Mindfulness-based therapy in the perinatal period: A review of the literature

Mindfulness is often defined in the psychological literature as nonjudgmental present-centred awareness. By allowing a break from destructive thinking patterns and creating a space for introspection, the practice of mindfulness may assist with cognitive change.[1] Mindfulness-based therapy (MBT) is growing in popularity in the Western world and is being used increasingly to treat psychiatric conditions in the general population.[2] Although evidence is sparse for the effectiveness of MBT in managing perinatal mood and anxiety disorders, recent research indicates potential benefit[3] and suggests that mindfulness-based therapy is an option for perinatal patients at high risk of experiencing psychiatric illness.[4] 

A brief history of mindfulness
Buddhism first emerged as an important spiritual tradition in northern India 2500 years ago, and since then has evolved to encompass a variety of forms and practices. Buddhist teachings outline a path to follow in order to achieve enlightenment or liberation from suffering, and describe various types of meditation to foster positive emotional energy in the present life and to free the mind.[5] 

The understanding of mindfulness as present-focused and nonjudgmental is only one aspect of the complex traditional view of mindfulness found in ancient Buddhist texts. These describe an introspective dimension to mindfulness that involves observing what pulls attention away from the present moment (i.e., thoughts, feelings, sounds, etc.), comprehending the experience, and evaluating the experience for potential positive and negative outcomes.[1,5] Although mindfulness is commonly associated with Buddhism, the concept and practice are embedded in other religious and spiritual traditions that involve prayer, contemplation, and meditation.[6]

Integration of mindfulness in mental health therapy
The definition of mindfulness used most frequently today was popularized by Jon Kabat-Zinn, a scientist and professor of medicine who developed a therapeutic approach to stress reduction after studying meditation under eminent Buddhist teachers.[5] Kabat-Zinn defined mindfulness as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.”[7] 

In 1979 Kabat-Zinn founded a stress reduction clinic at the University of Massachusetts Medical School, where he went on to develop several therapies integrating mindfulness, including mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). 

Kabat-Zinn developed MBSR by combining a variety of traditions, including Zen and insight meditation and Hatha yoga. He saw MBSR as a training vehicle that would promote nonjudgmental self-acceptance and help individuals cope with conditions such as chronic pain, cancer, and psychiatric disorders, including depression and anxiety.[2,8,9] 

MBCT was developed specifically to treat individuals suffering from repeated bouts of depression.[10] For this therapy, Kabat-Zinn combined meditative practices with cognitive therapy to teach people how to become more aware of their thoughts and feelings and to relate to them in a new way.[10] While the therapy was originally designed for people in remission from recurrent major depressive disorder (MDD), it is now widely used for those struggling with other psychiatric disorders, including symptomatic depression, bipolar spectrum disorder (BSD), anxiety, and social phobia.[11] 

MBT in the general population
Previous research has shown both MBSR and MBCT to be efficacious in clinical and nonclinical populations.[11-13] Meta-analyses have revealed improvements on measures of depression, anxiety, and quality of life after participants completed MBSR programs.[9,12] The most recent meta-analysis also found a relationship between the change in clinical outcomes (depression and anxiety) and level of mindfulness.[12] Similarly, meta-analyses have shown that those who attended a group MBCT program had a significant reduction in the risk of experiencing a depressive relapse when compared with control subjects.[8,11,13] This was most evident in patients who had experienced three or more previous episodes of depression. A meta-analysis by Kuyken and colleagues[13] also showed that MBCT was more effective at reducing symptoms of depression than other active treatments (cognitive therapy or maintenance antidepressants) and that these effects were not limited to a specific age or gender.

While some researchers have focused on the effectiveness of mindfulness-based therapy, others have examined the mechanisms leading to changes in clinical outcomes. Gu and colleagues[14] found that mindfulness training helped decrease negative reactivity and reduce rumination, thereby improving symptoms of anxiety and depression. Self-compassion and an increase in psychological flexibility are also thought to play a role, but evidence for this is limited.[14] With regard to physiological mechanisms, Annells and colleagues[15] found that meditation, including mindfulness training, can lead to physiological changes in the brain that counteract the atrophy associated with chronic depression and thus improve patient outcomes. 

MBT in the perinatal population
One of the most commonly occurring complications during the perinatal period is depression, which affects approximately 15% of women.[16] In many of these cases anxiety accompanies depression.[17] Mood and anxiety disorders not only impair maternal functioning but can also negatively affect the emotional well-being of children,[18,19] making timely and effective treatment crucial.

Although pharmacotherapy is considered the first-line treatment for moderate to severe perinatal mood and anxiety disorders, women often hesitate to take medications because of fears about stigmatization and fetal exposure.[17] For this reason, effective, nonpharmacological interventions for perinatal mood disorders are needed. Dimidjian and colleagues[3] hypothesized that MBCT could be adapted to treat perinatal mood disorders and would be a good option because the therapy targets those with a history of depression, which is an important risk factor for the onset of depressive illness in pregnancy and after childbirth. 

