Single Day CBT-Based Workshops for Mothers with Postpartum Depression

Although postpartum depression (PPD) affects about 15% of mothers after the birth of a child, recent studies have shown that as few as 10% of individuals with PPD access evidence-based treatment. A recent report suggests that a one-day workshop offering cognitive behavioral therapy (CBT) for PPD may be effective and may have the potential to reach larger numbers of individuals with PPD.

In this randomized controlled trial taking place at multiple sites in Ontario, Canada, participants were self-referred in response to social media advertisements or were referred by healthcare or postpartum providers.  Mothers (18 years or older, n=461) with an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or greater and a child younger than 12 months of age were eligible.  

Individuals randomized to the experimental group received treatment as usual (TAU) and participated in the 1-day workshop. Participants in the control group also received TAU but were put on a waitlist to receive the CBT workshop 12 weeks later.  Because Canada provides universal health care, TAU could involve care from a physician, nurse practitioner, and/or midwife, as well as pharmacotherapy and/or psychotherapy. 

In-person interactive workshops were delivered by a psychiatrist or registered psychotherapist and were held in community settings, such as libraries and community centers from 9:00 AM to 4:00 PM.  Free childcare was provided.

Each workshop consisted of four modules containing didactic teaching, group exercises and discussion, and role playing.  The modules included information on cognitive factors associated with PPD, cognitive skills including cognitive restructuring, behavioral skills such as problem solving, behavioral activation, assertiveness, and action planning.  These workshops were based on previous work from Brown and colleagues adapted for PPD (Brown, Cochrane, & Hancox, 2000).

An Efficacious, Scalable, and Cost-Effective Intervention

Participants were evaluated at 12 weeks after completing the intervention.  Workshops led to meaningful reductions in EPDS scores, and those attending the workshop had a  threefold greater likelihood of achieving a clinically significant decrease in depressive symptoms (odds ratio, OR 3.00, 95% confidence interval 1.93-4.67). Anxiety symptoms also improved, and participants had threefold greater likelihood of achieving a clinically significant decrease in anxiety symptoms (OR 3.20, 95% CI 2.03-5.04). Participants also reported improvements in mother-infant bonding and the quality of their relationship with the baby.

Future studies are needed to determine if this intervention could be used in other settings, for example as an intervention for women who screen positive for PPD in obstetric settings.  This study did not exclude women with more severe depression; however, the mean EPDS score was about 15, which is indicative of moderate depression.  It is not clear if women with more severe depressive symptoms would be able to benefit from this sort of intervention; however, within the framework of this workshop, those with more severe depressive symptoms could be identified and additional referrals could be initiated.  Furthermore, it is important to note that about half of the women were self-referred, a factor that may be associated with greater commitment to and confidence in the intervention.  

While further study is needed, there are notable strengths of this study.  This was a randomized study with a large number of participants, and the follow-up was relatively long (12 weeks).  Delivering the workshop on a single day (and offering free childcare!!) ensures greater compliance with the intervention.   Furthermore, providing the interventions has benefits, reducing social isolation and stigmatization of PPD. Offering the workshop in a community setting may also make the intervention more palatable.  

Providing an intervention to a group of 15-20 women also reduces cost.  After training the workshop leaders, the cost of the program is low: compensation for the workshop leader, childcare, and paper materials.  A ballpark estimate for the cost of each workshop would be about $1400.  What is also impressive about this intervention is that over the 12-week course of the study, workshop participants accrued on average $2077 in healthcare costs, while control group participants accrued $4679.  (The visits were mostly for visits with general practitioners, but also included higher cost items, such as inpatient hospitalization.  Imagine if you have a group of 15 women with PPD; for an upfront investment of $1400, there would be a healthcare savings of $39,030 ($2602 per participant).  

These findings replicate and extend those from a previous randomized control offering 1-day CBT-based online workshops for PPD delivered during the COVID-19 pandemic.  These studies suggest that this low-cost, low-intensity intervention is effective and can be scaled to deliver treatment to large numbers of individuals with PPD in stepped-care pathways.  Medium effect size improvements were seen in depression and anxiety in both in-person and online studies, as well as small effect size improvements in mother-infant bonding 

Seems like a pretty good investment to me.  

Ruta Nonacs, MD PhD

 

References:

Van Lieshout RJ, Layton H, Savoy CD, Xie F, Brown JSL, Huh K, Bieling PJ, Streiner DL, Ferro MA, Haber-Evans E. In-person 1-day cognitive behavioral therapy-based workshops for postpartum depression: a randomized controlled trial. Psychol Med. 2023 Mar 7:1-11. 

Van Lieshout RJ, Layton H, Savoy CD, Brown JSL, Ferro MA, Streiner DL, Bieling PJ, Feller A, Hanna S.  Effect of Online 1-Day Cognitive Behavioral Therapy-Based Workshops Plus Usual Care vs Usual Care Alone for Postpartum Depression: A Randomized Clinical Trial.  JAMA Psychiatry. 2021 Nov 1;78(11):1200-1207.