Brief Peer-Led Evidence-Based Intervention for Postpartum Depression

A peer-delivered brief cognitive behavioral therapy (CBT)-based workshop for birthing parents experiencing postpartum depression (PPD) was found to be feasible and to help improve symptoms. These findings, from a single-arm pre-post study, were published as a Brief Report in the Journal of Clinical Psychiatry.

Up to a fifth of mothers and birthing parents experience symptoms of PPD (Figure 1). However, only 10% of those experiencing symptoms receive evidence-based treatment. Two of the major barriers to seeking care for PPD are time constraints and perceived stigma. A brief, peer-led intervention has the potential to address both of these barriers.

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Investigators from McMaster University in Canada designed this study to evaluate the feasibility and potential utility of a peer-led CBT-based workshop for PPD. In 2021, peers (n=4) who had recovered from PPD were recruited by word-of-mouth and via social media. The peers attended a 2-day classroom training session comprising didactic teaching, skills practice, and role-playing. The peers then delivered a 7-hour mock workshop supervised by a psychiatrist. Feasibility of training was defined as completion of the training program.

The PPD group (n=64) was recruited via social media and had an infant aged less than     12 months and scored more than 10 points on the Edinburgh Postnatal Depression Scale (EPDS). The peer-led CBT intervention was delivered by 2 randomly assigned peers over Zoom from 9:00 am to 4:00 pm and involved education about PPD etiology, cognitive and behavioral skills, goal setting, and action planning. Feasibility and acceptability of the intervention were evaluated using recruitment, retention, attendance, and satisfaction outcomes.

The peer facilitators were aged 29 to 60 years, all were White women, they had experienced PPD 3 to 20 years previously, and their professions were administrative assistant, early childhood educator, and doula. The PPD group comprised mothers with a mean age of 30.8 (SD, 5.0) years, their infants were 4.6 (SD, 2.9) months old, and most (n=53) were White.

Most participants (73.4%) attended the workshop and provided feedback. The participants had an average satisfaction rating of 24.48 (SD, 4.78), indicating relative satisfaction.

Compared with before the workshop, significant changes in EPDS (mean difference [MD], -5.41; d, 1.02; P <.05), Generalized Anxiety Disorder-7 (MD, -5.57; d, 1.10; P <.05), and Social Provisions Scale (MD, 4.04; d, 0.51; P <.05) were observed postintervention. The impaired bonding (MD, -4.17; d, 0.65; P <.05), rejection and pathological anger (MD, -2.49; d, 0.60; P <.05), and infant-focused anxiety (MD, -1.92; d, 0.64; P <.05) subdomains of the Parent Bonding Questionnaire were also significantly improved from baseline.

For the Infant Bonding Questionnaire-Revised instrument, significant effects in the positive affectivity/surgency subdomain (MD, 0.73; d, 0.69; P <.05) were observed, but the intervention did not appear to have effects on the negative emotionality and effortful control subdomains.

The limitations of this study included the lack of a comparator group and the small sample size.

This study found that a brief peer-led evidence-based intervention for PPD was feasible and acceptable and had beneficial effects on some PPD symptom outcomes.

We spoke with Ryan J. Van Lieshout, MD, PhD, associate professor of psychiatry and behavioral neurosciences at McMaster University in Hamilton, Ontario, Canada about the study.

What were the motivations of your study?

Many people struggle with depression after they have a baby. In Canada, even though we have universally available health care, as few as 1-in-10 sufferers actually get evidence-based care because there’s always been a shortage of mental health care providers. We’ve been interested in trying to find new ways to get treatment to moms and birthing parents, so that they can recover. We’ve tried to task-shift the delivery of these services from psychiatrists, like me, or nurses, social workers, or psychologists, who are less plentiful, and certainly more expensive, to recovered peers.

The other thing that people struggle with after having a baby is a lack of time. Even though many people want to do psychotherapy or talking therapy after having a baby, they don’t have a lot of time to go to 12-15 sessions of psychotherapy. We wanted to try to create something that was briefer, so that they could try to get a bunch of tools at once and then go on.

Were you surprised by any of the outcomes?

When I run longer CBT groups, the thing that always strikes me is just how helpful the other members of the group are, not just the therapists, but the other members of the group. That’s what inspired us to try to harness the power of mothers and birthing parents supporting one another.

I think so highly of our peer facilitators, so I don’t want to put them down by saying I was surprised with how much participants’ symptoms improved, but I was very impressed. They are amazing people that are so giving of themselves to volunteer and to learn. They’ve been through PPD before and would say, ‘I do this because I wish there had been something like this when I was younger and when I went through it.’ They were so kind, giving, warm, and open. It was so powerful watching the peers and the participants bond by the end of the day and see the participants leave feeling better.

What aspects of CBT did you incorporate into this intervention?

It’s a 1-day workshop with about 6 hours of content broken into 4 modules. The first module was talking about how past experiences influence our thoughts and how that can impact the development of depression. In the second module, we introduce a number of what we call “cognitive skills,” like thought-stopping and cognitive restructuring. In the afternoon, we focus more on behavioral techniques, such as relaxation, self-care, and behavioral activation.

What aspects of the intervention did you find more successful and what aspects least successful?

At this point in time, it is not clear which ones are contributing the most. We’re doing another study with public health nurses to try to see what the active ingredients are. We will be doing some additional scales and qualitative interviews with participants to try to understand what is helping. It might be the peer facilitators, it might be the social support of the other moms and birthing parents connecting, or it might be a combination of all those things.

This randomized, controlled trial will recruit nearly 400 people, 200 to the treatment group and 200 to the treatment-as-usual group. We’re interested to see just if the intervention is still effective and how big the effect sizes are. We’re also going to try to look at the cost-effectiveness of the intervention.

What were common feedback themes from the participants?

For the most part, I think people were pleased with the program. Some people commented that it was a lot to do in a single day. Many said they thought the peer facilitators were great and some even commented that they felt that this program represented the best of both worlds in terms of getting to work with someone who truly understood their experience, yet it also utilized evidence-based techniques as opposed to just nonspecific support.

There were about 10%-20% that were less pleased. It’s difficult to find something that everyone really likes. People generally liked it, but some people didn’t.

What are the big take-home messages for fellow clinicians?

We’re excited to see if these 1-day workshops delivered by peers have the capacity to increase access to effective treatment. With the pandemic, and all of the things that have happened over the last couple of years, there are so many stresses and we just want to get any treatments out there that can help as many people as possible. We’re really excited about the potential that this study suggests that this intervention and delivery method has, and we’re excited to see if it can be scaled to help more mothers and birthing parents.