Postpartum depression isn’t always postpartum. It isn’t even always depression. A fast-growing body of research is changing the very definition of maternal mental illness, showing that it is more common and varied than previously thought.
Scientists say new findings contradict the longstanding view that symptoms begin only within a few weeks after childbirth. In fact, depression often begins during pregnancy, researchers say, and can develop any time in the first year after a baby is born.
Recent studies also show that the range of disorders women face is wider than previously thought. In the year after giving birth, studies suggest, at least one in eight and as many as one in five women develop symptoms of depression, anxiety, bipolar disorder, obsessive-compulsive disorder or a combination. In addition, predicting who might develop these illnesses is difficult, scientists say. While studies are revealing clues as to who is most vulnerable, there are often cases that appear to come out of nowhere.
As public awareness has grown, often spiking after a mother kills herself or her baby, a dozen states, including Illinois, New Jersey, Texas and Virginia, have passed laws encouraging screening, education and treatment, and New York and others are considering action. The federal Affordable Care Act contains provisions to increase research, diagnosis and care for maternal mental illness.
Sometimes cases are mild, resolving themselves without treatment. But a large analysis of 30 studies estimated that about a fifth of women had an episode of depression in the year after giving birth, about half of them with serious symptoms.
Jeanne Marie Johnson, 35, of Portland, Ore., had a happy pregnancy, but she began having visions right after her daughter, Pearl, was born. She said in an interview that she imagined suffocating her while breast-feeding, throwing her in front of a bus, or “slamming her against a wall.”
She said she was horrified at the idea of hurting her baby, and did not carry out the acts she envisioned. Yet while overlooking a shopping mall skating rink, “I pictured myself leaning over the bridge and letting her fall and bust like a watermelon,” she said. “I was actively thinking of ways to harm her.”
Most women experiencing such “intrusive thoughts,” as experts call them, never hurt their children. Some take extreme measures to protect their babies. One woman “scooched downstairs on her butt for months because she’d imagined throwing her baby downstairs,” said Wendy N. Davis, the executive director of Postpartum Support International.
But studies indicate that maternal stress may undermine women’s ability to bond with or care for their children, and that children’s emotional and cognitive health may suffer as a result.
A complex interplay of genes, stress and hormones causes maternal mental illness, scientists say. “Hormones go up more than a hundredfold,” said Dr. Margaret Spinelli, the director of the Women’s Program in Columbia University’s psychiatry department. After birth, hormones plummet, a roller coaster that can “disrupt brain chemistry,” she said.
Some women are genetically predisposed to react intensely to hormone changes. And some are more sensitive to stresses like difficulties with family, finances, childbirth or parenting.
Maternal mental illness is not new. It was recognized as early as the fifth century B.C., when Hippocrates proposed that fluid from the uterus could flow to the head after childbirth and cause delirium. In the Middle Ages, mothers with such symptoms were viewed as witches or victims of witchcraft. In the 1920s, one Freudian-inspired theory attributed these mood disorders to frigidity, suppressed homosexuality or incestuous urges.
Scientific understanding has come a long way and continues to evolve. The Diagnostic and Statistical Manual of Mental Disorders, the established reference for psychiatric illnesses, first described these symptoms in 1994 as “major depressive disorder” beginning within four weeks of childbirth. The latest manual, published last year, said symptoms often include “severe anxiety and even panic attacks,” and estimated that half of what is considered major postpartum depression actually begins during pregnancy.
Depression in pregnancy can be missed because symptoms like trouble sleeping and moodiness also occur in pregnant women who are not depressed. And doctors have historically been taught in medical school that “women don’t get depressed during pregnancy because they are happy,” said Dr. Katherine L. Wisner, a professor of psychiatry and obstetrics at Northwestern University.
In a 2013 study, the largest screening of women for postpartum depression to date, Dr. Wisner and colleagues found that 14 percent of 10,000 women had depression four to six weeks after birth, but that for a third of them it actually started during pregnancy.
Other research indicated that symptoms could emerge any time in the first year.
Another 2013 study assessed 461 women at two weeks and six months postpartum, and it found each time that 11 percent had obsessive-compulsive symptoms, about four times the rate for the general population of women. But it was “not the same 11 percent,” said an author, Dr. Dana Gossett, the chief of gynecology and obstetrics at Northwestern. “Half got better by six months and another half developed O.C.D.”
Research also shows that women can have several psychiatric disorders at once. In Dr. Wisner’s study, two-thirds of the women with depression also exhibited anxiety; nearly a quarter had bipolar disorder.
Tina Duepner, 34, of DeSoto, Mo., had symptoms ranging from racing thoughts to suicidal feelings. She said she heard God’s voice from a television, and other voices warning that her son, Landon, would be stolen from her.
She said stress in her life included a previous miscarriage, premature labor requiring bed rest, and a cesarean section.
Ms. Duepner said she was treated successfully, although she required three short psychiatric hospitalizations. She wanted more children, but said doctors advised against it so she had her tubes tied.
