. But that doesn’t always happen, and patients may choose to increase the dose on their own; and at that point, they’re abusing the drug.
Some of the most common physical signs and symptoms of Xanax abuse include slurred speech, poor motor coordination, confusion, blurred vision, drowsiness, dizziness, difficulty breathing, loss of consciousness, and an inability to reduce intake without symptoms of withdrawal. Beyond the physical symptoms, when a person begins to abuse Xanax, there will likely be noticeable changes in their behavior as well. Some of the most common behavioral signs of Xanax abuse include the following:
-Taking risks in order to buy Xanax: some people may do things they wouldn’t have previously considered in order to obtain it. For instance, they may steal, often from loved ones, in order to pay for Xanax.
-Losing interest in normal activities: as Xanax abuse takes a firmer hold in a person’s life, they commonly lose interest in activities they formerly enjoyed.
-Risk-taking behaviors: as Xanax abuse continues, the person may become more comfortable taking big risks, such as driving while on Xanax.
-Maintaining stashes of Xanax: to ensure that they will not have to go without Xanax, they will attempt to stockpile it.
-Relationship problems: Xanax abuse invariably leads to interpersonal problems and social issues, but this often isn’t enough to motivate the person to stop.
-Obsessive thoughts and actions: the person will spend an inordinate amount of time and energy obtaining and using Xanax. This may include activities like doctor shopping or looking for alternate sources of it, or asking friends, family, and/ or colleagues for it.
-Legal issues: this can be related to illegally obtaining Xanax, being arrested/ incarcerated for drugged driving, or for other disturbances as a consequence of use.
-Solitude and secrecy: when abusing Xanax, it’s very common for people to withdraw from friends and family to protect their use.
-Financial difficulties: to pay for Xanax, a person may drain their financial resources and/ or those of family and friends.
-Denial: this includes setting aside valid concerns about Xanax abuse to protect ongoing use of the drug. For example, minimizing or refusing to recognize the dangers of buying it on the street.
As Xanax abuse progresses, it reaches what most people would term an addiction. But the actual diagnosis recognized in the psych nerd’s bible, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) is termed use disorder. If the person is using Xanax, we call it sedative use disorder or Xanax use disorder, but there is opioid use disorder as well- essentially anything that is abused can fill in the blank. In order for a person to be diagnosed with a sedative use disorder, they must exhibit a certain number of signs and symptoms within a one year period. The more symptoms that are present, the higher the grading the sedative use disorder will receive, and this places the severity of the disorder on a continuum, be it mild, moderate, or severe.
Paraphrased versions of the assessed symptoms of Xanax use disorder are as follows:
-Repeated problems in meeting obligations in the areas of family, work, or school because of Xanax use.
-Spending a significant amount of time acquiring Xanax, using it, or recovering from side effects of use.
-Continued Xanax use despite hazardous circumstances.
-Continued Xanax use despite the complications it causes with social interactions and interpersonal relationships.
-Continued Xanax use despite experiencing one or more negative personal outcomes.
-Using more Xanax or using it for longer than recommended or intended.
-An inability to stop using Xanax despite an ongoing desire to do so.
-Obsessive craving for Xanax.
-Ceasing or reducing participation in work, social, or family affairs due to Xanax use.
-Building tolerance over time, necessitating the use of increasing amounts of Xanax to achieve desired effect.
-Experiencing withdrawal symptoms upon decreasing the dose of Xanax.
These last two signs- building tolerance that requires continual dosage increases, and experiencing withdrawal symptoms when dosage is decreased- are indicative of physical dependence and ultimately addiction. These are natural body processes that occur when the brain and body habituate to drug use over time. Once the body becomes accustomed to having the drug, a sort of new normal is established in its presence. Thereafter, when the drug use stops, the body will issue its demand for more of the drug in the form of withdrawal symptoms. And that’s exactly where we’ll pick up next week.
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The Skinny on Psychostimulants, Part 3: Modafinil
Over the past two weeks, we’ve been discussing the psychostimulants amphetamines and methylphenidate, which stimulate the central nervous system by increasing synaptic concentrations of the neurotransmitters dopamine and norepinephrine to varying degrees, and are used in pharmaceutical preparations primarily for treating ADHD, narcolepsy, obesity, and binge eating disorders. They are also used off label to treat cognitive dysfunction and depression in cancer patients and as part of a regimen in chronic pain patients, as well as being used recreationally to get high, study, take tests, improve focus, and/ or stay awake for extended periods of time. In this last installment on psychostimulants today, I’ll discuss a popular drug called modafinil.
While modafinil isn’t technically a psychostimulant, it acts “stimulant-ish,” and ultimately elicits similar effects as its stimulant brethren. It actually belongs to a class of drugs called eugeroics, which are wakefulness-promoting agents, and is also considered a nootropic. Nootropics are “smart drugs,” substances that can enhance brain performance or focus. Strictly speaking, the term nootropic is generally reserved for prescription and over the counter (OTC) pharmaceuticals and supplements that are not taken therapeutically to treat a particular illness, but rather to enhance cognitive function in healthy individuals beyond what is usually considered “normal” in humans. Nootropics or smart drugs can alternatively be referred to as performance enhancers or pharmacological cognitive enhancers (PCE’s). To cover all the bases and avoid ticking off the biohackers, I suppose you could call modafinil a nootropic eugeroic. Whatever!
