Transcript Psychotherapy and non-pharmacologic Treatments

Psychotherapy and nonpharmacologic Treatments
For Post-Partum Depression
Anne Hallward MD
MAPP 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?
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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.
Benefits of Breastfeeding
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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
The Baby Book, William and Martha
Sears
Beyond a treatment for Depression
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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
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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
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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
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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
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www.interpersonalpsychotherapy.org
University of Toronto
416-340-4462
[email protected]
Weissman, M et al. Comprehensive Guide
to Interpersonal Therapy. New York, NY:
Basic Books,,, 2000.
Research on IPT
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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
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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 (SIGHSAD) 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
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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
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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