Many women experiencing perinatal mood and anxiety disorders (PMADs) face significant barriers to accessing treatment. Although awareness has increased and we have a growing number of clinicians specializing in perinatal mental health, the availability of qualified specialists remains limited, particularly in low-resource and rural areas. Even where health systems are more 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.

Over the last decade, we have seen novel interventions using task-sharing to deliver treatment, where, rather than relying on psychiatrists, psychologists, or other mental health specialists, non-specialist providers are trained to provide targeted care to pregnant and postpartum individuals with depression and anxiety. 

Many of these interventions rely on peers, typically defined as individuals with lived experience of depression or anxiety or individuals who share similar sociodemographic characteristics with individuals seeking treatment.  Peer-administered interventions can help to improve access to care but using peers as non-specialist providers may offer additional advantages, addressing many individuals’ preferences to receive support and treatment from those with lived experience. 

A recent meta-analysis assessed the effectiveness of peer-administered interventions for treating perinatal depression or anxiety and asked whether variations in how these interventions were delivered had any impact on their effectiveness. Eligible studies were those involving a peer-administered intervention for perinatal depression or anxiety with a randomized controlled trial (RCT) design 

The study included 19 studies and 18 were included in the meta-analysis. A total of 3,821 participants were included, with the majority coming from high-income countries. Three types of interventions were identified: 

• Peer-delivered psychotherapies – Structured interventions in which peers receive training to deliver a particular type of psychotherapy (e.g., CBT). 
• Individual peer support – Peers receive training to deliver one-on-one support to participants, with or without a manual. 
• Peer discussion groups – Unstructured support groups in which the content of the discussions is flexible and determined by participants.

Effectiveness of Peer-Based Interventions

For the treatment of depressive symptoms, the meta-analysis indicated that peer-administered interventions were more effective in reducing symptoms of depression than standard care. 

• Peer-delivered psychotherapies had the largest effect sizes, followed by individual peer support. 
• Peer discussion groups yielded smaller effect sizes that were not statistically significant.
• Subgroup analyses suggested that group interventions may lead to greater improvement in symptoms than one-on-one treatment.
• Interventions relying on peers with lived experience had larger effect sizes for depression than interventions relying on peers without lived experience.
• Interventions were more effective for depression when initiated during the postpartum period compared to pregnancy.

For the treatment of anxiety, peer-administered interventions did not appear to be effective; however, subgroup analyses for anxiety revealed that peer-delivered psychotherapies were capable of leading to medium effect size improvements in anxiety symptoms. 

Clinical Implications

Over the last decade, we have seen more studies exploring the effectiveness of interventions relying on non-specialist providers to deploy evidence-based treatments for PMADs. For example, in the SUMMIT trial conducted in the United States, a behavioral activation intervention delivered by non-specialists was as effective as care delivered by specialists. In another trial, the Healthy Mother – Healthy Baby intervention carried out in Pakistan used non-specialist providers to provide CBT targeting anxiety symptoms and reduced the risk of postpartum depression by 81% compared to usual care. 

The authors note that when asked about their opinions of non-specialist providers, birthing parents reported that they most valued empathy, strong communication skills, and lived experience. Thus, peers may be a particularly knowledgeable, nonjudgmental and empathic source of support. In sharing information informed by their own lived experiences, peers can also help to combat stigma, provide role-model recovery, and normalize symptoms, further increasing participants’ motivation to seek and participate in treatment.

The current review and meta-analysis underscore the utility of peers in supporting and delivering treatment to individuals with PMADs. The value of peer support has long been recognized by organizations like Postpartum Support International, and their support groups play a vital role in helping women access treatment for and recover from perinatal mood and anxiety disorders. 

Whether peers are family, friends, or community members, they play such an important role in bringing individuals into treatment. As physicians, we can make a diagnosis and suggest a treatment, but what often carries more weight is when a patient hears a similar message from a peer, from somebody who has had a similar experience: “I had postpartum depression, and this is what I did. This is what really helped me.”

The review indicates that peers — who are widely available and typically so eager to help — can be an important element of treatment, especially if they are taught to deliver evidence-based interventions. Peer-based interventions can be used to improve mental health workforce shortages and represent a cost-effective, scalable, and effective strategy to provide effective treatments to individuals with PMADS. 

—Ruta Nonacs, MD PhD