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The postpartum period is recognized as a time of vulnerability to affective disorders, particularly postpartum depression. In contrast, the prevalence and clinical presentation of anxiety disorders during pregnancy and the postpartum period have received little research attention. In this article, we review the medical literature as it relates to the prevalence and clinical presentation of panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder during pregnancy and the postpartum period. MEDLINE (1966 to July 2005 week 1) and PsycInfo (1840 to July 2005 week 1) were searched using combinations of the following search terms: pregnancy, childbirth, postpartum, panic disorder, phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. All relevant papers published in English and reporting original data related to perinatal anxiety disorders were included. Studies were examined for data related to the prevalence, presentation, predictors/risk factors, new onset, course, and treatment of anxiety disorders during pregnancy and the postpartum period. Anxiety disorders are common during the perinatal period, with reported rates of obsessive-compulsive disorder and generalized anxiety disorder being higher in postpartum women than in the general population. The perinatal context of anxiety disorders presents unique issues for detection and management. Future research is needed to estimate the prevalence of perinatal anxiety disorders more precisely, to identify potential implications of maternal anxiety disorders for maternal quality of life and child development, and to determine safe and effective treatment methods.
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For Peer Review
A couples intervention for patients facing advanced cancer and their
spouse caregivers: Outcomes of a pilot study
Journal: Psycho-Oncology
Manuscript ID: PON-07-0228
Wiley - Manuscript type: Original Article
Date Submitted by the
Author:
09-Jul-2007
Complete List of Authors: McLean, Linda; Princess Margaret Hospital, Psychosocial Oncology
and Palliative Care; University of Toronto, Faculty of Medicine
Jones, Jennifer; Princess Margaret Hospital, Psychosocial Oncology
and Palliative Care; Toronto General Hospital Research Institute,
Behavioual Sciences and Health Research Division; University of
Toronto, Faculty of Medicine
Rydall, Anne; Princess Margaret Hospital, Psychosocial Oncology
and Palliative Care; Toronto General Hospital Research Institute,
Behavioual Sciences and Health Research Division
Walsh, Andrew; Princess Margaret Hospital, Psychosocial Oncology
and Palliative Care; Toronto General Hospital Research Institute,
Behavioual Sciences and Health Research Division
Esplen, Mary Jane; Toronto General Hospital Research Institute,
Behavioual Sciences and Health Research Division; Ontario Cancer
Institute, Psychosocial Oncology and Palliative Care Research
Division; Toronto General Hospital Research Institute, Cancer
Genetics Research Division; University of Toronto, Faculty of
Nursing
Zimmermann, Camilla; Princess Margaret Hospital, Psychosocial
Oncology and Palliative Care; University of Toronto, Faculty of
Medicine; Ontario Cancer Institute, Psychosocial Oncology and
Palliative Care Research Division
Rodin, Gary; Toronto General Hospital Research Institute,
Behavioual Sciences and Health Research Division; Princess
Margaret Hospital, Psychosocial Oncology and Palliative Care;
Ontario Cancer Institute, Psychosocial Oncology and Palliative Care
Research Division; University of Toronto, Faculty of Medicine
Keywords:
metastatic cancer, marital distress, couples intervention, end of life,
psychosocial distress
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A couples intervention for patients facing advanced cancer and their spouse
caregivers: Outcomes of a pilot study
Linda M. McLean, M.Sc., Ph.D., C.Psych.
1,4*
, Jennifer M. Jones, Ph.D.
1,3,4
, Anne C.
Rydall M.Sc.
1,3,
Andrew Walsh M.A.
1,3
, Mary Jane Esplen, Ph.D.
2,3,4,5
,Camilla
Zimmermann, M.D., M.Sc.,
1,2,4
, Gary M. Rodin, M.D.
1,2,3,4
1
Department of Psychosocial Oncology and Palliative Care, Princess Margaret
Hospital, University Health Network, Toronto,
Canada
2
Psychosocial Oncology and Palliative Care Research Division, Ontario Cancer
Institute, University Health Network, Toronto, Canada
3
Behavioral Sciences and Health Research Division, Toronto General Research
Institute, University Health Network, Toronto, Canada
4
Faculty of Medicine, University of Toronto, Toronto, Canada
5
Program of Psychosocial and Psychotherapy Research in Cancer Genetics Research
Division, Toronto General Research Institute, University Health Network, Toronto,
Canada
We extend our acknowledgement to the University Health Network, Allied Health
funding in support of this pilot study.
*Corresponding Author:
Dr. Linda M. McLean
Princess Margaret Hospital
Psychosocial Oncology and Palliative Care 16-755
610 University Avenue, Toronto, ON M5G 2M9 Canada
E-mail: linda.mclean@uhn.on.ca
Phone: 416.946.4501 ex. 3901
Fax: 416. 946.2047
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Abstract
Despite advocacy for the development of marital interventions focused on the specific
needs of cancer patients and their spouses, there remain only five reported studies for
those facing advanced cancer. The primary objective of this pilot study was to evaluate
the effectiveness of a couples intervention in improving marital functioning in patients
with advanced cancer and their spouse caregivers. A secondary objective was to
determine the impact in alleviating other symptoms of psychosocial distress. Using a
one-arm pre- and post-intervention prospective design, 16 cancer patients and their
spouse caregivers were provided 8 weekly sessions of Emotionally Focused Couple
Therapy (EFT), which was modified for an advanced cancer population and manualized.
Subjects’ marital functioning (Revised Dyadic Adjustment Scale (RDAS)) was assessed
at week 0 (baseline), week 4 (4 sessions), week 8 (8 sessions) and week 20 (3 months
post-intervention). Data from the couples show that RDAS scores improved significantly
from baseline to 8 weeks, with 87.5% of the couples showing significant improvement in
marital functioning, and 69% scoring within the non-distressed range (48 RDAS). At
week 20, improvement and non-distress were sustained by 60% of the couples (n=15).
RDAS scores did not differ significantly by sex, age, or by patient/caregiver status.
Providing support to couples at this challenging time may result in improved marital
functioning, and provide an opportunity for relational growth during the last stage of the
patient’s life. This study serves as the first step in the development of an empirically
validated intervention for couples facing advanced cancer.
Keywords: metastatic cancer, advanced cancer, marital distress, end of life, psychosocial
distress, couples intervention
Short Title: A pilot study of a couples intervention for advanced cancer
Introduction
Deleted:
of the intervention
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The emotional adjustment of cancer patients and their spouse caregivers may be
profoundly affected by the presence of the disease [1,2]. Spouse caregivers are inevitably
involved in providing care, and often experience distress related to the terminal illness in
their partner and their own anticipated bereavement [3,4]. The quality of support spouses
provide to one another in coping with life threatening illness is a strong predictor of
adaptation, and of health outcomes in cancer [5]. There now is an emerging research
literature that highlights the need to identify couples most at risk for psychological
distress during end-stage cancer [4, 6-8].
