The effect of digital health interventions on postpartum depression or anxiety: a systematic review and meta-analysis of randomized controlled trials

Abstract

Objective: This study aimed to examine the effect of digital health interventions compared with treatment as usual on preventing and treating postpartum depression and postpartum anxiety.

Data sources: Searches were conducted in Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov.

Study eligibility requirements: The systematic review included full-text randomized controlled trials comparing digital health interventions with treatment as usual for preventing or treating postpartum depression and postpartum anxiety.

Study appraisal and synthesis methods: Two authors independently screened all abstracts for eligibility and independently reviewed all potentially eligible full-text articles for inclusion. A third author screened abstracts and full-text articles as needed to determine eligibility in cases of discrepancy. The primary outcome was the score on the first ascertainment of postpartum depression or postpartum anxiety symptoms after the intervention. Secondary outcomes included screening positive for postpartum depression or postpartum anxiety --as defined in the primary study --and loss to follow-up, defined as the proportion of participants who completed the final study assessment compared with the number of initially randomized participants. For continuous outcomes, the Hedges method was used to obtain standardized mean differences when the studies used different psychometric scales, and weighted mean differences were calculated when studies used the same psychometric scales. For categorical outcomes, pooled relative risks were estimated.

Results: Of 921 studies originally identified, 31 randomized controlled trials-corresponding to 5532 participants randomized to digital health intervention and 5492 participants randomized to treatment as usual-were included. Compared with treatment as usual, digital health interventions significantly reduced mean scores ascertaining postpartum depression symptoms (29 studies: standardized mean difference, -0.64 [95% confidence interval, -0.88 to -0.40]; I²=94.4%) and postpartum anxiety symptoms (17 studies: standardized mean difference, -0.49 [95% confidence interval, -0.72 to -0.25]; I²=84.6%). In the few studies that assessed screen-positive rates for postpartum depression (n=4) or postpartum anxiety (n=1), there were no significant differences between those randomized to digital health intervention and treatment as usual. Overall, those randomized to digital health intervention had 38% increased risk of not completing the final study assessment compared with those randomized to treatment as usual (pooled relative risk, 1.38 [95% confidence interval, 1.18-1.62]), but those randomized to app-based digital health intervention had similar loss-to-follow-up rates as those randomized to treatment as usual (relative risk, 1.04 [95% confidence interval, 0.91-1.19]).

Conclusion: Digital health interventions modestly, but significantly, reduced scores assessing postpartum depression and postpartum anxiety symptoms. More research is needed to identify digital health interventions that effectively prevent or treat postpartum depression and postpartum anxiety but encourage ongoing engagement throughout the study period.

Keywords: digital health intervention; internet; perinatal mental health; postpartum anxiety; postpartum depression; smartphone application; text message.

Figure 1:

Flow Diagram for Study Selection

Figure 2:

Weighted mean difference of scores of first postnatal screen for (a) postpartum depression and (b) postpartum anxiety after digital health intervention versus treatment as usual for postpartum depression or anxiety Key: DHI = digital health intervention; TAU = treatment as usual. SMD = standardized mean difference. PPD= postpartum depression. PPA = postpartum anxiety. a) Scores on first screening for PPD after delivery b) Scores on first screening for PPA after delivery

Figure 2:

Weighted mean difference of scores of first postnatal screen for (a) postpartum depression and (b) postpartum anxiety after digital health intervention versus treatment as usual for postpartum depression or anxiety Key: DHI = digital health intervention; TAU = treatment as usual. SMD = standardized mean difference. PPD= postpartum depression. PPA = postpartum anxiety. a) Scores on first screening for PPD after delivery b) Scores on first screening for PPA after delivery

Figure 3:

Funnel plot with pseudo 95% confidence intervals for all studies included for postpartum depression screening

Figure 4:

Secondary outcomes after digital health intervention versus treatment as usual for postpartum depression or anxiety Key for all forest plots: DHI = digital health intervention. TAU = treatment as usual. SMD = standardized mean difference. CI = confidence interval. PPD = postpartum depression. PPA = postpartum anxiety. EPDS: Edinburgh Postnatal Depression Scale. GAD-7: Generalized Anxiety Disorder-7. LTFU: loss to follow-up. a) Scores on first EPDS screening for PPD after delivery b)Scores on first GAD-7 screening for PPA after delivery c) Screen positive for PPD d) Screen positive for PPA e) Loss to follow-up rates

Figure 4:

Secondary outcomes after digital health intervention versus treatment as usual for postpartum depression or anxiety Key for all forest plots: DHI = digital health intervention. TAU = treatment as usual. SMD = standardized mean difference. CI = confidence interval. PPD = postpartum depression. PPA = postpartum anxiety. EPDS: Edinburgh Postnatal Depression Scale. GAD-7: Generalized Anxiety Disorder-7. LTFU: loss to follow-up. a) Scores on first EPDS screening for PPD after delivery b)Scores on first GAD-7 screening for PPA after delivery c) Screen positive for PPD d) Screen positive for PPA e) Loss to follow-up rates

Figure 4:

Secondary outcomes after digital health intervention versus treatment as usual for postpartum depression or anxiety Key for all forest plots: DHI = digital health intervention. TAU = treatment as usual. SMD = standardized mean difference. CI = confidence interval. PPD = postpartum depression. PPA = postpartum anxiety. EPDS: Edinburgh Postnatal Depression Scale. GAD-7: Generalized Anxiety Disorder-7. LTFU: loss to follow-up. a) Scores on first EPDS screening for PPD after delivery b)Scores on first GAD-7 screening for PPA after delivery c) Screen positive for PPD d) Screen positive for PPA e) Loss to follow-up rates

Figure 4:

Secondary outcomes after digital health intervention versus treatment as usual for postpartum depression or anxiety Key for all forest plots: DHI = digital health intervention. TAU = treatment as usual. SMD = standardized mean difference. CI = confidence interval. PPD = postpartum depression. PPA = postpartum anxiety. EPDS: Edinburgh Postnatal Depression Scale. GAD-7: Generalized Anxiety Disorder-7. LTFU: loss to follow-up. a) Scores on first EPDS screening for PPD after delivery b)Scores on first GAD-7 screening for PPA after delivery c) Screen positive for PPD d) Screen positive for PPA e) Loss to follow-up rates

Figure 4:

Secondary outcomes after digital health intervention versus treatment as usual for postpartum depression or anxiety Key for all forest plots: DHI = digital health intervention. TAU = treatment as usual. SMD = standardized mean difference. CI = confidence interval. PPD = postpartum depression. PPA = postpartum anxiety. EPDS: Edinburgh Postnatal Depression Scale. GAD-7: Generalized Anxiety Disorder-7. LTFU: loss to follow-up. a) Scores on first EPDS screening for PPD after delivery b)Scores on first GAD-7 screening for PPA after delivery c) Screen positive for PPD d) Screen positive for PPA e) Loss to follow-up rates