Effectiveness of Cognitive Behavioural Therapy - Research Proposal Example

Effectiveness of Cognitive Behavioural Therapy (CBT) in the treatment of Postpartum Depression (PPD) Abstract Postpartum depression (PPD) is an emotional disorder, which is associated with giving birth. Four evidence-based treatments are used in women presenting with depression during the postpartum period. They include: psychotherapy, psychotropic, a combination of therapy and medication and support/educational groups. Even though these treatment options have shown a considerable good degree of efficacy in the treatment of depression, limited systematic studies have examined the effectiveness of these treatments in the PPD context. Thus, this study aims at establishing the effectiveness of CBT in the treatment of PPD. Antidepressants has been found to be effective in treatment of depression. However, breastfeeding mothers have been reluctant to take antidepressants due to possible milk transmission of the drugs to infants and the potential side effects to both mothers and the infants. This study is concerned with identification of the effectiveness of cognitive behavioural therapy (PPD). The findings of this study will inform healthcare providers on whether CBT can be used as an effective mono-therapy for mothers suffering from PPD. This study will use a randomized controlled trial design. The study will be carried out in maternal and child health centres randomly in the environment of the university. Thirty five women with a mean age of thirty years attending postnatal consultations 6-8 weeks after giving birth and diagnosed with minor or major depression (DSM-IV) will be sampled from maternal and child health centres around the university. The intervention group will undergo group cognitive behavioural therapy (CBT) while the control group will receive routine care. Progress will be monitored by a psychiatrist blinded to treatment group. Data will be analyzed using 2-tailed statistical tests at an alpha level of .05. The study is expected to run for a period of fourteen months. Introduction Postpartum depression (PPD) is an emotional disorder, which is associated with giving birth. It mainly affects women and men being less frequently affected. The prevalence for the disorder has been reported to range from 5% to 25% due to methodological differences used to carry out the studies (Milgrom, Schembril, Ericksen, Ross, and Gemmil, 2011). PPD can occur at any time during the first year after giving birth. Studies have consistently identified three main causes of the disorder. First is marriage problems and lack of social support especially from the fathers (Fitelson, Kim, Baker, and Leight, 2011). Second cause of PPD is infant problems, which may include pregnancy and delivery problems. The final major cause of PPD is a prior history of depression or other emotional problems (Cho, Kwon, and Lee, 2008). Four evidence-based treatments are used in women presenting with depression during the postpartum period (O’Hara, 2009). They include: psychotherapy, psychotropic, a combination of therapy and medication and support/educational groups. Treatment administered is usually based on the patient history, medical conditions, and current symptoms and patient’s treatment preferences (Leis, Mendelson, Tandom, and Perry, 2008). Even though these treatment options have shown a considerable good degree of efficacy in the treatment of depression, limited systematic studies have examined the effectiveness of these treatments in the PPD context (Ali, Ali, Azam, and Khuwaja, 2010). Preliminary studies have indicated possible effectiveness of traditional psychotherapy, especially interpersonal therapy, in the treatment of PPD (Flynn, 2010). Few studies have used cognitive behavioural therapy (CBT) as a mono-therapy for PPD. Thus, this study aims at establishing the effectiveness of CBT in the treatment of PPD. Literature review Even though postpartum depression has been recognized for many years, no optimal treatment strategy has yet been identified. Current management of PPD includes psychotherapy, psychotropic, medication and community and self-help groups. Due to ethical issues surrounding studies on treatment of PPD, very few such studies have been conducted in a controlled way. A combination of medications with psychotherapy is recommended clinically to manage PPD. For women who have previously suffered from depression it is recommended that they undertake preventive medication prior to giving birth. Due to efficacy of antidepressants such as selective serotonin reuptake inhibitors (SSRIs), they are the most used in treatment of PPD. They are preferred because of their efficacy, fewer side effects, safety in case of overdosing and the fact that they are taken once a day. In spite the efficacy that has been reported in the use of antidepressants for management of PPD; this method is limited by the desire to breastfeed (Grigoriadis, 2007). This is because all psychotropic medications are excreted into breast milk in varying amounts often too low to quantify. Since breastfeeding is recommended for the first year of infant’s life due to its dual benefit to both the mother and the infant, it is not ethical to recommend that mothers suffering from PPD should stop breastfeeding in order to take antidepressants (Munoz, Cuijper, Smit, Barrera, and Leykin, 2010). It is also unfortunate