American Journal of Orthopsychiatry 2003, Vol. 73, No.

4, 441454

Copyright 2003 by the Educational Publishing Foundation 0002-9432/03/$12.00 DOI: 10.1037/0002-9432.73.4.441

Psychotherapy for Postpartum Depression: A Preliminary Report

Roseanne Clark, PhD, and Audrey Tluczek, PhD
University of Wisconsin Medical School
A postpartum depression treatment efcacy study showed both a motherinfant psychotherapy group and interpersonal psychotherapy to be superior to a waiting-list comparison group in reducing maternal depressive symptoms, improving mothers perceptions of their infants adaptability and reinforcement value, and increasing mothers positive affect and verbalization with their infants. Clinical implications regarding the importance of early intervention for women experiencing major depression in the postpartum period and their families are discussed.

Amy Wenzel, PhD

University of North Dakota

Signicance of the Problem

Major depression in the postpartum period, occurring in 8%15% of all new mothers, represents a signicant public health problem (OHara, 1997; Weissman & Olfson, 1995). Thirty percent to 70% of these depressed women may experience the disturbance for a year or longer (Cutrona, 1982; OHara, 1991). Such depressive episodes may last from 4 weeks to more than 6 months (Murray & Cooper, 1997). Postpartum depression (PPD) is of particular concern not only in terms of the womans well-being but also for the risk it poses for disturbances in the motherinfant relationship and for developmental delays and subsequent psychopathology in the child (Cummings & Davies, 1994; Field, 1992; Goodman & Gotlib, 1999). There is evidence that spouses also suffer negative consequences from their wives PPD (Meighan, Davis, Thomas, & Droppleman, 1999; Milgrom & McCloud,
Roseanne Clark, PhD, and Audrey Tluczek, PhD, Department of Psychiatry, University of Wisconsin Medical School; Amy Wenzel, PhD, Department of Psychology, University of North Dakota. This research was funded in part by a grant from the Perinatal Foundation, Madison,Wisconsin, and the Research and Development Fund, Department of Psychiatry, University of Wisconsin Medical School. We thank the families who participated in this treatment study; Mary Siedl, MS, and Erica Anderson, PhD, for their contributions to the assessment of motherchild interactions; and Alan S. Gurman, PhD, and Marjorie H. Klein, PhD, for their editorial comments on an earlier version of this article. For reprints and correspondence: Roseanne Clark, PhD, Department of Psychiatry, University of Wisconsin Medical School, Wisconsin Psychiatric Institute and Clinics, 6001 Research Park Boulevard, Madison, Wisconsin 53719-1179. E-mail: rclark@wisc.edu 441

1996). Furthermore, although the newer selective serotonin reuptake inhibitors are highly effective in treating depression, psychopharmacologic treatment is still used cautiously in the postpartum period due to the secretion in breast milk and the paucity of studies of the physiological or developmental impact of these agents on breastfeeding infants (Llewellyn & Stowe, 1998). Thus, it is imperative that psychotherapeutic interventions for depression in the postpartum period address the needs of the woman in her multiple roles as well as address the needs of her infant and spouse. To date, there are no empirically validated interventions that take such a comprehensive approach to the treatment of PPD.

Impact of PPD on the Infant

Major depression during the postpartum period has been related to impairments in parenting and to a high incidence of insecure attachment (Lyons-Ruth, Zoll, Connell, & Grunebaum, 1986), depressed affect (Field, 1992; Radke-Yarrow, Nottelmann, Martinez, Fox, & Belmont, 1992), behavioral disturbances, and cognitive delays in infants and young children of women with PPD (Murray & Cooper, 1997). Field (1997) reviewed ndings from several studies documenting a prole of dysregulation in infants of depressed mothers, including less orienting behavior, more depressed affect, more irregular sleep, greater right frontal EEG activation, higher norepinephrine levels, and lower vagal tone than infants of nondepressed mothers. Moreover, the chronicity of the mothers depression in infancy and toddlerhood has been associated with delays in verbal abilities, behavioral problems, and a lack of school readiness skills (National Institute of Child Health and Human Development [NICHD] Early Child Care Research Network, 1999).

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Impact of PPD on the MotherInfant Relationship

One of the major mechanisms by which PPD may inuence infant outcomes is through the quality of the mothers affective and behavioral interactions during infancy, a critical time when physiological and emotional regulation and the capacity for human attachments are developing (Campbell & Cohn, 1997; Radke-Yarrow, Cummings, Kuczynski, & Chapman, 1985). Women experiencing PPD are often impaired in their ability to provide sensitive and predictable care for their infant, with maternal behavior being characterized as either sad and withdrawn or insensitive and intrusive and the dyad being described as less positive in its affective expressions (Cohn, Campbell, Matias, & Hopkins, 1990). In addition, women with PPD may exhibit irritability, self-absorption, guilt, feelings of inadequacy, and anxiety about causing psychological or physical harm toward their infant (Weissman & Olfson, 1995; Weissman, Paykel, & Klerman, 1972).

Treatment for Major Depression

Research on the efcacy of psychotherapy for depression has shown interpersonal psychotherapy (IPT) alone, medication alone, and combined medication and IPT to be superior to no treatment in relieving depressive symptoms (Di Mascio et al., 1979; Weissman et al., 1979). In addition, the National Institute of Mental Health Treatment of Depression Collaborative Research Program (Elkin et al., 1989) found IPT, cognitivebehavioral psychotherapy (CBT), and medication to be equally effective in reducing depressive symptoms. There are, however, few studies of empirically validated treatments for PPD. Although biological factors may contribute to the etiology of depressive symptoms following the birth of a child (OHara, 1997), psychological interventions have been found to be effective. In an early study, Holden, Sagovsky, and Cox (1989) found that each of three forms of structured psychosocial intervention (i.e., nondirective counseling, CBT, psychodynamic psychotherapy) was more effective than standard primary care in reducing depressed mood in the postpartum period. There is also some evidence to suggest that medication and psychotherapy are equally effective in reducing PPD symptoms (Appleby, Warner, Whitton, & Faragher, 1997). In a study comparing four conditions (routine primary care, nondirective counseling, CBT, and dynamic psychotherapy), Cooper and Murray (1997) found that all three active treatment groups were equally effective in increasing the rate of remission from depression but that none of the treatments resulted in change either in the motherchild interaction quality or in infant cognitive development or infant attachment status. However, early remission from maternal depression was found to be associated with a reduced rate of insecure attachments in the infants. Most recently, OHara, Stuart, Gorman, and Wenzel (2000) conducted the rst real clinical trial examining the efcacy of a psychotherapeutic approach for the treatment of PPD. They reported that, when compared with a waiting list control (WLC) group, a signicantly greater number of women who received IPT for PPD experienced signicant improvement in their depressive symptoms. However, there was no signicant difference between the control and IPT groups in womens reports about their relationships with their children. Psychotherapeutic interventions for women with major depression in the postpartum period need to provide a therapeutic context in which the woman may experience the social support as well as feelings

