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Internet Cognitive Behavioural Therapy for Women with ante- and postnatal Depression - the case of Angelina, a recipient of MumMoodBooster Professor Jeannette Milgrom 1,2,3 and Dr Alan Gemmill 1 Parent-Infant Research Institute 1 , Austin Health 2 and University of Melbourne 3 Thursday 25 th May 2017 CeBIT Australia 2017 © Parent-Infant Research Institute

CeBIT Australia 2017 - Prof Jeannette Milgrom - Internet cognitive behavioural therapy for women with ante and postnatal depression

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Internet Cognitive Behavioural Therapy for Women with ante- and postnatal Depression

- the case of Angelina,

a recipient of MumMoodBooster

Professor Jeannette Milgrom1,2,3 and Dr Alan Gemmill1

Parent-Infant Research Institute1, Austin Health2

and University of Melbourne3

Thursday 25th May 2017

CeBIT Australia 2017

© Parent-Infant Research Institute

The Parent-Infant Research Institute

Executive Director: Professor Jeannette Milgrom

Board Members: Leonie Young, Anthony Barnes, Jennifer Ericksen,Barbara Wellesley AM,

Wendy Peter

Manager Perinatal MH Services: Jennifer Ericksen

Deputy Director Research: Dr Alan Gemmill

Postdoctoral Fellows: Dr Charlene Holt, Dr Christopher Holt

Research Assistants: Vera Corbisieri, Eliza Hartley

Clinical Researchers: Elizabeth Loughlin, Dr Carmel Ferretti, Rachel Watts, Dr Felicity Holmes

Finance: Jessie Luan

Students: Research Students – Dr Lisa Milne, Claire Corbett, Laura Bleker;Clinical Postgraduate Students on Placement

Honorary: Professor Helen Skouteris, Dr Melissa Buultjens, Dr Carol Newnham,Dr Sofia Rallis, Dr Jessica Ross

Collaborative Partners: Maternal Child Health Nurses, Hospitals and ResearchersPart of Austin LifeSciences

A Major Aim of the Parent-Infant Research Institute

Research

Basic and Applied Research to Optimize Parent and Infant Wellbeing

© Parent-Infant Research Institute

Practitioner

Development

Public Health

& Community

Development

Direct

Service

Provision

Feelings After Birth

• Baby blues

80-90% of women feel tearful

3-4 days after birth for a short time

• Postnatal depression

10-20% of women feel depressed

onset in the first year after birth

• Psychosis

1 in 1000 women experience hallucinations,

delusions, etc. with an onset in first 6 weeks

Depressive Episode – DSMV

Diagnostic CriteriaFor a diagnosis of major depression, at least five symptoms listed

below must be present (at least one of which must be symptom a or

symptom b) on most days in the previous two weeks.

(a) Depressed mood

(b) Diminished interest/enjoyment

(c) Significant weight or appetite change

(d) Sleeping problems

(e) Fatigue

(f) Feelings of worthlessness/guilt

(g) Inability to think clearly

(h) Recurrent thoughts of death and/or suicide

(i) Psychomotor agitation and/or retardation

The new DSM 5 includes a specifier for “peripartum onset” covering

pregnancy until 4 weeks postpartum.

Consequences-

Ongoing Mood Symptoms plus

• Mother’s wellbeing

• Mother-infant relationships (62% dysfunctional

relationship)

• Impact on infant (cognitive and behavioural

difficulties)

• Partner relationship problems, partner depression

• Economic costs-LSE eight billion pounds per

cohort of births

Emerging Evidence of Longer Term

Effects to Adolescence

By the time of adolescence, children of mothers with

postnatal depression are at elevated risk for

behavioural and emotional problems poor academic

achievement and for serious mental health problems

such as depression.

Halligan, S. L., L. Murray, et al. (2007). Maternal depression and psychiatric

outcomes in adolescent offspring: a 13-year longitudinal study. Journal of

Affective Disorders 97(1-3): 145-154.

Korhonen, M., I. Luoma, et al. (2012). A longitudinal study of maternal prenatal,

postnatal and concurrent depressive symptoms and adolescent well-being.