Previous depression puts women at greatest risk of maternal mental illness. Having immediate relatives with bipolar disorder also increases vulnerability. Ms. Duepner did not have prior depression. But her mother, Marie Carr, has bipolar disorder, and both maternal grandparents had psychiatric illnesses, Ms. Carr said.
Financial strain, isolation, breast-feeding difficulties or unplanned pregnancy can also increase risk.
The Second Son
Emily Guillermo, 23, of Horizon City, Tex., had a smooth, joyous experience with her first child, even though her husband spent three months deployed with the Army in Iraq and watched Christopher’s birth on Skype.
“It felt very natural to become a mother to him,” she said.
Then, despite using contraception, she conceived again. Overwhelmed, she said that she and her husband agreed to abort but reconsidered after learning she was 20 weeks pregnant. She said she descended into depression during pregnancy, feeling “like my body had been invaded.”
When Benjamin was born, six weeks premature, Ms. Guillermo recalled thinking, “You’re not supposed to be mine. You were not supposed to be made.”
She had loved breast-feeding Christopher, but pumped milk for Benjamin. “I could not stand to have him at my chest,” she said. “I was like a robot. I changed him, I fed him, I burped him. Because I never held him, he started to get a flat head.”
She fantasized about abandoning Benjamin at a fire department, or faking an accident. She imagined driving at high speed into a wall, sparing Christopher’s life by intentionally wrecking the side of the car where Benjamin was strapped into a car seat.
Postpartum disorders can involve more intense visions than mental illnesses unrelated to childbirth, said Dr. Wisner.
Terrified she might hurt Benjamin, Ms. Guillermo said she thought about finding a family to adopt him. One night, “I just blurted out, ‘I don’t love Benjamin.’ ” She said her husband, stunned, assured her they would get her help, and said, “Until then, I will love him enough for both of us.”
Her first medication failed. Once, she forcibly shut Benjamin’s jaw when feeding him. During several baths, “I held the water over his face until he started to flail, he could not breathe,” she said. “I was hearing a voice saying, ‘Do it and he will stop crying. He’s not going to wake Christopher from his nap.’ ”
Something would make her stop and put him in his crib. But for a few seconds, she could not remember “if I had killed him, or if he had drowned, or what I had done,” she said. Benjamin became frightened. “When I’d walk into his room, he’d burst into tears.”
Suicidal, she tried to jump from a car as her husband drove, their sons in back, but she said he stopped her, telling her: “You will love Benjamin. We just need to get you on the right medication.”
The third drug combination she tried worked when Benjamin was 9 months old. She started feeling love toward him, and with Postpartum Support International’s help, worked to improve their relationship.
She said his development had regressed. Instead of distinct cries for hunger or sleepiness, he reverted to “one hysterical cry because he had grown accustomed to me taking my time to meet his needs.”
Benjamin is now 21 months old, and his development is back on track. “He still has a long way to go with me,” she said. “I’m his mother now, and he knows that, and I think Benny loves me now too.”
State Legislatures Respond
As more states pass laws relating to postpartum depression, the hope is to catch problems early. Symptoms are frequently treatable, though finding effective medication or therapy can take time.
Only New Jersey requires screening under a 2006 law championed by Mary Jo Codey, then the state’s first lady, who had had postpartum depression. That mandate has drawn mixed reviews. A study in New Jersey of poor women on Medicaid found that required screening has not resulted in more women being treated. Katy Kozhimannil, a University of Minnesota public health professor and an author of the study, said the law educated pediatricians and obstetricians, but did not compensate them for screening.
There are also not enough treatment options, Dr. Kozhimannil said. “If a woman comes with a baby, and it’s a place treating people with substance abuse or severe mental illness, she may be uncomfortable.”
In New York, State Senator Liz Krueger has introduced a bill to encourage screening and treatment, a proposal that will most likely pass and be approved by Gov. Andrew M. Cuomo, who vetoed a 2013 bill on technical grounds but encouraged the revised legislation.
Jeanne Marie Johnson, in Oregon, may have benefited from state laws encouraging awareness of postpartum mental illness. At her daughter, Pearl’s, two-week pediatric checkup, Ms. Johnson received a questionnaire. Her answers raised red flags and were forwarded to her midwife and a social worker. Ms. Johnson also called a number for a hotline the hospital gave her after a panic attack.
She saw a social worker, but resisted taking medication for months. Afraid to be alone with Pearl, she would insist her mother come over when her husband was out. “I called the doctor hotline constantly,” with nonexistent concerns, “because if I was talking on the phone I wouldn’t do anything harmful.”
She said she felt suicidal and escaped emotionally by drinking wine or gin while taking bubble baths.
Finally, after a nerve-racking emotional explosion, she agreed to take medication. That, combined with a support group and Pearl’s lessening colic, helped.
Until Pearl was 4 months old, “I did love her but I didn’t like her,” Ms. Johnson confessed.
Now, her relationship with 2-year-old Pearl is loving and untroubled, said Ms. Johnson, who sees a therapist, partly to grapple with three recent miscarriages, but no longer takes medication.
“I don’t know if I’ll need it if I have a baby again,” she said. “There are still times at the end of the day where I don’t have energy left. But even at really big stressful times, I haven’t felt panicky feelings or intrusive thoughts. It’s just a whole world of difference.”
