The effects of clinical aromatherapy for anxiety and depression in the high risk postpartum woman e A pilot study

Complementary Therapies in Clinical Practice 18(2012)164-168 Contents lists available at SciVerse ScienceDirect CLINICAL PRACTICE Complementary Therapies in Clinical Practice ELSEVIER journal homepage:www.elsevier.com/locate/ctcp The effects of clinical aromatherapy for anxiety and depression in the high risk postpartum woman-A pilot study Pam Conrad a.*,Cindy Adamsb Wellspring Pharmacy.Community Hospital North,Community Health Network,Indianapolis,IN 46077.USA PPatient Care Services,Community Health Network,Indianapolis,IN.USA ABSTRACT Keywords: Objectives:The aim of this study was to determine if aromatherapy improves anxiety and/or depression Aromatherapy in the high risk postpartum woman and to provide a complementary therapy tool for healthcare Essential oils Complementary therapy practitioners. Women's health Design:The pilot study was observational with repeated measures. Mental health Setting:Private consultation room in a Women's center of a large Indianapolis hospital. Depression Subjects:28 women,0-18 months postpartum. Interventions:The treatment groups were randomized to either the inhalation group or the aromatherapy hand m'technique.Treatment consisted of 15 min sessions,twice a week for four consecutive weeks.An essential oil blend of rose otto and lavandula angustifolia@2%dilution was used in all treatments.The non-randomized control group,comprised of volunteers,was instructed to avoid aromatherapy use during the 4 week study period.Allopathic medical treatment continued for all participants. Outcome measurements:All subjects completed the Edinburgh Postnatal Depression Scale (EPDS)and Generalized Anxiety Disorder Scale(GAD-7)at the beginning of the study.The scales were then repeated at the midway point (two weeks).and at the end of all treatments (four weeks). Results:Analysis of Variance (ANOVA)was utilized to determine differences in EPDS and/or GAD-7 scores between the aromatherapy and control groups at baseline,midpoint and end of study.No significant differences were found between aromatherapy and control groups at baseline.The midpoint and final scores indicated that aromatherapy had significant improvements greater than the control group on both EPDS and GAD-7 scores.There were no adverse effects reported. Conclusion:The pilot study indicates positive findings with minimal risk for the use of aromatherapy as a complementary therapy in both anxiety and depression scales with the postpartum woman.Future large scale research in aromatherapy with this population is recommended. 2012 Elsevier Ltd.All rights reserved. 1.Introduction with 10%of women developing anxiety either alone or in combi- nation with depression. 1.1.Background Allopathic treatment of depression in adults is predominately prescription antidepressant medication,the most prescribed class of Postpartum depression lies within the category of Perinatal medication in the US for those 20-59 years of age."Individual,group Mood Disorders and is defined as moderate to severe depression in and support therapies are also widely used in the treatment of a woman after she has given birth.It is the most common medical depression and anxiety with varying degrees of success.The post- complication of childbearing.Wei G et al2 found the total rate of partum woman,generally healthy,young and without medical major and minor postpartum depression for all cultures to be 25.3%. conditions requiring medications,is often reluctant to accept According to Moses-Kolko et al,'in the perinatal woman,there is a psychiatric diagnosis and prescriptions for medication.As a conse- a high co-morbidity between depression and anxiety symptoms, quence,these women's depression and anxiety are undetected and undertreated.New mothers,often fearful of pharmaceutical medi- cations for themselves or concerns for their breast-fed infant,seek Corresponding author complementary alternative therapies to treat their symptoms. E-mail addresses:pconrad@ecommunity.com, conradpam@gmail.com Complementary therapies are widely accessed for various (P.Conrad).CAdams@ecommunity.com(C.Adams). physical and emotional discomforts,especially among women. 1744-3881/S-see front matter 2012 Elsevier Ltd.All rights reserved. doi10.1016j.ctcp.2012.05.002

The effects of clinical aromatherapy for anxiety and depression in the high risk postpartum woman e A pilot study Pam Conrad a,*, Cindy Adams b aWellspring Pharmacy, Community Hospital North, Community Health Network, Indianapolis, IN 46077, USA b Patient Care Services, Community Health Network, Indianapolis, IN, USA Keywords: Aromatherapy Essential oils Complementary therapy Women’s health Mental health Depression abstract Objectives: The aim of this study was to determine if aromatherapy improves anxiety and/or depression in the high risk postpartum woman and to provide a complementary therapy tool for healthcare practitioners. Design: The pilot study was observational with repeated measures. Setting: Private consultation room in a Women’s center of a large Indianapolis hospital. Subjects: 28 women, 0e18 months postpartum. Interventions: The treatment groups were randomized to either the inhalation group or the aromatherapy hand m’technique. Treatment consisted of 15 min sessions, twice a week for four consecutive weeks. An essential oil blend of rose otto and lavandula angustifolia @ 2% dilution was used in all treatments. The non-randomized control group, comprised of volunteers, was instructed to avoid aromatherapy use during the 4 week study period. Allopathic medical treatment continued for all participants. Outcome measurements: All subjects completed the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder Scale (GAD-7) at the beginning of the study. The scales were then repeated at the midway point (two weeks), and at the end of all treatments (four weeks). Results: Analysis of Variance (ANOVA) was utilized to determine differences in EPDS and/or GAD-7 scores between the aromatherapy and control groups at baseline, midpoint and end of study. No significant differences were found between aromatherapy and control groups at baseline. The midpoint and final scores indicated that aromatherapy had significant improvements greater than the control group on both EPDS and GAD-7 scores. There were no adverse effects reported. Conclusion: The pilot study indicates positive findings with minimal risk for the use of aromatherapy as a complementary therapy in both anxiety and depression scales with the postpartum woman. Future large scale research in aromatherapy with this population is recommended.
