The effect of physician-based cognitive behavioural therapy among pregnant women with depressive symptomatology: a pilot quasi-experimental trial

'Asking for help': a qualitative interview study exploring the experiences of interpersonal counselling (IPC) compared to low-intensity cognitive behavioural therapy (CBT) for women with depression during pregnancy

BACKGROUND

Treating depression early in pregnancy can improve health outcomes for women and their children. Current low-intensity psychological therapy for perinatal depression is a supported self-help approach informed by cognitive behavioural therapy (CBT) principles. Interpersonal counselling (IPC) may be a more appropriate low-intensity talking therapy for addressing the problems experienced by pregnant women with depression. A randomised feasibility trial (ADAGIO) has compared the acceptability of offering IPC for mild-moderate antenatal depression in routine NHS services compared to low-intensity CBT. This paper reports on a nested qualitative study which explored women's views and expectations of therapy, experiences of receiving IPC, and Psychological Wellbeing Practitioners (PWPs - junior mental health workers) views of delivering the low-intensity therapy.

METHODS

A qualitative study design using in-depth semi-structured interviews and focus groups. Thirty-two pregnant women received talking therapy within the ADAGIO trial; 19 contributed to the interview study from July 2019 to January 2020; 12 who had IPC and seven who had CBT. All six PWPs trained in IPC took part in a focus group or interview. Interviews and focus groups were recorded, transcribed, anonymised, and analysed using thematic methods.

RESULTS

Pregnant women welcomed being asked about their mental health in pregnancy and having the chance to have support in accessing therapy. The IPC approach helped women to identify triggers for depression and explored relationships using strategies such as 'promoting self-awareness through mood timelines', 'identifying their circles of support', 'developing communication skills and reciprocity in relationships', and 'asking for help'. PWPs compared how IPC differed from their prior experiences of delivering low-intensity CBT. They reported that IPC included a useful additional emotional component which was relevant to the perinatal period.

CONCLUSIONS

Identifying and treating depression in pregnancy is important for the future health of both mother and child. Low-intensity perinatal-specific talking therapies delivered by psychological wellbeing practitioners in routine NHS primary care services in England are acceptable to pregnant women with mild-moderate depression. The strategies used in IPC to manage depression, including identifying triggers for low mood, and communicating the need for help, may be particularly appropriate for the perinatal period.

TRIAL REGISTRATION

ISRCTN 11513120. 02/05/2019.

Acceptance and Commitment Therapy for perinatal mood and anxiety disorders: A feasibility and proof of concept study

OBJECTIVES

The aim of the current study was to assess the feasibility, safety, and effectiveness of a newly developed Acceptance and Commitment Therapy (ACT) intervention developed specifically to address the unique context of pregnancy and parenthood. The intervention was delivered to women accessing a specialist Perinatal Community Mental Health Service (PCMHS).

DESIGN

An open-label pilot study was conducted of an 8-week, group-delivered ACT intervention targeting women with moderate-to-severe mood and/or anxiety disorders during pregnancy and/or postpartum.

METHODS

Outcomes included session attendance rates, dropout rates, crisis/inpatient service use, and standardized symptom scales. Participant's responses to open-ended questions contained in an end of therapy questionnaire were analysed using thematic analysis.

RESULTS

Seventy-four women were referred to the intervention with 65 (88%) completing treatment. The median number of sessions attended was 7. No women required input from crisis/inpatient services. All reported finding the intervention helpful. The implementation of ACT in daily life, therapist support, and group processes were cited as helpful aspects of the intervention. At post-treatment, there was a significant reduction in global distress (d = 0.99) and depressive symptoms (d = 1.05), and an increase in psychological flexibility (d = 0.93). On the secondary outcome of global distress, 38% of women were classified as recovered, 31% had reliably improved, 27% remained the same, and 4% had reliably deteriorated.

CONCLUSIONS

The delivery of ACT in a routine practice setting is feasible, safe, and effective. A randomized control trial (RCT) is needed to establish the efficacy and cost-effectiveness of this group-delivered ACT intervention.

PRACTITIONER POINTS

Group-delivered Acceptance and Commitment Therapy (ACT) is acceptable for women with moderate-to-severe perinatal mood and/or anxiety disorders and can be feasibly delivered in a routine practice setting. The trans-diagnostic nature of ACT enables the concurrent treatment of depressive and anxiety symptoms within the same intervention which is particularly helpful in the perinatal context given the comorbidity of mood and anxiety disorders. With training and supervision, mental health practitioners without extensive education in the delivery of psychological therapies can facilitate the ACT group programme. As this was a feasibility study, there was no control group, adherence to the manual was not assessed, and the absence of a follow-up period limits our knowledge of the longer-term benefits of the ACT group programme.

Effectiveness of an app-based cognitive behavioral therapy program for postpartum depression in primary care: A randomized controlled trial

OBJECTIVE

The objective of this study was to examine the effect of mobile phone applications (App) based cognitive behavioral therapy (CBT) on postpartum depression.

