A randomized controlled trial of ‘MUMentum Pregnancy’: Internet-delivered cognitive behavioral therapy program for antenatal anxiety and depression

Highlights

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

• Superior medium to large reductions in anxiety and psychological distress for iCBT.

• Small non-significant between-group differences for depression symptom severity.

• Participant credibility and satisfaction ratings were high with 76% adherence rate.

Abstract

Background

Anxiety and depression are common during pregnancy and associated with adverse outcomes for the mother and infant if left untreated. Despite the need to improve treatment accessibility and uptake in this population, no studies have investigated internet-delivered cognitive behavioural therapy (iCBT) for antenatal anxiety and depression. In a randomised controlled trial, we examined the efficacy and acceptability of a brief, unguided iCBT intervention – the MUMentum Pregnancy program – in pregnant women with anxiety and/or depression.

Methods

Participants meeting clinical threshold on validated self-report measures of generalised anxiety and/or depression were recruited online and randomised to iCBT (n = 43) or a treatment as usual (TAU) control (n = 44). Outcomes were assessed at baseline, post-treatment and four-week follow-up; and included anxiety, depression, psychological distress, antenatal bonding, quality of life, and treatment acceptability.

Results

Of the 36 women who started iCBT, 26 completed all three lessons of treatment (76% adherence rate). iCBT produced moderate to large effect size reductions for anxiety on the GAD-7 (Hedges’ g = 0.76) and psychological distress on the Kessler-10 (g = 0.88) that were superior to TAU. Only small nonsignificant differences were found for depression outcomes (g = < 0.35). Participants reported that iCBT was an acceptable treatment for antenatal anxiety and/or depression.

Limitations

Lack of an active control condition and long-term postpartum follow-up.

Conclusions

This is the first study to evaluate brief unguided iCBT for antenatal anxiety and depression. While our findings are promising, particularly for anxiety reduction, additional RCTs are required to establish treatment efficacy.

Introduction

During pregnancy, approximately one in five women experience clinically significant symptoms of anxiety and depression, and one in six meet diagnostic criteria for an anxiety and/or major depressive disorder (MDD; Becker et al., 2016, Dennis et al., 2017). Antenatal anxiety and depression are robust predictors of postpartum depression (Austin et al., 2007, Milgrom et al., 2008), and if left untreated, are associated with a range of adverse outcomes for both the mother and infant (e.g., reduced antenatal care; increased risk of preterm birth, low birth weight, and later childhood emotional difficulties; Ding et al., 2014, Goodman and Tyer-Viola, 2010, Grote et al., 2010). Despite this, anxiety and depression during the antenatal period remain under-detected and under-treated (Biaggi et al., 2016, Kingston et al., 2015).

Effective face-to-face treatments exist (e.g., Milgrom et al., 2015), with cognitive behavioural therapy (CBT) being the recommended psychological treatment for mild to moderate anxiety and depression during pregnancy (Austin et al., 2017, NICE 2014). However, there are a range of social, geographical, and logistical barriers that limit access and engagement with existing services (Kingston et al., 2015, Kopelman et al., 2008, Woolhouse et al., 2009). Delivering CBT via the internet (iCBT) provides an alternate option to face-to-face services that could improve treatment uptake in this population. iCBT is a well-established treatment for anxiety and depression in the general adult population (Andrews et al., 2018) and is effective in postpartum populations (Milgrom et al., 2016). iCBT offers several benefits over face-to-face psychotherapy including reduced out-of-pocket cost, increased privacy and convenience, and greater treatment fidelity. iCBT has been shown to be as effective as face-to-face CBT for some disorders (Andersson et al., 2013, Carlbring et al., 2018).

Whilst the evidence-base for iCBT for anxiety and depression is robust in the general adult population, support for its use within the antenatal period is in its infancy. First, most research to-date has focused only on the postpartum period (see Lau et al., 2017). These studies report moderate to large reductions in postpartum depressive symptoms. Only one RCT has evaluated iCBT for antenatal MDD: Forsell et al. (2017)) found large effect size reductions in depressive symptoms relative to treatment as usual (TAU) (Hedges’ g = 1.21). It is unclear whether these findings generalize to a wide range of pregnant women, particularly those who may not meet diagnostic criteria for MDD, but still experience disabling depressive symptoms.

Secondly, no study has investigated the effects of iCBT for the treatment of antenatal generalised anxiety disorder (GAD) symptoms or for the treatment of comorbid GAD and MDD. This is concerning given that these disorders frequently co-occur and that antenatal anxiety affects a comparable number of expectant mothers and results in similar adverse outcomes as depression (Dennis et al., 2017, Grigoriadis et al., 2011). Although no study has examined the effects of iCBT in treating GAD in the antenatal period, Nieminen et al.(2016)) evaluated the feasibility of iCBT for pregnant women with severe fear of childbirth in an open pilot trial, and demonstrated large and significant reductions in their fears (Cohen's d = 0.95). iCBT for postpartum depression appears to have a positive but small impact on anxiety symptoms relative to control conditions (Cohen's d = 0.36; Lau et al., 2017). This is an important area of investigation given the treatment of perinatal anxiety in the broader literature has also received very little attention (Goodman and Tyer-Viola, 2010, Loughnan et al., 2018b).

Third, no study has examined the effects of brief, and/or unguided (i.e., no therapist or clinician support or coaching) iCBT for antenatal symptoms of GAD and/or MDD. The evaluation of brief unguided interventions is important within the context of the antenatal period particularly given shorter programs may be more appealing to busy women, and unguided iCBT programs offering greater scalability and cost-effectiveness for large-scale dissemination. Finally, no study has explored the impact of iCBT beyond symptom change to other antenatal factors, such as maternal bonding. The development of a relationship with the unborn child is thought to be a key development task in successful psychological adjustment to pregnancy, and is associated with health behaviours of the mother and wellbeing of the child before and after birth (Dubber et al., 2015, Van den Bergh and Simons, 2009). However, little is known about the effects of anxiety and depression on the mother's bonding during pregnancy. These are important areas of investigation if we are to maximise treatment benefits for both the mother and infant.

To address these gaps in the literature, we developed a brief unguided iCBT program, “MUMentum Pregnancy”, designed to target symptoms of anxiety and depression during pregnancy (Loughnan et al., 2018a). This study aimed to test the efficacy and acceptability of this program compared to TAU control group. We hypothesised that the MUMentum Pregnancy 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 fetus and maternal quality of life; and (4) be acceptable to participants.