A pilot study to reduce risk for antepartum depression among women in a public health prenatal clinic

Culturally adapted psychological intervention for treating maternal depression in British mothers of African and Caribbean origin: A randomized controlled feasibility trial

BACKGROUND

Women are likely to suffer from maternal depression due to childbirth difficulties and parenting responsibilities, leading to long-term negative consequences on their children and families. British mothers of African/Caribbean origin uptake of mental healthcare is low due to the lack of access to culturally appropriate care.

METHODS

A mixed-methods randomized controlled feasibility trial was adopted to test the appropriateness and acceptability of Learning Through Play plus Culturally adapted Cognitive Behaviour Therapy (LTP+CaCBT) for treating maternal depression compared with Psychoeducation (PE). Mothers (N = 26) aged 20-55 were screened for depression using the Patient Health Questionnaire (PHQ-9). Those who scored >5 on PHQ-9 were further interviewed using the Revised Clinical Interview Schedule to confirm the diagnosis and randomized into LTP+CaCBT (n = 13) or PE (n = 13) groups. Assessments were taken at baseline, end of the intervention at 3- and 6-months post-randomization. N = 2 focus groups (LTP+CaCBT, n = 12; PE, n = 7) and N = 8 individual interviews were conducted (LTP+CaCBT, n = 4; PE, n = 4).

RESULTS

The LTP+CaCBT group showed higher acceptability, feasibility and satisfaction levels than the PE group. Participants experienced the intervention as beneficial to their parenting skills with reduced depression and anxiety in the LTP+CaCBT compared to the PE group.

CONCLUSIONS

This is the first feasibility trial of an integrated online parenting intervention for British African and Caribbean mothers. The results indicated that culturally adapted LTP+CaCBT is acceptable and feasible. There is a need to study the clinical and cost-effectiveness of LTP+CaCBT in an appropriately powered randomized control trial and include the child's outcomes.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov (no. NCT04820920).

Psychological interventions for maternal depression among women of African and Caribbean origin: a systematic review

BACKGROUND

Maternal depression is a leading cause of disease burden for women worldwide; however, there are ethnic inequalities in access to psychological interventions in high-income countries (HICs). Culturally appropriate interventions might prove beneficial for African and Caribbean women living in HICs as ethnic minorities.

METHODS

The review strategy was formulated using the PICo (Population, phenomenon of Interest, and Context) framework with Boolean operators (AND/OR/NOT) to ensure rigour in the use of search terms ("postpartum depression", "maternal depression", "postnatal depression", "perinatal depression" "mental health", "psychotherapy" "intervention", "treatment", "black Caribbean", "black African", "mothers" and "women"). Five databases, including Scopus, PsycINFO, Applied Social Science Index and Abstracts (ASSIA), ProQuest Central and Web of Science, were searched for published articles between 2000 and July 2020. 13 studies met the inclusion criteria, and the relevant data extracted were synthesised and thematically analysed.

RESULTS

Data syntheses and analyses of included studies produced four themes, including (1) enhance parenting confidence and self-care; (2) effective mother-child interpersonal relationship; (3) culturally appropriate maternal care; and (4) internet-mediated care for maternal depression.

CONCLUSION

In the quest to address maternal mental health disparities among mothers of African and Caribbean origin in HICs, the authors recommend culturally adapted psychological interventions to be tested in randomised control trials.

Culturally adapted psychotherapies for depressed adults: A systematic review and meta-analysis

BACKGROUND

There is current debate about the effectiveness and generalizability of evidence-based psychological therapies in treatment of depression for diverse ethno-cultural groups. This has led to increasing interest in culturally adapted psychotherapies (CAPs).

METHODS

Studies on CAPs for face-to-face treatment of depressed adults were identified using nine electronic database searches. Data on the process of adaptation was analysed using thematic analysis and treatment efficacy was assessed through meta-analysis of Randomized Controlled Trials.

