Danielle Johnson, MD, FAPA
Lindner Center of HOPE/Chief Medical Officer
University of Cincinnati College of Medicine Adjunct Assistant Professor of Psychiatry

Medications are undoubtedly an important tool in the treatment of mental illnesses. Expert application of psychopharmacology is a game changer in improving symptoms of mental illness and helping individuals achieve a manageable baseline. Complex co-morbidities and severe mental illness make prescribing even more complex.

Psychiatric medications can stabilize symptoms and prevent relapse. They work by affecting neurotransmitters in the brain. Serotonin is involved in mood, appetite, sensory perception, and pain pathways. Norepinephrine is part of the fight-or-flight response and regulates blood pressure and calmness. Dopamine produces feelings of pleasure when released by the brain reward system.

One in ten Americans takes an antidepressant, including almost one in four women in their 40s and 50s. Women are twice as likely to develop depression as men.

Selective Serotonin Reuptake Inhibitors (SSRIs) Side Effects

Selective serotonin reuptake inhibitors (SSRIs) increase levels of serotonin. Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro) treat depression, anxiety disorders, premenstrual dysphoric disorder, eating disorders, and hot flashes. Potential side effects include jitteriness, nausea, diarrhea, insomnia, sedation, headaches, weight gain, and sexual dysfunction.

Zoloft Side Effects in Women

Zoloft, also known by its generic name sertraline, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Zoloft include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido, difficulty reaching orgasm, and erectile dysfunction. In some cases, Zoloft may cause weight gain or weight loss, and it can also affect blood pressure and heart rate. Rare but serious side effects of Zoloft in women may include seizures, serotonin syndrome, and suicidal thoughts or behavior.

Prozac Side Effects in Women

Prozac, also known by its generic name fluoxetine, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Prozac include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido and difficulty reaching orgasm. Prozac may also cause weight gain or weight loss, and it can affect blood pressure and heart rate. Rare but serious side effects of Prozac in women may include serotonin syndrome, suicidal thoughts or behavior, and seizures.

Lexapro Side Effects in Women

Lexapro, also known by its generic name escitalopram, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Lexapro include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido and difficulty reaching orgasm. Lexapro may also cause weight gain or weight loss, and it can affect blood pressure and heart rate. Rare but serious side effects of Lexapro in women may include serotonin syndrome, suicidal thoughts or behavior, and seizures.

Serotonin-norepinephrine Reuptake Inhibitors (SNRIs) Side Effects

Serotonin-norepinephrine reuptake inhibitors (SNRIs) increase levels of serotonin and norepinephrine. Venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq) are used to treat depression, anxiety disorders, diabetic neuropathy, chronic pain, and fibromyalgia. Potential side effects include nausea, dry mouth, sweating, headache, decreased appetite, insomnia, increased blood pressure, and sexual dysfunction.

Tricyclic Antidepressants Side Effects

Tricyclic antidepressants (TCAs) also increase serotonin and norepinephrine. Amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin), nortriptyline (Pamelor), doxepin (Sinequan), trimipramine (Surmontil), protriptyline (Vivactil), and imipramine (Tofranil) are used to treat depression, anxiety disorders, chronic pain, irritable bowel syndrome, migraines, and insomnia. Possible side effects include sedation, forgetfulness, dry mouth, dry skin, constipation, blurred vision, difficulty urinating, dizziness, weight gain, sexual dysfunction, increased seizure risk, and cardiac complications.

Other Antidepressants Side Effects

Wellbutrin Side Effects in Women

Bupropion (Wellbutrin) increases levels of dopamine and norepinephrine. It treats depression, seasonal affective disorder, ADHD, and can be used for smoking cessation. It can also augment other antidepressants. Potential side effects include anxiety, dry mouth, insomnia, and tremor. It can lower the seizure threshold. There are minimal to no sexual side effects or weight gain.

