Maternal mental health conditions are some of the most prevalent complications for birth mothers during the perinatal period, which is defined as the time between when a woman becomes pregnant through up to one year after delivery (Howard & Khalifeh, 2020). Perinatal mental health conditions – which is an inclusive term to acknowledge parents’ mental health during this time – include mood-, anxiety-, psychosis-, and trauma-related disorders (Yeaton-Massey & Herrero, 2019). Postpartum depression (PPD) is the most prevalent of these conditions, affecting approximately one in eight new mothers (Bauman et al., 2020). Social factors contributing to mothers’ PPD include reduced social support, marital dissatisfaction, interpersonal violence, unemployment, and financial stress (Ghaedrahmati et al., 2017).

The perinatal period represents a substantial transition for individuals and families, and factors of influence span across individual, dyadic, relational, and intergenerational levels (Bost et al., 2002; Dun, 2010; Katz-Wise et al., 2010; Kluwer, 2010; Rauch-Anderegg et al., 2020). The couple’s relationship, for example, has been recognized to function as both a contributory and protective moderating factor for parents’ postpartum depressive symptoms (Çankaya & Dikmen, 2022; Kümpfel et al., 2025). Scholars suggest, too, that relationship dynamics that exist before the infant’s arrival become fortified, and subsequent changes in marital satisfaction can persist for years (Bogdan et al., 2022; Kluwer, 2010).

Few evidence-based interventions to prepare couples and families for the transition to parenthood exist. Early couple interventions (e.g., Becoming a Family Project; Cowan & Cowan, 1995) showed promising results wherein participating couples experienced fewer negative changes in role satisfaction compared to a control group. Shapiro and Gottman (2005) tested a prenatal couples’ workshop and found that the program had positive postpartum effects on depression, hostility, and marital quality, further highlighting the influence of the couple relationship on this period. More recently, practitioners and researchers have highlighted the importance of involving the entire family system in the treatment of PPD, beyond the couple relationship (Battle et al., 2023).

Although family-based interventions are still emerging, previous systematic reviews have attempted to address the question of their efficacy on maternal mental health more broadly and have demonstrated positive results. Cluxton-Keller and Bruce (2018), for example, found that family therapy reduced maternal depressive symptoms, but the effect size was moderated by intervention intensity (i.e., prevention or treatment) and level of family involvement. When integrated into pediatric care, parent interventions can improve parental mental health and parent-child interactions (Cluxton-Keller et al., 2015). A previous synthesis review by Noonan et al. (2021) examined studies of psychosocial interventions for PPD and anxiety published between 2010 and 2020 that included a partner or family member. They found nine interventions and concluded that there was a need to expand the study of intervention outcomes beyond the target parent, and to align respective studies’ outcomes to ease cross-study comparisons.

To expand on previous findings and examine the theoretical approaches, methodologies, and levels of family inclusion within extant literature, we centered the focus of our review on the following questions: (a) What are the strengths,limitations,and implications of current theoretical and methodological approaches used to study family interventions addressing maternal PPD?, and (b) How does the level of family inclusion impact postpartum depression outcomes? To address these questions, we synthesized the use of theories, research designs, and methods outlined in recent scholarship. To examine the levels of family involvement in literature, we applied a tiered model approach (Pratt & Sonney, 2020) that enables the translation of family science research into family-based interventions. We chose this model because it was designed to assess family involvement in care practices by operationalizing the inclusion of family members, ranging from low to high levels of inclusion.

Methods

Article Search Process

Initial database searches were conducted in October 2023, focusing on articles published between 2013 and 2023, using APA PsychINFO, PubMed, and Google Scholar (see Fig. 1). An additional search was conducted in December 2025 to ensure that all articles were captured. This decade in review allowed for an in-depth analysis of the current methodological approaches, empirical findings, and emerging trends of family interventions. Search terms across databases included variations of: [family therapy, couples therapy, psychotherapy, OR family intervention], AND [perinatal mood disorder, postpartum depression, peripartum depression, perinatal depression, OR mood disorder], AND [family, parents, caregivers, spouse, OR partner] AND [pregnancy, postpartum, perinatal, antenatal, OR peripartum] AND [primary care OR integrated care]. Twelve articles met inclusion criteria.