The medical profession is very concerned at the rising tide of obesity and all the ill-health this brings, but it appears the solutions are insurmountable. People like the wrong foods too much, and we are much less active. This equals major problems ahead.
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You can buy food from farmers — directly, through markets, any way you can find — and I hope you do. But unless you’re radically different from most of us, much of what you eat comes from corporations that process, market, deliver and sell “food,” a majority of which is processed beyond recognition.
The problem is that real food isn’t real profitable. “It’s hard to market fruit and vegetables without adding value,” says Marion Nestle, a professor of nutrition, food studies and public health at New York University. “If you turn a potato into a potato chip you not only make more money — you create a product with a long shelf life.” Potatoes into chips and frozen fries; wheat into soft, “enriched” bread; soybeans into oil and meat; corn into meat and a staggering variety of junk.
How do we break this cycle? You can’t blame corporations for trying to profit by any means necessary, even immoral ones: It’s their nature.
You can possibly blame them for stupidity: Even a mindless parasite knows that if it kills its host the party’s over, and by pushing products that promote “illth” — the opposite of health — Big Food is unwittingly destroying its own market. Diet-related Type 2 diabetes and cardiovascular disease disable and kill people, and undoubtedly we’ll be hearing more about nonalcoholic steatohepatitis, or NASH, an increasingly prevalent fatty liver disease that’s brought on by diet and may lead to liver failure.
Food companies are well aware of the health crisis their products cause, and recognize that the situation is unsustainable. But one theory has it that as long as even one of the big food companies remains cynical and uncaring about its market, they all must remain so.
Chief among the hopeful arguments is one that goes something like this: The first big food outfit to recognize that its future lies in creating a market for healthy and even environmentally neutral food (let’s throw in justice for workers and animal welfare while we’re at it!) may show the way to the future of healthy food as a sound business model. Some profitable corporations nibble at the edges of this already, but — as a piece in the current Harvard Business Review points out — American capitalists have become poor innovators.
Only the naïve, however, would believe that Big Food is generally working toward this. As Nestle and Michele Simon, author of “Appetite for Profit,” have been saying for years, these organizations represent not the public interest but the corporate one, and since they haven’t devised a way to improve or even maintain their bottom lines selling real food, they have to appear to be selling “better” food.
The food industry also wants us to ignore its use of that strategy to increase its market share and profits; and it wants to maintain legitimacy at a time when community groups and public health officials are, writes Ken, “demanding limits to their involvement” in supplying food to children.
Our efforts to demand limits on the sale of junk to children are a threat to Big Food. If we succeed, it fails, or at least suffers. But if industry succeeds, whether in selling blatant junk or re-engineered versions that are low in fat or sodium or gluten- or sugar-free or reduced-calorie or high fiber or whatever — companies can create any frankenfood they feel will sell — we will continue to suffer. (Nestle often says, “A slightly-better-for-you junk food is still junk food.”) Our health will decline further, the environment will be further degraded, and our health care system (and therefore economy) will spend an increasingly disproportionate amount of money on diet-generated chronic disease.
If the most profitable scenario means that most food choices are essentially toxic — in the sense that overconsumption will cause illness — that’s a failure of the market, not of individual choice. And government’s rightful role is not to form partnerships with industry so that the latter can voluntarily “solve” the problem, but to oversee and regulate industry. Its mandate is to protect public health, and one good step toward fulfilling that right now would be to regulate the marketing of junk to children. Anything short of that is a failure.
Kegel exercises have long been considered women’s work. Because they tone the pelvic floor muscles that support the uterus, doctors encourage women to do them during pregnancy and continue them for life. Done for a few minutes a day, Kegels can ease childbirth, help with recovery, prevent incontinence — even improve your sex life.
But Kegels are not just for women anymore. Pelvic floor exercises can help treat incontinence and perhaps sexual dysfunction in men, too, studies have found. Now the rush is on to persuade middle-aged men to get on the bandwagon.
“People do cardio exercises for their heart, and they do strength training and work on their six-pack, but the pelvic floor is neglected,” said Dr. Andrew L. Siegel, a urologist and author of a paper in the July issue of Urology that reviews the benefits of Kegels for men. “These muscles are the backboard of sexual and urinary health.”
Dr. Siegel is a co-founder of Private Gym, a company marketing a new pelvic floor exercise system for men that includes an instructional DVD as well as a rather unusual device: small, ultralight weights on a silicone band that fits around the penis, intended for men who want to add a bit of resistance training to their routines.
Men have the same network of pelvic floor muscles that women do, extending like a hammock from the tailbone to the pubic bone. The muscles support the back, abdomen, bladder and bowel, and help maintain fecal and urinary continence. In men, these muscles surround the base of the penis; they are activated during erection, orgasm and ejaculation, and are responsible for the surge of blood flow to the penis.
Like all muscles, these weaken with age, doctors say. In order to strengthen them, men are told to tighten the muscles they might normally use to cut off the flow of urine midstream or prevent passing gas in a closed space. The contractions are held for a few seconds, then released, with the motion repeated 10 to 15 times for each workout.
