Therapist-Supported Internet-Based Cognitive Behavior Therapy for Stress, Anxiety, and Depressive Symptoms Among Postpartum Women: A Systematic Review and Meta-Analysis

Author(s): Ying Lau , RN, RM, B HealthSc, BN(Hons), MNurs, PhD ¹ ^, , Tha Pyai Htun , MBBS, MPH ¹ , Suei Nee Wong , BSc (Hons), MSc ² , Wai San Wilson Tam , BSC, Mphil, PhD ¹ , Piyanee Klainin-Yobas , BSN, MSN, PhD ¹

Editor(s): Gunther Eysenbach

Other contributor(s): Phyllis Zelkowitz (Reviewer), Miriam Ashford (Reviewer), Tanjir Rashid Soron (Reviewer)

Publication date (Electronic): 28 April 2017

Journal: Journal of Medical Internet Research

Publisher: JMIR Publications

Keywords: Internet, post-traumatic stress disorders, stress, anxiety, depression, cognitive behavior therapy, meta-analysis

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Abstract

Background

A growing number of meta-analyses have supported the application of therapist-supported Internet-based cognitive behavior therapy (iCBT) for psychological disorders across different populations, but relatively few meta-analyses have concentrated on postpartum women.

Objective

This meta-analysis evaluated the efficacy of therapist-supported iCBT in improving stress, anxiety, and depressive symptoms among postpartum women.

Methods

A total of 10 electronic databases were used to search for published and unpublished trials. Cochrane Collaboration tool for assessing risk of bias was utilized to measure methodological quality. Meta-analysis was performed using the RevMan software (Review Manager version 5.3 for Windows from the Nordic Cochrane Centre, the Cochrane Collaboration, 2014). Among the 789 studies identified, 8 randomized controlled trials were selected, involving 1523 participants across 6 countries.

Results

More than half (65%) of the eligible studies had a low risk of bias with no heterogeneity. Results revealed that therapist-supported iCBT significantly improved stress ( d=0.84, n=5), anxiety ( d=0.36, n=6), and depressive symptoms ( d=0.63, n=8) of the intervention group compared with those of the control group at post-intervention.

Conclusions

This review revealed that therapist-supported iCBT significantly improves stress, anxiety, and depressive symptoms among postpartum women with small to large effects. Future effectiveness studies should establish the essential components, format, and approach of iCBT with optimal levels of human support to maximize a long-term effect.

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Waiting list may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis.

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Various control conditions have been employed in psychotherapy trials, but there is growing suspicion that they may lead to different effect size estimates. The present study aims to examine the differences among control conditions including waiting list (WL), no treatment (NT) and psychological placebo (PP). We comprehensively searched for all randomized controlled trials (RCTs) comparing cognitive-behaviour therapies (CBT) against various control conditions in the acute phase treatment of depression, and applied network meta-analysis (NMA) to combine all direct and indirect comparisons among the treatment and control arms. We identified 49 RCTs (2730 participants) comparing WL, NT, PP and CBT. This network of evidence was consistent, and the effect size estimates for CBT were substantively different depending on the control condition. The odds ratio of response for NT over WL was statistically significant at 2.9 (95% CI: 1.3-5.7). However, the quality of evidence, including publication bias, was less than ideal and none of the preplanned sensitivity analyses limiting to high-quality studies could be conducted, while findings of significant differences did not persist in post hoc sensitivity analyses trying to adjust for publication bias. There may be important differences in control conditions currently used in psychotherapy trials. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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Research has demonstrated that women develop postpartum PTSD. Prevalence of postpartum PTSD has ranged from 1% to 30%, and many risk factors have been identified as predictors of postpartum PTSD. While qualitative reviews have identified patterns of risk, the lack of quantitative reviews prevents the field from identifying specific risk factors and making a single estimate of the prevalence of postpartum PTSD. The current meta-analysis investigated prevalence and risk factors of postpartum PTSD, both due to childbirth and other events, among community and targeted samples. Prevalence of postpartum PTSD in community samples was estimated to be 3.1% and in at-risk samples at 15.7%. Important risk factors in community samples included current depression, labor experiences such as interactions with medical staff, as well as a history of psychopathology. In at-risk samples, impactful risk factors included current depression and infant complications. Further research should investigate how attitudes towards pregnancy and childbirth may interact with women's experiences during delivery. Additionally, studies need to begin to evaluate possible long-term effects that these symptoms may have on women and their families. Copyright © 2014 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

Ying Lau:

Alice Lee Centre for Nursing StudiesYong Loo Lin School of MedicineNational University of SingaporeLevel 2, Clinical Research Centre, Block MD11, 10 Medical DriveSingapore, 117597Singapore65 6601160365 67767135nurly@nus.edu.sg

ORCID: http://orcid.org/0000-0002-8289-3441

Journal

Journal ID (nlm-ta): J Med Internet Res

Journal ID (iso-abbrev): J. Med. Internet Res

Journal ID (publisher-id): JMIR

Title: Journal of Medical Internet Research

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Print): 1439-4456

ISSN (Electronic): 1438-8871

Publication date Collection: April 2017

Publication date (Electronic): 28 April 2017

Volume: 19

Issue: 4

Electronic Location Identifier: e138

Affiliations

[1] ¹Alice Lee Centre for Nursing Studies Yong Loo Lin School of Medicine National University of Singapore SingaporeSingapore

[2] ²Medical Resource Team, National University of Singapore Libraries SingaporeSingapore

Author notes

Corresponding Author: Ying Lau nurly@ 123456nus.edu.sg

Author information

Ying Lau http://orcid.org/0000-0002-8289-3441

Tha Pyai Htun http://orcid.org/0000-0001-5567-0392

Suei Nee Wong http://orcid.org/0000-0003-3086-2480

Wai San Wilson Tam http://orcid.org/0000-0003-0641-3060

Piyanee Klainin-Yobas http://orcid.org/0000-0003-2581-4572

Article

Publisher ID: v19i4e138

DOI: 10.2196/jmir.6712

PMC ID: 5429436

PubMed ID: 28455276

SO-VID: 1807e921-c76f-425b-ab4b-8c1a9c08904c

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

History

Date received : 30 September 2016

Date revision requested : 29 December 2016

Date revision received : 26 January 2017

Date accepted : 13 February 2017

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