Effectiveness of digital psychological interventions for mental health problems in low-income and middle-income countries: a systematic review and meta-analysis

Abstract

Background The effectiveness of digital psychological interventions in low-income and middle-income countries (LMICs) remains unclear. We aimed to systematically investigate the available evidence for digital psychological interventions in reducing mental health problems in LMICs. Methods In this systematic review and meta-analysis, we searched PubMed, PsycINFO, Embase, and Cochrane databases for articles published in English from database inception to March 9, 2020. We included randomised controlled trials investigating digital psychological interventions in individuals with mental health problems in LMICs. We extracted data on demographics, inclusion and exclusion criteria, details of the intervention, including the setting, digital delivery method, control group conditions, number of sessions, therapeutic orientation (eg, cognitive therapy or behaviour therapy), presence or absence of guidance, and length of follow-up, and statistical information to calculate effect sizes. If a study reported insufficient data to calculate effect sizes, the corresponding authors were contacted to provide data that could be aggregated. We did random-effects meta-analyses, and calculated the standardised mean difference in scores of digital psychological interventions versus control conditions (Hedges' g). Quality of evidence was assessed by use of the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary outcome was post-intervention mental health problems, as measured by selfreporting instruments or clinical interviews. This study is registered with PROSPERO, CRD42019137755. Findings We identified 22 eligible studies that were included in the meta-analysis. The included studies involved a total of 4104 participants (2351 who received a digital psychological intervention and 1753 who were in the control group), and mainly focused on young adults (mean age of the study population was 20-35 years) with depression or substance misuse. The results showed that digital psychological interventions are moderately effective when compared with control interventions (Hedges' g 0•60 [95% CI 0•45-0•75]; Hedges' g with treatment as usual subgroup for comparison 0•54 [0•35-0•73]). Heterogeneity between studies was substantial (I²=74% [95% CI 60-83]). There was no evidence of publication bias, and the quality of evidence according to the GRADE criteria was generally high. Interpretation Digital psychological interventions, which have been mostly studied in individuals with depression and substance misuse, are superior to control conditions, including usual care, and are moderately effective in LMICs. However, the considerable heterogeneity observed in our analysis highlights the need for more studies to be done, with standardised implementation of digital psychological intervention programmes to improve their reproducibility and efficiency. Digital psychological interventions should be considered for regions where usual care for mental health problems is minimal or absent.

Step-by-step: Feasibility randomised controlled trial of a mobile-based intervention for depression among populations affected by adversity in Lebanon

“…These two parallel RCTs will evaluate the effectiveness and cost-effectiveness of Step-by-Step among (a) Syrian displaced people and (b) Lebanese and other people residing in Lebanon ( van't Hof et al, 2021 ). There is a scarcity of RCTs testing internet-based interventions in low- and middle-income countries ( Fu et al, 2020 ). These settings pose challenging circumstances to the implementation of a trial.…”

“…In high-income countries, guided e-mental health interventions have been shown to be as effective as similar interventions delivered face-to-face ( Andersson et al, 2019 ; Cuijpers et al, 2019 ) and have been found to reduce symptoms of mental disorders in routine care ( Andersson and Titov, 2014 ). An increasing number of trials have been conducted in LMICs, with promising effect sizes ( Arjadi et al, 2015 ; Fu et al, 2020 ; Naslund et al, 2017 ). Despite the potential of such e-mental health interventions, challenges regarding uptake and adherence remain ( Torous et al, 2018 ; Watson et al, 2018 ).…”

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“…Several studies have shown the benefits of telemedicine, highlighting the volume of users it can reach, the reduction in waiting times, and its applicability under various risk conditions, although the need to deepen and broaden the research to evaluate the effectiveness of online psychological support has almost always been emphasized. Indeed, the usefulness of this kind of psychological consultation has frequently been relied on in emergency situations such as disasters, suicide attempts, trauma, or with cancer patients support [ 8 , 9 , 10 ], those with neuromuscular disorders [ 11 ], and in mental health disorders [ 12 , 13 ]. Subjects who underwent online mindfulness interventions experienced positive outcomes in terms of emotional regulation, anxiety management, and stress reduction support [ 14 ].…”