Culturally sensitive, preventive antenatal group cognitive-behavioural therapy for Chinese women with depression

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  • O R I G I N A L A R T I C L E

    Culturally sensitive, preventive antenatal groupcognitivebehavioural therapy for Chinese

    women with depression

    Sharron SK Leung PhD RN FHKANSchool Principal, School of Nursing, The Hong Kong Baptist Hospital

    Antoinette M Lee PhD BSocSc Reg PsycholAssistant Professor, Department of Psychiatry, The University of Hong Kong, Hong Kong

    Vico CL Chiang PhD MHA BN RN FHKCCCNAssistant Professor, School of Nursing, Hong Kong Polytechnic University, Hong Kong

    SK Lam MBBS (HK) FHKCOG FHKAM (O&G) FRCOG DCH (Ireland)Honorary Clinical Associate Professor, Department of Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong

    Yung Wai Kuen MBBS (HK) MRCOG FHKCOG FHKAM (O&G)Associate Consultant, Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong

    Daniel FK Wong PhD MSW BSW BAProfessor, Department of Applied Social Studies, City University of Hong Kong, Hong Kong

    Accepted for publication May 2012

    Leung SSK, Lee AM, Chiang VCL, Lam SK, Yung C, Wong DFK. International Journal of Nursing Practice 2013;19 (Suppl. 1): 2837

    Culturally sensitive, preventive antenatal group cognitivebehavioural therapy for Chinese womenwith depression

    Postnatal depression (PND) affects 1015% of postnatal women worldwide, yet it is poorly recognized and managed.Among the psychological interventions, which are used to manage PND, cognitivebehavioural therapy was found to beeffective and promising. In the past decade, research efforts have focused on developing effective antenatal interventionsto prevent PND. Strong antenatal predictors such as antenatal depressive symptoms have been identified for targeted earlyintervention or prevention to help reduce the risk of developing depression after childbirth. However, the findingsregarding effectiveness of antenatal preventive interventions have been inconsistent. Based on the reports of previousstudies, a brief group antenatal intervention using cognitivebehavioural approach is necessary, particularly one withsensitivity for Chinese woman. This paper reports the details of a nurse-led cognitivebehavioural programme developed

    Correspondence: Sharron S.K. Leung, The Hong Kong Baptist Hospital, C-Bons International Center, 108 Wai Yip Street, Kowloon, Hong Kong.Email:


    International Journal of Nursing Practice (2013) 19 (Suppl. 1), 2837

    doi:10.1111/ijn.12021 2013 Wiley Publishing Asia Pty Ltd

  • and tested in, and for use with a sample of Hong Kong pregnant women. The trial run showed that the programme wasfeasible to be implemented and well received by the participants.

    Key words: cognitivebehavioural therapy, nurses practice patterns, postnatal depression, prenatal care,preventive therapy.

    INTRODUCTIONPostnatal depression (PND) is a form of maternal mooddisorder with onset after childbirth. Its significantly nega-tive and long-term impact on women, infants and theirfamilies has been consistently reported around the world.1

    According to the World Health Organization,2 by 2020,major depression, including PND as a subcategory, will bethe second highest worldwide cause of death and disabil-ity. Therefore, developing effective antenatal preventiveinterventions for post-partum depression is crucial to notonly relieving the predicted burden on the health-caresystem, but also for enhancing maternal well-being,family functioning and infant health and development.This paper presents the current evidence and then thedesign and testing of feasibility of a brief interventionprogramme for PND that is culturally appropriate forpregnant Chinese women in Hong Kong.

    PND affects 1015% of post-partum women in theWest1 and 1119.8% in Asia including Hong Kong.3 Pre-vious studies yielded varying rates of PND (021%) indifferent Chinese populations in Singapore, Malaysia andChina.4,5 In Hong Kong, diagnostic interviews identifiedapproximately 6% of post-partum women with majordepression and 5% with minor depression during the firstpostnatal month,3 and 19.8% at the sixth postnatal weekbased on the self-reported questionnaire, the EdinburghPostnatal Depression Scale (EPDS) scores of 13 or above.6

    Postnatally depressed women were more likely tosuffer from long-term mental and cognitive dysfunctionsas well as physical illness.7 They were at increased risk ofdeveloping depression in the future and had lower self-perception, self-esteem, psychological well-being andreduced ability to take care of their babies.8 PND causedinsecurity, avoidance of attachment and bonding prob-lems between the mother and her infant,9 and their part-ners well-being was also affected. It was found that524% of the spouses of postnatally depressed womenwere found to have depression during the early postnatalperiod.10,11 And overall, men of partners with PND had2 to 2.5 times increased risk of developing depressionthemselves.12,13