METHOD

A non-blinded parallel-group randomized controlled trial was conducted. The study population consisted of women attended to three health care centers in Kerman, Iran. Participants were recruited between September and November 2018, and randomized 1:1 to either the intervention group (mobile application access) or control group (no mobile application access). All participants completed the Edinburgh Postnatal Depression Scale (EPDS) at the baseline and 2 months after baseline. Data were analyzed using inferential statistics including chi-square, independent sample t-test, paired t-test and linear regression.

RESULTS

A total of 75 women with an average age of 27 years participated in this study. Before the intervention, there was no statistically significant difference between the EPDS score between the two groups (p > 0.001). However, in the intervention group, the average EPDS score after intervention was 8.18 and in the control group was 15.05, which was statistically significant (p < 0.001).

CONCLUSION

These findings provide proof that providing a CBT program using a mobile application can lead to clinically important improvements in outcomes for mothers who suffer from postpartum depression.

Non-pharmacological interventions to reduce the symptoms of mild to moderate anxiety in pregnant women. A systematic review and narrative synthesis of women's views on the acceptability of and satisfaction with interventions

To assess women's views on the acceptability of and satisfaction with non-pharmacological interventions to reduce the symptoms of anxiety in pregnant women. A systematic review and narrative synthesis (Prospero protocol number CRD42015017841). Fourteen included studies were conducted in Australia, Canada, Germany, New Zealand, UK and USA. Interventions were cognitive behavioural therapy, mindfulness, yoga, psychological assessment, supportive and educational based interventions. Studies included women from general antenatal populations and women with anxiety or depression symptoms or risk factors for anxiety or depression. The findings were limited due to the small number of studies evaluating different types of interventions using various study methods. Some studies had too little procedural reporting to allow a full quality assessment. Women's views on the acceptability of and satisfaction with interventions were overwhelmingly positive. The review highlights women's motivations for and barriers to participation as well as the benefit women perceived from peer support and individual discussions of their situation. Interventions need to be further evaluated in randomised controlled trials. The inclusion of women's views and experiences illuminates how and why intervention components contribute to outcomes. Women's initial concerns about psychological screening and the benefit derived from peer support and individual discussion should be noted by providers of maternity care.

Psychotherapeutic Treatments for Depression During Pregnancy

Depression during pregnancy is a significant public health problem that is associated with adverse consequences for women and children. Despite the availability of treatment options, depression during pregnancy is often undertreated. Most pregnant women prefer nonpharmacological interventions over antidepressant medications. We review the evidence base for psychotherapeutic treatment approaches to depression during pregnancy. Treatments reviewed include interpersonal therapy, cognitive-behavioral therapy, behavioral activation, and mindfulness-based cognitive therapy. We review both traditional face-to-face delivery and digital interventions. We conclude with recommendations for treatment preferences, collaborative decision-making, and strategies to improve uptake of such services among prenatal women.

Treatment of depression, anxiety, and trauma-related disorders during the perinatal period: A systematic review

Women with psychiatric disorders during pregnancy and the postpartum period (i.e., perinatal period) are at increased risk for adverse maternal and child outcomes. Effective treatment of psychiatric disorders during the perinatal period is imperative. This review summarizes the outcomes of 78 studies focused on the treatment of depression, anxiety, and trauma-related disorders during the perinatal period. The majority of studies focused on perinatal depression (n = 73). Of the five studies focused on anxiety or trauma-related disorders, only one was a randomized controlled trial (RCT). The most studied treatment was cognitive behavioral therapy (CBT; n = 22), followed by interpersonal psychotherapy (IPT; n = 13). Other interventions reviewed include other talk therapies (n = 5), collaborative care models (n = 2), complementary and alternative medicine approaches (n = 18), light therapy (n = 3), brain stimulation (n = 2), and psychopharmacological interventions (n = 13). Eleven studies focused specifically on treatment for low-income and/or minority women. Both CBT and IPT demonstrated a significant benefit over control conditions. However, findings were mixed when these interventions were examined in low-income and/or minority samples. There is some support for complementary and alternative medicine approaches (e.g., exercise). Although scarce, SSRIs demonstrated good efficacy when compared to a placebo. However, SSRIs did not outperform another active treatment condition (e.g., CBT). There is a tremendous need for more studies focused on treatment of perinatal anxiety and trauma-related disorders, as well as psychopharmacological effectiveness studies. Limitations and future directions of perinatal treatment research, particularly among low-income and/or minority populations, are discussed.

Psychometric evaluation of a multi-dimensional measure of satisfaction with behavioral interventions

Treatment satisfaction is recognized as an essential aspect in the evaluation of an intervention's effectiveness, but there is no measure that provides for its comprehensive assessment with regard to behavioral interventions. Informed by a conceptualization generated from a literature review, we developed a measure that covers several domains of satisfaction with behavioral interventions. In this paper, we briefly review its conceptualization and describe the Multi-Dimensional Treatment Satisfaction Measure (MDTSM) subscales. Satisfaction refers to the appraisal of the treatment's process and outcome attributes. The MDTSM has 11 subscales assessing treatment process and outcome attributes: treatment components' suitability and utility, attitude toward treatment, desire for continued treatment use, therapist competence and interpersonal style, format and dose, perceived benefits of the health problem and everyday functioning, discomfort, and attribution of outcomes to treatment. The MDTSM was completed by persons (N = 213) in the intervention group in a large trial of a multi-component behavioral intervention for insomnia within 1 week following treatment completion. The MDTSM's subscales demonstrated internal consistency reliability (α: .65 - .93) and validity (correlated with self-reported adherence and perceived insomnia severity at post-test). The MDTSM subscales can be used to assess satisfaction with behavioral interventions and point to aspects of treatments that are viewed favorably or unfavorably.