RESULTS

Fifteen studies were included in the review, of which eight were included in a meta-analysis. Cognitive Behavioural Therapy and Behavioural Activation were commonly selected approaches for CAPs, mainly based on their strong evidence base for effectiveness. Twelve studies reported the adaptation process that follows all or some phases recommended by the Medical Research Council Framework for developing complex interventions. A meta-analysis of 16 RCTs, which included eight studies from the current review and eight studies from an earlier review (Chowdhary et al. (2014), demonstrated a statistically significant benefit in favour of CAPs, reducing symptom burden [standardized mean difference -0.63, 95% confidence interval -0.87 to -0.39]. Subgroup analysis showed a larger effect when the intervention was for the majority ethnic group in a population, rather than a minority group.

LIMITATIONS

Some studies did not report all relevant information, and in the subgroup analysis only three studies were of minority groups.

CONCLUSIONS

CAPs were confirmed to be more efficacious than control treatments. This supports the continued development and evaluation of culturally adapted psychotherapies for depression.

Psychological interventions for depression and anxiety in pregnant Latina and Black women in the United States: A systematic review

Black women and Latinas have more symptoms of depression and anxiety during pregnancy than do their non-Latina White counterparts. Although effective interventions targeting internalizing disorders in pregnancy are available, they are primarily tested with White women. This article reviews randomized controlled trials and non-randomized studies to better understand the effectiveness of psychological interventions for anxiety and depression during pregnancy in Latinas and Black women. Additionally, this review summarizes important characteristics of interventions such as intervention format, treatment modality, and the use of cultural adaptations. Literature searches of relevant research citation databases produced 68 studies; 13 of which were included in the final review. Most studies were excluded because their samples were not majority Latina or Black women or because they did not test an intervention. Of the included studies, three interventions outperformed a control group condition and showed statistically significant reductions in depressive symptoms. An additional two studies showed reductions in depressive symptoms from pretreatment to post-treatment using non-controlled designs. The remaining eight studies (seven randomized and one non-randomized) did not show significant intervention effects. Cognitive behavioral therapy was the modality with most evidence for reducing depressive symptoms in pregnant Black and Latina women. No intervention was found to reduce anxiety symptoms, although only two of the 13 measured anxiety as an outcome. Five studies made cultural adaptations to their treatment protocols. Future studies should strive to better understand the importance of cultural modifications to improve engagement and clinical outcomes with pregnant women receiving treatment for anxiety and depression.

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.

Performance of a Culturally Tailored Cognitive-Behavioral Intervention Integrated in a Public Health Setting to Reduce Risk of Antepartum Depression: A Randomized Controlled Trial

INTRODUCTION

Cognitive-behavioral group interventions have been shown to improve depressive symptoms in adult populations. This article details the feasibility and efficacy of a 6-week, culturally tailored, cognitive-behavioral intervention offered to rural, minority, low-income women at risk for antepartum depression.

METHODS

A total of 146 pregnant women were stratified by high risk for antepartum depression (Edinburgh Postnatal Depression Scale [EPDS] score of 10 or higher) or by low-moderate risk (EPDS score of 4-9) and randomized to a cognitive-behavioral intervention or treatment as usual. Differences in mean change of EPDS and Beck Depression Inventory (BDI)-II scores for low-moderate and high-risk women in the cognitive-behavioral intervention and treatment as usual for the full sample were assessed from baseline (T1), posttreatment (T2), and one-month follow-up (T3), and for African American women in the subsample.

RESULTS

Both the cognitive-behavioral intervention and treatment-as-usual groups had significant reductions in the EPDS scores from T1 to T2 and T1 to T3. In women at high risk for depression (n = 62), there was no significant treatment effect from T1 to T2 or T3 for the EPDS. However, in low-moderate risk women, there was a significantly greater mean change in the BDI-II scores from significant decrease in the BDI-II scores from T1 to T2 (4.92 vs 0.59, P = .018) and T1 to T3 (5.67 vs 1.51, P = .04). Also, the cognitive-behavioral intervention significantly reduced EPDS scores for African American women at high risk (n = 43) from T1 to T2 (5.59 vs 2.18, P = .02) and from T1 to T3 (6.32 vs 3.14, P = .04).

DISCUSSION

A cognitive-behavioral intervention integrated within prenatal clinics is feasible in this sample, although attrition rates were high. Compared to treatment as usual, the cognitive-behavioral intervention reduced depressive symptoms for African American women at high risk for antepartum depression and for the full sample of women at low-moderate risk for antepartum depression. These promising findings need to be replicated in a larger controlled clinical trial that incorporates methods to maintain greater participant engagement.

