Yoga for Perinatal : Preliminary Results and Potential Mechanisms of Effect

Maria Muzik, MD, MSc Director, Women's and Infants Mental Health Department of Psychiatry University of Michigan

Acknowledgements

Collaborators: • Katherine Lisa Rosenblum, PhD • Susan Hamilton, MS, tLLP

M-Yoga Instructors • Barbara Brooken-Harvey, LMSW • Marlene McGrath, LMSW Inward Bound Yoga, Ann Arbor

Objectives

• 1. At the conclusion of this presentation, the participants will be able to list current research evidence of yoga effects on depression based on several metaanalyses. • 2. At the conclusion of this presentation, the participants will be able to list current evidence for yoga effects on perinatal health , including moods and anxieties. • 3. At the conclusion of this presentation, the participants will be able to describe possible mechanisms of yoga treatment effect on perinatal depression. Depression in • There are three times in a woman’s life when she is at higher risk for developing depression: puberty, the perinatal period and perimenopause. • These times are often fraught with unfamiliar hormonal fluctuations, role transitions, emotional upheaval and many physical changes, leading to a natural increase in stress. • However, since these times are expected to be stressful, serious mood changes often go unnoticed by patients and untreated by clinicians.

4 Symptoms – Similar to depression at any other time in a woman’s life • Depressed/irritable mood • Inability to experience pleasure • Feelings of guilt/worthlessness • Sleep disturbance • Appetite or weight changes • Trouble concentrating • Decreased energy and Many symptoms overlap with changes experienced during pregnancy and are therefore not detected. 5 Risk Factors • Problems with infertility or past pregnancy loss • Previous diagnosis of depression, anxiety, or bipolar disorder • Significant trauma history • Lack of social support • Single parenthood • Low socioeconomic status • Chronic pain • Pregnancy during adolescence • Unstable home environment • History of sexual assault or domestic violence • Stopping antidepressant use due to pregnancy • Current or past substance abuse/dependence

6 Barriers to Treatment • 10%-16% of pregnant/postpartum women meet MDD criteria • Gaynes et al. (2005) found that 86% of pregnant women screened positive for depression in an obstetrics setting did not receive any form of treatment • Up to 50% of women taking antidepressants prior to conception choose to discontinue medication • Many women prefer psychosocial treatments, but face psychological and practical barriers to treatment initiation and adherence while pregnant

7 Consequences of Untreated Depression

• Mothers are more likely to engage in unhealthy behaviors: • Smoking, illicit substance use, poor nutrition, less compliant with prenatal care • Increased pain and discomfort during pregnancy • Poor pregnancy and birth outcomes: preeclampsia, low birth weight, smaller head circumference, surgical delivery interventions, premature deliveries, lower APGAR scores • Risk for • Infants cry more and have more sleep disturbances 8 Case Vignette Ashley was referred to our High Risk Perinatal Team by her OB in her first trimester, around 6 weeks. She is 28, unpartnered, has three other children (aged 10, 4 and 2) and a history of depression. When she calls intake at 13 weeks pregnant, she reports that this pregnancy is likely the result of a sexual assault, but has decided to keep the baby. She describes severe depressive symptoms, including insomnia, low appetite, feelings of worthlessness and thoughts of harming herself. In addition, she is having incapacitating panic attacks, and constantly worries about the safety of her children when she is not with them. She schedules an appointment with the Perinatal Team, but “no shows” twice before being seen in clinic. 9 Case Vignette When Ashley is finally seen in clinic, she is well into her 2nd trimester and brings her two youngest children with her. She tells the clinician that she was recently fired from her job as a cashier because she missed too many days of work, and is in the process of applying for Medicaid. She has never been in therapy before, and is reluctant to take antidepressants. During the intake session, Ashley's affect is flat, her mood depressed, and she has a hard time explaining her history due to the many interruptions by her 2 year old son. Despite her symptoms and a difficult first encounter, she seems to engage with the clinician and agrees to schedule a second appointment.

10 Pharmacological Treatment • ACOG: Women should consider psychotherapy prior to medications, but should remain on antidepressants during pregnancy if moderately or severely depressed. • 68% who discontinue medication during pregnancy experience relapse symptoms, compared with 26% of women who continue their medication (Cohen, et al, 2006). • Although research studies indicate that no major malformations are associated with antidepressant use during pregnancy, there is insufficient evidence that any specific antidepressant is completely safe. 11 Non-Pharmacological Treatment • Interpersonal Psychotherapy (IPT): Useful for interpersonal conflicts, role transitions, unresolved grief • Cognitive Behavioral Therapy (CBT): Targets negative thinking and behaviors that maintain depression • Alternative treatments are becoming more popular: Omega-3 fatty acids, bright light therapy, , St. John’s wort, acupuncture, mind-body modalities (such as progressive muscle relaxation, yoga, meditation)

