Vol 53: september ⢠septembre 2007â CanadianâFamilyâPhysicianââ˘âLeâMĂŠdecinâdeâfamilleâcanadienâ 1469FOR PRESCRIBING INFORMATION SEE PAGE 1585
An approach to interpersonal psychotherapy for postpartum depression Focusing on interpersonal changes
Sophie Grigoriadis MD MA PhD FRCPC Paula Ravitz MD FRCPC
ABSTRACT
OBJECTIVEâ Toâreviewâtheâprinciplesâofâinterpersonalâpsychotherapyâ(IPT)âforâtheâtreatmentâofâpostpartumâdepressionâ(PPD).
SOURCES OF INFORMATIONâ Empiricalâliterature,âIPTâmanualsâincludingâthoseâadaptedâforâPPD,âandâtheâauthorsââclinicalâexperience.
MAIN MESSAGEâ LevelâIâevidenceâsupportsâIPTâasâaâtreatmentâforâPPD.âInterpersonalâpsychotherapyâisâideallyâsuitedâbecauseâitâfocusesâonâtheâimportantâinterpersonalâchangesâandâchallengesâwomenâexperienceâduringâtheâpostpartumâperiod.âItâisâdeliveredâinâ12âsessionsâandâemphasizesâinterpersonalâdisputes,âroleâtransitions,âorâbereavement.âInâthisâarticle,âweâdescribeâtheâIPTâmodelâandâtherapeuticâguidelinesâforâtreatmentâofâPPD.
CONCLUSIONâ Postpartumâdepressionâisâanâimportantâpublicâhealthâproblemâwithâpervasiveâeffectsâonâmothers,âinfants,âandâfamilies.âInterpersonalâpsychotherapyâisâaârelevantâandâeffectiveâtreatmentâforâwomenâsufferingâfromâPPDâbecauseâitâhelpsâaddressâtheâmanyâinterpersonalâstressorsâthatâariseâduringâtheâpostpartumâperiod.âTheâprinciplesâofâIPTâcanâbeâintegratedâeasilyâintoâprimaryâcareâsettingsâasâIPTâisâpragmatic,âspecific,âproblemâfocused,âshort-term,âandâhighlyâeffective.
RĂSUMĂ
OBJECTIFâ PasserâenârevueâlesâprincipesâdeâlaâpsychothĂŠrapieâinterpersonnelleâ(PTI)âcommeâtraitementâdeâlaâdĂŠpressionâduâpost-partumâ(DPP).
SOURCES DE LâINFORMATIONâ LittĂŠratureâempirique,âmanuelsâdeâPTIâincluantâceuxâadaptĂŠsâpourâlaâDPPâetâlâexpĂŠrienceâcliniqueâdeâlâauteur.
PRINCIPAL MESSAGEâ LâutilisationâdeâlaâPTIâpourâtraiterâlaâDPPâestâsupportĂŠeâparâdesâpreuvesâdeâniveauâI.âCetteâapprocheâconvientâparfaitementâparceâquâelleâestâcentrĂŠeâsurâlesâchangementsâinterpersonnelsâimportantsâetâsurâlesâdĂŠfisâauxquelsâlesâfemmesâfontâfaceâdurantâleâpost-partum.âElleâseâdonneâenâ12âsĂŠancesâetâporteâsurtoutâsurâlesâconflitsâinterpersonnels,âlesâchangementsâdeârĂ´leâouâlesâdeuils.âCetâarticleâdĂŠcritâleâmodèleâdeâlaâPTIâetâlesâdirectivesâpourâleâtraitementâdeâlaâDPP.
CONCLUSIONâ LaâDPPâestâunâimportantâproblèmeâdeâsantĂŠâpubliqueâquiâaâdesâconsĂŠquencesânĂŠfastesâpourâlaâmère,âleânourrissonâetâlaâfamille.âLaâPTIâestâunâtraitementâpertinentâetâefficaceâpourâcellesâquiâsouffrentâdeâDPPâparceâquâelleâlesâaideâĂ âfaireâfaceâauxânombreuxâagentsâstressantsâinterpersonnelsâquiâsurviennentâdurantâleâpost-partum.âLesâprincipesâdeâlaâPTIâpeuventâfacilementâĂŞtreâintĂŠgrĂŠsâdansâunâcontexteâdeâsoinsâprimairesâpuisqueâcetteâthĂŠrapieâestâpragmatique,âspĂŠcifique,âaxĂŠeâsurâdesâproblèmes,âdeâcourteâdurĂŠeâetâhautementâefficace.
This article has been peer reviewed.Cet article a fait lâobjet dâune rĂŠvision par des pairs.Can Fam Physician 2007;53:1469-1475
Clinical Review
1470â CanadianâFamilyâPhysicianââ˘âLeâMĂŠdecinâdeâfamilleâcanadienâ Vol 53: september ⢠septembre 2007
Clinical Reviewâ An approach to interpersonal psychotherapy for postpartum depression
CaseMrsâ C,â aâ 40-year-oldâ lawyer,â isâ broughtâ toâ theâ officeâbyâherâhusbandâofâ10âyears.âHeâhasânoticedâthat,âsinceâtheâ birthâ ofâ theirâ nowâ 1-month-oldâ daughter,â Mrsâ Câhasânotâbeenâherânormalâself.âInâyourâofficeâsheâstartsâtoâcryâafterâyouâaskâherâaboutâtheâbaby.âMrsâCâexplainsâthatâsheâisânotâaâgoodâmotherâandâfeelsâworthlessâandâguiltyâaboutâhavingâhadâaâchild.âSheâisâoverwhelmed.âMostâofâtheâtimeâsheâisâirritableâandâanxiousâaboutâherâabilityâtoâcareâforâherâbaby.â
Postpartumâ depressionâ (PPD)â isâ aâ common,â poten-tiallyâ life-threateningâ andâ disablingâ condition.â Itâ isâ esti-matedâtoâaffectâ10%âtoâ15%âofâwomen,âandâitsâprevalenceârangesâ fromâ5%â toâmoreâ thanâ20%.1âEvidenceâ indicatesâthatâ bothâ pharmacologicâ andâ psychotherapeuticâ man-agementâ ofâ thisâ conditionâ areâ effective,â butâ thereâ areâconcernsâ withâ pharmacologicâ managementâ thatâ neo-natesâmightâbeâexposedâtoâantidepressantâdrugsâthroughâbreastâ milk.2â Studiesâ haveâ shownâ thatâ womenâ preferâpsychologicalâandâsocialâmanagementâoverâdrugsâduringâtheâperinatalâperiod.3â
Interpersonalâ psychotherapyâ (IPT),â aâ time-limitedâtreatment,â wasâ firstâ designedâ forâ treatingâ peopleâ withâmajorâ depressionâ whoâ didâ notâ haveâ bipolarâ diatheses,âpsychoses,âorâsubstanceâabuseâproblems.4âEmpiricalâevi-denceâsupportingâtheâefficacyâofâIPTâhasâgrownâsinceâitsâearlyâuse,âasâhasâtheâscopeâofâitsâclinicalâapplication.5-7
Familyâ physiciansâ needâ toâ beâ awareâ ofâ psychothera-peuticâ approachesâ toâ PPD.â Interpersonalâ psychotherapyâforâ PPDâ isâ anâ effectiveâ treatmentâ thatâ focusesâ onâ theâimportantâ interpersonalâ changesâ andâ challengesâ thatâwomenâ experienceâ duringâ theâ postpartumâ period.â Inâthisâ article,â weâ describeâ theâ IPTâ modelâ andâ therapeuticâguidelinesâforâtreatmentâofâPPD.
