Interventions for postnatal depression assessing the mother–infant relationship and child developmental outcomes: a systematic review

Figures & data

Figure 1 Schematic diagram of literature search for studies on treatment for PND with outcomes assessing mother–infant interaction and/or child outcomes.

Abbreviation: PND, postnatal depression.

Table 1 Participant characteristics including marital status, age of baby and mother, and level of depression (at baseline) across all studies

Study	Marital status	Age of baby	Level of depression (baseline)	Mean age of mother
Field et al^Citation79	Single parents only	1–3 months (range)	Not reported	17.3 years (range =14–19)
Horowitz et al^Citation80	Not reported	4–18 weeks (range)	14.4 (mean BDI)	31 years (range =17–41)
Onozawa et al^Citation68	91% married/cohabiting	8.6–9.0 months (median range)	Baseline EPDS (median scores)	18–45 years (range)
Clark et al^Citation78	84.6% married/cohabiting	8.9 months (range 1–24 months)	>16 (BDI)	31.4 years (range =19–44)
*Murray et al^Citation61	88% married/cohabiting	8 weeks	>12 (EPDS)	27.7 years (range =17–42)
*Cooper et al^Citation82
Milgrom et al^Citation60	79.6% with partner	18.13 weeks (mean)	17.0 (mean BDI)	29.9 years
Jung et al^Citation66	100% married/cohabiting	3.5 months (range =3–4 months)	>10 (BDI/EPDS)	33 years (range =21–41)
Forman et al^Citation34	100% married/cohabiting	6.1 months (mean)	Not reported	30.6 years
Clark et al^Citation65	Not reported	6.4 months (range =1.00–24.26 months)	22.3 (mean BDI)	31.3 years
O’Higgins et al^Citation67	87% married/cohabiting	19 weeks	13.5 (mean EPDS)	Not reported
**Van Doesum et al^Citation64	91.3% cohabiting	5.5 months (mean)	23.9 (mean BDI)	30.1 years
Logsdon et al^Citation55	55.5% single 40.7% married 3.7% divorced/separated	10 months (mean)	18.1 (mean HRSD)	24.5 years
**Kersten-Alvarez et al^Citation81	85% married/cohabiting 16% single	6 months (mean)	23.8 (mean)	35.7 years (range =25–43)
Beeber et al^Citation83	37% cohabiting	24.9 months (mean)	16.2 (HRSD)	26 years
Horowitz et al^Citation84	83% cohabiting	7.4 weeks (mean)	12.34 (EPDS)	31 years
Tsivos et al^Citation86	89% married/cohabiting 11% separated/divorced	6.2 months (mean)	32.4 (BDI-II)	28.4 years
Goodman et al^Citation85	59.5% married/cohabiting 16.6% single	6 weeks	12.3 (EPDS)	30.7 years

Notes:

* Cooper et al⁸² report the maternal mood data, and Murray et al⁶¹ report dyad and child outcome.

** Kersten-Alvarez et al⁸¹ report the dyad and child developmental outcomes of Van Doesum et al.⁶⁴

Abbreviations: BDI, Beck Depression Inventory; EPDS, Edinburgh Postnatal Depression Scale; HRSD, Hamilton Rating Scale for Depression.

Table 2 Characteristics of studies assessing interventions for PND which include either dyad or child developmental outcomes