Originally synthesized in France in the 1970’s, modafinil was approved by the FDA in 1998 and is used primarily to treat sleep disorders, including narcolepsy, shift-work sleep disorder, and residual/ excessive sleepiness in obstructive sleep apnea despite continuous positive airway pressure (CPAP).
It is used recreationally to increase focus and learning, for cognitive and physical performance enhancement, and to stay awake for extended periods of time. Modafinil is taken by mouth, usually once a day. Most people who work during the day take it in the morning on either a full or empty stomach, but shift workers who take it to promote wakefulness do so before their shifts begin. Modafinil is marketed under the trade name Provigil, while its R-enantiomer armodafinil is marketed under the name Nuvigil. If you recall, enantiomers are mirror image molecules, like left and right hands, that generally induce similar pharmacological effects. Indeed, the two are used to treat the same disorders, but armodafinil is a newer compound and has a slightly different side effect profile than its older sibling modafinil. More on that in a moment.
Both forms are Schedule IV drugs, which defines them as having a low potential for abuse and low risk of dependence. Some other examples of Schedule IV drugs are benzodiazepines like diazepam and alprazolam. That said, while I concur that (ar)modafinil has a low risk of abuse and dependence, I beg to differ on the risk of abuse and dependence being comparable to benzos. In my experience, benzos are far more commonly abused, and the incidence of dependence on benzos far exceeds that of modafinil. However, while studies have not shown any significant withdrawal effects from discontinuation of modafinil, any drug that provides stimulant effects to the brain can enforce drug taking to some extent, and thus carry the potential for dependency, which could lead to withdrawal symptoms upon cessation. Anecdotally, people have reported reduced energy, lack of motivation, and depression following discontinuation of modafinil; therefore, modafinil should always be tapered when discontinued if it has been used for a long period of time.
I’ve found that modafinil carries a very low risk of side effects, and a very mild profile when present, one that may be comparable to having an extra cup of coffee. The most common side effects are potentially occasional minor headaches, possibly some jitters, and sometimes trouble sleeping, which is usually related to the time of dosing being too late. But the official list of side effects also includes: dizziness, upper respiratory tract infection, nausea, diarrhea, nervousness, anxiety, agitation, and dry mouth. For armodafinil, you can add upset stomach to the list and take away upper respiratory tract infection. Something you have to be aware of when taking modafinil are the synergistic effects of other stimulants. If you consume coffee, energy drinks, or anything with caffeine, you’re likely to have much stronger stimulating effects, and these may include jitters or anxiety. It is wise to avoid anything else meant to make you or keep you awake when taking modafinil, at least until you are aware of its effects on your system, and even then you should still use great caution. As with any medication, if you take other prescription or OTC medications, be sure to disclose them with your prescribing physician to discuss potential interactions. Modafinil has a half-life of 12 hours, meaning that after 12 hours, the effects will start to wear off, but half of the drug will still remain in your system.
Modafinil’s off label and “lifestyle” use in healthy individuals to stay awake for extended periods of time and increase cognitive alertness and physical performance is well documented and likely exceeds its therapeutic utility as far as numbers go. In some professional groups such as pilots, academics, and scientists, modafinil use is reported in the ballpark of 20 to 30 percent; but I’d like to note that that is the reported use, not actual use, which I think is significantly higher, given how available it is on the internet. Modafinil’s popularity among college students, athletes, and the Silicon Valley techie set isn’t exactly a state secret, but its use among the military literally was until confirmed relatively recently. The US Armed Forces tested modafinil in improving performance despite sleep deprivation and in combating pilot fatigue; in fact, at one point, we led the world in military research on modafinil. I happened to catch part of a television show over the holidays that mentioned modafinil studies in Air Force fighter pilots. The show stated that it induced vigilance (aka kept them awake) for 40 hours, which, the show mentioned, is apparently a desired effect during times that necessitate flying to Iraq quickly. Now, I’ve never flown to Iraq, much less in a fighter jet, but I can’t imagine that it takes 40 hours to get there… but you get the point. If you were exhausted, but needed to get to Iraq all quick like, modafinil may be the compound of choice.
Of course, I had to look into these studies. Captain Obvious says that Uncle Sam has been “officially” dosing our Armed Forces for years, so modafinil is just another in a long line of compounds. I’ve had many patients that were/ are members of the US military, and I’ve been told of the sanctioned use of various drug combinations in all branches of it: hypnotics to induce them to sleep before a mission, followed by stimulants (in the form of dextroamphetamine) “go pills” to switch them back on just before, at “go time.” As far as modafinil is concerned, the experiments relating to sleep deprivation seem pretty ambitious, testing for 40, 60, or even 90 hours without sleep. In some journal articles, scientists speculated that with modafinil, troops might function for weeks(!) on as little as four hours of sleep a night.
