Psychotherapeutic Treatment Options for Perinatal Depression: Emphasis on Maternal-Infant Dyadic Outcomes

Psychotherapeutic Treatment Options for Perinatal Depression: Emphasis on Maternal-Infant Dyadic Outcomes

Maria Muzik, MD, MSc; Sheila M. Marcus, MD; and Heather A. Flynn, PhD

Increasing the options for effective treatment of perinatal depression with the aim of reducing maternal and child morbidity remains a critical public health goal. An estimated 13% of women experience major depressive disorder (MDD) during pregnancy,1 and an even greater number (up to 51% of women of low socioeconomic status) experience depressive symptomatology.2 Both elevated depressive symptomatology and MDD have been linked to a number of problematic obstetrical, infant, and parenting/ attachment outcomes.3-8 Unfortunately, fewer than 20% of depressed women receive any or adequate treatment around the time of childbearing,9 conferring burdensome and costly maternal and infant risk.

Treatment with antidepressants is effective for most patients, and medication discontinuation during pregnancy greatly increases risk for relapse.10 Although most studies have demonstrated the safety of antidepressant use during pregnancy and breastfeeding, this research is equivocal11,12 and often portrayed in a confusing manner in media reports. The concern about medication use that remains for many pregnant and postpartum patients and their clinicians may perpetuate the underutilization of treatment. Therefore, in order to broaden treatment options for women with the aim of improving maternal and infant outcomes, further study and dissemination of nonpharmacologic psychotherapeutic treatments are advantageous.

Evidence-based individual psychotherapies, such as interpersonal psychotherapy and cognitive-behavioral therapy, have demonstrated efficacy in reducing mothers’ depressive symptoms during the perinatal period,13 with overall depression remission rates similar to those of antidepressants.14 However, evidence indicates that treating postpartum depression alone may not be sufficient in protecting children against long-term poor outcomes.15-17 Accumulating evidence suggests that dyadically based postpartum interventions are more efficacious than individual psychotherapy for enhancing parenting and improving outcomes for infants of depressed mothers.18 These relationship-based treatments may be short- or long-term, and many are rooted in psychodynamic and attachment theories.19,20 Others draw on a variety of techniques including progressive relaxation, infant massage, and teaching about infant development using structured developmental assessments (eg, see references 21 and 22). Furthermore, treatment effects for these dyadic relationship-based psychotherapies appear to positively impact parenting and child outcomes somewhat independently of maternal depressive symptoms; that is, treatment effects for parenting sensitivity and child outcomes are often apparent despite mixed evidence for reduction and prevention of recurrence of depression in the mothers.23,24

Taken together, these results suggest that individual therapies during the prenatal and postnatal period are likely to be effective alternatives to medication for the reduction of depression symptoms in the perinatal period and that mother-infant dyadic therapies may be an important complement to these individual approaches, optimizing maternal, infant, and mother-infant relationship outcomes. With improved dissemination and public education, childbearing women will ideally have the ability to choose from a menu of several safe and effective treatment options for depression.

References

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Author affiliations: The Department of Psychiatry, Women’s Mental Health Program, University of Michigan Medical School, Ann Arbor. Financial disclosure: Dr Flynn has received grant/research support from the National Institutes of Health. Drs Muzik and Marcus report no financial or other relationships relevant to the subject of this commentary. Funding/support: None reported. Corresponding author: Maria Muzik, MD, Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Rachel Upjohn Building, Ann Arbor, MI 48109 ([email protected]).

doi:10.4088/JCP.09com05451

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