1. PresenterCompanyProductResearchOther: Wendy Cartern/a Disclosure

2. Wendy Carter, Ph.D., Sophie Grigoriadis, M.D., Ph.D., Lori Ross, Ph. D. & Paula Ravitz, M.D.

3. Objectives 1) Review existing literature on Postpartum Depression (PPD), relationship distress and psychotherapy interventions for PPD with couples 2) Describe a newly modified couples IPT approach (Conjoint IPT- PPD) to treating PPD in the context of relationship distress 3) Highlight and illustrate the applicability of this approach in a case study

4. Postpartum Depression  Approximately 13% of women meet criteria for a MDE with postpartum onset (APA, 2000; Dietz, 2007; O'Hara & Swain, 1996)  Women who become depressed within the first year following childbirth are more likely to:  become depressed following future pregnancies (Cooper & Murray, 1995)  have difficulty developing secure attachment with their children (Murray et al., 1999)

5. PPD and the Family System  PPD is linked to immediate and enduring delays in the social, emotional and cognitive growth of children  PPD negatively impacts the emotional well-being of partners  E.g. greater rates of anxiety and depression; increased stress in relationships with both partners and children

6. Relationship Distress and PPD  Relationship distress:  Identified as a moderate predictor of PPD (Beck, 2001)  Related to more severe depressive symptoms of greater duration (Fisher et al., 2002; Patel et al., 2002)  Related to increased risk for developing chronic mental health problems (Campbell et al., 1992; Viinamaki et al., 1997)  Depressive symptoms predicted postpartum relationship adjustment (Whisman, Davila, Goodman, 2011)  Postpartum relationship difficulties informed by attachment styles ( e.g. Feeney et al., 2003)

7. Sources of relationship distress  Increased conflicts and disputes in the postpartum period (Dennis & Ross, 2006; Johnstone et al., 2001)  Less instrumental and emotional support from partners (Dennis & Ross, 2006)  Women’s perceptions of unequal division of childcare and household responsibilities (e.g. Des-Rivieres- Pigeon et al., 2002; Terr et al., 1991)  Postpartum relationship difficulties informed by attachment styles ( e.g. Feeney et al., 2003)

8. Couple Interventions for PPD  Misri et al. 2000  Examined the impact of a partner-supported intervention on mood and relationship perception among 29 women diagnosed with PPD  Randomly assigned to either:  Control group (attended 7 psycho-educational sessions solo) OR  Intervention group (attended 3 sessions solo and 4 sessions with partner)  Women accompanied by their partners reported:  Reduced psychological distress  Fewer depressive symptoms  More positive perceptions of their relationships with partners

9. Couples Therapy for Depression  Barbat & D’Avanco (2008) –  meta-analysis comparing couple therapy to individual psychotherapy for depression  567 participants from 8 clinical trials  Findings:  Fewer Depressive Symptoms: Couples = Individual  Reduced Relationship distress: Couple > Individual  Only the couples form of IPT (IPT-CM) linked the context of depression to relationship distress in couples

10. Couples form of IPT: IPT-CM  Foley et al. (1989)--individual IPT and IPT-CM among 18 participants with comorbid depression and Role Disputes with their spouse  Fewer Depressive Symptoms:  IPT-CM = Individual IPT  Improved Relationship Adjustment:  IPT-CM = Individual IPT  Improved Relationship Functioning:  IPT-CM > Individual IPT

11. Rationale for Conjoint IPT-PPD  Relationship distress both a predictor and an outcome of PPD  IPT-CM demonstrated successful for treatment of depression and improved relationship functioning among couples whose primary issue is relationship disputes  IPT-PPD successfully adapted to for use with perinatal and postpartum women in the treatment of depression (O’Hara et al. 2000; Spinelli and Endicott 2003; Stuart and O’Hara 1995; Zlotnick et al. 2006)

12. Conjoint IPT-PPD Theory (Weissman et al., 2000; Stuart & Robertson, 2003) Postpartum context (Stuart & O’Hara, 1995) Integration of Attachment Theory (Ravitz, Maunder & McBride, 2007) IPT Couples Format (IPT-CM) (Foley, 1989)

