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Effects of a psychological nursing intervention on prevention of anxiety and depression in the postpartum period: a randomized controlled trial

Effects of a psychological nursing intervention on prevention of anxiety and depression in the... Background: Anxiety and postpartum depression are the most common psychological problems in women after delivery. Cognitive behavior intervention has been reported to have an effect in the therapy of postpartum depres- sion. This research aimed to investigate whether cognitive behavior intervention could prevent the pathogenesis of postpartum depression in primiparous women. Methods: In this randomized controlled trial, primiparous women who were prone to postpartum depression were recruited. Participates in the control group received routine postpartum care and those in the intervention group received both routine postpartum care and cognitive behavior intervention. Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), Edinburgh Postpartum Depression Scale (EPDS) and Pittsburgh Sleep Quality Index (PSQI) were evaluated before and after the intervention. Results: In the intervention group, the post-intervention scores of HAMA, HAMD, EPDS and PSQI were all significantly lower than the baseline scores (p = 0.034, p = 0.038, p = 0.004, p = 0.014, respectively). The proportion of participants with postpartum depression in the intervention group (11.5%) was significantly lower than the control group (24.3%) after the 6-week intervention. Participants in the intervention group were significantly more satisfied with the care than those in the control group (p = 0.032). Conclusion: This research provided evidence that cognitive behavioral intervention in postpartum period could alleviate anxiety and depression in primiparous women, and inhibit the pathogenesis of postpartum depression. Trial registry This clinical trial was registered in the Chinese Clinical Trial Registry (ChiCTR2000040076). Keywords: Anxiety, Postpartum depression, Cognitive behavioral intervention Background post-traumatic stress disorder [2]. It is demonstrated Pregnancy and delivery are two important physiologi- that the prevalence of post-traumatic stress disorder in cal phenomena for women. In this process, the preg- women after delivery is 37.7% [3]. About 5–20% of moth- nant woman’s mood will change and become sensitive ers are influenced by post-delivery anxiety [4]. Postpar - to psychological stimuli, leading to potential psycho- tum depression accounts for 12.5% of psychologically logical problems [1], such as anxiety, depression and related hospitalizations among women [5]. Impaired sleep duration and quality have been asso- ciated with concurrent mood disturbance and with *Correspondence: toubaoliumi2020@163.com increased risk of future mood problems during preg- Obstetrics Ward 3, Cangzhou Central Hospital, Xinhua West Road, Cangzhou 061000, Hebei, China nancy and the postpartum period [6]. Anxiety is the © The Author(s) 2020. 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The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/ zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Liu and Yang Ann Gen Psychiatry (2021) 20:2 Page 2 of 7 mental reaction to either imagined or real threat. The clinical trial was registered in the Chinese Clinical Trial symptoms of anxiety include smoking, high caffeine Registry (ChiCTR2000040076). consumption, physical disease, poor nutrition and lack 843 primiparous women were recruited in this of sleep [7]. Accumulation of anxiety to a certain degree research. Inclusion criteria were: (1) primiparous women can cause disability [8]. In mothers, postpartum anxiety with full-term delivery, (2) having single healthy new- and depression inhibit oxytocin secretion and breast milk born baby, (3) having no obstetric diseases (eclampsia, production [9]. As the most crucial postpartum stress placenta previa, and premature rupture of membranes, complication, postpartum depression triggers increased etc.), (4) having normal communication ability, and (5) vulnerability in both mothers and infants [10]. The role having propensity for postpartum depression [Edinburgh of the mother is affected by postpartum depression, and Postpartum Depression Scale (EPDS) score ≥ 9 points sometimes the mother’s attention in the child and the but < 13 points]. Exclusion criteria included: (1) EPDS family is also compromised. Thus, postpartum depres - score < 9 points (having no postpartum depression ten- sion is a major threat to the relationship between mother dency) or ≥ 13 points (having postpartum depression), and infant [11]. Normally, depression will heal gradu- (2) having serious underlying disease, including autoim- ally after delivery if it is left untreated. Longer period of mune disease, hypertension, or gestational diabetes, (3) depression triggers complications that further enhances having previous mental disease, and (4) having severe its severity [12]. complications in mothers or infants. After exclusion, 260 Recently, evidence has indicated that interventions patients remained in this research. Patients were centrally before and after delivery play a crucial role in reducing allocated (1:1) using concealed random allocation from a the risk of psychological problems in pregnant women. random number table generated by hospital IT staff who A meta‐analysis has demonstrated that several different were not involved any other part of the study. A hospi- interventions can be employed to alleviate the sever- tal nurse, who were not involved in any other part of the ity of postpartum anxiety and depression, including study, then assigned participants in different groups. All physical exercise, psychoeducation training, social sup- investigators, research staff, and the doctors treating the port groups and cognitive behavior intervention [13]. A patients were masked to treatment allocation. number of studies have shown that cognitive behavioral intervention and mental health care adjuvant therapy Intervention can effectively improve the condition of patients with In the control group, participants received routine post- postpartum depression. Clinical study has shown that partum care, which involved the registration in com- cognitive behavioral intervention significantly reduces munity, postpartum life and dietary guidance provided the scores of maternal postpartum depression scale and by the hospital and community, guidance for women in alleviates depression [14]. Another study has found that maternal and newborn care, perineal care, breastfeeding, strengthening mental health care treatment for patients changing diapers, newborn bathing, and