Dr. Brad Miller M.D.

Dear Ask the Expert,

My friend recently had a baby and I think she is experiencing postpartum depression. She is really sad, and says she hates to be alone with the baby. We’ve been friends for years, and I’ve never heard her this sad before. Every time we talk on the phone she starts to cry.  We don’t live in the same state so it’s hard for me to visit her, and I just don’t know how to help since I live so far away.  This is her second baby. Can women who have a second child get PPD even if they didn’t have it with their first child?

Thanks
Worried Friend

Dear Worried Friend,

I’m glad you wrote, because it sounds like a serious situation and your friend should definitely talk to her doctor. Particularly concerning is that you mentioned your friend “hates” to be left alone with her child. This is a red flag that your friend may have Postpartum Depression. Just because your friend did not have Postpartum Depression with her first child does not mean she can’t have PPD after having another child. However, having a history of PPD does increase the probability of PPD after having second and third babies.

In good news, there are a lot of resources for your friend. The biggest hurdle for most new moms is admitting how sad they are feeling and reaching out for help. Since your friend has already told you she is having a hard time and she is concerned, she will probably be open to getting help. Most often, PPD requires medication or psychological therapy. Some of the medications used to treat postpartum depression do seep in to breast milk and some new moms being treated for PPD are recommended to stop nursing.

Try talking with your friend about postpartum depression and maybe see if there is a support group in your area. If you think your friend or her baby is in imminent danger there are PPD emergency support hotlines you can call such as 1(800) 944 4PPD. With a little help, a good doctor, treatment and time your friend should be alright.

Dr. Brad Miller, MD
Medicine Think

According to the Mayo Clinic, there is no single cause of youth and adolescent depression. Some teens are more prone to becoming depressed than other, due to genetic factors and lifestyle stressors. However, there are many common symptoms of depression that you can look for in children and young adults. The most common symptoms include low energy, apathy, frequent crying, excessive weight loss or weight gain and a change in sleeping patterns.

Many times parents and teachers overlook the common signs of depression because they seem so similar to normal adolescent behavior. Being apathetic, angry, or sad may be seen as just a normal part of growing up. However, if these symptoms persist and increase in severity over several months, parents should try to talk to their teens about depression.

Teen and adolescent depression can be overcome with cognitive behavioral therapy, prescription medication, and/or mood boosting activities. Speaking with a counselor will help teens understand why they are feeling down and develop ways to overcome stress so it won’t be a problem in the future. A doctor may prescribe prescription drugs if the depression is a result of a hormonal imbalance or an imbalance of certain chemicals in the brain. A professional will also be able to determine if the teen is suffering from minor or major depression. Minor depression normally only lasts a few months and can be overcome with a short course of treatment. Major depressive episodes can be much worse and may lead to suicide. Mood boosting activities like exercise and journaling can help a teen deal with the symptoms of depression and change their perspective.

Coping strategies need to include the entire family and not just the depressed teen. Since depression is the leading cause of suicide, it’s also important to have open and honest discussions about it if a teen is depressed. Parents of depressed children and teens can learn their words and actions can help or hurt their child’s condition. Sometime family therapy can help get to the core of what is causing youth depression. There are also depression prevention programs available that can help families prevent a minor depression episode from becoming major depression. These programs will give you strategies to overcome problems as a family.

In general, a higher level of support from parents has been proven to protect children from major depressive symptoms. By showing your child that you care, taking interest in their problems and respecting their feelings, you can go a long way toward preventing teen depression.

People with bipolar disorder undergo extreme mood swings. The terms happiness and sadness are insufficient to describe the mental highs and lows suffered in this disorder. In the depressive phase, individuals may experience feelings of helplessness, hopelessness, and the darkest depression. Often, they will sleep for excessive periods of time, and otherwise evidence low energy, or even appear catatonic. In the manic phase the mood may be highly elevated, and individuals in this state often have the sensation that they can take on the world, beginning ambitious projects or making wild claims. They may  sleep very little in their manic phase, while continuing to feel energized and powerful. The term “bipolar disorder” refers to these two extremes, or poles.

Sometimes referred to as manic depression, bipolar disorder is caused by  emotional, biological, neurological, and environmental factors. Men and women  are equally affected. This disease is often diagnosed in late adolescence or early adulthood but it can develop later in life. Early onset bipolar disorder may also be seen in children and teens, and may be more severe than late onset bipolar disorder. Growing up with bipolar disorder presents a wide range of social and developmental problems for children.

