Mindfulness-based cognitive therapy for psychological distress in pregnancy: study protocol for a randomized controlled trial

Exploring relationship of poor sleeping habits with prenatal stress among pregnant women in Pakistan: a cross-sectional study

OBJECTIVE

Pregnancy is a complex phenomenon accompanied by biological, physiological and psychosocial changes for a mother. It is also regarded as a stressful life event where a woman's role, identity and interpersonal relationships are restructured. The present study from Pakistan explores the association of sleep quality and poor sleeping habits with prenatal stress using Pittsburgh Sleep quality Index.

RESULTS

There were a total of 516 women (mean age = 29.82 years), with more than half reporting poor sleep quality. Ethnically, a majority (395, 76.6%) were natives of the Punjab province while rest were non-natives. A high percentage of respondents reported poor subjective sleep quality (22.1%), sleep latency (44.1%), habitual sleep efficiency (27.5%), sleep disturbance (30.1%), use of medications (7.1%) and daytime dysfunction (29.5%). According to logistic regression analysis, respondents with poor sleep quality were 2.24 (95% CI = 1.55-3.22, P < 0.001) times more likely to have high stress levels (P < 0.001).

Mindfulness-Based Interventions for Postpartum Depression: A Systematic Review and Meta-Analysis

Background

We aimed to investigate the intervention effect of mindfulness-based interventions (MBIs) in patients with postpartum depression.

Methods

The method of computer and manual keyword retrieval was used to search PubMed, Web of Science, Cochrane Library. Literature included in the study was assessed for quality and meta-analysis was performed using RevMan 5.3 software.

Results

Twelve articles were finally included in the study and the meta-analysis showed that 6 articles used the Edinburgh Postnatal Depression Scale (EPDS) to compare MBIs with conventional therapy, and the statistical heterogeneity between the combined results was low (P=0.18, I2=32%). The level of depression in postpartum depression patients was lower in the MBIs group than in the conventional group [MD=3.13, 95%CI (2.57, 3.70), P<0.00001]. Based on the Beck Depression Inventory (BDI), the comparison between MBIs and conventional therapy had low statistical heterogeneity between the combined results (P=0.56, I2=0%). The level of depression in patients with postpartum depression who received MBIs was significantly lower than in the conventional care group [MD=5.89, 95%CI (4.88, 6.91), P<0.00001]. Subgroup analysis showed that the best intervention duration for MBIs for postpartum depression was within 4 weeks (SMD=-1.785), each session ≦60 minutes (SMD=-1.435), and participants had to complete the best three times per week (SMD=-2.185).

Conclusion

MBIs can alleviate depression in women, thereby facilitating their adjustment to new life. It is recommended to practice mindfulness meditation for 30 minutes per day.

Perinatal Understanding of Mindful Awareness for Sleep (PUMAS): A single-arm proof-of-concept clinical trial of a mindfulness-based intervention for DSM-5 insomnia disorder during pregnancy

OBJECTIVES

Cognitive-behavioral therapy is effective for prenatal insomnia, but unresolved cognitive arousal limits patient outcomes. Therapies aimed at reducing cognitive arousal may benefit pregnant women with insomnia. This proof-of-concept trial evaluated Perinatal Understanding of Mindful Awareness for Sleep (PUMAS, which combines mindfulness with behavioral sleep strategies) on insomnia, depression, and cognitive arousal.

METHODS

A single-arm trial of 12 pregnant women with DSM-5 insomnia disorder (n = 5/12 with comorbid depression) who received six sessions of PUMAS delivered individually via telemedicine. Pretreatment and posttreatment outcomes included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC; nocturnal cognitive arousal), perinatal-focused rumination (appended to PSASC), and Glasgow sleep effort scale.

