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. 2025 Aug 10;42:100866. doi: 10.1016/j.invent.2025.100866

Development and initial evaluation of an ultra-brief digital treatment for perinatal depression and anxiety symptoms

Madelyne A Bisby a,⁎, Noni Jervis a, Alana Fisher a, Amelia J Scott a, Nickolai Titov b, Blake F Dear a
PMCID: PMC12410172  PMID: 40917311

Abstract

Psychological treatments for perinatal depression and anxiety are effective when delivered in-person or remotely. However, new and expectant mothers face considerable barriers to receiving mental health care, especially on an ongoing basis or when delivered in-person. Very brief digital treatments may be able to support women during this time using less time than existing treatments. The current study reports the development and initial evaluation of a therapist-guided digital ultra-brief treatment for perinatal depression or anxiety. The treatment included one online lesson, supporting resources (e.g., practice exercises), and an optional consultation (telephone or secure messaging) with a clinical psychologist. We examined acceptability, satisfaction, and preliminary efficacy in a single-group trial of women with perinatal depression or anxiety symptoms (N = 47). This was accompanied by focus groups of women with lived experience (N = 9) and semi-structured feedback interviews with treatment participants (N = 7). The treatment was feasible to deliver and associated with high completion (90 %) and satisfaction (85 %) rates. Most participants (61 %) completed the treatment without therapist guidance. At 5-weeks post-baseline, participants reported significant reductions in depression (d = 0.79) and anxiety (d = 0.44), noting that the sample reported mild baseline symptom severity. Several areas of improvement to treatment content, delivery, and look and feel were identified. The study supports ultra-brief digital treatments as an acceptable and potentially efficacious way to support women with perinatal depression or anxiety symptoms.

Keywords: iCBT, Digital, Psychological treatment, Perinatal, Depression, Anxiety, Feasibility

Highlights

  • •

    Women with perinatal depression and anxiety face barriers in receiving treatment.

  • •

    We developed an ultra-brief digital treatment for perinatal depression or anxiety.

  • •

    Most participants completed treatment without therapist support.

  • •

    The treatment was feasible, acceptable, and perceived as helpful.

1. Introduction

Pregnancy, childbirth, and early parenthood are amongst the most significant experiences in a woman's life. Yet, these experiences can place considerable physical and psychological demands on women, which can lead to poor mental health. Globally, the prevalence of perinatal depression is estimated to be 26 % (Al-abri et al., 2023), while prevalence estimates for perinatal anxiety range from 15 % to 27 % (Dennis et al., 2017; Fawcett et al., 2019; Roddy Mitchell et al., 2023). The perinatal period is widely considered to span from pregnancy to 12-months post-partum. Perinatal mental health difficulties have been associated with negative impacts for new and expectant mothers, including pregnancy complications, impaired functioning, and increased suicide risk (Dagher et al., 2021). Furthermore, evidence suggests that perinatal mental health difficulties can also impact mother-infant bonding and children's long-term development (Dubber et al., 2015; Rees et al., 2019; Rogers et al., 2020).

Cognitive behaviour therapy (CBT)-based psychological treatments are associated with reductions in perinatal depression and anxiety symptoms at post-treatment, with most studies reporting continued symptom reductions at follow-up (Clinkscales et al., 2023; Cuijpers et al., 2023; Loughnan et al., 2019b; Mancinelli et al., 2022). As highlighted in recent meta-analytic research (Cuijpers et al., 2023), most of the existing perinatal-specific psychological treatments for depression have been designed to be delivered in-person (k = 40/43, 93 %) and require 6–12 sessions (k = 36/43, 84 %). Unfortunately, new and expectant mothers face considerable barriers in accessing mental health care. These include long waitlists for perinatal-specific services, a lack of time in which to travel to and attend treatment sessions around other appointments, and challenges attending in-person services with young infants (Viveiros and Darling, 2019; Webb et al., 2023). Some of these barriers can be overcome by accessing remotely delivered services, such as digital or telehealth treatments, without compromising the efficacy of psychological care (Hedman-Lagerlöf et al., 2023). Digital psychological treatments such as internet-delivered CBT (iCBT) provide participants with immediate access to information and skills at a time and place of their choosing and involve carefully developed online modules alongside support and guidance from a qualified mental health professional (Andersson and Titov, 2014).