Impact of PPD on Spouses/Fathers

There has been relatively little research examining the impact of PPD on the spousal relationship and the fatherinfant relationship. Meighan and colleagues (1999) interviewed eight spouses of women with PPD to examine the impact the womens symptoms had on the men and the family. The results showed that the spouses experienced worries about their wives welfare, confusion about PPD, frustration at their inability to relieve their wives depressive symptoms, and concerns about the uncertainty about the future. The spouses also reported making signicant changes in their lives in order to accommodate the needs of their wives and their children. In another study, the spouses of women with PPD reported higher levels of stress in their marital relationship and more concerns about their infants, as compared with spouses of women who did not experience PPD (Milgrom & McCloud, 1996). This research underscores a need to develop therapeutic interventions for PPD that focus not only on the depressive symptoms of the mother but also on the affective regulation and developmental skills of the infant and the quality of the motherinfant and family relationships. Despite the mounting evidence suggesting a need to include infant and motherinfant and family relationship outcomes when evaluating the efcacy of treatment for PPD, very few studies have done so.

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of competence in her maternal role so that she may develop a secure attachment relationship with her infant.

Why a Group?
Although several studies have documented the efcacy of group therapy using cognitivebehavioral or interpersonal approaches in the treatment of major depression (Hogg & Deffenbacher, 1988; Stravynski et al., 1994), there has been little research devoted to evaluating group interventions for major depression during the postpartum period. A psychoeducational group for women with PPD achieved a signicant reduction in depressive symptomatology (Morgan, Matthey, Barnett, & Richardson, 1997); however, the small sample size and lack of control group make it difcult to interpret these results. Meager and Milgrom (1996) found that women with PPD receiving a 10-week group therapy intervention reported more signicantly reduced depressive symptoms and parenting stress than did women assigned to a WLC condition. Finally, a social support intervention (Fleming, Klein, & Corter, 1992) did not result in decreased maternal depressive symptoms, but mothers showed increased attentiveness to their infants compared with women in a no treatment control group. Thus, an accumulating database suggests that individual or group psychosocial interventions can be successful in reducing PPD. However, studies that examine the efcacy of interventions for PPD focus primarily on the mothers depressive symptoms and response to treatment rather than on change in the motherinfant relationship. There have been no trials to date comparing a motherinfant therapy approach that targets not only the womans depressive symptoms but also the quality of the motherinfant relationship, the infants social emotional functioning, and family functioning.

minutes of music (rock or classical) was found to normalize frontal lobe EEG patterns in women with a history of chronic depression. Another study of infants who had received massage from their mothers showed greater weight gain, improved emotional regulation, increased social relatedness, and greater face to face contact than infants who had been rocked by their mothers. Field (1997) documented several coaching strategies found to be effective in increasing mothers abilities to read their infants cues and to respond to infants in a more sensitive manner. These included imitation techniques to decrease the overstimulation of intrusive mothers and attention-getting techniques to increase the social responsiveness of withdrawn mothers. Examining the efcacy of a manualized motherinfant relational group approach to the treatment of PPD is necessary to help elucidate the specic mechanisms that may contribute to negative outcomes and the most effective preventive intervention treatment strategies for promoting positive mental health outcomes for mothers, infants, and families.

Purpose of Study
Developmental theory and empirical evidence underscore the importance of moving beyond traditional individual treatment approaches for PPD to include the motherinfant and family relationships as targets of clinical interventions. This study extends the current research on the efcacy of PPD treatment by comparing a relationally focused motherinfant group model that addresses the needs of the mother, infant, and spouse, with an individual therapy approach, and with a waiting list comparison group.

Method Procedure

Why MotherInfant Dyadic Therapy?

Field (1997) described a program of research in which she evaluated the efcacy of multiple types of interventions for improving maternal mood and enhancing motherinfant interactions for women with depressive symptoms and their infants. Although both relaxation and massage were found to have positive effects on maternal mood, the massage condition was superior to relaxation in decreasing depression, anxiety, and stress, as measured by self-report and salivary cortisol levels of women. Additionally, massage was found to be associated with increased positive affect and less gaze aversion in infants. Twenty
Potential participants were recruited through health care provider referrals and newspaper advertisements. Letters and yers explaining the study were sent to obstetrician gynecologists, pediatricians, family practitioners, and public health nurses. Most of the participants were referred for treatment of clinical depression by primary care providers and staff in public health and community agencies. The same recruitment measures were used for participants in the three groups. Potential participants were screened by phone using a screening questionnaire based on the diagnostic criteria of the DSMIV and specially designed for this study. Women who met the criteria for major depression during the postpartum period and who provided written consent to participate in the study were sequentially assigned to one of the

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Table 1 Demographic Information

