Treating maternal depression?

P. J. McGrath

Psychology Department, Dalhousie University, Halifax, and IWK Health Centre, Halifax B3H 4J1, Nova Scotia, Canada

F. J. Elgar

School of Social Sciences, Cardiff University, Cardiff, UK

C. Johnston

Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada

D. J. A. Dozois

Department of Psychology, University of Western Ontario, London, Ontario, Canada

S. Reyno

Dalhousie University, Halifax, Nova Scotia, Canada

Cooper et al (2003) reported a randomised trial with mothers with post-partum depression that compared routine primary care, non-directive counselling, cognitive–behavioural therapy (CBT) and psychodynamic therapy and found that psychological therapy improved maternal mood in the short term but the long-term effect was no better than spontaneous remission. The trial was generally well done and the procedures reasonably described. However, the researchers did not, from a cognitive–behavioural perspective, treat maternal depression. Cooper et al describe that treatment used cognitive–behavioural techniques but focused not on depression but on the management of mother–infant interactions.

Several randomised placebo-controlled trials have shown that CBT – when done properly – is an effective treatment for post-partum depression (Holden et al, 1989; Appleby et al, 1997; Chabrol et al, 2002) and for major depressive disorders (Hollon et al, 2002). There is an important relationship between post-partum depression and mother–infant interactions but it is not, by any means, the entirety or even the essence of post-partum depression. Although it is advisable to customise CBT to patients’ circumstances, exclusive use of one focus, such as mother–child interactions, is not a test of the therapy. If the goal is to change depression, one should treat depression. Thus, the title is inaccurate and the discussion of the lack of effect of CBT for maternal depression is misleading.

EDITED BY STANLEY ZAMMIT

REFERENCES

Appleby, L., Warner, R., Whitton, A., et al (1997) A controlled study of fluoxetine and cognitive–behavioural counselling in the treatment of postnatal depression. BMJ, 314, 932 –936.[Abstract/Free Full Text]

Chabrol, H., Teissedre, F., Saint-Jean, M., et al (2002) Prevention and treatment of post-partum depression: a controlled randomized study on women at risk. Psychological Medicine, 32, 1039 –1047.[CrossRef][Medline]

Cooper, P. J., Murray, L., Wilson, A., et al (2003) Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. I. Impact on maternal mood. British Journal of Psychiatry, 182, 412 –419.[Abstract/Free Full Text]

Holden, J. M., Sagovsky, R. & Cox, J. L. (1989) Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. BMJ, 298, 223 –226.[Medline]

Hollon, S. D., Haman, K. L. & Brown, L. L. (2002) Cognitive–behavioral treatment of depression. In Handbook of Depression (eds I. H. Gotlib & C. L. Hammen), pp. 383–403, New York: Guilford Press.


 

Authors’ reply

P. J. Cooper and L. Murray

Winnicott Research Unit, Department of Psychology, University of Reading, Whiteknights, 3 Earley Gate, Reading, Berkshire RG6 6AL, UK

EDITED BY STANLEY ZAMMIT

There are many cognitive–behavioural therapies, with the precise form of the CBT shaped to the nature and context of the particular disorder. So, for example, CBT for panic disorder and CBT for bulimia nervosa (Hawton et al, 1989), although sharing a basic orientation and broad therapeutic principles, are very different from one another. The form of CBT in which we were interested had as its principal focus the mother–infant relationship and aspects of infant management. The reason for this was quite clear. It is well established that many forms of treatment for post-partum depression, including counselling (Holden et al, 1989), interpersonal psychotherapy (O’Hara et al, 2000), ‘cognitive–behavioural counselling’ (Appleby et al, 1997) and fluoxetine (Appleby et al, 1997), have significant anti-depressant effects, but it has not been established that any of these interventions has an impact on the quality of the mother–infant relationship and child developmental progress, both known to be compromised in the context of post-partum depression. (The evidence for the efficacy of CBT in this context is, incidentally, less certain. Indeed, none of the three studies cited by Professor McGrath and colleagues in support of this form of treatment delivered an orthodox CBT; and one, in fact, was not a study of CBT at all, but of non-directive counselling.) We were interested in determining whether treatment that addressed the maternal role, as part of a wider supportive therapeutic relationship, would have wider benefits. The form of CBT we investigated was shaped by these concerns, and the discussion refers explicitly to this treatment and is, therefore, wholly apposite.

In several respects the findings of our trial were not what we had expected and were, to us, disappointing. However, the data were what they were, and it was our job to try to understand them. When the first trials comparing CBT with interpersonal psychotherapy for major depression were published in the 1980s, British clinical psychology reverberated with the chunterings of the CBT faithful whose instinctive reaction to the equivalence conclusion was to query the probity of the trial CBT therapists. With time, a more mature position was evolved. The findings of our study, along with the broad failure of the trials of preventive treatments for post-partum depression, would seem to us to be cause for pause and reflection, rather than instinctive defensiveness.

REFERENCES

Appleby, L., Warner, R., Whitton, A., et al (1997) A controlled study of fluoxetine and cognitive–behavioural counselling in the treatment of postnatal depression. BMJ, 314, 932 –936.[Abstract/Free Full Text]

Hawton, K., Salkovskis, P., Kirk, J., et al (1989) Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford: Oxford University Press.

Holden, J. M., Sagovsky, R. & Cox, J. L. (1989) Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. BMJ, 298, 223 –226.[Medline]

O’Hara, M., Stuart, S. & Gormon, L. L., et al (2000) Efficacy of interpersonal psychotherapy for postpartum depression. Archives of General Psychiatry, 57, 1039 –1045.[Abstract/Free Full Text]





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