Effectiveness of digital psychotherapeutic intervention among perinatal women: A systematic review and meta-analysis of randomized controlled trials

doi:10.5498/wjp.v11.i4.133

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World Journal of Psychiatry

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Meta-Analysis

World J Psychiatr. Apr 19, 2021; 11(4): 133-152
Published online Apr 19, 2021. doi: 10.5498/wjp.v11.i4.133

Table 1 Characteristics of selected 25 randomised controlled trials

Ref.	Country/setting	Design	Population (nature)	Age (mean ± SD)	Intervention (name)	Comparator	Sample size	Outcome (Measures)	Attrition rate (%)	ITT/MDM	Protocol/registry	Grant
Barrera et al[61], 2015	23 countries/Community	2-arm RCT	Antenatal (mixed trimesters)	30.2 ± 5.6	Mood management internet intervention (Curso Internet de Mamás y Bebés)	Placebo (Information only)	I: 57; C: 54	Depression symptoms (CES-D)	66.1%	No/No	No/No	Yes
Duffecy et al[62], 2019	United States/Community	2-arm RCT	Antenatal (20–28 wk)	30.5 ± 4.1	Share (group) condition (Sunnyside)	Placebo (individual) condition	I: 18; C: 7	Depression symptoms (PHQ-8 and HDRS)	28%	No/No	No/Yes	Yes
Felder et al[63], 2020	United States/Community	2-arm RCT	Antenatal (≤ 28 wk, insomnia by SCI, EPDS ≥ 15)	33.6 ± 3.7	Digital cognitive behavioural therapy for insomnia (Sleepio)	Treatment as usual	I: 105; C: 103	Depression symptoms (EPDS), Anxiety symptoms (GAD-7)	11.1 %	Yes/No	No/Yes	Yes
Fonseca et al[64], 2019	Portugal /Community	2-arm RCT	Postnatal women (PDPI-R ≥ 5.5 or EPDS > 9	32.6 ± NR	Web-based intervention (Be a Mom)	Waitlist	I: 98; C: 96	Depression symptoms (EPDS)	24.2 %	Yes/Yes	No/Yes	Yes
Forsell et al[65], 2017	Sweden/Community	2-arm RCT	Antenatal (10-28 wk, major depression by SCID; MADRS-S: 15-35)	31.0 ± NR	Internet-delivered cognitive behaviour therapy (ICBT)	Treatment as usual	I: 22; C: 20	Depression symptoms (EPDS and MADRS-S), Anxiety symptoms (GAD-7)	7.1 %	Yes/Yes	No/Yes	Yes
Heller et al[66], 2020	Netherlands /Community	2-arm RCT	Antenatal (< 30 wk with CES-D ≥ 16, HADS-A ≥ 8)	32.0 ± NR	Internet- based problem-solving treatment (MamaKits Online)	Treatment as usual	I: 79; C: 80	Depression symptoms (EPDS and CES-D), Anxiety symptoms (HADS-A)	17.6%	Yes/Yes	Yes/Yes	Yes
Jannati et al[67], 2020	Iran/Community	3-arm RCT	Postnatal (≤ 6 mo, EPDS ≥ 13 and MINI)	27.7 ± 4.2	App-based cognitive behavioural therapy (Happy Mom)	Treatment as usual	I: 39; C: 39	Depression symptoms (EPDS)	3.9%	No/No	No/Yes	Yes
Jiao et al[68], 2019	Singapore/Hospital	3-arm RCT	Postnatal (first time mother < 6 wk)	30.7 ± NR	Web-based psychoeducational intervention (NR)	Treatment as usual	I: 68; C: 68	Depression symptoms (EPDS)	6.9%	Yes/Yes	Yes/Yes	Yes
Kalmbach et al[69], 2020	United States/Community	2-arm RCT	Antenatal (27.76 ± 0.87 wk with insomnia using ISI ≥ 10 and EPDS ≥ 19)	29.0 ± 4.2	Digital cognitive behavioural therapy for insomnia (Sleepio)	Placebo (Digital sleep education)	I: 46; C: 45	Depression symptoms (EPDS)	1.1%	Yes/Yes	No/Yes	Yes
Kersting et al[71], 2011	Germany/Community	2-arm RCT	Postnatal (loss of child with 5-43 wk)	34.3 ± 5.3	Internet-based cognitive behavioural treatment programme (NR)	Waitlist	I: 45; C: 33	Depression symptoms (GSI-D), Anxiety symptoms (GSI-A) Stress symptoms (IES)	22.9%	Yes/Yes	No/No	Yes
Kersting et al[70], 2013	Germany/Community	2-arm RCT	Postnatal (loss of child with 2-40 wk)	34.2 ± 5.2	Internet-based cognitive behavioural treatment programme (NR)	Waitlist	I: 115; C: 113	Depression symptoms (GSI-D) Anxiety symptoms (GSI-A) Stress symptoms (IES-R)	12.7%	Yes/No	No/No	Yes
King et al[85], 2009	United States/Community	2-arm RCT	Postnatal (≤ 12 mo)	32.5 ± NR	Internet-based stress management program (LivingSmart)	Face- to-Face control group	I: 28; C: 29	Depression symptoms (BDI-II), Anxiety symptoms (STAI) Stress symptoms (PSS)	33.1%	No/No	No/No	Yes