2012 Elsevier Ltd. All rights reserved. 1. Introduction 1.1. Background Postpartum depression lies within the category of Perinatal Mood Disorders and is defined as moderate to severe depression in a woman after she has given birth. It is the most common medical complication of childbearing.1 Wei G et al2 found the total rate of major and minor postpartum depression for all cultures to be 25.3%. According to Moses-Kolko et al,3 in the perinatal woman, there is a high co-morbidity between depression and anxiety symptoms, with 10% of women developing anxiety either alone or in combi￾nation with depression. Allopathic treatment of depression in adults is predominately prescription antidepressant medication, the most prescribed class of medication in the US for those 20e59 years of age.4 Individual, group and support therapies are also widely used in the treatment of depression and anxiety with varying degrees of success. The post￾partum woman, generally healthy, young and without medical conditions requiring medications, is often reluctant to accept a psychiatric diagnosis and prescriptions for medication. As a conse￾quence, these women’s depression and anxiety are undetected and undertreated.5 New mothers, often fearful of pharmaceutical medi￾cations for themselves or concerns for their breast-fed infant, seek complementary alternative therapies to treat their symptoms. Complementary therapies are widely accessed for various physical and emotional discomforts, especially among women. * Corresponding author. E-mail addresses: pconrad@ecommunity.com, conradpam@gmail.com (P. Conrad), CAdams@ecommunity.com (C. Adams). Contents lists available at SciVerse ScienceDirect Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp 1744-3881/$ e see front matter
2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2012.05.002 Complementary Therapies in Clinical Practice 18 (2012) 164e168

P.Conrad,C.Adams Complementary Therapies in Clinical Practice 18 (2012)164-168 165 Eisenberg5 found that 48.9%of women,mostly college educated. create a 2%dilution was used in all treatments.The essential oils use some form of complementary or alternative medicine in were sourced from Arlys,Ft Lauderdale Florida,USA,which treatment for a variety of conditions.In the 2007 statistics on provides gas chromatography and mass spectrometry (GC/MS) Complementary Alternative Medicine (CAM)use in the United analysis to validate chemical composition and purity.The carriers States,anxiety and depression rated in the top five conditions for for the essential oil blend were unscented white lotion in the hand self care with complementary therapies among the US population. m'technique and jojoba oil for the inhalation blend.The blend was Natural products,of which aromatherapy could be included,ranked compounded at Wellspring pharmacy,Indianapolis.A cosmetic as the #1 most popular category for CAM use.'Clinical Aroma- cotton pad,cost effective and readily available,was infused with 8 therapy,a sub-specialty practiced by nurses with advanced drops of the 2%blend for the inhalation group. aromatherapy education,is the therapeutic use of essentials oils to achieve measureable outcomes for a healthcare condition. 3.Methods 1.2.Aromatherapy for anxiety and depression In the study.28 postpartum women were recruited from maternity and neonatal intensive care hospital units,lactation and Wilkinson et al.9 studied aromatherapy massage in a large multi- postpartum support groups.Birdie Meyer,MA,RN,past president of center trial of cancer patients that experienced anxiety and/or Postpartum Support International (PSI),indicated that women depression.These patients experienced significant improvement in frequently request initial support one year postpartum after anxiety and/or depression for the six week randomization study, exhausting all personal resources(Personal communication)Based compared with those receiving usual care alone.Lee YL et al10 on expert information,inclusion for the study was 0-18 months reviewed sixteen randomized control trials of aromatherapy postpartum.The pilot study design was observational with studies for anxiety symptoms.Fourteen of the sixteen studies repeated measures.Inclusion required informed consent and reported positive findings as to the anxiolytic effects of aroma- a questionnaire to rule out conditions that would exclude partici- therapy,while the remaining two studies reported no effect of the pation,such as allergies to the essential oils and inability to attend aromatherapy toward anxiety symptoms.In these sixteen studies. eight treatment sessions.In addition,all qualifying women had to lavender was the most commonly used essential oil.Yim et all score 10 or higher on either the Edinburgh Postnatal Depression found a notable lack of studies on aromatherapy use for the treat- ment of depression or depressive symptoms.The six