Skip to main content
NCBI home page
Cambridge Open Access logoLink to Cambridge Open Access
. 2023 Mar 7;53(14):6888–6898. doi: 10.1017/S0033291723000454

In-person 1-day cognitive behavioral therapy-based workshops for postpartum depression: a randomized controlled trial

Ryan J Van Lieshout 1, Haley Layton 2, Calan D Savoy 1, Feng Xie 3, June S L Brown 4, Kathryn Huh 5,✉, Peter J Bieling 1, David L Streiner 1, Mark A Ferro 6, Erika Haber-Evans 1
PMCID: PMC10600825  PMID: 36878891

Abstract

Background

Postpartum depression (PPD) affects up to one in five mothers and birthing parents, yet as few as 10% access evidence-based treatment. One-day cognitive behavioral therapy (CBT)-based workshops for PPD have the potential to reach large numbers of sufferers and be integrated into stepped models of care.

Methods

This randomized controlled trial of 461 mothers and birthing parents in Ontario, Canada with Edinburgh Postnatal Depression Scale (EPDS) scores ⩾10, age ⩾18 years, and an infant <12 months of age compared the effects of a 1-day CBT-based workshop plus treatment as usual (TAU; i.e. care from any provider(s) they wished) to TAU alone at 12-weeks post-intervention on PPD, anxiety, the mother–infant relationship, offspring behavior, health-related quality of life, and cost-effectiveness. Data were collected via REDCap.

Results

Workshops led to meaningful reductions in EPDS scores (m = 15.77 to 11.22; b = −4.6, p < 0.01) and were associated with three times higher odds of a clinically significant decrease in PPD [odds ratio (OR) 3.00, 95% confidence interval (CI) 1.93–4.67]. Anxiety also decreased and participants had three times the odds of clinically significant improvement (OR 3.20, 95% CI 2.03–5.04). Participants reported improvements in mother–infant bonding, infant-focused rejection and anger, and effortful control in their toddlers. The workshop plus TAU achieved similar quality-adjusted life-years at lower costs than TAU alone.

Conclusions

One-day CBT-based workshops for PPD can lead to improvements in depression, anxiety, and the mother–infant relationship and are cost-saving. This intervention could represent a perinatal-specific option that can treat larger numbers of individuals and be integrated into stepped care approaches at reasonable cost.

Keywords: Anxiety, brief, cognitive behavioral therapy, cost effectiveness, depression, mental disorders, postpartum, psychotherapy, public health, randomized controlled trial, workshop

Postpartum depression (PPD) is among the most common complications of delivery, affecting as many as one in five mothers and birthing parents (Gavin et al., 2005; Lanes, Kuk, & Tamim, 2011). It is associated with an increased risk of future depressive episodes (Slomian, Honvo, Emonts, Reginster, & Bruyère, 2019), and more cognitive, emotional, and behavioral problems in offspring (Goodman & Gotlib, 1999; Murray et al., 2011; Netsi et al., 2018). When those with elevated levels of depressive symptoms are counted, as many as one in three individuals are affected (Meaney, 2018). Those with subsyndromal symptom levels also have poor outcomes as they often fail to seek treatment and are ineligible for clinical services, though many have parenting and offspring outcomes similar to those with formal major depressive disorder (MDD) diagnoses (Holopainen, 2002; Lovejoy, Graczyk, O'Hare, & Neuman, 2000).

While treating PPD can reduce its adverse effects (Krzeczkowski, Schmidt, & Van Lieshout, 2021; Letourneau, Dennis, Cosic, & Linder, 2017), timely and accessible interventions are essential for optimizing outcomes. Healthcare systems are poorly equipped to treat problems requiring urgent psychotherapy like PPD, and as few as one in 10 sufferers receive evidence-based care (Bowen, Bowen, Butt, Rahman, & Muhajarine, 2012; Cox, Sowa, Meltzer-Brody, & Gaynes, 2016). Barriers to treatment include a lack of time and preferences for psychotherapy over medication (Boath, Bradley, & Henshaw, 2004; Byatt, Simas, Lundquist, Johnson, & Ziedonis, 2012; Goodman, 2009; Jones, 2019).

Clinical practice guidelines recommend evidence-based psychotherapies (e.g. cognitive behavioral therapy (CBT)) for the vast majority of those with PPD (MacQueen et al., 2016; NICE, 2020). However, psychological treatments suffer from serious problems of capacity and waitlists can be long. To address this, there needs to be either a massive increase in the number of therapists or substantial changes to the way we treat PPD.

Even though international practice guidelines suggest that those with PPD should be a priority population for psychotherapy access (NICE, 2020), virtually no low-intensity interventions have proven effective in this population. While standard self-help approaches could be effective in those with PPD (Trevillion et al., 2020), they may not be ideally suited for this group. Many mothers and birthing parents also lack the time to engage in self-help exercises which are quite burdensome when added to existing role demands. Moreover, despite their convenience and ease of use, mobile applications (apps) have not proven clinically effective for PPD (Tsai et al., 2022).

One low-intensity approach to treating PPD is 1-day psychotherapy workshops. The delivery of psychotherapy in large groups (i.e. up to 30 participants) (Horrell et al., 2014; Yunus, Musiat, & Brown, 2019) may be capable of addressing the needs of those with PPD, as well as treating it on the scale required to address its prevalence. These 1-day interventions contain the core content of more comprehensive, evidence-based treatments, but their brevity and scalability make them easier to disseminate.

During the COVID-19 pandemic, a large (n = 403) randomized controlled trial (RCT) of 1-day CBT-based workshops for PPD delivered online led to reductions in PPD and anxiety, as well as improvements in the mother–infant relationship and infant temperament (Van Lieshout et al., 2021). However, some participants expressed a preference for in-person workshops citing difficulties participating online while minding an infant, concerns about privacy, and the benefits of face-to-face social support. The effectiveness of these workshops outside of the pandemic context also remains unclear, their impact on other children in the home is not well understood, and despite their efficiency, their cost-effectiveness is not known.

A few RCTs of treatments for PPD that have examined cost-effectiveness suggest that effective interventions are usually more expensive than treatment as usual (TAU). One trial of telephone-based peer-support showed that it was more effective than TAU and cost-effective (with an incremental cost-effectiveness ratio (ICER) of CAD$ 10 009), but the cost was higher in the intervention group (Dukhovny et al., 2013). Similarly, a facilitated self-help-based program for PPD was more effective but more costly than TAU at £13 324 per quality-adjusted life-year (QALY) (National Collaborating Centre for Mental Health, 2014). A probabilistic treatment model based on a National Institute for Health and Care Excellence (NICE) guideline found that structured psychological therapy was cost effective compared to TAU at an ICER of £17 481 (Hewitt et al., 2009; NICE, 2020) which is just below the cost-effectiveness threshold of less than £20 000 recommended by NICE (2013). Given the potential scalability of 1-day CBT-based workshops for PPD, understanding its cost-effectiveness will help determine their potential to treat PPD.

Given this background, we examined the effectiveness of in-person 1-day CBT-based workshops for PPD at improving depression, anxiety, the mother–infant relationship, and offspring behavior, as well as health-related quality of life and cost-effectiveness.

Method

Trial design and procedures

This parallel-group, multi-site, RCT took place in Ontario, Canada from 17 July 2018 to 28 February 2020, recruiting from seven geographic regions representing most of the provinces of Ontario's local health integration networks: Elgin county, Simcoe county, Prince Edward county, the city of Toronto, Huron county, Kitchener-Waterloo, and Halton regions. Community organizations, midwives, and public health units in these regions assisted with recruitment and provided workshop sites.

