Initial Phase
In the initial sessions (Sessions 1-3) of acute treatment, I obtained Ellen’s psychiatric history, set the framework for treatment, and began to build a therapeutic alliance. In the first session, I explained that IPT is a time-limited, diagnosis-targeted therapy that focuses on how recent life events affect mood and how mood symptoms make it difficult to handle current life events, especially interpersonal interactions. I explained that our sessions would focus not on the past but on current relationships and difficulties, such as her difficulty in making the transition to motherhood—a role transition. I explained that IPT has been shown in clinical studies to be effective for the treatment of various types of depression, including postpartum depression. I told Ellen that we would work together for twelve weeks; at the end of that time, we would decide together whether it made sense for us to continue working together. I administered the Hamilton Depression Rating Scale (Ham-D; Hamilton, 1960) and she scored 25, consistent with moderately severe depression. She also completed the Edinburgh Postnatal Depression Scale (EPDS, Cox et al., 1987), a 10-item self-report scale developed to adjust for the neurovegetative symptoms that are a normal part of the postpartum period. Women who score above 12 on the EPDS are likely to be suffering from depression; Ellen scored 24.
Based on my review of her symptoms and these scales, I determined that Ellen met criteria for major depressive disorder with postpartum onset. I gave her the diagnosis and the “sick role” (Weissman et al., 2007):
therapist: You have an illness called major depression. Depression after having a baby is referred to as “postpartum depression.” Depression is a very common illness, treatable and not your fault. You can feel better. When people are depressed, they often do not feel like socializing with friends as you described. Give yourself a break: this is how you are feeling for now, but you have started treatment and working on feeling better.
I asked her if this made sense.
ellen: Sort of. I just don’t understand why this would happen now. I thought I would be so happy when the baby was born. I’ve always wanted to be a mom and we worked so hard to conceive her.
therapist: Becoming a mother is a major life transition that shakes up various parts of your life and relationships. Even if you want a change like this, like having a baby, the transition can still be very challenging. Most women find the transition to motherhood challenging.
Ellen agreed that this made sense. I provided psychoeducation about PPD and reviewed her specific symptoms. I explained that her history of depression made her vulnerable to a recurrence of symptoms in the setting of stressful life events, like having a baby. I emphasized that this was not her fault and that her symptoms were treatable. I acknowledged the stigma related to PPD. I explained that women often feel ashamed that they have negative feelings about their baby and motherhood and unfortunately don’t share these feelings or seek help if they are depressed. In fact, it is normal to have both positive and negative feelings. We also discussed how she could explain PPD to her husband, Joe, and others. By the end of the first, consultation session, Ellen reported feeling relieved that she was “not going crazy,” that other new mothers also have a hard time, and that she could feel better.
In taking a thorough psychiatric history, I conducted an interpersonal inventory, a careful review of Ellen’s past and current social functioning and social relationships. The goal of the interpersonal inventory is to help both the therapist and patient understand how the patient interacts with other people; to identify her social supports, if any; and to determine how recent relationships might have contributed to or have been affected by the depression. Depressed individuals tend to withdraw from others. They tend to avoid seeking support when they feel down because they fear burdening others with their problems. They have difficulty asserting their needs in relationships, but feel disappointed when their expectations of others are not met. Depressed individuals tend to avoid expressing anger and other negative feelings towards others. The IPT therapist helps the depressed patient learn to identify and tolerate such affects, then how to assert herself and express her anger more effectively. The interpersonal inventory provides a framework for understanding the social and interpersonal context that contributed to the current depressive episode and should provide a treatment focus.
Ellen reported that she grew up in New York City and attended a good liberal arts college in Pennsylvania. She had an older brother with whom she felt close and spoke weekly. She and Joe visited him, his wife, and their children, ages three and five, about once a month. Ellen described having good relationships with her parents, who lived nearby. Since her daughter was born, she spoke to her mother daily and saw her several times a week. Her mother would come over a few times a week to help her take care of the baby. Ellen explained that she felt “uncomfortable” accepting her mother’s help: “I’m used to being very independent. I don’t like having to rely on her.” She suspected that her mother had suffered from depression in the past and that her brother was depressed when he was in high school. She denied knowing of any other psychiatric illness in her family.