studies meeting Scale(EPDS)5 or the Generalized Anxiety Disorder Scale(GAD-7).16 indicating mild to moderate depression or anxiety respectively.The their criteria suggested aromatherapy may improve the mood of 10 question Edinburgh Postnatal Depression Scale (EPDS).devel- patients with depressive symptoms and the team recommended oped in 1987,is a valuable and efficient way of identifying patients continuation of aromatherapy as a complementary therapy for at risk for "perinatal"depression.The EPDS is easy to administer patients with depressive symptoms.Imura et al12 examined the and has proven to be an effective worldwide screening tool by effect of aromatherapy-massage in healthy postpartum mothers.In women's health and mental health professionals.The EPDS was the aromatherapy-massage group.post treatment scores signifi- found to have satisfactory sensitivity and specificity,and was also cantly decreased in the Approach/Feeling toward Baby subscale. sensitive to change in the severity of depression over time.The Their results suggest that aromatherapy-massage might be an scale can be completed in about 5 min and has a simple method of effective intervention for postpartum mothers to improve physical scoring.15 The GAD-7 developed in 2006 is a useful tool with strong and mental status and to facilitate mother-infant interaction. criterion validity for identifying probable cases of General Anxiety Disorder.The GAD-7 is a valid and efficient tool that is self 1.3.Aromatherapy in maternity care administered and can be completed and scored in a few minutes.16 The aromatherapy treatment groups(N =14,6-inhalation and In Clinical Aromatherapy for Pregnancy and Childbirth,Tiran3 8-dilute skin application using the hand m'technique on both states that the essential oils most consistently used for anxiety hands)were randomized by picking a number 1 (inhalation)or 2 and depression are lavender,jasmine,ylang-ylang.sandalwood, (hand m'technique)from an envelope to either the inhalation bergamot and rose.Burns et all4 conducted an eight year experimental group or hand m'technique groups.The m'technique is a registered study of 8058 women and explored the use of ten essential oils to ease method of gentle stroking movements performed a set number of pain,anxiety,nausea and enhance contractions during labor and times,in a set pattern,at a set pressure and speed that never childbirth.Overall,laboring women rated the aromatherapy as helpful. change.The technique is completely structured and reproducible, with rose and lavender essential oils as the most beneficial for anxiety. making it useful in research.(Buckle 2003)8 The inhalation group In 2008,the Burns maternity aromatherapy program was replicated by were given a cotton pad infused with 8 drops of the 2%rose. the author and a group ofOB unit nurses at Community North Hospital lavender blend and instructed to inhale the blend for 15 min.One in Indianapolis,extending the treatments through the early post- partum period.The laboring and postpartum patients were the most woman in the m'technique treatment group dropped out of the study after 4 treatments/2 weeks due to transportation issues,thus frequent recipients of aromatherapy(47%and 33%respectively). at the end of the study,N =13 remained in the treatment group. The focus of this investigation grew from the results of the above Treatment consisted of 15 min sessions,twice a week for four mentioned studies,which suggested that further work exploring consecutive weeks.All participants repeated the EPDS and GAD-7 the effects of aromatherapy on anxiety and depression in the high risk postpartum woman might be beneficial. Table 1 Baseline,midpoint and final scores. 2.Materials and methods Baseline scores Midpoint scores Final scores 2.1.Materials Mean F Sig Mean F Sig Mean F Sig Edinburgh Control 15.90.020.8012.34.500.0412.17.000.01 An essential oil blend of rose otto.25(Rosa damascena,Bulgaria) Edinburgh-Intervention 16.1 9.2 7.1 and lavender.75(Lavandula angustifolia,France)2 drops of the GAD Control 12.41100.319.35.000.037.35.800.02 GAD-Intervention 13.9 5.9 4.4 rosellavender blend combined with 5 ml of carrier lotion or oil to