Substantially fewer digital psychological treatments have been developed for women with perinatal depression or anxiety compared to the general adult population, although their efficacy has been established (Cuijpers et al., 2023; Loughnan et al., 2019b; Savoia et al., 2025). For instance, in a 3-arm randomised controlled trial (n = 116), a 6-lesson digital CBT treatment with weekly coaching support was superior to 9-weeks of manualized face-to-face individual CBT (ds = 0.38–0.98) and treatment as usual (ds = 0.42–0.83) in reducing depression and anxiety after 9-weeks and for up to 21-weeks (Milgrom et al., 2021). This suggests that digital treatment can be at least as effective as face-to-face treatment during the perinatal period with potentially greater long-term efficacy (noting the high level of education and annual household income of the sample). More recently, the SUMMIT trial (N = 1230) of a 6–8 session behavioural activation treatment demonstrated that remote delivery (via videoconferencing) was non-inferior to in-person delivery in reducing depression and anxiety symptoms (Singla et al., 2025).

Interestingly, even briefer adaptations of digital CBT have successfully been developed for perinatal depression and anxiety. As the briefest protocols to date, Loughnan et al., 2019a, Loughnan et al., 2019c developed acceptable and effective 3-session unguided digital CBT programs for pregnancy and postpartum. Across two randomised controlled trials, the researchers demonstrated that the ultra-brief digital treatments resulted in moderate to large reductions in depression (gs = 0.65–1.42) and large reductions in anxiety (gs = 1.19–1.26) (Loughnan et al., 2019a, Loughnan et al., 2019c). Nevertheless, digital treatments which include 3–6 online modules require considerable time, effort, and motivation to complete at a time when women are taking on and adapting to new and additional commitments. Therefore, there is value in examining whether even briefer digital treatments could deliver similar results with greater acceptability and less burden.

Ultra-brief psychological treatments are designed to deliver evidence-based information and skills in a deliberately limited timeframe, such as in a single session (Schleider et al., 2025; Sperry and Binensztok, 2019). Ultra-brief approaches are supported by analyses identifying rapid symptom improvements frequently occur in the first few weeks of digital and face-to-face treatments (Bisby et al., 2023; Robinson et al., 2020) and real-world attendance of psychological services, whereby a large proportion of clients engage in only one session (Owen et al., 2016; Pirkis et al., 2022). The most comprehensively researched type of ultra-brief treatment is a single-session intervention, in which important information or skills are delivered in a single therapeutic encounter. A large umbrella review including 24 systematic reviews (Schleider et al., 2025) reported that single-session interventions are associated with small reductions in a variety of mental health outcomes (e.g., alcohol use, depression). Other ultra-brief treatments include more than one therapeutic encounter. For example, in a 3-arm randomised controlled trial (n = 242), a 1-lesson digital CBT treatment with therapist contact (telephone or secure messaging) was non-inferior to a 5-lesson digital CBT treatment with 8-weeks of therapist contact and superior to a waitlist control group in reducing depression and anxiety symptoms after 9-weeks (Bisby et al., 2024). Non-inferiority between the two treatments for anxiety symptoms, but not depression symptoms, was maintained 3-months later. These results suggest that some adults with depression and anxiety can significantly benefit from an ultra-brief digital CBT treatment, with especially durable effects for anxiety. To date, and despite their potential, no studies have examined such ultra-brief treatments for women in the perinatal period.

