Sabtu, Oktober 29, 2011

Psychosocial and Psychological Interventions for Treating Antenatal Depression



Recommendation
Insufficient evidence to determine if psychological therapies (psychosocial and psychological interventions) are effective treatment for antenatal depression. Study limitations include the lack of a control group and small number of subjects (I C)

Background
Mental illness is a major public health concern. According to the World Health Organization, by the year 2020 depression will be second disease in disability experienced worldwide. Although pregnancy is a time of emotional well-being for many women, conferring 'protection' against psychiatric disorders, a recent meta-analysis of 21 studies suggests that the mean prevalence rate of depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. There is no clear evidence to suggest that differences in prevalence rates exist between developed and developing countries (Danis 2008).

Although 10% of pregnant women meet criteria for major or minor depression, they often remain undiagnosed because the symptoms of depression are similar to somatic complaints of pregnancy. Making it important for women to pay careful attention to the changes taking place during pregnancy and note any prolonged symptoms of depression. Some signs of antenatal depression include: feelings of isolation, lack of energy, moodiness/ irritability, feeling foggy-headed/inability to concentrate, sadness, feeling unexcited or anxious about impending motherhood/ new baby, anxiety, withdrawal from other people, fatigue or poor sleep habits (insomnia), headaches, thoughts of harming oneself. While some of these feelings may be within the normal range of emotions and symptoms for some, a pregnant woman experiencing these warning signs about the possibility of depression.
Predisposing factors to antepartum depression are personal or family history of depression, marital dysfunction, young age, minimal education, and larger number of children.
Antenatal depression affects 10%–20% of pregnant women. Pregnant women who are depressed are at risk for anorexia, use of nicotine, drugs, and alcohol, and failure to obtain adequate prenatal care. It is associated with a greater risk of negative pregnancy outcomes, such as prematurity, fetal distress, neonatal behavioral differences, and a greater risk of postpartum depression. Recent data emphasize that relapse rates for depression are high during pregnancy. Cohen and colleagues found that 43% of a sample of pregnant women with a history of major depression experienced a major depressive episode during pregnancy (Freemann, 2007, Spinelli,1997)
Other negative effects to the newborn have been linked to antenatal depression including an "increased risk for irritability, less activity and attentiveness, and fewer facial expressions compared with those born to mothers without depression," according to a recent study conducted through a joint effort between The American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA) (Dennis and Allen, 2008)
The selection of treatment for depression in a pregnant woman must take into account the well-being of both mother and baby. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, non-pharmacological treatment options are needed (Dennis, Ross and Grigoriadis, 2007)
Treatment decisions should be collaborative, involving the mother, the baby’s father when appropriate, and health care providers. The risks and benefits of treatment are complex, and the weight given to the factors involved varies among individuals.
Treatment decisions should take into account the severity of symptoms, past history of depression and treatment response, and patient preferences. In cases of mild depression, non pharmacological treatments may be considered first. For pregnant women with moderate to severe depression, antidepressants are a reasonable part of a treatment plan. A history of previous postpartum depression or recurrent major depression is a risk factor for perinatal depression and may support the decision to use antidepressants during pregnancy.
In 5% of women, antenatal depression predicts postnatal depression. Since antenatal depression is a risk factor for postpartum depression, the safety of treatment during breastfeeding should also be considered. Despite a few case reports of possible adverse effects in infants breastfed by mothers taking antidepressants, most data on antidepressant levels in breast milk and infant serum suggest a low level of infant exposure to antidepressants via breastfeeding (Freemann 2007)

Supporting Evidence
Depression is a treatable illness but caution must be taken in pregnancy. Non-pharmacological interventions, such as enhanced social support and/or a psychological intervention should be considered before antidepressant treatment, especially if symptoms are mild or in early pregnancy (first trimester). Due to concerns about the safety of antidepressants in pregnancy, many mothers may prefer to trial psychological therapies before an antidepressant.
Among those are:
• psychosocial interventions, such as diverse supportive interactions including support groups;
• psychological interventions, such as cognitive behavioral therapy (a treatment that assists the individual in identifying and correcting erroneous beliefs and systematic distortions in information processing with the hopes of reducing distress and enhancing coping efforts); and
• interpersonal psychotherapy (a treatment where the connection between depressive symptomatology onset and interpersonal problems is used as a focus).
A 16-week open pilot trial was conducted with 13 pregnant women who met DSMIII-R criteria for major depression. The women’s mean depression ratings decreased significantly from week 0 to week 16 of the treatment program. In this study interpersonal psychotherapy for antepartum depression appears to be an effective alternative to pharmacotherapy in pregnancy (Spinelli,1997).
Other trial was incorporating 38 outpatient antenatal women who met Diagnostic and Statistical Manual for Mental Disorders-IV criteria for major depression. Interpersonal psychotherapy, compared to a parenting education program, was associated with a reduction in the risk of depressive symptomatology immediately post-treatment using the Clinical Global Impression Scale (one trial, n = 38; relative risk (RR) 0.46, 95% conīŦdence interval (CI) 0.26 to 0.83) and the Hamilton Rating Scale for Depression (one trial, n = 38; RR 0.82, 95% CI 0.65 to 1.03).

Conclusion
In small studies psychological therapies (psychosocial and psychological interventions) appears to be efficacious for antenatal depression and prevention of postpartum depression in women at risk .Psychotherapy can be given in a variety of formats including individual sessions, group therapy, family therapy or marital/couple therapy. Within these formats there are also different psychotherapy approaches that a mental health practitioner may utilise.


References

Dennis CL and Allen K. 2008 Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD006795.

Dennis C-L, Ross LE and Grigoriadis S. 2007, Psychosocial and psychological interventions for treating antenatal depression. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD006309.

Freeman MP,2007. Antenatal Depression: Navigating the Treatment Dilemmas Am J Psychiatry, 164:8.

Spinelli, M.G., 1997. Interpersonal Psychotherapy for Depressed Antepartum Women: A Pilot Study, Am J Psychiatry, 154:7


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