Postnatal (post-partum) depression remains a popular object of medical and psychological research. Thousands of women all over the world report “a loss of self” following the birth of their children. Almost every tenth delivery ends up in postnatal depression. Although, most cases terminate spontaneously in 4-6 months following the delivery, the effects and negative consequences of postnatal depression on women cannot be easily dismissed. Much has been written about the effectiveness of various psychological and pharmacological treatments of postnatal depression. Cognitive Behavioral Therapy (CBT) is widely applied among post-partum women and is believed to alleviate the burden of postnatal depression and its negative effects on women and the newborns. Unfortunately, the effectiveness of CBT in treating postnatal depression was not widely established. The body of empirical evidence comparing the effectiveness of CBT and other psychological and pharmacological options in the treatment of postnatal depression is extremely scarce. Based on the current state of research, it would be fair to assume that CBT is an effective approach to postnatal depression treatment, but not more effective than other forms of individual and group psychotherapy and pharmacological strategies.
Postnatal (Post-partum) Depression: A Brief Insight
Postnatal depression is a popular object of present day research. More and more women report depressive symptoms following the event of childbirth. Postnatal (postpartum) depression (PPD) is a serious health complication that usually emerges few weeks following the delivery and threatens health and wellbeing of women and their newborn infants. If treated improperly or untimely, PPD may result in a chronic course of depressive symptoms, which negatively affect the entire family. The difficulty of PPD is in that the symptoms and signs of this mood disorder vary considerably across individuals and may range from sadness and despair to sleep disturbances, loss of libido, dependency and fatigue. Many women report they are losing “their own self” (Horowitz & Goodman, 2004). Very often, the symptoms of PPD can be confused with other disorders, which make it difficult to diagnose and address the mood disorder in timely fashion. Basically, “the essential feature of the major depressive episode is a 2-week or longer period during which a woman has either depressed mood or loss of interest or pleasure in activities that is a change from previous functioning” (Horowitz & Goodman, 2004; p.264). This being said that CBT should become a relevant approach to treating postnatal depression in the majority of women.
CBT and Post-partum Depression (PPD)
CBT is one of the most widely documented approaches to psychotherapy (Butler et al., 2006). Between the 1986 and 1993, more than one hundred clinical trials were conducted to explore the benefits and implications of CBT in detail. As of today, at least 325 studies have been published officially to evaluate the effects and outcomes of CBT interventions in various disorders. Butler et al. (2006) found that the majority of earlier trials tested the efficacy of CBT in depression treatment. In case of depression, CBT was shown to have superior quality compared to other treatment alternatives. Butler et al. (2006) performed a detailed meta-analysis of the earlier clinical trials and discovered that, in the prevailing majority of depression studies, CBT had been much more efficient and preferable to pharmacotherapy, behavior therapy, untreated controls and other group therapies. Despite the profound similarities between depression and post-partum depression, this type of mood disorder is entirely different from other health complications. There is no wonder that the results of CBT applications in PPD have been mixed. The body of literature exploring the use of CBT in postnatal depression remains increasingly scarce. More often than not, researchers conclude that CBT is not more effective than other options available in the treatment of PPD.
According to Horowitz and Goodman (2004), an optimal strategy to treat PPD in women must always involve a coordinated team of interdisciplinary professionals and rely on a family-centered approach. Since nurses contact postnatal women most frequently, they are to become the primary carriers of anti-depression strategies and messages for women (Horowitz & Goodman 2004). Horowitz and Goodman (2004) suggested that CBT exemplified a form of time-limited treatment, typically lasting between 12 and 14 weeks. The principal benefits of CBT in postnatal depression treatment were that it emphasized the centrality of individual and the role of individual thoughts and behaviors (Horowitz & Goodman, 2004). The goal of CBT in PPD treatment is to learn how to replace negative thoughts and thinking patterns to develop more desirable emotional reactions (Horowitz & Goodman, 2004). The efficacy of CBT in postnatal depression was supported by Cooper et al. (2003). Cuijpers et al. (2010) also recommended that partner involvement in CBT would improve treatment outcomes. However, CBT is claimed not to be strategically more effective than other types of psychotherapies and pharmacological treatments.