“It’s as good as Viagra, without the costs and the side effects,” said Grace Dorey, a professor emeritus of physiotherapy and urology at the University of the West of England and an enthusiastic proponent of Kegels for men. “The pelvic floor muscles provide the base for the erection — for the penis to sit on, if you will.”
One of the main selling points of Private Gym is that healthy men can enhance their sexual function through a Kegel exercise regimen that includes those tiny weights. A small clinical trial is underway, but so far there’s no proof and some experts are skeptical.
“I’d be very cautious about claims of enhancing sexual function and orgasm,” said Dr. Roger Dmochowski, a professor of urologic surgery at Vanderbilt University Medical Center who specializes in incontinence. “There are other important factors that affect sexual function, like obesity and diet, overconsumption of alcohol, and smoking, which impacts blood flow and can have a negative impact.”
For most men, he says, lifestyle changes are the surest route to better sex. Yet there is strong evidence that pelvic floor exercises are important for men who undergo a radical prostatectomy and are at high risk for incontinence.
Studies showing that Kegels can hasten recovery from prostate surgery have been so convincing that surgeons now routinely recommend patients start Kegels before or shortly after the surgery. In one clinical trial of men about to undergo prostate surgery, patients were randomly assigned to start doing Kegels before the operation or to get standard care without exercises.
The difference in outcomes was startling, said Dr. Patricia S. Goode, medical director of the incontinence clinic at University of Alabama at Birmingham and one of the authors of the study, published in 2006.
“We were measuring the median time until the men were totally continent after the surgery, and in the trained group it was three and a half months,” she said. In the untrained group, half the men were not dry by six months, she added.
The American Urological Association also recommends Kegels, along with other behavioral modifications, for both men and women who have overactive bladders. Men with severe back pain should avoid Kegels, however, and anyone who has undergone surgery should consult their doctor. While many women have long experience with Kegel exercises, doctors find many men initially are baffled by them. Some have trouble simply locating the appropriate muscles.
Dr. Dorey has this simple advice: “It’s the area you sit on when you’re sitting on a horse.
Being a male and in this demographic, the decision whether to have a PSA test or not, is of the utmost importance to me. Many of my friends and acquaintances have had prostatectomies, with all the attendant sexual and urinary problems afterwards. Many of those probably had unnecessary operations, according to the evidence. This is the similar dilemma women have with mammograms, and overdaignosis and over treatment. See under”Breast screening- mammography” on this web-site.7 August 2014, 3.38pm AEST
Study urges caution about prostate cancer screening
Prostate cancer screening could reduce deaths from the disease but it should not be routine, according to a study published…
Prostate cancer screening could reduce deaths from the disease but it should not be routine, according to a study published today in the medical journal The Lancet.
The study, which looked at men between the ages of 50 and 74 from eight European countries, randomly divided participants into two groups – one that would receive the prostate specific antigen (PSA) test every four years (two years in Sweden) while the other was not screened.
“Going back 30 years, prostate cancer was mostly diagnosed when it was already too late to be successfully treated,” said Bruce Armstrong, professor of public health at the University of Sydney.
“All that changed when radical prostatectomy came along. And in around the same period of time, it was realised that PSA testing might be useful for early detection.”
The PSA test measures a prostate-specific antigen (an antigen is something that induces an immune response) in the blood. Although it’s the only practical tool we have for detecting prostate cancer early, it is not particularly accurate.
The perils of PSA
“The problem with the PSA test is that, although it’s prostate specific, it’s not prostate cancer specific,” said associate professor of evidence-based practice at Monash University Dragan Ilic.
“So men who have an enlarged prostate, for example, or an inflamed prostate due to some sort of bacterial infection may also have a very elevated PSA test result. That’s where the limitations of the PSA test arise.”
Widespread use of the PSA test saw prostate cancer rates shoot up, said Armstrong, and anyone looking at that and knowing about screening tests would say “wow, we’re finding a lot of cancer here and possibly quite a lot that would never come to light were it not for the PSA test”.
The PSA test is said to be only about 60% to 70% accurate, but all men who have above a certain level of prostate-specific antigen are usually sent for a trans-rectal ultrasound-guided biopsy. While necessary to diagnose prostate cancer, when it is there, biopsy carries a small risk of infection.
“The problem with the PSA test, and to some extent the biopsy, is that it can’t readily distinguish between slow-growing cancers of the prostate, which the majority are, and fast-growing cancers, which are the ones that threaten life,” said Ilic.
This appears to be the reason why the study authors do not recommend population-wide PSA screening. The worry of diagnosis of a cancer that was never itself going to cause harm is only the start of a series of harms.
Over diagnosis and over treatment
Study leader Professor Fritz Schröder from Erasmus University Medical Center in the Netherlands told The Lancet that while PSA screening delivered a substantial reduction in prostate cancer deaths, similar or greater to that reported in screening for breast cancer, over-diagnosis occurred in roughly 40% of cases detected by screening, resulting in a high risk of over-treatment and common side effects, such as incontinence and impotence.