umbilical care, with postpartum depression can effectively reduce their and answering questions from patients and families. depression self-rating scale scores and anxiety self-rating In the intervention group, in addition to routine post- scale scores, and improve their quality of life after deliv- partum care, participants received a 6-week cognitive ery [15]. behavior intervention, once a week, 1 h each time. Cogni- In this research, we aimed to investigate whether psy- tive behavior intervention was composed of five different chological nursing intervention had a beneficial effect parts. First, a psychological evaluation was conducted on in preventing anxiety and depression in the postpartum the parturient. Cognitive distortions from three perspec- period. tives were gently guided and corrected: the parturient to herself, to world she is in, and to the future. The partu - rient was made to understand some of the mental prob- lems that might occur after childbirth and to face them Methods correctly. Second, we assisted the mother to establish a Study design and participants self-activity plan (including control and joyful exercises, This study was a randomized controlled trial conducted cognitive rehearsals, self-independent training, role- on primiparous women who had postpartum depression playing, and transfer techniques, etc.), and encouraged tendency during delivery. Participants in this study were the parturient to regularly feedback to the doctor and recruited from Cangzhou Central Hospital by hospital make timely adjustment. Third, the mental health care, administration staff who were not involved in any other during which nurses communicated with mothers to part of the study. This research was approved by the eth - establish a good nurse–patient relationship. Meanwhile, ics commitment of Cangzhou Central Hospital with mentality, family and social background of mothers were informed consents signed by all the participants. This Liu and Y ang Ann Gen Psychiatry (2021) 20:2 Page 3 of 7 analyzed to conduct targeted mental health education, between baseline versus post-intervention. Chi-square stabilize postpartum anxiety, and provide appropriate test or Fisher’s exact test was used for assessing distri- emotional support. Soothing music was played to adjust bution of observations or phenomena between differ - mothers’ emotions and help them out of anxiety. Fourth, ent groups. Statistical analysis was significant when p we enhanced the care for patients after delivery, guided value < 0.05. Sample size was determined using estab- their breastfeeding, assisted them to complete post-natal lished statistical power analysis. Differences between status change. Fifth, we actively communicated with the means of each compared treatment groups were divided maternity husband and other family members, increased by the standard deviation to determine the standardized family members’ social support for the mother, improved effect size, then using 5% as significance level in Student their negative emotional state and encouraged fam- t test and 90% power, the minimum required sample size ily members, especially the husband, to accompany and was calculated, which was sufficient for our current sam - communicate with the patient and take care of the baby ple size after consideration of dropout. together. Results Research framework of this study is shown in Fig.  1. 843 Measurements primiparous women were assessed for eligibility. 102 Postpartum depression was identified through EPDS, patients refused to participate in this research and 481 which is a self‐report multiple-choice questionnaire with patients did not meet the inclusion criteria. 260 par- 10 items. The score of each item was from 0 to 3, and the ticipants were randomly assigned into the intervention total score was from 0 to 30. EPDS score ≥ 13 points was group (n = 130) and the control group (n = 130). In the considered to indicate postpartum depression. intervention group, 17 participants lost to follow-up, 12 Anxiety symptoms were assessed by the Hamilton Anx- of whom discontinued intervention and 5 were unable iety Scale (HAMA). HAMA evaluation criteria were: < 7 to contact. In the control group, 15 participants lost to points indicates anxiety-free; 7 ~ < 20 points indicates follow-up, 4 of whom discontinued intervention and 11 possible anxiety; 20 ~ < 29 points indicates anxiety; ≥ 29 were unable to contact. 113 participants in interven- points indicates severe anxiety. tion group and 115 in the control group completed this Depression symptoms were assessed by the Hamilton research and their data were recorded and analyzed. Depression Scale (HAMD). HAMD evaluation criteria Table  1 shows the socio-demographic characteristics were: < 8 points indicates depression-free; 8 ~ < 20 points of the participants. No statistically significant differences indicates possible depression; 20 ~ < 35 points indicates were observed in socio-demographic characteristics depression; ≥ 35 points indicates severe depression. between these two groups. The mean ages in the inter - Sleep quality was assessed using the Pittsburgh Index vention group and the control group were 26.89 ± 4.12 Scale (PSQI). PSQI is a self-report questionnaire con- and 27.31 ± 4.56 years, respectively. 60.2% of the women sisted of 19 items from seven subscales: sleep quality, in the intervention group and 53.1% in the control group sleep duration, sleep latency, sleep disturbance, sleep underwent vaginal delivery. In the intervention group, efficiency, sleep medication, and daily dysfunction. Each subscale had a score ranging from 0 to 3, and the total score was from 0 and 21. A higher score indicates worse sleep quality, and a total score > 7 indicates the presence of sleep disorders. Nursing satisfaction was evaluated using the nursing satisfaction questionnaire developed by our hospital. The total score was 100 points, where ≥ 90 points indi- cates very satisfied; 75 ~ < 90 points indicates satisfied; 60 ~ < 75 points indicates basically satisfied; < 60 indicates dissatisfied. Statistical analysis SPSS Statistics Version 22.0 software was employed for statistical analysis. Values were expressed as n (percent- age, %) or mean ± SD. p values derived from unpaired t test or Mann–Whitney test as appropriate between inter- vention group and control group. p values derived from Fig. 1 Research framework of this study paired t test or Wilcoxon signed rank test as appropriate Liu and Yang Ann Gen Psychiatry (2021) 20:2 Page 4 of 7 Table 1 Socio-demographic characteristics of participants analyzed Variable Study group p Intervention group (n = 113) Control group (n = 115) Age (years) 26.89 ± 4.12 27.31 ± 4.56 0.273 