Variable Mothers age (years) Childs age (months) Family income (dollars) Mothers education (years) Marital status (no. married) Race (no. Caucasian) Childs gender (no. female) M-ITG (n 13) IPT (n 15) WLC (n 11) F(2, 38) 5.65 2.54 2.23 0.86 0.12 1.64 3.15
2

p .007 ns ns ns ns ns ns

27.6 (5.0)* 6.3 (6.0) 23,550 (16,538) 14.9 (2.5) 11 13 8

32.4 (4.0) 8.2 (7.7) 42,996 (28,720) 15.5 (1.7) 13 14 5

34.6 (6.8) 12.8 (7.5) 30,897 (24,384) 16.0 (1.8) 9 11 7

Note. Signicance values represent difference from WLC group. Values in parentheses are standard deviations. M-ITG motherinfant therapy group; IPT interpersonal psychotherapy; WLC wait list comparison group. *p .05. rst two groups: a motherinfant therapy group (M-ITG) or a WLC group. A comparison, individual therapy condition was added, and a third group of women was recruited to the IPT group. While awaiting treatment, all potential participants were offered consultation regarding their current symptoms, encouraged to continue with any services they were receiving, and referred to an emergency clinic as needed. WLC participants were offered the opportunity to participate in the M-ITG at a later time. Participants in the active treatment groups (M-ITG and IPT) completed preand posttreatment (12 weeks) assessments. Those in the WLC were assessed at the point of entry into the study and 12 weeks later. All participants were reimbursed $35 for their participation. Participants in the WLC were accrued on the basis of their sociodemographic characteristics indicating a match with participants of the M-ITG cohort. Subsequently, IPT participants were also matched to the M-ITG cohort in a similar fashion. study were female. Maternal age ranged from 19 to 44 years, with a mean age of 31.4 years. Mothers educational levels included 2.6% (n 1) with some high school, 7.7% (n 3) with a high school diploma, 23.1% (n 9) with some college, 43.6% (n 17) with college education, and 23.1% (n 9) with a graduate degree. There was a mean educational level of 14.9 years for the M-ITG group, 15.5 years for IPT group, and 16 years for the WLC group. Family income ranged from $6,000 to $120,000, with a mean income of $33,353. The marital status of the women included 84.6% married/cohabiting and 15.4% single/divorced/separated. All participants in the M-ITG and WLC groups were Caucasian, and the IPT group consisted of 14 Caucasian women and 1 African American woman. Demographic characteristics of each group are presented in Table 1.

Treatments
M-ITG. The relationship-focused M-ITG model involved three treatment group components: (a) a mothers group that provided therapeutic intervention and peer support; (b) a concurrent infant developmental therapy group that assisted infants in becoming more emotionally regulated, focused, and socially engaged; and (c) a motherinfant dyadic group with activities designed to promote sensitive, responsive motherinfant interactions. The mothers group occurred simultaneously with the infants developmental therapy group, followed by the dyadic group. In this treatment condition, the mother and infant were the focus of treatment, with goals consisting of ameliorating maternal depressive symptoms, strengthening the mothers capacities in the mothering role, enhancing the relationship between the mother and infant, and preventing developmental delays and subsequent psychopathology in the infant. Fathers attended two of the group therapy sessions. The theoretical basis of this intervention included object relations theory, attachment theory, social learning theory, and revised learned helplessness theory. This model also integrated interpersonal, psychodynamic, and family systems approaches. These theoretical underpinnings and therapeutic approaches, in combination with ndings from empirical developmental research on infants of depressed mothers,

Participants
Of the 66 women recruited into the study, complete data were available for 24 M-ITG families, 17 IPT families, and 17 WLC families. Given that this study was designed to evaluate treatment efcacy for women experiencing major depression during the postpartum period, data were only analyzed for those participants with Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961) scores of 16 or higher. This cut-off was chosen to differentiate those women with moderate to severe depressive symptoms consistent with a major depressive episode during the postpartum period from women with mild or transient depressive symptomatology, commonly referred to as the baby blues. Thus, the sample of women meeting this criteria included 13 in the M-ITG group, 15 in the IPT group, and 11 in the WLC group. Participants were matched among the three groups for the following demographics: age and sex of the child, as well as maternal age, ethnicity, marital status, education, and family income. Children ranged in ages from 1 to 24 months, with a mean age of 8.9 months. Forty-two percent of the children in the

PSYCHOTHERAPY FOR POSTPARTUM DEPRESSION were incorporated in the development of this intervention model. Exercises and strategies also draw from cognitive behavioral (Beck, 1976; Burns, 1989) and interpersonal therapies (Klerman, Weissman, Rounsaville, & Chevron, 1984). Incorporating cognitivebehavioral exercises is important to address the negative self-schema and negative expectations regarding the sense of competence experienced by many of these women, especially in the mothering role. The interpersonal approaches appreciate the womans functioning in her multiple roles. Interpersonal factors can play a critical role in the onset, exacerbation, and maintenance as well as in the remission of depression. Social risk factors associated with PPD, such as social isolation and lack of societal and emotional support, warrant the use of a group approach to treatment that directly addresses both individual needs and family relationships. A group model was chosen for an intervention because the group provides several therapeutic factors (Vinogradov & Yalom, 1990; Yalom, 1985) that may be especially salient to women with PPD. A group format may reduce social isolation, facilitates mutual emotional support, fosters a sense of altruism, and provides interpersonal learning among women who share common experiences during the postpartum period. Group therapy also provides opportunities for the corrective reenactment of family of origin issues that may be particularly important to women struggling with their transition to the role of mother. A group model also permits the discussion of feelings and circumstances in general terms, providing a safe method for members to explore more personal meanings during a corrective emotional experience. At the same time, a therapeutic group can also create a sense of the universality of clients concerns. Group therapy recognizes and benets from the importance of interpersonal relationships. Therapeutic events may occur more quickly during group therapy than in individual therapy because women can learn vicariously through the experiences of the other women in the group. In addition, having two therapists allows one therapist to follow the process while the other follows content, allowing for more careful attunement (Clark, Keller, Fedderly, & Paulson, 1993). Following a 1.5-hr initial evaluation, the manualized M-ITG consisted of 12 weekly 1.5-hr sessions conducted by two therapists (Clark, 1994). Each group session was designed around a core theme, including expectations about baby, ambivalent feelings, coping with depression, nurturance and play, communication, independence/dependence, safety and security, self-esteem, individuality, mutuality, spousal relationship, and preventing future depressive symptoms. Simultaneously, infants were involved in a developmental therapy group with two therapists and graduate practicum students. They received responsive caregiving designed to help infants become more emotionally regulated, focused, and socially engaged. Strategies used with infants included providing affective attunement to help them experience and regulate a wider range of affect and support and stimulation of development. The nal portion of each session was half an hour in length and was devoted to motherinfant dyadic activities designed to promote

