Research Article

Cognitive Behavioral Therapy for Postpartum Depression: A Case Report

Shabana Noureen1, Shamaila Asad2, Saad Ullah3, Iqra Shafique Abbasi4 and Shakeel Ahmad5*

1Lahore School of Professional Studies, University of Lahore, Pakistan; 2Riphah Institute of Clinical and Professional Psychology, Riphah International University, Pakistan; 3Hazara University Sub-Campus Battagram, Pakistan; 4Department of Psychology, Hazara University Mansehra, Pakistan; 5School of Public Health, Nanjing Medical University China..

Received | November 27, 2022; Accepted | January 02, 2023; Published | February 09, 2023

*Correspondence | Shakeel Ahmad, School of Public Health, Nanjing Medical University China; Email: [email protected]

Citation | Noureen, S., S. Asad, S. Ullah, I.S. Abbasi and S. Ahmad. 2023. Cognitive behavioral therapy for postpartum depression: A case report. Journal of Innovative Sciences, 9(1): 13-17.

DOI | https://dx.doi.org/10.17582/journal.jis/2023/9.1.13.17

Keywords | Postpartum depression, Cognitive behavioral therapy, Intervention therapy, Case study

Copyright: 2023 by the authors. Licensee ResearchersLinks Ltd, England, UK.

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

1. Introduction

Postpartum depression is the mixture of emotional, physical, and behavioural changes that happen when a woman gives birth to a baby. DSM-5 states that postpartum depression is a type of major depression that starts within four weeks after delivery (Shorey et al., 2018). The diagnosis of postpartum depression depends on the length of time and severity of depressive symptoms. Postpartum depression is associated with the psychological, social, and chemical changes that happen in women’s bodies that new mothers experience. Postpartum depression can be treated with the help of medication or psychotherapy. The chemical changes include a rapid drop in the hormones after birth (Slomian et al., 2019).

The social and psychological changes in the body are the major cause of the symptoms of depression that become postpartum depression. Many mothers experience baby blues after delivery. About 1 out of 10 women develop long-lasting symptoms of depression after delivery. About 1 out of 1000 women develop postpartum psychosis which is a more serious condition. Another study reflected that about 5% of women experience high levels of postpartum depressive symptoms that last for three years (NIH, 2022).

2. Materials and Methods

2.1 Design

A single AB design has been used in the research. Intervention sessions started after three weeks of baseline that were based on CBT intervention for the next two weeks. Post-testing was taken during the sixth week of the session.

2.2 Research participant

2.2.1 Case introduction and presenting complaints

Zara is a 32 years old woman. She is married and has only one child and she is a housewife. The researcher omitted and altered non-crucial information to ensure the confidentiality of the participant. The client provided written consent to use her shared information for the case report. Zara was self-referred to the psychologist for her severe symptoms of postpartum depression as she experiences a jumble of powerful emotions from joy and excitement to fear and anxiety. She has evident mood swings, sadness, disturbing thoughts, and exhaustion. The presenting complaint in the verbatim statement was, (Jb se mera baby huwa Hy I think main tabi se kuch psychologically disturb hun to mje lga k mje kse psychologist ki madad leni chaheye). It means the client is saying that from the birth of his child, she is psychologically disturbed which is why she decided to get a consultation with a psychologist.

2.2.2 Case history

Zara married four years ago and living happily with her husband. After one year and a few months of marriage, she conceived a baby and now her baby is of two years. She is a highly strict mother and prefers that things can be done on time. It is difficult for her to handle her baby because of her lack of interest, low mood, and mood swings. She was having a job before the birth of her baby, but she left the job after 7 months of pregnancy because her physical health was not supporting her to continue her job. After the birth of the child, she had other responsibilities that stopped her to do any type of job. She lives in a nuclear family where she has to fulfil household duties and care for her child. She is the only caretaker of her child. A few months ago, she decided to continue her job but again she cannot trust the maid that she might not care about the way she is caring for her child. She is quite influenced by the social media reports regarding the child abuse case so cannot trust anyone. Her mood swings were quite high as sometimes she became a caring mother and some times she became quite strict towards the child. She has planned a strict schedule for her child such as eating, sleeping etc., and if the child cannot follow it then she became angry.

