Essex-Tavistock Professional Doctorate in Clinical Psychology

Essex-Tavistock Professional Doctorate in Clinical Psychology

Year 2

Service Related Project: Evaluatingtheeffectivenessofaprimary-carebasedgroupforwomenwithpostnataldepression

Candidate Number: 0922929

Word Count: 4997

Contents

Abstract 4
Introduction 6

Aims

Overview of Service

Method 10

Design

Measures

Data Collection

Referral Process

Inclusion/Exclusion Criteria

Sample

Ethical Consideration

Results13

Dissemination

Discussion16

Main findings

Strengths and limitations

Conclusions and recommendations

Reflexive comment

References 21

Appendix 133

Appendix 234

Appendix 335

Appendix 436

Appendix 543

Appendix 646

Appendix 747

ABSTRACT:

Background and aims:

Although giving birth is generally regarded as a joyous life event, this period oftransition consists of a multitude of abrupt changes, and is recognised as astressful life event. Following childbirth many women struggle with the newdemands a new baby brings such as sleep deprivation, loss of order androutine, lack of preparation and social support, and changes in their rolesincluding career decisions, the relationship with their partner and theirpartner’s possible absence owing to work commitments. These emotionaland physical difficulties can lead to depression of varying levels in vulnerable females. Up to 80% of women experience postnatal ormaternity blues following delivery, and 10-20% of them go ontodevelop Postnatal Depression (PND). A community interest company runs a groupcalled ‘Exploring ways to feel better after you have had a baby’ for womenwho are experiencing PND, however the effectiveness of this group has never been evaluated.

The aim of this project was to evaluate the short-term effectiveness of the group. Research has shown postnatal depression has an effect on the quality of life, self-esteem and anxiety levels of mothers. So to evaluate the group’s effectiveness these variables along with depression were measured before and after the intervention.

Method:

Data was collected at two points using four questionnaires, which were administered pre and post group during the group meeting. The four measures used to measure depression, self-esteem, anxiety and quality of life were the Edinburgh Postnatal Depression Scale; the Hospital Anxiety and Depression Scale; the Rosenberg Self-Esteem Scale; and the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form .

Results:

There was no statistically significant different between the pre and post group self-esteem, quality of life or anxiety scores. However there were statistically significant changes found for the HADS-Depression and EPDS; indicating the PND group was effective in reducing PND symptoms in the short term.

Discussion and dissemination:

The results of the evaluation of the effectiveness of the ‘exploring ways to feel better after you have had a baby’ group have led to the following recommendations:

Future research to control for variables like social circumstances, social support, divorce and relationship status, and financial difficulties; which are known to contribute to postnatal depression.
To conduct further evaluations of future groups and compare the outcome data.
To conduct follow-up measures a month to six weeks after the group ended to evaluate the longer term effectiveness of the intervention.

Introduction

Although giving birth is generally regarded as a joyous life event, this period of transition consists of a multitude of abrupt changes, and is recognised as a stressful life event (Curtona, 1983; Terry, 1991; Terry, Mayocchi, & Hynes, 1996). Following childbirth many women struggle with the new demands a new baby brings such as sleep deprivation, loss of order and routine, lack of preparation and social support, and changes in their roles including career decisions, the relationship with their partner and their partner’s possible absence owing to work commitments (Milgrom, Martin & Negri, 2006). In addition to these stresses, a new mother may also experience financial difficulties, relationship problems and break ups, social isolation, an unexpected difficult birth, and post birth complications. These emotional and physical difficulties can lead to depression of varying levels in vulnerable females (Milgrom et al., 2006).

While prevalence rates of PND vary according to different cultures, assessment method, and studied populations (O’Hara & Swain, 1996), between 10- 20% of women will go on to develop postnatal depression [PND] (Appleby, Gregoire, Platz, Prince, & Kumar, 1994;Briddon, 2008; Dennis, Janssen, & Singer, 2004; Elliot, 1989). Postnatal depression is a condition characterised by constant crying, social withdrawal, thoughts about death, difficulty concentrating, loss of interest in everyday life, feeling exhausted all the time, difficulty sleeping (even if baby is), disturbances in appetite, feelings of anxiety, sadness, worthlessness and guilt, feeling inadequate as a mother, and feelings of anxiety that would not normally be bothersome e.g. being alone in the house (Briddon, 2008). PND symptoms are not transitory and can persist in varying degrees for many years (Milgrom et al., 2006); affecting the woman’s psychosocial functioning and the baby’s social, cognitive and behavioural development (Kumar, 1994; Lieberman & Pawl, 1993; McDonough, 1993), as well as the woman’s relationship with her partner (Milgrom et al., 2006).Longitudinal studies of PND indicate it has a negative chronic effect on women’s mental health, the mother-infant relationship, child development and marital relationship (Ballard, Davis, Cullen, Mohan & Dean, 1994; Lovestone & Kumar, 1993; Milgrom & McCloud, 1996; Murray & Cooper, 1997; Murray, Fiori-Cowley, Hooper & Cooper, 1996; Pitt, 1968).

