Using Telehealth to Train Providers of a Cancer Support Intervention.

BACKGROUND: Group interventions are effective for addressing the transition from cancer treatment to survivorship but are not widely available outside of urban areas. In addition, minimal training is available for group facilitators outside of the mental healthcare discipline. Telehealth as a medium can facilitate conversation and interactive learning and make learning accessible to individuals in areas that lack resources for traditional classroom teaching. Little is known, however, regarding the feasibility and acceptability of a telehealth training program for group leaders. This project aimed to investigate the utility of a telehealth training program for the delivery of a copyrighted, manualized psychosocial group intervention, Cancer Transitions: Moving Beyond Treatment. MATERIALS AND METHODS: Nine group leaders attended one in-person orientation, four telehealth training classes, and four telehealth supervision sessions, completing self-report measures of content knowledge, quality satisfaction, and self-confidence. Following the completion of their last Cancer Transitions facilitation, group leaders participated in a focus group to provide qualitative feedback regarding their experiences in training for and leading the respective groups in eight urban and rural North Carolina communities. RESULTS: Group leaders rated the training program highly across the domains of content knowledge, quality satisfaction, and self-confidence. Satisfaction with the technology itself was equivocal. CONCLUSIONS: Telehealth represents a feasible avenue for training and supporting leaders of psychosocial interventions. In addition, telehealth is particularly well suited to the need for training group leaders in areas outside urban centers or academic communities.

Nonpharmacologic treatments for depression related to reproductive events.

There is a growing body of evidence suggesting that nonpharmacological interventions have an appropriate place in the treatment of major depressive disorders (MDDs) as both stand-alone and supplemental treatments. Because women may be reluctant to use psychotropic medications due to strong values or treatment preferences during specific reproductive events, clinicians need to be able to offer empirically based alternatives to medication. In this review, we present recent findings from studies of acupuncture, bright light therapy, electroconvulsive therapy, omega fatty acid supplementation, physical activity, and psychosocial intervention for women experiencing depressive symptoms in the contexts of menstruation, pregnancy, postpartum, and menopause.

Psychosocial interventions for substance use during pregnancy.

Psychosocial and behavioral interventions are used to address substance use and dependence during pregnancy, having particular value when providers and pregnant women are seeking to minimize drug exposures to the fetus. Numerous factors, including difficulty recruiting participants and the ethical challenges to conducting randomized controlled trials with women during pregnancy, have limited research in this area. The existing literature, however, does contain early investigations into the practicality and efficacy of contingency management, motivational support, and cognitive behavioral therapies adapted for pregnant women. This article describes these approaches to treatment, summarizes programmatic examples, and highlights the role nurses may play with this special population.

Screening to Treatment: Obstacles and Predictors in Perinatal Depression (STOP-PPD) in the Dallas Healthy Start program.

Healthy Start programs have made tremendous contributions toward improving the health of mothers and infants through the screening and early detection of perinatal depression. In a collaborative partnership with the Dallas Healthy Start (DHS) program, this pilot study investigated rates of follow-up to systematic referrals for the treatment of perinatal depression in the DHS, as well as identified specific barriers and predictors or treatment follow-up. Results of this study support strengthening existing community-based treatment programs for perinatal depression.

Adolescents, pregnancy, and mental health.