Ultimately, it really starts to bite when treatment is given for a cancer that would not otherwise have caused a problem, Armstrong said.
Somewhere around 70% of men will be rendered unable to obtain an erection firm enough for sexual intercourse following radical treatment, and around 15% will have some problem with urinary continence on a long-term basis, he added.
Ilic said the commonly used line was that men were more likely to die with prostate cancer than from it.
“Consider this 20% lower chance of dying. One way to look at that is if you look at the figure of one in ten lifetime risk of being diagnosed with cancer as the baseline,” he said. “A 20% reduction in 10% is not all that significant.”
“I see the evidence as currently favouring a beneficial effect from PSA testing but it remains an open question whether or in what circumstances the benefits are sufficiently great to counter the harms of what is fairly substantial over-diagnosis,” Armstrong said.
We may think of ourselves as just human, but we’re really a mass of microorganisms housed in a human shell. Every person alive is host to about 100 trillion bacterial cells. They outnumber human cells 10 to one and account for 99.9 percent of the unique genes in the body.
Katrina Ray, a senior editor of Nature Reviews, recently suggested that the vast number of microbes in the gut could be considered a “human microbial ‘organ’” and asked, “Are we more microbe than man?”
Our collection of microbiota, known as the microbiome, is the human equivalent of an environmental ecosystem. Although the bacteria together weigh a mere three pounds, their composition determines much about how the body functions and, alas, sometimes malfunctions.
Like ecosystems the world over, the human microbiome is losing its diversity, to the potential detriment of the health of those it inhabits.
Dr. Martin J. Blaser, a specialist in infectious diseases at the New York University School of Medicine and the director of the Human Microbiome Program, has studied the role of bacteria in disease for more than three decades. His research extends well beyond infectious diseases to autoimmune conditions and other ailments that have been increasing sharply worldwide.
In his new book, “Missing Microbes,” Dr. Blaser links the declining variety within the microbiome to our increased susceptibility to serious, often chronic conditions, from allergies and celiac disease to Type 1 diabetes and obesity. He and others primarily blame antibiotics for the connection.
The damaging effect of antibiotics on microbial diversity starts early, Dr. Blaser said. The average American child is given nearly three courses of antibiotics in the first two years of life, and eight more during the next eight years. Even a short course of antibiotics like the widely prescribed Z-pack (azithromycin, taken for five days), can result in long-term shifts in the body’s microbial environment.
But antibiotics are not the only way the balance within us can be disrupted. Cesarean deliveries, which have soared in recent decades, encourage the growth of microbes from the mother’s skin, instead of from the birth canal, in the baby’s gut, Dr. Blaser said in an interview.
This change in microbiota can reshape an infant’s metabolism and immune system. A recent review of 15 studies involving 163,796 births found that, compared with babies delivered vaginally, those born by cesarean section were 26 percent more likely to be overweight and 22 percent more likely to be obese as adults.
The placenta has a microbiome of its own, researchers have discovered, which may also contribute to the infant’s gut health and help mitigate the microbial losses caused by cesarean sections.
Other studies have found major differences in the microorganisms living in the guts of normal-weight and obese individuals. Although such studies cannot tell which came first — the weight problem or the changed microbiota — studies indicate obese mice have gut bacteria that are better able to extract calories from food.
Further evidence of a link to obesity comes from farm animals. About three-fourths of the antibiotics sold in the United States are used in livestock. These antibiotics change the animals’ microbiota, hastening their growth.
When mice are given the same antibiotics used on livestock, the metabolism of their liver changes, stimulating an increase in body fat, Dr. Blaser said.
Even more serious is the increasing number of serious disorders now linked to a distortion in the microbial balance in the human gut. They include several that are becoming more common in developed countries: gastrointestinal ailments like Crohn’s disease, ulcerative colitis and celiac disease; cardiovascular disease; nonalcoholic fatty liver disease; digestive disorders like chronic reflux; autoimmune diseases like multiple sclerosis and rheumatoid arthritis; and asthma and allergies.
Some researchers have even speculated that disruptions of gut microbiota play a role in celiac disease and the resulting explosion in demand for gluten-free foods even among people without this disease. In a mouse model of Type 1 diabetes, treating the animals with antibiotics accelerates the development of the disease, Dr. Blaser said.
He and other researchers, including a team from Switzerland and Germany, have also linked the serious rise in asthma rates to the “rapid disappearance of Helicobacter pylori, a bacterial pathogen that persistently colonizes the human stomach, from Western societies.” Once, virtually everyone harbored this microbe, which European researchers have shown protected mice from developing hallmarks of allergic asthma.
H. pylori colonization in early life encourages production of regulatory T-cells in the blood, which Dr. Blaser said are needed to tamp down allergic responses. Although certain strains of H. pylori are linked to the development of peptic ulcer and stomach cancer, other strains are protective, his studies indicate.
Still, it is not always possible for researchers to tell whether disruptions in gut microbiota occur before or after people become ill. However, studies in laboratory animals often suggest the bacterial disturbances come first.
