Women & Health

ISSN: 0363-0242 (Print) 1541-0331 (Online) Journal homepage: https://www.tandfonline.com/loi/wwah20

The efficiency of online cognitive-behavioral

therapy for postpartum depressive
symptomatology: a systematic review and meta-
analysis

Maria Roman, Ticu Constantin & Cristina Maria Bostan

To cite this article: Maria Roman, Ticu Constantin & Cristina Maria Bostan (2019): The efficiency
of online cognitive-behavioral therapy for postpartum depressive symptomatology: a systematic
review and meta-analysis, Women & Health

To link to this article: https://doi.org/10.1080/03630242.2019.1610824

Published online: 06 May 2019.

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WOMEN & HEALTH
https://doi.org/10.1080/03630242.2019.1610824

The efficiency of online cognitive-behavioral therapy for

postpartum depressive symptomatology: a systematic review
and meta-analysis
Maria Roman, Ticu Constantin, and Cristina Maria Bostan PhD in Psychology
Department of Psychology, Alexandru Ioan Cuza University of Iasi, Iasi, Romania

ABSTRACT ARTICLE HISTORY

Postpartum depression (PD) is a frequently occurring disorder that Received 25 March 2018
affects the cognitive, emotional and social development of a mother Revised 3 April 2019
after childbirth. Online cognitive-behavioral therapy (OCBT) is used as Accepted 6 April 2019
therapy for PD symptomatology, but no clear evidence is available KEYWORDS
about its effectiveness. The goal of this meta-analysis was to identify, Postpartum depression;
synthesize and analyze the empiric studies regarding the OCBT effec- online cognitive-behavioral
tiveness for PD. A search for indexed articles and unpublished theses therapy; meta-analysis
between 2000 and 2017 was made in Google Scholar, Proquest,
ScienceDirect, APA PsycNet, Cochrane, SpringerLink, Medline, PubMed
and Dissertations Abstract International. Six studies were selected based
on the following eligibility criteria: (1) papers published in English, (2)
papers about PD, (3) papers that empirically investigated the effective-
ness of OCBT for PD, and (4) papers comparing an experimental group
with a control group. Exclusion criteria included investigations of PD for:
(1) mothers diagnosed with another severe disorder and (2) mothers
with deceased children and (3) women with an age below 18 years old.
This meta-analytic study identified a moderate significant size-effect
(d = – 0.54, 95% CI [−0.716; −0.423]) of the OCBTs in reducing PD, and
practical implications and limitations are discussed.

Postpartum depression and therapeutic interventions

Postpartum Depression (PD) is one of the most frequent complications occurring after birth,
affecting 10–15% of the mothers and representing an important public health issue (Milgrom
et al. 2016; Yozwiak 2010). In addition to the classic symptomatology associated with a major
depressive episode, women with PD often say they have a lack of conviction in their ability to
take care of their child (Gaillard, Le Strat, Mandelbrot, Keita and Dubertret, 2014).
Various treatments are available for PD, including face-to-face or online psychotherapy,
pharmacotherapy, and various forms of psychosocial interventions, but these are rarely
considered by mothers (Yonkers et al. 2009). Despite the existence of effective treatments
for depression, most researchers have argued the need for online therapeutic interventions
because few women sought or accepted help after birth, even when they were identified as
depressed (Austin et al. 2008; Cox, Holden, and Sagovsky 1987; Milgrom et al. 2016).
Although several forms of online treatment are available, it is important to assess their effects.

CONTACT Cristina Maria Bostan cmbostan@gmail.com Str. Toma Cozma nr. 3, 700554, Iasi, Jud. Iasi, Romania
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wwah.
© 2019 Taylor & Francis Group, LLC
2 M. ROMAN ET AL.

