Inside the Black Box: What Accounts for Improvement in Internet-Delivered CBT for Maternal Depression

The World Health Organization ranks depression as the greatest contributor to disability world-wide. Mothers of young children are at high risk for depression, especially mothers experiencing economic difficulties. The impairment depression creates for women places their children at increased risk of emotional and behavioral difficulties. Though effective treatments exist, barriers such as work schedules, absence of transportation, lack of mental health providers in rural communities, and perceived stigma, severely limit the number of women who engage in depression treatment.

As a partial solution to addressing treatment barriers, Internet-delivered interventions have been increasingly used. Research indicates these interventions to be effective in treating depression, particularly those considered to be “guided” where clinical or nonclinical staff provides motivational support or facilitates on-line skill learning. In response to this research, we developed the Mom-Net maternal depression intervention, based largely on the well-validated Coping with Depression Course. We adapted the intervention for Internet delivery and tailored content to include a focus on depression and its impact on parenting young children. We developed this content working with low-income mothers of young children and created the content to reflect the realities of their lives. Mom-Net is a coach-facilitated, Internet-delivered Cognitive Behavioral Therapy (CBT) intervention that consists of 8 on-line sessions accompanied by weekly calls by a coach to promote engagement and learning. In two studies, we looked at Mom-Net’s effectiveness. In both studies, depressed mothers of Head Start children who were assigned to the Mom-Net intervention experienced larger decreases in depression when compared to mothers who were assigned to usual community treatment available to them.

Despite progress in developing, implementing, and testing Mom-Net as well as other on-line depression interventions, there has been less to celebrate with respect to our understanding of why and how these interventions work. For this reason, many treatments may be considered “black boxes” in that we do not know what goes on inside the intervention package. As such, there have been numerous calls to open this black box in order to further understand how and why change occurs during treatment (e.g., U.S. Department of Health and Human Services, National Institutes of Health, National Mental Health Institute, 2015). Doing so will enable us to identify the most important parts of the interventions needed to reduce maternal depression and allow us to fine tune our interventions.

The goal of the paper we recently published in Cognitive Behavior Therapy was to do just that with regard to the Mom-Net intervention. We examined three potential intervention skills hypothesized to explain improvement in maternal depressive symptoms. These skills focused on increasing Behavioral Activation (i.e., doing more social, active, pleasurable, or mastery activities), reducing in Negative Thoughts common among depressed persons (i.e., negative statements about self and future), and Savoring (i.e., one’s perceived ability to reflect on and enjoy positive outcomes and events). We tested these CBT components, or intervention mechanisms, across our two Mom-Net studies using the same measures of behavioral activation, negative thinking, and savoring of positive events. Measures were completed by mothers before and after the intervention in both studies. Study 1 included 70 mothers with elevated depressive symptoms who were randomized to either Mom-Net or to treatment as usual in the community. Study 2 included 266 mothers with elevated depressive symptoms who were randomized to either Mom-Net or to a motivational interviewing and referral to services condition.

The findings with respect to Mom-Net intervention mechanisms accounting for reduced depression were remarkably similar across the two studies, indicating that increases in behavioral activation and decreases in negative thinking fully accounted for the reduction in maternal depressive symptoms. Though savoring was shown to be greater at post-treatment in the Mom-Net group than in the comparison conditions, and related to depressive outcomes, the effects were less strong. Mom-Net intervention effects on Behavioral Activation and Negative thoughts are broadly consistent with those found in examinations of face-to-face CBT depression treatments. We take this as evidence that the Internet-delivered intervention teaches the same core processes effectively. The broader evidence regarding the effect of savoring on reducing depression is much more limited. It is possible that our findings indicate that savoring is a less important treatment focus or that it was not taught as effectively in the intervention. However, other researchers have argued that current methods of measuring savoring may not be adequate, so it is possible that we have not provided a strong enough test of the savoring process in our studies.

One important limitation of our work is worth noting. The mechanisms we examined in our studies were measured at the same time as the depression measure, which was the outcome measure. A core idea in examining mechanisms of change is that change in the mechanism occurs prior to change in the outcome measure.

A second limitation is that the low proportion of ethnic or racial diversity in the two samples makes it difficult to know if our findings will generalize to all mothers regardless of culture. As well, though the intervention included a focus on parenting, we did not examine change in parenting behavior or parenting self-efficacy as potential mediators of maternal depression. Each of these limitations provides an important direction for our future work.

In closing, results of our studies provide support for the role of increased behavioral activation and reduced negative thinking, with some indication that there may be a role for savoring of positive events, as mechanisms explaining the relationship between the Mom-Net intervention and reductions in depression. To our knowledge, this is the first study to explore these mediators in an Internet-delivered CBT intervention for maternal depression. Hence, the study advances our knowledge by peering into the “black box” of the intervention to identify processes accounting for change.

Text: John Seeley
Photo: Oleg Sidorenko

Read the full paper:
John R. Seeley, Lisa B. Sheeber, Edward G. Feil, Craig Leve, Betsy Davis, Erik Sorensen & Steve Allan (2018) Mediation analyses of Internet-facilitated cognitive behavioral intervention for maternal depression, Cognitive Behaviour Therapy, DOI: 10.1080/16506073.2018.1513554


John Seeley – one of the authors

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