Dr. Blaser, among many others, cautions against the overuse of antibiotics, especially the broad-spectrum drugs now commonly prescribed. He emphasized in particular the importance of using fewer antibiotics in children.
“In Sweden, antibiotic use is 40 percent of ours at any age, with no increase in disease,” he said. “We need to educate physicians and parents that antibiotics have costs. We need improved diagnostics. Is the infection caused by a virus or bacteria, and if bacteria, which one?
“Then we need narrow-spectrum antibiotics designed to knock out the pathogenic bacteria without disrupting the health-promoting ones,” Dr. Blaser added. “This will make it possible to treat serious infections with less collateral effect.
A threat to male fertility
The New York Times, 03/24/2014
To study the impact of everyday chemicals on fertility, federal researchers recently spent four years tracking 501 couples as they tried to have children. One of the findings stood out: while both men and women were exposed to known toxic chemicals, men seemed much more likely to suffer fertility problems as a result. The gender gap was particularly wide when it came to phthalates, those ubiquitous compounds used to make plastics more flexible and cosmetic lotions slide on more smoothly. Women who wore cosmetics often had higher levels of phthalates in their bodies, as measured by urinalysis. But only in their male partners were phthalate levels correlated with infertility. “It’s the males in the study that are driving the effect,” said Germaine Buck Louis, an epidemiologist at the National Institute of Child Health and Human Development and lead author of the report, published in February in Fertility and Sterility. “They’re the signal.
I am going to be away for most of December and part of January, so anyone wanting to see me should make an appointment ASAP, as my books are fillling up fast. If your script is going to run out over the holiday period, then I suggest you make an arrangement to have it filled before I return (Mid Jan).
Health Check: the ins and outs of burping and farting
To understand why we fart, you need to know something about the volume of gases produced in the bowels first. Imagine how much space 25 litres of gas would occupy – about one third of the interior of a…
To understand why we fart, you need to know something about the volume of gases produced in the bowels first.
Imagine how much space 25 litres of gas would occupy – about one third of the interior of a small car. That’s how much gas you produce every day in your intestines. So it’s little wonder that farting, bloating and burping are relatively common.
Much of this gas production is recycled – by re-absorption and use within the gut, particularly by the almost two kilograms of bacteria in your colon. Indeed, almost 22.5 litres is absorbed by the gut, used by gut bacteria or expires through the lungs.
Passing what remains
The remaining two and a half litres is what you pass through your bowels every day. On average, men fart 12 times a day while women fart seven times – in portions of 30 to 120 millilitres. The total is the equivalent of a blown-up party balloon.
The number of times someone passes gas varies with the time of day; some pass more in the mornings and others more in the evening. But it largely depends on the sensitivity of the nervous system in the your rectum. If you have an increased sensitivity, perhaps because of a condition such as irritable bowel syndrome, you may fart more often.
Most of the gas your body produces has no aroma, although about 40% of the population has the capacity to produce smelly hydrogen sulphide gas from the left side of the bowel because they carry a particular bacteria.
Smelly farts are of no great medical significance except in somebody with colitis, which is an inflammation of the large bowel or colon. A flare in colitis is often associated with the production of smelly gases, so have yourself checked out if you have smelly farts accompanied by diarrhoea or bleeding.
Previous pregnancy, particularly with complications, surgery and ageing may result in changes in the pelvic muscles that make it difficult to control gas. This can be socially awkward, especially if you pass smelly gas.
What’s making you gassy?
More gas is produced after meals, particularly those that contain lots of fibre, such as cereal, bread and pasta. Although there are many other foods, such as artichokes, beans, Brussels sprouts and eggplant, which also greatly influence the volume and aroma of farts.
Foods containing sulphur as a preservative, such as fruit juice, wine, processed meats and dried fruit also lead to more farting. These foods are used by the sulphur-producing bacteria in your guts to form hydrogen sulphide gas.
There are a variety of dietary ingredients that may increase farting as well as bloating, particularly high-fibre foods which ferment in the colon to produce gas.
One of these is fructose (a sugar contained in fruits), which leads to more gas production because we don’t have an enzyme to break it down. If consumed in large amounts, fructose can contribute to increased gas when it reaches the colon where it’s fermented by bacteria.
This is particularly true of apples and pears, and their juice. Another culprit is stone fruit. When stone fruits are not quite ripe, they have higher pectin content, which is also fermented in the colon.
Then there are unripe bananas, which have a higher content of starch and less sugar than ripe ones. This passes to the colon as resistant starch producing more gas from gut bacteria. Orange pith can similarly contribute to excessive gas.
Often, as we age, the function of the pancreas gland, which is involved in digestion, slowly wanes and we can’t handle fruits and vegetables we previously were able to eat with the same ease. The pancreas produces insulin to control blood sugar levels and these important enzymes are required to digest fat, protein and carbohydrates.
We should accept that farting is normal for the vast majority of people. If you feel your farting is a problem then you should look first to your diet before consulting a general practitioner about the potential for an underlying gastrointestinal problem.
Cindy Wachenheim was someone people didn’t think they had to worry about. She was a levelheaded lawyer working for the State Supreme Court, a favorite aunt who got down on the floor to play with her nieces and nephews, and, finally, in her 40s, the mother she had long dreamed of becoming.