While up to 80% of women experience postnatal or maternity blues following delivery (Miller, Pallant & Negri, 2006), PND is distinguished from that by the severity and increased duration of depressive symptoms. Research on maternal mood highlight the three days following the birth to be an accurate predictor of later PND (Cooper & Murray, 1998; Lane, Morris, Turner & Barry, 1997). Further research into the onset of PND indicates the majority of episodes start in the first three months following the birth (Kumar & Robson, 1984; O’Hara, 1997); and a significant number within the first five weeks after delivery (Cox, Murray & Chapman, 1993). Associated psychosocial risk factors for developing PND include previous history of depression (Milgrom, Martin & Negri, 2006; O’ Hara,Rehm, & Campbell 1982; O’ Hara, Neunaber , & Zekoski, 1984; O’ Hara, Schlechte, Lewis & Varner, 1991; O’ Hara & Swain, 1996), anxiety (Dennerstein,Varnavides & Burrows, 1986; Grossman, Eichler & Winickoff, 1990; Hayworth et al., 1980; Hopkins,Marcus, & Campbell , 1984); previous psychiatric history (Elliott, 1984; Paykel, Emms, Fletcher, & Rassaby, 1980; Watson, Elliott, Rugg & Brough, 1984),stressful life events (O’ Hara & Swaine, 1996), inadequate social support (Brugha et al.,1998), low self-esteem (Cox & Holden, 1994; Righetti-Veltema, Conne-Perreard, Bousquet, & Manzano, 1998);and maternal attitudes (Davids & Holden, 1970; Mills, Finchilescu, & Lea, 1995).

While PND is a well researched psychological complication of pregnancy (Elliott, 1989) there are no specific National Institute of Clinical Excellence (NICE) guidelines for women suffering from PND; instead there are NICE guidelines for antenatal and postnatal mental health for women (2010). These guidelines cover care for women with anxiety disorders, depression, and postnatal psychotic disorders (puerperal psychosis). The NICE guidelines make a point of not using the term ‘postnatal depression’ as it emphasises the term is often used inappropriately as a general term to describe any postnatal mental health disorder. Similarly, the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000) does not recognise postnatal depression as a separate diagnosis; rather, patients must meet the criteria for a major depressive episode and its onset must be within four weeks postpartum to be recognised as PND. NICE guidelines recommend the following for women who experience depression during pregnancy or during the postnatal period:self-help strategies (guided self-help, computerised cognitive behavioural therapy or exercise), non-directive counselling delivered at home (listening visits), and brief cognitive behavioural therapy or interpersonal psychotherapy.

Over the years there has been much research done on PND, and while there is a wealth of literature highlighting the detrimental effects of PND, most information about the condition remains descriptive, with limited detailed programmes to guide health professionals (Milgrom et al., 2006). Biochemical, behavioural, and cognitive theories of depression have influenced research and treatment of PND over the years (Milgrom et al., 2006), so it is important to consider the theoretical and empirical literature of depression in general to develop effective treatment approaches for PND. Behavioural theory for the treatment of depression indicates increasing pleasant activities, and decreasing unpleasant activities along with social skills, problem-solving, and relaxation training are effective in treating depression (Becker & Heimberg, 1985; Lewinsohn, Antonuccio, Steinmetz, & Teri, 1984; Lewinsohn & Gotlib, 1995; McClean & Hakstain, 1979,1990; Nezu, 1987; Thase, 1995). Cognitive and cognitive behavioural theories of depression emphasise various cognitive techniques (challenging cognitive distortions, cognitive restructuring, self-control procedures) to overcome depression (Glick, 1995; Hollon, Shelton & Davies, 1993; Robinson, Berman & Neimeyer, 1990; Scott, 1996) with better maintenance of treatment gains than pharmacology alone or short-term psychodynamic therapies for depression (Ensenck, 1994; Kovacs, Rush, Beck & Hollon, 1981; Miller, Norman, Keitner, Bishop & Dow, 1989; Scott, 1996; Svartberg & Stiles, 1991). Biochemical theorieshighlight antidepressant medication, such as selective serotonin reuptake inhibitors (SSRIs)as an effective treatment for depression (Milgrom et al., 2006), especially when combined with cognitive behavioural therapy (Clark, 1990; Kovacs et al., 1981; Prien & Kupfer, 1986; Rehm & Kaslow, 1984), however only if not maintained for longer than six months (Rehm & Kaslow, 1984; Rosenbaum & Merbaum, 1984). Despite the theories and treatment models, the bulk of the evidence shows the combination of psychological with drug approaches does not improve treatment effectiveness for depression (Glick, 1995; Milgrom et al., 2006; Olioff, 1991) ; instead well conducted short and long term Cognitive Behavioural Therapy (Clark, 1990; Lewinsohn et al., 1984; Lewinsohn & Gotlib, 1995) is efficacious.

