Comparing Treatments for Mood Disorders: A Focus on Postpartum Mood Disorders

Mood disorders are those disorders that have a disturbance in mood as their predominant feature. This group includes several nosoforms such as affective disorders, psychotic bipolar disorder and depressive disorders. The last are presented by the involutional and postpartum depression, dysthymic disorder and seasonal affective disorder. All listed conditions are very frequent - about 14.3% of the population is stroked by the mood disorders. The aim of this review is comparing the different treatments for the mood disorders by example of postpartum mood disorders. Databases searched for this review included PsycINFO only.

There are several risk factors of postpartum mood disturbances. After delivery the level of steroid hormones (estrogens, gestagens and cortisol) changes dramatically. Some women are very sensitive to these hormonal changes and can react with changes of the mood. Psychosocial risk factors include low income and inadequate social supports, recent negative life events, marital conflict or dissatisfaction. Heredity and individual susceptibility are risk factors for postpartum depression. Thus women with individual or family history of a mood disorder have higher risk of postpartum depression. A prior history of postpartum mood disorder increases the risk of recurrence of the depression in two folds.

Postpartum changes of the mood are not rare complications of accouchement. There are different symptoms of mood disturbance – from transitory and mild signs of postpartum blues and up to the severe postpartum depression and puerperal psychosis. Nonacs R. and Cohen LS. (1998) write that mood changes during the puerperium are often overlooked. This fact arouses the risk of the episodes of recurrent depression in mothers. Another important issue of the problem is a risk of the remote consequences of mother’s mood disturbance on the future mental and physical development of child. To prevent those long-term effects the early diagnostics and effective treatment interventions should be applied.

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Some forms of the postpartum mood disorder do not require any specific treatment, e.g. the most common (30-75% of new mothers) form of the mood disturbances, so called “baby blues” require only education, reassurance and support. More serious conditions, like postpartum depression, need more active interventions. This condition occurs in 15-20 % of all women recently confined. It is characterized by anxiety, irritability, insomnia, fatigue, low interest to the baby and other symptoms of major depression.

Seyfried LS and Marcus SM. (2003) indicate that pharmacological treatment for patients with postpartum depression can be limited because some psychoactive drugs are contraindicated in lactation and psychotherapeutic approaches became the method of the choice. On other hand, rare cases of postpartum psychosis require psychiatric emergency care and urgent drug treatment. Thus the differentiation of treatment mode is important element of the care in the postnatal changes of the mood.

Series of works by Dennis CL. et all. (2004) are dedicated to the problem of treatment of postpartum depression. Authors consider that the most effective schemes of psychotherapy include interpersonal psychotherapy, cognitive-behavioral therapy, peer and partner support, nondirective counseling, relaxation/massage therapy, infant sleep interventions, infant-mother relationship therapy, and maternal exercise.

Unfortunately the available clinical trials studied these methods and their effectiveness, were designed poorly and have low level of evidence. Thus definite conclusions about the relative effectiveness of the different treatments cannot be reached. Authors recommend to increase the number of randomized controlled trials needed for comparing different treatment schemes, examining the effectiveness of individual treatment components and selecting the optimum treatments for women with different anamnesis and status praesens objectivus.

Other group of interventions using in the psychiatry for treatment of postpartum depression includes antidepressant medication, estrogen therapy, critically timed sleep deprivation, and bright light therapy. Some of these interventions can be applied to other types of depressions unrelated to puerperium but the issues of pharmacological safety can limit them.

As an example of mentioned above we can use the results of the study by Reck C. et all. (2004). They found, that mother-infant interaction plays a central role in the treatment of postpartum depression. They explain this fact with high sensitivity of infants to their mothers' emotional state. The authors consider that postpartum depression is a risk factor for disturbances of children's development. They proposed the integrated model of treatment which is based on  mother-infant-centered interventions.

Similar propositions contains the research paper of Hofecker-Fallahpour M. et all. (2003). This group of Swiss investigators proposed the program of group therapy for depressive mothers, including those who has postpartum depression. The main therapeutic method in this program is behavioral therapy.

Clark R, Tluczek A. and Wenzel A. from the University of Wisconsin Medical School published work (2004) about the priorities of psychotherapy in the patients with postpartum depression. They think that group psychotherapy and interpersonal psychotherapy should be superior to other methods of non-pharmacological treatment.

The main objectives of the proposed treatment is “reducing maternal depressive symptoms, improving mothers' perceptions of their infants' adaptability and reinforcement value, and increasing mothers' positive affect and verbalization with their infants”. Authors urge that early intervention for mothers with postpartum depression is crucial point of successful treatment.

Different point of view was demonstrated by Cooper PJ, Murray L, Wilson A. and Romaniuk H. (2003). They think that psychological interventions for postnatal depression can be beneficial in the short term but this benefit is not superior to spontaneous remission in the long term. In their research Cooper PJ. et all. used routine primary care, non-directive counseling, cognitive-behavioral therapy and psychodynamic therapy. They found that all chosen treatments had a considerable impact at four months on maternal mood but only psychodynamic therapy reduced depression significantly.

