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Archives of Women's Mental Health

, Volume 14, Issue 6, pp 465–477 | Cite as

Efficacy of cognitive behavioral internet-based therapy in parents after the loss of a child during pregnancy: pilot data from a randomized controlled trial

  • Anette KerstingEmail author
  • Kristin Kroker
  • Sarah Schlicht
  • Katja Baust
  • Birgit Wagner
Original Article

Abstract

The loss of a child during pregnancy can be a traumatic event associated with long-lasting grief and psychological distress. This study examined the efficacy of an internet-based cognitive behavioral therapy program for mothers after pregnancy loss. In a randomized controlled trial with a waiting list control group, 83 participants who had lost a child during pregnancy were randomly allocated either to 5 weeks of internet therapy or to a 5-week waiting condition. Within a manualized cognitive behavioral treatment program, participants wrote ten essays on loss-specific topics. Posttraumatic stress, grief, and general psychopathology, especially depression, were assessed pretreatment, posttreatment, and at 3-month follow-up. Intention-to-treat analyses and completer analyses were performed. Relative to controls, participants in the treatment group showed significant improvements in posttraumatic stress, grief, depression, and overall mental health, but not in anxiety or somatization. Medium to large effect sizes were observed, and the improvement was maintained at 3-month follow-up. This internet-based cognitive behavioral therapy program represents an effective treatment approach with stable effects for women after pregnancy loss. Implementation of the program can thus help to improve the health care provision for mothers in this traumatic loss situation.

Keywords

Pregnancy loss Posttraumatic stress Depression Therapy Randomized controlled trial 

Notes

Acknowledgments

We are grateful to all the women who participated in this study. This project was fully funded by the German Federal Ministry for Family Affairs, Senior Citizens, Women, and Youth.