Participants in each region were centrally randomized in a 1:1 ratio to the experimental or control group. Individuals assigned to the experimental group received 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. In Ontario, healthcare is universally available, so TAU could involve care from a physician, nurse practitioner, and/or midwife, as well as pharmacotherapy and/or psychotherapy from a provincially funded program. They could also utilize the services of any private therapist.

Centralized randomization that used 77 blocks of size of four, six, and eight was used to allocate participants to experimental and control arms. The randomization scheme was created in R version 3.4.3 (R Core Team, n.d.) and implemented by the study coordinator in REDCap (Harris et al., 2009), enabling concealment of allocation sequence until group assignment. Staff making reminder calls and/or collecting data and the data analyst were unaware of participant group status. The study was approved by the Hamilton Integrated Research Ethics Board and was registered (ClinicalTrials.gov: NCT03654261).

Participants

Participants could self-refer after seeing social media advertisements or be referred by staff at a partnering organization. They had to be ⩾18 years old, have an infant <12 months of age, live in a recruitment region, and have an Edinburgh Postnatal Depression Scale (EPDS) score ⩾10. This cut-off is commonly used in clinical and research settings to identify those who may have PPD (Gavin et al., 2005; Lanes et al., 2011) and was chosen to maximize public health relevance [30% of mothers/birthing parents have these symptom levels (Meaney, 2018)]. Participants were also fluent in written and spoken English.

Intervention

Workshops were delivered by one psychiatrist or one registered psychotherapist randomly assigned to workshop dates. Their training involved review of the participant manual and workshop script. Each delivered one workshop and received feedback from the other prior to delivering study workshops. Workshops were held in community settings such as libraries and community centers, and free childminding was provided.

Each interactive workshop was run from 0900 to 1600 and consisted of four modules containing didactic teaching, group exercises/discussion, and role plays. The first reviewed PPD etiology with an emphasis on cognitive factors, and the second focused on cognitive skills including cognitive restructuring. The third built behavioral skills such as problem solving, behavioral activation, and assertiveness, and the fourth provided an opportunity for action planning. Workshops were based on previous work by Brown and colleagues, but adapted for PPD (Brown, Cochrane, & Hancox, 2000). Participants received a printed copy of the workshop manual.

Data collection and outcome measures

Data were collected from participants using REDCap (Harris et al., 2009) at baseline (T1) and 12 weeks later (T2). At enrollment, participants self-reported their sociodemographic characteristics (age, infant age, ethnicity, marital status, educational attainment, household income, antidepressant use, and past counseling).

We chose to assess our T2 outcomes at 12 weeks post-treatment because this corresponds to one of the most common post-treatment endpoints used in RCTs of gold-standard psychotherapies like interpersonal therapy (IPT) and CBT. This was intended to help determine if this very brief treatment could produce benefits over comparable periods of time of these well-established treatments. It was felt this could assist patients and clinicians determine if this briefer treatment could be effective and applicable to them.

The primary outcome (PPD) was assessed using the EPDS, a 10-item measure of symptoms of depression during the previous 7 days (Cox, Holden, & Sagovsky, 1987). Each item is scored on a 4-point scale (0–3) with higher scores indicating worse depressive symptoms. Based on Jacobson and Truax's reliable change index (1991), and consistent with the work of others (Affonso, De, Horowitz, & Mayberry, 2000; Matthey, 2004), we defined an EPDS score change of at ⩾4 points as indicative of clinically significant change in PPD.

Secondary outcomes included anxiety, mother–infant bonding, infant temperament, behavior of older children, and cost-effectiveness. The 7-item Generalized Anxiety Disorder Questionnaire (GAD-7) measured anxiety and contains seven items scored on a 0–3-point scale, with higher scores indicating worse anxiety (Spitzer, Kroenke, Williams, & Löwe, 2006). The GAD-7 has been validated for use in postpartum samples (Simpson, Glazer, Michalski, Steiner, & Frey, 2014). In accordance with previous research, ⩾4 point change in GAD-7 score was defined as clinically significant (Toussaint et al., 2020).

The Postpartum Bonding Questionnaire (PBQ) assessed the mother–infant relationship. Its 25-items are scored on a 5-point scale (0–5), and contains four subscales: impaired bonding, rejection and pathological anger toward the infant, infant focused anxiety, and incipient abuse (Brockington, Fraser, & Wilson, 2006). The incipient abuse scale was not examined due to past performance issues (Klier, 2006).

Infant temperament was rated by mothers with the Infant Behavior Questionnaire-Revised Very-Short Form (IBQ-R), a 37-item measure of infant temperament over the past week (Putnam, Helbig, Gartstein, Rothbart, & Leerkes, 2014). Items are scored on a 7-point scale and address three factors: positive affectivity/surgency, negative emotionality, and orienting/regulatory capacity.

Participants also rated the behavior of their 12–36-month-old children (when present) using the Early Childhood Behavior Questionnaire-Short Form (ECBQ), a 107-item measure of temperament comprised of surgency/extraversion, negative affectivity, and effortful control (Putnam, Gartstein, & Rothbart, 2006). Children older than 36 months were rated using the Strength and Difficulties Questionnaire (SDQ), a 25-item measure of child behavior consisting of five scales (emotional, conduct, hyperactivity/inattention, peer relationship problems, and prosocial behavior). The total problems scale, consisting of the first four scales above, was used here (He, Burstein, Schmitz, & Merikangas, 2013).

Participants reported their use of health resources on a scale created using the Canadian Community Health Survey and the Service Use and Resources Form, and adapted for the postpartum period (Government of Canada, 2007). Data on service usage including hospital, physician, and other healthcare provider visits were collected, as were those pertaining to diagnostic tests and medication usage. The costs of workshop delivery were added to healthcare costs determined using a public payer perspective. Service costs were determined primarily by using the Province of Ontario's standardized Schedule of Benefits and its Schedule of Facility Fees. When those were not available, recommended hourly averages reported by the profession's official Ontario association were used (e.g. for physiotherapists, occupational therapists, etc.). The costs of public health programs were averaged based on provincial funding in 2020 (online Supplementary Table S1). The costs of medications were calculated using the Ontario Drug Benefit Formulary.

The EuroQol Group's EQ-5D-3L is a preference-based health status questionnaire comprised of five domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each domain is measured through three-level response options indicating no, some, and extreme problems (van Dongen et al., 2021). This study utilized a Canadian value set (Bansback, Tsuchiya, Brazier, & Anis, 2012). These index values were used to compute QALYs to compare the difference in effect between the intervention and control groups (Petrou & Gray, 2011). The EQ-5D-3L can also be scored as a 100-point Visual Analog Scale (VAS), providing a holistic summary of health status across the EQ-5D's five domains (Whynes & the TOMBOLA Group, 2008). The VAS is reported as an outcome measure alongside the core results of this study.

Statistical analyses

Demographic data were compared using t tests and χ2 tests for continuous and dichotomous variables, respectively.

A priori sample size estimation suggested that a total of 476 participants would provide us with adequate statistical power to detect a medium effect size (d = 0.3) change in our primary outcome (EPDS) between groups (a group × time interaction). The power calculation used two-tailed statistical significance (α = 0.05) and 1 − β = 0.90. This estimation assumes a linear mixed model (LMM) applying a first-order autoregressive error covariance structure. This sample size estimate also presumed a 10% attrition rate between T1 and T2. Because of the COVID-19 pandemic, recruitment was stopped when 461 participants had been recruited. However, this sample size was still estimated to be capable of detecting significant effect sizes of similar magnitude (d ~ 0.33). Sample size and power estimations were calculated using RMASS (Bhaumik et al., 2008; Hedeker, Gibbons, & Waternaux, 1999; Roy, Bhaumik, Aryal, & Gibbons, 2007).