that there is very sparse data on the short term and long term adverse effects of antidepressants on children exposed to these psychotropic drugs during lactation. Of the little data available, antidepressants have been found to cause crying, sleep disturbance, vomiting and watery stools (Burns, 2008). Thus, antidepressants are considered unsafe for breastfeeding mothers. Thus, the healthcare provider needs to discuss the benefits and risks of antidepressants and their effects on breastfeeding to enable the mother to arrive at a decision regarding nursing (Romansand, 2006). The medication administered should have efficacy data for PPD and should be safe for breastfeeding mothers. The behaviours of infants should be monitored prior to initiation and after initiation of treatment to aid in identification of any, adverse effects as early as possible. Mothers of premature infants ought not to nurse if they are taking antidepressants since such infants cannot metabolize the medication due to underdeveloped liver enzymes needed for such metabolism. Due to possible side effect of antidepressants, psychotherapy might offer an alternative way of treating PPD. The commonly used group or individual psychotherapy approaches in the treatment of PPD are cognitive behavioural therapy (CBT) and interpersonal therapy (IPT) (Milgrom et al., 2011). Interpersonal therapy lays focus on marital strain and role transitions, which commonly take place after delivery. Randomized studies have shown that IPT is effective in women suffering from PPD. Research has shown that up to 59% of women suffering from PPD and undertaking group IPT attained full remission while 29% got partial remission from the disorder. Another study, which compared women in mother infant therapy and IPT controls, found lower depression scores in the treatment groups after 12 weeks. The therapy was found to improve the perceptions and interactions of the mothers with their infants. Some studies have also demonstrated that cognitive behavioural therapy (CBT) is effective in patients with PPD. CBT is known to change negative cognitive distortions and helps in the development of coping behaviours. Randomized controlled studies found that six sessions of CBT were as effective as fluoxetine in achieving remission in PPD. It was also found that counselling sessions improved the efficacy of CBT. A study conducted in France found a recovery rate as high as 66.6% in CBT treated women as compared to 6.6% in controls (Moss, Pierce and Montoya, 2009). CBT treatment is based on the assumption that the mood of a person is directly proportional to his or her patterns of thought. It is believed that negative dysfunctional thoughts affect the mood, sense of self, behaviour and physical state of a person. CBT helps a person to learn to recognize negative patterns of thought, evaluate their validity and replace them with healthier way of thinking (Pearlstein, 2008). CBT therapists help their patients to change patterns of behaviour that emanate from dysfunctional thinking. It is known that negative behaviour and thought predispose individuals to depression and make it almost impossible to escape its downward spiral (Clark, 2010). Thus changing patterns of behaviour and thoughts of such persons is believed to alter their moods. Medical evidence has shown that the benefits of cognitive therapy persist after treatment has ended and thus there is need to ascertain the efficacy of this treatment in PPD in order to avoid any future outbreak of PPD in patients who have undergone CBT treatment for PPD. Aims and objectives The aim of this study is to find out the effectiveness of Cognitive Behavioural Therapy (CBT) in the treatment of Postpartum Depression (PPD). The objective of the study is to determine effectiveness of CBT reducing symptoms related to PPD. Method This study will use a randomized controlled trial design. This design is chosen because it is the most commonly used in testing the effectiveness of healthcare services (Ellen, Cindy, Nikki, Cynthia & Brook, 2008). Since this study is interested in establishing the effectiveness of CBT in treatment of PPD, randomized controlled trial design is the appropriate design. This design will allow us to asses study subjects of eligibility and recruit them. It will also allow us to randomly allocate study subjects into two groups, that is, one to receive CBT intervention and the other to receive routine care. The two groups will then be followed up in the same way. The study subjects will be followed up for a period of twelve weeks. The study will be set in maternal and child health centres randomly selected in around the university. Thirty five women with a mean age of thirty years attending postnatal consultations 6-8 weeks after giving birth and diagnosed with minor or major depression (DSM-IV) will be sampled from the fifty maternal and child health centres in Northern Territory Australia (Milgrom et al., 2011). Among those identified, those with the following features will be excluded from the study: unable to give informed consent; non English speaking; suffering from other psychiatric disorders or major medical problems; already involved in a psychological program; birth weight of baby less than 2.5kg, birth defect, less than 37 or greater than 42 weeks of pregnancy or needing immediate help with crisis management. Nineteen patients will undergo group