Trazodone (Desyrel, Oleptro) affects serotonin and mirtazapine (Remeron) affects serotonin and norepinephrine. They are both used for depression and sleep. Mirtazapine has minimal sexual side effects.

Monoamine oxidase inhibitors (MAOIs) increase serotonin, norepinephrine, and dopamine. Isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), tranylcypromine (Parnate), and moclobemide are associated with more serious side effects than other antidepressants. There are dietary restrictions and numerous drug interactions. MAOIs are often used after other antidepressant classes have been tried. Other antidepressants need to be discontinued for a period of time prior to starting an MAOI.

Newer antidepressants include Viibryd (vilazodone) which affects serotonin, Fetzima (levomilnacipran) which affects serotonin and norepinephrine, and Brintellix (vortioxetine) which affects serotonin. Brintellix and Viibryd have mechanisms of action that make them unique from SSRIs. Viibryd is less likely to cause sexual side effects.

Excess serotonin can accumulate when antidepressants are used with other medications that effect serotonin (other antidepressants, triptans for migraines, certain muscle relaxers, certain pain medications, certain antinausea medications, dextromethorphan, St. John’s Wort, tryptophan, stimulants, LSD, cocaine, ecstasy, etc.) Symptoms of serotonin syndrome include anxiety, agitation, restlessness, easy startling, delirium, increased heart rate, increased blood pressure, increased temperature, profuse sweating, shivering, vomiting, diarrhea, tremor, and muscle rigidity or twitching. Life threatening symptoms include high fever, seizures, irregular heartbeat, and unconsciousness.

Estrogen Levels With Antidepressants in Females

Varying estrogen levels during the menstrual cycle, pregnancy, postpartum, perimenopause, and menopause raise issues with antidepressants and depression that are unique to women. Estrogen increases serotonin, so a decrease in estrogen at certain times in a woman’s reproductive life cycle can reduce serotonin levels and lead to symptoms of depression. Hormonal contraception and hormone replacement therapy can reduce or increase depressive symptoms; an increase in symptoms may be more likely in women who already had major depressive disorder. During pregnancy, antidepressants have a potential risk to the developing baby but there are also risks of untreated depression on the baby’s development. With breastfeeding, some antidepressants pass minimally into breast milk and may not affect the baby. The benefits of breastfeeding may outweigh the risks of taking these medications.   Antidepressant sexual side effects in women are vaginal dryness, decreased genital sensations, decreased libido, and difficulty achieving orgasm. Women should communicate with their psychiatrist and/or OB/GYN to discuss the risks and benefits of medication use vs. untreated illness during pregnancy and breastfeeding; the use of hormonal treatments to regulate symptoms associated with menses and menopause; and the treatment of sexual dysfunction caused by antidepressants.

It has been observed that some antidepressants can affect estrogen levels in women. For instance, selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) have been shown to decrease estrogen levels in women. On the other hand, other antidepressants such as venlafaxine (Effexor) and duloxetine (Cymbalta) have been shown to increase estrogen levels. The exact mechanisms behind these effects are not fully understood, but it is thought to be related to the interactions between the medication and the hypothalamic-pituitary-gonadal (HPG) axis, which is responsible for regulating estrogen production. It is important for women to discuss any potential effects of antidepressants on estrogen levels with their healthcare provider, especially if they have a history of hormonal imbalances or are taking hormonal therapies.

It is important for women to discuss any potential side effects with their healthcare provider before starting any depression medication.

Lindner Center of HOPE’s Approach

Lindner Center of HOPE’s residential services employ full-time psychiatrists with expertise in psychopharmacology. These prescribing physicians are designated members of each residential client’s treatment team. Medication management within Lindner Center of HOPE’s residential programs is also supported by 24/7 psychiatry and nursing staff, onsite pharmacy and an innovative Research Institute.

