Tweetable abstract:
EMDR-treatment for women with PTSD after childbirth leads to successful
outcomes after on average 5 treatment sessions.
IntroductionPosttraumatic stress disorder (PTSD) following childbirth occurs
relatively frequent. Prevalence rates range from 3% in community
samples and 15% in at risk populations 1. PTSD after
childbirth is most typically related to a traumatic delivery2 and is characterized by the re-experiencing of the
traumatic event (intrusion, such as flashbacks and nightmares),
avoidance, negative changes in mood and cognition and hyperarousal3. PTSD after childbirth not only negatively affects
the mother’s health and the partner-relationship 4,
but also child outcomes. Maternal PTSD has a negative impact on the
development and sensitivity of the stress-system in the infant, the
mother-child bond, the attachment style of the child, and the child’s
social-emotional and cognitive development 5-9. To
reduce the mother’s disease burden and to prevent transgenerational
transmission of mental health problems, treatment is warranted as soon
as possible. As starting a new pregnancy with untreated PTSD has shown
to be related with unfavourable fetal development and obstetric
outcomes, poor maternal well-being, fear of childbirth, avoidance of
pregnancy care and maternal requests for caesarean section, treatment
should be initiated before a subsequent pregnancy10-12. In addition, treating women with severe PTSD
symptoms who do not fulfill all diagnostic criteria should also be
considered 13, 14 as PTSD symptoms after childbirth
may lead to a chronic disorder 12. Altogether, this
makes a strong case for early recognition and referral for
evidence-based treatment of PTSD in women after giving birth. So far
however, data on treatment programs for this group are limited and
indeed recent papers emphasize the need for exploration of effective
interventions for perinatal PTSD 15,
16.
Eye Movement and Desensitization and Reprocessing
(EMDR)-therapy is an evidence-based treatment for PTSD and recommended
in international guidelines, for example those of NICE17-19. EMDR is effective in treating PTSD, with large
effect sizes compared to control conditions, and comparable effects
compared to cognitive behavioral therapies 20. In a
recent review we showed that EMDR- therapy may be a promising
intervention for PTSD following childbirth 16.
However, referral for such treatment may be impeded for several reasons21, including lack of a structure for efficient
referral for treatment. Therefore, the aim of this study is to
investigate the feasibility of an EMDR-treatment program for women with
PTSD following child birth and to evaluate the outcomes of such
treatment.
Methods
Design The current study was a prospective cohort-study with pre- and post
measurements. The study was approved by the medical scientific research
Ethical Committee of the Erasmus University Medical Centre and
(evaluated as exempt, reference number MEC-2018-1234). Study inclusion
took place from January 2019 to June 2020. All participants gave written
informed consent. No external funding was obtained for this study.Participants Women suspected of PTSD following childbirth could be referred for this
study. We recruited women at three different departments from the
Erasmus MC, a large academic hospital in Rotterdam, the Netherlands.
These departments were: the department of Obstetrics and Gynecology, the
department of Psychiatry and the department of Child and Adolescent
Psychiatry. All physicians from those departments could refer women for
the current study. In case of doubt or questions about referral,
physicians could consult the Psychiatry colleagues by email or direct
phone line. Inclusion criteria were: giving birth to a living baby at
least 4 weeks ago; a PTSD diagnosis, or severe PTSD-symptoms combined
with another DSM-5 diagnosis; and written informed consent. Exclusion
criteria were: insufficient understanding of Dutch/English language,
< 18 years of age, (other) severe psychopathology that would
require immediate treatment first, for example high suicidality risk or
active psychosis.Procedures Before the start of this study, members of the Psychiatry department
(LK, MLvdB and EK) provided clinical lessons on PTSD following
childbirth for the colleagues of the department of Obstetrics and
Gynecology. During these meetings, attention was paid to recognizing
PTSD symptoms in women who recently gave birth. In addition, clinical
training was given on how to discuss these symptoms and the
possibilities for treatment. Education was given on how to pose the two
most important questions in this respect: “Have you experienced any
event during pregnancy, delivery or childbed period that you would
describe as extremely stressful?” and 2. “If so, are you still
suffering from this? For instance, do you have nightmares about what
happened, or do you avoid talking/thinking about what has happened? Are
you constantly alert as if something bad is about to happen?” To
further enhance the screening process on PTSD after childbirth,
screening questions were incorporated in the standard Patient Related
Outcome Measures (PROMs)-assessment of women in the perinatal trajectory
as part of value-based healthcare. In case women answered positive on
these screening questions, outcomes were discussed during the following
consultation with their gynecologists and obstetricians. Healthcare
providers of the departments of Psychiatry received no clinical lessons,
but were actively informed about this study during regular weekly team
meetings in which treatment advice for women presenting with psychiatric
complaints was decided upon. Women who seemed eligible for study
participation and treatment could then be referred. The department of
Child and Adolescent Psychiatry offers a so-called mother-child
treatment program, focusing on mother-child interaction and bonding in
women with perinatal psychiatric disorders. As one reason for impaired
mother-child interaction is PTSD after childbirth in the mother, this
department was informed about the study as well. Referred women were
invited for an intake at the outpatient clinic of the Psychiatry
department. Intakes were performed by a health care psychologist (LK)
and psychiatrist specialized in the field of perinatal psychiatry
(MLvdB). During intake, a DSM-5 classification was established and
questionnaires were administered (see below, measures). If women met the
inclusion criteria and gave informed consent, EMDR therapy was offered
(see below, intervention).
