From the Editor
She was so excited about the pregnancy; in our sessions, she expressed joy. But, as with some women after childbirth, her mood declined. She couldn’t properly care for her son, which she reported with shame and guilt. Perinatal depression is common – and yet many women in Canada and other high-income countries don’t receive care.
What can be done to help them? Could nonspecialist providers – like nurses, midwives, and doulas – be trained up to deliver psychotherapy effectively? Can telemedicine be used? In a new paper for Nature Medicine, Daisy Singla (of the University of Toronto) and her co-authors attempt to answer these questions. In their study, SUMMIT, they conducted a pragmatic, noninferiority trial comparing specialist and nonspecialist providers, delivering care in person or through telemedicine. Participants received eight treatment sessions of behavioural activation. They found noninferiority with both providers and modality of treatment. “This trial suggests compelling evidence for task-sharing and telemedicine to improve access to psychotherapies for perinatal depressive and anxiety symptoms.” We discuss the paper and its implications.
Daisy Singla
Alternative treatments – think mindfulness, acupuncture, yoga – have been historically popular with patients but generally lacking in evidence. Times have changed: mindfulness as a psychotherapy, for instance, is included in the CANMAT depression guidelines. What about yoga? Does depression care include the downward dog? In the second selection, a new episode of Quick Takes, I speak with Dr. Vanika Chawla (of Stanford University) who is part of that university’s lifestyle medicine team and a registered yoga teacher. “I think yoga is a wonderful way to expand providers’ toolbox of existing treatments.”
And in the third selection, Caroline Donelle writes about the suicide of her daughter. In a deeply personal essay for The Globe and Mail, she notes the loss, her decision to move across the country, and her slow healing. “I’m not the person I was when she died and never will be again. I’ve evolved and grown in unexpected ways.”
DG
Selection 1: “Task-sharing and telemedicine delivery of psychotherapy to treat perinatal depression: a pragmatic, noninferiority randomized trial”
Daisy R. Singla, Richard K. Silver, Simone N. Vigod, et al.
Nature Medicine, 3 March 2025
One in five women experience depression or anxiety during the perinatal period (pregnancy up to the year following childbirth). Treatment is essential given the negative, long-term and intergenerational impact on maternal and child developmental outcomes. Brief psychotherapies are first-line, evidence-based treatments. They are preferred by perinatal populations over pharmacotherapy and recommended by major clinical guidelines… However, access is limited, with barriers including costs, stigma and the inequitable distribution of mental health professionals. As a result, only 10% of affected perinatal patients in high-income countries (HICs) receive psychotherapy.
Both task-sharing and telemedicine are scalable, patient-centered solutions to improve access to psychotherapy. Scalability is defined as the potential of an intervention to reach large numbers of individuals. In task-sharing, nonspecialist treatment providers – individuals without a specialized degree or prior experience delivering mental healthcare – are trained to deliver brief, manualized psychotherapies and have been shown to treat a range of mental health conditions worldwide. A previous systematic review yielded 45 randomized controlled trials of nonspecialist-delivered psychological treatments for perinatal populations with common mental health conditions. The results suggested that nonspecialists – namely nurses and midwives – could be trained to deliver psychological treatments for perinatal populations with depressive and anxiety symptoms in HICs. However, in both low- and middle-income and HICs, most trials use an inactive control group (for example, a waitlist) and no trials, to our knowledge, evaluated whether different provider types were able to deliver the same treatments comparably. Thus, while the efficacy of this approach has been shown to reduce perinatal depressive and anxiety symptoms worldwide, the relative effectiveness of nonspecialists compared with specialist providers remains unknown.
So begins a paper by Singla et al.
Here’s what they did:
- They conducted a pragmatic, multisite, noninferiority, four-arm trial to compare “the effectiveness of provider (nonspecialist versus specialist) and modality (telemedicine versus in-person) in the delivery of one psychotherapy known as behavioral activation (BA) therapy.”
- Participants were recruited from five academic sites across North America (Mount Sinai Hospital, Women’s College Hospital, St. Michael’s Hospital, University of North Carolina and Endeavor Health).
- Pregnant and postpartum adult participants were offered weekly behavioral activation treatment sessions. They were randomized to nonspecialist telemedicine, nonspecialist in-person, specialist telemedicine and specialist in-person.