Medical practitioners and researcher divide this disease into 2 categories: bipolar 1 and bipolar 2. Bipolar 1 is characterized by manic episodes, or constantly elevated moods, which last at least one week. Some people may experience psychotic symptoms in this phase, including delusions, hallucinations, and extreme feelings of power, euphoria, and well being. Bipolar 1 patients may or may not experience a true depressive phase. Bipolar 2 includes both hypomanic episodes, which are less debilitating that true mania, along with depressive phases, typically experiencing both extremes with the same week, sometimes cycling back and forth quite rapidly. Bipolar affective disorder refers to mixed episodes in which happiness and sorrow may be experienced at the same time.

A bipolar diagnosis requires a medical examination, at which time a doctor will also take the patient’s history, along with that of his or her family, if possible. Clinical screening is also helpful in evaluating any associated problemw.

Many people find that their bipolar disorder can be treated with a variety of medications, which may manage the extreme moods and, in some cases, psychosis. Common drugs used in the treatment of bipolar disorder include lithium, carbonate, divalproex sodium, and carbamazepine. Cognitive behavioral therapy can also be helpful for some patients.

In the darker Arctic regions of the world (such as Finland) there is a higher diagnosis of SAD than most other places, so it is believed that the disorder is caused by the lower light levels associated with the winter months. While some treat SAD with drugs, one form of treatment that is rising in popularity recently is the light therapy box. Light therapy products mimic certain wavelengths of light associated with the warmer, summer months and aid in reducing depressive symptoms during days when natural sunlight is not available. SAD light therapy causes a biochemical change in the brain that can elevate mood and reduce symptoms of depression.

While it’s possible to make your own seasonal affective disorder lights, it’s more practical to buy a SAD light box over-the-counter so that you’re assured the proper wavelengths of light to alleviate depressive symptoms. Because the Food and Drug Administration has not officially approved the depression light box, it’s important to research the seller before buying to ensure that it’s a reputable retailer.

When shopping for the best SAD light box, consider the degree of UV protection, light intensity, and light direction. It is important to buy a light box that offers some sort of ultraviolet light protection in order to avoid eye and skin damage. Intensity is also important because if it’s not high enough, the light therapy lamp might only be effective from a few inches away. Boxes with higher intensity stay effective up to several feet away. Also, light direction needs to come from above eye-level, so find a box shaped to direct light downward and place it in a spot just over head level.

Another effective treatment of seasonal affective disorder is the use of vitamin D supplements. Low vitamin D levels may cause depressive symptoms, and as sun exposure is a major provider of vitamin D, it’s only logical that lowered levels during winter months could be a cause of the disorder. Eating foods rich in vitamin D, such as eggs and fatty fish like salmon, or taking vitamin D tablets can effectively treat SAD if low vitamin D is the cause. Some people find that as little as fifteen minutes a day of direct sunlight exposure on the bare skin of the face of hands can elevate vitamin D levels.

So even though seasonal affective disorder only occurs at certain times of the year, it should still be treated just as seriously as others forms of depression. Through the use of a light therapy lamp and other alternative methods of treatment, there is a high possibility of alleviating some, if not all of your depressive symptoms.

Postpartum Psychosis

Massachusett’s General Hospital Center for Women’s Mental Health says, “It may be useful to conceptualize these disorders as existing along a continuum, where postpartum blues is the mildest and postpartum psychosis the most severe form of postpartum psychiatric illness.”

Only 1 to 2 out of 1000 mothers will experience Post Partum Psychosis. Usually beginning within the first few days following childbirth, symptoms are severe. UNC School of Medicine says, “Often mothers who develop postpartum psychosis are having a severe episode of a mood disorder, usually bipolar (manic-depression) disorder with psychotic features.” Those experiencing Post Partum Psychosis often suffer delusions and suicidal or homicidal thoughts.

Postpartum Depression Symptoms

While not as severe, Postpartum Depression usually occurs within the first month after childbirth. Symptoms include emotional extremes, feelings of inadequacy, intense sadness, or worthlessness; a change from interest in activities to lack of interest; a change in appetite or sleeping patterns (beyond the change due to nighttime feedings); the inability to concentrate; unwarranted worry about the baby; even thoughts of suicide. Postpartum Depression is marked by a lack of energy, both physical and mental.

