Postpartum depression (PPD) is a serious clinical condition affecting approximately 13% of Portuguese women after childbirth [1
]. When left untreated, PPD poses adverse and persistent consequences for the entire family system. It affects the woman’s health (e.g., increased tiredness [2
], decreased quality of life [3
]) and mother–child interaction (e.g., mother-child bonding, lower parenting self-efficacy) [3
]. Moreover, it can have consequences for the infant’s development (e.g., infant sleep patterns, emotional development) [3
] and for the entire family environment, including the couple’s relationship [5
Despite the existence of effective treatments (e.g., cognitive–behavioral therapy [CBT]) [6
], few women with PPD seek professional help [7
]. A Portuguese study revealed that only 13.6% of women with depressive symptoms during the perinatal period sought professional help to address their emotional difficulties [8
]. Time and financial constraints and struggles with transportation and childcare issues are some of the structural barriers to seeking professional help reported by postpartum women [9
], suggesting the need for new delivery formats to improve women’s access to evidence-based PPD interventions.
E-mental health tools are an innovative form of treatment delivery that use digital technology, including web-based technology, in the mental health field [11
]. These tools can overcome PPD treatment uptake barriers given their reduced costs, flexibility, and improved accessibility [12
]. Women in the postpartum period already use the internet frequently to search for information about PPD [10
]. Moreover, e-mental health tools have been perceived as acceptable and useful among Portuguese women in the perinatal period, particularly among those women presenting clinically relevant depressive symptoms [13
Existing web-based interventions for PPD treatment based on CBT have proven to be effective in the reduction of postpartum depressive symptoms [14
]. Interventions such as MomMoodBooster [17
], NetMums [18
], and Mom-Net [19
] have shown promising results not only in reducing postpartum depressive symptoms but also in improving self-efficacy, marital relationship, and mother–child bonding.
However, there is also evidence that web-based interventions suffer from important limitations related to the accuracy of diagnosis, which is based only on online assessments [20
], and with low engagement and high attrition rates [15
] due to the absence of therapist support during the intervention [15
]. Web-based interventions also lack nonverbal communication as well as the opportunity to discuss specific problems and to deal with crises [21
]. Instead of replacing traditional psychological interventions, e-mental health tools can be an important complement to them [23
Blended treatment is the combination of face-to-face treatment with web-based interventions that are integrated and used sequentially in one treatment protocol [24
]. Therefore, delivering PPD treatment using a blended format could benefit from the potential of both treatment modalities (face-to-face and online) [23
]. Blended treatment presents the advantages of the utilization of e-mental health tools, namely, flexibility in application, good accessibility, and travel time savings [21
]. Additionally, online sessions can improve patient self-management and help patients better prepare for a session with a therapist [21
]. Blended treatment allows professional guidance in the therapeutic process, which increases adherence, prevents dropout, facilitates increased treatment intensity, and leads to better results compared to unguided treatments [20
]. CBT therapists recognize that blended intervention formats support the patient’s motivation, can be adjusted to the patient’s specific needs, and reduce the treatment gap between sessions [23
]. Online sessions can also replace some face-to-face sessions with the therapist, allowing for time savings in healthcare systems as well as decreased treatment costs [24
There is growing evidence of the efficacy of blended treatments for several psychological disorders [24
], including depression [21
]. Existing studies have indicated that blended treatment for depression is perceived positively by patients [22
]. Despite its advantages and considering the aforementioned barriers to professional help-seeking in the postpartum period [9
], to our knowledge, there is no blended treatment format targeting PPD.
This article presents the study protocol for a blended CBT intervention combining face-to-face sessions with the online program Be a Mom for the treatment of PPD in the Portuguese context. In Portugal, the Be a Mom program was developed as a culturally sensitive web-based CBT intervention that is designed as a self-guided tool for the prevention of PPD. Preliminary evidence of Be a Mom’s pilot trial suggests its effectiveness in reducing depressive symptoms among women presenting early-onset PPD symptoms [30
], thus supporting its potential as a PPD treatment tool integrated into a blended treatment protocol.
Therefore, we herein outline the protocol for a randomized controlled trial to examine the acceptability and efficacy of a blended CBT intervention for PPD treatment, considering postintervention and follow-up improvements in primary and secondary outcomes. It is expected that the blended CBT intervention will be as effective as treatment usually provided for PPD in decreasing depressive symptoms. In this study, we will evaluate the mediating role of psychological competences (self-compassion, emotion regulation, psychological flexibility) in treatment response. These mechanisms have been core psychological processes underlying the development of the Be a Mom program [31
]. Moreover, previous studies have found that these psychological mechanisms were associated with improvements in depressive symptoms in the perinatal period [30
]. We will also examine the moderator effect of characteristics of the patient (e.g., sociodemographic characteristics, motivation for therapy) and of the therapeutic process (e.g., therapeutic relationship, user’s satisfaction) in the efficacy of the blended intervention for PPD.
Despite the existence of effective treatment, few women seek professional help to deal with their depressive symptoms in the postpartum period [7
], indicating the need for a new and innovative format of treatment that can overcome help-seeking barriers. This study aims to evaluate the acceptability and effectiveness of a blended CBT intervention for the treatment of PPD in the Portuguese context by integrating face-to-face sessions with the web-based program Be a Mom.
To our knowledge, this will be the first study to develop a blended CBT treatment protocol for PPD. Blended Be a Mom benefits from both treatment formats, offering the flexibility, accessibility, and self-management of e-health tools as well as clinical support, increased motivation, and higher treatment intensity [21
]. Moreover, it can potentially decrease the number of face-to-face sessions and reduce costs in healthcare systems. A blended CBT intervention can therefore increase help-seeking behaviors among women in the postpartum period by providing treatment that mitigates the impact of the identified barriers in professional help-seeking.
Existing studies have revealed that blended treatment for depression can be effective in reducing depressive symptoms and maintaining these gains over a period of six months [28
]. Additionally, previous findings have shown that blended interventions are more effective compared to control groups without intervention (i.e., waiting lists) [24
] and that it can be as effective as standard CBT treatments [29
]. We expect that Blended Be a Mom will be as effective as TAU with regard to long-term effects on primary and secondary outcomes. The feasibility, acceptability, and usability of the blended intervention will be considered in addition to its cost-effectiveness.
Despite its advantages, there is still limited knowledge about the suitability of blended treatment for every patient [20
]. Characteristics such as age, severity of symptoms, or the ability to use technology should be considered and further studied to optimize the effectiveness of blended interventions. The results of our study will provide insights into the processes underlying the treatment effects of blended intervention and the characteristics that moderate the effectiveness of blended intervention.
Our study will also be innovative due to the inclusion of daily ecological momentary assessments during the intervention. This approach allows the collection of information in women’s natural environment in real time and therefore prevents retrospective biases [39
]. This will provide important information about intraindividual variations over the treatment, the dynamic evolution of PPD symptoms over time, and temporal relationships between mood and other experiences. The inclusion of ecological momentary assessment is recommended in RCTs because it can optimize statistical power effects, improve measurements precision, and potentially increase treatment’s adherence [54
]. This data collection method has previously been used both in the postpartum period and in depression disorders, and it was considered feasible and acceptable by the users [55