She also feels regret when she became extremely strict with such a quite young child. She thinks that her son is quite young to understand the logic that her mother has other commitments too. Through a thorough discussion with her, she informed me that she is depressed because she cannot go outside because of her child. My child cannot spend time without her as he needs mama to sleep and everything. She is bound now and cannot enjoy the vast social circle that she does before the birth of a child. She develops anxiety about general things. Her husband is the key support figure who is a businessman and is quite busy. She feels relaxed at her mother’s home because many members are there who can take care of the child. When she get back to her husband’s home, her symptoms again started. Her sleep is getting disturbed day by day due to the child. She also receives comments from the maternal grandmother that she might not care about the child’s health appropriately. Even if the child cannot sleep then her maternal grandmother says that she did not train her child. Zara is pressurized by other comments and her increased responsibilities. She is not expressive in her emotions to anyone. She is not aggressive and even cannot reply to other comments. Her mental level was disturbed which ensure that her postpartum depression was prolonged.

2.3 Measures

Two types of measurements have been used to assess the severity of the client’s problem. First, the level of severity on the face scale was measured in which ‘0’ means no pain, and ‘10’ means ‘worst pain possible. The client mentioned ‘7’ level of severity that she was experiencing for the past two years. Second, the symptoms of postpartum depression were assessed through Edinburg Postnatal Depression Scale (EPDS) (Levis et al., 2020). The 10 items scale is a valuable and efficient way of identifying patients at risk for depression. The EPDS is easy to administer and has proven to be an effective screening tool. The scale indicates how the mother has felt during the previous week. The scale has reversed items as well to increase its validity. The maximum score on the scale is 30 and the possible depression score is 13 or higher. The client reported a score of 20 on EPDS which reflects that client has severe postpartum depression.

2.4 Intervention

The therapist who gave cognitive behavioural therapy intervention was a psychologist trained in CBT. During the application of intervention, the psychologist practised a detailed therapist manual and was supervised by an experienced psychologist. A total of eight sessions were given to the client including two additional follow-up sessions.

In session 1, the therapist established a therapeutic relationship with Zara and conducted a brief cognitive-behavioural clinical evaluation and understand the underlying patient’s difficulties. The influence of stress situations and vulnerability situations she experienced within the past two years on the development of depression has been explained. Besides the role of negative thinking pattern and their relationship with behaviours and emotions have been highlighted. The therapist built rapport with the client in the first session and continued taking the history. The history continued till session 2. After getting high scoring on the postpartum depression, CBT was applied to the client in the very next session.

In session 3, psychoeducation about postpartum depression was provided to the client including its symptoms, prevalence, associated myths, risk factors, and possible consequences if left untreated. The possible discrepancy exists between the expected emotions felt during the postpartum period and their link with the emotions, thoughts, and behaviours was explained to Zara. The client got the opportunity to reflect on the content provided by the therapist. She was motivated to change her symptoms. This readiness help her to improve her mood and during the last weeks, she was able enough to maintain her physical and mental health by giving quality time to the child.

In session 4, the therapist informed that motherhood changes and social expectations influence depressive symptomatology. Zara was an educated lady so was aware of the myth that weak mothers can develop postpartum depression that in turn influence her behaviours. She was also experiencing social pressure to become a perfect mother from her maternal grandmother. The therapist discussed psychoeducation about the adaptive function of emotions to promote noncritical evaluation and acceptance. Thought restricting technique of CBT was applied to the client by asking her to identify a recent situation and associate it with her emotions, thoughts, and behaviours. This exercise helped her in the promotion of cognitive flexibility to think about the possible alternative interpretations for that situation. The patient was motivated to perform the thought record by using this exercise.

In session 5, the therapist defined, identified, and clarified parenthood values and promote behavioural activation through using value-based actions. Zara showed more energy and a better mood. She showed increased cognitive flexibility in interpreting daily situations. The major issue identified about Zara’s inadequate sleep was that she does home chores when a child sleeps and the child wakes up during her sleep hours. Now she sleeps when the child sleeps and manages the home chores by involving the child in some play activities. Earlier, she wished to start a job so that her social circle maintained for her therapist to help her to join an office where she can get a daycare facility. She never focused on options available to her, but now she is able enough to view different options to manage her symptoms. Besides, assertive communication skills were taught to ask for support from her husband and deal with people’s comments while she always remains quiet.