The first author conducted initial title screening, abstract screening, and data extraction. Theoretical frameworks, research questions, measures of individual and dyadic functioning, research methods, interventionist qualifications, and studies’ geographic location were systematically extracted and reviewed by all team members (see Table 1). Extracted information was used to identify themes, strengths, and limitations across the literature. Pratt and Sonney’s (2020) model was then applied to determine the level of family inclusion, which was reviewed and approved by all authors.

Inclusion/Exclusion Criteria

Articles were included if: (a) perinatal mothers and an identified support person also participated in services with them, which was labeled “family involvement” (e.g., spouse, co-parent, parent, caregiver, relative); (b) focus on mental health services during pregnancy, perinatal, and/or postpartum periods; (c) postpartum depression outcomes were addressed; (d) healthcare providers, primary care clinics, hospitals, antenatal clinics, or integrated care clinics were involved in conducting the intervention; (e) written in English; and (f) peer-reviewed. Articles were excluded if: (a) samples included only mothers individually; (b) examined perinatal health (e.g., medical procedures or physical conditions) without mental health service engagement; (c) focused solely on substance use treatment or online interventions without a facilitator; (d) sample focus outside of the perinatal/pregnancy/postpartum period; (e) not written in English; and (f) not peer-reviewed (e.g., book chapters, dissertations, grey literature).

Results

Theoretical Approaches

To fully grasp how the current literature understands the role of family when treating PPD, it is important to examine how theory lays the foundation for studies in this analysis. Of the 12 articles examined, five identified at least one theoretical framework; six of them identified at least one therapeutic framework; and one was unspecified (see Table 1). In this analysis, all frameworks were divided into three categories, including: sociocultural, integrated, and implied.

Sociocultural

Four studies identified multidimensional internal, external, and contextual factors that impact a mother’s mental health postpartum. For example, Geller et al. (2018) utilized social energy exchange theory for postpartum depression (SEED), which asserts that women with PPD aim to achieve balance between themselves and their sociocultural networks (Posmontier & Waite, 2011). Giallo et al. (2022) implemented an intervention derived from the family stress model and emotional security theory, highlighting how external factors (e.g., finances, parental conflict) impact family cohesion. These systemic theories challenge current frameworks of PPD (e.g., those that treat women in isolation) by highlighting the dynamic support and care for mothers and their social contexts.

Integrated

Gambrel et al. used interpersonal neurobiology (IPNB) in both their mixed-methods study (2015a) and qualitative study (2015b). IPNB is an interdisciplinary framework that conceptualizes well-being as a product of holistic integration of different parts of the brain to complete tasks and link with each other to create a state of flexibility, adaptability, coherence, energy, and stability (Siegel & Drulis, 2023).

Implied

Implied theoretical approaches include unspecified theories and therapeutic frameworks. For example, Daley-McCoy et al. (2015) argue that couples experience significant changes during the transition to parenthood stage of their family life cycle, aligning with life course theory, but they did not name how a specific theory applied to their work. Implied approaches also include studies that did not name a theory but identified a therapeutic framework guiding the work. Theories are often the foundation for therapeutic frameworks, albeit implicitly, whereas therapy itself is a practical application of a framework using a set of skills and interventions. Six studies identified three therapeutic frameworks (see Table 1), including: (a) cognitive behavioral therapy (CBT) to enhance cognitive restructuring and improve negative communication patterns, (b) dialectic behavioral therapy (DBT) to improve participating family members’ emotion regulation and interpersonal effectiveness, and (c) creative music therapy (CMT) to activate neonatal neural processes and promote bonding between infants and parents.