Research indicates that women with perinatal mental health difficulties prefer mental health care which is tailored to the specifics of the perinatal period (Westgate et al., 2023). Therefore, the current study aimed to evaluate a perinatal-specific adaptation of the therapist-guided ultra-brief digital CBT treatment for women experiencing perinatal depression or anxiety symptoms (Bisby et al., 2024). Using a single-group trial design, we examined the acceptability and preliminary efficacy of the treatment for women with perinatal depression or anxiety symptoms. We adopted a single-group design to ensure the treatment was acceptable, and to allow for patient-informed revisions to the treatment protocol prior to definitively testing efficacy in a randomised controlled trial. For these reasons, we retained the therapist guidance component of the ultra-brief treatment. We expected that the treatment would be feasible to deliver and perceived as acceptable and helpful by most participants. In addition, we expected that women would report reductions in depression and anxiety symptoms after treatment, using 4-weeks post-baseline as the primary timepoint. To gather feedback on the treatment content and delivery ahead of further clinical trials, we conducted (1) focus groups with women with lived experience, and (2) semi-structured interviews with treatment participants.

2. Methods

2.1. Participants

Individuals were recruited online using paid social media advertising (Facebook) which directed individuals to read more about the study and apply on the research clinic website (www.ecentreclinic.org). Interested individuals completed an initial online assessment followed by a brief telephone call (M = 15.74 min, SD = 3.81 min, range 11–27 min) with a registered clinical psychologist (NJ) to confirm eligibility. Participants were eligible for inclusion if they were (1) aged 18 years or older; (2) identified as female or assigned female at birth; (3) currently in the perinatal period [defined as pregnancy to 12-months post-partum]; and (4) self-reported experiencing difficulties with depression or anxiety. Exclusion criteria included (1) residing outside Australia; (2) unable to read and understand English; (3) actively suicidal or unable to keep themselves safe; and (4) significant risk of harming someone else. The study was approved by the Macquarie University Human Research Ethics Committee. The clinical trial was prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12623001074684).

2.2. Treatment

Treatment content and delivery were adapted from a previously evaluated ultra-brief digital treatment for the general adult population (Bisby et al., 2024). The treatment included one online lesson in the form of a slide show, comprising 46 slides, one practice guide, case stories, and one additional resource about managing worry and problem solving. The lesson included psychoeducation about the nature of depression and anxiety during the perinatal period, as well as three core strategies: thought challenging, arousal management (including activity scheduling), and graded exposure. The duration of the entire treatment is estimated to take under two hours. Participants were given one month to access the treatment and one week to contact the psychologist after completing the lesson. Adherence was determined based on (a) completing the lesson online, or (b) downloading the lesson to complete offline.

2.3. Therapists

A registered clinical psychologist (NJ) completed the telephone assessments and supported participants during treatment. During the treatment, participants could choose whether to have contact with the therapist. The therapist proactively introduced themselves and invited the participants to contact them, explaining that participants had 1-week after completing the lesson to attend a phone consultation. The number and duration of reciprocal therapeutic interactions between the psychologist and participants were documented (e.g., phone call, messaging exchange).

2.4. Measures

2.4.1. Edinburgh Postnatal Depression Scale (EPDS)

The EPDS was designed to assess symptoms of postpartum depression, but is also sensitive to antenatal depression (Cox et al., 1987; Levis et al., 2020). Total scores range from 0 to 30 and higher scores are indicative of greater depressive symptoms.

2.4.2. Generalized Anxiety Disorder – 7 item (GAD-7)

The GAD-7 assesses anxiety symptoms on a 4-point Likert scale from 0 (not at all) to 3 (nearly every day) (Spitzer et al., 2006). Total scores range from 0 to 21 and higher scores are indicative of greater anxiety.

2.4.3. Patient Health Questionnaire – 9 item (PHQ-9)

The PHQ-9 assesses depressive symptoms on a 4-point Likert scale from 0 (not at all) to 3 (nearly every day) (Kroenke et al., 2001). Total scores range from 0 to 27 and higher scores are indicative of greater depressive symptoms.

2.4.4. Credibility and Expectancy Questionnaire

This 6-item questionnaire was used to assess treatment credibility and expectancy (Devilly and Borkovec, 2000). Participants completed the measure at pre-treatment.

2.4.5. Antenatal Risk Questionnaire (ANRQ)

The ANRQ is 9-item questionnaire is designed to assess key psychosocial factors associated with the risk of perinatal mental health difficulties (Austin et al., 2013). The ANRQ was administered at initial assessment.