STUDY OBJECTIVE: Pregnancy during adolescence is a risk factor for adverse medical and psychosocial outcomes, including psychiatric illness. Psychiatric illness is linked with obstetric complications along with impaired maternal functioning in the postpartum period. This article provides a comprehensive review of the research examining the intersection of psychopathology and adolescent pregnancy and the postpartum period. DESIGN: A literature search was conducted using PubMed (Medline), PsycINFO, and CINAHL for articles published between 1990 and 2013 that examined depression, anxiety, bipolar disorder, and psychosis during pregnancy and the postpartum period in adolescents age 21 years or younger. Articles were selected that covered the following topics: Prevalence or incidence, comorbidity, psychosocial correlates, birth outcomes, parenting, child outcomes, and psychosocial treatment. Forty articles were found and reviewed. RESULTS: There is a substantial research base examining self-reported depressive symptoms in adolescents during pregnancy and the postpartum period. Existing research suggests that pregnant and parenting adolescents are at greater risk for experiencing depressive symptoms than pregnant and postpartum adult women. Depression in the perinatal period is also a risk factor for substance and alcohol abuse and a harsher parenting style in adolescents. Areas for future research in this population include investigating the prevalence, psychosocial correlates, and outcomes of clinically diagnosed Major Depressive Disorder, developing and empirically validating psychotherapeutic treatments, and focusing upon other psychiatric diagnoses such as bipolar disorder, anxiety, and psychosis.

Evaluating the clinical effectiveness of a specialized perinatal psychiatry inpatient unit.

Women experiencing severe perinatal mental illness during pregnancy or postpartum have unique needs when psychiatric hospitalization is indicated. Although many countries have established mother-baby psychiatric units, similar facilities have not been available in the US. In 2011, the University of North Carolina at Chapel Hill inaugurated the first Perinatal Psychiatry Inpatient Unit in the US. We describe the unique characteristics of the patient population and report clinical outcomes guiding development and refinement of treatment protocols. Ninety-two perinatal patients were admitted between September 2011 and September 2012, and 91 completed self-report measures at admission and discharge. Perinatal unipolar mood disorder was the most frequent primary diagnosis (60.43 %), and 11 patients (12 %) were admitted with psychosis. The data document clinically and statistically significant improvements in symptoms of depression, anxiety, and active suicidal ideation between admission and discharge (p < 0.0001), as assessed by the Edinburgh Postnatal Depression Scale, Patient Health Questionnaire, and Generalized Anxiety Disorder Scale. Overall functioning was also improved, demonstrated by a significant mean difference of -10.96 in total scores of the Work and Social Adjustment Scale (p < 0.0001). Data suggest that delivering specialized and targeted interventions for severe maternal mental illness in a safe and supportive setting produces positive patient outcomes.

Impact of reproductive status and age on response of depressed women to cognitive therapy.

OBJECTIVE: Previous research suggests that reproductive hormones are potential affective modulators in mood disorders and may influence response to antidepressant medications. To our knowledge, there are no data on relationships between hormonal status and response to psychotherapy for recurrent major depressive disorder (MDD). METHODS: At two sites, female outpatients (n=353), aged 18-70, with recurrent MDD received 12-14 weeks of cognitive therapy (CT). Menopausal status and age were based on self-report. In the parent study, nonresponse to therapy was defined as persistence of a major depressive episode (MDE) as defined by the DSM-IV or a final Hamilton Rating Scale for Depression-17-Item (HRSD(17)) score of ≥ 12 or both. More traditional definitions of response (at least a 50% reduction in pretreatment HRSD(17)) and remission (a final HRSD(17) ≤ 6) were also examined. RESULTS: Controlling for pretreatment HRSD(17) scores, there were no significant differences found in the rates of response to CT or symptom status among premenopausal, perimenopausal, and postmenopausal women. CONCLUSIONS: We found no support for the hypotheses that response to CT or the rates of change in depressive symptoms are moderated by reproductive status. The findings, however, are limited by the absence of early follicular phase serum sampling/analysis to estimate hormone levels and the reliance on self-report to establish menopausal status. These data motivate a full investigation of the effects of reproductive status on response to psychosocial interventions.

Proof of concept: Partner-Assisted Interpersonal Psychotherapy for perinatal depression.