Methodology

Research Design

Three studies included in this review were mixed methods investigations; eight were quantitative; and one was qualitative (see Table 1). Of the 11 quantitative and mixed-methods studies, five were part of a randomized control trial (RCT), two were program evaluations, and one was an effectiveness/implementation hybrid. All articles identified trained (e.g., specific training to ensure intervention fidelity) and/or credentialed (e.g., licensed clinician) professional(s) leading the study interventions (see Table 1). Interventions were administered in a variety of settings, e.g., hospitals or hospital clinics (n = 4), videoconferences (n = 3), day treatment programs (n = 1), participants’ homes (n = 1), and unspecified (n = 3). Seven studies included a spouse/partner and five included family members chosen by the mother (see Table 2).

Samples

All 12 articles used unspecified sampling methods but identified a set of inclusion criteria, suggesting purposive sampling methods. Participants were recruited from regional hospitals (n = 5), primary care clinics (n = 2), family health or home visitor services (n = 3), and other referral sources (e.g., birthing centers, prenatal classes, local businesses; n = 2). All studies conducted in the U.S. (n = 7) identified participants’ race in the results. Only one U.S. study reported a non-white majority sample. Studies conducted in China (n = 1), Iran (n = 1), Australia (n = 1), Switzerland (n = 1), and the United Kingdom (n = 1) did not report race as a primary identifier, but two reported participants’ nationalities or birth country. Ten studies reported the demographics of both the mother and her support person, which was an important contextual element given that this body of literature examined the role of a said support person. Only two studies reported same-sex and/or queer couples within their sample. In six studies, most mothers had a bachelor’s degree or higher, and one study reported that over 70% of their sample attended some college (Geller et al., 2018). Three studies reported that most of their sample had less than a college degree. Five studies reported that a majority of their participants were employed.

Measures

Measures (n = 41; see Table 2) assessed participants’ interpersonal functioning and PPD severity in various ways, ranging from maternal mental health and well-being (n = 13) to dyadic/family functioning and communication (n = 20), aspects of parenthood (n = 4), and intervention satisfaction (n = 4). The quantitative and mixed-methods studies demonstrated clear rationales for the self-report measures they utilized.

Postpartum Mental Health and Maternal Functioning. Maternal functioning was assessed with 13 different measures. The Edinburgh Postpartum Depression Scale (EPDS) was the most employed instrument across studies (n = 6). Investigators utilized EPDS to (a) screen for the presence of depressive symptoms and (b) assess maternal functioning, distress, and/or severity of depressive symptoms as a primary outcome. Two used the EPDS to assess depressive symptoms for both partners (Daley-McCoy et al., 2015; Kehl et al., 2020).

The second most common instrument used to measure maternal well-being was the Depression, Anxiety, and Stress Scale (DASS-21; n = 3). In two studies, the DASS-21 was administered to both mothers and fathers. Three studies used the Beck Depression Inventory – Second Edition (BDI-II); one study used the original BDI; and three used versions or subscales of the State Trait Anxiety Inventory (STAI). Other measures were only used once across the literature to assess maternal health and well-being (see Table 2).

Dyadic or Family Functioning. All reviewed articles used different instruments (n = 20) to assess relationship quality and/or communication. However, many of the instruments assessed similar constructs (e.g., communication, relationship satisfaction, conflict resolution). Some measures were applicable to family relationships, not just partnerships (e.g., Perceived Hostility Scale); some assessed co-parenting (e.g., Coparenting Relationship Scale); and some assessed couples’ relationships (e.g., Dyadic Adjustment Scale). Although it appears to be an individual measure, Gambrel and Piercy (2015a) used the Five Facet Mindfulness Questionnaire to measure participants’ mindfulness, which they argue positively affects intrapersonal attunement, dyadic interactions, and overall interpersonal functioning.

Parenting and Parenthood. Three studies assessed different aspects of parenting using four instruments. For example, Geller et al. (2018) used the Parental Stress Scale (PSS) to explore parents’ perceptions about positive and negative aspects of their parenting role. Others examined physical and social stressors, assessed parental warmth, and parental hostility (see Table 2).

