A randomised controlled trial of ‘MUMentum postnatal’: Internet-delivered cognitive behavioural therapy for anxiety and depression in postpartum women

Highlights

• RCT of a brief unguided iCBT program for postpartum anxiety and depression.

• Large between-group superiority of iCBT over TAU for anxiety, depression, distress and bonding.

• Gains maintained at four-week follow-up in iCBT group.

• Large improvements in parenting confidence and quality of life after treatment.

• Participant credibility and satisfaction ratings were high with 75% program completion rate.

Introduction

Maternal anxiety and depression is common during the first 12 months after childbirth (i.e., postpartum period), with 10–15% of mothers likely to meet diagnostic criteria for an anxiety disorder or Major Depressive Disorder (MDD; Dennis, Falah-Hassani, & Shiri, 2017; Woody, Ferrari, Siskind, Whiteford, & Harris, 2017). If left untreated, anxiety and depression adversely affect both the mother and infant (e.g., reduced maternal self-care, poor childhood emotional and behavioural development; Stein et al., 2014). Despite the deleterious effects of postpartum mental health problems, effective treatments exist.

Cognitive behavioural therapy (CBT) is recommended for the treatment of mild to moderate anxiety and/or depression in postpartum women (Austin, Highet, & Expert Working Group, 2017). Yet, due to an absence of routine screening in primary care, postpartum anxiety and depression remain under-detected and undertreated (Biaggi, Conroy, Pawlby, & Pariante, 2016). Indeed, less than half of the women who are anxious or depressed seek help or receive evidence-based treatment such as CBT (Austin et al., 2008; Goodman & Tyer-Viola, 2010). This is due to a range of barriers that limit mothers’ access and engagement with traditional face-to-face treatment services, including long waiting lists, out-of-pocket costs, geographical distance to services, logistical issues (e.g., childcare), and perceived stigma associated with seeking help (Woolhouse, Brown, Krastev, Perlen, & Gunn, 2009).

Delivering CBT via the Internet (iCBT) is one solution to overcoming known barriers to accessing treatment and improving treatment coverage. ICBT is private and convenient, affordable, and has high treatment fidelity (Andrews et al., 2018). In the general adult population, iCBT is well-established in the treatment of anxiety and depressive disorders and has been shown to be as effective as face-to-face CBT for some disorders (Carlbring, Andersson, Cuijpers, Riper, & Hedman-Lagerlöf, 2018). In postpartum populations, therapist-guided iCBT has been demonstrated to be effective in treating depression with moderate to large reductions in symptoms (pooled between-group effect size, Cohen's d = 0.63, Lau, Htun, Wong, Tam, & Klainin-Yobas, 2017). ICBT supported by low-intensity telephone coaching has been shown to be effective in six sessions (Milgrom et al., 2016). Of the women that received iCBT, 79% no longer met diagnostic criteria for depression compared to 18% in the TAU condition. Milgrom et al. (2016) showed a large effect favouring iCBT in reducing depression symptom severity (d = 0.83) and small to medium effects for anxiety and stress. However, the number of studies of iCBT for postpartum depression is small, and almost non-existent for the specific treatment of postpartum anxiety, resulting in several gaps in our understanding about treating postpartum anxiety and depression using iCBT.

Firstly, no studies have investigated the effects of iCBT on generalized anxiety disorder (GAD), or comorbid GAD and MDD in postpartum women. This is despite postpartum anxiety affecting a comparable number of women as depression, and resulting in similar adverse outcomes (Goodman, Watson, & Stubbs, 2016). Comorbid anxiety and depression is also common, and associated with greater symptom severity, poorer short- and long-term outcomes, and increased suicidality (Field et al., 2010; Ross, Evans, Sellers, & Romach, 2003). One recent study (Ashford, Olander, Rowe, Fisher, & Ayers, 2018) investigated the potential efficacy of delivering a self-help psychoeducational booklet online to women experiencing postpartum anxiety. No group differences were evident between the treatment and control group at post-treatment, with the study suffering from high rates of dropout and non-usage attrition. Greater clinical attention to postpartum anxiety, including comorbidity with depression, is therefore warranted, particularly given depression-specific iCBT interventions appear to have only a small to moderate impact on anxiety symptom improvements compared to control conditions (d = 0.36; Lau et al., 2017).

Secondly, no studies have investigated the effects of unguided (i.e., no supervision or coaching) or very brief (i.e., less than six lessons) iCBT in treating postpartum anxiety or depression. In general adult populations, studies have demonstrated that unguided iCBT is comparable to guided iCBT in improving anxiety and depression (e.g., Titov et al., 2013), although in some studies, adherence is lower in unguided iCBT (Morgan et al., 2017). Brief unguided iCBT programs that can be accessed without reliance on specialist mental health clinicians for guidance may offer a more scalable, cost-effective way to teach new mothers how to manage anxiety and depression. In addition, very brief unguided programs may be more appealing to busy mothers who are time-poor and unable to commit to longer treatment, and for mothers residing in rural and remote geographical regions in which access to a supervising therapist may be limited. Lastly, few studies have investigated the impact of symptom change on maternal factors such as bonding (e.g., O'Mahen et al., 2014) and quality of life (QOL; Pugh, Hadjistavropoulos, & Dirkse, 2016). As a result, little is known about the effects of postpartum anxiety and depression on these outcomes and whether iCBT can offer additional benefits to the mother, infant, and family.

To address these limitations in the literature, we developed a brief unguided iCBT intervention, ‘MUMentum Postnatal’, to target symptoms of anxiety and depression in postpartum women (Loughnan, Newby et al., 2018). This program was created alongside our iCBT intervention for antenatal anxiety and depression, ‘MUMentum Pregnancy’ (Loughnan, Sie et al., 2018). The MUMentum Pregnancy program was previously evaluated in depressed and anxious pregnant women, producing large and superior reductions in anxiety (between groups, Hedges g = 0.76) and psychological distress (g = 0.88) relative to treatment as usual (TAU). Adherence to iCBT was high (71%), as was patient satisfaction.

The current study aimed to evaluate the efficacy and acceptability of the three-lesson unguided MUMentum Postnatal program in postpartum women with elevated symptoms of depression and/or generalized anxiety compared to TAU. We hypothesized that the MUMentum Postnatal program would: (1) significantly reduce symptoms of anxiety, depression, and general psychological distress; (2) be significantly more effective at reducing these symptoms than TAU; (3) improve maternal feelings of emotional bonding to the infant, parenting confidence, and QOL; and (4) be acceptable to participants.