Back to fighter pilots: in the study I looked at, Air Force scientists looked at the effects of being awake for 37 hours on pilot alertness and flight performance; this was evaluated through simulator tests repeated every five hours to track the pilots’ level of fatigue. The same experiment was conducted with and without modafinil, and also in a rested state without modafinil for comparison. What did they find? While on modafinil, the pilots’ performance significantly improved, especially at time points after 25 hours without sleep, and the pilots sustained brain activity at almost normal levels despite their sleep deprivation. Further, while under the influence of modafinil, flight performance degraded by 15 to 30 percent. Now that doesn’t sound great, until you consider that performance by pilots without modafinil (and without sleep) degraded by 60 to 100 percent (hell-ooo!!) as compared to rested levels. All of the findings led researchers to conclude that modafinil “significantly” reduced the effects and impacts of fatigue during flight maneuvers, even though sleep deprived pilots on modafinil were unable to maintain the same performance as they exhibited during a rested state off of modafinil. I’ll say… Degraded by 60 to 100 percent?! Bottom line: clearly, if a pilot can’t get sleep, they should get modafinil. Ultimately, they stated that until more research is done, a 100 mg dose of modafinil is viewed as an option to, but not a replacement for, a 10 mg dose of dextroamphetamine.
All of that said, most of us are not fighter pilots, much less operating a complicated machine at mach speed and 50,000 feet, under stress, and sleep deprived… and thankfully so. Most of the people that ask me about modafinil are everyday people looking to focus better at work, get excellent scores on SAT’s to get into a great school, win a medal or a pro poker tournament (pro poker players love modafinil) or maybe beat out somebody at work for a promotion. In my experience, for all of those things and more, modafinil is a safe and effective tool, and lots of folks want it in their tool box. It’s been around long enough to have some significant studies done; all findings echo my experience, and one another: it works well and nobody’s dropping dead at their desks.
The University of Oxford and Harvard Medical School conducted a formal review of all research papers on cognitive enhancement with modafinil in non-sleep-deprived individuals, dated from January 1990 to December 2014. They found and evaluated 24 studies, which included more than 700 participants total, dealing with different benefits associated with taking modafinil, including planning and decision making, flexibility, creativity, and learning and memory. They also surveyed overall performance enhancing capabilities and side effect reporting. Findings were as follows:
Modafinil made no apparent difference to working memory or flexibility of thought, but did improve executive function, the ability to sift through new information and make plans based on it.
As to side effects: (70 percent the of 24 studies looked at the effects of modafinil on mood and the side effects of modafinil) In those where side effects were studied, there were very few side effects overall, although a very small number reported insomnia, headache, stomach ache, or nausea, but these were also reported in the placebo group, meaning those who were unwittingly given a “sugar pill” with no biological action.
As to overall performance enhancing capacity of modafinil: this was found to vary according to the task; the longer and more complex the task tested, the more consistently modafinil conferred cognitive benefits.
Modafinil clearly and reliably enhanced cognition, especially in higher brain functions that rely on contribution from multiple simple cognitive processes.
Some snippets of findings from other studies:
“It has been shown to increase resistance to fatigue and improve mood.”
In healthy adults, modafinil improves “fatigue levels, motivation, reaction time and vigilance.”
Modafinil is effective at reducing “impulse response,” meaning it reduced the incidence of poor decision making.
Modafinil “…improved brain function in sleep deprived doctors.”
Modafinil “enhanced the ability to pay attention, learn, and remember.”
There is some evidence that modafinil only helps people with lower IQ, but I read validated accounts of years of use associated with validated corresponding increases in IQ, though this could theoretically be due to other unrelated factors.
How Does Modafinil Work?
Scientists haven’t gotten it all figured out quite yet, but like the psychostimulants we’ve already discussed, modafinil increases the production of norepinephrine and dopamine in the CNS, the neurotransmitters linked to emotional well being, motivation, memory, and focus. At the same time, modafinil may also reduce the production of neurotransmitters that are known for blocking communication between neurons. It also increases the production of histamine, which increases the oxygen concentrations travelling to the brain, making you more awake, or so it’s theorized. Just as the anti-histamine Benadryl dampens histamine and puts some people to sleep, modafinil boosts histamine levels, which has a tendency to wake you up and increase alertness. If you’ve ever had an acute allergy, especially an anaphylactic reaction, and experienced the typical increase in heart rate and blood pressure associated with it (which is also associated with wakefulness and alertness) then you’ve felt the acute effects of excess histamine production. Obviously, modafinil doesn’t cause this level of histamine release, that’s just an explanation of how the release of histamines from taking modafinil are thought to cause a feeling of wakefulness or alertness: from the increase in heart rate and blood pressure associated with their release. Though scientists aren’t exactly sure how it works, they have elucidated that modafinil also enhances several other CNS neurotransmitters, including serotonin, glutamate, and GABA.
The Ethics of Modafinil Use
Pharmacological cognitive enhancers (PCE’s) like modafinil may be used to treat cognitive impairments in patients, but they are more commonly used by healthy individuals in an effort to improve focus, stay awake and alert for extended periods of time, and boost mental and physical performance. This lifestyle use of modafinil by healthy people is increasing, and in fact, it appears that it far exceeds the therapeutic use of modafinil for cognitive impairment and sleep abnormalities. As it enhances cognition and has effects on attention, learning, memory, planning, and problem solving, this lifestyle use raises a number of ethical issues.
In societies and populations that foster or encourage academic and professional competition, access to knowledge about how to gain a competitive edge and how to perform better in the workplace is a valuable commodity, but not one that tends to be equally distributed across all social groups. As modafinil rises in popularity, will we soon be locked in a productivity arms race, pounding out after-hours spreadsheets with one hand while Googling “latest nootropic advancements” with the other? Some sports organizations already ban the use of prescription psychostimulant drugs- including methylphenidate- without an official ADHD diagnosis, for the same reasons they ban steroids and other performance enhancing drugs. Will employer drug screens soon test for off label modafinil use in an effort to avoid its presence in the workplace? Or will the opposite be the case; will CEOs welcome super sharp workers who never need sleep? Think about the Bezos’ and the Musk’s of the world… will they be adding modafinil to the water coolers?