RESULTS

Eleven of 12 patients completed all sessions. Intent-to-treat analyses revealed a 10.83-point reduction in ISI (Cohen's dz = 3.05), resulting in 83.3% insomnia remission. PUMAS produced large reductions in EPDS (Cohen's dz = 2.76 in depressed group), resulting in all five baseline depressed patients remitting from depression. PUMAS produced large reductions in nocturnal cognitive arousal, perinatal-focused rumination, and sleep effort (all Cohen's dzs>2.00). Patients were highly satisfied with PUMAS and identified the telemedicine format and meditation app as positive features of its delivery. Patients rated sleep restriction and guided meditations as the most helpful treatment components.

CONCLUSION

Prenatal insomnia patients were highly engaged in PUMAS, which produced large acute reductions in insomnia, depression, and cognitive arousal. These findings support the concept and feasibility of PUMAS for pregnant women with insomnia who present with or without comorbid depression.

CLINICALTRIALS

GOV ID

NCT04443959.

Individual participant data systematic review and meta-analysis of randomised controlled trials assessing adult mindfulness-based programmes for mental health promotion in non-clinical settings

Introduction

Mindfulness-based programmes (MBPs) are widely used to prevent mental ill-health that is becoming the leading global cause of morbidity. Evidence suggests beneficial average effects but wide variability. We aimed to confirm the effect of MBPs on psychological distress, and to understand whether and how baseline distress, gender, age, education, and dispositional mindfulness modify the effect of MBPs on distress among adults in non-clinical settings.

Methods

We conducted a pre-registered systematic review and individual participant data (IPD) meta-analysis (PROSPERO CRD42020200117). Thirteen databases were searched in December 2020 for randomised controlled trials satisfying a quality threshold and comparing in-person, expert-defined MBPs in non-clinical settings with passive control groups. Two researchers independently selected, extracted, and appraised trials using the revised Cochrane Risk-of-Bias Tool (RoB2). Anonymised IPD of eligible trials were sought from collaborating authors. The primary outcome was psychological distress (unpleasant mental or emotional experiences including anxiety and depression) at 1 to 6 months after programme completion. Data were checked and imputed if missing. Pairwise, random-effects, two-stage IPD meta-analyses were conducted. Effect modification analyses followed a within-studies approach. Public and professional stakeholders were involved in the planning, conduct and dissemination of this study.

Results

Fifteen trials were eligible, 13 trialists shared IPD (2,371 participants representing 8 countries, median age 34 years-old, 71% women, moderately distressed on average, 20% missing outcome data). In comparison with passive control groups, MBPs reduced average distress between one- and six-months post-intervention with a small to moderate effect size (standardised mean difference (SMD) -0.32; 95% confidence interval (CI) -0.41 to -0.24; p-value < 0.001; 95% prediction interval (PI) -0.41 to -0.24 (no heterogeneity)). Results were robust to sensitivity analyses, and similar for the other psychological distress time point ranges. Confidence in the primary outcome result is high. We found no clear indication that this effect is modified by baseline psychological distress, gender, age, education level, or dispositional mindfulness.

Conclusions

Group-based teacher-led MBPs generally reduce psychological distress among community adults who volunteer to receive this type of intervention. More research is needed to identify sources of variability in outcomes at an individual level.

Mindfulness as an Adjunct or Alternative to CBT-I

Mindfulness-based interventions (MBIs) are programs that teach mindfulness concepts through guided meditation and self-regulation practices. MBIs have been found to improve sleep and reduce cognitive arousal, which are central to the development and perpetuation of insomnia. In this article, we review theoretic frameworks and clinical trial effectiveness data supporting MBIs for insomnia. Based on this review, we provide suggestions for using MBIs as an adjunct or alternative treatment option to CBT-I with regard to how, when, and for whom. We conclude with an agenda for future directions that can clarify the use of mindfulness as a treatment option for insomnia.