To investigate the effectiveness of 1-day CBT workshops on continuous outcomes, we utilized LMMs with restricted maximum-likelihood estimation. A two-level hierarchy was employed in which outcomes at each timepoint (pre- and post-workshop) were nested within participant (split by group), allowing us to assess the effect of the intervention over time between experimental and control groups. A random-effects intercept was also included in the model controlling for unobserved heterogeneity at the level of the individual participant. These models also included workshop facilitator as a fixed effect covariate to control for individual differences in intervention effectiveness that may exist between workshop leaders. For outcome measures that revealed a significant group × time interaction, models stratified by group were employed to identify the magnitude of change in outcome measure score following workshop completion by the experimental group. Cohen's d defined the effect size of the change in mean scale score between baseline and follow-up. Finally, logistic regression was used to compare the odds of participants experiencing a ⩾4-point decrease in EPDS and GAD-7 scores (indicative of clinically significant improvement) between T1 and T2. Analyses were performed in SPSS 24 (IBM SPSS Statistics).

In conjunction with the QALY values calculated using the EQ-5D-3L Canadian index scores, healthcare cost data over the 12-week study period were used to calculate the ICER, comparing the cost-effectiveness of the workshop plus TAU v. TAU alone. In keeping with the intent-to-treat approach and given the limitations of imputing missing QALY and service use data, complete case analysis was employed. However, non-parametric bootstrapping was applied to the complete cases to estimate the uncertainty of the computed ICER across 1000 bootstrapped simulations. Finally, a cost-effectiveness acceptability curve (CEAC) was derived from the bootstrapped data, illustrating the probability of cost-effectiveness across a range of willingness-to-pay values per QALY gained.

Results

A total of 1435 participants were assessed for eligibility and 461 were randomized to experimental (n = 229) or control (n = 232) groups. Sixty-nine participants declined to participate prior to T1 data collection, so 392 (experimental n = 189, control n = 203) completed baseline (T1) measures (Fig. 1).

Fig. 1.

Fig. 1.

Open in a new tab

Flowchart of participants through the trial.

The majority of participants self-referred to the study after seeing information on social media (56%), on a partnering agency's website (5%), or after hearing about the study from family/friends (4%). Others (15%) were referred by healthcare providers including public health nurses, midwives, and/or family doctors. Remaining referral sources included community groups and early years centers.

In total, 33 workshops were run in regions across southern Ontario including Elgin county, Simcoe county, Prince Edward county, the city of Toronto, Huron county, Kitchener-Waterloo, and Halton regions. Workshops were delivered by a registered psychotherapist (n = 16) or a psychiatrist (n = 17). The baseline characteristics of experimental and control group participants are given in Table 1. There were no statistically significant differences between groups. A total of 48 (12%) participants were lost to follow-up between T1 and T2, of which 31 were in the experimental group and 17 in the waitlist control group (χ2 = 5.87, p = 0.015). Other than group assignment, no other baseline characteristics predicted dropout. At T1, 37 experimental and 44 control participants completed the ECBQ for their eligible toddlers, and 52 children of those in the experimental group and 55 control participants had children who were age-eligible for SDQ completion.

Table 1.

Baseline characteristics of experimental and control participants

Demographics Experimental group Control group t/χ2 p
N 189 203
Ethnicity (% white) 134 (69%) 107 (60%) 3.26 0.07
Latino/Hispanic 3 (2%) 11 (6%)
Middle Eastern 6 (3%) 3 (2%)
African 2 (1%) 4 (2%)
Caribbean 5 (3%) 10 (6%)
South Asian 19 (10%) 11 (6%)
East Asian 9 (5%) 14 (8%)
Mixed 8 (4%) 11 (6%)
Other 9 (5%) 8 (5%)
Age, years (s.d.) 31.6 (5.2) 32.3 (4.3) 1.39 0.17
Range, years 20–47 19–41
Infant age, months (s.d.) 5.2 (3.6) 5.6 (3.6) 0.99 0.32
Avg. number of children (s.d.) 1.5 (0.8) 1.5 (0.9) 0.08 0.93
Marital status (% married/common law) 55 (90%) 50 (96%) 2.2 0.53
Years of education 15.6 (2.1) 15.5 (2.1) 0.24 0.81
Household income (CAD) $80 016 ($17 540) $82 021 ($19 764) 0.22 0.82
Prior use of talk therapy 79 (44%) 78 (40%) 0.72 0.4
Use of psychotropic medication 16 (8%) 21 (10%) 0.4 0.52
EPDS Baseline score 15.8 (5.9) 15.1 (4.9) 1.3 0.2
GAD-7 Baseline score 11.4 (4.8) 11.4 (4.9) 0.08 0.93
PBQ-IB 13.04 (8.22) 11.79 (6.82) 0.76 0.44
PBQ-RPA 7.05 (5.38) 5.91 (4.45) 1.57 0.12
PBQ-IFA 3.52 (3.71) 3.61 (2.99) 0.65 0.52
IBQ-R-SUR 4.28 (1.31) 4.36 (1.08) 1.13 0.26
IBQ-R-EC 5.14 (1.04) 5.24 (0.87) 0.73 0.47
IBQ-R-NA 3.73 (1.36) 3.82 (1.13) 1.04 0.30
ECBQ-SUR 5.4 (3.26) 5.24 (2.55) 0.14 0.88
ECBQ-NEG 3.31 (2.39) 2.94 (1.88) 1.45 0.15
ECBQ-EC 4.70 (2.56) 5.04 (2.01) 2.00 0.05
SDQ TOTAL 11.20 (11.88) 10.16 (9.8) 0.84 0.40
EQ-5D-VAS 56.46 (21.96) 56.99 (18.72) 0.33 0.74
Open in a new tab

s.d., standard deviation; CAD, Canadian dollars.

After adjusting for the fixed effect of workshop facilitator, statistically significant group × time interactions predicted EPDS, GAD-7, PBQ-IB, PBQ-RPA, PBQ-IFA, ECBQ-EC, and EQ-5D-3L scores (Table 2). After stratifying by group, experimental group participants reported statistically significant decreases in EPDS scores from T1 to T2, with scores decreasing from 15.77 pre-treatment to 11.22 post-treatment (p < 0.01, Cohen's d = 0.62). Statistically significant decreases in GAD-7 scores 11.36 to 7.14 (p < 0.01, d = 0.56), PBQ-IB (13.04 to 10.27; p < 0.01, d = 0.27), PBQ-RPA (7.05 to 4.89; p < 0.01, d = 0.32), ECBQ-EC (4.70 to 4.94, p = 0.04, d = 0.08), and EQ-5D-VAS (56.46 to 65.63; p < 0.01, d = 0.33) were also observed. While a statistically significant interaction between group and time predicted change in PBQ-IFA scores, no difference was detected between T1 and T2 among experimental group participants (3.52 v. 3.79, p = 0.25, d = 0.06) (Table 3).

Table 2.

