Interpersonal Psychotherapy for Peripartum Depression
KATHRYN L. BLEIBERG
Major depression during the antepartum and postpartum periods is fairly common among women. It is estimated that about 10% to 12% of women experience depression during pregnancy (Spinelli & Endicott, 2003) and 10% to 15% of women experience postpartum depression (Halbreich & Karkun, 2006). Symptoms of depression during the antepartum and postpartum periods can be misattributed—by depressed, pregnant, and postpartum women and those around them—to pregnancy or a “normal” reaction to life with a newborn. Many women who are pregnant or taking care of a newborn report getting little sleep, complain of fatigue or physical discomfort, and report appetite disturbance and decreased libido—all somatic symptoms of depression. Postpartum women may similarly assume that symptoms like insomnia, fatigue, anhedonia, and low motivation are “normal” or are related to having a difficult child (Weissman et al., 2000).
Depression during pregnancy not only causes suffering in the pregnant woman but can compromise fetal development. Depressed pregnant women are at risk for not obtaining adequate prenatal care, for poor nutrition due to depression-related low appetite, and for engaging in other unhealthy behaviors such as cigarette use and alcohol abuse during pregnancy (Spinelli & Endicott, 2003). Depression during pregnancy has also been associated with an increased risk for pregnancy complications (Wisner, 2009).
Postpartum depression (PPD) can interfere with a new mother’s ability to bond with her baby and has been associated with insecure attachment and other cognitive, emotional, and behavioral problems in children (Wisner, 2006). Furthermore, PPD can negatively affect a woman’s relationship with her partner. Depression during the antepartum and postpartum periods carries a greater burden of illness than at other times during a woman’s life as it often affects infants, children, and partners (Birndorf & Sachs, 2008).
Given the prevalence of depression related to childbearing and the potential negative impact of depression on both mothers and their children, it is crucial to identify and treat peripartum depression. Pregnant and breastfeeding women and doctors generally prefer to avoid antidepressant medication when possible because of the potential adverse effects on their babies (Birndorf & Sacks, 2008). Although the limited observational research to date suggests that many psychiatric medications are relatively safe for use during pregnancy, the U.S. Food and Drug Administration (FDA) has yet to identify any of these medications as safe. Current knowledge about the use of antidepressants during pregnancy and lactation is complicated by the lack of systematic and prospective data. Pregnant women have historically been excluded from randomized controlled trials, and studying the effects of medications on a developing fetus or nursing baby has raised ethical concerns (Birndorf & Sacks, 2008; Wisner et al, 2009). Thus, nonpharmacological treatments for these women are preferable when possible.
IPT is a great treatment option for these women for several reasons. First, antepartum and postpartum depression are life-event-based illnesses, and IPT is a life- event-based treatment. They are distinguished from other subtypes of mood disorders not so much by symptoms as by timing: they are defined by major transitions in a woman’s life (Halbreich & Karkun, 2006). In fact, the DSM-IV does not distinguish major depression that occurs antepartum or postpartum as a distinct mood disorder. The DSM-IV includes a qualifier of “postpartum onset” for women with major depression that begins within four weeks of giving birth (APA, 1994).
Pregnancy and having children inevitably affect relationships with one’s partner, other children, parents, friends, employers, colleagues, and others, often leading to interpersonal conflicts on which IPT can focus. The demands of motherhood force new mothers to reconfigure their priorities and adjust their expectations of themselves in relationships and other areas in their life. Thus, childbearing involves major role transitions often involving interpersonal conflicts—focal problem areas that IPT targets (Weissman et al., 2000).
The time limit of IPT appeals to pregnant women and new mothers. Pregnant women often feel a sense of urgency to feel better as they want to be able to enjoy their pregnancy and feel better before their baby arrives. Some fear the potential impact of their depression on their unborn child. They may anticipate not having time for treatment once the baby comes. New mothers are often overwhelmed by the new responsibilities of caring for a new baby, which may make a focused, time- limited psychotherapy seem manageable. The fact that IPT is the most tested psychotherapy and has the most demonstrated efficacy for the treatment of peripartum depression is encouraging for these women, who feel they do not have time to try different treatments.
Unfortunately, depression and other mental disorders still carry a stigma, which deters some from seeking treatment. Depression during and following pregnancy carries an added stigma. Women who experience negative feelings about their pregnancy or motherhood often feel ashamed and unable to share their feelings with others. The use of the medical model in IPT can help reduce this stigma. The IPT therapist explains that these are major life transitions that are challenging for most women and that it is normal to have both negative and positive feelings about them. The therapist tells the patient that major depression at any time in a woman’s life is an illness that is not her fault.
In the event that a women reports symptoms that are severe and that interfere with her ability to make use of psychotherapy, a consultation with a psychiatrist specializing in the use of psychotropic medications during pregnancy and lactation should be considered. Fortunately, IPT’s medical model makes it is compatible with pharmacotherapy.
As IPT is a natural fit for this population, adaptations require minimal changes to the basic IPT approach.