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. Andersson G (2009) Using the internet to provide cognitive behaviour therapy. Behav Res Ther 47:175–180PubMedCrossRefGoogle Scholar
  2. Andersson G, Cuijpers P (2009) Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cogn Behav Ther 38(4):196–205PubMedCrossRefGoogle Scholar
  3. Badenhorst W, Riches S, Turton P, Hughes P (2006) The psychological effects of stillbirth and neonatal death on fathers: systematic review. J Psychosom Obstet Gynaecol 27(4):245–256PubMedCrossRefGoogle Scholar
  4. Bergner A, Beyer R, Klapp BF, Rauchfuss M (2008) Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping. J Psychosom Obstet Gynaecol 29(2):105–113PubMedCrossRefGoogle Scholar
  5. Berth H, Puschmann AK, Dinkel A, Balck F (2008) Trauma Fehlgeburt: Einflussfaktoren auf das Angsterleben nach dem frühen Verlust eines Kindes [The trauma of miscarriage: factors influencing the experience of anxiety after early pregnancy loss]. Psychother Psychosom Med Psychol 59(8):314–320PubMedCrossRefGoogle Scholar
  6. Boelen PA, de Keijser J, van den Hout MA, van den Bout J (2007) Treatment of complicated grief: a comparison between cognitive behavioral therapy and supportive counseling. J Consult Clin Psychol 75:277–284PubMedCrossRefGoogle Scholar
  7. Bradley R, Greene J, Russ E, Dutra L, Westen D (2005) A multi-dimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry 162:214–227PubMedCrossRefGoogle Scholar
  8. Brier N (2004) Anxiety after miscarriage: a review of the empirical literature and implications for clinical practice. Birth 31(2):138–142PubMedCrossRefGoogle Scholar
  9. Brier N (2008) Grief following miscarriage: a comprehensive review of the literature. J Womens Health (Larchmt) 17(3):451–464CrossRefGoogle Scholar
  10. Buchner A, Erdfelder E, Faul F (1997) How to use G*Power. http://www.psycho.uni-duesseldorf.de/aap/projects/gpower/how_to_use_gpower.html. Accessed 10 February 2010
  11. Carter D, Misri S, Tomfohr L (2007) Psychologic aspects of early pregnancy loss. Clin Obstet Gynecol 50(1):154–165PubMedCrossRefGoogle Scholar
  12. Cohen J (1992) A power primer. Psychol Bull 112:155–159. doi: 10.1037/0033-2909.112.1.155 PubMedCrossRefGoogle Scholar
  13. Cougle JR, Reardon DC, Coleman PK (2003) Depression associated with abortion and childbirth: a long-term analysis of the NLSY cohort. Med Sci Monit 9(4):105–112Google Scholar
  14. Derogatis LR (1993) Brief Symptom Inventory (BSI), administration, scoring, and procedures manual. National Computer Services, MinneapolisGoogle Scholar
  15. Dunlap WP, Cortina JM, Vaslo WJB, Burke MJ (1996) Meta-analysis of experiments with matched groups or repeated measures designs. Psychol Methods 1:170–177CrossRefGoogle Scholar
  16. Engelhard IM, van den Hout MA, Arntz A (2001) Posttraumatic stress disorder after pregnancy loss. Gen Hosp Psychiatry 23(2):62–66PubMedCrossRefGoogle Scholar
  17. First MB, Spitzer RL, Williams JB, Gibbon M (1997) Structured clinical interview for DSM-IV clinical version (SCID-I/CV). American Psychiatric Association, Washington DCGoogle Scholar
  18. Foa EB, Jaycox LH (1999) Cognitive-behavioral theory and treatment of posttraumatic stress disorder. In: Spiegel D (ed) Efficacy and cost effectiveness of psychotherapy. Amercian Psychiatric Press, Washington DC, pp 23–61Google Scholar
  19. Geller PA, Kerns D, Klier CM (2004) Anxiety following miscarriage and the subsequent pregnancy: a review of the literature and future directions. J Psychosom Res 56(1):35–45PubMedCrossRefGoogle Scholar
  20. Geller PA, Psaros C, Kerns D (2006) Web-based resources for health care providers and women following pregnancy loss. J Obstet Gynecol Neonatal Nurs 35(4):523–532PubMedCrossRefGoogle Scholar
  21. Geller PA, Psaros C, Kornfield SL (2010) Satisfaction with pregnancy loss aftercare: are women getting what they want? Arch Womens Ment Health 13(2):111–124PubMedCrossRefGoogle Scholar
  22. Gold KJ, Dalton VK, Schwenk TL (2007) Hospital care for parents after perinatal death. Obstet Gynecol 109(5):1156–1166PubMedCrossRefGoogle Scholar