Postpartum Anxiety

Postpartum Anxiety Symptoms frequently accompany Postpartum Depression. Feelings of dread and doom overwhelm and dominate the emotional spectrum.  According to UNC School of Medicine, Postpartum Anxiety symptoms include “panic attacks, hyperventilation, repeated thoughts or images of frightening things happening to the baby, excessive worry and restless sleep.” There is no energy for physical activity but seemingly endless and agitated mental energy for worrying and imagining worst-case scenarios.

Postpartum Depression Treatment

Postpartum Depression Treatment includes a combination of talk therapy and medication. A physician may prescribe anti-depressants, anti-anxiety or anti-psychotic medications. Hormone therapy may be indicated. Breast-feeding mothers will want to consult with their doctor about the medications most apt to ensure the health of both the mother and the baby.

Postpartum Support

According to Katherine Stone in “Postpartum Depression by the Numbers,” more women suffer from Postpartum Depression than are diagnosed with breast cancer each year, yet fewer people know about PPD. Talking with other mothers who suffer in a PPD support group or one-on-one with a professional can reduce stress, helping the mother access ongoing support and develop coping skills.

Postpartum Exercise

Postpartum Exercise can also reduce stress. University of Michigan Health System says to exercise according to your physical shape in the days after childbirth. Any combination of exercise—walking, stretching or weight lifting, for example—for 30 minutes a day contributes not only to physical health but to mental health as well. MayoClinic.com says, “Your body will even release endorphins, natural painkillers that promote an increased sense of well-being.”

In addition, teens deal with high school pressures, including schoolwork, trying to fit in with their peers, and dating. With all the changes going in in their bodies and around them, it’s no wonder that a teen can go through some major changes in mood. A blue mood that sticks around for more than a couple of weeks is not just someone feeling sad; it could be a sign of depression and it needs to be treated just like any other medical condition.

Adolescent depression treatment can be effective, but the person who is feeling depressed may not know how to ask for help. If you know a young person who seems to be more down than usual or who isn’t showing his or her usual enthusiasm for things they used to enjoy, it’s time to make an appointment to see a doctor. If it turns out that the young person is depressed, reassure them that this condition is treatable and they will get better.

It will take some time, but with proper treatment, the young person will start to have a more positive outlook. Family members can provide support and reassure the teen that there are many factors that can cause depression. It’s not his or her fault, any more than having to get treatment for a physical condition is something that they should be blaming themselves for.

Once the condition has been diagnosed, the next step is to start depression treatment. Teens may be prescribed certain antidepressant medications as part of an overall treatment plan. A combination of talk therapy and antidepressants is an effective way to deal with depression, and the teen should see a therapist to discuss his or her feelings.

If the young person expresses suicidal thoughts, then the level of teen depression help needed is more serious. The young person needs to be seen by a doctor immediately. If the family doctor isn’t available, then a trip to the local Emergency Room is warranted.  A teenager who gives away his or her possessions or talks a lot about death and dying may be exhibiting signs of suicidal intention and in need of intervention.

It would be a mistake to assume that the teen is simply going through a phase or is making morbid statements for shock value. While it’s possible, parents would do well to err on the side of caution and take all of these types of statements seriously. Depression is a highly treatable condition, and no one has to live in that state when there is effective help available.

A multitude of factors can make it difficult to diagnose and manage bipolar disorder in your child.

Many children act hypomanic by nature. Symptoms of bipolar depression and bipolar mania are often confused with other childhood disorders that are on the increase. Most commonly, symptoms of bipolar disease are mistaken for those of attention deficit disorder (ADD). It also shares psychotic symptoms with schizophrenia. The co-existence of more than one disorder, especially Conduct Disorder, also makes identification difficult.

One way of differentiating between bipolar disorder and ADHD in your child is to observe how they respond to medication, according to Dr. Elizabeth Weller, a specialist in pediatric psychiatry in an article in Psychiatric News. Bipolar children will respond very well to mood stabilizers, which may not have a significant effect on ADHD children. ADHD stimulants, on the other hand, can push a bipolar child into manic episodes.

At different ages, children will exhibit different symptoms. Preschool children are more likely to show signs of irritability, but as the child ages mania becomes more prevalent. Chronic irritability without mania is also a symptom of ADHD, according to the National Mental Health Institute’s How is Bipolar Disorder Detected in Children and Teens. In differentiating between bipolar and ADHD, the NIMH also considers family history and brain function.

Experts agree that parents must play a vital role in monitoring and charting symptoms and watching closely for any changes, which can be dramatic in children with bipolar affective disorder. In the treatment of all mental disorders, positive results are being produced from the movement to more talk therapy over medication. Pediatric mental health workers can also help you zone in on the underlying causes of your child’s mood swings.