Our study sought to analyze the significance of the effects of one specific therapeutic inter-
vention that is used for PD – online cognitive behavioral therapy (OCBT).
Three recently published systematic reviews (Ashford, Olander, and Ayers 2016; Lau,
Htun, Wong, Tam andKlainin-Yobas2017; Lee et al. 2016) have synthesized information
on web-based interventions for mothers in the perinatal period. These reviews have
included studies which focused on depression, anxiety, grief, stress, and posttraumatic
stress disorder. We argue that PD is distinct and should not be combined with data from
studies such as these, for example, in which mothers lost their babies and are perhaps
experiencing a bereavement rather than PD (DSM-IV-TR 2003/ICD10 1992).
Data suggest that web-based therapies delivered in the postnatal period for perinatal
depression play a role in improving maternal mood (Ashford, Olander, and Ayers 2016;
Lee et al. 2016). Lau et al. (2017) revealed that internet-based cognitive behavior therapies
significantly reduced the frequency or intensity of PD (d = 0.63, meta-analysis based on
eight studies) in the intervention group, compared with the control group.
Still, the studies that were included in the previous reviews (Ashford, Olander, and
Ayers 2016; Lau et al. 2017; Lee et al. 2016) examined different types of depression.
Different from the meta-analysis performed by Lau and his collaborators (2017), we
limited our selection of papers for review to those concerned with PD and excluded the
antenatal period, which differs from the postnatal period in needs, requirements and
responsibilities (NICE 2014a). The symptoms reported are more severe during pregnancy
than in postnatal women (Evans et al. 2001). Further, antenatal depression and PD are
associated with different psychosocial factors (Mohammad, Gamble, and Creedy 2010).
We also excluded studies concerned with women who were suffering after the loss of
a pregnancy and studies that measured depression through posttraumatic stress.
Depression after the loss of pregnancy (Kersting, Kroker, and Schlicht 2011) is not
considered PD according to the DSM IV in which criterion E from the diagnosis of
Major Depressive Episode excludes simple mourning. In conclusion, the loss of a child
during pregnancy can be considered a period of mourning, a traumatic event associated
with long-term pain (Kersting, Kroker, and Schlicht 2011). Finally, CBT protocols differ
for posttraumatic stress from those for depression (Fontaine and Fontaine 2006), and
although depressive and anxiety symptoms overlap, both of them have different ante- and
postpartum processes (Leigh and Milgrom 2008).

Online cognitive behavioral therapy (OCBT) in treating postpartum

depression
According to data from clinical trials (Pugh, Hadjistavropoulos, and Dirkse 2016;
Ruwaard 2012), Cognitive – Behavioral Therapy (CBT) is one of the most effective
treatments for PD, with significant positive clinical effect (Cuijpers et al. 2013; Sheeber
et al. 2012). One solution to the mother`s difficulties (i.e.limited freedom of movement
and willingness to think about her and her problems) can be addressed through online-
CBT (OCBT; O‘ Mahen et al. 2013; O’Mahen et al. 2014). So far, OCBT is generally
defined as a usual professional interaction that uses the internet as a means to connect
qualified health professionals and their clients (David 2006). OCBT can help mothers
reduce the time for transportation and provides for a more comfortable environment,
confidentiality and quality of services.
 WOMEN & HEALTH 3

Regarding the channel for therapy, five important tools exist to provide online therapy:
e-mail, web messages, instant chat messaging, videoconferences, telephone and internet-
based therapy (eTherapy.com 2001). Besides the characteristics of CBT that are proven to
be efficient for reducing depression symptoms, implementing it through technology also
has the advantage of providing clear therapeutical techniques, which can be easily trans-
posed online (Butler et al. 2006).
OCBT showed a high rate of satisfaction by patients (Ruwaard 2012), but only a few
studies have analyzed the significance of the effects of OCBT. For example, Barak et al.
(2008) showed in their meta-analysis that OCBT provided a medium effect size (d = 0.53),
concluding that internet-based therapies are as efficient as traditional face-to-face therapies.
Promising evidence of a treatment effect for the internet CBT-based interventions in PD was
previously found with moderate-to-large effect sizes (d= −0.62; 95% CI [−0.80, – 0.44]; Adey
2016) for reduction of symptoms.
Aim of the study: To evaluate evidence for the effectiveness of online CBT interven-
tions for mothers‘ depression in the postnatal period.

Methods
Purpose of the study
In this study, we sought to: (a) identify and systemize the empiric studies that have used
OCBT for PD and (b) analyze the effectiveness of OCBT through meta-analysis.

Search strategy
An extended search was made to identify specific indexed articles from Google Scholar,
PsycINFO, Proquest, ScienceDirect, APA PsycNet, Cochrane, Medline, PubMed, and
Dissertation Abstract International. The following keywords were used in the search: “post-
partum depression” or “postnatal depression” and combinations of the terms “online CBT”,
“internet therapy” and “effective cognitive behavioral therapy” (Table 1). The search included
articles published in 2000 and 2017. Inclusion criteria were: (1) articles published in English,
(2) articles regarding PD, (3) empiric results regarding the effectiveness of online CBT, (4)
studies that included both experimental and control groups. Exclusion criteria included
mothers with psychotic disorders or deceased newborns. Results were limited to peer-
reviewed articles, articles published in psychology and social sciences and also unpublished
Ph.D. theses (Table 1). Out of 5256 of analyzed abstracts, we included six studies that
corresponded to our pre-established criteria of inclusion and exclusion.
The meta-analysis used the “Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA)” model (Moher et al. 2009; Figure 1). The reporting of this
review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA; Moher et al. 2009). The Population, Intervention, Condition,
Outcome, Study – Design (PICOS) method was also used to identify the parameters of
the search: (a) Population – mothers (women aged ≥18 years) in the postpartum period
(first year after childbirth); (b) Intervention – internet CBT (therapist-supported was
delivered over phone, or by email, or on websites); (c) Condition – postpartum depres-
sion; (d) Outcome – effect of intervention on mood and (e) Study design – RCT.
4 M. ROMAN ET AL.