Study	Country	N	Study design	PND diagnosis	Maternal mood	Dyad assess	Child assess	Follow-up	Treatment/target	TX length	CTAM score	Format	Key findings
Beeber et al^Citation83	USA	226	RCT	Y	Y	Y	N	Y	IPT (D)	10 weekly sessions		Individual	Both IPT and TAU reported significant reductions in depressed scores (HRSD)
									TAU	+1 month of booster telephone calls			IPT associated with significant increases in positive attunement (closeness, positive affect, affection, and warm touch)
Clark et al^Citation78	USA	39	SGA	Y	Y	Y	Y	N	M-ITG (D)	1–1.5 hours	30	Individual	Both M-ITG and IPT groups reported significantly fewer depression symptoms (CES-D) than WLC. No significant differences in BDI scores between any of the groups. Significant differences were also reported on parenting stress
									IPT (M)	12 weeks			M-ITG and IPT both showed significant improvements in perception of child adaptability and more reinforcement from their children
									WLC				M-ITG and IPT groups both scored significantly higher on Maternal Positive Affective Involvement and Verbalization than WLC No differences were found across any groups on infant development
Clark et al^Citation65	USA	32	SGA	Y	Y	Y	N	N	M-ITG (D)	Part 1: 1.5 hours (therapy group for mums, developmental therapy for infants) Part 2: 30-minute dyadic group therapy	40	Group	M-ITG showed significant fewer depressive symptoms, and mothers experienced their infants as reinforcing their efforts and parenting more rewarding. M-ITG also exhibited significantly more positive affective involvement and communication after treatment
*Cooper et al^Citation82	UK	193	RCT	Y	Y	N	N	Y	TAU (M) Nondirective counseling (M) CBT (D) Psychodynamic therapy (D)	Weekly from 8 weeks to 18 weeks postpartum	72	Individual	All treatments had significant impact on mood at 4.5 months. Psychodynamic therapy rate of reduction of depression was significantly greater than TAU. Benefit of treatment was not maintained at 9 months. Treatment did not reduce subsequent episodes
Field et al^Citation79	USA	40	RCT	Y	N	N	Y	N	Baby massage (D)	15 minutes 2 days/week 6 weeks	46	Group	Babies in massage therapy group were observed to be more awake and alert and less drowsy and sleepy than comparison group. Crying and cortisol levels in the baby massage group also decreased compared with rocking group
Forman et al^Citation34	USA	176	RCT	Y	N	Y	Y	Y	IPT (M)	12 weekly sessions	80	Individual	Treatment was reported to only affect parenting stress. Women receiving IPT had significant improvements in parenting stress compared with WLC but not the nondepressed comparison sample
									WLC				At 18-month follow-up, women who received IPT continued to rate their children lower in attachment security, higher in behavioral problems, and more negative in their temperament compared with nondepressed comparison sample
Goodman et al^Citation85	USA	42	RCT	Y	Y	Y	N	Y	PDP (D) Usual care + telephone depression monitoring	1 hour, 8 sessions	79	Individual	There were significant decreases in symptoms of anxiety and depression and increases in maternal self-esteem across both groups. There were no significant differences between the groups across parenting stress or dyadic interaction
Horowitz et al^Citation80	USA	117	RCT	N	Y	Y	N	N	Interactive coaching (D) support group	15 minutes, 3 time points	77	Individual	Treatment group showed significantly higher level of responsiveness at posttreatment. Both groups demonstrated significant reduction in depression scores
**Horowitz et al^Citation84	USA	134	RCT	Y	Y	Y	N	Y	Interactive coaching (D) control group	1 hour, 5 time points	65	Individual	Both treatment and control groups showed significant increases in quality of mother–infant interaction and decreases in symptoms of depression
Jung et al^Citation66	Canada	11	SGA	N	N	Y	N	N	Keys to Caregiving (D)	5 weekly sessions	19	Group	Post-intervention infants displayed marked increase in interest and joy during interaction with mothers
**Kersten- Alvarez et al^Citation81	Netherlands	58	RCT	Y	N	Y	Y	Y	Mother–infant pairs videotaped and provided with feedback. Control group – minimum 3 phone calls (15 minutes maximum) providing practical parenting advice (D)	60–90 minutes, 8–10 sessions. Initially weekly, then reduced to every 2 weeks	69	Individual	No lasting effects of the intervention at 5-year follow-up. However, the authors reported an effect for child-externalizing behavior problems associated with family stressful life events. Children in the intervention group had fewer instances of externalizing behavior problems associated with family stressful life events
Logsdon et al^Citation55	USA	27	RCT	Y	Y	Y	N	N	Antidepressant medication (M)	8 weeks of treatment	42	Individual	Improved gratification of maternal role but not self-efficacy or mother–infant interaction
Milgrom et al^Citation60	Australia	117	RCT	N	Y	Y	N	N	CBT (D)	12 weekly sessions	29	Individual	There was a statistically significant decrease in overall parenting stress scores
*Murray et al^Citation61	UK	193	RCT	Y	N	Y	Y	Y	Nondirective counseling (M) CBT (D) Psychodynamic therapy (M) TAU	Weekly from 8 weeks to 18 weeks postpartum	72	Individual	All three treatments were associated with significant improvements in maternal reports of relationships with their infants. Counseling gave better infant emotional ratings at 18 months and sensitive early dyad interactions. No significant benefit on maternal management of infant behavior problems, security of dyad attachment, infant cognitive development, or any child outcomes at 5 years
Mulcahy et al^Citation62	Australia	50	RCT	N	Y	Y	N	Y	IPT-G	2 hours and 1×2 hour partner evening	54	Individual (2 sessions) and group (8 sessions)	IPT-G showed significant improvement in depression scores compared with TAU. Improvement maintained at follow-up IPT-G showed significant improvement in perception of infant caregiving, marital functioning, and social support. IPT-G showed nonsignificant improvements at follow-up
O’Higgins et al^Citation67	UK	62	RCT	N	Y	Y	N	Y	Baby massage (D) support group	1 hour, 6 sessions	70	Group	Post treatment, both control and baby massage groups obtained higher scores on the EPDS than nondepressed group. The massage group showed nonsignificant reductions on depression scales At 12-month follow-up, depressed group was still scoring significantly higher on the EPDS scale than nondepressed controls. Although, significantly more of the massage group achieved clinical reductions in EPDS scores and nondepressed levels of sensitivity in interactions with their babies compared with support group
Onazowa et al^Citation68	UK	34	RCT	N	Y	Y	N	N	Baby massage (D)	1 hour, 5 weekly sessions	45	Group	Significant improvement in mother–infant interaction only in massage group
Tsivos et al^Citation86	UK	27	RCT	Y	Y	Y	N	Y	Baby Triple P (D)	60–90 minutes, 8 weekly home sessions	51	Individual	Significant improvements were reported across both treatment and TAU groups. There were no between-group differences
Van Doesum et al^Citation64	Netherlands	71	RCT	Y	Y	Y	Y	Y	Mother–baby intervention (quality of dyad relationship) (D)	60–90 minutes, 8–10 home visits over 3–4 months	62	Individual	At (T3), treatment group had significantly higher AQS scores than controls. Treatment group was significantly more competent (ITSEA subscale) than control group, but no differences were seen on other subscales. Increase in maternal sensitivity in treatment group was seen