  23. Horowitz MJ, Wilner NR, Alvarez W (1979) Impact of event scale: a measure of subjective stress. Psychosom Med 41:209–218PubMedGoogle Scholar
  24. Jacobson NS, Truax P (1991) Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 59:12–19PubMedCrossRefGoogle Scholar
  25. Johnson MP, Baker SR (2004) Implications of coping repertoire as predictors of men’s stress, anxiety and depression following pregnancy, childbirth and miscarriage: a longitudinal study. J Psychosom Obstet Gynaecol 25(2):87–98PubMedCrossRefGoogle Scholar
  26. Kersting A, Dorsch M, Kreulich C, Reutemann M, Ohrmann P, Baez E, Arolt V (2005) Trauma and grief 2–7 years after termination of pregnancy because of fetal anomalies: a pilot study. J Psychosom Obstet Gynecol 26(1):9–14CrossRefGoogle Scholar
  27. Kersting A, Kroker K, Steinhard J, Lüdorff K, Wesselmann U, Ohrmann P, Arolt V, Suslow T (2007) Complicated grief after traumatic loss: a 14-month follow up study. Eur Arch Psychiatry Clin Neurosci 257(8):437–443PubMedCrossRefGoogle Scholar
  28. Kersting A, Kroker K, Steinhard J, Hoernig-Franz I, Wesselmann U, Lüdorff K, Ohrmann P, Arolt V, Suslow T (2009a) Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth—a 14-month follow-up study. Arch Womens Ment Health 12(4):193–201PubMedCrossRefGoogle Scholar
  29. Kersting A, Schlicht S, Kroker K (2009b) [Internet therapy. Opportunities and boundaries]. Nervenarzt 80(7):797–804, article in GermanPubMedCrossRefGoogle Scholar
  30. Kersting A, Kroker K, Schlicht S, Wagner B (2011) Internet-based treatment after pregnancy loss: concept and case study. J Psychosom Obstet Gynaecol 32(2):72–78PubMedCrossRefGoogle Scholar
  31. Klier CM, Geller PA, Neugebauer R (2000) Minor depressive disorder in the context of miscarriage. J Affect Disord 59(1):13–21PubMedCrossRefGoogle Scholar
  32. Klier CM, Geller PA, Ritsher JB (2002) Affective disorders in the aftermath of miscarriage: a comprehensive review. Arch Womens Ment Health 5(4):129–149PubMedCrossRefGoogle Scholar
  33. Knaevelsrud C, Maercker A (2007) Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled trial. BMC Psychiatry 7:13PubMedCrossRefGoogle Scholar
  34. Korenromp MJ, Page-Christiaens GC, van den Bout J, Mulder EJ, Hunfeld JA, Potters CM, Erwich JJ, van Binsbergen CJ, Brons JT, Beekhuis JR, Omtzigt AW, Visser GH (2007) A prospective study on parental coping 4 months after termination of pregnancy for fetal anomalies. Prenat Diagn 27(8):709–716PubMedCrossRefGoogle Scholar
  35. Korenromp MJ, Page-Christiaens GC, van den Bout J, Mulder EJ, Visser GH (2009) Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months. Am J Obstet Gynecol 201(2):160.e1–160.e7CrossRefGoogle Scholar
  36. Kramer PRL, Jarve RK, Yaron YK (1998) Determinants of parental decision after prenatal diagnosis of Down syndrome. Am J Med Genet 79:172–174PubMedCrossRefGoogle Scholar
  37. Lange A, Schrieken B, Blankers M, van de Ven J-P, Slot M (2000a) [Construction and validation of the screening device for psychotic disorder]. Dir Ther 20:162–173, NetherlandsGoogle Scholar
  38. Lange A, Schrieken B, van de Ven J, Bredeweg B, Emmelkamp PMG, van der Kolk J et al (2000b) Interapy: the effects of a short protocolled treatment of posttraumatic stress and pathological grief through the internet. Behav Cogn Psychother 28:175–192Google Scholar
  39. Lange A, Rietdijk D, Hudcovicova M, van de Ven J, Schrieken B, Emmelkamp PMG (2003) Interapy: a controlled randomized trial of the standardized treatment of posttraumatic stress through the internet. J Consult Clin Psychol 71:901–909PubMedCrossRefGoogle Scholar
  40. Litz B, Engel C, Bryant R, Papa A (2007) A randomized, controlled proof-of-concept trial of an internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder. Am J Psychiatry 164:1676–1683PubMedCrossRefGoogle Scholar
  41. Mansfield C, Hopfer S, Mareau TM (1999) Termination rates after prenatal diagnosis of Down syndrome, spina bifida, anencephaly, and Turner and Klinefelter syndromes: a systematic literature review. European Concerted Action: DADA (decision-making after the diagnosis of a fetal abnormality). Prenat Diagn 19:808–812PubMedCrossRefGoogle Scholar