13. Conjoint IPT-PPD  90 minute sessions for 12 weeks with trained IPT therapist  Adaptations specific to the postpartum period  Psycho-education about depression in the postpartum period  Review expectations of parenthood and changes in dynamics since the birth of the child  While the identified problem area is Role Disputes, postpartum is a major time of transition and may integrate work on Role Transitions

14. Indications for Treatment PPD, less than one year postpartum and experiencing relationship distress Couples in an established relationship Both interested and willing to participate Contraindications for Treatment Actively suicidal, currently psychotic, or have bipolar disorder or chronic depression Interpersonal violence Have already made a decision to terminate the relationship

15. Initial Phase Sessions 1-4 Middle Phase Sessions 5-10 Final Phase Sessions 11-12

16. Case Study: Ellen & Daniel  Both in their early thirties  Together for 3 years  Two children (2 years and 4 months)  Ellen– diagnosed with a MDE with postpartum onset  symptoms perpetuated by the distress in their relationship  Pre-treatment Edinburgh Postnatal Depression Scale=16

17. Pre-test Scores Dyadic Adjustment Scale (Spanier, 1976) E LLEN D ANIEL Overall Dyadic Adjustment 93*109* Dyadic Consensus5550* Dyadic Satisfaction 25*37* Affectional Expression 4*8* Dyadic Cohesion11*15

18. P HASE O BJECTIVES Initial Phase Sessions 1-4  Provide psycho-education about PPD  Link PPD to relationship distress  Clarify the therapeutic contract  Assess the mental health functioning of both the mother and her partner  Conduct individual interpersonal inventories  Explore relationship models  Explore the history and current conflicts in the relationship  Assign homework to clarify each party’s “dispute list” Middle Phase Sessions 5-10  Identify key disputes  Develop an action plan  Renegotiate key disputes Final Phase Sessions 11-12  Acknowledge and explore issues related to termination  Recognize growth and improvements  Navigate ongoing issues and future obstacles  Impart a sense of hope  Evaluate the need for future treatment

19. P HASE O BJECTIVES Initial Phase Sessions 1-4  Provide psycho-education about PPD  Link PPD to relationship distress  Clarify the therapeutic contract  Assess the mental health functioning of both the mother and her partner  Conduct individual interpersonal inventories  Explore relationship models  Explore the history and current conflicts in the relationship  Assign homework to clarify each party’s “dispute list” Middle Phase Sessions 5-10  Identify key disputes  Develop an action plan  Renegotiate key disputes Final Phase Sessions 11-12  Acknowledge and explore issues related to termination  Recognize growth and improvements  Navigate ongoing issues and future obstacles  Impart a sense of hope  Evaluate the need for future treatment

20. IPT T ECHNIQUES Use of Affect Role playing Decision Analysis Psycho- education Change between sessions Communication Analysis

21. P HASE O BJECTIVES Initial Phase Sessions 1-4  Provide psycho-education about PPD  Link PPD to relationship distress  Clarify the therapeutic contract  Assess the mental health functioning of both the mother and her partner  Conduct individual interpersonal inventories  Explore relationship models  Explore the history and current conflicts in the relationship  Assign homework to clarify each party’s “dispute list” Middle Phase Sessions 5-10  Identify key disputes  Develop an action plan  Renegotiate key disputes Final Phase Sessions 11-12  Acknowledge and explore issues related to termination  Recognize growth and improvements  Navigate ongoing issues and future obstacles  Impart a sense of hope  Evaluate the need for future treatment

22. Dyadic Adjustment Scale EllenDaniel Pre-TestPost-TestPre-TestPost-Test Overall Dyadic Adjustment 93*126109*133 Dyadic Consensus 555850*52 Dyadic Satisfaction 25*3837*45 Affectional Expression 4*98*12 Dyadic Cohesion11*201523

23. Conclusion and Next Steps  To date, no other couples therapy approaches where at least one member of the dyad was clinically depressed have included modifications that overtly address depression during the postpartum or at any other specific life stage  Conjoint IPT-PPD may be a useful psychotherapeutic intervention with couples struggling in the postpartum period to negotiate conflicts  A randomized controlled clinical trial is now required to study the effectiveness of conjoint IPT-PPD in comparison to usual practice