BMI (kg/m ) 18.5–24.9 48 (42.4%) 54 (46.9%) 0.789 25–29.9 42 (37.2%) 40 (34.8%) ≥ 30 23 (20.4%) 21 (18.3%) Delivery Vaginal delivery 68 (60.2%) 61 (53.1%) 0.277 Caesarian section 45 (39.8%) 54 (46.9%) Education status Junior high school and below 23 (20.4%) 20 (17.4%) 0.601 Senior high school or polytechnic school 71 (62.8%) 70 (60.9%) College and above 19 (16.8%) 25 (21.7%) Husband education status Junior high school and below 15 (13.3%) 24 (20.9%) 0.310 Senior high school or polytechnic school 72 (63.7%) 66 (57.4%) College and above 26 (23.0%) 25 (21.7%) Working status Does not work 32 (28.3%) 41 (35.7%) 0.258 Works 81 (71.7%) 74 (64.3%) The sex of baby Girl 67 (59.3%) 57 (49.6%) 0.146 Boy 46 (40.7%) 58 (50.4%) Supports for caring the baby Yes 27 (23.9%) 34 (29.6%) 0.371 No 86 (76.1%) 81 (70.4%) Values were expressed as n (percentage, %) or mean ± SD. p values for each group were derived from either unpaired t test or Mann–Whitney test as appropriate. Chi- square test or Fisher’s exact test was used for assessing distribution of observations or phenomena between different groups BMI body mass index 16.8% of the patients graduated from college and 71.7% Table 2 Comparison of  frequency distribution had work, while in the control group, the relative pro- of  postpartum depression between  the  two groups in different time points portions were 21.7% and 64.3%, respectively. 76.1% of the women in the intervention group and 70.4% in the Time Variable Study group p control group had no support of child caring. These data Intervention Control indicated that the participants in these two groups were group group homogenous. (n = 113) (n = 115) The incidence of postpartum depression in both groups Baseline Depressed 0 (0%) 0 (0%) 1.000 were evaluated before and after the 6-week intervention. Post-intervention Depressed 13 (11.5%) 28 (24.3%) 0.015 In this research, the patient was thought to have postpar- Values were expressed as n (percentage, %). Chi-square test or Fisher’s exact tum depression when the score of EPDS ≥ 13 points. As test was used for assessing distribution of observations or phenomena between shown in Table  2, the incidence of postpartum depres- different groups sion in the control group (24.3%) was significantly higher Edinburgh Postnatal Depression Scale (EPDS) was used to diagnose the postpartum depression when the score ≥ 13 than that of the intervention group (11.5%). This result Italic value indicates the presence of statistical significance (p < 0.05) showed that our intervention could effectively reduce the incidence of postpartum depression in women. We further investigated the satisfaction of the care in satisfied, 15.9% were basically satisfied, and 7.1% were these two groups. In the intervention group, 51.3% of not satisfied. Meanwhile, in the control group, the rela - the patients were very satisfied with the care, 25.7% were tive proportions were 35.6%, 31.3%, 15.7%, and 17.4%, Liu and Y ang Ann Gen Psychiatry (2021) 20:2 Page 5 of 7 Table 3 Comparison of  satisfaction of  the  care EPDS and PSQI were all significantly lower than the between the two groups baseline scores. However, the scores of HAMD and PSQI were significantly elevated during the 6-week routine Time Study group p postpartum care in the control group. In primiparous Intervention group Control group women, the performance of cognitive behavior interven- (n = 113) (n = 115) tion together with routine postpartum care significantly Very satisfied 58 (51.3%) 41 (35.6%) 0.032 reduced the incidence of anxiety and depression. Satisfied 29 (25.7%) 36 (31.3%) Basically satisfied 18 (15.9%) 18 (15.7%) Discussion Not satisfied 8 (7.1%) 20 (17.4%) This randomized, controlled clinical trial was performed Values were expressed as n (percentage, %). Chi-square test was used for to analyze the effect of psychological nursing interven - assessing distribution of observations or phenomena between different groups tion on postpartum depressive and anxiety symptoms. Italic value indicates the presence of statistical significance (p < 0.05) When compared with routine postpartum care, cog- nitive behavioral intervention significantly alleviated postpartum depressive and anxiety during delivery. The Table 4 Assessment of  HAMA, HAMD, EPDS and  PSQI performance of cognitive behavioral intervention (psy- before and after the intervention chological nursing intervention) was able to effectively reduce the incidence of postpartum depression in pri- Iteams Study group p miparous women who had a postpartum depression Intervention Control group tendency. group (n = 113) (n = 115) In recent decades, puerperium has become an impor- HAMA tant stage after delivery, and has gradually attracted Baseline 13.24 ± 2.89 14.12 ± 3.21 0.134 wide attention from obstetricians and pregnant women. Post-intervention 10.21 ± 2.16 15.55 ± 2.76 0.007 During pregnancy and childbirth, parturient women p value 0.034 0.089 often experience both physical and psychological HAMD changes, resulting in a significantly increased prob - Baseline 14.36 ± 3.04 13.89 ± 2.93 0.117 ability of mental problems after childbirth [16]. Clinical Post-intervention 11.51 ± 2.85 16.58 ± 3.34 0.021 studies have shown that sudden changes in social roles p value 0.038 0.037 of women after childbirth, coupled with rapid changes EPDS in social relationships and functions, exacerbate nega- Baseline 11.24 ± 3.05 10.95 ± 2.75 0.217 tive emotions such as anxiety and depression, lead- Post-intervention 8.11 ± 2.18 11.45 ± 2.73 0.008 ing to recurring unhealthy mental states [17]. Among p value 0.004 0.283 these unhealthy mental states after delivery, postpar- PSQI tum depression is a common, disabling and treatable Baseline 9.12 ± 1.36 9.88 ± 1.53 0.172 reproductive complication [18]. Worldwide statistical Post-intervention 7.38 ± 1.09 12.03 ± 1.62 0.006 data indicate that 8–13% of primiparous women suf- p value 0.014 0.037 fer from postpartum depression [19]. In the Greater China Region, the incidence of postpartum depression Values were expressed as mean ± SD. p values derived from paired t test or Wilcoxon signed rank test as appropriate between baseline versus post- increases to around 20%, which becomes a great burden intervention. p values derived from unpaired t test or Mann–Whitney test as on medical system and society [19]. Recent research appropriate between intervention group and control group has demonstrated that postpartum depression patients Italic values indicate the presence of statistical significance (p < 0.05) could be divided into three different types: gradually cured (50.4%), partially improved (41.8%), and chronic severe (7.8%) [20]. Although most patients’ postpar- respectively, which were