12 The role of Complementary & Alternative Medicine (CAM) in treating Antenatal Stress, Depression or Anxiety • Few women suffering from perinatal mental illness actually receive treatment, due to a variety of barriers. • The social stigma surrounding perinatal depression or anxiety leads many women to believe that they are alone in their struggle, and hesitant to seek help even if they know where to go. The role of Complementary & Alternative Medicine (CAM) • When traditional treatments for perinatal depression are rejected or feared, there is evidence that CAM is more acceptable to the average women, possibly serving as a gateway to effective treatments for women who may have never considered CAM before becoming pregnant What is Yoga?

• Yoga is an ancient practice that involves meditative focus combined with physical poses • Yoga has been shown to have many positive health effects, from reducing stress and improving chronic pain to decreasing the incidence of symptoms associated with psychiatric illnesses What is Mindfulness?

• Moment-to-moment observation of the mind-body process, through calm and focused awareness, without judgment. • Being fully aware of whatever is happening in the present moment, without filters or attachment to a particular outcome. • Simply observing, watching, examining. You are not a judge but a scientist.

What is Mindfulness? What is Mindfulness? • Historically rooted in ancient Buddhist meditative disciplines, but also an important part of many spiritual traditions, including Christianity, Judaism, Islam and Hinduism • Has expanded far beyond its spiritual roots into a wide variety of contexts, including medicine, neuroscience, psychology, education and business • Doctors are prescribing training in mindfulness practice to help patients deal with stress, pain and illness

How does mindfulness work? • Think of your mind as the surface of a lake or the ocean. • There are always waves on the water. • Sometimes they are big, sometimes they are small, sometimes almost imperceptible. • The water’s waves are churned up by winds, which come and go and vary in direction and intensity, just as the winds of stress and change in our lives, which stir the waves in our minds.

Research

• Studies have found the following benefits for people who have completed mindfulness training and practice mindfulness meditation: – More fluid adaptation to change and development of more effective coping strategies – Lasting decreases in a variety of stress-related physical symptoms, including chronic pain – Significant decreases in anxiety and depression – Considerable reduction in depression relapse – Improved concentration and creativity – Improved immune system functioning – Decreased symptoms secondary to cancer

Why Mindfulness Yoga?

Mindfulness and yoga are natural partners during times of stress and physical pain, particularly as the body progresses through the normal aches, pains and emotional changes of pregnancy. Yoga, Mindfulness and Pregnancy

• In healthy women, several studies have shown that prenatal yoga significantly reduces duration of labor and pregnancy- related physical discomfort, as well as the incidence of hypertension, preterm labor and fetal growth retardation (Curtis, Weinrib, & Katz, 2012) • A prenatal mindfulness-based intervention significantly reduced anxiety and negative emotions (Vieten & Astin, 2008)

Yoga, Mindfulness and Pregnancy • Together, mindfulness practice and yoga have been shown to significantly decrease stress and the perception of pain during labor (Beddoe & Lee, 2008) • Many women seeking treatment for depression are interested in prenatal yoga, but no research has yet examined yoga as a treatment (Battle, Uebelacker, Howard & Castaneda, 2010)

Previous Research

• Research is limited, but encouraging • Beddoe (2009) found that Iyengar yoga and mindfulness-based stress reduction (MBSR) significantly decreased emotional stress and physical pain in pregnant women with a history of depression Previous Research • However, since women meeting criteria for current psychopathology were excluded in this study, it is unclear whether benefits can be generalized to pregnant women with psychiatric illness • The present study is the first attempt to close this gap in the literature; we are exploring the efficacy of M- Yoga in reducing symptoms of depression and anxiety among pregnant women with current and lifetime psychiatric diagnoses Hypotheses

• Mindfulness yoga (M-Yoga) will improve mental health by increasing women’s positive feelings of empowerment towards the pregnancy and motherhood, leading to: – Enhanced mindfulness – More effective coping – Reduced social isolation – Enriched attachment to the unborn child Recruitment

• In 2009-2010, pregnant women were recruited through University-based clinics and flyers. • Free participation in a 10-week prenatal M-Yoga class to improve well being and decrease stress.

