Psychotherapy Brown Bag

New dads can get depressed, too

by Joye C. Anestis   

Wow, things are certainly different around here since the last time I sat down to write a post, over 4 months ago.  I ask for your patience as I put my writing hat back on and scramble to post things during naptimes...this should be interesting! 

In honor of the wonderful reason behind my absence on PBB, I thought I would write about an interesting article on paternal prenatal and postpartum depression I came across recently in JAMA (the Journal of the American Medical Association). 

Now I know from recent firsthand experience, that bringing a new baby home is tough...for everyone - mom, dad, and in our case, cats and dogs too!  Thanks to recent high-profile stories about postpartum depression in moms, health care professionals are on the lookout for warning signs.  It is discussed in appointments with healthcare providers, both prenatal and postpartum (be it OBs, midwives, doulas, etc.).  It is discussed in childbirth classes.  The focus, however, is entirely on moms (for information on postpartum depression in moms, check out these previous articles) - for good reason, of course, maternal postpartum depression can be scary and has many negative consequences.  But, what about dads?  No one really asks them how they're feeling at prenatal appointments or childbirth classes.  Are dads at risk for depression as well?  James Paulson and Sharnail Bazemore set out to see what the existing literature had to say about that (you can check out the original article in JAMA).

After applying exclusion criteria, Paulson & Bazemore identified 43 studies (total of 28,004 participants) which reported data on paternal depression.  They then utilized meta-analytic techniques to answer the following questions:

What are the rates of paternal depression between the first trimester and 1 year postpartum?

The overall estimate of paternal depression across studies was 10.4%.  This is a high rate in general...but even more concerning considering that recent national estimates of depression in men is 4.8% (Kessler et al., 2003).  There is evidence to suggest that early parental depression can have negative effects on child development (Paulson et al., 2009; Ramchandani et al., 2008), so it behooves us to screen and provide resources for both mom and dad.  With all the focus on moms, dads may slip under the radar.

Does depression risk change at different points between the first trimester and 1 year postpartum?

Moderator analyses found significant variability between different time periods.  The 3-6 month postpartum period had the highest rate (25.6%) and the first 3 months post-birth had the lowest rate (7.7%). The authors do caution our interpretation of these findings, however, since such a small number of studies contained the 3-6 month postpartum time period.  I would have loved for the authors to hypothesize about potential reasons for this spike in depression rates at this point in time (since I'm living the 3-6 month postpartum period now, I can guess that complete lack of sleep hygiene playing a large role!). 

Is there an association between paternal and maternal depression?

The overall correlation between paternal and maternal depression was significantly larger than 0 (r = 0.308).  This moderate correlation is not surprising - it makes sense (at least to me) that, if one parent is depressed, the other might be as well.  We should remember, however, that this correlation says nothing about causation.  Data do not yet exist to tell us if a maternal depression causes paternal depression or vice versa.

What is the prevalence of maternal prenatal and postpartum depression in studies focusing on paternal depression?

Prevalence of maternal depression was higher than the rate in dads (maternal depression rate of 23.8%).  Depression estimates were higher for moms during the 3-6 month postpartum period (41.6%).  I am always astounded by how high estimates of maternal depression are.  So many women struggling during this important time in life.  I also find this spike interesting because, at this point in time, doctor's appointments for mom have ended and there are generally less people checking in on her.  In light of this data, perhaps that should be modified.

How are published rates of paternal depression affected by methodological factors?

Methodological factors influenced paternal depression rates across the studies included.  Depression rates in U.S. fathers (average of 14.1%) were higher than the rates reported in international studies (average of 8.2%).  The method of depression measurement affected the depression rates, with interview-based definitions resulting in lower overall prevalence estimates (4.9% vs. 11.0% for rating scales).   Similarly, maternal depression estimates were lower when interviews were used (9.8%) versus rating scales (25.5%).  There was a non-significant trend for U.S. moms (29.6%) to have higher depression rates than international moms (19.7%).

Of course, I can't write about any meta-analysis without acknowledging the problems inherent in this type of study.  We've talked at length about the downfalls of meta-analysis (here, for example).  Admirably, Paulson & Bazemore took strides to bolster their findings.  First, they examined the studies for evidence of publication bias.  The three tests they reported (funnel plots, the Egger intercept, and the Orwin fail-safe procedure) revealed no evidence of publication bias.  The authors also conducted sensitivity analyses to ensure that no one study was unduly influencing the findings.  They sequentially removed each study and reanalyzed the remaining data set.  No study effected the overall estimate more than 0.5%.  In other words, they tried really hard to make their findings be as solid as possible, while at the same time acknowledging that meta-analysis is imperfect.

