While postpartum depression (PPD) affects about 10%-15% of women, most women with PPD do not receive any treatment.  Over the last decade, we have made progress in increasing awareness of postpartum mental health issues; however, there are still significant obstacles to obtaining treatment.  Women are not able to find appropriate treaters or cannot access care in a timely fashion, especially in more remote areas.  They may not have reliable childcare and thus cannot attend their own appointments.  Or they may simply be too depressed or anxious to leave their homes.

The internet has become an important tool for women with young children, allowing them to access important information and to connect with other mothers.  The internet has also been used to disseminate information on postpartum depression (PPD) to women who suffer from this illness.   This has certainly increased women’s awareness of PPD; however, we have yet to explore the ability of internet-based programs to deliver treatment to this population.

Netmums has been one of the most successful organizations in terms of using the internet to connect with and provide support to new mothers.  Founded in 2000, Netmums (www.netmums.com) is the United Kingdom’s fastest-growing online parenting organization with over 1.6 million members. Netmums is a network of local sites that cover the UK, each site offering information to mothers on a wide variety of subjects, including pregnancy, childbirth, feeding and nutrition, child development, and childcare.

A new study has explored the feasibility of using such a site to deliver treatment.  Postpartum women (n=910) were recruited via Netmums.com.  Women scoring above 12 on the Edinburgh Postnatal Depression Scale (EPDS) were randomly assigned to receive either an internet-delivered Postnatal Behavioral Activation (iBA) intervention or treatment-as-usual (TAU).

The researchers developed an online behavioral activation (BA) treatment that was specifically adapted to the concerns of postpartum women. BA is basically cognitive-behavioral therapy or CBT without the cognitive components; using only the behavioral components of CBT, has been shown to be as effective for treating depression as traditional CBT.  (If you want to learn more about BA for depression, this article provides a thorough discussion of the technique.)

Recruitment in the original feasibility study was excellent; 1261 women, 961 of whom met inclusion criteria, signed up for the trial within two 2-week recruitment periods. Retention, however, was quite low with only 38% of the women completing the 15-week outcome assessment. Of those who completed 15-week assessment, fewer women were depressed (EPDS of >12) in the Postnatal-iBA group (n=66/181 or 36.5%) than in the TAU group (n=91/162 or 56.2%).

Given the high rates of attrition, the researchers modified the BA intervention. Women in the original trial reported difficulty in keeping up with the provided materials and struggled to individualize the materials. The treatment materials were thus modified to take a modular approach, and a guided support component was added in order to improve treatment understanding and adherence.

In the second trial, a total of 249 women were recruited via Netmums.com. A total of 83 women meeting DSM-IV criteria for major depressive disorder were randomized to receive the postpartum BA intervention (n = 41) or treatment-as-usual (TAU; n = 42). 71 (86%) completed the EPDS at post-treatment, and 71% (59/83) were assessed at the 6-month follow-up. Women completed an average of eight out of 12 telephone support sessions and five out of 12 modules. Working women and those with less support completed fewer modules.

Women receiving the BA intervention improved with regard to depressive symptoms, anxiety, work and social functioning at post-treatment compared with women in the TAU group.  The effect sizes were large.  The differences between the two groups remained significant at six months post-treatment.

These trials demonstrate that not only is it possible to screen for postpartum depression using the internet, we might also be able to harness the internet to deliver treatment to women who might otherwise not be able to access care in a conventional setting.  Future studies will help to determine which women are best suited to this type of intervention.

Ruta Nonacs, MD PhD

O’Mahen HA, Woodford J, McGinley J, et al.  Internet-based behavioral activation–treatment for postnatal depression (Netmums): a randomized controlled trial.  J Affect Disord. 2013 Sep 25; 150(3):814-22.

O’Mahen HA, Richards DA, Woodford J, Wilkinson E, McGinley J, Taylor RS, Warren FC.  Netmums: a phase II randomized controlled trial of a guided Internet behavioural activation treatment for postpartum depression.  Psychol Med. 2013 Oct 23:1-15.  (Full text available.)