Introduction
Perinatal depression, which encompasses severe or mild depressive episodes that occur during pregnancy and postpartum, is one of the most common medical complications [
1]. It is reported to occur in 1 in 7 women worldwide [
1] and thoughts of intentional harm to themselves or their babies accompany the typical symptoms of depression [
2]. Perinatal depression is regarded as a major public health challenge because if left untreated, it can incur major losses and expenses for not only the affected women but also their families and the communities [
3].
Since perinatal depression occurs during pregnancy or the first 12 months after delivery [
1] and postpartum depression (PPD) develops during or after pregnancy [
4], early management of depression during pregnancy is of the utmost importance. To detect depression in its early stages, pregnant women are recommended to receive screening for depression throughout pregnancy, and those who are at high risk for depression or experience suicidal thoughts are closely monitored [
1]. However, even women who receive scores exceeding the threshold for depression in a screening test often do not receive active treatment due to the lack of time, limited access to medical services (in terms of time, location, and transportation), stigma related to psychiatric treatment, and a lack of awareness of the need for mental health management [
4].
Individuals vulnerable to depression have dysfunctional attitudes toward themselves, the world, and the future, and they can have automatic thoughts and cognitive errors [
5]. Dysfunctional attitudes and irrational beliefs based on past experiences lead to the deployment of selective attention to external stimuli [
5] and distorted patterns of responses to feedback [
6]. Automatic thoughts refer to a pattern of thinking that recurs in connection with specific situations and is activated by dysfunctional beliefs [
5]. In a qualitative study on the experience of depression, pregnant women had distorted perceptions of reality in relation to childhood experiences or negative situations, and they lost control of their emotions due to the recurrence of negative thoughts [
7].
Cognitive behavioral therapy (CBT) is effective for changing irrational, distorted thoughts into rational thoughts and reducing negative automatic thoughts [
8]. It is also a type of psychotherapy that helps people learn to understand and correct destructive and distorted thinking patterns that negatively affect emotions and behaviors [
9]. According to Beck’s cognitive theory [
10], since an individual’s thinking or cognition determines his or her emotions and behaviors, a cognitive approach to cognitive biases or erroneous beliefs can achieve new adaptive thoughts and behavior changes. In other words, CBT can be expected to bring about changes in emotions and behaviors through changes in negative thinking, such as dysfunctional attitudes and automatic thoughts. Changes in thoughts shift individuals’ core beliefs and dysfunctional beliefs derived from automatic thoughts, thereby playing an important role in preventing depression [
11]. Likewise, depression, automatic thoughts, and dysfunctional attitudes are closely related, making it necessary to verify them as variables affected by CBT aiming to reduce depression.
In CBT, feedback and communication between the therapist and the client are important; thus, the coronavirus disease 2019 (COVID-19) pandemic has made the application of face-to-face CBT difficult. However, online CBT is advantageous insofar as it enables interventions involving interactions between the therapist and the client without restrictions on time and place [
12]. Compared to individual treatment, group CBT is more efficient in terms of time and cost, since it provides the benefits of treatment to many people [
12] and is effective at alleviating negative psychological effects such as depression, automatic thoughts [
8], emotion regulation [
9], and anxiety [
12]. Furthermore, the ability of video communication to enable real-time communication among users and immediate feedback is expected to augment the effect of therapeutic interventions in CBT.
Previous international studies have demonstrated that CBT reduces depression in pregnant women [
13-
15] and that online CBT is effective [
16,
17]. In South Korea, however, there is a paucity of research on interventions using CBT, although there are reports on prenatal education programs with spouse participation [
18] and PPD counseling programs for husbands [
19].
This study aimed to develop a video communication-based group CBT program to reduce depression during pregnancy and to verify its effectiveness. The specific objectives were as follows. First, to develop a video communication-based group CBT program for pregnant women with depressed mood. Second, to investigate the effectiveness of the video communication-based group CBT program by applying it to depressed pregnant women. Third, to identify the correlations between automatic thoughts, dysfunctional attitudes, and depression in depressed pregnant women.
This study had the following hypotheses.
• Hypothesis 1. There will be differences in depression among pregnant women before and after participating in the video communication-based group CBT program.
• Hypothesis 2. There will be differences in the automatic thoughts of pregnant women before and after participating in the video communication-based group CBT program.
• Hypothesis 3. There will be differences in dysfunctional attitudes of pregnant women before and after participating in the video communication-based group CBT program.
• Hypothesis 4. There will be significant correlations between automatic thoughts, dysfunctional attitudes, and depression in depressed pregnant women.
Discussion
The purpose of this study was to develop a video communication-based group CBT program for reducing depression in pregnant women and to verify the effects of the program on depression, automatic thoughts, and dysfunctional attitudes after participation in the program. Referring to the elements of cognitive therapy, we designed the program to have the following therapeutic elements: exploration of automatic thoughts and core beliefs in daily life and pregnancy situations, identification of stress, self-reflection, emotion control training, and exploration of problem-solving methods.
