4 - (OP3) Scaling up Psychotherapies for Perinatal Depression Through Task-sharing and Telemedicine: Findings from a Pragmatic, Multi-site Noninferiority Trial

Perinatal depression is a leading cause of disability worldwide, affecting 1 in 5 perinatal women. Evidence-based cognitive and behavioral psychotherapies are effective and preferred over medications but remain largely inaccessible resulting in annual estimated costs of $2 CAD billion in Canada and $14 USD billion in the USA. Barriers include cost, access to in-person care, and shortage of specialized providers. Task-sharing – care provision from nonspecialist providers (those without formal mental health training, e.g., nurses, midwives, doulas) - and telemedicine may improve access. To our knowledge, no trial has compared both task-sharing and telemedicine with in-person care in real world settings, or evaluated their cost-effectiveness.
SUMMIT Trial is a pragmatic, multi-site, randomized non-inferiority trial for perinatal depression (N=1230), implemented in Toronto, Chapel Hill, and Chicago. It compared task-sharing and telemedicine-delivered psychotherapy to gold-standard specialist and in-person psychotherapy. All participants received an 8-session manualized behavioral activation (BA) treatment. Primary results showed non-inferiority between provider types (nonspecialist vs. specialist-delivered psychotherapy) and modalities (telemedicine vs. in-person psychotherapy) for depressive symptoms (EPDS) at 3-months post-randomization.
We will present mixed-methods results: (1) the sustained treatment trajectories comparing treatment providers and modalities up to 12-months post-randomization and by baseline severity; (2) the cost-effectiveness of the different provider and modality strategies; and (3) the process evaluation of relevant barriers and facilitators from a multi-stakeholder perspective.
A linear mixed-effects model showed a statistically significant decrease in EPDS scores over time in both provider and modality groups (p < 0.0001). The rate of EPDS score reduction did not statistically differ between provider and modality groups. Cost-effectiveness analyses indicated that nonspecialist care and telemedicine modality were more likely to be cost-effective than specialist care (>50% probability of willingness-to-pay), and in-person modality (>85% probability of willingness-to-pay), respectively.
Qualitative findings highlighted existing barriers, including waitlists and system navigation challenges. BA and its training were perceived as practical and beneficial, with minimal delivery barriers. Stakeholders identified limited funding and potential provider resistance as barriers to adoption, implementation, and sustainability.
These results provide robust evidence that psychotherapy for perinatal depression can be delivered by trained nonspecialist providers via telemedicine with comparable clinical benefits to specialist, in-person care and meaningful economic advantages. The trial’s support innovative, patient-centered and scalable solutions to transform access and quality of care for mothers worldwide.