Addressing perinatal depression in a group of underserved urban women: a focus group study

BACKGROUND

Perinatal mental health problems are common complications of pregnancy that can go undetected and untreated. Research indicated that mental health complications are more prevalent in women from disadvantaged communities, yet women from these communities often experience barriers to accessing treatments and interventions. Untreated depression during pregnancy can lead to poor self-care, increased substance abuse, poor obstetrical outcomes, developmental delay in children, and increased risk of postpartum depression. In this study we investigated the perceived perinatal mental health needs of our participants and they wanted to address their perceived needs.

METHODS

In this qualitative study, we invited women who resided in an underserved, urban community who were pregnant or who delivered within the past year to participate in focus groups.

RESULTS

Thirty-seven women participated in seven focus groups. Thirteen themes emerged which were described in relation to mental health needs, help currently accessed and the type of support wanted. The themes included the various mental health needs including dealing with changing moods, depression, feelings of isolation, worrying and a sense of being burdened. Women described using a limited range of supports and help. Participants expressed a preference for mental health support that was empowerment focused in its orientation, including peer support. Women also described the compounding effect that social and economic stresses had on their mental health.

CONCLUSIONS

Participants wanted access to a greater range of supports for mental health than were currently available to them, including peer support, and wanted assistance in addressing social and economic needs. These findings offer a challenge to further broaden the types of services offered to women, and demonstrate that those services need to be responsive to the challenging contexts of women's lives. Integrating women's views and experiences into the development of services may help to overcome barriers to care.

When she says "no" to medication: psychotherapy for antepartum depression

Many women suffering from major depressive disorder during pregnancy are hesitant to initiate or continue antidepressant treatment during preconception planning, conception, pregnancy, and lactation (perinatal period). Over the past few decades, various psychotherapeutic approaches have been found to be efficacious for depression in general population research. Several observational and quasi-experimental studies also suggest that psychotherapy can be a safe first-line treatment for perinatal women with mild to moderate depression. This article summarizes findings to date regarding the use of psychotherapy for depression occurring during pregnancy and describes the adaptations made to tailor the treatment to the unique needs of women in the perinatal period.

The validity of DSM symptoms for depression and anxiety disorders during pregnancy

BACKGROUND

The applicability of the symptom criteria for diagnostic mood and anxiety disorders has in recent times been questioned for women in the perinatal period, due to the overlap of diagnostic symptoms with normal symptoms due to the physical changes of pregnancy or postpartum, (e.g., sleep difficulties).

METHOD

118 women in their second or early third trimester of pregnancy participated in a telephone interview that included the depression and anxiety modules of the MINI diagnostic interview, and an attributional probe question asking the woman whether endorsement of a symptom was due to the physical changes of her pregnancy or due to her mood or worries.

RESULTS

66% of pregnant women who met criteria for major depression reported that a sufficient number of their symptoms were due to the normal physical changes of their pregnancy, such that they would no longer meet criteria for a diagnosis of major depression. Attributional probing resulted in the rate of major depression falling from 6.8% to 1.7%. The impact on anxiety disorders appears to be less.

LIMITATIONS

An important issue is whether women's attributional perceptions are valid, though the face validity of some of their responses means that credence should be given to the findings. In addition, it would be useful from a validity perspective to undertake the same attributional probing with other populations where symptom presence is most likely due to mood, such as unemployed or recently separated adults without physical complaints.

CONCLUSION

Rates of depressive disorders in pregnancy, using DSM symptom criteria, are significantly over-estimated due to the natural occurrence of many of the symptoms as a result of the pregnancy. Rates of anxiety disorders are also inflated, but to a lesser degree. This means that the validation of self-report mood measures, typically done against DSM diagnoses, is likely to have produced erroneous findings (e.g., optimum cut-off scores). It is probable that a similar finding would be obtained for the postpartum period. Thus future use of DSM symptom criteria for depression and anxiety in perinatal mental health work should use some form of attributional probing question to more accurately understand the applicability of symptoms to a diagnosis in this population.