Notes:

* Report different outcomes from same study.

** Reports dyad and child developmental outcomes of Van Doesum et al.⁶⁴

Abbreviations: AQS, Attachment Q-Set; BDI, Beck Depression Inventory; CES-D, Centre for Epidemiological Studies Depression Scale; CBT, cognitive behavior therapy; CTAM, Clinical Tool for Assessment of Methodology; D, dyadic focus; EPDS, Edinburgh Postnatal Depression Scale; HRSD, Hamilton Rating Scale for Depression; IPT, interpersonal psychotherapy; IPT-G, interpersonal psychotherapy group; ITSEA, Infant Toddler Social Emotional Assessment; M, maternal depression focus; M-ITG, mother–infant therapy group; N, no; PDP, perinatal dyadic psychotherapy; PND, postnatal depression; RCT, randomized controlled trial; SGA, Single Group Assignment; TAU, treatment as usual; TX, treatment; WLC, waitlist control; Y, yes.

Table 3 Means, SDs, Cohen’s d, and effect sizes on measures of maternal depression and dyad measures across studies

Study	Maternal depression	MeanTX	Mean TAU	SD TX	SD TAU	Cohen’s d	Effect size r	Dyad measure	Mean TX	Mean TAU	SD TX	SD TAU	Cohen’s d	Effect size r
Field et al^Citation79	Not measured							Not measured
Horowitz et al^Citation80	BDI	10.99	10.10	0.96	0.84	0.99	0.44	DMC	9.73	8.77	1.65	1.72	0.57	0.27
Onazowa et al^Citation68	Insufficient information							Insufficient information
Clark et al^Citation78	BDI M-ITG	15.9	20.6	8.5	9.2	0.53	0.26	PCERA M-ITG (F1)	3.7	3.1	0.6	0.6	1.0	0.45
	BDI IPT	16.4	20.6	10.2	9.2	0.43	0.21	PCERA M-ITG (F2)	4.6	5.0	0.7	0.1	−0.8	−0.37
								PCERA IPT (F1)	4.2	3.1	0.6	0.6	1.83	0.66
*Murray et al^Citation61	See Notes							Insufficient information
*Cooper et al^Citation82	EPDS counseling	9.9	11.3	5.9	4.8	0.26	0.13
	EPDS psychodynamic	8.9	11.3	4.2	4.8	0.53	0.26
	EPDS CBT	9.2	11.3	4.8	4.8	0.44	0.21
Milgrom et al^Citation60	Insufficient information							Insufficient information
Jung et al^Citation66	Not reported							N/A single-group design
Forman et al^Citation34	Not reported							Negative emotion	0.01	−0.04	0.59	0.67	0.08	0.03
								Positive emotion	−0.11	0.10	0.59	0.77	−0.31	−0.15
								AQS	0.44	0.48	0.17	0.14	−0.26	−0.13
Clark et al^Citation65	BDI	12.42	20.50	7.08	7.27	1.13	0.50	PCERA (F1)	3.67	3.10	0.52	0.54	1.08	0.47
								PCERA (F2)	4.65	5.02	0.46	0.48	−0.79	−0.37
								PCERA (F6)	4.41	4.83	0.78	0.80	−0.53	−0.26
								PCERA (F7)	3.38	3.03	0.59	0.60	0.59	0.28
O’Higgins et al^Citation67	EPDS	13.19	13.81	3.84	4.98	0.14	0.07	Global ratings	3.27	3.26	0.7	0.91	0.01	0.01
**Van Doesum et al^Citation64	BDI	18.9	17.2	11.0	9.3	0.17	0.08	EAS (Mat sensitivity)	4.28	3.79	1.78	1.86	0.27	0.13
								EAS (Mat structuring)	3.12	2.71	1.09	1.06	0.38	0.19
								EAS (child responsiveness)	4.26	3.18	1.48	1.74	0.67	0.32
								EAS (child involvement)	3.74	2.79	1.83	1.91	0.51	0.25
								AQS	0.41	0.26	0.30	0.35	0.46	0.22
