In-Home CBT for Postpartum Depression in First-Time Mothers in Home Visitation
Maternal Depression: Causes, Consequences, and InterventionRobert T. Ammerman, Ph.D, ABPP Every Child Succeeds and Cincinnati Childrens Hospital Medical Center
Delaware Healthy Mother and Infant Consortium Annual SummitApril 9, 2014
Depression in MothersDetermined by self-reportEdinburgh Postnatal Depression ScaleCenter for Epidemiological Studies Depression Scale (CES-D)Beck Depression Inventory-II (BDI-II)Patient Health Questionniare-9 (PHQ-9)Diagnosis of major depressive disorder (MDD)Postpartum onset 6 monthsPrenatal
Symptoms of Major Depressive Disorder (MDD)SadnessCryingFatigueDisinterestSleep problemsAppetite problemsAgitation or slownessPoor memoryPoor concentrationLow self-esteemGuiltLow motivationHopelessness Suicidal thoughtsDecreased libidoCONSISTENT&PERSISTENT2 weeks
PhenomenologyPervasive lossLoss of controlLoss of selfSocial disconnectionLoss of voiceSpiraling downwardAnxietyOverwhelmedRuminationObsessive thinkingAngerGuiltFrom C.T. Beck, 2002
Phenomenology (cont.)Expectations and realityShattered dreamsFailure & incompetenceFear of negative evaluationMaking gainsSurrenderingDespair and hopelessnessStruggle
Epidemiology of MDDLifetime prevalence for the general population is as high as 1 in 3, often begins in childhood or adolescenceLifetime prevalence in women postpartum: 13-26%Average length of episode: 3-6 monthsImpairment: 87% report significant role impairment (social, home, relationships, work)Comorbidity: 71% (anxiety disorders, substance use disorders)Risk for subsequent episodes: 80%Odds of relapse within 2 years: 50%First episodes in postpartum period: 50%
Associated FeaturesNationally, 57% receive treatment. Only 64% get at least minimally adequate treatment.20-30% of women depressed postpartum receive treatment, less among low income.Failure to successfully treat the first episode increases risk for subsequent episodes and increases likelihood of treatment resistant depression.Suicide risk: between 4-15%
Maternal Depression is ExpensiveMotherEmploymentEducationHealth care utilizationLifetime earningsChildPreterm birthCognitive delays, special educationMental health treatmentInjury and illnessChild abuse and neglect
Maternal depression is a multigenerational issue.
Economic CostsWorld Health Organization (2012)Depression is the leading cause of disability worldwideDepression in adults costs $83.1 billion annually, including 31% direct medical costs, 62% workplace costs (absenteeism, presenteeism and disability) and 7% for suicide/mortality costs Depressed employees miss 27.2 days of work per yearMaternal depression is associated with an increase in pre-term births which average $51,600 per birthFamily lifetime loss in income potential is $300,000 due to childhood onset of psychological problemsIdentification and effective treatment saves money and protects investments in other programs.
Depression 2 years Postpartum
Sample: 1,359 women over 2 years postpartumMeasure:Edinburgh PostnatalDepressionScaleFrom Mayberry et al., 2007
Center on the Developing Child, Harvard University, 2009
Video ExampleDiagnostic Interview with a Depressed Mother in Home Visiting
Risk Factors for DepressionHistory of depressionCognitive and emotional vulnerability: pessimism, anxiety, low self-esteemStressful life eventsTrauma historyLow social supportPovertyUnmarriedUnwanted pregnancy
Causes of DepressionGeneticsDisruptions in HPA axis and stress responseSensitivity to hormonal changesSocial disconnectionCognitive distortions
Key Features of Infant Social and Emotional DevelopmentInfants can imitate facial expressions and show preferences for caregivers.Infants have a need to seek out communication with others.Infants can elicit social and emotional responses from caregivers.
Key Features of Infant Social and Emotional DevelopmentCommunication between mothers and infants is organized around face, voice, gesture, and gaze--a dance.Secure attachment is the cornerstone of early social and emotional development.Communication directly influences, and is influenced by, brain development and emerging physiological regulation.
