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Effectiveness of digital psychological interventions for mental health problems in low-income and middle-income countries: a systematic review and meta-analysis
Open accessAbstract
Background The effectiveness of digital psychological interventions in low-income and middle-income countries (LMICs) remains unclear. We aimed to systematically investigate the available evidence for digital psychological interventions in reducing mental health problems in LMICs. Methods In this systematic review and meta-analysis, we searched PubMed, PsycINFO, Embase, and Cochrane databases for articles published in English from database inception to March 9, 2020. We included randomised controlled trials investigating digital psychological interventions in individuals with mental health problems in LMICs. We extracted data on demographics, inclusion and exclusion criteria, details of the intervention, including the setting, digital delivery method, control group conditions, number of sessions, therapeutic orientation (eg, cognitive therapy or behaviour therapy), presence or absence of guidance, and length of follow-up, and statistical information to calculate effect sizes. If a study reported insufficient data to calculate effect sizes, the corresponding authors were contacted to provide data that could be aggregated. We did random-effects meta-analyses, and calculated the standardised mean difference in scores of digital psychological interventions versus control conditions (Hedges' g ). Quality of evidence was assessed by use of the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary outcome was post-intervention mental health problems, as measured by self-reporting instruments or clinical interviews. This study is registered with PROSPERO, CRD42019137755. Findings We identified 22 eligible studies that were included in the meta-analysis. The included studies involved a total of 4104 participants (2351 who received a digital psychological intervention and 1753 who were in the control group), and mainly focused on young adults (mean age of the study population was 20–35 years) with depression or substance misuse. The results showed that digital psychological interventions are moderately effective when compared with control interventions (Hedges' g 0·60 [95% CI 0·45–0·75]; Hedges' g with treatment as usual subgroup for comparison 0·54 [0·35–0·73]). Heterogeneity between studies was substantial ( I 2 =74% [95% CI 60–83]). There was no evidence of publication bias, and the quality of evidence according to the GRADE criteria was generally high. Interpretation Digital psychological interventions, which have been mostly studied in individuals with depression and substance misuse, are superior to control conditions, including usual care, and are moderately effective in LMICs. However, the considerable heterogeneity observed in our analysis highlights the need for more studies to be done, with standardised implementation of digital psychological intervention programmes to improve their reproducibility and efficiency. Digital psychological interventions should be considered for regions where usual care for mental health problems is minimal or absent. Funding None. Translations For the Persian, Chinese, Hindi, Portuguese, Bahasa, Turkish, Romanian, Spanish and Thai translations of the abstract see Supplementary Materials section.
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“The results add to the growing evidence base for low-threshold digital mental health offers aimed at underserved populations in low- and middle-income countries [20,57].”
From Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial (2024) · cites this paper as [57]
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“…are superior to control conditions, including usual care, there is considerable heterogeneity between studies and more studies with standardized implementation of digital psychological intervention programmes are needed to improve their reproducibility and efficiency (Fu et al., 2020).”
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“Despite the strong evidence base, attempts to integrate DMHSs into primary care systems around the world have met with varying success [12,13], indicating that there remain significant challenges related to service model design, implementation, and regulation.”
BackgroundGhosh, A., Cherian, R. J., Wagle, S., Sharma, P., Kannan, K. R., Bajpai, A., & Gupta, N. (2023) · Journal of Medical Internet Research · doi:10.2196/41005 · Cited by 25
“predominantly in high-income countries [36]; however, systematic reviews on depression and mental health disorders in LMICs have been done by Martínez et al [37] and Fu et al [38], respectively.”