The Case for the Patient-Centric Development of Novel Digital Sleep Assessment Tools in Major Depressive Disorder

Background

Depression imposes a major burden on public health as the leading cause of disability worldwide. Sleep disturbance is a core symptom of depression that affects the vast majority of patients. Nonetheless, it is frequently not resolved by depression treatment and may even be worsened through some pharmaceutical interventions. Disturbed sleep negatively impact patients' quality of life, and persistent sleep disturbance increases the risk of recurrence, relapse, and even suicide. However, the development of novel treatments that might improve sleep problems is hindered by the lack of reliable low-burden objective measures that can adequately assess disturbed sleep in this population.

Summary

Developing improved digital measurement tools that are fit for use in clinical trials for major depressive disorder could promote the inclusion of sleep as a focus for treatment, clinical drug development, and research. This perspective piece explores the path toward the development of novel digital measures, reviews the existing evidence on the meaningfulness of sleep in depression, and summarizes existing methods of sleep assessments, including the use of digital health technologies.

Key Messages

Our objective was to make a clear call to action and path forward for the qualification of new digital outcome measures which would enable assessment of sleep disturbance as an aspect of health that truly matters to patients, promoting sleep as an important outcome for clinical development, and ultimately ensure that disturbed sleep will not remain the forgotten symptom of depression.

Promotion of psychosocial wellbeing in new mothers through mindfulness-based cognitive therapy

Physical wellness, mental wellbeing, psychological state (feelings, emotions, beliefs, perspectives), and social relationships (connections, behaviours, cultural values, and the influence of family, school, colleagues, and community) all have an impact on an individual's psychosocial well-being as stated by WHO. In order to understand the circumstances, Mindfulness-Based Cognitive Therapy (MBCT) involves mindful, walking, breathing smiling, indepth looking. accepting, love, compassion,  a need to alleviate pain and create happiness are always the benefits of being attentive, touching intimately the present moment. MBCT has evolved into something that can help with a variety of concerns which includes anxiety, stress, sadness, overwhelm, frustration as well as behavioural issues like anger control. It's also a great approach to live a more mindful life. MBCT therapists employ these strategies to teach clients how to break free from negative thought patterns that might lead to a depressed state, allowing them to battle depression before it takes hold. It's a method of being in the world as well as a practise. This study is planned as a quasi-experimental study to see if mindfulness training, which includes balanced nutrition, physical activity, self-care, positive affirmations, self-introspection, stress-relieving exercises, and meditation, can help new moms improve their psychological well-being.

The relationship of trait mindfulness to physical and psychological health during pregnancy

INTRODUCTION

Research on mindfulness has extended to the prevention of psychopathology and physical conditions during pregnancy. The purpose of this study was to investigate the relationship between trait mindfulness assessed in the first or early second trimester to health outcomes throughout pregnancy.

METHODS

A total of 510 women were recruited at McGill University-affiliated obstetrics clinics (average gestational age: 13.43 weeks, sd = 1.2). The Mindful Awareness and Attention Scale (MAAS) was administered at baseline. At three timepoints during pregnancy, participants completed the Perceived Stress Scale (PSS-10), the Edinburgh Postnatal Depression Scale (EPDS), the Prenatal Distress Questionnaire-revised (PDQR) and a measure of pregnancy symptom intensity and indicated whether they had been diagnosed with gestational diabetes or high blood pressure.

RESULTS

Higher MAAS scores predicted lower PSS, EPDS and PDQR scores and less severe physical discomforts throughout pregnancy. MAAS scores were a stronger predictor of PSS scores earlier in pregnancy. Logistic regressions found that trait mindfulness did not predict the presence of physical discomforts, diabetes or high blood pressure.

CONCLUSIONS

These results indicate that trait mindfulness is an important predictor of subjective stress, depression, anxiety and the severity of physical discomforts during pregnancy. These findings suggest that interventions earlier in pregnancy may increase the impact of mindfulness on maternal health.

