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.