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: sharronskleung@hkbh.org.hk

    bs_bs_banner

    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

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  • 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 intervention, whichmight have been a confounding variable. The comparisongroup was also offered one tailored antenatal session withCBT strategies for PND, community resources and post-natal telephone follow-up. Furthermore, insignificant dif-ferences could also be due to the low mean EPDS scores(6.888.16) at baseline for both intervention and controlgroups. Besides, the participants were identified as at-risk group for PND with a questionnaire of nine psycho-social risk factors developed by Austin19 rather than byelevated depressive scores.

    The emerging evidence in the literature showed thatantenatal preventive psychological intervention is a prom-ising intervention for PND. However, given the incon-sistent findings, greater effort is still needed in developingefficacious antenatal intervention programmes. As manyexperiences during pregnancy and in the post-partumperiod are very much determined by cultural values, atti-tudes and practices, there is also a need for an interventionthat is culturally appropriate for Chinese women in HongKong. The following section reports an antenatal CBTintervention, which was developed for, and tested with,Chinese pregnant women for the purpose of preventingPND. Table 1 shows the comparison of this interventionwith the two antenatal CBT interventions as reviewedpreviously.25,26

    AimsThis paper reports a brief group-based intervention usingthe cognitivebehavioural approach to reduce depressionand depressive symptoms of Chinese pregnant women inHong Kong and to prevent PND. Main features, format,outline and quality assurance of the intervention as well asuseful information for recruitment and recommendedmeasures are presented here and results of the trial run ofthe programme presented elsewhere.27

    CULTURALLY SENSITIVE ANTENATALCBT FOR CHINESE WOMEN

    The main features of this group intervention are that1. It is a brief intervention with participants recruited

    as early as in their second trimester to maximizeretention.

    30 SSK Leung et al.

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  • 2. It is relatively inexpensive, and accessible, beingconducted in a group format and facilitated bynon-specialists.

    3. It identifies the at-risk group based on a validatedscreening tool for depressive symptoms.

    4. It is culturally appropriate for Chinese populations.The programme was developed with specific reference

    to Chinese cultural norms and beliefs to maximize theeffect of the CBT. The key to such a programme is toidentify the irrational thoughts and to help the pregnantwomen to generate more positive and rational thinking,which will, in term, help to regulate their emotions. Theprogramme was modified, and originally found to beeffective, from a longer programme for depressive adultpatients in Hong Kong with mild to moderate depressivesymptoms.28 Participants in the intervention groups at theend of this longer 10-week programme reported signifi-cantly less depressive symptoms, dysfunctional rules andnegative emotions, as well as significantly more adaptivecoping skills than those in the control groups. The pro-gramme was modified to suit participants with a Chinesecultural background such as exploration of dysfunctionalrules relating to Chinese beliefs of family relationships

    and detailed explanation of the exercises.28 Worksheetsand exercises were developed and used to facilitate dis-cussion and application of the CBT concepts. Terms andconcepts used in these exercises were hence translatedand rephrased using colloquial expressions to ensure cul-tural appropriateness.28

    Wongs28 programme was condensed to a 6-week pro-gramme, then case studies, common irrational thoughtsand underlying constraining beliefs were adapted to preg-nancy and parenthood. This shortened programme aimsto help mothers to uncover their own misconception ofthe myths about motherhood.29 By identifying and recon-structing irrational thoughts, participants can generatealternatives to the traditional views of maternal caring andmotherhood. Cultural-specific modification is thusrequired particularly in the identification of rules andbeliefs of irrational thoughts as well as identifying strate-gies to relax those restraining rules. For example,mothers commonly expressed that I am not a goodmother if I cannot exclusively breastfeed and provide allthe best to my baby; I should not show any disagreementwith my parents-in-law, including childcare approachesand perinatal care; If my mother-in-law does not

    Table 1 Comparison of antenatal preventive interventions using cognitivebehavioural approaches for preventing postnatal depression

    Muzo et al.25 Austin et al.26 Leung et al.27

    Participants 41 Latina pregnant women in the USA; 38

    per group

    191 pregnant women in Australia 97 pregnant women in Hong

    KongScreening for

    high risk

    Identify high risk by: past history of major

    depressive episodes, and/or CES-D 16

    EPDS 12 EPDS 10

    Intervention 12 sessions and 4 postnatal booster sessions Six sessions, 2 h each, and one later

    follow-up session

    Six sessions, 2 h each

    Interventionist Faculty, postdoctoral fellows, advanced

    doctoral graduate students in clinical

    psychology; weekly supervised by

    licensed clinical psychologist

    Clinical psychologist and one trained

    midwife as co-therapist

    Trained social worker and

    nurses

    Foci Emphasize prevention; focuses on managing

    challenges of pregnancy, labour and

    childbirth, develop secure attachment,

    and increase awareness of physiological

    effects of stress, increase positive

    activities, modify cognitive distortions

    and automatic thoughts, increase social

    network, learnt parenting strategies

    Cognitive: unhelpful attitudes,

    assertiveness skills, how to develop

    social support network.