Even if we are cautious about how we interpret these findings, it is apparent that the prenatal and postpartum period is a time of depression risk for new and expecting dads.  One thing the authors did not mention is the treatment options available for prenatal and postpartum depression in dads.  I'm not aware of any data indicating specialized treatments for dads in this time period...and I wonder if the standard ESTs for depression would be effective.  I assume they would.  Although I question the application of standard depression treatments for postpartum moms due the hormonal factors which could be involved, I don't have the same concern for dads.  Of course, this is purely my opinion... if any of you know of any data on treatments for prenatal/postpartum depression in dads, let me know!

Check out our online bookstore for more information on depression.

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

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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If you would like to learn more about the topics discussed on PBB, we recommend that you consult our online store of scientifically-based psychological resources.

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

What are the risks of SSRIs for depression & untreated depression during pregnancy?

by Joye C. Anestis, M.S.

According to a new study in the American Journal of Psychiatry (Wisner et al., 2009), both the use of selective serotonin reuptake inhibitors (SSRIs; a common class of antidepressant medications) and untreated major depressive disorder had the same effects on the developing fetus.  In this prospective observational study, the researchers divided their sample of 238 women into 5 non-overlapping groups: no SSRI, no depression; continuous SSRI exposure (took SSRIs for the entire pregnancy); continuous depression, no SSRI; partial SSRI exposure (took SSRIs at some point during the pregnancy, with at least 1 full trimester without SSRIs); partial depression, no SSRI (depression at some point during the pregnancy, with at least 1 trimester of remission).  Among their many findings, they found that neither SSRI treatment nor unmedicated depression were related to minor or major psychical anomalies in the babies; however, the results indicated that both continuous depression & continuous SSRI exposure were related to premature births.  This study joins a growing literature demonstrating a three-fold increase in risk for preterm births for women treated with SSRIs during pregnancy, but it also adds to this literature by demonstrating a similar effect for untreated depression.

For many women, the issue of how to tackle psychiatric problems while pregnant is a significant concern.  Because the prevalence of depression in women is highest during the childbearing years (Kessler et al., 2003), the question of how best to manage antenatal depression becomes even more important (it occurs in 10% of pregnant women; Gotlib, Whiffen, & Mount, 1989; O'Hara, Zekoski, Philipps, & Wright, 1990).  What was most striking to me about the Wisner et al. study is that there was no mention of alternatives to medication for the treatment of depression.  This oversight was shocking considering that many studies have found psychotherapy  (specifically, cognitive therapy and cognitive behavioral therapy) and medications to be equally effective in the treatment of depression and the prevention of relapse (DeRubeis, Gelfand, & Simons, 1999; Dimidjian et al., 2006; Hollon et al., 2005). 

With this in mind, what do we know about alternatives to medication for pregnant women?  While the clinical psychology literature on antenatal depression is sparse, several studies have demonstrated treatment efficacy for interpersonal psychotherapy (IPT) with depressed, pregnant women & adolescents (Miller, Gur, Shanok, & Weissman, 2008; Spinelli, 1997; Spinelli & Endicott, 2003).  IPT is a brief treatment which focuses on interpersonal factors in the development and maintenance of mental illnesses (see Comprehensive Guide To Interpersonal Psychotherapy; comprehensive review of IPT available through our online store for recommended products).  At the outset of IPT, the patient chooses one domain of interpersonal functioning to focus on: role transitions, interpersonal disputes, grief, or interpersonal deficits.  The focus on interpersonal functioning, and especially the role transitions domain, seems like a logical choice for treating pregnant women, whose depressive symptoms may be related to transitioning from a single person to a mother. There is considerable empirical support for IPT for a number of mental illnesses, including major depressive disorder (e.g., Elkin et al., 1989) and bulimia nervosa (e.g., Fairburn et al., 1995).   Other forms of psychotherapy have not been systematically investigated in sample of pregnant women, but I'm not sure there is a reason to believe that psychosocial treatments known to be effective for depression in non-pregnant samples would operate differently in pregnant women.

Joye Anestis is a doctoral candidate at Florida State University.