In some cases, patients over the course of treatment for mental illnesses accumulate many prescriptions. In cases like this, Lindner Center of HOPE’s residential units can offer a safe environment for medication assessment and adjustment. While the client participates in appropriate evaluation and treatment, their psychiatrist can also work with them on reaching rational polypharmacy — in other words, medication optimization.

For patients with more severe, treatment-resistant mental illness, Lindner Center’s psychiatrists can implement the most complicated, and often hard to use, treatments, in a safe environment, while under their observation.

If medication adjustments result in decompensation on the residential units, a patient can be temporarily stepped up to an acute inpatient unit on the same campus.

By Danielle Beltz, MSN, PMHNP-BC, Psychiatric Nurse Practitioner, Lindner Center of HOPE

Pregnancy and childbirth can be one of the most rewarding and fulfilling things a woman can do in her
lifetime but can hand in hand be one of most challenging and emotionally taxing times.
A female goes through not only physical changes throughout pregnancy but also hormonal, emotional,
and psychological changes. In addition, a pregnancy can bring stress and emotional hardship to their
interpersonal dynamics.

A lot of new moms experience postpartum “baby blues” after giving birth which differentiates from
postpartum depression. Symptoms usually include sadness, irritability, moodiness, crying spells, and
decreased concentration. Baby blues usually begin within 2 to 35 days after childbirth and can persist up
to 2 weeks. When these symptoms last longer than 2 weeks this is when the mother should consider talking
to a healthcare provider.

About one in seven women develop postpartum depression. It most commonly occurs 6 weeks after delivery but can begin prior to
delivery as well. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) a major depressive episode with the onset
of pregnancy or within 4 weeks of delivery is considered postpartum depression. Five of the nine symptoms must be present nearly every
day for at least two weeks and constitute a change from previous functioning to be diagnosed. Depression or loss of interest in addition
to the following symptoms must be present:

• Depressed mood (subjective or observed) most of the day
• Diminished interest or pleasure in all or most activities
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Feelings of worthlessness or guilt
• Loss of energy or fatigue
• Recurrent suicidal ideation, thoughts of death or attempts
• Diminished concentration or indecisiveness
• Change in weight or appetite (5% weight change over 1 month)

Fifty percent of postpartum major depressive episodes begin before
delivery so collectively these episodes are described as peripartum
episodes. Mothers with peripartum major depressive episodes commonly have severe anxiety and panic attacks.

The exact etiology of postpartum depression is unknown. Several factors have been reported to contribute to the development of
postpartum depression. The physical and hormonal fluctuations resulting from pregnancy influence postpartum women to develop
depression when stressful and emotional events coincide with childbirth. Some of these factors include the stress of motherhood, difficult
labor, poor financial and family support, and harmful health outcomes of childbirth. Lower socioeconomic demographic, personal or
family history of depression, anxiety, or postpartum depression, PMDD, complications in pregnancy and birth, and mothers who have
gone through infertility treatments have also all been suggested to be strong contributors.

Postpartum depression not only affects the mother’s health but also the relationship the mother has with her infant and that child’s
development. Studies have shown that children are at a greater probability of developing behavioral, cognitive, and interpersonal problems
whose mothers have postpartum depression. It can also lead to inability to breastfeed and marital conflict.

Postpartum psychosis is another severe kind of depression but is not the same thing as postpartum depression. Around 1 in 500 or 1 in
1,000 women has postpartum psychosis after delivering a baby. It commonly starts the first 2 weeks after giving birth. Women who are
also diagnosed with bipolar disorder or schizoaffective disorder are more prone to have postpartum psychosis than women who are not
diagnosed with other mental health conditions.

Postpartum psychosis is considered a psychiatric emergency with a capacity of suicide and infanticidal threat. Some symptoms include
delusions, hallucinations, unusual behavior, paranoia, and sleep disturbances. If postpartum psychosis is suspected help should be sought
immediately.

