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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
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
• 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
• 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)
• 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
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
• 03-94964009
(C) PIRI
Team