  42. Neal LA, Walter B, Rollins J, Herepath R, Strike P, Turnbull G (1994) Convergent validity of measures of post-traumatic stress disorder in a mixed military and civilian population. J Trauma Stress 7:447–455PubMedCrossRefGoogle Scholar
  43. Neugebauer R, Kline J, Shrout P, Skodol A, O’Connor P, Geller P, Stein Z, Susser M (1997) Major depressive disorder in the 6 months after miscarriage. JAMA 277:383–388PubMedCrossRefGoogle Scholar
  44. Neugebauer R, Kline J, Bleiberg K, Baxi L, Markowitz JC, Rosing M, Levin B, Keith J (2007) Preliminary open trial of interpersonal counseling for subsyndromal depression following miscarriage. Depress Anxiety 24(3):219–222PubMedCrossRefGoogle Scholar
  45. Nijenhuis ERS, Spinhoven P, van Dyck R, van der Hart O, Vanderlinden J (1997) The development of the Somatoform Dissociation Questionnaire (SDQ-5) as a screening instrument for dissociative disorders. Acta Psychiatr Scand 96:311–318PubMedCrossRefGoogle Scholar
  46. Nikcevic AV, Kuczmierczyk AR, Nicolaides KH (2007) The influence of medical and psychological interventions on women’s distress after miscarriage. J Psychosom Res 63:283–290PubMedCrossRefGoogle Scholar
  47. Prigerson HG, Maciejewski PK, Reynolds CF, Bierhals AJ, Newsom JT, Fasiczka A, Frank E, Doman J, Miller M (1995) Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss. Psychiatry Res 59(1–2):65–79PubMedCrossRefGoogle Scholar
  48. Puddifoot JE, Johnson MP (1997) The legitimacy of grieving: the partner’s experience at miscarriage. Soc Sci Med 45(6):837–845PubMedCrossRefGoogle Scholar
  49. Shear K, Frank E, Houck PR, Reynolds CF III (2005) Treatment of complicated grief: a randomized controlled trial. JAMA 293:2601–2608PubMedCrossRefGoogle Scholar
  50. Sundin EC, Horowitz MJ (2002) Impact of Event Scale: psychometric properties. Br J Psychiatry 180:205–209PubMedCrossRefGoogle Scholar
  51. Swanson KM, Chen HT, Graham JC, Wojnar DM, Petras A (2009) Resolution of depression and grief during the first year after miscarriage: a randomized controlled clinical trial of couples-focused interventions. J Womens Health (Larchmt) 18(8):1245–1257CrossRefGoogle Scholar
  52. Turton P, Hughes P, Evans CDH, Fainman D (2001) Incidents, correlates and predictors of posttraumatic stress disorder in the pregnancy after stillbirth. Br J Psychiatry 178:556–560PubMedCrossRefGoogle Scholar
  53. van der Houwen K, Schut H, van den Bout J, Stroebe M, Stroebe W (2010) The efficacy of a brief internet-based self-help intervention for the bereaved. Behav Res Ther 48(5):359–367PubMedCrossRefGoogle Scholar
  54. Vance JC, Boyle FM, Najman JM, Thearle MJ (1995) Gender differences in parental psychological distress following perinatal death of sudden infant death syndrome. Brit J Psychiatr 167:806–811CrossRefGoogle Scholar
  55. Wagner B, Maercker A (2007) A 1.5-year follow-up of an internet-based intervention for complicated grief. J Trauma Stress 20(4):625–629PubMedCrossRefGoogle Scholar
  56. Wagner B, Maercker A (2008) An internet-based preventive intervention (CBT) for complicated grief: a pilot study. Psicologia Applicata alla Medicina del Lavoro e della Riabilitazione 30:B43–B47Google Scholar
  57. Wagner B, Knaevelsrud C, Maercker A (2005) Complicated grief and internet-based treatment for complicated grief: concepts and case study. J of Loss and Trauma 10:1–24Google Scholar
  58. Wagner B, Knaevelsrud C, Maercker A (2006) Internet-based cognitive-behavioral therapy for complicated grief: a randomized controlled trial. Death Stud 30(5):429–453PubMedCrossRefGoogle Scholar
  59. Wittouck C, Van Autreve S, De Jaegere E, Portzky G, van Heeringen K (2011) The prevention and treatment of complicated grief: a meta-analysis. Clin Psychol Rev 1:69–78CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Anette Kersting
    • 1
    Email author
  • Kristin Kroker
    • 2
  • Sarah Schlicht
    • 2
  • Katja Baust
    • 2
  • Birgit Wagner
    • 1
  1. 1.Department of Psychosomatic MedicineUniversity of LeipzigLeipzigGermany
  2. 2.Department of PsychiatryUniversity of MuensterMuensterGermany

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