Perinatal depression is a major public health concern and a leading risk factor for suicide, a leading cause of maternal mortality. Behavioral activation (BA) is a psychotherapy technique based on the simple idea that action precedes emotion. In other words, making yourself do an activity that typically makes you happy, even though you don’t feel like it, could in fact increase your mood and reduce symptoms of depression. BA is recommended as a first-line treatment for perinatal depression and may reduce suicidality by increasing awareness of maladaptive behaviors and can be delivered by nonspecialists via telemedicine. In this study, Kaliush and colleagues examine whether BA leads to reductions in perinatal suicidal ideations.

This study utilized a secondary analysis of the SUMMIT (Scaling Up Maternal Mental Health Care by Increasing access to Treatment) randomized clinical trial. SUMMIT was a multisite, noninferiority randomized clinical trial where they found that BA delivered by nonspecialists and telemedicine was noninferior to specialist, in-person care. The current study assesses whether the likelihood of endorsing suicidal ideation changed throughout treatment and at 3 months post-randomization. They also examine whether these changes varied by clinician or delivery type all using the Edinburgh Postnatal Depression Scale (EPDS). This study included 1117 women who received 1 or more treatment sessions and provided 1 or more weeks of EPDS data over 6-8 weekly sessions, where item 10 of the EPDS was the primary indicator of suicidal ideation.

23.6% of participants endorsed suicidal ideation during treatment, with those endorsing SI more likely to be younger, reporting more trauma symptoms, and more often having prior depression or anxiety. BA intervention showed significant reductions in SI where each additional BA session reduced the odds of endorsing SI by 25%. After 3 months, the odds of SI were reduced by 80% compared to treatment onset. It is important to note that 10 participants did not exhibit reductions in SI and needed more intensive interventions.

Overall, BA substantially reduced perinatal SI during and after treatment, regardless of delivery format or provider type. The limitations of this study include that there was an absence of a non-treatment control group. Additionally, women at the highest suicide risk were excluded, which limits generalizability. In conclusion, BA psychotherapy seems to be an effective way to mitigate postpartum SI for most.

Reference:

Kaliush PR et al. JAMA Psychiatry 2025;Epub ahead of print. Abstract