Innovative Strategies for Improving the Care of Women at Risk of Postpartum Depression

There is considerable interest in the use of wearable tracking devices and mobile health technology to enhance clinical care and the delivery of personalized treatment for patients with mood and anxiety disorders.  Ecological momentary assessment or EMA refers to assessments which are conducted at designated times throughout the day and can be easily collected using wearable trackers and mobile devices.  Previous research indicates that this method of real-world data collection may help to reduce recall bias in reporting mood and anxiety symptoms and may give a more accurate picture of the hour-to-hour and day-to-day fluctuations in symptoms.

EMA may be active, where the user is prompted to answer specific questions about their current status, or EMA may be passive, where  information about activity level, heart rate, and sleep quality is collected by the device without prompting.  Recent studies have indicated that EMA data has the potential to predict mood and anxiety episodes in at-risk individuals; however, the use of EMA in pregnant and postpartum women has not yet been assessed.  

In 2016, the app, PPD ACT (now called Mom Genes Fight PPD), was released in order to rapidly and efficiently recruit, screen and enable DNA collection from women with a lifetime history of postpartum depression (PPD).  In an effort to increase engagement with the PPD ACT app, an Apple Watch module was created which would allow for daily tracking of mood, anxiety, sleep quality, and exercise.  

During the COVID-19 pandemic, a pilot study was carried out to determine if this app could be used to more closely track symptoms in  women at risk for PPD.  Apple watches were donated by Apple, Inc. and were loaned to participants for the 6-week duration of the study.  Participants completed three in-person research visits and questionnaires assessing depression, anxiety, and maternal functioning.  In addition, participants provided daily self-reported ratings of symptoms and passively collected physiological data via the Apple Watch (heart rate, activity level, and sleep quality).

Of the 26 women enrolled, 23 (88%) completed the 6-week study. On average, the participants completed 67% of all active daily assessments and 74% of all passive measures.  EMA ratings of mood and anxiety collected using the Apple watch between clinical appointments correlated with and were predictive of scores on validated scales for mood and anxiety, including the EPDS, PHQ-9 and GAD-7.  (This report did not include information on the predictive value of passively collected EMA data.)

Moving Forward

The results of this pilot study are promising and suggest that EMA tracking could be useful in assessing symptoms of depression and anxiety during the postpartum period.  One of the limitations of this study is that it was conducted in women who had a history of PPD and all but one of the women were in treatment.  Would this strategy be as successful in monitoring symptoms in women with no history of depression or anxiety?  Furthermore, could the information gathered by the device be used to encourage women with significant symptoms to pursue treatment?

Feedback from the clinicians involved in this study was positive and suggested that the EMA tracking could be used to signal both patients and clinicians to worsening of mood or anxiety, prompting changes in the treatment plan.  This type of monitoring could help to determine when appointments are needed and could serve as an additional safety check for postpartum women in between scheduled appointments. In addition, clinicians observed that EMA tracking appeared to increase participants’ insight into their mental health status and to improve their engagement in and discussion of treatment.

Although this study indicates that EMA tracking was feasible over the course of the 6-week study, it is unclear for how this monitoring would be acceptable and feasible.  Other studies indicate that engagement with apps and mobile monitoring drops significantly over time; however, given that women completed two-thirds of the assessments during the first six weeks postpartum, a time when the risk of postpartum psychiatric illness is the highest, this sort of monitoring would give us an opportunity to identify many, or even most , of the women with more significant postpartum illness. 

Ruta Nonacs, MD PhD

Krohn H, Guintivano J, Frische R, Steed J, Rackers H, Meltzer-Brody S.  App-Based Ecological Momentary Assessment to Enhance Clinical Care for Postpartum Depression: Pilot Acceptability Study.  JMIR Form Res. 2022 Mar 23;6(3):e28081. Free article.