But when her baby was a few months old, she became obsessed with the idea that she had caused him irrevocable brain damage. Nothing could shake her from that certainty, not even repeated assurances from doctors that he was normal.
“I love him so much, but it’s obviously a terrible kind of love,” she agonized in a 13-page handwritten note. “It’s a love where I can’t bear knowing he is going to suffer physically and mentally/emotionally for much of his life.”
Ms. Wachenheim’s story provides a wrenching case study of one woman’s experience with maternal mental illness in its most extreme and rare form. It also illuminates some of the surprising research findings that are redefining the scientific understanding of such disorders: that they often develop later than expected and include symptoms not just of depression, but of psychiatric illnesses.
Now these mood disorders, long hidden in shame and fear, are coming out of the shadows. Many women have been afraid to admit to terrifying visions or deadened emotions, believing they should be flush with maternal joy or fearing their babies would be taken from them.
But now, advocacy groups on maternal mental illness are springing up, and some mothers are blogging about their experiences with remarkable candor. A dozen states have passed laws encouraging screening, education and treatment. And celebrities, including Brooke Shields, Gwyneth Paltrow and Courteney Cox, have disclosed their postpartum depression.
Ms. Wachenheim’s sister, Deb, is among those breaking the silence.
“We did try to help her, but perhaps if we had been more knowledgeable about postpartum mood disorders, including the fact that postpartum depression is just one of an array of such mood disorders, we could have done something differently that would have maybe saved her life,” she wrote in an email.
Cindy Wachenheim’s experience defied the long-held belief among doctors and experts that symptoms emerge within a few weeks after birth. She seemed fine until her son was about 4 months old, said family and friends. And as a healthy, active woman, Cindy had no risk factors that would signal a mother likely to become delusional and suicidal.
“She loved life, she loved family, she was social,” said her sister-in-law, Karen Wachenheim.
In fact, Cindy, long interested in women’s issues and social justice, had, years earlier, identified postpartum depression in Karen. “Cindy would call at least once a day to check on me,” Karen recalled. “She said, ‘Maybe you have postpartum; I think it’s past the baby blues.’ ” At Cindy’s urging, Karen got therapy and medication, recovering quickly.
A Son Who Was ‘My Heart’
Cindy grew up in Colonie, N.Y., outside Albany, where she was her high school’s valedictorian. She attended the State University of New York at Buffalo and Columbia Law School. She valued public service and took a job doing research and writing for judges on the State Supreme Court in Manhattan.
When her mother became ill with leukemia, and later her father with lung cancer, Cindy would travel upstate to go to their medical appointments with them. When her siblings or their children had medical checkups, Cindy jotted the dates in notebooks, and called the night before to remind them to fill her in.
“I think she even kept all those books too, in a shoe box,” said her brother, Ron. “People collect stamps; she collected that stuff.”
She married at 40, and she and her husband underwent fertility treatment. She miscarried twice. But family and friends said that while mourning those losses and dealing with fertility hormones, she remained hopeful, noting that doctors said it was a good sign she had been able to become pregnant.
“She just thought that she’s going to keep trying and take each step as it came,” said a longtime friend, Julie Knapp.
Experts say little evidence links fertility treatment to postpartum mental illness; indeed, becoming pregnant may bring more joy than stress. Still, Wendy N. Davis, the executive director of Postpartum Support International, said some women experience cumulative stress from “fertility treatments, many losses, and the very, very high expectation she will enjoy this new baby.”
Eventually, Cindy was able to conceive and have an uneventful pregnancy, her only out-of-the-ordinary response being a tendency to be hyperaware of whether the fetus was kicking.
Cindy gave birth normally and adored her son, often calling him “my heart.”
“Not unlike a lot of high-achieving women, she was somewhat of a perfectionist, and she also wanted to be the perfect mother,” Deb said. Still, she was pretty easygoing in the first months of her son’s life, even when she had to introduce formula early because she produced too little breast milk, Deb said.
But when her son was 4 months old, Cindy emailed Deb that he was making “strange/jerky movements w/his right arm,” almost “flapping like a wing.”
The pediatrician said it was nothing to worry about, but Cindy scoured the Internet for diagnoses. She fixated on an instance a few weeks earlier, in August when, while washing clothes, she briefly left the baby on a play mat on the floor. He fell while pushing up, hitting his head.
She believed this minor episode had caused him severe neurological problems: seizures, autism, concussion. She blamed herself for leaving the room, for placing the play mat on the hardwood floor. Other incidents alarmed her, and she decided he was more irritable, smiling less.
She visited two pediatric neurologists. Then she saw an expert in cerebral palsy because her son did not always exhibit the Landau reflex, a Superman-like pose babies make when held aloft, stomach-down.
In October 2012, when her son was 5 months old, she emailed a doctor she had seen that day: “When you said babies can’t injure their brains from even several floor-level head hits on a wooden floor, did that include hits even if they are turning and hit back or side of head on the floor?”
