Psychotherapy and non-pharmacologic Treatments

For Post-Partum Depression

Anne Hallward MDMAPP Meeting, May 16, 2008

Overview

Why psychotherapy

Themes in psychotherapy

Research on psychotherapy

Research on non-pharmacologic Treatment

Description of a therapy group.

Why Psychotherapy?

• distrust of medications, • stigma, • commitment to breastfeeding, • need for emotional support/ social isolation• finding meaning,• Wanting to parent well.• Combined with medication.

Choice of Treatment• Small study at Brown, N=23, (Pearlstein, TB,

2006)• 21/23 women chose IPT with or without sertraline.• Women with prior depression more likely to

choose sertraline (86%)• Breastfeeding women more likely to choose

psychotherapy alone (66.7%)• Treatment across all arms showed clinical

improvement on BDI, EPDS and HDRS (approx 70% in scores).

• No additional benefit from adding sertraline to IPT.

Breastfeeding Impact on treatment

• Battle et al. 2006• Brown Partial Hospital for perinatal

psychiatric disorders• 61% of 74 breastfeeding moms willing to

try Rx• 86% of 145 non-breastfeeding moms

willing to try Rx.

Breastfeeding

• May worsen depression: sleep deprivation, sense of overwhelm and helplessness, fears about adequate volume, pain, lack of confidence, may limit choice of psychopharmacology, ?role of hormones

• May help with Depression: multiple benefits to baby, self-esteem, one thing doing right, calming role of oxytocin, supports bond, faster weight loss.

The Baby Book, William and Martha Sears

Benefits of Breastfeeding

• Higher IQ• Better vision• Fewer ear infections• Better dental alignment• Healthier heart• Fewer respiratory infections• Improved digestion

• Fewer intestinal infections• Less constipation• Leaner bodies (1.5 lb at 1 year)• less diabetes• Healthier skin• Increased immunity• Healthier growth

Beyond a treatment for Depression• heal old wounds• repair relationships, build one with baby• so as not to repeat with ones’ own child• self-understanding, finding meaning• Integrate the trauma of birth• Seeking an intimate relationship of support

Research on therapy for PPD, doesn’t tend to measure these.

The Postpartum Experience

• Are we having fun yet? • Sentimentalization of motherhood• Fears that ambivalence will harm the child• Culture of silence about difficulty• Stigma• Birth experience• Winnicott

Birth

• Encounter with death, either fear of dying or wish to die

• Powerful experience of something larger than you, happening to you, can re-trigger traumatic memories.

• Perfectionism• Polarization of parenting approaches• Inanna myth as metaphor

Crying

• Exposure to infant’s crying a trigger to one’s own unresolved grief, and one’s own experiences of being comforted or not.

• Response to child’s distress often overwhelming, frantic, helpless.

• siren

Psychotherapy Themes

• Attachment• self-esteem• Trauma• childhood memories• Body Image• affect regulation• Relationship change• anxiety

• Fears• guilt• Change in identity and role• Stigma• Grief and loss• Failure• shame

Shame and Guilt

• Shame• A deep sense of one’s whole being as

defective, unworthy• Affects the sense of self.

• Guilt• A sense of having done something bad• Has to do with behavior

Shame

• What kind of a mother am I?• What does it mean about me that I don’t

love the baby, don’t love being a mother, am not happy, am not grateful….

• Feel deeply unworthy, while at the same time longing to be worthy.

Guilt

• What if my depression is hurting my baby?• I have already failed, no way to redeem

what has already happened• What if the child finds out I didn’t want

him/her even briefly… • I am burdening my husband/partner/family

so much

Lessons from Brooke Shields

• Risk factors: prior loss, death of father, spouse who traveled, lack of help at home, pressure to maintain public image

• Combined medication and psychotherapy• Continued to breastfeed• Stigma was the biggest barrier to getting treatment• Getting more help at home made a tremendous

difference

Issues In her therapy• Differentiation from her mother, sense of her

primary loyalty shifting to her child.• “the inner voice in my head finally became louder

than my mother’s.”• Balancing her own needs with the needs of her

child• Integrating the sense of responsibility and fear for

another life.• Fears of her daughter not liking her.• Trying to find other mothers willing to talk.

Research on Psychotherapy

• Interpersonal psychotherapy (IPT)• Cognitive Behavioral Psychotherapy (CBT)• Psychodynamic• Group Therapy• Psychosocial Treatments: peer support,

telephone support, home nurse visits

Big Picture• Very little is effective preventively• All psychotherapies found to be effective as

treatment• See initial benefit of individual over group

treatment initially, which equalizes 6 months after treatment

• Combination of medication plus CBT did not confer additional benefit, individually they were equally effective. (Misri, S 2005)

• Quality of studies poor, small sample size, poor randomization, lack of placebo

Summary of Research on Prevention

• Antenatal classes focused on post-partum depression, not helpful

• In-hospital psychological debriefing, home visit by lay community support worker, early postpartum follow-up with OB/midwife not helpful

• Identifying “at risk” mothers and providing frequent, professional home visits is the most promising form of treatment. (Dennis, CL 2008)

