effectiveness of mindfulness-based interventions on maternal perinatal mental health outcomes:...
TRANSCRIPT
Welcome!Effectiveness of mindfulness-
based interventions on
maternal perinatal mental
health outcomes: What's the
evidence?
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3
What’s the evidence?
Shi Z, & MacBeth A. (2017). The effectiveness of
mindfulness-based interventions on maternal
perinatal mental health outcomes: A systematic
review. Mindfulness, 8(4), 823–847.
https://www.healthevidence.org/view-
article.aspx?a=effectiveness-mindfulness-
based-interventions-maternal-perinatal-
mental-health-30209
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Poll Question #3
CPsychol, AFBPsS, Lecturer in Clinical
Psychology, Honorary Principal Clinical
Psychologist, Department of Clinical and
Health Psychology, School of Health in Social
Science, The University of Edinburgh
Angus MacBeth
Pregnancy and mental health
• Pregnancy and the postnatal period is a time of
rapid and significant change in a women’s life,
encompassing biological, social and psychological
changes.
• Estimates of the prevalence of anxiety and
depression:
– Perinatal anxiety affects ~10% of pregnant
women (Andersson et al. 2006)
– Antenatal depression ~20% of pregnant women
– Postnatal depression ~12 to 16% of women
Impact of perinatal mental
health
Parental Mental Health
Birth
Antenatal MH Postnatal MH
Perinatal MH
Influence Of Parental MH
Health of Offspring
Prenatal MH
Mindfulness-based interventions (MBIs)
• Kabat-Zinn (1994)
– “paying attention in a particular way: on purpose, in
the present moment, and nonjudgmentally"(p. 4).
• Includes acceptance of situations, relationships as they
are.
• Facilitate compassionate, open minded approach.
• Impact on reduced anxiety and fear.
• Evidence-based reviews (Hoffman et al., 2010).
– Moderate effect size of MBIs on anxiety and mood reduction for
all participants.
– Strong effect size for reducing anxiety (g = 0.97) and mood (g =
0.95) symptoms for those participants with pre-existing anxiety
and mood disorders.
Hoffman, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: a meta- analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169–183.
Mindfulness interventions
• Different definitions:
– ‘mindfulness’
– ‘mindfulness techniques’
– ‘mindfulness approaches’
– ‘mindfulness-based cognitive therapy
(MBCT)’
– ‘mindfulness-based interventions/treatments
(MBI’s/MBT’s)’
– ‘mindfulness- based stress reduction (MBSR)’
– ‘mindful yoga’
– ‘mindful meditation’
Mindfulness & yoga in
pregnancy
• Yoga integrated with meditation has been
demonstrated to improve maternal physical health in
pregnancy and improve labor and birth outcomes
(Curtis et al. 2012; Narendran et al. 2005).
• Yoga practice in pregnancy reduces perinatal anxiety
and depression (Newham et al. 2014).
• Non-pharmacologic interventions in pregnancy such as
yoga and MBIs share overlapping common
characteristics such as meditation and regulated
breathing.
Aims of review
• Number of recent meta-analyses of MBI’s in pregnancy
(Hall et al. 2016; Taylor et al., 2016; Dhillon et al.,
2017).
– Varied in their approach to study designs,
assessment of risk of bias and definitions of MBIs.
• We sought to systematically review the evidence for
the effectiveness of MBIs (MBCT, MBSR and mindfulness-
informed yoga) on common mental health difficulties
(specifically anxiety, depression and stress) in
pregnancy.
– Focus on a narrative synthesis of the theoretical and
methodological challenges in the current literature
and methodological variance in the literature.
Method
• PRISMA review.
• Search from 1980 – end September 2016.
• Yoga interventions only included where there was
clear evidence from the intervention description
of several components consistent with integrated
mindfulness practice.
– e.g. techniques to encourage a non-
judgmental focus on sensation experienced in
the current moment, meditation, breathing,
body scan, deep relaxation)
• Not simply a description of yoga practices per se.
Inclusion criteria• Prima- or multigravida.
• Measurement of depression and/or anxiety symptoms
using validated self-report or interview measures.
• Or met diagnostic criteria for a depressive or anxiety
disorder.
• Assessed either during pregnancy or during first year
after delivery.
• Aged between 16 and 45 years old.
• Compared MBI with a control group or without a control
group.
