The perinatal period (the time throughout pregnancy and the first postnatal year) is important in a number of ways. Not only is new life developing and entering into the world, but parents experience a significant transition into parenthood, frequently requiring a number of new demands and adaptations to life with a new-born.

Although many new parents will experience a mixture of positive emotions, up to 20% of new parents are reported to experience a mental health difficulty during this transition, including (but not limited to) anxiety, depression, post-traumatic stress and postpartum psychosis (Bauer et al., 2014). Although prevalence is thought to be higher amongst women, these difficulties are not specific to new mothers; fathers also report onset of mental health difficulties during this time-period.

Perinatal mental health difficulties can hold significant implications for parents’ day-to-day wellbeing, as well as having possible impacts on infants’ social, emotional and developmental outcomes. These potential impacts highlight the need for timely and effective perinatal interventions to alleviate and reduce the effects on families (NICE, 2014).

Despite growing awareness of perinatal mental health difficulties, it can be hard for parents to access and utilise perinatal mental health services during this time. Stigma, shame, fear and guilt may stop a parent admitting to difficulties or seeking support, and a number of barriers may prevent access to services, such as location of services, opening hours, childcare needs or work demands (Ashford et al., 2016).

In response, computer or web-based therapies have been developed to increase access. These interventions typically allow access to electronic therapeutic materials, with or without the support of a therapist. Evidence for these interventions in the general population appears to be strong (Andrews et al., 2010), yet little is known about the efficacy of such interventions in the postnatal period. This recent paper by Ashford and colleagues (2016) reviews the evidence in this field to date, as well as exploring the characteristics of these interventions.

Methods

Twelve electronic databases were searched for published and unpublished papers, printed in English. Papers included those exploring interventions with a self-help component, aimed to prevent or alleviate mental health difficulties from the beginning of pregnancy up to 1 year postpartum, specifically reporting results on mental health outcomes. Studies were excluded if they reported on computer or online-based counselling or support groups (therefore not including an element of accessible self-help material) or those that were qualitative or case study designs.

Results

• Eleven papers were identified for inclusion in the review, reporting on nine intervention programmes.
• The authors reported that the small number of papers and their methodological variations and limitations (e.g. varying sample sizes [n=12-910] and attrition rates [0-62%], use of different outcome measures) prevented a meta-analytical approach, and thus presented data narratively within the review.

Characteristics of the intervention programmes

• Referral pathways varied between self-referral (6/11), professional referral (1/11) and a mixture of both (4/11)
• Only three of the eleven studies included male partners, and none focused exclusively on fathers
• The therapeutic approach varied between studies:
  • Cognitive behaviour therapy: 5/9
  • Behavioural activation: 1/9
  • A combination of relaxation with biofeedback, mindfulness or stress-management: 2/9
  • One study did not report its therapeutic approach
• Studies included a mixture of preventative and alleviative interventions, targeting a number of antenatal and postnatal mental health difficulties, including depression, stress, complicated grief following pregnancy loss, and overall psychological ‘wellbeing’
• Duration of intervention ranged from 4-17 weeks
• The amount of information covered in the programmes varied widely from 4 to 199 topic
• Therapist contact was included in the majority of programmes (6/9) with contact varying between face-to-face, telephone, email or online contact

Effectiveness of computer or web-based interventions

• Based on effect sizes calculated for the review, the authors conclude that:
  • Post-treatment figures indicate positive improvements in mental health outcomes
  • The intervention appears to be effective compared to control groups
  • Overall, it seems that those interventions targeting existing mental health difficulties were more effective than those aiming at prevention
  • These positive results appear to be largely based on improvements in depressive symptoms, asa opposed to other mental health outcomes
• However, combining the results like this loses some important detail of individual studies. Across the eleven studies, the results were mixed as to the effectiveness of the intervention on the mental health outcomes assessed
  • Some results within the individual studies indicated greater reduction of depression, anxiety and stress symptoms in control participants compared to those receiving an intervention (although it is unclear what services or support control groups had access to during these studies).

• Despite the mixed results, the authors conclude that the evidence seems promising for delivery and effectiveness of this type of intervention in the perinatal period, particularly for depressive symptoms.

Strengths and limitations

• The review used a clear systematic search strategy to extract papers to explore its aims
• The paper provides a useful summary of the evidence in this field to date, combining both a descriptive element of the interventions included in the review as well as a summary of the key findings from these studies
• Despite the varying methodologies and the mixed results regarding effectiveness of the computer or web-based programmes, the authors conclude that the results are promising, and make some interesting suggestions as to why negative results may have been found, based on methodologies used within the studies
• However, some caution is warranted when interpreting these results. Can we ignore results indicating that control participants’ mental health fared better than that of intervention participants?
• Management of participant risk is not mentioned, which is a potentially important factor to consider when delivering interventions over the internet or via computer, and not assessing this face-to-face.

Conclusions and comments

This is an important field, and the review indicates that work is being done to find ways to improve access and treatment uptake amongst parents in the perinatal period. However, this area warrants further investigation to improve the longer-term outcomes for parents and families.

Based on the fairly limited evidence to-date, it would seem that web or computer-based interventions may be an effective form of therapeutic intervention in the perinatal period, but this picture is not clear-cut. For some participants, receiving this type of intervention may be less effective than continuing with treatment as usual.

As the authors note, the anonymity offered by web-based therapies may make this type of intervention particularly accessible and attractive to parents in the perinatal period. However, as also noted, many parents typically choose to access informal methods of support from friends and family during this time-period; sometimes as an alternative to formal mental health services, sometimes alongside these sources of support. It is interesting to consider whether offering increased levels of computer-based interventions may have any negative impacts on the use of general social support networks within the perinatal period.

Some studies had a high participant attrition rate (over 60%); patient acceptability and therapeutic alliance during this type of intervention may therefore require further consideration before these programmes are rolled out more widely. Studies comparing effectiveness of computer or web-based interventions to face-to-face interventions may be important in starting to understand this further.

Further consideration needs to be given to fathers’ use of these interventions, and whether this therapeutic format is effective and accessible to fathers during this time-period.

Links

Primary paper

Ashford MT, Olander EK, Ayers S. (2016) Computer- or web-based interventions for perinatal mental health: A systematic review. Journal of Affective Disorders http://dx.doi.org/10.1016/j.jad.2016.02.057

Other references

Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. (2010) Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis. PLoS One 5, e13196. doi:10.1371/journal.pone.0013196

Bauer A, Parsonage M, Knapp M, Iemmi V, Adelaja B. (2014) Costs of perinatal mental health problems. http://www.centreformentalhealth.org.uk/costs-of-perinatal-mh-problems. London School of Economics & Centre for Mental Health.

National Institute for Health and Clinical Excellence (2014). Antenatal and postnatal mental health: clinical management and service guidance (CG192).

Photo credits

• Adam Selwood CC BY 2.0
• Oakley Originals CC BY 2.0
• Stefan Erschwendner CC BY 2.0
• Marco Zanferrari CC BY 2.0
• DVIDSHUB CC BY 2.0