One-Day Peer-Delivered Cognitive Behavioral Therapy-Based Workshops for Postpartum Depression: A Randomized Controlled Trial.

INTRODUCTION: Myriad treatment barriers prevent birthing parents with postpartum depression (PPD) from receiving timely treatment. We aimed to determine whether a peer-delivered online 1-day cognitive behavioral therapy (CBT)-based workshop added to treatment as usual (TAU) improves PPD and its comorbidities and is more cost-effective than TAU alone. METHODS: This parallel-group, randomized controlled trial took place in Ontario, Canada (June 7, 2021, to February 18, 2022). Participants were ≥18 years old, had an infant ≤12 months old, and an Edinburgh Postnatal Depression Scale (EPDS) score ≥10. Participants were allocated to receive the workshop plus TAU (n = 202) or TAU and waitlisted to complete the workshop 12 weeks later (n = 203). The primary outcome was change in PPD (EPDS score) from enrollment to 12 weeks later. The secondary outcome was cost-effectiveness and tertiary outcomes included anxiety, social support, partner relationship quality, the mother-infant relationship, parenting stress, and infant temperament. RESULTS: Participants had a mean age of 32.3 years (SD = 4.30) and 65% were White. The workshop led to a significant reduction in EPDS scores (15.95-11.37; d = 0.92, p < 0. 01) and was associated with higher odds of exhibiting a clinically significant decrease in EPDS scores (OR = 2.03; 95% CI: 1.26-3.29). The workshop plus TAU was more cost-effective than TAU alone. It also led to improvements in postpartum anxiety, infant-focused anxiety, parenting stress, and infant temperament. CONCLUSIONS: Peer-delivered 1-day CBT-based workshops can improve PPD and are a potentially scalable low-intensity treatment that could help increase treatment access.

Healthcare utilization before and during the COVID-19 pandemic among mothers and birthing parents with elevated levels of postpartum depression symptoms.

Little is known about the healthcare utilization of mothers and birthing parents experiencing elevated levels of symptoms of postpartum depression (PPD), particularly during the COVID-19 pandemic. This study examined how healthcare utilization changed in these individuals during COVID-19. Individuals living in Ontario, Canada, with Edinburgh Postnatal Depression Scale Scores ≥ 10 were recruited into two separate randomized controlled trials of a 1-day intervention for PPD before (pre-COVID-19, n = 441) and during the pandemic (COVID-19, n = 287). Participants in both samples completed the same health resource use questionnaire, self-reporting the number of virtual and/or in-person visits to specific healthcare services over the three months preceding their treatment intervention. Use of medications, mental health care, primary care, hospital-based care, allied health care, and overall healthcare utilization were compared between the pre-COVID-19 and COVID-19 groups. While participants had higher levels of PPD symptoms during COVID-19, differences were not seen in the use of specific categories of care (e.g. mental health and primary care). However, before and after statistically adjusting for covariates, overall healthcare utilization decreased from an average of 9.5 visits prior to COVID-19 to 6.9 during COVID-19 (p < .001), a change that was at least partly contributed to by reductions in visits to allied health professionals (e.g. dentists and physiotherapists). Overall healthcare utilization decreased by 27 % in mothers and birthing parents seeking treatment for elevated levels of PPD symptoms during the COVID-19 pandemic in Ontario, Canada - despite higher levels of PPD symptoms - highlighting the need to support and address barriers to postpartum care.

In-person 1-day cognitive behavioral therapy-based workshops for postpartum depression: a randomized controlled trial.

