November 18, 2025

Task-Sharing: A Behavioral Activation Intervention for Perinatal Depression Could Expand Access to Care

Postpartum Depression, Postpartum Psychiatric Disorders, Treatment

Behavioral activation intervention, whether delivered by specialists or non-specialists, was effective for the treatment of perinatal depression and anxiety.

Ruta Nonacs, MD PhD

Currently, many women experiencing perinatal mood and anxiety disorders (PMADs) face significant barriers to accessing treatment. Although awareness has increased and we have more clinicians providing perinatal mental health care, the availability of qualified specialists remains limited, particularly in low-resource and rural areas. Even where health systems are robust, treatment rates for PMADs are low, due to persistent provider shortages, inequities in healthcare access, and gaps in continuity of care during pregnancy and the postpartum period.

Initiatives such as perinatal psychiatry access programs have been working to improve identification and treatment initiation rates. However, recent studies show that only a small percentage of women with these disorders receive psychotherapy or other evidence-based treatments.

What is Task-Sharing?

Task-sharing is a collaborative, team-based strategy for mental healthcare delivery in which specific clinical tasks can be delivered by non-specialists—such as community health workers, nurses, or lay counselors—who receive targeted training and supervision. This model has been successfully implemented in rural communities to improve the delivery of mental health services.

With task-sharing, the role of mental health specialists shifts away from providing direct clinical care toward training, supervising, and supporting non-specialist providers, thus expanding the reach of services and helping close treatment gaps. Task-sharing can also be paired with telemedicine and digital interventions, enabling regular supervision and quality assurance regardless of provider location.

Behavioral Activation Intervention for PMADs

Behavioral activation (BA) is a structured, evidence-based psychotherapy designed to help individuals with depression and mood disorders by increasing their engagement in meaningful and rewarding activities. It is based on the understanding that depression often leads to avoidance and withdrawal from positive experiences, which in turn worsens mood. By systematically encouraging patients to participate in activities aligned with their values and interests, behavioral activation aims to reverse this cycle, thereby improving mood and reducing depressive symptoms.

The SUMMIT (Scaling Up Maternal Mental Health Care by Increasing Access to Treatment) trial assessed the effectiveness of BA in women with perinatal depression. This was 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 who presented with depressive symptoms, defined as an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or higher.

Participants were randomized to one of four treatment conditions:

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

Participants were offered eight weekly sessions of BA. Details of the BA intervention used in this study can be found HERE.

Participants in all groups experienced clinically meaningful reductions in depression and anxiety symptoms. BA was effective for depression whether mild, moderate, or severe. Outcomes were comparable across specialist and non-specialist providers, and between in-person and telehealth formats. Additionally, secondary analysis showed that BA reduced suicidal ideation.

Expanding Access to Treatment

Over the past several decades, awareness of PMADs has grown, and screening efforts have increased. Despite a larger number of perinatal mental health providers, many women struggle to find affordable mental health services.

The SUMMIT Trial demonstrates that behavioral activation is effective for the treatment of depressive symptoms and anxiety, regardless of who delivered the intervention (specialist or non-specialist) or the format (in-person or telehealth). This study is in line with other studies using non-specialists to provide treatment to individuals with PMADs. A previous systematic review of 45 randomized controlled trials of nonspecialist-delivered psychological interventions for perinatal populations demonstrated that nonspecialists, typically nurses and midwives, could be trained to deliver psychological treatments for perinatal populations with depressive and anxiety symptoms.

Globally, task-sharing has been a promising approach to expanding access to mental healthcare in under-resourced areas where there are inadequate numbers of mental health providers. In the United States, we have more mental health professionals than in other countries; however, specialist providers are overburdened, scarce, unevenly distributed and often work in private practice. The results of the SUMMIT Trial suggest that training nonspecialists to provide BA could markedly increase the mental health workforce and improve access to effective and relatively brief psychotherapies such as BA. Even when there are geographical separations between perinatal specialists, non-specialists delivering treatment, and patients, this study demonstrates that telehealth can be used to bridge the gaps.

The authors of this study have made the training manual available to the public online at no cost (www.thesummittrial.com).

Ruta Nonacs, MD PhD

References

Singla DR, Meltzer-Brody SE, Silver RK, et al. Scaling up maternal mental healthcare by increasing access to treatment (SUMMIT) through non-specialist providers and telemedicine: a study protocol for a non-inferiority randomized controlled trial. Trials. 2021;22(1):186.

Singla DR. Expanding the reach and scalability of perinatal mental health interventions. Nat Med. 2024 Mar;30(3):638-639.

Singla DR, Silver RK, Vigod SN, Schoueri-Mychasiw N, Kim JJ, La Porte LM, Ravitz P, Schiller CE, Lawson AS, Kiss A, Hollon SD, Dennis CL, Berenbaum TS, Krohn HA, Gibori JE, Charlebois J, Clark DM, Dalfen AK, Davis W, Gaynes BN, Leszcz M, Katz SR, Murphy KE, Naslund JA, Reyes-Rodríguez ML, Stuebe AM, Zlobin C, Mulsant BH, Patel V, Meltzer-Brody S. Task-sharing and telemedicine delivery of psychotherapy to treat perinatal depression: a pragmatic, noninferiority randomized trial. Nat Med. 2025 Apr; 31(4):1214-1224.