Group × time interaction predicting clinical outcomes

Outcome measure B Std. error t p
EPDS −2.97 0.46 −6.49 <0.001*
GAD −2.90 0.49 −5.92 <0.001*
PBQ-IB −1.41 0.68 −2.08 0.04*
PBQ-RPA −1.51 0.43 −3.54 <0.001*
PBQ-IFA −0.66 0.31 −2.15 0.03*
IBQR-SUR 0.17 0.12 1.49 0.14
IBQR-EC 0.12 0.09 1.42 0.16
IBQR-NA 0.07 0.11 0.66 0.51
ECBQ-SUR 0.16 0.22 0.72 0.48
ECBQ-EC 0.42 0.19 2.16 0.04*
ECBQ-NEG −0.06 0.19 −0.30 0.77
SDQ-TOTAL 0.63 0.99 0.64 0.52
EQ-5D-VAS 7.37 2.12 3.47 <0.001*
Open in a new tab

EPDS, Edinburgh Postnatal Depression Scale; GAD-7, General Anxiety Disorder-7 Scale; PBQ, Postpartum Bonding Questionnaire; IB, impaired bonding; RPA, rejection and pathological anger; IFA, infant focused anxiety; IBQ-R, Infant Behavior Questionnaire-Revised; ECBQ, Early Childhood Behavioral Questionnaire; SUR, surgency; EC, effortful control; NA, negative affect; SDQ, Strengths and Difficulties Questionnaire; EQ-5D-VAS, EuroQol 5-Dimensional Health Questionnaire Visual Analog Scale.

Note: Analyses were conducted using LMMs controlling for workshop facilitator as a fixed effect.

*

Statistically significant (p < 0.05) mean difference.

Table 3.

Changes from T1 to T2 for primary and secondary outcome measures

Experimental group (N = 189) Control group (N = 203)
Time 1 Time 2 Time 1 Time 2
Mean s.d. Mean s.d. Δmean p value Mean s.d. Mean s.d. Δmean p value
EPDS 15.77 5.87 11.22 6.15 −4.55 <0.01* 15.05 4.89 13.49 5.04 −1.56 <0.01*
GAD 11.36 6.08 7.14 6.41 −4.22 <0.01* 11.32 5.06 10.01 5.24 −1.31 <0.01*
PBQ IB 13.04 8.22 10.27 8.62 −2.77 <0.01* 11.79 6.82 10.46 7.02 −1.34 0.01*
PBQ RPA 7.05 5.38 4.89 5.62 −2.16 <0.01* 5.91 4.45 5.26 4.57 −0.65 0.03*
PBQ IFA 3.52 3.71 3.79 3.57 0.27 0.23 3.61 2.99 4.54 2.85 0.93 <0.01*
IBQ-R SUR 4.28 1.31 4.86 1.37 0.58 <0.01* 4.36 1.08 4.76 1.13 0.40 <0.01*
IBQ-R EC 5.14 1.04 5.27 1.11 0.12 0.06 5.24 0.87 5.24 0.90 −0.01 0.94
IBQ-R NA 3.73 1.36 3.90 1.43 0.18 0.03* 3.82 1.13 3.92 1.17 0.10 0.16
ECBQ SUR 5.40 3.26 5.47 3.46 0.07 0.68 5.24 2.55 5.15 2.71 −0.09 0.54
ECBQ NEG 3.31 2.39 3.47 2.58 0.16 0.27 2.94 1.88 3.15 2.02 0.21 0.09
ECBQ EC 4.70 2.56 4.94 2.75 0.24 0.10 5.04 2.01 4.86 2.17 −0.18 0.17
SDQ TOTAL 11.20 11.88 11.80 12.02 0.60 0.20 10.16 9.80 10.29 9.40 0.12 0.47
EQ-5D-VAS 56.46 21.96 65.63 23.34 9.18 <0.01* 56.99 18.72 58.83 19.26 1.84 0.23
Open in a new tab

EPDS, Edinburgh Postnatal Depression Scale; GAD-7, General Anxiety Disorder-7 Scale; PBQ, Postpartum Bonding Questionnaire; IB, impaired bonding; RPA, rejection and pathological Anger; IFA, infant focused anxiety; IBQ-R, Infant Behavior Questionnaire-Revised; ECBQ, Early Childhood Behavioral Questionnaire; SUR, surgency; EC, effortful control; NA, negative affect; SDQ, Strengths and Difficulties Questionnaire; EQ-5D-VAS, EuroQol 5-Dimensional Health Questionnaire Visual Analog Scale.

Note: Analyses were conducted using LMMs controlling for workshop facilitator as a fixed effect, yielding estimated marginal means.

*

Statistically significant (p < 0.05) mean difference and group × time interaction.

58% of the experimental group v. 31% control group had a clinically significant change (>4 points) in EPDS score.

54% of the experimental group v. 27% control group had a clinically significant change (>4 points) in GAD-7 score.

Among experimental group participants, 58% reported clinically significant (⩾4-point) decreases in EPDS scores at T2, compared to 31% of control group participants [odds ratio (OR) 3.00, 95% confidence interval (CI) 1.93–4.67, number needed to treat (NNT) = 3.8]. Likewise, 54% of experimental group participants reported a ⩾4-point decrease in GAD-7 scores at T2 v. 27% of control group participants (OR 3.20, 95% CI 2.03–5.04, NNT = 3.7).

The largest healthcare costs that accrued between T1 and T2 were attributable to general practitioner use (219 participants with at least one visit). Diagnostic imaging procedures (42 participants) were common but represented highly variable costs. While infrequent (eight participants), overnight hospital admissions also represented sizeable healthcare costs. Over the 12-week course of the study, experimental group participants accrued on average $2076.64 in healthcare costs, while control group participants accrued $4678.78.

QALYs were calculated for the 12-week time horizon between T1 and T2 for all participants who provided EQ-5D-3L index scores at T2 (experimental group n = 150, control group n = 179). The mean QALY increase was larger for experimental group participants [0.17 (s.d. = 0.02)] than for the control group [0.16 (s.d. = 0.03)] (the maximum of QALY over 12 weeks is 0.23). This difference was not statistically significant (t = −1.48, p = 0.14). However, the 1-day CBT workshop plus TAU achieved similar QALY at lower costs than TAU alone. The probability of the 1-day CBT workshop being cost-effective was 0.74 at a willingness-to-pay threshold of $0 and increased to 0.8 at $100 000 (Fig. 2).

Fig. 2.

Fig. 2.

Open in a new tab

CEAC of treatment across increasing willingness to pay thresholds.

Discussion

In this RCT of 461 mothers and birthing parents with PPD, a 1-day CBT-based workshop for PPD added to TAU led to statistically and clinically significant reductions in depression and anxiety relative to TAU alone. The workshops also resulted in improvements in the mother–infant relationship and the behavior of toddlers. In addition to its clinical effects, the workshops were cost-saving.

These findings replicate and extend those of an RCT of 1-day CBT-based workshops for PPD delivered online during the COVID-19 pandemic, and provide converging evidence supporting their effectiveness as a low-intensity intervention in stepped-care pathways (NICE, 2020; PCMCH Guidance Document: Perinatal Mental Health, 2021). Indeed, medium effect size improvements were seen in PPD and anxiety in both in-person and online studies, and small effect size increases in the bonding subscale of the PBQ were seen in both interventions. The effectiveness of this 1-day workshop approach to depression treatment is also supported by studies that have examined 1-day interventions for general population samples of adults with depression (Horrell et al., 2014) and/or anxiety (Brown et al., 2000), and adolescents (Brown et al., 2019), as well as other, briefer single-session interventions (Dobias, Schleider, Jans, & Fox, 2021; Schleider et al., 2022). The magnitude of the treatment effects seen are also similar to 1-day workshops in these other groups, as well as longer CBT treatment protocols previously utilized to treat depression in the perinatal period (Sockol, 2015).