Journal of Affective Disorders 136(3): 680-692.

Murray, L., A. Arteche, et al. (2011). Maternal postnatal depression and the

development of depression in offspring up to 16 years of age. J Am Acad of

Child and Adolescent Psychiatry 50(5): 460-470.

Psychological Treatments

Dennis CL, Hodnett ED. Psychosocial and

psychological interventions for treating postpartum

depression. Cochrane Database of Systematic

Reviews ( 2009) Article No: CD006116.

Conclusion

“the meta-analysis results suggest that psychosocial

and psychological interventions are an effective

treatment option for women suffering from

postpartum depression”

IPT and CBT are leading contenders (O’Hara et al, 2000; Morell et al 2009;

Milgrom et al 2005)

• Encouraging results have been reported for web

based CBT programs for mental health in general

- Depression (Christensen et al 2004)

- Panic disorder (Carlbring et al 2003)

- Posttraumatic stress disorder (Knaevelsrud & Maercker 2007)

- Complicated grief (Wagner et al 2006)-

When we began this project, no research had examined an intervention specifically for the treatment of PND, despite the special needs of women who are depressed while caring for a new infant.

© Parent-Infant Research Institute

Internet Based Mental Health

Interventions

Jeannette Milgrom1&2 Brian Danaher3 Charlene Schembri2

John Seeley3 Jennifer Ericksen2 Milagra Tyler3 Alan Gemmill3 Peter

Lewinsohn3 & Scott Stuart4

1. Psychological Sciences, University of Melbourne

2. Parent-Infant Research Institute

3. Oregon Research Institute

4. Deparment of Psychiatry & Psychology, University of Iowa

Getting Support

· Types of support

· Relating to baby &

partner

· My contacts

Solving Problems

· Identify problem

· List solutions

· Assess pros & cons

· Pick a solution

· Be realisticManaging Your Stress

· Stressful times

· Strategies

· Portable strategies

· Personal plan

Communication Skills

· Situations

· “Sandwich” strategy

· Barriers

Managing Your Time

· Setting goals

· Flexible routine

· Procrastination

· Taking care

Welcome

Browsing content

IF Returning, review:· Mood rating

· Tracking pleasant

activities

· Sticking with program

Link to relevant content

Session #2

Managing Your Mood

· Mood rating form

· Stress & anxiety

· Relaxation

· Personal goals

· Recap & preview

Session #6

Planning for the Future

· Program concepts

· Your strategies

· New routine

· Watch & respond

· Commitment

· Questions

· Recap & preview

Your Baby’s Needs

· Read cues

· Personal style

· Communication

· Facilitate interaction

· Learn through play

· Play strategies

· Good enough

Online Support Forum

·

Website Help

Sleep and Caring

· Sleep needs

· Sleep strategies

· Crying & feeding Web Resources

Session #4

Managing Negative Thoughts

· Extreme thoughts

· Controlling

· Practice change

· Positive thoughts

· Recap & preview

Session #5

Increasing Positive

Thoughts

· Why increase?

· Types

· Practice change

· Recap & preview

Session #3

Increasing Pleasant Activities

· Strategies

· Tracking

· Setting goals

· Viewing charts

· Practice change

· Recap & preview

Session #1

Getting Started

· Symptoms in PND

· Myths & Facts

· CBT approach

· Partner support

· Mood rating

· Recap & preview

Access Optional Tools & Sequential Modules

Access to Any/All

Browsing Modules At Any Time

Internet

You and Your Partner

· Your needs

· Your partner’s needs

Tools

Add & Remove Pictures

My Status

Mood Tracking

My Pleasant Activities

© Parent-Infant Research Institute

• Sequential access through six sessions structured to

optimize engagement and resulting behaviour change.

• Unrestricted access to browse library on different

topics ranging from relaxation, problem solving, to

getting support for parenting, and a moderated Web

forum plus a Partner support website.

• Video & audio content to provide coping models and

enhance participant’s self-efficacy to accomplish

recommended strategies.

