Transcript Impact of Mental Health on ART Outcome: Strategies for

The Mind/Body Connection: Innovative Techniques
to Compliment Medical Therapy
Alice D. Domar, Ph.D
Director, Domar Center for Mind/Body Health,
Boston IVF, Beth Israel Deaconess Medical
Center
Harvard Medical School
• Alice D. Domar, Ph.D, does not have a financial
interest or affiliation with any of the research
being presented
What’s a Nurse To Do?
• Understand the psychological challenges
facing our patients
• Be familiar with the most common
psychological reactions to infertility
• Be aware of the resources available to your
patients
• Don’t take their distress personally
Infertility Treatment as the Cause…
• Numerous forms of infertility treatment are
associated with the development of
depressive symptoms:
– 80% of women taking leuprolide acetate scored
higher than 20 on the Hamilton Rating Scale*
– 75% of women using GnRH agonist medication
reported depressive symptoms**
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*Warnock et al, Fertil Steril 2000; 74: 984-6
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**Steingold et al, Obstet Gynecol 1987; 69: 403-11
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• In a very large study in Denmark, more than 42,000
women who underwent IVF were assessed for a
depression diagnosis*. Of those who were
diagnosed:
• 34.7% prior to ART
• 4.7% during ART
• 60.7% after ART
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Sejbaek et al Hum Reprod 2013; 28: 1100-9
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• Thus, be aware of the huge psychological toll
that treatment takes on our patients
• Women who had a depression diagnosis prior
to undergoing ART underwent significantly
fewer cycles and experienced fewer live births
than women who did not have a depression
diagnosis prior to ART treatment.
• Women who are depressed are significantly
more likely to drop out of treatment after one
ART cycle than women who are not depressed
Prevalence of Depressive Symptoms
• Measuring the prevalence of symptoms in this
patient population can be challenging. Patients may
want to “fake good” so as to ensure entry into
treatment and in some cultures, revealing
psychological distress is frowned upon*. It is not at
all uncommon for a patient to deny any level of
depression and actually score 0 on a depression
scale.
* Lewis et al, Arch Womens Mental health 2013; 16: 87-92
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• Suicide is a real risk in infertile women who
are not successful with treatment:
– In a study of 51,221 infertile women, the risk of suicide in
women who did not conceive was more than two times
that of the suicide rate of women who did*
– Women with secondary infertility also had an increased
risk, but it was not statistically significant
*Kjaer et al Hum Reprod 2011
Impact of Depressive Symptoms on
Treatment Outcome
• The research is unclear as to the impact of
depression on treatment outcome.
• Most studies indicate that distress prior to or
during an IVF cycle is associated with lower
pregnancy rates but some studies have not
shown a relationship
• It is challenging research for several reasons:
– Distress is associated with prognosis, so patients
with a better prognosis report less distress, and
also have higher pregnancy rates, but it might not
be cause and effect
– Patients may not accurately report their true level
of distress
Treatment for Distress
• Interventions currently offered to patients include:
– Individual therapy
– Couples therapy
– Support groups
– Mind/body groups
– Medication
– Complementary or Alternative Medicine (CAM)
• There is little data to support the efficacy of
individual or couples therapy in the decrease
of distress or the increase in pregnancy rates
but there has been minimal research
• There is some data on support groups
indicating increased pregnancy rates and a
decrease in distress
• In one study of 31 patients with major depressive
disorder randomized to either 12 sessions of
interpersonal psychotherapy (IPT) or brief supportive
psychotherapy*:
– IPT patients had a better response, with >2/3 achieving a
>50% reduction in symptoms and improvements persisted
six months later
*Koszycki et al Arch Womens Ment Health 2012
• Two meta-analyses have been done on the efficacy of
psychological interventions with infertility patients:
– One concluded that interventions which included skills
acquisition training were more effective than those
which emphasized emotional expression or support*
– The other concluded that programs that were at least
six sessions were the most effective**
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*Boivin Soc Sci Med 2003
** Hammerli et al Human Reprod 2009
Mind/Body Groups for Infertility
• Efficacy:
– Significant decrease in psychological symptoms
such as depression, anxiety, and hostility
– Decrease in physical symptoms such as insomnia,
headaches, and abdominal pain
– Significant increase in pregnancy rates: in an RCT*,
the take home baby rate for the m/b subjects was
55%, compared to 20% in the control group.