Eisenberg6 found that 48.9% of women, mostly college educated, use some form of complementary or alternative medicine in treatment for a variety of conditions. In the 2007 statistics on Complementary Alternative Medicine (CAM) use in the United States, anxiety and depression rated in the top five conditions for self care with complementary therapies among the US population. Natural products, of which aromatherapy could be included, ranked as the #1 most popular category for CAM use.7 Clinical Aroma￾therapy, a sub-specialty practiced by nurses with advanced aromatherapy education, is the therapeutic use of essentials oils to achieve measureable outcomes for a healthcare condition.8 1.2. Aromatherapy for anxiety and depression Wilkinson et al.9 studied aromatherapy massage in a large multi￾center trial of cancer patients that experienced anxiety and/or depression. These patients experienced significant improvement in anxiety and/or depression for the six week randomization study, compared with those receiving usual care alone. Lee YL et al10 reviewed sixteen randomized control trials of aromatherapy studies for anxiety symptoms. Fourteen of the sixteen studies reported positive findings as to the anxiolytic effects of aroma￾therapy, while the remaining two studies reported no effect of the aromatherapy toward anxiety symptoms. In these sixteen studies, lavender was the most commonly used essential oil. Yim et al11 found a notable lack of studies on aromatherapy use for the treat￾ment of depression or depressive symptoms. The six studiesmeeting their criteria suggested aromatherapy may improve the mood of patients with depressive symptoms and the team recommended continuation of aromatherapy as a complementary therapy for patients with depressive symptoms. Imura et al12 examined the effect of aromatherapy-massage in healthy postpartum mothers. In the aromatherapy-massage group, post treatment scores signifi- cantly decreased in the Approach/Feeling toward Baby subscale. Their results suggest that aromatherapy-massage might be an effective intervention for postpartum mothers to improve physical and mental status and to facilitate mothereinfant interaction. 1.3. Aromatherapy in maternity care In Clinical Aromatherapy for Pregnancy and Childbirth, Tiran13 states that the essential oils most consistently used for anxiety and depression are lavender, jasmine, ylangeylang, sandalwood, bergamot and rose. Burns et al14 conducted an eight year experimental study of 8058 women and explored the use of ten essential oils to ease pain, anxiety, nausea and enhance contractions during labor and childbirth. Overall,laboringwomen rated the aromatherapy as helpful, with rose and lavender essential oils as the most beneficial for anxiety. In 2008, the Burnsmaternity aromatherapy programwas replicated by the author and a group of OB unit nurses at Community North Hospital in Indianapolis, extending the treatments through the early post￾partum period. The laboring and postpartum patients were the most frequent recipients of aromatherapy (47% and 33% respectively). The focus of this investigation grew from the results of the above mentioned studies, which suggested that further work exploring the effects of aromatherapy on anxiety and depression in the high risk postpartum woman might be beneficial. 2. Materials and methods 2.1. Materials An essential oil blend of rose otto .25 (Rosa damascena, Bulgaria) and lavender .75 (Lavandula angustifolia, France) 2 drops of the rose/lavender blend combined with 5 ml of carrier lotion or oil to create a 2% dilution was used in all treatments. The essential oils were sourced from Arlys, Ft Lauderdale Florida, USA, which provides gas chromatography and mass spectrometry (GC/MS) analysis to validate chemical composition and purity. The carriers for the essential oil blend were unscented white lotion in the hand m’technique and jojoba oil for the inhalation blend. The blend was compounded at Wellspring pharmacy, Indianapolis. A cosmetic cotton pad, cost effective and readily available, was infused with 8 drops of the 2% blend for the inhalation group. 3. Methods In the study, 28 postpartum women were recruited from maternity and neonatal intensive care hospital units, lactation and postpartum support groups. Birdie Meyer, MA, RN, past president of Postpartum Support International (PSI), indicated that women frequently request initial support one year postpartum after exhausting all personal resources (Personal communication) Based on expert information, inclusion for the study was 0e18 months postpartum. The pilot study design was observational with repeated measures. Inclusion required informed consent and a questionnaire to rule out conditions that would exclude partici￾pation, such as allergies to the essential oils and inability to attend eight treatment sessions. In addition, all qualifying women had to score 10 or higher on either the Edinburgh Postnatal Depression Scale (EPDS)15 or the Generalized Anxiety Disorder Scale (GAD-7),16 indicating mild to moderate depression or anxiety respectively. The 10 question Edinburgh Postnatal Depression Scale (EPDS), devel￾oped in 1987, is a valuable and efficient way of identifying patients at risk for “perinatal” depression. The EPDS is easy to administer and has proven to be an effective worldwide screening tool by women’s health and mental health professionals. The EPDS was found to have satisfactory sensitivity and specificity, and was also sensitive to change in the severity of depression over time. The scale can be completed in about 