Considering modafinil’s popularity, you can be sure that more cognitive enhancing drugs are right around the corner. Will everyone be able to compete? What if you can’t get access to a cognitive enhancer, can’t afford it, or can’t take it due to negative interactions or side effects… are you destined to be stuck in a dead end job or hit an impenetrable corporate ceiling while you watch your friends and co-workers climb the corporate ladder? How about your kids? If you think things are competitive now… just wait ten years. Will they be able to get into a good pre-school without putting modafinil or some other enhancer in their kool-aid, or juice, or whatever you’ll put in their sippy cups? Seriously, will they be able to compete… to get into a good school without cognitive enhancement? In a cognitively enhanced society, what happens to the benefits and self-satisfaction of earning something by the sweat of the brow… especially when that’s just. not. good. enough? Could this lead to a devaluation of hard work and generate less engagement with the world? And if so, what happens to a society where few people see the value of civic work or doing something for the greater good rather than getting ahead? These won’t be hypothetical questions for very long. How about things less under our direct control? Will the FDA save us by prioritizing drugs that preserve lives, or will they bow to pressures from big pharma to prioritize drugs that will undoubtedly be more popular among healthy individuals, have a far larger market, and make more money?
Hey people… these are things to think about. Don’t shoot the messenger.
In situations where there is a deficit in performance due to sleep deprivation or fatigue, a medical diagnosis, or learning disorder, there’s no doubt that modafinil can even the playing field. But what about in “normal” healthy individuals? Proponents of modafinil use in healthy individuals argue that it reduces fatigue-related and work-related accidents and improves learning outcomes; in other words, it’s a good thing, so use it. But when it comes to “enhancement” or “optimization” of performance, do the ends always justify the means? To use a sports analogy, does enhancement corrupt the “rules of the game”? If so, does it make the game pointless? Or is enhancement or optimization a slippery slope that leads to the desire to “perfect” human beings? The increase in medical options available to affect human characteristics and abilities over recent decades certainly offers more options to do so, but the desire to want to do so is hardly novel. The difference is that now we’re getting much closer to being able to actually do it. The door is open, and people are walking through it. Some people are running through it. But can we ever turn around to get back to where we were if/ when we find we don’t like what’s on the other side? What happens when average abilities become less the norm, and more of a negative exception… would average people feel fundamentally inadequate?
The ethical implications of the use of modafinil in particular, and smart drugs in general, has become one of the biggest issues in neuroethics and bioethics; it’s got ethics nerds everywhere red faced and arguing, and it’s certainly a favorite topic in the popular media as well, with tons of hype. What about the ethics of biohacking, using any and all, drug and non-drug technologies to improve cognition; ie training and nutrition to boost brainpower, and/ or the application of transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), or brain-computer interfaces (BCI)? There are plenty of biohackers out there- do they have an unfair competitive advantage, or is it mostly acceptable, because a lot of it requires at least more effort and dedication than just swallowing a pill? If most people biohack themselves in order to become cognitively superior, when is superior… superior enough? There could be serious ramifications concerning attitudes towards conventional human abilities in the long term.
I certainly don’t suppose that I have the answers to these questions, but I know that I’m not the only one asking them. The last question I’ll pose that is still unanswered is: when will we be forced to confront all of the above questions… and then some? Because that day is coming. Of that, I have no doubt.
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Postpartum Depression: o
Signs, Symptoms, New Treatment?
Last week, we talked about sex and orgasms, so it seems only fitting that this week, I talk about the potential ‘homework’ that may come after the sex and orgasms: pregnancy… and the postpartum depression that may accompany it.
It is one of life’s greatest joys, and for me personally, the proudest moment of my entire life: the birth of a child. But no matter how much you love that baby or how you’ve looked forward to its arrival, having a baby is stressful on both parents for many reasons. However, there are specific reasons that make it more physically and emotionally taxing on mom. Captain Obvious says that there are many physical, emotional, and chemical changes in a woman’s body that allow them to (help) create, carry, and birth these little miracles. And add to that the onset of new responsibilities, sleep deprivation, and lack of time for any personal care, it’s not a big shock that lots of new moms get overwhelmed and feel like they’re on an emotional rollercoaster from hell. In fact, the mild depression and mood swings that are so common in new mothers have earned them a name, “the baby blues.” But how do you know if what mom is feeling goes beyond the blues? What should you look for, and when should you seek help?
The majority of women experience at least some symptoms of the baby blues immediately after childbirth. Why? It’s all down to female hormones: specifically, progesterone and estrogen, the big kahunas in the female hormone universe.