In addition to reductions in PPD, in-person and online workshops were both associated with meaningful improvements in anxiety. CBT is a first-line treatment for anxiety in adults (Andrews et al., 2018; Katzman et al., 2014), and a growing body of evidence supports the effectiveness of CBT in those with postpartum anxiety (e.g. Nillni, Mehralizade, Mayer, & Milanovic, 2018). The size of the effect of this intervention on anxiety is comparable to our previous online workshop, as well as existing RCTs of CBT for anxiety (Loughnan et al., 2019; Maguire, Clark, & Wootton, 2018), and suggest that these workshops may be capable of reducing comorbid anxiety in those with PPD.

This intervention also led to some improvement in aspects of the mother–infant relationship including bonding, rejection, and pathological anger, and infant-focused anxiety. These findings replicate those of our previous online RCT (Van Lieshout et al., 2021), as well as other recent trials of CBT for PPD (Amani et al., 2021; Stein et al., 2018; Van Lieshout et al., 2022). Whether these changes are due to improvements in depression or anxiety, or the ways in which mothers interact with their infants are not known. However, while participants reported improvements in the mother–infant relationship, they did not note changes in infant temperament. This is at odds with the findings of the previous online 1-day trial where small but statistically significant increases in surgency were noted. Whether this is due to differences in our sampling frame, sample, or delivery modality (in-person v. online) is not known.

Despite the lack of statistically significant changes in infant temperament or the behavior of the participants' older children, improvements in the temperament (effortful control) of their toddlers were reported. Relatively few studies have examined the impact of interventions for PPD on non-infant offspring, even though it is well-known that PPD can have an adverse impact on their emotional and behavioral development. Pre-pandemic studies showed that children exposed to PPD manifest elevated levels of anxiety (Walker, Davis, Al-Sahab, & Tamim, 2013), as well as hyperactivity and concentration difficulties at 2 years of age (Avan, Richter, Ramchandani, Norris, & Stein, 2010). It is not clear why workshops may have had a positive effect on toddlers but not infants or older children. Perhaps changes in toddlers occur more quickly than in infants, or were more easily observable, and/or that the changes occur in temperament, but not child behavioral difficulties. However, replication in future samples is required in order to better understand the potential effects of workshops on offspring.

We found that 1-day CBT-based workshops plus TAU were associated with similar QALYs to TAU alone, but were less expensive. This finding contrasts with a systematic review that found group CBT interventions to be associated with QALY gains but at a cost of £39 875 per QALY gained (Stevenson et al., 2010), well above the NICE-recommended cost-effectiveness threshold of less than £20 000–30 000 (NICE, 2013), suggesting that these interventions may not be cost-effective. However, our cost-effectiveness analyses suggested that 1-day CBT-based workshops for PPD added to TAU may be more effective and less expensive than TAU alone. In this study, the waitlist group also had worse overall health outcomes, though the incremental QALY difference was small. Regardless, these results support demonstrate the potential of the 1-day workshop model to be cost-effective, though further confirmation in future studies would be of value.

While promising, the findings of this study do need to be interpreted in light of its limitations. First, the intervention was delivered by only two expert therapists from a single center and occurred in-person prior to the pandemic. Facilitators of participation in in-person psychotherapies like implementing and clearly communicating safety protocols, conducting sessions outside of hospital settings, the provision of childcare, as well as flexible scheduling should be kept in mind in order to optimize participation in workshops delivered face-to-face (Andrejek et al., 2021).

While some prefer to attend interventions in-person, this modality may now be less popular than online delivery for some mothers and birthing parents. Online treatments have gained popularity since the COVID-19 pandemic for their increased accessibility (Simpson, Richardson, Pietrabissa, Castelnuovo, & Reid, 2021), families and healthcare providers have expressed significant interest in using telemedicine for PPD (Singla et al., 2020), and online therapeutic alliances have been rated as strongly as in in-person settings (Simpson & Reid, 2014).

While full-day workshops are effective, we should acknowledge that some may prefer the intervention be delivered in two half-days. However, in our online trial, just 10 of 161 participants in the experimental group (6%) expressed a preference that it be delivered differently (e.g. in half-days). Of these, 155 (96%) remained online for the entire session and 140 (87%) indicated that they were very satisfied with the full-day workshop (Van Lieshout et al., 2021).

While facilitated interventions are often preferred by individuals with PPD over other self-guided options (Goodman, 2009), future research should focus on exploring alternative delivery modalities, along with an examination of the potential moderators (e.g. therapist type, participant PPD severity, delivery in a single-day v. two half-days) and mediators (intervention fidelity, cognitive, and/or behavioral skill use) of intervention effectiveness. In the interim, asking those with PPD what they feel might work best for them is likely the optimal approach.

This study also took place in Canada where healthcare is universally available and so our findings may not generalize to all settings. Attrition was also higher in the experimental group in this study, but this may be due to the anticipation of those on the waitlist to receive the workshop. This is a consistently observed effect in studies of 1-day CBT-based workshops (Horrell et al., 2014; Van Lieshout et al., 2021). While the workshops did produce clinically significant improvements in PPD and anxiety, we did not conduct structured clinical interviews and so participants may not have had syndromal MDD or GAD, nor did they necessarily experience remission. However, since PPD is commonly seen as a continuous construct and the improvements observed in this and our previous study are clinically meaningful, the intervention may still have clinical utility. It is also important to note that all outcomes were self-reported by participants and so improvements in the mother–infant relationship and offspring outcomes may be contributed to by maternal symptom improvement. Moreover, it is possible that spontaneous remission could have contributed to our findings. Indeed, in previous trials of those with PPD, approximately 25% of participants were thought to have experienced spontaneous recovery (Li et al., 2022; Sockol, 2015, 2018). We feel that we should also emphasize that while we chose to assess our outcomes at a single timepoint (3 months post-intervention) to try to optimize the comparability of our post-treatment findings to trials of full courses of structured psychotherapies, we did not assess participants immediately post-treatment (the day after the workshop). Because our study was powered to detect a moderate (d = 0.3) treatment effect in our primary outcome of interest (EPDS), it had less statistical power than might have been necessary to detect an equivalent effect in those outcomes that applied only to those with toddlers. Future studies may more comprehensively investigate the effect of CBT treatment on these outcomes with a larger sample size, specifically recruiting participants with children aged 2–3 years. Finally, we utilized a waitlist control design which may have inflated the size of the effects observed and prevented us from assessing the longer-term impact of the intervention.

Those focused on the mental health of mothers and birthing parents are in urgent need of safe, efficient, economical, evidence-based, and scalable means of treating PPD. One-day CBT-based workshops may be an effective treatment for PPD delivered in-person or online and has significant potential for scaling and task-shifting. It is also consistent with mothers' preferences and the proportionate universalism approach to public mental health utilized around the world, which attempts to address the whole population while providing additional (selective/targeted/indicated) support for groups at risk. These workshops may also represent a perinatal-specific option that could be integrated into stepped care approaches at reasonable cost. If successful, this intervention could provide the scope to deliver treatment to large numbers of individuals with PPD, an important goal given the staggering cost of this disorder and the importance of parental mental health to children, families, and society.

Acknowledgments

The authors would like to acknowledge the study participants and their families, as well as Orillia Soldiers' Memorial Hospital, Toronto Public Health, Hastings Prince Edward Public Health, Huron Perth Public Health, Southwestern Public Health, Blue Heron Midwives, and ROCK EarlyON.

Supplementary material

For supplementary material accompanying this paper visit https://doi.org/10.1017/S0033291723000454.