• Animation to enhance interactivity and provide

animated tutorials to increase engagement and learning.

• Personal Coach Calls to participants during each of the

6 weeks corresponding to the 6-session MMB program.

Ericksen © PIRI

© Parent-Infant Research Institute

Animated Downward Spiral

© Parent-Infant Research Institute

© Parent-Infant Research Institute

Host Video

© Parent-Infant Research Institute

© Parent-Infant Research Institute

Mood Tracking

Contributing

factors

Tension list Web pages

opened

• Too tired to meet

all my baby’s

demands AND

cook dinner

• Baby

management -

sleeping/feeding

• One income

• Mother not

available - lives

away/passed

away/is estranged

• 5-7 pm dinner

time

• Getting ready to

go out

• Getting baby to

sleep

• Tantrums at the

supermarket

• Long trips in the

car with

screaming baby

Personal goals

Stress & anxiety

Relaxation

Mood rating form

Managing your

mood

Summary

© Parent-Infant Research Institute

Type or press list button>

Type or press list button>

Type or press list button>

Type or press list button>

By Yourself

?With Friends/Family

Type or press list button>

Type or press list button>

Type or press list button>

Save to My Pleasant

Activity List

Type or press list button>

Type or press list button>

With Partner

With Baby

Type or press list button>

Type or press list button>

Type or press list button>

Type or press list button>

Type or press list button>

Type or press list button>

Type or press list button>

list

list

list

list

list

list

list

list

list

list

list

list

list

list

list

list

list

list

list

list

Type or press list button>

Type or press list button>

Type or press list button> Type or press list button>

My Pleasant Activities List

© Parent-Infant Research Institute

© Parent-Infant Research Institute

© Parent-Infant Research Institute

Workbook

Milgrom & Ericksen (C) PIRI

• Each participant has their own telephone coach who can review visits, PHQ9, entries, etc

• Coaches are trained

• Establishes support, checks comprehension

• Contact after each session (½ hour)

• Coach reviews participant engagement and provides positive reinforcement

• Not directive or “therapy” but advice, eg. pace yourself

Milgrom & Ericksen (C) PIRI

Coaching

© Parent-Infant Research Institute

• Usability Trial

• Feasibility Trial

• 2 Trials of MumMoodBooster

• Antenatal Depression Treatment

Danaher, Milgrom et al Mommoodbooster Web-Based

Intervention for Postpartum Depression (2013) J Med

Internet Res 15(11) p242

Feasibility and Randomised

Controlled Trials To Date

Focus group participant comments were overwhelmingly

positive: eg. “really hopeful, like you can do something

about it,” and “I think this is wonderful, because you can do it

at home.” SUS scores can range from 0 [negative] to 100

[positive]). Example SUS items include “I think that I would like

to use this website frequently” and “I felt very confident using

the website.” SUS results (Figure 2) indicated

MumMoodBooster to have excellent usability: Mean = 86.2

(SD=2.13).

© Parent-Infant Research Institute

Focus Group

There are few published controlled trials

examining the efficacy of internet-based treatment for

postnatal depression (PND) and none that assess

diagnostic status (clinical remission) as the primary

outcome.

This is despite the need to improve treatment uptake and

accessibility as fewer than 50% of postnatally depressed

women seek help, even when identified as depressed.

Milgrom, J., Danaher, B.G., Gemmill, A.W., Holt, C., Holt, C. J., Seeley, J.R.,

Tyler, M.S., Ross, J. & Ericksen, J. (2016). "Internet Cognitive-Behavioural

Therapy for Women with Postnatal Depression: A Randomised Controlled

Trial of MumMoodBooster". Journal of Medical Internet Research, 18(3):e54.

Effectiveness Shown in

Randomized Trial

Results:

At the end of the study, 78.9% of women who received

the internet CBT treatment no longer met diagnostic

criteria for depression on the SCID-IV. This contrasted

with only 18.2% remission in the treatment as usual

condition.

