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An evaluation of perinatal mental health interventions: An integrative literature review
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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
REVIEW ARTICLE
An evaluation of perinatal mental health interventions: An integrative literature review Theressa J. Lavender a,*, Lyn Ebert b, Donovan Jones c a School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia b Program Convenor, Midwifery Studies, School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia c Deputy Program Convenor, Bachelor of Midwifery, School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia
A R T I C L E I N F O
Article history: Received 19 November 2015 Received in revised form 28 March 2016 Accepted 4 April 2016 Keywords: Perinatal Mental health Health promotion Evaluation studies Behavior therapy
A B S T R A C T
Background: National statistics related specifically to the mental health of women in the perinatal period is poorly acknowledged in Australia. Maternal deaths related to mental health in the perinatal period can be attributed to a lack of appropriate treatment and/or support. A barrier to women’s help-seeking behaviors is the lack of discrete, perinatal specific interventions where women can self-assess and access support. Aim: This review examines original research evaluating perinatal mental health interventions used by women to improve mental health. Method: An integrative literature review was undertaken. A comprehensive search strategy using 5 electronic databases resulted in the retrieval of 1898 articles. Use of an inclusion and exclusion criteria and Critical Appraisal Skills Program tools resulted in 4 original research papers. Thematic analysis identified universal themes. Findings: Cognitive Behavioral Therapy, Behavioral Activation and Mindfulness-based interventions, specifically adapted to meet the needs of women in the perinatal period, demonstrate an overall improvement in mental health. Women involved in the interventions experienced both improvements in symptoms of anxiety and depression as well as secondary benefits from participating in the research. Conclusion: To improve perinatal mental health outcomes, innovative modes of providing effective perinatal mental health interventions that address the unique needs of women in the perinatal period are needed. Future development of perinatal mental health interventions require adaptions of Cognitive Behavioral Therapy, Behavioral Activation and/or Mindfulness-based methods to address mental health outcomes for women in the perinatal period. ß 2016 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Summary of relevance Problem/issue Perinatal mental health is a prevalent issue for childbearing women in society and is poorly recognised or acknowledged. Non-pharmacological treatment options exist, however there is a lack of available evidence regarding the efficacy of such interventions.
What is already known Mental health affects a significant number of people in today’s society. Compared to the general public, the perinatal period has it’s own specific challenges with regard to mental health issues.
What this paper adds This paper highlights the issues surrounding perinatal mental health and explores current evaluation of treatment interventions used by women to improve their mental health.
* Corresponding author. Tel.: +61 0437772614. E-mail address: [email protected] (T.J. Lavender). http://dx.doi.org/10.1016/j.wombi.2016.04.004
1871-5192/ß 2016 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Please cite this article in press as: Lavender TJ, et al. An evaluation of perinatal mental health interventions: An integrative literature review. Women Birth (2016), http://dx.doi.org/10.1016/j.wombi.2016.04.004
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1. Introduction Mental health in Australia continues to be a concern in today’s society, with approximately 45% of the general population facing longstanding mental health issues and around 20% suffering any form of mental illness over a 12-month period.1 Australian women are at a higher risk of experiencing mental health issues (in comparison to males) with current statistics indicating a rate of 22% of women experiencing some form of mental health issue compared to 18% for males.1 Women in the perinatal period have a 10% chance of experiencing symptoms of anxiety and/or depression, with 9% suffering from antenatal depression and 16% developing postnatal depression.2 Maternal mental health statistics also indicate 15.2% of childbearing women in Australia experience illnesses related to poor mental health and the deaths of 1 in 136 mothers (from 2008 to 2012) were attributed to inadequate management of mental health issues during the perinatal period.3 National statistics related specifically to the mental health of women in the perinatal period is poorly acknowledged, with statistics concentrating on the general female population.1 Additionally, the criteria used to diagnose mental health disorders, fails to distinguish between ‘depression’ and ‘postnatal depression’, adding to the poor recognition of women in the perinatal period.4 Maternal deaths in Australia related to mental health issues in the perinatal period have been attributed to a lack of appropriate treatment and/or supportive assistance.3 The incidence of maternal deaths in Australia connected with psychosocial problems (an average of 12 deaths per year) has been shown to have a similar prevalence as maternal deaths due to an obstetric haemorrhage.3 These statistics emphasise the need for an improvement in the detection, management and early treatment of maternal mental health issues. Barriers to seeking mental health support have been shown to incorporate both structural and attitudinal obstacles, whereby individuals with mental health issues either decide to stop treatment or resist attempts to seek help.5 Economic adversity, geographic remoteness and inaccessibility of services can be perceived as potential structural barriers to seeking mental health treatment.5 Attitudes held by individuals may include believing they do not have a mental health problem, having a perception of being judged negatively if they disclose a potential mental health disorder, preferring not to be offered pharmacological solutions, having experienced negative assistance in the past and feeling what they are experiencing is not serious enough to seek help.5 Women in the perinatal period may develop emotional distress from a variety of sources including variations in hormone levels, unwanted advice from individuals, social influences on their role as a mother and/or parent, perceived negative opinions of others and minor discomforts related to pregnancy.6,7 Pharmacological treatment remains the preferred method within the healthcare system for mental health issues, however behavioral and/or alternative therapies that compliment pharmacological methods are emerging.8 In today’s age of technology, online mental health information and support websites are also a valuable and appealing way for individuals to carry out their own research about mental health issues, explore care options available and access information autonomously without the fear of disclosure.9,10 However, the quality of open access sites is problematic. A study by Moore and Ayers10 examining mental health websites reported there is a lack of research regarding how websites are evaluated for quality and efficacy. In pregnancy, women are increasingly exploring the use of alternative therapies that focus on the connections between the mind and body to assist with physical and emotional wellbeing.11 Anxiety reducing therapies in pregnancy (such as meditation, yoga,
hypnotherapy, tai chi, and other methods of relaxation) have been shown to improve emotional wellbeing. However more research is needed to find a direct correlation between the use of alternative therapies and the prevention of anxiety and/or depression within the perinatal period.11,12 Group education interventions for expecting couples is another method of providing information about the stresses associated with the changing demands related to transitioning to parenthood. These interventions offer both a supportive group environment and individual methods of dealing with physical and emotional issues during this stage of their lives. Parenting interventions provided in a group environment have shown to provide shortterm positive emotional health effects. Further research and development of these interventions are needed to maintain the positive effects of emotional wellbeing for a sustained period.13 This integrative literature review examines current evidence related to the evaluation of perinatal mental health interventions used by women in the perinatal period to improve their mental health. This review defines the ‘perinatal period’ as the period from conception through to 12 months post-birth. 2. Methodology This review utilises an integrative literature review methodology framework as described by Whittemore and Knafl.14 Integrative literature reviews encapsulate original experimental and nonexperimental research on a specific subject to provide an allencompassing understanding of the topic question. The broader understanding of the phenomenon available through an integrative review also allows for multiple realities to be presented.14 Whittemore and Knafl outline a five-stage strategy for an integrative literature review that includes problem identification, literature search, evaluation of data, analysis of data and presentation of results/findings.14 2.1. Problem Identification The mental health of women in the perinatal period continues to be a concerning issue in society. Perinatal mental health interventions currently exist, however there is a paucity of available research evaluating the effectiveness of such interventions. In order to evaluate the use of perinatal mental health interventions used by women to improve their mental health, three research questions were formulated. These questions were used to focus the integrative literature review: 1. ‘What current perinatal mental health interventions have been evaluated with regard to improvements in mental health outcomes for women in the perinatal period?’. 2. ‘What are women’s experiences in utilising evaluated mental health interventions in the perinatal period to enhance mental health outcomes?’. 3. ‘What measurements are used to determine improvements in existing perinatal mental health interventions?’.
2.2. Literature search The search strategy was aimed at supporting the evaluation of perinatal mental health interventions used by women to improve their mental health. Key search terms (see Table 1), in conjunction with Boolean operators, truncation and synonyms were used to source articles. The following online databases were used to search current literature concerning the evaluation of current mental health interventions for women in the perinatal period – Cumulative Index to Nursing and Allied Health Literature
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Table 1 Search strategy used for five databases. (1) mental health (2) depress* (3) anxiety (4) wellness (5) 1 or 2 or 3 or 4 (6) program* (7) tool* (8) plan (9) course (10) intervention (11) education* (12) 6 or 7 or 8 or 9 or 10 or 11 (13) evaluat* (14) effect* (15) assess* (16) question* (17) survey* (18) ethnograph* (19) 13 or 14 or 15 or 16 or 17 or 18 (20) self-initiat* (21) help seeking (22) self* (23) self-help (24) guid* (25) 20 or 21 or 22 or 23 or 24 (26) therap* (27) cognitive behavioural therapy (28) CBT (29) interpersonal psychotherapy (30) ITP (31) mindfulness (32) group support (33) peer support (34) support* (35) face to face (36) face-to-face (37) psycho* (38) telephone (39) counsel* (40) consult* (41) 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 (42) technolog* (43) online (44) e-health (45) ehealth (46) web based (47) web-based (48) mobile (49) app* (50) internet (51) 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50 (52) improve* (53) reduc* (54) benefi* (55) 52 or 53 or 54 (56) women (57) maternal (58) mother* (59) 56 or 57 or 58 (60) perinatal* (61) antenatal* (62) prenatal* (63) pregnan* (64) postnatal* (65) postpartum (66) 60 or 61 or 62 or 63 or 64 or 65 (67) austral* (68) 5 and 12 and 19 and 25 and 41 and 51 and 55 (69) 59 and 66 and 68 (70) 67 and 68 (71) 67 and 69
Table 2 Inclusion/exclusion criteria. Inclusion criteria Women in the perinatal period Mental health interventions used for depression and/or anxiety Women experiencing symptoms relating to stress, depression and/or anxiety in the perinatal period Literature published between 2005 and 2015 Primary or original research (qualitative, quantitative and/or mixed methods) Exclusion criteria Non-English literature that has not been translated Mental health interventions involving pharmacological and/or hospitalisation Women currently being treated for a mental health disorder other than depression and/or anxiety Women experiencing suicidal ideation or substance abuse Literature that does not meet critical appraisal
(CINAHL), Medline, Mosby’s Index, PsycINFO, Embase and Maternity & Infant Care Database. These databases were utilised as they are considered to contain comprehensive literature relating to nursing, midwifery, psychology, humanities, medicine, science and healthcare.15 The search strategy used to source appropriate literature is outlined in Table 1. The search strategy included
Fig. 1. Search results. *CASP, Critical Appraisal Skills Program.
