Nonpharmacologic treatments for maternal mental health conditions / Elyse Couch [and ten others].

Format:

Book

Author/Creator:

Couch, Elyse, author.

Series:

Comparative effectiveness review ; 271.

Comparative Effectiveness Review ; 271

Language:

English

Subjects (All):

Mental illness--Treatment.

Mental illness.

Physical Description:

1 online resource.

Place of Publication:

Rockville, MD : Agency for Healthcare Research and Quality, 2024.

Summary:

OBJECTIVES: This systematic review evaluates nonpharmacologic treatments for mental health conditions during the perinatal period (pregnancy and up to 12 months postpartum). We evaluated nonpharmacologic treatments for perinatal individuals with depressive disorders, anxiety disorders, bipolar disorder, post-traumatic stress disorder (PTSD), or obsessive-compulsive disorder (OCD). DATA SOURCES AND REVIEW METHODS: We searched MEDLINE(r), PsycINFO(r), Embase(r), CINAHL(r), the Cochrane Register of Clinical Trials, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from January 1, 2000, to January 17, 2024, to identify relevant randomized controlled trials (RCTs). Nonpharmacologic interventions of interest included, among others, cognitive behavioral therapy (CBT), interpersonal therapy (IPT), exercise, non-directive counseling, behavioral activation, bright light therapy, eye movement desensitization and reprocessing (EMDR), and acupuncture. Outcomes of interest were improvement in scores on psychological assessment tools, cure or resolution of symptoms, suicide-related outcomes, and adherence to treatment. PROSPERO registration number: CRD42023440650. RESULTS: We identified 103 RCTs. Nonpharmacologic treatments were compared to control or each other in 101 RCTs and to pharmacologic treatments in 2 RCTs. The risk of bias was moderate for the majority of included studies, mostly related to lack of blinding. For perinatal individuals with depressive disorders, CBT was more effective than treatment as usual (TAU) to reduce depressive and anxiety symptoms (both moderate strength of evidence [SoE]); IPT was more effective than TAU to treat depressive symptoms (moderate SoE) and anxiety symptoms (low SoE); and both behavioral activation (a CBT technique, with low SoE) and exercise interventions (moderate SoE) were more effective than TAU to reduce depressive symptoms. Remission rates for depressive symptoms were higher with CBT and IPT compared to TAU (both low SoE) and higher with specific acupuncture than nonspecific or sham acupuncture (low SoE). There were no differences between CBT and non-directive counseling (an active patient-led intervention), between counseling and TAU, and between bright light and placebo light therapy (all low SoE). CBT was more effective than TAU to reduce anxiety and depressive symptoms for individuals with combined depressive and anxiety disorders (low SoE). Few (or no) eligible studies evaluated individuals with anxiety disorder, PTSD, OCD, or bipolar disorders, precluding conclusions for these conditions. There was also insufficient evidence for suicide-related outcomes, potential harms of treatment, and adherence to treatment, and for comparisons of nonpharmacologic with pharmacologic treatments. CONCLUSION: Several nonpharmacologic treatments are more effective than TAU for perinatal mental health conditions, with the strongest evidence for CBT and IPT to reduce depressive symptoms among perinatal individuals with depressive disorders or combined depressive and anxiety disorders. Future research is needed to evaluate the comparative effectiveness of lesser studied nonpharmacologic interventions and lesser studied perinatal mental health conditions.

Contents:

Executive Summary ES-1

1 Introduction 1

11 Background 1

12 Purpose of This Review 2

2 Methods 3

21 Review Approach 3

22 Key Questions 3

23 Analytic Framework 4

24 Literature Search 5

25 Study Eligibility 6

251 Population 7

252 Intervention/Comparator 7

253 Outcomes 8

26 Screening Studies for Eligibility 9

27 Data Extraction and Management 10

271 Classification of Studies for Full Data Synthesis or Appendix Evidence Map 10

272 Extraction and Management for Studies Meeting Criteria for Full Data Synthesis 11

28 Intervention Coding 11

281 Acupuncture 11

282 Behavioral Activation 12

283 Bright Light Therapy 12

284 Cognitive Behavioral Therapy 12

285 Exercise 12

286 Eye Movement Desensitization and Reprocessing Therapy 12

287 Interpersonal Therapy 12

288 Non-Directive Counseling 13

289 Psychoeducational Interventions 13

2810 Yoga 13

2811 Treatment as Usual 13

2812 Delivery Characteristics 13

29 Assessment of Risk of Bias in Individual Studies 14

210 Data Synthesis 14

211 Grading the Strength of Evidence for Major Comparisons and Outcomes 14

212 Assessing Applicability 15

213 Peer Review and Public Commentary 15

3 Results 16

31 Literature Search Results 16

32 Description of Included Evidence 17

33 KQ 1: Comparative Effectiveness of Nonpharmacologic Treatments 18

331 KQ 1: Key Points 19

332 KQ 1: Nonpharmacologic Treatments for Depressive Disorders 20

333 KQ 1: Nonpharmacologic Treatments for Anxiety Disorders 67

334 KQ 1: Nonpharmacologic Treatments for Depressive and Anxiety Disorders 71

335 KQ 1: Nonpharmacologic Treatments for Depressive and/or Anxiety Disorders 76

336 KQ 1: Nonpharmacologic Treatments for PTSD 80

337 KQ 1: Nonpharmacologic Treatments for OCD 87

338 Nonpharmacologic Treatments for Bipolar Disorder 88

34 KQ 2: Nonpharmacologic Versus Pharmacologic Treatments 88

341 Key Points 88

342 KQ 2: Nonpharmacologic Versus Pharmacologic Treatments for Depressive Disorders 88

343 KQ 2: Nonpharmacologic Versus Pharmacologic Treatments for Anxiety Disorders 89

344 KQ 2: Nonpharmacologic Versus Pharmacologic Treatments for PTSD 89

345 KQ 2: Nonpharmacologic Versus Pharmacologic Treatments for OCD 89

346 KQ 2: Nonpharmacologic Versus Pharmacologic Treatments for Bipolar Disorder 89

4 Discussion 90

41 Key Findings 90

42 Findings in Relation to What Is Already Known 94

421 KQ 1: Nonpharmacologic Treatments for Depressive Disorders 94

422 KQ 1: Nonpharmacologic Treatments for Anxiety Disorders 95

423 KQ 1: Nonpharmacologic Treatments for Depressive and/or Anxiety Disorders 95

424 KQ 1: Nonpharmacologic Treatments for PTSD 95

425 KQ 1: Nonpharmacologic Treatments for OCD 96

426 KQ 1: Nonpharmacologic Treatments for Bipolar Disorder 96

427 KQ 2: Nonpharmacologic Compared With Pharmacologic Treatment for Perinatal Mental Health Conditions 96

43 Applicability 96

44 Strengths and Limitations 97

441 Strengths and Limitations of the Systematic Review Process 97

442 Strengths and Limitations of the Evidence Base 98

45 Implications for Clinical and Policy Decision Making 99

46 Implications for Research 100

47 Conclusions 101

References 102

Abbreviations and Acronyms 115

Tables

Table A Summary of nonpharmacologic treatments for depressive or anxiety disorders 3

Table 1 Inclusion and exclusion criteria 6

Table 2 Number of studies extracted fully and extracted to the evidence map by Key Question 17

Table 3 KQ 1: Number of studies that met criteria for full extraction by perinatal mental health

disorder and intervention comparisons 19

Table 4 KQ 1: Strength of evidence of nonpharmacologic treatments for depressive disorders 21

Table 5 Specific versus non-specific acupuncture for depressive disorders: Description of interventions and comparisons 23

Table 6 Behavioral activation versus placebo light therapy for depressive disorders: Description of interventions and comparisons 27

Table 7 Bright light therapy versus placebo light therapy for depressive disorders: description of interventions and comparisons 31

Table 8 CBT versus non-directive counseling for depressive disorders: Description of interventions and comparisons 33

Table 9 CBT versus TAU for depressive disorders: Description of interventions and comparisons 37

Table 10 CBT versus TAU for depressive disorders: Depressive symptoms by CBT delivery mode 45

Table 11 CBT versus TAU for depressive disorders: Depressive symptoms by delivery setting 45

Table 12 Counseling versus TAU for depressive disorders: Description of interventions and comparisons 51

Table 13 Exercise versus TAU for depressive disorders: Description of interventions and comparisons 55

Table 14 IPT versus TAU for depressive disorders: Description of interventions and comparisons 59

Table 15 IPT versus TAU for depressive disorders: Depressive symptoms by IPT delivery mode 64