Information and models for unipolar depression have been adapted for use with PND(Cramer et al., 1990;McDonough,1993;Stern, 1995)-as diagnostically it is regarded as a major depressive disorder- with an emphasis on non-biological interventions (Dennis, 2004), especially postpartum. Evidence from controlled trials suggests psychological interventions for PND are effective, namely non-directive counselling, cognitive-behavioural therapy (CBT), psychodynamic therapy, and interpersonal therapy (Appleby, Warner,Whitton,Faragher,1997;Holden, Sagovsky, & Cox, 1989; Wickberg & Hwang, 1996); and NICE recommends psychological therapies for ante and postnatal mental illnesses, including depression, as first-line treatment (2007).

As previously mentioned, there arethere are strong links between pre and postnatal depression and anxiety. Research shows pathological anxiety is a frequent accompaniment to PND, but is not often addressed in clinical intervention trials (Beck, 2010; Milgrom, Negri, Gemmell, McNeil & Martin, 2005; Robertson, Grace, Wallington, Stewart, 2004).And research shows anxiety and PND are associated with substantial impairment in the quality of life and functioning of women (Pyne, et al., 1997). Giving birth is a stressful life event, and after this stressor the immediateeffect of a new family member is a specific stress which lowers self-esteem and leads to the development of a depressive disorder (Cox, Murray, & Chapman,1993; Kendell, Chalmers, Platz, 1987). In addition, self-esteem is a reliable contributing factor to the susceptibility to depression in the early postpartum period (Fontaine & Jones, 1998).The evaluated PND group intervention addressed the negative cognitive-behavioural triad depicted in the biopsychosocial model of postnatal depression (Milgrom, Martin and Negri, 2006) (appendix 6). The 11 sessions addressed the following: depression and other emotions (anger, anxiety, sadness); meditational cognitive factors (negative automatic thoughts, poor parenting self-efficacy, my internal dialogue, developing more helpful thinking style, challenging my internal critic); behaviour and coping strategies (lethargy, indecision, social withdrawal, marital conflict, difficulties dealing with an infant, introducing pleasant activities into your life, relaxation on the run, self-esteem and assertiveness). This model draws on the cognitive behavioural theories of depression, and incorporates biological, cultural and social factors, like quality of life, into the model.

Based on the supporting PND literature, research, and the biopsychsocial model of postnatal depression (Milgrom, Martin & Negri, 2006) and the content of the intervention, it was concluded the PND intervention group would be evaluated on the following four outcome variables: depression, anxiety, self-esteem and quality of life.

Aims:

The Ministry of Parenting run a group called ‘Exploring ways to feel better after you have had a baby’ for women who are experiencing postnatal depression. This is the second time this group is being run, however its effectiveness has never been evaluated. So the aim of this service evaluation is to provide datato show if the postnatal depression group run by the Ministry of Parenting is an effective short-term intervention for women with postnatal depression symptoms, in terms of reducing symptoms of depression and anxiety, and increasing self-esteem and quality of life.