Table 1. Description of the database used for searching articles, the filters used and results identified in
each database.
Database Filters Results
PubMed Subject area: Psychology and Social Science 60
Language: English
Document type: Article
Google Scholar Subject area: Psychology and Social Science 4320
Language: English
Document type: Article
Medline Language: English 250
ScienceDirect Document type: Article 375
APA PsycNet Topic: postpartum depression, CBT online”, CBT telephone. 42
Proquest 40
Cochrane 35
PsycINFO Subject area: Psychology and Social Science 137
Language: English
Document type: Article
Dissertations Abstract International Subject area: Psychology and Social Science 15
The searching terms were: ”postpartum depression” or ”postnatal depression” and combinations of: “CBT online,” “CBT
telephone,” “internet therapy,” and “effectiveness cognitive behavioral therapy.”

Results obtained after searching Results obtained after additional

Identification

in the database (n = 5256) search (n = 15)

Results obtained after eliminating

duplicates (n = 1630)
Screening

Results verified by title and abstract Excluded results

(n =1630) (n =1600)
Eligibility

Eligible whole studies

Whole studies excluded
(n=30)
(n = 24)

Publications selected for meta-

analysis (n=6)

Figure 1. PRISMA flowchart.

 WOMEN & HEALTH 5

Figure 2. Forest plot for post-partum depression effect sizes.

Quality assurance
Studies were reviewed by each of the authors, and disagreements were resolved through
discussions. We assessed study design aspects that could introduce bias, and we decided to
select and assess only studies: (a) published in international and recognized databases, (b)
that targeted PD, not other forms of depression related to pregnancy (i.e. antenatal depres-
sion, pregnancy loss), (c) that used identical or similar assessments, and (d) that used OCBT.

Data extraction
The characteristics of the identified trials and the elements of the OCBT interventions
were extracted from each study through structure summaries as: location where the study
was conducted, number of participants, type of assessments used and methods of diag-
nosis, type of intervention that was used, number of sessions for each study, and methods
for recruiting and randomizing participants.

Data analysis
Comprehensive Meta-Analysis v. 3 was used to analyze the data. The effects of the
interventions were evaluated using the standardized mean difference (Borenstein et al.
2009). To compute the standardized mean difference, the following were extracted from
studies means, standard deviations and size of participant population from both inter-
vention and control group. Based on the instruments used to assess depression, a negative
effect would suggest the effectiveness of OCBT in reducing the severity of PD.

Results
Selected studies
We included six studies that corresponded to our pre-established criteria of inclusion and
exclusion (Figure 1). A number of 635 patients were treated through the internet in the six
studies included in the analysis, all participants had children up to 1-year-old and were
randomized with the help of a computer program before participation.
6 M. ROMAN ET AL.

These studies used OCBT interventions in the form of online self-help with telephone
or internet-based guidance for women with PD symptomatology. Out of the six studies,
five were published in specialized journals (Milgrom et al. 2016; O‘Mahen et al. 2013,
2014; Pugh, Hadjistavropoulos, and Dirkse 2016; Sheeber et al. 2012), and one of them
(Bagnall 2014) was available through an unpublished but online Ph.D. thesis, at Exeter
University in the UK.

Characteristics of included studies

Assessing postpartum depression
The studies investigated the efficacy of OCBT for PD, and PD was measured using: (a)
self-evaluation scales for depression (Edinburgh Postnatal Depression Scale – EPDS;
Patient Health Questionnaire-9 – PHQ-9; Beck Depression Inventory-II – BDI-II) and (b)
structured clinical interviews (Structured Clinical Interview for DSM Disorders – SCID-IV).

Therapeutic intervention and control groups

In all OCBTs delivered, a therapist was present to assist (i.e. limited support was offered by
a contact person through e-mail or telephone) for online access and to help patients under-
stand course-related documents. The number of sessions varied from 6 to 12, and courses of
therapy were standardized. Milgrom et al. (2013), O`Mahen et al. (2014) and Bagnal (2014)
used a manual to guide the contacts during sessions. The contact persons that supported the
patients were instructed to concentrate on the content of the course and to help participants to
understand the use of the techniques. OCBTs were based on cognitive-behavioral strategies:
cognitive restructuring (Milgrom et al. 2016; Pugh, Hadjistavropoulos, and Dirkse 2016;
Sheeber et al. 2012); behavioral activation (Bagnal 2014; O`Mahen 2013, 2014) with additional
elements of psychoeducation (Pugh, Hadjistavropoulos, and Dirkse 2016). The control groups
from the studies were waiting lists (WL) and five control groups receiving the treatment as
usual intervention (TAU).

