More than the baby blues: Searching for data on the treatment of postpartum mental illness

by Joye C. Anestis

When I sat down to research this post on treating postpartum mood (e.g., depression, bipolar I & II), anxiety, and psychotic disorders, I thought it would take no time to come up with some clear data on the empirically-supported treatment(s) for postpartum conditions.  After all, I reasoned, there has been so much press on the seriousness of postpartum mental illness (for example, Brooke Shields) that surely hundreds of researchers must have jumped at the opportunity and published article after article.  Disappointingly, that is not the case - treatments for postpartum illnesses are not mentioned in any lists of ESTs.  Certainly, treatment research exists (some of which I review below) but not enough to draw any firm conclusions about appropriate courses of treatment.  What concerns me most about the relative lack of research on psychotherapy for postpartum mental illness is the clear need for non-medication treatment alternatives, given the risks that could potentially arise from taking psychotropic medications while breastfeeding.  Expectant mothers are taught that breastfeeding is the best for their infant, but mothers grappling with devastating postpartum illness often must choose between the risks to herself & her family that would arise from not taking medication vs. the risks inherent in choosing medication options.  Clear, well-constructed research on effective alternatives are necessary.   That being said, I wonder if little research is done on psychotherapies for specific postpartum mental illnesses because of a general impression that there is no reason to think that treatment we already know are effective for non-postpartum mental illness wouldn't work for postpartum women (e.g., exposure & ritual prevention for OCD).  Perhaps that is the case, but it certainly flies in the face of scientific thinking to make that assumption without data to back it up - especially considering the unique situations postpartum women are in (e.g., hormonal fluctuations, sleep deprivation, the stress of changing relationships with a partner, of course the stress of having a baby to tend to).  If we are going to advocate ESTs, we need evidence that treatments work in the postpartum as well.  

So here's what I'm going to do.  Below, I'll briefly review the 2 meta-analytic studies I've found examining the handful of treatment studies that exist.  And then over the next few weeks, I'll continue to cull databases and the internet in general, looking for more information.  In the meantime, if you are aware of more data that I am missing, please let me know in the comments section!

• Cuijpers, Brannmark, & van Straten (2008) identified 17 studies that compared an intervention for postpartum depression diagnosed with a structured clinical interview &/or self-report questionnaire to a control or other active treatment condition.  The authors note that the methodological quality of the available and included studies was poor (e.g., lack of random assignment).  This meta-analysis found moderate effect sizes for psychological treatments (including interpersonal psychotherapy, counseling, and social support), but note that the effect sizes were smaller than those typically reported.  The authors stress that too few studies were found to make any definitive conclusions.
• Bledsoe & Grote (2006) identified 11 studies on prenatal and postpartum depression to include in their review.  Again, the overall quality of the literature available was poor (Only 5 of the 11 studies included were considered "high" quality by the authors.  Many studies lacked random assignment, control groups, etc.).  The treatments with significant effect sizes were (in order from largest to smallest effect size): medication + CBT; medication alone; a group therapy with cognitive-behavioral, educational, and transactional analysis components; interpersonal psychotherapy; and CBT.  Yet again it is stressed that too few studies, and too few studies of quality, exist to draw any real conclusions.

From briefly perusing theoretical articles, it appears that there is some literature on interpersonal psychotherapy for postpartum depression (I have previously written briefly about IPT during pregnancy).  This seems, in my opinion, a reasonable treatment to investigate.  Many childbirth experts (e.g., Gaskin, 2003) theorize that increases in postpartum mental illness are directly related to the decrease in social support new mothers currently receive, as our society moves further and further away from the communities our ancestors created.  I will summarize this treatment in a future post, although it's important to note that it's empirical support for postpartum depression is not definitive.  And I will continue to search for information on other postpartum disorders.  Depression seems to be the most commonly discussed postpartum mental illness, but some women are at risk for other conditions such as psychotic episodes and OCD.  So be on the lookout for future posts on this subject!

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Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.