As we move toward universal screening for perinatal depression, one of our most significant challenges will be to evaluate and deliver care to the women who are identified as being depressed.  It is discouraging to note that recommendations regarding screening have not necessarily resulted in increased rates of treatment in women with perinatal depression.  Dr. Nancy Byatt and colleagues published an analysis of 17 studies (published between 1999 and 2014) where women were screened for perinatal depression.  An average of 22% (13.8-33.0%) of women who screened positive for depression received at least one mental health visit.

One of the primary problems here is that many women cannot access care.  They cannot find treaters with expertise in the treatment of perinatal psychiatric illness, or they may not be able to afford mental health services which are not covered by insurance.  Having to care for children may limit their ability to regularly attend visits.  Thus there is a clear need for innovative strategies for women who need treatment for depression and anxiety in this setting.

Cognitive-behavioral therapy or CBT is an effective treatment for depression and anxiety and has been used successfully in pregnant and postpartum women.  A recent randomized controlled trial has looked at the effectiveness of therapist-assisted, internet-delivered CBT (TA-ICBT) for postpartum women with depressive symptoms.

This study carried out in in Saskatchewan, Canada included 50 women who gave birth in the past year and who were identified as being depressed, with scores of 10 or greater on the Edinburgh Postnatal Depression Scale (EPDS).  Participants were randomized to receive either TA-ICBT (n = 25) or waitlist conditions (n = 25).

TA-ICBT for PPD was adapted from a TA-ICBT program for depression offered through the Online Therapy Unit for Service Education and Research ( in Saskatchewan, Canada. The intervention included 7 modules, and participants were encouraged to complete one module per week although more time was often taken.   Each module included a range of media (e.g., text, graphics, animation, audio, video), as previous research has suggested that multimedia options enhance the effectiveness of Internet-delivered treatment.

The efficacy of the treatment was investigated at  7 and 10 weeks. TA-ICBT participants were also contacted four-weeks following treatment completion. Women receiving TA-ICBT experienced a greater reduction in depressive symptoms than women in the waitlist group  (average reduction of 6.24 points and 2.42 points on the EPDS, respectively).  These results were maintained at four-week follow-up. Women receiving TA-ICBT also demonstrated a reduction in postpartum anxiety, general stress, and parental distress, and an an improvement in quality of life as compared to the waitlist control participants.

This is a small study, yet the results are promising, indicating that therapist-assisted, Internet-delivered CBT may be helpful for managing depressive symptoms and anxiety in postpartum women.  In addition, there were relatively high levels of adherence, with participants completing, on average, 5.92 of the seven modules (60% completed the entire program).

It should be noted, however, that most of the women included in this study had mild to moderate depressive symptoms, with a mean EPDS of 15.68.  Further studies are necessary to determine if this intervention is suitable and efficacious for women with more severe depressive symptoms.  Nevertheless, TA-ICBT appears to be a novel way to provide treatment to women who might not normally be able to access care.

Ruta Nonacs, MD PhD

A Randomised Controlled Trial of Therapist-Assisted, Internet-Delivered Cognitive Behavior Therapy for Women with Maternal Depression.

Pugh NE, Hadjistavropoulos HD, Dirkse D.

PLoS One. 2016 Mar 1;11(3). Free Article


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