Progesterone’s role in pregnancy is so vital that it’s referred to as the “pregnancy hormone.” Actually, progesterone comes into play long before pregnancy, as it is one of the hormones secreted by the ovaries that governs ovulation and menstruation in post-pubescent women. Then upon conception, it gets the uterus ready to accept, implant, and maintain a fertilized egg, and it also prevents the uterine muscle contractions that would otherwise cause a woman’s body to reject it. During fetal gestation, it helps create an environment that nurtures the developing baby. It makes it sound like progesterone is in there painting, hanging curtains, and fluffing pillows, but its role goes way beyond that. The placenta, which is the structure inside the uterus that provides oxygen and nutrients to a developing baby, will itself begin to produce progesterone after about 8 to 10 weeks of pregnancy. At this point, the placenta increases progesterone production to a much higher rate than the ovaries ever thought about making. Those high levels of progesterone throughout the pregnancy cause the mom’s body to stop producing more eggs, as well as prepare her breasts to produce milk.
Also produced by the ovaries when not pregnant, and then later by the placenta during pregnancy, estrogen helps the uterus grow, maintains the uterine lining where the budding baby is nestled, steps up blood circulation, and activates and regulates the production of other key hormones. In early pregnancy, it also helps mom develop her milk-making machinery. And baby benefits too, as estrogen triggers the development of those teeny tiny organs and regulates bone density in those cute little developing arms that wave and legs that kick.
The increased levels of progesterone and estrogen during pregnancy actually make mom feel good and feel bonded to baby, even though she may be crying her eyes out for virtually no reason (sorry ladies) in the beginning. Levels of both hormones continue to increase as the pregnancy advances, and mom’s body actually gets used to these high levels. Then when the baby is born, there’s no more placenta, so mom’s progesterone and estrogen levels drop suddenly and precipitously, in a matter of hours. So mom goes essentially cold turkey from high hormone levels to comparatively no hormone levels. Sudden hormonal change + stress + isolation + sleep deprivation + fatigue = tearful + overwhelmed + emotionally fragile mom. Generally, these feelings can start within just the first day or so after delivery, peak at around one week, and taper off by the end of the second, third, or maybe up to the fourth week postpartum; that’s if it’s the baby blues.
These baby blues are perfectly normal, but if symptoms are extreme, don’t go away after a month, or get worse, mom may be suffering from postpartum depression and likely needs help.
Postpartum Signs & Symptoms
Though they share some symptoms, postpartum depression is a much more serious problem than the baby blues, and should never be ignored. Shared symptoms of the two include mood swings, crying jags, sadness, insomnia, and irritability.
Postpartum depression is the most common complication of childbearing, and it occurs in 10% to 20% of all moms after delivery. It is different from the baby blues in that the symptoms are more severe and longer lasting. It is an issue that can’t be blown off or underestimated, because it begins at a critical time, when mom is caring for a helpless infant and needs to be bonding with them.
Symptoms of postpartum depression can include suicidal thoughts, an inability to care for the newborn child, and in extreme cases, even thoughts of harming the baby. Postpartum can be extremely debilitating, and certain signs can put the lives of mom and/ or baby in jeopardy.
Beyond the Blues
Common Red Flags for Postpartum:
-Mom withdraws from partner
-Mom’s unable to bond well with baby
-Mom’s anxiety gets out of control, preventing ability to sleep and/ or eat
-Mom feels guilty, worthless, useless, overwhelmed
-Mom seems preoccupied with death or wishing she were no longer alive
There’s no single reason why some new moms develop postpartum depression and others don’t, but a number of interrelated causes and risk factors are generally at play.
Postpartum Causes/ Triggers
Hormonal changes after childbirth cause fatigue and depression:
-Progesterone/ estrogen levels drop
-Thyroid levels can drop
-Changes in blood pressure, immune system functioning, metabolism
Numerous physical/ emotional changes after delivery:
-Physical delivery pain
-Difficulty losing baby weight
-Insecurity, especially in physical/ sexual attractiveness
Significant stress of caring for a newborn:
-Mom is sleep deprived
-Mom is overwhelmed/ anxious about her abilities to properly care for baby
-Mom has difficulty adjusting
All of the above factors are especially true in first time moms, as they must also get used to an entirely new identity at the same time.
Postpartum Risk Factors
Several factors can predispose a mom to suffer from postpartum depression:
-History of postpartum depression
A prior episode can increase the chances of a repeat episode by 30% to 50%.
-History of non-pregnancy related depression and/ or family history of mood disturbances
-Social stressors, including lack of emotional support, abusive relationship, and/ or financial uncertainty
-Significantly increased risk in women who discontinue medications abruptly for purposes of pregnancy.
Postpartum psychosis is an even more rare, and more extremely serious disorder that can also develop after childbirth. Characterized by a loss of contact with reality, postpartum psychosis poses an extremely high risk for suicide or infanticide, and hospitalization is nearly always required to keep both mom and baby safe. Postpartum psychosis develops suddenly, usually within the first two weeks after delivery, and sometimes within a matter of 48 hours.
Postpartum Psychosis Symptoms
Postpartum psychosis is considered a medical emergency requiring immediate medical attention.
-Hallucinations: seeing things and/ or hearing voices that aren’t real
-Delusions: paranoid, irrational beliefs
-Extreme agitation and anxiety
-Suicidal thoughts or actions
-Confusion and disorientation
-Rapid mood swings
-Inability or refusal to eat or sleep
-Thoughts of harming or killing baby
There is a screening tool that can be used to detect postpartum depression, called the Edinburgh Postnatal Depression Scale. I will put the questions and explain the scoring of this scale at the conclusion of this blog. It can be helpful if mom or partner isn’t quite sure if symptoms are the baby blues or true postpartum depression.
