Nurses, midwives and doulas can treat depression and anxiety symptoms experienced during pregnancy and after delivery, a new study says.
The clinical trial, published Monday in the journal Nature Medicine, suggests training non-mental-health specialists in short-term behavioural therapy can make treatment available for people who don't have a psychologist or psychiatrist.
Depression and anxiety symptoms affect one in five women who are pregnant or postpartum in Canada and the U.S., said lead author Dr. Daisy Singla, a senior scientist at the Centre for Addiction and Mental Health in Toronto.
The researchers randomly assigned 1,230 participants to eight sessions of behavioural activation therapy delivered by either a mental health specialist or a non-mental-health specialist who had received training on the treatment.
The participants were also randomly assigned to receive the therapy — where the provider helps patients to refocus negative thoughts and behaviours into positive actions — either in-person or virtually.
The study found that after three months, participants who received their treatment from trained nurses, midwives and doulas experienced the same improvement in their mental health as those who were treated by a psychologist or psychiatrist — and that in-person and telemedicine care worked equally well.
Singla, who is also a psychologist-scientist at Mount Sinai Hospital in Toronto, said short-term talk therapy, including behavioural activation, is recognized as an effective treatment for perinatal anxiety and depression symptoms.
But it is "widely inaccessible" in Canada and the U.S. because of factors such as lack of availability of psychiatrists and psychologists or out-of-pocket fees for patients, she said. Expanding the range of health-care providers who can deliver the therapy can help address those barriers.
"(This study) offers hope to so many who want access to effective talk therapies or effective psychotherapy, but can’t," she said in an interview, noting that the nurses, midwives and doulas were selected based on their interpersonal skills, received more than 20 hours of training and had weekly supervision by a mental health professional.
Demonstrating that the therapy is as effective online as it is in person removes geographical and logistical barriers for busy new moms, Singla said.
"It's difficult to arrange things like child care (and) transportation," she said, adding scheduling in-person appointments as a new parent "can be very challenging."
The cross-border clinical trial, called SUMMIT (Scaling Up Maternal Mental health care by Increasing access to Treatment), recruited participants from January 2020 to October 2023 at Mount Sinai Hospital, Women's College Hospital and St. Michael's Hospital in Toronto and at the University of North Carolina and Endeavor Health in the U.S.
Andrea Fagundez, a 38-year-old from Toronto, signed up for the trial two months after giving birth at St. Michael's Hospital in March 2022.
During her pregnancy, she struggled with anxiety about whether she would be a good mom. After her daughter Maia was born, she started having symptoms of depression, worsened by difficulties breastfeeding.
"I was crying a lot,” Fagundez said in an interview. "It was mainly an overwhelming feeling of sadness competing with the joy of having a baby.”
She was randomly assigned to do behavioural activation therapy online with a psychiatrist. It gave her "real tools" to manage her postpartum depression, she said, including helping her reframe the way she was thinking about using a breast pump after she was unable to get Maia to latch.
Fagundez felt like the time she spent pumping was lost time away from her baby. But after three sessions, she remembers turning a corner.
“I started saying, 'Oh, I'm producing milk and I can see this is a positive thing' ... I felt that it was more like a blessing, something that I could give to my daughter.”
Another therapy exercise addressed Fagundez's feelings of being isolated from others.
"I remember clearly, like there were three or four circles around yourself, like you have to draw it. And then you have to put in those circles the names of the people that you know that you can call for help or for support," she said.
"The tools I keep to this day. It's just a way of thinking and helps you to see the glass full instead of empty,” Fagundez said.
Although she was assigned a psychiatrist during the study, Fagundez believes she would have benefited just as much if she had been paired with a trained nurse, midwife or doula for her therapy.
"Having access is key regardless of who delivers it, because this (therapy) is something that is very well structured," she said.
“I would say, like someone who has a good bedside manner, I think that is what is important.”
Michelle Amato, a registered nurse with labour and delivery experience who was one of the non-specialists delivering the therapy in the trial, said although she was excited to do mental-health work, she was "a bit skeptical" at first.
"I remember thinking, 'I'm not a mental-health provider. Are they sure that a nurse who is not a mental-health provider can do this?'" Amato said in an interview Monday.
But her nervousness disappeared as she worked with women who would start out with "quite significant symptoms" of depression, anxiety or both, Amato said.
"Seeing how the (behavioural activation) model ... was so life-changing for them and the differences that it made from week to week. Seeing their progress was really so moving for me," she said.