significantly lower than the tum depression symptoms can be relieved after 1  year, intervention group (Table  3). Thus, the performance of there are still some patients who remain depressed intervention dramatically enhanced the satisfaction of for a long time, and may even become more severe, the care. leading to increased incidence of adverse events [21]. Table  4 demonstrates the HAMA, HAMD, EPDS and Thus, the identification of risk factors and the therapy PSQI scores of the women in both groups. After 6-week for postpartum depression have become the focus of intervention, the HAMA, HAMD, EPDS and PSQI scores clinical work. The pathogenic factors of postpartum of the women in the intervention group were all dramati- depression are complicated. Previous clinical study has cally lower than the control group. In the intervention illustrated the correlations between the pathogenesis group, the post-intervention scores of HAMA, HAMD, Liu and Yang Ann Gen Psychiatry (2021) 20:2 Page 6 of 7 of postpartum depression and altered levels of prena- of postpartum depression and related symptoms [28]. tal hormones, worrying about delivery and inadequate Meanwhile, employment is considered as a protective preparation for childbirth [22]. Another study further factor for postpartum depression symptomatology [29]. confirmed the contribution of limited postpartum Of note, in the current study, these factors showed no health education, insufficient psychological support, significant differences between the two groups. and inability to adapt to postpartum roles to the occur- Previous studies focused on the effect of cognitive rence of postpartum depression in the early postpar- behavioral intervention on the therapy of postpartum tum period [21]. depression. However, whether cognitive behavioral Cognitive behavioral intervention is commonly per- intervention has an effect on the prevention of postpar - formed together with mental health care adjuvant treat- tum depression pathogenesis is still unknown. In this ment for clinical therapy of patients with depression [23]. research, EPDS was employed for evaluating the degree As a complicated treatment system, cognitive behavioral of postpartum depression in primiparous women. intervention is composed of rational-emotive therapy, Patients with EPDS score ≥ 9 and < 13 points were flooding therapy, systematic desensitization, relaxation considered prone to postpartum depression. If EPDS training, social skills training and supportive treatment score is ≥ 13 points, the patient is confirmed to have [24]. In cognitive behavioral intervention, the therapist postpartum depression. To investigate the function of evaluates the motivation and progression of treatment cognitive behavioral intervention in the prevention of through observing the clinical performance, subjective postpartum depression pathogenesis, the EPDS scores needs and introspection of the patient, and adopts indi- of primiparous women who had postpartum depression vidualized treatment schemes depressed patients [25]. tendency were evaluated after the 6-week intervention. Evidence has shown that cognitive behavioral interven- Before the intervention, all participants in both groups tion and mental health care adjuvant therapy can effec - had postpartum depression tendency. 6 weeks later, the tively improve the condition of postpartum depression proportion of participants with postpartum depression patients. Based on the results of several clinical stud- in the intervention group was dramatically lower than ies, the score of EPDS and the levels of serum adrena- in the control group. This result indicated that cogni - line and norepinephrine are significantly reduced by tive behavioral intervention played a beneficial role in cognitive behavioral intervention [26]. Another study inhibiting postpartum depression pathogenesis in pri- showed that enhanced mental health care treatment for miparous women. The results of nursing satisfaction postpartum depression patients effectively reduced the questionnaire also illustrated the benefit of cognitive depression self-assessment scale score and anxiety self- behavioral intervention in improving patients’ satisfac- assessment scale score, and improved the quality of life tion of the care. of postpartum patients [14]. In this research, the scores There are several limitations in the current study. First, of HAMA, HAMD and EPDS in the intervention group the HAMD, HAMA and EPDS were screening tools for were all significantly reduced by the 6-week cognitive anxiety and depression, rather than diagnostic param- behavior intervention. However, the scores of HAMA, eters. Although symptoms of anxiety and depression HAMD and EPDS were elevated during the 6-week rou- were analyzed in this research, clinical assessment and tine postpartum care in the control group. These results diagnosis of depression and anxiety were not performed. demonstrated that cognitive behavior intervention could Another limitation in our study was the short follow- alleviate postpartum anxiety and depression in primipa- up period, and a follow-up period longer than 8  weeks rous women, whereas the routine postpartum care failed in future studies may further confirm the results. Third, to do so. Studies have shown that negative emotional participants in the intervention group were encouraged states are often closely related to the body’s endocrine to create self-activity plan and perform these practices. and metabolic functions. Negative emotions, such as anx- However, the actual time spent in home practice was not iety and depression, can cause disturbances in the levels tracked. The performance of self-activity plan should be of related hormones in the maternal body, which can sig- examined in future research. nificantly compromise maternal sleep quality [27]. In this research, the significantly decreased PSQI score in the intervention group suggested the function of cognitive Conclusion behavior intervention in improving the sleep quality of In summary, this research provided evidence that the primiparous women. It is reported that cesarean section performance of cognitive behavioral intervention in the was associated with increased risk of postpartum depres- postpartum period alleviated anxiety and depression in sion [18]. Another study in Japan indicated that lower primiparous women and inhibited the pathogenesis of education level was associated with higher prevalence postpartum depression. Liu and Y ang Ann Gen Psychiatry (2021) 20:2 Page 7 of 7 Acknowledgements 15. Milgrom J, Danaher BG, Gemmill AW, Holt C, Holt CJ, Seeley JR, Tyler None. MS, Ross J, Ericksen J. Internet cognitive behavioral therapy for women with postnatal depression: a randomized controlled trial of mummood- Authors’ contributions booster. J Med Internet Res. 2016;18(3):e54. HL and YY conceived and designed the experiments; YY performed the 16. Rusner M, Berg M, Begley C. 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Effects of a psychological nursing intervention on prevention of anxiety and depression in the postpartum period: a randomized controlled trial