Vieten and Astin[20] were the first to conduct a pilot study investigating the use of mindfulness techniques in pregnant subjects introduced to the benefits of yoga, meditation, and relaxation training. Aspects of MBSR and MBCT were combined and tailored to meet the needs of pregnant women with undiagnosed mood concerns. It was predicted that this intervention would reduce stress, negative affect, and symptoms of depression and anxiety in pregnancy and that these effects would be maintained into the early postpartum period. In this study, pregnant women who identified themselves as having mood concerns attended a Mindful Motherhood program (n = 13) or were put on a wait list (n = 18). When compared with the women in the wait list (control) group, the women who attended the Mindful Motherhood program experienced a significantly greater decline in anxiety and negative affect and a clinically relevant decline in depression.

Based on the preliminary evidence from earlier studies, Dunn and colleagues[21] tested the efficacy of an MBCT program designed to reduce stress, depression, and anxiety in pregnant women. Adaptations to the mindful movement practices were made to ensure these were appropriate for pregnant women. A clinically significant decline in depression, stress, and anxiety that continued into the postpartum period was observed in the treatment group. No such decline was observed in the control group. 

Having obtained promising results from a pilot study[22] to test the usefulness of MBCT in preventing recurrence of depression, Dimidjian and colleagues went on to conduct a randomized controlled trial[3] that saw only 18.4% of subjects in the treatment group experiencing relapse compared with 50.2% in the control group. These findings suggest that MBCT during pregnancy could prevent the return of depressive symptoms in the postpartum period. Researchers also suggest that attending an MBT group could lead to less stigmatization than receiving psychotherapy, as mindfulness training is often seen as a healthy lifestyle activity rather than a form of treatment.[3]

There is a paucity of research into how patients with bipolar spectrum disorder respond to mindfulness therapy. Miklowitz and colleagues[23] studied MBCT in a sample of women with a history of either MDD (n = 25) or BSD (n = 7) who were trying to conceive, were pregnant, or were postpartum. Women experiencing a current episode of depression, mania, or hypomania were excluded from the study. After eight sessions of mindfulness therapy, depression scores were significantly reduced in the MDD group but not in the BSD group. Properly designed studies are still needed to elucidate the role of mindfulness therapy in perinatal women with BSD.

Perez-Blasco and colleagues[24] were the first researchers to investigate mindfulness-based therapy for women following childbirth. While previous studies focused on reducing psychological distress during pregnancy, this was the first to examine the effects of mindfulness on self-efficacy in breastfeeding mothers. In the treatment group, subjects attended a program teaching MBSR and MBCT techniques. Subjects who completed the intervention reported significantly higher levels of maternal self-efficacy and self-compassion when compared with those in the control group. The treatment group also experienced a reduction in anxiety and stress scores, although statistical significance was not achieved. 

Most studies of mindfulness-based therapy have focused on patients in the general population with depression, while very little research has explored the efficacy of MBT for patients in the perinatal population with anxiety disorders. Recognizing the need for nonpharmalogical approaches to treating anxiety in this population, Goodman and colleagues[25] completed a pilot study of MBCT for pregnancy-related anxiety and found the present-focused nature of mindfulness was effective in controlling excessive worrying, a major symptom of generalized anxiety disorder (GAD). Of the 23 women who completed the CALM Pregnancy study, 16 met the criteria for GAD at baseline. After successful completion of the treatment, subjects showed clinically and statistically significant declines from baseline measures in both anxiety and worry.

While the CALM study focused on GAD alone, a study by Woolhouse and colleagues tested the effects of mindfulness techniques on both anxiety and depression.[26] In the first (nonrandomized) stage of this two-part study, 20 subjects referred for treatment were assessed for stress, depression, and anxiety, with 60% scoring above the clinical cutoff for depression and 65% above the cutoff for anxiety.[26] Over the course of the MindBabyBody mindfulness intervention, scores declined significantly on both the depression scale (P = .01) and the anxiety scale (P = .04). The second (randomized) stage of this study was conducted with 32 women attending an antenatal clinic.[26] As in the first stage of the study, subjects who completed the intervention were found to have significantly reduced anxiety symptoms after the intervention (P = .02). 

Despite the small sample sizes and different methodologies used in the studies described here, the results suggest that MBT can be useful for managing both clinical and nonclinical anxiety symptoms in pregnant women. 

Future directions
A growing body of research suggests that mindfulness-based therapy can benefit perinatal women. While MBT appears to reduce symptoms of depression and anxiety during pregnancy, less is known about the benefits for the postpartum period and for perinatal women with other psychiatric conditions such as bipolar disorder. Further research with larger sample sizes and a greater range of subjects (postpartum women as well as pregnant women) is necessary. Because the practice of mindfulness is considered a positive and proactive activity rather than a form of treatment, patients may feel less stigmatized than they would if using antidepressants or attending psychotherapy sessions. The social acceptability of mindfulness-based therapy eliminates a significant barrier faced by pregnant and postpartum women when deciding whether to seek mental health treatment.

Competing interests
None declared.

Acknowledgments
The authors thank Ashley Clark and Gene-vieve Breau for their help with manuscript revisions.

This article has been peer reviewed.

Ms Badker is a research assistant in the Department of Psychiatry at the University of British Columbia. Dr Misri is a clinical professor of psychiatry and obstetrics and gynecology at the University of British Columbia. She is also founding director of the BC Reproductive Mental Health Program at BC Children’s and Women’s Hospital and Health Centre.