“I’m not the only one with depression”: Women’s perceptions of in-person group formats of depressive symptom interventions

Abstract

Background

A standard format for depression management has long been the in-person group-based intervention, yet recent calls for scalable interventions have increased interest in individual online formats. However, the perspectives and preferences of women are largely missing in the literature.

Methods

This secondary qualitative data analysis using a phenomenological method of inquiry explored the lived experiences of pregnant and non-pregnant women with depressive symptoms (n=44) who participated in two studies involving group-based face-to-face mindful physical activity interventions for depressive symptom self-management.

Results

Four main themes emerged regarding the group format: shared experiences enhanced the feeling of safety and impact of the group interventions; group instructors played a key role in fostering a safe environment; participants wished for more group interactions; and, participants preferred a synchronous group-based intervention over a technology-based or asynchronous alternative for depressive symptom management.

Conclusion

The findings from this study suggest that women with depression enjoy synchronous group-based interventions and find them to be beneficial for the shared experiences with other women and the safe environment created by group instructors. Future research should include study designs that consider these factors in the context of hybrid or fully online intervention formats for depression management.

Precis

This study gives voice to pregnant and non-pregnant women with depression regarding experiences with group-based symptom management interventions.

Introduction

Depression is a major cause of morbidity and mortality in the United States (U.S.) and worldwide, with approximately 300 million individuals affected worldwide by depressive disorders, with higher prevalence in females.¹ The experience of depressive symptoms can be debilitating, with symptoms such as anhedonia, apathy, anxiety, and feelings of low self-worth.^1,2 These symptoms are common in the perinatal period, such that up to 20% of women may experience depressive symptoms during their pregnancy and/or in postpartum, and have significant implications for maternal-child health.^2,3

The current standard of care for depressive symptoms includes psychotherapy and/or pharmacological treatment. These treatment options for depressive symptoms provide adequate symptom management for some individuals, however over half of individuals with depressive symptoms are not able to access these interventions regularly, or they are not effective, or appropriate treatment for the symptoms experienced.⁴ Significant barriers, both structural and attitudinal, exist preventing affected individuals from accessing these traditional treatment modalities for depressive symptoms and therefore other adjunctive interventions are necessary to consider. For example, as outlined by Eustis and colleagues⁵ several promising self-management approaches are being investigated for efficacy and clinical effectiveness, including physical activity, mindfulness, mindful physical activity (e.g., yoga), among others. Irrespective of the specific intervention itself, however, one major question in the intervention literature surrounds what is the ideal format for delivery, whether it be face-to-face as an individual or with a group, or through the use of technologies such as the internet and smartphones. It is more critical now than ever, in the setting of an international pandemic related to COVID-19, to consider the efficacy and effectiveness of these interventions’ methods. The pandemic has pushed researchers to rely on technology in ways that could have never been anticipated. It is the duty of investigators to ensure the safest, most clinically effective treatment methods are being designed, studied, and offered to the public.

Due to recent calls for inexpensive and scalable interventions, in-person group-based delivery methods are increasingly being phased out in favor of technology-based delivery.⁶ However, it is unclear whether the mechanism or potency of in-person group-based psychological therapies may be lost when delivered via technology. According to Moshe and colleagues⁷, there has yet to be an in-depth analysis of how technology-based interventions have evolved. The current study contributes to this area of research by conducting a secondary data analysis from two recent studies of group-based mindful physical activity interventions for management of depressive symptoms. The purpose of this study is to examine individuals’ lived experiences of group-based face-to-face interventions for depressive symptoms.

