This week is not just about one article, because just one article did not provide enough evidence to convince me. There is a lot of biased information out there, a lot of people trying to sell products, and a lot of people with very little education/expertise who tout being “experts” in this subject. Even after researching this, I’m still left with a lot of questions and this is because there is still research that needs to be done in regards to vitamins and their link to mental illness. See below for information reviewed for this post.
Since there was not just one article, I will pick my favorite of the ones listed below, titled “Dubious MTHFR Gene Mutation Testing.” While reading this article, I assumed it was written by someone in the medical field; however, I was very surprised to find the author, Jann Bellamy, is actually an attorney. I greatly appreciate her writing and valid points. If you have time, please read it.
This (horribly time-consuming) rabbit hole started after being contacted by a pharmaceutical company trying to promote their medication (a $150/month multivitamin) for prevention and treatment of depression in pregnancy. After our discussion, I was convinced this was a great medication. The “pharm rep,” as they’re typically called, said this medication is ideal for women who want to get off of antidepressants during pregnancy and take a more “natural” approach to treatment. The pharm rep said recent research was done by a Harvard psychiatrist showing that, in women trying to become pregnant or in pregnant women <28 weeks gestation, this medication prevented depression symptoms from occurring in those with a history of depression, and significantly decreased symptoms in those who already were experiencing depression. One concerning piece of this study though, and there were several, is it only followed these women for 12 weeks, and did not look at the time that women are most vulnerable for depression relapse - in postpartum. The pharm rep followed up by sending me the other peer-reviewed journal articles referenced in our discussion, but after reading these articles, I realized they actually didn’t provide any evidence for using that particular multivitamin.
So I began my own search of the scientific literature, and looked to my frienemy, “Dr. Google,” to help me figure out whether or not this medication is worth the cost since most insurances don’t cover it. I discovered that a woman can get the same benefits for much less money by taking a prenatal vitamin and some l-methylfolate over the counter. My next quest was to find out if genetic testing for MTHFR (which this pharm company conveniently sells a kit for, as well) was necessary.
Through this, I learned that MTHFR gene mutation testing is essentially pointless, unless there is concern for homocystinuria - a rare and potentially fatal genetic disorder. Otherwise, testing homocysteine levels will provide just as much information. I won’t go into the boring biochemistry, but checking for elevated homocysteine levels is actually more accurate, and cheaper, than testing for a genetic mutation in MTHFR. This is because, carrying a variant of the MTHFR gene (or two), doesn’t necessarily mean the MTHFR enzyme is not functioning adequately. Some variant mutations function just fine and do not necessarily affect the enzyme’s ability to process dietary folic acid.
If serum homocysteine is elevated, it means folic acid and/or homocysteine are not being properly broken down. This could be either because of a defective MTHFR enzyme, or it could be due to malnutrition. Either way, the “cure” is to take vitamins. All of the vitamins necessary for this reaction are actually found in the majority of prenatal vitamins (+DHA). The only one missing is l-methylfolate (rather than folic acid). Just pick up 10-15 mg of l-methylfolate from a local pharmacy, add it to a DHA prenatal vitamin, and viola! it’s essentially a DIY version of their medication for a fraction of the cost. It’s important to point out this medication does not have all of the components of a prenatal vitamin. So, although the inventor told me it can be used in leu of a prenatal vitamin, I highly disagree. Furthermore, I personally would be concerned about using this in addition to a prenatal vitamin, since some vitamins are in both and would be above the recommended upper limit in pregnancy. I also want to point out that the inventor argues this medication is superior to prenatal vitamins because the components are all in their “reduced” forms, meaning they do not need to be metabolized. While this is helpful for a very small portion of the population, this is not necessary for the majority of patients.
I haven’t really answered the initial question of whether or not vitamins can treat depression. For that, I could not find consistent evidence in scientific literature. Bottom line, we need better research studies to give us this answer. Eating healthy food though, will generally improve mood (not clinical depression) without any associated risk. When Deplin, an expensive prescription form of l-methylfolate, is used by itself, we do not see the robust effect we had anticipated. Like most illnesses though, the cause of depression is multifactorial. Those who use just one approach to treat it, typically don’t see the same positive results that are seen by people using multiple modalities. So while everyone would love an “all-natural” pill that cures depression, I just don’t think that will ever exist. Moderate to severe mental illness, like most biological illness, needs medication, a healthy diet, exercise, and meditation/therapy to treat it.
1. About MTHFR by EnBraceHR
2. Overview of homocysteine and folate metabolism by Blom et al
3. Reprotox.org for researching effects of different dosages of vitamins on fetal and infant development when ingested by the mother.
