Mood changes during and after pregnancy are common although they do not always result in clinically significant depressive episodes. However, both severe and the moderate/milder forms of depression during the perinatal period and postnatal can be a source of major problems to mothers, their babies, and even other family members. Symptoms of postpartum depression (PPD) include, but are not limited to, concentration difficulties, poor sleep, heightened anxiety, feelings of inadequacy, ruminative fears and compulsive thoughts, loss of attachment sentiments, and guilt feelings [1]. The physiological effects of prenatal depression such as elevated cortisol can adversely affect the baby’s development and result in negative consequences that remain undetected into adulthood [2].

The costs of PPD, both for the mother and her child, are concerning, especially since the incidence of PPD reaches 7.1% in the United States (US) and is as high as 19.2% when minor depressive episodes are included [3]. It is estimated that the global incidence of PPD is even higher than within the United States [4], suggesting a pressing global health concern for women and their children. Additionally, there is research that demonstrates a relationship between lower income areas and higher PPD prevalence [5], demonstrating that communities who already lack access to adequate health and mental health resources are further affected by untreated PPD in their communities.

Even though the human and financial costs of untreated PPD are well-established, adequate resources to address the global need of women suffering from PPD or who are at risk of developing PPD do not yet exist. Presently, the first line of psychological treatment for PPD is cognitive behavioral therapy (CBT). However, in a review of five randomized controlled trials (RCTs) comparing CBT with standard postpartum care, only two trials demonstrated better outcomes in the CBT group [6]. While preliminary Interpersonal Therapy (IPT), with a focus on handling the interpersonal disputes that occur during childbirth and childcare, has shown some promise in addressing this pressing need [7]. The first line of treatment for PPD continues to be medication [8], particularly selective serotonin reuptake inhibitors (SSRIs), which show some level of efficacy and perform equal to psychotherapy in randomized trials [8,9]. However, there are concerns regarding the safety of antidepressants for pregnant and nursing women [10].

There are many practical limitations to treatment seeking, not least being the availability of appropriately qualified therapists. In addition, issues such as stigma, childcare difficulties, lack of knowledge, and financial constraints can inhibit help seeking [11]. As such, psychological resources that do not require women to leave their homes may allow for more women to participate in psychological interventions. In general, Internet interventions can be private and used anonymously, accessed repeatedly at any time, and from any location, and Internet interventions may provide a much-needed service to users who feel marginalized or stigmatized [12]. Clatworthy’s [13] meta-analysis did not find a relationship between the length of an in-person preventative intervention and its effectiveness, suggesting that increasing the length of psychological interventions is not an important factor in enhancing benefit. However, there is research to show that interventions based on psychological models tend to be more effective than interventions that are not based on these models [13], meaning that researchers seeking to create new resources for women should maintain fidelity to empirically supported psychological models.

As a result of the limitations that preclude many women from seeking in-person resources, Internet interventions offer promise in providing care with less financial and practical barriers. Additionally, Internet interventions can be used as adjuncts to in-person treatments or replacements in other cases [14], and perhaps offer even more promise for reducing health disparities. Nonconsumable interventions, or those that can be reused with minimal cost for each additional participant, can help to close the gap in services through offering assistance without needing the support of a clinician or operator on the other end [15]. Currently, there is a dearth of research on Internet interventions for perinatal women or to address PPD [16].

Importantly, over the last 20 years different psychotherapies have been developed that are increasingly rooted in the scientific understanding of psychological processes, including those associated with attachment. For example, compassion focused therapy (CFT) is based on evolutionary insights of brain function, particularly the importance of building and developing affiliative and prosocial relationships with self and other [17,18]. This model in particular articulates the role of affiliative emotion and motivation in threat regulation and how these can be cultivated through (1) addressing issues of self-criticism and shame and (2) with affiliation building exercises (compassion cultivation). This is important because at the heart of many depression difficulties is a harshly self-critical relationship with the self and at times nonaffiliative relations with self and with others. In addition, helping to build affiliative relationships between mothers and their babies is obviously important. There is now considerable evidence that compassion cultivation has an impact on a range of physiological systems including the immune system, frontal cortex, and cardiovascular systems [19]. It also promotes prosocial and empathic behavior [20]. This makes compassion cultivation an especially important focus for intervention for this population.