Up to half of adult cancer patients and their spouses have been found to report
clinically significant psychological distress and psychological dysfunction [6-10], which
can threaten both partners’ attachment security, and the stability of and satisfaction with
the marital bond [1,2,11,12]. These difficulties are particularly salient during the terminal
phase of advanced cancer when patients are most likely to endorse symptoms of
emotional distress, such as: depression; worry about disease progression and physical
suffering; the unpredictability of future losses [13]; restricted social contact [14,15];
unresolved relationship issues; and concerns for loved ones [16]. Patient distress most
often increases significantly in the last two to three months prior to death [17,18]. Spouse
caregivers report levels of distress that are similar to, or higher than those in cancer
patients [19-21], and more specifically, report difficulty in carrying out their work, family
and social roles, and concerns about the adverse impact of the illness on finances
[18,22,23].
Couples where one is facing advanced disease and who have adjustment
difficulties often experience less intimacy, mutual support and cohesion, and greater
marital conflict, especially amplified as end of life approcahes [24,25]. This may occur
because the diagnosis of a life threatening illness can change communication patterns,
social roles, and the requirement to adjust to the demands of illness progression, and end
of life may impose specific stresses and demands [26,27]. However, couples with strong
and positive attachment bonds may be able to sustain more optimal levels of cohesion
and connectedness, drawing on their stable foundation of mutual trust, affection, and
respect during end of life challenges [28]. Good communication between spouses can
enhance effective coping at the end of life due to the ease of sharing fears, and the
security of attention to both physical and psychological comfort [16].
Providing support to couples at this challenging time can result in a reduction of
psychological pain and psychosocial distress in both partners, and may in fact provide an
opportunity to enhance the appreciation and significance of loved ones, and to form
deeper emotional connections [16, 29-31]. Moreover, a couples approach may prepare the
spouse caregiver for bereavement therapy, reducing the potential of future complicated
grief and mental health difficulties [32]. This is especially important in that survivors
who perceive a lack of preparedness for the death of their spouse may be at higher risk
for psychiatric morbidity, secondary to bereavement [16,33]. Others have expressed
caution about the benefit of exploring the anticipation of death, with concern that the
trauma associated with it may outweigh the benefits associated with preparedness [34].
Despite advocacy for the development of couples interventions focused on the specific
needs of the cancer patients and their spouses [3,6, 7-10,29,35,36], there remain only a
handful of couple-based interventions for those facing advanced cancer [23,30,37-41].
Furthermore, there are few adequate empirical studies of the effectiveness of marital
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interventions in this population [30,40]. Evidence suggests that the suffering of distressed
couples remains largely under-recognized and under-treated in couples where one is
facing terminal cancer [31,40,42].
This pilot study examined the benefit of an 8-session weekly couple-based
intervention aimed at improving spousal relationships and, at reducing psychosocial
distress related to the impact of advanced cancer. We hypothesized that this couples
intervention would improve marital functioning after 8 weekly sessions, and would
secondarily, reduce psychological distress manifest in symptoms of depression, and
hopelessness. We also intended to explore the relationship of attachment security to
marital functioning. Specific goals of the pilot study were to inform the development of a
future randomized controlled trial (RCT) with regard to: feasibility of recruitment;
attrition rate; feasibility of the intervention; the appropriateness of the measures, and
number of sessions; the level of increase in marital functioning that is clinically
significant; the percentage of couples with stable and/or improved marital functioning to
warrant further study.
Theoretical framework and description of the intervention
The intervention used was adapted from emotionally focused couple therapy
(EFT) [43,44] for the end-stage cancer population. EFT was formulated in the 1980s by
Johnson and Greenberg [45-47], and is a synthesis of experiential [48] and systemic [49]
approaches, with theoretical origins based in attachment theory [50,51]. Within this
framework, marital distress is considered to arise from the way in which people process
their emotional experience, and their habitual patterns of interaction in which they
engage. The goal of EFT is to restructure a couple’s pattern of interaction through
assessment and processing of the emotions underlying the positions taken by individual
partners. Flexible positions are fostered through the focus on safety, trust, and emotional
engagement, facilitating a more secure attachment bond.
EFT is a short-term (8-20 sessions), manualized intervention that is well
supported by empirical outcome studies [52]. It has been shown to be effective with a
wide variety of couples varying in age, cultural background, and in psychiatric co-
morbidity in the family [44,53,54]. We modified and manualized EFT for the advanced
cancer population and their spouse caregivers to address particular issues that challenge
such couples [16,17,55,56]. Themes interwoven throughout EFT related to problems
facing couples with advanced cancer were influenced by the work of Kuhl [56], Block
[16], Cohen and Block [55], McWilliams [39], and include the following: i) the impact of
the terminal diagnosis and the need to effectively communicate together and with the
health care professionals [55,56]; ii) awareness of the trajectory of the disease and control
of physical symptoms such as pain and sedation in the patient, advocating that the couple
address any concerns with their medical team (16,55]; iii) distinguishing sadness and
grief from clinical depression, the latter requiring referral to psychiatry for assessment of
pharmacologic intervention [55]; iv) assessment of the patient and caregiver’s needs for
help with decision making, such as designating a health care proxy, addressing financial
concerns, writing a will, planning practical arrangements for dependent others and family
issues [55]; v) addressing fears and the couple’s changing perceptions of time and how to
spend it in a meaningful way [16,39]; vi) financial concerns and the adverse impact on
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the spouse caregiver’s work [55]; vii) the impact of physical changes and decline in the
patient that result in role changes for the couple, and facilitating ways in which the
patient can continue to support the spouse caregiver [16,55]; viii) the importance of
security in the relationship, of being touched and being attuned to oneself and one’s
partner [16]; ix) the process of reviewing one’s life [16,56]; x) the need to belong and to
understand who they were/are as a couple [16,56]; xi) the ability to “hold” the other in
mind even when they are physically apart, including for the spouse caregiver, after
patient death [39,56]; and xii) existential issues that include meaning, value, spirituality
and in some couples, religiousness in a belief in God [16,55,56].
Our primary goal for this pilot study of modified EFT was to facilitate relational
reparation, increased mutual understanding, emotional engagement, attachment security,
and change in habitual and distressing patterns of interaction to enhance a sense of
meaning, and existential well-being in cancer patients and their spouses at the end of life.
Methods
Subjects and eligibility
A prospective one-arm pre- and post-intervention pilot study was designed to
evaluate the effects of an emotionally focused couples’ intervention (EFT) on marital
functioning, and other psychosocial outcomes of patients with advanced cancer and their
spouse caregivers. Potential participants were recruited through referrals from the
Department of Psychosocial Oncology and Palliative Care (POPC) at Princess Margaret
Hospital, part of the University Health Network, and a large, urban comprehensive cancer
center located in Toronto, Canada. Recruitment of the total sample took place over a 44
week time period between March 2006 and January 2007. Patients were eligible for the
study if they had advanced cancer of any type, defined as a confirmed diagnosis of
metastatic cancer, or recurrence of cancer following a disease-free interval. Other patient
criteria included; adult (M 18 years), English fluency, Karnofsky Performance Status
[KPS; 57] of 70 (estimated by the EFT clinician), cognitive ability to participate as
measured by the Short Orientation-Memory-Concentration Test [SOMC; 58] (score M 20
or N 10 errors), married or common-law partnership of M 1 year, and intermediate to
moderate marital distress (32-47 on the Revised Dyadic Adjustment Scale) [RDAS; 59]).