*Domar et al Fertil Steril 2000; 73: 805-11
• In another RCT* on the impact of the
mind/body program on pregnancy rates in
women undergoing their first IVF cycles,
participants in the mind/body group had a
52% pregnancy rates compared to a 20% rate
in the control group*
*Domar et al Fertil Steril 2011; 95: 2269-73
Mind/body groups
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10 session group program
Buddy system
Peer counselors co-lead
Partners attend three of the ten sessions
Patients have a variety of diagnoses
• First half hour is an optional sharing support
time
• Different relaxation technique taught each
week
• Hand in weekly diary sheet to group leader
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Skills include:
Numerous relaxation techniques
Cognitive strategies
Lifestyle modifications
How to handle anger/shame/guilt
Recommendations about alternative
treatments
• Group support
• A recent study on a similar program, the
Mindfulness-Based Program for Infertility*
had similar results:
– Participants reported a significant decrease in
depressive symptoms, shame, entrapment and
defeat
*Galhardo et al Fertil Steril 2013
Antidepressant Medications
In a recent study at Boston IVF*:
• 11.1% of the patients self-reported on the patient
portal that they were currently taking antidepressant
medication
• However…
• Only 3% reported antidepressant use to the
anesthesiologist prior to their oocyte retrieval
*Domar et al Fertil Steril 2013
Impact of SSRI Use on IVF
– Klock et al 2004:
• pregnancy rates:
– SSRI users: 46%
– Non users: 63%
– Friedman et al 2009
• cycle cancellation rates:
– SSRI users: 26.8%
– non-users: 10%
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Risks:
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Spontaneous abortion (miscarriage)
Birth defects
Preterm birth
Preeclampsia
Smaller fetal head size
Decreased fetal growth
Newborn behavioral syndrome (seizures)
Persistent pulmonary hypertension of the newborn (PPHN)
Neonatal EKG changes
Death within the first year of life
Long-term neurobehavioral effects (? Autism ? Language?)
Long-term health effects (Pulmonary, GI, Sexual)
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“Never before in human history have we artificially
changed the architecture of brain development.”
---- Feng Zhou, Ph.D.
Indiana University School of Medicine
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AD Work
AD Don’t
Work
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Alternatives to Medications for the
Treatment of Depressive Symptoms
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Psychotherapy
Exercise
Relaxation training
Yoga
Acupuncture
Nutritional supplements
Psychotherapy
• The majority of research on non-pharmacological
treatment of depression is on the efficacy of
psychotherapy, specifically cognitive-behavioral
therapy (CBT).
• CBT is short-term, typically 4-10 sessions
• Patients recognize and challenge distorted
automatic beliefs
CBT
• Huge amount of evidence that CBT is
equivalent to antidepressant medication in the
treatment of mild to moderate symptoms
• Recent research shows it is effective in the
treatment of severe symptoms as well
• Psychiatric research concludes that CBT is the
optimal first line treatment for depression
CBT vs SSRIs
• Relapse rates are lower for CBT than for
medication
• CBT is more costThoughts
effective than
medication
Behaviors
Emotions
SSRI vs CBT
• 89 infertile women with depressive
symptoms*
• Randomized to receive CBT, fluoxetine (20
mg for 90 days) or placebo.
