Tag Archives: Dennis & Creedy

Murray-Cooper IPMH weekend, Part III: Interventions for PND

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The next day, Peter Cooper, focused on interventions. He referred to studies that trained non-professional women in either “non directive counseling” or “CBT” and sent them to the homes of recruited depressed women in the third trimester of pregnancy (Rahmin et al, 2008, Lancet). The results demonstrated a higher rate of recovery in both groups, the CBT group higher than the group with non-directive counselors. Cooper and Murray wanted to know if it were some simple principle of intervention that breaks the isolation, someone to do nonjudgmental listening; they wondered if that were just as good as some specific technique. They had done a study in the early 90’s in which they compared groups of about 40 – controls with routine care from health visitors (the typical system in the U.K., in which minimally trained women are sent out to the home of each mother who has just given birth to act in a supportive and educative role.) – and three kinds of treatment – counseling, CBT, and psychodynamic therapies. The routine care group got no additional treatment; the non-directive counseling group focused on the mother’s mood; the CBT focused on the mother-infant relationship with behavior modification and cognitive interventions; and the psychodynamic focused on the mother-infant relationship with a focus on attachment, through the mother ‘s own personal history (This was inspired by B Cramer, 1993.). 

Here are some of the differences among the interventions that were studied: In the counseling group, the counselor followed a Rogerian (Rogers, 1951) technique in which the counselor provided an ear and encouraged elaboration of how the mother felt. In the CBT group, the counselor took a more concrete problem solving approach, for example, “It sounds as if you need some help in the afternoon so that you can have a bath. What are the possibilities? Do you have friends who can watch the baby? In the psychodynamic approach, following Cramer, the counselor explored the mother’s history with her own mother, starting with a modified AAI (Adult Attachment Inventory, cite). Then whatever issues the mother was finding difficult with her own baby would be considered from the point of view of the AAI material (aspects of her mother’s behavior that this mother was unconsciously repeating with her own child). Finally, there was an IPT group. IPT was developed by Myrna Weissman and Gary Klerman and conceives of depression as a relationship problem that occurs when one is not getting satisfaction from one’s relationships (cite); so the therapy is about examining and renegotiating relationships. The results of the IPT group were as good as the CBT group.  It turns out that both therapies were rather equally effective.

Yet, surprisingly, by 9 months the findings showed that there was no difference between those who did not get treatment and those who did. In other words, despite the fact that the three treatment groups had different foci of attention in their interventions, they did not have a treatment-specific effect. Not only that, but there was no enduring benefit of the treatment on the mother’s depression. The study showed that treatment is highly beneficial in the short run, and all treatments are moderately effective. However, about a third are not helped; this significant minority does not respond and goes on to be depressed and also to have disturbed relationships with their children.

What about medication for PND? There is only one good trail (Appleby et al 1997) in which a group of 87 were randomized to fluoxetine and either had CBT or not, and were then compared with placebo and CBT or not. All groups improved. Fluoxetine is better than placebo, and six sessions of CBT is better than one, but it is not additive. There did not seem to be any advantage to receiving both CBT and fluoxetine!

In 2004, Dennis and Creedy reviewed the studies and concluded that there was not benefit to prevention (Dennis and Creedy, 2004). However, Lynne and Peter felt that if you focused more on the quality of the early relationship and improving it, than you did on treating the mother’s depression, you could have greatest benefit. By creating a “predictive index” that included general adversity factors (poor housing, et.) obstetrical factors, and psychiatric factors, they were able to predict depression but just not very well. Why was that? One possibility is that the neonatal factors that you can’t pick up ante-natally played a important role. High irritability in the baby increases the risk of PND three fold, more than past history of maternal depression. Poor motor control in the infant is also very important as a risk factor. Maternal reports of difficult infant behavior is important too, though less, and maternal “blues” is also significant, though least powerful. Peter says that there is cumulative risk, so for example if you have high risk from previous depression and a highly irritable baby, you are at most risk for PND). Lynne and Peter found that when the mother had good support, the irritability of the baby did not add risk, but irritability plus no support added 4-fold risk. 

Questions and Comments from the Group:

In the US, there has been a focus on the trauma of childbirth (typical childbirth), but also a romanticization of pregnancy and childbirth. There was a discussion about the “grandiosity” of neonatal experience of mothers. There was another question about the effect of physiological factors, such as sleep deprivation. This has not been studied well. In the 30’s to 50’s they studied sleep a lot because they did a lot of EEG studies. Studies showed that during pregnancy the fetus developed two rhythms related to the mother’s rhythm and sleep cycle, and at birth the baby lost one and kept one. In DST terms, one rhythm was well organized and one was not. One might have been a maternal rhythm and one was related to fetal organismicity. If the mother in the pregnancy had a dysregulated sleep cycle, maybe the infant would be born with a really (doubly) dysregulated sleep. 

Reading Trial of Preventive supportive interaction treatment

This was a study of the preventive effect of health visitors to pregnant mothers. The mothers felt supported and understood, and the treatment was well appreciated. Yet, they found that at 8 weeks there was no impact on PND development. In other words, there is no evidential base to support the introduction of preventive therapeutic programs for PND. The best predictors from this questionnaire were marital conflict and previous depression. No studies have found to show that method of delivery apart from past psychiatric history had an effect. 

However, these studies typically eliminate the outliers. It may be that we need alternative models to analyze these data, such as dynamic systems models. For example, birth trauma may be a factor for a particular person. A nonlinear model that takes seriously these outlier situations may be more useful for clinical work. Instead of talking of “cumulative risk”, it may be necessary to dimensionalize the risk factors into factors such as financial factors, loss, etc., and in that way gain significance. Cindy Liu found that that significance varied in terms of ethnicity. For example, the occurrence of loss was much greater in the African American group and so were financial factors (Liu, ). The detailed contextualization is crucial. 

Summary and conclusions – 

PND is generally effectively treated with psychotherapy of a variety of forms; severe depression is less likely to improve and may require antidepressant medication and or longer term psychotherapy, but mothers are likely to experience further episodes. Preventive treatments do not seem to be effective. 

The manner of treatment does not seem to bear upon the outcome, though the issue of whether or not you have treatment at all is important. At 18 months the mothers report better behavior with treatment, and the teacher reports better behavior at 5 years. When mothers were under social stress, treatment improved the quality of mother-infant engagement.

The findings of the Reading study included the facts that the preventive intervention had no impact on the occurrence of depression, the quality of the M-I relationship, the infant security of attachment, or the infant cognitive and emotional outcome

Treatments directed at maternal depression even when successful have a minimal impact on the quality of the -I relationship and child developmental outcome. Treatments directed at the M-I relationship even when successful have no impact on maternal mood. It is therefore necessary that specific treatments be provided for both the maternal mood disorder and the associated disturbed m-child relationship. Depression does seem to be manifested in disturbances in the relationship in various domains. Mothers become depressed, the relationship becomes disturbed in certain ways, and patterns of relationship become established and gain a life of their own. Then the depression goes up and down. In other words, it is the depression that is causal, but once the problematic patterns are established, they just trundle along.

Cramer, Bertrand (1993) Are postpartum depressions a mother-infant relationship disorder, Infant Mental Health Journal, Vo. 14, Issue 4, pp. 283-297.

Dennis, CL & Creedy, D (2004). Psychosocial and psychological interventions for preventing postpartum depression, Cochrane Library, 2007, Issue 4, Wiley.

Rahmin (could not find reference).

Rogers, Carl (1951). Client-Centered Therapy, Cambridge, MA, The Riverside Press

 

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