Psychotherapy and antidepressant medications are the first line treatments for postpartum depression. Psychotherapy is considered first
line for women with mild to moderate depression or if they have concerns of starting a medication while breastfeeding. For moderate to
severe depression therapy and antidepressant medications are recommended. The most common medication for postpartum depression is
an SSRI or selective serotonin reuptake inhibitor. Once an efficacious dose is reached, treatment should persist for 6-12 months to prevent
relapse of symptoms. Risk versus benefits of treated versus untreated depression while breastfeeding or pregnant should be discussed.
Transcranial Magnetic Stimulation (TMS) is an alternate therapy that can be used for women who have concerns about their child being
exposed to a medication. Although, the risk of taking an SSRI while breastfeeding is relatively low. ECT is another option for women with
severe postpartum depression who do not respond to traditional treatment. It can be particularly helpful with psychotic depression.

Zurzuvae (zuranolone) is the first oral medication approved by the FDA specifically for the treatment of postpartum depression in adults.
Until August 2023, treatment for PPD was only available as an IV (Brexanolone) and was only available at certified healthcare facilities.

People with depression especially new mothers and postpartum mothers may not identify or accept that they’re depressed. They also
may be unaware of the signs and symptoms of depression. If you are questioning whether a friend or family member has postpartum
depression or is developing signs of postpartum psychosis, assist them in pursuing medical treatment and recognize that help is accessible.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Commissioner, O. of the. (n.d.). FDA approves first oral treatment for postpartum depression. U.S. Food and Drug Administration. https://www.fda.
gov/news-events/press-announcements/fda-approves-first-oral-treatment-postpartum-depression#:~:text=Today%2C%20the%20U.S.%20Food%20
and,the%20later%20stages%20of%20pregnancy
Guo, L. , Zhang, J. , Mu, L. & Ye, Z. (2020). Preventing Postpartum Depression With Mindful Self-Compassion Intervention. The Journal of Nervous and
Mental Disease, 208 (2), 101-107. doi: 10.1097/NMD.0000000000001096.
Mayo Foundation for Medical Education and Research. (2023, April 14). “I’m happy to be a new mom. but why am I feeling
so sad?” Mayo Clinic. https://mcpress.mayoclinic.org/mental-health/im-happy-to-be-a-new-mom-but-why-am-i-feeling-sosad/?
mc_id=global&utm_source=webpage&utm_medium=l&utm_content=epsmentalhealth&utm_
campaign=mayoclinic&geo=global&placementsite=enterprise&invsrc=other&cauid=177193
Miller, L. J. (2002). Postpartum depression. JAMA : The Journal of the American Medical Association, 287(6), 762-765. https://doi.org/10.1001/jama.287.6.762
Mughal S, Azhar Y, Siddiqui W. Postpartum Depression. [Updated 2022 Oct 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519070/
Postpartum depression. March of Dimes. (n.d.). https://www.marchofdimes.org/find-support/topics/postpartum/postpartum-depression?gad_
source=1&gclid=EAIaIQobChMIqKLemfTfggMVq0VyCh3ouwGDEAAYBCAAEgKxjPD_BwE
Silverman, M. E., Reichenberg, A., Savitz, D. A., Cnattingius, S., Lichtenstein, P., Hultman, C. M., Larsson, H., & Sandin, S. (2017). The risk factors for postpartum
depression: A population-based study. Depression and Anxiety, 34(2), 178–187. https://doi-org.uc.idm.oclc.org/10.1002/da.22597
Stewart, D. E., & Vigod, S. (2016). Postpartum depression. The New England Journal of Medicine, 375(22), 2177-2186. https://doi.org/10.1056/NEJMcp1607649

Women appear to be particularly vulnerable to depression during the perimenopause years and in the years immediately after menopause. An estimated 8 – 15% of all women experience menopausal depression symptoms.  Unfortunately, problems are often misdiagnosed, because many menopausal depression symptoms mimic those of normal menopause. The causes of menopausal depression are mostly tied to estrogen levels. Symptom management tends to be the focus of menopausal depression treatment and can include hormone replacement, antidepressants and psychotherapy.