BACKGROUND: Postpartum depression (PPD) affects up to one in five mothers and birthing parents, yet as few as 10% access evidence-based treatment. One-day cognitive behavioral therapy (CBT)-based workshops for PPD have the potential to reach large numbers of sufferers and be integrated into stepped models of care. METHODS: This randomized controlled trial of 461 mothers and birthing parents in Ontario, Canada with Edinburgh Postnatal Depression Scale (EPDS) scores ⩾10, age ⩾18 years, and an infant <12 months of age compared the effects of a 1-day CBT-based workshop plus treatment as usual (TAU; i.e. care from any provider(s) they wished) to TAU alone at 12-weeks post-intervention on PPD, anxiety, the mother-infant relationship, offspring behavior, health-related quality of life, and cost-effectiveness. Data were collected via REDCap. RESULTS: Workshops led to meaningful reductions in EPDS scores (m = 15.77 to 11.22; b = -4.6, p < 0.01) and were associated with three times higher odds of a clinically significant decrease in PPD [odds ratio (OR) 3.00, 95% confidence interval (CI) 1.93-4.67]. Anxiety also decreased and participants had three times the odds of clinically significant improvement (OR 3.20, 95% CI 2.03-5.04). Participants reported improvements in mother-infant bonding, infant-focused rejection and anger, and effortful control in their toddlers. The workshop plus TAU achieved similar quality-adjusted life-years at lower costs than TAU alone. CONCLUSIONS: One-day CBT-based workshops for PPD can lead to improvements in depression, anxiety, and the mother-infant relationship and are cost-saving. This intervention could represent a perinatal-specific option that can treat larger numbers of individuals and be integrated into stepped care approaches at reasonable cost.

Fidelity Assessment of Peer-Delivered Cognitive-Behavioral Therapy for Postpartum Depression.

OBJECTIVE: Fidelity assessment of peer-administered interventions (PAIs) by expert therapists can be costly and limit scalability. This study's objective was to determine whether peer facilitators could assess the fidelity of peer-delivered group cognitive-behavioral therapy (CBT) for postpartum depression as effectively as an expert psychiatrist or a trained graduate student. METHODS: Intervention adherence and competence were assessed by three peers (N=9 sessions) and by one expert psychiatrist and one graduate student (N=18 sessions). Interrater reliability was assessed with intraclass correlation coefficients (ICCs). RESULTS: ICCs were good to excellent (0.88-0.98) for adherence and competence ratings among the three types of raters (psychiatrist vs. peers, psychiatrist vs. student, and student vs. peers). CONCLUSIONS: Trained peers may be able to reliably rate the fidelity of a PAI for postpartum depression. This preliminary study represents the first step toward peer-led feedback as an alternative to expert-led supervision of peer-delivered group CBT for postpartum depression.

Public Health Nurse-delivered Group Cognitive Behavioural Therapy for Postpartum Depression: A Randomized Controlled Trial.

OBJECTIVES: To examine the effectiveness of group cognitive behavioural therapy (CBT) for postpartum depression (PPD) delivered by public health nurses with little to no previous psychiatric training at improving depression, worry, social support and the mother-infant relationship. METHODS: Mothers (n = 141) living in Ontario, Canada with Edinburgh Postnatal Depression Scale Scores ≥10 and an infant <12 months of age were randomized to receive nine weekly 2-h sessions of in-person group CBT for PPD delivered by two public health nurses plus treatment as usual (TAU; experimental group) or TAU alone (control group). Primary outcomes were change in EPDS score and current major depressive disorder (Mini International Neuropsychiatric Interview) assessed immediately post-treatment (T2). Secondary outcomes included maternal worry, social support, and quality of the mother-infant relationship. All outcomes were assessed again six months post-treatment (T3). RESULTS: Participants in the experimental group had statistically significantly greater reductions in PPD symptoms immediately post-treatment (T2) (B = -5.35, p < 0.01), were more likely to manifest a clinically significant improvement in EPDS scores (≥4 points; OR = 3.44, 95%CI: 1.49-7.94), and no longer have symptoms consistent with current MDD (OR = 5.31, 95% CI: 1.78-15.83). Six months post-treatment (T3), experimental group participants had higher odds of clinically significant PPD improvement (OR = 5.10, 95%CI: 1.89-13.78), while 25% of the experimental group and 70% of remaining control group participants reported current MDD (p < 0.01). Statistically significant improvements in worry and the mother-infant relationship were also observed, decreases maintained at six months post-treatment. CONCLUSIONS: Public health nurses with little to no previous psychiatric training can be trained to deliver effective group CBT for PPD to improve depression, worry, and the mother-infant relationship. Task shifting PPD treatment with group CBT to public health nurses could improve treatment uptake and lead to better outcomes for mothers, families, and the healthcare system.(Trial Registration NCT03039530).

Public health nurse delivered group cognitive behavioral therapy (CBT) for postpartum depression: A pilot study.

