Literature review

REVIEWARTICLE

Interpersonal psychotherapy for postpartum depression: a systematic review

Mario Miniati & Antonio Callari & Simona Calugi & Paola Rucci & Mario Savino & Mauro Mauri & Liliana Dell’Osso

Received: 23 January 2014 /Accepted: 11 June 2014 /Published online: 24 June 2014 # Springer-Verlag Wien 2014

Abstract Interpersonal psychotherapy (IPT) is a dynamically informed and present-focused psychotherapy originally con- ceived for patients with unipolar depression and subsequently modified for other disorders, including postpartum depression (PPD). The aim of this paper is to review the evidence on the efficacy of IPT for PPD. We conducted a systematic review of studies published between 1995 and April 2013 assessing the efficacy of IPT for PPD using PubMed and PsycINFO. We included the following: (i) articles that presented a combina- tion of at least two of the established terms in the abstract, namely, interpersonal [all fields] and (“psychotherapy” [MeSH terms] or psychotherapy [all fields]) and (perinatal [all fields] or postpartum [all fields]) and (“depressive disor- der” [MeSH terms] or (“depressive” [all fields] and “disorder”

[all fields]) or depressive disorder [all fields] or “depression” [all fields] or depression [MeSH terms]); (ii) manuscripts in English; (iii) original articles; and (iv) prospective or retro- spective observational studies (analytical or descriptive), ex- perimental, or quasi-experimental. Exclusion criteria were as follows: (i) other study designs, such as case reports, case series, and reviews; (ii) non-original studies including edito- rials, book reviews, and letters to the editor; and (iii) studies not specifically designed and focused on IPT. We identified 11 clinical primary trials assessing the efficacy of IPT for PPD, including 3 trials with group interventions (G-IPT) and one that required the presence of the partner (PA-IPT). We also identified six studies interpersonal-psychotherapy-oriented preventive interventions for use in pregnancy. IPT studies showed overall clinical improvement in the most commonly used depression measures in postpartum depressed women (EPDS, HDRS, BDI) and often-full recovery in several cases of treated patients. Evidence from clinical trials indicates that, when administered in monotherapy (or in combination with antidepressants), IPT may shorten the time to recovery from PPD and prolong the time spent in clinical remission.

Keywords Interpersonal psychotherapy . Postpartum depression . Depression . Treatment efficacy

Introduction

Postpartum depression (PPD) is a subtype of major depres- sion, characterized by the onset within 4 weeks after delivery (American Psychiatric Association 2000) and by a number of symptoms including depressed mood, anxiety, feelings of inadequacy or guilt specifically related to the ability to care for the newborn, inability to cope, loss of control, intrusive presence of compulsive thoughts, irrational fears, and despair. Sometimes, new mothers develop suicidal and/or infanticide

M. Miniati: A. Callari (*): M. Mauri: L. Dell’Osso Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Via Roma, 67, 56100 Pisa, Italy e-mail: [email protected]

M. Miniati e-mail: [email protected]

M. Mauri e-mail: [email protected]

L. Dell’Osso e-mail: [email protected]

S. Calugi: P. Rucci Department of Medicine and Public Health, Alma Mater Studiorum, University of Bologna, Scuola di Eccellenza dell’Università di Bologna, Via Zamboni, 33, 40126 Bologna, Italy

S. Calugi e-mail: [email protected]

P. Rucci e-mail: [email protected]

M. Savino Istituto Neurologico C. Besta, Via Celoria 11, 20133 Milano, Italy e-mail: [email protected]

Arch Womens Ment Health (2014) 17:257–268 DOI 10.1007/s00737-014-0442-7

thoughts and plans (Miller 2002) or precipitate in a chronic depressive episode (Cooper and Murray 1995; Goodman and Santangelo 2011). Approximately 13 % of women fulfill the diagnostic criteria for a major depressive episode with post- partum onset (APA 2000; Dietz et al. 2007; O’Hara and Swain 1996). A recent study estimated the point prevalence for major and minor depression, ranging from 8.5 to 11.0 % during pregnancy and from 6.5 to 12.9 % during the first postpartum year (Gaynes et al. 2005). Postpartum depression can nega- tively impact both on mothers and on newborns. They tend to develop attachment insecurity and impaired emotional/ cognitive development (Field 1995; Tronick and Reck 2009; Grace et al. 2003). The negative effects on newborns are also described for the infants of women who suffer from sub- clinical or incomplete forms of depression (Weinberg et al. 2001; Tronick and Reck 2009).

Effective pharmacological treatments for PPD are avail- able, but according to the literature, very low percentages of depressed women receive a specific treatment during postpar- tum (Goodman and Tyer-Viola 2010; Horowitz and Cousins 2006; Marcus et al. 2003). Antidepressants are considered effective for PPD (Cohen et al. 2001; Appleby et al. 1997; Yonkers et al. 2008; Wisner et al. 2006), even if the vast majority of data in this field derives from case reports, case series, or open trials (Abreu and Stuart 2005; Dennis and Stewart 2004). To our knowledge, no data are available from randomized or controlled studies, and many observations exclude mothers who are breastfeeding (Appleby et al. 1997; Misri and Kendrick 2007). Although data suggests minimal or no short-term adverse effects in infants (Burt et al. 2001; Misri and Kostaras 2002; Weissman et al. 2004), mothers are frequently hesitant when asked to start a treatment with antidepressants (Sit and Wisner 2005) and have a pref- erence for psychotherapy (Whitton et al. 1996a, b). Boath and Henshaw (2001) reported that 31 % of breastfeeding mothers with PPD refused antidepressants. Moreover, even if not breastfeeding, many women are reluctant to take medication (Goodman 2009), mainly for the subjective perception of an excessive sedation (“not hearing the baby at night”) and for the fear of “potential long-term side effects” (Boath and Henshaw (2001). As a consequence, psychotherapies have been proposed in monotherapy or in combined/sequential treatment for this special population, with the rationale of providing effective treatments devoid of side effects. Several studies support the clinical usefulness of individual and group psychotherapies for postpartum depression (Appleby et al. 1997; Misri and Kendrick 2007; O’Hara et al. 2000; Dennis and Stewart 2004; Goodman and Santangelo 2011; Mulcahy et al. 2010; Milgrom et al. 2005; Clark et al. 2003).