Intervention Satisfaction. Four studies used self-report surveys to measure participants’ satisfaction with intervention(s) received. Two studies used two different versions of the Client Satisfaction Questionnaire (CSQ) assessed intervention acceptability and program satisfaction. Two other articles used a separate survey designed by the researchers to assess aspects (i.e., content, logistics) of their interventions (see Table 2).

Analyses

Quantitative Analyses

The mixed methods and quantitative studies included in this review used several different analyses to compare interventions’ effects. Descriptive statistics, specifically mean and standard deviations, were computed at baseline and post-intervention across 11 studies. Five studies used non-parametric analyses (e.g., Wilconxon signed-rank test, Mann-Whitney U-test) to account for small sample sizes, nonindependence, and violations of the normality assumption. Other analyses included paired t-tests to assess participant changes from across multiple time points, independent t-tests and repeated measures tests, Hedge’s g, and generalized linear mixed models to determine main intervention effects for both control and intervention groups.

Mixed Methods and Qualitative Analyses

To examine qualitative interviews, the three mixed methods studies used thematic analysis coded by multiple researchers. Gambrel and Piercy (2015a) used qualitative data to “expand and explain quantitative results” (p. 8). Giallo et al. (2022) and Kehl et al. (2020) utilized post-intervention qualitative interviews to identify intervention satisfaction, improvements, and outcomes.

The sole qualitative study, by Gambrel and Piercy (2015b), provided a detailed account of a grounded theory process to highlight the experiences of participants in a mindfulness intervention. The researchers used an iterative process with three stages of coding: open, axial, and whole text analysis (Strauss & Corbin, 1998). They reviewed codes to reach consensus and took additional steps to assure rigor and trustworthiness (e.g., recruited additional coders, implemented clear documentation methods, peer/team consultation, member checking).

Findings

This body of literature demonstrates that a family-involved approach to addressing postpartum depression is beneficial for both mothers and partners. Maternal rates of depressive symptoms are statistically significantly reduced when her partner engages in family-focused interventions (Battle et al., 2023; Cluxton-Keller & Bruce, 2018; Cluxton-Keller & Olson, 2023; Cluxton-Keller et al., 2023; Dafei et al., 2021; Geller et al., 2018; Ngai et al., 2020). Evidence showed that maternal rates of anxiety, negative paternal affect, and psychological distress also decreased, while overall rates of interpersonal functioning (e.g., communication, conflict resolution, co-parenting support) improved (Cluxton-Keller and Olson 2023; Daley-McCoy et al. 2015; Gambrel and Piercy 2015a). Daley-McCoy et al. (2015) found that postpartum couples experienced decreases in relationship satisfaction, but those who participated in interventions exhibited less decline in relationship satisfaction than control groups. Men who participated in mindfulness interventions reported improved relationship satisfaction post-intervention (Gambrel and Piercy 2015a). Inclusion of a family member, not just the coparent, demonstrated reduced conflict with the participating mother over time (Cluxton-Keller & Olson, 2023).

Levels of Family Inclusion

We applied Pratt and Sonney’s (2020) model to this literature to examine the extent that families were included to address PPD. We found that there were high (n = 7), moderate (n = 2), and low (n = 3) levels of family inclusion (see Table 2). Even low levels of family inclusion demonstrated positive effects on maternal PPD. Dafei et al. (2021) argued that the simple presence of a spouse in treatment improves maternal outcomes due to their partner’s level of increased knowledge and involvement in the pregnancy. Studies with high levels of family inclusion demonstrated strong results with statistically significant reductions in depressive symptoms (e.g., Cluxton-Keller & Olson, 2023; Cluxton-Keller et al., 2018, 2023) and medium to large effect sizes of their outcome measures (Battle et al. 2023; Gambrel and Piercy 2015a; Giallo et al. 2022), supporting the idea that perinatal mental health impacts whole families. These studies reportedly improved interpersonal functioning for participants by improving communication between partners, increasing quality time spent with one another, and reducing conflict. The varying levels of family inclusion highlight an ongoing shift in health care towards more family-centered approaches (Lamson et al., 2022).

