Can We Prevent Postpartum Depression?

Size: px

Start display at page:

Download "Can We Prevent Postpartum Depression?"

Douglas Golden
5 years ago
Views:

1 Can We Prevent Postpartum Depression? Cindy-Lee Dennis, PhD Professor in Nursing and Psychiatry, University of Toronto Canada Research Chair in Perinatal Community Health Shirley Brown Chair in Women s Mental Health, Women s College Hospital

2 Clinical Importance of Depression Depression is one the most common health problems women experience It is estimated that 20-25% of women will experience depression during their lifetime Further, for 30-50% of women who do experience depression, it is estimated to become a chronic recurring condition

Perinatal Depression Perinatal depression is an episode of depression with an onset either during pregnancy or the first 12 months postpartum

3 Perinatal Depression Perinatal depression is an episode of depression with an onset either during pregnancy or the first 12 months postpartum Antenatal depression is an episode of depression with an onset during pregnancy Postpartum depression is an episode of depression the first 12 months postpartum

4 Antenatal Depression Prevalence Prevalence across pregnancy: 12.7% (18.4% with minor depression) (Gavin et al, 2005) Postpartum Depression (PPD) Prevalence in the first 12 weeks postpartum: 13% (O Hara & Swain, 1996) For women with a history of depression, 35% PPD rate For women with depression during pregnancy, 50% PPD rate

5 Most frequent form of maternal morbidity following childbirth

6 Persistence of PPD For the majority of mothers, PPD starts within the first 12 weeks postpartum National Canadian data suggest 8% of mothers will continue to experience PPD past the first 5 months postpartum and into the following year (Dennis, et al 2012) this rate is more than 4 times the 1.4% point prevalence for depression among women found in the Canadian Community Health Survey

7 Common Symptoms Uncontrollable crying Fear of harming self or baby Anxiety Irritability Worry Inability to enjoy things that she used to Exhaustion Feeling heavy Inability to sleep, even when the baby is sleeping Inability to concentrate or make decisions

8 Next Steps?

9 Maternal PPD Risk Factors Depression during pregnancy Prenatal anxiety Previous history of depression Childcare stress Life stress Lack of social support Marital dissatisfaction/conflict Low self-esteem Low socio-economic status Single marital status Unwanted/unplanned pregnancy

10 Unfortunately, PPD occurs at a time when the infant is: Maximally dependent on parental care Highly sensitive to the quality of the interaction

11 Given the persistence of PPD and its association with recurrent depressive episodes (Copper et al 2003; Nylen et al 2010), concern for child development is warranted as maternal depression can: 1. Be incompatible with good parenting cognitions and behaviours 2. Cause significant distress for children due to a stressful home environment (Goodman &Gotlib 1999)

12 Health Promotion Consequences Research suggests maternal health promotion behaviours are diminished as mothers with PPD are less likely than non-depressed mothers to: Breastfeed Attend well-child visits Complete immunizations Use home safety devices Put infants to sleep on their back Engage in enriching activities (e.g., reading, singing, outdoor activities) (Zajicek-Farber 2009; Cadzow et all 1999)

13 Child Developmental Consequences Mothers with PPD also have children with poorer developmental trajectories Risk transmission through altered maternal-child interaction (Rishel, 2012)

14 What are the effects of maternal-child interaction difficulties on child development? Cognitive development General consensus that PPD predicts poorer language and IQ development in children and that this effect is found across childhood into adolescence Behavioural development Meta-analysis of 193 studies small but significant association between maternal depression and child behavioural outcomes Emotional development Meta-analyses consistent associations between PPD and insecure attachment and difficulty in establishing effective selfregulation skills (Martins and Gaffan, 2000; Atkinson et al., 2000; Campbell et al., 2004)

15 Intergenerational Effect Point prevalence rates for psychiatric disorders among children of depressed mothers are 2 to 5 times above community populations (Beardslee et al, 1998) signifying a strong intergenerational effect

16 Costs of Perinatal Mental Health Problems 2014 Report released by London School of Economics and Centre for Mental Health, UK This report for the first time in the published literature provides comprehensive estimates of the costs of perinatal mental health problems, including the adverse effects on the child as well as the mother

17 Taken together, perinatal depression, anxiety and psychosis carry a total long-term cost to society of about 8.1 billion for each one-year cohort of births in the UK Nearly three-quarters (72%) of this cost relates to adverse impacts on the child rather than the mother

18 Postpartum Depression: A Family Affair

19 Paternal PPD Prevalence A recent meta-analysis suggests that approximately 10.4% of fathers will experience depression in the first year postpartum Growing evidence that PPD in fathers begins later, often following the onset in mothers and with the rate increasing over the first year postpartum Risk factor maternal PPD (Paulson et al. 2010)

20 PPD = Major Childhood Adversity International experts have clearly identified maternal depression as a major childhood adversity and that effective interventions to address this condition are one of the most important public health preventive strategies we can implement to reduce the long-term negative outcomes among children

21 Not only focus on individual treatment but also include preventive approaches to the management of PPD

22 Preventive Approach Moving beyond a model where we wait for a mother to develop major depressive symptoms and then provide evidence-based treatment A NEW Philosophy FOCUS on the long-term healthy development of mothers and their children PROACTIVELY provide resources to support this healthy development

Cochrane Systematic Review Psychosocial and Psychological Interventions for the Prevention of Postpartum Depression: An Update Dennis, C-L.