- The primary outcome: depressive symptoms as measured by the Edinburgh Postnatal Depression Scale (EPDS) at 3 months post-randomization. They also measured anxiety.
Here’s what they found:
- Of the 3 629 individuals approached, 1 543 agreed to participate with 1 230 participants ultimately enrolled. The randomization: 472 were assigned to the nonspecialist-telemedicine arm, 469 to specialist-telemedicine, 145 to nonspecialist in-person and 144 to specialist in-person.
- Demographics. The mean age of participants was 33.27 years. Many identified as Black, Indigenous, or Persons of Color (47.15%) and most were nulliparous (54.49%).
- Illness experience. Most participants reported a history of depression or anxiety (85.73%), with almost one in four taking psychotropic medications at enrollment. Baseline EPDS score: 15.77.
- Primary outcome. “Noninferiority was met for the primary outcome comparing provider (EPDS: nonspecialist 9.27… versus specialist 8.9…) and modality (EPDS: telemedicine 9.15… versus in-person 8.92…) for both intention-to-treat and per protocol analyses.”
- Secondary outcome. “Noninferiority was also met for anxiety symptoms in both comparisons.”
- Adverse events. There were no serious or adverse events related to the trial.
A few thoughts:
1. This is an impressive study, with big implications, published in a major journal.
2. The main finding in a sentence: “In this large, multisite trial, we found that nonspecialists (individuals without a specialized mental health background), were noninferior to specialists in delivering BA, whether BA was provided in-person or via telemedicine.”
3. Wow.
4. Are there implications for care delivery? The authors clearly think so. “Our results… suggest that training nonspecialists can increase the mental health workforce and improve access to relatively brief, evidence-based psychotherapies such as BA. Globally, task-sharing has been examined with the promise to scale access to a large number of services – including mental healthcare – because of the decreased reliance on specialist providers who are overburdened, scarce, inequitably distributed and often work in the private sector, beyond the reach of the majority of populations in most countries.”
5. The thinking behind this study draws heavily from experiments in low-income countries, where providers are scarce. There is a huge distance between rural India and urban North America, but in both settings, the evidence suggests that nonspecialists can be trained up for some basic psychotherapies without standards being watered down.
6. Like all studies, the authors note limitations, including: “Most of the participants (70.07%) had a university degree, thus potentially limiting the generalizability of our sample.”
7. Task-sharing has been discussed in past Readings, including one that summarized a podcast interview with Dr. Vikram Patel (of Harvard University) – who helped supervise the SUMMIT study. Dr. Patel discussed his work in Goa and the use of laypeople to deliver mental healthcare. You can find it here:
The full Nat Med paper can be found here:
https://www.nature.com/articles/s41591-024-03482-w
Selection 2: “Yoga and practice”
Vanika Chawla
Quick Takes, 26 March 2025
In this episode of Quick Takes, I speak with Dr. Chawla, a psychiatrist who trained at the University of Toronto. She speaks about her interest in yoga and its clinical relevance. Our conversation covers everything from the literature to future research.
Here, I highlight several comments:
On her clinical work
“I am running a yoga psychotherapy group. It’s a 12-week group and transdiagnostic. Typically, patients present with issues related to mood, anxiety, trauma and we focus on stress reduction. So, it integrates yoga-based interventions and philosophy, with a goal to help people with nervous system regulation, stress reduction, improving things like self-compassion. There are parallels between some of those interventions and existing third wave psychotherapies like MBSR (Mindfulness-based stress reduction) and ACT (Acceptance and Commitment Therapy)…”
On the components of yoga
“The three components are the postures, the breathwork, and the meditative-based practices. So, integrating it clinically, I’ve done that in a few different ways, and it really depends on the context – depending on if it’s individual or group-based work and depending on the patient’s needs. That’s the cool thing about yoga; it can be applied in different ways and based on what the patient is needing.”
On the appeal of yoga
“Alternative therapies really expand our toolbox and they give people more tools and more options.
“So, a lot of psychotherapies, for example, focus on the ‘top down’ – they’re cognitively focused. Whereas yoga brings in this nice aspect of ‘bottom up,’ a shift to our respiratory and cardiovascular systems… more options to self-regulate, to manage symptoms, to find a sense of resilience. And then that can really complement some of the more top-down work that is being done.”
