First Annual Bay Area Maternal Mental Health Conference: Psychotherapy and Nonpharmacologic Treatment Modalities, Risk Factors for Psychiatric Illness and “The Difficult Patient” Katherine E. Williams, M.D. Director, Women’s Wellness Clinic Stanford Center for Neuroscience in Women’s Health Associate Clinical Professor of Psychiatry and Behavioral Sciences
Disclosure of Relevant Financial Relationships • Under the ACCME Standards for Commercial Support, everyone who is in a position to control the content of an education activity must disclose all relevant financial relationships with any commercial interest. A “commercial interest” includes any proprietary entity producing health care goods or services, with the exemption of non- profit or government organizations and non-health care related companies. A financial relationship is relevant if it pertains to the activity ’ s content matter including any related health care products or services to be discussed or presented. • Dr. Williams has disclosed that she has no relevant relationships with commercial or industry organizations. The CME Department has reviewed the disclosure information for the planner(s) and/or committee/faculty for this program and they do not have relationships that present a relevant conflict of interest.
Lecture Goals • Identification of Women at Risk for Perinatal Mood Disorders • Review Psychotherapy and Nonpharmacologic Treatments for Perinatal Mood Disorders • Rationale • Evidence basis • Unique challenges • Future research directions • “ Difficult patients” • Differential diagnosis and treatment options
Screening to Improve PPD Recognition/Treatment Pediatrician ??????? Risk Factors for Perinatal “Universal Screening” Infant Sleep Mood Disorders Problems vs. • Irritability Anxiety during pregnancy Screening Select Groups • History of Major Asking Depression OBGYN Psychiatrist the Right • History of abuse Poor maternal History of Questions • Pregnancy Complications self care Anxiety/ in the • Domestic Violence Pregnancy Depressive Right • Complications Substance Abuse Disorder Places • Breast Feeding Problems PCP • Infant Sleep Problems Unexplained somatic Review: Rhodes, A and Biaggi A. et al. J Affect Disord. concerns Sebre L. Arch Women’s 2016; 191:62-77. Ment Health 2013 Domestic abuse
The Evolving Field of Perinatal Mood Disorders Research Demographic and Psychosocial Specific Clinical Variables Variables Populations at Risk • Age • High Risk OB • Socioeconomic Populations • Stressful Life factors • Anxiety Events • Prior Psychiatric Disorders • Partner including History Support Subclinical • Family History of Depression Specific Personality Types and Attachment Styles at Risk
Predictive Value of Antenatally Obtained Measures for Postnatal EPDS 0.7 Pearson Correlation 0.6 0.5 0.4 0.3 Mood do hx 0.2 Antenatal EPDS 0.1 Antenatal ASQ 0 Predictive Value of Antenatally Obtained Measures for Postnatal CESD 0.8 Pearson Correlation 0.6 0.4 Mood do hx 0.2 Antenatal CESD 0 Antenatal ASQ Robakis, T. et al.. J Affect Dis. 2016. 19: 623-31
PPD: Personality Characteristics Major PPD Controls N=122 N=115 % % p High Perfectionism Total Score 33.6 10.4 <.001 High concern over mistakes 33.6 7.8 <.001 High personal standards 24.6 12.2 .014 High parental criticism 37.7 12.2 <.001 High doubt about actions 22.1 5.2 <.001 High parental expectations 23.8 16.5 0.165 High organization 40.2 33.0 0.256 Gelabert E. et al. J Affect Disord , 2011
The Percent of Physicians Who Correctly Diagnosed 5 Clinical Vignettes Vignettes Correct Diagnosis Correct (%) Depression 92.2 Panic disorder 54.9 Generalize anxiety disorder (GAD) 32.3 No clinical diagnosis 1 29.4 No clinical diagnosis 2 8.5 Coleman VH et al. J Psychosom Obstet Gynaecol 2008: 29: 173-184.
Why Psychotherapy? • Preferred treatment for depression in nonpregnant depressed women and men 1,2 • Preferred treatment for perinatal depression by: Women 3-6 ? Partners ? Health Care providers • Improved treatment compliance? 7 1 van Shaik DJ, et al. Gen Hosp Psychiatry . 2004; 26(3): 184-9. 2 Houle J, et al. J Affect Disord . 2013; 147(1-3): 94-100; 3 Chabrol H, et al. J Repro Infant Psychol . 2004; 22: 5-12; 4 Omahen HA , Flynn HA. J Womens Health (Larchmt) . 2008; (8):1301-9; 5 Pearlstein T, et al. Arch Women’s Ment Health 2006; 9:303-308; 6 Whitton A, et al. B J Gen Pract. 1996; 36: 427-428; 7 Pampallons S, et al. Arch Gen Psychia try. 2004; 61(7):
What is the evidence that psychotherapy is an effective treatment for depressed perinatal women?