Overview of Service:

The Ministry of Parenting is a Community Interest Company and as a not-for-profit organisation is a form of social enterprise. It works with children, parents, professionals and organisations developing creative evidence-based solutions to the challenges faced by families in society today. In partnership with complementary services, The Ministry of Parenting aims to raise self-esteem, confidence, emotional resilience and mental wellbeing amongst parents and children and to promote social integration to enhance and support current good practice, training, evaluation, promotion of healthy living and providing equity of access. The Ministry of Parenting abides by its own professional code of conduct and demonstrates adherence to internal company policies. Both directors came to the organisation from positions in the NHS and whilst not directly working for a specific NHS Trust they are commissioned to deliver services by many of the NHS Trusts in Essex and surrounding counties; and often work in partnership with the Trusts to deliver services. The directors are experienced in consultancy, community development and parental mental health; and deliver courses and training workshops across Essex and the Eastern Region counties.The provision of the postnatal depression group is one such collaboration as The Ministry of Parenting co-facilitated the group with an employee of the Mid Essex Primary Care Trust.

METHOD

Design:

This is an evaluation of an intervention group for women with postnatal depression, i.e. a within participant design. Data was collected at two points using four questionnaires, which were administered pre and post group during the group meeting. It was felt this design was appropriate as it was hoped the majority of women would be happy to complete questionnaires as they do notrequire much time to complete, but interviews would require meeting each woman individually outside of the group, and this method would have place more demands on the depressed mothers.

Measures:

Four measures were used todetermine depression, self-esteem, anxiety and quality of life pre and post intervention in a group of women with PND symptoms.

The Edinburgh Postnatal Depression Scale (EPDS), [Cox, Holden, & Sagovsky, 1987] is a ten-item Likert format, valid postpartum depression assessment scale, developed for professionals working in primary health care. Each statement has four possible answers and women underlines the statement most applicable to how she has been feeling during the last 7 days.Items are scored on a 0–3 scale, giving a total range of 0–30. Scores above 9 indicate 'possible depression' while scores above 12 indicate 'probable depression' (Cox et al., 1987). It is recommended when using the EPDS in primary care settings, the cut-off of 12/13 is used instead of 9/10 to prevent over-inclusiveness (Cox & Holden, 2003). The reliability of the 10-item EPDS is 0.88 and the standardised α coefficient 0.87. (Kumar & Riley, 1994). Most women are able to complete the scale in less than five minutes, and it is generally well received by women who have recently given birth. The scale is a screening tool for postnatal depression and does not assess anxiety, phobias or neuroses (Cox & Holden, 2003).

As the EPDS does not assess for anxiety, and given that anxiety is a characteristic of PND (Briddon, 2008), the Hospital Anxiety and Depression Scale [HADS] (Snaith & Zigmond, 1983) was used. The HADS is divided into anxiety and depression subscales (HADS-A and HADS-D). Cronbach’s alpha for HADS-A ranged from .68 to .93 (mean .83), and for HADS-D .67 to .90 (mean .82) (Bjelland et al, 2001). The HADS has a two-week test-retest reliability coefficient of .84 (Marinus et al., 2001). The HADS comprises of 14 statements which measure anxiety (7 statements) and depression (7 statements); and has a four point (0–3) response category so possible scores ranged from 0 to 21 for both anxiety and depression (Snaith, 2003). Scores of 7 and below indicates normal levels of anxiety and depression, while 8-10 suggests mild depression or anxiety, 11-15 moderate, and 16 – 21 severe depression and/or anxiety.

The Rosenberg Self-Esteem Scale (SES) (Rosenberg, 1965) consists of 10 items: five positively worded and five negatively worded phrases; and scores range from 10 to 40, where high scores suggest high self-esteem. Scores of 15-25 indicates normal self-esteem, while scores below 15 indicates low self-esteem. The SES has high reliability, and test-retest correlations range from .82 to .88, and Cronbach's alpha for various samples are in the range of .77 to .88, including antenatal and postnatal depression samples (Leigh & Milgrom, 2008). Like the EPDS, it takes no longer than 10 minutes to complete.

The Quality of Life Enjoyment and Satisfaction Questionnaire Short Form [QLESQ-SF] (Endicott, Nee, Harrison, & Blumenthal, 1993) is a 16-item self-report form, rated on a 5-point scale. A total score is obtained from the first 14 items, computed and reported as a percentage of the maximum score of 70. The two global measures (items 15 and 16) are not included in the total score. The QLESQ- SF has been validated for use in samples of adults with depression and anxiety (Rapaport, Clary, Fayyad, & Endicott, 2005). QLESQ-SF has a Cronbach's alpha value of 0.86 (Stevanovic, 2011), and a test-retest consistency for overall rating of life satisfaction of 0.71 (Rapaport et al., 2005). Any participant who scores within 10% of the mean of the community sample is considered within normal range (Rapaport et al., 2005).