4. PubChem Compound Database to review various vitamin compounds
5. Prenatal Vitamins by WebMD
6. Dietary Supplement Fact Sheet by NIH
7. B vitamins and homocysteine by Harvard
8. Various pages from Ben Lynch’s website, MTHFR.net
9. MTHFR Mutation Test by Medline Plus
10. Blog post by 23andMe
11. MTHFR gene overview by NIH’s Genetics Home Reference website
12. A Genetic Test you Don’t Need by Cleveland Clinic Health Essentials
13. Dubious MTHFR Gene Mutation Testing by Science Based Medicine
By Sarah Rivers Deal, PhD, LPC With Perinatal Loss month in October, I wanted to introduce myself through this blog as well as cast a light in the often dark places that hold this kind of silent, disenfranchised grief. As a psychotherapist that specializes and has been trained in infertility counseling, I too experienced my own reproductive trauma. Five years of fertility and alternative medicine treatments yielded a roller coaster of emotions, existential crises, and ultimately, two small graves in our back yard. Allow me to share something I wrote after my first miscarriage. We read to know that we are not alone – and – you are not alone. If you’re like me, the struggle to create life took over my life. It was all I thought out, dreamt about, planned for, spoke about, made exceptions for, ate for, stopped drinking my favorite red wine for – you name it. Life became hinged on hypotheticals – What if we get pregnant after I accept this new position? What if I accept this invitation then can’t travel in a few months because I’m pregnant? Should we buy the house in the better school district or wait until little one is here? What if little one never gets here? As much as I tried to balance my life, infertility crept in at every turn. In her insightful memoir, The Art of Waiting, Belle Boggs describes this all-consuming experience, calling it the Take Over – “…the problem with infertility is that it is not a patient, serene kind of waiting, not a simple delay in your plans; it happens for many of us in the context of consuming struggle, staggering expense, devastating loss.” Deciding to pursue fertility treatments put my barrenness on the front burner, making it difficult to escape. After five years in fertility clinics, more people had seen my vagina than the inside of my home. What was supposed to be private and magical between my partner and I was now public and scientific. All around me, women were “blessed” with babies, flaunting them as little “miracles.” These terms are especially painful for those struggling to conceive, as it implies that certain people are chosen while others are not. As much as I tried to participate in the world, being around pregnant women or infants was hazardous to my mental health. I remember attending my first baby shower in several years, believing I was safe now because my partner and I were months away from our daughter (by way of adoption) being born. Hope had begun to blossom again in my heart, as I believed that soon I would be a mom too. While I was emotionally prepared for my friend Serena to be eight months pregnant (after years of trying and two miscarriages), I wasn’t informed that the shower host was visibly pregnant too, and to boot – after only one round of I.V.F. with the same doctor I used. As we munched on our blue painted cookies shaped like pacifiers, I learned that the champagne drinking host had a 9-year-old son already, and became recently engaged after finding out about the pregnancy. I wish I could say I genuinely celebrated her happy news, but on the inside, I was fuming. On the drive home, with no other car in sight, I blasted the radio and screamed bloody murder. Despite various challenging life experiences up to this point, I still somehow believed in the concept of justice – a philosophy of how fairness is administered. To put it simply, it seemed unfair to me that this host woman was pregnant and going to be a mom – for the second time – and all I had to show were memorial stones in my yard commemorating two pregnancy losses. Unfair that I had earned high marks for effort and still wasn’t getting to graduate. Unfair that I wasn’t stroking my own belly, marveling at the miracle of science and creation itself. Infertility or perinatal loss may be experienced as an existential crisis, planting seeds of doubt in life questions you thought you had basically addressed, figured out, or had plenty of time to answer. What legacy will I leave behind? Who will carry on my values? Who will remember me after I’m gone? Am I broken? Dr. Anne Malavé, mental health expert in the field of infertility, wrote – “Infertility is like trying to find your children. The child, the imagined and expected child whose presence is palpable yet missing, feels near. It feels like searching for a lost child–you keep looking and searching around every corner. To stop trying can feel like an abandonment of an actual baby, of “my/our own baby.” Pamela Mahoney Tsigdinos in her raw, genuine book Silent Sorority, poignantly captures this existential crisis – “One instant you are like everyone else. The next, you’re not. Your DNA now ends with you. You are infertile. Your branch of the family tree will forever be just a truncated twig. You’ve been denied a rite of passage, a biological imperative. You had no say in the matter. It wasn’t a conscious choice. The comfortable sense of continuity and legacy others take for granted disappears in an instant.” After experiencing perinatal loss in 1999, Amy Douglas poetically wrote: “A life inside me, a love so strong. She died inside me, but the love lives on. It broke my heart for her to go. I love her, I need her like she’ll never know.” If infertility and/or pregnancy loss have ever been downplayed as a less significant human loss, Tsigdinos, Malavé, and Douglas legitimize the profound