Depression scores on the BDI-II and the PHQ-9 showed

large effects favouring the intervention group. Small to

medium effects were found on measures of anxiety and

stress. Adherence to the program was very good with

86% of users completing all sessions and satisfaction

with the program was rated 31/4 on average.

Randomized Trial

Ericksen (C) PIRI

0

2

4

6

8

10

12

14

Baseline Week 3 Week 5 Week 9 (Post-test)Week 12 (Follow-up)

Sco

re

Figure 4: Depression over time (PHQ-9)

Intervention Usual Care

• ROLL-OUT Mum and Mom MoodBooster versions

• ANTENATAL VERSION RCT

• COMPLETION OF NHMRC large RCT of MMB

compared to face to face treatment

• COACH vs NO COACH

• E-HUGS

• Translation to the real-world

• We are interested in collaboration with other

groups to trial in different perinatal populations.

© Parent-Infant Research Institute

Where To Now?

A CASE STUDY

• Angelina is a 33-year old first time

mother of two and half month old Lee

who self-referred (via Mum Mood

Booster on Facebook)

• Angelina reported that she has not felt

“herself” since the birth of Lee ten weeks

ago.

• Married to Peter, described as a very

supportive partner

• History of panic attacks that were

precipitated by a car accident in 2005

(support from a GP and psychologist)

• Six months ago had workplace

accident and broken ankles

History

• Difficult pregnancy, with morning

sickness for the first six months

• Anxiety and several panic attacks

during pregnancy

• Anxious and possible affect on Lee.

• Three hour labour that felt “traumatic”

Pregnancy & Birth

• Breastfed for the first eight weeks and

also found this challenging.

• Took four weeks to develop a

connection with Lee

Perinatal Experience

Genogram

Tests Administered and Results

• Patient Health Questionnaire (PHQ-9)

• Structured Clinical Interview for DSM-IV-TR Axis I Disorders – Research

Version (SCID-1)

Assessment Results

• Angelina’s responses to the SCID-1: Angelina met a clinical diagnosis of

Major Depressive Disorder; moderate, with peripartum onset.

• She reported no previous depressive episodes. Angelina’s responses on

the PHQ-9 reflected a severe level of major depression in the past two

weeks.

• Fleeting suicidal thoughts, most recently 2-3 weeks ago (eg. “that Peter

and Lee would be better off without her”) triggered by a falling out with

her mother.

Risk Assessment

• Nil intent/plan. Angelina reported no current or past thoughts/intent/plan

of harm towards Lee. She reported no DSH. Her presentation was

consistent with low risk.

Assessment

• Angelina completed the six online modules of

the MMB program

• Angelina engaged well with content and

made multiple attempts to complete homework

tasks in between sessions (eg. rating daily

mood)

• Angelina referred her partner’s website which

she reported that he had found “helpful”

MumMoodBooster Treatment

• The PHQ was completed throughout treatment

at 3, 5, 9, 12 and 16 weeks

• Angelina’s initial responses on the PHQ-9

reflected a severe level of major

depression in the past two weeks. This

shifted a minimal level of mood symptoms in

week 3, moderate in week 5 and 9. By week

12 Angelina consistently reported a

minimal level of depressive symptoms

Safety Monitoring

• Angelina completed the 21 week follow-up

SCID-1 assessment and feedback

questionnaire. Angelina’s responses on the

SCID-1 indicated that Angelina no longer met

a clinical diagnosis of MDD.

Post-Treatment Assessment

• Angelina reported that overall that online CBT for

PND program as “very helpful”.

• She indicated that she was “somewhat satisfied” with

mood tracking, web forum, the Partner Support

Program and video resources, “moderately satisfied”

with strategies to reduce negative and increase

positive thinking and “very satisfied” with pleasant

activities.

Post-Treatment Assessment

Conclusion: Our results suggest that our internet CBT

program, MumMoodBooster, is an effective treatment

option for women clinically diagnosed with PND. This is

one of only two controlled evaluations of specialised

online psychological treatment internationally for women

clinically diagnosed with PND.

Randomized Trial

• Contact us

• www.piri.org.au

[email protected]

• 03-94964009

(C) PIRI

Team