Klein et al[72], 2012	Scotland/Community	2-arm RCT	Postnatal (Miscarriage with < 24 wk)	33.0 ± 6.3	Web-based intervention (Miscarriage matters)	Treatment as usual	I: 33; C: 34	Depression symptoms (HADS-D), Anxiety symptoms (HADS-A)	35.8%	Yes/Yes	No/No	Yes
Loughnan et al[73], 2019	Australia/Community	2-arm RCT	Antenatal (13-30 wk, GAD-7 > 9 and/or PHQ-9 > 9)	31.6 ± 4.0	Internet-delivered cognitive behavioural therapy program (MUMentum Pregnancy)	Treatment as usual	I: 43; C: 44	Depression symptoms (EPDS), Anxiety symptoms (GAD-7) Stress symptoms (K-10)	11.5%	Yes/Yes	Yes/Yes	Yes
Matvienko-Sikar et al[74], 2017	Sweden/Community	3-arm RCTs	Antenatal (10-22) wk	33.8 ± 3.0	Novel positive psychological intervention (BodyScan and Reflection)	Treatment as usual	I: 32; C: 14	Depression symptoms (EPDS) Stress symptoms (PDQ)	6.5%	No/No	No/No	No
Milgrom et al[75], 2016	Australia/Community	2-arm RCT	Postnatal (< 12 mo, EPDS 11-23)	31.6 ± NR	Internet cognitive behavioural therapy (MumMoodBooster)	Treatment as usual	I: 21; C: 22	Depression symptoms (BDI-II), Anxiety symptoms (DASS-21-A), Stress symptoms (DASS-21-S)	6.9%	Yes/Yes	No/Yes	Yes
Missler et al[76], 2020	Netherlands/Community	2-arm RCT	Antenatal (26-34 wk)	32.5 ± NR	Psycho-educational Intervention (NR)	Waitlist	I: 68; C: 69	Depression symptoms (EPDS), Anxiety symptoms (HADS-A), Stress symptoms (PSI)	11.7%	Yes/Yes	Yes/Yes	Yes
Molenaar et al[77], 2020	Netherlands/Community	2-arm RCT	Antenatal (12-16 wk, depression history)	32.2 ± 4.9	Discontinuation of anti-depressants with Preventive Cognitive Therapy (STOP)	Treatment as usual	I: 24; C: 20	Depression symptoms (EPDS and HDRS), Anxiety symptoms(STAI)	13.6%	No/No	Yes/Yes	Yes
Nieminen et al[78], 2016	Sweden/Community	2-arm RCT	Postnatal (≥ 3 mo, TES ≥ 30)	34.6 ± 4.8	Internet-based trauma-focused cognitive behaviour therapy (TF-ICBT)	Waitlist	I: 28; C: 28	Depression symptoms (BDI-II and PHQ-9), Anxiety symptoms (BAI), Stress symptoms (IER-R)	9.8%	Yes/Yes	No/No	Yes
O'Mahen et al[80], 2013	United Kingdom/Community	2-arm RCT	Postnatal (< 12 mo, EPDS > 12)	32.3 ± NR	Internet-based behavioral activation (Netmums)	Treatment as usual	I: 462;C: 448	Depression symptoms (EPDS)	61%	Yes/No	No/No	Yes
O'Mahen et al[79], 2014	United Kingdom/Community	2-arm RCT	Postnatal (< 12 mo, EPDS > 12)	32.3 ± NR	Internet behavioral activation treatment (NetmumsHWD)	Treatment as usual	I: 41; C: 42	Depression symptoms (EPDS), Anxiety symptoms (GAD-7)	13.2%	Yes/Yes	No/No	Yes
Pugh et al[81], 2016	Canada/Community	2-arm RCT	Postnatal (< 12 mo, EPDS ≥ 10)	≥ 18 ± NR	Therapist assisted, Internet-delivered cognitive behavior therapy (TA-ICBT)	Waitlist	I: 25; C: 25	Depression symptoms (DASS-21-D), Anxiety symptoms (DASS-21-A), Stress symptoms (DASS-21-S)	18%	Yes/Yes	No/Yes	Yes
Scherer et al[82], 2016	Switzerland/Community	2-arm RCT	Postnatal (preterm labour with 18-32 wk)	32.7 ± 3.0	Internet-based cognitive behavioral stress management (IB-CBSM)	Placebo (Limited support)	I: 51; C: 42	Anxiety symptoms (STAI-S), Stress symptoms (PSS)	37.6%	No/No	No/Yes	Yes
Urech et al[83], 2018	Switzerland/Community	2-arm RCT	Postnatal (preterm labour with 18-32 wk)	32.6 ± 3.7	Internet-based cognitive behavioral stress management (IB-CBSM)	Placebo (Generic information)	I: 50; C: 43	Depression symptoms (EPDS), Anxiety symptoms(STAI-S and PRA), Stress symptoms (PSS)	44.1%	No/Yes	No/No	Yes
Yang et al[84], 2019	China/Hospital	2-arm RCT	Antenatal (24-30 wk, GAD-7 > 4 or PHQ-9 > 4)	30.9 ± NR	Online mindfulness intervention (NR)	Placebo (Wechat)	I: 62; C: 61	Depression symptoms (PHQ-9), Anxiety symptoms (GAD-7)	13.8%	Yes/Yes	No/No	Yes