5 min and has a simple method of scoring.15 The GAD-7 developed in 2006 is a useful tool with strong criterion validity for identifying probable cases of General Anxiety Disorder. The GAD-7 is a valid and efficient tool that is self administered and can be completed and scored in a few minutes.16 The aromatherapy treatment groups (N ¼ 14, 6-inhalation and 8-dilute skin application using the hand m’technique on both hands) were randomized by picking a number 1 (inhalation) or 2 (hand m’technique) from an envelope to either the inhalation group or hand m’technique groups. The m’technique is a registered method of gentle stroking movements performed a set number of times, in a set pattern, at a set pressure and speed that never change. The technique is completely structured and reproducible, making it useful in research. (Buckle 2003)8 The inhalation group were given a cotton pad infused with 8 drops of the 2% rose, lavender blend and instructed to inhale the blend for 15 min. One woman in the m’technique treatment group dropped out of the study after 4 treatments/2 weeks due to transportation issues, thus at the end of the study, N ¼ 13 remained in the treatment group. Treatment consisted of 15 min sessions, twice a week for four consecutive weeks. All participants repeated the EPDS and GAD-7 Table 1 Baseline, midpoint and final scores. Baseline scores Midpoint scores Final scores Mean F Sig Mean F Sig Mean F Sig Edinburgh e Control 15.9 0.02 0.80 12.3 4.50 0.04 12.1 7.00 0.01 Edinburgh e Intervention 16.1 9.2 7.1 GAD e Control 12.4 1.10 0.31 9.3 5.00 0.03 7.3 5.80 0.02 GAD e Intervention 13.9 5.9 4.4 P. Conrad, C. Adams / Complementary Therapies in Clinical Practice 18 (2012) 164e168 165

166 P.Conrad.C.Adams Complementary Therapies in Clinical Practice 18(2012)164-168 Table 2 Table 4 ANOVA change scores. Aromatherapy combined vs controL Group statistics. Sum of df Mean Sig. Aromatherapy N Mean Std. Std.error squares square vs control deviation mean Edinburg Between groups 135.692 67.846 5.941 0.008 Edinburg change mid 14 3.57 3.031 0.810 change mid Within groups 285522 25 11421 14 6.86 4.171 1.115 Total 421214 27 Edinburg change end 1 13 4.27 3.127 0.867 Edinburg Between groups 160.777 2 80.388 4.206 0.028 2 13 9.04 5.285 1.466 change end Within groups 439.608 23 19.113 GAD change mid 1 14 307 3.990 1066 Total 600.385 25 2 14 7.93 4.160 1.112 GAD change mid Between groups 170863 85.432 5.012 0.015 GAD change end 13 4.62 3.595 09g7 Within groups 426.137 17.045 10.00 4.564 1.266 Total 597.000 27 GAD change end Between groups 196.587 98.293 5.6950.010 Within groups 396.952 23 17.259 Total 593538 25 medication for depression.All allopathic medical treatments and therapies continued for all participants throughout the study duration.They were requested to advise the author of any medi- cation changes.All participants had access to the nurse aroma- questionnaires at the midway point(two weeks),and at the end of therapist for questions during the study duration. all treatments (four weeks).The EPDS and GAD-7 scores were entered into a confidential excel data program.The nurse/aroma- To ensure the safety of the participants,a mental health thera- therapist conducted all treatments alone on weekday mornings pist was available for the women during the study.This proved to be a prudent precaution as a few women indicated on the EPDS with the mothers in the same quiet room,without conversation or questionnaire that they had considered harming themselves in the children. previous 7-14 days.One woman demonstrated suicidal tendencies The non-randomized control group(N=14).continued tradi- and was immediately referred to the crisis team.Another woman tional medical treatment,support groups and individual therapy as displayed manic behavior and was admitted to the hospital for needed but did not receive or use any aromatherapy for the four mental health treatment.The mental health assessment protocol week period of their participation.The control group was non- randomized as women found the guidelines of time commitment was an important adjunct to this study,and any follow-up work in this area should include a mental health network. and childcare for the treatment group difficult so if eligible,they volunteered for the control group in order to support the study.One woman in the control group dropped out after the midway point, 4.Results thus N=13 at the end if the study in the control group.They also completed the EPDS and GAD-7 questionnaires at the beginning. Statistical analysis was performed using SPSS version 17.0. midway point(two weeks).and at the end of all treatments(four Descriptive statistics indicated that among the 28 subjects,the weeks). mean age was 32(range 25-43 years,SD 4.4).The mean number of Overall,57.1%of the women had a prior history of anxiety and pregnancies was 1.4(range 1-5,SD.9).The mean