Meta-Analysis
Copyright ©The Author(s) 2021.
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], 201523 countries/Community2-arm RCTAntenatal (mixed trimesters)30.2 ± 5.6Mood management internet intervention (Curso Internet de Mamás y Bebés)Placebo (Information only)I: 57; C: 54Depression symptoms (CES-D)66.1%No/NoNo/NoYes
Duffecy et al[62], 2019United States/Community2-arm RCTAntenatal (20–28 wk)30.5 ± 4.1Share (group) condition (Sunnyside)Placebo (individual) conditionI: 18; C: 7Depression symptoms (PHQ-8 and HDRS)28%No/NoNo/YesYes
Felder et al[63], 2020United States/Community2-arm RCTAntenatal (≤ 28 wk, insomnia by SCI, EPDS ≥ 15)33.6 ± 3.7Digital cognitive behavioural therapy for insomnia (Sleepio)Treatment as usualI: 105; C: 103Depression symptoms (EPDS), Anxiety symptoms (GAD-7)11.1 %Yes/NoNo/YesYes
Fonseca et al[64], 2019Portugal /Community2-arm RCTPostnatal women (PDPI-R ≥ 5.5 or EPDS > 932.6 ± NRWeb-based intervention (Be a Mom)WaitlistI: 98; C: 96Depression symptoms (EPDS)24.2 %Yes/YesNo/YesYes
Forsell et al[65], 2017Sweden/Community2-arm RCTAntenatal (10-28 wk, major depression by SCID; MADRS-S: 15-35)31.0 ± NRInternet-delivered cognitive behaviour therapy (ICBT)Treatment as usualI: 22; C: 20Depression symptoms (EPDS and MADRS-S), Anxiety symptoms (GAD-7)7.1 %Yes/YesNo/YesYes
Heller et al[66], 2020Netherlands /Community2-arm RCTAntenatal (< 30 wk with CES-D ≥ 16, HADS-A ≥ 8)32.0 ± NRInternet- based problem-solving treatment (MamaKits Online)Treatment as usualI: 79; C: 80Depression symptoms (EPDS and CES-D), Anxiety symptoms (HADS-A)17.6%Yes/YesYes/YesYes
Jannati et al[67], 2020Iran/Community3-arm RCTPostnatal (≤ 6 mo, EPDS ≥ 13 and MINI)27.7 ± 4.2App-based cognitive behavioural therapy (Happy Mom)Treatment as usualI: 39; C: 39Depression symptoms (EPDS)3.9%No/NoNo/YesYes
Jiao et al[68], 2019Singapore/Hospital3-arm RCTPostnatal (first time mother < 6 wk)30.7 ± NRWeb-based psychoeducational intervention (NR)Treatment as usualI: 68; C: 68Depression symptoms (EPDS)6.9%Yes/YesYes/YesYes
Kalmbach et al[69], 2020United States/Community2-arm RCTAntenatal (27.76 ± 0.87 wk with insomnia using ISI ≥ 10 and EPDS ≥ 19)29.0 ± 4.2Digital cognitive behavioural therapy for insomnia (Sleepio)Placebo (Digital sleep education)I: 46; C: 45Depression symptoms (EPDS)1.1%Yes/YesNo/YesYes
Kersting et al[71], 2011Germany/Community2-arm RCTPostnatal (loss of child with 5-43 wk)34.3 ± 5.3Internet-based cognitive behavioural treatment programme (NR)WaitlistI: 45; C: 33Depression symptoms (GSI-D), Anxiety symptoms (GSI-A) Stress symptoms (IES)22.9%Yes/YesNo/NoYes
Kersting et al[70], 2013Germany/Community2-arm RCTPostnatal (loss of child with 2-40 wk)34.2 ± 5.2Internet-based cognitive behavioural treatment programme (NR)WaitlistI: 115; C: 113Depression symptoms (GSI-D) Anxiety symptoms (GSI-A) Stress symptoms (IES-R)12.7%Yes/NoNo/NoYes
King et al[85], 2009United States/Community2-arm RCTPostnatal (≤ 12 mo)32.5 ± NRInternet-based stress management program (LivingSmart)Face- to-Face control groupI: 28; C: 29Depression symptoms (BDI-II), Anxiety symptoms (STAI) Stress symptoms (PSS)33.1%No/NoNo/NoYes
Klein et al[72], 2012Scotland/Community2-arm RCTPostnatal (Miscarriage with < 24 wk)33.0 ± 6.3Web-based intervention (Miscarriage matters)Treatment as usualI: 33; C: 34Depression symptoms (HADS-D), Anxiety symptoms (HADS-A)35.8%Yes/YesNo/NoYes
Loughnan et al[73], 2019Australia/Community2-arm RCTAntenatal (13-30 wk, GAD-7 > 9 and/or PHQ-9 > 9)31.6 ± 4.0Internet-delivered cognitive behavioural therapy program (MUMentum Pregnancy)Treatment as usualI: 43; C: 44Depression symptoms (EPDS), Anxiety symptoms (GAD-7) Stress symptoms (K-10)11.5%Yes/YesYes/YesYes
Matvienko-Sikar et al[74], 2017Sweden/Community3-arm RCTsAntenatal (10-22) wk33.8 ± 3.0Novel positive psychological intervention (BodyScan and Reflection)Treatment as usualI: 32; C: 14Depression symptoms (EPDS) Stress symptoms (PDQ)6.5%No/NoNo/NoNo