BAI: Beck anxiety inventory; BDI-II: Beck depression inventory-II; C: Control; CES-D: Center for epidemiological studies depression; CES-D: Centre for epidemiologic studies-depression scale; DASS-21-A: Depression, anxiety and stress scales-21- anxiety subscale; DASS-21-D: Depression, anxiety and stress scales-21- depression subscale; DASS-21-S: Depression, anxiety and stress scales-21- stress subscale; EPDS: Edinburgh postnatal depression scale; GAD-7: Generalized anxiety disorder scale; GSI-A: Global severity index-anxiety subscale; GSI-D: Global severity index-depression subscale; HADS-A: Hospital anxiety and depression scale-anxiety subscale; HADS-A: Hospital anxiety and depression scale-anxiety subscale; HADS-D: Hospital anxiety and depression scale-depression subscale; HDRS: Hamilton depression rating scale; I: Intervention; IES: Impact of event scale; IES-R: Impact of event scale-revised; ISI: Insomnia severity index; ITT: Intention-to-treat analysis; K-10: Kessler psychological distress 10-item scale; MADRS-S: Montgomery-Asberg depression rating scale self-report version; MDM: Missing data management; MINI: International neuropsychiatric interview; NR: Not reported; PDPI-R: Postpartum depression predictors inventory-revised; PDQ: Prenatal distress scale; PHQ-8: Patient health questionnaire-8; PRA: The pregnancy related anxiety test; PSI: Parenting stress index; PSS: Perceived stress scale; RCT: Randomised controlled trial; SCI: Sleep condition indicator; SCI-I: Structural clinical interview for DSM Axis I disorders; STAI: State trait anxiety inventory; STAI-S: Spielberger state trait anxiety inventory; TES: Traumatic event scale.

