By Ahizechukwu C. Eke, MD, PhD, MPH
Associate Professor in Maternal Fetal Medicine, Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore
SYNOPSIS: This study demonstrated that combined use of universal depression screening and MomMoodBooster2, a cognitive behavioral therapy-based e-health program, were effective tools for treating women with depression in the perinatal period.
SOURCE: Danaher BG, Seeley JR, Silver RK, et al. Trial of a patient-directed ehealth program to ameliorate perinatal depression: The MomMoodBooster2 practical effectiveness study. Am J Obstet Gynecol 2022; Sep 26:S0002-9378(22)00760-8. doi: 10.1016/j.ajog.2022.09.027. [Online ahead of print].
Perinatal depression affects approximately 10% to 20% of women during pregnancy and postpartum in the United States.1 It is a mood disorder characterized by loss of interest, fatigue, sleep disturbance, changes in appetite, thoughts of guilt or worthlessness, reduced self-esteem, and recurrent thoughts of suicide and death.2,3 Perinatal depression could be mild, moderate, or severe depending on the number and severity of symptoms, and has potential adverse maternal and fetal complications.4,5 Hence, it needs to be recognized and treated.
Because perinatal depression and other mood disorders can have disastrous implications if left untreated, it is crucial to detect pregnant and postpartum women who are depressed.6 As such, several screening tools have been validated for use during pregnancy and postpartum (most commonly the Edinburgh Postnatal Depression Scale [EPDS]), since there is evidence that screening identifies women at high risk for depression.7 In addition, several treatment options have been used to manage women with perinatal depression. These include psychotherapy (cognitive behavioral therapy [CBT] and interpersonal therapy), and the use of antidepressant medications.8 Results from systematic reviews and meta-analyses demonstrate that CBT is effective for managing depression.9 Based on encouraging results from prior studies, Danaher and colleagues investigated the effectiveness and acceptability of MomMoodBooster2 (MMB2; a CBT-based e-health program) in ameliorating perinatal depression.10
MMB2 was a pragmatic open-label, randomized clinical trial conducted as part of the Perinatal Depression Program (PDP) at the NorthShore University HealthSystem (consisting of six hospitals) in Chicago. The PDP program includes universal perinatal outpatient depression screening with centralized scoring and outreach, a network of community mental health providers, and a 24/7 crisis hotline to respond to urgent mental health needs.
Inclusion criteria into MMB2 were pregnant women or postpartum women who were less than a year after giving birth; > 18 years of age, without any current suicidal thoughts; with access to broadband internet by desktop or laptop, tablet, or smartphone; and competent in speaking English. Women who indicated they would self-harm on the EPDS were included in the trial if a social worker’s assessment determined that they were at low risk of suicide. Women were excluded if they had an active suicidal ideation. Participants were randomized in a 1:1 ratio to receive either the PDP or a combination of the PDP and MMB2 e-health programs.
The primary outcome was severity of depressive symptoms (assessed using the EPDS or the Patient Health Questionnaire-9 [PHQ-9]). Secondary outcomes included stress severity, behavioral activation, negative thoughts associated with depression, and behavioral self-efficacy to assess confidence in using MMB2. A total sample size of at least 190 women was sufficient to demonstrate a 33% reduction in the rate of the primary outcome (assuming the minimal clinically important difference [MCID] used to evaluate the clinical significance of the primary outcome, with a baseline-to-post-test MCID reduction of at least five points), 80% power, and a type 1 error rate of 5%. The statistical analysis was performed using intention-to-treat analysis, and differences between groups were considered statistically significant if the P-value was < 0.05.
From September 2015 to March 2021, 191 pregnant women (96 in the MMB2 arm and 95 in the routine PDP screening program arm) met inclusion criteria after screening 11,201 women for eligibility. The population was predominantly non-Hispanic (84%), white (67%), married or in a long-term relationship (94%), and 32 years of age, on average. The primary outcome — depression screen scores — did not significantly differ between the two groups (MMB2 + PDP: 15.0 ± 2.9; PDP: 15.2 ± 3.2; P = 0.932).
The secondary outcomes also were similar in the two groups. There were increases in behavioral activation and self-efficacy and significant decreases in depression severity, anxiety, stress, and automatic thoughts from baseline to post-test when comparing the MMB2 + PDP to the PDP group. Although the two groups (MMB2 + PDP vs. PDP) did not differ in depression outcome scores at baseline, significant group-by-time interactions showed that the MMB2 + PDP group saw considerably higher baseline to post-test decreases in stress (P = 0.019) and depression severity (P = 0.003) when compared to PDP. Other group-by-time interactions for self-efficacy, automatic thinking, behavioral activation, and anxiety favored MMB2 + PDP, but were not statistically significant. Additionally, the primary baseline EPDS and PHQ-9 score and baseline perinatal status did not have any discernible moderating effects.
