By Lauren Dyer, MSA, LAc, DiplAc (NCCAOM)
Postpartum depression (PPD) is a sensitive and stigmatized condition that afflicts 1 in 71 or 11-20%2 of women each year. Even a 15% average3 of 4 million live births4 each year in the United States means that nearly 600,0005 women a year suffer from PPD. These figures do not account for women who miscarry or whose babies are stillborn, and can still experience PPD symptoms. With consideration to these marginalized yet clinically recognized pregnancies, the estimated total women suffering from PPD is closer to 1 million annually.6 Unfortunately, only a fraction of women receive professional treatment. According to PostPartumProgress.org, “850,000 women each year are not getting the help they need”7 This stark lack of support is the result of empirical cultural and socioeconomic factors.
For instance, when societal and self-induced expectations of the 'maternal instinct'8 are unmet, a sense of isolation, incompetence, and shame ensues—i.e. the stigma of a “bad mother” emerges. Moreover, a lack of policies supporting paid maternity leave, job protection, and financial assistance also pose barriers for new mothers who lack the means (familial proximity, availability and/or financial) to take the time to care for themselves as well as their child. This barrier is exemplified by the United States, the only developed country devoid of partial-to-full paid maternity benefits unlike Sweden, the United Kingdom, and France9.
Unlike ancient, multicultural customs that honored the season of new motherhood—that understood “she was as vulnerable as her newborn, requiring her own steady stream of attention and care”10— in today's society, more concern is placed on the mother during the pre-natal and birthing phase. This attention is not just from physicians, but echoed in magazines, self-care books, and inadvertently the family too. Dr. Kendall Tacket, a health psychologist and International Board Certified Lactation Consultant poignantly describes this dynamic in the following manner:
“While a woman is pregnant, people may offer to help her carry things... to ask how she is feeling. Friends (or family) will give her a baby shower...there are prenatal classes and prenatal checkups, and many people wanting to know about the details of her daily experience... After she has her baby, however, mother-focused support rapidly declines. Typically a woman is discharged from the hospital within 24 to 48 hours after a vaginal birth, or 2 to 4 days after a cesarean... She may or may not have anyone to help her at home... Her mate will probably return to work within the week, and she is left alone to make sure she has enough to eat, to teach herself how to breastfeed, and to recuperate from birth... the people who do comearound are more interested in the baby...(and) she must wait to see her physician until her 6-week postpartum checkup.”11
These sentiments are part of an insidious interplay in which modern new mothers are “pressure(d) to bounce-back—(bounce) back to (their) pre-pregnancy productivity, back to (their) pre-pregnancy body, and back to (their) pre-pregnancy spirits”12. It is worth elucidating these cultural dynamics and disparities to demonstrate that the demands of a new mother are not to be underestimated or overlooked as exacerbating factors to PPD. These pressures only perpetuate more (unreasonable) expectations that can generate greater feelings of guilt, self-doubt, and despondency. Alleviating these pressures where possible through cultural awareness, public policy, and professional medical help (the focus of this paper), will serve to foster healthy child development and family dynamics.
Although postpartum depression is indeed perpetuated by our cultural paradigm exalting busy lifestyles, high demands, “supermoms”, and the like, it should also be understood within the context of its physiological manifestations and essential etiology—taxation on a physical, mental, and emotional level as a result of labor and embarking on a paramount life transition “from expecting woman to new mother”13.
What follows is a discussion of postpartum depression's a) mechanisms from a biomedical and traditional Chinese medical (TCM) perspective, b) common TCM patterns and acupuncture treatment approaches therein, and c) a summary of research on Acupuncture's efficacy for postpartum depression and depression as a whole.
According to The National Institute of Mental Health (NIMH), the biomedical cause of PPD is attributed to drastic and erratic changes in hormone levels following birth, with recognition given to compounding factors such as sleep deprivation, physical discomfort, and exhaustion.14 PPD can become pronounced immediately after birth and at any time during the child's first year. Most women with PPD will exhibit symptoms by their 3rd week postpartum. A range in severity of clinical symptoms from the NIMH include: a) feelings of depression, irritability, rage, restless and/or moodiness; b) crying easily with or without perceived anxiety, worry, or fearfulness; c) difficulty concentrating; d) a loss of interest or withdrawing from social situations, family, and activities once found enjoyable; e) feeling disconnected and/or apathetic towards their child; and f) consistently doubting their ability to care for their child and/or considering harming themselves or their child”15.
The risk of developing PPD is higher in women who have a history (or family history) of drug/alcohol abuse and depression. The occurrence of a traumatic event occurs at or around the time of birth, as a lack of emotional support from their spouse, family, and friends are all predisposing factors as well16. Current biomedical treatments for PPD include counseling/talk therapy and pharmacological intervention, with anti-depressants the primary medication prescribed.
In TCM, “birth is a shift from a yang state, in which the pregnant woman's body is warm with the high volume of circulating blood and full due to the presence of a baby in her womb, to a more yin state—the empty and cold counterbalance to yang”17. During birth, a woman loses an abundance of qi, blood, fluids, and jing essence, becoming deficient in these vital substances.