Key Features of Infant Social and Emotional DevelopmentIn normal mothers interactions with babies, 42% of time is spent exhibiting positive affect. For babies, 15% of time.Mothers guide the quality of the interaction and the direction of development. They provide the scaffolding needed for successful development.
Characteristics of Depressed MothersWithdrawn: disengaged, flat, unresponsive, little support.Intrusive: rough, angry, interruptUnable to read cues.Rejecting.Imbalanced, discordant.
Characteristics of Depressed MothersDont enjoy parenting.View themselves as less competent and ineffective.View children as more difficult.Less tolerant.More likely to attribute inappropriate intent in children.See their behavior as caused by outside influences.Preoccupied, less attentive, dont anticipate.Slower and less effective problem-solvers.
Course of Depression & Development (illustrative)
1st episode4 months2nd episode 9 months3rd episode 2 monthsAge 16Baby born(age 20)child 1 year old= depressive episode= normal mood4th episode 3 monthschild 3 years oldtime
Impact on Infants and DevelopmentAvoid mom, look away (for intrusive moms), docile, typically following maternal rejection.Fussy, cries, focus on self-regulation (for withdrawn moms).Crystallizing of communication patterns.Delays in emotional regulation, and physiological organization.Attentional problems.
IMPORTANT: timing, length, severity, frequency,inter-episode functioning, partner support, other adults
Exposure to Maternal Depression in Infancy & IQ15 pointsBOYS AT AGE 11Hay et al., 2001
Video ExampleMother-Child Interaction Using Still-Face Paradigm
Treatment OptionsAntidepressant medicationsInterpersonal PsychotherapyCognitive Behavioral TherapyNon-traditional and emerging: Listening Visits, yoga, mindfullness therapy, lay counselors
Treatment ChallengesTreatment capacityAvailability of evidence-based treatmentAccess and disparitiesChoice and engagementAntidepressant medications: adherence, effect on developing fetus, cost, trauma issues
Moving Beyond DepressionOvercoming barriers, fostering collaboration, and engaging depressed mothers in a non-traditional setting
www.movingbeyonddepression.org
Unique Opportunity in Home VisitingReach mothers who might not otherwise receive treatment.Appeal to mothers interest in their babys development.Lower barriers to treatment.Identify mothers early in the MDD episode.Leverage relationship between mother and home visitor.Leverage ongoing and lengthy home visitation services to optimize outcomes.
12% receive mental health treatmentAmmerman et al., 200974.8%withtraumahistory
Essential Intervention ElementsAmeliorate depressive symptomsHelp mother and home visitor/serviceCollaborate with home visitor, no burdenImplement in home to remove barriersUse evidence-based treatmentFit with population, setting, & service
IH-CBT: Adaptations to SettingPOPULATIONSERVICESETTING
Overcome barriers to treatment to reach mothersObserve mothers in natural environmentObserve important features that would not be evident in officeMaximize learning and application of new skillsLogistical challenges: privacy, other family, distractionsUnexpected challenges and crises
IH-CBT: Adaptations to PopulationPOPULATIONSERVICE
New mothers with limited parenting experienceYoung mothers with few social supportsEmerging adulthoodEducational underachievement & lower IQCultural sensitivityPoverty and hardshipTrauma history & intimate partner violencePsychiatric comorbidityPOPULATION
IH-CBT: Adaptations to ServicePOPULATIONSERVICE
Collaborative relationship with home visitorLogistical coordination of multiple servicesFrequent contacts with home visitorCoordination of careAvoid triangulationSERVICE
Conceptual representation of IH-CBT collaborationMOMTHERAPISTHOME VISITORprimarilyHV domainsprimarilydepressiondomains
MIDIS DesignScreening: EPDS 11Eligibility/Pre-treatment AssessmentSCID Diagnosis of MDDIH-CBT15 sessions + boosterOngoing home visitationTypical Home VisitationCommunity resourcesOngoing home visitationPost-treatment Assessment3 Month Follow-Up AssessmentInclusionary:ECS participant16 years oldBaby 2
