Scott Stuart, M.D.
Associate Professor, Department of Psychiatry, University of Iowa

Michael W. O'Hara, Ph.D.
Professor and Chair, Department of Psychology, University of Iowa

IPT for perinatal depression has been extensively studied at the University of Iowa Treatment of Depression Clinical Research Center. In addition to our work with postpartum women (O'Hara, Stuart et al. 2000) (Stuart and O'Hara 1995), we are currently conducting a large scale study investigating the use of IPT for depression during pregnancy. Within the next several months, we will also be launching a study investigating the use of IPT for relapse prevention for postpartum women.

The use of IPT for this population is extremely important for several reasons. First, many pregnant and breastfeeding women strongly prefer not to use medication under any circumstances for fear it will adversely affect their children. Second, it is well documented that postpartum depression is associated with the development of attachment and behavior problems in children. Similarly, depression during pregnancy is associated with poor prenatal health and a risk for delivery complications. Consequently, it is imperative to treat depression during these times, and IPT appears to be an effective and well accepted alternative to antidepressant medication.

Our work using IPT with a perinatal population has led us to make several modifications for use these women. Research has shown that depressed postpartum women often attribute mood changes and symptoms such as anhedonia and low motivation to normal changes after childbirth, or to difficult children. As a consequence, many postpartum women with significant symptoms of depression will under report their difficulties. Additionally, many of the symptoms of depression, such as poor sleep and lack of energy, are similar to changes which women experience during a normal prenatal or postpartum course. Information must also be collected regarding the patient's expectations about motherhood, and her feelings regarding her child and their relationship. It is essential to obtain information regarding the planning of the pregnancy, the course of the pregnancy, and the labor and delivery process.

We have found it useful to conceptualize most cases of perinatal depression as role transitions. Placing perinatal depression within this problem area provides a reasonable rationale for patients to understand their problems, and makes intuitive sense to most patients. In addition, it also implies that the depression will be time-limited. Role transitions in the postpartum period are typically associated with the need to develop new parenting skills and the ability to manage new responsibilities while attempting to maintain old relationships. A patient may find herself in the position of having to juggle several different roles, each with increasing demands. A decrease in self-esteem is often the result, as well as confusion regarding which relationships and responsibilities should be given priority. Though it is infrequent that familiar social supports are lost entirely, they often have to be modified to a large degree.

A typical example of a role transition in the postpartum period is a working woman who is now faced with the role of "mother" in addition to her previous roles of "spouse" and "employee." In such a situation, the patient may become overwhelmed if she is unable to reconfigure her priorities and time and emotional commitments. A difficult spouse or employer could easily exacerbate the problems faced by such a patient. A strategy we often employ is to assist the patient to understand the types of relationships she has with her spouse and her employer, and her expectations about those relationships. The patient is helped to develop a balanced view of her needs, and the degree to which they are being met. The therapist then assists the patient to clearly communicate her needs to her significant others as the relationships are renegotiated.

The patient should also be made aware that others in her interpersonal sphere have also undergone significant role transitions. The patient's husband or significant other must also make significant adjustments as he takes on the role of "father". The same is true to a lesser degree for extended family members. As the patient begins to appreciate that others are in a transition period as well, she is able to shift from a "blaming" stance to one in which negotiation with her significant other is possible.

Interpersonal disputes are also quite frequently associated with depression in perinatal women. Antenatally, disputes frequently involve changes in the woman's relationship with her significant other. In our experience, this is particularly true of women with poor social support and those from lower socioeconomic backgrounds. Typical postpartum conflicts involve disputes between the patient and her husband regarding child care responsibilities, and conflicts with extended family members regarding the patient's management of her newborn. We advise therapists to thoroughly explore the expectations the patient had prior to delivery as well as examining the communication patterns in the conflict.

We have found it helpful to include the patient's husband or significant other in one or two therapy sessions when role transitions or interpersonal disputes are at issue. The purposes of this includes obtaining ancillary information about the patient's behavior, examining in detail the alternative point of view of the other party in the dispute, and allowing the therapist to examine the "in-vivo" interactions between the patient and her significant other. Psychoeducational information can be provided to the partner as well. This often involves information about normal sexual changes and sexuality during the postpartum period.

IPT for Postpartum Depression: Research Data

We have recently completed a large scale investigation of the efficacy of IPT for postpartum depression (O'Hara, Stuart et al. 2000). In this study we compared the efficacy of standard IPT, in which women were assigned to treatment with IPT for 12 consecutive weeks, to a group assigned to a waiting list. A total of 120 women were enrolled in the study. The outcome data for the 99 women who completed either the IPT treatment (n=48) or the 12 week waiting period (n=51) are summarized below.

Repeated measures analysis showed significant Group X Time interaction effects for both the Beck Depression Inventory (Beck, Ward et al. 1961), F (3,95) = 8.53, p < .001, and Hamilton Rating Scale for Depression (Hamilton 1967), F (3,95) = 10.00, p < .001. Follow-up ANOVAS revealed that the mean BDI and HRSD scores at 12 weeks for the waiting list group were significantly higher than scores for the IPT group. Absolute scores are for both groups are shown below.

Treatment of Postpartum Depression with IPT: Acute Outcome Data

Chi-square analysis showed that significantly fewer women in the IPT group met criteria for a major depressive episode at the 12 week assessment compared to women in the WAITING LIST group, X ² (1, N = 97) = 32.1, p < .001, 12.5% vs. 68.6%, respectively. Based on recovery criteria for the BDI (<= 9) and the HRSD (<= 6), 43.8% and 37.5% of the IPT group and 13.7% and 13.7% of the WAITING LIST group respectively were recovered at the end of 12 weeks. There was no difference in outcome based on the patient having had a prior episode of depression.

Conclusion

In summary, IPT is clearly beneficial to depressed postpartum women, and appears to be helpful to depressed pregnant women as well. Further research is needed regarding the optimum length of treatment and the prevention of relapse following acute treatment.

References

Beck, A. T., C. H. Ward, et al. (1961). An inventory for measuring depression. Archives of General Psychiatry 4: 561-571.

Hamilton, M. A. (1967). Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology 6: 278-296.

O'Hara, M. W., S. Stuart, et al. (2000). Efficacy of interpersonal psychotherapy for postpartum depression. Archives of General Psychiatry 57: 1039-1045.

Stuart, S. and M. W. O'Hara (1995). Interpersonal psychotherapy for postpartum depression: a treatment program. Journal of Psychotherapy Practice and Research 4: 18-29.