    Cognitive: automatic thoughts,

    constraining beliefs,

    cognitive reconstruction

    Behavioural: pleasant event scheduling,

    relaxation training, goal setting,

    problem solving

    Behavioural: plan pleasurable

    events, 5S strategies

    EPDS, Edinburgh Postnatal Depression Scale; CES-D, Center for Epidemiological Studies Depression Scale.

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  • change, I will never be happy again. The participantswere invited to discuss the thoughts related to their spe-cific life events, and members in the group helped toidentify thought traps, underlying rules and alternativeviews to relax those rules.

    The literature relating to studies on pregnant and post-natal women in Hong Kong was utilized as a foundationfor enhancing the cultural sensitivity of the CBT. Previousstudies in Hong Kong revealed stress among antenatal andpostnatal women relating to cultural and social norms.Among 11 postnatally depressed women at the sixth post-natal month, stress-related issues included perceived lackof competence in childcare and conflict within a culturaland traditional context.30 The Chinese postnatal ritual ofdoing the month could also be a source of stress whenthe preference of the new mother was in conflict with thistraditional custom.31 A study on 551 couples also foundthat the stress associated with doing the month mightcontribute to postnatal paternal and maternal depressionin Hong Kong.32

    Chan et al.33 reported the experience of postnatallydepressed women in Hong Kong and compared them withthose in mainland China and Australia.34 Experiencesunique to Hong Kong Chinese were identified, whichincluded marital problems and power relationship withthe in-laws. The practice of doing the month and therelationship with the mother-in-law were also unique toChinese culture.35 In particular, the problems of tradi-tional perinatal rituals as described in detail in Gaoet al.s35 and Leung et al.s31 studies form the basis forformulating strategies that take into account the specificcultural issues pertinent to Chinese postnatal women. Aspecific cultural factor, concern for face, of Chinesewomen was noted in another study.36 Those who werehighly concerned about face were more likely to showearly depressive symptoms and less likely to seek help,36

    because they perceived seeking help as evidence ofincompetence. In the group, participants were facili-tated to discuss their plans and preparation for post-partum rituals and care, whether they sought and receivedany help from parents, parents-in-law and other friendsor family members, and how they perceived thosesupport.

    Format and outline of the interventionThe CBT intervention could be offered for individuals orin groups. Although individual-based intervention mightbe more effective than group based for preventing PND,37

    group intervention has the advantages of efficient use oftime and group dynamics to facilitate interpersonal learn-ing.25 Group treatment has been shown to be as efficaciousas individual therapy for treating depressed individuals innon-specialist settings.38 The proposed programme is anurse-led, group-based intervention with six weekly ses-sions of 2 h duration, each with carefully designed objec-tives and activities (Table 2). A consistent structure isused in each session. In the beginning of the session, thegroup reviews the homework and each participant reportstheir emotional status, and at the end of the session, theysummarize their perception of the session in one sentence.In the first session, the group is introduced to the pro-gramme purpose and session agenda. An ice-breakinggame is used to establish rapport and introduce the groupmembers to each other. Participants are then introducedto the concept of emotional temperature and a thermom-eter to assess their own emotional status of the last 7 dayson a scale of 110 (1 = very unhappy; 10 = very happy).Mood problems that are common in the antenatal andpostnatal period are briefly explained. Two paper cases ofdepression are used to introduce the activating events,beliefs and consequences (ABC) model used in CBT tohighlight the salience of negative thoughts and their rela-tionship to depressive symptoms. Common stressfulevents among Chinese pregnant and postnatal womenwere used to design paper cases. Those stressful eventswere reported in qualitative studies and previous trial rungroups on Hong Kong Chinese perinatal women. Finally,participants are assigned the homework of recording on aworksheet their negative thoughts and activating events inthe coming week.

    In the second session, homework assignments arereviewed and participants share an activating event thatresulted in negative feelings. Participants help each otherto learn identifying the physiological, emotional, cogni-tive and behavioural responses and, particularly, the typesof irrational thoughts that mediate the relationshipbetween activating events and negative consequences.Common irrational thoughts, particularly those related toChinese perinatal rituals and childcare, were noted inprevious studies, and trial run group sessions wereadopted to develop the worksheets on irrational thoughtsand underlying core beliefs.

