Evaluating the effectiveness of a brief group cognitive behavioural therapy intervention for perinatal depression

Public health nurse-delivered cognitive behavioral therapy for postpartum depression: Assessing the effects of maternal treatment on infant emotion regulation

The effects of maternal postpartum depression (PPD) on offspring emotion regulation (ER) are particularly deleterious as difficulties with ER predict an increased risk of psychopathology. This study examined the impact of maternal participation in a public health nurse (PHN)-delivered group cognitive behavioral therapy (CBT) intervention on infant ER. Mothers/birthing parents were ≥ 18 years old with an Edinburgh Postnatal Depression Scale (EPDS) score ≥ 10, and infants were < 12 months. Between 2017 and 2020, 141 mother-infant dyads were randomized to experimental or control groups. Infant ER was measured at baseline (T1) and nine weeks later (T2) using two neurophysiological measures (frontal alpha asymmetry (FAA) and high-frequency heart rate variability (HF-HRV)), and informant-report of infant temperament. Mothers were a mean of 30.8 years old (SD = 4.7), 92.3% were married/ common-law, and infants were a mean of 5.4 months old (SD = 2.9) and 52.1% were male. A statistically significant group-by-time interaction was found to predict change in HF-HRV between T1 and T2 (F(1,68.3) = 4.04, p = .04), but no significant interaction predicted change in FAA or temperament. Results suggest that PHN-delivered group CBT for PPD may lead to adaptive changes in a neurophysiological marker of infant ER, highlighting the importance of early maternal intervention.

Fidelity Assessment of Peer-Delivered Cognitive-Behavioral Therapy for Postpartum Depression

OBJECTIVE

Fidelity assessment of peer-administered interventions (PAIs) by expert therapists can be costly and limit scalability. This study's objective was to determine whether peer facilitators could assess the fidelity of peer-delivered group cognitive-behavioral therapy (CBT) for postpartum depression as effectively as an expert psychiatrist or a trained graduate student.

METHODS

Intervention adherence and competence were assessed by three peers (N=9 sessions) and by one expert psychiatrist and one graduate student (N=18 sessions). Interrater reliability was assessed with intraclass correlation coefficients (ICCs).

RESULTS

ICCs were good to excellent (0.88-0.98) for adherence and competence ratings among the three types of raters (psychiatrist vs. peers, psychiatrist vs. student, and student vs. peers).

CONCLUSIONS

Trained peers may be able to reliably rate the fidelity of a PAI for postpartum depression. This preliminary study represents the first step toward peer-led feedback as an alternative to expert-led supervision of peer-delivered group CBT for postpartum depression.

Do treatments for mental disorders affect relationship satisfaction? A systematic review and meta-analysis

Objective: Psychiatric disorders have been linked to poor social functioning, including deficits in relationship satisfaction. Treatments have shown strong effectiveness in reducing clinical symptoms for a range of disorders, though less is known of the effects disorder-focused treatments have on relationship satisfaction.

Methods: The present study describes a systematic review that was conducted to determine the efficacy of treatments for specific psychiatric disorders in improving relationship satisfaction. Surprisingly, only seventeen studies were identified and included in the review.

Results: We found that a majority of these studies reported modest improvement in relationship satisfaction among people who completed treatment. However, studies were severely hampered by methodological limitations, and all therapy-related improvements could be attributable to placebo effects or the passage of time.

Conclusion: Important gaps in the literature were found that future research should seek to address to maximize treatment outcomes and psychosocial functioning.

Longitudinal Association Between Youth Multimorbidity and Psychological Distress: Impact of the COVID-19 Pandemic

This research examined longitudinal associations between youth physical-mental multimorbidity and psychological distress before and during the COVID-19 pandemic; assessed the contextual impact of the pandemic on these associations; and, investigated potential moderating factors. The Multimorbidity in Youth across the Life-course, an ongoing study of youth aged 2-16 years (mean 9.4; 46.9% female) with physical illness, was used as the sampling frame for this COVID-19 sub-study, in which 147 parent-youth dyads participated. Psychological distress was measured using the Kessler-6 (K6). Multimorbidity was associated with higher pre-pandemic, but not with intra-pandemic distress. Disability moderated pre-pandemic distress-multimorbidity was associated with higher K6 among youth with high disability, but not among youth with low disability. Age moderated intra-pandemic distress-multimorbidity was associated with higher K6 in older youth, but not among younger youth.