Brief Interpersonal Psychotherapy for depression during pregnancy in a low-income population: A randomized controlled trial

BACKGROUND

Depression is common in low-income pregnant women, and treatments need to be fitted to meet their needs. We conducted a randomized controlled trial comparing brief Interpersonal Psychotherapy (brief-IPT) to enhanced treatment as usual (ETAU) for perinatal depression in low-income women. The brief-IPT model is designed to better engage low-income women by utilizing an engagement session, providing flexible delivery of sessions, and pragmatic case management.

METHODS

Pregnant women, aged ≥18, between 12 and 30 weeks gestation were recruited from an urban prenatal clinic. Women scoring ≥10 on the Edinburgh Depression Scale and meeting depressive disorder criteria were randomized to either brief-IPT (n=21) or ETAU (n=21). We assessed treatment outcomes, acceptability, and feasibility of the intervention (measured by session attendance).

RESULTS

Depression scores significantly decreased in both brief-IPT and ETAU. Brief-IPT participants reported significant improvements in social support satisfaction as compared to ETAU participants, even after controlling for concurrent depressive symptoms. Brief-IPT participants reported high satisfaction with the program. However, many participants did not participate in the full 9-session course of treatment (average sessions attended =6, range 0-17).

LIMITATIONS

Small sample size, use of self-report measures, and lack of an active psychotherapy control group limits interpretation of study results.

CONCLUSIONS

Brief-IPT for perinatal depression is acceptable to low-income women and is helpful for improving depressive symptoms and social support. However, feasibility of the treatment was limited by relatively low session attendance in spite of efforts to maximize treatment engagement. Additional modifications to meet the needs of low-income women are discussed.

Comparison of group cognitive behavioral therapy and interactive lectures in reducing anxiety during pregnancy: A quasi experimental trial

BACKGROUND

Anxiety during pregnancy and its adverse effects on mother and baby is a health concern worldwide. This study aimed to investigate the effects of group cognitive behavioral therapy (GCBT) compared with interactive lectures (IL) on anxiety during pregnancy.

METHODS

This quasi experimental trial was conducted in Sari city, in north Iran, from March to July 2015. Participants were 91 obstetrically and medically low-risk nulliparous women with a mild to moderate anxiety level, as assessed by Spielberger's State-Trait Anxiety Inventory. Participants were selected from the general population by cluster sampling and assigned to 3 groups: a cognitive behavioral therapy (CBT) group (n = 31), an IL group (n = 30), and a control group (n = 30). All participants completed a demographic characteristics form and the Speilberger State-Trait Anxiety Inventory. The inventory was completed again by the CBT and IL groups 4 weeks after the interventions, and 4 weeks after the initial questionnaire by the control group. Data were analyzed with chi-squared tests, independent t-tests, paired t-tests, ANOVA, and Dunnett post hoc test.

RESULTS

A significant decline in state and trait anxiety was found in the CBT and IL groups at 4 weeks (P < 0.001). GCBT was more effective than IL in reducing participants' anxiety, but the difference was not significant (P > 0.05).

CONCLUSION

GCBT and IL had beneficial effects in reducing anxiety in pregnancy. The psychological status of pregnant women in prenatal care services should be investigated and either of these methods used to manage maternal anxiety, depending on the available healthcare service resources.

Toward a Conceptualization and Operationalization of Satisfaction With Nonpharmacological Interventions

BACKGROUND

Although satisfaction is recognized as an essential aspect in the evaluation of interventions' effectiveness, there is lack of clarity on its conceptualization and operationalization. In this article, we present conceptual and operational definitions that specify the domains and attributes of satisfaction with nonpharmacological interventions.

METHODS

An integrative review of conceptual and empirical literature was conducted to generate the conceptual and operational definitions of satisfaction with interventions. Fifty-six publications were included in the review. The definitions of satisfaction and the content of instruments measuring satisfaction were reviewed, compared, and contrasted to identify the domains and attributes of the concept.

RESULTS

Satisfaction is defined as the appraisal of the interventions' process and outcome. It is operationalized in 4 domains of process: (a) suitability and utility of the intervention's components, (b) attitude toward and desire to continue with the intervention, (c) competence and interpersonal style of interventionist, and (d) implementation (format and dose) of the intervention. The outcome domain includes improvement in the health problem and in everyday functions, discomfort, and attribution of the outcomes to the intervention.

CONCLUSIONS

The conceptual and operational definitions can guide the development of instruments to assess satisfaction with nonpharmacological interventions, which can point to aspects of interventions that are viewed favorably or unfavorably.