aftershocks of devastation experienced by those affected. From my personal and professional experience, I want you to know that the takeover is part of the journey. Well- meaning partners and friends might advise you to find a hobby to try to get your mind off of it, to relax, but that probably won’t help. It IS where you are right now, and that’s okay. Most people will be uncomfortable with your discomfort, and you’ll likely receive your fair share of unsolicited and unhelpful advice. Being the recipient of said advice, I tried to remind myself to listen to their intentions, not words. Week after week, clients that struggled with infertility would say something like – “These next few weeks I want to focus on my work and getting back into exercise” or “I want to start hanging out with my friends again and expanding my social circle.” We would set vague or concrete goals, depending on the client, and vow to focus on balance and self-care. And then, week after week, these same clients would come in ashamed, embarrassingly admitting that even if they did go to the gym or see an old friend, the ghost of infertility haunted them. They wanted to be more present in the here-and-now, they really did. Although I truly believe the takeover must run its course, there may be some coping skills and strategies to help it along. And I’m certain that whatever I tell you won’t always work. Some days the takeover will allow some wiggle room to remember the other aspects of your life; other days – it won’t. If you’ve felt quite low more days than not, and for an extended period of time, please check it out with a doctor. I will share with you the most salient professional (and personal) guidance here, and hope that on a few days, it might help. But please, don’t beat yourself up if it doesn’t. Honor the takeover, but also look for windows where you can see the larger picture. 1. Do something that has direct, observable results. You likely have felt powerless for a while. I want to you to do something, no matter how simple, where you can see results. Start with something easy. Make your bed. If you feel relatively competent cooking, use a recipe to create something, then share it with someone. Plant something that you can watch grow. Start with a plant that’s native and more likely to survive; you do not need a failure right now. Rearrange furniture in your space; a new look often evokes new feelings. 2. Practice Self-Compassion Breaks. I adopted this idea from the lovely Dr. Kristin Neff, a self-compassion researcher and professor from my town in Austin, Texas. Here’s the step-by-step process: a) When you notice that the Take Over has happened, say to yourself: “This is a moment of suffering” or “This hurts.” (It may help to place one hand over your heart = self-soothing gesture) b) Then say, “Suffering is a part of life.” c) Then, “May I give myself the compassion or understanding that I need right now.” Then breathe in and out, consciously and with intention. 3. Mindfulness (paying attention on purpose) is an Eastern practice, but its application has hit Western shores, and I’m a firm believer that it’s a necessary healing tool in your toolbox. You can become a conscious consumer of your mind, observing with a curious and gentle sense what’s going on in there. None of us would believe that a face cream could make us look a certain way after a few applications. However, we often experience our thoughts as facts, then experience powerful emotions as a result. It’s important to get some space from our thoughts, and see them for what they are – potentially unhelpful narratives. Use the letters N-N-R to remember the steps: a) Notice. Your mind is an active, interesting narrator that tries to piece information together but often falls short. Become a neutral, curious observer of your mind. Think of it as a radio, always playing music (some songs on repeat). b) Name (thoughts, feelings, body sensations, urges). For example, you may be ruminating (circular thinking that goes nowhere except down) something like “It’s not fair Tamara is pregnant. She didn’t even want another baby” and so on. As soon as you notice you’re stuck on a loop, say to yourself – “That’s a thought” You may notice tightness in your chest. Ask yourself what your feeling. Then say, “I’m having a feeling of sadness.” Noticing and naming gives you critical space to honor what’s going on with you without letting it suck you in automatically. c) Re-engage: Get back to what you were doing before you got caught in the loop. Re-engage in the moment. 4. Make a playlist or soundtrack for various themes throughout your fertility/infertility journey. For example, weeks before my 2nd I.V.F. transfer, I made a compilation of uplifting songs, burned them on a CD that I titled “Hope,” and played it every chance I got. A week after my first miscarriage, I made another playlist, calling it “Coping.” These songs were instrumental in helping me process the often contradictory emotions I experienced. Your body’s limitations don’t define you. Focus on what your body CAN do for you right now. Can you walk, jog, skip, hop, swim, or hug someone? It’s easy and completely understandable to get caught on a failure-loop narrative. But you’re not a failure. This is your roadblock, your life challenge, your grief and sorrow, your call to action. Answer the call, my friends. Above all, be patient with yourself. You are not alone. (Originally written September 2017; Revised September 2020) Dr. Sarah Rivers Deal is an Austin-based licensed professional counselor that specializes in infertility and reproductive trauma. She’s a member of the American Society for Reproductive Medicine (ASRM) and has participated in numerous trainings on infertility counseling and perinatal loss.
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