Interpersonal psychotherapy (IPT) is a time-limited, dy- namically informed, and present-focused psychotherapy that emphasizes the interpersonal context of depression (Klerman et al. 1984). Mainly based on Sullivan’s Interpersonal Theory

and on Bowlby’s Attachment Theory (Sullivan 1953; Bowlby 1969; Stuart 2006) and originally conceptualized for “pure” unipolar depression, IPT has been subsequently modified for other disorders, including postpartum depression (Stuart and O’Hara 1995; Stuart and Robertson 2003; Stuart 2006, 2012. IPT has been proposed mainly considering its bifocal ap- proach to mood disorders that enhances the importance of both biological and psychosocial factors in the pathogenesis of postpartum depression (Cox et al. 1983; Meltzer-Brody 2011; Ross et al. 2004). The clinical manifestations of post- partum depression are affective, cognitive, neurovegetative, and behavioral. As a consequence, symptoms disrupt inter- personal relationships and social functioning at different levels (O’Hara 1994). Lower income problems, the lack of perceived interpersonal support (especially poor practical or emotional support from partners and reduced social and family support), and the physiological role transition related to motherhood have been shown to be specific risk factors for the occurrence of depression during the postpartum period (O’Hara and Swain 1996). Moreover, controversial familial expressed emotions may exacerbate the course of depressive symptoms or complicate treatment response (Miklowitz and Hooley 1998). The aim of this paper is to provide a systematic review of the major findings for efficacy of IPT for postpartum depression.

Methods

We conducted a review of studies published between 1995 and May 2013 assessing the efficacy of IPT for postpartum depression using PubMed and PsycINFO databases. Analysis of the articles followed previously established inclusion and exclusion criteria. We included the following: (i) articles that presented a combination of at least two of the established terms in the abstract, namely, interpersonal [all fields] and (“psychotherapy” [MeSH terms] or psychotherapy [all fields]) and (perinatal [all fields] or postpartum [all fields]) and (“de- pressive disorder” [MeSH terms] or (“depressive” [all fields] and “disorder” [all fields]) or depressive disorder [all fields] or “depression” [all fields] or depression [MeSH terms]); (ii) manuscripts in English; (iii) original articles; and (iv) prospec- tive or retrospective observational studies (analytical or de- scriptive), experimental, or quasi-experimental. Exclusion criteria were as follows: (i) other study designs, such as case reports, case series, and reviews; (ii) non-original studies including editorials, book reviews, and letters to the editor; and (iii) studies not specifically designed and focused on IPT. Initially, the search retrieved 58 papers including 20 reviews of literature and 3 meta-analyses. After analyzing their titles and abstracts, according to the eligibility criteria, 47 papers were excluded and 11 were chosen and included in the final sample (Fig. 1).

258 M. Miniati et al.

Results

Table 1 summarizes the studies assessing IPT for PPD re- trieved by the search. The first open trial with IPT for PPD was a 12-week study on six patients who met the DSM-III-R criteria for a major depressive episode during the postpartum period (MDD) (Stuart and O’Hara 1995). Patients were in remission at the end of the study, according to the Beck Depression Inventory (BDI) (Beck et al. 1961), the Hamilton Rating Scale for Depression (HRSD) (Hamilton 1967), and the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al. 1987). They also showed a significant improvement with the Social Adjustment Scale (SAS) (Weissman and Bothwell 1976). None of the patients met the DSM criteria of major depressive episode at the end of treatment. A randomized study on 120 subjects subsequently compared IPT vs a “waiting list condition” (WLC) (O’Hara et al. 2000). Patients randomized to WLC remained without therapy and waited 12 weeks before receiving treatment. They were followed up with a bi-weekly telephone assessment, in order to evaluate the suicide risk. A significantly greater

proportion of women who received 12 weekly individual session of IPT recovered from their depressive episode when compared to women randomized to WLC, with an important improvement of their social adjustment. IPT showed long- term benefits after the acute treatment phase: 20 patients out of 35 (57 %) recovered with the acute IPT treatment and achieved sustained recovery during the follow-up. Moreover, the 80 % of women who did not recover during the acute treatment achieved recovery, at some point during the follow- up. Posttreatment depression severity, personal history of depression, and weeks of treatment were significant predictors of recovery in the mid-term.

In an interesting brief report from Nylen et al. (2010) the mid-term course and the potential predictors of postpartum depression in the 18 months following IPT have been de- scribed. Evaluations at 6, 12, and 18 months posttreatment were completed. This study revealed that 20 patients (57 %) achieved sustained recovery during follow-up out of 35 who recovered with acute treatment. The average time to recur- rence was 33.40 weeks (SD±18.43 weeks). Over 80 % of women who did not recover with acute treatment experienced

Fig. 1 Flow chart summarizing the procedure for selecting studies for review

Interpersonal psychotherapy for postpartum depression 259

T ab

le 1

E v id en ce

o f ef fi ca cy

of IP T fo r po st p ar tu m

d ep re ss io n

A u th o rs

N u m b er

D es ig n

S el ec ti o n cr it er ia

In st ru m en ts

IP T in te rv en ti o n s

R es u lt s

S tu ar t an d O ’H

ar a (1 9 9 5 )

1 2

O pe n tr ia l

M D D (D

S M -I II -R )

H R S D B D I E P D S

In d iv id u al IP T , 1 2 w ee k s

M ea n b as el in e B D I sc o re

2 7 .7 ± 5 .7 . M ea n

H R S D b as el in e sc o re

1 8 .2 ± 6 .2 . M ea n

en d p o in t B D I sc o re

5 .4 ± 4 .8 ; m ea n

en d p o in tH

R S D sc o re 5 .2 ± 4 .1 (p < 0 .0 2 ).

