Suicide remains a leading cause of maternal death in the perinatal period. Despite its urgency, there are currently no interventions specifically designed to reduce suicidal ideation (SI) and behavior among pregnant and postpartum women. Standard clinical practice focuses on treating underlying conditions like depression, anxiety, or psychosis, but whether this adequately addresses suicide risk is unclear.
A new study published in JAMA Psychiatry examined how suicidal ideation changed in women receiving a brief behavioral activation (BA) intervention for perinatal depression.
What is Behavioral Activation?
Behavioral activation is a structured, evidence-based psychotherapy that helps individuals identify patterns of avoidance and inactivity that worsen depression. The treatment emphasizes engaging in activities that provide a sense of meaning, mastery, and reconnection to personal values. For perinatal women, this can include re-establishing daily routines, increasing social support, and reconnecting with meaningful roles at a time when depressive symptoms may feel overwhelming. BA is considered a first-line psychotherapy for perinatal depression and can be delivered effectively in brief formats.
Overview of the SUMMIT Trial
The current study is a secondary analysis of data from the SUMMIT (Scaling Up Maternal Mental Health Care by Increasing Access to Treatment) trial, a large four-arm, noninferiority randomized controlled trial conducted across five academic health networks in Chicago, Illinois, Chapel Hill, North Carolina and Toronto, Ontario.
Eligible participants were pregnant women up to 36 weeks’ gestation or postpartum women 4 to 30 weeks after delivery presenting with depressive symptoms, defined as an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or higher.
Participants were randomized to one of four treatment arms:
- Specialists (psychiatrists, psychologists, social workers) delivering BA in person
- Specialists delivering BA via telemedicine
- Nonspecialists (nurses, midwives, doulas) delivering BA in person
- Nonspecialists delivering BA via telemedicine
Each participant received 6–8 weekly individual BA sessions according to a structured, manualized protocol.
Suicidal ideation was assessed using EPDS item 10: “In the past 7 days, the thought of harming myself has occurred to me” (scored 0–3, where higher scores indicate more frequent SI).
Results
A total of 1,230 women enrolled, and 1,117 completed at least one BA session. The mean age was 33.4 years. During treatment, 264 participants (23.6%) reported suicidal ideation. These individuals were more likely to be younger, to report more severe trauma symptoms at baseline, and to have a history of depression or anxiety compared with those who did not experience SI.
Key findings included:
- With each additional BA session, the odds of reporting SI decreased by 25% (OR 0.75; 95% CI, 0.58–0.96).
- At three months post-randomization, the odds of endorsing SI had decreased by 80% (OR 0.20; 95% CI, 0.14–0.27; P < .001).
- Reductions in SI did not vary by clinician type (specialist vs. nonspecialist) or delivery mode (in-person vs. telemedicine).
Notably, 10 participants (0.9%) did not show reductions in SI or reported worsening SI during later sessions. These individuals tended to be postpartum and had higher trauma and depressive symptoms.
Key Considerations and Future Directions
The current study demonstrates that a brief behavioral activation intervention significantly reduces suicidal ideation among perinatal women with depressive symptoms. Importantly, the effectiveness of BA was independent of whether the intervention was delivered by specialists or nonspecialists, and whether sessions occurred in person or via telehealth. This suggests that BA is a scalable and accessible intervention that could expand access to evidence-based care at a time when mental health resources for perinatal women remain limited.
In addition to reducing depressive symptoms, BA may mitigate suicide risk by increasing engagement in meaningful activities, reducing withdrawal and avoidance, and alleviating hopelessness through connection to personal values. Even in a relatively brief intervention, BA addresses many treatment priorities reported by women experiencing suicidal thoughts.
While participants were selected to participate in this study based on elevated EPDS scores, this measure is not diagnostic. Some women may have had bipolar or anxiety disorders rather than unipolar depression, raising questions about whether BA is effective across different diagnostic groups.
Additionally, some women continued to report SI despite treatment, suggesting that BA may need to be supplemented with other interventions for those with severe or trauma-related psychopathology. It is also important to recognize that SI can emerge independently of depression, particularly in the setting of trauma or substance use disorder; thus some individuals may require different interventions specifically targeting suicidality.
Future research should examine whether BA is comparably effective to other brief, targeted interventions and whether combined treatment approaches offer greater protection for high-risk subgroups.
Ruta Nonacs, MD PhD
References:
Kaliush PR, Molina NC, Berenbaum TS, Dennis CL, Gaynes BN, Meltzer-Brody S, Reyes-Rodríguez ML, Silver RK, Stuebe AM, Vigod SN, Schiller CE, Singla DR. Behavioral Activation for Perinatal Suicide Ideation: Secondary Analysis of a Noninferiority Randomized Clinical Trial. JAMA Psychiatry. 2025 Aug 20:e252116.
Singla DR, Silver RK, Vigod SN, et al. Task-sharing and telemedicine delivery of psychotherapy to treat perinatal depression: a pragmatic, noninferiority randomized trial. Nat Med. 2025; 31(4):1214-1224.