Cooper et al. (2003) involved 120 women who had recently become mothers in interpersonal CBT, aimed to help the women to change their roles, improve their behaviors and enhance their psychosocial functioning. Cooper et al. (2003) found that CBT was an effective approach to postnatal depression and, more importantly, helped to prevent postpartum depression in 35 economically disadvantaged women. Simultaneously, CBT appeared to be no more effective than a combination of psychotherapy and pharmacological treatment or pharmacological treatment alone (namely, fluoxetine). The author reported that the effects of various types of psychotherapy, including CBT, on postnatal depression in women were mostly the same. The results of the study by Spek et al. (2007) were similar: Spek et al. (2007) used Internet-based cognitive behavior therapy to women diagnosed with postnatal depression and concluded that Internet-based cognitive behavioral therapy outcomes did not differ significantly from the standard approaches to CBT and PPD. The use of Internet-based cognitive behavioral therapy resulted in treatment effects similar to those in the waiting list groups; in other words, CBT did not lead to any tangible treatment results (Spek et al., 2007). In a similar fashion, it was found empirical evidence that psychological treatments, including CBT, had only moderate effects on PPD outcomes. Some slight effects of CBT on treatment outcomes were readily observed, but the effect size found in the treatment group was much smaller than expected. By contrast, pharmacological treatments of PPD had higher effect sizes, meaning that the use of pharmacological treatments was a more relevant approach to PPD. One possible reason why pharmacological treatments are more effective than psychotherapy is that biological factors in PPD are much more pronounced than mood and psychological issues. It is also possible that smaller effect sizes are associated with the use of care-as-usual control groups, which reduce the significance of statistical findings. Yet, even if the results of CBT in PPD treatment are distorted short-term, there is no evidence that CBT is a relevant approach to postnatal depression in long-term perspectives. The course and development of postnatal depression in women make it difficult to trace the changes in women’s psychological health in the long run. More difficult is the analysis of CBT and its long-term effects on women. In light of these findings, CBT can be a useful element of PPD treatment, when used in a combination with other treatment options, for example, pharmacological treatment.
The information available on the subject is extremely scarce. With the absence of empirical information, researchers draw their conclusions from the earlier studies of CBT and compare their effects to those of other methods of treating postpartum depression. Gjerdingen (2003) searched medical literature using the key terms “postpartum depression”, “therapy”, “treatment” and “breastfeeding”. Gjerdingen (2003) discovered that the symptoms of postpartum depression were reduced or successfully eliminated with antidepressants, hormonal therapy (estrogen), individual and group psychotherapy and nurse home visits. The utility of the latter was later proved by Ammerman et al. (2005). Based on these findings, no treatment of postpartum depression is better than the other one; in other words, it would be fair to say that cognitive-behavior therapy is as efficacious in dealing with postnatal depression as estrogen and antidepressants (Gjerdingen, 2003).
In a similar fashion, Cuijpers et al (2010) examined the effect sizes of 117 trials that compared psychotherapy to other control conditions in postpartum women with major depressive symptoms. Cuijpers et al. (2010) calculated the mean effect size (0.67), which after the adjustment to publication bias was reduced to 0.42. These results suggest that the potential benefits of CBT in treating postnatal depression are significantly overestimated, due to publication bias (Cuijpers et al., 2010). It is out of question that meta-analyses display considerable flaws; in most cases, secondary data analyses make it impossible to reduce the authors’ prejudice and bias. However, even with the bias and prejudice considered, these results do not contradict to the current thought in CBT and its application in postpartum depression. These results warrant further empirical study of CBT and its relationship with other therapies, namely, antidepressant and hormonal treatments.
Surprisingly, not all researchers unanimously agree that CBT is not more effective than other instruments of PPD treatment. A few studies were conducted to confirm the relevance of CBT, when applied to PPD. However, whenever the effectiveness of CBT is confirmed, the researchers list the conditions and barriers to CBT implementation in PPD contexts. Ammerman et al. (2005) discovered that CBT was a relevant approach to treating depression in mothers, but the model of CBT Ammerman et al. (2005) used was based on the provision of in-home therapies by attending nurses. The use of CBT was justified by the fact that CBT was considered extremely appealing in dealing with maladaptive thoughts in postpartum mothers (Beck & Indman, 2005). It was also suggested that the use of CBT in postpartum women facilitated the creation and maintenance of social ties betwween them and their environment. In case of Ammerman et al. (1996), the delivery of CBT in-house was the main prerequisite of its therapeutic success. In-house CBT was delivered by a licensed social worker, and these findings can be used to develop future CBT strategies targeting postpartum women (Ammerman et al., 1996).