    There is growing evidence showing that PND signifi-cantly affected the motherchild relationship, as well as thechilds cognitive, behavioural and emotional develop-ment.14 Long-term effects of PND on children werereported including behaviour problems such as sleep dis-turbances, eating problems, temper tantrums, suboptimalcognitive development and difficulties in social and inter-personal interactions.8 Available treatment for PNDincluded pharmacological, psychological and combinationof these two approaches. A meta-analyses15 of 27 interven-tion studies showed that psychological interventions(n = 17) for perinatal depression were effective with anaverage effect size (0.67) comparable with the overalleffect size (0.65) including pharmacological, psychologicaland combined studies. The most commonly reported psy-chological interventions were cognitivebehavioural psy-chotherapy and interpersonal psychotherapy. Moreover,PND women preferred psychotherapy over pharmacologi-cal treatment,16 and the acceptability of psychotherapy wasas high as 95% of PND women.17

    In Hong Kong, a recent study on 357 pregnantwomen18 found that antenatal depression was prevalent inall three trimesters (22.1%, 18.9%, 21.6%, respec-tively). Besides, both antenatal depression and anxietywere significantly predictive of PND at the sixth weekafter delivery. In view of the global data and convincinglocal Hong Kong findings, there is a pressing need todevelop and test the effectiveness of early interventionstargeting pregnant women with depressive symptoms.

    Antenatal prevention for PNDThe literature calls for continuous efforts to generateclear evidence on preventive interventions for womenwith PND. Two systematic reviews on antenatal inter-ventions for PND concluded that there was still insuffi-cient evidence on the effectiveness of the psychologicalinterventions.19,20

    A systematic review of five studies reported that onlytwo found significant differences between the interven-tion and comparison groups.19 All those studies targetedwomen at high risk for PND but used different

    Culturally sensitive antenatal cognitivebehavioural therapy 29

    2013 Wiley Publishing Asia Pty Ltd

  • approaches. One of the two that reported significant find-ings tested a psychoeducational and empowerment-basedgroup intervention21 and found that the interventiongroup had significantly lower depressive symptoms thanthe control group in first-time mothers, but not in second-time mothers. Another study reported that interpersonaltherapy was effective in reducing depressive symptoms inthe intervention group, compared with participants in thecontrol group.22 However, this study targeted only anunderserved minority ethnic group. Similarly, anothersystematic review noted that the studies demonstratedmixed outcomes due to several limitations of the studiessuch as varied definition of at risk status of target popu-lation, small sample and high attrition. Authors noted thatthe weak findings of these studies reflected more about thequality of study designs than the promise of the interven-tions. The authors concluded that there is a pressing needfor research on psychological intervention particularlyamong antenatal women.

    Cognitivebehavioural therapy (CBT) showed encour-aging findings in several studies in reducing depressivesymptoms among postnatal women.17,23,24 Two studiesreported the use of group CBT with pregnant women,however, the findings were inconclusive. One involveda RCT of a 12 week group programme using CBT on41 low-income pregnant women.25 Participants werescreened by the Center for Epidemiological StudiesDepression Scale, and at 12 months follow-up, those inthe intervention group reported significantly fewer majordepressive episodes (14%) than those in the comparisongroup (25%). Participants in the comparison groupreceived usual medical care and information of local socialservices upon request. However, the authors noted a lowadherence rate with average attendance of only 7 out ofthe 12 sessions and some participants delivered theirbabies before the last session. The authors suggestedrecruiting participants earlier in the pregnancy and toshorten the programme.

    Another study in Australia, reported a randomizedcontrolled trial (RCT) of a six-session antenatal groupCBT intervention with 191 pregnant women.26 The CBTintervention comprised six 2 h sessions and a follow-upsession. The focus was on prevention and management ofstress, anxiety and low mood, with more emphasis onbehavioural strategies than cognitive intervention. TheCBT group was not superior to the comparison groupbased on the intention-to-treat analysis, although par-ticipants with EPDS scores of 12 or above had a 50%

    reduction in depressive symptoms from baseline to thefourth-month postnatal follow-up. The authors explainedthat the comparison group received comprehensive infor-mation despite not attending the intervent