Difficulty in Interpreting the Literature What is meant by “psychotherapy”? WHO, WHAT, WHERE and WHY? Who delivers ? What type ? Peer Nondirective counseling Nurse Psychoeducation Psychotherapist Cognitive Behavioral Where? Interpersonal Home Psychodynamic School Church Why? Clinic “At risk” populations Private practice Mild vs. Moderate MDD
Meta-Analysis of Psychotherapy in Perinatal Depression Author Study Populations Types of Studies included Results Cuijpers, et al. (2008) 1 Postpartum Controlled Moderate Effect only 17 total d=0.61 (95% CI: 0.37-0.85) Dennis, et al. Postpartum only Controlled Moderate Effect (2009) 2 10 total RR=0.75 (95% CI: 0.63-0.88) Sockol, et al. (2011) 3 Antenatal and postpartum Controlled and open Moderate Effect 27 total g=.65 (95% CI: 0.45-0.86) Claridge (2012) 4 Antenatal and postpartum Controlled and open Large- Moderate Effect 24 total d=1.14 one group d=0.4 control groups 1 Cuijpers P, et al. J Clin Psych. 2008; 64: 102-118; 2 Dennis CL, and Hodnett, E. Cochrane Database Syst Rev. 2007; 17(4): 1-30; 3 Sockol L, et al. Clin Psychol Review. 2011; 31: 839-849 ;4 Claridge AM. Arch Women’s Ment Health 2014; 17: 3-15
Meta-Analysis of Psychotherapy in General Population 1 Therapy Treatment Focus Methods Effect Size Meta-Analysis Supportive 2 Coping skills and defenses Problem solving d=0.58 Conscious The efficacy of psychotherapy for Emotional support (95% CI: .45-.72) conflicts/problems CBT 3 depressed perinatal patients is Cognitions/Automatic Thought records d=.67 (95% CI 0.60 – 0.75) thoughts comparable to that for depressed IPT 4 Interpersonal relationships Expression of affect d=0.63 Communication analysis (95% CI: .36-.90) Role playing patients in the general population. Decision analysis Brief Unconscious emotions, Exploration, uncovering, d=0.69 (95% CI: 0.30 – 1.08), Psycho- conflicts, defenses interpretation dynamic 5 Transference work 1 Cuijpers P, et al. Nord J Psych . 2011; 65(6): 354-64; 2 Cuijpers P, et al. Clin Psychol Review 2012; 32: 280-291; 3 Cuijpers P, et al. Br J Psychiatry. 2010; 196: 173 – 178; 4 Cuijpers P, et al. Am J Psych. 2011; 168: 581-592; 5 Driessen E, et al. Clin Psychol Rev . 2010; 30(1): 25-36.
Psychotherapy for Perinatal Mood Disorders: Review of Specific Therapies
Interpersonal Psychotherapy for Perinatal Depression • Time limited (12-24 weeks) • Informed by attachment theory/psychodynamic theory • Focus on: • Role Transitions • Interpersonal Role Disputes • Grief and Loss Stuart S . Psychol Psychother . 2012; 19: 134-140.
Clinical Characteristics of Postpartum Women with Unipolar Major Depression Prevalence of Interpersonal Stressors: • Marital problems 43.1% • Work stress 31.3% • In-law problems 20.6% • Recent move 16.9% • Given high prevalence of interpersonal stressors, IPT may be well suited to treatment of perinatal depression • Study population: N=75 • Inclusion Criteria: DSM IV R unipolar MDD Williams, KE, et al. International Marce Society, 2012
Interpersonal Psychotherapy for Perinatal Depression Author N Design Results Postpartum RCT Significant improvement: 12 week Ohara, et al. (2000) 1 99 Response: 43.8% vs. 13.7% p=.001 IPT vs. Wait List Control Remission: 37.5% vs. 13.7% p=.007 Significant improvement: Antenatal RCT Spinelli and Endicott (2003) 2 50 16 weeks Response : 52.4% vs. 29.4% p=.002 IPT vs. Parent Education Remission: 60.0% vs. 15.4% p=.02 Significant improvement: Antenatal RCT Response: 80% vs. 29% p<.001 Grote, et al. (2009) 3 53 8 weeks with monthly follow-up Remission: 95% vs. 58% p<.003 (E IPT-B) vs. enhanced usual care (E UC) Postpartum: Patients selected either IPT alone Medication alone Significant clinical improvement in Pearlstein et al. (2006) 23 IPT + Sertraline (titrated to max all treatment groups (p<.01) of 150 mg/d) 12 weeks 1 O’Hara M, et al. Arch Gen Psychiatry . 2000;57(11):1039-45.; 2 Spinelli MG and Endicott. Am J Psychiatry . 2003;160(3):555-62.; 3 Grote NK, et al: Psychiatr S erv. 2009; 60(3):313-21; 4 Pearlstein T. Et al. Arch Women’s Ment Health. 2006; 9: 303-308.
IPT Treatment Considerations “ Poorer responders” or “ nonresponders ” to IPT in • nonperinatal depressed patients: • Chronicity • Severity of depression • Comorbid anxiety disorders (panic, social phobia) • Comorbid substance abuse Ravitz P, McBride C, and Maunder R. J Clin Psychol. 2011; 67(11): 1129-1139.
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