In session 6 the therapist reinforced the patient’s therapeutic progress by using the postpartum depression measure in which the client reported quite fewer depressive symptoms that were almost negligible. She was able enough to alter her thoughts with the most suitable alternatives. The patient started to involve in pleasurable activities such as outings with friends and also made up her mind to start the job. The client and therapist collaboratively reviewed the learned skills and a relapse prevention plan was developed with the client for which two next follow-up sessions were planned with a gap of one year. The client did not relapse and develop positive changes in her symptoms. She is able enough to deal with her negative thoughts and conduct value-based actions with the use of helpful strategies. The proposed difficulties of the client such as restrictions towards her child, sleep disturbances, burdened, disturbed social life, and inability to do the job due to child responsibilities were sorted out with the help of CBT. The client’s routine has been set up so that she can sleep properly and can manage her remaining tasks. In the end, Zara was praised for her dedication and motivation for treatment and she was encouraged to continually practice skills to maintain her attained gains.

3. Results and Discussion

In this case report, treatment has been thoroughly described in which a client with postpartum depression is successfully treated within the short time frame of six weeks and these effects have been checked for the next two months in the form of two follow-up sessions. For this treatment, cognitive behavioural therapy has been used to help the client to come out from the symptoms of postpartum depression. The symptoms of postpartum depression are quite common in new mothers, but the present case was critical because the depression was extended up to two years. The client has now learned skills to manage her symptoms and improved her cognition by working on her cognitive distortions. Now she is away from the symptoms of postpartum depression and can better care for her child as well as enjoy her life as well. The treatment approach in the present case study was in line with the existing studies that reflected that CBT is a quite effective therapy to manage the symptoms of postpartum depression.

Empirical evidence supports the notion that CBT is the key treatment option for anxiety, depression, and other mental health issues (Van Lieshout et al., 2020). It is considered a well-studied method for the effective treatment of postpartum depression. A review study by Sockol (2015) stated that CBT is quite effective for the prevention and treatment of postpartum depression. After reviewing 40 scientific studies, the researcher found that CBT helps in declining depressive symptoms in the perinatal and postnatal periods. Pregnant mothers who get CBT during their pregnancy have fewer chances to develop postpartum depression. The early intervention and preventive efforts are quite helpful while later interventions demonstrate the importance of CBT for postpartum depression. Therefore, CBT was preferred in the current case study to deal with the prolonged symptoms of postpartum depression. With the help of the intervention plan, the client showed positive changes in the symptoms.

Conclusions and Recommendations

In short, the researcher helped the client to manage her symptoms with the help of CBT. The study is highly informative as it helps the reader to understand the strategic way of dealing with the client experiencing postpartum depression for an extended period.

Limitations

The study included a baseline-controlled time phase and it was not a controlled study the researcher only treated one patient so the findings of the study cannot be generalized to other patients with postpartum depression. Future studies can conduct an experimental study on patients with postpartum depression to know the effectiveness of CBT on the group.

Acknowledgment

I would like to express my deepest appreciation to all the individuals who helped me to complete this research.

Novelty Statement

This study is highly information as it will assist the reader to understand the systematic way of dealing with the client experiencing postpartum depression for an extended period.

Author’s Contribution

Each author equally take part in the study from initiation to completion.

Conflict of interest

The authors have declared no conflict of interest.

References

Levis, B., Negeri, Z., Sun, Y., Benedetti, A., and Thombs, B.D., 2020. Accuracy of the edinburgh postnatal depression scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. Br. Med. J., 371. https://doi.org/10.1136/bmj.m4022

NIH, 2022. Postpartum depression may last for years. National Institute of Health. Retrieved 5 August 2022, from https://www.nih.gov/news-events/nih-research-matters/postpartum-depression-may-last-years.

Shorey, S., Chee, C.Y.I., Ng, E.D., Chan, Y.H., San Tam, W.W., and Chong, Y.S., 2018. Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis. Journal of psychiatric research, 104: 235-248. https://doi.org/10.1016/j.jpsychires.2018.08.001

Slomian, J., Honvo, G., Emonts, P., Reginster, J.Y., and Bruyère, O., 2019. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Women’s Health, 15. https://doi.org/10.1177/1745506519844044

Sockol, L.E., 2015. A systematic review of the efficacy of cognitive behavioural therapy for treating and preventing perinatal depression. Journal of Affective Disorders, 177: 7-21. https://doi.org/10.1016/j.jad.2015.01.052

Van Lieshout, R.J., Layton, H., Feller, A., Ferro, M.A., Biscaro, A., and Bieling, P.J., 2020. Public health nurse delivered group cognitive behavioural therapy (CBT) for postpartum depression: A pilot study. Public Health Nursing, 37(1): 50-55. https://doi.org/10.1111/phn.12664