Post-natal depression: Definition, clinical features, risk factors, and effects
Post-partum period has been associated with mood disturbances since Hippocrates’ times . It is reported that PND started being officially used in psychiatric manuals in 1994 . It was “officially objectified” in the 1950s . PND was given some “diagnostic criteria” at that time as practitioners began to notice that some women, after giving birth, would experience a psychological pattern with depressive characteristics.
In the earlier days, science was trying to understand PND in the context of causes. These varied from the socio-economic background of the individual to unplanned pregnancy . In more recent years, clinicians have gained a better understanding of PND. They give emphasis to the combination of risk factors rather than single causes . Risk factors can vary from low socio-economic background, family history of depression or personal history of mental health issues, low social support, smoking habits, sexuality issues, and immigration issues .
The Diagnostic and Statistical Manual of Mental Disorders - fourth edition (DSM-IV)  initially linked PND with major depression with post-partum onset within 4 weeks of birth. However, a study for the treatment of PND  highlights the variations amongst studies which define the onset of PND, from the first month up to the end of the first year following the infant’s birth.
The Diagnostic and Statistical Manual of Mental Disorders, DSM-5  places PND in the category of unspecified depressive disorders where the main symptoms can cause significant distress or impairment on various levels in the individual’s life. PND includes different sub-categories called specifiers, amongst which are the peri-partum onset. This refers to the onset of depression during pregnancy or postpartum for the time following the birth of the child. According to the same manual, a large number of postpartum major depressive episodes begin during pregnancy, thus they are also called peri-partum episodes. These episodes range from mild to severe, with or without psychotic features. The individual may also experience hallucinations or delusions.
A study by Hewitt et al.  describes depression as a very serious mental health problem with important consequences on a societal level. In this study they estimate that depression will become the second-highest health problem by 2020. According to the same authors, PND is considered to be a very important category of depression with often serious consequences. It can affect both the mother and the infant, as well as the immediate and/or the extended family. PND can have long-lasting effects on the development of the infant on a cognitive and emotional level, including attachment issues amongst others .
PND can cause significant distress or impairment on various levels in the individual’s life, e.g. lack of motivation, affected mood, sleep and appetite issues, lack of concentration, rumination, unintentional or intentional suicidal ideation, or psychotic phenomena such as hallucinations or delusions.
PND affects 13% of women , and between 4 and 25% in men in the first 2 months after the baby is born . Other research suggests that the proportion of mothers who suffer from PND is one in seven . According to the same article, the mentality of organisations and health providers is changing, especially in the United States where there is a shift towards more systematic screening of mothers-to-be or young mothers who might experience symptoms of depression.
Psychological treatments of PND
Regarding treatment for PND, Rudlin lists its main therapeutic approaches . They vary from medication, home visits, education, phone contact, one-to-one counselling, group therapy, and self-help resources such as books. CBT, together with interpersonal psychotherapy (IPT) are considered two efficacious non-pharmacological treatments for PND .
A meta-analysis  examined how effective psychological treatments are for PND in primary care. It was found that psychological interventions such as CBT and IPT, along with counselling, psychodynamic therapy and support groups can be very effective in reducing the symptoms of depression up to 6 months post-intervention.
CBT’s main focus is identifying distorted negative thinking patterns. It emphasises the link between thoughts, feelings and behaviour. Dalby  highlights Albert Ellis’s theory of irrational thinking patterns and how they could trigger emotional disturbance to the individual.
A common characteristic of people who suffer from depression is their tendency to experience automatic thoughts, usually of negative content. Beck  highlights that the negative automatic thoughts usually carry negative meaning in relation to the notion of the past or the future, about the individual themselves, and/or the world around the person.
CBT helps the individual to understand that identifying their own distorted negative thinking patterns allows them an opportunity to change them. By changing their thinking, the individual can change how they view and feel about themselves, and ultimately, change their behaviour . CBT integrates many approaches in clinical practice such as problem solving, modelling, and cognitive restructuring, amongst others .
IPT focuses on four areas in the person’s life: grief about someone’s own sense of self or changes within their relationships, changes in roles, unresolved disagreements in interpersonal relationships, and a lack of life events. It focuses on strengthening the relationships of the individual, on increasing social support, and improves communication .
Conversely, Barlow  refers to the negative effects, or no effects of psychological interventions for various disorders, including trauma and addictions. Dimidjian and Hollon  talk about the adverse effect of psychotherapy, but this is yet to be researched adequately. There is no real agreement in the scientific community about ways to investigate and identify harmful psychological interventions. A review  published by the World Health Organisation (WHO) for psychological interventions on depression discusses the under-investigated but very real possibility of a negative effect of psychological therapies on depression. Some of those effects include the symptomatology of the individual becoming exacerbated or the individual experiencing a “relapse”.
Lambert  makes the point that psychological treatments for depression and other disorders have shown to be effective overall. Positive outcomes depend on the patients’ characteristics, but also the therapists’ “actions” or “inactions”. Lambert also highlights the reality of negative clinical outcomes for patients who experience depression. Lambert does, however, identify ways to minimise clinical negative impact and maximise positive outcomes which can be achieved through “measuring, monitoring, and tracking client treatment response with standardised scales”.
