What Were We Thinking (WWWT) is a psychoeducational program for couples which was designed to prevent postpartum mood and anxiety disorders in first-time mothers.  The hope is that by addressing relevant and potentially modifiable risk factors for postpartum depression and anxiety, this type of intervention can reduce the risk of postpartum mental health issues.  This manualized intervention is based on the following theoretical principles:

  • Improvements in day-to-day interpersonal interactions within families are of fundamental importance to preventing common mental disorders;
  • Partner and infant behaviours can be modified to decrease those that contribute to psychological distress and increase those that promote confidence and sense of competence;
  • Women prefer to receive emotional care and practical support within their intimate relationships than increased care from health professionals;
  • Depressive and anxiety disorders are not easily distinguished and prevention strategies should use a transdiagnostic approach;
  • Readily-understood, evidence-informed knowledge and opportunities for active learning and skills-development need to be made available at the critical developmental stage at which they are needed;
  • A psychoeducational approach addresses plausible psychological mechanisms using education to meet salient learning needs;
  • Women’s experiences of humiliation can be reduced by increasing their partners’ appreciation and empathy, and reducing critical and controlling behaviours;
  • Experiences of entrapment can be countered by promoting infant care as a shared endeavour in which parents with comparable competence can permit each other independent or shared leisure;
  • Cognitively-focused rather than emotion-focused responses to infant crying can be promoted by building skills to respond actively and effectively, rather than avoidantly;
  • Occupational fatigue among parents is minimised by teaching them how to understand and promote adequate infant sleep using evidence-informed behaviour management strategies;
  • Together these lead to increased confidence and competence, and reduced depression, anxiety and adjustment disorders.

Based on an educational framework, WWWT consists of structured, easy-to-understand learning activities and was implemented in primary maternal and child healthcare (MCH) services in Melbourne, Australia.  The intervention  includes (1) primary care from a WWWT-trained nurse, (2) printed materials, and (3) face-to-face seminar offered at 6–8?weeks postpartum.

English-speaking primiparous women receiving primary care at MCHCs were randomized to receive either the intervention (204) or treatment as usual (196). Of these, 187 (91.7%) and 177 (90.3%) provided complete data. The primary outcome was any DSM IV diagnosis of a depressive, anxiety or adjustment disorder in the prior 30?days at 6?months postpartum.

At the end of the trial, women in the intervention group had lower rates of postpartum mood and anxiety disorders compared to women in the treatment as usual group (adjusted OR (AOR) 0.36, 95% CI 0.14 to 0.95).  However, they observed this difference only when the women received all three components of the intervention (primary care, printed materials, and eminar).

While further research is required to assess the effectiveness and acceptability of this sort of intervention in other settings, it appears that WWWT  might be a promising intervention.  It is manualized and therefore could easily be integrated into maternal and child primary care.  The key advantages of this approach are its simplicity and the fact that it is not resource-intensive.  Psychotherapy, including interpersonal psychotherapy (IPT) and mindfulness-based cognitive therapy (MBCT) have been shown to be effective for the prevention of postpartum depression; however, it is often difficult to access mental health professionals with expertise in these therapies.   

We have recently seen several interventions which are effective in reducing risk for postpartum depression and anxiety by providing parents with practical support and strategies for managing problems that may emerge during the postpartum period (such as sleep deprivation and crying).  We don’t yet know if these sorts of interventions are effective for women at high risk for postpartum psychiatric illness, such as women with histories of  mood disorder or postpartum depression, but I imagine that all families would benefit from a supportive intervention like WWWT.  Furthermore, an intervention available to all parents may help to destigmatize depression and would allow us to identify families who are struggling early on.

Ruta Nonacs, MD PhD

Gender-informed, psychoeducational programme for couples to prevent postnatal common mental disorders among primiparous women: cluster randomised controlled trial.Fisher J, Rowe H, Wynter K, Tran T, Lorgelly P, Amir LH, Proimos J, Ranasinha S, Hiscock H, Bayer J, Cann W.

BMJ Open. 2016 Mar 7;6(3):e009396. Free PMC Article