Depression significantly decreased after the intervention. Although a direct comparison is difficult due to the absence of previous studies including a single group, a comparable finding was reported in a study where CBT treatment improved depressive symptoms in pregnant women more effectively than conventional treatment [
13]. In an overseas study that applied a 1-hour online video CBT for 13 weeks, patients’ depression level was significantly reduced from moderate to low [
27]. Real-time CBT can be expected to effectively reduce depression by identifying unrealistic or erroneous expectations among depressed subjects and by managing their expectations through explorations of possible problems that can occur if expectations are not managed [
28]. This study’s decrease in depression score from moderate to low after the intervention may be related to participants developing the will to resolve depression on their own by recognizing their emotions and thoughts and confronting depression through the program. Our interpretation is supported by the results of Kwon and Lee [
11], who reported that depression could be reduced through CBT, which changed individuals’ negative thinking systems by enabling them to examine and verify their thoughts. Since both cognition and behavior are closely related to mood [
2], if it is possible to separate emotions through CBT, depressive emotions could be reduced by detecting errors and changing thoughts. In particular, it was possible to establish a good cooperative relationship for treatment through real-time video communication [
28], and a possible reason why depression was reduced may have been that the participants felt empathy and comfort while sharing their pain and conflicts related to pregnancy. Early detection and treatment of depression during pregnancy are vital to prevent PPD [
2]. Screening pregnant women at high risk of depression and providing them with a video communication CBT program could reduce depression during pregnancy, thereby preventing a transition to PPD. An EPDS tool effective for screening PPD should be used at antenatal visits to keep the level of depression in pregnant women in check, and CBT experts should be systematically trained and dispatched to adjacent obstetrics and gynecology clinics. In addition, it is necessary to encourage social awareness that depressive symptoms can frequently occur in pregnant women, that treatment is possible, and that pregnant women should seek out treatment for depression if necessary.
Automatic thoughts were significantly reduced after the intervention using the video communication-based group CBT program compared to before the intervention. In a prior study of low-income children and adolescents [
8], a CBT program also reduced negative automatic thoughts, and the effect remained present at 8 weeks after the intervention. Examining cognitive errors reflected in automatic thoughts is a very effective way to change automatic thoughts [
29], which makes it possible to achieve the ultimate goal of CBT for depression. In order to reduce automatic thoughts, we designed our program to include exercises for locating cognitive errors by exploring the automatic thoughts felt in negative situations and for changing thoughts and emotions in a stepwise manner. In addition, video communication may have facilitated the detection of automatic thoughts and errors through the interactive exchange of opinions or feedback between the researchers and the participants.
Dysfunctional attitudes were significantly reduced after the intervention, which in is line with a prior study testing CBT for adolescents by Jeong and Kim [
29], dysfunctional attitude scores significantly decreased after the intervention. People with depressive disorder have negative views about incidents in daily life, and the purpose of treatment for depression in CBT is to help clients process information in a rational way [
6]. This change in dysfunctional beliefs helps people better cope with negative life incidents, thereby lowering the recurrence of depression even after treatment [
25]. However, in the study of Jo and Son [
30] that investigated the effect of a group CBT program for college students (twice a week, 90 minutes per session, for a total of 12 times), there was no significant difference in dysfunctional attitude scores before and after the intervention, contrary to the result of our study. As the latter study [
30] CBT program was applied to participants who had job stress scores and dysfunctional attitude scores in the top 25%, the difference in job-related situations among the participants, negative beliefs or their coping methods might have been difficult to identify. In our program participants were more homogeneous, e.g., had depressive mood and were coping with the same pregnancy-related situations, and thus, could share their problem recognition and problem-solving methods. We believe this may have helped them become aware of their own attitudes that interfered with problem-solving when they had difficulty in adjusting to pregnancy and dealing with uncomfortable situations, thereby reducing dysfunctional attitudes.
Depression showed a significant positive strong correlation with automatic thoughts and dysfunctional attitudes. Higher levels of depression were associated with higher levels of automatic thoughts and dysfunctional attitudes, which are factors that influence the onset of depression [
11]. In addition, negative thoughts are related to depressive mood and act as a vulnerability factor for the onset of depression [
11]; therefore, negative thoughts are considered to have a proportional relationship with depression. Dysfunctional attitudes showed a significant positive correlation with automatic thoughts. Since automatic thinking is one of the characteristics of dysfunctional thinking [
11], the close correlation is logical. However, since a moderate or higher correlation was noted for automatic thoughts and dysfunctional attitudes, it may be difficult to isolate the effect of each variable completely, undermining the accuracy of the results.
The main limitation of this study is that it is difficult to generalize its results, since the study contained only an experimental group, without a control group, and the sample size was small due to the difficulty of recruiting study participants. In addition, although participants were at different stages of pregnancy, it was not possible to investigate aspects of negative psychology according to pregnancy stage; and in some cases online access for video communication was not smooth. However, as a preliminary study, it offers information for utilizing a group video communication CBT program for pregnant women with depressed mood in the future. Strategic planning for targeted recruitment, and ensuring online connection may be needed. Furthermore, to confirm the lasting effects of the program, future research needs to consider longitudinal changes in depression and the characteristics of each pregnancy period.
In conclusion, this nurse-led eight-session group CBT program for pregnant women with depressed mood via video communication appeared to be helpful in reducing levels of depression, automatic thought, and dysfunctional attitude after 4 weeks. The significant changes in main variables noted after the program may be attributed to the formation of trust between the therapist and group members through video communication, which facilitated self-disclosure. This pilot study also it demonstrated the feasibility and applicability of an online-based group CBT program format, in that the participants were able to reveal their faces to other pregnant peers and immerse themselves in the program. The group activities involving pregnancy context helped the participants obtain empathy and comfort from other participants who were in the same situation, which may have buffered their negative psychology about pregnancy and childbirth. This study has potential for alleviating prenatal depression and preventing PPD, especially when activities for pregnant women are socially limited, e.g., due to the ongoing COVID-19 pandemic, and should be further examined in future studies.