OBJECTIVES: Although postpartum depression (PPD) affects 1 in 5 women, just 15% receive treatment. Cognitive Behavioural Therapy (CBT) is a first-line treatment for PPD. The objective of this pilot study was to determine the feasibility and acceptability of public health nurse (PHN)-delivered group CBT for PPD and to determine preliminary estimates of effect. DESIGN: A pre-posttest design was used. Participants provided data before and after the CBT groups. SAMPLE: Seven women who were over the age of 18 and had given birth in the past year participated. MEASUREMENTS: Feasibility and acceptability focused on PHN training, recruitment, retention, and adherence to the intervention. Participants provided data on depression, worry, health care utilization and mother-infant relations. Women and their partners reported on infant temperament. INTERVENTION: Participants attended a 9-week CBT group delivered by two PHNs. RESULTS: The PHN training, CBT intervention and our study protocol were found to be feasible and acceptable to participants. Reductions were seen in depression and worry. The number of health care visits decreased; mother-infant relations improved. CONCLUSIONS: These findings highlight the feasibility of PHN-delivered group CBT for PPD and suggest that it could reduce the burden of PPD on women and their children.

Public health nurses' experiences learning and delivering a group cognitive behavioral therapy intervention for postpartum depression.

OBJECTIVES: Public Health Nurses (PHNs) often provide support to women with postpartum depression (PPD) in the absence of specialized training. The objective of this study was to explore the experiences of six PHNs who were trained to deliver a group cognitive behavioral therapy (CBT) intervention for PPD in the public health setting, and to describe how learning and delivering this intervention affected their professional roles and personal lives. DESIGN: This qualitative study employed a phenomenological approach. SAMPLE: Six PHNs who completed the CBT training program and delivered at least one CBT group in their community. MEASUREMENTS: Individual in-depth interviews were conducted and transcribed verbatim. Transcripts were analyzed according to thematic derivation procedures. RESULTS: The themes that emerged from the interviews with the PHNs included: (a) components of the CBT training program that nurses most valued, (b) benefits of training for their professional role as a PHN, (c) implications for practice, and (d) using CBT skills in their personal lives. CONCLUSIONS: The provision of CBT training to PHNs may not only positively impact their work with clients with mental illness, but may also have the potential to provide broader clinical and professional benefits for these skilled professionals and their other clients.

Mothers' and birthing parents' experiences with 1-day cognitive behavioural therapy-based workshops for postpartum depression: A descriptive qualitative study.

WHAT IS KNOWN ABOUT THE SUBJECT?: One in five mothers and birthing parents are affected by postpartum depression (PPD), yet only a small proportion of those with PPD receive treatment. Given cost and accessibility barriers to treatment, brief therapies (e.g. 1 day) could help address PPD on a large scale, though understanding participants' unique experiences with this novel treatment will help guide its refinement and use. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper describes the experiences, perspectives and satisfaction of participants who attended a 1-day workshop for PPD. Participants appreciate being taught practical techniques and the receipt of social support from facilitators and other attendees in the group setting, while some recommended further 'booster sessions' to enhance effectiveness. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: One-day CBT-based workshops may be an effective, low-intensity treatment option that provides helpful skills and builds social networks for individuals with PPD. Additional post-workshop booster sessions may enhance participant satisfaction with this new treatment by providing a reinforcement of their learning and an opportunity to re-connect with other birthing parents. ABSTRACT: INTRODUCTION: Postpartum depression (PPD) affects up to one in five mothers and birthing parents. Understanding their perceptions of therapeutic interventions is key to their effectiveness and scalability. AIM: The aim of the study was to understand participants' experiences attending an in-person or online 1-day cognitive behavioural therapy (CBT)-based workshop for PPD and compare their experiences participating in either modality. METHOD: This descriptive qualitative study was embedded in two separate randomized controlled trials evaluating the effectiveness of 1-day CBT-based workshops for PPD delivered in-person or online. Responses were provided by 94 in-person and 95 online participants about their experiences. Content analysis was used to code and categorize the data. RESULTS: Participants appreciated learning skills to improve PPD symptoms and joining a community of individuals with shared experiences. Integrating practical coping techniques after the workshop was reported to be most useful, though some wanted additional post-workshop support. Online participants identified additional barriers to workshop engagement. DISCUSSION: Participants who attended either workshop found them to be valuable and effective. Participants valued psychoeducation, social connections and applying practical CBT techniques. IMPLICATIONS FOR PRACTICE: One-day CBT-based workshops may be an accessible treatment option for individuals with PPD, providing new skills and social support, though some prefer to receive additional post-workshop support.