Reported results in the studies

O`Mahen and his collaborators (2013) reported a significant clinical reduction in the
average severity level of PD symptoms for61.3% of participants from the treatment group
(N= 181) compared to 41.4% of the participants from the group control (N= 162) (Table 2).
A significant statistical difference between groups was also obtained in the O`Mahen et al.
study (2014), with a significant clinical reduction of severity in PD in the intervention group
(N = 37) compared to the control group (N = 34). In both studies, the OCBT was delivered in
11 or 12 sessions.
Milgrom and his collaborators (2016) registered a high effect size of OCBT over the
mean of PD scores in the intervention group (d = 0.83, 95% CI [0.20–1.45]). The efficacy
of the MumMoodBooster intervention for treating PD was assessed based on DSM-IV
diagnosing criteria. The assistance was delivered by psychology specialists, specifically by
three psychology graduates, three clinical psychologists, and one health psychologist.
A total of 21 participants in the treatment group and 22 participants in the control
group completed the evaluations after 12 weeks.
Table 2. Descriptive statistics and information regarding the studies included in the meta-analysis.
Pugh,
Hadjistavropoulos, and
Dirkse 2016
O‘Mahen et al., (2014) Milgrom et al. 2016 TA-
Kara Marie Bagnal, 2014 O‘Mahen et al., 2013 (a) Netmums (b) Mum mood iCBTMaternalDepression Sheeber et al. 2012
Long Term Follow-up of 16 Postnatal-Iba HWD Booster Online Mom Net
months Netmums HWD 15 weeks 17 weeks 12 weeks 10 weeks 26 weeks
Location UK UK UK Australia Canada USA
No. GI 16 months = 29 GI = 181 GI = 37 GI = 21 GI = 25 GI 26 weeks = 35
participants GC 16 months = 30 GC = 162 GC = 34 GC = 22 GC = 24 GC 26 weeks = 35
Mean and GI 16m; 9,03 (4,22) GI; 10,94(5,57) GI; 11,05(4,71) GI; 14,5 (12,2) GI; 8,68 (3,8) GI 26w; 11,4 (10,6)
Standard GC 16m; 10,15 (6,1) GC; 14,28(6,63) GC; 14,26(5,11) GC; 23 (7,5) GC; 12,71 (3,7) GC 26w; 13,3 (9,4)
deviation
Diagnose 2.EPDS ≥13 2.EPDS˃12 2.EPDS ≥13 2.EPDS≥11 2. EPDS≥10 2. PHQ9 ≥ 10/BDI II;
1.DSM severe PD 1. DSM-IV (SCID-IV) severe PD 1. DSM-IV (SCID-IV) minor, moderate and moderate and severe
2.scale moderate and severe PD moderate and severe PD severe PD PD
No. of sessions 12 sessions of 11 sessions of online CBT, 12 sessions of CBT 6 sessions of 7 sessions of CBT 8 sessions of Mama-
delivered NetmumsInterventionHWD. The behavioral activation consisted of behavioral OCBTMumMoodBooster delivered online (TA- Net intervention
program consisted of behavioral (IBA) and treatment for activation classes, optional program consisted of ICBT) for postpartum based on CBT and
activation classes, two optional problems specific to classes and for preventing online sessions and PD. delivered from
classes and one additional class for postnatal period relapses telephonic counseling for -internet therapist distance.
preventing relapses (postnatal-IBA) -additionally, patients using the program. offered support and It is consisted of both
received weekly encouragement and online tutorials and
telephonic assistance from answered questions. telephonic sessions
mental health workers. with qualified trainers
Control group TAU TAU TAU TAU Waiting list (WL) TAU
access to general information on access to general -e-mail, support and -access to internet -information brochure -guidance to access
the chat room information on the chat counseling resources consisted with communitaryagencies
room education for postnatal that offered
education counseling services
and assistance
Size-effect -intervention effect -significant effect -intervention effect -intervention effect Chi-square showed –the interventions
(d = −0.22, 95% CI [−0.72, 0,30]) between groups (d = −0.87 95% CI −1.32- (d = .83, 95% CI differences between the effect is significant
Postnatal group-iBA (n = −0.42) 0.20–1.45). two statistic conditions. according to the
115/181;63%) compared χ2 (1) = 2,93, p = .08, following values
to TAU group (n = 71/ Cramer V = 0.026.
WOMEN & HEALTH

t = −4,03, p < .001,

162;43,8%, P < 0,001). Hedges’ g = 0,89.
(Continued )
7
 8
M. ROMAN ET AL.