Sleeping for two: study protocol for a randomized controlled trial of cognitive behavioral therapy for insomnia in pregnant women

BACKGROUND

Insomnia and sleep disturbances are common in pregnancy and have potentially significant consequences for both maternal and infant health. There is limited research examining the effectiveness of cognitive behavioral therapy for insomnia (CBT-I) during pregnancy. With increased distress and limited access to services during the COVID-19 pandemic, there is also an unprecedented need for telehealth delivery of treatment programs for pregnant women. The aims of this trial are to evaluate the impact of the Sleeping for Two adaptation of CBT-I in pregnancy (in-person or telehealth) versus treatment as usual (TAU) in reducing symptoms of insomnia (primary outcome), as well as increasing gestational length and reducing symptoms of depression (secondary outcomes).

METHODS

A two-arm, single-blinded, parallel group randomized controlled trial (RCT) design with repeated measures will be used to evaluate the impact of CBT-I compared to TAU among a sample of 62 pregnant women, enrolled between 12 and 28 weeks of gestation, who self-identify as experiencing insomnia. Five weekly individual sessions of CBT-I will be delivered in person or via telehealth depending on physical distancing guidelines. Assessment of insomnia diagnosis by structured interview, self-reported insomnia symptom severity and sleep problems, and sleep quantity and quality as measured by a daily diary and actigraphy will occur at 12-28 weeks of pregnancy (T1), 1 week post-treatment (T2), and 6 months postpartum (T3).

DISCUSSION

CBT-I delivered in pregnancy has the potential to reduce symptoms of insomnia and depression and could lead to reduced risk of preterm birth, all of which can minimize risk of negative maternal and child health and developmental consequences in the short (e.g., infant death) and long terms (e.g., developmental delays). This RCT builds on a successful open pilot trial conducted by our team and will provide further evaluation of a novel evidence-based treatment for pregnancy-related insomnia, which can be widely disseminated and used to treat individuals that are most in need of intervention. Findings will enhance understanding of pregnancy-related sleep problems, as well as means by which to improve the health and sleep of mothers and their children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03918057. Registered on 17 April 2019.

Effect of supportive counseling on pregnancy-specific stress, general stress, and prenatal health behaviors: A multicenter randomized controlled trial

OBJECTIVE

The aim of this study was to investigate the effects of group supportive counseling (SC) on pregnancy-specific stress, general stress, and healthy behavior of pregnant women.

METHODS

This randomized controlled trial study was conducted on 80 pregnant women in two groups; SC for six sessions, once a week for two hours (n = 40), and antenatal usual care (AUC) (n = 40). All Participants completed questionnaires measuring pregnancy-specific stress, state anxiety, prenatal health behaviors, perceived stress, and provided a saliva sample for measurement of cortisol at pre-intervention and 6-week post-intervention.

RESULTS

The post-intervention results indicated that the outcome scores decreased more significantly in group SC than in the AUC for total NuPDQ, for state-anxiety, for PSS-14, and for unhealthy behaviors with a large effect size. Also, healthy behaviors were promoted more significantly in SC group than in AUC. However, salivary cortisol levels did not differ between group SC and AUC groups.

CONCLUSION

Group supportive counselling can promote pregnancy stress and healthy behaviors.

PRACTICE IMPLICATIONS

Addition of supportive counseling to prenatal usual care may be suggested for pregnant women with any gestational age who seek methods for improving pregnancy stress and healthy behaviors.

Concerns of women regarding pregnancy and childbirth during the COVID-19 pandemic

OBJECTIVE

Better understand knowledge, attitudes and practices of pregnant women and mothers of infants around coronavirus disease 2019 (COVID-19).

METHODS

A 58-item electronic survey was distributed to pregnant and postpartum women (infants <12 months) who were >15 years, English-speaking and enrolled in prenatal programs. Data is summarized using central tendency, frequencies and nonparametric statistics.

RESULTS

Of 114 (51 % response rate) participants, 82.5 % reported negative changes in mental status measures (e.g. stress, anxious thoughts, changes in sleep patterns). All reported risk-reduction behavior changes (e.g. handwashing/use of sanitizer, social distancing). Significant changes were reported in employment and financial status due to the pandemic. Increases in alcohol consumption among postpartum women were also reported. Few reported changes in prenatal, infant or postpartum healthcare access.