Sources of informationGuidelinesâforâtreatmentâofâdepressiveâdisordersâfromâbothâtheâ Canadianâ Psychiatricâ Associationâ andâ itsâ AmericanâcounterpartârecommendâIPTâasâanâeffectiveâtreatmentâforâdepression.8,9âFiveâstudiesâevaluatingâIPTâforâtreatmentâofâ
PPDâprovideâlevelâIâevidenceâofâeffectivenessâforâtreatingâmajorâdepressionâwithâpostpartumâonset:â1âopenâ trial,â 1âwait-listârandomizedâcontrolledâtrial,âandâ3âsmallâstudiesâevaluatingâgroupâapproaches.10-14
Modificationsâofâ IPTâ forâPPDâpresentedâ inâ thisâarticleâareâ basedâ onâ theâ workâ ofâ Klermanâ etâ al,4â Stuartâ andâOâHara,15â andâ theâ authorsââ clinicalâ experience.â Theâ IPTâguidelinesâ andâ theâ IPT-specificâ therapeuticâ techniquesâ(bothâofâwhichâareâpublishedâ inâmanuals)âhelpâpatientsâworkâthroughâcommonlyâencounteredârelationalâdifficul-tiesâandâareâeasilyâintegratedâintoâprimaryâcareâsettings.
Main messageInterpersonalâpsychotherapyâ isâaâproven,âeffectiveâ treat-mentâ forâ mild-to-moderateâ PPDâ andâ anâ alternativeâ toâpharmacotherapy,â especiallyâ forâ breastfeedingâ women.âItâ reducesâ depressiveâ symptomsâ andâ improvesâ socialâadjustment.âForâwomenâwithâpsychoticâfeatures,âbipolar-ity,âorâsevereâsymptoms,âincludingâsuicidalâorâinfanticidalâthoughts,âIPTâaloneâisânotâsufficient,âandâaâcombinationâofâ medicationsâ andâ possiblyâ hospitalizationâ shouldâ beâconsidered4,9,16â(Table 1).
Otherâ treatmentsâ forâ womenâ withâ PPDâ haveâ beenâtestedâ inâ pharmacologicâ treatmentâ studies,â onlyâ 3âofâ whichâ wereâ randomizedâ controlledâ trialsâ (RCTs).âOneâ RCTâ comparedâ fluoxetineâ withâ aâ hybridâ cogni-tiveâ behaviouralâ counselingâ approach,â anotherâ com-paredâ paroxetineâ withâ cognitiveâ behaviouralâ therapy,âandâ theâ thirdâ comparedâ sertralineâ withâ nortriptyline.âOtherâ studiesâ includedâ 1â openâ trialâ ofâ sertraline,â 1âopenâ trialâ ofâ venlafaxine,â aâ caseâ seriesâ onâ fluoxetine,âandâ 1â retrospectiveâ chartâ reviewâ involvingâ severalâantidepressants.17-23âBasedâonâtheâRCTs,âfluoxetineâandâ
Dr Grigoriadis is Academic Leader of the Reproductive Life Stages Program at Womenâs College Hospital in Toronto, Ont, Fellowship Director in the Department of Psychiatry at the University Health Network, and an Assistant Professor of Psychiatry at the University of Toronto. She is an Ontario Mental Health Foundation New Investigator and is mentored through the Canadian Institutes of Health Research Randomized Controlled Trials Mentoring Program. Dr Ravitz is Associate Head of the Psychotherapy Program in the Department of Psychiatry at the University of Toronto. She is Head of the Interpersonal Psychotherapy Clinic at the Centre for Addiction and Mental Health and is Director of the Mount Sinai Psychotherapy Training Institute.
Table 1. Interpersonal psychotherapy (IPT) for postpartum depression (PPD)Suitability criteria Patients with nonpsychotic, nonbipolar major depression with postpartum onset. Those less likely to be helped by a time-limited, structured treatment, such as IPT, include patients with a history of severe and complex trauma and those with profound disturbances in personality functioning.
Goals of treatment ⢠To remit depression ⢠To alleviate interpersonal distress ⢠To assist with building or with making better use of social supports
Refer for psychiatric consultation or consider hospitalization when patients ⢠endorse suicidal thoughts or homicidal thoughts; ⢠have moderate-to-severe symptoms and do not respond to IPT alone; ⢠have a history of severe depression in the past or have had other reproductive-related depressive disorders, such as premenstrual dysphoric disorder or previous PPD; ⢠need more support and monitoring than you can provide; or ⢠have psychotic, manic, or substance-abuse symptoms.
