Tag Archives: post natal depression – PND

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


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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Murray-Cooper IPMH weekend, Part II



Post Natal Depression: Part II

How do mothers affect the development of emotional regulation in infants? Murray showed a film of a study with mothers and 14-month infants in which the mother is first asked not to interact with the child when the researcher puts a toy frustratingly out of reach. The child naturally becomes distressed and remains so. When the mother is allowed to support her child, she responds quickly with an empathic facial expression. Then she says, “Oooh, how do you feel? Perhaps we can do something!” while giving a hopeful and suggestive facial expression. The mother begins to occupy the child by playing a little game with her fingers so that it distracts the child from her frustration at not being able to get the toy. It is clear how this kind of interaction repeated over and over can support the child’s growing tolerance for frustrating experiences.

In another wonderful film, a (non-depressed) mother is giving a bath to a 15-month girl. The mother is washing her face, and the child is tolerating this relatively well, but when she tries to brush her teeth, the child objects forcefully. This child turns out to have a firey temperament with a low threshold for frustration, and the mother must take account of the temperamental characteristics of her baby. The mother pauses a bit. She has a little toy that squirts water and uses it to squirt water on the toy the baby is playing with, making a connection with her. The baby responds happily, and then the mother builds on this connection and focuses on what the baby is doing. Mother pretends to brush her own teeth. The baby smiles and lets the mother brush her teeth, then takes the tooth brush and tries to do it herself. Of course, depressed mothers have little tolerance for this step-by-step reciprocal play at bath time. They are more likely to either forcefully take the toothbrush and get the job done over the objections of the baby, or withdraw. 

What are the mechanisms by which the early mother-child relationship affects the development of depression in the child? First there is emotional contagion (Field, 1984, 1988). There are also effects on the HPA axis (Murray et al, 2010 a). Finally, there is the link between insecure attachment and low resilience (Sroufe et al, 2005). One of my favorite studies, given my interest in vocal tones and non-symbolic communication, is one in which mothers were coded according to their speech tones (Murray, 2010). Falling intonation, non-rhythmicity, and monotony were significantly more prominent in PND mothers. In the non-depressed mothers, there was a rhythmic quality, with variability in pitch. What is the human equivalent of Michael Meaney’s “low licking mothers” whose babies had elevated cortisol levels? It is the low engagement of depressed human mothers. Halligan et al,, in 2004 and 2007) found that the 13-yo children of depressed mothers had elevated morning cortisol levels, which was predictive of depressed state. In one film of a 7-year old child of a PND mother playing a game with a peer, the child was initially triumphant when she was winning, but when she lost the advantage, she also lost her composure. Even when you control for marital conflict, maternal depression at the beginning of the infant’s life proves to be a predictor of depression at 16 years (Murray et al, 2011).

In conclusion, PND is associated with a range of disturbances in the mother-infant relationship. Babies’ outcome is affected in diverse domains- cognition, behavior, and affect, to name several important ones. Each outcome might have a specific developmental trajectory, such that for example, a depressed child may have no cognitive impairment. One of the most important take away points from this presentation is that obstetricians and pediatricians must get better and better at identifying and treating mothers with PND. Another point, though with less immediate importance, is for mental health clinicians learn to elicit the history of a PND in their evaluations of children with psychiatric problems. Finally, it is crucial to remember that nothing is written in stone. These problematic patterns may be interrupted at any point in the process – whether by the early intervention I have just been advocating, psychotherapy in the older child or adolescent, or by positive life events – a new supportive partner for the mother, the healing of an important relationship from the past, a better work situation, a new group of supportive friends for the child, the discovery of a talent in the child that brings positive self esteem to the whole family – that change the family trajectory in a better direction. Pointing out risk factors is never helpful without an equal emphasis on the resiliency factors that create a natural correction on a family life turning off course. 

Murray L, Marwick H, & Arteche A, (2010). Sadness in mothers’ ‘baby-talk’ predicts affective disorder in adolescent offspring, Infant Behavior and Development, 33:361-364.

Murray L, Halligan S, Goodyer I, & Herbert J, (2010 a). Disturbances in early parenting of depressed mothers and cortisol secretion in offspring: A preliminary study, J Affective Disorders, 122:218-223.  

Murray L, Arteche A, Fearon P, Halligan S, Goodyer, I, & Cooper P (2011). Maternal postnatal depression and the development of depression in offspring up to 16 years of age, J Amer Acad Child Adol Psychiat, 50(3):460-470. 

 Photo – Joshua Sparrow, M.D., Nov. 2012 


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