• Four week IPT group with at risk pregnant women was 100% preventive at 3 mos, vs. 6/18 in TAU (Zlotnick et al, 2001)

Interpersonal Psychotherapy

• What it is:• 12 week manualized therapy focusing on

one or two of these three areas• Role transition• Grief and loss• Interpersonal conflicts/disputes• And Relationship with the newborn

Interpersonal Role Disputes

• Non-reciprocal role expectations• Communication analysis• Assessment of behavioral patterns that exacerbate

conflict• Assessment of partner’s level of support• Enhancing connections with other people• Help patients to evaluate expectations, learn to

communicate needs and emotions, and expand their understanding and perspectives

Role Transitions

Events that lead to changes in social roles that define people’s sense of identity

Facilitate mourning and acceptance of the loss of the old role.

Help the patient to find opportunities in regard to the new role.

Help the patient restore self-esteem

Grief and Loss• Make links between interpersonal events related to

the death and symptoms• Review the details of the loss• Explore both positive and negative aspects of the

lost relationship• Explore both positive and negative aspects of how

things were before the loss• Explore the challenges of adjusting to the loss and

the interpersonal opportunities in the present and future

• Help the patient reestablish interests and relationships.

Training

• www.interpersonalpsychotherapy.org• University of Toronto• 416-340-4462• Sophie.grigoriadis@uhn.on.ca• Weissman, M et al. Comprehensive Guide

to Interpersonal Therapy. New York, NY: Basic Books,,, 2000.

Research on IPT

• O’hara MW et al, 2000• N=99 (out of 120) completed protocol• Individual IPT vs. wait list (WL)• IPT Decline in HRSD from 19.4 to 8.3, WL

decline was 19.8 to 16.8• IPT decline in BDI from 23.6 to 10.6, vs WL 23 to

19.2• Full recovery was 37.5 % HRSD, 43.8%BDI vs

13.7% for WL (both scales).

Research on IPT-G

• Reay, R 2005 • N=18, 8 week group plus 2

individual sessions. • Severity scores on the BDI, EPDS

and the HDRS decreased• 67% of pts on anti-depressants, no

control group

Cognitive Behavioral Therapy

• Chabrol et al, 2002 • N=48, 6 CBT home visits vs. control group.• HAM-D score of <7 in 66.6% of the

treatment group, vs. 6.6% of control.• Poor study, treatment group different at

baseline with far higher attrition.

Combined CBT and medication

• Misri et al. 2004: Paroxetine and CBT for comorbid PPD and anxiety.

• N=35• Two groups: Rx alone (16), Rx plus CBT for 12

weeks ( 19).• Both with highly significant improvement in Sx

(p<0.01), groups did not differ on measures of MDD, anxiety or OCD.

• Trend toward faster remission in combination therapy group (1.7 weeks earlier)

Combination Treatment

• Appleby et al. 1997• N=87, 4 arms: fluoxetine vs. placebo, with

1-6 sessions of CBT each.• Excluded breastfeeding women• Fluoxetine superior to placebo, 6 sessions

superior to 1, but no additional benefit of adding Rx to Tx on specific measures. Tx as effective as Rx.

Psychodynamic Psychotherapy

• Cooper et al. 2003• N=193, 4 arms, TAU, Non-directive counseling,

CBT or psychodynamic Tx.• At 4.5 months, all three treatment arms superior to

control (by EPDS), psychodynamic tx the only one effective in reducing depression (SCID)

• At 9 mos, treatment groups equal to spontaneous remission.

Weekly Home Visits by a Nurse

• Wickberg et al, 1996 N=41 weekly supportive visits from a nurse. Vs. TAU

• 80% recovery from PPD, vs. 25% in control group.

• Armstrong et al, 1999. N=181 women with “vulnerable families.” 6 weekly visits then 6 qowk. Vs TAU.

• Post-treatment EPDS of 5.7 vs7.9 in control

Limitations of Therapy

• Access to care:• Financial• Availability of childcare• Transportation• Language• Availability of clinicians• Severity of illness/dangerousness

Psychosocial Interventions

Rationale for social Support

• Study of 60 women with PPD(Small et al, 1997), two top self-explanatory causes for depression:

• Lack of support• Feeling isolated.• Top Recommendation: find someone to talk

to.

Support Groups

Honey et al. 2002. N=45, 23 in 8 week psycho-education group, vs routine care

Immediately post treatment: 35% (intervention) vs 27%(routine) improvement in EPDS, but 6 mos later, 65% vs. 36%.

Fleming, 8 weekly unstructured groups, no benefit. (mothers with and without ppd.)

Chen et al, 2000, N=60, half control, half in 4 weekly support groups, at 4 weeks, 66% recovery in group, vs. 40% in control.

Telephone Peer Support

• Dennis 2003,N=42 tele-support group vs. control• At 8 wks, 85% improved (by EPDS<12) in group,

vs 48% of the mothers in the control group.• Ugarizza and Schmidt, 2006. Pilot study, • 10 week telecare group with CBT, relaxation

techniques and psycho-education/problem solving.

