Feasibility and efficacy of an internet treatment for postnatal depression utilising a behavioural activation approach
- Correspondence to: Professor Jeannette Milgrom, Clinical and Health Psychology Department, 1st Floor, South Wing of the Centaur Building, Heidelberg Repatriation Hospital, Austin Health, 300 Waterdale Road, Heidelberg Heights, Melbourne, Victoria 3081, Australia;
Implications for practice and research
There is considerable demand for online treatment from depressed perinatal women.
Online depression treatment tailored to postnatal women represents a feasible intervention.
Potentially broad perinatal nursing applications exist in a stepped-care model, where broad low-intensity interventions are offered as a first-line and specialised treatments are offered for more complex cases.
Postnatal depression (PND) is prevalent and debilitating, and presents unique barriers to appropriate treatment. Many new mothers do not access help due to stigma, a lack of specialised treatments, the difficulty of scheduling appointments around infant care and through preference for non-pharmacological treatment while breastfeeding. Hence, rates of help-seeking and treatment uptake for PND are consistently low. Online treatment has the potential to overcome barriers to uptake while lowering costs and increasing reach. There is a growing body of evidence related to online treatment of various mental health conditions. The paper describes the development and controlled evaluation of a specialised internet treatment, tailored specifically for PND and based on cognitive behavioural therapy (CBT) principles. The study utilised a behavioural activation (BA) approach, focused on behaviour change (rather than cognitive restructuring) to better suit constraints on the time and attention of new mothers.
The study was a two-group randomised controlled trial, designed to evaluate the feasibility and clinical impact of the online BA treatment. Participants were recruited via the popular parenting website Netmums. A total of 910 women were recruited and allocated across the treatment and control (waitlist) conditions. Depressive symptoms were assessed at baseline and at 15 weeks using the Edinburgh Postnatal Depression Scale (EPDS). Programme usage was recorded (number of sessions; visits to chat room and online clinic) and acceptability of the programme was addressed by survey.
Attrition was very high, with only 38% of participants remaining in the trial after 15 weeks. Session attendance fell off sharply after session two. After treatment, there was a significant reduction in numbers scoring above threshold on the EPDS compared with control (n=66/181 vs n=91/162, OR=2.16). Survey results indicated that acceptability of the programme was good.
The online BA treatment assessed in this study was designed to address the needs of postnatal women. Eleven sessions of core behavioural content included a focus on normalisation, problem-solving and social support, supplemented by an online clinic and a chat room. With over 1400 applicants to the trial in just 4 weeks of open recruitment, a central message from this work is the high demand from depressed perinatal women for online treatment. However, attrition was high and the authors, echoing previous findings,1 point to the possibility of enhancing adherence by the addition of guided support. Indeed, a recent feasibility trial of an online treatment for PND reported excellent adherence to a programme that utilised telephone coaching and included both cognitive and behavioural strategies.2 High rates of attrition in real-world settings (ie, outside of clinical trials) are common, yet it is also true that recent real-world studies of online CBT confirm its effectiveness for depression. Furthermore, a sizeable proportion of patients who ‘drop out’ of treatment nevertheless obtain significant benefits in terms of mood.3–5
This study demonstrates the feasibility of online treatment for PND in a sample defined by a screening instrument rather than by diagnosis, but is nonetheless consistent with emerging evidence suggesting that even those in the ‘severe’ range of depression can derive therapeutic benefit.4 ,6 Such low-intensity interventions could provide a first rung in a stepped-care approach to the management of PND.