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sensitive, responsive motherinfant interactions. This approach offered mothers and infants therapeutic support to promote positive affective experiences and the capacity to be more responsive and reciprocal in interactions, thereby enhancing the mothers feelings of competence in the parenting role. Techniques included interactive activities and games, promoting nurturing physical and eye contact, assisting mothers in reading and responding sensitively to their infants cues, and extending and supporting the mothers positive affect and behavior with their infants. Fathers attended two of the group therapy sessions. One focused on demystifying depression, and the second focused on enhancing mutual spousal support through the use of communication and problem-solving exercises. Fathers also joined the mother and infant in the interactional activities during the last half hour of each of those sessions. IPT. This treatment condition consisted of a 1.5-hr initial evaluation and 12 weekly 1-hr individual therapy sessions. The individual therapy model used in this study was grounded in the theoretical underpinnings of IPT, which has been shown empirically to be an effective treatment for depression (Klerman & Weissman, 1987) and is consistent with the current standard of practice for treating depression. Treatment consisted of 12 weekly psychotherapy sessions and included the therapeutic procedures described by Klerman and colleagues (1984), with adjustments made to address the issues specic to PPD described by Stuart and OHara (1995). The early phase of the intervention involved identifying interpersonal patterns that contributed to the womans depressive symptoms. Subsequent therapeutic interventions focused on helping the woman develop strategies to relieve depressive symptoms; address issues related to life changes, loss, and conicts; and increase self-understanding. Although not specically focused on the motherinfant relationship, the IPT approach focused on helping women develop new ways of relating to their partners, children, and others. We monitored and provided supervision to all therapists administering interventions. WLC. The WLC group consisted of women who were waiting to receive M-ITG. Therapist training. Over the course of the study, there were four mothers group therapists and four infant developmental therapy group therapists, as well as supervised graduate practicum students, providing the M-ITG and four therapists providing the IPT. Therapists included three licensed psychologists, three social workers, three psychology interns, and three postdoctoral fellows with at least 2 years of clinical experience. This clinical experience included working with depressed women, group therapy, and/or working with the children of depressed women in therapeutic settings. All therapists administering the study treatments participated in 40 hr of didactic training for each and followed the treatment manuals for M-ITG (Clark, 1994) and IPT (Klerman et al., 1984). The M-ITG manual provided specic session guides and strategies for addressing goals for each session. The IPT manual provided strategies for each phase of treatment. Training for the M-ITG consisted of reviewing literature on maternal depression; infant social,

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CLARK, TLUCZEK, AND WENZEL interview ratings (rs .46 to .53; Shaw, Valles, & McCabe, 1985). The PSI is a 120-item, self-report inventory measuring the number and severity of specic stressors in the parentchild relationship that are associated in the literature with dysfunctional parenting. The PSI measures stress related to (a) the child domain (e.g., to what extent the child is experienced as acceptable, reinforcing, demanding), (b) the parent domain (e.g., to what extent the parent feels competent, socially isolated, healthy; and quality of spousal relationship), and (c) other life circumstances domain (e.g., divorce, changes in income, pregnancy). The majority of items are scored on a 5-point Likert scale (1 strongly agree, 5 strongly disagree), except for the 19 items that compose the Life Stress Scale. For these latter items, the respondent simply indicates whether a specic life event has occurred within the last 12 months. A total stress score is calculated by combining the scores from the child and parent domains. Abidin (1986) used a normative sample of 534 parents and found internal consistency reliability coefcients of .95 for the Total Stress Score, .89 for the Child Domain, and .93 for the Parent Domain. Testretest reliability was measured with a sample of 54 parents over a 3-month period (Zakreski, 1983) and yielded coefcients of .88 for Total Stress Score, .77 for the Child Domain, and .69 for the Parent Domain. Infant development measure. The BSID, used extensively in child development research, assesses the cognitive and motor developmental level of infant and toddlers up to 30 months of age. Only the Mental Scales were used for this study. These scales included items for infants 1 to 24 months of age: sensoryperceptual abilities; the acquisition of object constancy and memory; learning and problem-solving abilities; vocalizations and early language skills; and the ability to classify and form generalizations, the basis of abstract thinking. The BSID was normed on a sample of 1,262 children. The children in each age group were representative of the national population in sociodemographic variables based on the 1960 United States census (Bayley, 1969). Interrater reliability for the Mental and Motor Scales of the BSID have been found to be .89 and .93, respectively, and testretest reliability has been reported to be .76 and .75, respectively. Motherinfant interaction measure. The PCERA was used to assess the quality of the motherchild relationship. The PCERA consists of parent, child, and dyadic scales that were developed to assess the affective and behavioral quality of the motherchild interaction. Items on these scales were derived from theory, empirical studies, and clinical observations of high-risk and well-functioning motherinfant dyads (Ainsworth, Bell, & Stayton, 1972; Clarke-Stewart, 1973; Emde, 1981; Kohut, 1971; Lewis & Goldberg, 1969; Sander, 1964; Stern, 1985; Vygotsky, 1978; Winnicott, 1965). In the present study, mothers and children were videotaped for 5 min of free play. A free play situation was videotaped because it allows an assessment of the mothers capacity to be playful with and enjoy her child and to facilitate her childs capacity for exploratory and representational play. The dyads capacity for social interaction, mutuality, and reciprocity was observable. Instructions given to the mother prior to the videotaping included, This is a free play

emotional and developmental functioning; object relations; attachment and family systems theory and group, cognitivebehavioral, and interpersonal strategies; and parentinfant dyadic therapy techniques as well as reviewing videotapes of M-ITG sessions. Training for IPT consisted of seminars reviewing the manual and literature on IPT and review of videotapes.