N o pa ti en ts m ee ti ng

cr it er ia fo r M D E at

en d p o in t.

O ’H

ar a et al . (2 0 0 0 )

1 2 0

R an d o m iz ed

co n tr o ll ed

tr ia l

M D D b y D S M -I V

in te rv ie w , H R S D ≥1

2 H R S D B D I

In d iv id u al IP T (1 2 w ee k s)

v s W L C

H R S D : IP T

g ro u p fr o m

1 9 .4

to 8 .3

v s

W L C

g ro u p fr om

1 9 .8

to 1 6. 8 . B D I:

IP T g ro u p fr o m

2 3. 6 to

1 0 .6

(e n d p o in t

1 2 w ee k s)

P er ce n ta g es

o f re m is si o n at

en d p o in t (1 2 w ee k s) . H R S D ≤ 6 : IP T

(3 7 .5

% )>

W L C

(1 3 .7 ) o f w om

en re ce iv in g IP T

re co v er ed

B D I≤

9 : IP T

(4 3 .8

% )>

W L C

(1 3 .7

% ). IP T p at ie n ts

h ad

si g n if ic an t im

p ro v em

en t in

P PA

Q an d S A S -S R

sc o re s

K li er

et al . 2 00 1

1 7

O p en

tr ia l

M D D o r m M D ac co rd in g to

D S M -I V -R

in te rv ie w

E P D S H R S D

G ro up

IP T (1 2 se ss io n s)

D ep re ss io n sc o re s d ec re as ed

si g n if ic an tl y

(2 1 -i te m

H R S D fr o m

1 9. 7 to

8 .0 ; E P D S

fr o m

1 6 .1 to

8 .9 ) (p < 0 .0 1 ). P ar ti ci p an ts ’

d ep re ss io n sc o re s at 6 -m

o n th

fo ll o w -u p

w er e si g n if ic an tl y lo w er

th an

at b as el in e

(E P D S F = 2 4 .3 0 , p < 0 .0 0 1 ; H R S D -2 1

F = 3 3 .5 9 , p < 0 .0 0 1 ).

C la rk

et al . (2 0 0 3 )

6 6

Q u as i- ra n d o m iz ed

cl in ic al tr ia l

M D D (q u es ti o n n ai re

w it h

D S M – IV

cr it er ia )

C E S -D

B D I

M o th er /i n fa n t th er ap y

(M -I T G ) v s in d iv id u al

IP T (1 2 w ee k s) v s W L C

M -I T G B D I fr o m 2 6 .9 to 1 5 .9 ;C

E S -D

fr o m

4 1 .1 to

1 9 .2

(p < 0 .0 2 ); IP T B D I fr om

2 6 .2 to

1 6 .4 ; C E S -D

fr o m

36 .2 to

2 0 .1

(p < 0 .0 4 ); W L C B D I fr o m

2 4 .5 to

2 0 .6 ;

C E S -D

fr o m

3 2 .4 to

2 6 .6 (p = n s)

R ea y et al . (2 0 0 6 )

1 8

O p en

tr ia l

E P D S ≥ 1 3 M D D ac co rd in g

to D S M -I V -R

cr it er ia

H R S D E P D S B D I

G ro up

IP T (2

in d iv id u al

se ss io n s, 8 g ro u p

se ss io n s+

2 h p ar tn er s

ev en in g )

B D I (2 6 .1 6 – 1 5 .1 7 ),

E P D S (1 8 .3 3 – 9 .1 6 )

an d H R D S (1 3 .9 4 – 7 .8 9 ) se v er it y

sc o re s d ec re as ed

fr o m

p re - to

p o st -

tr ea tm

en t. T h es e re su lt s w er e

m ai n ta in ed

af te r th e 3 -m

o n th s fo ll o w

u p . 5 8 %

fu ll re m is si o n (p o st -t re at m en t

H R S D

sc o re

< 9 ). 2 9 %

pa rt ia l

re m is si o n (p o st -t re at m en t H R S D

sc o re < 5 0 % ) 11

% n o im

p ro v em

en t.

P ea rl st ei n et al . (2 0 0 6 )

2 3

Q u as i- ra n d o m iz ed

cl in ic al tr ia l

M D D (c li n ic al in te rv ie w )

B D I ≥ 2 5 o r 1 7 it em

s H R S D ≥ 1 4

E P D S B D I E P D S

S er tr al in e v s IP T vs

th ei r

co m b in at io n 1 2 -w

ee k s

st u d y

C o m p le te rs o f th e 3 tr ea tm

en t g ro u p s

si g n if ic an tl y im

p ro v ed . IP T H R S D fr o m

1 7 .4 to 5 .5 (p < 0 .0 0 1 ); B D I fr o m

2 0 .0 to

6 .3 (p < 0 .0 0 1 ); E P D S fr o m

1 6 .7 to

6 .4

(p < 0 .0 0 1 ); S er tr al in e H R S D fr o m

2 0 .5

to 1 0 .0 ; B D I fr o m

20 .0 to

7 .0 ; E P D S

260 M. Miniati et al.

T ab

le 1

(c o n ti n u ed )

