Introduction
Suicide remains a leading cause of maternal mortality in the postpartum period, underscoring a pressing need for effective, evidence-based interventions tailored for perinatal women. Perinatal depression, affecting both pregnant and postpartum individuals, often coexists with suicidal ideation (SI), posing significant risks to maternal and infant health. Behavioral activation (BA) psychotherapy, a structured intervention focusing on increasing engagement with rewarding and meaningful activities, has emerged as a promising treatment for depression, but its impact on perinatal suicide ideation requires further elucidation.
Study Background
The SUMMIT (Scaling Up Maternal Mental Health Care by Increasing Access to Treatment) trial was designed to evaluate the effectiveness and scalability of brief BA delivered by different clinician types and through varied modalities to pregnant and postpartum adults with elevated depressive symptoms. Given the grave consequences of perinatal suicide, understanding whether BA can mitigate SI across diverse clinical settings is critical for expanding mental health care access during this vulnerable period.
Study Design and Methods
This secondary analysis utilized data from a large, multisite, noninferiority, randomized clinical trial conducted between January 2020 and October 2023 across university-affiliated networks in Chicago, Illinois; Chapel Hill, North Carolina; and Toronto, Canada. Participants included 1230 pregnant (≤36 weeks gestation) and postpartum (4-30 weeks) adults presenting with depressive symptoms, quantified by an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or greater.
Participants were randomized across four arms: clinician type (nonspecialist vs. specialist) and modality (telemedicine vs. in-person) for delivering a manualized 6- to 8-session weekly BA intervention. The primary outcome was suicidal ideation, assessed using EPDS item 10 weekly during treatment and at 3 months postrandomization. Endorsements of SI prompted further evaluation with the Columbia Suicide Severity Rating Scale (C-SSRS) for safety monitoring. Statistical analysis involved cumulative link mixed models to examine SI trends over time and the effects of clinician and modality types.
Key Findings
Out of 1117 participants who completed at least one treatment session and provided follow-up data, 264 (23.6%) endorsed SI during the treatment course. The mean participant age was 33.4 years. Statistical modeling revealed a significant reduction in the odds of endorsing SI by 25% per successive BA session (OR 0.75, 95% CI 0.58-0.96, P = .03). At 3 months postrandomization, the odds of SI endorsement decreased markedly by 80% compared to any point during treatment (OR 0.20, 95% CI 0.14-0.27, P < .001).
Importantly, no significant differences in SI reduction were observed based on clinician type—whether nonspecialists or specialists delivered the intervention—or treatment modality—telemedicine versus in-person sessions. Goodness-of-fit chi-square tests further established that participants were more likely to endorse SI at treatment onset on the C-SSRS, with substantial improvements seen thereafter.
Expert Commentary
This robust analysis from a large, diverse cohort offers compelling evidence that brief BA psychotherapy is effective in reducing suicidal ideation among perinatal individuals with depression. Notably, the comparable outcomes across nonspecialist and specialist clinicians and telehealth versus in-person delivery speak to BA’s scalability and adaptability—traits essential for addressing disparities and access barriers in perinatal mental health care.
The findings align with theoretical models positing that behavioral activation mitigates depressive symptoms and suicidal thoughts by re-engaging patients in positively reinforcing activities, thereby disrupting negative cognitive-emotional cycles. The durability of SI reduction up to 3 months post-treatment reinforces BA’s potential for lasting benefit.
Limitations include the secondary nature of the analysis, reliance on self-reported SI with EPDS item 10, and potential selection bias given participants’ willingness to enroll in psychotherapy trials. Further research might explore long-term outcomes past three months, integration with other suicide prevention strategies, and implementation in broader community settings.
Conclusion
The SUMMIT trial’s secondary analysis demonstrates that brief behavioral activation psychotherapy significantly reduces suicide ideation in perinatal adults with depression, irrespective of clinician expertise or mode of delivery. These findings advocate for the integration of scalable BA interventions into maternal mental health services to enhance suicide prevention efforts during pregnancy and postpartum. Future directions may focus on policy implementation, training of nonspecialist providers, and dissemination strategies to expand reach.
Funding and Trial Registration
This research was supported by institutional and external funding bodies as per the original SUMMIT trial protocol. The study is registered at ClinicalTrials.gov with identifier NCT04153864.
References
Kaliush PR, Molina NC, Berenbaum TS, et al. Behavioral Activation for Perinatal Suicide Ideation: Secondary Analysis of a Noninferiority Randomized Clinical Trial. JAMA Psychiatry. 2025 Aug 20:e252116. doi: 10.1001/jamapsychiatry.2025.2116. Epub ahead of print. PMID: 40833774; PMCID: PMC12368783.