2.4.6. Treatment Satisfaction Questionnaire

Treatment satisfaction was assessed using a purpose-built questionnaire which included questions around perceived treatment benefits, areas of improvement, and concurrent service use (Bisby et al., 2024).

2.5. Qualitative feedback

Two focus group consultations comprising nine women with a personal lived experience of pre- or post-natal anxiety or depression were co-facilitated by two authors (AF, NJ). Focus group participants were recruited through a social media invitation by the Centre for Perinatal Excellence (COPE) and were asked to review the treatment materials. Participants represented a diverse range of sociodemographic characteristics (e.g., education level, location), parenting and birth experiences (e.g., pregnant vs. postpartum, history of birth trauma), and clinical characteristics (e.g., treatment history, medication use). The demographic characteristics of focus group participants are reported in Supplementary Table 1. The focus groups were held via Zoom while the trial was ongoing.

For the semi-structured interviews, eligible participants (i.e., those who had completed the lesson) were sent an invitation via email to participate in the interviews; consenting participants were then invited to attend an interview by the clinical psychologist (NJ). Semi-structured interviews were conducted with seven participants; demographic characteristics are reported in Supplementary Table 2. For both the focus groups and interviews, a purpose-designed, semi-structured question guide was used during the group to elicit likes, dislikes, and suggestions for improvement in content, look and feel, and use of additional guides and resources. After the completion of the clinical trial, meeting transcripts and accompanying notes were thematically analysed by one author (NJ or AF). Participants were also asked what they did and did not like about the treatment they received at Week 5. The responses were reviewed and coded using a conventional content analysis approach (Hsieh and Shannon, 2005).

2.6. Statistical analysis

The study was powered to detect a within-group effect size of d ≥ 0.50 in depression and anxiety symptoms from pre-treatment to post-treatment (4-weeks later). A minimum of 27 participants was required when alpha was set at 0.05 and power was set at 0.80. Analyses were conducted with the intent-to-treat sample (i.e., all participants who completed pre-treatment). Multiple imputation was used to handle missing data; baseline symptom severity and lesson completion were entered as predictors (Karin et al., 2021). Generalized estimating equations with a gamma distribution, log-link function, and unstructured working correlation matrix were used to examine symptom change over time (pre-treatment, 2 weeks later [Week 3], and 4 weeks later [Week 5, primary timepoint]). We reported mean difference, Cohen's d, and percentage change. We considered a ≥ 30 % reduction in symptoms to be a clinically meaningful improvement in symptoms and report the proportion of participants who achieved this after 2-weeks and after 4-weeks.

3. Results

3.1. Sample characteristics

Between March to June 2024, 82 individuals completed an online assessment, and 47 eligible and consenting participants were subsequently enrolled in treatment following telephone interview (57.3 %) (see Fig. 1). The sample had an average age of 33.53 years, almost all participants were in a married or de facto relationship (n = 45, 96 %), all participants had received a university education (n = 47, 100 %), most were employed full-time (n = 32, 68 %), and most resided in a capital city or surrounding suburbs (n = 32, 68 %; see Table 1). Most of the sample self-identified Oceania to describe their ethnicity (n = 22, 47 %) and had at least one child (n = 42, 89 %). Almost half the sample had had at least two pregnancies (n = 22, 47 %), while a third of participants reported a prior traumatic birth experience (n = 17, 36 %). Few participants were taking medications for mental health (n = 8, 17 %). A third of the sample had never received psychological treatment before (n = 16, 34 %) and reported that their symptoms began prior to pregnancy (n = 21, 45 %). Almost half the sample (n = 20, 43 %) were considered at risk of mental health difficulties according to the ANRQ. On average, the sample reported mild symptoms of depression and anxiety at baseline according to self-report measures. In those participants who completed pre-treatment (N = 38), treatment was perceived as moderately credible (CEQ credibility M = 19.21, SD = 4.67, range 3–27, max score 30) and participants expected it to be somewhat effective (CEQ expectancy M = 14.11, SD = 5.49, range 1–24, max score 28).