A u th o rs

N u m b er

D es ig n

S el ec ti o n cr it er ia

In st ru m en ts

IP T in te rv en ti o n s

R es u lt s

fr o m

1 5 .0

to 4 .5 ; S er tr al in e + IP T H R S D

fr o m

1 8 .8

to 3 .8 ; B D I fr o m

2 5 .3

to 6 .1 ;

E P D S fr o m

1 8 .7 to

5 .5

G ro te et al . (2 0 0 9 )

5 3

R an d o m iz ed

co n tr o ll ed

tr ia l

E P D S > 1 2

E P D S B D I

A n te n at al en g ., 8 IP T -B

se ss io n s b ef o re

bi rt h , IP T -

M (6

m o n th s. ) vs

T A U

E nd po in t si x m on th af te r de li ve ry

50 %

im pr ov em

en t on

th e E P D S sc or es

88 %

of re sp on se

w it h IP T vs

25 %

w it h T A U .

M u lc ah y et al . (2 0 1 0 )

5 0

R an d o m iz ed

co n tr o ll ed

tr ia l

M D D b as ed

on D S M -I V

cr it er ia

M C M I- II I H R D S -1 7 ≥ 1 4

E P D S B D I- II

G ro up

IP T V S . T A U

(t re at m en t as

u su al )

fo r 8 w ee k s

T A U

an d IP T -G

g ro u p s si g ni fi ca n tl y

im p ro v ed

(m ea n sc o re s at

B D I- II

an d

E P D S ). T h e IP T -G

w om

en im

p ro v ed

si g n if ic an tl y m o re

an d h ad

co n ti n u ed

im p ro v em

en ts

af te r 3 m o n th s o f

fo ll o w -u p .

N y le n et al . 2 0 1 0

1 2 0

R an d o m iz ed

co n tr o ll ed

tr ia l

M D D (D

S M -I V -R

in te rv ie w )

L IF E ID

D H R D S B D I

In d iv id u al IP T , 1 2 w ee k s

v s. W L C

T h ir ty -f iv e w o m en

re co v er ed

(L IF E

cr it er ia ) in

ac u te ; 2 0 w o m en

ac h ie v ed

su st ai n ed

re co v er y d ur in g fo ll o w -u p .

A v er ag e ti m e to

re cu rr en ce

33 .4 w ee ks

(± 18 .4 ). 80

% of

w om

en w ho

di d no t

re co ve r in ac ut e ex pe ri en ce d re co ve ry

at so m e po in td ur in g fo llo w -u p. A ve ra ge

tim e

to re co ve ry

28 .6

w ee ks

(± 17 .5 ).

R ea y et al . (2 0 1 2 )

5 0

R an d o m iz ed

co n tr o ll ed

tr ia l

S ee

M u lc ah y et al . 2 0 1 0

S ee

M u lc ah y et al . 2 0 1 0

G ro up

IP T

A t 2 -y ea r p o st tr ea tm

en t, m o th er s w h o

re ce iv ed

IP T -G

im p ro v ed

m o re

ra p id ly

in th e sh or t- te rm

an d w er e le ss

li k el y to

d ev el o p p er si st en t d ep re ss iv e sy m p to m s

in th e lo n g -t er m .5 7 %

o f IP T -G

m o th er s

m ai n ta in ed

th ei r re co v er y o v er

th e

fo ll o w -u p p er io d .L

im it at io n s in cl u d e th e

u se o f se lf -r ep o rt q u es ti o n n ai re s to d ef in e

re co v er y an d u se

o f an ti d ep re ss an t.

H ow

ev er ,m

ot he rs w ho

re ce iv ed

co m bi ne d

IP T -G

an d an tid ep re ss an t m ed ic at io n di d

no t sh ow

a si gn if ic an tly

gr ea te r

im pr ov em

en t in de pr es si on

co m pa re d to

th os e w ho

re ce iv ed

IP T -G

al on e.

B ra n d o n et al . (2 0 1 2)

1 5

O p en

tr ia l

1 7 -i te m

H R S D ≥ 1 6 M D D

(D S M -I V -R

in te rv ie w )

H R S D E P D S D A S

P ar tn er -A

ss is te d IP T .

9 o f 1 0 w o m en

(9 0 % ) m et cr it er ia fo r

cl in ic al re sp o n se

(H R S D 1 7 < 9 ) at th e

en d o f ac u te ph as e; 8 o f ni n e (8 9 % )

at a 6 -w

ee k fo ll o w -u p as se ss m en t m et

cr it er ia fo r re co v er y. W o m en

h ad

h ig h

le v el s o f d ep re ss iv e sy m p to m s at in ta k e

(m ea n ± S D ) (1 9. 11

± 6. 13 ) th at de cl in ed

si gn if ic an tl y by

se ss io n ei gh t( 6. 00

± 4. 47 )

an d re m ai ne d lo w at th e 6- w ee k fo ll ow

-

Interpersonal psychotherapy for postpartum depression 261

recovery at some point during follow-up, and the average time to recovery was 28.60 weeks (SD±17.51 weeks). Several predictors were identified with growth curve modeling tech- niques, namely, the posttreatment depressive severity, the length of the index episode (as predictors of changes in depression over time), a personal history of depression, and the weeks of treatment in the follow-up. The strength of this study was mainly on the adoption of gold-standard instru- ments, such as the Structured Clinical Interview for DSM-IV (First et al. 1997) to assess symptoms criteria, the HRSD, the BDI, and the Longitudinal Interval Follow-Up Evaluation (LIFE) (Keller et al. 1987) to evaluate course and outcomes.

