Postpartum Depression

There has been little systematic research on pharmacological treatment of postnatal depression. Although progesterone treatment has been enthusiastically advocated (Lawrie, Herxheimer, and Dalton 2000), there has been no systematic evaluation of its clinical utility. By the end of the twentieth century, there has been only one controlled trial of an antidepressant medication, and it showed significant antidepressant effect for both the active drug and the comparison psychological treatment (Appleby et al. 1997). However, there was no additive effect of the two treatments, and the drug treatment was not found to be superior to the psychological treatment. It should be noted that less than half of those invited to take part in the study agreed, mainly because of reluctance to take the medication. This suggests that this line of treatment is not appropriate as a first line treatment, especially in view of the positive results obtained using other forms of intervention which are highly acceptable to women, and that pharmacological treatment should be reserved for those with particularly severe depression or those whose mood disturbance fails to respond to other measures.

There have been a number of controlled trials of psychological treatment of postpartum depression. In an early study, whose findings were later replicated, Holden and her colleagues (Holden, Sagovsky, and Cox 1989) found that improvement in maternal mood in women visited an average of nine times in thirteen weeks by Health Visitors trained in non-directive counselling was substantially greater than in the control group who received routine primary care. Similar positive benefits to maternal mood have been reported for other forms of psychological intervention, such as cognitive behavior therapy, psychodynamic therapy (Cooper and Murray 1997; Cooper and Murray 2001), and interpersonal psychotherapy (O'Hara et al. 2000).

Few studies have examined the impact of treating postpartum depression on the quality of the mother-infant relationship and child development. One controlled psychological treatment trial found that intervention was associated with significant improvement in maternal reports of infant problems, both immediately after treatment (4 to 5 months postpartum) and at a follow-up at eighteen months postpartum; these benefits were confirmed by independent teacher reports of behavior problems at age five (Cooper and Murray 1997; Murray and Cooper 2001). Moreover, early remission from depression, itself significantly associated with treatment, was related to a reduced rate of insecure infant attachment at eighteen months. Similar benefits have been reported in a study of Health Visitor practice (Seeley, Murray, and Cooper 1996). Training was provided to all the Health Visitors working in one National Health Service sector and a cohort study was conducted to assess Health Visitors' clientele before their training and then during a post-training period. Again, significant benefits were apparent in terms of both maternal mood and maternal reports of the quality of the mother-infant relationship.

Marital therapy has been proposed as a treatment for postpartum depression (Apfel and Handel 1999) and as "the treatment of choice" in cases where the marital relationship is in crisis because of the partner's inability to respond empathically to their spouse's distress (Whiffen and Johnson 1998). However, there is no reliable evidence to support such a proposal. Indeed, such an approach is likely to be appropriate only in a selected subgroup of those with postpartum depression where the spouse is available and willing to engage in a therapeutic process of this sort.