literature published between the years of 2005 to 2015 to ensure currency of available literature. The results of the literature search are detailed in Fig. 1. The initial search resulted in 1898 articles with 94 duplicate articles excluded (leaving 1804). Titles and abstracts were reviewed for relevance (excluding 1735 articles) with 69 articles remaining for further evaluation. Reference lists from the 69 articles were reviewed to source additional articles, with a further 18 articles included for further evaluation (total of 87 articles remaining). 2.3. Evaluation of data Evaluation of the remaining 87 articles comprised of two levels of assessment – the elimination of literature based around the inclusion and exclusion criteria (see Table 2) and a critical appraisal of the literature to determine appropriate levels of methodological quality (see Tables 3a and 3b). Seventy-seven (77) articles were excluded with 10 articles identified for inclusion and
Table 3a CASP qualitative studies evaluation checklist.
1. 2. 3. 4. 5. 6.
Was there a clear statement of the aims of the research? Is the qualitative methodology appropriate? Was the research design appropriate to address the aims of the research? Was the recruitment strategy appropriate to the aims of the research? Was the data collected in a way that addressed the research issue? Has the relationship between researcher and participants been adequately considered? 7. Have ethical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is there a clear statement of the findings? 10. How valuable is the research Methodological quality score I7 cut off
Goodman et al.18
Dunn et al.19
Scherer et al.20
Pugh et al.21
1 1 1 1 1 1
1 1 0 1 1 1
1 1 1 0 0 0
1 1 1 0.5 0 0
0 1 1 1 9
1 0 0 0 6
1 0 0.5 0.5 5
0.5 0 0 0 4
0 = no; 0.5 = unsure/partially; 1 = yes.
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4 Table 3b CASP randomised controlled trials checklist.
1. 2. 3. 4. 5. 6.
Did the trial address a clearly focused issue? Was the assignment of patients to treatments randomised? Were patients, health workers and study personnel blinded? Were the groups similar at the start of the trial? Aside from the experimental interventions, were the groups treated equally? Were all of the patients who entered the trial properly accounted for at its conclusion? 7. How large was the treatment effect? 8. How precise was the estimate of the treatment effect? 9. Can the results be applied in your context or to the local population? 10. Were all the clinically important outcomes considered? 11. Are the benefits worth the harms and costs? Methodological quality score I7 cut off
Caramlau et al.22
Heller et al.23
O’Mahen et al.7
1 1 0 0 0 0
1 1 1 0 0.5 0
1 1 1 1 1 1
0 0 0 0 0 2
0 0 0 0 0 3.5
1 1 1 1 1 11
O’Mahen et al.24
Reay et al.25
a Woolhouse et al.26
1 1 1 1 1 1
1 0 0 0.5 0 0
1 1 0 1 1 0.5
0.5 0.5 0.5 1 1 9.5
0 1 0 0 0 2.5
0.5 1 1 1 1 9
0 = no; 0.5 = unsure/partially; 1 = yes. a Focus on the RCT component of this study (the non-randomised trial not included).
further evaluation. The remaining 10 articles were evaluated for methodological quality using the appropriate Critical Appraisal Skills Program (CASP) tool.16 Katrak et al.17 undertook a systematic review of critical appraisal tools. The authors of this systematic review concluded that ‘‘there is no gold standard critical appraisal tool for any study design’’17 and that appraisal tools should be chosen for the task and intent of the review. CASP tools allow for the assessment of methodological quality by using checklists that are designed specifically for various research designs.16 The checklists provided through the CASP allows for a systematic and rigorous method of assessing the quality of research studies regardless of the methodology. A methodological quality score of 7 (from a possible 10 for qualitative studies and 11 for quantitative studies) was determined to be a cut off point for inclusion. The authors determined a score of 7 would achieve a sufficient degree of methodological rigor. As a result, 10 articles were excluded with 4 articles that met the strict criteria for inclusion in this integrative review. Various forms of behavioral therapies were used in the four remaining studies examining the effects of interventions on perinatal mental health outcomes. Table 4 outlines details of the four studies. One study7 included a modified Cognitive Behavioral Therapy (CBT) intervention. One study used Mindfulness practices26 with another study using another form of mindfulness therapy – Mindfulness-based Cognitive Therapy (MBCT).18 The fourth study used an online version of a modified Behavioral Activation (BA) intervention.24 The interventions used within each study were adapted to meet the needs of women during the perinatal period. All four articles focused on depression at various times throughout the perinatal period,7,18,24,26 three of the four articles also focused on anxiety18,24,26 with one also focusing on stress.26
Three of the studies addressed the antenatal period,7,18,26 with one study exploring the postnatal period.24 Two studies were based in the United States of America (USA),7,18 one in Australia26 and one in the United Kingdom (UK).24 2.4. Analysis of data Thematic analysis is the preferred method for data analysis when conducting an integrative literature review as it allows for the comparison of patterns and relationships of concepts to be explored.14 The four articles were reviewed and various themes and concepts were identified, which were amalgamated to develop overarching or main themes. 2.5. Presentation of result/findings The results of the review are presented as themes, drawn from all four included studies. A number of the studies contained more than one theme as well as recurring themes. Three main themes were identified – 1. Variations in perinatal mental health interventions; 2. Women’s experiences of interventions; 3. Evaluation of interventions. Sub-themes were also determined and discussed. 2.5.1. Variations in perinatal mental health interventions The perinatal mental health interventions in the four remaining studies included the use of modified CBT,7 Mindfulness,26 MBCT18 and modified BA.24 CBT aims to decrease the incidence of automatic negative thinking, identify how emotions affect behaviors, ultimately resulting in more positive behaviors and productive outcome.7 CBT has been found to be effective in the treatment of depression in the general population, however the use of CBT for depression during pregnancy and the postnatal period
Table 4 Four original research studies. Author(s) Country
Intervention
Period of mental health focus
Sample size
Research method
Goodman et al.18 USA
MBCT
Antenatal Anxiety & depression
26
Qualitative – Pilot study
O’Mahen et al.7 USA
Modified CBT
Antenatal Depression
55
Quantitative – Randomised controlled trial pilot
O’Mahen et al.24 UK
Online modified behavioral activation
Postnatal Anxiety & depression
83
Quantitative – Randomised controlled trial
9.5
Woolhouse et al.26 Australia
Mindfulness
Antenatal Anxiety, depression & stress
32
Qualitative – Randomised controlled trial
9
CASP score 9
11
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has not been shown to be as effective.7 The study evaluating CBT carried out a pilot Randomised Controlled Trial (RCT) that adapted the CBT intervention to meet the specific needs of women in the perinatal period, with interventions also individualised for each woman.7 The practice of Mindfulness allows the individual to consciously turn their attention to the ‘here and now’ with an attitude of acceptance.26 Mindfulness teaches cognitive awareness and changes in thought patterns in order to empower the individual to manage negative experiences in a more calm and positive way.26 The Mindfulness intervention used in the RCT comprised of 6 group sessions focused on reducing the symptoms of anxiety, depression and stress during pregnancy and how the mind affects both the woman and her baby.26 MBCT uses a combination of mindfulness and meditation techniques with Cognitive Behavioral Therapy (CBT). This therapy teaches individuals how emotions affect the physical body and allows the individual to develop awareness of their thoughts, to accept their emotional feelings and to observe their physical reactions to situations in the moment.18 By learning how to alter reactions to negative stimulus, individuals are better able to develop flexibility in their thought patterns, become more accepting and develop positive self-regulating coping mechanisms to reduce levels of stress and/or symptoms of anxiety.18 The MBCT intervention used a group-based intervention consisting of eight sessions with content of each session focusing on mindfulness techniques that were suited to women’s needs during pregnancy.18 One of the studies used the BA technique as an intervention.24 BA allows an individual to identify the reasons behind their behavior and find ways to modify behaviors in order to achieve specific goals.24 It uses behavioral features of CBT, but excludes the cognitive elements of this therapy.24 This RCT study evaluated an online BA intervention, consisting of 12 educational modules that were adapted to the needs of women in the postnatal period including intervention follow-up telephone support services.24 2.5.2. Women’s experiences of interventions 2.5.2.1. Structure of interventions. The delivery method of interventions in the studies revealed differences in women’s experiences as research participants. Two studies using Mindfulness and MBCT interventions were attended in a group-based setting with attendance over 6 sessions (for the Mindfulness intervention)26 and 8 sessions (for the MBCT intervention).18 Initially, some women found being part of a group uncomfortable, however this feeling of discomfort reduced as the participants began to connect with each other and found the experience of being in a group setting to be pleasurable.26 Women within the group based settings reported enhanced feelings of supportiveness and connectedness with others and discovered their personal suffering was not isolated to themselves.18 One study provided the modified CBT intervention as 12 individual face-to-face sessions, carried out in the home setting or other suitable location.7 The location for sessions were determined by the women, with 73% held at the woman’s home, 12% conducted in the office of the therapist, 8% within the obstetric clinic, 6% attended over the phone and 1% in other locations.7 However, this study was not able to correlate any relationship between the method of delivery or the location of the sessions with outcomes of the study.7 One study using an online mode of intervention delivery (using 12 sessions of BA) was not able to demonstrate any positive or negative outcomes in relation to the mode of intervention delivery.24 2.5.2.2. Changes in thought patterns. Mindfulness based techniques based around the interventions utilised in two studies, allowed the women to experience changes in thought patterns.18,26 In one
5