Edinburgh Score 64.3%had a prior history of depression.At the time of the study, at baseline was 16(range 10-25,SD 3.8)A score of 10 or greater is 46.4%were on medication for anxiety and 57.1%were on indicative of possible depression.5 The mean GAD Score at baseline Table 3 Tukey's HSD post hoc analysis.Multiple comparisons. Dependent variable (treatment group (treatment group Mean difference (I-) Std.error Sig. 95%confidence interval Lower bound Upper bound Edinburg change mid Control rest Inhalation -1.491 1498 0586 -522 224 Hand massage -5.6793 1.649 0.006 -9.79 -1.57 Inhalation Control rest 1491 1.498 0.586 -224 522 Hand massage -4.188 1.825 0.075 -8.73 036 Hand massage Control rest 5.6791 1.649 0.006 1.57 9.79 Inhalation 4.188 1.825 0.075 -036 8.73 Edinburg change end Control rest Inhalation -3.981 1.965 0.128 -8.90 0.94 Hand massage -6.0311 2301 0.039 -11.79 -2.7 Inhalation Control rest 3.981 1965 0.128 -0.94 8.90 Hand massage -2.050 2.492 0.693 -829 4.19 Hand massage Control rest 6.0311 2.301 .039 027 11.79 Inhalation 2.050 2.492 0.693 -4.19 829 GAD change mid Control rest Inhalation -4304 1830 0.06 -886 025 Hand massage -5.595 2.015 .027 -10.61 -0.58 Inhalation Control rest 4.304 1830 0.067 -025 8.86 Hand massage -1.292 2230 0.832 -6.85 426 Hand massage Control rest 5.595 2.015 0.027 0.58 10.61 Inhalation 1.292 2230 0.832 -426 685 GAD change end Control rest Inhalation -4.7603 1.867 0.045 -9.43 -0.08 Hand massage -6.3852 2.186 0020 -1186 -0.91 Inhalation Control rest 4.760 1867 0.045 0.08 9.43 Hand massage -1.625 2.368 0.774 -7.56 431 Hand massage Control rest 6.385 2.186 0.020 091 1186 Inhalation 1.625 2.368 0.774 -4.31 7.56 The mean diffe significant at the 0.05 level

questionnaires at the midway point (two weeks), and at the end of all treatments (four weeks). The EPDS and GAD-7 scores were entered into a confidential excel data program. The nurse/aroma￾therapist conducted all treatments alone on weekday mornings with the mothers in the same quiet room, without conversation or children. The non-randomized control group (N ¼ 14), continued tradi￾tional medical treatment, support groups and individual therapy as needed but did not receive or use any aromatherapy for the four week period of their participation. The control group was non￾randomized as women found the guidelines of time commitment and childcare for the treatment group difficult so if eligible, they volunteered for the control group in order to support the study. One woman in the control group dropped out after the midway point, thus N ¼ 13 at the end if the study in the control group. They also completed the EPDS and GAD-7 questionnaires at the beginning, midway point (two weeks), and at the end of all treatments (four weeks). Overall, 57.1% of the women had a prior history of anxiety and 64.3% had a prior history of depression. At the time of the study, 46.4% were on medication for anxiety and 57.1% were on medication for depression. All allopathic medical treatments and therapies continued for all participants throughout the study duration. They were requested to advise the author of any medi￾cation changes. All participants had access to the nurse aroma￾therapist for questions during the study duration. To ensure the safety of the participants, a mental health thera￾pist was available for the women during the study. This proved to be a prudent precaution as a few women indicated on the EPDS questionnaire that they had considered harming themselves in the previous 7e14 days. One woman demonstrated suicidal tendencies and was immediately referred to the crisis team. Another woman displayed manic behavior and was admitted to the hospital for mental health treatment. The mental health assessment protocol was an important adjunct to this study, and any follow-up work in this area should include a mental health network. 4. Results Statistical analysis was performed using SPSS version 17.0. Descriptive statistics indicated that among the 28 subjects, the mean age was 32 (range 25e43 years, SD 4.4). The mean number of pregnancies was 1.4 (range 1e5, SD .9). The mean Edinburgh Score at baseline was 16 (range 10e25, SD 3.8) A score of 10 or greater is indicative of possible depression.15 The mean GAD Score at baseline Table 2 ANOVA change scores. Sum of squares df Mean square F Sig. Edinburg change mid Between groups 135.692 2 67.846 5.941 0.008 Within groups 285.522 25 11.421 Total 421.214 27 Edinburg change end Between groups 160.777 2 80.388 4.206 0.028 Within groups 439.608 23 19.113 Total 600.385 25 GAD change mid Between groups 170.863 2 85.432 5.012 0.015 Within groups 426.137 25 17.045 Total 597.000 27 GAD change end Between groups 196.587 2 98.293 5.695 0.010 Within groups 396.952 23 17.259 Total 593.538 25 Table 3 Tukey’s HSD post hoc analysis. Multiple comparisons. Dependent variable (I) treatment group (J) treatment group Mean