Menopausal Depression Symptoms

Increased fatigue, appetite and sleep disturbance, difficulty concentrating, and increased irritability are symptoms of both clinical depression and peri-menopause (the 8-10 years prior to full menopause) or menopause.

Extended periods of sadness or melancholy, accompanied by feelings of hopelessness or helplessness, call for medical intervention, as clinical depression may be present.  Untreated, depression can lead to a host of emotional and physical problems, and, in extreme cases, even suicide. Several recent studies point to an increased risk of depression in menopausal women, even those without any history of the disorder.  One study, published in the Archives of General Psychiatry, found that women were four times more likely to develop depressive symptoms in peri-menopause than prior to its onset.

Causes of Menopausal Depression

The most frequent culprit in the development of women’s midlife depression is the significant drop in estrogen levels that accompanies the onset of menopause.   Emotional changes associated with low estrogen levels include depression, anxiety, and increased irritability. With the loss of estrogen, other hormones and neurochemicals become imbalanced as well.  In particular, those affecting stress and mood, such as cortisol and serotonin, may be disrupted.  Low serotonin levels are frequently associated with the development of depression.

The stress caused by other menopausal symptoms can also contribute to feelings of depression.  Insomnia, night sweats, mood swings – symptoms such as these can make the most emotionally balanced person feel out of kilter.  An individual who is biologically more prone to depression may find such menopausal symptoms to be a trigger for a depressive episode.

Finally, age-related stressful life changes and events may coincide with menopause, such as the loss of fertility, “empty nest” syndrome, occupational changes, parental care giving, and marital strife.  These stressors may contribute to feelings of depression.

Women more likely to suffer menopausal depression include those with a history of depression and those who experience a surgical menopause, due to the sudden loss of estrogen.

Menopausal Depression Treatment

Menopausal depression can be treated successfully, with significant symptom management. The most common form of treatment is hormone replacement therapy.  Often used to manage menopausal symptoms such as hot flashes, estrogen therapy has also been found to reduce depressive symptoms. A study reported in the American Journal of Obstetrics and Gynecology found that 80% of menopausal women reported positive mood changes as the result of oral estrogen doses.

Antidepressants can also provide benefit to women with menopausal depression.  Those which help the body raise its serotonin levels are particularly effective.

Psychotherapy has also been found to be an effective treatment method. Trained professionals can assist individuals in learning how to re-frame negative thoughts and reduce stress levels.

A focus on appropriate self-care is helpful for any woman facing menopause. Many symptoms can be managed through practicing such strategies as vigorous physical activity, stress management exercises, good sleep habits, and healthy eating.

“Cada persona debe vivir su vida como un modelo para otros.”

Rosa Park

Tenia muchas ideas para esta columna de marzo, fundamentalmente dedicarla al tema de la Mujer (a razón del día internacional de la mujer) y a las mujeres de mi vida y sus grandes hazañas pero para ello ya habra tiempo…

Creo que desde hace unas semanas todos estamos tratando de entender y explicar esta experiencia global sin precedentes que es la pandemia del coronavirus COVID-19 y por sobretodos las cosas intentado mantener la calma y la cordura.

Por norma, toda  situación de incertidumbre produce un desbordamiento de la angustia y debilita nuestras defensas habituales para manejarla.  Sin darnos cuenta, nuestros horarios, hábitos, rutinas y en general el orden del mundo exterior juegan un papel importante en nuestra propia organización interior y en nuestra identidad. Así, la incertidumbre y este quiebre en nuestra cotidianidad pueden dar origen a un cuadro emocional de confusión. Nosotros como inmigrantes estamos en una posición aún más vulnerable pues en nuestra identidad ya puesta a prueba, esta confusión puede reactivar la experiencia traumática vivida alrededor del proceso migratorio y enfrentarnos a fenómenos de “Deja Vu” y des-realizacion como manifestaciones de una angustia desbordada.