On the evidence for yoga
“There’s been much interest in yoga over the past several years but the literature has had challenges – though it’s been improving. Most of the systematic reviews and meta analyses are generally positive. The literature has been focused on mood, anxiety, trauma, with some studies out of India on schizophrenia. Though the positive results need to be interpreted with caution given the methodological limitations. For example, one recent paper published in JAMA in 2023 comparing yoga to cognitive processing therapy for veterans with trauma, and they found yoga to have equivalent effectiveness to CPT. There was also a nice study comparing Kundalini yoga to CBT and stress education for people with GAD. It was an RCT and they found that yoga was more effective than stress education, but not as effective as first-line treatment with CBT.”
On unanswered research questions
“Yoga is a really heterogeneous kind of intervention. There are different components. And there aren’t any clear answers around what components for what diagnoses, for how long, and for how often… So what is an ideal yoga protocol for someone with GAD versus PTSD versus depression? And what are the different components that need to be emphasized?”
The above answers have been edited for length.
The podcast can be found here, and is just over 19 minutes long:
Selection 3: “I discovered there is a long arc of grief when your child dies by suicide”
Caroline Donelle
The Globe and Mail, 9 March 2025
Some things cannot be fixed; they can only be carried. Grief like yours, love like yours, can only be carried.
I read this astonishing quote in Megan Devine’s book It’s OK that you’re not OK many years after my daughter Ashley died. It resonated so much, I wish I’d read it earlier because when the second year after her death came around, I didn’t feel better at all.
Books I’d read on suicide (and they were the only books I read) warned me this was the case. How could that be? Had I not grieved enough? I was half expecting a reprieve to come galloping in, but it never came.
So begins an essay by Donelle.
She discusses the loss. “Once when I thought I spotted my daughter in a crowd, I thought I’d gone crazy. When it happened a second time I thought, was it her? Of course, it wasn’t. I dreamt about my daughter so often, it felt pathological. I dreaded falling asleep. In my dreams, she was always showing me things and taking me places. She was so happy and well. In every dream, I’d end up unable to keep following her on account of some physical obstruction; a tunnel narrowing, a stairway ending, a road disappearing, water rushing in. I’d have to stop and could only watch her keep going without me: ‘Don’t go.’ Throughout these dreams, she was always smiling, full of life, encouraging me to keep up: ‘C’mon Mom!’ Then I’d wake up and cry my heart out all over again.”
She talks about the decision to return to work. “Exhausted, unrecovered and still living in sad-land, I returned to work after a long absence. While work was the last place I wanted to be, my therapist said that regular human contact was a good idea, and I reluctantly agreed. Colleagues hadn’t seen me in months. ‘Oh, I was so sorry to hear…’ greeted me in corridors, elevators and meeting rooms. In the beginning, it was every day, then weekly, then once a month, then never again. I’d politely say thank you and quickly retreat back to my office to close the door and cry, wipe my face, breathe and put on my ‘I’m fine’ face for the remainder of the working day.”
She decides to move. “Two-and-a-half years later after that bitterly cold February eve when we learned Ashley had died by suicide, I sold everything I owned, packed up the car and the dog, said my goodbyes and drove 3,000 miles across the country. I wanted to be in a place where I knew no one; I had no job, no friends, no therapist, no plans. I could start over there.” It was a big change. “It wasn’t easy to resettle in an unfamiliar place where I knew no one. I’m grateful for my dog and the many miles of walking and hiking and running… It took many years to be able to talk about my daughter’s suicide and that long, dark period without stopping to sob.”
She notes her healing. “Time has a way of softening the edges and clearing perspective.” She continues:
“My daughter’s death taught me a lot about love and loss, the long arc of grief and the enduring sorrow. Once I learned to live with it, I was able move on with my life. When the anniversary of Ashley’s death comes around now, I look through all the photos of a beautiful young woman who will never grow old. It’s then that I remember how much I loved her, how I’ll always miss her and how lucky I was to have been her mother.”
A couple of thoughts:
1. This is an amazing essay.
2. It’s difficult to imagine how anyone could heal after experiencing such a loss.
The full Globe essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
Recent Comments