Milgrom et al[75], 2016Australia/Community2-arm RCTPostnatal (< 12 mo, EPDS 11-23)31.6 ± NRInternet cognitive behavioural therapy (MumMoodBooster)Treatment as usualI: 21; C: 22Depression symptoms (BDI-II), Anxiety symptoms (DASS-21-A), Stress symptoms (DASS-21-S)6.9%Yes/YesNo/YesYes
Missler et al[76], 2020Netherlands/Community2-arm RCTAntenatal (26-34 wk)32.5 ± NRPsycho-educational Intervention (NR)WaitlistI: 68; C: 69Depression symptoms (EPDS), Anxiety symptoms (HADS-A), Stress symptoms (PSI)11.7%Yes/YesYes/YesYes
Molenaar et al[77], 2020Netherlands/Community2-arm RCTAntenatal (12-16 wk, depression history)32.2 ± 4.9Discontinuation of anti-depressants with Preventive Cognitive Therapy (STOP)Treatment as usualI: 24; C: 20Depression symptoms (EPDS and HDRS), Anxiety symptoms(STAI)13.6%No/NoYes/YesYes
Nieminen et al[78], 2016Sweden/Community2-arm RCTPostnatal (≥ 3 mo, TES ≥ 30)34.6 ± 4.8Internet-based trauma-focused cognitive behaviour therapy (TF-ICBT)WaitlistI: 28; C: 28Depression symptoms (BDI-II and PHQ-9), Anxiety symptoms (BAI), Stress symptoms (IER-R)9.8%Yes/Yes No/NoYes
O'Mahen et al[80], 2013United Kingdom/Community2-arm RCTPostnatal (< 12 mo, EPDS > 12)32.3 ± NRInternet-based behavioral activation (Netmums)Treatment as usualI: 462;C: 448Depression symptoms (EPDS)61%Yes/NoNo/NoYes
O'Mahen et al[79], 2014United Kingdom/Community2-arm RCTPostnatal (< 12 mo, EPDS > 12)32.3 ± NRInternet behavioral activation treatment (NetmumsHWD)Treatment as usualI: 41; C: 42Depression symptoms (EPDS), Anxiety symptoms (GAD-7)13.2%Yes/YesNo/NoYes
Pugh et al[81], 2016Canada/Community2-arm RCTPostnatal (< 12 mo, EPDS ≥ 10)≥ 18 ± NRTherapist assisted, Internet-delivered cognitive behavior therapy (TA-ICBT)WaitlistI: 25; C: 25Depression symptoms (DASS-21-D), Anxiety symptoms (DASS-21-A), Stress symptoms (DASS-21-S)18%Yes/YesNo/YesYes
Scherer et al[82], 2016Switzerland/Community2-arm RCTPostnatal (preterm labour with 18-32 wk)32.7 ± 3.0Internet-based cognitive behavioral stress management (IB-CBSM)Placebo (Limited support)I: 51; C: 42Anxiety symptoms (STAI-S), Stress symptoms (PSS)37.6%No/NoNo/YesYes
Urech et al[83], 2018Switzerland/Community2-arm RCTPostnatal (preterm labour with 18-32 wk)32.6 ± 3.7Internet-based cognitive behavioral stress management (IB-CBSM)Placebo (Generic information)I: 50; C: 43Depression symptoms (EPDS), Anxiety symptoms(STAI-S and PRA), Stress symptoms (PSS)44.1%No/YesNo/NoYes
Yang et al[84], 2019China/Hospital2-arm RCTAntenatal (24-30 wk, GAD-7 > 4 or PHQ-9 > 4)30.9 ± NROnline mindfulness intervention (NR)Placebo (Wechat)I: 62; C: 61Depression symptoms (PHQ-9), Anxiety symptoms (GAD-7)13.8%Yes/YesNo/NoYes
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 natureAntenatal women8[62,65,66,69,73,74,76,84]622-0.240.16Q = 2.95, P = 0.09
Postnatal women11[67,68,70-72,75,78-81,85]1114-0.67< 0.001c
Theoretical principleCognitive behavioural therapy and others3[67,73,78]185-1.110.19Q = 4.13, P = 0.13
Cognitive behavioural therapy only8[62,65,69-71,79-81]447-0.56< 0.001c
Other psychotherapy8[66,68,72,74-76,84,85]691-0.190.26
Digital platformWebsite17[64-66,68-76,78-81,85]1538-0.32< 0.001cQ = 2.49, P = 0.11
Mobile application2[67,84]198-1.930.06
AimPrevention9[62,68,70-74,76,85]741-0.250.09Q = 3.31, P = 0.07
Treatment10[65-67,69,75,78-81,84]995-0.71< 0.001c
GuidanceSelf-guided4[65,67,73,85]211-0.830.23Q = 0.37, P = 0.54
Therapist-guided15[62,66,68-72,74-76,78-81,84]1525-0.40< 0.001c
Number of sessions< 8 sessions8[66,69,73,75,76,81,84,85]650-0.260.15Q = 2.47, P = 0.12
≥ 8 sessions11[62,65,67,68,70-72,74,78-80]1086-0.66< 0.001c
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
CovariatesUnivariate meta-regression
Multivariate meta-regression
β
SE
95%CI
P value
β
SE
95%CI
P value
Age0.180.080.03, 0.330.02b0.140.070.01, 0.270.04a
Cognitive behavioral therapy1-0.0770.23-1.23, 0.31< 0.001c-0.0700.24-1.16, -0.23< 0.001c
Year of trials-0.020.04-0.10, 0.060.66----
Sample size< 0.001< 0.001-0.00, 0.000.94----
Numbers of session-0.050.04-0.13, 0.030.20----
Duration of intervention (wk)-0.070.05-0.16, 0.020.13----
1Reference group: Non-cognitive behavioral therapy.
aP < 0.05.
bP < 0.01.
cP < 0.001.
β: Coefficient; SE: Standard error; CI: Confident interval.