• BDI scores significantly lower, psycho-education rated as highest benefit.

Partner Support

• A poor marital relationship is the most consistent psychosocial predictor of PPD

• An appreciative partner is protective for PPD (Marks et al, 1996)

• Misri et al, 2000 Can J Psychiatry45, 554-8 N=29, 7 psychoeducational visits, control group without partners, treatment with.

• At week 7, decrease in EPDS 14.7 vs 8.6 (p<0.02)

Non-Pharmacological Therapies

Social/Political Remedies• History of PPD support groups from the feminist

movement and the Boston Women’s Health Collective

• Saw PPD as a reaction to profound gender inequality and disempowerment/isolation.

• Prevention to be found in:• 1. More equitable gender roles at home• 2. More support of parenting through paid parental

leave(Canada), state-supported daycare (France), national health system, more contexts for social support.

Omega 3 Fatty Acids

• Maternal seafood consumption >340 g a day during pregnancy associated with higher verbal IQ, prosocial behaviour, fine motor, communication, and social development scores. (Hibbeln et al, Lancet, 2007)

• Countries with higher seafood consumption and higher DHA in breastmilk see lower PPD. Hibbeln, 2002

• Role of O3FA in treatment of affective disorders.• O3FA role in pregnancy outcomes: lower rates of

preeclampsia, CP and preterm labor. (McGregor, 2001)

Fish Consumption

• Browne et al, 2005, N=80 primagravid mothers, fish consumption during pregnancy was not correlated with PPD. It was correlated with PP O3 levels.

Omega-3 Fatty Acids

• Freeman et al, 2006 study comparing 3 doses with pregnant and PPD women, all groups saw 50% decrease in Ham-D and EPDS, but no difference with dose (no placebo group).

• Freeman et al, 2008 N=51. All pts received supportive psychotherapy, with or without 1.9g of DHA +EPA for 8 weeks.

• No additional benefit conferred by O3FA• Both groups had signficant decreases in Ham-D

and EPDS, P<0.0001.

Limitations of O3FA studies

• Included both pregnant and PPD women• O3FA group had a history of more AD

trials, suggesting more recurrent illness• Given severely low fish intake (<0.5

serving per month) dose may have been too low

Exercise: rationale

• In major depression, exercise clearly shown to improve depression

• Theoretical justification, through increased bdnf. • See increased cortical volume, neurogenesis,

depression as an illness of decreased neural plasticity.

• Endorphins, confidence and self-esteem, improved body image.

• No stigma, low cost, easy access, no professional.

Exercise and PPD

• Armstrong et al, 2003 N=20: three times weekly pram walking plus once weekly social support vs. TAU.

• Approx half on AD and some in counseling in both groups.

• At 12 weeks, EPDS were 4.6 vs. 14.8, p<0.01 (Baseline 17.4 vs. 18.4)

Exercise and PPD

• Armstrong et al, 2004. N=19 twice-weekly pram walking, vs. unstructured social group.approx 55% in both in counseling and/or on AD.

• After 12 weeks EPDS 6.3, vs. 13.3 p<0.05, also saw improvements in aerobic fitness. No group rated improved social support.

• Edinburgh report on exercise classes for women with PPD: rated discussion with other women as more important than exercise. (May, 1995)

Light Therapy

• Oren et al,2002 study of 10 antepartum women, a trend toward benefit of 7000 lux, vs. 500, at 5 weeks. At ten weeks, see significant improvement, 49% improvement in depression scores (SIGH-SAD) p<0.01

• Corral et al,2000 N=15, 6 wks, 10,000 lux, vs. 600.Both groups saw 49% reduction in EPDS, CGI, SIGH-SAD) p<0.001, no differences.

• Non-specific treatment benefit, vs. placebo.

Massage Therapy

• Field et al,1996, N= 32 adolescents with PPD at week 4. Ten thirty minute massage sessions over 5 weeks, vs. relaxation. In massage group only saw: decrease in salivary and urine cortisol, and pulse. And lower anxiety by self-report.

• Onozawa et al, 2001. N=34 infant massage class+ support grp.vs support group x5 wks.

• EPDS fell in both, measure of mother-infant interaction only better in massage group.

Alternative Therapies

• Herbal remedies• Homeopathy• Chinese medicine• Ayurvedic medicine• Mantle, F, The role of alternative Medicine in Treating

Postnatal Depression. Complementary therapies in Nursing and Midwifery, 2002 8, 197-203.

Additional Interventions

Infant sleep intervention

Critically timed sleep deprivation• Anti-inflammatories/anti-oxidants• EMDR• ECT

Description of a local Group

• 6 sessions, 4 participants• 1. Permission to speak your own truth• 2. Birth story• 3. Legacy of the mothering received• 4. Tyranny of the ideal mother/self-acceptance• 5. Naming needs, voicing fears• 6. Motherhood self defined.

Summary

• Psychotherapy is treatment of choice for many mothers, especially those who are breastfeeding.

• Key role of shame • Treatment works• Relationship matters