Vol 53: september ⢠septembre 2007â CanadianâFamilyâPhysicianââ˘âLeâMĂŠdecinâdeâfamilleâcanadienâ 1471
An approach to interpersonal psychotherapy for postpartum depressionâ Clinical Review
paroxetineâwereâshownâtoâbeâhelpfulâforâsomeâbutânotâallâwomen.âAlthoughâsertralineâandânortriptylineâwereâbothâ helpful,â womenâ takingâ sertalineâ wereâ identifiedâearlier.â Manyâ mothersâ withâ PPDâ breastfeed,â andâ theâamountâofâantidepressantâenteringâtheirâbreastâmilkâisâofâconcernâtoâsomeâwomen,âandâtheyâareâreluctantâtoâuseâtheâmedication.â
Psychotherapiesâ haveâ beenâ studiedâ asâ alternativesâtoâantidepressantâtreatment.âAlthoughâoneâofâtheâaboveâstudiesâ evaluatedâ cognitiveâ behaviouralâ therapyâ andâfoundâitâeffective,âtheâsampleâsizeâwasâsmall,âwhichâlim-itsâtheâconclusionsâthatâcanâbeâdrawn.
Theâ bestâ evidenceâ forâ psychotherapyâ asâ anâ effectiveâtreatmentâforâPPDâisâforâIPT.âItâwasâevaluatedâinâanâRCTâwithâ aâ largeâ sampleâ size.11â Ofâ 120â womenâ diagnosedâwithâ PPDâ recruited,â 99â completedâ theâ 12-weekâ study.âTheâwomenâwereârandomlyâassignedâtoâ12âweeksâofâIPTâorâtoâaâwait-listâcontrolâgroup.âSignificantlyâmoreâwomenâinâtheâIPTâgroupâachievedâremissionâofâdepressionâthanâwomenâ inâ theâ wait-listâ groupâ didâ (37.5%â vsâ 13.7%).âFurtherâ evidenceâ forâ theâ efficacyâ ofâ IPTâ forâ PPDâ comesâfromâsmallerâtrialsâasâmentionedâabove.âOtherânonphar-macologicâ talkingâ therapiesâ evaluatedâ includeâ cogni-tiveâ behaviouralâ therapy,17,22,24,25â counselingâ byâ healthânurses26âorâhealthâvisitors,27âpeerâsupportâgroups,28-30âandâpartnerâsupportâsessions.31âTheseâapproachesâhaveâbeenâ
foundâ toâ beâ helpful,â althoughâ RCTsâ withâ largeâ sampleâsizesâstillâneedâtoâbeâconducted.
Aâ limitationâ onâ allâ psychotherapeuticâ approachesâ isâtheâ timeâ commitmentâ necessaryâ forâ newâ mothersâ andâclinicians.â Also,â psychotherapeuticâ approachesâ mightânotâbeâappropriateâasâstand-aloneâtreatmentâforâwomenâwithâ moderateâ toâ severeâ depressiveâ symptoms.â Gettingâaccessâ toâ trainedâpsychotherapistsâ forâpatientsâandâget-tingâtrainingâinâpsychotherapyâskillsâforâcliniciansâcanâbeâchallenging,âespeciallyâinâremoteâregions.â
Manyâ ofâ theâ interpersonalâ problemsâ ofâ socialâ adjust-mentâ womenâ withâ PPDâ faceâ canâ beâ addressedâ byâ IPTâbecauseâitâfocusesâonâcurrentâpersonalârelationships4,6,7,32âratherâ thanâ onâ intrapsychicâ orâ cognitiveâ aspectsâ ofâdepression.â Theâ focalâ interpersonalâ problemâ areasâ ofâIPTâ areâ derivedâ fromâ researchâ thatâ hasâ demonstratedâtheâprotectiveâ functionâofâ interpersonalâsupportâasâwellâasâtheâassociationsâbetweenâinterpersonalâadversityâandâdepression.â Itâ usesâ aâ biopsychosocialâ model33â toâ under-standâ patientsâ andâ framesâ depressionâ asâ aâ medicalâ ill-nessâ thatâ occursâ inâ aâ socialâ contextâ whichâ isâ disruptedâduringâtimesâofâillness.âAlthoughâIPTârecognizesâtheâroleâofâ biologicalâ andâ psychologicalâ factorsâ inâ theâ causeâ ofâandâvulnerabilityâtoâdepression,â itâ focusesâonâsocialâfac-torsâandâworkingâthroughâinterpersonalâproblems6,7,32,34-39âtoâalleviateâdepressionâ(Figure 1).
Figure 1. Formulation worksheet for postpartum depression
MDDâmajor depressive disorder, PPDâpostpartum depression, PMDDâpremenstrual dysphoric disorder.
Interpersonal precipitantsRole transitionsGrief and loss
Interpersonal disputesInterpersonal sensitivity
Birth of babyBreastfeeding difficulties
Postpartum issuesâlack of sleep, etc
Patient name
Psychological factorsPersonality characteristics
Attachment styleCognitive style
Coping techniquesLossesâown mother?