24 Cochrane Systematic Review Psychosocial and Psychological Interventions for the Prevention of Postpartum Depression: An Update Dennis, C-L., Dowswell, T. (2013). Psychosocial and psychological interventions for preventing postpartum depression. The Cochrane Database of Systematic Reviews, Issue 2.

25 Primary Objective To assess the effects of psychosocial and psychological interventions compared with usual antepartum, intrapartum, or postpartum care to reduce the risk of PPD

26 Secondary Objectives 1. the effectiveness of specific types of psychosocial interventions 2. the effectiveness of specific types of psychological interventions 3. the effects of intervention provider (professionally-based versus lay-based) 4. the effects of intervention mode (e.g. individual versus groupbased interventions)

27 5. the effects of intervention duration (e.g. single-contact interventions versus multiple-contact interventions) 6. the effects of intervention onset (e.g. antenatal-only, versus antenatal and postnatal interventions, versus postnatal-only interventions) 7. the effects of sample selection criteria (e.g. interventions targeting women with specific risk factors versus the general population).

28 Types of Studies All published and unpublished studies were eligible if they fulfilled the following criteria: Were a randomised controlled trial Evaluated a psychosocial or psychological intervention in which the primary or secondary aim was a reduction in risk to develop PPD Quasi-randomised trials were excluded from the analysis

29 Types of Participants Pregnant women and new mothers less than 6 weeks postpartum, including those at no known risk and those identified as at-risk to develop PPD Trials where > 20% of participants were depressed at trial entry were excluded

30 Types of Interventions A psychosocial or psychological intervention incorporated a variety of non-pharmaceutical strategies including: Psycho-educational sessions Cognitive behavioural therapy Interpersonal psychotherapy Non-directive counselling Psychological debriefing Various supportive interactions Excluded interventions that solely evaluated an educational intervention

31 Electronic Search Searched the Cochrane Pregnancy and Childbirth Group Trials Register by contacting the Trials Search Co-ordinator Register contains trials identified from: quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL); weekly searches of MEDLINE; handsearches of 30 journals and the proceedings of major conferences; weekly current awareness alerts for a further 44 journals plus monthly BioMed Central alerts. Trials published in all languages were considered

32 Risk of Bias Assessment Based on recommendations by the Cochrane Collaboration the following were examined: Generation of Allocation Sequence (selection bias) classified as low risk if based on computer generated numbers, tables of random numbers, or similar Allocation Concealment (selection bias) classified as low risk if based on central randomisation, sealed envelopes, or similar Blinding (performance bias) classified as low risk if a blinded outcome assessment was conducted Completeness of Follow up Data (attrition bias) Did not exclude studies based on rate of incomplete data sensitivity analysis was completed if a < 80% follow-up rate was achieved

33 Review Characteristics 28 trials Almost 17,000 women Published between 1995 and 2010 Conducted primarily in Australia and the UK Five trials were conducted in the USA One trial was conducted in the follow countries: Canada, China, Germany, and India

34 Summary Overall psychosocial and psychological interventions may decreased the risk of developing PPD by approximately 22%

35 There is beginning evidence to suggest the importance of: 1. Additional professional support initiated postnatally 2. Telephone-based peer support initiated postnatally 3. Interpersonal psychotherapy (IPT)

36 Interventions are more likely to be beneficial if they are: Initiated postnatally Individually-based Include multiple contacts Target at risk women

37 Postnatal interventions that were successful administered Edinburgh Postnatal Depression Scale (EPDS) early in the postpartum period to identify depressive symptomatology Secondary preventive interventions

38 Postpartum Depression Peer Support Trial (Dennis et al. BMJ 2009) Funded by Canadian Institutes of Health Research (CIHR)

39 Purpose To evaluate the effect of peer (mother-to-mother) support on the prevention of PPD among mothers identified as high-risk

40 Design Overview A randomized controlled trial with stratification based on previous history of depression including PPD was conducted Seven Ontario health regions participated in the trial: Halton Ottawa Peel Sudbury Toronto Windsor York