Public Health Nurse-delivered Group Cognitive Behavioural Therapy for Postpartum Depression: A Randomized Controlled Trial

OBJECTIVES

To examine the effectiveness of group cognitive behavioural therapy (CBT) for postpartum depression (PPD) delivered by public health nurses with little to no previous psychiatric training at improving depression, worry, social support and the mother-infant relationship.

METHODS

Mothers (n = 141) living in Ontario, Canada with Edinburgh Postnatal Depression Scale Scores ≥10 and an infant <12 months of age were randomized to receive nine weekly 2-h sessions of in-person group CBT for PPD delivered by two public health nurses plus treatment as usual (TAU; experimental group) or TAU alone (control group). Primary outcomes were change in EPDS score and current major depressive disorder (Mini International Neuropsychiatric Interview) assessed immediately post-treatment (T2). Secondary outcomes included maternal worry, social support, and quality of the mother-infant relationship. All outcomes were assessed again six months post-treatment (T3).

RESULTS

Participants in the experimental group had statistically significantly greater reductions in PPD symptoms immediately post-treatment (T2) (B = -5.35, p < 0.01), were more likely to manifest a clinically significant improvement in EPDS scores (≥4 points; OR = 3.44, 95%CI: 1.49-7.94), and no longer have symptoms consistent with current MDD (OR = 5.31, 95% CI: 1.78-15.83). Six months post-treatment (T3), experimental group participants had higher odds of clinically significant PPD improvement (OR = 5.10, 95%CI: 1.89-13.78), while 25% of the experimental group and 70% of remaining control group participants reported current MDD (p < 0.01). Statistically significant improvements in worry and the mother-infant relationship were also observed, decreases maintained at six months post-treatment.

CONCLUSIONS

Public health nurses with little to no previous psychiatric training can be trained to deliver effective group CBT for PPD to improve depression, worry, and the mother-infant relationship. Task shifting PPD treatment with group CBT to public health nurses could improve treatment uptake and lead to better outcomes for mothers, families, and the healthcare system.(Trial Registration NCT03039530).

Effectiveness of digital psychotherapeutic intervention among perinatal women: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The perinatal period is a challenging time of substantial emotional, physiological, social, and relational changes. Depression, anxiety, and stress symptoms are common, and co-exist in the perinatal period. Digital technology continues to grow at an unprecedented pace with wide application, including psychotherapeutic intervention. A growing number of meta-analyses supported the application of digital psychotherapeutic intervention across different populations, but relatively few meta- and meta-regression analyses have concentrated on perinatal women.

AIM

To evaluate the effectiveness of digital psychotherapeutic intervention on improving psychological outcomes among perinatal women and identify its essential features.

METHODS

Randomized controlled trials (RCTs) were obtained from eight databases, including Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, Scopus, PsycINFO, PubMed, Web of Science, and ProQuest Dissertation and Theses from inception up until November 24, 2020. Comprehensive Meta-analysis 3.0 software was used to conduct meta- and meta-regression analyses. The Cochrane risk-of-bias tool and the Grading of the Recommendation, Assessment, Development, and Evaluation system were adopted to assess the individual and overall qualities of the evidence, respectively.

RESULTS

A total of 25 RCTs that included 3239 women were identified. Meta-analyses revealed that intervention significantly improved depression (Hedges's g = 0.49), anxiety (g = 0.25), and stress (g = 0.47) symptoms compared to the control. Subgroup analyses demonstrated that a website platform with ≥ eight therapist-guided sessions using the theoretical principle of cognitive behavioral therapy was more effective than other treatments in improving depression symptoms in postnatal women. Meta-regression analyses observed that the age of perinatal women and the type of psychotherapy also had statistically significant effects on depression symptoms. Egger's regression asymmetry tests suggested that no publication biases occurred, but the overall quality of the evidence was very low.

CONCLUSION

This review suggests that digital psychotherapeutic intervention may be a potential solution to reduce psychological problems in perinatal women. Further high-quality RCTs with large sample sizes are needed.

Changes in infant emotion regulation following maternal cognitive behavioral therapy for postpartum depression

BACKGROUND

Exposure to maternal postpartum depression (PPD) increases the risk for emotion regulatory and psychiatric problems in offspring. This study aimed to determine if maternal cognitive behavioral therapy (CBT) for PPD improves infant emotion regulatory capacity.