Background

To date, the use of technology for delivery of depressive symptom interventions has been highly supported in the literature,^8–13 yet it is clear that an aspect of person-to-person contact enhances the effects of the intervention. For example, findings from several systematic reviews support the use of technology-based interventions for depressive symptoms in a variety of populations.^8–10 Cuijpers and colleagues¹⁰ conducted a meta-analysis of self-guided intervention trials, showing a small-to-medium effect size of d=0.28. Of note, several other meta-analyses suggest that an aspect of person-to-person contact is critical for enhancing the symptom reductions. Andersson and colleagues¹¹ found that the addition of some element of person-to-person contact increased the effect size (d=0.61) compared to that of an intervention (d=0.25) which involved an individual using an internet intervention without any human contact. Another meta-analysis of 19 randomized controlled trials found a greater effect size of interventions involving some degree of contact (d=0.78) versus unguided internet-based interventions (d=0.36).¹² As researchers move study designs towards individual-focused interventions that are dependent upon a technological medium, there is the risk that interventions may lose potency or impact without an in-person or group context.

The voice of the individual participant may be lost in quantitative studies and meta-analyses; thus, it can be unclear whether and how an intervention imparts its effects. When evaluating delivery format of an intervention, there is a research imperative to consider participants’ experiences and preferences. For example, in a descriptive study of postpartum women, Maloni and colleagues¹³ found that, although women agreed to participate in a technology-based intervention for postpartum depression, more than 60% of participants expressed an interest in some kind of person-to-person mechanism for engagement, such as a group blog, chat room, or real “live” (synchronous) chats. Similarly, of concern in person-to-person group-based studies, research protocols measure individual-level outcomes, often with minimal consideration for the impact of interpersonal dynamics as a mechanism of the treatment effect. In a qualitative meta-synthesis of post-partum women, Hadfield and Wittkowski¹⁴ concluded that engagement, compassionate care, and decreasing shame and stigma surrounding PPD are all effective ways to decrease barriers for accessing care in this population They noted that many participants desired access to another woman who had experienced PPD and recovered from it. The researchers hypothesized that these themes could be accomplished through group- or individual-based interventions and further research is needed.¹⁴

One of the most common methods for delivery of interventions for individuals with depressive symptoms is still the face-to-face setting, despite the burgeoning field of technology-based interventions. In-person group-based interventions offer an opportunity for individuals with common symptoms or other characteristics to engage with an intervention while also benefiting from shared experiences with peers. A qualitative meta-synthesis reviewed six studies of postpartum women in a group-based cognitive based therapy setting and concluded there are definite group-based benefits as well as negative aspects related to group therapy to consider when using this type of intervention.¹⁵ One example of an in-person group-based intervention that has received recent attention for women with depressive symptoms is a mindful physical activity intervention which involves yoga classes. There is ample research discussing the benefits of yoga-based interventions for management of depressive symptoms in various populations.^16–18 Findings suggest that yoga may be an effective intervention for treating depressive symptoms, in part because the coping skills learned by participants have the potential to outlast the intervention.¹⁹ However, these studies have not previously examined the impact of group context, including participant-to-participant and instructor-to-participant, and how the format of intervention delivery may affect results.

Methods

In this secondary qualitative data analysis, interview data were pooled from two studies of women with depressive symptoms (n=44), both pregnant and non-pregnant, who participated in group-based face-to-face interventions for depressive symptom self-management. Participants in these studies were interviewed after the interventions were completed and asked to reflect on various aspects of the study, such as: perceptions about the group-based delivery format, the group instructor, and alternatives to in-person group delivery format. The first parent study²⁰ was a randomized clinical trial of 27 women with moderate to severe depressive symptoms (score of 10 or higher on the Patient Health Questionnaire-9) who were randomized to either an 8-week yoga intervention or an 8-week attention control group. In this study, participants engaged in semi-structured interviews at the completion of the intervention period, with open-ended questions about experiences with the intervention and experiences with depressive symptoms.²⁰ The second parent study²¹ was a longitudinal pilot trial of a 12-week yoga-based intervention with pregnant women with depressive symptoms (score of 10 or higher on the Patient Health Questionnaire-9). Semi-structured interviews were conducted at an early postpartum study visit with open-ended questions about participants’ experiences with depressive symptoms and with the intervention.²¹

A phenomenological data analysis lens was used to analyze the pooled data in order to describe the lived experience of participants in a group-based in-person intervention.²² The data analysis process started first with reflexivity practices to identify potential biases of the two authors (PK, CA) involved in analysis; using reflexivity practices suggested by Finley,²³ the authors bracketed personal experiences and potential biases in order to allow the participants’ experiences to remain in focus. Then, following methods outlined by Cohen, Kahn, and Steeves,²² the authors independently and collaboratively read all interview transcripts to identify strips of data, or quotes to examine and interpret as recurrent categories that represented commonalities in the experiences of participants. An iterative approach was used, whereby the authors engaged in a recurrent process of moving between the transcription data and categories in order to allow common themes to emerge.²² The themes were used to construct a picture of participants’ experiences with the intervention within the context of the group delivery format.