S0033291723000454sup001.pdf (89.4KB, pdf)

click here to view supplementary material

Financial support

This study was funded by the Canada Research Chairs Program.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

References

  1. Affonso, D. D., De, A. K., Horowitz, J. A., & Mayberry, L. J. (2000). An international study exploring levels of postpartum depressive symptomatology. Journal of Psychosomatic Research, 49(3), 207–216. doi: 10.1016/s0022-3999(00)00176-8 [DOI] [PubMed] [Google Scholar]
  2. Amani, B., Merza, D., Savoy, C., Streiner, D., Bieling, P., Ferro, M. A., & Van Lieshout, R. J. (2021). Peer-delivered cognitive-behavioral therapy for postpartum depression: A randomized controlled trial. The Journal of Clinical Psychiatry, 83(1), 21m13928. doi: 10.4088/JCP.21m13928 [DOI] [PubMed] [Google Scholar]
  3. Andrejek, N., Hossain, S., Schoueri-Mychasiw, N., Saeed, G., Zibaman, M., Puerto Niño, A. K., … Singla, D. R. (2021). Barriers and facilitators to resuming in-person psychotherapy with perinatal patients amid the COVID-19 pandemic: A multistakeholder perspective. International Journal of Environmental Research and Public Health, 18(22), 12234. doi: 10.3390/ijerph182212234 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Andrews, G., Bell, C., Boyce, P., Gale, C., Lampe, L., Marwat, O., … Wilkins, G. (2018). Royal Australian and New Zealand college of psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian & New Zealand Journal of Psychiatry, 52(12), 1109–1172. doi: 10.1177/0004867418799453 [DOI] [Google Scholar]
  5. Avan, B., Richter, L. M., Ramchandani, P. G., Norris, S. A., & Stein, A. (2010). Maternal postnatal depression and children's growth and behaviour during the early years of life: Exploring the interaction between physical and mental health. Archives of Disease in Childhood, 95(9), 690–695. doi: 10.1136/adc.2009.164848 [DOI] [PubMed] [Google Scholar]
  6. Bansback, N., Tsuchiya, A., Brazier, J., & Anis, A. (2012). Canadian valuation of EQ-5D health states: Preliminary value set and considerations for future valuation studies. PLoS ONE, 7(2), e31115. doi: 10.1371/journal.pone.0031115 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Bhaumik, D. K., Roy, A., Aryal, S., Hur, K., Duan, N., Normand, S.-L. T., … Gibbons, R. D. (2008). Sample size determination for studies with repeated continuous outcomes. Psychiatric Annals, 38(12), 765–771. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Boath, E., Bradley, E., & Henshaw, C. (2004). Women's views of antidepressants in the treatment of postnatal depression. Journal of Psychosomatic Obstetrics and Gynaecology, 25(3–4), 221–233. doi: 10.1080/01674820400017889 [DOI] [PubMed] [Google Scholar]
  9. Bowen, A., Bowen, R., Butt, P., Rahman, K., & Muhajarine, N. (2012). Patterns of depression and treatment in pregnant and postpartum women. The Canadian Journal of Psychiatry, 57(3), 161–167. doi: 10.1177/070674371205700305 [DOI] [PubMed] [Google Scholar]
  10. Brockington, I. F., Fraser, C., & Wilson, D. (2006). The postpartum bonding questionnaire: A validation. Archives of Women's Mental Health, 9(5), 233–242. doi: 10.1007/s00737-006-0132-1 [DOI] [PubMed] [Google Scholar]
  11. Brown, J., Blackshaw, E., Stahl, D., Fennelly, L., Mckeague, L., Sclare, I., & Michelson, D. (2019). School-based early intervention for anxiety and depression in older adolescents: A feasibility randomised controlled trial of a self-referral stress management workshop programme (‘DISCOVER’). Journal of Adolescence, 71, 150–161. doi: 10.1016/j.adolescence.2018.11.009 [DOI] [PubMed] [Google Scholar]
  12. Brown, J. S. L., Cochrane, R., & Hancox, T. (2000). Large-scale health promotion stress workshops for the general public: A controlled evaluation. Behavioural and Cognitive Psychotherapy, 28(2), 139–151. doi: 10.1017/S1352465800001053 [DOI] [Google Scholar]
  13. Byatt, N., Simas, T. A. M., Lundquist, R. S., Johnson, J. V., & Ziedonis, D. M. (2012). Strategies for improving perinatal depression treatment in North American outpatient obstetric settings. Journal of Psychosomatic Obstetrics and Gynaecology, 33(4), 143–161. doi: 10.3109/0167482X.2012.728649 [DOI] [PubMed] [Google Scholar]
  14. Cox, E. Q., Sowa, N. A., Meltzer-Brody, S. E., & Gaynes, B. N. (2016). The perinatal depression treatment cascade: Baby steps toward improving outcomes. The Journal of Clinical Psychiatry, 77(9), 1189–1200. doi: 10.4088/JCP.15r10174 [DOI] [PubMed] [Google Scholar]
  15. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry, 150, 782–786. doi: 10.1192/bjp.150.6.782 [DOI] [PubMed] [Google Scholar]
  16. Dobias, M. L., Schleider, J. L., Jans, L., & Fox, K. R. (2021). An online, single-session intervention for adolescent self-injurious thoughts and behaviors: Results from a randomized trial. Behaviour Research and Therapy, 147, 103983. doi: 10.1016/j.brat.2021.103983 [DOI] [PubMed] [Google Scholar]
  17. Dukhovny, D., Dennis, C.-L., Hodnett, E., Weston, J., Stewart, D. E., Mao, W., & Zupancic, J. A. F. (2013). Prospective economic evaluation of a peer support intervention for prevention of postpartum depression among high-risk women in Ontario, Canada. American Journal of Perinatology, 30(8), 631–642. doi: 10.1055/s-0032-1331029 [DOI] [PubMed] [Google Scholar]
  18. Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Gartlehner, G., & Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. Obstetrics and Gynecology, 106(5 Pt 1), 1071–1083. doi: 10.1097/01.AOG.0000183597.31630.db [DOI] [PubMed] [Google Scholar]
  19. Goodman, J. H. (2009). Women's attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth (Berkeley, Calif.), 36(1), 60–69. doi: 10.1111/j.1523-536X.2008.00296.x [DOI] [PubMed] [Google Scholar]
  20. Goodman, S. H., & Gotlib, I. H. (1999). Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychological Review, 106(3), 458–490. doi: 10.1037/0033-295x.106.3.458 [DOI] [PubMed] [Google Scholar]
  21. Government of Canada, S. C. (2007). Canadian Community Health Survey (CCHS). Retrieved 5 May 2022, from https://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&Id=3359.
  22. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. doi: 10.1016/j.jbi.2008.08.010 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. He, J.-P., Burstein, M., Schmitz, A., & Merikangas, K. R. (2013). The strengths and difficulties questionnaire (SDQ): The factor structure and scale validation in U.S. adolescents. Journal of Abnormal Child Psychology, 41(4), 583–595. doi: 10.1007/s10802-012-9696-6 [DOI] [PubMed] [Google Scholar]
  24. Hedeker, D., Gibbons, R. D., & Waternaux, C. (1999). Sample size estimation for longitudinal designs with attrition: Comparing time-related contrasts between two groups. Journal of Educational and Behavioural Statistics, 24, 70–93. doi: 10.3102/10769986024001070. [DOI] [Google Scholar]
  25. Hewitt, C., Gilbody, S., Brealey, S., Paulden, M., Palmer, S., Mann, R., … Richards, D. (2009). Methods to identify postnatal depression in primary care: An integrated evidence synthesis and value of information analysis. Health Technology Assessment, 13(36), 1–145, 147–230. doi: 10.3310/hta13360 [DOI] [PubMed] [Google Scholar]