difference (IJ) Std. error Sig. 95% confidence interval Lower bound Upper bound Edinburg change mid Control rest Inhalation 1.491 1.498 0.586 5.22 2.24 Hand massage 5.679a 1.649 0.006 9.79 1.57 Inhalation Control rest 1.491 1.498 0.586 2.24 5.22 Hand massage 4.188 1.825 0.075 8.73 0.36 Hand massage Control rest 5.679a 1.649 0.006 1.57 9.79 Inhalation 4.188 1.825 0.075 0.36 8.73 Edinburg change end Control rest Inhalation 3.981 1.965 0.128 8.90 0.94 Hand massage 6.031a 2.301 0.039 11.79 2.7 Inhalation Control rest 3.981 1.965 0.128 0.94 8.90 Hand massage 2.050 2.492 0.693 8.29 4.19 Hand massage Control rest 6.031a 2.301 .039 0.27 11.79 Inhalation 2.050 2.492 0.693 4.19 8.29 GAD change mid Control rest Inhalation 4.304 1.830 0.067 8.86 0.25 Hand massage 5.595a 2.015 .027 10.61 0.58 Inhalation Control rest 4.304 1.830 0.067 0.25 8.86 Hand massage 1.292 2.230 0.832 6.85 4.26 Hand massage Control rest 5.595a 2.015 0.027 0.58 10.61 Inhalation 1.292 2.230 0.832 4.26 6.85 GAD change end Control rest Inhalation 4.760a 1.867 0.045 9.43 0.08 Hand massage 6.385a 2.186 0.020 11.86 0.91 Inhalation Control rest 4.760a 1.867 0.045 0.08 9.43 Hand massage 1.625 2.368 0.774 7.56 4.31 Hand massage Control rest 6.385a 2.186 0.020 0.91 11.86 Inhalation 1.625 2.368 0.774 4.31 7.56 a The mean difference is significant at the 0.05 level. Table 4 Aromatherapy combined vs control. Group statistics. Aromatherapy vs control N Mean Std. deviation Std. error mean Edinburg change mid 1 14 3.57 3.031 0.810 2 14 6.86 4.171 1.115 Edinburg change end 1 13 4.27 3.127 0.867 2 13 9.04 5.285 1.466 GAD change mid 1 14 3.07 3.990 1.066 2 14 7.93 4.160 1.112 GAD change end 1 13 4.62 3.595 0.997 2 13 10.00 4.564 1.266 166 P. Conrad, C. Adams / Complementary Therapies in Clinical Practice 18 (2012) 164e168

P.Conrad,C.Adams Complementary Therapies in Clinical Practice 18(2012)164-168 167 Table 5 Independent samples t-test Levene's test t-test for equality of means for equality of df variances Sig.(2-tailed)Mean Difference Std.error Difference 95%confidence interval of the ditterence Sig. Lower Upper Edinburg change mid Equal variances assumed 19630.173-2.38426 0025 -3.286 1.378 -6.118-0.453 Equal variances not assumed -2.800 24 0.010 -4.769 1.703 -8.284 -1.254 Edinburg change mid Equal variances assumed 1.4600.239 -2.800 24 0.010 -4.769 1.703 -8.328 -1.254 Equal variances not assumed -2800 19.4820011 -4769 1.703 -8.328 -1210 GAD change mid Equal variances assumed 0.084 0.774 -3.153 26 0.004 -4.857 1.540 -8.023 -1691 Equal variances not assumed -3.153 25.955 0004 -4857 1.540 -8024 -1691 GAD change end Equal variances assumed 1.8120.191 -3.342 24 0.003 -5.385 1.611 -8.710 -2.059 Equal variances not assumed -3.342 22.7510.003 -5.385 1.611 -8.720 -2.049 was 13 (range 4-18,SD 3.9).A score of 10 or greater on the GAD-7 5.Discussion represents a reasonable cut point for identifying cases of General Anxiety Disorder.Scores of 5.10,and 15 are interpreted as repre- The study design used two separate aromatherapy interven- senting mild,moderate,and severe levels of anxiety on the GAD- tions,inhalation and the m'technique(touch),and both interven- 7.16 tion methods employed the same essential oil blend.Although the Analysis of Variance(ANOVA)was utilized to determine differ- m'technique demonstrated a higher statistically significant differ- ences in Edinburgh or GAD scores between the intervention and ence from the control group than the inhalation technique,both control groups at baseline.No significant (p0.05 for all 2002:347No3194-9. 2.Wei G.Greaver LB.Marson SM,Herndon CH,Rogers J.Robeson Healthcare comparisons).(Table 5). Corporation.Postpartum depression:racial differences and ethnic disparities in

was 13 (range 4e18, SD 3.9). A score of 10 or greater on the GAD-7 represents a reasonable cut point for identifying cases of General Anxiety Disorder. Scores of 5, 10, and 15 are interpreted as repre￾senting mild, moderate, and severe levels of anxiety on the GAD- 7.16 Analysis of Variance (ANOVA) was utilized to determine differ￾ences in Edinburgh or GAD scores between the intervention and control groups at baseline. No significant (p 0.05 for all comparisons). (Table 5). 5. Discussion The study design used two separate aromatherapy interven￾tions, inhalation and the m’technique (touch), and both interven￾tion methods employed the same essential oil blend. Although the m’technique demonstrated a higher statistically significant differ￾ence from the control group than the inhalation technique, both aromatherapy methods showed improvement. Since the final GAD mean score for inhalation showed a significant difference from the control group, this suggests the inhalation technique may require longer or more frequent exposure to enact a positive cumulative effect upon anxiety. If future studies are conducted, it is recommended to have larger sample sizes with more frequent treatments (4 times per week). In addition to the population in this study, the author recommends conducting aromatherapy studies for those diagnosed with anxiety and/or depression in the general population. 