study, a participant reported how she realised previous unhelpful patterns of thought became overwhelming and was able to recognise these negative patterns and shift her focus to more positive and adaptive approaches.18 In the other study, one participant reported how they noticed a change in their reactions when exposed negative or challenging situations.26 Instead of automatically reacting to their thoughts, feelings and actions in a negative and damaging way, they were able to emotionally remove themselves and take time to think about how to better respond to the situation they were facing.26 2.5.2.3. Social support. In both the studies using the Mindfulness and MBCT group-based interventions, participant’s experienced increased levels of social and emotional support.18,26 In the study using the MBCT intervention, 67% of participants reported feeling comforted and connected with other participants.18 One participant in the Mindfulness intervention noticed improvements in their relationships with not only individuals they were close to (i.e.: partners, family and friends), but also how they related to people in general.26 Being more proactive in seeking support and asking for help from others also led to increased personal selfconfidence and self-compassion.18 The two studies using interventions other than group-based MBCT were unable to demonstrate outcomes relating to emotional and/or social support experienced by participants.7,24 2.5.2.4. Impact of behaviors. Women participating in the Mindfulness and MBCT interventions also reported the experience had a positive impact on behavioral alterations. In the Mindfulness intervention one women reported being able to control her reactions to negative stimulus rather than letting her reactions spiral out of control.26 In the same study, one participant reported increased levels of self-compassion.26 Participants in the MBCT intervention, 58.3% reported they were able to increase their levels of self-acceptance and able to treat themselves with kindness when faced with situations that can induce feelings of anxiety.18 In the same study, 41.7% of women reported they became more adaptable with their reactions to stressful triggers and 29.2% of participants reported they were better able to control reactions to overwhelming thoughts.18 Women experiencing distress regarding past negative experiences in the perinatal period were more able to address these previous negative emotions (with the use of Mindfulness and MBCT) and bring their attention to the present with a more accepting and positive approach. Women suggested that their perceptions of the past were altered, allowing them to focus more on the present and/or future.18,26 2.5.2.5. Coping mechanisms. Developing coping mechanisms was shown to be an additional benefit of intervention participation for some women. Breathing, practicing yoga or using body scan techniques were shown to assist with symptoms of anxiety in 83.4% of participants.18 Another coping mechanism prominent in both the Mindfulness and MBCT interventions was teaching participants to focus on the present moment to reduce levels of stress.18,26 Gaining insight regarding reactions to anxiety through reflection and understanding of how thoughts and feelings can trigger anxiety was a coping mechanism that was reported to be beneficial in both the Mindfulness intervention and in 29.2% of women participating in a MBCT intervention.18,26 2.5.3. Evaluation of interventions 2.5.3.1. Use of mental health assessment tools. A number of validated tools to assess the participant’s symptomatic levels of anxiety, depression, stress and mindfulness were used in the studies. The use of validated mental health evaluation tools pre and
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6 Table 5 Timing of assessment tools. Study 18
Goodman et al. O’Mahen et al.7 O’Mahen et al.24 Woolhouse et al.26
Before intervention
During intervention
End of intervention
Post-intervention
Baseline Baseline Baseline Baseline
Weeks 3, 5, and 7 Not measured Not measured Not measured
Measured Not measured Not measured Measured
Immediate post-intervention 16 weeks 17 weeks Not measured
Table 6a Randomised controlled trials intervention outcomes. O’Mahen et al.7 – Intervention: Modified CBT Measurement/outcomes
Baseline
Intervention group Control group
BDI-II BDI-II
16 weeks post randomisation 29.93 26.56
BDI-II BDI-II
15.85 22.24
O’Mahen et al.24 – Intervention: Modified BA Measurement/outcomes
Baseline
Intervention group
EPDS GAD-7
20.24 13.90
EPDS GAD-7
11.05 8.71
Control group
EPDS GAD-7
21.07 14.12
EPDS GAD-7
14.26 11.29
a
17 weeks post intervention
Woolhouse et al.26 – Intervention: Mindfulness
Measurement/outcomes
Baseline
RCT intervention group
CES-D DASS depression STAI DASS Anxiety Mindfulness
14.42 7.23 35.92 8.62 121.55
CES-D DASS depression STAI DASS Anxiety Mindfulness
12.08 4.31 32.83 4.62 134.55
RCT control group
CES-D DASS depression STAI DASS anxiety Mindfulness
13.70 8.00 34.78 7.00 126.50
CES-D DASS depression STAI DASS anxiety Mindfulness
10.10 5.60 33.00 4.80 133.50
a
Post intervention
RCT component of study only used.
post-intervention allowed the researchers to establish baseline levels and measure variations in the participant’s mental health status again post-intervention (see Table 5). Tools used to measure mental health status and other aspects of social/emotional wellbeing included – the Beck Anxiety Inventory (BAI),18 Beck Depression Inventory-II (BDI-II),7,18 Centre for Epidemiologic Studies Depression Scale Revised (CES-D),26 Depression, Anxiety and Stress Scale (DASS),26 Edinburgh Postnatal Depression Scale (EPDS),24 Generalised Anxiety Disorder Scale (GAD-7),24 Mindfulness (consisting of the Five-Factor Mindfulness Questionnaire)26 and the State-Trait Anxiety Scale (STAI).26 However, not all of these tools were common to all four studies (see Tables 6a and 6b). 2.5.3.2. Outcomes of perinatal mental health interventions. The studies assessed changes in symptoms of anxiety, depression and mindfulness. A comparison of the interventions and changes in mental health status are shown in Tables 6a and 6b. For the
Table 6b Qualitative research intervention outcomes. Goodman et al.18 – Intervention: MBCT Measurements/outcomes Pre-intervention Number/percentage of participants in clinical range for anxiety or depression Post-intervention Number/percentage of participants recovered
BAI
BDI-II
11/47.8%
23/100%
7/63.6%
11/47.8%
modified CBT intervention statistical analysis of symptom reduction revealed the effect size of Cohen’s d = 0.71 (95% CI 4.93, 5.70) at 16 weeks post-randomisation.7 The authors concluded that there was no clinically significant difference in the outcomes.7 The modified BA intervention, statistical analysis at 17 weeks postrandomisation revealed an effect size of Cohen’s d = 0.87 (95% CI 0.42 to 1.32, p 0.01) for EPDS.24 The GAD-7 measurement revealed an effect size of Cohen’s d = 0.59 (95% CI 1.11 to 0.07, p 0.03).24 The authors concluded that there was a large effect size for women receiving modified BA in the management of their symptoms of anxiety and depression.24 Statistical analysis of the RCT for the Mindfulness intervention for DASS (anxiety) revealed a mean difference at post intervention of Cohen’s d = 0.7 (95% CI 0.69–7.31, p 0.02).26 The authors of this study concluded participants involved in the Mindfulness intervention showed statistically significant improvement in symptoms of anxiety.26 Goodman et al.18 concluded that of the participants considered to be clinically depressed or anxious prior to the intervention, 47.8% of depressed participants and 63.6% of participants experiencing symptoms of anxiety recovered. Further, participants showed improvements in their symptom of anxiety and depression by 18.2% and 21.7% respectively.18 The authors of this study concluded that there was a reliable improvement in symptoms of anxiety and depression for participants involved in the MBCT intervention.18 2.5.3.3. Intervention adherence. The modified CBT intervention consisted of 12 sessions with participants completing four or more session defined as adhering to treatment.7 Sixty percent
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(60%) of participants completed 4 sessions and 43% completed 7 sessions.7 Women who were experiencing work and/or social issues and increased EPDS scores were 17% more likely to withdraw from the intervention after the first session.7 Obstacles such as trying to meet the needs of a new baby, illness of children, discomforts of pregnancy, housing issues and privacy were reported by women to reduce their likelihood of adhering to intervention treatment.7 Twelve online modified BA sessions resulted in 5% of women completing 8 sessions with only 1.9% of women completing all 12 sessions.24 An average of 5.36 sessions were completed and 6.74 sessions viewed (but not completed) by participants.24 The number of sessions completed was dependent upon the level of network of support, work and/or study commitments and financial resources available to the woman.24 The study by Goodman et al.18 reported 87.5% of women attended six out of eight MBCT sessions with all participants averaging a completion of 6.96 sessions. The Mindfulness study was unable to provide an evaluation regarding intervention adherence due to the loss of participants who had given birth to their babies before completion of the six sessions.26 2.5.3.4. Limitations of studies. All four studies had small sample sizes, thereby reducing the statistical strength associated with overall results. The participant sample in one study were primarily well-educated women, which is not an indicative demographic of the general population and excludes women with lower levels of education.18 One study did not allow for post-intervention assessment of mental health outcomes due to the inability of follow-up assessments to be carried on participants who had given birth.26
3. Discussion This integrative literature review identified four interventions used by women that employed Mindfulness, MBCT, CBT or BA therapies to improve symptoms of mental health issues such as anxiety, depression and/or awareness of mindfulness.7,18,24,26 The various modalities employed focused on supporting women to alter thought patterns, explore behavior modification, develop an awareness of the mind-body connection and to acquire enhanced coping mechanisms in an aim to improve emotional health and well-being.7,18,24,26 All of the interventions were altered to meet the unique needs of women both in pregnancy and the postnatal period.7,18,24,26 The structure of these interventions included individual faceto-face sessions,7 group participation18,26 and one internet-based option.24 Women found intervention delivery via a group-based setting enabled them to appreciate the value of having alternative supportive networks and connections with others to be of enormous benefit.18,26 This sense of enhanced support may be due to the characteristics of the facilitator for individualised faceto-face interventions and may not occur for women in online modes of delivery. Study participants were able to realise positive outcomes in terms of decreasing their stress levels. Women were better able to understand how their thoughts and feelings related to the signs and symptoms of anxiety and/or depression and also better able to acknowledge how emotions had a direct correlation to both their physical and mental well-being.18 Some women experienced secondary benefits from participating in the studies such as connecting with others in a similar situation, increased awareness of negative thought processes, greater awareness of the mind-body connection, increased number of coping strategies, ability to proactively seek support from others and learning acceptance.18,26