Measures
Assessment measures. Pre- and postassessment data were collected from mother and child participants in all groups. Assessment data for mothers consisted of two selfreport depression questionnaires, the BDI (Beck et al., 1961), the Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977), and a measure of the mothers perception of her child and of herself in the parenting role, the Parenting Stress Index (PSI; Abidin, 1986). The Bayley Scales of Infant Development (BSID; Bayley, 1969) were used to assess the developmental functioning of the infants. The Parent-Child Early Relational Assessment (PCERA; Clark, 1985) was used to examine the affective and behavioral quality of the motherinfant interaction. Clinical intake interviews were conducted with each woman. Each measure was obtained prior to and following the 12-week interventions. The same assessment data were collected from the WLC group at two data points 12 weeks apart. Measures of maternal symptoms. The BDI is a 21-item, self-report inventory designed to measure the severity of depression. Items on the questionnaire are answered by one of four statements (scored 0 to 3) that reect increasing severity of depressive symptoms for that item. Item scores are summed in order to yield an overall score that can range from 0 to 63. BDI scores are categorized as follows: non depressed 09, mildly depressed 1015, moderately depressed 1623, and severely depressed 2463. The internal consistency of the BDI has been shown to range from .58 to .93. The average itemtotal correlation is .68. Testretest reliability ranges from .69 to .90. Correlations between clinicians estimates of depression severity and the BDI range from .62 to .77. The CES-D is a 20-item scale designed to assess symptoms of depression in the general population. The selfreport format was used for this study. The items for the scale were derived from other, previously validated assessment measures, such as the Minnesota Multiphasic Personality InventoryDepression Scale, the BDI, and the Zung SelfRating Depression Scale. Items of the scale emphasize the frequency with which a particular item has occurred during the past week (ranging from 0 rarely or not at all to 3 most of the time). Total scores range from 0 to 60. A score of 16 or higher indicates the presence of depressive symptoms. The CES-D has good internal consistency, with average alphas of .86 for the general population and .91 for a clinical sample. The testretest reliability is .54. The CES-D correlates well with other depression measures, such as the BDI and the Zung Self-Rating Depression Scale (rs .81 and .90. respectively) and more moderately with

PSYCHOTHERAPY FOR POSTPARTUM DEPRESSION time with your child. You or [name of child] may choose the toy(s) that you would like to play with together. PCERA ratings were made on a 5-point Likert scale for 65 items, with 5 always being the most positive score. PCERA raters receive 40 hr of training and were blind to the treatment group assignment. The amount, duration, and intensity of affect and behavior exhibited by the parent, child, and dyad were rated. Variables include (a) items that assess aspects of maternal behavior and affect, including maternal positive and negative affect, sensitivity and contingent responsivity to childs cues, exibility/rigidity, and capacity to structure and mediate the environment. (b) Child items include positive and negative affect, somber/serious mood, irritability, social initiative and responsiveness, interest/ gaze aversion, assertion/aggressivity, persistence, impulsivity, and emotional regulation, all important aspects of infant functioning and vulnerable to stress and family functioning. (c) Dyadic items include mutual enjoyment, tension, reciprocity, and joint attention. See Table 2 for the factors derived from these scales. PCERA ratings of early motherinfant interactions have been found to be correlated with both later quality of motherchild interactions at 12 months and security of attachment behaviors in infants (e.g., Mothander, 1990; Teti, Nakagawa, Das, & Wirth, 1991). Internal consistency of subscales, interrater reliability, and predictive and discriminant validity have been established for the PCERA in a number of studies with normative and high-risk populations (Clark, 1983, 1999; Clark, Hyde, Essex, & Klein, 1997; Clark et al., 1993).

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ANCOVA examining group differences on the BDI was not signicant, F(2, 34) 1.67, ns. However, the ANCOVA examining group differences on the CES-D was signicant, F(2, 30) 3.60, p .04. Both the women in the M-ITG and those in the IPT condition reported fewer symptoms on this measure posttreatment than did those in the WLC group (ps .02 and .04, respectively), but the two treatment groups did not differ from each other on this variable. Thus, there is evidence that participation in the treatment groups resulted in a signicant reduction in depressive symptoms as compared with a WLC group.

Parenting Stress
Table 4 summarizes scores on scales of the PSI by group. Pretreatment scores on these inventories and maternal age were used as covariates in ANCOVAs. The ANCOVA examining group differences showed group differences on the Child Adaptability scale, F(2, 32) 3.68, p .036. The M-ITG and IPT groups did not differ from each other; however, both showed signicant improvement as compared with the WLC group (ps .034 and .016, respectively). Additionally, mothers in both the M-ITG and the ITP group reported their infants to be more reinforcing and differed significantly from the WLC group mothers, F(2, 32) 11.40, p .001, p .000, and p .000, respectively however, the two active treatment groups did not differ from each other. There were no signicant group differences for the PSI Total Stress, Acceptability, Demandingness, Mood, and Distractibility/ Hyperactivity scales of the Child Domain or any individual scales of the Parent Domain. Thus, results suggest that participating in an active psychotherapeutic treatment was associated with improvement in mothers perceptions of their childrens adaptability and more reinforcement derived from their children than being in the WLC group.

Results Demographics
Table 1 summarizes the demographic characteristics of the three samples. A one-way analysis of variance revealed signicant differences among the three groups for mothers age, F(2, 38) 5.65, p .007. Mothers in the M-ITG group were signicantly younger than mothers in the WLC group variable (p .05). There were no signicant differences among the three groups for childs age, family income, mothers education, marital status, race, and childs gender. Although there were no signicant differences among the groups in their demographics, the M-ITG participants tended to report more severe symptoms of depression, documented by the BDI and CES-D, as compared with the IPT and WLC groups.

ParentChild Early Relational Assessment

Table 5 summarizes maternal, infant, and mother infant dyadic factors of the PCERA as well as internal consistency and reliability for each factor. Table 5 summarizes pre- and posttreatment scores on scales of the PCERA by group. Pretreatment inventory scores and maternal age were used as covariates in ANCOVAS. An ANCOVA showed signicant group differences for Factor 1, Maternal Positive Affective Involvement and Verbalization, F(2, 34) 6.27, p .005. Both the M-ITG and the IPT group scored higher on this factor than the WLC group ( ps .019

Depression
Table 3 presents the mean scores on the depression self-report inventories by group. Pretreatment scores on these inventories and maternal age were used as covariates in analyses of covariance (ANCOVAs). The