INCLUSION 1st time mother EXCLUSION English-speaker Active substance abuse Scoring above 9 on the EPDS depression screen Psychosis Not taking medications for Suicidality mental health conditions Less than 26 weeks gestation Recruitment

Began M-Yoga Completed M-Yoga Intervention Intervention Eligible Women (completed screened for N=20 N=18 baseline inclusion over measures) a 4 week period

N=49 N=22

Dropped out after N=2 attending 1 class % Frequency (N) Participant Demographics or M (SD) Ethnicity (N=22) Minority 27% (6) Education (N=22) Less than Bachelors Degree 14% (3) Bachelors Degree Only 32% (7) Masters Degree or Higher 60% (12) Marital Status (N=22) Living with Partner 72% (17) Income (N=12) Under 25,000 0% (0) 25,000-50,000 15% (3) More than 50,000 45% (9) Age (N=22) 32.41 (4.98)

Gestational age baseline (N=22) 21.80 weeks (5.96)

Gestational age after classes (N=18) 34.49 weeks (5.97) Participant Mental Health Before Intervention

Current Past Psychopathology Psychopathology % Frequency (N) % Frequency (N) SCID Dx No diagnosis 50.0% (11) 13.6% (3) MDD 9.1% (2) 54.5% (12) PTSD 18.2% (4) 36.4% (8) Anxiety disorder (GAD, 45.5% (10) 9.1% (2) Phobias, Panic Disorder) Substance Abuse/Dependence 0% 45.5% (10) Note: 73% of participants had more than one SCID diagnosis M-Yoga Classes • In the US, yoga is frequently taught in gym-like settings, resulting in an epidemic of classes that omit mindfulness and concentrate on yoga as “exercise” • Unlike typical prenatal hatha yoga, M-Yoga highlights mindfulness practice, with targeted instructions, reminders, and readings • Each 90 minute session focused on a variety of yoga poses taught specifically for the pregnant body and with mindful awareness of the growing baby M-Yoga Classes • Sessions opened with a 10-15 minute check-in, allowing each woman to share how she was feeling physically and emotionally with the group • Group yoga activities were taught specifically for the pregnant body and modified for any level of yoga experience or stage of pregnancy • Teachers customize the poses and instruction to address participants’ current issues. For example, if irritability is an issue, instructions include finding compassion towards oneself as the body experiences the hormonal changes of pregnancy. • Classes end with a 15-20 minute restorative pose, including a full body relaxation exercise, along with a mindfulness reading, and a 5-10 minute informal interaction while participants prepare to leave

M-Yoga Instructors’ Language • Practice the pose for your body without judgment • Bring your attention to your breath, always practicing with awareness of your growing baby • Bring your awareness and focus inward to your breath • Allow your inhalation to bring an extension to your spine • Observe the base of your posture equally balancing your weight on the four corners of each foot Measures • Participating women underwent an initial psychiatric interview, and completed self-report questionnaires at baseline and after the final yoga class – Mental health (Beck Depression Inventory-II, Edinburgh Postnatal Depression Scale) – Mindfulness (Five Factor Mindfulness Questionnaire) – Mother-baby attachment (Maternal Fetal Attachment Scale) Results: Demographics

• Maternal age was significantly positively correlated with baseline resiliency scores and maternal-fetal attachment • Gestational age was negatively correlated with PTSD symptoms • Marital status had a significant effect on social support scores and PTSD scores such that women who are single (n=5) have lower satisfaction with social support and more PTSD symptoms than women living with romantic partners (n=17). Intervention Effect for Total Group: Maternal Mental Health • Symptoms of depression were significantly reduced.

Post Baseline Intervention t df p Beck Depression 13.95 (6.84) 9.63 (6.99) 2.40 17 .025* Inventory Edinburgh Postnatal 12.45 (3.41) 7.60 (4.16) 4.41 19 .000** Depression Scale Intervention Effect: Mindfulness Skills • Mindfulness skills (FFMQ) total score improved significantly over the course of the intervention. • This result was mainly driven by significant results on one subscale, Non-Judgment, and trend level change in the Observe subscale. Post Baseline Intervention t df p Total 131.17 (14.23) 137.56 (16.79) -3.09 17 .007** Observe 27.78 (3.95) 29.28 (3.56) -1.92 17 .072t Describe 27.06 (4.00) 27.61 (3.68) -1.13 17 ns Awareness 27.50 (3.76) 28.11 (4.57) -0.65 17 ns Non-Judgment 28.89 (6.25) 28.94 (6.76) -2.20 17 .042 Non-React 21.94 (4.76) 23.61 (5.29) -1.71 17 ns Intervention Effect: Maternal-Fetal Attachment • Maternal-fetal attachment significantly increased for the total score, and on all five subscales.