The eligibility criteria for spouse caregivers were the same as those for the patient, with
the exception of medical diagnosis, and KPS [57]. Spouse caregiver was defined as the
significant partner identified by the patient as his or her primary source of physical and
emotional support throughout illness, and confirmed by the spouse. Couples were
excluded if they presented with major psychiatric illness, such as schizophrenia or
psychosis, or were currently in couple therapy. This study received approval from the
University Health Network Research Ethics Board, and all patients and spouses
voluntarily provided written, informed consent.
Procedures
Staff members (nurses, physicians, psychiatrists, psychologists, social workers) of
the multidisciplinary POPC program served as a referral source. Staff members identified
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eligible patients attending outpatient clinics in the hospital, determined if they had an
eligible spouse caregiver, advised them of the study, and obtained their permission to be
referred to an EFT-trained clinician for both a written and verbal explanation about the
study. Voluntary written informed consent to participate was obtained before
determination of study eligibility criteria (see subjects and eligibility), that was conducted
by the EFT-clinician during the initial assessment session with both partners. Following
screening procedures, questionnaire packages were given to eligible participants at week
0 (baseline [T0]), following 4 couples sessions at week 4 (4 weeks after baseline [T1]),
after 8 sessions at week 8 (8 weeks after baseline [T2]), and again by mail at week 20 (3
months post-intervention [T3]).
Measures
Medical and demographic data extracted from the medical record of each patient
and from an initial brief questionnaire included: information on cancer type, recurrence
versus non-recurrence, current status of active or non-active treatment, and time since
diagnosis. Both partners’ current individual involvement with mental health
professionals, and any current pharmacologic intervention for depression were recorded.
Patient KPS scale [57] was recorded at week 0 (baseline), week 4, and week 8.
Demographic variables included: age, sex, primary language, religious affiliation, highest
level of education completed, years of marriage, and number of children. Both partners’
health history was reviewed through clinical interview as part of the initial
assessment/intervention session.
Marital functioning was measured by the total Revised Dyadic Adjustment Scale
(RDAS) [59,60] score in both patients and spouse caregivers. The RDAS is a
standardized 14-item self-report measure of marital functioning and relationship quality
and is one of the most widely used scales to evaluate both individual and dyadic
adjustment in distressed relationships. The RDAS consists of three subscales: the Dyadic
Consensus Subscale, the Dyadic Satisfaction Subscale, and the Dyadic Cohesion
Subscale, which are summed to obtain an overall marital functioning score. Total scores
range from 0 – 69 with a reliable cutoff score of 48 [60] to classify individuals or couples
as martially distressed (N 47), or non-distressed (M 48). Subscales have an internal
consistency of Q = 0.80, with the total RDAS having an Q of 0.90. Confirmatory factor
analysis has substantiated the 3-point factor structure of the scale, and its validity has
been established [59]. The RDAS has been used in cancer populations [36].
Depression was measured with the Beck Depression Inventory-II [BDI-II; 61].
The BDI-II is a 21-item self-report measure to assess the intensity of depression and is
consistent with the criteria of the Diagnostic and Statistical Manual of Mental Disorders
[DSM-IV-R; 62] for major depressive disorder. A cut-off score of 15-16 has been
recommended for cancer populations, and corresponds to a sensitivity and specificity of
over 90% [63]. It has been extensively used in cancer populations [64-66].
Hopelessness was measured with the Beck Hopelessness Scale [BHS; 67]. The
BHS is a 20-item true/false scale with higher scores indicating more hopelessness. A cut-
off score of 8 has been recommended for cancer populations. High internal consistency,
concurrent and construct validity has been reported [67], and it has been used in
terminally ill cancer populations [23,68,69].
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Attachment style was measured with the Experiences in Close Relationships
Inventory [ECR; 70]. The ECR, revised to refer to close relationships, is a 36-item self-
report scale that assesses attachment style. Participants rate the degree to which items
describe their feelings in close relationships on a 7-point Likert scale that ranges from 1
‘not at all’ to 7 ‘very much’. Eighteen of the items tap attachment anxiety and 18 items
tap attachment avoidance. The reliability (Cronbach Q=0.83-0.94) and validity of this
measure have been established [70], and it has been used in cancer populations [19,72].
Satisfaction and benefit from the couples’ intervention was measured with the
Satisfaction and Benefit Questionnaire (SBQ), developed by our research team to
determine each partners’ satisfaction and benefit from the couples EFT intervention.
Fifteen questions are rated on a 5-point Likert scale ranging from 1 ‘strongly disagree’ to
5 ‘strongly agree’. Seven items address each partner’s satisfaction with the couples
intervention, and 7 items tap each partner’s experience of benefit. One question is neutral
and inquires about ‘time to attend’ the sessions. Total scores range from 15 – 75, with
higher scores reflecting greater satisfaction and benefit from the intervention. The
reliability and validity of this measure have not been established, therefore it is limited to
face validity.
Statistical analyses
The main goal of this pilot study was to explore the impact on marital functioning
of a couples intervention for advanced cancer patients and their partners. Additional
secondary psychosocial outcomes including depression and hopelessness were also
examined. Individual attachment security (i.e., insecure attachment avoidance and
anxiety) was examined to determine its relationship to marital dysfunction. SPSS 14.0 for
Windows was used to examine the demographic characteristics of the subjects, and
medical data of the patients. Using PROC Mixed in SAS (9.1), a 3-way repeated
measures ANOVA was used to examine effects of time, sex, age, and patient and spouse
caregiver status on the total mean RDAS score. Subjects were nested within a couple, a
couple was considered a random effect, and time period was a repeated measure for each
subject. We included years since diagnosis and age as covariates to help understand
whether time alone explained improvement in RDAS scores or whether some of the
improvement could be attributed to the intervention. An ANOVA set up as for RDAS,
was run for similar testing of the BDI-II, BHS, and ECR (avoidance and anxiety subscale
scores). Post-hoc analyses were conducted using Tukey-Kramer, a common multiple
comparison test. Additional analysis included a 2-way repeated measures ANOVA for
the three subscales of the RDAS to examine if there were aspects of the marital
relationship more amenable to change. In contrast to the above analysis that looked at
“total RDAS score” and included all 14 items, in this analysis, the subscale items per
couple were averaged (vs. total the scores for the two subjects within a couple), and the
score per couple over all 16 couples (n=15 couples at week 20 [T3]) were then averaged.
A minimum level of significance of .05 was used for all analyses.