Fig. 1.

Fig. 1

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CONSORT Flow diagram.

Table 1.

Baseline demographic and clinical characteristics (n = 47).

N (%)
Age – M (SD) 33.53 (3.80) Number of children
Sex  None 5 (11)
 Female 47 (100)  One 25 (53)
Marital Status  Two or more 17 (36)
 Single 2 (4) Number of pregnancies
 Married or de facto 45 (96)  One 25 (53)
Education  Two or more 22 (47)
 High school or less 0 (0) Experience of birth trauma
 Undergraduate/ associate diploma 3 (6)  No 14 (30)
 Undergraduate degree 28 (60)  Yes 17 (36)
 Postgraduate degree 16 (34)  Not applicable 16 (34)
Employment Medication
 Full-time paid work 32 (68)  No 39 (83)
 Part-time paid work 7 (15)  Yes 8 (17)
 Casual work 1 (2) Mental health treatment
 Student 1 (2)  Never 16 (34)
 At-home parent 5 (11)  Previous, but not current 21 (45)
 Unemployed, seeking work 1 (2)  Current 10 (21)
Location Symptom onset
 Capital city or surrounding suburbs 32 (68)  Prior to pregnancy 21 (45)
 Other urban region 9 (19)  During pregnancy 13 (28)
 Rural or remote 6 (13)  After pregnancy 11 (23)
Ethnicitya  I don't know 2 (4)
 Americas 1 (2) Antenatal Risk
 North-West Europe 9 (19)  ANRQ M (SD) 22.06 (7.94)
 Oceania 22 (47)  ANRQ score ≥ 23 20 (43)
 South-East Asia 8 (17) Symptom scores – M (SD)
 Southern and Central Asia 2 (4)  EPDS 13.00 (4.42)
 Southern and Eastern Europe 2 (4)  GAD-7 8.47 (4.09)
 Sub-Saharan Africa 1 (2)  PHQ-9 8.52 (4.12)
 I would prefer not to answer 3 (6)
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a

Participants could select more than one option.

3.2. Treatment engagement

Almost all participants read the treatment lesson, either online or in a downloadable format (n = 34, 90 %; see Table 3). A majority of participants also completed the other treatment components, including the practice guide (n = 29, 76 %), case stories (n = 28, 74 %), or additional resource (n = 26, 68 %).

Table 3.

Treatment engagement (n = 38).

Treatment component N (%)
Lesson completion 34 (90)
 Online 32 (84)
 Downloadable copy 20 (53)
Practice guide 29 (76)
Case stories 28 (74)
Additional resource 26 (68)
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3.3. Therapist engagement

Less than half of participants completed the course with therapist guidance (n = 15; 39 %). The psychologist spent an average of 12.71 min (SD = 17.72; range 1–63 min) with participants. This included an average of 1.95 private messages (SD = 1.43; range 1–7) and 0.62 telephone calls (SD = 0.68; range 0–2). The consultation occurred an average of 4.00 days after participants completed the lesson (SD = 3.55; range 0–13). On two occasions, the consultation occurred more than one week after completing the lesson (8 days, 13 days).

3.4. Treatment satisfaction

Overall, most participants reported being satisfied or very satisfied with the treatment (85 % [95 % CI 65 %, 107 %]) and that the treatment was sufficient in addressing their mental health difficulties (64 % [95 % CI 44 %, 83 %]). All participants felt the treatment was worth their time (100 % [95 % CI 100 %, 100 %]) and most would recommend the treatment to others (90 % [95 % CI 78 %, 102 %]). While some participants experienced a worsening of their symptoms during the study (14 % [95 % CI 0 %, 27 %]), none attributed this worsening to the study or treatment. Of the 29 participants who completed the Week 5 questionnaires, most participants had not sought other psychological treatment (n = 19). Several participants sought other treatment during the study (n = 2), after the study (n = 5), or both during and after the study (n = 3). No adverse events were reported.