If not replenished quickly and abundantly through rest and nutrition, these deficiencies can have nearly irrevocable or at least long-lasting effects on her health and vitality with respect to the functionality and harmony between her zang-fu organs and “anima”18 (spirits: shen, hun, po, yi, zhi). In other words, TCM recognizes PPD, it just does so under the lens of specific patterns and their distinctive expressions through the anima that arise due to taxation/deficiency following childbirth.
As women are more yin in nature, TCM practitioners are aware that the nature of birth coupled with inadequate rest and nourishment make women more susceptible to Blood and yin deficiencies, explicitly of the Liver Blood/yin, Heart Blood/yin, Spleen qi/yang, and Kidney yin/jing essence. If the placenta is retained for too long, or if there is residual scarring from birth, Blood stasis (and qi stagnation)19 is also a pattern worth considering.
In addition to deficiencies of vital substances, there can also be imbalanced interactions between vital organs, i.e. Heart Blood and Spleen qi, Heart and Kidney yin, and Heart and Lung qi. The Lung and Po spirit can also be afflicted by grief, most obviously in cases of trauma during pregnancy/birth including stillborn deliveries or miscarriages, both of which can still lead to symptoms of PPD. This pattern, as aforementioned, would most likely manifest in persistent sadness related to Heart and Lung qi constraint20. All patterns can be complicated by Liver qi constraint and mixed in nature. Postpartum patients seeking acupuncture will often complain of depression, sadness, worry, fear, fatigue, insomnia, melancholy, difficulty concentrating, and/or poor appetite/digestion, with possible accompaniment by head/body aches and pains.
A traditional Chinese approach to the postpartum period is characterized by the phrase “zuo yuezi”21, which refers to “(the) Gateway...a threshold between one way of being (pre-natal) to another (postpartum)”22. It is also translated as “confinement”23 or “retreat”24 meant to convey the importance of mothers and their babies guarding themselves not just from the outside world (noises, people, and exogenous pathogens), but their relationship to one another in the earliest stages. During zuo yuezi, mothers are encouraged to reinvigorate their yang by sipping herbal teas and eating warm, soft, easily digestible substances that serve to a) strengthen the Spleen, b) nourish Blood and yin (especially for producing breast milk), and of course c) build qi. Ideal foods include soups, bone broths, congee, cooked vegetables, and animal protein (if vegetarian, ensuring an abundance of plant-based protein and iron from legumes, tofu/tempeh, whole grains (quinoa, oatmeal), plus nuts and seeds.
Research conducted on acupuncture for postpartum depression yields promising findings when comparing acupuncture to pharmacological treatment. According to “Observation on therapeutic effects of acupuncture plus psychological intervention for postpartum depression,” researchers found that
“acupuncture combined with psychological intervention has a similar total efficacy rate for the treatment of postpartum depression as the drug fluoxetine hydrochloride (Prozac®)”25. The total efficacy rate for acupuncture plus counseling was 90.7%, while that of Prozac® alone was 90.5%26. At first glance, perhaps this is not impressive. However, consideration should be made for the fact that, despite the lack of statistical significance in the difference between total efficacy rates, acupuncture did not elicit any of the side effects experienced with Prozac® such as “nausea, dizziness, and loss of appetite”27. Therefore, acupuncture and counseling combined is just as good as if not slightly more effective than medication for depression alone. For this trial, acupuncture was performed once a day, five times a week, for six weeks altogether. “The acupuncture points used in the study were: Baihui (GV20), Sishencong (EX-HN1), Neiguan (PC6), Taichong (LR3), Sanyinjiao (SP6), Zusanli (ST36)”28. For the explanation of these point selections, as described by researchers, please reference
TABLE A: Postpartum Acupuncture Point Protocol Summary29
Where the mind is housed & yang channels gather
Where the mind is housed & yang channels gather
Luo-Connecting: benefits heart, calms mind
Regulates qi, blood, yin, yang (with Hegu LI-4)
Access 3-Foot-Yin Channels, regulate qi & blood
Benefits blood production, ST qi, source qi
These findings on acupuncture's efficacy are consistent with a more recent meta-analysis and systematic review showing that acupuncture paired with antidepressant eases depression severity more than pharmacological intervention with SSRIs (selective serotonin re-uptake inhibitors) alone30.
Physiological mechanisms that enable acupuncture to ease depression severity include its ability to regulate gene expression and the body's levels of melatonin, serotonin, dopamine, norepinephrine, and endogenous opioid-peptides31. In other words, acupuncture facilitates a shift in the central nervous system's state—from 'fight or flight' (sympathetic) to 'rest and digest' (parasympathetic), promoting relaxation and regeneration on a cellular level. The common thread through these studies is their promising implications for acupuncture as an “effective, safe and well-tolerated monotherapy for depression” and postpartum depression alike.