Table 2. (Continued).
Pugh,
Hadjistavropoulos, and
Dirkse 2016
O‘Mahen et al., (2014) Milgrom et al. 2016 TA-
Kara Marie Bagnal, 2014 O‘Mahen et al., 2013 (a) Netmums (b) Mum mood iCBTMaternalDepression Sheeber et al. 2012
Long Term Follow-up of 16 Postnatal-Iba HWD Booster Online Mom Net
months Netmums HWD 15 weeks 17 weeks 12 weeks 10 weeks 26 weeks
Recruiting -online -online -online -online -online - screening program
pacients website- ‘Netmums website- ‘Netmums website- ‘Netmums Google AdWords, -posters
Facebook, Twitter and -media
HelthCenters
Randomization randomly and with the help of randomly and with the randomly and with the randomly and with the randomly and with the Individually
a computerized program help of a computerized help of a computerized help of a computerized help of a computerized randomized with
program program program program a report of 1: 1
GI-intervention group; GC – control group; EPDS – Edinburgh Postnatal Depression Scale; PHQ9 – Patient Health Questionnaire-9; BDI II – Beck Depression Inventory-II; DSM-IV (SCID-IV) – Structured
Clinical Interview for DSM Disorders (SCID-IV); TAU – usual intervention group; WL – waiting list.
 WOMEN & HEALTH 9

Bagnall (2014) obtained small and non-significant effects of the intervention (−0.22,
95% CI [−0.72, 0,30]). The authors explained that a longer period was needed to observe
a significant small or medium size effect (Andrews et al. 2010). Also, the size of the groups
was relatively small, 29 in the treatment group and 30 in the control group, which likely
provided inadequate statistical power to detect this modest effect as statistically significant.
Additional explanations suggest that depressive symptoms naturally dissipate over the
postnatal period without intervention (Heron et al. 2008).
The MomNet interventions (Sheeber et al. 2012) had a significant large effect (t = −4.03,
p < .001, Hedges’ g = 0.89), leading to decreased intensity of PD in the intervention group
(N = 35), compared to the control group (N = 35). Pugh and collaborators (2016) showed
that the differences between the two groups reached statistical significance (χ2(1) = 2.93,
p = .08, Cramer’s V = 0.026), meaning that PD in the treatment group (N = 24) was
significantly reduced in its severity, compared to the control group (N = 25).

The effectiveness of OCBT for PD symptoms

The average effect size across the six included studies was significant (SE = −0.546, 95% CI
[−0.761; −0.342]), and the effect was the medium size (i.e. below 0.55; Cohen 1988; Lipsey
and Wilson 1993). Significant effects in reducing PD were observed in the intervention
groups with insignificant effects in the control groups.
The level of difference between studies was assessed using a chi-square test and the I2
variability index. The tests of heterogeneity indicated no major variability in results among
the studies which was below 50% (Q = 6.68, df = 5, p = .24, I2 = 25.19%). The small size of
the indices indicates that we can have confidence that the effects of the tested interven-
tions were accurate and reliable (Borenstein et al. 2009). A statistically non-significant
Q test associated with a low I2 indicates that the low variability in the magnitude of the
effect size among studies was likely due to sampling error. The existent differences can be
further explained by the fact that the sample sizes were larger in the O`Mahen et al. (2014)
study (Figure 2).

Publication bias
Publication bias is a potential problem for any meta-analysis due to the variety of methods
used in studies. In the present review, we investigated publication bias through the funnel
plot (Figure 3). The funnel plot graphic was symmetrical, indicating that publication bias
was unlikely. Still, because fewer than ten studies were included in the meta-analysis, no
additional tests can be assessed and interpreted (Borenstein et al. 2009).

Discussion
After analyzing the contribution of the available international studies, we can conclude that
substantial empiric evidence exists to support the use of OCBT for PD symptoms and that data
were consistent regarding its effectiveness. Among the first meta-analyses that investigated the
effectiveness of OCBT to help mothers with PD symptoms was one by Adey (2016; i.e.“Enjoy
your baby, Internet-based CBT for mothers with babies”, Glasgow University).Results showed
a medium-size effect that favored the intervention group (d = −0,62 (95% CI[−0,80, −0,44]). The
10 M. ROMAN ET AL.

Funnel Plot of Standard Error by Std diff in means

0.0

0.1

Standard Error
0.2

0.3

0.4

-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0

Std diff in means

Figure 3. Funnel plot of published studies in the meta-analysis.