3.5. Qualitative feedback

The question guide and associated feedback from the focus groups and semi-structured interviews with treatment participants are provided in Supplementary Table 3. Revisions made to the treatment package are indicated alongside the feedback; these revisions have been made to the treatment ahead of a Phase II randomised controlled trial. Participants suggested areas for improvement to treatment content, including more examples of diverse family structures, additional prompts to use resources, and adjusting explanations of key skills. Suggested areas of improvement to additional resources included more specific examples (e.g., multiple births, intrusive thoughts), adjusting instructions for activity scheduling, and more space for note taking. Suggested areas for improvement to the look, feel, and accessibility of the treatment included updating the colour scheme, including fillable sections within documents, and reducing the reading level.

Feedback from treatment participants gathered during the post-treatment questionnaires are provided in Table 4. Participants reported several features of the treatment that they liked, including support received from the therapist, the self-paced nature of the treatment, the case stories, and the practice exercises. Participants also reported that some features of the course could be improved, such as providing continued support in applying strategies, and reducing the amount of text. Several features of the treatment had conflicting feedback, including course duration (too quick vs. too slow), level of detail (appropriate vs. insufficient), and accessibility (easy to use vs. hard to load on mobile).

Table 4.

Qualitative feedback.

Component Further information Indicative quote
“What did you like about the course?”
Course content and duration Brief; content was not overwhelming; appropriate amount of information “Bite sized … Could do while breastfeeding”
Level of detail Accessible level of information “Short enough to be easily accessible but long enough to still be informative”
Accessibility Online format; resources available for ongoing review “The course was easy to follow and I was able to make it work around the baby and me”
Therapist support Perceived as supportive and helpful “She provided a valuable listening ear, validated my feelings and suggested many helpful tips (that I need to implement to help myself).”
Self-paced Importance of being able to be completed at own pace and own time “The fact that I could read through it at my own leisure. That's really helpful with a newborn who is unpredictable.”
Case stories Normalising to see other examples; reduced feelings of isolation “The information and case studies provided were detailed and helpful.”
Practice exercises Perceived as useful “… gave activities to put strategies in practice”



“What did you not like about the course?”
Course duration Hard to find time to call psychologist within a brief timeframe; too long and time consuming “I wish I could have been in touch with the psychologists more, but was … trying to navigate being a mum of a three week old too”
Level of detail More examples relating to specific situations; including more coping strategies; course did not apply to specific concerns. “At times that it was short and didn't address my specific personal concerns, however I understand that this is not possible with a course like this one and that is not the purpose of it.”
Accessibility Issues accessing materials on phone “An app would probably be easier …”
Assistance in applying strategies Difficulty remembering what they had learned; addition of a weekly reminder email would be helpful “Perhaps, a short weekly email with some of the tips or materials in the course to remind participants and refresh their memory”
Too much text A lot of reading; preference for audio and video content “A lot of reading mixed media would be better”
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3.6. Treatment outcomes

Participants reported significant reductions in depressive symptoms on the EPDS from pre-treatment to post-treatment (p < .001; see Table 2). Participants reported a 26 % reduction (95 % CI 11 %, 41 %) in EPDS scores and reached a within-groups effect size of d = 0.79 (95 % CI 0.31, 1.25). By Week 5, almost half of participants (42 %, 95 % CI 25 %, 58 %) had experienced a clinically meaningful improvement in depressive symptoms on the EPDS.

Table 2.

Estimated marginal means and clinical improvement metrics.

Mean (SEM) Mean Difference
(95 % CI)		 Percentage Change (95 % CI) Cohen's d
(95 % CI)		 Proportion ≥ 30 % reduction (95 % CI)
Depression Symptoms (EPDS)
Week 1 12.63 (0.67) – – – –
Week 3 10.44 (0.73) 2.19 (0.22, 4.16) 17 (2,33) 0.51 (0.05, 0.96) 36 (20, 52)
Week 5 9.37 (0.67) 3.26 (1.37, 5.15) 26 (11, 41) 0.79 (0.31, 1.25) 42 (25, 58)