7
The interventions studied demonstrated that various perinatal mental health interventions have promising value. Although the studies used small sample sizes, authors reported statistical improvement is apparent in the mental health outcomes for women in the perinatal period. While valuable information and insights into issues surrounding perinatal mental health were provided, there is a need for larger studies to be conducted in order for statistical data to drive clinical practice directions and provide advancements in future perinatal mental health interventions available for women. The modified CBT and BA interventions, Mindfulness and MBCT interventions have shown additional value for the treatment of overall emotional health in the perinatal period.18,26 In a separate study by O’Mahen et al.,27 it was found that interventions dealing with cognitive and behavioral therapies that were modified for to cater for concerns specific to women in the perinatal period were more effective in the treatment of overall mental health. The Mindfulness, MBCT, CBT and BA interventions included in this integrative review have the potential to manage and improve perinatal mental health, nevertheless, further research in to the modes of delivery and modifications to behavioral therapies for women during the perinatal period are required. Three out of the four studies focused on intervention delivery within the antenatal period,7,18,26 highlighting the importance of early interventions to assist with treatment and management of emotional well being in pregnancy that can also carry through to the postnatal period. Immediate and short-term positive outcomes in mental health status can be perceived as improving overall mental health. However, achieving long-term improvements is important in sustaining positive mental health outcomes. This was demonstrated in two of the studies that measured outcomes from 16 weeks to 17 weeks post-intervention.7,24 In evaluating perinatal mental health interventions in terms of their effectiveness in improving mental health outcomes for women, the use of validated assessment tools pre and post intervention is vital in strengthening statistical and clinical significance. This integrative literature review found that there is a small number of methodologically sound research studies concerning the promotion, management and treatment of perinatal mental health and there is a need for future research to be conducted to evaluate the effectiveness of interventions. 4. Conclusion Perinatal mental health continues to be an issue for the women, their families and our society. This integrative literature review explored the literature surrounding the evaluation of perinatal mental health interventions. Due to the limited research on this topic, further research is required to evaluate the types of interventions that are appropriate for women in the perinatal period. Furthermore, future interventions should be rigorously evaluated in order to validate the effectiveness and efficacy of such interventions for the prevention and treatment of perinatal mental health. Findings suggest that the development of interventions utilising Mindfulness, MBCT, CBT and BA methods have the potential to benefit women experiencing symptoms of anxiety and depression during the perinatal period. As pregnancy is a time where women are more responsive to receiving additional information and skills to assist them in transitioning to their new role as a mother, mental health interventions need to be made available and easily accessible to women early in pregnancy, with interventions tailor-made to meet the complex needs of women transitioning to motherhood. The introduction of improved perinatal mental health interventions for women, have the ability to achieve sustained improvement in mental health outcomes for the woman and ultimately her family.
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Women can present with co-morbid symptoms of anxiety and depression in the perinatal period.7,18,24,26 To achieve improvements in symptoms of anxiety and/or depression can make a significant difference to an individual’s experience of mental health. Combining the methods from Mindfulness, MBCT and modified versions of CBT and BA (in line with the demands associated with the perinatal period) may provide women in the perinatal period with mental health interventions that can be effective in addressing their emotional needs and produce more positive outcomes. While these types of interventions are currently available and women have benefited from participation, the interventions have not been validated and their efficacy is unknown. Therefore, there is a need for future development and design of interventions that meet the mental health needs of women in the perinatal period (with emphasis on commencement of intervention in the antenatal period) through large sample randomised controlled trials and longitudinal studies. This integrative literature review has synthesised the results of studies evaluating the effectiveness of perinatal mental health interventions. Findings suggest that development of interventions utilising Mindfulness, MBCT, CBT and BA has the potential to benefit women experiencing symptoms of anxiety and/or depression during the perinatal period. The future involvement of midwives in the design, implementation and facilitation of these interventions into mainstream midwifery practice, will assist in ensuring women have access to appropriately evaluated and validated interventions. Conflicts of interest The authors declare that there are no potential conflicts of interest or financial support in relation to the research, composition and/or publication of this literature review. References 1. Australian Bureau of Statistics. National survey of mental health and wellbeing: summary of results. Canberra: Australian Bureau of Statistics; 2007. 2. BeyondBlue. Pregnancy and early parenthood: mental health conditions. 2015. http://www.beyondblue.org.au/resources/for-me/pregnancy-and-earlyparenthood/mental-health-conditions [accessed 05.03.15]. 3. Australian Institute of Health and Welfare. Maternal deaths in Australia 2008– 2012. Canberra: Australian Institute of Health and Welfare; 2015. 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013. 5. Andrade LH, Alonso J, Mneimneh Z, Wells JE, Al-Hamzawi A, Borges G, et al. Barriers to mental health treatment: results from the WHO World Mental Health surveys. Psychol Med 2014;44(6):1303–17. 6. Goodman JH, Guarino AJ, Prager JE. Perinatal dyadic psychotherapy: design, implementation, and acceptability. J Fam Nurs 2013;19(3):295–323. 7. O’Mahen H, Himle JA, Fedock G, Henshaw E, Flynn H. A pilot randomized controlled trial of cognitive behavioral therapy for perinatal depression adapted for women with low incomes. Depress Anxiety 2013;30(7):679–87.
8. Shinohara K, Honyashiki M, Imai H, Hunot V, Caldwell DM, Davies P, et al. Behavioural therapies versus other psychological therapies for depression. Cochrane Database Syst Rev 2013. http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD008696.pub2/abstract [accessed 03.03.15]. 9. Bennett A, Reynolds J, Christensen H, Griffiths KM. e-hub: an online self-help mental health service in the community. Med J Aust 2010;192(11):S48–52. 10. Moore D, Ayers S. A review of postnatal mental health websites: help for healthcare professionals and patients. Arch Womens Ment Health 2011;14(6): 443–52. 11. Marc I, Toureche N, Ernst E, Hodnett ED, Blanchet C, Dodin S, et al. Mind-body interventions during pregnancy for preventing or treating women’s anxiety. Cochrane Database Syst Rev 2011. http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD007559.pub2/abstract [accessed 16.04.15]. 12. Sado M, Ota E, Stickley A, Mori R. Hypnosis during pregnancy, childbirth, and the postnatal period for preventing postnatal depression. Cochrane Database Syst Rev 2012. http://onlinelibrary.wiley.com/doi/10.1002/14651858. CD009062.pub2/abstract [accessed 15.04.15]. 13. Barlow J, Smailagic N, Huband N, Roloff V, Bennett C. Group-based parent training programmes for improving parental psychosocial health. Cochrane Database Syst Rev 2014. http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD002020.pub4/abstract [accessed 12.03.15]. 14. Whittemore M, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005;52(5):546–53. 15. Schneider Z, Whitehead D. Nursing and midwifery research: methods and appraisal for evidence-based practice. 4th ed. Sydney: Mosby Elsevier; 2013. 16. Program CAS. CASP checklists. 2013. http://www.casp-uk.net [accessed 30.03.15]. 17. Katrak P, Bialocerkowski AE, Massy-Westropp N, Kumar S, Grimmer KA. A systematic review of the content of critical appraisal tools. BMC Med Res Methodol 2004;4:22. 18. Goodman JH, Guarino A, Chenausky K, Klein L, Prager J, Petersen R, et al. CALM pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety. Arch Womens Ment Health 2014;17(5):373–87. 19. Dunn C, Hanieh E, Roberts R, Powrie R. Mindful pregnancy and childbirth: effects of a mindfulness-based intervention on women’s psychological distress and well-being in the perinatal period. Arch Womens Ment Health 2012;15(2): 139–43. 20. Scherer S, Urech C, Ho¨sli I, Tschudin S, Gaab J, Berger T, et al. Internet-based stress management for women with preterm labour – a case-based experience report. Arch Womens Ment Health 2014;17(6):593–600. 21. Pugh N, Hadjistavropoulos H, Fuchs C. Internet therapy for postpartum depression: a case illustration of emailed therapeutic assistance. Arch Womens Ment Health 2014;17(4):327–37. 22. Caramlau I, Barlow J, Sembi S, McKenzie-McHarg K, McCabe C. Mums 4 Mums: structured telephone peer-support for women experiencing postnatal depression. Pilot and exploratory RCT of its clinical and cost effectiveness. Trials 2011;12(88). 23. Heller HM, van Straten A, de Groot CJM, Honig A. The (cost) effectiveness of an online intervention for pregnant women with affective symptoms: protocol of a randomised controlled trial. BMC Pregnancy Childbirth 2014;14(1):1–7. 24. O’Mahen HA, Richards DA, Woodford J, Wilkinson E, McGinley J, Taylor RS, et al. Netmums: a phase II randomized controlled trial of a guided Internet behavioural activation treatment for postpartum depression. Psychol Med 2014;44(8): 1675–89. 25. Reay R, Fisher Y, Robertson M, Adams E, Owen C, Kumar R. Group interpersonal psychotherapy for postnatal depression: a pilot study. Arch Womens Ment Health 2006;9(1):31–9. 26. Woolhouse H, Mercuri K, Judd F, Brown SJ. Antenatal mindfulness intervention to reduce depression, anxiety and stress: a pilot randomised controlled trial for the MindBabyBody program in an Australian tertiary maternity hospital. BMC Pregnancy Childbirth 2014;14(369). 27. O’Mahen H, Fedock G, Henshaw E, Himle JA, Forman J, Flynn HA. Modifying CBT for perinatal depression: what do women want? A qualitative study. Cogn Behav Pract 2012;19:359–71.