Weight gain and body image
Social factorsIntimate relationships
SupportsPeople at work
Biological factorsHistory of MDD, PPD, PMDD
Family historySubstance use
Preganancy or delivery complicationsBreastfeeding
Medical illnesses and medications
Formulation
1472â CanadianâFamilyâPhysicianââ˘âLeâMĂŠdecinâdeâfamilleâcanadienâ Vol 53: september ⢠septembre 2007
Clinical Reviewâ An approach to interpersonal psychotherapy for postpartum depression
What happens during a course of IPT?Beginningâ phase.â Inâ theâ beginningâ (sessionsâ 1â andâ 2),âaâ comprehensiveâ assessmentâ isâ conductedâ toâdiagnoseâPPDâ andâ exploreâ theâ interpersonalâ contextâ toâ establishâtheâ focusâ ofâ therapy.â Theâ needâ forâ medicationâ isâ evalu-ated,â andâ depressionâ isâ discussedâ asâ aâ medicalâ illnessâwithâinterpersonalâantecedentsâandâsequelaeâinâaâsocialâcontext.âCliniciansâmustâdifferentiateâbetweenâtheâsymp-tomsâofâclinicalâdepressionâandâthoseâofânormalâpostpar-tumâexperiences.âForâexample,âMrsâCâwouldâbeâexpectedâtoâcomplainâofâfatigue,âweightâloss,âandâlittleâsleep;âbutâifâsheâmeetsâfullâDiagnostic and Statistical Manual of Mental Disorders,â 4thâ edition,â textâ revision,â criteriaâ forâ depres-sion,â thatâneedsâ toâbeâ identifiedâandâ treated.âTheâ focusâofâ therapyâ isâdeterminedâaccordingâ toâ theâcurrentâ inter-personalâ problemsâ thatâ areâ relatedâ toâ theâ onsetâ andâperpetuationâ ofâ theâ patientâsâ currentâ depressiveâ epi-sode.âToâinstillâpositiveâexpectations,âgoalsâareâexplicitlyâexplainedâ toâ patients:â toâ remitâ depressionâ andâ toâ helpâresolveâspecificâinterpersonalâproblems.4,34,40
Educatingâpatientsâaboutâpsychotherapyâ isâanâ impor-tantâtaskâinâtheâinitialâphaseâofâtreatment.âTheâfollowingâpointsâshouldâbeâexplainedâtoâMrsâC.â˘â Sheâisâsufferingâfromâdepression.â˘â Depressionâisâaâlegitimate,âtreatableâmedicalâillness.â˘â Depressionâ isâ explainedâ withinâ theâ biopsychosocialâ
modelâ asâ aâ biologicalâ illnessâ thatâ occursâ inâ aâ socialâcontext.
â˘â Postpartumâdepressionâandâdepressionâ inâgeneralâareârelativelyâcommon.
â˘â Specificâ treatmentsâ areâ availableâ forâ depressiveâ ill-nessesâ includingâ psychotherapiesâ (cognitiveâ behav-iouralâtherapyâandâIPT)âandâpharmacotherapy.âMrsâCâwouldâbeâencouragedâtoâuseâfamilyâandâfriendsâ
andâcommunityâinfant-motherâgroupsâtoâreduceâherâiso-lationâandâimproveâherâsocialâsupport.âMrsâCâsâdepressiveâsymptomsâ wouldâ beâ placedâ inâ anâ individuallyâ tailoredâinterpersonalâcontext.
Anâinterpersonalâinventoryâisâtaken,âandâtheâimportantârelationshipsâ inâ patientsââ livesâ areâ reviewed.â Pertinentâinformationâ aboutâ relationshipsâ withâ significantâ oth-ersâ shouldâ includeâ expectationsâ theyâ hadâ beforeâ child-birthâ forâ socialâ support,â theânatureâofâ theirâ interactionsâandâ communications,â satisfactoryâ andâ unsatisfactoryâaspectsâofârelationships,âandâwaysâinâwhichâtheyâwouldâideallyâlikeâtoâchangeâtheârelationships.âOtherâimportantâinformationâ toâobtainâ includesâ theirâexpectationsâaboutâmotherhood,â theirâ feelingsâ regardingâ theâchildâandâ thatârelationship,âtheâdetailsâofâtheâpregnancyâ(whetherâitâwasâplanned,â itsâ course,â labourâ andâ delivery),â interpersonalâramificationsâofâtheâbirthâofâtheâchild,âandâtheirârelation-shipsâwithâothersâpotentiallyâaffectedâbyâorâinvolvedâwithâtheâbirthâorâsubsequentâcareâofâtheâchildâ(Table 2).
Middleâ phaseâ andâ focalâ problemâ areas.â Focalâ areasâguideâ therapeuticâ interventionsâ throughâ theâ middleâ
phaseâ ofâ IPTâ therapyâ (sessionsâ 3â toâ 10)â andâ linkâ symp-tomsâ ofâ depressionâ toâ interpersonalâ events,â losses,â orâchanges.â Interpersonalâ psychotherapyâ helpsâ patientsâwithâPPDâtoâunderstandâtheirâassociatedâlifeâexperiencesâwithinâ 3â problemâ areas:â interpersonalâ disputes;â roleâtransitions;âandâbereavement.
Eachâ focalâ areaâ hasâ aâ differentâ setâ ofâ therapeuticâguidelines.â Patientsâ areâ expectedâ toâ participateâ activelyâandâworkâduringâtheâcourseâofâtherapyâtoâeffectâchangeâwithinâ theirâ identifiedâ problemâ areas.â Cliniciansâ shouldâmonitorâsymptomsâweekly.âGenerally,â1âorâ2âfocalâareasâareâ chosen.â Ifâ patientsâ areâ worseningâ orâ notâ improv-ing,âitâ isâcriticallyâimportantâtoâconsiderâpsychiatricâcon-sultationâ andâ addingâ antidepressantâ medication.â Itâ isâalsoâimportantâtoâscreenâforâbothâsuicidalâorâinfanticidalâthoughts,âandâifâpresent,âtoâconsiderâhospitalization.
Interpersonal role disputes:âTheseâareâdefinedâasâânon-reciprocalâ roleâ expectationsââ ofâ importantâ peopleâ inâpatientsââ livesâ (eg,â aâ maritalâ disputeâ betweenâ Mrâ andâMrsâC,âorâdisputesâwithâparentsâorâin-laws)âandâareâoftenâaccompaniedâ byâ poorâ communicationâ orâ misalignedâinterpersonalâ expectations.â Duringâ therapy,â behaviourâpatternsâareâexaminedâthroughâcommunicationâanalysis,âanâIPTâtechniqueâusedâtoârevealâwaysâinâwhichâpatientsâinteractâwithâothersâthatâmightâinadvertentlyâexacerbateâconflictsâthroughâactsâofâcommissionâorâomission.â
Variousâ waysâ ofâ understandingâ andâ communicat-ingâ withinâ relationshipsâ areâ exploredâ toâ facilitateâ moreâsatisfactoryâ waysâ ofâ relating.â Itâ isâ importantâ toâ assessâhowâwellâbothâmothersâandâtheirâspousesâperceiveâtheyâareâ adjustingâ toâ theirâ newbornsâ andâ toâ exploreâ theirâexpectationsâ regardingâ childâ care.â Aâ spouseâsâ levelâ ofâemotionalâ andâ instrumentalâ support,â theâ rolesâ ofâ otherâimportantâpeopleâ(includingâotherâchildren),âandâtheâsta-tusâ ofâ allâ theseâ relationshipsâ beforeâ andâ afterâ theâ preg-nancyâshouldâbeâassessedâ(Table 3).
