Mamma Mia - an internet intervention for preventing and reducing perinatal depressive symptoms: A multi-site cluster-randomized trial.

An internet intervention for preventing post-partum depression Web-based interventions can be as effective as face-to-face treatment when used in combination with guidance by health professionals. Such interventions can be particularly valuable to those who are reluctant to seek treatment due to perceived stigma, or who for other reasons have difficulties meeting in person. Mamma Mia Mamma Mia is an internet intervention intended to prevent postpartum depression. It provides the mother with guidance and support on the path to becoming a mom and follows the pregnant woman from the 21st week of pregnancy until the child is six months old. Women complete questions regarding symptoms of depression seven times during the intervention, and receive customized feedback based on their replies. They also receive information on where they can get more assistance if necessary. Quick assistance is important, as untreated depression in some cases can affect the interaction with the child. In a study of Mamma Mia, results showed that women who used Mamma Mia had somewhat fewer symptoms of depression and enhanced subjective well-being, compared those who did not. The effect was largest for those who had the highest initial depressive scores. These women were also more prone to drop-out of the study. Based on results from other studies, it is likely the effect would be even greater if Mamma Mia had been combined with the guidance of a health professional. It is also likely that fewer would drop out. Mamma Mia with guidance In the present study, we will systematically implement and evaluate Mamma Mia with-, and without guidance from well-baby clinics in municipalities where «Early In» has been implemented. Early in is a training program for health care personnel tasked with early intervention and prevention of mental illness, substance abuse and domestic violence among pregnant women and parents with young children. The present study will yield valuable information about the characteristics of women who require guidance in order to benefit from Mamma Mia, as well as the amount of guidance and resources needed to achieve a meaningful effect on depressive symptoms. We have have recruited 31 municipalities from across Norway to take part in the study. The municipalities have been randomized to either Mamma Mia with guidance og Mamma Mia as self-help. All the municipalities that will provide Mamma Mia with guidance have completed their training and are in the process of providing Mamma Mia with guidance. Useful and economical for society Mamma Mia is now to be further developed and improved in collaboration with an American research group. The overall goal for this cooperative project will be to test the effect of Mamma Mia in combination with guidance from a midwife or public health nurse. If the results of the study are positive, Mamma Mia may spare society of major health expenses, and will be a useful aid for health professionals working with families during pregnancy and the postnatal period.

Despite high prevalence, perinatal depression is often undetected and untreated. Mamma Mia is a universal preventive internet-based program for perinatal depression and a recent RCT demonstrated its effectiveness (Haga et al., 2018). Interviews with 65 users showed that many wanted Mamma Mia to be integrated in ordinary care (Drozd et al., 2017). Moreover, internet-based programs, guided by persons with lived experience or health personnel, have shown promising results for depression, with effect sizes equivalent to those of face-to-face treatment (Cuijpers et al., 2010). Consequently, clinical and implementation guidelines for a blended care model (Mamma Mia with guidance) that includes up to 5 contact points with practitioners in well-baby clinics were designed (Drozd et al, 2017). Hence, the overall aim of the current project is to test the effectiveness and implementation of Mamma Mia with guidance compared to unguided Mamma Mia and usual care on perinatal depression. As the effectiveness of unguided Mamma Mia vs. usual care already has been evaluated in Norway, the primary aims of the Norwegian study-arm are to 1) compare the effectiveness of the blended care model of Mamma Mia in a primary care setting on perinatal depressive symptoms, and assess 2) if guidance can reduce drop-out among those with higher depressive scores and lower education, compared to the unguided intervention. Secondary aims are to assess the implementation in terms of reported use of the program, adherence to guidelines among health personnel, and barriers/facilitators to implementation. An important R&D challenge is to successfully implement Mamma Mia in health services, which is why we will redeem personnel to work locally with the services. Cooperation with our US partners enables continued development of Mamma Mia, and allow evaluation in more diverse populations. This project will contribute substantially to improve women’s mental health and well-being in a public health perspective.