Cognitive Behavioral Couple Therapy for Perinatal Distress

The research questions of the study are

• How effective will psychopharmacological treatment, CBCT (with or without Zikr) and combined medicine-CBCT (with or without Zikr) interventions be in reducing symptoms of distress among couples during the perinatal period through a randomized clinical trial?

• Will dyadic coping strategies, social support, domains of quality of life, and well-being be improved in couples at the post-test level compared to the pre-test level by therapeutic intervention through a randomized clinical trial?
• What will be the effect size of post-test intervention?

Procedures and Protocol

The investigator will ask willing participants (screened for high risk) to select one of their preferred treatment modes out of the following

• Medications (antidepressants and/or anxiolytics).
• Cognitive Behavioural Therapy without Zikr.
• Cognitive Behavioural Therapy with Zikr.
• Combination of medications and cognitive behavioral therapy.
• Combination of medications, cognitive behavioral therapy, and Zikr.

A list of willing participants will be prepared. Each participant will have one in five chances of getting the preferred treatment mode after study is over. There will be two groups (experimental and control). To put people into one of the two groups, the investigator will select by randomization via online calculator random number generation.

Participants will not know to which group they actually belong. This information will be recorded in the investigator's files, but the research assistant will not look at these files until after the research is finished. This is the best way the investigators have to testing without being influenced by what they think or hope might happen. Thus, the participants and the research assistant will be double blinded in the trial. The investigator and research assistant will then compare which of the two has the best results.

The healthcare professionals (consultant gynecologists and investigator's research assistant) will be looking after the participants very carefully during the study. If there are anything participants are concerned about or that is bothering them about the research they will talk to the researcher, research assistant, gynaecologist or staff.

A placebo or inactive medicine looks like real medicine but it is not. It is a dummy or pretend medicine. It has no effect on a person because it has no real medicine in it. The investigator wants to know whether medicine is good, therefore some people will be given the medicine and others will be given the pretend or a dummy medicine. For the research to be good, it is important that participants do not know whether they have been given real medicine or pretend or dummy medicine. This is one of the best ways the investigator have for knowing what the medicine that are being tested really does. But the participants given a placebo or no intervention will be informed at the end of the study and will be given treatment with medication as they are wait-list control. Moreover, the participants in the intervention group will receive their preferred treatment after the completion of the study.

Participants will receive psychopharmacological treatment according to the National Institute for Health and Care Excellence (NICE) guidelines.

Description of the Process

During the research, a couple has to make ten visits to attend ten sessions in the hospital.

• In the first visit, rapport will be built and pre-test assessment will be done in the following two approaches

Quantitative Approach

• Indigenously developed Parental Perinatal Distress Scale (PPDS).
• Multidimensional Scale for Perceived Social Support (MSPSS).
• Dyadic Coping Inventory (DCI).
• Flourishing Scale (FS).
• World Health Organization's Quality of Life Brief (WOLQOL-BREF)

Qualitative Approach • In a qualitative approach, the semi-structured interviews will be conducted to explore the present stressors and expectations, and perceptions about the effectivity of treatments for perinatal distress among couples.

Group 1 will be given medications or placebo for two weeks and/or for four to five weeks maximum (as per requirement) by the consultant gynaecologist. They have to visit after two weeks for post-test assessment. After treatment, the medicine will be tapered off to stop the intake. As explained before, neither participant will know whether they have received the medicine or the placebo. But in the end placebo participants will be debriefed and will be continued with real medication.

Group 2, Group 3, Group 4 and Group 5 will continue the following 10 sessions (two sessions, each one hour per week) of CBCT with the investigator.

• In the second session, participants will be psycho-educated for perinatal period distress, couples' physical and mental health and impact on the fetus-infant, the prevalence of depression and anxiety, and the significance of identification. Progressive muscle relaxation exercises will be carried out along with deep breathing. Feedback on the session will be taken.

• In the third session, participants will be psycho-educated on the theoretical model of cognitive-behavioral couple therapy with some historical highlights and empirical standing. A thought log will be given for homework. Feedback for deep breathing and progressive muscle relaxation will be carried out.

• In the fourth, fifth, sixth, seventh, eighth, and ninth session, feedback will be taken on homework and session. Various techniques of Cognitive Behavioural Couple Therapy will be applied based on the nature and contents of identified precipitating, perpetuating, and present stressors. In addition, relevant techniques will be incorporated from other modalities with eclecticism. Tasbeeh in Zikr will be given to group 3 and group 5 who opted for it in the screening process.

• On the tenth visit, feedback on the session and homework will be taken. post-test assessment will be done in the following two approaches Group 6 will be exposed to one of the two conditions. 50% of couples will get a placebo and 50% will receive routine treatment care with no intervention. However, after the completion of the research, intervention groups and waitlist group (control) will be briefed and will be delivered with an intervention mode of treatment of their choice as selected earlier.

Posttest assessment will be carried out by the following instruments Quantitative Approach • Indigenously developed Parental Perinatal Distress Scale (PPDS). • Multidimensional Scale for Perceived Social Support (MSPSS). • Dyadic Coping Inventory (DCI).

• Flourishing Scale (FS).
• World Health Organization's Quality of Life Brief (WOLQOL-BREF) Qualitative Approach
• In a qualitative approach, the semi-structured interview will be conducted to explore the conception about the perinatal distress and perceptions about effectivity of treatments for perinatal distress among couples.

Duration The research takes place from 15th August, 2023 to 30th September, 2023. Screening (for Major Depressive Disorder, Generalized Anxiety Disorder) with PPDS will be carried out on the couples who visit the gynecological ward of the hospital in August. After screening and signed informed consent, it will be necessary for participants to come to the clinic/hospital for 10 days in total, for one hour session each day in end of August and whole month of September (two sessions per week, each for one hour).

The investigator and the research assistant would like to meet with participants twice in the upcoming month after the participant's last session visit for a final check-up in follow-ups.

Inclusion criteria

• The fourth month of pregnancy till the seventh month of the antenatal period.
• One week after delivery/birth till one year of a child in the postnatal period.
• Screened by PPDS as high-risk couples (for the level of severe symptomology) for Major Depressive Disorder (cut-off score 29 to 42) and/or Generalized Anxiety Disorder (cut-off score 17 to 24), and their Comorbidity.
• Dose requirements in any one of the antidepressant and/or anxiolytic, such as escitalopram (5-10 mg), sertraline (12.5-25 mg), and/or alprazolam (0.25-0.50 mg) per day.
• Wives accompanied by their husbands.
• Willingness to participate as a couple in the study.
• No physical disorder is present and/or no medication use.
• No psychiatric disorder history or presence
• No psychotropic medication use (presence or history)
• No disability is present.

Exclusion criteria

• Unwilling couples to participate in the study.
• Wife and/or couple is in an emergency.
• Wife and/or couple has unstable mental health.
• Wife accompanied by close relatives other than a spouse.
• Wife in the first week of delivery.
• Dose requirements in any one of the antidepressant and/or anxiolytic, such as escitalopram (above10 mg), sertraline (above 25 mg), and/or alprazolam (above 0.50 mg) per day.
• Couples screened with depressive disorder and/or anxiety disorder having psychotic features.
• Couples screened with depressive disorder and/or anxiety disorder having suicidal ideation.
• Couples screened with depressive disorder and/or anxiety disorder having mania/hypomanic features.
• Couples having diabetes.
• Couples having cardiovascular disorders.
• Presence or history of any physical or psychiatric disorder and/or use of medications
• Any intellectual, visual, or hearing disability present in either spouse of a couple.