Role transitions:â Theseâ involveâ lifeâ eventsâ thatâ leadâtoâ bigâ changesâ inâ socialâ rolesâ thatâ areâ centralâ toâ peo-pleâsâsenseâofâidentityâinârelationships.âForâwomenâwithâPPD,â theâ challengeâ isâ toâ integrateâ theirâ newâ socialâ roleâasâ motherâ withâ theirâ previouslyâ definedâ senseâ ofâ them-selvesâwithinâ theirâ families,â theirâworkplaces,âandâ theirâcommunities.
Mrsâ C,â forâ example,â needsâ toâ developâ newâ skillsâandâ expandâ theâ scopeâ ofâ herâ responsibilitiesâ whileâ
Table 2. Beginning phase take-home points
Educate patients about depression and its functional and interpersonal effects
Carefully evaluate symptoms, safety, functioning, relationships, and supports
Choose a current interpersonal problem focal area that is linked to the onset or perpetuation of symptoms
Encourage patients to use or recruit supports
Vol 53: september ⢠septembre 2007â CanadianâFamilyâPhysicianââ˘âLeâMĂŠdecinâdeâfamilleâcanadienâ 1473
An approach to interpersonal psychotherapy for postpartum depressionâ Clinical Review
maintainingâ orâ adjustingâ oldâ relationships.â Sheâ hasânumerousâ newâ socialâ rolesâ toâ integrateâ inâ thisâ timeâ ofâchange,âasâmother,âco-parent,âandâlawyer.âEachâofâtheseârolesâ hasâ demandsâ andâ responsibilitiesâ thatâ canâ beâ dif-ficultâ toâ prioritize.â Theâ courseâ ofâ IPTâ willâ helpâ Mrsâ Câdevelopâ aâ moreâ balancedâ viewâ ofâ eachâ role,â evaluateâandâmodifyâexpectations,âandâsetâpriorities.âMrsâCâmightâhaveâtoârenegotiateâtimeâcommitmentsâandâresponsibili-tiesâ inâ orderâ toâ adaptâ toâ newâ time,â physical,â andâ emo-tionalâconstraints,âwhileâbalancingâneedsâandâwishesâinâherâmultipleâroles.âAsâinâallâfocalâareasâofâIPT,âcommuni-cationâisâexaminedâinâdetailâinâorderâtoâhelpâMrsâCâmoreâeffectivelyâexpressâherâemotionsâandâneedsâsoâ thatâsheâcanâbetterâuseâherâsupportsâ(Table 4).
Bereavement: Thisâproblemâareaâisâchosenâasâaâfocusâinâ IPTâ whenâ theâ onsetâ ofâ depressionâ coincidesâ withâtheâ deathâ orâ anniversaryâ ofâ theâ deathâ ofâ aâ significantâother.â Therapyâ allowsâ patientsâ toâ workâ throughâ loss.âPositiveâ andâ negativeâ aspectsâ ofâ theâ lostâ relationshipâareâexploredâtoâachieveâaâmoreârealisticâviewâofâtheâlostâperson.âDetailsâofâtheâdeathâareâreviewed,âincludingâsup-portâprovidedâaroundâtheâtimeâofâtheâfuneral.âInâtheâlatterâstagesâofâtreatment,âpatientsâareâencouragedâtoâreplaceâaspectsâofâwhatâwasâlostâinâtheârelationshipâandâtoâbeginâtoâmoveâforwardâinâtheirâlives.
WomenâwithâPPDâcanâhaveâgriefâreactionsârelatedâtoâtheâ deathâ ofâ aâ newbornâ orâ significantâ otherâ duringâ theâneonatalâ period.â Theyâ mightâ alsoâ haveâ delayedâ mourn-ingâforâaâpastâlossâduringâtheâantepartumâorâpostpartumâ
period.âTheâgoalâofâtherapyâisâtoâfacilitateâmourning,âandâinâsoâdoing,âremitâtheâdepressionâ(Table 5).
Relationshipâwithâtheânewborn.â InâadditionâtoâfocusingâonâIPTâproblem-specificâgoals,âitâisâimportantâtoâattendâtoâtheâevolvingârelationshipâwithâtheânewborn.âAttachmentâbetweenâmotherâandâinfantâisâcrucialâinâdevelopmentâofâtheâ infantâsâ senseâofâ securityâandâsafety.â Itâ isâ criticalâ toâassistâ mothersâ withâ PPDâ toâ developâ nurturingâ relation-shipsâwithâ theirâ children.âTherapistsâcanâassistâpatientsâtoâbeâmoreâattunedâandâresponsiveâ toâ theirâ infantsâdur-ingâ theirâ periodâ ofâ recoveryâ andâ toâ recruitâ orâ useâ sup-portsâtoâhelpâwithâcareâofâtheâchild.
Endingâ therapy.â Inâ theâ concludingâ orâ terminationâphaseâ ofâ IPTâ (sessionsâ 11â andâ 12),â therapeuticâ gainsâareâreviewed.âItâisâhopedâthatâtheâgoalâofâtreatmentâhasâbeenâ achieved:â remissionâ ofâ depressiveâ symptomsâ andâimprovementâ inâ interpersonalâ functioning.âContingencyâplansâ areâ discussedâ inâ theâ eventâ ofâ recurrence,â andâpatientsâareâencouragedâtoâcontactâaâphysicianâforâearlyâtreatment.âFutureâproblemsâandâstressorsâwouldâbeâdis-cussedâ withâ Mrsâ Câ toâ facilitateâ autonomousâ problemâsolving.âMrsâCâwouldâbeâhelpedâ toâdifferentiateânormalâsadnessâ fromâ clinicalâ depression,â andâ feelingsâ associ-atedâ withâ theâ endingâ ofâ therapyâ wouldâ beâ openlyâ dis-cussed.â Inâ theâ eventâ thatâ Mrsâ Câ hasâ notâ improved,â itâwouldâbeâimportantâtoâconsiderâextendingâtheâcourseâofâIPTâorâ recommendingâalternativeâ treatmentsâ thatâmightâincludeâ pharmacotherapyâ orâ familyâ therapyâ alongâ withâpsychiatricâconsultation.