A continuación, algunos cambios a los que debemos estar atentos:

  • Dificultad para distinguir nuestras emociones  (impotencia, rabia, tristeza, frustración, euforia, angustia)
  • Distorsión de la realidad, bien sea minimizando o negando los hechos reales  o magnificándolos de una forma desproporcionada. (“No pasa nada vs el mundo se va a acabar”)
  • Cambios bruscos en nuestro estado de animo (cansancio e indiferencia  o hiperactividad )
  • Problemas para enfocarnos y concentrarnos en el trabajo o en el estudio.
  • Diversas y múltiples manifestaciones de la angustia: problemas para dormir o mantener el sueno, trastornos de la alimentación o de la vida sexual, malestares físicos, ataques de pánico, fobias o ansiedad generalizada.
  • Tendencia a la auto-medicacion  a través del incremento en el uso de tranquilizantes, alcohol, cigarrillos o drogas

Qué hacer ?

  • No intentar escapar de la realidad. No es posible. Mantenernos desinformados nos debilita aun mas.  Debemos mantener canales de percepción para estar informados de lo que acontece y acatar todas las medidas sanitarias recomendadas por el CDC (center for disease control ) mientras  también preservamos canales que nos protegen de la sobre-exposicion a la “noticia del día”. Con más razón aun, Mantengamonos nuestra mente y nuestro cuerpo activo a través del ejercicio y la meditación en cualquiera de sus formas.
  • Dale espacio a la creatividad. Muchos tendrán mas tiempo libre en sus manos si les corresponde quedarse en casa. Utilicen ese tiempo para darse permiso y hacer algo que siempre hubieran querido hacer y nunca encuentran el tiempo. Escriban esa canción que siempre sonaron con escribir.  Hagan música como los italianos en cuarentena desde sus balcones en Sicilia y otras ciudades. Comiencen por fin ese proyecto que tienen pendiente comenzar “algún día”. No permitan que el aburrimiento les gane esta partida.
  • Mantener la capacidad de disfrute-  lNo permitas que a rabia y la tristeza por lo que perdemos (planes de viaje de trabajo o vacaciones , carreras cortas, maratones para los que nos hemos estado entrenando, la visita tan esperada de familiares o amigos que nos impulsa a diario a no sentirnos tan lejos de nuestra tierra de origen) te impida disfrutar de lo que si conservamos.
  • Pensar en que nuestras acciones individuales afectan el colectivo – Mientras escribo este articulo, me tope con mensaje en twitter que decía lo siguiente: Han visto a muchísima gente correr a los mercados a comprar todo lo posible al mismo tiempo y en el mismo momento en lugar de limitarse a comprar lo que verdaderamente necesitan para la semana o la quincena. Ahora imagínense la misma dinámica en los hospitales. En lugar de papel higiénico serian camas y ventiladores en la terapia intensiva que no serian suficientes para cubrir la demanda.
  • Cuida tus relaciones familiares y de amistad más allá de la necesidad de “distanciamiento social”. Se nos ha pedido evitar el contacto social y sobretodo físico en todas las areas de nuestra vida para prevenir el contagio viral. Cuando estes en casa o en tu lugar de trabajo No uses a tus seres queridos como “basureros” de tu angustia. Más importante que nunca es importante conservar y no poner en riesgo nuestras relaciones mas significativas.   Usa el teléfono para textos y llamadas de video conferencia para mantenerte juntos “cercanamente lejos”.
  • Busca ayuda psicológica lo antes posible – Mientras más temprano busques ayuda especifica mas fácil sera poder empezar a sentirte mejor. El uso excesivo de tranquilizantes sin prescripción medica puede disminuir nuestra capacidad para pensar y reaccionar frente a las crisis.