Pharmacogenetics, although still a new science, is already helping fine-tune drug dosages and treatment length in children with bipolar disorder. The fatal overmedication of a Washington state four-year-old with bipolar disorder highlights the dangers of prescribing the right doses to children. Signs of severe depression and fatigue in children on antipsychotic drugs could indicate overmedication.

Pharmacogenetics has been successfully used on children with mood disorders to determine how the child will metabolize a drug. A normal dosage of Risperdal, for example, on a New York state five-year-old boy with a slow metabolism was determined to be an overdose. Like the young girl in Washington state, both children showed signs of depression and lethargy as a result of the overdose.

These cases underscore the usefulness of relying on more professional resources to help diagnose and treat a child with mood disorders. Notably, it raises the question of whether, in some cases, the drugs are contributing to depression in children. The bipolar boy from New York was first diagnosed with attention deficit disorder, and only developed mood swings after he began taking an antipsychotic drug.

Advances in genetic research hold the greatest promise of using gene therapy in the prenatal or early years to treat bipolar disorder. A recent study in BMC Psychiatry has identified malfunctioning circadian clock genes in the development of bipolar disorder in children. Disturbed sleeping patterns, or circadian rhythms, are not prevalent in children with ADD.  

An accurate diagnosis is essential in order to receive the proper treatment. Therefore, recognizing the symptoms and signs of Bipolar Disorder and reporting them to your doctor or therapist are essential steps to receiving the help that you need.

Some individuals may have difficulty in recognizing Bipolar Disorder symptoms in themselves, so I often give clients a list of the symptoms and ask them to share the list with someone who knows them well and can give them appropriate feedback. If you think you may have Bipolar Disorder, you may find it helpful to review the signs and symptoms with someone you trust.

Mental Health: A Report of the Surgeon General lists the criteria for a Major Depressive and Manic Episodes, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Signs and symptoms of a Major Depressive Episode include:

• feeling depressed most of the day, nearly every day
• a loss of interest or pleasure in activities that were once enjoyable
• significant weight gain or weight loss without dieting, or an increase or decrease in appetite
• experiencing either insomnia or an excessive amount of sleep
• psychomotor agitation (for example, pacing, nail biting, or difficulty sitting still) or psychomotor retardation (such as walking and working at slower paces or speaking more slowly and less frequently than usual)
• fatigue or a loss of energy
• feelings of worthlessness, excessive feelings of guilt, or feeling guilty about situations for which you are not at fault
• difficulty thinking, concentrating, or making decisions
• suicidal thoughts

Manic episodes include:

• an elevated or irritable mood
• inflated self-esteem or grandiosity (which can be delusional)
• decreased need for sleep, sometimes needing only two hours of sleep to feel rested, and in some cases, being able to go three days with no sleep at all without feeling tired
• being more talkative than usual, an urge to keep talking, or rapid speech
• racing thoughts that often shift from one topic to another
• being easily distracted by unimportant situations
• an increase in goal-directed activity, and often, the goals are grandiose and unrealistic
• reckless or excessive involvement in activities that have a high potential for negative consequences (such as overspending, excessive gambling, or sexual indiscretions)

Some people with Bipolar Disorder experience Mixed Episodes, which, as the name implies, includes signs and symptoms of both Major Depressive and Manic Episodes. The mood swings of Bipolar Disorder tend to be more rapid during a Mixed Episode. Bipolar Disorder Today states that a Mixed Episode is often informally described as “rapid cycling” Bipolar Disorder, but explains that rapid cycling technically consists of at least four Major Depressive, Manic, Mixed, or Hypomanic Episodes within a 12-month period.

Bipolar symptoms in kids often present themselves differently than bipolar symptoms in adults.  Demitri Papolos, MD and Janice Papolos, authors of The Bipolar Child, believe that the DSM-IV needs to be updated to reflect what Bipolar Disorder looks like in children. They assert that children with Bipolar Disorder may experience rapid mood shifts many times throughout the day. Papolos and Papolos say that children with Bipolar Disorder can be very oppositional, defiant, and easily frustrated. They often have difficulty making transitions.  They may experience prolonged temper tantrums that often lead to aggression or violence. Many of them have horrible nightmares.

If you believe you or your child may have Bipolar Disorder, consult with a physician or mental health professional. He or she may choose to refer you to a psychiatrist for an evaluation to confirm or rule out the diagnosis and to discuss treatment options.

