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Effectiveness of mindfulness-based interventions on maternal perinatal mental health outcomes: What's the evidence?

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Health Evidence™ hosted a 60 minute webinar examining the effectiveness of mindfulness-based interventions (MBIs) on maternal perinatal mental health outcomes. Click here for access to the audio recording for this webinar: https://youtu.be/NzStoRa87fY

Dr. Angus MacBeth, 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 led the session and presented findings from their recent systematic review:

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.

Estimates suggest that at least 10% of pregnant women experience perinatal anxiety, 20% suffer prenatal depression and between 12 and 16% are likely to suffer postnatal depression. This review examines the effectiveness of MBIs in reducing the severity of perinatal anxiety and depression. Seven randomized control trials, 2 non-randomized control trials, and 9 treatment evaluations with 640 participants were included in this review. Maternal participation in an MBI was associated with reductions in perinatal anxiety of moderate to large magnitude. Results for the effect of MBIs on depression were less consistent, with pre-post treatment reductions of moderate magnitude, but no significant differences in depression scores when MBI was compared with a control group. There was some evidence that MBIs were associated with increased mindfulness.

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Effectiveness of mindfulness-based interventions on maternal perinatal mental health outcomes: What's the evidence?

  1. 1. Welcome! Effectiveness of mindfulness- based interventions on maternal perinatal mental health outcomes: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  2. 2. Poll Questions: Consent • Participation in the webinar poll questions is voluntary • Names are not recorded and persons will not be identified in any way • Participation in the anonymous polling questions is accepted as an indication of your consent to participate Benefits: • Results inform improvement of the current and future webinars • Enable engagement; stimulate discussion. This session is intended for professional development. Some data may be used for program evaluation and research purposes (e.g., exploring opinion change) • Results may also be used to inform the production of systematic reviews and overviews Risks: None beyond day-to-day living
  3. 3. After Today • The PowerPoint presentation and audio recording will be made available • These resources are available at: – PowerPoint: http://www.slideshare.net/HealthEvidence – Audio Recording: https://www.youtube.com/user/healthevidence /videos 3
  4. 4. 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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  7. 7. Poll Question #1 How many people are watching today’s session with you? A. Just me B. 2-3 C. 4-5 D. 6-10 E. >10
  8. 8. The Health Evidence™ Team Maureen Dobbins Scientific Director Heather Husson Manager Susannah Watson Project Coordinator Students: Emily Belita (PhD candidate) Jennifer Yost Assistant Professor Olivia Marquez Research Coordinator Emily Sully Research Assistant Liz Kamler Research Assistant Zhi (Vivian) Chen Research Assistant Research Assistants: Claire Howarth Rawan Farran Kristin Read Research Coordinator
  9. 9. What is www.healthevidence.org? Evidence Decision Making inform
  10. 10. Why use www.healthevidence.org? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  11. 11. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
  12. 12. Stages in the process of Evidence-Informed Public Health National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
  13. 13. Poll Question #2 Have you heard of PICO(S) before? A. Yes B. No
  14. 14. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
  15. 15. How often do you use Systematic Reviews to inform a program/services? A. Always B. Often C. Sometimes D. Never E. I don’t know what a systematic review is Poll Question #3
  16. 16. 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
  17. 17. 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
  18. 18. Impact of perinatal mental health Parental Mental Health Birth Antenatal MH Postnatal MH Perinatal MH Influence Of Parental MH Health of Offspring Prenatal MH
  19. 19. 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.
  20. 20. 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’
  21. 21. 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.
  22. 22. 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.
  23. 23. 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.
  24. 24. 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.
  25. 25. 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.
  26. 26. 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
  27. 27. 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).
  28. 28. 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).
  29. 29. 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
  30. 30. 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.
  31. 31. 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?
  32. 32. 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).
  33. 33. 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)
  34. 34. 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?
  35. 35. 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
  36. 36. THANK YOU angus.macbeth@ed.ac.uk Twitter: @gusmacbeth
  37. 37. Poll Question #4 The information presented today was helpful A. Strongly agree B. Agree C. Neutral D. Disagree E. Strongly disagree
  38. 38. What can I do now? Visit the website; a repository of over 4,800+ quality-rated systematic reviews related to the effectiveness of public health interventions. Health Evidence™ is FREE to use. Register to receive monthly tailored registry updates AND monthly newsletter to keep you up to date on upcoming events and public health news. Tell your colleagues about Health Evidence™: helping you use best evidence to inform public health practice, program planning, and policy decisions! Follow us @HealthEvidence on Twitter and receive daily public health review- related Tweets, receive information about our monthly webinars, as well as announcements and events relevant to public health. Encourage your organization to use Health Evidence™ to search for and apply quality-rated review level evidence to inform program planning and policy decisions. Contact us to suggest topics or provide feedback. info@healthevidence.org
  39. 39. Poll Question #5 What are your next steps? [Check all that apply] A. Access the full text systematic review B. Access the quality assessment for the review on www.healthevidence.org C. Consider using the evidence D. Tell a colleague about the evidence
  40. 40. Thank you! Contact us: info@healthevidence.org For a copy of the presentation please visit: http://www.healthevidence.org/webinars.aspx

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