Discussion

There are many assumptions about postpartum depression (PPD) in extant literature, alongside best practices about how to address it. Geller et al. (2018) highlighted internal and external factors, as well as micro- and macro-processes, that contribute to postpartum experiences. This systemic perspective promotes maternal well-being while recognizing the important roles and impact(s) of social networks. However, at the same time that partners and other family members often want to be involved in perinatal care, they may experience ambivalence and barriers in doing so. More structural support is needed to ensure that women, particularly those at high risk, are supported during this critical time (Hoang et al., 2022; Taylor et al., 2018).

In the review presented here, we examined guiding frameworks, methodologies, and levels of family involvement in interventions centered on these important foci. We considered the validity, reliability, timing, operationalization, and cultural sensitivity of instruments employed by researchers, and examined whether the constructs that they intended to assess were appropriate for their targeted populations. A strength across the studies is that many used the Edinburgh Postpartum Depression Scale (EPDS) as a baseline and post-intervention measure to determine changes in depressive symptom severity. Presently, the EPDS is the most accepted and valid measure to assess symptoms and severity for perinatal groups (Cox et al., 1987; Kendall-Tackett, 2024). Since its initial development, it has been validated for both pregnancy and postpartum timeframes in eight different languages, as well as for fathers (Kozinsky & Dudas, 2015; Levis et al., 2020; Matthey et al., 2001).

Caution is still indicated, though. In a review of validation studies, Kozinszky and Dudas (2015) found that the EPDS may generate a considerable number of false positives, and that it also may miss positive cases of PPD. These mixed findings may be a result of providers using the EPDS to diagnose PPD, rather than for its intended screening use (Kendall-Tackett, 2024). Researchers have examined, too, the validation of the EPDS with diverse populations and suggested alternative cut-offs and item adaptations to account for cultural nuances of depressive symptoms (Chan et al., 2021; Salehi et al., 2023; Levis et al., 2020). For example, Moyer et al. (2023) created a trauma-informed EPDS instrument to incorporate more colloquial language for U.S. populations. While no standardized tool is perfect, the EPDS is a convenient screening tool to assess for depressive symptoms in both mothers and partners during the perinatal period – but it is important for researchers and providers to be aware of its limitations.

In contrast to the widely used Edinburgh Postpartum Depression Scale (EPDS), there was minimal overlap when assessing interpersonal and/or dyadic functioning across this set of articles. No two studies used the same instrument to assess the relationship between mothers and their support person. This lack of consistency across dyadic measures makes it difficult to compare studies’ results. Some authors did not fully explain their rationale for choosing the instruments that they administered. For example, while the Dyadic Adjustment Scale is widely used to assess marital satisfaction, it may not accurately measure the components affecting new parents or their relationship with one another (Bogdan et al., 2022). It would benefit the literature for authors to rationalize their use of instruments and identify how those tools capture desired constructs of relationship functioning, particularly with dyadic data wherein interdependence is a necessary consideration. Some dyadic functioning measures were only administered to the participating mothers, which limited the analysis of relationship-level variables. Emerging literature would benefit from a standardization of instruments to measure dyadic functioning during the perinatal period.

The family-focused interventions within this set of literature appeared to be a strength, but they may be difficult to implement across healthcare sites. Many of the interventions consisted of psychoeducation therapy sessions or skills groups in various formats (e.g., in-person, concurrent telehealth). For example, Geller et al. (2018) implemented an ideal model of intensive support services for mothers in the perinatal period with moderate levels of family inclusion. Their intervention(s) demonstrated positive results for maternal functioning, parental stress, emotion regulation, and dyadic adjustment. However, such an intensive model may be difficult to advance due to funding, reimbursement rates, clinical training, and institutional support (or lack thereof). More accessible approaches for providers and patients, with more modest levels of family inclusion (e.g., a two-hour psychoeducational workshop; Daley-McCoy et al., 2015), have still shown promising results in the alleviation of PPD and couple distress during the perinatal period.