Measurements All questionnaires were administered at baseline. The PCL-5 was
administered both before and after treatment.Demographic data Age, previous and current psychopathology and obstetric data were
collected at the moment of intake or were retrieved from the already
present patient hospital records.
Trauma history and PTSD symptoms
Life events checklist (LEC-5)22 and PTSD Checklist for
DSM-5 (PCL-5) 23 combined version.The LEC-5 is a self-report questionnaire to screen for 17 lifetime
potentially traumatic events. Respondents indicate whether they have
experienced one or more of sixteen listed events. The last item consists
of an additional question, where respondents can indicate whether they
have experienced a stressful event, other than the events mentioned in
the previous items. Items are scored with regard to the type of
exposure: direct experience; witnessing the trauma; learning that a
traumatic event has happened to a close family member or friend and;
experiencing a traumatic event as a part of the daily job. The PCL-5 is
a widely used and well validated 20-item self-report questionnaire
assessing the 20 symptoms of PTSD according to DSM-5. Respondents report
the level of PTSD symptoms that they have experienced in the past month.
Items are scored on a scale from 0 (not at all) to 4 (extremely). Scores
range from 0-80, with higher scores representing more PTSD symptoms. The
test-retest reliability of the total score of the PLC-5 is good
(r = .82). Convergent and discriminant validity are strong
(rs .74 to .85 and .31 to .60, respectively)23. A cut-off score of 31 is often used as indicator
for the presence of PTSD 24 and a 10-20 point change
on this scale is perceived as clinically significant22.Childhood trauma questionnaire-short form (CTQ-SF)25This widely used self-reported childhood trauma questionnaire of 25
items is the short version of the original CTQ (70 items). It is used to
investigate five types of traumatic experiences of neglect (physical and
emotional) and abuse (physical, emotional and sexual) in childhood and
adolescence. CTQ-SF items are rated on a 5-point scale, ranging from 1
(never true) to 5 (very often true). Items 2, 5, 7, 12, 17, 23 and 25
are scored in reverse. Scores range from 25-125, with higher scores
indicating more trauma experiences. Reliability coefficients (Cronbach’s
alpha) of the subscales range from 0.61 to 0.95 25.
Childbirth Perception Scale (CPS) 26The 12-item CPS consists of two dimensions, namely the perception of
delivery and the first week after delivery, both measured with six
items. Example statements from both categories are: “My labour
was a lot worse than I expected ” and “I truly enjoyed the first
week after delivery ”. All items are scored on a 4-point scale from 0
(fully agree) to 3 (completely disagree). Items 1, 2, 5, 6, 7, 8 and 10
are scored in reverse. Scores range from 0 to 36, with higher scores
indicating a more adverse perception towards childbirth. The total
scale, as well as both subscales, have a good reliability (Cronbach’s
alphas > .75) 26.
Intervention: EMDR therapy All women received up to eight weekly 90-minute sessions of
EMDR-therapy in the context of this study (see also supplementary file
S1, “What is EMDR-therapy?”). The first session was allocated for case
conceptualization. During this session, LEC-5, CTQ-SF and CPS outcomes
were thoroughly discussed. The reason for this is that previous trauma,
be it pregnancy-related or not, can influence the development and
persisting of actual PTSD symptoms. Based on this
case-conceptualization, the course of treatment was designed. In session
2-7, women received EMDR-therapy following the latest version of the
Dutch EMDR protocol 27. During each session, the
target images, cognitive domains, the validity of (positive) cognitions
(lowest and highest score), the subjective unit of distress (lowest and
highest scores) were registered. Targets images refer to specific
disturbing memory images of the traumatic event. A cognitive domain
refers to the type of cognitions that make that a specific memory image
still causes distress in the present, even though the event belongs to
the past and even though the event may have had a good ending after all.
The cognitive domains as applied in the Dutch EMDR protocol are:
powerlessness, safety, self-evaluation and guilt. For instance, a memory
image can have high load on the domain “self-evaluation”, if negative
cognitions about the self are most prominent when a woman is confronted
with the disturbing memory image. Session 8 consisted of an evaluation
of treatment. If symptoms diminished and there was loss of diagnosis
before session 8, treatment ended. If after session 8 symptoms
persisted, the treatment plan was adjusted and women were offered
appropriate continuation of treatment. Treatment was performed or
supervised by a licensed EMDR Europe practitioner.
Data-analysis Data were analyzed by means of descriptive statistics in IBM SPSS
statistics (version 25). Results Forty-four women were referred. For all women referred, psychiatric
treatment was indicated and offered. However, for the results presented
below, only data from women who met the inclusion criteria are
presented. Main reasons for exclusion were based on psychiatric
assessment, in that another psychiatric disorder (than PTSD) was more
prominent and/or required treatment first. Twenty-six women were
included and 25 completed treatment. We had one drop-out due to adverse
social and physical events, which made continuation of EMDR therapy not
possible for her at the time. Respondent characteristics and main
outcomes are presented in Table 1. Mean age was 32, and women were
referred on average 10 months after giving birth. In most cases there
was a comorbid psychiatric disorder present, most often depression. Most
women had received mental health treatment earlier in life. Almost all
women had some history of psychotrauma, as is shown by their scores on
the LEC-5 and CTQ. The mean PCL-5 score at baseline was 44.84 (SD
15.77), and after treatment, the mean score was 14.58 (SD 11.97).
Table 2 shows the treatment specific characteristics. Average treatment
duration was 4.96 (SD 3.67) sessions. All women lost their PTSD
diagnosis. Per treatment, on average 3.12 (SD 2.37) “targets” were
neutralized. The cognitive domain powerlessness was most common for the
selected memory images.