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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
REVIEW ARTICLE
An evaluation of perinatal mental health interventions: An integrative literature review Theressa J. Lavender a,*, Lyn Ebert b, Donovan Jones c a School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia b Program Convenor, Midwifery Studies, School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia c Deputy Program Convenor, Bachelor of Midwifery, School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia
A R T I C L E I N F O
Article history: Received 19 November 2015 Received in revised form 28 March 2016 Accepted 4 April 2016 Keywords: Perinatal Mental health Health promotion Evaluation studies Behavior therapy
A B S T R A C T
Background: National statistics related specifically to the mental health of women in the perinatal period is poorly acknowledged in Australia. Maternal deaths related to mental health in the perinatal period can be attributed to a lack of appropriate treatment and/or support. A barrier to women’s help-seeking behaviors is the lack of discrete, perinatal specific interventions where women can self-assess and access support. Aim: This review examines original research evaluating perinatal mental health interventions used by women to improve mental health. Method: An integrative literature review was undertaken. A comprehensive search strategy using 5 electronic databases resulted in the retrieval of 1898 articles. Use of an inclusion and exclusion criteria and Critical Appraisal Skills Program tools resulted in 4 original research papers. Thematic analysis identified universal themes. Findings: Cognitive Behavioral Therapy, Behavioral Activation and Mindfulness-based interventions, specifically adapted to meet the needs of women in the perinatal period, demonstrate an overall improvement in mental health. Women involved in the interventions experienced both improvements in symptoms of anxiety and depression as well as secondary benefits from participating in the research. Conclusion: To improve perinatal mental health outcomes, innovative modes of providing effective perinatal mental health interventions that address the unique needs of women in the perinatal period are needed. Future development of perinatal mental health interventions require adaptions of Cognitive Behavioral Therapy, Behavioral Activation and/or Mindfulness-based methods to address mental health outcomes for women in the perinatal period. ß 2016 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Summary of relevance Problem/issue Perinatal mental health is a prevalent issue for childbearing women in society and is poorly recognised or acknowledged. Non-pharmacological treatment options exist, however there is a lack of available evidence regarding the efficacy of such interventions.
What is already known Mental health affects a significant number of people in today’s society. Compared to the general public, the perinatal period has it’s own specific challenges with regard to mental health issues.
What this paper adds This paper highlights the issues surrounding perinatal mental health and explores current evaluation of treatment interventions used by women to improve their mental health.
* Corresponding author. Tel.: +61 0437772614. E-mail address: [email protected] (T.J. Lavender). http://dx.doi.org/10.1016/j.wombi.2016.04.004
1871-5192/ß 2016 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
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1. Introduction Mental health in Australia continues to be a concern in today’s society, with approximately 45% of the general population facing longstanding mental health issues and around 20% suffering any form of mental illness over a 12-month period.1 Australian women are at a higher risk of experiencing mental health issues (in comparison to males) with current statistics indicating a rate of 22% of women experiencing some form of mental health issue compared to 18% for males.1 Women in the perinatal period have a 10% chance of experiencing symptoms of anxiety and/or depression, with 9% suffering from antenatal depression and 16% developing postnatal depression.2 Maternal mental health statistics also indicate 15.2% of childbearing women in Australia experience illnesses related to poor mental health and the deaths of 1 in 136 mothers (from 2008 to 2012) were attributed to inadequate management of mental health issues during the perinatal period.3 National statistics related specifically to the mental health of women in the perinatal period is poorly acknowledged, with statistics concentrating on the general female population.1 Additionally, the criteria used to diagnose mental health disorders, fails to distinguish between ‘depression’ and ‘postnatal depression’, adding to the poor recognition of women in the perinatal period.4 Maternal deaths in Australia related to mental health issues in the perinatal period have been attributed to a lack of appropriate treatment and/or supportive assistance.3 The incidence of maternal deaths in Australia connected with psychosocial problems (an average of 12 deaths per year) has been shown to have a similar prevalence as maternal deaths due to an obstetric haemorrhage.3 These statistics emphasise the need for an improvement in the detection, management and early treatment of maternal mental health issues. Barriers to seeking mental health support have been shown to incorporate both structural and attitudinal obstacles, whereby individuals with mental health issues either decide to stop treatment or resist attempts to seek help.5 Economic adversity, geographic remoteness and inaccessibility of services can be perceived as potential structural barriers to seeking mental health treatment.5 Attitudes held by individuals may include believing they do not have a mental health problem, having a perception of being judged negatively if they disclose a potential mental health disorder, preferring not to be offered pharmacological solutions, having experienced negative assistance in the past and feeling what they are experiencing is not serious enough to seek help.5 Women in the perinatal period may develop emotional distress from a variety of sources including variations in hormone levels, unwanted advice from individuals, social influences on their role as a mother and/or parent, perceived negative opinions of others and minor discomforts related to pregnancy.6,7 Pharmacological treatment remains the preferred method within the healthcare system for mental health issues, however behavioral and/or alternative therapies that compliment pharmacological methods are emerging.8 In today’s age of technology, online mental health information and support websites are also a valuable and appealing way for individuals to carry out their own research about mental health issues, explore care options available and access information autonomously without the fear of disclosure.9,10 However, the quality of open access sites is problematic. A study by Moore and Ayers10 examining mental health websites reported there is a lack of research regarding how websites are evaluated for quality and efficacy. In pregnancy, women are increasingly exploring the use of alternative therapies that focus on the connections between the mind and body to assist with physical and emotional wellbeing.11 Anxiety reducing therapies in pregnancy (such as meditation, yoga,
hypnotherapy, tai chi, and other methods of relaxation) have been shown to improve emotional wellbeing. However more research is needed to find a direct correlation between the use of alternative therapies and the prevention of anxiety and/or depression within the perinatal period.11,12 Group education interventions for expecting couples is another method of providing information about the stresses associated with the changing demands related to transitioning to parenthood. These interventions offer both a supportive group environment and individual methods of dealing with physical and emotional issues during this stage of their lives. Parenting interventions provided in a group environment have shown to provide shortterm positive emotional health effects. Further research and development of these interventions are needed to maintain the positive effects of emotional wellbeing for a sustained period.13 This integrative literature review examines current evidence related to the evaluation of perinatal mental health interventions used by women in the perinatal period to improve their mental health. This review defines the ‘perinatal period’ as the period from conception through to 12 months post-birth. 2. Methodology This review utilises an integrative literature review methodology framework as described by Whittemore and Knafl.14 Integrative literature reviews encapsulate original experimental and nonexperimental research on a specific subject to provide an allencompassing understanding of the topic question. The broader understanding of the phenomenon available through an integrative review also allows for multiple realities to be presented.14 Whittemore and Knafl outline a five-stage strategy for an integrative literature review that includes problem identification, literature search, evaluation of data, analysis of data and presentation of results/findings.14 2.1. Problem Identification The mental health of women in the perinatal period continues to be a concerning issue in society. Perinatal mental health interventions currently exist, however there is a paucity of available research evaluating the effectiveness of such interventions. In order to evaluate the use of perinatal mental health interventions used by women to improve their mental health, three research questions were formulated. These questions were used to focus the integrative literature review: 1. ‘What current perinatal mental health interventions have been evaluated with regard to improvements in mental health outcomes for women in the perinatal period?’. 2. ‘What are women’s experiences in utilising evaluated mental health interventions in the perinatal period to enhance mental health outcomes?’. 3. ‘What measurements are used to determine improvements in existing perinatal mental health interventions?’.
2.2. Literature search The search strategy was aimed at supporting the evaluation of perinatal mental health interventions used by women to improve their mental health. Key search terms (see Table 1), in conjunction with Boolean operators, truncation and synonyms were used to source articles. The following online databases were used to search current literature concerning the evaluation of current mental health interventions for women in the perinatal period – Cumulative Index to Nursing and Allied Health Literature
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Table 1 Search strategy used for five databases. (1) mental health (2) depress* (3) anxiety (4) wellness (5) 1 or 2 or 3 or 4 (6) program* (7) tool* (8) plan (9) course (10) intervention (11) education* (12) 6 or 7 or 8 or 9 or 10 or 11 (13) evaluat* (14) effect* (15) assess* (16) question* (17) survey* (18) ethnograph* (19) 13 or 14 or 15 or 16 or 17 or 18 (20) self-initiat* (21) help seeking (22) self* (23) self-help (24) guid* (25) 20 or 21 or 22 or 23 or 24 (26) therap* (27) cognitive behavioural therapy (28) CBT (29) interpersonal psychotherapy (30) ITP (31) mindfulness (32) group support (33) peer support (34) support* (35) face to face (36) face-to-face (37) psycho* (38) telephone (39) counsel* (40) consult* (41) 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 (42) technolog* (43) online (44) e-health (45) ehealth (46) web based (47) web-based (48) mobile (49) app* (50) internet (51) 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50 (52) improve* (53) reduc* (54) benefi* (55) 52 or 53 or 54 (56) women (57) maternal (58) mother* (59) 56 or 57 or 58 (60) perinatal* (61) antenatal* (62) prenatal* (63) pregnan* (64) postnatal* (65) postpartum (66) 60 or 61 or 62 or 63 or 64 or 65 (67) austral* (68) 5 and 12 and 19 and 25 and 41 and 51 and 55 (69) 59 and 66 and 68 (70) 67 and 68 (71) 67 and 69
Table 2 Inclusion/exclusion criteria. Inclusion criteria Women in the perinatal period Mental health interventions used for depression and/or anxiety Women experiencing symptoms relating to stress, depression and/or anxiety in the perinatal period Literature published between 2005 and 2015 Primary or original research (qualitative, quantitative and/or mixed methods) Exclusion criteria Non-English literature that has not been translated Mental health interventions involving pharmacological and/or hospitalisation Women currently being treated for a mental health disorder other than depression and/or anxiety Women experiencing suicidal ideation or substance abuse Literature that does not meet critical appraisal
(CINAHL), Medline, Mosby’s Index, PsycINFO, Embase and Maternity & Infant Care Database. These databases were utilised as they are considered to contain comprehensive literature relating to nursing, midwifery, psychology, humanities, medicine, science and healthcare.15 The search strategy used to source appropriate literature is outlined in Table 1. The search strategy included
Fig. 1. Search results. *CASP, Critical Appraisal Skills Program.
literature published between the years of 2005 to 2015 to ensure currency of available literature. The results of the literature search are detailed in Fig. 1. The initial search resulted in 1898 articles with 94 duplicate articles excluded (leaving 1804). Titles and abstracts were reviewed for relevance (excluding 1735 articles) with 69 articles remaining for further evaluation. Reference lists from the 69 articles were reviewed to source additional articles, with a further 18 articles included for further evaluation (total of 87 articles remaining). 2.3. Evaluation of data Evaluation of the remaining 87 articles comprised of two levels of assessment – the elimination of literature based around the inclusion and exclusion criteria (see Table 2) and a critical appraisal of the literature to determine appropriate levels of methodological quality (see Tables 3a and 3b). Seventy-seven (77) articles were excluded with 10 articles identified for inclusion and
Table 3a CASP qualitative studies evaluation checklist.