    In the third session, after sharing the results of previoushomework, participants are introduced to body signalsrelating to depression and the 5S approach in managingdepressive symptoms. The 5S in short is a set of

    32 SSK Leung et al.

    2013 Wiley Publishing Asia Pty Ltd

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    Culturally sensitive antenatal cognitivebehavioural therapy 33

    2013 Wiley Publishing Asia Pty Ltd

  • five strategies that guide participants to use cognitivebehavioural approaches to manage their own emotions instressful situations. The strategies included: (i) awarenessof the signs of physiological responses due to stress ordistress, and to differentiate those due to pregnancy; (ii)halting the automatic thought; (iii) asking themselvesreflective questions to challenge the automatic thought;(iv) engaging in behaviours that are safe to themselves andtheir foetuses, to divert attention; (v) writing up smartcards with wisdom quotes as self-reminders. Participantshelp each other to challenge the negative cognitions byapplying the 5S approach. For homework, participantscontinue to identify negative thoughts but are asked to tryto replace them with positive thoughts. They then listpleasurable activities and rate the feasibility and perceivedenjoyment levels of the activities. They are encouraged inat least one pleasurable activity in the coming week.

    In the fourth session, participants share the results ofreconstructed thoughts. The group also share any difficul-ties encountered in applying the 5S and help each other toidentify solutions. They learn the dysfunctional rules andrestraining beliefs that govern their thought patterns andinfluence their emotions. Many of those beliefs are relatedto roles and expectation in Chinese family relationships.Participants help each other to understand their own dys-functional rules and restraining beliefs. They also discusspleasurable activities that they engage in and the impact ofthose activities on their mood. For homework, participantsare asked to identify dysfunctional and restraining beliefsand to engage in another pleasurable activity.

    In the fifth session, participants share their homeworkprogress. They then learn ways to relax the restrainingbeliefs. Examples are provided to facilitate learning andparticipants are encouraged to share their own restrain-ing beliefs and practice together with the group in relaxingthose beliefs. They are asked to practice relaxing oneof their restraining beliefs in the following week ashomework.

    In the sixth session, participants discuss their experi-ences of relaxing beliefs. They are introduced to examplesof thought-transforming statements that help relaxingbeliefs and correcting negative thoughts. Participants areasked to write up their own statements and keep them forfuture use. At the end of the session, participants consoli-date what they have learnt in all the previous sessions,share their progress of applying the ABC model and thenplan ahead for social contacts or situations that mighttrigger negative thoughts and depressed mood.

    Quality assurance of interventionThe intervention content was developed by first author(SL) and senior author (DW), who is a RegisteredCognitiveBehavioural Therapist, based on a validated10-session group for depressed adults in Hong Kong.24

    The sessions were conducted by the first author (SL) anda trained interventionist. Quality assurance was main-tained by using detailed intervention manual to guide theprogramme delivery and fidelity checking. Interventionsessions were video-taped and reviewed by independentfidelity raters. A clear fidelity rating form was used totrack the interventionists adherence of facilitation asstated in the intervention manual.

    Trial run of the programmeA trial of the programme was conducted using quasi-experimental design at a public hospital from April 2009 toJune 2010. Pregnant women were recruited at the antena-tal clinic by convenience sampling. Eligible participantswere pregnant women (first- and second-time mothers)between 14 and 28 weeks gestation, aged 18, Hong Kongresident, able to communicate in Chinese and scored 10 orabove on the EPDS.39 Participants were excluded if theydid not stay in Hong Kong after childbirth or were diag-nosed with mental illness and requiring medication. Datawere collected at recruitment as baseline and then within1 week after the intervention. Chinese versions of vali-dated measurements were used that included: (i) the EPDSand the Hospital Anxiety and Depression Scale (HAD)40 fordepression; (ii) the Perceived Stress Scale (PSS)41 for per-ceived stress; (iii) Dysfunctional Attitudes Scale42 for irra-tional thoughts; (iv) Family APGAR (Appearance, Pulse,Grimace, Activity, Respiration)43 for satisfaction withfamily functioning; and (v) demographic information. Theeffectiveness of the intervention was examined by groupdifferences between intervention and control groups afterthe intervention using repeated measure analysis of vari-ance controlled for baseline measure. Intention-to-treatapproach was used for analysis. Parameters for thosewithdraw or lost contacts were considered unchanged withthe last observation to replace missing values at post-intervention measure (carried-forward method).