To ensure rigor and trustworthiness of the analysis process and results, several methods were used following guidelines by Rodgers and Cowles²⁴ and by Lincoln and Guba.²⁵ First, the authors used prolonged engagement with the data in order to enhance confidence that the results are accurate representations of the participants’ experiences, to enhance credibility or “truth value” of the qualitative findings.²⁵. Second, an audit trail was maintained throughout all decision-making to establish dependability of the results; specifically, the authors maintained a detailed written document outlining all decisions made about categories and theme development, as well as thoughts arising during the reflexivity/ bracketing process.^22,24 Finally, the authors talked about the decisions and analysis process with colleagues who were not involved in the initial data analysis process; this process of peer debriefing was intended to enhance the consistency and neutrality of the results, whereby the peer debriefer would help bring to light ideas not previously considered by the authors and would challenge assumptions of the authors to assist in limiting bias in the analysis.^24,25

Results

Of the women interviewed in the two parent studies, twenty-four had engaged in a mindful physical activity intervention (weekly group prenatal yoga classes) for pregnant women with moderate-to-severe depressive symptoms on the PHQ9; fourteen had engaged in a mindful physical activity intervention (weekly group yoga classes) for women with moderate-to-severe depressive symptoms on the PHQ9; and six had engaged in a health education group intervention for women moderate-to-severe depressive symptoms on the PHQ9. Participants in the pregnancy-specific parent study had a mean age of 28.8 (4.88) with approximately 49% self-identifying as Black; participants in the non-pregnancy-specific parent study had a mean age of 43.3 (15.57), with 37% identifying as non-White. The majority of participants in both studies had at least some college education or more.

Four main themes emerged from the data and quotes are provided to support each of the themes. Figure 1 provides a visual representation of the themes and Table 1 provides representative quotes for each of the four themes.

Figure 1.

Visual Depiction of Qualitative Themes

Table 1.

Themes and Representative Quotes from Participants

Theme	Direct quotes from participants to support theme
Shared experiences enhanced the feeling of safety and impact of the intervention	Some women had anxiety, some women had depression, some women were just generally feeling bad– it was just good to know that I wasn’t alone… being in a group of women having similar life experiences is helpful. Being around other pregnant women who are saying similar things… can give hope to the other women. That part of the group is really effective in normalizing what is happening I also got a lot out of being around the other women. There was mutual support that seems to emerge, even though we didn’t even always talk.
Group instructors played a key role in fostering the safe environment with positive impact on symptoms	I really loved [the instructor], I think she was my favorite part, the things that the said, the way that she said them. Having someone who was really empathetic and understanding to everybody… it just makes you feel good to be around that type of person.
Participants wished for more group interactions	Everybody has been going through the same thing. It would have been nice to be supportive and talk to people [after class].
Participants felt a technology-based alternative to the group format would not be as effective for depressive symptom management	I’ve tried to do some yoga stuff online where it’s just videos. It’s kind of a bummer. You don’t really get into the energy of the class when it’s like that because you can’t respond to the environment in the same way. The best part about it all was the community-building. It’s really powerful to have women together like that. I really liked that I was getting out of the house with a purpose.

Theme 1: Shared experiences enhanced the feeling of safety and impact of the intervention

Participants consistently mentioned the importance of a safe space created through shared experiences with others dealing with depression. Knowing that others in the group were experiencing depressive symptoms was impactful for participants and changed the group dynamic from the start of the intervention. For example, one participant summarized this as:

Just having other women who were in the same mindset, having similar problems that I’ve had in the past was helpful… Some women had anxiety, some women had depression, some women were just generally feeling bad– it was just good to know that I wasn’t alone… being in a group of women having similar life experiences is helpful.