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Table 2 ParentChild Early Relational Assessment Internal Consistency and Reliability for Each Mother, Infant, and Dyadic Factor
Factor 1Maternal Positive Affective Involvement and Verbalization Factor items Maternal component 2. Expressive, nonat voice tone 4. Expressed positive affect 7. Lack of depressed, withdrawn mood 12. Enjoyment, pleasure 15. Visual contact 16. Amount of verbalization 17. Quality of verbalizations 18. Social initiative 21. Structures and mediates environment 24. Mirroring 26. Creativity 1. Angry, hostile tone of voice 5. Expressed negative affect 6. Angry, hostile mood 11. Displeasure 20. Contingent responsivity to negative behavior 8. Anxious mood 14. Quality and amount of physical contact: negative 15. Amount of verbalization 21. Lack of structuring/mediating 22. Insensitivity/unresponsiveness to childs cues 25. Rigidity 27. Intrusiveness 28. Inconsistency/unpredictability Infant component 30. Expressed positive affect 32. Happy, pleasant, cheerful mood 33. No apathetic, withdrawn mood 36. No sober/serious mood 39. Social initiative 55. Visual contact 56. Communicative competence 57. Readability 33. No apathetic, withdrawn mood 38. Alertness/interest 44. Motoric competence and quality 45. Quality of exploratory play 46. Attentional abilities 47. Robustness 48. Persistence 50. Self-regulation/organization 56. Communicative competence 57. Readability 31. Expressed negative affect 35. Irritability/angry mood 37. Emotional lability 43. Aggressivity 49. Impulsivity 50. Lack of self-regulation/organization Dyadic component 59. No at, empty, constricted affect 61. Enthusiasm, joie de vivre 63. Reciprocity 65. State similarity 58. Anger, hostility/irritability 60. Tension, anxiety 63. Lack of joint attention, activity 64. Dyadic organization/regulation 65. Lack of state similarity .91 Interclass r .88

2Maternal Negative Affect and Behavior

.91

.83

3Maternal Intrusiveness, Insensitivity, and Inconsistency

.86

.73

4Infant Positive Affect, Communicative and Social Skills

.87

.76

5Infant Quality of Play, Interest, and Attentional Skills

.87

.72

6Infant Dysregulation and Irritability

.83

.63

7Dyadic Mutuality and Reciprocity

.87

.75

8Dyadic Disorganization and Tension

.78

.74

PSYCHOTHERAPY FOR POSTPARTUM DEPRESSION

449

Table 3 Depressive Symptomatology

M-ITGa (n Measure BDI CES-D Pre 26.9 (7.3) 41.1 (7.6) 9) Post 15.9 (8.5) 19.2 (10.2)* Pre 26.2 (8.2) 36.2 (9.2) IPT (n 15) Post 16.4 (10.2) 20.1 (12.9)a WLC (n Pre 24.5 (6.4) 32.4 (6.9) 11) Post 20.6 (9.2) 26.6 (10.0) F 1.67 3.60c
b

p ns .04

Note. Signicance values represent difference from WLC group. Values in parentheses are standard deviations. M-ITG motherinfant therapy group; IPT interpersonal psychotherapy; WLC wait list comparison group; Pre pretreatment; Post posttreatment; BDI Beck Depression Inventory; CES-D Center for Epidemiological Studies Depression Scale. a n 9 for M-ITG group due to missing data. bdf 2, 34. cdf 2, 30. *p .05.

and .002, respectively), but the two treatment groups did not differ from each other on this variable. Thus, mothers in both of the treatment groups demonstrated more positive affective involvement and verbalization with their infants after participation in treatment than did mothers in the WLC group. In addition, there were signicant group differences on Factor 2, Maternal Negative Affect and Behavior, F(2, 34) 3.71, p .035. Mothers in the WLC condition evidenced signicantly less negative affect and behavior at 12 weeks on this factor as compared with the women in the M-ITG (p .006), and those participating in the IPT did not differ signicantly from the WLC group on this factor.

Discussion
When compared with a WLC group, the two active 12-week psychotherapeutic treatments (M-ITG and IPT) appeared to be equally effective in reducing symptoms for women experiencing major depression during the postpartum period. However, results suggest that of the three groups, the women in the M-ITG group experienced the highest level of initial depressive symptoms (as measured by higher mean BDI and CES-D scores) and the greatest improvement (as demonstrated by the lowest posttreatment mean scores). Despite their improvement, some women from both treatment groups continued to experience mild to moderate depressive symptoms after the 12-week treatment programs. We speculate that the sample in this study represented a more severely depressed population of women than in other PPD studies because the women in this study were recruited from a clinical population of patients referred to a

Infant Developmental Status

There were not signicant differences found at posttesting among the three groups on the Mental Scale of the BSID.

Table 4 Parenting Stress Index Scales

M-ITG (n Child domain Total child score Adaptability Acceptability Demandingness Mood Distractibility/ Hyperactivity Reinforces Parent (n Pre 12) 13) (n Post 13) (n IPT (n Pre 14) 15) (n Post 15) (n WLC (n Pre 11) 11) (n Post 11) F(2, 32) 1.70 3.68 0.18 1.74 3.19 1.29 11.40 p ns .036 ns ns ns ns .000

112.9 (25.0) 26.0 (6.8) 14.1 (4.5) 22.7 (8.8) 9.8 (4.1) 27.1 (5.2) 12.9 (3.9)

99.0 (18.8) 109.2 (22.7) 100.5 (16.5) 113.2 (18.1) 23.0 (4.3)* 27.6 (4.6) 24.9 (3.9)* 29.6 (6.5) 12.7 (4.4) 14.4 (4.1) 13.1 (4.6) 13.2 (3.1) 17.2 (4.4) 20.4 (4.8) 19.8 (4.2) 22.0 (6.8) 10.1 (2.9) 12.0 (3.8) 9.5 (3.0) 11.7 (4.3) 25.4 (3.5) 22.3 (6.0) 23.7 (5.0) 26.6 (6.4) 10.6 (3.5)* 11.6 (3.5) 9.5 (2.6)* 10.5 (3.1)

114.6 (15.6) 29.6 (3.6) 13.2 (2.9) 21.6 (5.1) 12.4 (2.8) 18.5 (9.3) 18.5 (9.3)

Note. The parent domain is not shown because no parent subscales were signicant. Signicance values represent difference from WLC group. Standard deviations are in parentheses. M-ITG motherinfant therapy group; IPT interpersonal psychotherapy; WLC wait list comparison group; Pre pretreatment; Post posttreatment. *p .05.