DiscussionInterpersonalâ psychotherapyâ offersâ anâ effective,â spe-cific,â problem-focused,â short-termâ approachâ toâ treat-mentâofâPPD.âStrengthsâ includeâtheâempiricalâsupport;âtheâ focusâ onâ universalâ relationalâ experiencesâ ofâ loss,âchange,â orâ conflict;â andâ theâ factâ thatâ theâ goalsâ andâtechniquesâ ofâ IPTâ areâ allâ published.â Manualsâ clearlyâarticulateâ theâ goalsâ ofâ therapyâ andâ standardizeâ
Table 5. Middle-phase tasks of interpersonal problem area (bereavement) take-home pointsMake links between interpersonal events related to the death and symptoms
Review the details of the death, the funeral, and the subsequent period of bereavement
Explore both positive and negative aspects of the lost relationship
Explore both positive and negative aspects of how things were before the loss
Explore the challenges of adjusting to the loss and the interpersonal opportunities in the present and future
Improve communication
Assist patient to better use or recruit supports
Table 4. Middle-phase tasks of interpersonal problem area (role transition) take-home points
Make links between interpersonal events related to transition and symptoms
Explore both positive and negative aspects of how things were in her previous role, before the birth of her infant
Explore the challenges and brainstorm regarding opportunities in the new role, since the birth of her infant
Improve communication
Assist patient to better use or recruit supports
Table 3. Middle-phase tasks of interpersonal problem area (disputes) take-home pointsMake links between interpersonal events related to dispute and symptoms
Identify issues that are in dispute
Identify maladaptive patterns of communication
Help patients to evaluate expectations, learn to communicate needs and emotions, and expand their understanding and perspectives
Assist patients to better use or recruit supports
1474â CanadianâFamilyâPhysicianââ˘âLeâMĂŠdecinâdeâfamilleâcanadienâ Vol 53: september ⢠septembre 2007
Clinical Reviewâ An approach to interpersonal psychotherapy for postpartum depression
techniques.â Briefâ therapies,â includingâ IPT,â however,âareâ notâ suitableâ forâ allâ patients,â andâ accessingâ IPTâcanâ beâ difficult,â especiallyâ inâ ruralâ orâ remoteâ regions.âThereâisâcertainlyâroomâforâdevelopmentâofâalternativeâmethodsâofâdeliveringâpsychotherapy,â suchâasâbyâ tele-phoneâorâoverâtheâInternet.â
Regardlessâofâ theâdebateâoverâwhetherâ theâdisordersâthatâmanifestâduringâ theâpostpartumâperiodâareâdistinctâfromâtheâmoodâdisordersâthatâmanifestâatâotherâtimesâinâlife,41âPPDâisâaâmoodâdisorderâwithâaâprofoundâeffectâonâmothers,â infants,â andâ theirâ families.â Itâ isâ imperativeâ forâphysiciansâ toâ screenâ forâ andâ treatâ PPDâ inâ aâ timelyâ andâeffectiveâmanner.â
Familyâpractitionersâshouldâalsoâbeâpreparedâtoâ treatârelapsesâ orâ toâ takeâ onâ maintenanceâ treatment,â whichâtheyâoftenâhaveâ toâdoâ inâ treatmentâofâmoodâdisorders.9âThereâisâevidenceâsupportingâuseâofâIPTâforâmaintenanceâtreatmentâ forâ majorâ depressionâ toâ preventâ relapse,42âalthoughâ thisâ remainsâ toâ beâ testedâ forâ PPD.â AlthoughâIPTârequiresâanâinvestmentâofâtimeâbyâbothâpatientsâandâtheirâ doctors,â theâ techniquesâ ofâ IPTâ areâ appealingâ toâfamilyâ practitionersâ becauseâ theyâ canâ beâ incorporatedâeasilyâintoâaâbusyâpracticeâandâappliedâtoâmanyâpatientsâwhoâ experienceâ theâ interpersonalâ problemsâ addressedâbyâthisâtherapy.
ConclusionWomenâ withâ PPDâ typicallyâ experienceâ aâ multi-tudeâ ofâ stressorsâ associatedâ withâ theirâ depression.43âInterpersonalâpsychotherapyâisâwellâsuitedâtoâtreatmentâofâPPDâbecauseâofâtheâmanyâinterpersonalâdisruptionsâassociatedâ withâ thisâ timeâ ofâ lifeâ andâ becauseâ itâ isâ aâspecific,â problem-focused,â andâ short-termâ approachâtoâ treatmentâ ofâ PPDâ andâ canâ beâ learnedâ readilyâ andâappliedâ inâ familyâ practice.â Toâ acquireâ clinicalâ com-petenceâ inâ IPT,â practitionersâ shouldâ participateâ inâ aâdidactic,â accreditedâ continuingâ educationâ IPTâ work-shopâandâthenâbeâsupervisedâthroughâaâminimumâofâ2âcases,â asâ recommendedâ inâ theâ IPTâ manual.7â TrainingâisâavailableâatâtheâUniversityâofâTorontoâthroughâyearlyâcontinuingâ educationâ workshops.â Theâ InternationalâSocietyâ ofâ Interpersonalâ Therapyâ isâ aâ goodâ sourceâ ofâotherâ trainingâ opportunitiesâ (www.interpersonalpsy-chotherapy.org).â
Competing interestsNone declared
Correspondence to: Dr Sophie Grigoriadis, Psychiatry, University Health Network, Reproductive Life Stages Program, Womenâs College Hospital, 200 Elizabeth St, Toronto, ON M5G 2C4; telephone 416 340-4462; fax 416 340-4198; e-mail [email protected]
references1.âOâHaraâMW,âSwainâAM.âRatesâandâriskâofâpostpartumâdepressionâaâmeta-
analysis.âInt Rev Psychiatryâ1996;8:37-54.