Hearing that other participants in the group shared in daily struggles helped the women feel less isolated in the experience of depressive symptoms or anxiety. Participants appreciated sharing in a community where personal issues could be freely expressed. When asked directly about in-person group formats, participants verbalized that the interaction with others experiencing the same symptoms created a safe space to share and grow. The pregnant participants, in particular, consistently expressed relief about knowing the intervention involved other individuals experiencing depressive symptoms. For example, one woman summarized that she found the group-based intervention helped normalize her symptom experience:

Being around other pregnant women who are saying similar things… can give hope to the other women. That part of the group is really effective in normalizing what is happening.

Participants felt empowered to share personal experiences knowing it could help others in the group. One participant stated that sharing experiences created a sense of being in an “ultra-safe space.” Completing a group-based yoga intervention in a familiar and safe group environment was a unique and powerful experience for many of the women, and it gave them a perspective on the importance of being around other women and supporting each other.

Participants remarked that the group-based interventions with fellow individuals experiencing depressive symptoms was important because they would not feel judged by the others. Participants felt it was a safe place to be pushed beyond their comfort-zone, or even fail. An example of a participant quote regarding this sentiment is:

It was safe to try… for me, it gave me a renewed sense of motivation… which is very helpful because with depression a lot of times you feel so helpless, like you can’t do anything, and even if you try something it’s going to be wrong.

Participants consistently remarked that much of the support was non-verbal and that the support emerged naturally. That non-verbal support lingered even beyond the group meetings, such that:

You walk out of there feeling in touch with the condition of others— not just what’s going on with me, but what’s going on with everything, which is very reassuring. When you’re in a depressed state, you feel very alone. But feeling whole, part of a whole is where the value is really is. Whether it’s breathing together… or whatever.

Almost all the participants in the group-based yoga interventions agreed with this sentiment that the positive safe space played an important role in the success of the intervention for symptom management.

Theme 2: Group instructors played a key role in fostering the safe environment with positive impact on symptoms

Every participant in the group-based yoga interventions remarked that the group instructors played a key role in creating a safe environment where one could be open, make mistakes, and learn from others in the group. For example, participants remarked:

She [the instructor] just definitely was good at creating that kind of safe space every single time we came – where we felt safe to open up and share our stories.

and

They [instructors] were so welcoming and they created an environment where it was ok to make a mistake, so we all kind of relaxed and were able to work together as a group.

Further, participants remarked that moments of participant growth and self-reflection were possible due to the safe and accepting environment created by the group-instructors. Participants expressed feeling understood by the group instructors which enhanced their enjoyment of the intervention. The pregnant participants noted that there was an environment in which to be honest, vulnerable, and open as well as garner support from other pregnant individuals, as summarized by one participant:

It was this safe space where you know you could be honest about how you felt and we would all support each other…and understanding what everyone was saying and I felt like that was a really positive environment.

Theme 3: Participants wished for more group interactions

Most participants expressed a desire for more group interactions during and after the interventions to help motivate each other and to cultivate richer relationships for positive effects on depressive symptom management. One participant had an idea for how to do this:

There were a couple of women I wished I could have called for encouragement or just to say—let’s do yoga and then call each other back. I do better with things if I have an accountability partner of sorts.

Increased interactions between participants may have had the potential to amplify intervention effects, as when a participant described that she connected with another student in the class with whom she was planning to take more yoga classes together. In addition, participants desired more interaction between the participants outside of the confines of the study. Several women provided ideas for how this could be accomplished. For example, some participants suggested a reunion after the end of the study. Other women who were in the pregnancy-based intervention suggested play dates in the future to be able to see each other’s babies. Several participants suggested the creation of a private social media page or other online forum to share experiences and maintain connection.