Ellen reported that she had several close female friends: one from elementary school, a few from high school and college, and a couple she met through work. She described herself as “shy at first” when meeting new people, but eventually able to open up and form lasting friendships. She admitted that she tended to avoid conflict when angry at her friends. She explained that instead of telling her friends how she felt, she would keep her feelings to herself, feel down, and avoid phone calls or contact for at least a few days until the feelings dissipated. She had not seen many of her friends since the baby was born. They offered to come over, but she was embarrassed that her apartment was a mess and she felt too overwhelmed to entertain guests. In addition, Ellen felt self-conscious about her appearance: it was sometimes difficult to take a shower while taking care of the baby and she had not lost all of the weight she had gained during her pregnancy. Ellen explained that about half of her friends also had children, but that they had started their families six or seven years earlier, so none of her close friends had babies. She had not yet met any other new moms.
Ellen reported that she began dating in high school and had a few relationships with men before meeting Joe, each one lasting two or three years. She met Joe while working as the head of the recruiting department at a prestigious Manhattan law firm. Joe, an attorney at another firm, met her at a career fair where they were each presenting their respective firms. They married after dating for two years. She related that she and Joe “had a lot of fun together” before their daughter was born. She described him as a “really nice guy.” When asked how they handle conflict, Ellen said that they generally got along well, but that when she was angry at him, she tended to be “passive aggressive” and had difficulty telling him how she felt. She would become withdrawn, irritable, and terse until he asked her why she was upset. Ellen described a longstanding difficulty asserting herself with others—a difficulty that was exacerbated in the setting of depression and that would be addressed in IPT.
Ellen had worked in legal recruiting since graduating from college, quickly working her way up to heading a recruiting department where she managed a team of ten people. While very successful in her field, she reported feeling unfulfilled intellectually and tired of the very long hours her job required. Ellen and Joe agreed that it made sense for her to leave her job when the baby arrived. They planned to have more than one child and assumed that she would pursue a different career after staying home to take care of their children for a few years. When I asked her how she felt about leaving her job, she replied: “I don’t miss the work and the stress, but I miss being with other adults and getting out of the apartment.” I asked her how she felt about not earning money and relying on her husband’s income. She replied that she felt a little uncomfortable, as she had been financially independent for over fifteen years, but had saved a lot of money.
Ellen was “so excited to have a baby" She and Joe began trying to conceive about a year after marrying. She denied ever having been pregnant prior to conceiving her daughter. At thirty-seven, after a year of unsuccessful attempts, her OB-GYN recommended intrauterine insemination to improve her chances of conceiving. Ellen became pregnant after their third insemination procedure. She and Joe “were ecstatic" when they learned she was pregnant. An avid exerciser, Ellen exercised throughout her pregnancy and “felt great” most of the time. As she approached term and grew more uncomfortable and tired, however, she felt unable to exercise as much and began feeling “like I was losing myself" She reported that Joe was affectionate and doted on her throughout her pregnancy, and that she felt very close to him. He was beside her in the birthing room for the delivery and tried to be helpful, but was very anxious; at times she felt like she had to calm him down.
Ellen reported that while her delivery was normal and uneventful, she had a difficult time nursing her baby in the hospital and received assistance from a lactation consultant. “I didn’t think breastfeeding would be so difficult . . . I felt incompetent as soon as my daughter was born" After bringing Sara home, her nursing difficulties continued. Despite following the lactation consultant’s instructions, she could not produce enough milk to feed her daughter. Her pediatrician told her to supplement the breast milk with formula. She “felt like a failure" and became more depressed. Ellen also related becoming increasingly anxious about Sara getting sick or hurt:
ellen: I feel like I have no idea what I am doing . . . I’m used to working really hard and getting things done . . . Everyone else makes it look so easy. therapist: You are so hard on yourself! You are right—you’ve been an expert at your job at the firm and highly effective. Being a mother is a brand-new role for you, and you’re not expected to be an expert right away. We can work on your feeling more comfortable as a mother.
Ellen described Joe as somewhat helpful with the baby, but wished that he would do more and give her a break. When I asked her if he knew what she wanted, she answered: “He should know . . . I am obviously exhausted." She resented that he had the freedom to have lunch with his colleagues and get out of the house every day. When I asked if she had shared these feelings with him, she stated that she had not. Although they had not been arguing, Ellen related feeling distant from him. She reported his supportive response when she told him what she had learned about PPD, and he frequently told her that he thought she was a great mother.