Coping with Postpartum Depression
Four Tips for Moms:
1) Create a secure attachment with baby.
The emotional bonding process between mom and child, known as attachment, is the most important task of infancy. The success of this wordless relationship enables a child to feel secure enough to develop fully, and affects how he or she will interact, communicate, and form relationships throughout their entire lives.
A secure attachment is formed when moms respond warmly and consistently to baby’s physical and emotional needs. When baby cries, quickly soothe them. If baby laughs or smiles, respond in kind. In essence, the goal is for mom and baby to be in synch, and to be able to recognize and respond to each other’s emotional signals.
Postpartum depression can interrupt this bonding. Depressed moms can be loving and attentive at times, but at other times may react negatively or not respond at all. Moms with postpartum depression are generally inconsistent in their care, and tend to interact less with their babies; they are also less likely to breastfeed, play with, and read to them. Postpartum is sinister in this way, as learning to bond with baby not only benefits the child, it also benefits mom by releasing endorphins that make mom feel happier and more confident. By its very presence, postpartum makes the bonding process difficult, and therefore mom is less likely to produce those endorphins that would make her feel better. It’s a vicious cycle.
If mom didn’t experience a secure attachment as an infant, she may not know how to create a secure attachment as a mom. However, this can be learned, as human brains are definitively primed for this kind of nonverbal emotional connection that creates so much pleasure for both mom and baby.
2) Lean on others for help and support.
Human beings are social creatures. Positive social contact relieves stress faster and more efficiently than any other means of stress reduction. Historically, and from an evolutionary perspective, new moms have typically received help from those around them after childbirth. In today’s world, new moms often find themselves alone, exhausted, and lonely for supportive adult contact.
Ideas to better connect with others:
-Make relationships a priority. When feeling depressed and vulnerable, it’s more important than ever to stay connected to family and friends, even if you’d rather be alone. Isolating will only make the situation feel even bleaker, so make adult relationships a priority. Let loved ones know your needs and how you wish to be supported.
-Don’t hide feelings. In addition to the practical help that friends and family can provide, they can also serve as a much-needed emotional outlet. Share experiences- good, bad, and ugly- with at least one other person, and preferably face to face. It doesn’t matter who mom talks to, so long as that person is willing to listen without judgment and offer reassurance and support.
-Be a joiner. Even if mom has supportive friends, she may want to consider seeking out other women who are dealing with the same transition into motherhood. It’s very reassuring to hear other mothers share the same worries, insecurities, and feelings. Good places to meet other new moms include support groups for new parents or organizations such as ‘Mommy and Me.’ Pediatricians can also be excellent neighborhood resources.
3) Take care of yourself. One of the best things moms can do to relieve or avoid postpartum depression is to take care of themselves. The more moms care for their mental and physical well-being, the better they’ll feel.
Simple lifestyle changes can go a long way toward helping moms feel more like themselves again.
-Skip the housework. Make yourself and baby the priority, and give yourself the permission to concentrate on just that. Remember that being a 24/7 mom is far more work than holding down a traditional full-time job.
-Ease back into exercise. Studies show that exercise may be just as effective as medication when it comes to treating depression, so the sooner moms get back up and moving, the better. No need to overdo it: a 30-minute walk each day will work wonders. Stretching exercises, like those found in yoga, have shown to be especially effective.
-Practice mindfulness meditation. Research supports the effectiveness of mindfulness for making moms feel calmer and more energized. It can also help moms become more aware of what they feel and need.
-Don’t skimp on sleep. A full eight hours may seem like an unattainable luxury when dealing with a newborn, but poor sleep makes depression worse. Moms must do whatever they can to get plenty of rest- from enlisting the help of the partner or family members, to catching naps at every opportunity.
-Set aside quality time for yourself to relax and take a break from mom duties. Find small ways to pamper yourself, like taking a bubble bath, savoring a hot cup of tea, lighting scented candles, or getting a massage at a day spa, or even calling a masseuse to come to you.
-Make meals a priority. Nutrition often suffers during depression. What mom eats has an impact on her mood, and also the quality of breast milk the baby requires, so always make the best effort to establish and maintain healthy eating habits, for yourself and baby.
-Get out in the sunshine. Sunlight lifts the mood, so try to get at least 10 to 15 minutes of sun each day.
4) Make time for your relationship with your partner. More than half of all divorces take place after the birth of a child. For many men and women, the relationship with their partner is their primary source of emotional expression and social connection. The demands and needs of a new baby can get in the way and fracture this relationship, unless couples put time, energy, and thought into preserving their bond.
-Don’t scapegoat. The stress from nights of no sleep and new or expanded responsibilities can leave parents feeling overwhelmed and exhausted. It’s all too easy to play the blame game and turn frustrations onto your partner. Instead of finger pointing, remember that you’re in this together. If you tackle parenting challenges as a team, you’ll find that you’ll become an even stronger unit.
-Keep the lines of communication open. Many things change following the birth of a baby, including roles and expectations. For many couples, a key source of strain is the post-baby division of household and childcare responsibilities. It’s important to talk about these issues, rather than letting them fester. Don’t assume your partner has a crystal ball or knows how you feel or what you need, because you’re bound to feel perpetually disappointed and frustrated if you do.