Although poor partner support is a key risk factor for depression in pregnant and postpartum women, partners are not generally involved in treatment beyond psychoeducation. The aim of this "proof of concept" study was to test safety, acceptability, and feasibility of Partner-Assisted Interpersonal Psychotherapy (PA-IPT), an intervention that includes the partner as an active participant throughout treatment. Women more than 12 weeks estimated gestational age and less than 12 weeks postpartum were invited to participate if they fulfilled DSM-IV criteria for Major Depressive Disorder and reported moderate symptom severity (HAM-D(17) ≥16). The open trial included eight acute-phase sessions and a 6-week follow-up assessment. Ten couples completed the acute phase treatment and nine presented for a 6-week follow-up assessment. There were no study-related adverse events, and no women had symptomatic worsening from intake to Session Eight. All partners attended all sessions, no couples dropped out of treatment, and all reported positive treatment satisfaction at the conclusion of the study. Nine of ten women (90 %) met the criteria for clinical response (HAM-D(17) = 9) at the conclusion of acute phase treatment, and eight of the nine (89 %) presenting at a 6-week follow-up assessment met criteria for symptomatic recovery. Incorporating partners in the treatment of major depressive disorders during the perinatal period is safe, acceptable, and feasible, but needs further testing in a larger population to evaluate efficacy.

When she says "no" to medication: psychotherapy for antepartum depression.

Many women suffering from major depressive disorder during pregnancy are hesitant to initiate or continue antidepressant treatment during preconception planning, conception, pregnancy, and lactation (perinatal period). Over the past few decades, various psychotherapeutic approaches have been found to be efficacious for depression in general population research. Several observational and quasi-experimental studies also suggest that psychotherapy can be a safe first-line treatment for perinatal women with mild to moderate depression. This article summarizes findings to date regarding the use of psychotherapy for depression occurring during pregnancy and describes the adaptations made to tailor the treatment to the unique needs of women in the perinatal period.

Antenatal depression: a rationale for studying exercise.

BACKGROUND: Major depressive disorder (MDD) in pregnancy or antenatal depression poses unique treatment challenges and has serious consequences for mothers, unborn babies, and families when untreated. This review presents current knowledge on exercise during pregnancy, antidepressant effects of exercise, and the rationale for the specific study of exercise for antenatal depression. METHOD: A systematic literature review was performed using English language articles published in Medline, PsycINFO, CINAHL, and the Cochrane Library from 1985 to January 2010. RESULTS: There is a broad literature supporting the antidepressant effects of exercise, but a paucity of studies specifically for antenatal depression. A small number of observational studies have reported that regular physical activities improve self-esteem and reduce symptoms of anxiety and depression during pregnancy. To date, there have not been randomized controlled studies of exercise for the treatment of MDD in pregnant women. CONCLUSIONS: Systematic studies are needed to assess exercise as a treatment alternative for MDD during pregnancy. In consideration of the benefits of exercise for the mother and baby, and the burden of depression, studies are needed to determine the role of exercise for pregnant women with depression.

A systematic review of the combined use of electroconvulsive therapy and psychotherapy for depression.

OBJECTIVE: Electroconvulsive therapy (ECT) is one of the most effective treatments for severe major depressive disorder. However, after acute-phase treatment and initial remission, relapse rates are significant. Strategies to prolong remission include continuation phase ECT, pharmacotherapy, psychotherapy, or their combinations. This systematic review synthesizes extant data regarding the combined use of psychotherapy with ECT for the treatment of patients with severe major depressive disorder and offers the hypothesis that augmenting ECT with depression-specific psychotherapy represents a promising strategy for future investigation. METHODS: The authors performed 2 independent searches in PsychInfo (1806-2009) and MEDLINE (1948-2009) using combinations of the following search terms: Electroconvulsive Therapy (including ECT, ECT therapy, electroshock therapy, EST, and shock therapy) and Psychotherapy (including cognitive behavioral, interpersonal, group, psychodynamic, psychoanalytic, individual, eclectic, and supportive). We included in this review a total of 6 articles (English language) that mentioned ECT and psychotherapy in the abstract and provided a case report, series, or clinical trial. We examined the articles for data related to ECT and psychotherapy treatment characteristics, cohort characteristics, and therapeutic outcome. RESULTS: Although research over the past 7 decades documenting the combined use of ECT and psychotherapy is limited, the available evidence suggests that testing this combination has promise and may confer additional, positive functional outcomes. CONCLUSIONS: Significant methodological variability in ECT and psychotherapy procedures, heterogeneous patient cohorts, and inconsistent outcome measures prevent strong conclusions; however, existing research supports the need for future investigations of combined ECT and psychotherapy in well-designed, controlled clinical studies. Depression-specific psychotherapy approaches may need special adaptations in view of the cognitive effects of ECT.

