Evaluating the overall efficacy of digital health interventions

We welcome the article by Lewkowitz et al1Lewkowitz A.K. Whelan A.R. Ayala N.K. et al.The effect of digital health interventions on postpartum depression or anxiety: a systematic review and meta-analysis of randomized controlled trials.Am J Obstet Gynecol. 2024; 230: 12-43Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar who compared the impact of digital health interventions (DHI) with treatment as usual (TAU) for postpartum depression (PPD) and anxiety (PPA). We were pleased to see the study's clear distinction between and awareness of PPD and PPA. This expanded behavioral health scope may further assist clinicians with individualizing care and optimizing treatments that address the spectrum of mental health disorders in the postpartum period. We would like to propose 3 concepts that may further explain differences that lead to higher lost-to-follow-up (LTFU) rates with DHIs than with TAU. First, there may be an increased ease of leaving DHIs when in noninteractive live formats. It seems that the use of bidirectional communication within the interactive format offers a responsive component and increases patient adherence behavior, thus leading to lower LTFU rates.2O'Cathain A. Drabble S.J. Foster A. et al.Being human: a qualitative interview study exploring why a telehealth intervention for management of chronic conditions had a modest effect.J Med Internet Res. 2016; 18: e163Crossref Scopus (19) Google Scholar We recommend further review that compares the rates of attrition between the interactive DHI treatment (interaction with the clinician, ie, including face to face video chat, online audio, or telephone communication) and the noninteractive DHI treatment (ie, online videos and audio recordings, self-guided modules, or exercise tools). Furthermore, it may be helpful to investigate a hybridized model of treatment that combines the components of TAU and DHI used to treat PPD and PPA. Second, a closer inspection of the range of PPD and PPA scores may explicate the increased ease of leaving DHIs. Participant scores at the ends of the spectrum for PPD or PPA assessments could offer additional insight.3Mitchell S. Mitchell R. Shannon C. Dorahy M. Hanna D. Effects of baseline psychological symptom severity on dropout from trauma-focused cognitive behavior therapy for posttraumatic stress disorder: a meta-analysis.Traumatology. 2023; 29: 112-124Crossref Scopus (3) Google Scholar For the patients at the higher end, they could feel overwhelmed or feel that the current treatment is not sufficient, thus leading to discontinuation. Conversely, the participants at the lower end could feel that the temporary use of DHI ameliorated symptoms sufficiently for the participants to continue their daily lives, thus leading to discontinuation. To further explore this idea, we would be interested in the comparative analysis of the severity range of scores for PPD or PPA at the beginning of the intervention and the last recorded score before discontinuation. Third, LTFU rates may indeed be impacted by a myriad of contributing factors that impact the accessibility to the internet and devices. Although a significant amount of people in the United States have stable access to both resources, there is still a considerable proportion without access or inconsistent access. For example, during the COVID-19 pandemic, the rapid transition from in-person to virtual learning further exposed the disparities in accessing electronic devices and the internet in rural areas. Some solutions included student loaner devices, and in some cases, the only Wi-Fi access was provided through school buses stationed at designated locations within the neighborhood.4Chaabane S. Doraiswamy S. Chaabna K. Mamtani R. Cheema S. The impact of COVID-19 school closure on child and adolescent health: a rapid systematic review.Children (Basel). 2021; 8: 415PubMed Google Scholar Hence, we would also be interested in further evaluation of the differences among LTFU rates between developed countries vs developing countries. In conclusion, evaluating the overall efficacy of DHI and identifying and mitigating any causes for attrition can contribute to monumental improvements in maternal and infant health. Perinatal digital mental health interventions: further analysis of risk factors for high loss-to-follow-up ratesAmerican Journal of Obstetrics & GynecologyPreviewWe thank Ms Humayun and Dr Callins for their favorable response to our meta-analyses that examined the effect of digital health interventions (DHI) on symptoms of postpartum depression (PPD) and anxiety (PPA).1,2 We agree with their assessment that, overall, the risk of not completing the final study assessment was higher among those randomized to DHIs than among those randomized to treatment as usual (TAU) and that multiple factors likely affected the loss-to-follow-up (LTFU) rates in these studies. Full-Text PDF