The Detection and Treatment of Perinatal Depression in Medical Settings Ryan J Van Lieshout, MD, PhD, FRCP(C) Albert Einstein/Irving Zucker Chair in Neuroscience Assistant Professor, Department of Psychiatry McMaster University Healthy Human Development Collective Impact Table Webinar: July 16 th, 2015
Detecting Perinatal Depression Women & Partners Other Family Members (parents, siblings, etc) L&D Nurses and SW Formal or Informal Screening (e.g., Public Health) Midwives Family physicians Psychiatrists
UK (NICE) Stepped Care Model
What Really Happens (for most) Reassurance, Family Support, Silent suffering Professional Support: midwives, public health nurses Referral and Formal Treatment Family Physicians & OHIP covered counsellors Private (non-ohip) counsellors (SW, RN, PhD) Psychiatrists (more rarely)
What Do They Usually Get? 1. Supportive psychotherapy 2. Medications 3. Evidence-Based Psychotherapy (more rarely) a) Interpersonal Psychotherapy b) Cognitive Behavioural Therapy
What Should They Get: Pregnancy Mild to Moderate MDD 1 st Line: CBT or IPT (Individual or Group) Previously Effective Treatment* 2 nd Line: Sertraline, Citalopram, Escitalopram* Combination SSRI + (CBT or IPT)* *1 st Line for Severe MDD
What Should They Get: PPD (If Breastfeeding) Mild to Moderate MDD 1 st Line: CBT or IPT (Individual or Group) Previously Effective Treatment* 2 nd Line: Sertraline, Citalopram, Escitalopram, Fluvoxamine* Combination SSRI + (CBT or IPT)* *1 st Line for Severe MDD
Evidence Based Psychotherapies Interpersonal Psychotherapy 10-15 Sessions, structured Areas of Foci (Role Transition, Grief & Loss, Interpersonal Dispute, Interpersonal Sensitivity) Key Methods: Improve relationships (conflicts/transitions) Improve social supports, process changes Perinatal Pros: effective, no homework, flexible Perinatal Cons: less structured from a therapists perspective, training may be more complex
Evidence Based Psychotherapies Cognitive Behavioural Therapy 8 (brief) - 15 Sessions, Structured Based on Cognitive Model of Depression Key Methods: Become aware of depressogenic thoughts & behaviours Improve mood by changing these using thought & behaviour records (in session and via homework) Perinatal Pros: effective, manualizable, very structured Perinatal Cons: homework
WHCC Perinatal Depression CBT Group A brief CBT perinatal depression treatment that utilizes group support and can be tailored and used in a variety of settings Format: 9 x 2 hour weekly sessions, up to 10 participants, newborns welcome CBT: 1 hour, Psychoeducation/Discussion: 1 hour Eligibility: MDD, dysthymic disorder ± comorbidities are eligible Minimize patients with acute issues that are likely to disrupt group or not benefit (psychosis, mania/hypomania, active substance use disorders, unstable borderline PD)
Group Content
Results To Date EPDS Mean Pre-Group Score=15 Mean Improvement=6.3, SD=3.8, p=0.002 (Effect Size=1.7 (Large)) Beck Depression Inventory Mean Pre-Group Score=25 (moderate severity) Mean Improvement=15.4, SD=11.7, p=0.007 (Effect Size=1.32 (Large)) Postnatal Bonding Questionnaire Mean Improvement=11.3, SD=10.7, p=0.02 (Effect Size=1.05 (Large)) Social Provisions Scale Mean Improvement=26.6, SD=6.3, p<0.001 (Effect Size=4 (Large)) Dyadic Adjustment Scale Mean Improvement=22.7, SD=25.3, p=0.05 (Effect Size=0.90 (Large)) CSQ-8 Scores Mean=27.9, SD=3.7 (above average for adults in mental health settings)
Participant Feedback When I heard the other mothers talking about their experiences, I felt better knowing I wasn t alone and that there wasn t something defective about me. I didn t have to keep this a secret anymore! I feel like, for the first time, I have some control over my brain It was so helpful to be able to explain what was happening inside of my head to my husband, and show him how he can help me
Future Directions Continue to collect data, publish our findings Tailor group to other settings (i.e., public health) and pilot test We have worked with Niagara Public Health to tailor the group to their needs and will commence training shortly Training effectiveness will be measured as will group effectiveness Study brain changes in women and offspring of the group