-Carve out couple time. It’s essential to make time for just the two of you when you can reconnect. But don’t put pressure on yourself to be romantic or adventurous, unless you’ve discussed it and found you’re both game. And you don’t need to go out on a date to enjoy each other’s company. Just spending even 15 or 20 minutes together, undistracted and focused on each other, can make a big difference in how close you feel to each other.
Treatment for Postpartum Depression
If, despite self-help and the support of family, mom is still struggling with postpartum depression, it’s best to seek professional treatment.
-Individual therapy/ marriage counseling A good therapist can help moms deal better with the adjustments of motherhood. If moms or partners are experiencing marital difficulties or are feeling unsupported at home, marriage counseling can also be very beneficial.
-Antidepressants. In postpartum cases where mom’s ability to function adequately for herself or baby is compromised, antidepressants may be an option, though they are more effective when accompanied with psychotherapy. Obviously, medication must be closely monitored by a physician.
-Hormone therapy: Estrogen replacement therapy can sometimes be helpful in combating postpartum depression, and is often used in combination with an antidepressant. There are risks that go along with hormone therapy, so moms must be sure to talk to their doctor about what may be best, and safest, for them.
Helping New Moms with Postpartum
If your loved one is a mom experiencing postpartum depression, the best thing you can do is to offer support, give her a break from her childcare duties, provide a listening ear, and always be patient and understanding. But, be sure to take care of yourself too. Dealing with the needs of a new baby is hard for the partner as well as mom. And if your significant other is depressed, that means you are dealing with two major stressors.
Tips for Partners:
-Encourage mom to talk about her feelings. Listen without judgement and without making demands. Instead of trying to ‘just fix’ things, simply be there for mom to lean on.
-Offer help around the house. Chip in with the housework and childcare responsibilities, and don’t wait for mom to ask… trust me on this one!
-Make sure mom takes time for herself. Rest and relaxation are even more important after a new edition. Encourage her to take breaks, hire a babysitter, or schedule some date nights.
-Be patient if she’s not ready for sex. Depression affects sex drive, so it may be a while before mom’s in the mood. Offer her physical affection, but don’t push it if she’s not up for anything beyond that.
-Getting exercise can make a big dent in depression, but it’s hard for moms to get motivated when they’re feeling low. So do something simple, like going going for a walk with mom. Better yet, make walks a daily ritual for just the two of you, or for the whole family.
There is a fairly new breakthrough drug called Zulresso (brexanolone). Approved in 2019, Zulresso is a neuropathic drug, and first in its class. So what is it? Basically, it’s an aqueous (water-based) solution of progesterone products. They have taken the component product of progesterone and put it into solution; it is then administered to a new mom with postpartum depression. And then a miracle happens… seriously! This lifts postpartum depression like a kid does candy. It is a scientific breakthrough; never before have we had a drug that treats postpartum depression faster than any drug for any type of depression, ever. That’s the good news, but guess what comes next… the bad. While we know it works, very well and very quickly, there are some major disadvantages of this drug. The first one is that it can only be administered by IV infusion. So that means that you have to place an IV map into mom’s vein and drip the drug in with IV fluid. That brings me to the next big disadvantage: it can only be administered in a hospital setting. Why is that? Well, studies show that during administration, which takes place over about 60 hours, two and a half days, some moms can become very dizzy and faint, can lose consciousness, and can even stop breathing. For all of these reasons, moms must be medically monitored with an oximeter and telemetry for two and a half days, during which time they must be checked on every two hours. And they cannot be in charge of baby during this hospital stay, because they may be in and out of consciousness and/ or have severe respiratory issues. While that’s no bueno, the last disadvantage is muy loco, people. Are you ready? The drug costs $34,000. Yep. But wait, it gets better, which in this case, actually means worse. That little $34K is just for the drug! The hospitalization and monitoring costs more… a lot more. And to add insult to injury, you have to shell out the cash to pay for a sitter to watch baby, as mom could potentially be very busy losing consciousness and going into respiratory distress.
Needless to say, Zulresso is not used very much, even though it is an amazing breakthrough product, essentially curing the notoriously difficult-to-treat postpartum depression in a mere 60 hours. There are some other anti-depressants that work pretty well. Effexor (venlafaxine, desvenlafaxine) and Wellbutrin (bupropion) with antipsychotics like Abilify help to speed up the treatment process generally show some progress in about a week.
So while I’m very impressed with Zulresso as a novel, first-in-class drug, you can see my practical issues with it. Although, I suppose that everything is relative: if my wife were suffering from serious postpartum depression, to the point that she was suicidal, or the baby’s life was in danger, and it was refractory, meaning all other treatment options had been tried and failed, I would find a way to get the Zulresso treatment; I’d make it happen, by contacting the manufacturer for patient support options. Or maybe by selling a kidney. Whatever it took.
Edinburgh Postnatal Depression Scale
This 10-question self-rating scale has proven to be an efficient way of identifying patients at risk for “perinatal” or postpartum depression. While this test was specifically designed to be administered by a medical professional, to a woman who is pregnant or has just had a baby, it can be used as an effective at-home guide to determine if you or someone you care about has postpartum depression. Just make sure to follow all of your score’s corresponding action(s).
For each of the 10 questions, please check mark the answer that comes closest to how you have felt in the past 7 days. Scoring is explained after the questions.1) I have been able to laugh and see the funny side of things.
