A review assessing the current treatment strategies for postnatal psychological morbidity with a focus on post-traumatic stress disorder
Introduction
Post-traumatic stress disorder (PTSD) is an anxiety disorder with the following symptoms; re-experiencing (e.g. nightmares and flashbacks), persistent avoidance of reminders (e.g. loss of memory of the event) and hyperarousal (e.g. irritability, difficulty concentrating) (APA, 1994). Postnatal PTSD has been acknowledged in the Diagnostic and Statistical Manual of the American Psychiatric Association fourth edition (DSM-IV) since 1994 and may be due to birth trauma related to a woman believing that her life or that of her child has been in danger or her perception of the event is that it was physically or psychologically traumatic. Postnatal PTSD has been reported in the literature since the mid-1990s (Ballard et al., 1995) and could be a concern in terms of public health, since the prevalence ranges from 1.5% to 6% (Ayers, 2001, Beck, 2006, Creedy et al., 2006). However, up to 30.1% of women may be partially symptomatic (Soet et al., 2003). Unlike Postnatal Depression (PND), PTSD levels are not routinely assessed postnatally and some authors suggest that possibly 25% of women, symptomatic with PTSD, remain undetected (Czarnocka and Slade, 2000). Prevalence of PTSD may be increasing due to further medicalisation of childbirth and women's dissatisfaction with the level of care during labour (Fisher et al., 1997, Creedy, 2000). The impact may be serious as women with postnatal PTSD experience impaired quality of life, changes in their physical well-being, mood, behaviour, social interaction, relationship with partner, mother baby bond and desire to have further children (Ayers et al., 2006b, Parfitt and Ayers, 2009).
The current recommended treatment in the UK is Cognitive Behavioral Therapy (CBT) (National Institute for Health and Clinical Excellence, 2005); however Ayers et al. (2008) discuss the often inadequate resources available to treat PTSD postnatally. Eye movement desensitisation and reprocessing (EMDR) is also recommended for non-childbirth related PTSD treatment. (American Psychiatric Association (APA), 2004, INSERM, 2004, National Institute for Health and Clinical Excellence, 2005). Sandstrom et al. (2008) piloted its use with postnatal women and it was found to be effective, but it has not been widely applied and more research is needed. Sandstrom et al. (2008) report that the therapy is straightforward and time-efficient when compared with CBT. Written emotional disclosure has also been found to be effective in treating PTSD. Lange et al. (2000) reported that expressive writing reduced PTSD symptoms, while Sloan et al. (2007) reported improvement in psychological and physical health after therapy. van Emmerik et al. (2008) also found that expressive writing compared well to CBT.
Authors show a lack of agreement about how to treat postnatal PTSD, as traditional counselling approaches do not always work (Gamble et al., 2004a, Gamble et al., 2004b). Ayers et al. (2006a) report that 94% of hospitals in the United Kingdom (UK) offer postnatal services for women who have experienced difficult births but many have been set up in response to perceived need, without any strong evidence base regarding efficacy, while the service differs from hospital to hospital. Rose et al. (2009) found that the use of debriefing for PTSD unrelated to childbirth was ineffective and could put people at risk of developing PTSD symptoms. As a consequence the most recent UK and US guidelines recommend against the use of debriefing for the treatment of PTSD (Foa et al., 1999, National Institute for Health and Clinical Excellence, 2005).
Olde et al. (2006) suggested a multistep psychosocial approach for treatment involving crisis management for those traumatised by their birth experience. This involves identification by screening immediately after birth, provision of a supportive environment where the woman can talk to health professionals and referral for CBT if necessary.
Steele and Beadle (2003) reported inconsistency in management of perinatal mental health between 46 maternity units surveyed in two regions of England. This inconsistency was again highlighted by Rowan et al. (2007), who reported the disparity between current practice and postnatal mental health policy. They stressed the importance of offering a service for both those who perceive their birth experience as traumatic (but may not subsequently develop a mental health problem) and for those who develop symptoms of PTSD requiring a specific treatment. A generalised approach in terms of a ‘birth afterthoughts’ service may not be appropriate for all women but a co-ordinated approach to the management of perinatal mental health services is necessary.
In view of this lack of consistency in management of postnatal PTSD, a systematic review of the current treatments available is required. The aim of the systematic review reported in this paper was to assess the efficacy of current treatments for postnatal PTSD.
Section snippets
Methods
The review process was based on the Potsdam guidelines for systematic reviews (Cook et al., 1995, p. 167) which defines a systematic review as
The application of scientific strategies that limit bias to the systematic assembly, critical appraisal and synthesis of all relevant studies on a specific topic.
The guidance published was adhered to regarding the following; posing a relevant hypothesis, searching for eligible studies, using robust scoring systems to ascertain the quality of studies and
Findings
Table 1 provides an overview of each individual study.
Discussion
The main limitations of this review were the low number of papers which met the inclusion criteria and the heterogeneity of the studies. Several authors focused on psychological morbidities other than PTSD which were diagnosed as a consequence of childbirth. For example the main outcome measure in the Kershaw et al. (2005) study was fear of childbirth; however the authors used other measures in the study which assessed PTSD symptoms. In addition, Lavender and Walkinshaw (1998) and Tam et al.
Conclusions
Since this review found three types of intervention to be effective it can be concluded that there is insufficient evidence to determine which treatment strategy works best.
A co-ordinated approach to develop and utilise a universal PTSD instrument, encourage awareness of previous psychological trauma and investigate suitable timing of interventions is necessary to facilitate improved management of perinatal mental health problems.
Conflict of interest
None.
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