medium effect size of the OCBT intervention obtained in our analysis supports previous
findings and suggests a constant moderate effect.
We believe that the favorable results were found due to the components specific to the
OCBT intervention. One important factor is represented by having therapeutic assistants
to deliver and follow the principles and techniques specific to CBT. Moreover, among the
therapists who delivered the intervention, both specialists and non-specialists were
employed. More specifically, OCBT was delivered and assisted as follows: (a) a clinical
psychologist was involved in monitoring and planning the activity of patients (Bagnall
2014; O`Mahen et al., 2014); (b) a health specialist or a clinical psychologist helped
mothers to understand the OCBT (O`Mahen et al. 2013); (c) two Ph.D. students in
clinical psychology that were supervised by a registered psychologist in CBT assisted
(Pugh, Hadjistavropoulos, and Dirkse 2016); (d) two health supervisors assisted mothers
to understand CBT strategies (Sheeber et al. 2012); and (e) a psychologist, a clinical
psychologist, and a health psychologist helped mothers to use the online intervention
program (Milgrom et al. 2016).
The basic intervention for OCBT is a cognitive restructuring. It is usually delivered
using specific techniques that are responsible for the effectiveness of this therapy.
Similarly, the studies included in the meta-analysis used different forms of techniques
from CBT. We believe that the following techniques are the active components responsible
for the effectiveness of OCBT: (a) behavioral activation, various methods of support,
communication and strategies for managing conflicts and solving problems (Bagnall
2014; O`Mahen et al. 2014); (b) self-monitoring, functional analysis, alternative behaviors
and communication strategies (O‘ Mahen et al. 2013); (c) developing positive thinking and
enhancing pleasurable activities (Milgrom et al. 2016); (d) behavioral activation in devel-
oping interpersonal and cognitive abilities (Sheeber et al. 2012); and (e) cognitive-
behavioral competencies relevant for the adaptation of mothers (Pugh,
Hadjistavropoulos, and Dirkse 2016). In general, most of the courses or indications used
as guidelines for the interventions included both cognitive and behavioral elements.
The reduced number of sessions used in the OCBT indicates that it is similar to
traditional forms of cognitive therapies in that it can reduce the symptoms of PD in
 WOMEN & HEALTH 11

relatively short periods of time. The number of sessions in the interventions reviewed in
the studies for this meta-analysis varied from 6 to 12, and the results showed positive and
significant effects favoring the intervention that had a post-evaluation 10 or 26 weeks after
the intervention was completed. The only study that had a post-evaluation after 10 and 16
months showed a small and non-significant effect size (d = −0.28, 95% CI [−0.79, 0.23]).

Limitations and future direction for research

Although we have shown favorable results for OCBT, some limitations must be consid-
ered. First, taking into consideration the rapid expansion of treatments across the internet,
it is possible that the present project has missed several important studies because the
search was very narrow due to only including OCBT studies. Also, every study reported
different ways of delivery, and none of them used the forms of standard cognitive
therapies – i.e. cognitive therapy (CT), cognitive behavioral therapy (CBT) (Beck,
Freeman, and Denise 1979) or rational emotive behavior therapy (REBT) in CBT (Ellis
and Dryden 1997; Ellis and Grieger 1977).
Second, the follow-up period for the intervention effect was short, making it difficult to
make any conclusions about the stability of the effects over time. Further, future studies
should also investigate whether OCBT effects are stable without the assistance of the
supervisors and/or explore the specific components of the assistance that are active in
reducing PD.
Research could also clarify whether the online interventions are effective for all types of
PD or if they are efficient only for mild to moderate PD. The Health and Clinical Excellence
National Institute recommends using computerized intervention for people with mild PD
(Adey 2016), but we believe that that OCBT can also be useful as an informational source for
those with severe PD. For example, Williams et al. (2013) found evidence supporting iCBT as
effective for reducing symptoms of depression when combined with computerized cognitive –
bias modification. The present meta-analysis included participants with severe PD, but the
results were debatable due to the lack of statistical significance, which likely was the result of
inadequate sample size for the subgroup with severe PD to detect modest but meaningful
reductions as statistically significant.
One of the clinical concerns for OCBT is the difficulty or incapacity to establish a strong
therapeutic alliance in the absence of nonverbal communication. Although previous research
has indicated that face-to-face communication is superior, the debate is ongoing (Lindner
et al. 2014). We believe that OCBTs cannot pretend to be a replacement for face-to-face
therapies, but they do provide various advantages for reducing stigma and limited access to
mental health services. Moreover, mothers can learn practical skills to deal with PD sympto-
matology in a short and practical period of time.
Beyond these limitations, we believe that our results are rather favorable and reliable to
recommend the use of online-guided CBT for PD and that it can be used as an alternative
or be adjunct to psychotherapy. Finally, one of the most frequently cited benefits of OCBT
emphasizes that the online treatment provides comfort and enhanced access for clients
and therapists (Suler 2002) and that OCBT has also the potential to serve people with
limited mobility, time restrictions and limited access to mental health services.
12 M. ROMAN ET AL.