Post Baseline Intervention t df p Maternal-Fetal Attachment Total 83.56 (10.12) 95.50 (10.53) -5.65 17 .000** Role Taking 17.39 (2.45) 18.23 (2.08) -2.30 17 .035* Diff of Self from Fetus 14.17 (2.96) 17.06 (2.41) -4.96 17 .000** Interaction with Fetus 16.67 (3.16) 19.22 (3.42) -4.21 17 .001** Not Attrib. Char. to Fetus 17.72 (3.34) 22.67 (4.33) -3.99 17 .001** Giving of Self 19.78 (3.00) 22.22 (2.05) -3.04 17 .007** Correlations Between Pre and Post Group Measures

Post Maternal- Post Measures Post BDI Fetal Mindfulness Attachment

Pre BDI .642** -.556* -.272

Pre Mindfulness -.470* .853** .234 Pre Maternal- Fetal Attachment -.549* .004 .623** *p<.05 and **p<.01 Formative Evaluation • Women felt yoga was a helpful coping strategy and benefited the child as well – “Yoga helped me to cope with a high-risk pregnancy—and my son is the most calm and gentlest of souls. The stress reduction REALLY helps the baby, too.” • Social support of group was highlighted – “Hearing from the other moms made me feel much less alone.” – “I really benefited emotionally from sharing with the other participants and benefited physically from breathing and relaxation .” • Teaching content and instructors were perceived as positive – “The breathing and mindfulness exercises allowed me to have the delivery I wanted. It was perfect.” – “I loved all of it—the readings were excellent and the instructors have a true passion for helping pregnant women.” Discussion • Our findings suggest that the M- Yoga intervention is acceptable and effective for women with mild to moderate antenatal depression. • For severely depressed women, we speculate that M-Yoga would prove beneficial if offered as adjuvant treatment modus in combination with traditional pharmacotherapy. Discussion • The strongest impact was on maternal-fetal attachment, which improved significantly, independent of symptom level and presence of current psychopathology • Women who completed the intervention became more comfortable assuming the role of a mother, enjoyed interaction with the fetus, easily separated themselves from the fetus and were more likely to engage in healthy behaviors because of the pregnancy. Discussion It is possible that strengthening mindfulness skills, increasing resilience to stress and enhancing maternal-fetal attachment helped women with minimal depressive symptoms at baseline avoid a potential episode of MDD while they were enrolled in the M-Yoga intervention. Limitations

• Limitations of this study include the small sample size, the homogeneity of the sample population and the lack of a control group. • However, the data collected provides a solid foundation for future research. Limitations

• More research is needed to explore the effects of M-Yoga on pregnant women who are unpartnered, <25, from diverse ethnic backgrounds and with fewer resources Current Project Randomized Control Trial • Intervention: M-Yoga classes taught by experienced instructors • Control: Home practice with a free mindfulness yoga DVD and weekly check-in calls from study staff Eligibility criteria expanded • Targeted recruitment to a more diverse sample, including younger women (age 15+)

Case Vignette

Ashley has been scheduling therapy appointments weekly. She “no shows” or cancels about once a month, but seems to be making some progress. After establishing rapport, her therapist has made several accommodations to address the variety of barriers to getting care, such as offering child care for her son and daughter during sessions in an adjacent room, conducting brief sessions by phone when she is unable to come to the clinic and helping her enroll in the Maternal Infant Health Program, which offers transportation assistance, nutritional guidance and counseling sessions while she waits at her OB appointments.

47 Case Vignette At 26 weeks gestation, Ashley is still reluctant to try medication, so her therapist is helping her integrate traditional psychotherapy with alternative approaches such as meditation and exercise. During therapy sessions, Ashley is learning ways to manage her depression and PTSD symptoms, improve her social functioning, adjust to role transitions and work through her traumatic experiences by way of an interpersonal and cognitive-behavioral therapy approach. Finally, Ashley has enrolled in a prenatal mindfulness yoga class, allowing her to interact with other pregnant women at risk for psychopathology and learn new ways to cope. The yoga class, taught by an therapist connected with the Perinatal Team, facilitates social support by pairing each pregnant woman with a fellow class member who is further along in her pregnancy and is designed to continue into the postpartum period, encouraging women to bring their babies to class. 48 Case Vignette Ashley delivered a small, but healthy, baby boy at 38 weeks gestation. During labor, she used many of the yoga poses learned in class to manage pain, but ultimately elected to have an epidural after 30 hours of labor. Her baby was observed in the NICU for 2 days to ensure adequate weight gain and then discharged home. Ashley started breastfeeding while still in the hospital and plans to continue. Her therapist spoke with the hospital social worker on- call during Ashley’s stay to assist with coordinating postpartum care and plans to check in by phone later in the week. Ashley is looking forward to her first postpartum yoga class, especially after one of her classmates came to visit her in the maternity ward. Ashley’s therapist will continue to stay in touch with her by phone until she is ready to schedule another appointment or assist with referrals to other community resources.

49 Questions?

50