2.âWeissmanâAM,âLevyâBT,âHartzâAJ,âBentlerâS,âDonohueâM,âEllingrodâVL,âetâal.âPooledâanalysisâofâantidepressantâlevelsâinâlactatingâmothers,âbreastâmilk,âandânursingâinfants.âAm J Psychiatryâ2004;161:1066-78.
3.âBuistâA,âBilsztaâJ,âBarnett,âMilgromâJ,âEricksenâJ,âCondonâJ,âetâal.âRecognitionâandâmanagementâofâperinatalâdepressionâinâgeneralâpractice.âAust Fam Physicianâ2005;34:787-90.
4.âKlermanâGL,âWeissmanâMM,âRounsavilleâBJ,âChevronâES.âInterpersonal psy-chotherapy of depression.âNewâYork,âNY:âBasicâBooks;â1984.
5.âDeâMelloâMF,âDeâJesusâMariâJ,âBacaltchukâJ,âVerdeliâH,âNeugebauerâR.âAâsyste-maticâreviewâofâresearchâfindingsâonâtheâefficacyâofâinterpersonalâtherapyâforâdepressiveâdisorders.âEur Arch Psychiatry Clin Neurosciâ2004;255(2):75-82.
6.âStuartâS,âRobertsonâM.âInterpersonal psychotherapy: a clinicianâs guide.âLondon,âEngl:âArnold;â2003.
7.âWeissmanâMM,âMarkowitzâJW,âKlermanâGL.âComprehensive guide to interper-sonal psychotherapy.âNewâYork,âNY:âBasicâBooks;â2000.
8.âAmericanâPsychiatricâAssociation.âPractice guideline for the treatment of patients with major depressive disorder.â2ndâed.âArlington,âVA:âAmericanâPsychiatricâAssociation;â2000.âAvailableâfrom:âwww.psych.org/psych_pract/treatg/pg/Depression2e.book.cfm.âAccessedâ2006âMayâ6.
9.âSegalâZV,âWhitneyâDK,âLamâRW;âCANMATâDepressionâWorkâGroup.âClinicalâguidelinesâforâtheâtreatmentâofâdepressiveâdisorders:âpsychotherapy.âCan J Psychiatryâ2001;46(Supplâ1):S29-37.
10.âKlierâCM,âMuzikâM,âRosenblumâKL,âLenzâG.âInterpersonalâpsychotherapyâadaptedâforâtheâgroupâsettingâinâtheâtreatmentâofâpostpartumâdepression.âJ Psychother Pract Resâ2001;10:124-31.
11.âOâHaraâMW,âStuartâS,âGormanâLL,âWenzelâA.âEfficacyâofâinterpersonalâpsy-chotherapyâforâpostpartumâdepression.âArch Gen Psychiatryâ2000;57:1039-45.
12.âStuartâS,âOâHaraâMW.âTreatmentâofâpostpartumâdepressionâwithâinterper-sonalâpsychotherapy.âArch Gen Psychiatryâ1995;52:75-6.
13.âZlotnickâC,âJohnsonâSL,âMillerâIW,âPearlsteinâT,âHowardâM.âPostpartumâdepressionâinâwomenâreceivingâpublicâassistance:âpilotâstudyâofâanâinterper-sonal-therapy-orientedâgroupâintervention.âAm J Psychiatryâ2001;158:638-40.
14.âReayâR,âFisherâY,âRobertsonâM,âAdamsâE,âOwenâC,âKumarâR.âGroupâinter-personalâpsychotherapyâforâpostnatalâdepression:âaâpilotâstudy.âArch Womens Ment Healthâ2006;9:31-9.
EDITORâS KEY POINTS
⢠Postpartum depression (PPD) is common; it affects 10% to 15% of women after delivery.
⢠Some women prefer psychotherapy over medica-tion to treat PPD. Interpersonal psychotherapy is a proven, effective treatment for mild-to-mod-erate PPD.
⢠Interpersonal psychotherapy could be helpful for patients with severe PPD in conjunction with other treatments (eg, medications, hospitalization). Its major limitations include the need for training for physicians and the time commitment required from both physicians and patients. Principles of interper-sonal psychotherapy can be incorporated easily into family practice.
POINTS DE REPèRE DU RĂDACTEUR
⢠La dĂŠpression post-partum (DPP) est un problème frĂŠquent qui touche 10-15% des femmes après lâaccouchement.
⢠Comme traitement de la DPP, certaines femmes prÊfè-rent la psychothÊrapie aux mÊdicaments. La psychothÊ-rapie interpersonnelle (PTI) a dÊmontrÊ son efficacitÊ comme traitement de la DPP lÊgère à modÊrÊe.
⢠AssociĂŠe Ă dâautres formes de traitement (par ex., mĂŠdication, hospitalisation), la PTI pourrait ĂŞtre utile dans les cas de DPP sĂŠvère. Ses limitations principales incluent la nĂŠcessitĂŠ de formation pour le mĂŠdecin et les contraintes de temps pour le mĂŠdecin comme pour le patient. Les principes de la PTI peuvent facilement ĂŞtre incorporĂŠs dans la pratique familiale.
Vol 53: september ⢠septembre 2007â CanadianâFamilyâPhysicianââ˘âLeâMĂŠdecinâdeâfamilleâcanadienâ 1475
An approach to interpersonal psychotherapy for postpartum depressionâ Clinical Review
15.âStuartâS,âOâHaraâMW.âInterpersonal psychotherapy for postpartum depression: a treatment manual.âUnpublished.
16.âGrigoriadisâS.âPostpartumâandâitsâmentalâhealthâproblems.âIn:âSeemanâMV,âRomansâS,âeditors.âWomenâs mental health: a lifecycle approach.âPhiladelphia,âPA:âLippincottâWilliamsâ&âWilkins;â2006.
17.âApplebyâL,âWarnerâR,âWhittonâA,âFaragherâB.âAâcontrolledâstudyâofâfluox-etineâandâcognitive-behaviouralâcounsellingâinâtheâtreatmentâofâpostnatalâdepression.âBMJâ1997;314:932-6.