ORCID
Cristina Maria Bostan http://orcid.org/0000-0002-8733-725X

References
Adey, C. 2016. Enjoy your baby- Internet-based CBT for mothers with babies,PhD diss., Glasgow
University Theses Service, UK http://theses.gla.ac.uk/theses@gla.ac.uk
Andrews, G., P. Cuijpers, M. G. Craske, P. McEvoy, and N. Titov. 2010. Computer therapy for the
anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis.
PloS one 5 (10). doi: 10.1371/journal.pone.0013196.
Ashford, M. T., E., . K. Olander, and S. Ayers. 2016. Computer- or web-based interventions for
perinatal mental health: A systematic review. Journal of Affective Disorders 197:134–46.
doi:10.1016/j.jad.2016.02.057.
Austin, M., M. Frilingos, J. Lumley, D. Hadzi-Pavlovic, W. Roncolato, and S. Acland. 2008. Brief
antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depres-
sion and anxiety: A randomised controlled trial. Journal of Affective Disorders 105 (1–3):35–44.
doi:10.1016/j.jad.2007.04.001.
Bagnall, K. M. 2014. Long-term follow-up of netmums HWD: A feasibility randomised controlled
trial of telephone supported online behavioural activation for postnatal depression at 16 months
post-randomisation, Ph. D. dissertation, University of Exeter.
Barak, A., L. Hen, M. Boniel-Nissim, and N. Shapira. 2008. A comprehensive review and a
meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of
Technology in Human Services 26 (2–4):109–60. doi:10.1080/15228830802094429.
Beck, A. T., A. Freeman, and D. D. Denise. 1979. Cognitive therapy of personality disorders.
New York: Guilford Press.
Borenstein, M., L. V. Hedges, J. P. T. Higgins, and H. R. Rothstein. 2009. Introduction to meta-
analysis, 414. John Wiley & Sons, Ltd. doi:10.1002/9780470743386
Butler, A. C., J. E. Chapman, E. M. Forman, and A. T. Beck. 2006. The empirical status of
cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review 26:17–31.
doi:10.1016/j.cpr.2005.07.003.
Cohen, J. 1988. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence
Erlbaum Associates, Publishers.
Cox, J. L., J. M. Holden, and R. Sagovsky. 1987. Detection of postnatal depression: Development of
the 10- item edinburgh postnatal depression scale. British Journal of Psychiatry 150:782–86.
Cuijpers, P., M. Berking, G. Andersson, L. Quigley, A. Kleiboer,And, and K. S. Dobson. 2013. A
meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison
with other treatments. Canadian Journal of Psychiatry 58:376–85. http://journals.sagepub.com/
doi/pdf/10.1177/070674371305800702.
David, D. 2006. Cognitive and behavioral psychotherapy. Iasi: Polirom.
DSM-IV-TR. 2003. Revised text, 4th ed. A. Romela. Bucharest: Publishing House of Free
Psychiatrists Association.
Ellis, A., and R. M. Grieger. 1977. Handbook of rational-emotive therapy. New York: Springer
PublishingCo. http://psycnet.apa.org/record/1986-98458-000.
Ellis, A., and W. Dryden. 1997. The practice of rational emotive behavior therapy . 2nd ed. NewYork:
Springer Publishing Company.
eTherapy.com. 2001. eTherapy.com [Online]. Accessed January 22, 2017. http://www.etherapy.com
Evans, J., J. Heron, H. Francomb, S. Oke, and J. Golding. 2001. Cohort study of depressed mood
during pregnancy and after childbirth. BMJ (Clinical Research Ed.) 323 (7307):257–60. PMID:
11485953.
Fontaine, O. P., and P. Fontaine. 2006. Guide clinique de therapie comportamentaleet cognitive,
494–535. Paris: Retz.
 WOMEN & HEALTH 13

