Major psychotherapy trial has implications for prenatal and postpartum mental health care

Pregnancy and birth often bring tremendous joy, but many expectant and new parents also face mental health challenges during this vulnerable time. Approximately one in five of pregnant and postpartum people experience depression and anxiety, yet less than 10 per cent receive proper treatment.

To address this problem, a team of interdisciplinary researchers from Canada and the United States investigated if talk therapy can be effectively delivered by non-mental health specialists and telemedicine to increase access. In a Nature Medicine paper, the team shared results from the Scaling Up Maternal Mental health care by Increasing access to Treatment (SUMMIT) Trial, which reveals promising strategies to provide support and treatment more effectively and inclusively for pregnant and postpartum populations. 

The SUMMIT trial demonstrated that trained nurses, midwives, and doulas can deliver talk therapy as effectively as psychologists and psychiatrists. After receiving up to eight treatment sessions patients reported significant improvement in symptoms of depression and anxiety regardless of the treatment provider type. The sessions are not meant to replace therapy from trained specialists, but to offer access to patients who face common but often untreated mental health conditions due to the shortage of specialist providers.

The trial also investigated the effectiveness of delivering talk therapy through telemedicine compared to in-person sessions. While in-person sessions have long been the gold standard in psychotherapy, the trial has shown that online therapy is equally beneficial.

“Talk therapy is effective but largely inaccessible. As our health systems grapple with a shortage of specialists and the rising costs of care, many pregnant and post-partum individuals suffer in silence. Leveraging simple, pragmatic solutions of task-sharing and telemedicine has the potential to transform health care and improve access to essential mental health services,” said Daisy Singla, SUMMIT’s lead principal investigator. Singla is a clinician scientist at the Lunenfeld-Tanenbaum Research Institute (LTRI), part of Sinai Health, a senior scientist at the Centre for Addiction and Mental Health and an associate professor of psychiatry at the University of Toronto.

The psychotherapy trial, conducted in hospitals across North America, was among the largest in the world. Most of the participants were recruited from Mount Sinai Hospital and others were recruited from Women’s College Hospital and St. Michael’s Hospital in Toronto, the Women’s and Neuroscience Hospitals associated with the University of North Carolina in Chapel Hill, and Endeavor Health in Chicago. Of the 1,230 participants, almost 50 per cent identified as racialized minorities.

Participants received between six and eight weekly sessions of behavioral activation, a form of talk therapy that encourages engagement in meaningful activities aligned with personal values and has been shown to alleviate symptoms of depression and anxiety.

Following treatment, depression scores decreased from an average of 16 to 9 on the Edinburgh Postnatal Depression Scale, moving below the mild depression threshold of 10. Anxiety scores also fell from an average of 12 to 7 on the General Anxiety Disorder-7 scale, dropping below the clinical threshold of 8. These improvements occurred regardless of symptom severity before the treatment.

The behavioural activation training program for non-specialist providers included comprehensive instruction on behavioral activation, supervision by mental health specialists and practical role-play exercises, amounting to 20-25 hours of training.

According to Richard Silver, chair of obstetrics & gynecology at Endeavor Health, talk therapy is often preferred over medication for common conditions such as depression and anxiety, especially for pregnant and postpartum people.

“Finding effective ways to treat these patients is critical – and specifically, ways that don’t involve medication, which some would rather avoid while pregnant or breastfeeding. We need a safe and effective alternative treatment -- talk therapy can help fill this gap,” said Silver who is also site lead at Endeavor Health.

Untreated, depression and anxiety can lead to severe consequences, including maternal mortality, obstetrical complications and developmental problems in children.

“Sinai Health has global reputation for perinatal health care, and we are grateful to our patients for being part of this research. By demonstrating that trained non-specialists can deliver effective psychotherapy via telemedicine, it has the potential to reduce wait times for new parents struggling with mental health – and create a healthier future for their children,” said Anne-Claude Gingras, director of LTRI and vice president of research at Sinai Health and professor of molecular genetics.

While research continues to determine whether the benefits of therapy delivered by non-specialists extend beyond three months, the team is also conducting a separate economic evaluation of these innovations within the Canadian and U.S. health-care systems. 

The research was supported by funding from the Patient-Centered Outcomes Research Institute.