41 Trial Schema PHN Screening EPDS > 9 EPDS < 10 Verbal consent for further contact Contact details to DCC No further contact Eligibility Assessment Consent Randomization Usual Postpartum Care Usual Postpartum Care Plus Peer Support Outcomes at 12 weeks Outcomes at 12 weeks Evaluation of Peer Support Outcomes at 24 weeks Outcomes at 24 weeks

42 Randomization 701 mothers randomized using web-based randomization ( 349 mothers intervention group (usual care plus telephonebased peer support) 352 mothers control group (usual care) No significant differences between groups on baseline variables

43 Peer Volunteers Peer volunteer selection criteria was: Ability to speak and understand English Self-reported history of and recovery from PPD Not currently suffering from depression Over 205 peer volunteers were recruited and attended a 4-hour training session Provided with a training manual and a list of local community resources for new mothers

44 Intervention Dosage Mothers received a mean of 8.8 (SD=6.0) contacts with their peer volunteer 49.5% were telephone conversations initiated by the peer volunteer The mean duration of these discussions was 14.1 minutes (SD=18.5) 33.4% of contacts were messages were left on mothers answering machines Only 6.5% contacts were initiated by the mothers 2.3% were interactions

45 Postpartum Depression: EPDS > 12 at 12 weeks Peer n (%) Control n (%) χ 2 p OR 95% CI 40 (14%) 78 (25%) Number needed to treat = 8 Relative risk reduction = 0.46 ( )

46 Summary Telephone-based peer support may be effective in preventing PPD among high-risk mothers Mothers who received peer support were at half the risk to develop PPD

47 Underlying Mechanisms of Peer Support Peer support can: Increase social networks Reinforce help-seeking behaviours Decrease barriers to care Encourage effective coping Promote social comparisons Increase self-efficacy Aid self-esteem

48 NICE Guideline for Depression

49 Management of Perinatal Depression

Case Identification The first step in the management of PPD is case identification Research consistently demonstrates that informal surveillance is imprecise with

50 Case Identification The first step in the management of PPD is case identification Research consistently demonstrates that informal surveillance is imprecise with less than 50% of mothers with perinatal depression identified despite various interactions with health professionals (Yawn et al 2012; Goodman & Tyer-Viola, 2010)

51 Antenatal Screening You can screen antenatally but most effective if it is to identify women with current depressive symptoms needing intervention decreased predictive validity when trying to identify asymptomatic women at risk of developing PPD Flag women at high risk to develop PPD History of depression Elevated anxiety History of abuse Migrant status Poor marital relationship

52 Postnatal Screening Edinburgh Postnatal Depression Scale (EPDS) 10-item self-report instrument Scores range from 0 to 30 Cut-off 12/13 (> 12) probable PPD Cut-off 9/10 (> 9) possible PPD Widely available and free

53 Validated for antenatal use EPDS Translated and psychometrically tested in many non- English populations over 30 different languages Surveys of large samples of perinatal women have found acceptability to be high (80-90%) Critical factor Provides a common language Enables comparability of clinical and research results

54 Does perinatal depression screening increase the number of mothers who recover?

55 Research is Clear Screening alone is insufficient to ensure the provision of appropriate treatment and thus ultimately improving clinical outcomes

56 The U.S. Preventive Services Task Force recommends screening adults for depression in clinical practices that have systems in place to assure: 1. Accurate diagnosis 2. Effective treatment 3. Follow-up

57 Effective Treatment Tools Pharmacological Psychological Interpersonal psychotherapy (IPT) Cognitive behavioural therapy (CBT) Alternative Relaxation/Massage Exercise Yoga Bright light therapy Mindfulness-based strategies Psychosocial Peer support /support groups Non-directive counselling

58 Pharmacological interventions are a very effective treatment Many mothers are reluctant to take antidepressant medication due to concerns about breast milk transmission or potential side-effects

59 Maternal Treatment Preferences The majority of mothers prefer talking therapies especially if they are breastfeeding Interpersonal psychotherapy (IPT) is a common and effective talking therapy for depression IPT is a brief, highly structured, manual-based psychotherapy that addresses interpersonal issues in depression such as: conflict, role disputes, social isolation, prolonged grief Intervention teaches: More effective communication with family and friends Skills for obtaining social support Effective coping techniques to use during times of need and during life changes

60 Unfortunately, IPT is not widely available, especially in rural and remote areas There are often long wait-times to receive IPT from a trained psychiatrist or psychologist Therapy is typically provided face-to-face in a clinic/hospital setting PPD treatment has unique barriers (e.g. childcare issues) and high attrition rates in group or clinic-based PPD treatment programs

61 Telepsychiatry To improve access to care, telepsychiatry has been introduced and includes the provision of psychiatric/mental health services via telephone Telepsychiatry can play an important adjunct role within an integrated health care system It is predicted to become an increasingly acceptable alternative to traditional face-to-face services The provision of IPT by trained nurses can also increase the clinical utility and feasibility of this treatment option