18.âStoweâZN,âCasarellaâJ,âLandreyâJ,âNemeroffâCB.âSertralineâinâtheâtreatmentâofâwomenâwithâpostpartumâmajorâdepression.âDepressionâ1995;3:49-55.
19.âCohenâLS,âVigueraâAC,âBouffardâSM,âNonacsâRM,âMorabitoâC,âCollinsâMH,âetâal.âVenlafaxineâinâtheâtreatmentâofâpostpartumâdepression.âJ Clin Psychiatryâ2001;62:592-6.
20.âRoyâA,âColeâK,âGoldmanâZ,âBarrisâM.âFluoxetineâtreatmentâofâpostpartumâdepressionâ[abstract].âAm J Psychiatryâ1993;150:1273.
21.âHendrickâV,âAltshulerâL,âStrouseâT,âGrosserâS.âPostpartumâandânonpostpar-tumâdepression:âdifferencesâinâpresentationâandâresponseâtoâpharmacologicâtreatment.âDepress Anxietyâ2000;11:66-72.
22.âMisriâS,âReebyeâP,âCorralâM,âMilisâL.âTheâuseâofâparoxetineâandâcognitive-behavioralâtherapyâinâpostpartumâdepressionâandâanxiety:âaârandomizedâcontrolledâtrial.âJ Clin Psychiatryâ2004;65:1236-41.
23.âWisnerâKL,âHanusaâBH,âPerelâJM,âPeindlâKS,âPiontekâCM,âetâal.âPostpartumâdepression:âaârandomizedâtrialâofâsertralineâversusânortriptyline.âJ Clin Psychopharmacolâ2006;26:356-60.
24.âChabrolâH,âTeissedreâF,âSaint-JeanâM,âTeisseyreâN,âRogeâB.âMulletâE.âPreventionâandâtreatmentâofâpost-partumâdepression:âaâcontrolledârandomizedâstudyâonâwomenâatârisk.âPsychol Med 2002;32:1039-47.
25.âMeagerâI,âMilgromâJ.âGroupâtreatmentâforâpostpartumâdepression:âaâpilotâstudy.âAust N Z J Psychiatryâ1996;30:852-60.
26.âWickbergâB,âHwangâCP.âCounsellingâofâpostnatalâdepression:âaâcon-trolledâstudyâonâaâpopulationâbasedâSwedishâsample.âJ Affect Disordâ1996;39:209-16.
27.âHoldenâJM,âSagovskyâR,âCoxâJL.âCounsellingâinâaâgeneralâpracticeâset-ting:âcontrolledâstudyâofâhealthâvisitorâinterventionâinâtreatmentâofâpostnatalâdepression. BMJ 1989;298:223-6.
28.âChenâCH,âTsengâYF,âChouâFH,âWangâSY.âEffectsâofâsupportâgroupâinter-ventionâinâpostnatallyâdistressedâwomen.âAâcontrolledâstudyâinâTaiwan. J Psychosom Resâ2000;49:395-9.
29.âMorganâM,âMattheyâS,âBarnettâB,âRichardsonâC.âAâgroupâprogrammeâforâpostnatallyâdistressedâwomenâandâtheirâpartners.âJ Adv Nursâ1997;26:913-20.
30.âDennisâCL.âTheâeffectâofâpeerâsupportâonâpostpartumâdepression:âaâpilotârandomizedâcontrolledâtrial.âCan J Psychiatryâ2003;48:115-24.
31.âMisriâS,âKostarasâX,âFoxâD,âKostarasâD.âTheâimpactâofâpartnerâsupportâinâtheâtreatmentâofâpostpartumâdepression.âCan J Psychiatryâ2000;45:554-8.
32.âRavitzâP.âTheâinterpersonalâfulcrum:âinterpersonalâtherapyâforâtreatmentâofâdepression.âCan J Psychiatry Bullâ2004;Feb:15-9.
33.âMeyerâA.âPsychobiology: a science of man.âSpringfield,âIll:âCharlesâCâThomas;â1957.34.âBrownâGW,âHarrisâTO.âSocial origins of depression: a study of psychiatric dis-
orders in women.âLondon,âEngl:âTavistock;â1978.35.âHendersonâS,âByrneâDG,âDuncan-JonesâP.âNeurosis and the social environ-
ment.âSydney,âAust:âAcademicâPress;â1982.36.âBrownâGW.âGeneticâandâpopulationâperspectivesâonâlifeâeventsâandâdepres-
sion.âSoc Psychiatry Psychiatr Epidemiolâ1998;33:363-72.37.âMaddisonâD,âWalkerâWL.âFactorsâaffectingâtheâoutcomeâofâconjugalâberea-
vement.âBr J Psychiatryâ1967;113:1057-67.38.âWalkerâKN,âMacBrideâA,âVachonâML.âSocialâsupportânetworksâandâtheâcrisisâ
ofâbereavement.âSoc Sci Medâ1977;11:35-41.39.âWeissmanâMM,âPaykelâES.âThe depressed woman: a study of social relations-
hips.âChicago,âIL:âUniversityâofâChicagoâPress;â1974.40.âThaseâME,âGreenhouseâJB,âFrankâE,âReynoldsâCF,âPilkonisâPA,âHurleyâK,âetâal.â
Treatmentâofâmajorâdepressionâwithâpsychotherapyâorâpsychotherapy-phar-macotherapyâcombinations.âArch Gen Psychiatryâ1997;54(11):1009-15.
41.âWhiffenâVE.âIsâpostpartumâdepressionâaâdistinctiveâdiagnosis?âClin Psychol Revâ1992;12:485-508.
42.âFrankâE,âKupferâDJ,âPerelâJM,âCornesâC,âJarrettâDB,âMallingerâAG,âetâal.âThree-yearâoutcomesâforâmaintenanceâtherapiesâinârecurrentâdepression. Arch Gen Psychiatryâ1990;47:1093-9.
43.âStuartâS.âInterpersonalâpsychotherapyâforâpostpartumâdepression.âIn:âMillerâL,âeditor.âPostpartum psychiatric disorders.âWashington,âDC:âAmericanâPsychiatricâPress;â1999.âp.â143-62.
âś âś âś