Annals of General Psychiatry , Volume 20 (1) – Jan 4, 2021

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Springer Journals
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Copyright © The Author(s) 2020
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1744-859X
DOI
10.1186/s12991-020-00320-4
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Abstract

Background: Anxiety and postpartum depression are the most common psychological problems in women after delivery. Cognitive behavior intervention has been reported to have an effect in the therapy of postpartum depres- sion. This research aimed to investigate whether cognitive behavior intervention could prevent the pathogenesis of postpartum depression in primiparous women. Methods: In this randomized controlled trial, primiparous women who were prone to postpartum depression were recruited. Participates in the control group received routine postpartum care and those in the intervention group received both routine postpartum care and cognitive behavior intervention. Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), Edinburgh Postpartum Depression Scale (EPDS) and Pittsburgh Sleep Quality Index (PSQI) were evaluated before and after the intervention. Results: In the intervention group, the post-intervention scores of HAMA, HAMD, EPDS and PSQI were all significantly lower than the baseline scores (p = 0.034, p = 0.038, p = 0.004, p = 0.014, respectively). The proportion of participants with postpartum depression in the intervention group (11.5%) was significantly lower than the control group (24.3%) after the 6-week intervention. Participants in the intervention group were significantly more satisfied with the care than those in the control group (p = 0.032). Conclusion: This research provided evidence that cognitive behavioral intervention in postpartum period could alleviate anxiety and depression in primiparous women, and inhibit the pathogenesis of postpartum depression. Trial registry This clinical trial was registered in the Chinese Clinical Trial Registry (ChiCTR2000040076). Keywords: Anxiety, Postpartum depression, Cognitive behavioral intervention Background post-traumatic stress disorder [2]. It is demonstrated Pregnancy and delivery are two important physiologi- that the prevalence of post-traumatic stress disorder in cal phenomena for women. In this process, the preg- women after delivery is 37.7% [3]. About 5–20% of moth- nant woman’s mood will change and become sensitive ers are influenced by post-delivery anxiety [4]. Postpar - to psychological stimuli, leading to potential psycho- tum depression accounts for 12.5% of psychologically logical problems [1], such as anxiety, depression and related hospitalizations among women [5]. Impaired sleep duration and quality have been asso- ciated with concurrent mood disturbance and with *Correspondence: toubaoliumi2020@163.com increased risk of future mood problems during preg- Obstetrics Ward 3, Cangzhou Central Hospital, Xinhua West Road, Cangzhou 061000, Hebei, China nancy and the postpartum period [6]. Anxiety is the © The Author(s) 2020. 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The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/ zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Liu and Yang Ann Gen Psychiatry (2021) 20:2 Page 2 of 7 mental reaction to either imagined or real threat. The clinical trial was registered in the Chinese Clinical Trial symptoms of anxiety include smoking, high caffeine Registry (ChiCTR2000040076). consumption, physical disease, poor nutrition and lack 843 primiparous women were recruited in this of sleep [7]. Accumulation of anxiety to a certain degree research. Inclusion criteria were: (1) primiparous women can cause disability [8]. In mothers, postpartum anxiety with full-term delivery, (2) having single healthy new- and depression inhibit oxytocin secretion and breast milk born baby, (3) having no obstetric diseases (eclampsia, production [9]. As the most crucial postpartum stress placenta previa, and premature rupture of membranes, complication, postpartum depression triggers increased etc.), (4) having normal communication ability, and (5) vulnerability in both mothers and infants [10]. The role having propensity for postpartum depression [Edinburgh of the mother is affected by postpartum depression, and Postpartum Depression Scale (EPDS) score ≥ 9 points sometimes the mother’s attention in the child and the but < 13 points]. Exclusion criteria included: (1) EPDS family is also compromised. Thus, postpartum depres - score < 9 points (having no postpartum depression ten- sion is a major threat to the relationship between mother dency) or ≥ 13 points (having postpartum depression), and infant [11]. Normally, depression will heal gradu- (2) having serious underlying disease, including autoim- ally after delivery if it is left untreated. Longer period of mune disease, hypertension, or gestational diabetes, (3) depression triggers complications that further enhances having previous mental disease, and (4) having severe its severity [12]. complications in mothers or infants. After exclusion, 260 Recently, evidence has indicated that interventions patients remained in this research. Patients were centrally before and after delivery play a crucial role in reducing allocated (1:1) using concealed random allocation from a the risk of psychological problems in pregnant women. random number table generated by hospital IT staff who A meta‐analysis has demonstrated that several different were not involved any other part of the study. A hospi- interventions can be employed to alleviate the sever- tal nurse, who were not involved in any other part of the ity of postpartum anxiety and depression, including study, then assigned participants in different groups. All physical exercise, psychoeducation training, social sup- investigators, research staff, and the doctors treating the port groups and cognitive behavior intervention [13]. A patients were masked to treatment allocation. number of studies have shown that cognitive behavioral intervention and mental health care adjuvant therapy Intervention can effectively improve the condition of patients with In the control group, participants received routine post- postpartum depression. Clinical