• Treatment component used either manualized
protocols, accredited facilitators or was delivered by
health professional with specific training in facilitation
of MBIs.
Exclusion criteria
• Participants had current psychosis or other
complex mental disorders.
• Depressive and/or anxiety symptoms were
comorbid symptoms with a specific physical
disorder.
• A priori identified as medically defined high-
risk pregnancies (e.g. multiple pregnancies).
• Qualitative studies, case studies, book
chapters and literature reviews.
Effect size calculation (Cohen,
1988)
• Revised Cochrane Risk of Bias tool used to
evaluate methodological biases (Higgins
et al. 2011).
Effect Size Convention
Trivial d ≤ 0.2
Small d > 0.2
Moderate d > 0.5
Large d > 0.8
Very Large d > 1.3
Characteristics and demographics
• 17 studies representing 18 cohorts.
• Designs:
– 7 RCTs
– 2 Non-randomized trials
– 9 Non-controlled evaluations
• N=640 participants; reporting on n=603
completers.
• Most studies conducted in USA (k=12),
Australia (k=4).
Types of intervention
• MBCT – 7 studies.
• MBSR – 9 studies.
• Mindfulness Yoga - 1 study.
• Prenatal Yoga - 1 study.
• Mean sessions = 8 weeks (range of 6-10).
• 2 hour mean session length.
• Engagement mostly high (except Zhang &
Emory 2015).
Effectiveness of intervention:
Depression
• Depression RCT/NCTs (6 studies):
– 3 studies showed significant reductions.
• Approximately d=0.4-0.5
• Mostly for MBCT
– 2 trend level change; 1 no significant diffs.
• Depression open trials (10 studies):
– 8 showed significant improvement.
– Moderate to large ES’s
• d=0.32 – 1.23
Effectiveness of intervention:
Anxiety
• Anxiety RCT/NCTs (7 studies):
– 5 studies showed significant reductions –
mostly moderate to large effects.
– No effect on pregnancy specific anxiety.
• Anxiety open trials (5 studies)
– Non-significant results but inconsistent effect
sizes.
Effectiveness of intervention:
Stress
• Stress RCT/NCTs (7 studies):
– Results equivocal
• 1 study reporting significant effect.
• 1 reporting clinical improvement.
• Stress open trials (4 studies)
– Similar findings
• However, large within-subjects effects
– Effects washed out in comparisons?
Mechanisms of change
• 13 studies evaluated change in
mindfulness:
– 5 RCTs reported significant change (moderate
to large effect).
– 1 NCT suggested positive trend.
– 5 of 6 open trials suggested change.
• Magnitude of effect varied.
• All studies used Five Facet Mindfulness
Questionnaire (FFMQ).
Our review vs Dhillon (2017)
Dhillon, A., Sparkes, E. and Duarte, R.V., 2017. Mindfulness-Based Interventions During Pregnancy: a Systematic Review and Meta-analysis. Mindfulness, pp.1-17.
Overlap (k=9)•Beddoe et al (2010)
•Duncan & Bardacke (2010)
•Dunn et al. (2012)
•Byrne et al. (2014)
•Goodman et al. (2014)
•Guardiano et al. (2014)
•Vieten & Astin (2008)
•Dimidjian et al. (2015)
•Dimidjian et al. (2016)
Shi & MacBeth (k=8)•Muzik et al. (2012)
•Perez-Blasco et al. (2013)
•Woolhouse et al. (2014)
•Battle et al. (2015)
•Narimani & Musavi (2015)
•Miklowitz et al. (2015)
•Zhang & Emory (2015)
•Felder et al (2016)
Dhillon (k=4)•Matvienko-Sikar & Dockray
(2016)
•Bowen et al. (2014)
•Shahtaheri et al. (2016)
•Muthukrishnan et al (2016)
Discussion
• Some evidence of effectiveness on
depression and anxiety:
– Effect washed out compared to control.
• Equivalence effects?
• For depression MBCT designed with
preventative function.
• For anxiety impact via cognitive and
physiological routes?
Discussion
• Methodological limitations:
– Sample size
– Treatment heterogeneity
– Sampling differences
– Measurement issues (self-reports)
• Implications:
– Targeting of treatment vs universal provision
– Sleeper effects?
– Methodological rigor in trials
THANK YOU
Twitter: @gusmacbeth
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