The last kind of therapy focused on patient's experience and bygone conflicts of childhood and adolescence. All benefits of the treatment were not longer by nine months after delivery and did not reduce of recurrent episodes of depression in long-term perspective. These scientists urge that postnatal depression is associated with adverse child cognitive and socio-emotional outcome (2003). They found that early psychotherapeutic intervention had the short-term benefit to the mother-child relationship and infant behavior.

In summarizing of foresaid we could said that the treatment of mood disorders in puerperal period includes two main components: medical interventions and psychotherapy. The choice of the methods and their combination depend on the severity of signs and risk of the recurrence of mood disorder. Women with mild disturbances of mood (postpartum blues) do not need specific treatment. This condition typically resolves spontaneously during first weeks.

Because the medical interventions are not the subject of our competence we will focus on the findings in the field of psychotherapy. This approach is especially useful in women with mild or moderate severity of postnatal depression. The most of authors recommend group psychotherapy (cognitive-behavioral and interpersonal therapy), but individual therapy is effective too. These methods can be combined with educational programs.
O'Hara MW. and his coauthors evaluated efficacy of different methods of psychotherapy for postpartum depression. They proposed interpersonal psychotherapy as the method of the choice in treatment of postpartum depression.

They found that “interpersonal psychotherapy reduced depressive symptoms and improved social adjustment, and represents an alternative to pharmacotherapy, particularly for women who are breastfeeding”.
We can see that the main benefit of psychotherapy is absence of adverse effects of taking medications. But in severe cases of postnatal depression or when patients do not respond to non-pharmacological treatment and in all cases of postpartum psychosis the pharmacological treatment is indicated.

The prevalent forms of psychotherapy in the postnatal depression include cognitive therapy, behavioral therapy and interpersonal psychotherapy. Both individual and group therapy can be used. All types of non-pharmacological treatment are effective in mild and moderate severity of the depression.

Untreated mood disorders place the mother at risk for recurrent disease. Furthermore, maternal depression is associated with long-term cognitive, emotional, and behavioral problems in the child. One of the most important objectives is to increase awareness across the spectrum of health care professionals who care for women during pregnancy and the puerperium so that postpartum mood disorders may be identified early and treated appropriately.

Effective pharmacological and non-pharmacological therapies are available. Every approach has the advantages and demerits. But to compare their effectiveness we need better-designed clinical trials and the unification of the approaches to the examining of the effectiveness of individual treatment components. Selecting the optimum treatments for women with different background and severity of the postnatal depression should be evidence-based and take into consideration the possibility of long-term effects of the mood disorder.

References:
1.Clark R, Tluczek A, Wenzel A. (2003) Psychotherapy for postpartum depression: a preliminary report. Am J Orthopsychiatry. Oct; 73(4) p. 441-454.
2.Cooper PJ, Murray L, Wilson A, Romaniuk H. (2003) Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. I. Impact on maternal mood. Br J Psychiatry. May; 182: p. 412-419.
3.Dennis CL, Stewart DE. (2004) Treatment of postpartum depression, part 1: a critical review of biological interventions. J Clin Psychiatry. Sep; 65(9): p. 1242-1251.
4.Dennis CL. (2004) Treatment of postpartum depression, part 2: a critical review of nonbiological interventions. J Clin Psychiatry. Sep; 65(9): p. 1252-1265.
5.Hofecker-Fallahpour M., Zinkernagel-Burri C., Stöckli B., Wüsten G., Stieglitz RD., Riecher-Rössler A. (2003) Gruppentherapie bei Depression in der frühen Mutterschaft Erste Ergebnisse einer Pilotstudie Der Nervenarzt Sep.; Band 74, Nummer 9; S.: 767 – 774
6.Murray L, Cooper PJ, Wilson A, Romaniuk H. (2003) Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother-child relationship and child outcome. Br J Psychiatry. May; 182: p. 420-427.
7.Nonacs R, Cohen LS. (1998) Postpartum mood disorders: diagnosis and treatment guidelines. J Clin Psychiatry. 59 Suppl 2: p. 34-40.
8.O'Hara MW, Stuart S, Gorman LL, Wenzel A. (2000) Efficacy of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry. Nov; 7(11) p. 1039-1045.
9.Reck C., Weiss R., Fuchs T., Möhler E., Downing G., Mundt C. (2004) Psychotherapie der postpartalen Depression Mutter-Kind-Interaktion im Blickpunkt. Der Nervenarzt. November Band 75, Nummer 11 S.: 1068 - 1073
10.Seyfried LS, Marcus SM. (2003) Postpartum mood disorders. Int Rev Psychiatry.  Aug; 15(3) p. 231-242.

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