Depression Symptoms (PHQ-9)
Week 1 8.97 (0.66) – – – –
Week 3 7.42 (0.70) 1.55 (−0.37, 3.47) 17 (−4, 39) 0.37 (−0.09, 0.82) 42 (25, 58)
Week 5 6.38 (0.57) 2.59 (0.85, 4.33) 29 (10, 48) 0.68 (0.21, 1.14) 55 (36, 75)



Anxiety Symptoms (GAD-7)
Week 1 8.66 (0.57) – – – –
Week 3 6.83 (0.60) 1.83 (0.18, 3.48) 21 (2, 40) 0.51 (0.05, 0.96) 54 (37, 71)
Week 5 7.05 (0.62) 1.61 (−0.07, 3.29) 19 (−1, 38) 0.44 (−0.02, 0.89) 42 (25, 60)
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Similarly, depressive symptoms measured by the PHQ-9 reduced significantly from pre-treatment to post-treatment (p < .001). Participants reported a 29 % reduction (95 % CI 10 %, 48 %) in PHQ-9 scores and reached a within-groups effect size of d = 0.68 (95 % CI 0.21, 1.14). By Week 5, over half of participants (55 %, 95 % CI 36 %, 75 %) had experienced a clinically meaningful improvement in depressive symptoms on the EPDS.

Participants also reported significant reductions in anxiety symptoms on the GAD-7 over time (p < .001). Anxiety scores reduced by 19 % (95 % CI -1 %, 38 %) and reached a within-groups effect size of d = 0.44 (95 % CI -0.02, 0.89). By Week 5, almost half of participants (42 %, 95 % CI 25 %, 60 %) experienced a clinically meaningful improvement in anxiety symptoms on the GAD-7.

4. Discussion

The current study reports the preliminary evaluation of an ultra-brief digital treatment for women with perinatal depression or anxiety symptoms. Although the sample mostly had mild symptoms at baseline, the treatment was associated with high treatment completion, high satisfaction, and significant reductions in depression and anxiety symptoms after 4-weeks. These outcomes were achieved despite a minority of participants receiving therapist guidance, and the relatively brief study period (4-weeks). Overall, the feedback provided by treatment participants and focus group participants were supportive of the potential of the ultra-brief digital treatment approach.

The treatment was feasible to deliver and perceived as acceptable and helpful by most participants. Indeed, the majority of participants read the lesson, engaged with the additional treatment components (e.g., illustrative examples and practice exercises), and expressed satisfaction with the treatment they received. Few participants reported that their symptoms worsened during the study, and none attributed their symptoms worsening to the study or treatment. Notably, there was very limited uptake of concurrent psychological services by participants during the study period. These findings suggest ultra-brief interventions may offer an adequate and accessible alternative for many women, especially those seeking low-burden, self-guided care. This suggestion is consistent with the low uptake of therapist guidance during treatment. This is unlikely to be due to low accessibility, as the psychologist actively contacted participants after lesson completion, and remained accessible for the duration of their participation.

There are several explanations for these findings. One possible explanation for low uptake of therapist guidance may be the unpredictable nature of scheduling during the perinatal period, in which participants are navigating increased demands (e.g., caring for young infants, attending a higher volume of healthcare appointments) which are further compounded by the impacts of depression and anxiety symptoms. These factors may culminate in a reduced capacity to engage with additional services during this time (Cross and Alvarez-Jimenez, 2024), and highlights the need for accessible and effective treatments which do not significantly add to existing demands. On the other hand, the engagement patterns seen in the current study may instead reflect the needs of this particular population; that is, brief and on-demand support that serves as an entry point to mental health services, particularly when symptoms are in the mild range. Indeed, scalable digital treatments could serve to reduce the barriers to accessing care during a period marked by heightened demands. Future research should explore how ultra-brief treatments can complement existing services for perinatal mental health difficulties, either as first-line intervention or as part of a stepped-care model that aligns with individual preferences and symptom severity. Regardless, future research should examine the impact of therapist guidance on the efficacy of digital ultra-brief treatments. The requirement for ultra-brief treatments such as these to include (or at least offer) a clinical consultation has significant implications for scalability and implementation – particularly when the consultation is provided by a highly trained professional (e.g., Clinical Psychologist). Future research could explore whether self-guided adaptations of this treatment may offer a more scalable approach to providing perinatal mental healthcare.