• CBT patients had 79% decrease in
symptoms compared to 50% in fluoxetine
patients and 10% in placebo patients
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*Faramarzi et al, J Affec Dis 2008; 108: 159-64
Exercise
• Randomized controlled trials comparing
SSRIs vs exercise have indicated that
exercise is equivalent in the treatment of
depressive symptoms
• It can be difficult however to motivate
depressed patients to institute an exercise
routine and vigorous exercise might be
contraindicated in some infertility patients
Relaxation training
• Requires less time and training than CBT
• More effective than no treatment, but less
effective than CBT
Yoga
• There is limited research on the impact of
yoga on depressive symptoms, although
some small studies have shown significant
results
• Since yoga has no side effects, it is worth
considering in patients
with mild to moderate
symptoms
Acupuncture
• There is recent research which supports the
efficacy of acupuncture to treat symptoms of
depression and anxiety in infertile women*,
including at least one RCT in women with
PCOS**
*Anderson et al Altern Ther Health Med 2007, **Stener-Victorin et al BMC Complement Altern Med 2013
• There are numerous studies which support
the efficacy of acupuncture to treat symptoms
of depression and anxiety during pregnancy*
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• The response rates are equivalent or better
than the response rates to antidepressant
medication
*Da Silva, Acupunc Med 2007 **Manber et al, Obs Gyn 2010
Nutritional Supplements
• There is recent research which indicates
that omega-3 fatty acids and myo-inositol
may have some antidepressant effects*.
• Since the data is still limited, they are
considered to be adjunctive treatment
options.
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*Domar et al Human Reprod 2013;28:160-71
Treatments for Depression
(Khan, Faucett, Lichtenberg, Kirsch, & Brown, 2012)
Summary: The Mind/Body
Connection and Infertility
• Depression is a common symptom in infertile
women and may well be exacerbated by
treatment
• Psychological interventions, including
mind/body groups and CBT, as well as
acupuncture should be considered as a first
line treatment for distress
Summary
• Exercise has many physical and
psychological advantages and should be
considered as an initial option for
motivated patients
• Yoga, relaxation training, and nutritional
supplements should be considered as
additional options, but not stand-alone
treatments, unless new research supports
their efficacy
The Domar Center for Mind/Body
Health at Boston IVF
• Services include:
– Acupuncture
– Psychotherapy: CBT, individual, couples
– Nutritional counseling
– The mind/body program
– Yoga
Patient Support
• Acupuncture is available 7 days/week, 365
days/year
• Any Boston IVF patient in crisis can be seen
within the hour by one of the psychologists
• Any patient who has bad results from a
prenatal ultrasound has the option of being
seen for 5-10 minutes within the hour and a
regular appointment within 24 hours
• Every Boston IVF patient who has an
unsuccessful treatment cycle is offered a free
30 minute consultation with a psychologist to
process the negative results and plan support
for the next treatment cycle
Employee Support
• Employees receive one free acupuncture visit
and 25% off all future visits
• “Stress lunches” are offered periodically
throughout the year to all employees
• Crisis interventions are provided to employees
when needed, free of charge
Self Care
• Working with this patient population can be
challenging for a variety of reasons:
– Patients are highly distressed yet often assertive
– Patients seek out potentially erroneous
information from the internet
– Nurses may be put in the situation of being the
gatekeeper from the physician
• It is vital to recognize symptoms of stress:
– physical: insomnia, headaches, neck and/or back
pain, gastrointestinal distress, shortness of breath,
chest pain, fatigue
– emotional: anxiety, sadness, tearfulness,
irritability, anger, hopelessness
– behavioral: decreased motivation to exercise,
more sweet or salty cravings, more alcohol intake,
increased gum chewing, increased smoking
Most Effective Stress Reduction
Strategies
• Physical: relaxation techniques such as
meditation or yoga, mini relaxation
techniques, appropriate nutrition, exercise
• Emotional: cognitive restructuring, social
support, journaling, self-nurturance
Summary
• Infertility patients experience significant distress but
there are treatment modalities which can effectively
lower that distress
• It is vital that the nurses who take care of infertility
patients feel comfortable discussing the emotional
impact of infertility as well as ways to minimize it
• It is equally vital that nurses understand the impact
of these patients on their own mental health,
recognize stress-warning signs, and take steps to
remain physically and emotionally healthy