cognitive behavioural therapy (CBT) which will entail seven weekly 1.5-hour sessions plus three partner sessions which will be facilitated by a senior therapist. The sessions will focus on mood, life events and practical issues. Another group of sixteen patients will undergo routine care, which will entail referral from child health nurse to other agencies if necessary. Progress will be monitored by a psychiatrist blinded to treatment group using Hamilton Rating Scale for Anxiety, Hamilton Rating Scale for Depression, Yale-Brown Obsessive Compulsive Scale, Edinburgh Postnatal Depression Scale and Clinical Global Impressions scale and results recorded appropriately. Data will be analyzed using 2-tailed statistical tests at an alpha level of .05. Ethical issues Study participants will be required to sign an informed consent form prior to being included in the study. The consent form will be prepared after consulting with ethical department of the university. Exclusion of mothers who are non English speaking; suffering from other psychiatric disorders or major medical problems; already involved in a psychological program; birth weight of baby less than 2.5 kg, birth defect, less than 37 or greater than 42 weeks of pregnancy or needing immediate help with crisis management may raise some ethical issues (Milgrom et al., 2011). However, to effectively get results that are credible and reliable this group will have to be excluded from the study in order to inform health providers more appropriately on the effectiveness of CBT in treatment of PPD (Cuijpers, Brannmark and Straten, 2007). All personal information of study participants will be concealed in order to avoid ethical issues related to confidentiality from arising. Work plan Activity Activity Proposal writing May 2011 Proposal presentation June 2011 Sample recruitment July 2011 to Jan 2012 CBT and sample follow up July 2011 to Apr 2012 Data collection July 2011 to Apr 2012 Data analysis March 2012 Report writing April 2012 Budget The following items/resources will be required for the project: photocopying, computer, and Psychiatrist and Senior therapists Expected outcomes We expect that the results will show that CBT is an effective method of treating PPD. If this is found out then CBT will be the best alternative to antidepressants which are known to have some side effects on both the lactating mother and the infant. References Ali, N., Ali, B., Azam, I., and Khuwaja, A. 2010. Effectiveness of counselling for anxiety and depression in mothers of children ages 0-30 months by community workers in Karachi, Pakistan: a quasi-experimental study. BMC Psychiatry, vol. 10, no. 57. Available at http://www.biomedcentral.com/1471-244X/10/57/ Burns, J. 2008. Role of family factors in postpartum depression. PhD Thesis, School of Psychology, the University of Queensland. Cho, H., Kwon, J., and Lee, J. 2008. Antenatal Cognitive-behavioural Therapy for Prevention of Postpartum Depression: A Pilot Study. Yonsei Med J., vol. 49, no. 4, pp. 553-562 Clark, J. 2010. Living beyond Postpartum Depression: Help and Hope for the Hurting Mom and Those around Her. London: NavPress Cuijpers, P., Brannmark, J., and Straten, A. 2007. Psychological treatment of postpartum depression: a meta-analysis. Journal of Clinical Psychology, vol. 64, no. 1, pp. 103-118 Cuijpers, P., Straten, A., Warmerdam, L., and Smits, N. 2007. Characteristics of effective psychological treatments of depression: a metaregression analysis. Psychotherapy Research, vol. 18, no. 2, pp. 225-236 Ellen, A., Cindy, V., Nikki, L., Cynthia, F., & Brook, M. 2008. The Reciprocal Effects of Eating Disorders and the Postpartum Period: A Review of the Literature and Recommendations for Clinical Care. Journal of Women's Health, vol. 17, no. 2, pp. 227-239. Fitelson, E., Kim, S., Baker, A., and Leight, K. 2011. Treatment of postpartum depression: clinical, psychological and pharmacological options. Int J Womens Health, vol. 3, pp. 1–14 Flynn, H. 2010. Depression and postpartum disorders. A Public Health Perspective of Women’s Mental Health, vol. 2, pp. 109-120 Grigoriadis, S. 2007. An approach to interpersonal psychotherapy for postpartum depression: Focusing on interpersonal changes. Canadian Family Physician, vol. 53, no. 9, pp. 1469-1475 Leis, J., Mendelson, T., Tandom, S., and Perry, D. 2008. A systematic review of home-based interventions to prevent and treat postpartum depression. Archives of Women’s Mental Health, vol. 12, no. 1, pp. 3-13 Milgrom, J., Schembril, C., Ericksen, J., Ross, J., and Gemmil, L. 2011. Towards parenthood: An antenatal intervention to reduce depression, anxiety and parenting difficulties. Journal of Affective Disorders, vol. 130, no. 3, pp. 385-394 Moss, S., Pierce, J., and Montoya, C. 2009. Can counselling prevent or treat postpartum depression? Journal of Family Practice, vol. 58, no. 3, pp. 152+. Munoz, R., Cuijper, P., Smit, F., Barrera, A., and Leykin, Y. 2010. Prevention of major depression. Annual Review of Clinical Psychology, vol. 6, pp. 181-212 O’Hara, M. 2009. Postpartum depression: what we know. Journal of Clinical Psychology, vol. 65, no. 12, pp. 1258-1269 Pearlstein, T. 2008. Perinatal depression: treatment options and dilemmas. J Psychiatry Neuroscience, vol. 33, no. 4, pp. 302–318. Romans, S., and Seeman, M. 2006. Women's mental health: a life-cycle approach. New York: Lippincott Williams & Wilkins. Read More