Online Public Health Nurse-Delivered Group Cognitive Behavioral Therapy for Postpartum Depression: A Randomized Controlled Trial During the COVID-19 Pandemic.

Objective: Rates of postpartum depression (PPD) increased during the COVID-19 pandemic, further highlighting the need for effective, accessible treatments for PPD. While public health nurses (PHNs) can be trained to help treat PPD, it is not known if they can effectively deliver evidence-based psychotherapies online to those with PPD.Methods: Mothers (n = 159) living in Ontario, Canada, with an Edinburgh Postnatal Depression Scale (EPDS) score ≥ 10 and an infant < 12 months of age were randomized to receive a 9-week group cognitive behavioral therapy (CBT) intervention delivered by PHNs over Zoom, between October 2020 and November 2021. Experimental group participants received CBT plus treatment as usual (TAU), and control participants received TAU alone. Participants were assessed at baseline (T1), 9 weeks later (T2), and 6 months after T2 (T3). Primary outcomes were changes in EPDS score and current major depressive disorder (MDD) as measured by the Mini International Neuropsychiatric Interview. Secondary outcomes included worry, social support, the mother-infant relationship, and infant temperament.Results: At T2, experimental group participants showed clinically and statistically significant reductions on the EPDS (d = 0.65) and decreases in postpartum worry (d = 0.38) and rejection and pathological anger toward their infant (d = 0.44). They were also less likely to meet diagnostic criteria for current MDD compared to control participants (OR = 5.09; 95% CI, 1.18-21.98; number needed to treat [NNT: 3.7]). These improvements remained stable 6 months later (T3).Conclusions: PHNs can be trained to deliver effective online group CBT for PPD to reduce depression and worry and improve aspects of the mother-infant relationship, and they represent an important way to increase access to effective treatment for PPD.Trial Registration: ClinicalTrials.gov identifier: NCT04928742.

The impact of the COVID-19 pandemic on the mental health of women seeking treatment for postpartum depression.

BACKGROUND: While research has examined the mental health of general population samples of postpartum women during the COVID-19 pandemic, the pandemic's impact on women seeking treatment for postpartum depression (PPD) is not well known. This study compared levels of depression and anxiety, the quality of social relationships, and the temperament of infants of treatment-seeking mothers in Ontario, Canada prior to and during the pandemic. METHODS: Mothers with Edinburgh Postnatal Depression Scale scores ≥10 and seeking treatment for PPD prior to COVID-19 (n = 100) were compared to those who sought treatment during the pandemic (n = 120). Mothers self-reported symptoms of depression, worry/anxiety, partner relationship quality, social support, as well as aspects of the mother-infant relationship and infant temperament. RESULTS: There were no statistically significant differences in symptoms of depression, anxiety, or the quality of social relationships between women seeking treatment for PPD before or during the pandemic. However, mothers reported poorer relationships with their infants, and there was evidence of more negative emotionality in their infants during COVID-19. CONCLUSIONS: The pandemic may not have worsened depression, anxiety, relationships with partners, or social support in mothers seeking treatment for PPD, but appears to have contributed to poorer mother-infant interactions and maternal reports of more negative emotionality in their infants. These findings highlight the importance of identifying women with possible PPD, supporting mother-infant interactions, and monitoring their infants during COVID-19 and beyond.

Depression, Anxiety, and Mother-Infant Bonding in Women Seeking Treatment for Postpartum Depression Before and During the COVID-19 Pandemic.