Process model of emotion regulation-based digital intervention for emotional problems
Qu, D., Liu, D., Cai, C., Zhang, X., Yu, J., Zhang, Q., Liu, K., Wei, Z., Tan, J., Cui, Z., et al. (2023) · Digital Health · doi:10.1177/20552076231187476 · Cited by 20
Beneria, A., Santesteban‐Echarri, O., Daigre, C., Tremain, H., Ramos‐Quiroga, J. A., McGorry, P. D., & Álvarez‐Jiménez, M. (2021) · Early Intervention in Psychiatry · doi:10.1111/eip.13226 · Cited by 20
Aemissegger, V., López‐Alcalde, J., Witt, C. M., & Barth, J. (2022) · Journal of Medical Internet Research · doi:10.2196/36978 · Cited by 20
“Thus, iCBT can help patients avoid traveling to physical consultations and can mitigate the shortage of professionals [6,34-36].”
BackgroundPersonalisation and Recommendation for Mental Health Apps: A Scoping Review
Matthews, P., & Rhodes-Maquaire, C. (2024) · Behaviour and Information Technology · doi:10.1080/0144929x.2024.2356630 · Cited by 20
Digital mental health: a potential opportunity to improve health equity in China
Sit, H. F., Chen, W. L., Wu, D., Huang, Y., Xu, D. R., & Hall, B. J. (2024) · The Lancet Public Health · doi:10.1016/s2468-2667(24)00249-4 · Cited by 20
Dominguez-Rodriguez, A., Martínez-Luna, S. C., Hernández Jiménez, M. J., De La Rosa-Gómez, A., Arenas-Landgrave, P., Esquivel Santoveña, E. E., Arzola-Sánchez, C., Alvarez Silva, J., Solis Nicolas, A. M., Colmenero Guadián, A. M., et al. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.644782 · Cited by 18
“In low and middle-income countries where usual care for mental health problems is scarce (Fu et al., 2020), the UX approach is cost wise.”
BackgroundBurchert, S., Alkneme, M. S., Alsaod, A., Cuijpers, P., Heim, E., Hessling, J., Hosny, N., Sijbrandij, M., van’t Hof, E., Ventevogel, P., et al. (2024) · PLoS Medicine · doi:10.1371/journal.pmed.1004460 · Cited by 18
Gitonga, I., Desmond, D. M., Duda, N., & Maguire, R. (2022) · Psycho-Oncology · doi:10.1002/pon.6019 · Cited by 17
“Technology‐based approaches to care, such as connected health (CH), may help overcome challenges by facilitating increased access to individualised support.(4,16) CH is a fast‐growing paradigm in healthcare innovation where devices, interventions and services are designed around patients' needs through efficient data…”
BackgroundListiyandini, R. A., Andriani, A., Afsari, N., Krisnamurthi, P. B. U., Moulds, M. L., Mahoney, A., & Newby, J. M. (2024) · Mindfulness · doi:10.1007/s12671-024-02346-1 · Cited by 27
“However, research in LMICs remains limited (Fu et al., 2020).”
Weng, J. H., Hu, Y., Heaukulani, C., Tan, C., Chang, J. K., Phang, Y. S., Rajendram, P., Tan, W. M., Loke, W. C., & Morris, R. J. T. (2024) · Journal of Medical Internet Research · doi:10.2196/44443 · Cited by 18
“Wearable devices and smartphones provide increased accessibility and less-stigmatizing avenues for mental health care [9], and there is evidence to support the use of internet-based interventions for mental health treatment [10,11] and self-help [12,13].”
BackgroundAn Empathetic AI Coach for Self-Attachment Therapy
Alazraki, L., Ghachem, A., Polydorou, N., Khosmood, F., & Edalat, A. (2021) · IEEE International Conference on Cognitive Machine Intelligence (CogMI) · doi:10.1109/cogmi52975.2021.00019 · Cited by 18
“Moreover, patients in low and middle-income countries and rural areas encounter a further barrier to accessing specialised care, due to low local ratios of mental health professionals per capita [4], [5].”
BackgroundCraig, A. T., Lawford, H. L. S., Miller, M., Chen-Cao, L., Woods, L. S., Liaw, S., & Godinho, M. A. (2025) · Journal of Medical Internet Research · doi:10.2196/66288 · Cited by 21
Tong, A. C. Y., Ho, F. S., Chu, O. H., & Mak, W. W. S. (2023) · Journal of Medical Internet Research · doi:10.2196/39029 · Cited by 19
“A psychological intervention is considered digital when technology is used in its delivery [16].”