62 Interpersonal Psychotherapy Trial Telephone-Based Interpersonal Psychotherapy for the Treatment of Postpartum Depression Funding: Canadian Institutes of Health Research

63 Design Overview Randomized controlled trial to evaluate the effect of telephone-based IPT by trained nurses among clinically depressed mothers (SCID positive) 36 health regions across Canada from 6 provinces: Nova Scotia Ontario Manitoba Saskatchewan Alberta British Columbia

64 Randomization 241 mothers randomized using web-based randomization ( 120 mothers IPT group 121 mothers Control group (standard care) No significant differences between groups on baseline variables

65 Intervention Mothers received 12 weekly 1-hour IPT sessions at a regularly scheduled time based on maternal convenience IPT nurse and mother never met Nurses completed an activity log per participant to document all IPT session details All telephone sessions were digitally recorded and ed to the trial coordinator Guide supervision Ensure intervention fidelity

66 IPT Nurses 7 Toronto-based nurses hired and trained by two psychiatrists (Ravitz & Grigoriadis) to provide IPT 3 nurses with psychiatric experience 2 public health nurses 1 pediatric nurse 1 ER nurse

67 Clinical Depression: SCID Positive Weeks Follow-up IPT Group n (%) Control Group n (%) χ 2 p OR 95% CI 12 weeks (N = 204) 11 (10.6) 35 (35) < weeks (N = 202) 11 (10.9) 34 (33.7) <

68 Maternal Evaluation Mothers felt the IPT nurses were competent and well-trained Telephone-based IPT was convenient and met their needs There was only one negative comment would like more sessions Overall, mothers were highly satisfied and would recommend it to a friend

69 Conclusion Mothers who received IPT were significantly more likely to have a reduction in depressive symptoms Nurses can effectively deliver telephone-based IPT among clinically depressed mothers The remission remained across time to 6 months post-treatment Significant in anxiety and in relationship quality with partner

70 Technology plays a major role in the development and evolution of our lives It has percolated into all aspects including education, banking, and business management

71 E-Health The implementation of technology in the health sector, popularly known as ehealth, is emerging as one of the most rapidly growing areas in healthcare today It encompasses a whole range of purposes from purely administrative through to health care delivery

72 E-Mental Health E-Mental health has tremendous potential to address the gap between the identified need for mental health services and the limited capacity to provide conventional care Applications can address four areas of mental health service delivery: 1. Information provision 2. Screening, assessment, and monitoring 3. Intervention 4. Social support Primarily based on its ability to improve reach

73 Technologies Transforming Mental Health Mobile Therapy Foster Collaboration Internetbased Treatment Increase Access to Services Engage Individuals Telepsychiatry Online Peer Support Groups

74 Outstanding Clinical Problem While effective treatment tools exists for PPD Adequate treatment = treatment to remission

75 Barrier to treatment accessibility Maternal treatment preference Cultural Factors History of psychiatric treatment Severity

76 New treatment approaches are required to address the GAP between the existence and uptake of effective PPD treatment tools

Collaborative Care Collaborative care is an approach to treatment that is highly effective for the management of general depression In a collaborative care model, case

77 Collaborative Care Collaborative care is an approach to treatment that is highly effective for the management of general depression In a collaborative care model, case identification occurs at the primary care level A depression care manager directs individuals to appropriate treatment and monitors progress all in collaboration with a mental health specialist

78 Treatment Follow-Up Part of the success of this approach is that it actively promotes treatment initiation and adherence while addressing patient preferences and perceived barriers Also ensures appropriate follow-up and treatment to remission

79 Evaluating Collaborative Care for Postpartum Depression in Primary Care Settings Funded by CIHR

80 Design Overview Randomized controlled trial Telephone-based collaborative care intervention for PPD Diverse maternal and infant outcomes Mothers between 0 to 6 months postpartum with depressive symptomatology (EPDS >9) Identified during well-child visits in eight primary care practices across Toronto

81 1. A multi-professional approach to care 2. Structured management plan 3. Scheduled patient follow-ups 4. Enhanced inter-professional communication

82 Summary Importance of clinical depression for women Prevalence and risk factors Impact on child development - cost Postpartum depression is a family affair Need to be proactive prevent first then treatment if necessary Psychosocial and psychological interventions for prevention Peer support a simple yet effective secondary intervention Identification (screening) and treatment (talking therapy) Nurse-provided telephone-based IPT and the use of technology New approach to management collaborative care Ensure treatment to remission to improve child development

83 Cindy-Lee Dennis, PhD Professor and Canada Research Chair University of Toronto

Perinatal Depression: Current Management Issues

Perinatal Depression: Current Management Issues Cindy-Lee Dennis, PhD Professor in Nursing and Psychiatry, University of Toronto Canada Research Chair in Perinatal Community Health Shirley Brown Chair