METHODS

Participants were 40 infants of mothers with a primary diagnosis of major depressive disorder matched 1:1-40 healthy control infants of nondepressed mothers on infant age, sex, and socioeconomic status. Mothers with PPD received nine weeks of group CBT. Dyads were tested at two time points. Visit 1 occurred following the first CBT session (baseline visit for control infants). Visit 2 took place after CBT (nine weeks post-baseline for controls). At both visits, infant emotion regulation was assessed using resting-state frontal electroencephalography alpha asymmetry (FAA), heart rate variability (HRV), and maternal and partner ratings of orientation or regulation behaviors (infant behavior questionnaire-revised [short form]). Changes in maternal characteristics (depression, bonding, and emotion regulation) from pretreatment to posttreatment were examined to determine if they explained infant changes.

RESULTS

At Visit 1, infants of women with PPD exhibited poorer emotion regulation relative to the healthy control infants. At Visit 2, following maternal PPD treatment, infants exhibited improved emotion regulation (shifted from right to left FAA [p = .01, d = 0.60], increased HRV [p = .003, d = 0.56], mother [p = .015, d = 0.29] and partner [p = .049, d = 0.35] reported orientation or regulation behaviors) such that they no longer differed from the healthy control infants. Changes in maternal characteristics did not appear to account for these changes.

CONCLUSION

Treating PPD may promote adaptive changes in physiological and behavioral systems underlying infant emotion regulation.

Maternal and Infant Performance on the Face-to-Face Still-Face Task following Maternal Cognitive Behavioral Therapy for Postpartum Depression

OBJECTIVE

This study examined the impact of treating postpartum depression (PPD) with cognitive-behavioral therapy (CBT) on mother and infant behavior on the face-to-face still-face (FFSF) paradigm.

METHODS

Data from 68 mothers and their infants, 35 women with PPD within 12 months of delivery, and 33 healthy control dyads matched on infant age, sex and familial socioeconomic status were examined. Women with PPD received nine weeks of group CBT and were compared with healthy control dyads with at three timepoints on changes in mother-infant performance on the FFSF.

RESULTS

A significant group x FFSF phase x visit interaction was observed for infant withdrawn behavior at the three months post-treatment (p=0.006). Infants of mothers with PPD displayed significantly less withdrawn behavior after treatment, normalizing to levels of control infants.

LIMITATIONS

A relatively small sample consisting predominantly of Caucasian mother-infant dyads and the presence of comorbid anxiety in the PPD group.

CONCLUSION

Three months after group CBT for PPD, infants' withdrawn behavior appears to normalize to levels seen in the infants of healthy controls. Future studies should investigate whether treatments focused on the mother-infant dyad have distinctive effects on mothers and their infants' behaviors.

Public health nurses' experiences learning and delivering a group cognitive behavioral therapy intervention for postpartum depression

OBJECTIVES

Public Health Nurses (PHNs) often provide support to women with postpartum depression (PPD) in the absence of specialized training. The objective of this study was to explore the experiences of six PHNs who were trained to deliver a group cognitive behavioral therapy (CBT) intervention for PPD in the public health setting, and to describe how learning and delivering this intervention affected their professional roles and personal lives.

DESIGN

This qualitative study employed a phenomenological approach.

SAMPLE

Six PHNs who completed the CBT training program and delivered at least one CBT group in their community.

MEASUREMENTS

Individual in-depth interviews were conducted and transcribed verbatim. Transcripts were analyzed according to thematic derivation procedures.

RESULTS

The themes that emerged from the interviews with the PHNs included: (a) components of the CBT training program that nurses most valued, (b) benefits of training for their professional role as a PHN, (c) implications for practice, and (d) using CBT skills in their personal lives.

CONCLUSIONS

The provision of CBT training to PHNs may not only positively impact their work with clients with mental illness, but may also have the potential to provide broader clinical and professional benefits for these skilled professionals and their other clients.

Quality assurance assessment of a specialized perinatal mental health clinic

Background

Mood and anxiety issues are the main mental health complaints of women during pregnancy and the postpartum period. Services targeting such women can reduce perinatal complications related to psychiatric difficulties. This quality assurance project aimed to examine changes in mood and anxiety symptoms in pregnant and postpartum women referred to the Women’s Health Concerns Clinic (WHCC), a specialized outpatient women’s mental health program.

