dCBT: prevent postpartum depression with a digital version of cognitive behavioral therapy

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A digital version of cognitive behavioral therapy, or dCBT, that previously had been shown to reduce insomnia during pregnancy may also prevent postpartum depression and reduce insomnia and anxiety in women up to six months after they give birth, according to a new study by researchers at UC San Francisco.

The study, which appears in the current issue of the journal Sleep, is unique in showing that non-depressed women who received dCBT for insomnia during pregnancy also slept better and had less depression several months into the postpartum period.

The study is a follow-up to research that appeared January 2020 in JAMA Psychiatry showing the treatment reduced insomnia, depression, and anxiety symptoms during pregnancy.

“We were curious to see whether the benefits of dCBT for insomnia would maintain after the birth of the child, especially given the demands of having a young infant,” said Jennifer Felder, PhD, assistant professor of Psychiatry and core research faculty at the UCSF Osher Center for Integrative Health at UCSF, who led the study.

“We were particularly excited to see the benefits lasted to six months not just for insomnia, but for mental health more broadly.”


What Is BDigital CBT for Insomnia?

CBT has traditionally been a face-to-face talking therapy, delivered in a direct one-to-one relationship between patient and therapist. It also has been demonstrated that CBT can be pro- vided successfully as a group therapy [4], in large workshops [5], as a self-help bibliotherapy [6], or by telephone [7].

These methods reflect attempts at Bscaling^ CBT to meet the popu- lation need. However, they are by no stretch sufficient if our ambition is to make CBT as ubiquitous as pharmacotherapy. It is in fact a perfectly reasonable ambition to provide CBT to the tens of millions of people who might benefit, considering that CBT’s evidence base is stronger than that of pharmaco- therapy – the problem is that providing CBT to a large population is not even remotely feasible using traditional methods of dissemination.

Potentially, technology can bridge that feasibility gap, with digital solutions offering the possibility of true scalability.

Although several terms have been used to describe technological advances, for example internet CBT (iCBT), comput- erized CBT (cCBT), electronic CBT (eCBT), or online CBT (oCBT), we have suggested that the field recognizes and evolves towards the term Bdigital CBT (dCBT)^ to reflect the contemporary spectrum of digital technology, rather than one specific, and most likely historical aspect (e.g. computer or internet) that will soon enough be lost in the mists of time [3].

There can be little doubt that the pace of change in this digital age will afford unrelenting opportunity for the dissem- ination of dCBT. The corollary to this, however, is that all forms of dCBT will be perpetually out of date unless they remain at the forefront of digital innovation.

Consequently, it will not be the provenance, content, validation, or outcome data associated with any particular dCBT program that determines its longevity but its level of execution.

For clinicians and patients wherever they may be to have ready and sustained access to high quality, engaging, and effective CBT, we need both clinical excellence and creative genius, as illustrated in Fig. 1.

Fig. 1 Defining and developing Digital Medicine: essential components. Digital Medicine, including dCBT, is the product of interaction across four essential domains (technology, design, clinical, research). Advanced knowledge and expertise of the specific components within each of the domains is critical to developing a safe, clinically effective, scalable, and sustainable product. dCBT digital Cognitive Behavioral Therapy, RCT randomized controlled trial, SCED single-case experimental designs

Insomnia in pregnancy is common, yet understudied

About 38 percent of women experience insomnia during pregnancy, which in turn is associated with a 30 percent increased risk of pre-term birth. Yet there has not been a great deal of research on whether sleep interventions are effective for pregnant women.

Studies on how to prevent postpartum depression, which affects up to 15 percent of women, have focused on women with a history of depression or sub-clinical depression symptoms. No research has studied whether treating insomnia may prevent postpartum depression.

“I’ve heard patients say, over and over, that their post-partum mental health began to suffer when their insomnia started, suggesting there is a link,” Felder said. “We know that postpartum can be a vulnerable time for becoming depressed, and it is possible that this intervention may prevent that.”

The current study involved 208 participants, 105 of whom were randomized to the dCBT treatment – a self-paced sleep app called Sleepio that patients used for 20 minutes at a time for up to six sessions. At three months postpartum, 4 percent of women who used the app were rated as likely depressed, compared to 18 percent of the women who got usual care.

Digital therapy: More affordable, more scalable

Usual care included medication or general sleep hygiene tips from physicians and others. dCBT may work better because it’s more individualized and addresses the factors known to perpetuate insomnia, Felder said.

“Participants can set their own goals, and their treatment recommendations are tailored based on what their previous week’s sleep looked like,” Felder said.

“The magic of the treatment is what happens between sessions, the tactics the participants put into practice, such as keeping a sleep diary, stabilizing their wake time, spending less time in bed tossing and turning, and prioritizing an adequate wind down before bed.”

Given the shortage of mental health clinicians who are trained to deliver cognitive behavioral therapy, it’s important to test treatments that women can actually access, Felder added: “This is a scalable intervention with a low risk profile – and it works.”

Felder said she and her colleagues plan to conduct a large-scale study in the near future to determine conclusively whether dCBT for insomnia prevents postpartum depression.

Additionally, she is currently piloting a mindfulness-based intervention to help pregnant people cope with sleep disturbances caused by discomfort, pain, or an active mind.

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