  26. Holopainen, D. (2002). The experience of seeking help for postnatal depression. The Australian Journal of Advanced Nursing, 19(3), 39–44. [PubMed] [Google Scholar]
  27. Horrell, L., Goldsmith, K. A., Tylee, A. T., Schmidt, U. H., Murphy, C. L., & Bonin, E.-M., … CLASSIC trial group. (2014). One-day cognitive-behavioural therapy self-confidence workshops for people with depression: Randomised controlled trial. The British Journal of Psychiatry: The Journal of Mental Science, 204(3), 222–233. doi: 10.1192/bjp.bp.112.121855 [DOI] [PubMed] [Google Scholar]
  28. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12–19. doi: 10.1037//0022-006x.59.1.12 [DOI] [PubMed] [Google Scholar]
  29. Jones, A. (2019). Help seeking in the perinatal period: A review of barriers and facilitators. Social Work in Public Health, 34(7), 596–605. doi: 10.1080/19371918.2019.1635947 [DOI] [PubMed] [Google Scholar]
  30. Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M., & the Canadian Anxiety Guidelines Initiative Group on behalf of the Anxiety Disorders Association of Canada/Association Canadienne des troubles anxieux and McGill University (2014). Canadian Clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry, 14(1), S1. doi: 10.1186/1471-244X-14-S1-S1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Klier, C. M. (2006). Mother–infant bonding disorders in patients with postnatal depression: The postpartum bonding questionnaire in clinical practice. Archives of Women's Mental Health, 9(5), 289–291. doi: 10.1007/s00737-006-0150-z [DOI] [PubMed] [Google Scholar]
  32. Krzeczkowski, J. E., Schmidt, L. A., & Van Lieshout, R. J. (2021). Changes in infant emotion regulation following maternal cognitive behavioral therapy for postpartum depression. Depression and Anxiety, 38(4), 412–421. doi: 10.1002/da.23130 [DOI] [PubMed] [Google Scholar]
  33. Lanes, A., Kuk, J. L., & Tamim, H. (2011). Prevalence and characteristics of postpartum depression symptomatology among Canadian women: A cross-sectional study. BMC Public Health, 11(1), 302. doi: 10.1186/1471-2458-11-302 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Letourneau, N. L., Dennis, C.-L., Cosic, N., & Linder, J. (2017). The effect of perinatal depression treatment for mothers on parenting and child development: A systematic review. Depression and Anxiety, 34(10), 928–966. doi: 10.1002/da.22687 [DOI] [PubMed] [Google Scholar]
  35. Li, X., Laplante, D. P., Paquin, V., Lafortune, S., Elgbeili, G., & King, S. (2022). Effectiveness of cognitive behavioral therapy for perinatal maternal depression, anxiety and stress: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review, 92, 102129. doi: 10.1016/j.cpr.2022.102129 [DOI] [PubMed] [Google Scholar]
  36. Loughnan, S. A., Sie, A., Hobbs, M. J., Joubert, A. E., Smith, J., Haskelberg, H., … Newby, J. M. (2019). A randomized controlled trial of ‘MUMentum pregnancy’: Internet-delivered cognitive behavioral therapy program for antenatal anxiety and depression. Journal of Affective Disorders, 243, 381–390. doi: 10.1016/j.jad.2018.09.057 [DOI] [PubMed] [Google Scholar]
  37. Lovejoy, M. C., Graczyk, P. A., O'Hare, E., & Neuman, G. (2000). Maternal depression and parenting behavior: A meta-analytic review. Clinical Psychology Review, 20(5), 561–592. doi: 10.1016/s0272-7358(98)00100-7 [DOI] [PubMed] [Google Scholar]
  38. MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., & Lieshout, R. J. V., … CANMAT Depression Work Group. (2016). Canadian network for mood and anxiety treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 6. Special populations: Youth, women, and the elderly. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 61(9), 588–603. doi: 10.1177/0706743716659276 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Maguire, P. N., Clark, G. I., & Wootton, B. M. (2018). The efficacy of cognitive behavior therapy for the treatment of perinatal anxiety symptoms: A preliminary meta-analysis. Journal of Anxiety Disorders, 60, 26–34. doi: 10.1016/j.janxdis.2018.10.002 [DOI] [PubMed] [Google Scholar]
  40. Matthey, S. (2004). Calculating clinically significant change in postnatal depression studies using the Edinburgh Postnatal Depression Scale. Journal of Affective Disorders, 78(3), 269–272. doi: 10.1016/S0165-0327(02)00313-0 [DOI] [PubMed] [Google Scholar]
  41. Meaney, M. J. (2018). Perinatal maternal depressive symptoms as an issue for population health. The American Journal of Psychiatry, 175(11), 1084–1093. doi: 10.1176/appi.ajp.2018.17091031 [DOI] [PubMed] [Google Scholar]
  42. Murray, L., Arteche, A., Fearon, P., Halligan, S., Goodyer, I., & Cooper, P. (2011). Maternal postnatal depression and the development of depression in offspring up to 16 years of age. Journal of the American Academy of Child and Adolescent Psychiatry, 50(5), 460–470. doi: 10.1016/j.jaac.2011.02.001 [DOI] [PubMed] [Google Scholar]
  43. National Collaborating Centre for Mental Health. (2014). Case identification and assessment, psychological and psychosocial interventions for the prevention or treatment of mental health problems. In L. Howard (Chair, Guideline Development Group), C. Taylor (Senior editor, NCCMH), N. Ernest (Assistant editor, NCCMH), & S. Pilling (Director, NCCMH), Antenatal and postnatal mental health: The NICE guideline on clinical management and service guidance (update) (pp. 81–647). Leicester, UK: British Psychological Society and The Royal College of Psychiatrists. [Google Scholar]
  44. Netsi, E., Pearson, R. M., Murray, L., Cooper, P., Craske, M. G., & Stein, A. (2018). Association of persistent and severe postnatal depression with child outcomes. JAMA Psychiatry, 75(3), 247–253. doi: 10.1001/jamapsychiatry.2017.4363 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. NICE (2013). Guide to the methods of technology appraisal. NICE. Retrieved from https://www.nice.org.uk/process/pmg9/chapter/foreword. [PubMed]
  46. NICE (2020). Antenatal and postnatal mental health: Clinical management and service guidance. NICE. Retrieved from https://www.nice.org.uk/guidance/cg192. [PubMed]
  47. Nillni, Y. I., Mehralizade, A., Mayer, L., & Milanovic, S. (2018). Treatment of depression, anxiety, and trauma-related disorders during the perinatal period: A systematic review. Clinical Psychology Review, 66, 136–148. doi: 10.1016/j.cpr.2018.06.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Perinatal Mental Health: Guidance for the identification and management of mental health in pregnant or postpartum individuals (2021). Provincial Council for Maternal and Child Health.