    Pregnant women were invited to participate duringtheir visits to the antenatal clinic. Among the 630 poten-tial participants approached, 517 of them had an EPDSscore < 10 and 143 (22.7%) scored greater than 10. Outof 143 eligible participants, 97 (68%) agreed to partici-pate with 47 in the intervention and 50 in the control

    34 SSK Leung et al.

    2013 Wiley Publishing Asia Pty Ltd

  • groups. Forty-six did not agree to participate due to a lackof interest, work schedule clashes with the programme orthey preferred avoiding hospital, where the interventionprogramme was held, as it was during the influenzaseason. Table 3 showed the means and standard deviationof the findings. Repeated measures analysis of covarianceshowed significant group differences favoured the inter-vention group on: (i) EPDS (F1, 95 = 5.02, P = 0.02); (ii)HAD (F1, 95 = 4.54, P = 0.03); (iii) PSS (F1, 95 = 5.04,P = 0.03); and (iv) Family APGAR (F1, 95 = 6.93,P = 0.01).

    Post-intervention evaluation collected immediatelyafter intervention by self-designed evaluation question-naires showed very positive feedback from the interven-tion groups.27 All participants (100%) agreed or stronglyagreed that the content was easy to understand. Themajority (90%) reported that most or some of the mate-rials or the discussion were useful. The programme wascommended for providing examples that stimulateddiscussion and sharing, providing insight to stimulate

    reflection and assisting them to analyze dysfunctionalthinking patterns, thus gaining insight for improvement.The trial run showed that the proposed recruitment pro-cedures were feasible and sufficient to recruit participantsfrom the antenatal clinic.

    IMPLICATIONSThis paper is the first to document the details of a cultur-ally sensitive, nurse-led group CBT for PND. Specificcultural issues identified from previous studies on thetarget population were taken into consideration in thedesign of the intervention. The presented programmedetails would enable nurses to design their own pro-grammes to be conducted in other settings. Simple home-work sheets with clear instructions, consistent structureof the sessions and end of session feedback are helpfulto engage the participants. Post-session evaluation withsimple survey about specific intervention content is alsouseful for improving the programme. Successful imple-mentation depends on the consistency in delivery of the

    Table 3 Means (SD) of intervention and control groups at baseline (T1), post-intervention follow-up (T2)

    Intervention (n = 47) Control (n = 50) Group mean difference Cohen d

    Mean SD Mean SD F1, 95 (P)

    EPDST1 12.17 2.33 13.92 2.87 5.02 (0.02) 0.24T2 9.04 3.76 12.69 5.89

    HAD-anxietyT1 6.64 2.56 7.82 1.83 0.63 (0.43) 0.15T2 6.41 3.54 6.73 3.20

    HAD-depressionT1 6.00 3.00 4.82 2.81 4.54 (0.03) 0.16T2 5.64 3.11 5.41 2.81

    DAST1 163.90 28.17 157.30 19.48 1.06 (0.31) 0.13T2 166.45 14.78 154.10 22.45

    PSST1 6.61 3.04 7.75 2.30 5.04 (0.03) 0.20T2 6.22 1.81 8.50 3.71

    Family APGART1 11.54 2.99 11.00 3.09 6.93 (0.01) 0.19T2 12.69 1.84 11.09 3.03

    Repeated measures ANCOVA controlled for baseline measure and income. Cohen d effect sizes: 0.20 (small), 0.50 (medium) and 0.80

    (large). DAS, Dysfunctional Attitude Scale (Weissman and Beck41); EPDS, Edinburgh Postnatal Depression Scale (Cox et al.39); Family

    APGAR (Smilkstein et al.43); HAD, Hospital Anxiety and Depression Scale (Zigmond and Snaith40); PSS, Perceived Stress Scale (Cohen and

    Hoberman42).

    Culturally sensitive antenatal cognitivebehavioural therapy 35

    2013 Wiley Publishing Asia Pty Ltd

  • programme that needs to be carefully monitored. Moni-toring can be done by providing the facilitators with adetailed intervention manual and maintaining a fidelitychecking system. RCT with larger sample and post-intervention and postnatal follow-ups is needed to evalu-ate the effectiveness of the programme in short term andover time. Assessment of the outcomes should includeboth the depressive symptoms as well as diagnosis ofdepression during pregnancy and after delivery. Cost-effective analysis to be assessed in future studies is alsonecessary to provide crucial information for managementdecision before incorporating this programme into theservice.

    CONCLUSIONThe review of the literature showed that there is an urgentneed for developing effective antenatal preventive inter-vention for PND. CBT is a promising approach withrather strong evidence of effectiveness among postnatalwomen. Initial testing of this nurse-led, brief antenatalcognitivebehavioural intervention indicated that theintervention was feasible for Hong Kong women andacceptable to the pregnant women. This paper providesuseful information for development and further testing ofthe intervention. A well-designed RCT is needed to ascer-tain the efficacy of such intervention.

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