Klier et al. (2001) utilized a group IPT (G-IPT) approach (12 sessions) in a sample of 17 women diagnosed with PPD, according to DSM-IV criteria. Mean scores of HDRS and EPDS decreased significantly comparing the pre-treatment and the posttreatment period. Moreover, examination of indi- vidual 21-item HDRS score profiles revealed that 10 patients (58 %) achieved a full remission (posttreatment score <9) and five patients (29 %) demonstrated a partial remission (score decrease >50 %) at the end of treatment. Only two patients (11 %) did not improve. Study limitations included the ab- sence of a control group, the small sample size, the possible bias in therapist’s assessments, and the lack of monitoring adherence, which may have jeopardized the accuracy of the results.

The postpartum depression efficacy study performed by Clark et al. (2003) was a quasi-randomized clinical trial with a comparison of three conditions: mother/infant therapy, WLC, and individual IPT (12 sessions). Women who met the criteria for major depression during the postpartum period were se- quentially assigned to one of the first two conditions: a mother/infant therapy (M-ITG) or a WLC. A comparison, individual IPT, was added. Participants in the active treatment groups (M-ITG and IPT) completed a pre- and a posttreatment (12 weeks) assessment. Those in the WLC were assessed at the point of entry into the study and 12 weeks later. The relationship-focused M-ITG model utilized for this study in- volved three treatment group components: (a) a mother’s group that provided therapeutic intervention and peer support; (b) a concurrent infant developmental therapy group that assisted infants in becoming more emotionally regulated, focused, and socially engaged; and (c) a mother/infant dyadic group with activities designed to promote sensitive, respon- sive mother/infant interactions. Fathers attended two of the group therapy sessions, one focused on demystifying depres- sion and the second focused on enhancing mutual spousal support through the use of communication and problem- solving exercises. Fathers also joined the mother and infant in the interactional activities during the last half hour of each of those sessions. Sixty-six women were recruited into the study. Nonetheless, data were only analyzed for participants who scored 16 or higher at the BDI. This cutoff was chosen toT

ab le 1

(c o n ti n u ed )

A u th o rs

N u m b er

D es ig n

S el ec ti o n cr it er ia

In st ru m en ts

IP T in te rv en ti o n s

R es u lt s

up . W om

en ha d hi gh

le ve ls of

E P D S at

in ta ke

(1 7. 30

± 4. 47 ) th at de cl in ed

by se ss io n ei gh t (6 .0 0 ± 3. 97 ). P ar tn er s ra te d

th e in te ns it y of

w om

en ’s de pr es si ve

sy m pt om

s as

lo w er at in ta ke

(E P D S -P

01 3. 80

± 3. 36 ). A t se ss io n 8, pa rt ne r

ra ti ng s de m on st ra te d go od

ag re em

en t

w it h w om

en ’s ra ti ng s (6 .1 0 ± 4. 48 ).

D S M -I II -R

D S M

R ev is ed

T h ir d E d it io n (A

m er ic an

P sy ch ia tr ic A ss oc ia ti o n 1 9 8 7 ), D S M -I V D S M

F o u rt h E d it io n (A

m er ic an

P sy ch ia tr ic A ss oc ia ti o n 2 0 0 0 ), B D I B ec k In v en to ry

D ep re ss io n (B ec k et al .

1 9 6 1 ), H R S D H am

il to n R at in g S ca le fo r D ep re ss io n (H

am il to n 1 9 6 7) ,E

P D S E d in b u rg h P o st n at al D ep re ss io n S ca le (C O X et al .1 9 8 7 ), P PA

Q P o st pa rt u m A d ju st m en t Q u es ti o n n ai re (O

’H ar a et al .1 9 9 2) ,

S A S -S R S o ci al A d ju st m en tS ca le -S el f R ep o rt (W

ei ss m an

an d B o th w el l1 9 7 6 ), L IF E L o n g it u d in al In te rv al F o ll o w -U

p E v al u at io n (K

el le r et al .1 9 8 7 ), C E S -D

C en te r fo r E p id em

io lo g ic al S tu d ie s D ep re ss io n

S ca le (R ad lo ff 1 9 7 7 ), ID

D In v en to ry

to d ia g n os e D ep re ss io n (Z im

m er m an

an d C o ry el l 1 9 8 7 ), M C M I- II I M il lo n C li n ic al M u lt ia x ia l In v en to ry -I II (M

il lo n et al . 1 9 9 7 ), D A S D ya d ic A d ju st m en t S ca le

(S p an ie r 1 9 7 6 )

262 M. Miniati et al.

differentiate women with moderate to severe depressive symptoms consistent with a major depressive episode during the postpartum period from women with mild or transient depressive symptoms, commonly referred to as the “baby blues.” The sample of women meeting this criterion included 13 patients in the M-ITG group, 15 in the IPT group, and 11 in the WLC group. The two active 12-week treatments (M-ITG and IPT) were equally effective in reducing symptoms for women experiencing major depression during the postpartum period, when compared with the WLC group. However, wom- en in the M-ITG group experienced the highest level of depressive symptoms at baseline (as measured by higher mean BDI and Center for Epidemiological Studies Depression Scale (CES-D) scores (Radloff 1977)) and the greatest improvement (as demonstrated by the lowest posttreatment mean scores). M-ITG and IPT were superior to WLC in improving the perceptions of mothers on their newborns’ adaptability/ reinforcement value and in increasing mothers’ positive affect/verbalization with their children. Nonetheless, despite their improvement, some women from both treatment groups continued to experience mild to moderate depressive symp- toms after the 12-week treatment programs.