Table 2 Subgroup analyses of digital psychotherapeutic intervention on depression symptoms

Deign	Subgroups	No of trials	Sample size	g	P value	Subgroup differences, P value
Population nature	Antenatal women	8[62,65,66,69,73,74,76,84]	622	-0.24	0.16	Q = 2.95, P = 0.09
Population nature	Postnatal women	11[67,68,70-72,75,78-81,85]	1114	-0.67	< 0.001^c	Q = 2.95, P = 0.09
Theoretical principle	Cognitive behavioural therapy and others	3[67,73,78]	185	-1.11	0.19	Q = 4.13, P = 0.13
	Cognitive behavioural therapy only	8[62,65,69-71,79-81]	447	-0.56	< 0.001^c
	Other psychotherapy	8[66,68,72,74-76,84,85]	691	-0.19	0.26
Digital platform	Website	17[64-66,68-76,78-81,85]	1538	-0.32	< 0.001^c	Q = 2.49, P = 0.11
Digital platform	Mobile application	2[67,84]	198	-1.93	0.06	Q = 2.49, P = 0.11
Aim	Prevention	9[62,68,70-74,76,85]	741	-0.25	0.09	Q = 3.31, P = 0.07
Aim	Treatment	10[65-67,69,75,78-81,84]	995	-0.71	< 0.001^c	Q = 3.31, P = 0.07
Guidance	Self-guided	4[65,67,73,85]	211	-0.83	0.23	Q = 0.37, P = 0.54
Guidance	Therapist-guided	15[62,66,68-72,74-76,78-81,84]	1525	-0.40	< 0.001^c	Q = 0.37, P = 0.54
Number of sessions	< 8 sessions	8[66,69,73,75,76,81,84,85]	650	-0.26	0.15	Q = 2.47, P = 0.12
Number of sessions	≥ 8 sessions	11[62,65,67,68,70-72,74,78-80]	1086	-0.66	< 0.001^c

Hedges’s g: Effect size; Q: Cochran’s statistic; Z: z-statistics.

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

Table 3 Random-effects univariate and multivariate meta-regression analyses of covariates on depression symptoms

Covariates	Univariate meta-regression				Multivariate meta-regression
Covariates	β	SE	95%CI	P value	β	SE	95%CI	P value
Age	0.18	0.08	0.03, 0.33	0.02^b	0.14	0.07	0.01, 0.27	0.04^a
Cognitive behavioral therapy¹	-0.077	0.23	-1.23, 0.31	< 0.001^c	-0.070	0.24	-1.16, -0.23	< 0.001^c
Year of trials	-0.02	0.04	-0.10, 0.06	0.66	-	-	-	-
Sample size	< 0.001	< 0.001	-0.00, 0.00	0.94	-	-	-	-
Numbers of session	-0.05	0.04	-0.13, 0.03	0.20	-	-	-	-
Duration of intervention (wk)	-0.07	0.05	-0.16, 0.02	0.13	-	-	-	-

¹Reference group: Non-cognitive behavioral therapy.

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

β: Coefficient; SE: Standard error; CI: Confident interval.

Citation: Lau Y, Cheng JY, Wong SH, Yen KY, Cheng LJ. Effectiveness of digital psychotherapeutic intervention among perinatal women: A systematic review and meta-analysis of randomized controlled trials. World J Psychiatr 2021; 11(4): 133-152
URL: https://www.wjgnet.com/2220-3206/full/v11/i4/133.htm
DOI: https://dx.doi.org/10.5498/wjp.v11.i4.133