Unfortunately, most studies avoid the so-called “comparative angle”. More often than not, researchers who claim that CBT is an appealing method of treating postpartum depression in women do not compare their results to other treatment. A good exception to this rule is the study by Gjerdingen (2003), who performed a meta-analysis of the earlier findings in terms of treating postpartum depression. Gjerdingen (2003) confirmed that individual and group psychotherapy was effective, when dealing with postpartum depression. However, again, the researcher cited the conditions at which the use of CBT would be effective, including the need of partner participation in psychotherapy sessions and adherence to the prescribed treatment regimens (Gjerdingen, 2003). Apparently, the researcher implies that individual psychotherapy for postpartum women loses its relevance when not supported by antidepressant treatment. The latter is the most common element of depression treatment in postpartum women. Nevertheless, researchers believe that given that the majority of postpartum women need to breastfeed their newborn infants, psychotherapy without the use of antidepressant and hormonal treatment must become the first order of treatment (Anonymous, 2003; Miller, 2002). Here, the relevance of other psychological and non-psychological methods of treatment cannot be disregarded. Present day research provides a wealth of information on the principles, strategies and advantages of various postpartum depression treatments.
Freeman et al. (2006) tested the efficacy of omega-3 fatty acids in treating postpartum depression. The study did not yield any significant results, but the researchers suggested that omega-3 fatty acids could become a relevant alternative to other pharmacological approaches to postpartum depression (Freeman et al., 2006). The mechanisms of treating postpartum depression with omega-3 acids remain unclear, and future research is needed to validate the preliminary results. It was applied to an extremely nontraditional method of treating postnatal depression, namely, the use of the morning light therapy. The latter presupposes that women expose themselves to the direct influence of daylight, for at least 3-5 weeks. Despite the fact that after the trial the ratings of depression in postpartum women improved by half, it is doubtful that the proposed strategy will become an important element of postpartum depression in women. It was found that the use of exercises was effective in treating postpartum depression; but whether or not their effectiveness can be compared to that of cognitive behavior therapy. Simultaneously, CBT can be effectively supplemented by the use of transdermal estradiol, which was found to reduce the symptoms and complications of postpartum depression. Again, the comparative effectiveness of hormonal and psychotherapy needs to be considered in more detail. Here, the findings of Gjerdingen (2003) have to be taken into account, as the author suggests that psychotherapy, including CBT, is of low efficiency without medication and hormonal treatment.
Needless to say, the results of CBT use in postpartum depression are mixed. Most probably, the difficulty with evaluating the effectiveness of CBT is justified by the complexity of the postpartum depression phenomenon. Bennet and Indman (2003) and Beck and Indman (2005) specify that postnatal depression is a hidden illness, whose symptoms and signs vary considerably. Despite the centrality of CBT in many moods and psychological disorders, the exact effects of CBT on postpartum depression are yet to be established. Future research must focus on the analysis of CBT, its use and role in treating postpartum depression, its potential to prevent the development of postpartum depression complexities, and its comparative efficacy in combination with other pharmacological and non-pharmacological treatments.
Cognitive behavior therapy is one of the most popular approaches to the treatment of adult depression. Postpartum depression is no exception: thousands of postpartum women report “losing their self” and cannot cope with their emotions and feelings. Treating postpartum depression is not an easy task, since its signs and symptoms vary considerably across individuals. Unfortunately, the body of empirical evidence comparing the effectiveness of CBT and other psychological and pharmacological options in the treatment of postnatal depression is extremely scarce. More often than not, researchers who claim that CBT is an appealing method of treating postpartum depression in women do not compare their results to other treatment. Nevertheless, it is possible to assume that CBT is not more advantageous that other forms of depression treatment in postpartum women. Based on the current state of research, it would be fair to assume that CBT is an effective approach to postnatal depression treatment, but not more effective than other forms of individual and group psychotherapy and pharmacological strategies.