study has shown that partum care, which involved the registration in com- cognitive behavioral intervention significantly reduces munity, postpartum life and dietary guidance provided the scores of maternal postpartum depression scale and by the hospital and community, guidance for women in alleviates depression [14]. Another study has found that maternal and newborn care, perineal care, breastfeeding, strengthening mental health care treatment for patients changing diapers, newborn bathing, and umbilical care, with postpartum depression can effectively reduce their and answering questions from patients and families. depression self-rating scale scores and anxiety self-rating In the intervention group, in addition to routine post- scale scores, and improve their quality of life after deliv- partum care, participants received a 6-week cognitive ery [15]. behavior intervention, once a week, 1 h each time. Cogni- In this research, we aimed to investigate whether psy- tive behavior intervention was composed of five different chological nursing intervention had a beneficial effect parts. First, a psychological evaluation was conducted on in preventing anxiety and depression in the postpartum the parturient. Cognitive distortions from three perspec- period. tives were gently guided and corrected: the parturient to herself, to world she is in, and to the future. The partu - rient was made to understand some of the mental prob- lems that might occur after childbirth and to face them Methods correctly. Second, we assisted the mother to establish a Study design and participants self-activity plan (including control and joyful exercises, This study was a randomized controlled trial conducted cognitive rehearsals, self-independent training, role- on primiparous women who had postpartum depression playing, and transfer techniques, etc.), and encouraged tendency during delivery. Participants in this study were the parturient to regularly feedback to the doctor and recruited from Cangzhou Central Hospital by hospital make timely adjustment. Third, the mental health care, administration staff who were not involved in any other during which nurses communicated with mothers to part of the study. This research was approved by the eth - establish a good nurse–patient relationship. Meanwhile, ics commitment of Cangzhou Central Hospital with mentality, family and social background of mothers were informed consents signed by all the participants. This Liu and Y ang Ann Gen Psychiatry (2021) 20:2 Page 3 of 7 analyzed to conduct targeted mental health education, between baseline versus post-intervention. Chi-square stabilize postpartum anxiety, and provide appropriate test or Fisher’s exact test was used for assessing distri- emotional support. Soothing music was played to adjust bution of observations or phenomena between differ - mothers’ emotions and help them out of anxiety. Fourth, ent groups. Statistical analysis was significant when p we enhanced the care for patients after delivery, guided value < 0.05. Sample size was determined using estab- their breastfeeding, assisted them to complete post-natal lished statistical power analysis. Differences between status change. Fifth, we actively communicated with the means of each compared treatment groups were divided maternity husband and other family members, increased by the standard deviation to determine the standardized family members’ social support for the mother, improved effect size, then using 5% as significance level in Student their negative emotional state and encouraged fam- t test and 90% power, the minimum required sample size ily members, especially the husband, to accompany and was calculated, which was sufficient for our current sam - communicate with the patient and take care of the baby ple size after consideration of dropout. together. Results Research framework of this study is shown in Fig.  1. 843 Measurements primiparous women were assessed for eligibility. 102 Postpartum depression was identified through EPDS, patients refused to participate in this research and 481 which is a self‐report multiple-choice questionnaire with patients did not meet the inclusion criteria. 260 par- 10 items. The score of each item was from 0 to 3, and the ticipants were randomly assigned into the intervention total score was from 0 to 30. EPDS score ≥ 13 points was group (n = 130) and the control group (n = 130). In the considered to indicate postpartum depression. intervention group, 17 participants lost to follow-up, 12 Anxiety symptoms were assessed by the Hamilton Anx- of whom discontinued intervention and 5 were unable iety Scale (HAMA). HAMA evaluation criteria were: < 7 to contact. In the control group, 15 participants lost to points indicates anxiety-free; 7 ~ < 20 points indicates follow-up, 4 of whom discontinued intervention and 11 possible anxiety; 20 ~ < 29 points indicates anxiety; ≥ 29 were unable to contact. 113 participants in interven- points indicates severe anxiety. tion group and 115 in the control group completed this Depression symptoms were assessed by the Hamilton research and their data were recorded and analyzed. Depression Scale (HAMD). HAMD evaluation criteria Table  1 shows the socio-demographic characteristics were: < 8 points indicates depression-free; 8 ~ < 20 points of the participants. No statistically significant differences indicates possible depression; 20 ~ < 35 points indicates were observed in socio-demographic characteristics depression; ≥ 35 points indicates severe depression. between these two groups. The mean ages in the inter - Sleep quality was assessed using the Pittsburgh Index vention group and the control group were 26.89 ± 4.12 Scale (PSQI). PSQI is a self-report questionnaire con- and 27.31 ± 4.56 years, respectively. 