1. 2. 3. 4. 5. 6.
Was there a clear statement of the aims of the research? Is the qualitative methodology appropriate? Was the research design appropriate to address the aims of the research? Was the recruitment strategy appropriate to the aims of the research? Was the data collected in a way that addressed the research issue? Has the relationship between researcher and participants been adequately considered? 7. Have ethical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is there a clear statement of the findings? 10. How valuable is the research Methodological quality score I7 cut off
Goodman et al.18
Dunn et al.19
Scherer et al.20
Pugh et al.21
1 1 1 1 1 1
1 1 0 1 1 1
1 1 1 0 0 0
1 1 1 0.5 0 0
0 1 1 1 9
1 0 0 0 6
1 0 0.5 0.5 5
0.5 0 0 0 4
0 = no; 0.5 = unsure/partially; 1 = yes.
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4 Table 3b CASP randomised controlled trials checklist.
1. 2. 3. 4. 5. 6.
Did the trial address a clearly focused issue? Was the assignment of patients to treatments randomised? Were patients, health workers and study personnel blinded? Were the groups similar at the start of the trial? Aside from the experimental interventions, were the groups treated equally? Were all of the patients who entered the trial properly accounted for at its conclusion? 7. How large was the treatment effect? 8. How precise was the estimate of the treatment effect? 9. Can the results be applied in your context or to the local population? 10. Were all the clinically important outcomes considered? 11. Are the benefits worth the harms and costs? Methodological quality score I7 cut off
Caramlau et al.22
Heller et al.23
O’Mahen et al.7
1 1 0 0 0 0
1 1 1 0 0.5 0
1 1 1 1 1 1
0 0 0 0 0 2
0 0 0 0 0 3.5
1 1 1 1 1 11
O’Mahen et al.24
Reay et al.25
a Woolhouse et al.26
1 1 1 1 1 1
1 0 0 0.5 0 0
1 1 0 1 1 0.5
0.5 0.5 0.5 1 1 9.5
0 1 0 0 0 2.5
0.5 1 1 1 1 9
0 = no; 0.5 = unsure/partially; 1 = yes. a Focus on the RCT component of this study (the non-randomised trial not included).
further evaluation. The remaining 10 articles were evaluated for methodological quality using the appropriate Critical Appraisal Skills Program (CASP) tool.16 Katrak et al.17 undertook a systematic review of critical appraisal tools. The authors of this systematic review concluded that ‘‘there is no gold standard critical appraisal tool for any study design’’17 and that appraisal tools should be chosen for the task and intent of the review. CASP tools allow for the assessment of methodological quality by using checklists that are designed specifically for various research designs.16 The checklists provided through the CASP allows for a systematic and rigorous method of assessing the quality of research studies regardless of the methodology. A methodological quality score of 7 (from a possible 10 for qualitative studies and 11 for quantitative studies) was determined to be a cut off point for inclusion. The authors determined a score of 7 would achieve a sufficient degree of methodological rigor. As a result, 10 articles were excluded with 4 articles that met the strict criteria for inclusion in this integrative review. Various forms of behavioral therapies were used in the four remaining studies examining the effects of interventions on perinatal mental health outcomes. Table 4 outlines details of the four studies. One study7 included a modified Cognitive Behavioral Therapy (CBT) intervention. One study used Mindfulness practices26 with another study using another form of mindfulness therapy – Mindfulness-based Cognitive Therapy (MBCT).18 The fourth study used an online version of a modified Behavioral Activation (BA) intervention.24 The interventions used within each study were adapted to meet the needs of women during the perinatal period. All four articles focused on depression at various times throughout the perinatal period,7,18,24,26 three of the four articles also focused on anxiety18,24,26 with one also focusing on stress.26
Three of the studies addressed the antenatal period,7,18,26 with one study exploring the postnatal period.24 Two studies were based in the United States of America (USA),7,18 one in Australia26 and one in the United Kingdom (UK).24 2.4. Analysis of data Thematic analysis is the preferred method for data analysis when conducting an integrative literature review as it allows for the comparison of patterns and relationships of concepts to be explored.14 The four articles were reviewed and various themes and concepts were identified, which were amalgamated to develop overarching or main themes. 2.5. Presentation of result/findings The results of the review are presented as themes, drawn from all four included studies. A number of the studies contained more than one theme as well as recurring themes. Three main themes were identified – 1. Variations in perinatal mental health interventions; 2. Women’s experiences of interventions; 3. Evaluation of interventions. Sub-themes were also determined and discussed. 2.5.1. Variations in perinatal mental health interventions The perinatal mental health interventions in the four remaining studies included the use of modified CBT,7 Mindfulness,26 MBCT18 and modified BA.24 CBT aims to decrease the incidence of automatic negative thinking, identify how emotions affect behaviors, ultimately resulting in more positive behaviors and productive outcome.7 CBT has been found to be effective in the treatment of depression in the general population, however the use of CBT for depression during pregnancy and the postnatal period
Table 4 Four original research studies. Author(s) Country
Intervention
Period of mental health focus
Sample size
Research method
Goodman et al.18 USA
MBCT
Antenatal Anxiety & depression
26
Qualitative – Pilot study
O’Mahen et al.7 USA
Modified CBT
Antenatal Depression
55
Quantitative – Randomised controlled trial pilot
O’Mahen et al.24 UK
Online modified behavioral activation
Postnatal Anxiety & depression
83
Quantitative – Randomised controlled trial
9.5
Woolhouse et al.26 Australia
Mindfulness
Antenatal Anxiety, depression & stress
32
Qualitative – Randomised controlled trial
9
CASP score 9
11
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has not been shown to be as effective.7 The study evaluating CBT carried out a pilot Randomised Controlled Trial (RCT) that adapted the CBT intervention to meet the specific needs of women in the perinatal period, with interventions also individualised for each woman.7 The practice of Mindfulness allows the individual to consciously turn their attention to the ‘here and now’ with an attitude of acceptance.26 Mindfulness teaches cognitive awareness and changes in thought patterns in order to empower the individual to manage negative experiences in a more calm and positive way.26 The Mindfulness intervention used in the RCT comprised of 6 group sessions focused on reducing the symptoms of anxiety, depression and stress during pregnancy and how the mind affects both the woman and her baby.26 MBCT uses a combination of mindfulness and meditation techniques with Cognitive Behavioral Therapy (CBT). This therapy teaches individuals how emotions affect the physical body and allows the individual to develop awareness of their thoughts, to accept their emotional feelings and to observe their physical reactions to situations in the moment.18 By learning how to alter reactions to negative stimulus, individuals are better able to develop flexibility in their thought patterns, become more accepting and develop positive self-regulating coping mechanisms to reduce levels of stress and/or symptoms of anxiety.18 The MBCT intervention used a group-based intervention consisting of eight sessions with content of each session focusing on mindfulness techniques that were suited to women’s needs during pregnancy.18 One of the studies used the BA technique as an intervention.24 BA allows an individual to identify the reasons behind their behavior and find ways to modify behaviors in order to achieve specific goals.24 It uses behavioral features of CBT, but excludes the cognitive elements of this therapy.24 This RCT study evaluated an online BA intervention, consisting of 12 educational modules that were adapted to the needs of women in the postnatal period including intervention follow-up telephone support services.24 2.5.2. Women’s experiences of interventions 2.5.2.1. Structure of interventions. The delivery method of interventions in the studies revealed differences in women’s experiences as research participants. Two studies using Mindfulness and MBCT interventions were attended in a group-based setting with attendance over 6 sessions (for the Mindfulness intervention)26 and 8 sessions (for the MBCT intervention).18 Initially, some women found being part of a group uncomfortable, however this feeling of discomfort reduced as the participants began to connect with each other and found the experience of being in a group setting to be pleasurable.26 Women within the group based settings reported enhanced feelings of supportiveness and connectedness with others and discovered their personal suffering was not isolated to themselves.18 One study provided the modified CBT intervention as 12 individual face-to-face sessions, carried out in the home setting or other suitable location.7 The location for sessions were determined by the women, with 73% held at the woman’s home, 12% conducted in the office of the therapist, 8% within the obstetric clinic, 6% attended over the phone and 1% in other locations.7 However, this study was not able to correlate any relationship between the method of delivery or the location of the sessions with outcomes of the study.7 One study using an online mode of intervention delivery (using 12 sessions of BA) was not able to demonstrate any positive or negative outcomes in relation to the mode of intervention delivery.24 2.5.2.2. Changes in thought patterns. Mindfulness based techniques based around the interventions utilised in two studies, allowed the women to experience changes in thought patterns.18,26 In one