450

CLARK, TLUCZEK, AND WENZEL

Table 5 ParentChild Early Relational Assessment

M-ITG (n Factor 1 2 3 4 5 6 7 8 Pre 3.1 (0.6) 4.4 (0.8) 3.6 (0.6) 2.8 (0.6) 3.4 (0.7) 4.0 (0.7) 2.9 (0.6) 3.5 (0.5) 13) Post 3.7 (0.6)* 4.6 (0.7)* 4.0 (0.6) 3.4 (0.8) 4.1 (0.8) 4.4 (1.0) 3.4 (0.7) 3.8 (0.9) IPT (n Pre 3.6 (0.5) 4.8 (0.3) 3.9 (0.5) 3.2 (0.8) 4.0 (0.7) 4.3 (0.8) 3.2 (0.8) 3.6 (0.6) 15) Post 4.2 (0.6)* 4.9 (0.3) 4.3 (0.6) 3.5 (0.8) 4.3 (0.5) 4.8 (0.3) 3.5 (0.9) 4.0 (0.4) WLC (n Pre 3.1 (0.8) 4.7 (0.7) 3.8 (0.5) 3.1 (0.6) 3.9 (0.6) 4.4 (0.5) 2.9 (0.7) 3.7 (0.5) 11) Post 3.1 (0.6) 5.0 (0.1) 3.8 (0.5) 3.3 (0.5) 4.2 (0.5) 4.7 (0.3) 3.0 (0.5) 3.7 (0.4) F(2, 34) 6.27 3.71 2.99 0.17 1.40 2.99 0.83 1.87 p .005 .035 ns ns ns ns ns ns

Note. Signicance values represent difference from WLC group. Standard deviations are in parentheses. High scores indicate more positive affect and behavior (i.e., on Factors 2, 3, 6, and 8), high scores respectively indicate a lack of maternal negative affect and behavior, maternal intrusiveness, insensitivity and inconsistency, infant dysregulation and irritability, and dyadic disorganization and tension. M-ITG motherinfant therapy group; IPT interpersonal psychotherapy; WLC wait list control group; Pre pretreatment; Post posttreatment. *p .05.

psychiatric facility rather than from general population screening as in other studies (e.g., OHara et al., 2000). These ndings suggest that the more comprehensive therapeutic nature of the M-ITG intervention, which focuses on the multiple roles and experiences of women as well as their depressive symptoms, may be especially suited to women who are more severely depressed. The ndings also suggest that more treatment sessions or booster sessions may be necessary to produce complete recovery. Posttreatment, women from both active treatment groups also viewed their children as being more adaptable, and they reported that they experienced their children as more reinforcing than did women in the WLC. Women from both treatment groups also showed an improvement in their positive affective involvement and verbalization with their infants. Improvement in positive affect is consistent with the ndings that mothers experienced fewer depressive symptoms after treatment. However, this relational variable also includes ratings of the mothers tone of voice, quality of verbalizations, visual contact, and nature of social initiatives while interacting with her infant. It is likely that as the womans depressive symptoms abate, she may become more available and aware of her infants cues and better able to respond in a sensitive way. Consequently, her infant may reciprocate with increased responsiveness, leading the mother to perceive her infant as more adaptable and for her to view parenting her infant as more enjoyable. It is not surprising that the two active treatment groups showed similar posttreatment outcomes. The approach taken to IPT for this preliminary study more

closely resembled the motherinfant relational aspect of the M-ITG and, thus, the two contained similar therapeutic elements. In contrast to traditionally administered IPT, and although not part of the design, in this study mothers and infants often attended the IPT sessions together. In addition, although it was not a specic goal of the IPT approach (but is consistent with IPTs focus on role transitions), parenting issues or concerns were often addressed on an individual basis during sessions. Additionally, the infants presence offered opportunities to discuss the meaning of the child, explore issues of projective identication, amplify the mothers strengths in parenting, and foster a positive relationship between mother and childall therapeutic elements of the dyadic group component of the M-ITG. The nding of positive outcomes for mothers perceptions of their infants in the IPT group provides further support for the interpersonal or relational theoretical underpinnings of the M-ITG model. Mothers in the M-ITG condition were more severely depressed than mothers in the IPT and WLC conditions (as evidenced by signicantly higher CES-D scores) and showed more disturbances in motherinfant interactions (as evidenced by lower scores on the PCERA) as compared with the IPT and the WLC mothers. Although not statistically signicant, the additional PCERA maternal factors and the motherinfant dyadic factors for both treatment groups showed trends toward clinically signicant improvement in the quality of the motherinfant interactions. The small sample size may have contributed to the lack of statistical signicance. The Negative Affect and Behavior measure (Factor 2) of

PSYCHOTHERAPY FOR POSTPARTUM DEPRESSION

451

the PCERA showed the WLC mothers to have statistically better posttreatment scores as compared with the M-ITG mothers. These ndings may actually represent the fact that mothers in the M-ITG were more severely depressed than the mothers in the WLC. M-ITG mothers pretreatment Factor 2 scores were much lower than those of the WLC mothers, whose pretreatment scores were already very high, with very little evidence of negative affect or behavior to begin with. These ndings are similar to those of Cooper and Murray (1997) in their comparison of treatments designed to improve the quality of motherinfant interactions of depressed mothers. They speculated that studies examining motherinfant interactions may fail to nd signicant posttreatment improvement because disturbances in such interactions tend to be very subtle. The sequential method used for group assignment in this study occurred over several years, with initial comparisons occurring between the M-ITG and the WLC and the second active treatment condition being added as a comparison later. Earlier ndings indicated signicant differences between the M-ITG and the WLC groups in amelioration of depressive symptoms, in improvement in mothers perceptions of their infants, and lessening of parenting stress as well as in the quality of motherchild interactions (Clark, 1996). The addition of the individual treatment condition allowed us to begin to explore whether a group relational approach is more benecial for the treatment of depression in the postpartum period. The results of the National Institute of Mental Health treatment of depression study (Elkin et al., 1995) and the study of IPT for PPD (OHara et al., 2000) prompted our interest in comparing M-ITG with IPT, as it has been found to be an effective individual psychotherapy. Due to the salience of relationships in PPD, IPT was chosen as the individual therapy comparison group for its relational theoretical underpinnings and techniques. However, the addition of ITP treatment as a comparison group occurred at a later point in time, when selective serotonin reuptake inhibitors were increasingly being prescribed for the treatment of major depression during the postpartum period, even for breastfeeding women. Therefore, women in the IPT group were more likely to have received antidepressant medication as an adjunct to their treatment than were women in the M-ITG group or WLC group. In fact, a review of the data showed that more women in the IPT group (60%) than the M-ITG (38%) were taking antidepressant medication while in the study. Still, there were no signicant differences between the two active treatment groups in the measure of