CONCLUSION

This study provides initial insight into the knowledge, attitudes and practices of pregnant and postpartum women during the COVID-19 pandemic. This study is limited as participants represent a single Midwest community and social desirability response bias may have impacted responses. However, results may inform future interventions to support pregnant women and mothers of infants during pandemics.

PRACTICE IMPLICATIONS

Providers should consider the impact of such events on mental status, access to resources and changes in behaviors.

Effects of cognitive-behavioural therapy for stress management on stress and hair cortisol levels in pregnant women: A randomised controlled trial

OBJECTIVE

To demonstrate the effectiveness of a cognitive behavioural therapy for stress management in pregnant women in the reduction of psychological stress and hair cortisol levels.

METHODS

The trial was controlled and randomised, with a total of 78 pregnant women: control group (n-39) and Cognitive Behavioural Therapy group (n-39). To test the therapy's efficacy, an evaluation of the primary outcome (hair cortisol levels) and secondary outcomes (psychological stress, psychopathological symptomatology and resilience) was conducted before and after the treatment. The therapy was conducted during 8 sessions (one per week) in a group setting. The study was registered as a Randomised Controlled Trial with the code NCT03404141.

RESULTS

The results showed a group time interaction between hair cortisol levels, psychological stress (perceived and pregnancy-specific), and in the exacerbation and severity of psychopathological symptoms. These variables presented reductions after treatment only in the Cognitive Behavioural Therapy group.

CONCLUSIONS

Using a novel way of assessing chronic stress (psychological and objective measures as hair cortisol levels), this is the first study that has shown a decrease in both the levels of cortisol in hair and in psychological stress. This decline could have implications for maternal and fetal health.

Mindfulness interventions during pregnancy: A narrative review

Pregnancy is a period of major transformations in a woman's life; increased stress, and mood and sleep disorders are frequent. This review evaluates mindfulness interventions during pregnancy and their ability to help manage stress, anxiety, depression, emotional regulation, level of mindfulness and sleep quality. A search of English language scientific literature relevant to mindfulness interventions for pregnant women was conducted using PubMed, Scopus and Web of Science, without restriction on publication date. Inclusion criteria were randomized clinical trials with pregnant women, using mindfulness as an intervention for at least three weeks, in one of our main areas of interest, and using only validated scales to measure outcomes. Two hundred and thirty studies were identified in our searches of research databases, and thirteen were included in our analysis. We found a large diversity of mindfulness programs, heterogeneity among the instruments used to evaluate outcomes, and inconsistency in the gestational periods used in the studies. Mindfulness interventions were beneficial for stress, anxiety and depression. Mindfulness was also effective when applied in pregnant women with a history of depression or experiencing depression. Considering emotional regulation and the level of mindfulness, there were signs of improvement, but more studies are needed. None of the studies evaluated sleep quality. Our review provides information about current mindfulness programs, an overview of the effects of mindfulness interventions, a description of the measurements used so far, and recommendations for developing high-quality mindfulness protocols for pregnant women.

Feasibility of incorporating mindfulness based mental health promotion to the pregnancy care program in Sri Lanka: a pilot study

Background: Though widely discussed, mindfulness-based interventions (MBI) to improve maternal mental health is limited by lack of studies with system incorporation. We evaluate the feasibility of incorporating a MBI program into routine antenatal care (ANC) in Sri Lanka.

Methods: MBI included learning mindfulness concepts, practicing mindfulness sitting/reclining meditation, performing mindful movements and practicing mindfulness in daily life. Feedback from the participants were obtained through an anonymous, self-administered, semi-structured questionnaire to determine the program’s cultural appropriateness, usefulness, and feasibility.