Reay et al. (2006) treated 18 mothers fulfilling the DSM-IV criteria for postpartum depression, with two start-up sessions of individual IPT, followed by 8 sessions of IPT-G. Expectations about helpful group behaviors were explained, including promptness, remaining focused on “here and now” interpersonal issues, working actively on their goals between group sessions, and refraining from contact or socializing together during the duration of the group. The group sessions with patients were scheduled for the first 2 weeks, and mid- way during the group therapy, partners attended an education- al evening with the group therapists, with special emphasis on considering effective ways to support and respond to a woman affected by postpartum depression. Women were asked to stay focused on the interpersonal goals, to express their feelings about group sessions, and to give feedback to each other, with the aim to anticipate future difficulties. Patients were consid- ered eligible for the study if they had an infant 12 months old or less and continued to have a health professional involved with whom the researchers could communicate with. An individual session was also scheduled 6 weeks after the last group session, with the aim to consolidate progress, to plan for future contingencies, and to document early warning signs of relapse or recurrence of depressive symptoms. The outcome measures of this pilot study were the 17-item HRSD, the BDI, the EPDS, and the SAS Self-Report (SAS-SR). As described by the study results, scores on the HRSD, the BDI, and the EPDS significantly decreased from pre- to posttreatment as- sessment. Nonetheless, it is noteworthy that, for example, the mean HRSD scores were very low at baseline (13.94±5.99), raising questions on unusually mild severity of depressive symptomatology in the recruited sample. Moreover, a wide

percentage of patients (67 %) were concomitantly treated with antidepressants.

A randomized controlled trial on 50 patients with postpar- tum depression compared outcomes from an 8-week IPT-G for postnatal depression with “treatment as usual” (TAU), namely, antidepressants, natural remedies, non-directive counseling, and other interventions (Maternal and Child Health Nurse support, community support groups, and indi- vidual psychotherapy or group therapy) currently accessed by women in the Australian Capital Territory (ACT) community (Mulcahy et al. 2010). The 8-week group intervention for postnatal depression was developed and adapted during the pilot of the treatment, as already published by Reay et al. (2006) A specifically targeted treatment manual described the stages, strategies, and techniques of IPT-G for this popu- lation and included the use of the processes of “modelling” and “social reinforcement” by group members as well as group brainstorming. Special attention was given in this study in highlighting the universality of the women’s concerns and encouraging mothers to learn vicariously through the experi- ences of others in the group. IPT-G consisted of two individual sessions, eight group therapy sessions (2 h duration) and an additional 2-h partner’s evening. Women were given a per- sonalized invitation to give to their partner and a courtesy phone call was made by the group therapists to encourage attendance at a partners evening. The evening was specifically developed for the men only and involved psycho-education about PND, with a special emphasis on effective ways to support and respond to their partners. The study was conduct- ed with an accurate screening of participants. Ninety mothers initially referred to the study and were screened with a tele- phone interview. Seventy-one subjects were suitable and screened for the inclusion/exclusion criteria assessment. The inclusion criteria for the study was a diagnosis of postnatal depression based on DSM-IV criteria for major depression and an infant aged 12 months or younger. The exclusion criteria were the presence of severe personality disorder, acute psychosis, suicidality, significant substance abuse, and child abuse or neglect. Mothers were included in the study if they fulfilled the criteria for a major depressive disorder using the Millon Clinical Multiaxial Inventory-III (Millon et al. 1997) and scored >14 at the 17-item HRSD. Fifty-seven mothers were randomized (29 to IPT-G and 28 to TAU), and 50 were included in the analyses. Seven mothers were discontinued for several reasons (immediate improvement, relocated interstate, preference for individual therapy, dissatisfaction for alloca- tion, domestic violence). Three assessments were scheduled as follows: at baseline, week 4, and week 8. Planned compar- isons, using the EPDS and BDI-II scores, indicated a signif- icant improvement in the depression’s scores for IPT-G par- ticipants by the end of treatment. The TAU and the IPT-G groups significantly improved in terms of mean HRSD scores. However, patients treated with IPT-G improved significantly

Interpersonal psychotherapy for postpartum depression 263

more than those treated with TAU and showed a sustained improvement after 3 months. Furthermore, women who re- ceived IPT-G displayed significant improvement in terms of marital functioning and perceptions of the mother-newborn relationship if compared to TAU participants. The main strength of this study was the presence of a strong comparison group. Thus, TAU participants accessed a range of treatments from primary, secondary, and tertiary services, such as antide- pressant medication, support groups, and individual psycho- therapy. The second strength of the study was the adoption of a relatively short treatment schedule, if compared with other IPT group or group therapies. The main limitation of the study was due to the characteristics of the sample. Participants were predominantly white Australian-born mothers, in a relatively stable relationship with a partner and well educated. A second important limitation of the study relates to the finding at 3- month follow-up that a large proportion of the women over the course of the RCT were taking antidepressant medication. Although the sample size provided sufficient power to make comparisons between group interpersonal therapy and treat- ment as usual at baseline, mid-treatment, end of treatment, and 3-month follow-up, there was a limited scope to examine the role of antidepressant medications, such as that afforded by comparing IPT-G and medication alone, combination IPT-G and medication with IPT-G alone, or medication alone.