posttreatment depressive symptoms. Although this differential timing of the interventions represents a limitation of the study design, these serendipitous ndings suggest that M-ITG may represent an effective therapeutic alternative to antidepressants for some women who prefer not to take medication while breastfeeding. In summary, these ndings support the benets of a relational approach for the treatment of PPD in improving the affective state of mothers while enhancing maternal perceptions of the infant and the quality of the motherinfant relationship. A relational approach to treating PPD focusing on the motherinfant and family relationships in addition to the individual needs and functioning of the mother dened the unique, comprehensive approach of the MIT-G condition. The presence of infants during the IPT condition in this preliminary study may have obscured the potential differences between these therapeutic approaches. Thus, having the infant present during IPT for mothers with PPD may provide added therapeutic benets to the motherinfant relationship. The lack of signicant ndings on the infant variables in this study is consistent with the ndings of OHara and his colleagues (2000). Follow-up assessments were not conducted in the present study for two reasons. First, there was no untreated group, as the WLC group received treatment following the 12-week waiting period. Funding limitations also precluded follow-up assessments, which may have revealed subsequent developmental delays or disturbances, particularly in an untreated group. Other research (NICHD Early Child Care Research Network, 1999) has shown that 3-year olds whose mothers have been depressed during infancy experience signicant developmental delays and behavioral problems. The chronicity of the mothers depressive symptoms appears to pose a signicant risk to the childs developmental trajectory. In addition, maternal sensitivity was found to moderate the impact of maternal depression on the childs development. Thus, early detection and relational intervention for major depression in women during the postpartum period are essential not only for the mothers well-being but also for the childs development. Adding a family component to the treatment of psychiatric disorders in children has been found to add to the robustness and lasting impact of treatment efcacy (Webster-Stratton & Hammond, 1997). This positive effect may be a result of including treatment components that specically address the context in which the person experiencing a psychiatric disorder is functioning and that provide information and social support to family members

452

CLARK, TLUCZEK, AND WENZEL Burns, D. (1989). Feeling good: The new mood therapy. New York: New American Library. Campbell, S., & Cohn, J. (1997). Timing and chronicity of postpartum depression: Implications for infant development. In L. Murray & P. Cooper (Eds.), Postpartum depression and child development (pp. 165197). New York: Guilford Press. Carter, A., & Kaslow, N. (1992). Phenomenology and treatment of depressed women. Psychotherapy, 29, 603609. Clark, R. (1983). Interactions of psychiatrically ill and well mothers and their young children: Quality of maternal care and child competence. Unpublished doctoral dissertation, Northwestern University. Clark, R. (1985). The ParentChild Early Relational Assessment. Unpublished instrument, Department of Psychiatry, University of WisconsinMadison Medical School. Clark, R. (1994). Manual for postpartum depression group therapy for mothers and infants: A relational approach. Madison, WI: Author. Clark, R. (1996). Group therapy for postpartum depressed women: Evaluations of a manualized approach [abstract]. Presented at International Conference on Infant Studies, Providence, RI. Clark, R. (1999). Factorial validity of the ParentChild Early Relational Assessment. Educational and Psychological Measurement, 59, 821846. Clark, R., Hyde, J. S., Essex, M. J., & Klein, M. H. (1997). Length of maternity leave and quality of motherinfant interactions. Child Development, 68, 364383. Clark, R., Keller,A., Fedderly, S., & Paulson,A. (1993). Treating the relationships affected by postpartum depression: A group therapy model. Zero to Three, 13, 1623. Clarke-Stewart, K. A. (1973). Interactions between mothers and their young children: Characteristics and consequences. Monographs of the Society for Research on Child Development, 38, 67. Cohn, J. F., Campbell, S. B., Matias, R., & Hopkins, J. (1990). Face-to-face interactions of postpartum depressed and nondepressed motherinfant pairs at 2 months. Developmental Psychology, 26(1), 1523. Cooper, P. J., & Murray, L. (1997). The impact of psychological treatment of postpartum depression on maternal mood and infant development. In P. J. Cooper & L. Murray (Eds.), Postpartum depression and child development (pp. 201220). New York: Guilford Press. Cummings, E. M., & Davies, P. T. (1994). Maternal depression and child development. Journal of Child Psychology and Psychiatry, 35, 73112. Cutrona, C. (1982). Nonpsychotic postpartum depression: A review of recent research. Clinical Psychology Review, 2, 487503. Di Mascio, A., Weissman, M. M., Prusoff, B. A., Neu, C., Zwilling, M., & Klerman, G. L. (1979). Differential symptom reduction by drugs and psychotherapy in acute depression. Archives of General Psychiatry, 36, 14501456. Elkin, I., Gobbons, R. D., Shea, M. T., Sotsky, S. M., Watkins, J. T., Pilkonis, P. A., & Hedeker, D. (1995).

experiencing stress. Long-term posttreatment followup is needed to examine the effects of a motherinfant relational approach for the treatment of PPD relative to recurrence of depressive episodes, the quality of the motherchild relationship, and the childs development during the preschool and transition to school years. A large scale randomized controlled clinical trial comparing manualized approaches with adherence measures for both the M-ITG and IPT is currently underway and will help to further identify the specic therapeutic elements that are most effective for which women. Not having the infant present in the IPT condition would allow a clearer explication regarding the contribution of a dyadic focus in the M-ITG. Assessments of the fathers functioning and of the fatherchild and spousal relationships pre- and posttreatment would also allow further examination of the efcacy of this family-focused approach for the woman and for other family members. As suggested by Carter and Kaslow (1992), a gender-sensitive approach to the treatment of depression in women is warranted and should include exploration of individual, dyadic, and family historical events, with connections made to current depressive symptoms and associated interactional processes. Including the infants and spouses in the treatment of PPD may reduce stress and support the development of competence in the parenting and marital roles, thereby inoculating women against recurrences of depressive episodes, which can be so debilitating for them and which have been found to be the most robust risk factor in predicting subsequent behavioral and developmental disturbances for their children (NICHD Early Child Care Research Network, 1999).

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Received February 11, 2002 Revision received August 26, 2002 Accepted August 28, 2002