La invitación este mes es a ser un modelo para otros, a cuidarnos todos, tanto del virus como de la “locura” que puede producir.

by: Margot Brandi, MD,Sibcy House, Medical Director

 

Margot Brandi, MD
Staff Psychiatrist
Sibcy House, Medical Director
Lindner Center of HOPE

-“ Y hasta cuándo cree usted que podemos seguir en este ir y venir del carajo? – pregunto.

Florentino Ariza tenia la respuesta preparada desde hacia cincuenta y tres anos, siete meses y once días con sus noches.

 -Toda la vida – dijo.”
Gabriel Garcia Marquez en El amor en los tiempos del cólera.

En este mes de febrero, en el que querámoslo o no el asunto del amor se convierte en protagonista ,pienso en esta frase del final de El amor en los tiempos del cólera, que tal vez no sólo habla de una relación (Fermina y Florentino), sino también del arraigo  a un pueblo, de las rutinas pesadas del proceso de inmigración.Siempre la he pensando como una propuesta irreverente ante la eternidad del amor, la idea de un vinculo que perdura para siempre como el vinculo con el lugar de nuestro origen.  Pero, de qué amor estamos hablando…?

En el más reciente  juego de super bowl, justo entre el primer y segundo cuartos, me quede hipnotizada frente al comercial de una compañía de seguros que en 60 segundos paseaba al espectador a través de los 4 tipos de amor según el lenguaje de los antiguos griegos. EL comercial comenzaba explicando cómo los griegos tenían cuatro palabras para referirse al amor. La primera es PHILIA, que se refiere al afecto que crece desde la amistad. La segunda es STORGE que tiene que ver con el tipo de amor que se desarrolla hacia los padres o hacia los hermanos. El tercero es EROS que alude a la incontrolable urgencia de decir “te amo”. EL cuarto se llama AGAPE y es el más admirable, el amor como una acción, implica coraje, sacrificio y fuerza. Es aquello que nos inspira a poner las necesidades del otro primero que las nuestras. Es la búsqueda por convertirnos en la mejor version de nosotros mismos. El intento por construir un mejor futuro para aquellos que amamos.  El comercial es un reconocimiento a las acciones que tomamos todos los días para proteger a nuestros seres queridos. La emigración puede tomar esa forma. Lo que me pareció genial no fue tanto el comercial sino el “timing” del mismo. Me refiero a presentar estas ideas cuando nuestra mente esta básicamente atrapada por un sentimiento de rivalidad entre dos equipos, y el foco principal apuntando a  un consumismo descarado. Lograr una pausa para capturar nuestra atención y recordarnos nuestras prioridades. ( claro, y también vender muchos seguros) como si alguien hubiese cambiado el canal del televisor sin darnos cuenta.

Mi reflexion de este mes es la de tomarnos el mes de febrero como una pausa que nos permita recordarnos el poder del amor como acción, bien sea a través del mas pequeño de los gestos o la mas difícil de las decisiones como lo puede ser emigrar. Recordar de qué se alimenta la tan llamada fuerza de voluntad de un emigrante que empaca sus sueños en una maleta en busca de construir un mejor futuro para si mismo y sobretodo para nuestros seres queridos. Se trata de levantarnos todos los días y “seguir en este ir y venir “de nuestro diario vivir como inmigrantes, así como lo hizo Florentino, el protagonista de El amor en los tiempos del cólera. Poder mirar atrás con un amor melancólico, en mi caso por un país perdido irremisiblemente, o hacia adelante con la esperanza de que “en este ir y venir” nos construyamos un porvenir que trascienda nuestra geografía y nuestra generación.

 

 

By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief of Adult Psychiatry

May is Maternal Mental Health Awareness Month.  One in five women will develop a maternal mental health disorder.  They are also referred to as perinatal mood and anxiety disorders (PMADs) to emphasize that women experience more than postpartum depression during pregnancy and after birth.  Women who have symptoms of PMADs might not seek help because of guilt, shame, or embarrassment for feeling something different than the expected norms of motherhood.  Awareness and education are important to reduce stigma so mothers and babies get the help they need.