Etchevers, M. J., Garay, C. J., Putrino, N., Helmich, N., & Lunansky, G. (2021) · Clinical Psychology in Europe · doi:10.32872/cpe.4519 · Cited by 18
Yen, K. Y., Cheng, J. Y., Jinqiu, L., Toh, Z. A., & He, H. G. (2024) · Supportive Care in Cancer · doi:10.1007/s00520-024-08415-4 · Cited by 18
“…overcome barriers relating to gynaecological cancer-related stigma [69] and practical barriers [70–72], by providing patients with several benefits over traditional in-person interventions, including comfortability, convenience, anonymity, flexible scheduling, and geographic mobility [26, 29, 30].”
Olisaeloka, L., Udokanma, E. E., & Ashraf, A. (2024) · International Journal of Mental Health Systems · doi:10.1186/s13033-024-00642-w · Cited by 22
“Innovative solutions like task-shifting (use of non-mental health professionals), cultural adaptation, and the use of digital technologies have been tested with mixed results [45, 46].”
BackgroundSuicidality in the Arab World: Results from an Online Screener
Daouk, S., Dailami, M., Barakat, S., Awaad, R. Y., Muñoz, R. F., & Leykin, Y. (2023) · Community Mental Health Journal · doi:10.1007/s10597-023-01129-7 · Cited by 18
“The value of Internet resources extends to individuals who are low-income or less educated or those residing in low- and middle-income countries (Brodie et al., 2000; Fu et al., 2020).”
BackgroundDigital Mental Health Amid COVID-19
Balcombe, L., & Leo, D. D. (2021) · Encyclopedia · doi:10.3390/encyclopedia1040080 · Cited by 19
“for young adults with depression or substance misuse in low-income and middle-income countries, found moderate effectiveness when compared with control interventions [21].”
BackgroundUsing the Stay Strong App for the Well-being of Indigenous Australian Prisoners: Feasibility Study
Perdacher, E., Kavanagh, D. J., Sheffield, J. K., Healy, K. L., Dale, P., & Heffernan, E. (2022) · JMIR Formative Research · doi:10.2196/32157 · Cited by 14
“The most widely evaluated group of digital interventions include those that target depression and anxiety in the general population, with greater support for guided digital interventions than unguided [35-41].”
BackgroundGhosh, A., Krishnan, N. C., Kathirvel, S., Pillai, R. R., Basu, D., George, B. B., Aswathy, P. V., Sharma, K., & Kumar, A. (2023) · Asia-Pacific Psychiatry · doi:10.1111/appy.12527 · Cited by 15
Mehjabeen, D., Blignault, I., Taha, P. H., Reavley, N. J., & Slewa‐Younan, S. (2023) · BMC Public Health · doi:10.1186/s12889-023-17395-9 · Cited by 20
“While these challenges are common among migrants and refugees [147–149], culturally tailored technology-mediated platforms, including self-care apps, show promise in transit settings (UMICs and LMICs) with limited mental health services [150, 151].”
BackgroundYoon, S., Goh, H., Low, X. C., Weng, J. H., & Heaukulani, C. (2024) · BMJ Health & Care Informatics · doi:10.1136/bmjhci-2024-101045 · Cited by 16
“19 20 Although there is a plethora of research on the effectiveness of digital platforms in improving mental wellness outcomes, relatively limited attention has been devoted to their relevance and user engagement, particularly concerning the working population.”
Digital Treatment Paths for Substance Use Disorders (SUDs)
Bonfiglio, N. S., Mascia, M. L., & Penna, M. P. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19127322 · Cited by 15
“Due to the considerable heterogeneity observed in the literature about digitals mental health tools, more studies are needed to demonstrate the effectiveness of digital health and to implement standardised digital intervention programs to improve their reproducibility and efficiency [24].”
