Dr. Ryan J Van Lieshout, MD, PhD, FRCPC
*A note from Climb Out of the Darkness Waterloo Region: Postpartum Depression is one of six diagnosable conditions which affect birthing parents during the postpartum period. This group of conditions, Perinatal Mood and Anxiety Disorders, can be experienced at any point during pregnancy and postpartum. The blog post below speaks directly to research, treatment and affects of Postpartum Depression. For more information regarding other Perinatal Mood and Anxiety Disorders, continue to follow us on Facebook at https://www.facebook.com/ClimbOutTeamWaterlooRegion throughout May and June as we share more knowledge and expertise from Waterloo Region.
Postpartum Depression and Its Impact
Postpartum depression (PPD) is the most common complication of childbirth, affecting 20% of mothers. Left untreated PPD increases the risk of future depressive episodes, parenting difficulties, and problems with mother-infant attachment. The children of mothers with PPD struggle more in school and are three times more likely to develop emotional and behavioural problems. They also have five times the risk of these problems in adolescence, and are eight times more likely to develop depression in adulthood.
The COVID-19 pandemic has further exposed vulnerabilities in systems that lead to inequalities for mothers with mental health problems and their children and has profoundly changed mothers’ preferences for receiving mental healthcare (i.e., to virtual/online). Even under ideal conditions, the healthcare system is poorly equipped to treat problems requiring urgent psychotherapy, and as few as one in ten mothers with PPD receive evidence-based care. Even when detected, mothers rarely have access to the treatments they most prefer (i.e., psychotherapy), and are treated by their family doctors with medications. They also face long wait times to access specialist psychiatric services or have to pay up to $225 per hour for private psychological treatment.
Current clinical practice guidelines recommend evidence-based psychotherapies (e.g., cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT)) for the majority of mothers with PPD. Medications are recommended after psychotherapy, but are often prescribed before them because psychotherapy is so difficult to access.
The Impact of Treatment
Without treatment, up to 40% of women will have PPD symptoms until their children enter school. While treating PPD can reduce its adverse effects, safe, timely, accessible interventions are essential to optimizing for mothers, their partners and their children. Treating PPD not only helps mothers, but can have significant positive effects for their partners and children. Indeed, studies of evidence-based psychotherapies or mother-infant interventions (those focused on mother-infant interactions) suggest that treating mothers has the potential to improve the mother-infant relationship and reduce expressions of sadness, fussiness and disengagement among infants. Treating PPD also reduces parenting stress and improves maternal reports of emotion regulation in infants. Emotion regulation is particularly important because it is associated with a 3-fold increase in the risk of later school failure, polysubstance dependence, and criminal conviction,11 and is implicated in the development of almost all forms of psychiatric problems.
Recently, our group used neurophysiological methods to show that PPD treatment results in healthy changes in the brain and behavioural systems core to emotion regulation in infants. In this work, maternal receipt of group CBT for PPD led to a normalization of brain and parasympathetic nervous system physiology to that seen in the infants of non-depressed mothers.
Innovation in Increasing Access to Psychotherapy
One of the biggest barriers to realizing these improvements is the difficulty women have accessing psychotherapy for PPD. The need for engaging, easily accessible, safe, and effective psychotherapeutic treatments is urgent. While computerized CBT and psychotherapy apps are widely available, significant time and motivation are required for success, discontinuation rates are high, and therapist support is required for clinically meaningful gains.
In order to meet the need of women for psychotherapy in the perinatal period, researchers have recently developed several novel methods of service delivery that can increase the number of women receiving effective treatment for PPD. These methods capitalize on the widespread availability of reliable internet connections, the efficiency of group therapy, and the concept of task-shifting (the process of delegation whereby tasks are moved from specialized experts to those with less training (e.g., nurses, recovered peers)).
For example, we recently trained public health nurses to provide group CBT for PPD, and recent data suggest that this is effective regardless of whether it is delivered in-person or online. We have also task-shifted group delivery of CBT-informed support for PPD to women who have previously experienced and recovered from PPD. Recovered peers are seen as a particularly credible, non-judgemental, and empathic source of support, reducing stigma and judgement. Peers can normalize symptoms for women with PPD, provide valuable knowledge based on experience, and serve as positive role models, highlighting different pathways to recovery. The early results of this work suggest that when such interventions are delivered by peers, they can increase treatment uptake and effectively treat PPD.
Finally, we recently developed and are in the process of testing a 1-day CBT-based workshop for PPD. The delivery of psychotherapy in large groups (up to 30 participants) is a relatively new idea, but may be capable of addressing mothers’ needs as well as treating the number of women with PPD that are required to reduce its burden on a large scale. Brief (i.e., 1-Day) interventions are appealing because contain the core content of longer treatments, but their efficiency makes them easier to deliver beyond traditional treatment settings. The early results of these workshops suggest that they may effectively reduce depression and anxiety whether they are delivered face-to-face or online. We now hope to test the effectiveness of these workshops delivered by public health nurses to increase their scalability.
The Future of PPD Treatment
Researchers around the world are also testing out different models of psychotherapy delivery that could increase availability and uptake. Refinements to online and app-delivered psychotherapies, as well as the evolution of chatbots (artificial intelligence software that can simulate a conversation or chat with a user in natural language through apps, website, and telephone) could improve access in Canada and around the world.
Research suggests that treating PPD can have benefits for mothers and their families, and that a many different types of interventions can be effective. However, the best outcomes are obtained by mothers and their families when they have easy access to the evidence-based treatments that they want and need. Many new and innovative approaches to increasing psychotherapy engagement and availability are being developed and tested, and could help mothers to recover and lead happier and healthier lives, with benefits for them and their families.
*Dr. Van Lieshout is a perinatal psychiatrist and Co-Director of Elle Psychotherapy (elletherapy.ca). He is also the Canada Research Chair in the Perinatal Programming of Mental Disorders and the Albert Einstein/Irving Zucker Chair in Neuroscience at McMaster University where his research focuses on increasing access to evidence-based psychotherapies, as well as their impact on offspring brain development.