Interpersonal psychotherapy is a proven, effective treatment for mild-to-moderate PPD and an alternative to pharmacotherapy, especially for breastfeeding women. It reduces depressive symptoms and improves social adjustment. For women with psychotic features, bipolarity, or severe symptoms, including suicidal or infanticidal thoughts, IPT alone is not sufficient, and a combination of medications and possibly hospitalization should be considered4,9,16
Interpersonal psychotherapy (IPT) for postpartum depression (PPD)
Other treatments for women with PPD have been tested in pharmacologic treatment studies, only 3 of which were randomized controlled trials (RCTs). One RCT compared fluoxetine with a hybrid cognitive behavioural counseling approach, another compared paroxetine with cognitive behavioural therapy, and the third compared sertraline with nortriptyline. Other studies included 1 open trial of sertraline, 1 open trial of venlafaxine, a case series on fluoxetine, and 1 retrospective chart review involving several antidepressants.17–23
Based on the RCTs, fluoxetine and paroxetine were shown to be helpful for some but not all women. Although sertraline and nortriptyline were both helpful, women taking sertaline were identified earlier. Many mothers with PPD breastfeed, and the amount of antidepressant entering their breast milk is of concern to some women, and they are reluctant to use the medication.
Psychotherapies have been studied as alternatives to antidepressant treatment. Although one of the above studies evaluated cognitive behavioural therapy and found it effective, the sample size was small, which limits the conclusions that can be drawn.
The best evidence for psychotherapy as an effective treatment for PPD is for IPT. It was evaluated in an RCT with a large sample size.11
Of 120 women diagnosed with PPD recruited, 99 completed the 12-week study. The women were randomly assigned to 12 weeks of IPT or to a wait-list control group. Significantly more women in the IPT group achieved remission of depression than women in the wait-list group did (37.5% vs 13.7%). Further evidence for the efficacy of IPT for PPD comes from smaller trials as mentioned above. Other nonpharmacologic talking therapies evaluated include cognitive behavioural therapy,17,22,24,25
counseling by health nurses26
or health visitors,27
peer support groups,28–30
and partner support sessions.31
These approaches have been found to be helpful, although RCTs with large sample sizes still need to be conducted.
A limitation on all psychotherapeutic approaches is the time commitment necessary for new mothers and clinicians. Also, psychotherapeutic approaches might not be appropriate as stand-alone treatment for women with moderate to severe depressive symptoms. Getting access to trained psychotherapists for patients and getting training in psychotherapy skills for clinicians can be challenging, especially in remote regions.
Many of the interpersonal problems of social adjustment women with PPD face can be addressed by IPT because it focuses on current personal relationships4,6,7,32
rather than on intrapsychic or cognitive aspects of depression. The focal interpersonal problem areas of IPT are derived from research that has demonstrated the protective function of interpersonal support as well as the associations between interpersonal adversity and depression. It uses a biopsychosocial model33
to understand patients and frames depression as a medical illness that occurs in a social context which is disrupted during times of illness. Although IPT recognizes the role of biological and psychological factors in the cause of and vulnerability to depression, it focuses on social factors and working through interpersonal problems6,7,32,34–39
to alleviate depression ().
Formulation worksheet for postpartum depression