The present study therefore seeks to assess the efficacy of an Internet-based Compassionate Mind Training (CMT) program, the intervention component of CFT, compared to a standard CBT program in a sample of childbearing and perinatal women. As there is currently a lack of Internet interventions for maternal mental health, the research team intends to assess the relative efficacy of CMT as a resource for women during this period.

It is expected that participants randomized to both Internet-based CMT and CBT will demonstrate improved affect as well as reduced depression and anxiety at similar, if not better, levels which are the secondary outcome measures of this trial. However, in terms of the primary outcome measures, we expect that Internet-based CMT will provide unique benefit above and beyond CBT in the constructs of self-reassurance, self-criticizing, self-attacking, and self-compassion, as CMT is specifically targeted towards these constructs.

The present study has the aim to assess relative efficacy of Internet-based CMT compared to CBT for perinatal women through conducting a randomized controlled trial. While there is currently some research to support Internet-based CBT for perinatal women [30-32], there is still a clear need for additional Internet-based psychological resources for this vulnerable population. As such, research into additional Internet-based psychological programs for perinatal women is important to meet this need.

Trial status: as of April 2015, participants were being enrolled in the study. Participants were recruited continuously throughout the enrollment period. Recruitment ended in September 2015.

The current study is a two condition randomized controlled trial comparing brief Internet-based CBT and CMT in enhancing the well-being of perinatal women and women with future intentions of pregnancy. As far as the research team is aware, this is the first trial to assess the relative efficacy of an automated compassion meditation program to a CBT program for working with current and future perinatal women over the Internet. The results are expected to impact the future direction of Internet interventions for perinatal women. It is important to note that the trial is not recruiting women based on depression status, but rather a sample of general population perinatal women. As such, the research team will be unable to make decisive conclusions about the treatment effectiveness of the CMT course based on results from this trial. However, upon completion of this preliminary study, future studies will employ a prevention model approach in order to assess the preventative effectiveness of CMT with respect to PPD development among women in their second and third trimesters. Participant feedback from the current study will allow the research team to update the CMT course material in order to better meet the needs of the target population in phase two of the trial. Finally, and with the intention to make the resources widely available to a global population of women, the research team hopes to translate the study materials into additional languages in order to better serve a more diverse group of perinatal women.

The more that is known about differential effects of Internet interventions, the more researchers can start to tailor certain Internet interventions towards the population that is likely to show benefit from that particular content. To this end, in addition to examining the primary and secondary outcomes of this current pilot study, the research team aims to explore several additional questions. For example, perhaps some groups within the included sample of this study will benefit more from utilizing one condition relative to the other. Alternatively, perhaps the data may indicate that women from certain parts of the world respond better to one condition of the intervention relative to the other. Finally, perhaps the effectiveness of each condition of the intervention will be moderated by the levels of depression the woman are currently experiencing at study entry or the demographics of those women. These are all possible avenues for exploration that the research team will aim to examine once all data have been collected for this pilot trial. The long-term goal for this line of research will be to contribute to the psychological community’s understanding of how best to create and disseminate Internet interventions that are targeted towards women who may benefit from them the most.

In addition to the important implications that exist, there are also several limitations to the current study. First, since the majority of recruitment is being conducted using the MTurk system, we lack the capacity to verify the demographics of the individuals who take part in the study. While this is a known issue for MTurk [33], there is evidence to support that running research with an MTurk sample tends to produce near equivalent results as trials conducted in a laboratory setting [34]. Additionally, MTurk workers tend to be more demographically diverse than standard Internet samples and college students that comprise samples of many trials [34], which is a strength to using MTurk as a recruitment tool.

MTurk workers received compensation when they completed post course data at two weeks. There is an inherent limitation with a highly motivated sample of women who will receive compensation for completing post course data in order to receive payment for their participation. Internet-based research has a high level of attrition [35], and thus the completion rates witnessed with an MTurk sample are unlikely to be generalizable to a broader group of international perinatal women. As such, it is impossible to know what actual attrition rates would be in a non-MTurk group of women if the majority of recruitments comes from this source.

Perhaps the most important and glaring limitation of the current trial is the lack of a more distal time point for measurement of outcome variables. The limited follow-up with participants, only occurring at two weeks post course, does not allow the team to make inferences about the longer-term maintenance of improvements in either condition. As the ultimate goal of psychological Internet interventions is to decrease suffering on a global scale, knowledge of longer-term utility of these resources is crucial. In order to account for this limitation during future research along this same line, we will add another follow-up after pregnancy, which can be up to six months after providing baseline data.