More recently, the same research group (Reay et al. 2012) investigated the presence of depressive symptoms and the inter- personal functioning of the participants of the abovementioned randomized controlled trial, at 2 years posttreatment. Reay et al. examined the so-called long-term recovery trajectories, namely, whether participants maintained their recovery status, if they achieved later recovery or if they showed recurrences or a persistent symptomatology. They used a case categorization system that took into account the severity and the duration of symptoms, according to the criteria set by Shapiro et al. (1995) and the recommended EPDS cutoff score (EPDS=12 or less) (Sit and Wisner 2005). Women in both conditions were com- pared in terms of the proportions of those who: (a) “maintained” recovery (classified “recovered” at all three follow-up points), (b) achieved (later) recovery (“not recovered” at the end of treatment but EPDS=12 or less at 3-month and 2-year follow- up), (c) recurred (recovered at the end of treatment but EPDS= 13 or more at 3-month and/or 2-year follow-up), and (d) showed a persistent (chronic) depression (not recovered at all follow-up points). Approximately 2 years posttreatment, all women in the original RCT (N=50) were invited to participate in a mailed follow-up. A repeated measure analysis of variance assessed differences between the treatment and control conditions on depression and interpersonal scores across five measurement occasions: baseline, mid-treatment, end of treatment, 3-month, and 2-year follow-up. The 57 % of mothers with IPT-G main- tained their recovery over the follow-up period, when interviewed 2 years posttreatment. Overall, IPT-G participants

were significantly less likely to require follow-up treatment. Mothers who received IPT-G improved more rapidly in the short-term and were less likely to develop persistent depressive symptoms in the long-term. Limitations included the use of self- report questionnaires to classify recovery and the use of antide- pressant medication. Thus, 28 of 44 women took antidepres- sants during both the short- and long-term follow-up periods; however, there was no statistically significant association be- tween antidepressant use and better recovery outcomes. Moreover, IPT-G mothers taking adjunct medication were no more likely to be classified as having maintained or achieved recovery compared to those receiving IPT-G alone.

Pearlstein et al. (2006) addressed “the dilemma of choosing treatment” in an interesting study on a sample of patients with postpartum depression recruited from a psychiatric day hos- pital serving pregnant and postpartum women. Eligible pa- tients were offered three treatments over 12 weeks: sertraline alone, IPT alone, or combined (sertraline+IPT). The patients selected treatment choice, and there was no random assign- ment of treatment condition. Sertraline was titrated in a flexible-dose regimen up to 150 mg daily based on clinical response (by interview) and tolerability. Sertraline was started at 25 mg daily and could be increased to 50 mg daily after 2 weeks, to 100 mg daily after 4 weeks, and to 150 mg daily after 8 weeks. IPT was administered in 12 individual 50-min sessions by one of two psychotherapists who had received IPT training and who received regular supervision throughout the study. Treatment outcome was monitored with the clinician- rated 17-item HRSD, the self-rated EPDS, and the BDI ob- tained at baseline, 4, 8, and 12 weeks. All patients experienced a significant clinical improvement on the HRSD, BDI, and EPDS scores, with no statistical differences between the three groups. The most relevant finding was that women in the study at first depressive episode, when informed of the advan- tages and concerns of both IPT and sertraline, selected IPT with or without the addition of sertraline. Conversely, there was a trend for women with a history of previous depressive episodes to choose sertraline as a treatment alone or with IPT. Moreover, this study confirmed the trend for breastfeeding women to be less likely to choose antidepressants than psy- chotherapy. The authors concluded that a previous depression or previous antidepressant treatment might be associated with pharmacotherapy as preferred choice, while breastfeeding might be associated with psychotherapy.

A brief culturally enhanced version of IPT (IPT-B) was administered to a sample of 53 pregnant women meeting criteria for depression according to the EPDS scale (score >12 on a scale of 0 to 30), and it was continued through the postpartum period (Grote et al. 2009). The primary aim of this study was to assess if a culturally relevant, enhanced brief interpersonal psychotherapy might be efficacious in treating depression in a special population of pregnant women of low socio-economic status. This study is different from the

264 M. Miniati et al.

previous ones, for several reasons. First, treatment was started during pregnancy and then continued in the postpartum peri- od. Second, the enhanced IPT-B is a multi-component model of care consisting of an engagement session (acute IPT-B) and maintenance IPT, augmented with culturally relevant modifi- cations. The engagement session is based on principles of motivational interviewing and ethnographic interviewing and is designed to promote engagement by building trust and addressing the practical, psychological, and cultural bar- riers to care experienced by individuals who are socio- economically disadvantaged. More specifically, during en- gagement, the interviewer elicits each participant’s unique barriers to care and engages in collaborative problem solving to ameliorate each barrier. In addition, the interviewer ap- proaches the participant in a culturally sensitive manner con- sistent with the principles of ethno-graphic interviewing: the interviewer adopts a one-down position as a learner; he/she tries to understand the cultural perspectives and values of the woman without bias; and he/she inquires about the woman’s view of depression, health-related beliefs, and coping prac- tices and asks what the woman would like in a therapist, including the importance of race-ethnicity. This study showed that the depressive outcome was significantly improved by IPT if compared with “enhanced usual care” (patients who received depression education materials and a referral to the behavioral health center in the same obstetrics and gynecology clinic). All patients displayed significant reductions in depres- sive symptoms before childbirth (3 months postbaseline) and 6 months after the delivery. The main finding from the study was that the culturally relevant enhanced IPT-B prevented depressive relapse and improved social functioning up to 6 months postpartum in a very difficult-to-engage, non- treatment-seeking population, raising the question of the use- fulness of IPT as an easy tool for the reduction of racial and economic disparities in access to and engagement in mental health treatment. This study confirmed a previous finding of a pilot study conducted with a brief group-psychotherapeutic intervention based on the principles of IPT by Zlotnick et al. (2001) The proposed approach was effective in preventing the occurrence of major depression during the postpartum period in a sample of 37 financially disadvantaged pregnant women, receiving public assistance. They were randomly assigned to a four-session group intervention or to treatment as usual (TAU). Six of the 18 women (33 %) in the TAU condition developed a postpartum major depressive episode; conversely, none of the 17 women in the intervention condition suffered for a depressive episode in the same timeframe. The efficacy of the brief intervention was confirmed by the same authors in a larger sample of pregnant women (n=99): within 3 months after delivery, eight (20 %) of the women in the standard antenatal care condition had developed postpartum major depressive disorder, compared with two (4 %) in the interven- tion condition (Zlotnick et al. 2001).

