Antepartum Depression: Treatment With Computer-Assisted Cognitive-Behavioral Therapy

To the Editor: Depression affects 7%−12% of pregnant women (1), and left untreated, it is associated with adverse outcomes including preterm birth and lower birth weight (2). Many pregnant women do not pursue treatment because of practical barriers (e.g., lack of time or child care) or fear of adversely affecting fetal health with antidepressant use (3). Computer-assisted cognitive-behavioral therapy (CBT), with demonstrated efficacy in nonpregnant depressed samples (4), uses a web-based multimedia program integrated with abbreviated CBT to reduce the scheduling burden on the patient and to circumvent the risks of antidepressant use. We report here on a patient with a major depressive episode during pregnancy who underwent computer-assisted CBT.

“Ms. B,” a 29-year-old woman, gravida 1, para 0, with two previous depressive episodes, presented at 18 weeks gestation with depressive symptoms including low mood, anhedonia, hypersomnia, low energy, and guilt. A diagnosis of recurrent major depressive disorder was confirmed using the Structured Clinical Interview for DSM-IV. Ms. B had discontinued sertraline (100 mg) 8 months earlier for pregnancy planning. Computer-assisted CBT comprised eight therapy sessions over 6 weeks with a clinical psychologist (3.75 hours of direct contact), with between-session web-based modules (“Good Days Ahead”; Empower Interactive, San Francisco) (5). Therapy sessions included collaborative agenda setting, reviewing skill implementation, and previewing web-based content. Web-based modules included video vignettes, psychoeducational content, and exercises (e.g., automatic thought records). Ms. B had good adherence and experienced remission. She exhibited a 94% reduction in her Hamilton Depression Rating Scale scores from the pretreatment assessment (score, 17) to the posttreatment assessment (score, 1). Her Beck Depression Inventory scores (pretreatment score, 26; posttreatment score, 2) and Edinburgh Postnatal Depression Scale scores (pretreatment score, 17; posttreatment score, 5) also decreased markedly. Her Global Assessment of Functioning score improved from 55 to 90. Subjective report indicated that Ms. B found computer-assisted CBT acceptable, and she expressed satisfaction in avoiding antidepressant use during pregnancy.

Computer-assisted CBT represents a short-term accessible treatment for antepartum depression. Adapting technologies to patient populations facing practical barriers is critical to improving mental health care accessibility. Few randomized controlled trials have assessed CBT for antepartum depression (6), and none have assessed computer-assisted CBT in this population. This case report suggests the need for larger-scale research on the effectiveness of computer-assisted CBT for antepartum depression.