6. Conclusion The pilot study indicates positive findings for the use of aromatherapy as an adjunct to, but not a replacement of, allopathic care for both anxiety and depression with the high risk postpartum woman. Limiting factors in this study were the non-randomized control group and small sample size; however, due to the positive findings, future large scale research is recommended. Conflict of interest statement No competing financial interests exist. Acknowledgements The author wishes to acknowledge the Alliance of International Aromatherapists (AIA) for awarding the grant to conduct this study. Sue Detamore, Director of Wellspring pharmacy for support of the study. Cindy Adams PhD, ANP-BC, RN, Chief Nursing Officer at Community Health Network for the statistical analysis, Birdie Meyer RN, MA, past president of PSI for her expertise in perinatal mood disorders and Marcia Boring LCSW for providing mental health support for the study participants. Most of all many thanks to all of the women who shared their time and experiences and to Barb, the inspiration for the study. References 1. Wisner KL, Parry BL, Piontek CM. Postpartum depression. N Engl J Med July 18, 2002;347(No 3):194e9. 2. Wei G, Greaver LB, Marson SM, Herndon CH, Rogers J, Robeson Healthcare Corporation. Postpartum depression: racial differences and ethnic disparities in Table 5 Independent samples t-test. Levene’s test for equality of variances t-test for equality of means t df Sig. (2-tailed) Mean Difference Std. error Difference 95% confidence interval of the difference F Sig. Lower Upper Edinburg change mid Equal variances assumed 1.963 0.173 2.384 26 0.025 3.286 1.378 6.118 0.453 Equal variances not assumed 2.800 24 0.010 4.769 1.703 8.284 1.254 Edinburg change mid Equal variances assumed 1.460 0.239 2.800 24 0.010 4.769 1.703 8.328 1.254 Equal variances not assumed 2.800 19.482 0.011 4.769 1.703 8.328 1.210 GAD change mid Equal variances assumed 0.084 0.774 3.153 26 0.004 4.857 1.540 8.023 1.691 Equal variances not assumed 3.153 25.955 0.004 4.857 1.540 8.024 1.691 GAD change end Equal variances assumed 1.812 0.191 3.342 24 0.003 5.385 1.611 8.710 2.059 Equal variances not assumed 3.342 22.751 0.003 5.385 1.611 8.720 2.049 P. Conrad, C. Adams / Complementary Therapies in Clinical Practice 18 (2012) 164e168 167

168 P.Conrad.C.Adams Complementary Therapies in Clinical Practice 18 (2012)164-168 a tri-racial and bi-ethnic population.Matern Child Health 2008 and depression in patients with cancer:a multicenter randomized controlled Nov:12(6):699-707.Epub20070ct23. trial.I Clin Oncol 2007:25:532-9. 3.Moses-Kolko EL.Roth EK.Antepartum and postpartum depression: 10.Lee YL,Wu Y,Tsang HW.Leung AY,Cheung WM.A systematic review on the healthy mom,healthy baby.J Am Med Womens Assoc 2004:59(3):181-91. anxiolytic effects of aromatherapy in people with anxiety symptoms.J Altern Summer. Complement Med 2011:17(2):101- 8 4.Gu Q,Dillon CF.Burt VL Prescription drug use continues to increase:U.S. 11.Yim VW.Nig AK,Tsang HW.Leung AY.A review on the effects of aromatherapy for ta10:2)Hlle patients with depressive symptoms JAlter Complement Med2009:15(2):18795. 12.imura M.Misao H.Ushijima H.The psychological effects of aromatherapy- 5.Marcus S.Depression during pregnancy:rates,risks and consequences.Can J massage in healthy postpartum mothers.J Midwifery Womens Health Clin Pharmacol Winter 2009:16(1). 2006:5121-7. 6.Eisenberg DM,Davis RB.Ettner SL,Appel S,Wilkey S,Van Rompay M.et al. 13.Tiran D.Clinical aromatherapy for pregnancy and childbirth.2nd ed.Edinburgh: Trends in alternative medicine use in the United States,1990-1997:results of Churchill Livingstone:2000. a follow-up national survey.JAMA 1998 Nov 11:280(18):1569-75. 14.Burns EE,Blamey C.Ersser SJ.Barnetson L Lloyd AJ.An investigation into the 7.Barnes PM,Bloom B.Nahin R.Complementary and alternative medicine use use of aromatherapy in intrapartum midwifery practice.J Altem Complement among adults and children:United States,2007.CDC national health statistics Med2000:6(2):141-7. report #12 December 2008. 15.Cox JL Holden JM,Sagovsky R.Detection of postnatal depression:development 8.Buckle J.Clinical aromatherapy essential oils in practice.2nd ed.Churchill Liv- of the 10-item Edinburgh postnatal depression scale.Br J Psychiatry ingston:2003. 1987:150:782-6. 9.Wilkinson SM.Love SB.Westcombe AM,Gambles MA,Burgess CC.Cargill A. 16.Spitzer RL,Kroenke K,Williams JBW.Lowe B.A brief measure for assessing et al.Effectiveness of aromatherapy massage in the management of anxiety generalized anxiety disorder:the GAD-7.Arch Inter Med 2006:166:1092-7

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