Impact of Maternal Childhood Abuse and Neglect on the Outcomes of a Perinatal Depression Trial

Background and Purpose. Traumatic experiences of abuse and neglect during childhood have been linked with a greater risk in adulthood of insecure attachment (Mickelson et al.,1997), depression (Widom et al.,2007), PTSD (Breslau,1999), and quality of life (Rikhye et al.,2008). Depression during pregnancy has been demonstrated to be one of the strongest predictors of postpartum depression (O'Hara & Swain,1996) and may emerge, in part, or be exacerbated by maternal trauma exposure in childhood. One of the aims of this randomized pilot study was to investigate whether the effects of using a brief, evidence-based psychotherapy to treat antenatal depression --brief Interpersonal Psychotherapy (IPT-B; 8 acute sessions, plus monthly maintenance IPT sessions up to 6 months postpartum) would be moderated by childhood trauma exposure in depressed, pregnant women on low incomes who attended an Ob/Gyn clinic in a large urban hospital. IPT-B was enhanced to be culturally relevant to women disadvantaged by race and/or poverty in order to engage and retain them in treatment.

Methods. Using a randomized, controlled trial design, 53 pregnant African American and White women on low-incomes, entered the study and were randomly assigned to 8 weekly sessions of IPT-B(n=25) delivered on site in the Ob/Gyn clinic or to a referral to treatment-as-usual (TAU) at a behavioral health center on site in the clinic(n=28). Primary inclusion criteria included 18 years or older, a score of >13 on the Edinburgh Postnatal Depression Scale, 12-28 weeks gestation, fluent in English, and access to a household phone. Exclusion criteria included acute suicidal behavior, psychosis, organic problem, bipolar disorder, substance abuse/dependence within the past six months, or current intimate partner violence. Participants were assessed before and after treatment on depressive symptoms, depression diagnoses, anxiety symptoms, and social functioning. They were also assessed before treatment on childhood traumatic experiences and anxiety disorder diagnoses. Data analyses included descriptive statistics and repeated measures MANOVA, using the intent-to-treat approach.

Results. 45% and 51% of the sample, respectively, reported high levels of childhood trauma and at least one current anxiety disorder. At the post-treatment and 6-month postpartum assessments, intent-to-treat analyses showed that women in the IPT-B group displayed significant reductions in depressive and anxiety symptoms, in depression diagnoses, and improved social functioning, compared to those in the TAU group, regardless of trauma or anxiety disorder status. However, those with more trauma exposure showed more impairment on post-treatment and 6-month postpartum outcomes compared to those with less trauma exposure.

Conclusions and Implications. Findings suggest that an evidence-based psychotherapy, modified to be culturally relevant, ameliorates antenatal depression and improves social functioning, even in depressed women exposed to childhood trauma or suffering from a comorbid anxiety disorder. Results also show that women with more trauma exposure, though improved, were still at more risk for depressive relapse than were women with less exposure. In planning to disseminate this treatment to depressed, pregnant women in a large public health setting, we think it judicious to provide maintenance sessions up to 12 months postpartum to sustain recovery, especially in women exposed to childhood trauma.