The digital ultra-brief treatment was associated with improvements across depression and anxiety symptom measures. This preliminary efficacy is broadly consistent with the findings of other digital treatments for perinatal depression and anxiety when considering treatment intensity and follow-up periods. The ultra-brief digital treatment in the current study was associated with similar reductions in depression symptoms and larger reductions in anxiety symptoms, compared to an unguided behavioural activation app for antenatal depression in a pilot study (n = 18) after 4-weeks (Vanderkruik et al., 2024). On the other hand, the treatment outcomes in this study appear smaller than those observed for more intensive digital treatments, such as the 6-session MumMoodBooster (which includes weekly coaching calls) after 21-weeks (Milgrom et al., 2021). Loughnan and colleagues developed two 3-session unguided digital CBT programs for depression and anxiety: one for pregnancy and one for postpartum. In a randomised controlled trial of MUMentum Pregnancy (n = 87), the ultra-brief digital treatment was delivered over 4-weeks and associated with large within-group reductions in anxiety (g = 1.19) and depression (g = 0.65–0.81) at post-treatment. Larger improvements were seen in the randomised controlled trial of MUMentum Postnatal (n = 131), in which the ultra-brief digital treatment was delivered over 6-weeks. Significant within-group reductions were reported for anxiety (g = 1.26) and depression (g = 1.41–1.42) (Loughnan et al., 2019a). These comparisons are tentative: some previous trials have used less conservative analysis methods, and the current participant sample reported lower baseline symptom levels, possibly contributing to smaller effect sizes. Nevertheless, there is a need for larger randomised controlled trials with longer follow-up periods to examine who benefits from ultra-brief digital treatments for perinatal depression and anxiety.

This study has several limitations. First, the current sample appeared well-educated and in married/ de facto relationships, limiting the generalizability of these findings. Future research should include broader recruitment pathways, such as through public health or perinatal-specific services, to reach a broader range of women who are experiencing perinatal mental health difficulties. Second, the current sample exhibited mild symptoms of depression and anxiety, and the acceptability and efficacy of the treatment may differ for those with moderate to severe symptoms. A larger randomised controlled trial with a minimum symptom threshold, or with the power to conduct sensitivity analyses according to baseline symptom severity, would be required. Third, due to the preliminary nature of this study we did not double code qualitative data and therefore cannot report inter-rater reliability. Fourth, we did not systematically collect data regarding perinatal status (i.e., prenatal or postnatal). A follow-up randomised controlled trial of the current treatment is underway; sensitivity analyses are planned to examine whether treatment outcomes differ depending on perinatal status.

Ultra-brief digital treatments appear to be feasible and acceptable for women with perinatal depression and anxiety symptoms. Most participants completed the treatment, reported that they found the treatment helpful, and that they were satisfied with the treatment they received. We also found some preliminary support for treatment efficacy; however, definitive randomised controlled trials are required to examine the efficacy of the ultra-brief digital treatment against a control group, and to examine the maintenance of symptom reductions over time. The current sample were highly educated and reported mild symptoms at baseline, potentially impacting the generalisability of these findings. Nevertheless, this study supports the viability of ultra-brief digital treatments as an alternative for women with perinatal depression or anxiety symptoms who are unable, or would prefer not to, commit to longer and more intensive treatments.

Funding

This work was supported by a project grant from the Liptember Foundation. MB is supported by a Macquarie University Research Fellowship.

Declaration of competing interest

MB, BD, and NT are on the editorial team for Internet Interventions.

MB and BD developed the treatment used in the current study but derive no financial benefit.

Acknowledgements

The authors thank the Centre of Perinatal Excellence for recruiting women with lived experience to participate in the focus groups.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.invent.2025.100866.

Appendix A. Supplementary data

Supplementary tables

mmc1.docx (46.8KB, docx)

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