60.2% of the women sisted of 19 items from seven subscales: sleep quality, in the intervention group and 53.1% in the control group sleep duration, sleep latency, sleep disturbance, sleep underwent vaginal delivery. In the intervention group, efficiency, sleep medication, and daily dysfunction. Each subscale had a score ranging from 0 to 3, and the total score was from 0 and 21. A higher score indicates worse sleep quality, and a total score > 7 indicates the presence of sleep disorders. Nursing satisfaction was evaluated using the nursing satisfaction questionnaire developed by our hospital. The total score was 100 points, where ≥ 90 points indi- cates very satisfied; 75 ~ < 90 points indicates satisfied; 60 ~ < 75 points indicates basically satisfied; < 60 indicates dissatisfied. Statistical analysis SPSS Statistics Version 22.0 software was employed for statistical analysis. Values were expressed as n (percent- age, %) or mean ± SD. p values derived from unpaired t test or Mann–Whitney test as appropriate between inter- vention group and control group. p values derived from Fig. 1 Research framework of this study paired t test or Wilcoxon signed rank test as appropriate Liu and Yang Ann Gen Psychiatry (2021) 20:2 Page 4 of 7 Table 1 Socio-demographic characteristics of participants analyzed Variable Study group p Intervention group (n = 113) Control group (n = 115) Age (years) 26.89 ± 4.12 27.31 ± 4.56 0.273 BMI (kg/m ) 18.5–24.9 48 (42.4%) 54 (46.9%) 0.789 25–29.9 42 (37.2%) 40 (34.8%) ≥ 30 23 (20.4%) 21 (18.3%) Delivery Vaginal delivery 68 (60.2%) 61 (53.1%) 0.277 Caesarian section 45 (39.8%) 54 (46.9%) Education status Junior high school and below 23 (20.4%) 20 (17.4%) 0.601 Senior high school or polytechnic school 71 (62.8%) 70 (60.9%) College and above 19 (16.8%) 25 (21.7%) Husband education status Junior high school and below 15 (13.3%) 24 (20.9%) 0.310 Senior high school or polytechnic school 72 (63.7%) 66 (57.4%) College and above 26 (23.0%) 25 (21.7%) Working status Does not work 32 (28.3%) 41 (35.7%) 0.258 Works 81 (71.7%) 74 (64.3%) The sex of baby Girl 67 (59.3%) 57 (49.6%) 0.146 Boy 46 (40.7%) 58 (50.4%) Supports for caring the baby Yes 27 (23.9%) 34 (29.6%) 0.371 No 86 (76.1%) 81 (70.4%) Values were expressed as n (percentage, %) or mean ± SD. p values for each group were derived from either unpaired t test or Mann–Whitney test as appropriate. Chi- square test or Fisher’s exact test was used for assessing distribution of observations or phenomena between different groups BMI body mass index 16.8% of the patients graduated from college and 71.7% Table 2 Comparison of  frequency distribution had work, while in the control group, the relative pro- of  postpartum depression between  the  two groups in different time points portions were 21.7% and 64.3%, respectively. 76.1% of the women in the intervention group and 70.4% in the Time Variable Study group p control group had no support of child caring. These data Intervention Control indicated that the participants in these two groups were group group homogenous. (n = 113) (n = 115) The incidence of postpartum depression in both groups Baseline Depressed 0 (0%) 0 (0%) 1.000 were evaluated before and after the 6-week intervention. Post-intervention Depressed 13 (11.5%) 28 (24.3%) 0.015 In this research, the patient was thought to have postpar- Values were expressed as n (percentage, %). Chi-square test or Fisher’s exact tum depression when the score of EPDS ≥ 13 points. As test was used for assessing distribution of observations or phenomena between shown in Table  2, the incidence of postpartum depres- different groups sion in the control group (24.3%) was significantly higher Edinburgh Postnatal Depression Scale (EPDS) was used to diagnose the postpartum depression when the score ≥ 13 than that of the intervention group (11.5%). This result Italic value indicates the presence of statistical significance (p < 0.05) showed that our intervention could effectively reduce the incidence of postpartum depression in women. We further investigated the satisfaction of the care in satisfied, 15.9% were basically satisfied, and 7.1% were these two groups. In the intervention group, 51.3% of not satisfied. Meanwhile, in the control group, the rela - the patients were very satisfied with the care, 25.7% were tive proportions were 35.6%, 31.3%, 15.7%, and 17.4%, Liu and Y ang Ann Gen Psychiatry (2021) 20:2 Page 5 of 7 Table 3 Comparison of  satisfaction of  the  care EPDS and PSQI were all significantly lower than the between the two groups baseline scores. However, the scores of HAMD and PSQI were significantly elevated during the 6-week routine Time Study group p postpartum care in the control group. In primiparous Intervention group Control group women, the performance of cognitive behavior interven- (n = 113) (n = 115) tion together with routine postpartum care significantly Very satisfied 58 (51.3%) 41 (35.6%) 0.032 reduced the incidence of anxiety and depression. Satisfied 29 (25.7%) 36 (31.3%) Basically satisfied 18 (15.9%) 18 (15.7%) Discussion Not satisfied 8 (7.1%) 20 (17.4%) This randomized, controlled clinical trial was performed Values were expressed as n (percentage, %). Chi-square test was used for to analyze the effect of psychological nursing interven - assessing distribution of observations or phenomena between different groups tion on postpartum depressive and anxiety symptoms. Italic value indicates the presence of statistical significance (p < 0.05) When compared with routine postpartum care, cog- nitive behavioral intervention significantly alleviated postpartum depressive and anxiety during delivery. The Table 4 Assessment of  HAMA, HAMD, EPDS and  PSQI performance of cognitive behavioral intervention (psy- before and after the intervention chological nursing intervention) was able to effectively reduce the incidence of postpartum depression in pri- Iteams Study group p miparous women who had a postpartum depression Intervention Control group tendency. group (n = 113) (n = 115) In recent decades, puerperium has become an impor- HAMA tant stage after delivery, and has gradually attracted Baseline 13.24 ± 2.89 14.12 ± 3.21 0.134 wide attention from obstetricians and pregnant women. Post-intervention 10.21 ± 2.16 15.55 ± 2.76 0.007 During pregnancy and childbirth, parturient women p value 0.034 0.089 often experience both physical and psychological HAMD changes, resulting in a significantly increased prob - Baseline 14.36 ± 3.04 13.89 ± 2.93 0.117 ability of mental problems after childbirth [16]. Clinical Post-intervention 11.51 ± 2.85 16.58 ± 3.34 0.021 studies have shown that sudden changes in social roles p value 0.038 0.037 of women after childbirth, coupled with rapid changes EPDS in social relationships and functions, exacerbate nega- Baseline 11.24 ± 3.05 10.95 ± 2.75 0.217 tive emotions such as anxiety and depression, lead- Post-intervention 8.11 ± 2.18 11.45 ± 2.73 0.008 ing to recurring unhealthy mental states [17]. Among p value 0.004 0.283 these unhealthy mental states after delivery, postpar- PSQI tum depression is a common, disabling and treatable Baseline 9.12 ± 1.36 9.88 ± 1.53 0.172 reproductive complication [18]. Worldwide statistical Post-intervention 7.38 ± 1.09 12.03 ± 1.62 0.006 data indicate that 8–13% of primiparous women suf- p value 0.014 0.037 fer from postpartum depression [19]. In the Greater China Region, the incidence of postpartum depression Values were expressed as mean ± SD. p values derived from paired t test or Wilcoxon signed rank test as appropriate between baseline versus post- increases to around 20%, which becomes a great burden