Methods

We extracted patient characteristics and service utilization from electronic medical records of women referred between 2015 and 2016. We also extracted admission and discharge scores on the Edinburgh Postnatal Depression Scale (EPDS) and the Generalized Anxiety Disorder-7 (GAD-7) scale.

Results

Most patients accessed the WHCC during pregnancy (54%), had a diagnosis of major depressive disorder (54.9%), were prescribed a change in their medication or dose (61.9%), and accessed psychotherapy for perinatal anxiety (30.1%). There was a significant decrease in EPDS scores between admission and discharge (t(214) = 11.57; p = .000; effect size d = .86), as well as in GAD-7 scores (t(51) = 3.63; p = .001; effect size d = .61). A secondary analysis showed that patients with more severe depression and anxiety symptoms demonstrated even greater effect sizes.

Conclusions

Changes in EPDS and GAD-7 scores indicate that the WHCC is effective in reducing mood and anxiety symptoms associated with the perinatal period. This project highlights the importance of quality assurance methods in evaluating the effectiveness of clinical services targeting perinatal mental health, in order to inform policy and funding strategies.

Effectiveness and acceptability of cognitive-behavioural therapy based interventions for maternal peripartum depression: a systematic review, meta-analysis and thematic synthesis protocol

INTRODUCTION

Peripartum depression is a common mental health difficulty associated with a range of negative impacts for the mother, infant and wider family. This review will examine the effectiveness of cognitive-behavioural therapy (CBT) based interventions for peripartum depression. Secondary aims are to explore the effect of CBT-based interventions targeted at peripartum depression on novel secondary outcomes and moderators potentially associated with effectiveness. To date, there has been little examination of effect on important secondary outcomes (eg, anxiety, stress and parenting), nor clinical and methodological moderators. Further, this review aims to explore the acceptability of CBT-based interventions for women with peripartum depression and examine important adaptations for this population.

METHODS AND ANALYSIS

Electronic databases (e.g., MEDLINE; ISI Web of Science; CINAHL; CENTRAL; Prospero; EMBASE; ASSIA; PsychINFO; SCOPUS; And Swemed+) will be systematically searched. Database searches will be supplemented by expert contact, reference and citation checking, and grey literature. Primary outcomes of interest will be validated measures of symptoms of depression. A proposed meta-analysis will examine: (1) the overall effectiveness of psychological interventions in improving symptoms of depression (both self-reported and diagnosed major depression) in the peripartum period; (2) the impact of interventions on secondary outcomes (eg, anxiety, stress and parenting); (3) clinical and methodological moderators associated with effectiveness. A thematic synthesis will be conducted on qualitative data exploring the acceptability of CBT-based intervention for postpartum depression including participants' experience and perspectives of the interventions, satisfaction, barriers and facilitators to intervention use, intervention relevance to mothers' situations and suggestions for improvements to tailor interventions to the peripartum client group.

ETHICS AND DISSEMINATION

Formal ethical approval is not required by the National Ethical Review Board in Sweden as primary data will not be collected. The results will be disseminated through a peer-reviewed publication and inform the development of a new psychological intervention for peripartum depression. This study including protocol development will run from March 2019 to March 2020.

Public health nurse delivered group cognitive behavioral therapy (CBT) for postpartum depression: A pilot study

OBJECTIVES

Although postpartum depression (PPD) affects 1 in 5 women, just 15% receive treatment. Cognitive Behavioural Therapy (CBT) is a first-line treatment for PPD. The objective of this pilot study was to determine the feasibility and acceptability of public health nurse (PHN)-delivered group CBT for PPD and to determine preliminary estimates of effect.

DESIGN

A pre-posttest design was used. Participants provided data before and after the CBT groups.

SAMPLE

Seven women who were over the age of 18 and had given birth in the past year participated.

MEASUREMENTS

Feasibility and acceptability focused on PHN training, recruitment, retention, and adherence to the intervention. Participants provided data on depression, worry, health care utilization and mother-infant relations. Women and their partners reported on infant temperament.

INTERVENTION

Participants attended a 9-week CBT group delivered by two PHNs.

RESULTS

The PHN training, CBT intervention and our study protocol were found to be feasible and acceptable to participants. Reductions were seen in depression and worry. The number of health care visits decreased; mother-infant relations improved.

CONCLUSIONS

These findings highlight the feasibility of PHN-delivered group CBT for PPD and suggest that it could reduce the burden of PPD on women and their children.