COMMENTARY
The findings from this study by Danaher et al demonstrate that, although the outcomes (depression severity, anxiety, stress, automatic thoughts, behavioral activation, and self-efficacy) were significantly improved in both groups, the MMB2 + PDP group significantly outperformed the PDP group in lowering depression severity, stress, and self-efficacy.
Screening for depression is important in pregnant and postpartum women to avert consequences of unrecognized/untreated depression that include poor quality of life, increased risk of suicidal ideation, and maternal mortality.11 Screening during pregnancy should involve evaluation of risk factors for depression, such as unintended pregnancy, maternal anxiety, prior history of depression, stress, substance use, history of sexual abuse, lack of social support, domestic violence, and challenges in pregnancy.12 Using the EPDS and PHQ-9, the two most common tools used for depression screening in pregnant and postpartum persons, women diagnosed with depression during pregnancy can be referred to mental healthcare providers for counseling and therapy.
In women who screen positive for depression, psychotherapy (CBT and/or interpersonal therapy) usually is a first-line treatment option that has been shown to be effective. Several studies have shown that psychotherapy can improve maternal motivation, cognitive flexibility, thought self-regulation, and negative emotion restructuring.8 As such, healthcare providers should screen all pregnant and postpartum women for depression and be ready to refer these patients to the right mental/behavioral health facilities as necessary. If psychotherapy fails, medical therapy is an alternative that has been shown to be effective in the treatment of depression (especially when combined with psychotherapy). Optimal care of pregnant and postpartum women with depression occurs when OB/GYNs work together with mental healthcare providers. According to recent research, collaborative care approaches enhance long-term patient results.
In summary, screening and treatment of depression during pregnancy is critically important. The American College of Obstetricians and Gynecologists (ACOG) advises OB/GYNs and other obstetric care specialists to use a systematic, validated test to assess patients for depression and anxiety symptoms at least once throughout the perinatal period.13 ACOG also recommends that women who screen positive for depression should be treated to avert adverse pregnancy/postpartum outcomes.13
REFERENCES
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- O’Connor E, Rossom RC, Henninger M, et al. Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the US Preventive Services Task Force. JAMA 2016;315:388-406.
- Ko JY, Rockhill KM, Tong VT, et al. Trends in postpartum depressive symptoms – 27 states, 2004, 2008, and 2012. MMWR Morb Mortal Wkly Rep 2017;66:153-158.
- Acheampong K, Pan X, Kaminga AC, et al. Risk of adverse maternal outcomes associated with prenatal exposure to moderate-severe depression compared with mild depression: A fellow-up study. J Psychiatr Res 2021;136:32-38.
- Howard LM, Khalifeh H. Perinatal mental health: A review of progress and challenges. World Psychiatry 2020;19:313-327.
- Fitelson E, Kim S, Baker AS, Leight K. Treatment of postpartum depression: Clinical, psychological and pharmacological options. Int J Womens Health 2010;3:1-14.
- Levis B, Negeri Z, Sun Y, et al. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: Systematic review and meta-analysis of individual participant data. BMJ 2020;371:m4022.
- Li C, Sun X, Li Q, et al. Role of psychotherapy on antenatal depression, anxiety, and maternal quality of life: A meta-analysis. Medicine (Baltimore) 2020;99:e20947.
- Li X, Laplante DP, Paquin V, et al. Effectiveness of cognitive behavioral therapy for perinatal maternal depression, anxiety and stress: A systematic review and meta-analysis of randomized controlled trials. Clin Psychol Rev 2022;92:102129.
- Danaher BG, Seeley JR, Silver RK, et al. Trial of a patient-directed eHealth program to ameliorate perinatal depression: The MomMoodBooster2 practical effectiveness study. Am J Obstet Gynecol 2022; Sep 26:S0002-9378(22)00760-8. doi: 10.1016/j.ajog.2022.09.027. [Online ahead of print].
- Chan J, Natekar A, Einarson A, Koren G. Risks of untreated depression in pregnancy. Can Fam Physician 2014;60:242-243.
- Lancaster CA, Gold KJ, Flynn HA, et al. Risk factors for depressive symptoms during pregnancy: A systematic review. Am J Obstet Gynecol 2010;202:5-14.
- [No authors listed]. ACOG Committee Opinion No. 757: Screening for perinatal depression. Obstet Gynecol 2018;132:e208-e212.