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Results
Follow-up and attrition
Seventeen couples were approached to participate in this study. Sixteen patients
and their spouse caregivers voluntarily agreed to participate, and one couple refused for
personal reasons. Sixteen couples attended an average of 11.5 sessions (range 8-22) of
the modified EFT intervention. Additional sessions were provided based on couple
request and a clinical evaluation of benefit, although all questionnaire packages were
given at the four times outlined in the pilot study protocol. The attrition rate was 0% for
up to week 8 (8 sessions), which was the specified time interval and number of sessions
for measurement of the primary outcome. At week 8, there was a 100% completion of
questionnaire packages following 8 sessions, and at week 20 (3-month post-intervention
follow-up), the questionnaire completion rate was 94% (n=15 couples).
Subject characteristics
There were 15 married couples where one partner had metastatic cancer or
recurrent non-metastatic cancer. In one of the 16 couples, both partners had cancer. In the
latter couple, the male patient who had recurrent non-metastatic cancer with a KPS rating
of 70 at baseline was considered the patient; his wife who had metastatic cancer in
remission, and a KPS rating of 80 at baseline, was his primary caregiver, and was
included with the spouse caregivers. The subjects ranged in age from 30 to 69 years of
age, with an average age of 48.0 years (SD=11.4). Couples were married for an average
of 16.1 years (SD=14.6). The average number of children was 1.6 (SD=1.4), with 25%
(n=4) of the couples reporting no children (range 0 – 4). The primary language was
English for 87.5% (n=14) of the couples. The majority of the couples reported being
Catholic or Protestant (63%), and 37% reported no religion. Ninety-seven percent (n=31)
of the subjects reported levels of education from college to postgraduate. Twenty-eight
percent (n=9) of the subjects (N=32) were involved in concurrent individual therapy at
the time of study enrolment, and 31% (n=10) were currently on an antidepressant
medication. Two percent (n=3) of the subjects reported that they changed antidepressant
medication during the intervention. Patient characteristics and medical information are
reported in Table 1.
Correlational analyses Correlational analyses revealed that the RDAS is moderately and
negatively correlated with the BHS (r =-0.24, P N 0.001), and to the ECR avoidance
subscale (r =-0.33, P N 0.0001). The BDI-II is significantly positively correlated to the:
BHS (r = 0.37, P N 0.0001); the ECR avoidance subscale (r =0.33, P N 0.0001); and to the
ECR anxiety subscale (r =0.43, P N 0.0001). The BHS is significantly positively
correlated to the ECR avoidance subscale (r =0.23, P N 0.001), and to the ECR avoidance
subscale (r =0.43, P N 0.0001). The ECR avoidance subscale is significantly positively
correlated to the ECR anxiety subscale (r =0.25, P N 0.001).
Effectiveness of the pilot intervention
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The means, standard deviations, ranges of scores and sample sizes for the main
study measures (RDAS, BDI-II, BHS, ECR avoidance and anxiety subscales) at time
periods week 0 (baseline, T0), week 4 (T1), week 8 (T2), and week 20 (3-month follow-
up [T3]) are found in Table 2.
RDAS scores improved significantly over time following 8 sessions of the
couples intervention. Paired t-tests corrected for multiple testing, revealed statistically
significant differences between the following time periods: week 0 (baseline,T0) and
week 8 (T2) (t = 4.5, df =105; P = <0.001), week 0 and week 20 (T0 and T3) (t = 4.1, df
=105; P = <0.0006), week 4 (T1) and week 8 (T2) (t = 3.3, df=105; P = <0.0066), and
between week 4 (T1) and week 20 (3-month follow-up, T3) (t = 0.2, df=105; P = 0.0385)
(see Figure 1).
Sixty-nine percent (n=11) of the 16 couples fell into a level of non-distress on the
RDAS (M48) [59, 60] marital functioning scale at week 8, following 8 sessions of the
intervention, considered clinically significant improvement. This level of marital non-
distress was maintained at week 20 (3-month post-intervention follow-up) by 60% (n=9)
of the couples (n=15). We also examined the percentage of couples that remained stable
(had RDAS values of change M0.5 to 5), improved ( > 5), or declined (>-5) from week 0
(T0) to week 8 (T2), and from week 0 (T0) to week 20 (T3) on total mean RDAS couple
scores, and the percentage who sustained improvement from week 8 to week 20 (3-month
follow-up, T2 –T3) (n=15) (see Table 3). At week 8, 87.5% of the couples showed either
a positive change and stability in marital functioning of M 0.5 – 5 points (37.5%) from
baseline, and 50% of the couples (n=10) improved by > 5 points on their average RDAS
score from week 0 to week 8. No couples decreased in average RDAS score by more than
3 points from week 0 to week 8 (12.5%, n=2). Thirteen percent of the couples (n=2)
improved by > 5 points on their average RDAS score from week 8 to week 20; 46.7%
(n=7) maintained stability (change of M 0.5 to 5 points). Four couples (26.7%) had
average scores that decreased by 0 to -5 points from week 8 to week 20, and 13.3% (n=2)
couples deteriorated from week 8 to week 20 (i.e., RDAS points of > -5). We also looked
at the fifteen couples who showed percentage change in marital functioning from week 0
to week 20. Seventy-three percent of the couples were either stable (n=4, 26.7%), or
improved (n=7, 46.7%) from baseline to week 20 in their marital functioning. The
percentage of couple deterioration (>-5 points) was 0% (see Table 3).
The change in total mean BDI-II, and BHS scores over time are inconclusive due
to low statistical power. The mean patient scores for BDI-II (n=16) at week 0 (M=19.6,
SD=9.5), at week 4 (M=19.0, SD=11.7), and week 8 (M=16.4, SD=10.1) were above the
clinically significant cutoff of > 15. At week 20, the mean had dropped for patients below
the clinical cutoff of > 15 (M=14.1, SD=10.7). The mean caregiver scores fell well below
clinical significance at all four periods of measurement (see Table 2). In comparing total
mean scores on the BDI-II for the total sample at week 0 and week 20, the total mean
BDI-II score for the 30 subjects was reduced by a mean score of 3.8 points (95% CI = -
1.05 to 8.70, P = 0.1215). The mean BHS scores were not clinically or statistically
significant across time (i.e., patients and caregivers scored below the clinically significant
cutoff of <8 at all time points).
A 3-way repeated measures ANOVA was employed to examine effects of time,
age, sex, and patient and spouse caregiver status on the total mean RDAS scores. The
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results show that RDAS scores differ significantly across time periods (F (3, 105) = 8.2,
P < 0.001), but do not differ significantly by sex, age, or participant status.
A 2-way repeated measures ANOVA was employed to examine the effects of sex
and time on the average RDAS of each of the three subscales. The results show that time
is statistically significant for each of the three subscales: Consensus F(3,44) = 4.3, P
<0.01; Satisfaction F(3,44) = 4.1, P <0.005; Cohesion F(3,44) = 7.5, P <0.0004 (see
Figure 2).