The doctor replied: “That’s right. Little bumps on the head at floor level that a baby may cause themselves in the course of normal spontaneous movements would not cause any injury. Babies are really very hardy (thank goodness)!”
Cindy sent the doctor a video of her son, noting that “he almost always moves the right hand when holding a toy, reaching to grab something, etc.”
The doctor responded: “All of his movements look like normal, age-appropriate movements to me.”
Her siblings assured her that their children had made similar movements, but she was implacable. Without telling her sister, Deb called the pediatrician, who said she was also concerned about Cindy. Deb said Cindy’s husband worried too, although “part of him said: ‘Maybe she’s right. She is smart and was with the baby all the time.’ ”
Still, both Cindy’s husband and siblings urged her to seek therapy.
“I just really want you to see someone,” Deb emailed Cindy. “You cannot continue like this, for your sake and for his sake.”
Cindy agreed, but insisted that she had no postpartum mental illness. She told her family she was simply depressed because of the harm she had done to the baby.
“You can hardly imagine how it feels to strongly believe he has brain damage and that I caused it,” she emailed Deb. “It must be one of the top one or two nightmares for any parent. iloveyou, cindy.”
Consumed With Worry
Experts say such breaks from reality are likely symptoms of postpartum psychosis, which affects only one or two in 1,000 mothers. About 4 percent of those hurt their children; about 5 percent kill themselves. Flagrant cases usually emerge soon after birth; women may hear voices or feel compelled to inflict harm, like Andrea Yates, who drowned her five children in a bathtub in 2001, or Dena Schlosser, who in 2004 cut off her infant’s arms. Both women were ultimately found not guilty by reason of insanity.
“More subtle forms of psychosis are going to be picked up later,” said Dr. Katherine Wisner, a professor of psychiatry and obstetrics at Northwestern University. These women “tend to have prolonged delusional thinking: ‘there’s something really wrong with my baby.’ ”
Most other maternal mood disorders do not involve such unshakably unrealistic convictions; most women know something is wrong, and although they fear they will harm their children, they rarely do.
At Thanksgiving in 2012, Cindy’s family gathered at her brother Ron’s home outside Albany, and Cindy, normally outgoing, seemed consumed with her son’s supposed problems. She told Deb she had thought about suicide, saying “How can you go on knowing that you’ve ruined your baby’s life and it was your fault?” Deb was stunned. She and Cindy’s husband discussed the situation, hopeful that therapy would help.
Later that visit, the baby rolled off a low bed. It was one of several times that Cindy panicked and took him to the emergency room, where doctors pronounced him fine.
The next month, Cindy began seeing a psychiatrist, who prescribed Zoloft, an antidepressant. She briefly visited other counselors for talk therapy. Friends offered support and company.
One January weekend at Ron’s house, she seemed more engaged, smiling more. When Deb asked, she acknowledged still having thoughts of suicide, but said her psychiatrist had told her it was not too worrisome “as long as they’re not getting more frequent,” Deb recalled.
Family and friends wonder now if she was feigning feeling better. “Now I think maybe she was backing off so everyone wouldn’t think she was crazy,” Karen said.
Experts said postpartum psychosis symptoms can fluctuate. Sometimes women are “lucid and not delusional,” said Dr. Davis of Postpartum Support International. “Then they slip back into delusions more easily than with other types of psychosis.”
The mixed signals from Cindy continued into March. She discussed returning to work and finding day care. On a visit to her mother-in-law on Long Island, she called Deb while strolling by the ocean and sounded good. But the next day, Sunday, the baby fell while pulling up on a chair in his grandmother’s kitchen. Cindy considered it another disastrous “head hit.”
On Tuesday, Cindy uncharacteristically canceled her psychiatrist’s appointment, citing rain. On Wednesday, as she sometimes did, Cindy asked her husband to come home from work. When he arrived, she said their son’s morning had been rough, but that she was feeling better. After a few hours, he returned to work.
That afternoon, with her baby snug to her chest, she jumped.
“I am so unbearably sorry, which I know does nothing to undo the evil I have done,” her farewell note began. “I wanted to be a mother so badly and I hoped to be a wonderful one, and instead I have become the worst of the worst.”
Searching for anything to blame herself for, she described minor, harmless moments: tucking a light blanket over his face for warmth, letting him suck a leaf, briefly putting a dime in his mouth and immediately removing it. “These things I did were horrible,” she wrote.
She was sure her son would never walk, and said she believed his most recent fall caused a concussion. “I’m so so sorry, but I can’t bear for him to suffer more and more.”
She said she knew others would see her suicide as a result of “postpartum depression/psychosis.” But, she said: “I know I am right that I mistakenly harmed him. I’m not claiming a voice told me to do this.”
She even chastised herself for crumbling emotionally, saying she made her son a less happy baby.
“I don’t know if there is a hell,” she wrote, “but I hope so.”
Cindy Wachenheim would never know that in her last act, her body cushioned the fall for her son and saved his life. Weeks later, the healthy little boy took his first steps.
A version of this article appears in print on June 17, 2014, on page D1 of the New York edition with the headline: After Baby, an Unraveling .