On the morning of our third session, Ellen’s mother, who was scheduled to watch the baby during our session, became ill. Ellen called me and asked if she could bring her baby to our session. I agreed that she could. Although I generally find it distracting for both the patient and me to have a baby in session, it is helpful to see how a depressed new mother interacts with her baby. I also appreciated and wanted to accommodate Ellen’s interest in keeping our appointment. She arrived with the baby prepared with everything the baby could need for the excursion to my office. Ellen seemed natural and relaxed holding her daughter, who appeared well taken care of. She made loving and happy faces at her daughter. She seemed connected to her baby and did not resemble the incompetent mother she had described. I shared my observations with Ellen, and she replied, tearfully, “I want to believe you. I am relieved that you think so.”
I ndeed, I felt relieved too. Unlike Ellen, depressed new mothers can appear uncomfortable with their babies, seem unable or unsure how to hold or care for them, or emotionally disconnected from their babies. When working with women with PPD, therapists often have to deal with concerns about the health of both mother and child. Therapists may feel uncomfortable raising concerns about the depressed mother’s capacity to care for her child or about the potential impact of her untreated illness on her baby. Patients may feel criticized, resulting in a rupture in the treatment. The medical model and the sick role can be helpful: depression does make it difficult to care for a child and to emotionally connect, so it is not the new mother’s fault. The IPT therapist can encourage the patient to get help taking care of her baby from another caregiver while she is still depressed. The therapist tells the patient that she is not expected to know how to do everything in her new role and that she can learn how to care for their baby. I have referred patients with very poor insight and judgment about taking care of their babies to mother-infant specialists who work with mothers having difficulty bonding with and taking care of their babies. In New York State, mental health professionals are obligated to report mothers who describe behaving in ways that put their children in imminent danger to the Office of Children and Family Services. Similarly, therapists working with depressed pregnant women who are not practicing good prenatal care or using substances that can potentially harm the fetus may feel compelled to address the health of the developing fetus.
Concluding the initial phase of acute treatment (Session 3), I suggested that we choose one or at most two issues to focus on. IPT for major depression usually focuses one of four interpersonal problem areas: a role dispute, a role transition, grief, or (if none of the preceding fits) interpersonal deficits. Women with PPD by definition are in the midst of a role transition, which often also involves a role dispute, so the interpersonal deficits problem area is never a focus. I connected Ellen’s symptoms of depression to her interpersonal situation in an IPT formulation (Markowitz & Swartz, 2007).
As Ellen’s chief complaint focused on her adjustment to motherhood, my formulation emphasized her role transition into motherhood:
therapist: You have been having a difficult time adjusting to becoming a mother. In IPT we call any shift to a major new role a role transition. There have been many changes in your life since Sara was born. For example, you gave up your career. You’re used to being an expert at your job, but you’re now in a new role that feels unfamiliar. You are used to being very independent, but now need to rely on others to help you. Before Sara was born, you spent a lot more time with other adults—your husband, colleagues, and friends. You also used to have a lot more freedom to take care of yourself. There’s a connection between what is happening in your life and your mood. Role transitions can trigger symptoms of depression in vulnerable individuals, and, conversely, depressive symptoms can make it difficult to handle role transitions. If we can help you navigate this transition to motherhood, your mood should improve. Also, if we can help you to better understand and manage your depressive symptoms, you’ll be better able to deal with this major life change.
I asked her if this made sense. She agreed that it did.
therapist: In addition, your relationship with your husband has changed since your baby was born—the two of you have had to negotiate the new responsibilities of parenting and have less time for each other. From what you’ve told me, you’ve had difficulty expressing how you feel to Joe and you two have been in conflict. Depression affects how people function in relationships. People with depression tend to withdraw from others and have difficulty asserting themselves. I think that if you can express your needs more effectively to him, you’ll be able to feel more connected to him and feel better. Does this make sense to you?
She said it did. Ellen agreed that working on her role transition should be the focus of treatment. With this agreement we entered the middle phase of treatment.
At the end of the acute phase, I repeated the Ham-D and also had Ellen complete another EPDS. Her Ham-D score fell to 19 and her EPDS score to 20. We reviewed together that the improvement in her scores reflected her feeling somewhat less depressed, more hopeful, and less anxious.