A 3-way repeated measures ANOVA was employed to examine effects of time,
age, sex, and patient and spouse caregiver status on the total mean BDI-II, BHS, and
ECR scores. BDI-II scores did not differ across time or by sex, but were statistically
significantly higher for patients than for caregivers (F (1, 105) = 13.5, P = 0.0004). The
mean score for patients was 17.3 (SD= 9.9) (above the clinically significant cut-off of >
15), and the mean score for caregivers was 10.5 (SD=8.4). A similar test was run for
BHS. Mean scores on the BHS did not change significantly over time. The mean total
score for the Satisfaction and Benefit Questionnaire administered at week 4, week 8, and
week 20 was 53.8 (SD=7.0), with a range of 35.5 – 62.6. There was no statistically
significant change in scores overtime.
We also examined attachment style and found attachment style (ECR total, and
avoidance and anxiety subscales) remained a stable variable, with no statistically
significant change in this sample across four times of measure, indicating moderate levels
of attachment style avoidance (M=3.5, SD=1.0), and anxiety (M=3.3, SD= 1.2) in this
sample.
Post-intervention events
One couple divorced following the intervention. However both partners felt the
intervention had increased their understanding of each other, and had resulted in a more
amicable separation, and movement toward independent living. One subject committed
suicide 6 months following termination of the 8 sessions of the couples intervention, and
13 weeks following post-intervention follow-up by mailed questionnaire package. While
both partners reported benefit from the couple sessions, this subject had a number of
complex co-morbid factors that were pre-existing and not related to the couples
intervention. This subject for several years prior to the couples intervention, and up to
and including time of death, was also followed weekly in individual therapy by a
psychiatrist.
Discussion
The modified EFT intervention tested in this pilot study was directed at improving
marital functioning in couples facing advanced cancer and end of life. Findings revealed
a statistically and clinically significant improvement in marital functioning for both
patients and spouse caregivers. Sixty-nine percent of the couples reached levels of non-
distress in marital functioning after 8 weeks of EFT sessions, which is most encouraging.
Non-distress at 3-month post-intervention follow-up was maintained by 60% of the
couples. The ANOVAs of the average RDAS subscale scores showed that time was
statistically significant for each of the subscales; Consensus, Satisfaction, and Cohesion.
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In looking at Figure 2, we see that of the three subscales, there was a trend for the
Consensus subscale to be more amenable to change as a result of the intervention. It is
clear however, that the significance of the total RDAS score (over time) was not due to
just one of the three subscales. The degree of couple improvement in marital functioning
is similar to other randomized controlled trials of EFT in a variety of non-cancer
populations with comparable sample sizes [52,53].
While the intervention was not specifically directed at depression or hopelessness,
there was nonetheless a trend towards improvement in symptoms of depression among
patients over time, and a statistically significant difference among patients and spouse
caregivers, with patients endorsing higher levels of depressive symptoms when compared
with spouse caregivers. Since the intervention was directed at marital functioning, the
improvement in depression in patients was likely mediated by an improvement in overall
marital functioning. Antidepressant medication may have influenced depression scores at
baseline, however all subjects referred to the couple intervention who were in individual
therapy and/or on medication were so prior to beginning this pilot study, and only three
subjects (9.3%) reported a change in their antidepressant medication during the course of
this intervention. Spouse caregivers did not have BDI-II scores consistent with clinically
significant depressive symptoms at baseline, or at any time across all points of measure.
This finding is in contrast to a recent study [19] of distress in spouse caregivers (N=101),
that found the proportion of spouse caregivers with clinically significant depressive
symptoms to be twice as high as their partners with cancer. In the present study, patients
and their spouse caregivers reported low levels of hopelessness at baseline (and over the
course of the study), suggesting there was little room for measurable improvement in this
sample. It may have been difficult to detect any statistically significant changes in BDI-II
and BHS scores over time due to the small sample size and, thus, the low statistical
power to detect changes in these outcomes. Recent longitudinal data [73] do not show
much increase in depression measured by the BDI-II in patients with lung or metastatic
gastrointestinal cancer over time, supportive of our findings.
Results in this sample suggest that there is stability in attachment style over time,
a finding that is in keeping with previously published theories on individual attachment
style [e.g., 74]. Other theorists suggest the potential for change with an intervention such
as EFT [43,44]. In the present study, we were interested in determining the level of
anxious (i.e., worry about issues of rejection, abandonment, or feeling unloved by
significant others), and avoidant (i.e., the individuals limitation of, or avoidance of
intimacy and interdependence with others) attachment styles in our couples facing end of
life issues. We found that there was a statistically significant negative correlation
between increased avoidance subscale scores of the ECR and decreases in marital
functioning measured by the RDAS, suggesting that there is a relationship between
marital distress and avoidant attachment style. The literature suggests that subjects with
insecure avoidant and anxious attachment styles are inclined to perceive negative support
from their partners, which is in turn, consistent with their chronic negative internal
‘working models’ [e.g., 72]. In the context of cancer and couples, insecure attachment
may influence the cancer patient’s experience of increasing dependency and needs
around care. Insecure avoidant and anxious attachment style in spouse caregivers may
also contribute to the couple’s experience of distress [44], and to how both partners relate
to health care professionals [75]. However, the stability of the ECR scores in this sample
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must be interpreted with caution as findings may also be due to the small sample size,
duration of the intervention, low statistical power, and relatively short duration of the
intervention, and follow-up period. Due to the small sample size of our pilot study, we
did not examine the impact of attachment style on marital functioning.
Feasibility of the study was established through the successful recruitment of 16
couples over 44 weeks, and by their attendance of an average of 11.5 sessions of therapy.
The attrition rate was 0% at week 8, and completion of self-report measures at week 8
(T2) was 100%, and 93.5% (n=15 couples) at week 20 (3-month follow-up [T3]). The
fact that we were able to recruit and retain couples where one partner faced advanced
cancer with an attrition rate of 0 % by week 8 is in and of itself encouraging, as the
literature identifies the significant difficulties in recruiting and retaining patients and their
caregivers facing end of life to participate in prospective research [76]. In regard to the
primary outcome measure, the RDAS proved an appropriate and effective measure of
marital functioning.
Advanced cancer and facing end of life can change marital relationships, creating
strain as well as an opportunity for reduced suffering, enhanced quality of life, and
relational growth in the final stage of life. This involves a concurrent focus on
disengagement while maintaining and strengthening connections [55, p. 182]. Attention
to the continuum of psychological suffering in distressed couples where one is facing
metastatic, or recurrent metastatic cancer is both a humane component of end of life care,
and critical to the quality of a patient death and their spouse’s course of bereavement.
Findings from this pilot study are encouraging and definitive in supporting the need for a
future, larger randomized controlled trial (RCT), but need to be interpreted with caution
due to the small sample size, lack of control group, and potential for inconclusive
findings due to low statistical power.
Acknowledgements
We are grateful to the patients and their spouse caregivers for their participation and
contribution to this study. We would also like to thank the members of the Psychosocial
Oncology and Palliative Care Program for their assistance in the referral process. We
extend appreciation to members of the Palliative and Supportive Care research group for
their contributions and support of this project. Finally, we thank University Health
Network (UHN) Allied Health who contributed funding for this project.