intervention. p values derived from unpaired t test or Mann–Whitney test as on medical system and society [19]. Recent research appropriate between intervention group and control group has demonstrated that postpartum depression patients Italic values indicate the presence of statistical significance (p < 0.05) could be divided into three different types: gradually cured (50.4%), partially improved (41.8%), and chronic severe (7.8%) [20]. Although most patients’ postpar- respectively, which were significantly lower than the tum depression symptoms can be relieved after 1  year, intervention group (Table  3). Thus, the performance of there are still some patients who remain depressed intervention dramatically enhanced the satisfaction of for a long time, and may even become more severe, the care. leading to increased incidence of adverse events [21]. Table  4 demonstrates the HAMA, HAMD, EPDS and Thus, the identification of risk factors and the therapy PSQI scores of the women in both groups. After 6-week for postpartum depression have become the focus of intervention, the HAMA, HAMD, EPDS and PSQI scores clinical work. The pathogenic factors of postpartum of the women in the intervention group were all dramati- depression are complicated. Previous clinical study has cally lower than the control group. In the intervention illustrated the correlations between the pathogenesis group, the post-intervention scores of HAMA, HAMD, Liu and Yang Ann Gen Psychiatry (2021) 20:2 Page 6 of 7 of postpartum depression and altered levels of prena- of postpartum depression and related symptoms [28]. tal hormones, worrying about delivery and inadequate Meanwhile, employment is considered as a protective preparation for childbirth [22]. Another study further factor for postpartum depression symptomatology [29]. confirmed the contribution of limited postpartum Of note, in the current study, these factors showed no health education, insufficient psychological support, significant differences between the two groups. and inability to adapt to postpartum roles to the occur- Previous studies focused on the effect of cognitive rence of postpartum depression in the early postpar- behavioral intervention on the therapy of postpartum tum period [21]. depression. However, whether cognitive behavioral Cognitive behavioral intervention is commonly per- intervention has an effect on the prevention of postpar - formed together with mental health care adjuvant treat- tum depression pathogenesis is still unknown. In this ment for clinical therapy of patients with depression [23]. research, EPDS was employed for evaluating the degree As a complicated treatment system, cognitive behavioral of postpartum depression in primiparous women. intervention is composed of rational-emotive therapy, Patients with EPDS score ≥ 9 and < 13 points were flooding therapy, systematic desensitization, relaxation considered prone to postpartum depression. If EPDS training, social skills training and supportive treatment score is ≥ 13 points, the patient is confirmed to have [24]. In cognitive behavioral intervention, the therapist postpartum depression. To investigate the function of evaluates the motivation and progression of treatment cognitive behavioral intervention in the prevention of through observing the clinical performance, subjective postpartum depression pathogenesis, the EPDS scores needs and introspection of the patient, and adopts indi- of primiparous women who had postpartum depression vidualized treatment schemes depressed patients [25]. tendency were evaluated after the 6-week intervention. Evidence has shown that cognitive behavioral interven- Before the intervention, all participants in both groups tion and mental health care adjuvant therapy can effec - had postpartum depression tendency. 6 weeks later, the tively improve the condition of postpartum depression proportion of participants with postpartum depression patients. Based on the results of several clinical stud- in the intervention group was dramatically lower than ies, the score of EPDS and the levels of serum adrena- in the control group. This result indicated that cogni - line and norepinephrine are significantly reduced by tive behavioral intervention played a beneficial role in cognitive behavioral intervention [26]. Another study inhibiting postpartum depression pathogenesis in pri- showed that enhanced mental health care treatment for miparous women. The results of nursing satisfaction postpartum depression patients effectively reduced the questionnaire also illustrated the benefit of cognitive depression self-assessment scale score and anxiety self- behavioral intervention in improving patients’ satisfac- assessment scale score, and improved the quality of life tion of the care. of postpartum patients [14]. In this research, the scores There are several limitations in the current study. First, of HAMA, HAMD and EPDS in the intervention group the HAMD, HAMA and EPDS were screening tools for were all significantly reduced by the 6-week cognitive anxiety and depression, rather than diagnostic param- behavior intervention. However, the scores of HAMA, eters. Although symptoms of anxiety and depression HAMD and EPDS were elevated during the 6-week rou- were analyzed in this research, clinical assessment and tine postpartum care in the control group. These results diagnosis of depression and anxiety were not performed. demonstrated that cognitive behavior intervention could Another limitation in our study was the short follow- alleviate postpartum anxiety and depression in primipa- up period, and a follow-up period longer than 8  weeks rous women, whereas the routine postpartum care failed in future studies may further confirm the results. Third, to do so. Studies have shown that negative emotional participants in the intervention group were encouraged states are often closely related to the body’s endocrine to create self-activity plan and perform these practices. and metabolic functions. Negative emotions, such as anx- However, the actual time spent in home practice was not iety and depression, can cause disturbances in the levels tracked. The performance of self-activity plan should be of related hormones in the maternal body, which can sig- examined in future research. nificantly compromise maternal sleep quality [27]. In this research, the significantly decreased PSQI score in the intervention group suggested the function of cognitive Conclusion behavior intervention in improving the sleep quality of In summary, this research provided evidence that the primiparous women. 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Published: Jan 4, 2021

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