Ethical issues in perinatal mental health research.

PURPOSE OF REVIEW: To review the background of current ethical standards for the conduct of perinatal mental health research and describe the ethical challenges in this research domain. RECENT FINDINGS: Current literature reflects a growing sentiment in the scientific community that having no information regarding the impact of psychiatric treatment on the mother and developing fetus/infant poses dangers that may exceed the risks involved in research. However, without sufficient consensus across the scientific community, both regulatory bodies and perinatal researchers find themselves without a framework for decision making that satisfactorily limits the risks and facilitates the benefits of participation of pregnant and lactating women in clinical research. SUMMARY: Psychiatric research in perinatal mental health is critically important as it enables clinicians and patients to participate in informed decision-making concerning treatment for psychiatric disorders. Specific areas of concern include fetal safety, maternal risk, the therapeutic misconception, commercial interests, forensic/legal issues, the informed consent process, and study design. Developing guidelines that address ethical challenges and include the views and concerns of multiple stakeholders could improve the access of perinatal women to the benefits of participation in mental health research in addition to providing evidence-based mental healthcare for this subpopulation.

A HISTORY OF THE THEORY OF PRENATAL ATTACHMENT.

John Bowlby's theory of human attachment has become widely applied across disciplines and across the stages of human development. This discussion explores the evolution of an application of Bowlby's theory to the experience of pregnancy, from both maternal and paternal perspectives. Although the theoretical construct of maternal fetal attachment (MFA) requires continued theoretically-driven research, existing studies have associated this proposed construct with health behaviors, marital relationship, depressive symptoms, and the postpartum mother-infant relationship, pointing toward its relevance for academicians and clinicians devoted to the service of women and infants.

Prenatal depression in women hospitalized for obstetric risk.

OBJECTIVE: Little is known about depression during pregnancy in women with high maternal or fetal risk, as this population is often excluded from research samples. The aim of this study was to evaluate depressive symptoms and known risk factors for depression in a group of women hospitalized with severe obstetric risk. METHOD: In the antenatal unit, 129 inpatients completed the Edinburgh Postnatal Depression Scale (EPDS), the Dyadic Adjustment Scale (DAS), and the Maternal Antenatal Attachment Scale (MAAS) from October 2005 through December 2006. A subset of women were administered the Mood Disorders module of the Structured Clinical Interview for DSM-IV Axis I Disorders based on a score of > or = 11 on the EPDS. Obstetric complications were classified according to the Hobel Risk Assessment for Prematurity. RESULTS: Fifty-seven of the 129 women (44.2%) scored 11 or greater on the EPDS, and at least 25/129 (19.4%) met the DSM-IV criteria for major depressive disorder. Mothers reporting high attachment to the fetus on the MAAS reported lower severity of depressive symptoms (rho = -0.33, p < .0001); those reporting interpersonal relationship dissatisfaction on the DAS endorsed higher depressive severity (rho = -0.21, p = .02). Severity of obstetric risk was unrelated to depression, but one complication, incompetent cervix, was positively associated with level of depressive symptomatology. CONCLUSION: Findings indicate a higher prevalence rate of major depressive disorder in women with severe obstetric risk than that reported in low-risk pregnancy samples, suggesting the need for routine depression screening to identify those who need treatment. Fewer depressive symptoms were reported by mothers reporting strong maternal fetal attachment and greater relationship satisfaction.