Role of the funding source
The UHN Allied Health contributed funding for this study however, had no role in study
design, data collection, analysis, interpretation of the findings, or the writing of this
manuscript.
Conflict of interest statement
No conflict of interest declared.
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Table 1. Characteristics of study patients
Couple
Patient
Sex
Age
Type of
Cancer
Years
Since
Diagnosis
Recurrence?
Treatment
Active?
KPS
Score
Week 0
Baseline
(T0)
1 M 40 Leukemia 3 Yes Yes 80
2 F 37 Gastrointestinal 2 Yes Yes 90
3 F 47 Breast 5 No Yes 65
4 M 43 Head/Neck 1 No No 70
5 F 30 Gynaecological
1 No Yes 70
6 F 40 Breast 1 No Yes 80
7 M 61 Gastrointestinal
1 Yes Yes 70
8 M 60 Leukemia 5 Yes Yes 60
9 F 48 Head/Neck 1 Yes Yes 90
10 M 56 Head/Neck 1 No Yes 50
11 M 46
Central
Nervous
System
5 No Yes 80
12 M 69 Head/Neck 2 Yes Yes 60
13 F 59 Breast 2 No Yes 90
14 F 42 Breast 3 Yes Yes 50
15 F 61 Gynaecological
4 Yes No 80
16 F 31 Breast 4 No Yes 90
Mean
or %
F =
56.25%
48.1
2.6 Yes = 50%
Yes =
87.50%
73.4
SD
11.65
1.59
13.75
KPS,Karnofsky Performance Status Scale.
SD, standard deviation.
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Table 2. Means, standard deviations, and sample sizes for measures at week 0 (baseline),
week 4 (T1), week 8 (T2), and week 20 follow-up (T3)
Week 0
(T0)
(N=32)
Week 4 (T1)
(N=32)
Week 8 (T2)
(N=32)
Week 20
follow-up (T3)
(N=30)
SCALE
SCORES
Mean ± SD
CG
a
n=16
PT
b
n=16
CG
a
n=16
PT
b
n=16
CG
a
n=1
6 G
PT
b
n=16
T
CG
a
n=15
n=15n
=15G
PT
b
n=15
T
Revised
D
yadic
Adjustment
Scale
45.4
(6.9)
41.3
(9.1)
44.6
(9.7)
47.0
(9.3)
50.6
(8.5)
50.8
(8.6)
50.9
(7.6)
49.5
(10.4)
Beck
Depression
Inventor
y-II
10.6
(9.4)
19.6
(9.5)
12.1
(10.1)
19.0
(11.7)
10.4
(8.8)
16.4
(10.1)
8.4
(4.9)
14.1
(10.7)
Beck
Hopelessness
Scale
6.2
(4.1)
6.4
(5.1)
6.4
(4.6)
5.7
(4.5)
6.9
(4.8)
4.7
(4.4)
5.4
(4.8)
5.5
(5.3)
Experience in
Close
Relationships
Avoidance
3.2
(1.0)
3.8
(0.8)
3.4
(1.2)
3.6
(0.9)
3.5
(0.8)
3.6
(1.1)
3.5
(0.9)
3.6
(1.0)
Experience in
Close
Relationships
Anxiety
3.1
(1.0)
3.6
(1.2)
3.0
(1.1)
3.8
(1.36)
3.1
(0.9)
3.5
(1.4)
3.1
(0.9)
3.5
(1.4)
a
CG, spouse caregiver/partner.
b
PT, patient.
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Table 3. RDAS total score difference and percentage change over time periods
RDAS T0 – T2
Week 0- Week
8
T0 – T3
Week 0-Week
20
follow-up
T2 T3
Week 8 –
Week 20
Difference # Couples
(N=16)
%
Couples
# Couples
(n=15)
%
Couples
# Couples
(n=15)
%
Couples
> -5 0 0 2 13.3%
-5 to 0 2 12.5% 4 26.6% 4 26.7%
M0.5 to 5 6 37.5% 4 26.6% 7 46.6%
> 5 8 50.0% 7 46.6% 2 13.3%
RDAS, Revised Dyadic Adjustment Scale.
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... Anxiety symptoms play an important role in PPD (Ross et al., 2003;Ross & McLean, 2006). Also, anxiety is one of the most frequently assessed symptoms in rodent models of MS (see Table 2). ...
... Also, anxiety is one of the most frequently assessed symptoms in rodent models of MS (see Table 2). Researchers have reported comorbid anxiety in nearly 50% of women suffering from PPD indicating a strong role for anxiety symptoms (Ross et al., 2003;Ross & McLean, 2006). ...
... In humans, anxiety disorders or anxiety symptoms are often comorbid in mothers suffering from PPD (Falah-Hassani et al., 2016;Reck et al., 2008). Rates of 57%-100% for this comorbidity have been reported (Matthey et al., 2003), furthermore highlighting that anxiety and panic attacks are common symptoms in PPD (Matthey et al., 2003;Ross & McLean, 2006). Therefore, further anxiety measurements in rodents and interactions are crucial and behavioral tests after MS ...
Article
The postpartum period is a sensitive time where women are especially vulnerable to develop postpartum depression (PPD), with 10%-15% of women affected. This review investigates whether the maternal separation (MS) paradigm in rodents holds the potential to help to understand mothers suffering from PPD. MS is a well-established stress model to investigate effects on infants, whereas effects on the dam are often overlooked. The database PubMed was searched for studies investigating effects of daily MS within the first weeks after parturition on dams in rats and mice and compared to findings in PPD mothers. MS was categorized as brief MS (5-45 min) with or without handling of pups and long MS (3-4 h and longer). MS alters maternal care, depressive-like behavior, anxiety, and aggression; leads to alterations in neuronal gene expression; and affects hormone and neurotransmitter levels similar to observations in PPD patients. Even though there are disparities between human and rodent mothers, with some results differing in directionality, as well as the reason for separation (self-induced in PPD, externally induced in MS), the overall effects found on neurobiological, hormonal, and behavioral levels mostly coincide. Thus, the MS paradigm can add relevant knowledge to existing PPD animal models, further advancing the study of PPD.
... Sixth, the current study focused on postnatal maternal symptoms of panic and social anxiety given that these symptoms are common during the postpartum period (Fawcett et al., 2019;Goodman et al., 2016;Watson et al., 2007), and because prior work suggests that these symptoms are associated with distinct maternal parenting behaviours (Feldman et al., 2009;Murray et al., 2007;Warren et al., 2003) and risk for social and emotional difficulties in offspring (Kaitz et al., 2010;Murray et al., 2008;Schneider et al., 2002). Nonetheless, it is unclear whether the results we observed generalize to other types of anxiety symptoms that may be common during the postpartum period, such as generalized anxiety symptoms as well as postnatal-specific anxieties (e.g., anxiety about motherhood and parenting, as well as anxiety related to infant health and wellbeing; Dennis et al., 2017;Fallon et al., 2016;Ross & McLean, 2006). Moving forward, future research may consider incorporating measures that examine a broader range of anxiety symptoms, including postnatal-specific anxiety symptoms (Fallon et al., 2016) and to examine their associations with maternal parenting behaviours and infant neural responses. ...