Objective: The conditions created by the COVID-19 pandemic could negatively affect maternal mental health and the mother-infant relationship. The aim of this study is to determine the impact of the COVID-19 pandemic on depression, anxiety, and mother-infant bonding among women seeking treatment for postpartum depression (PPD).Methods: Baseline data collected in two separate randomized controlled trials of a psychoeducational intervention for PPD in the same geographic region, one prior to COVID-19 (March 2019-March 2020) and one during the COVID-19 pandemic (April-October 2020), were compared. Eligible participants had an Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 10, were ≥ 18 years of age, had an infant < 12 months old, and were fluent in English. Outcomes included PPD (EPDS), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), and mother-infant relationship (Postpartum Bonding Questionnaire [PBQ]). All were measured continuously and dichotomized at accepted clinical cutoffs.Results: Of the 603 participants (305 pre-COVID-19; 298 during COVID-19), mothers enrolled during the COVID-19 pandemic reported higher levels of symptoms of PPD (B = 1.35; 95% CI, 0.64 to 2.06; Cohen d = 0.31) and anxiety (B = 1.52; 95% CI, 0.72 to 2.32; Cohen d = 0.30). During COVID-19, women had 65% higher odds of clinically significant levels of depression symptoms (OR = 1.65; 95% CI, 1.13 to 2.31) and 46% higher odds of clinically relevant anxiety symptoms (OR = 1.46; 95% CI, 1.05 to 2.05). However, there were no statistically significant differences in mother-infant bonding.Conclusions: The findings of this study suggest that rates and severity of PPD and anxiety symptoms among women seeking treatment for PPD have worsened in Canada during the COVID-19 pandemic. However, treatment-seeking mothers have consistently maintained good relationships with their infants. Considering the difficulties women with PPD face when accessing treatment, it is important that strategies are developed and disseminated to safely identify and manage PPD to mitigate potential long-term adverse consequences for mothers and their families.Trial Registration: ClinicalTrials.gov identifiers: NCT03654261 and NCT04485000.

Effect of Online 1-Day Cognitive Behavioral Therapy-Based Workshops Plus Usual Care vs Usual Care Alone for Postpartum Depression: A Randomized Clinical Trial.

Importance: Postpartum depression (PPD) affects as many as 20% of mothers, yet just 1 in 10 of these women receives evidence-based treatment. The COVID-19 pandemic has increased PPD risk, reduced treatment access, and shifted preferences toward virtual care. Objective: To determine whether an online 1-day cognitive behavioral therapy (CBT)-based workshop added to treatment as usual improves PPD, anxiety, social support, mother-infant relationship quality, and infant temperament more than treatment as usual alone. Design, Setting, and Participants: This randomized clinical trial included 403 women with PPD who were recruited across Ontario, Canada, during the COVID-19 pandemic (April 20 to October 4, 2020). Women with Edinburgh Postnatal Depression Scale (EPDS) scores of at least 10 who were 18 years or older and had an infant younger than 12 months were eligible. Interventions: Women were randomly assigned to receive a live, interactive online 1-day CBT-based workshop delivered by a registered psychotherapist, psychiatrist, or clinical psychology graduate student in addition to treatment as usual (n = 202) or to receive treatment as usual and wait-listed to receive the workshop 12 weeks later (n = 201). Main Outcomes and Measures: The primary outcome was change in PPD (EPDS scores) in experimental and wait list control groups 12 weeks after baseline. Secondary outcomes included maternal anxiety (7-item Generalized Anxiety Disorder Questionnaire [GAD-7]), social support (Social Provisions Scale), quality of the mother-infant relationship (Postpartum Bonding Questionnaire), and infant temperament (Infant Behavior Questionnaire-Revised Very Short Form). Results: Participants all identified as women with a mean (SD) age of 31.8 (4.4) years. The workshop led to significant mean (SD) reductions in EPDS scores (from 16.47 [4.41] to 11.65 [4.83]; B = -4.82; P < .001) and was associated with a higher odds of exhibiting a clinically significant decrease in EPDS scores (odds ratio, 4.15; 95% CI, 2.66-6.46). The mean (SD) GAD-7 scores decreased from 12.41 (5.12) to 7.97 (5.54) after the workshop (B = -4.44; 95% CI, -5.47 to -3.38; P < .001) and participants were more likely to experience a clinically significant change (odds ratio, 3.09; 95% CI, 1.99-4.81). Mothers also reported improvements in bonding (B = -3.22; 95% CI, -4.72 to -1.71; P < .001), infant-focused anxiety (B = -1.64; 95% CI, -2.25 to 1.00; P < .001), social support (B = 3.31; 95% CI, 1.04 to 5.57; P < .001), and positive affectivity/surgency in infants (B = 0.31; 95% CI, 0.05 to 0.56; P < .001). Conclusions and Relevance: In this randomized clinical trial, an online 1-day CBT-based workshop for PPD provides an effective, brief option for mothers, reducing PPD and anxiety as well as improving social support, the mother-infant relationship, and positive affectivity/surgency in offspring. Trial Registration: ClinicalTrials.gov Identifier: NCT04485000.