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study, a participant reported how she realised previous unhelpful patterns of thought became overwhelming and was able to recognise these negative patterns and shift her focus to more positive and adaptive approaches.18 In the other study, one participant reported how they noticed a change in their reactions when exposed negative or challenging situations.26 Instead of automatically reacting to their thoughts, feelings and actions in a negative and damaging way, they were able to emotionally remove themselves and take time to think about how to better respond to the situation they were facing.26 2.5.2.3. Social support. In both the studies using the Mindfulness and MBCT group-based interventions, participant’s experienced increased levels of social and emotional support.18,26 In the study using the MBCT intervention, 67% of participants reported feeling comforted and connected with other participants.18 One participant in the Mindfulness intervention noticed improvements in their relationships with not only individuals they were close to (i.e.: partners, family and friends), but also how they related to people in general.26 Being more proactive in seeking support and asking for help from others also led to increased personal selfconfidence and self-compassion.18 The two studies using interventions other than group-based MBCT were unable to demonstrate outcomes relating to emotional and/or social support experienced by participants.7,24 2.5.2.4. Impact of behaviors. Women participating in the Mindfulness and MBCT interventions also reported the experience had a positive impact on behavioral alterations. In the Mindfulness intervention one women reported being able to control her reactions to negative stimulus rather than letting her reactions spiral out of control.26 In the same study, one participant reported increased levels of self-compassion.26 Participants in the MBCT intervention, 58.3% reported they were able to increase their levels of self-acceptance and able to treat themselves with kindness when faced with situations that can induce feelings of anxiety.18 In the same study, 41.7% of women reported they became more adaptable with their reactions to stressful triggers and 29.2% of participants reported they were better able to control reactions to overwhelming thoughts.18 Women experiencing distress regarding past negative experiences in the perinatal period were more able to address these previous negative emotions (with the use of Mindfulness and MBCT) and bring their attention to the present with a more accepting and positive approach. Women suggested that their perceptions of the past were altered, allowing them to focus more on the present and/or future.18,26 2.5.2.5. Coping mechanisms. Developing coping mechanisms was shown to be an additional benefit of intervention participation for some women. Breathing, practicing yoga or using body scan techniques were shown to assist with symptoms of anxiety in 83.4% of participants.18 Another coping mechanism prominent in both the Mindfulness and MBCT interventions was teaching participants to focus on the present moment to reduce levels of stress.18,26 Gaining insight regarding reactions to anxiety through reflection and understanding of how thoughts and feelings can trigger anxiety was a coping mechanism that was reported to be beneficial in both the Mindfulness intervention and in 29.2% of women participating in a MBCT intervention.18,26 2.5.3. Evaluation of interventions 2.5.3.1. Use of mental health assessment tools. A number of validated tools to assess the participant’s symptomatic levels of anxiety, depression, stress and mindfulness were used in the studies. The use of validated mental health evaluation tools pre and
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6 Table 5 Timing of assessment tools. Study 18
Goodman et al. O’Mahen et al.7 O’Mahen et al.24 Woolhouse et al.26
Before intervention
During intervention
End of intervention
Post-intervention
Baseline Baseline Baseline Baseline
Weeks 3, 5, and 7 Not measured Not measured Not measured
Measured Not measured Not measured Measured
Immediate post-intervention 16 weeks 17 weeks Not measured
Table 6a Randomised controlled trials intervention outcomes. O’Mahen et al.7 – Intervention: Modified CBT Measurement/outcomes
Baseline
Intervention group Control group
BDI-II BDI-II
16 weeks post randomisation 29.93 26.56
BDI-II BDI-II
15.85 22.24
O’Mahen et al.24 – Intervention: Modified BA Measurement/outcomes
Baseline
Intervention group
EPDS GAD-7
20.24 13.90
EPDS GAD-7
11.05 8.71
Control group
EPDS GAD-7
21.07 14.12
EPDS GAD-7
14.26 11.29
a
17 weeks post intervention
Woolhouse et al.26 – Intervention: Mindfulness
Measurement/outcomes
Baseline
RCT intervention group
CES-D DASS depression STAI DASS Anxiety Mindfulness
14.42 7.23 35.92 8.62 121.55
CES-D DASS depression STAI DASS Anxiety Mindfulness
12.08 4.31 32.83 4.62 134.55
RCT control group
CES-D DASS depression STAI DASS anxiety Mindfulness
13.70 8.00 34.78 7.00 126.50
CES-D DASS depression STAI DASS anxiety Mindfulness
10.10 5.60 33.00 4.80 133.50
a
Post intervention
RCT component of study only used.
post-intervention allowed the researchers to establish baseline levels and measure variations in the participant’s mental health status again post-intervention (see Table 5). Tools used to measure mental health status and other aspects of social/emotional wellbeing included – the Beck Anxiety Inventory (BAI),18 Beck Depression Inventory-II (BDI-II),7,18 Centre for Epidemiologic Studies Depression Scale Revised (CES-D),26 Depression, Anxiety and Stress Scale (DASS),26 Edinburgh Postnatal Depression Scale (EPDS),24 Generalised Anxiety Disorder Scale (GAD-7),24 Mindfulness (consisting of the Five-Factor Mindfulness Questionnaire)26 and the State-Trait Anxiety Scale (STAI).26 However, not all of these tools were common to all four studies (see Tables 6a and 6b). 2.5.3.2. Outcomes of perinatal mental health interventions. The studies assessed changes in symptoms of anxiety, depression and mindfulness. A comparison of the interventions and changes in mental health status are shown in Tables 6a and 6b. For the
Table 6b Qualitative research intervention outcomes. Goodman et al.18 – Intervention: MBCT Measurements/outcomes Pre-intervention Number/percentage of participants in clinical range for anxiety or depression Post-intervention Number/percentage of participants recovered
BAI
BDI-II
11/47.8%
23/100%
7/63.6%
11/47.8%
modified CBT intervention statistical analysis of symptom reduction revealed the effect size of Cohen’s d = 0.71 (95% CI 4.93, 5.70) at 16 weeks post-randomisation.7 The authors concluded that there was no clinically significant difference in the outcomes.7 The modified BA intervention, statistical analysis at 17 weeks postrandomisation revealed an effect size of Cohen’s d = 0.87 (95% CI 0.42 to 1.32, p 0.01) for EPDS.24 The GAD-7 measurement revealed an effect size of Cohen’s d = 0.59 (95% CI 1.11 to 0.07, p 0.03).24 The authors concluded that there was a large effect size for women receiving modified BA in the management of their symptoms of anxiety and depression.24 Statistical analysis of the RCT for the Mindfulness intervention for DASS (anxiety) revealed a mean difference at post intervention of Cohen’s d = 0.7 (95% CI 0.69–7.31, p 0.02).26 The authors of this study concluded participants involved in the Mindfulness intervention showed statistically significant improvement in symptoms of anxiety.26 Goodman et al.18 concluded that of the participants considered to be clinically depressed or anxious prior to the intervention, 47.8% of depressed participants and 63.6% of participants experiencing symptoms of anxiety recovered. Further, participants showed improvements in their symptom of anxiety and depression by 18.2% and 21.7% respectively.18 The authors of this study concluded that there was a reliable improvement in symptoms of anxiety and depression for participants involved in the MBCT intervention.18 2.5.3.3. Intervention adherence. The modified CBT intervention consisted of 12 sessions with participants completing four or more session defined as adhering to treatment.7 Sixty percent
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(60%) of participants completed 4 sessions and 43% completed 7 sessions.7 Women who were experiencing work and/or social issues and increased EPDS scores were 17% more likely to withdraw from the intervention after the first session.7 Obstacles such as trying to meet the needs of a new baby, illness of children, discomforts of pregnancy, housing issues and privacy were reported by women to reduce their likelihood of adhering to intervention treatment.7 Twelve online modified BA sessions resulted in 5% of women completing 8 sessions with only 1.9% of women completing all 12 sessions.24 An average of 5.36 sessions were completed and 6.74 sessions viewed (but not completed) by participants.24 The number of sessions completed was dependent upon the level of network of support, work and/or study commitments and financial resources available to the woman.24 The study by Goodman et al.18 reported 87.5% of women attended six out of eight MBCT sessions with all participants averaging a completion of 6.96 sessions. The Mindfulness study was unable to provide an evaluation regarding intervention adherence due to the loss of participants who had given birth to their babies before completion of the six sessions.26 2.5.3.4. Limitations of studies. All four studies had small sample sizes, thereby reducing the statistical strength associated with overall results. The participant sample in one study were primarily well-educated women, which is not an indicative demographic of the general population and excludes women with lower levels of education.18 One study did not allow for post-intervention assessment of mental health outcomes due to the inability of follow-up assessments to be carried on participants who had given birth.26
3. Discussion This integrative literature review identified four interventions used by women that employed Mindfulness, MBCT, CBT or BA therapies to improve symptoms of mental health issues such as anxiety, depression and/or awareness of mindfulness.7,18,24,26 The various modalities employed focused on supporting women to alter thought patterns, explore behavior modification, develop an awareness of the mind-body connection and to acquire enhanced coping mechanisms in an aim to improve emotional health and well-being.7,18,24,26 All of the interventions were altered to meet the unique needs of women both in pregnancy and the postnatal period.7,18,24,26 The structure of these interventions included individual faceto-face sessions,7 group participation18,26 and one internet-based option.24 Women found intervention delivery via a group-based setting enabled them to appreciate the value of having alternative supportive networks and connections with others to be of enormous benefit.18,26 This sense of enhanced support may be due to the characteristics of the facilitator for individualised faceto-face interventions and may not occur for women in online modes of delivery. Study participants were able to realise positive outcomes in terms of decreasing their stress levels. Women were better able to understand how their thoughts and feelings related to the signs and symptoms of anxiety and/or depression and also better able to acknowledge how emotions had a direct correlation to both their physical and mental well-being.18 Some women experienced secondary benefits from participating in the studies such as connecting with others in a similar situation, increased awareness of negative thought processes, greater awareness of the mind-body connection, increased number of coping strategies, ability to proactively seek support from others and learning acceptance.18,26
