Using Short-Term Group Psychotherapy

Richard A. Pessagno, DNP, RN, APN-C, CGP, is Clinical Assistant Professor, Rutgers, The State University of New Jersey, College of Nursing, Newark, New Jersey, USA; and Diane Hunker, PhD, MBA, RN, is Assistant Professor, Chatham University, Pittsburgh, Pennsylvania, USA.

Search terms: First-time mothers, group psychotherapy, postpartum depression, psychiatric nursing

Author contact: Richard.Pessagno@rutgers.edu, with a copy to the Editor: gpearson@uchc.edu

Conflict of Interest Statement There are no financial disclosures to make relative to this manuscript.

First Received March 12, 2012; Final Revision received June 25, 2012; Accepted for publication June 27, 2012.

doi: 10.1111/j.1744-6163.2012.00350.x

PURPOSE: The purposes were to (a) provide an 8-week, short-term, psychotherapy group as a nonpharmacologic, evidence-based intervention for first-time mothers at risk for postpartum depression (PPD) and (b) determine if women’s scores in the Edinburgh Postnatal Depression Scale changed after participation in the intervention. CONCLUSION: The women who participated in the short-term group psycho- therapy intervention experienced a decrease in their Edinburgh Postnatal Depres- sion Scale scores, reducing their risk for PPD. PRACTICE IMPLICATIONS: Group psychotherapy is an effective, evidence-based intervention to reduce the risk for PPD and should remain a current competency of psychiatric advanced practice nurses.

Postpartum depression (PPD) is a serious medical condition that dates back to 400 B.C. (Tovino, 2009). Although it has been noted that nearly 85% of women experience some type of mood change after giving birth (Horowitz & Goodman, 2005), the actual prevalence of PPD is between 10% and 20% (Gjerdingen & Yawn, 2007). While in-hospital postpar- tum screening has helped to increase the recognition of those at risk for developing PPD (Perfetti, Clark, & Fillmore, 2004), fewer than half of those women who are screened and who develop PPD will actually be identified and treated (Gjerdingen & Yawn, 2007; Logsdon, Wisner, & Pinto-Foltz, 2006). As women are discharged from acute care hospitals quickly after giving birth, inpatients often lack readily avail- able access to interventions, even for women identified at risk for PPD.

Pharmacological interventions are a common treatment option for PPD, but many women leave the acute setting, opting not to take medication and having limited resources to access mental health services. Taking medication, specifically psychotropic medication, can raise concerns for many women, especially for first-time mothers (Gjerdingen, 2003). Often, concerns are raised about the use of medications, espe- cially among those breast-feeding mothers, relative to the

potential risk to their infants. Identifying and accessing timely nonpharmacological treatment can be difficult for women who are at risk for PPD or who have PPD. This article describes an evidence-based practice intervention that used short-term group psychotherapy as a nonpharmacologcial intervention with first-time mothers who were identified as being at risk for PPD.

Background

While various factors have been examined in relation to the etiology of PPD, such as hormonal and metabolic changes, lifestyle adjustments, obstetric factors, and changing new roles (Flores & Hendrick, 2002), epidemiological studies have fairly consistently demonstrated that the etiology of PPD is most closely linked to psychosocial factors (Beck, 1996a). PPD has often been associated with women who are from lower socioeconomic backgrounds, who are less educated, and who lack occupational prestige (Séguin, Potvin, St-Denis, & Loiselle, 2001). Yet Anderson (2009) found that PPD is also found in significant numbers among women who are well educated, middle class, and in stable relationships. These findings support the need to adequately screen and provide

Perspectives in Psychiatric Care ISSN 0031-5990

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early intervention to all women who give birth, and not only profiled women from disadvantaged backgrounds.

The risk for PPD may be greatest for first-time mothers who hold high expectations regarding childbearing but no personal experience with which to compare their experiences (Epperson, 1999). Because new mothers may not be aware that they are experiencing PPD, they may normalize their feelings. New mothers may fear that others judge their feel- ings as an inappropriate maternal response (Logsdon, Foltz, Scheetz, & Myers, 2010). First-time mothers are less apt to express the need for help during the postpartum period because of the perceived stigma of being depressed, as well as the hesitancy to report depressive symptoms (Thurgood, Avery, & Williamson, 2009). The results can leave first-time mothers feeling even more isolated and unprepared to cope with multiple changes that can negatively impact their health status and parenting effectiveness (Reich, Silbert-Mazzarella, Spence, & Siegel, 2005).

Impact of PPD

The detrimental effects of PPD have gained increasing public awareness, with some extreme cases of PPD in which mothers have harmed their children (Logsdon, Wisner, & Shanahan, 2007). Untreated PPD in first-time mothers, coupled with a lack of maternal experience and fear, can lead to a host of mal- adaptions for both the mother and her baby. These maladap- tions can include issues such as severe social isolation, decreased mother–child bonding, decreased maternal ability to care for the infant, increased incidence of developmental delay in infants, and a reduced rate of identifying infant cues (Reich et al., 2005). Although women who have given birth more than once have also been shown to be at risk for PPD, women with more than one child tend to seek intervention at a higher rate than first-time mothers (Rich-Edwards et al., 2006). The occurrence of PPD has been linked to a host of negative outcomes. Beck (1998) noted that women with PPD can negatively impact infant behaviors and influence child- hood development through the age of 14. A review of eight phenomenological studies on women with PPD suggested that mothers with PPD were often filled with guilt, had feel- ings of loss, and engaged in irrational thinking. These themes were linked to mothers experiencing a sense of detachment from their infants, as well as failure to respond to clues from her children (Beck, 1996b). Current research suggests that there is a negative relationship between the presence of PPD and infant development (Beck, Records, & Rice, 2006).

Treatment of PPD

Treatments for depression and PPD are varied and include psychotherapy, psychoeducation, and support groups, as well as pharmacotherapy. Treatment choices for patients depend

on multiple factors, including availability, cost, convenience, the influence of family and friends, and patient preference (Burlingame, Fuhriman, & Mosier, 2003). The cost- effectiveness of group psychotherapy draws many patients to this treatment option (Burlingame et al., 2003; McRoberts, Burlingame, & Hoag, 1998).

Group psychotherapy has been supported in the literature as being an efficient, cost-effective, nonpharmacologic, evidence-based intervention that can be used for patients exhibiting depressive symptoms. A meta-analysis of 48 research studies examining the effect of group psychotherapy on depression revealed that group psychotherapy was effec- tive in reducing depressive symptoms, further noting that 43 of the studies evidenced that group psychotherapy provided a statistically significant decrease in depressive symptoms for group participants (McDermut, Miller, & Brown, 2001).