Young women with depression experience a higher rate of unintended pregnancy and sexually transmitted infections (STIs) than young women, in general.1 The challenge for family planning clinicians is to find an effective intervention to help them prevent pregnancy and maintain their health.

Results of one study revealed that an intervention using counseling and mobile health can reduce the risk of both pregnancy and STIs.1

“We developed this intervention, which involves a counseling session in a clinical setting and four weeks of receiving prompts to take brief surveys on a personal smartphone,” says Lydia Shrier, MD, MPH, director of research in the division of adolescent/young adult medicine at Boston Children’s Hospital.

The intervention also includes a booster session after four weeks. This session features the original counselor in the clinic in which the original counseling session took place, or held via video call, she adds.

At a three-month follow-up vs. baseline, investigators found participants reported lower frequency of sex, lower proportion of condom-unprotected sex events, and more consistent condom use among those who were using effective contraception.1

“We saw a decline in depressive symptoms over three months. While we can’t attribute that decline to anything we did, it could have been a natural course of events for the participants,” Shrier says. “We were certainly glad to see that.”

The participants also demonstrated improvement in depressive conditions after three months. They showed more confidence in using cognitive restructuring.1

The study enrolled young women at high risk of sexual behavior and featured a pilot intervention. The participants were engaged with the intervention and found it helpful, Shrier says.

“Part of the intervention is delivered through a smartphone,” she says.

The intervention can be translated, partially, to a remote platform, which would prove important during the COVID-19 pandemic, Shrier notes.

“We lose a little something when we’re not in person,” she adds. “In this case, the intervention hinges on the counselor developing rapport with the young woman, and that hinges on an in-person meeting.”

Shrier and co-investigators hope to receive funding for a larger feasibility trial. They also plan to produce an intervention that can be widely replicated.

“The timing of our larger feasibility trial would be in the fall when we hope we’re back to providing in-person care in some form,” Shrier says. “There is only so much people can do remotely. My hope is we’ll eventually return to live care, and we wouldn’t start recruitment until the fall — if we’re fortunate enough to be funded this summer.”

Teach Participants Cognitive Restructuring

The intervention’s target population of young women is based on the researchers’ clinical experience with that population, which experiences a high prevalence of sexual risk behaviors, she notes.

“The highest rates of STIs are seen in young adult women,” Shrier says. “We know that adolescent and young adult women experience very high rates of depression. That doesn’t mean all those things overlap, but there is a lot of evidence that they do.”

When young adult women experience depression, they are more likely to experience difficulty with social communication. They may have substance abuse issues that affect their decision-making ability, she says.

“They can have cognitive difficulties — a foggy brain, distortions about information that they’re receiving in their environment, and problems with risk perception and information processing,” Shrier says.

Young women with depression also experience more partner violence than women who are not depressed. “They have more problems negotiating condom use than other women, and they may be ambivalent about taking steps to prevent pregnancy,” Shrier explains. “Pregnancy is a very meaningful and normal, healthy event in a woman’s reproductive life under the right circumstances. But when a woman is struggling with depression, she may be of two minds about whether a pregnancy at this time in her life is good for her.”

Young adult and adolescent women with depression also are more likely to have sex with multiple partners and to have sex under the influence of substances.1,2 They are less likely to use long-acting, reversible contraception (LARC), which would be more effective for them.1

The intervention’s counseling sessions are designed to be in the context of sexual reproductive health counseling, but they specifically acknowledge the role that depression may be playing in a woman’s health and decision-making, Shrier says.

“One of the main skills we teach is cognitive restructuring from cognitive behavioral therapy,” she explains. “It’s the process of learning to identify and challenge negative thoughts and depression and to change your own thinking to be more positive, which can improve your mood.”

Counseling sessions, which were administered to females with depressive symptoms, ages 15 to 23 years, consisted of an in-person or video call session. One investigator conducted the session, while another investigator observed the sessions and took field notes. The counselor met with each participant a second time to review the changes and solicit feedback, assessing whether the participant’s specific concerns, comments, and recommendations were addressed.1

Cognitive restructuring also can improve decision-making. “If a young woman is having negative thoughts about herself, and she thinks she is not worthy because of something that happened that day, then she does not feel she deserves to be healthy and she will not advocate for her own sexual relationship,” Shrier says. “If she doesn’t want to have sex, she might not be able to say, ‘No, I don’t want to have sex.’”

It also can be difficult for the young woman to ask her partner to use a condom, to schedule an appointment for contraception, or to take a contraceptive pill each day.

When these young women learn cognitive restructuring skills, they learn to think about things in a different way. This helps them live a healthier life. It teaches them to think of themselves as worthy to take self-care steps, Shrier says.

“We teach these skills through education, examples, and practice, prompted by the smartphone,” she explains. “The part about the smartphone is based on what young women say in their survey.”

Their messages are designed by their own responses about what they want these messages to be. For example, women can select messages that are in the first person, using the word, “I,” or in the second person, using the word, “you.” They can select messages that are more encouraging and validating, and there are different styles of messages to choose, Shrier says.

“If a woman says she is really sad, she might get a message that encourages her to look at positive things in her life or to do things that help her feel good,” she says. “The messages can provide reminders that she is valuable, that she is worthy — depending on what she said in the survey.”

The messages continually encourage women to use the cognitive restructuring skills they learned. “We found in the pilot study that the young women who participated felt more confident in their ability to do that skill, and reported using that skill,” Shrier says. “All but one woman, who reported on the smartphone, had used the skill at least once. Many used it on more than one day.”

Women are taught to understand their own needs. “We assess their desire to have sex for mood-related reasons,” Shrier says. “People may be less safe in their choices if they are seeking out sexual encounters to feel valued or to feel loved; they might make compromises with themselves about partner choices or the use of contraception.”

The counseling sessions are designed to assess women’s confidence in using condoms and contraception. They focus on the interplay between depression and sexual risk, and also use motivational interviewing techniques, she says.

“Motivational interviewing may be very helpful in pregnancy- and disease-prevention interventions,” Shrier says. “In counseling, the young woman and counselor are identifying what type of behavior she wants to change. She develops a plan for change with the counselor.”

The counselor can be someone who regularly counsels on sexual and reproductive health. For the pilot study, counselors include a registered nurse and family nurse practitioner, but they could include someone with a master’s degree in social work who also performs case management, Shrier says.

One of the challenges — and the strengths — of the intervention is that it crosses areas of health, combining sexual and reproductive health with mental health.

“Finding people who have comfort with how to manage both of those areas, or at least be willing to learn both, is definitely a challenge,” Shrier says. “It takes a special person to do that. To help with that, we’ve made a manual of the counseling sessions, so someone could read the manual and deliver the intervention.”

The goal is to make the intervention widely available, Shrier says.

“We would only want to offer something to scale if we were really confident it would help people and if we had a robust understanding of risk and mitigation plans,” she adds.

REFERENCES

  1. Shrier LA, Burke PJ, Parker S, et al. Development and pilot testing of a counseling-plus-mHealth intervention to reduce risk for pregnancy and sexually transmitted infection in young women with depression. Mhealth 2020;6:17.
  2. Lehrer JA, Shrier LA, Gortmaker S, et al. Depressive symptoms as a longitudinal predictor of sexual risk behaviors among US middle and high school students. Pediatrics 2006;118:189-200.