Of note, while much of the feedback about the group setting was positive, a few participants did not have positive experiences with the group discussions in the interventions. One participant expressed having social anxiety, which made the group discussions difficult:

I did not like [talking] at all. It made me feel awkward because I’m comparing myself to all these other women and they obviously are going through depression and everything but they all seemed really happy and I wasn’t happy.

However, several participants remarked that positive outcomes occurred when pushing beyond personal social anxieties and out of the comfort-zone:

I was kind of nervous about going into a group where I didn’t know anybody but it was a very positive social experience for something that is normally something very anxiety provoking for me.

Another participant reported having social phobia, but that overcoming that difficulty proved to be helpful because just the act of showing up was beneficial.

Theme 4: Participants felt a technology-based alternative to the group format would not be as effective for depressive symptom management

In response to questions about technology-based alternatives to group-based formats, participants were unanimous in preference for group interventions:

Practice with the group is better. I could see that I’m not the only one going through depression. I can ask other people about what they’re going through. It’s a great experience to have other people to attend classes with.

Participants’ comments suggested that in-person group interventions were important for motivation and retention throughout the multi-week interventions. Participants endorsed a sense of empowerment and community-building when completing the yoga class in person with other individuals experiencing similar symptoms. In comparison, participants found that home-based practice using a DVD or a web-based option was less appealing and participants reported rarely using those options even when provided them through the study. Reported reasons for this lack of use included lack of time, lack of direction or uncertainty about assignments or poses, or a general sense of lacking motivation when not in the group setting. Some participants reported feeling guilty about not completing or putting effort towards the homework, and it was often implied that part of the reason it was not completed was a from a lack of motivation outside of the group setting.

When asked to consider a technology-based format, some participants acknowledged that technology could be a reasonable supplement to an in-person intervention. For example, participants acknowledged that, if homebound with a sick child, a synchronous session (in which all participants are engaged at the same time) could be a reasonable option. However, participants did not seem interested in using a one-sided technology in which they would not be able to engage with the group; for example, participants were less interested in a previously recorded session without the benefit of the life group.

Discussion

The purpose of this study was to understand these women’s lived experience with the group aspect for depressive symptom management. This study involved a secondary data analysis of qualitative interviews with 44 women who engaged in group-based face-to-face mindful physical activity interventions. Overall, the findings suggest that the participants were satisfied with and perceived a benefit of the group format; participants often expressed a desire for more contact with other group members. The majority of participants did not endorse an interest in an online-only option; however, participants felt that a hybrid format could be helpful for enhancing access, particularly in light of family responsibilities. The overwhelming majority of participants found that the group aspect was directly related to the positive impact of the intervention on symptom management. The sense of safety reported by participants seemed to stem from common symptom experiences with fellow participants and from the compassionate environment fostered by the group instructors.

When asked whether technology-based individual delivery formats would be appealing, the majority of participants did not favor not being able to engage with others and with instructors in an asynchronous manner. This is consistent with other studies suggesting that synchronous sessions and instructor-led sessions can significantly enhance the effects of an intervention.^26–28 For example, in studies of cognitive-based therapies delivered via technology, the effect sizes are much stronger when the intervention has some aspect of synchronous person-to-person engagement, such as with a therapist.²⁶ Despite that technology-assisted interventions (e.g., using smartphone applications [“apps”]) have been shown to be as effective as in-person interventions, higher rates of attrition are noted in app-based interventions and few studies have directly compared in-person to app-based interventions.²⁷ In a study with peer-to-peer telephone support, no relation was found between depression scores and peer-telephone interactions; however, study results did suggest that the support of peers was satisfactory to participants and may decrease attrition.²⁸ Similarly, many technology-based intervention studies experience higher rates of attrition than those of face-to-face interventions and some aspect of participant contact or group contact may offset those attrition rates.^27,28 As a supplement to the in-person class format, participants did endorse the concept of remote classes through a video-chat medium whereby the instructor and the group could be seen in real time.