Bipolar disorder

Bipolar disorder (formerly referred to as manic depression) is diagnosed when a patient meets the criteria set out in the Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV) which is published by the American Psychiatric Association and is used to appropriately diagnose mental health disorders. The Manual lists criteria for manic episodes, depressive episodes and for mixed episodes, which are times when both extremes are present nearly every day for at least a week. It also defines what is known as a hypomanic episode. In simplest terms, a hypomanic episode has the same types of behaviors or symptoms as a manic one, but they are not as severe or as long lasting as a full manic episode.

There are three types of bipolar disorder- Bipolar I disorder, Bipolar II disorder, and Cyclothymic disorder. With Bipolar I disorder, you have definitely had at least one manic or mixed episode, but not necessarily a major depressive disorder. Bipolar II disorder means you have had at least one major depressive episode and at least one hypomanic episode, but not necessarily a full manic or mixed episode. Cyclothymic disorder means you have several hypomanic episodes and several depressive periods, but not a full manic, major depressive or a mixed episode.

The first step in diagnosing bipolar disorder is usually a screening test like the one developed by Ivan Goldberg, or the Bipolar Mood Disorder Questionnaire used by many mental health professionals as a screening tool. By assessing the answers to a few simple questions, patients and doctors can begin to get a picture of whether bipolar disorder is responsible for ups and downs in life that seem to be more than just the average ebb and flow of life. A bipolar disorder quiz can also be used as a bipolar self test to help someone realize he or she should see a doctor for further evaluation.

The crux of a Bipolar Disorder Test or a Manic Depressive Test is an assessment of an overall pattern of moods and related behavior, not just a short-term period of problems.

The manic or “up” stages of the disorder are evaluated by periods of talkativeness or extreme energy, lack of sleep, impulsive behaviors such as spending too much money, risky behaviors including sexual promiscuity, among others. The depression or “down” periods of the disorder are addressed through questions about sleeping too much, feeling hopeless, restless, anxious, or suicidal as well as a prolonged sadness and loss of energy.

Although a bipolar disorder test is merely a screening tool, it is an important part of a professional diagnosis. While a questionnaire can never fully asses all situations with accuracy, they are useful when diagnosing bipolar disorder and other mental health conditions. They are best used to help you define and narrow down your symptoms and explain them to your doctor so you can get the proper help and treatment in dealing with bipolar symptoms.

Those with SAD experience a pattern of depression during certain times of the year, usually winter, with symptoms alleviated in spring. It is thought that the body reacts to the decrease in sunlight in two ways:

• Melatonin, a naturally occurring chemical produced by the brain connected to sleep, increases as the amount of daylight decreases. Melatonin has been linked to SAD and other forms of depression.
• Variations in the amount of daylight may affect the circadian rhythm, or biological internal clocks as they similarly do in animals which hibernate

Typical Symptoms of Those with Seasonal Affective Mood Disorder

Many of the symptoms are similar to depression though symptoms are generally alleviated in the spring and summer months.

• Depression, hopelessness, feelings of unworthiness
• Anxiety, increased fear, low tolerance to common stresses
• Sleep disturbances
• Problems concentrating
• Mood swings
• Lethargy
• Weight gain
• Irritability
• Loss of sex drive

Prevalence

SAD is believed to be widely under diagnosed. A combination of sufferers not seeking diagnosis and treatment and the difficulty in standard testing does not always identify SAD  disorder specifically. Of those diagnosed, three out of four are women.

• Most sufferers are women
• Can affect anyone, anywhere but increases with latitude and weather conditions
• More common in those who have family members also suffering from SAD

Treatments

Once diagnosed, the treatment is usually comprised of two components, light therapy and antidepressant medications. Fortunately, most people experience significant and immediate improvement in their symptoms by simply increasing their exposure to either natural or other light sources.

• Light Therapy, also called phototherapy, is most frequently prescribed for seasonal depression. It is necessary for the light intensity to be 25 times greater than the normal light intensity of that in most rooms, generally obtained through light boxes with an intensity of 10,000 lux for 30 minutes. It is believed that the intensity, rather than the source, is the key. According to  The National Alliance on Mental Illness studies show between 50% to 80% of those using light therapy experience complete reduction in symptoms while continuing the treatment.
• Antidepressants have also been found to helpful in the treatment of SAD, and is generally prescribed in conjunction with light therapy, if at all.

Seeking Options

If you believe that you are suffering from a seasonal mood disorder, contact your physician for recommendations. SAD is very easily treatable, and does not have to be silently endured.