Two other studies (Grote et al. 2007, 2008) showed that preventive interventions based on the principles of interper- sonal psychotherapy intervention, as well as other preventive group interventions (Kozinszky et al. 2012), seems to be effective in preventing the occurrence of major depression during postpartum period in a subgroup of financially disad- vantaged women with PPD. On the other hand, two recent Chinese study showed the benefit of an interpersonal- psychotherapy-oriented childbirth education program (consisting of two 90-min antenatal classes and a telephone follow-up within 2 weeks after delivery) in improvement of perceived social support postpartum depressive symptoms and psychological well-being when compared with the control group (Gao et al. 2010, 2012). The presence of a poor partner support has been recently investigated as key risk factor for depression in pregnant and postpartum women.

An adaption of IPT that included the partner as an active participant throughout treatment (Partner-Assisted Interpersonal Psychotherapy, PA-IPT) was tested with an experimental design that aimed at investigating the safety, acceptability, and feasibility of PA-IPT in perinatal women with MDD (Brandon et al. 2012). The primary outcomes were the ability to recruit participants, treatment response at mid- point and final session, session attendance, and couple sat- isfaction with treatment. Thus, the main goal of the PA-IPT is to involve the partner as a literal therapy “partner,” extending the therapy to life between sessions. The partner’s role in PA-IPT is to hear the patient’s articulation of what support she might need, learn how to respond to her so that she might perceive the availability of requested support, explore other resources for support for the couple, and engage the identified individuals/avenues to secure help. This adaptation of IPT incorporates specific elements borrowed from Emotionally Focused Couple Therapy (EFCT) that aims to strengthen the interpersonal bond and address relationship distress by highlighting the attachment needs humans have of one another and restructuring the ways partners express these needs (Johnson 2004). Results were promising, even if the sample was small. Fifteen women were invited to participate. Those with interested partners were scheduled for a second visit at which the process of consent was completed and both partners re- ceived the Structured Clinical Interview for the Diagnosis of Axis I Mental Disorders (SCID-IV, Research version) and the 17-item HRSD. They were considered study eligible if the woman met full criteria for MDD and if her HRSD score was greater than 16. Two women were excluded because partners had untreated psychiatric illness and con- tinued individual treatment. Eleven women and their part- ners fulfilled the inclusion and exclusion criteria; nonethe- less, one couple was disqualified after session two, at which time partner violence (female upon male) was revealed. Two women who met study criteria were on stable doses of

Interpersonal psychotherapy for postpartum depression 265

antidepressants (one pregnant and one postpartum) at study entry, and one pregnant woman was on a stable dose of an antipsychotic (continuation of drug prescribed to her from her native country). An additional pregnant participant who responded to PA-IPT but had history of severe postpartum depression chose to initiate an antidepressant a few weeks before delivery. Couples attended eight weekly psychothera- py sessions, with 12 weeks allowed for completion of the eight sessions to accommodate unexpected events and changes in schedule. Results were promising: nine of 10 mothers met the criteria for clinical response (HRSD<9) at the end of acute phase treatment and eight of the nine (89 %) presenting at 6-week follow-up assessment met criteria for symptomatic recovery. Nonetheless, the study had several limitations, in addition to the small sample size. First, the sample was selected on the basis of the partner’s willingness to participate in the treatment. Moreover, the sample was widely heterogeneous in terms of parity, esti- mated gestational age, parturition, and weeks postpartum. Finally, no control or comparison group was selected, rais- ing questions on potential confounders such as time, thera- pist, and regression-to-the-mean effects.

Concluding remarks

IPT is a new studied form of psychotherapy for the postpartum depression. We identified 11 recent clinical trials (only one study was published before 2000) that examined the efficacy of this individual and group psychotherapy for PPD. An open trial also examined the efficacy of PA-IPT that required the involvement of the partner during the therapy. Individual and group interpersonal psychotherapy seem to be promising interventions for mothers with postpartum depression. Moreover, engaging relatives’ support signifi- cantly influences treatment response. Providing exhaustive information about postpartum depression to partners and relatives could enhance collective collaboration and reduce ambivalent feelings and behaviors, although the degree of their involvement is strictly related to the chosen interper- sonal focus. Postpartum is a prototypical example of a series of normative role transitions that coincide with the multiple biological changes of postpartum. The available data suggested that the ideal time for intervention with IPT is during the acute depressive phase. Even when IPT is not immediately associated with more rapid remission than an intensive clinical management, it leads to a better mid-term/long-term outcome. Two recent meta-analyses of psychotherapeutic treatments for PPD supported the use of IPT for postpartum depression. The first showed that IPT for PPD has a substantial effect size (Cuijpers et al. 2008); the second indicated that those psychotherapeutic interven- tions for PPD that utilized interpersonal interventions have

a greater effect size than those using cognitive interventions (Sockol et al. 2011). Moreover, Goodman and Santangelo (2011), in their systematic review, provided support for the role of group therapy in the treatment of PPD, including G- IPT. We suggest that IPT should be considered as one of the first-line treatments for PPD (at least for mild or moderate forms of depression) for two main reasons: data from available studies support the efficacy of individual/group IPT for wom- en with PPD; moreover, this special population of patients frequently prefer psychotherapy over treatment with medica- tions for their concerns about infant exposure to antidepres- sants with breastfeeding.

Acknowledgments The authors gratefully acknowledge the assistance of Dr. Giulia Gray of the University of Pisa, Italy, for the English revision.

Conflict of interests None

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