Gaillard, A., Y. Le Strat, L. Mandelbrot, H. Keïta, and C. Dubertret. 2014. Predictors of postpartum
depression: Prospective study of 264 women followed during pregnancy and postpartum.
Psychiatry Research 215:341–46. doi:10.1016/j.psychres.2013.10.003.
Heron, J., T. Deave, J. Evans, and A. Emond. 2008. The impact of maternal depression in pregnancy
on early child development. BJOG: an International Journal of Obstetrics &Gynaecology
115:1043–51. doi:10.1111/j.1471-0528.2008.01752.x.
ICD/International Statistical Classification of Diseases and Health-Related Problems. 1992. Geneva,
10th ed., World Health Organization.
Kersting, A., K. Kroker, and S. Schlicht. 2011. Efficacy of cognitive behavioral internet-based
therapy in parents after the loss of a child during pregnancy: Pilot data from a randomized
controlled trial. Archives of Women‘S Mental Health 14 (6):465. doi:10.1007/s00737-011-0240-4.
Lau, Y., T. P. Htun, S. N. Wong, W. S. W. Tam, and P. Klainin-Yobas. 2017. Therapist-supported
internet-based cognitive behavior therapy for stress, anxiety, and depressive symptoms among
postpartum women: A systematic review and meta-analysis. Journal of Medical Internet Research
19 (4). doi: 10.2196/jmir.6712.
Lee, E. W., F. C. Denison, K. Hor, and R. M. Reynolds. 2016. Web-based interventions for
prevention and treatment of perinatal mood disorders: A systematic review. BMC Pregnancy
and Childbirth 16:38. doi:10.1186/s12884-016-0831-1.
Leigh, B., and J. Milgrom. 2008. Risk factors for antenatal depression, postnatal depression and
parenting stress. BMC Psychiatry 8:24. doi:10.1186/1471-244X-8-24.
Lindner, P., E. L. Olsson., A. Johnsson, M. Dahlinc, M. Andersson, and P. Carlbring. 2014. The
impact of telephone versus e-mail therapist guidance on treatment outcomes, therapeutic alliance
and treatment engagement in Internet-delivered CBT for depression: A randomised pilot trial.
Internet Interventions 1 (4):182–218. doi:10.1016/j.invent.2014.09.001.
Lipsey, M. W., and D. B. Wilson. 1993. The efficacy of psychological, educational, and behavioral
treatment confirmation from meta-analysis. The American Psychological Association. Inc. 48
(12):1181–209
Milgrom, J., B. G. Danaher, A. W. Gemmill, C. Holt, C. J. Holt, J. R. Seeley, M. S. Tyler, J. Ross, and
J. Ericksen. 2016. Internet cognitive behavioral therapy for women with postnatal depression:
A randomized controlled trial of mumMoodBooster. Journal of Medical Internet Research 18 (3):
e54, 1–18. doi:10.2196/jmir.4993.
Milgrom, J., H. Skouteris, T. Worotniuk, A. Henwood, and L. Bruce. 2013. The association between
ante- and postnatal depressive symptoms and obesity in both mother and child: A systematic
review of the literature. Women’s Health Issues 22:e319–e28. doi:10.1016/j.whi.2011.12.001.
Mohammad, B. N., J. Gamble, and P. D. K. Creedy. 2010. Prevalence and factors associated with the
development of antenatal and postnatal depression among Jordanian women. Midwifery 27 (6):
e238–e245. doi:10.1016/j.midw.2010.10.008.
Moher, D., A. Liberati, J. Tetzlaff, and D. D. Altman. 2009. Preferred reporting items for systematic
reviews and meta-analyses: The PRISMA statement. PLoS Medicine 6 (7):e1000097. The PRISMA
Group, Published. doi:10.1371/journal.pmed.1000097.
NICE. 2014a. National institute for health and care excellence. Antenatal and postnatal mental
health: clinical management and service guidance from. https://www.nice.org.uk/guidance/cg192
O‘ Mahen, H. A., J. Woodford, McGinley, F. C. Warren, D. A. Richards, T. R. Lynch, and
R. S. Taylor. 2013. Internet-based behavioral activation—Treatment for postnatal depression
(Netmums): A randomized controlled trial. Journal of Affective Disorders 150:814–22.
doi:10.1016/j.jad.2013.03.005.
O’Mahen, H. A., D. A. Richards, J. Woodford, E. Wilkinson, J. McGinley, R. S. Taylor, and
F. C. Warren. 2014. Netmums: A phase II randomized controlled trial of a guided internet
behavioural activation treatment for postpartum depression. Psychological Medicine 44:1675–89.
doi:10.1017/S0033291713002092.
Pugh, N. E., H. D. Hadjistavropoulos, and D. Dirkse. 2016. A randomised controlled trial of
therapist- assisted, internet-delivered cognitive behavior therapy for women with maternal
depression. PloS one 11 (3):e0149186. doi:10.1371/journal.pone.0149186.
14 M. ROMAN ET AL.

Ruwaard, J. 2012. The efficacy and effectiveness of online CBT. Amsterdam: Department of Clinical
Psychology, University of Amsterdam. http://hdl.handle.net/11245/1.392677.
Sheeber, L. B., J. Seeley, E. G. Feil, B. Davis, E. Sorensen, D. B. Kosty, and P. M. Lewinsohn. 2012.
Development and pilot evaluation of an internet-facilitated cognitive-behavioral intervention for
maternal depression. Journal Consultation and Clinical Psychology 80 (5):739–49. doi:10.1037/
a0028820.
Suler, J. 2002. The basic psychological features of cyberspace.In the psychology of cyberspace.
Accessed January 25, 2017. http://www.rider.edu/suler/psycyber/basicfeat.html
Williams, A. D., S. E. Blackwell, A. Mackenzie, E. A. Holmes, and G. Andrews. 2013. Combining
imagination and reason in the treatment of depression: A randomized controlled trial of
internet-based cognitive-bias modification and internet-CBT for depression. Journal of
Consulting and Clinical Psychology 81 (5):793–99. doi:10.1037/a0033247.
Yonkers, K.A., Wisner, K.L., Stewart, D.E., Oberlander, T.F., Dell, D.L., Stotland, N., Lockwood, C.
2009. The management of depression during pregnancy: A report from the American psychiatric
association and the American College of Obstetricians and Gynecologists. General Hospital
Psychiatry 31 (5):403–13. Internet Research 18(3): e54. doi:10.2196/jmir.499338.
Yozwiak, J. A. 2010. Postpartum depression and adolescent mothers: A review of assessment and
treatment approaches. Journal of Pediatric and Adolescent Gynecology 23 (3):172–78. doi:10.1016/
j.jpag.2009.09.003.