  49. Petrou, S., & Gray, A. (2011). Economic evaluation alongside randomised controlled trials: Design, conduct, analysis, and reporting. BMJ, 342, d1548. doi: 10.1136/bmj.d1548 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Putnam, S. P., Gartstein, M. A., & Rothbart, M. K. (2006). Measurement of fine-grained aspects of toddler temperament: The early childhood behavior questionnaire. Infant Behavior and Development, 29(3), 386–401. doi: 10.1016/j.infbeh.2006.01.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Putnam, S. P., Helbig, A. L., Gartstein, M. A., Rothbart, M. K., & Leerkes, E. (2014). Development and assessment of short and very short forms of the infant behavior questionnaire-revised. Journal of Personality Assessment, 96(4), 445–458. doi: 10.1080/00223891.2013.841171 [DOI] [PubMed] [Google Scholar]
  52. R Core Team. (n.d.). R: A language and environment for statistical computing. Retrieved 2 May 2022, from https://www.R-project.org/.
  53. Roy, A., Bhaumik, D. K., Aryal, S., & Gibbons, R. D. (2007). Sample size determination for hierarchical longitudinal designs with differential attrition rates. Biometrics, 63(3), 699–707. doi: 10.1111/j.1541-0420.2007.00769.x [DOI] [PubMed] [Google Scholar]
  54. Schleider, J. L., Mullarkey, M. C., Fox, K. R., Dobias, M. L., Shroff, A., Hart, E. A., & Roulston, C. A. (2022). A randomized trial of online single-session interventions for adolescent depression during COVID-19. Nature Human Behaviour, 6(2), 258–268. doi: 10.1038/s41562-021-01235-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Simpson, S., Richardson, L., Pietrabissa, G., Castelnuovo, G., & Reid, C. (2021). Videotherapy and therapeutic alliance in the age of COVID-19. Clinical Psychology & Psychotherapy, 28(2), 409–421. doi: 10.1002/cpp.2521 [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Simpson, S. G., & Reid, C. L. (2014). Therapeutic alliance in videoconferencing psychotherapy: A review. Australian Journal of Rural Health, 22(6), 280–299. doi: 10.1111/ajr.12149 [DOI] [PubMed] [Google Scholar]
  57. Simpson, W., Glazer, M., Michalski, N., Steiner, M., & Frey, B. N. (2014). Comparative efficacy of the generalized anxiety disorder 7-item scale and the Edinburgh Postnatal Depression Scale as screening tools for generalized anxiety disorder in pregnancy and the postpartum period. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 59(8), 434–440. doi: 10.1177/070674371405900806 [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Singla, D. R., Lemberg-Pelly, S., Lawson, A., Zahedi, N., Thomas-Jacques, T., & Dennis, C.-L. (2020). Implementing psychological interventions through nonspecialist providers and telemedicine in high-income countries: Qualitative study from a multistakeholder perspective. JMIR Mental Health, 7(8), e19271. doi: 10.2196/19271 [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Slomian, J., Honvo, G., Emonts, P., Reginster, J.-Y., & Bruyère, O. (2019). Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Women's Health, 15, 1745506519844044. doi: 10.1177/1745506519844044 [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Sockol, L. E. (2015). A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression. Journal of Affective Disorders, 177, 7–21. doi: 10.1016/j.jad.2015.01.052 [DOI] [PubMed] [Google Scholar]
  61. Sockol, L. E. (2018). A systematic review and meta-analysis of interpersonal psychotherapy for perinatal women. Journal of Affective Disorders, 232, 316–328. doi: 10.1016/j.jad.2018.01.018 [DOI] [PubMed] [Google Scholar]
  62. Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. doi: 10.1001/archinte.166.10.1092 [DOI] [PubMed] [Google Scholar]
  63. Stein, A., Netsi, E., Lawrence, P. J., Granger, C., Kempton, C., Craske, M. G., … Murray, L. (2018). Mitigating the effect of persistent postnatal depression on child outcomes through an intervention to treat depression and improve parenting: A randomised controlled trial. The Lancet. Psychiatry, 5(2), 134–144. doi: 10.1016/S2215-0366(18)30006-3 [DOI] [PubMed] [Google Scholar]
  64. Stevenson, M. D., Scope, A., Sutcliffe, P. A., Booth, A., Slade, P., Parry, G., … Kalthenthaler, E. (2010). Group cognitive behavioural therapy for postnatal depression: A systematic review of clinical effectiveness, cost effectiveness and value of information analyses. Health Technology Assessment, 14(44), 1–135. doi: 10.3310/hta14440 [DOI] [PubMed] [Google Scholar]
  65. Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item generalized anxiety disorder questionnaire (GAD-7). Journal of Affective Disorders, 265, 395–401. doi: 10.1016/j.jad.2020.01.032 [DOI] [PubMed] [Google Scholar]
  66. Trevillion, K., Ryan, E. G., Pickles, A., Heslin, M., Byford, S., Nath, S., … Howard, L. M. (2020). An exploratory parallel-group randomised controlled trial of antenatal guided self-help (plus usual care) versus usual care alone for pregnant women with depression: DAWN trial. Journal of Affective Disorders, 261, 187–197. doi: 10.1016/j.jad.2019.10.013 [DOI] [PubMed] [Google Scholar]
  67. Tsai, Z., Kiss, A., Nadeem, S., Sidhom, K., Owais, S., Faltyn, M., & Lieshout, R. J. V. (2022). Evaluating the effectiveness and quality of mobile applications for perinatal depression and anxiety: A systematic review and meta-analysis. Journal of Affective Disorders, 296, 443–453. doi: 10.1016/j.jad.2021.09.106 [DOI] [PubMed] [Google Scholar]
  68. van Dongen, J. M., Ben, ÂJ, Finch, A. P., Rossenaar, M. M. M., Biesheuvel-Leliefeld, K. E. M., Apeldoorn, A. T., … Bosmans, J. E. (2021). Assessing the impact of EQ-5D country-specific value sets on cost-utility outcomes. Medical Care, 59(1), 82–90. doi: 10.1097/MLR.0000000000001417 [DOI] [PubMed] [Google Scholar]
  69. Van Lieshout, R. J., Layton, H., Savoy, C. D., Brown, J. S. L., Ferro, M. A., Streiner, D. L., … Hanna, S. (2021). 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, 78(11), 1200–1207. doi: 10.1001/jamapsychiatry.2021.2488 [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Van Lieshout, R. J., Layton, H., Savoy, C. D., Haber, E., Feller, A., Biscaro, A., … Ferro, M. A. (2022). Public health nurse-delivered group cognitive behavioural therapy for postpartum depression: A randomized controlled trial. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 67(6), 432–440. 10.1177/07067437221074426. [DOI] [PMC free article] [PubMed] [Google Scholar]
  71. Walker, M. J., Davis, C., Al-Sahab, B., & Tamim, H. (2013). Reported maternal postpartum depression and risk of childhood psychopathology. Maternal and Child Health Journal, 17(5), 907–917. doi: 10.1007/s10995-012-1071-2 [DOI] [PubMed] [Google Scholar]
  72. Whynes, D. K. & the TOMBOLA Group. (2008). Correspondence between EQ-5D health state classifications and EQ VAS scores. Health and Quality of Life Outcomes, 6(1), 94. doi: 10.1186/1477-7525-6-94 [DOI] [PMC free article] [PubMed] [Google Scholar]
  73. Yunus, W. M. A. W. M., Musiat, P., & Brown, J. S. (2019). Evaluating the feasibility of an innovative self-confidence webinar intervention for depression in the workplace: A proof-of-concept study. JMIR Mental Health, 6(4), e11401. doi: 10.2196/11401 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

For supplementary material accompanying this paper visit https://doi.org/10.1017/S0033291723000454.

S0033291723000454sup001.pdf (89.4KB, pdf)

click here to view supplementary material

Articles from Psychological Medicine are provided here courtesy of Cambridge University Press

RESOURCES