Article
Affective exchanges between mothers and infants are key to the intergenerational transmission of depression and anxiety, possibly via adaptations in neural systems that support infants' attention to facial affect. The current study examined associations between postnatal maternal symptoms of depression, panic and social anxiety, maternal parenting behaviours, and infants' neural responses to emotional facial expressions portrayed by their mother and by female strangers. The Negative Central (Nc), an event-related potential component that indexes attention to salient stimuli and is sensitive to emotional expression, was recorded from 30 infants. Maternal sensitivity, intrusiveness, and warmth, as well as infant's positive engagement with their mothers, were coded from unstructured interactions. Mothers reporting higher levels of postnatal depression symptoms were rated by coders as less sensitive and warm, and their infants exhibited decreased positive engagement with the mothers. In contrast, postnatal maternal symptoms of panic and social anxiety were not significantly associated with experimenter-rated parenting behaviours. Additionally, infants of mothers reporting greater postnatal depression symptoms showed a smaller Nc to their own mother's facial expressions, whereas infants of mothers endorsing greater postnatal symptoms of panic demonstrated a larger Nc to fearful facial expressions posed by both their mother and female strangers. Together, these results suggest that maternal symptoms of depression and anxiety during the postpartum period have distinct effects on infants' neural responses to parent and stranger displays of emotion.
... The prenatal period is marked by pronounced physiological and psychosocial changes, and previous work has shown that general anxiety, pregnancy-related anxiety, and psychosocial stress are common in pregnant women [1][2][3][4][5][6]. Maternal stress and anxiety during pregnancy is also known to be associated with adverse neonatal outcomes while stress is associated with adverse obstetric outcomes [7][8][9]. ...
Article
Full-text available
Background Pregnancy can be a stressful time and the COVID-19 pandemic has affected all aspects of life. This study aims to investigate the pandemic impact on pregnancy experience, rates of primary childhood immunisations and the differences in birth outcomes in during 2020 to those of previous years. Methods Self-reported pregnancy experience: 215 expectant mothers (aged 16+) in Wales completed an online survey about their experiences of pregnancy during the pandemic. The qualitative survey data was analysed using codebook thematic analysis. Population-level birth outcomes in Wales: Stillbirths, prematurity, birth weight and Caesarean section births before (2016–2019) and during (2020) the pandemic were compared using anonymised individual-level, population-scale routine data held in the Secure Anonymised Information Linkage (SAIL) Databank. Uptake of the first three scheduled primary childhood immunisations were compared between 2019 and 2020. Findings The pandemic had a negative impact on the mental health of 71% of survey respondents, who reported anxiety, stress and loneliness; this was associated with attending scans without their partner, giving birth alone, and minimal contact with midwives. There was no significant difference in annual outcomes including gestation and birth weight, stillbirths, and Caesarean sections for infants born in 2020 compared to 2016–2019. There was an increase in late term births (≥42 weeks gestation) during the first lockdown (OR: 1.28, p = 0.019) and a decrease in moderate to late preterm births (32–36 weeks gestation) during the second lockdown (OR: 0.74, p = 0.001). Fewer babies were born in 2020 (N = 29,031) compared to 2016–2019 (average N = 32,582). All babies received their immunisations in 2020, but there were minor delays in the timings of immunisations. Those due at 8-weeks were 8% less likely to be on time (within 28-days) and at 16-weeks, they were 19% less likely to be on time. Interpretation Whilst the pandemic had a negative impact on mothers’ experiences of pregnancy. Population-level data suggests that this did not translate to adverse birth outcomes for babies born during the pandemic.
... Infection in pregnancy is common-64% according to one national sample (Collier et al., 2009)-and so presents a potential confound in studies of other prenatal risk exposures. Reciprocally, mood disorders in pregnancy are common (Ross & McLean, 2006;Woody et al., 2017) and may confound the impact of alternative prenatal risk exposures for child health outcomes. ...
Article
Prenatal maternal infection and anxiety have been linked, in separate lines of study, with child neurodevelopment. We extend and integrate these lines of study in a large prospective longitudinal cohort study of child neurodevelopment. Data are based on the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort; prenatal maternal anxiety was assessed from self-report questionnaire; prenatal infection was derived from reports of several conditions in pregnancy (n = 7,042). Child neurodevelopment at approximately 8 years of age was assessed by in-person testing, reports of social and communication problems associated with autism, and psychiatric evaluation. Covariates included psychosocial, demographic, and perinatal/obstetric risks. Prenatal infection was associated with increased likelihood of co-occurring prenatal risk, including anxiety. Regression analyses indicated that both prenatal infection and prenatal anxiety predicted child social and communication problems; the predictions were largely independent of each other. Comparable effects were also found for the prediction of symptoms of attention problems and anxiety symptoms. These results provide the first evidence for the independent effects of prenatal infection and anxiety on a broad set of neurodevelopmental and behavioral and emotional symptoms in children, suggesting the involvement of multiple mechanisms in the prenatal programming of child neurodevelopment. The results further underscore the importance of promoting prenatal physical and mental health for child health outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Challenges during pregnancy can cause the development of postpartum psychiatric disorders (PPDs) (1). PPDs, such as depression and anxiety, are relatively common and are described as emotional conditions with frequent anxiety symptoms and episodes of low attention span, tiredness, muscle tension, and excitement (2). ...
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Maternal anxiety symptoms in the perinatal period might have long-term health effects on both the mother and the developing child. Valerian is a phytotherapeutic agent that is widely used for the treatment of anxiety. This study investigated the effects of valerian treatment in postpartum rats on maternal care, toxicity, and milk composition. Postnatal development, memory, and anxiety behavior in the offspring were also assessed. Postpartum Wistar rats received the valerian (500, 1000, or 2000 mg·kg-1·day-1) by oral gavage. Clinical and biochemical toxicity was evaluated with commercial kits. Maternal behavior was observed daily. Milk composition was analyzed by colorimetric methods. Physical and neuromotor tests were used to analyze postnatal development. Anxiolytic activity was assessed by the elevated plus maze, and memory was evaluated by the step-down inhibitory avoidance task. Maternal toxicity and care behavior were not altered by the treatment, while only the highest dose promoted a significant increase of lactose, and the doses 1000 and 2000 mg·kg-1·day-1 promoted a reduction of protein contents in milk. Postnatal development was similar in all offspring. Adult offspring did not display altered anxiety behavior, while long-term memory was impaired in the female adult offspring by maternal treatment with 1000 mg·kg-1·day-1. These results suggested that high doses of valerian had significant effects on important maternal milk components and can cause long-term alterations of offspring memory; thus, treatment with high doses of valerian is not safe for breastfeeding Wistar rat mothers.
