Digitalized Cognitive Behavioral Interventions for Depressive Symptoms During Pregnancy: Systematic Review

Abstract

Background Studies have shown a high prevalence of depression during pregnancy, and there is also evidence that cognitive behavioral therapy (CBT) is one of the most effective psychosocial interventions. Emerging evidence from randomized controlled trials (RCTs) has shown that technology has been successfully harnessed to provide CBT interventions for other populations. However, very few studies have focused on their use during pregnancy. This approach has become increasingly important in many clinical areas due to the COVID-19 pandemic, and our study aimed to expand the knowledge in this particular clinical area. Objective Our systematic review aimed to bring together the available research-based evidence on digitalized CBT interventions for depression symptoms during pregnancy. Methods A systematic review of the Web of Science, Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, Embase, PsycINFO, Scopus, ClinicalTrials.gov, and EBSCO Open Dissertations databases was carried out from the earliest available evidence to October 27, 2021. Only RCT studies published in English were considered. The PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analyses) guidelines were followed, and the protocol was registered on the Prospective Register of Systematic Reviews. The risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomized trials. Results The review identified 7 studies from 5 countries (the United States, China, Australia, Norway, and Sweden) published from 2015 to 2021. The sample sizes ranged from 25 to 1342 participants. The interventions used various technological elements, including text, images, videos, games, interactive features, and peer group discussions. They comprised 2 guided and 5 unguided approaches. Using digitalized CBT interventions for depression during pregnancy showed promising efficacy, with guided intervention showing higher effect sizes (Hedges g=1.21) than the unguided interventions (Hedges g=0.14-0.99). The acceptability of the digitalized CBT interventions was highly encouraging, based on user feedback. Attrition rates were low for the guided intervention (4.5%) but high for the unguided interventions (22.1%-46.5%). A high overall risk of bias was present for 6 of the 7 studies. Conclusions Our search only identified a small number of digitalized CBT interventions for pregnant women, despite the potential of this approach. These showed promising evidence when it came to efficacy and positive outcomes for depression symptoms, and user feedback was positive. However, the overall risk of bias suggests that the efficacy of the interventions needs to be interpreted with caution. Future studies need to consider how to mitigate these sources of biases. Digitalized CBT interventions can provide prompt, effective, evidence-based interventions for pregnant women. This review increases our understanding of the importance of digitalized interventions during pregnancy, including during the COVID-19 pandemic. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42020216159; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=216159

The Efficacy of Digital Cognitive–Behavioral Interventions in Supporting the Psychological Adjustment and Sleep Quality of Pregnant Women with Sub-Clinical Symptoms: A Systematic Review and Meta-Analysis

“…The interventions’ efficacy in terms of the anxiety symptoms is in line with the previous evidence on the efficacy of in-person CBTs for perinatal anxiety symptoms [ 40 ]. Similarly, the interventions’ efficacy in terms of the depression symptoms is consistent with the findings of a recent meta-analysis focused on digital CBTs administered to perinatal women [ 41 ] and a systematic review based on digital CBTs deployed to pregnant women [ 42 ]. However, both papers included studies regardless of the women’s psychological symptom level.…”

“…Previous reviews and meta-analyses have already highlighted the efficacy of in-person CBTs deployed during the perinatal period in reducing depression, anxiety, and stress symptoms [ 39 , 40 ]. However, the efficacy of digital CBTs seems only supported for a reduction in depression symptoms [ 41 , 42 ], since to date no review has been conducted to assess their efficacy in reducing anxiety or stress symptoms. On a similar note, the efficacy of digital CBTs in improving insomnia symptoms was reported for adults at large [ 43 ], yet there are no available reviews or meta-analyses focused on perinatal sleep issues.…”

“…A further evaluation of the available literature highlighted that studies investigating the efficacy of CBTs and third-generation CBTs have greatly focused on women in the postpartum period [ 47 , 48 ] or on the broader perinatal period (i.e., both ante- and postnatal) [ 49 ]. Moreover, these studies were based either on specific intervention protocols (e.g., traditional CBTs) [ 41 , 42 ] or conversely included psychological interventions at large [ 50 , 51 ], despite their specific theoretical background. In addition, among the studies that placed attention on pregnancy, the involved women presented either clinically relevant psychological symptoms or mental disorders, such as major depression [ 52 , 53 ], or were instead recruited from the general population regardless of their symptomatology level [ 41 , 42 , 54 ].…”

“…Moreover, these studies were based either on specific intervention protocols (e.g., traditional CBTs) [ 41 , 42 ] or conversely included psychological interventions at large [ 50 , 51 ], despite their specific theoretical background. In addition, among the studies that placed attention on pregnancy, the involved women presented either clinically relevant psychological symptoms or mental disorders, such as major depression [ 52 , 53 ], or were instead recruited from the general population regardless of their symptomatology level [ 41 , 42 , 54 ]. The only available study that solely included women with sub-clinical symptoms and no prior mental disorder considered the broader perinatal period and investigated the efficacy of in-person MBIs [ 46 ].…”

Internet-assisted cognitive behavioral intervention with telephone coaching versus an educational control for antenatal depression: protocol for a randomized controlled trial with population-based screening

“…Consequently, psychotherapies are also feasible for pregnant women, regardless of whether they are delivered face-to-face, individually or in groups (O' Connor et al, 2019;Sockol, 2015). Furthermore, digitally delivered internet-assisted CBT (iCBT) seems like a promising treatment format Wan Mohd Yunus et al, 2022). Importantly, iCBTs reduce logistical and practical barriers, including childcare, transport and scheduling di culties and metaanalyses have found signi cant treatment effects for general and perinatal depression (Cuijpers et al, 2019;Cuijpers, Franco, et al, 2021;Luo et al, 2020 Previous randomized controlled trials (RCTs) on iCBT for antenatal depression have reported promising e cacy for reducing core symptoms of depression (Forsell et al, 2017;Haga et al, 2013;Loughnan et al, 2019) with high acceptability of the iCBT interventions (Forsell et al, 2017;Loughnan et al, 2019).…”