Discussion
Main FindingsAll women in our study showed a major and clinically relevant decrease in PTSD symptoms after on average 5 weekly sessions of EMDR. The average decrease was 30 points on the PCL-5, whereas a decrease of 10-20 points on this scale is already considered clinically significant22. All women lost their PTSD diagnosis. These outcomes are extra promising, as they were achieved in quite a complex group, in women with relatively high psychiatric comorbidity and high rates of previous mental health treatment.
Strengths and limitations One strength of the study is that it is driven by both current literature and clinical practice. Both perspectives acknowledge the need for adequate referral-and treatment lines for women with PTSD after childbirth. In this respect, our study fits within the currentZeitgeist by starting to fill a gap in literature. A second, related strength of this study it its practical character. Just because we were strongly motivated by the wish to further improve treatment, we took a naturalistic approach with an open attitude towards possible questions and referrals. An important recommendation for the clinical field in this respect is that even though not all referrals from the Department of Obstetrics and Gynaecology resulted in an EMDR-treatment offer, the referrals were all relevant in the fact that psychiatric treatment was warranted for all women referred. These findings are encouraging and reassuring for other hospitals to set up comparable programs. A limitation of the study is the lack of a control group. Future research should apply more advanced research designs and preferably also include outcome-measures for child outcomes and cost-effectiveness.
Interpretation In many women in our sample a comorbid depressive disorder was present. PTSD and depressive disorder often co-exist and interfere, and depression both during pregnancy and after childbirth influence the trauma response 2, 28. There is an overlap in symptoms between depression and PTSD 3, 15, which may make it sometimes difficult to disentangle both disorders. King et al.28 found that negative cognitions about the self in relation to the birth were the strongest cognitive behavioral predictors of PTSD. These findings underscore the need to explicitly address feelings of shame, self-blame, guilt and responsibility in making an adequate plan for treatment. We indeed found that these types of emotions were common, next to feelings of powerlessness. These emotions could relate to the delivery itself, but could also be associated with the pregnancy or the puerperium period. This is also reflected in the CPS-scores, which showed negative perceptions of both the delivery and of the first week after childbirth. Furthermore, it is important to pay close attention to previous trauma, as we did in our study by administering the CTQ and LEC-5-questionnaires. Although PTSD after childbirth can be the direct result of a pregnancy, birth or childbed-related event, pregnancy-related experiences can also trigger the memories of previous trauma, such as adverse sexual experience2, 28. In this study, we started treatment with a thorough case conceptualisation in collaboration with the women. In general, women were well able to indicate which symptoms were most burdensome, how these related (or not) to previous traumatic experiences, and consequently which complaints needed treatment first. In all but one case of this study sample, EMDR-therapy was started directly after establishing treatment plan. Furthermore, one woman in our study received EMDR-therapy while admitted to our inpatient perinatal psychiatry clinic. Her traumatic experiences were related to her psychiatric decompensation in her first days after childbirth at home, after which she had been admitted to our clinic. She was afraid of discharge, because she feared to lose control again upon return to home. EMDR-therapy helped her to process the memories of what had happened at home and contributed to a successful discharge.
We found that the cognitive domain of “powerlessness” was by far the most prevalent cognitive domain in explaining why certain memory images were still disturbing. This high prevalence of the cognitive domain “powerlessness” is in line with findings on the treatment of non-childbirth related PTSD 29. So, in this respect, PTSD following childbirth is comparable to “other PTSDs”. Furthermore, the high prevalence of the cognitive domain “powerlessness” makes sense conceptually, as pregnancy and childbirth are by definition situations where a certain unpredictably and loss of control are rather rule than exception.
Women were referred on average 10 months after they gave birth, however there was a wide range in the period between delivery and referral. Long-time intervals can be explained by the fact that women sometimes were referred when they came to the Obstetrics and Gynaecology department with a wish for a next pregnancy, or even were already pregnant again. Although so far only few studies have reported on the EMDR outcomes in pregnant women 30, our results with this subgroup were promising. In fact, the maximum number of treatment sessions for the pregnant women in our study (n=4) was three sessions. Another reason for a delay in referral may be that we started with a new treatment program and that it takes time before referrals get running. Our hypothesis is that the favourable results of the first women increased awareness for PTSD following childbirth and readiness for recognition and referral for suspected PTSD. Overall, the practices and outcomes described above have led to the implementation of a specialized outpatient EMDR-treatment program for women with post-partum PTSD. Although we started with only one psychiatrist and health care psychologist with limited timeslots, we now have three health care psychologists regularly treating women with PTSD after childbirth with EMDR. Referrals are continuous and seem to have stabilized in numbers. In our experience it is important to ensure bi-directional low-key options for consultation and advice, including regular interdisciplinary meetings. Moreover, we noticed that informing women on these lines of collaboration between Psychiatry and Gynaecology and Obstetrics departments adds to the trust of the women in their treatment. Although women’s trust in treatment may increase the chance for successful treatment outcomes in general, trust is especially important in this specific group whose trust, in themselves or others, may have been violated.
Conclusion Implementing an EMDR-therapy treatment program for women with PTSD after childbirth in the context of a large academic hospital is feasible and effective. Treatment led to clinically significant decrease of symptoms and loss of PTSD diagnosis in all cases. Results can be achieved in a short time-span, even in pregnant women and women with comorbid psychiatric disorders and/or a history of previous mental treatment. Key factors for success are incorporating standardized screening for PTSD into regular follow-up consultations, close collaboration between the relevant hospital departments and a thorough case conceptualisation addressing the aetiology of the PTSD after childbirth.