Limitations

It is important to note the following limitations of the review presented here. Homogeneity across many of the samples suggests that this review primarily captures the experiences of a particular population (i.e., this literature skewed toward white, higher educated samples). Whether that is representative of others’ experiences with PPD is difficult to say. There were also a wide variety of methodologies, foci, and measures across the literature. For example, some studies focused on psychoeducation (e.g., Dafei et al., 2021; Ngai et al., 2020) with a partner present and others were focused on family support and interpersonal dynamics (e.g., Battle et al., 2023; Giallo et al., 2022). While this variety across studies offers considerable perspective, it is challenging to make broad comparisons. It is apparent, however, that any level of family inclusion is better than nothing.

Future Directions

Given the well-established mental- and physical- health disparities for Black, Indigenous, People of Color (BIPOC) mothers, this literature could also benefit from the application of an intersectional or culturally specific framework (Hoang et al., 2022). According to Hill et al. (2022), for example, Black and AI/AN mothers experience higher rates of maternal mortality compared to non-Hispanic White mothers in the U.S., who can be better understood vis-a-vis the intersection of social and economic factors (e.g., gender, race, socioeconomic status, environment) shaping health outcomes. Further, an inclusive framework (e.g., social determinants of health) would allow for the integration of extended family into care by recognizing family diversity and the importance of kinship ties in communities of color (Bernardes, 1999; Gerstel, 2011; Herman & Newland, 2022). By applying an intersectional framework to this literature, researchers can increase diverse family participation and address systemic inequalities that contribute to maternal health disparities.

All but one study examined in this review included self-report measures. Battle et al. (2023) used a clinician-rated instrument (i.e., Modified Hamilton Rating Scale for Depression) to assess participants’ symptoms. In this population, there is an opportunity to utilize other approaches (e.g., observational, archival, physiological) to measure aspects of the perinatal period (Leary, 2016). Relying primarily on self-report measures does not fully capture the complexity of interpersonal dynamics in dyadic research. By addressing issues of validity for diverse populations, interdependence of data, and standardization of dyadic measures, future studies can enhance rigor and relevance of dyadic research within the perinatal population.

While this literature demonstrated the importance of partner-involvement, future studies can examine levels of family inclusion (Pratt & Sonney, 2020) to provide more nuanced evaluations of how family involvement impacts perinatal health. Examining the role of extended support for mothers (e.g., relatives, friends, peers) could reveal critical information about improving maternal mental health. Additionally, longitudinal studies to determine long-term outcomes of perinatal interventions could provide valuable insight into the effectiveness of early interventions and whether families are better equipped to navigate future parenting challenges.

Clinical Implications

The limited literature on evidence-based therapeutic interventions within the context(s) of the perinatal period indicates a need – and an opportunity – to clinically address the mental health of pregnant parents and expanding families. It is critical for couple and family therapists (CFTs) to be aware of how family interventions influence perinatal mental health outcomes. The perinatal period is a vital time to engage families because it is a period marked by heightened changes in identity, relationship dynamics, levels of stress, and role adjustments. CFTs have a unique skillset to engage families and implement interventions while maintaining high levels of family involvement. During this time, CFTs can utilize their systemic training to effectively incorporate biological and/or chosen family into treatment to support new parents and their infants. Leveraging additional support(s) for mothers can improve both individual and interpersonal outcomes, as results from this review imply. Insight into the perinatal period and how it affects interpersonal dynamics allows for greater systemic improvement with the potential for positive long-term effects on family well-being.

Conclusion

This review synthesized the theoretical and methodological strengths and limitations of 12 articles examining how family involvement impacts postpartum depression (PPD). Findings show that engaging a family member in treatment to support perinatal adjustment can improve PPD and interpersonal functioning. Future research should incorporate diverse samples into their designs to increase understandings about the nuanced experiences of PPD for families. Additionally, longitudinal studies should be conducted during the perinatal period to demonstrate the effects on maternal and infant/child health outcomes, family cohesion, and interpersonal functioning over time. Couple and family therapists are uniquely situated to engage families at this critical time, and using an inclusive framework will allow for greater integration of essential supports.