Logsdon et al^Citation55	Insufficient information							Insufficient information
**Kersten-Alvarez et al^Citation81	Not reported, see Notes							Quality of interactive bhvr	0.24	−0.24	0.26	0.26	1.85	0.68
								Attachment to mother	12.98	13.29	0.72	0.72	−0.43	−0.21
Mulcahy et al^Citation62	BDI	16.95	23.11	8.14	10.64	0.65	0.31	MAI	97.18	92.28	5.35	10.14	0.60	0.29
Beeber et al^Citation83	HRSD	Means and standard deviations not reported						HOME subscales	Means and standard deviations not reported
Horowitz et al^Citation84	EPDS	7.19	6.40	3.8	3.8	0.21	0.10	NCATS	53.16	53.71	8.3	7.0	−0.07	−0.04
								Responsiveness subscale	7.44	7.03	3.1	3.1	0.13	0.06
Tsivos et al^Citation86	BDI	Data not suitable for analysis						CARE Index scales	Data not suitable for analysis
Goodman et al^Citation85	EPDS	6.19	6.35	3.64	5.45	−0.03	−0.01	CIB (maternal sensitivity)	3.69	3.95	0.59	0.55	−0.46	−0.22
								CIB (infant involvement)	3.20	3.34	0.69	0.78	−0.20	−0.09
								CIB (dyadic reciprocity)	3.46	3.60	0.68	0.83	−0.18	−0.09

Notes:

* Cooper et al⁸² report the maternal mood data, and Murray et al⁶¹ report dyad and child outcome.

** Kersten-Alvarez et al⁸¹ report the dyad and child developmental outcomes of Van Doesum et al.⁶⁴

Abbreviations: AQS, Attachment Question-Set; BDI, Beck Depression Inventory; bhvr, behavior; CBT, cognitive behavior therapy; CIB, Coding Interactive Behavior; DMC, Dyadic Mutuality Code; EAS, Emotional Availability Scale; EPDS, Edinburgh Postnatal Depression Scale; F, factor; HRSD, Hamilton Rating Scale for Depression; IPT, interpersonal psychotherapy; MAI, Maternal Attachment Inventory; Mat, maternal; M-ITG, mother-infant therapy group; N/A, not applicable; NCATS, Nursing Child Assessment Teaching Scale; PCERA, Parent-Child Early Relational Assessment; SD, standard deviation; TAU, treatment as usual; TX, treatment.

Table 4 Means, SDs, Cohen’s d, and effect sizes on measures of child development across studies

Study	Measure	Mean TX	Mean TAU	SD TX	SD TAU	Cohen’s d	Effect size r
Field et al^Citation79	Emotionality	12.2	13.0	4.0	5.0	−0.12	−0.08
	Sociability	19.9	18.4	4.0	4.0	0.36	0.18
	Soothability	18.5	15.6	4.0	5.0	0.64	0.31
	Serotonin	1,427.9	1,132.4	779.0	517.0	0.45	0.22
	Cortisol	656.4	1,016.8	340.0	523.0	−0.82	−0.34
Murray et al^Citation61	Insufficient information
Forman et al^Citation34 (compared treated recovered with treated non-recovered)	CBC internalizing	46.14	49.06	7.23	7.49	−0.40	−0.20
	CBC externalizing	47.34	46.50	9.05	10.10	0.09	0.04
Van Doesum et al^Citation64	ITSEA (competence)	1.40	1.22	0.28	0.30	0.64	0.30

Abbreviations: CBC, Child Behaviour Checklist; ITSEA, Infant Toddler Social Emotional Assessment; SD, standard deviation; TAU, treatment as usual; TX, treatment.

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