PMADs can occur during pregnancy or up to one year after giving birth. The most common PMAD is the “baby blues”, affecting up to 80% of new mothers.  Symptoms include sudden mood swings, loneliness, sadness, crying spells, loss of appetite, problems sleeping, irritability, restlessness, and anxiety.  These symptoms are a normal adjustment to changes in hormones and resolve without treatment in two to three weeks.

About 10% of women experience depression during pregnancy and about 15% during the first year postpartum.  Feeling sad, hopeless, helpless, or worthless; fatigue, difficulty sleeping or sleeping too much, appetite changes, difficulty concentrating, crying, loss of interest or pleasure; lack of interest in, difficulty bonding with, or excessive anxiety about the baby; feelings of being a bad mother, and fear of harming the baby or self are symptoms of peripartum depression.  Risk factors include poverty, being a teen mother, advanced maternal age; personal or family history of depression, anxiety, or postpartum depression; premenstrual dysphoric disorder, inadequate support, financial stress, relationship stress; complications in pregnancy, birth or breastfeeding; a history of abuse or trauma, a major recent life event, birth of multiples, babies in neonatal intensive care, infertility treatments, thyroid imbalance, and diabetes.

Anxiety can occur alone, or with depression, in 10% of new mothers.  Symptoms include constant worry, racing thoughts, inability to sit still, changes in sleep or appetite, feeling that something bad is going to happen; and physical symptoms like dizziness, hot flashes, and nausea.  Some mothers may also have panic attacks with shortness of breath, chest pain, dizziness, a feeling of losing control, and numbness and tingling.  Risk factors are a personal or family history of anxiety, previous perinatal depression or anxiety, and thyroid imbalance.

Post-traumatic stress disorder (PTSD) can occur in up to 6% of mothers following a traumatic childbirth.  Possible traumas are prolapsed cord, unplanned C-section, use of vacuum extractor or forceps to deliver the baby, baby going to NICU; and feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery.  Women who have experienced a previous sexual trauma are also at a higher risk for developing postpartum PTSD.  Intrusive re-experiencing of the traumatic event, flashbacks or nightmares; avoidance of stimuli associated with the event; increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response); anxiety and panic attacks, and feeling a sense of unreality and detachment are symptoms of PTSD.

Obsessive-compulsive disorder (OCD) can occur in 3% to 5% of new mothers.  Obsessions are persistent, repetitive thoughts or mental images, often related to the baby. Obsessions can be so bizarre or disturbing that they can be mistaken as psychosis.  Compulsions are repetitive acts performed to reduce obsessions.   Mothers are distressed by the obsessions which can lead to a fear of being left alone with the baby or hypervigilance in protecting the baby.  Mothers with postpartum OCD know that their thoughts are out of the ordinary and are unlikely to ever act on them.

Postpartum psychosis is the most severe of the PMADs.  It is often associated with an episode of bipolar disorder. It is rare, occurring in 1 to 2 per 1000 women.  The onset is abrupt, within 48 to 72 hours and up to two weeks after delivery. This is a psychiatric emergency, requiring immediate treatment.  Mothers may experience hallucinations (hearing voices or seeing things) and/or delusions (believing things that aren’t true.)  If psychosis occurs as part of a bipolar manic episode, there might be additional symptoms such as irritability, hyperactivity, decreased need for or inability to sleep, paranoia and suspiciousness, rapid mood swings, difficulty communicating, and confusion or memory loss. Risk factors are a personal or family history of bipolar disorder or a psychotic disorder.  Most women with postpartum psychosis do not have violent delusions but there is an up to 5% rate of infanticide or suicide due to acting on delusions or having irrational judgement.

PMADs are the most common complication of pregnancy and childbirth.  They are treatable with psychotherapy and/or medication and early intervention provides relief for the mother and ensures the baby’s wellbeing.