Archive for October 19, 2013

Vacant Mother? Spit in the Cup

What alarmed me was their timing. The first person to notice me in the doorway of their family room was the baby in the corner of the crib in the corner of the room. She locked onto me long enough to tag me as a stranger and then let out a slow, cat-like wail—loud but empty of urgency. Her father, Mitch, who faced the half-curtained window while folding baby pajamas near the laundry basket on the floor, finished his folding and carefully laid the pajamas on one of the stacks on the table before turning first to the baby and then to me.  Apparently he hadn’t heard his mother greet me at the front door and or the shuffle of my feet in the doorway, even though the TV was on mute. He lumbered over to hand the baby her stray bottle in the crib and crossed the room to show me in.

In front of the muted TV in a recliner with her back to me and the rest of the room, sat Tina. It was only a few more seconds before she got up, but a notable few seconds too long. The room seemed to be under a spell.  They were out of step with each other.

And when Tina stood up, she turned to me without a glance at her baby and greeted me, smiling with her mouth but not her eyes.  In my embrace she seemed to shrink away rather than fill my arms, as she once had.  I’d never seen her with make-up on a Saturday morning at home. As we talked about her job dilemma—whether to go for full-time and a possible promotion or back off to half-time–I felt a rising impatience with her.   What was this vacant look in her eye-shadowed eyes, this pausing in her speech, this monotone voice, this new twitch with her right thumbnail flicking the raw hangnail on her index finger? Her timing was off. She looked exhausted. I resisted the impulse to shake her and shout, “Wake up!!”

This friendly visit ended without a word about maternal depression because it’s not that kind of friendship. But I fear for the girl in the crib in the corner. What I really wanted to ask Tina was to spit in a cup—all three of them, really—and talk about the elephant in the room.  My interest in collecting spit comes most recently from a fascinating article just published about a study of the role of oxytocin in maternal depression. Oxytocin is the hormone that facilitates breast-feeding and attachment, not only in mothers and infants but also attachment in men and throughout life.

Spurred by the observation that post-partum depression raises the risk for trouble in the newborn child and for some years after (anxiety, developmental delays, poor school performance), this study examined depressive symptoms in a group of healthy mothers in Israel during the first year after childbirth and 6 years later.  The investigators also collected salivary oxytocin levels and oxytocin genetic samples on the mothers, fathers, and children during the six year study.  It’s amazing what a little spit can tell you about our internal worlds.

Not only did the chronically depressed mothers have low oxytocin levels, but so did their husbands and their children!  By age six the children of the chronically depressed mothers had four times the rate of mental disorders (anxiety, oppositional behaviors, ADHD) as the children of non-depressed mothers. And the children of depressed mothers showed less capacity for empathy and social engagement than the children of non-depressed mothers.  One genotype associated with low oxytocin was more common in the depressed mothers, as well as their husbands and children. On the other hand,  a child whose depressed mother had the genotype associated with better oxytocin functioning was protected against high risk for mental disorders at age six.

Why is this such big news?  At least two reasons.  First, this study points to a new approach to identifying who is at risk for maternal depression. In addition to the traditional risk factors such as severity of depressive symptoms and a personal or family history of clinical depression, oxytocin levels and oxytocin genotyping may improve our estimates of risk for maternal depression and risks for the children. This study reminds us that it’s not just the mothers, but the children and, amazingly, the husbands too who bear the risk.

Depression is sometimes a disorder of attachment. The pathway to depression for families is partly genetic and partly environmental: detached people disrupt the attachment systems of those around them, especially those who are genetically vulnerable to poor attachment patterns.

Second, spotlighting the oxytocin system in its relationship to depression opens new possibilities for treatment.  So far, no antidepressant medications developed over the past 40 years have targeted oxytocin. This study suggests that treatments for maternal depression, whether pharmacologic or behavioral, could focus on shoring up the disrupted oxytocin-related attachment system. Interventions that help the depressed mother stay in contact with her newborn may spare the whole family much trouble in their first 6 years of raising the child.

Should we all start spitting in cups? Not yet. An editorial accompanying this report of the study from Israel details some of the technical barriers to developing medication treatments aimed at correcting deficiencies in the oxytocin system. But it’s not too soon to change how we approach maternal depression.  Timely care for the depressed mother can spare the child.