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Infant development depends on warm, responsive social interactions that richly stimulate the senses, acting through multiple pathways to orchestrate healthy maturation of the neonatal brain, mind, and body. Conversely, adverse early experiences seed vulnerabilities for poor cognition and emotional instability. Although we routinely measure many aspects of infant physical health (hearing, weight), no clinical tools currently exist to measure early psychosocial health and brain development. Here, neural sociometrics (real-time multi-sensor imaging of adult–infant social interactive behavior and neurophysiology) is discussed as one possible precision measurement framework. Early psychosocial health screening, paired with precision therapeutics, could fundamentally alter a child's development trajectory toward lifelong mental well-being and productivity. Further, population-level measurements of social brain health could forecast mental capital growth (and deficits) for entire communities and generations. This article calls for the prioritized development of early scalable diagnostic instruments to reveal the status of infant mental wellbeing and brain health.
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In the present research, we examined whether attachment anxiety and avoidance in support recipients were related to the extent to which social support received from a romantic partner matched the actual needs of the recipient. Two-hundred and forty-five first-time mothers, currently involved in romantic relationships, participated in study 1, in which perceptions of support were appraised over the previous month using self-reports. In study 2, we sought to replicate these findings using an experience sampling method to examine the association between attachment and momentary support perceptions in the daily life of mothers with babies (N = 40). Results indicated that high levels of attachment avoidance or anxiety in mothers were associated with negative appraisals of support matching. Receiving support which matched the needs of the mother (i.e., adequate support) was beneficial to mood, but not constructive to relationship satisfaction or perceptions of maternal efficacy.
Chapter
The development of the Skilful surfing Online For Anxiety Reduction (SO-FAR) in pregnancy (SO-FAR) mental health (mHealth) application (app) was supported by previous research which modelled the theory of Skilful Surfing. The model informed the app development, with each facet of the model corresponding to a different intervention included in the app. The aim of this chapter was to report the development of an mHealth app to relieve pregnancy-specific health anxiety. App content inclusion was based on previous literature and recommendations for mHealth app inclusions. Overall, the chapter provides the reader with a comprehensive account of the development of the SO-FAR app which may reduce levels of pregnancy-specific HA by encouraging women to become more adept when navigating through online health information, self-aware, and educated and promoting the ability to identify triggers and understand when and why they are experiencing maladaptive cognition and rumination in a self-guided manner.
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Objective To examine pregnancy outcomes in women with treated and untreated anxiety in a well-characterized cohort. Study Design Secondary analysis of the NuMoM2b study, a prospective multi-center cohort of nulliparous women. Anxiety was assessed at 6 weeks 0 days − 13 weeks 6 days using the State Trait Anxiety Inventory (STAI-T). Women were divided into three groups: anxiety and medical treatment, anxiety and no medical treatment, and no anxiety (controls). The primary outcome was a composite of preterm birth, small for gestational age infant, placental abruption (clinically diagnosed), and hypertensive disorders of pregnancy. Multivariable logistic regression was used to adjust for potential confounding variables. Results Among 8293 eligible women, 24% (n = 1983) had anxiety; 311 were treated medically. The composite outcome (preterm birth, small for gestational age infant, placental abruption, hypertensive disorders of pregnancy) occurred more often in women with untreated anxiety than controls (28.6% vs 25.9%, p=.02), with no difference between treated anxiety and controls (27.7% vs 25.9%, p=.49). After adjustment for confounders, including controlling for depression, there were no differences in the primary outcome among groups. Untreated anxiety remained associated with increased odds of neonatal intensive care unit admission. Conclusion Anxiety occurred in almost a quarter of nulliparas. There was no association between treated or untreated anxiety and our primary outcome of adverse pregnancy outcomes after adjustment for confounders. However, neonates born to women with untreated anxiety were at increased risk for NICU admission.
Article
Full-text available
Objective: The main aim of this study was to describe and conduct a bibliometric analysis of the state of research on stress, anxiety, and postpartum depression in mothers of preterm infants in the Neonatal Intensive Care Unit. Background: Women affected by premature births are particularly exposed to mental health difficulties in the postpartum period. The desire to comprehend and the growing interest in research on stress, anxiety, and postpartum depression in mothers of preterm infants in neonatal intensive care have led to a substantial rise in the number of documents in this field over the last years. Thus, it makes it vital to regularly review the state of knowledge on this phenomenon in order to identify progress and constraints, to stimulate reflection, and to encourage progress in future research. Method: This study examined 366 articles published in the Scopus database (1976-2020). Keyword analysis was also used to identify hot research trends to be developed in future studies. This study complies with the PRISMA-Scr guidelines for quality improvement research in the EQUATOR network. Results: Our results reveal that research in this field is in a period of high production and allows this flourishing body of work to be organized into different periods, highlighting the most important themes. In such a way, our research enriches the lively field by presenting a comprehensive understanding of the field. Discussion: The key contribution of this study is the development of a conceptual map of research on stress, anxiety, and postpartum depression in mothers of preterm infants in neonatal intensive care units.
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Full-text available
This guideline focuses on the pharmacotherapy of obsessive compulsive disorder(OCD). OCD is characterised by obsessions and compulsions. A number of other disorders are also characterised by repetitive thoughts and rituals and may also respond to modifications of standard OCD treatment.
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In a sample of 200 postpartum couples the symptom profile of mothers with RDC generalised anxiety disorder was independent of the symptom profile of RDC minor or major depression. Amongst fathers however there was a strong positive correlation between the symptom profiles of anxiety and depression. This would suggest that postpartum anxiety is a separate disorder amongst mothers but not fathers. The prevalence rate of the disorder amongst mothers exceeds 6%, it is hence a common problem in need of further investigation.
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This book is a revision and updating of the 1996 book titled Emotionally Focused Marital Theory. It is intended to serve as the basic therapeutic manual for Emotionally Focused Couple Therapy (EFT). As in the first edition, there is also one chapter on Emotionally Focused Family Therapy (EFFT).
Conference Paper
Mounting empirical evidence suggests that adult love represents an attachment process, in which the emotional bond forged between partners reflects an innate human tendency to seek out close relationships that provide safety and security. Emotionally Focused Therapy (EFT) for couples is an empirically supported psychological intervention based on the premise that chronic problems in intimate relationships in adulthood result from underlying attachment difficulties. From an EFT perspective, the resolution of problems in couple relationships therefore necessitates the strengthening of the emotional bond between partners. The principle goals of this presentation are to explain the 9 steps of EFT for couples and to illustrate the effects of EFT on specific aspects of attachment in couples, including trust, relationship satisfaction (Judy, stuff from course & book) and affect regulation (made to measure). This brief review of relevant research on EFT and attachment will lead into a discussion of preliminary findings from a study of the direct effects of EFT on adult attachment that our research term is currently conducting. Empirical research and clinical experience both indicate that healthy emotional dependency is an integral component of satisfying couple relationships, and EFT for couples can help solidify the attachment bonds that foster such emotional closeness.