Results: Participants reported that the training reduced the stress of their daily life, brought a sense of calmness to their mind and body, and improved their anger management. Participants felt strongly that this training would be very useful and a shortened version be included in the national ANC program.

Conclusions: This pilot study suggests that an interventional study to evaluate system incorporation of a MBI to improve maternal mental health is feasible.

Is cognitive behavioral therapy a better choice for women with postnatal depression? A systematic review and meta-analysis

The present study evaluated the combined effectiveness of cognitive behavioral therapy (CBT) for postnatal depression. A systematic search was conducted across databases including PubMed, Embase, and the Cochrane library to identify the randomized controlled trials (RCTs) that assessing CBT versus control for postnatal depression until March 2017. Data was extracted by two reviewers, independently. The Review Manager 5.3 and Stata 11.0 were used to calculate the synthesized effect of CBT on depression, and anxiety. A total of 20 RCTs involving 3623 participants were included. The results of meta-analysis showed that CBT was associated with a better Edinburgh Postnatal Depression Scale (EPDS) than control in short-term (mean difference = -2.86, 95% CI: -4.41--1.31; P<0.05) and long-term (mean difference = -1.68, 95% CI: -1.81-1.56; P<0.05). CBT also improved short-term (mean difference = -6.30, 95% CI: -11.32--1.28; P<0.05) and long-term (mean difference = -4.31, 95% CI: -6.92--1.70; P<0.05) Beck Depression Inventory (BDI). Subgroup analysis based on intervention types showed that in-home and telephone-based therapy exhibited significant reductions in EPDS scores (P<0.05 for all). CBT significantly improved the short-term [odds ratio (OR) = 6.57, 95% CI: 1.84-23.48; P<0.05] and long-term (OR = 2.00, 95% CI: 1.61-2.48; P<0.05) depressive symptomatology as compared to control. CBT also reduced the score of Depression Anxiety Stress Scales (DASS), though without significance. In conclusion, CBT effectively improved the symptoms and progression of postnatal depression.

The effects of computer-based mindfulness training on Self-control and Mindfulness within Ambulatorily assessed network Systems across Health-related domains in a healthy student population (SMASH): study protocol for a randomized controlled trial

BACKGROUND

Self-control is an important ability in everyday life, showing associations with health-related outcomes. The aim of the Self-control and Mindfulness within Ambulatorily assessed network Systems across Health-related domains (SMASH) study is twofold: first, the effectiveness of a computer-based mindfulness training will be evaluated in a randomized controlled trial. Second, the SMASH study implements a novel network approach in order to investigate complex temporal interdependencies of self-control networks across several domains.

METHODS

The SMASH study is a two-armed, 6-week, non-blinded randomized controlled trial that combines seven weekly laboratory meetings and 40 days of electronic diary assessments with six prompts per day in a healthy undergraduate student population at the Johannes Gutenberg University Mainz, Germany. Participants will be randomly assigned to (1) receive a computer-based mindfulness intervention or (2) to a wait-list control condition. Primary outcomes are self-reported momentary mindfulness and self-control assessed via electronic diaries. Secondary outcomes are habitual mindfulness and habitual self-control. Further measures include self-reported behaviors in specific self-control domains: emotion regulation, alcohol consumption and eating behaviors. The effects of mindfulness training on primary and secondary outcomes are explored using three-level mixed models. Furthermore, networks will be computed with vector autoregressive mixed models to investigate the dynamics at participant and group level. This study was approved by the local ethics committee (reference code 2015_JGU_psychEK_011) and follows the standards laid down in the Declaration of Helsinki (2013).

DISCUSSION

This randomized controlled trial combines an intensive Ambulatory Assessment of 40 consecutive days and seven laboratory meetings. By implementing a novel network approach, underlying processes of self-control within different health domains will be identified. These results will deepen the understanding of self-control performance and will guide to just-in-time individual interventions for several health-related behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02647801 . Registered on 15 December 2015 (registered retrospectively). .