Feasibility and Acceptability of a Novel Digital Intervention to Prevent Paternal Postpartum Depression

Pilot Randomized Trial of Together in Parenting, a Novel Digital Paternal Postpartum Depression Prevention Intervention

Postpartum depression (PPD) occurs almost as often among men as it does among women. However, while there have been multiple programs designed to prevent maternal PPD, few, if any, interventions exist that have been created specifically to prevent paternal PPD. After engaging in evidence-based qualitative research with soon-to-be or new fathers, a novel interpersonal-therapy based digital program was created to prevent paternal PPD called Together in Parenting (TIP), which comprises multiple podcasts and digital educational handouts. The proposed pilot study will examine the feasibility and acceptability of using TIP as a paternal PPD intervention, will determine the optimal timing of administering TIP to future/new fathers, and will generate preliminary estimates of effect of the intervention to support a future efficacy study.

Postpartum depression (PPD) PPD affects 10-15% of women and 8-10% of men. Despite the similar prevalence, the United States Preventive Services Task Force (USPSTF) endorses psychotherapy approaches to prevent PPD for mothers, but no stand-alone preventive interventions specifically targeting paternal PPD exist. Primary paternal PPD prevention is crucial because paternal PPD is underdiagnosed and undertreated. It is hard to identify fathers who have PPD because PPD symptoms affect fathers differently than mothers due to cultural conceptions of masculinity, leading to the risk that fathers do not recognize their symptoms as PPD and engage in avoidant or numbing behavior instead of PPD treatment. Even if they recognize their PPD, men are less likely than women to pursue help due to the stigma of mental health care, resulting in delays in PTD diagnosis and treatment. Furthermore, the American Psychological Association recommends altering depression treatment to patient demographics because the efficacy of psychological interventions varies by patient factors. Since there is no psychotherapy for paternal PPD, the most common non-pharmacological treatment strategy for paternal PPD is to provide fathers with maternal PPD therapy, which likely reduces its effectiveness. Fathers' lack of awareness and aversion to treatment leads to untreated PPD, which drastically increases risk of PPD for mothers and impaired cognitive development for children. Given the barriers fathers face being diagnosed with PPD and the lack of tailored treatment, a targeted intervention for fathers that effectively prevents paternal PPD is urgently needed to prevent maternal PPD and decrease the risk of profound intergenerational consequences for fathers, mothers, and infants.

Interpersonal therapy (IPT) is an evidence-based psychotherapy approach for depression that views relationship attachments, effective communication, and disruption in social support as intimately linked with psychological symptoms. In 2019, the USPSTF's maternal PPD statement indicated IPT prevents maternal PPD. IPT may be even more suitable for paternal PPD prevention: fathers have been shown to prefer psychology over pharmacotherapy for PPD. In fact, IPT-based counseling has mechanistic plausibility to prevent paternal PPD: by helping fathers improve communication within their relationships, change expectations about those relationships, and/or build or better utilize an extended social support network, IPT can help fathers develop the interpersonal support needed to deal with the crises precipitating depressive symptoms (birth or infant care).

Online interventions reduce the stigma associated with mental health care, are widely utilized by men, and reduce depressive symptoms. Online peripartum mental health care effectively prevents and treats maternal PPD. Though there are currently no ongoing studies examining the effect of online IPT for paternal PPD prevention, online IPT will be accessible to most fathers: In the US, 90% of adults own a smartphone and 80% have home broadband internet. Also, unlike current IPT-based maternal PPD prevention interventions, which require trained providers for intervention fidelity, online IPT could be disseminated without impacting intervention fidelity.

Together in Parenting (TIP) is a novel online paternal postpartum depression (PPD) prevention intervention that utilizes interpersonal-therapy-based strategies to reduce interparental conflicts and increase social support in the newborn period, thereby preventing PPD among fathers. An iterative end-user centered design process allowed qualitative interviews with 25 fathers at high-risk of paternal PPD-as defined by the fact that their partners attended prenatal care at the clinic for federally insured pregnant people-to transform TIP's appearance and features. Specifically, TIP was originally conceptualized as a smartphone application but has evolved iteratively from feedback from target end-users during the qualitative interviews to become a scripted audio- and video-recorded podcast, mimicking friends casually discussing parenting and relationships. Each of the 12 podcasts, referred to as lessons on the website, range between 8 to 15 minutes (most are less than 11 minutes) and include a digital handout to encourage participant engagement with the progressive IPT-based curriculum. There are also 10 digital handouts to encourage engagement. TIP is hosted on a password-protected website. User-specific log-ins allow TIP to contain an embedded analytic platform to monitor duration of use and modules accessed as well as responses to digital handouts.

The proposed study is a pilot randomized control trial that aims to examine the feasibility, acceptability, and preliminary estimates of effects of TIP (intervention) when compared to routine care (control). Ultimately, the goal is to use TIP to prevent PPD among fathers at high-risk for the condition due to those with structural or personal risk factors.

For this pilot study, the primary purpose will not be to determine TIP's efficacy at PPD prevention but to demonstrate the feasibility and acceptability of TIP as a digital intervention among fathers with newly born infants at high risk of PPD. The dual primary outcome for this study will be feasibility and acceptability. In order to obtain a preliminary estimate of effect for TIP on PPD outcomes to support a future efficacy trial, the proposed pilot study will also assess clinically meaningful perinatal mental health outcomes (depression and anxiety) and mediators (dyadic adjustment, stress, loneliness, and parenting confidence). These metrics will be collected at multiple time points after randomization to allow for longitudinal assessment of symptom trajectories postpartum as well as pre/post-intervention analyses comparing scores at randomization to those at various postpartum intervals. The effect of TIP on maternal well-being will be examined by having mothers complete some psychometric at study completion. Lastly, the most effective timing of intervention delivery will be determined using a mixed-methods approach nested within the proposed pilot randomized trial.

Inclusion Criteria:

1. English-speaking (for now, TIP is only available in English)
2. age >18 years old,
3. smartphone ownership or access to home internet,
4. partner or patient received or receiving prenatal care from a resident or nurse-practitioner/midwifery clinic at the Obstetrics and Gynecologic Care Center (OGCC) at Women & Infants Hospital of Rhode Island (WIHRI) or receiving an ultrasound at the WIHRI's Prenatal Diagnosis Center ,
5. planned delivery or status post delivery at WIHRI.

Exclusion Criteria:

1. Any self-reported active diagnosis or history of mental health conditions including depression, anxiety, or other psychiatric condition, as per patient report;
2. Endorsing active suicidality on intake survey or screening positive on the MDS (≥13)16 or GAD-7 (≥8) at time of enrollment;
3. prisoners;
4. infant with genetic abnormality, significant anatomic malformation, or NICU admission at time of enrollment;
5. inability to consent. If new results on the MDS or GAD-7 indicate a positive screening or the father's infant(s) is diagnosed with a genetic abnormality, significant anatomic malformation, or NICU admission after the enrollment and randomization period, the father will still be eligible to continue participation in the study. This information will be tracked in the REDCap database.