Table 16 KQ 1: Strength of evidence of nonpharmacologic treatments for anxiety disorder 68

Table 17 Multicomponent intervention versus TAU for anxiety disorders: Description of interventions and comparisons 69

Table 18 CBT versus TAU for anxiety disorders: Description of interventions and comparisons 70

Table 19 KQ 1: Strength of evidence of nonpharmacologic treatments for depressive and anxiety disorders 72

Table 20 Yoga and tai chi versus TAU for depressive and anxiety disorders: Description of interventions and comparisons 73

Table 21 CBT versus TAU for depressive and anxiety disorders: Description of interventions and comparisons 74

Table 22 KQ 1: Strength of evidence of nonpharmacologic treatments for depressive or anxiety disorders 77

Table 23 CBT versus TAU for depressive or anxiety disorders: Description of interventions and comparisons 78

Table 24 KQ 1: Strength of evidence of nonpharmacologic treatments for PTSD 81

Table 25 CBT versus TAU for PTSD: Description of interventions and comparisons 82

Table 26 EMDR versus TAU for PTSD: Description of interventions and comparisons 84

Table 27 CBT versus TAU for PTSD: Description of interventions and comparisons 85

Table 28 Counseling versus TAU for PTSD: Description of interventions and comparisons 86

Table 29 KQ 1: Strength of evidence of nonpharmacologic treatments for OCD 87

Table 30 CBT versus TAU for OCD: Description of interventions and comparisons 87

Table 31 KQ 1: Summary of nonpharmacologic treatments for depressive or anxiety disorders by treatment type 91

Figures

Figure 1 Analytic framework for Key Questions 1 and 2: Nonpharmacologic interventions for mental health conditions in perinatal individuals 5

Figure 2 Literature flow diagram 16

Figure 3 Specific versus nonspecific acupuncture for depressive disorders: Remission 24

Figure 4 Specific versus nonspecific acupuncture for depressive disorders: Response 25

Figure 5 Behavioral activation versus TAU for depressive disorders: Depressive symptoms 29

Figure 6 Bright light therapy versus placebo light therapy for depressive disorders: Depressive symptoms 32

Figure 7 CBT versus counseling for depressive disorders: Depressive symptoms at the end of treatment 34

Figure 8 CBT versus TAU for depressive disorders: Depressive symptoms at the end of

treatment by diagnostic or screening tool used at enrollment 44

Figure 9 CBT versus TAU for depressive disorders: Remission of depressive symptoms at the end of treatment 46

Figure 10 CBT versus TAU for depressive disorders: Remission of anxiety symptoms at the end of treatment 46

Figure 11 CBT versus TAU for depressive disorders: Quality of life (EQ-5D) 47

Figure 12 CBT versus TAU for depressive disorders: Availability of social support 48

Figure 13 CBT versus TAU for depressive disorders: PBQ impaired bonding at the end of treatment 49

Figure 14 CBT versus TAU for depressive disorders: PBQ infant anxiety at the end of treatment 49

Figure 15 CBT versus TAU for depressive disorders: PBQ rejection/anger at the end of treatment 50

Figure 16 Counseling versus TAU for depressive disorders: Depressive symptoms at the end of treatment 52

Figure 17 Exercise versus TAU for depressive disorders: Depressive symptoms at the end of treatment 56

Figure 18 IPT versus TAU for depressive disorders: Depressive symptoms at the end of treatment 63

.

Figure 19 IPT versus TAU for depressive disorders: Remission of depressive symptoms at the end of treatment or followup 64

Figure 20 IPT versus TAU for depressive disorders: Anxiety symptoms at the end of treatment 65

Figure 21 CBT versus TAU for depressive and anxiety disorders: Depressive symptoms at the end of treatment 75

Figure 22 CBT versus TAU for depressive and anxiety disorders: Anxiety symptoms at the end of treatment 76

Figure 23 CBT versus TAU for depressive or anxiety disorders: Depressive symptoms at the end of treatment 79

Figure 24 CBT versus TAU for depressive or anxiety disorders: Anxiety symptoms at the end of treatment 79

Appendixes

Appendix A Methods

Appendix B Excluded Studies

Appendix C Evidence Map Tables, Study Design, and Baseline Tables

Appendix D Outcomes

Appendix E Risk of Bias Tables

Appendix F Results Tables.

Notes:

Description based on publisher supplied metadata and other sources.