A meta-analysis by Cuijpers et al. , which we did not include in our initial search, investigates the effect of psychological treatments for PND. It was found that CBT, IPT, counselling and social support have an overall positive effect on PND, but they were less effective than what they have been on other psychological disorders. There was no real difference in therapeutic outcome between different psychological therapies. The same study also concluded that medication and electroconvulsive therapy can have higher effect size for PND than psychological treatments but that needs to be further investigated. In addition, it was found that the initial positive therapeutic effect of psychological treatments on PND could not be confirmed 6months or longer post-intervention. However, the authors of this meta-analysis highlight that some of these findings need to be interpreted with caution due to the small number of studies included, and that the quality of the studies was not the highest.
Virtual reality: Definition and its advantages
A question worthy of investigating in relation to the treatments of PND is whether they can be improved for better clinical outcomes using other treatments, such as virtual reality (VR).
VR is defined as “a way for humans to visualise, manipulate, and interact with computers, and it can be viewed as an advanced form of human-computer interface that allows the user to interact immersed in more intuitive and naturalistic fashion” .
VR promotes a sense of presence for the user in an environment which is computer based. According to Turner and Casey , VR can enhance the therapeutic effectiveness of psychological interventions. It expands beyond the strict boundaries of technology. VR is seen as a form of communication. It comprises elements such as an experience, visualisation and interaction .
Some of VR’s advantages in research and practice is that it can act as a powerful and effective tool which can complement traditional therapies such as CBT . It is a form of therapy which enhances sense of control and raises self-efficacy. It uses technological means to help the individual. It is 3-dimensional and interactive. The VR user has the ability to “explore and engage” within the virtual environment.
VR can be delivered in a safe and controlled way . It can be affordable, easy to access, and the therapist themselves can have control of how, what and when it is to be applied, which creates a sense of safety for the user . One of VR’s main features and characteristics is that it can empower the individual, a very basic and essential ingredient in order for therapy to occur. The combination of CBT with VR can have a tremendous positive impact .
VR or virtual reality exposure therapy (VRET) has been used to explore a large number of topics, from stress, anxiety, phobias, acute pain, body image disturbances, eating disorders, training of children in spatial and navigation learning skills, functional skills , post-traumatic stress disorder (PTSD) [33,34,35], fear of heights and also fear of flying [36, 37].
Improvement of traditional treatments for PND
There appears to be a gap in the literature relating to the combination of VR with traditional therapies for the treatment of PND. A brief literature review so far identified only one study on the efficacy of VR on depression. A pilot study conducted by Falconer et al. investigated the concept of compassion and self-criticism in a virtual environment . They examined whether compassion could be taught to subjects in a virtual environment. The study revealed that its participants, all adults with depression, were able to practice compassion both as a life-sized avatar and as a child avatar interacting with one another through the process of embodiment. Although this particular study was limited, being a small group (n = 15), and having no control group, its results were promising. Results indicated that most of the study’s participants had become more compassionate and less self-critical one-month post-intervention.
Our research group is exploring the utility of using VR in the treatment of PND, the final aim being to improve the treatment that mothers with PND receive. This could potentially be beneficial for the health and well-being of mothers, their families, and society in general. The investigation of the combination of CBT and VR could possibly provide a better treatment for PND from a clinical point of view, which could save on resources including time and money spent at an organisational level.
In order to explore the possibility of combining psychological therapies with VR for the treatment of PND, we decided to review past and current published literature on traditional therapies for PND. We wanted to find out what therapies work best, and under what circumstances. Our investigation researched other reviews, within the same clinical subject area. However, our review differs from other reviews, whether systematic or narrative reviews, in three methodological aspects. It focuses purely on the treatment of PND, rather than prevention, or prevention and treatment of PND. A second difference is that this review investigates mainly CBT as treatment for PND. A third advantage of this review is around population characteristics. We focused our research mainly on the post-partum clinical population and not on other types such as the ante-natal population. However, there was one exception where the clinical population was in the last trimester of their pregnancy in the beginning of the study, but it became post-partum at a later stage. We believe this three research characteristics help this research project make a clear contribution to the literature.
We formulated the design of this review based on the working hypothesis that CBT is a successful treatment for various psychological disorders, amongst them PND. It is a therapeutic approach which is scientific based. It can follow a clinical protocol, where its clinical methods can be replicated. Its clinical efficacy can be tested and measured. We hypothesised that CBT is the most widely used and efficacious treatment for depression and PND.
We searched for specific parameters which we believe contribute to the efficacy of CBT. We wanted to pay particular attention to the types of participants, especially the ones who had been diagnosed with PND through a structured clinical interview. Another parameter was around the types of interventions or treatment components of CBT for PND. We searched for specific aspects of the CBT approach, in particular, cognitive restructuring, goal setting, and problem-solving.
In order to start this line of research and to design our PND intervention protocol, supported with VR, our first aim is to review the scientific literature relating to the most effective CBT treatments for PND. Then to identify the parameters that make those treatments effective. It will also investigate whether VR has previously been used as a treatment for PND.
More specifically, this review will answer the following three research questions:
What CBT psychological treatments are effective for PND?
What are the parameters that make those treatments have a successful clinical outcome?
Has VR previously been used for the treatment of PND?