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The interventions studied demonstrated that various perinatal mental health interventions have promising value. Although the studies used small sample sizes, authors reported statistical improvement is apparent in the mental health outcomes for women in the perinatal period. While valuable information and insights into issues surrounding perinatal mental health were provided, there is a need for larger studies to be conducted in order for statistical data to drive clinical practice directions and provide advancements in future perinatal mental health interventions available for women. The modified CBT and BA interventions, Mindfulness and MBCT interventions have shown additional value for the treatment of overall emotional health in the perinatal period.18,26 In a separate study by O’Mahen et al.,27 it was found that interventions dealing with cognitive and behavioral therapies that were modified for to cater for concerns specific to women in the perinatal period were more effective in the treatment of overall mental health. The Mindfulness, MBCT, CBT and BA interventions included in this integrative review have the potential to manage and improve perinatal mental health, nevertheless, further research in to the modes of delivery and modifications to behavioral therapies for women during the perinatal period are required. Three out of the four studies focused on intervention delivery within the antenatal period,7,18,26 highlighting the importance of early interventions to assist with treatment and management of emotional well being in pregnancy that can also carry through to the postnatal period. Immediate and short-term positive outcomes in mental health status can be perceived as improving overall mental health. However, achieving long-term improvements is important in sustaining positive mental health outcomes. This was demonstrated in two of the studies that measured outcomes from 16 weeks to 17 weeks post-intervention.7,24 In evaluating perinatal mental health interventions in terms of their effectiveness in improving mental health outcomes for women, the use of validated assessment tools pre and post intervention is vital in strengthening statistical and clinical significance. This integrative literature review found that there is a small number of methodologically sound research studies concerning the promotion, management and treatment of perinatal mental health and there is a need for future research to be conducted to evaluate the effectiveness of interventions. 4. Conclusion Perinatal mental health continues to be an issue for the women, their families and our society. This integrative literature review explored the literature surrounding the evaluation of perinatal mental health interventions. Due to the limited research on this topic, further research is required to evaluate the types of interventions that are appropriate for women in the perinatal period. Furthermore, future interventions should be rigorously evaluated in order to validate the effectiveness and efficacy of such interventions for the prevention and treatment of perinatal mental health. Findings suggest that the development of interventions utilising Mindfulness, MBCT, CBT and BA methods have the potential to benefit women experiencing symptoms of anxiety and depression during the perinatal period. As pregnancy is a time where women are more responsive to receiving additional information and skills to assist them in transitioning to their new role as a mother, mental health interventions need to be made available and easily accessible to women early in pregnancy, with interventions tailor-made to meet the complex needs of women transitioning to motherhood. The introduction of improved perinatal mental health interventions for women, have the ability to achieve sustained improvement in mental health outcomes for the woman and ultimately her family.
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Women can present with co-morbid symptoms of anxiety and depression in the perinatal period.7,18,24,26 To achieve improvements in symptoms of anxiety and/or depression can make a significant difference to an individual’s experience of mental health. Combining the methods from Mindfulness, MBCT and modified versions of CBT and BA (in line with the demands associated with the perinatal period) may provide women in the perinatal period with mental health interventions that can be effective in addressing their emotional needs and produce more positive outcomes. While these types of interventions are currently available and women have benefited from participation, the interventions have not been validated and their efficacy is unknown. Therefore, there is a need for future development and design of interventions that meet the mental health needs of women in the perinatal period (with emphasis on commencement of intervention in the antenatal period) through large sample randomised controlled trials and longitudinal studies. This integrative literature review has synthesised the results of studies evaluating the effectiveness of perinatal mental health interventions. Findings suggest that development of interventions utilising Mindfulness, MBCT, CBT and BA has the potential to benefit women experiencing symptoms of anxiety and/or depression during the perinatal period. The future involvement of midwives in the design, implementation and facilitation of these interventions into mainstream midwifery practice, will assist in ensuring women have access to appropriately evaluated and validated interventions. Conflicts of interest The authors declare that there are no potential conflicts of interest or financial support in relation to the research, composition and/or publication of this literature review. References 1. Australian Bureau of Statistics. National survey of mental health and wellbeing: summary of results. Canberra: Australian Bureau of Statistics; 2007. 2. BeyondBlue. Pregnancy and early parenthood: mental health conditions. 2015. http://www.beyondblue.org.au/resources/for-me/pregnancy-and-earlyparenthood/mental-health-conditions [accessed 05.03.15]. 3. Australian Institute of Health and Welfare. Maternal deaths in Australia 2008– 2012. Canberra: Australian Institute of Health and Welfare; 2015. 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013. 5. Andrade LH, Alonso J, Mneimneh Z, Wells JE, Al-Hamzawi A, Borges G, et al. Barriers to mental health treatment: results from the WHO World Mental Health surveys. Psychol Med 2014;44(6):1303–17. 6. Goodman JH, Guarino AJ, Prager JE. Perinatal dyadic psychotherapy: design, implementation, and acceptability. J Fam Nurs 2013;19(3):295–323. 7. O’Mahen H, Himle JA, Fedock G, Henshaw E, Flynn H. A pilot randomized controlled trial of cognitive behavioral therapy for perinatal depression adapted for women with low incomes. Depress Anxiety 2013;30(7):679–87.
8. Shinohara K, Honyashiki M, Imai H, Hunot V, Caldwell DM, Davies P, et al. Behavioural therapies versus other psychological therapies for depression. Cochrane Database Syst Rev 2013. http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD008696.pub2/abstract [accessed 03.03.15]. 9. Bennett A, Reynolds J, Christensen H, Griffiths KM. e-hub: an online self-help mental health service in the community. Med J Aust 2010;192(11):S48–52. 10. Moore D, Ayers S. A review of postnatal mental health websites: help for healthcare professionals and patients. Arch Womens Ment Health 2011;14(6): 443–52. 11. Marc I, Toureche N, Ernst E, Hodnett ED, Blanchet C, Dodin S, et al. Mind-body interventions during pregnancy for preventing or treating women’s anxiety. Cochrane Database Syst Rev 2011. http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD007559.pub2/abstract [accessed 16.04.15]. 12. Sado M, Ota E, Stickley A, Mori R. Hypnosis during pregnancy, childbirth, and the postnatal period for preventing postnatal depression. Cochrane Database Syst Rev 2012. http://onlinelibrary.wiley.com/doi/10.1002/14651858. CD009062.pub2/abstract [accessed 15.04.15]. 13. Barlow J, Smailagic N, Huband N, Roloff V, Bennett C. Group-based parent training programmes for improving parental psychosocial health. Cochrane Database Syst Rev 2014. http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD002020.pub4/abstract [accessed 12.03.15]. 14. Whittemore M, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005;52(5):546–53. 15. Schneider Z, Whitehead D. Nursing and midwifery research: methods and appraisal for evidence-based practice. 4th ed. Sydney: Mosby Elsevier; 2013. 16. Program CAS. CASP checklists. 2013. http://www.casp-uk.net [accessed 30.03.15]. 17. Katrak P, Bialocerkowski AE, Massy-Westropp N, Kumar S, Grimmer KA. A systematic review of the content of critical appraisal tools. BMC Med Res Methodol 2004;4:22. 18. Goodman JH, Guarino A, Chenausky K, Klein L, Prager J, Petersen R, et al. CALM pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety. Arch Womens Ment Health 2014;17(5):373–87. 19. Dunn C, Hanieh E, Roberts R, Powrie R. Mindful pregnancy and childbirth: effects of a mindfulness-based intervention on women’s psychological distress and well-being in the perinatal period. Arch Womens Ment Health 2012;15(2): 139–43. 20. Scherer S, Urech C, Ho¨sli I, Tschudin S, Gaab J, Berger T, et al. Internet-based stress management for women with preterm labour – a case-based experience report. Arch Womens Ment Health 2014;17(6):593–600. 21. Pugh N, Hadjistavropoulos H, Fuchs C. Internet therapy for postpartum depression: a case illustration of emailed therapeutic assistance. Arch Womens Ment Health 2014;17(4):327–37. 22. Caramlau I, Barlow J, Sembi S, McKenzie-McHarg K, McCabe C. Mums 4 Mums: structured telephone peer-support for women experiencing postnatal depression. Pilot and exploratory RCT of its clinical and cost effectiveness. Trials 2011;12(88). 23. Heller HM, van Straten A, de Groot CJM, Honig A. The (cost) effectiveness of an online intervention for pregnant women with affective symptoms: protocol of a randomised controlled trial. BMC Pregnancy Childbirth 2014;14(1):1–7. 24. O’Mahen HA, Richards DA, Woodford J, Wilkinson E, McGinley J, Taylor RS, et al. Netmums: a phase II randomized controlled trial of a guided Internet behavioural activation treatment for postpartum depression. Psychol Med 2014;44(8): 1675–89. 25. Reay R, Fisher Y, Robertson M, Adams E, Owen C, Kumar R. Group interpersonal psychotherapy for postnatal depression: a pilot study. Arch Womens Ment Health 2006;9(1):31–9. 26. Woolhouse H, Mercuri K, Judd F, Brown SJ. Antenatal mindfulness intervention to reduce depression, anxiety and stress: a pilot randomised controlled trial for the MindBabyBody program in an Australian tertiary maternity hospital. BMC Pregnancy Childbirth 2014;14(369). 27. O’Mahen H, Fedock G, Henshaw E, Himle JA, Forman J, Flynn HA. Modifying CBT for perinatal depression: what do women want? A qualitative study. Cogn Behav Pract 2012;19:359–71.
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