____ As much as I always could
____ Not quite so much now
____ Definitely not so much now
____ Not at all2) I have looked forward with enjoyment to things.
____ As much as I ever did
____ Rather less than I used to
____ Definitely less than I used to
____ Hardly at all3) I have blamed myself unnecessarily when things went wrong.
____ Yes, most of the time
____ Yes, some of the time
____ Not very often
____ No, never4) I have been anxious or worried for no good reason.
____ No not at all
____ Hardly ever
____ Yes, sometimes
____ Yes, very often5) I have felt scared or panicky for no very good reason.
____ Yes, quite a lot
____ Yes, sometimes
____ No, not much
____ No, not at all6) Things have been getting on top of me.
____ Yes, most of the time I haven’t been able to cope at all
____ Yes, sometimes I haven’t been coping as well as usual
____ No, most of the time I have coped quite well
____ No, I have been coping as well as ever7) I have been so unhappy that I have had difficulty sleeping.
____ Yes, most of the time
____ Yes, sometimes
____ Not very often
____ No, not at all8) I have felt sad or miserable.
____ Yes, most of the time
____ Yes, sometimes
____ Not very often
____ No, not at all9) I have been so unhappy that I have been crying.
____ Yes, most of the time
____ Yes, quite often
____ Only occasionally
____ No, never10) The thought of harming myself has occurred to me.
____ Yes, quite often
____ Hardly ever
SCORING VALUES AND GUIDE
Grade each of your checked answers with the specifically stated score, then add the scores together. Take that sum and apply to the interpretation/ action scale and follow the stated suggestion.1) I have been able to laugh and see the funny side of things
0 As much as I always could
1 Not quite so much now
2 Definitely not so much now
3 Not at all 2) I have looked forward with enjoyment to things
0 As much as I ever did
1 Rather less than I used to
2 Definitely less than I used to
3 Hardly at all 3) I have blamed myself unnecessarily when things went wrong
3 Yes, most of the time
2 Yes, some of the time
1 Not very often
0 No, never 4) I have been anxious or worried for no good reason
0 No, not at all
1 Hardly ever
2 Yes, sometimes
3 Yes, very often 5) I have felt scared or panicky for no very good reason
3 Yes, quite a lot
2 Yes, sometimes
1 No, not much
0 No, not at all 6) Things have been getting on top of me
3 Yes, most of the time I haven’t been able to cope
2 Yes, sometimes I haven’t been coping as well as usual
1 No, most of the time I have coped quite well
0 No, I have been coping as well as ever 7) I have been so unhappy that I have had difficulty sleeping
3 Yes, most of the time
2 Yes, sometimes
1 Not very often
0 No, not at all8) I have felt sad or miserable
3 Yes, most of the time
2 Yes, quite often
1 Not very often
0 No, not at all 9) I have been so unhappy that I have been crying
3 Yes, most of the time
2 Yes, quite often
1 Only occasionally
0 No, never 10) The thought of harming myself has occurred to me
3 Yes, quite often
1 Hardly ever
EPDS Score Interpretation/ Action
Score of 8 or less: depression not likely, but continue to seek support.
Score of 9 to 11: depression is possible, continue seeking support and re-screen in 2 to 4 weeks. Seriously consider appointment with primary care provider or established mental health professional.
Score of 12 to 13: fairly high possibility
of depression. Continue to monitor and seek support. Make appointment to see primary care provider or established mental health professional.
Score of 14 and higher: this is a positive screen for probable postpartum depression. Diagnostic assessment is required to determine appropriate treatment. See mental health specialist or primary care provider for referral to same.
Note: if there is any positive score (a rating of 1, 2, or 3) on question 10 (suicidality risk) definite immediate discussion and possible emergency management is required. Refer to primary care provider, mental health specialist, or emergency resource for further assessment and intervention as appropriate. The urgency of the referral will depend on several factors, including: whether suicidal ideation is accompanied by a plan, whether there has been a history of suicide attempt(s), whether symptoms of a psychotic disorder are present, and/ or if there is concern about harm to the baby.
So that’s all the news on postpartum depression. If you liked this, please share with friends and family. Look for new blogs here every Monday, and check out my book, Tales from the Couch, for more education and patient stories, available on Amazon.com. See my YouTube channel for new lectures- I post them all the time. And I’d appreciate it if you hit that subscribe button, people! Thanks everybody, be well.
The biggest reason people stop medication is they don’t like taking pills. Some people just forget. Others start doing well so they say, “I don’t need it anymore”. Side effects that are uncomfortable are another big problem. Dry mouth, constipation, nausea, and dizziness can occur with a lot of medications. People stop medications because they don’t believe that they are sick or that the medication will help. Individuals are in denial about illness. Lately I’m seeing people stop medication because it’s too expensive. Sometimes people stop medication because they like the manic state and don’t want anything to stop.
One patient told me he wanted to use alcohol and didn’t want to take his medication with alcohol. I think that makes sense.
How do we keep people on medication? First education is the key. Educating them on the risks of the mental illness. Psychiatric illness can be damaging to the brain. Untreated mental illness results in breakup of relationships, loss of jobs, legal problems and problems in marriages.
Going off medications may result in withdrawal syndromes. Stopping medications can make a lot of things worse. Depressive disorders, anxiety disorders and psychiatric disorders become worse. Untreated mental illness may predispose people to addiction and self medication with drugs of abuse. (more…)Learn More