Although most participants reported an overall positive experience with the groups, a small number of participants reported feeling uncomfortable with sharing thoughts or feelings in a group. This is consistent with typical comorbid symptoms of depression of social phobia and anxiety.^1,2,29 Others felt there were a few participants who were disruptive in class or distracting to the instructors or others and took away from the positive milieu of the class environment. Future studies that will rely on group interventions may consider screening for individuals who have high levels of social anxiety as a covariate. Prevatt and colleagues²⁹ noted similar concerns reported by participants and recommended that group facilitators in future studies should implement desensitization before group sessions and encourage participants to practice self-care during and after the sessions. These suggestions could help alleviate some of the social anxiety that a few participants reported when in-group settings.

Of note, the characteristics of a group instructor may play a pivotal role in the success of a group-based intervention. Some participants in this study noted that certain instructors fostered better group discussions and experiences than others. The majority of participants appreciated and praised the instructors’ experience and ability to relate to the participants on a personal level. This helped the participants feel at ease and allowed for increased bonding of the group. This is supported in the literature by Stevens et al. and consistent with several other studies using group instructors.^30–32 The right group dynamic plays an integral role in the success of a group. Particularly in studies with rolling-admission, the instructor may be the only constant in a group. Exceptional instructors can help with outcomes of the study and aide in retention throughout longitudinal studies. Instructors can also play an important role in offsetting social anxiety concerns and encourage participants to utilize self-care tools when discussing distressing topics.²⁸ Future studies should state clearly the relevant instructor characteristics for the study and measure these characteristics across instructors, as possible covariates for outcomes.

Interventions that blend the best aspects of group and technology-based delivery formats warrant future research. Technology-based delivery provides convenience and cost-savings, and group-based delivery offers the benefits of group bonding in a safe, empowering space. Blended group interventions have been shown to be successful in treating depressive symptoms. In a study by Schuster and Laireiter,³³ the attrition rate was 9% which is lower than the average depressive intervention study, which on average has an attrition rate of close to 20%. Additional research is needed to assess whether blended modality group interventions have increased success in retaining participants and decreasing participants’ symptoms.

Strengths and Limitations

As with any study, there are limitations to be considered. First, this was a small sample of women with depressive symptoms (n=44), the majority of whom were pregnant (n=24). Based on this demographic and the qualitative methodology, it would be difficult to generalize findings to other demographics or groups with mixed ages and other genders. Second, in this study, there was no technology-based individual format and because of that, the participants’ perceptions about the format were purely speculative. Participants were asked hypothetically whether they felt they would have received the same experience if the study had been technologically based, but there are no data from this study to definitively show the differences between in-person and tech-based groups. Future research should consider direct comparisons between these intervention delivery methods.

The strengths of this study are that the qualitative design has allowed for a deep exploration of participants’ experiences, hence illuminating several implications for practice and future research. Future research and clinical practice must take into account the fact that women with depressive symptoms perceive there to be great benefits of in-person and group-based interventions. However, the realities of a technology-based society calls for additional research to evaluate how to integrate these benefits into new formats. For example, the current global COVID-19 pandemic has pushed clinicians and researchers alike to consider the role of technology in interventions; yet, it is essential to consider the important role of group dynamics and the experience of instructors when conducting any intervention for perinatal depression. The findings from this study suggest that individually-delivered technology-based interventions may remove a layer of person-to-person contact that many women find to be important in addressing depressive symptoms. Considerations should be taken regarding use of experienced group instructors who foster positive group dynamics. Future research is warranted that compares group-based interventions with technology-based or individualized interventions. Individual- and technology-based study designs may appear to be more attractive through a convenience or cost-effective lens, but such designs might be better considered as supplements to group-based interventions. Further research is needed to evaluate whether these findings extend to differing populations and participant groups with various illnesses. Additionally, an experimental study should be conducted to directly compare the efficacy and cost-effectiveness differences between an in-person and a technology-based group intervention.

Conclusion

The findings from the secondary qualitative data analysis suggest that women with depressive symptoms perceive there to be great benefit to synchronous group-based interventions. Participants in two studies involving group-based in-person mindful physical activity interventions reported an appreciation for having shared experiences with other women and the safe environment created by group instructors. Future research and clinical practice should consider these factors in the context of hybrid or fully online individual or group-based intervention formats for depression management.