When working with new mothers, TCM practitioners have the opportunity to pass on the tenants of zuo yuezi, the 'gateway' and 'retreat', by nurturing their patient's transition into motherhood with grace. We can do this by encouraging patience in the phases and healing process ahead, and create space for self-acceptance therein. Whether a new mother exhibits or expresses experiencing postpartum depression/anxiety, combining point protocols found efficacious via evidence based research as well as those which address the nuances in patient's pattern or patterns are ideal. Combining such a holistic approach of acupuncture, Eastern dietary therapy, and herbal therapy (not discussed but nonetheless applicable) in a stigma-free space can ensure not only expedient but empowered postpartum healing.
Lauren Dyer, MSA, LAc, DiplAc (NCCAOM), is co-owner of EMPOWER Chiropractic & Acupuncture in New Gloucester, Maine. She earned her master’s from the Finger Lakes School of Acupuncture and Oriental Medicine (FLSAOM) and is in the process of earning her doctorate of acupuncture (DAc) from Pacific College of Oriental Medicine. She is passionate about spreading awareness of acupuncture's viability in our healthcare system and is dedicated to providing patients with the highest standards of care. Lauren specializes in acupuncture for women's health, especially postpartum care.
Acupuncture Alleviates Postpartum Depression. (2014, December 21). Retrieved October 24, 2017, from http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1411-acupuncture- alleviates-postpartum-depression
Acupuncture Antidepressant Pairing Eases Depression. (2015, February 02). Retrieved October 24, 2017, from http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1424- acupuncture-antidepressant-additive-depression-relief
Chan, Yuan-Yu, Wan-Yu Lo, Szu-Nian Yang, Yi-Hung Chen, and Jaung-Geng Lin. "The benefit of combined acupuncture and antidepressant medication for depression: A systematic review and meta-analysis." Journal of Affective Disorders (2015).
Huang, Han-ling, Li Peng, Su Zheng, and Lu-shan Wang. "Observation on therapeutic effects of acupuncture plus psychological intervention for postpartum depression." Journal of Acupuncture and Tuina Science 12, no. 6 (2014): 358-361.
Maclean, W., & Lyttleton, J. (2010). Clinical Handbook of Internal Medicine: The Treatment of Disease With Traditional Chinese Medicine (Vol. 3, Qi, Blood, Fluid, Channels). Pangolin Press.
Ou, Heng., Belger, Marissa., & Greevan, Amely. (2016). The First Forty Days: The Essential Art of Nourishing the New Mother. Stewart, Tabari & Chang: ABRAMS Press.
Postpartum Depression Facts. (n.d.). Retrieved October 24, 2017, from https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml
Tackett, Kendall Dr., “How Cultures Protect the New Mother.” Women's Health Today. Praeclarius Press: Excellence in Women's Health. Published 30 Jul. 2017. Retrieved Oct 24, 2017. http://womenshealthtoday.blog/2017/07/30/how-cultures-protect-the-new-mother/
“The Statistics.” Post-Partum Progress.org. (Published 2013, December 18). Retrieved October 24, 2017, from http://postpartumprogress.org/the-facts-about-postpartum-depression/
1“The Statistics.” Post-Partum Progress.org. (Published 2013, December 18). Retrieved October 24, 2017, from http://postpartumprogress.org/the-facts-about-postpartum-depression/
- “The Statistics.” Post-Partum progress.org.
- Postpartum Depression Facts. (n.d.). Retrieved October 24, 2017, from https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml
- “The Statistics.” Post-Partum progress.org.
- Maternal Instinct meaning the expectation for new mothers to immediately bond with their child
- Heng Ou, Marissa Belger & Amely Greevan. (2016). The First Forty Days: The Essential Art of Nourishing the New Mother. Stewart, Tabari & Chang: ABRAMS Press., “Maternity Leave Around The World.” Chapter 2.
- Heng Ou, et. al., The First Forty Days., “Introduction,” 3.
- Dr. Kendall Tackett, “How Cultures Protect the New Mother.” Women's Health Today. Praeclarius Press: Excellence in Women's Health. Published 30 Jul. 2017. Retrieved Oct 24, 2017. http://womenshealthtoday.blog/2017/07/30/how- cultures-protect-the-new-mother/
- Heng Ou, et. al., The First Forty Days., “Introduction,” 3.
- 13 Ibid.
14Postpartum Depression Facts. (n.d.). Retrieved October 24, 2017, from National Institute Health, https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml
25“Acupuncture Alleviates Postpartum Depression.” (2014, December 21). Retrieved October 24, 2017, from http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1411-acupuncture-alleviates-postpartum-depression
Reference: Han-ling Huang, et. al. "Observation on therapeutic effects of acupuncture plus psychological intervention for postpartum depression." Journal of Acupuncture and Tuina Science 12, no. 6 (2014): 358-361.
30Acupuncture Antidepressant Pairing Eases Depression. (2015, February 02). Retrieved October 24, 2017, from http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1424-acupuncture-antidepressant-additive- depression-relief
31Acupuncture Antidepressant Pairing Eases Depression., Ibid.