BackgroundDropping the E: The potential for integrating e-mental health in psychotherapy
Daele, T. V., Best, P., Bernaerts, S., Assche, E. V., & Witte, N. A. J. D. (2021) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2021.02.007 · Cited by 14
“These do not only have a large reach, but can also be integrated with relative ease as a part of current practice (in high-income countries) or address unmet needs (in middle- to low-income countries) [41, 42].”
BackgroundA Narrative Review of Compassion Focused Therapy on Positive Mental Health Outcomes
Kotera, Y., Beaumont, J., Edwards, A., Cotterill, M., Kirkman, A., Tofani, A. C., McPhilbin, M., Takhi, S. K., Barnes, K., Todowede, O. O., et al. (2024) · Behavioral Sciences · doi:10.3390/bs14080643 · Cited by 17
“Our findings will help researchers and practitioners to understand the current status of CFT on PMH, and to plan future research and applications.”
BackgroundHossain, A. T., Rahman, H., Manna, R. M., Akter, E., Islam, S. H., Hossain, M. A., Ara, T., Usmani, N. G., Chandra, P., Khan, M. H., et al. (2024) · JMIR Pediatrics and Parenting · doi:10.2196/65912 · Cited by 14
“Evidence suggests that digital psychological interventions for mental health problems in developing countries are effective when usual care for mental health problems is minimal [27].”
Nakamura, C. A., Scazufca, M., Moretti, F. A., Didone, T. V. N., Martins, M. M. D. S., Pereira, L. A., de Souza, C. H. Q., de Oliveira, G. M., da Costa, M. O., Machado, M., et al. (2022) · Trials · doi:10.1186/s13063-022-06623-z · Cited by 14
“Evidence of the effectiveness of digital interventions for depressive symptoms is beginning to emerge from LMICs [8], including Brazil [9].”
BackgroundInfluentialhAnrachtaigh, É. Ó., Brown, G. P., Beck, A. F., Conway, R., Jones, H. G., & Angelakis, I. (2024) · Depression and Anxiety · doi:10.1155/2024/5037662 · Cited by 17
“While examining other promising low-cost interventions, such as digital self-help interventions [87, 88, 89] was beyond the focus of the current study, it will also be important to examine how these compare to transdiagnostic interventions in terms of ef fi cacy and cost-effectiveness given the…”
BackgroundTan, C.-H., Koo, A. C., Rahmat, H., Siew, W. F., Cheang, A. W. O., & Sharji, E. A. (2022) · International Journal of Mental Health Promotion · doi:10.32604/ijmhp.2022.025004 · Cited by 17
A call for digital inclusion initiatives in mental health services: An integrative review
Petrou, C., Jameel, L., Nahabedian, N., & Kane, F. (2023) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/jpm.12931 · Cited by 19
Castro‐Ramirez, F., Pérez, M. A. P., McGuire, T. C., Rankin, O., García-Alfaro, M. C., Melchor-Audirac, A., Campuzano, M. L. G., Coady, P., Núñez-Delgado, M. J., Mañaná, J., et al. (2023) · Journal of Behavioral and Cognitive Therapy · doi:10.1016/j.jbct.2023.04.001 · Cited by 13
Kawakami, N., Imamura, K., Watanabe, K., Sekiya, Y., Sasaki, N., Sato, N., & SMART-CBT Project Team (2021) · JMIR Research Protocols · doi:10.2196/30305 · Cited by 12
“This might limit the dissemination and implementation of CBT programs in a low-resource setting, such as small enterprises and middle-and low-income countries [13].”
Berardi, C., Hinwood, M., Smith, A., Melia, A., & Paolucci, F. (2021) · PLoS ONE · doi:10.1371/journal.pone.0259995 · Cited by 17
Wasir, R., Rahma, F. A., Ariyanto, J., Syamsir, S. B., Suparni, S., Raharjo, A., Jannah, F., & Basrowi, R. W. (2025) · The Open Public Health Journal · doi:10.2174/0118749445393540250506115107 · Cited by 12
Olaya, B., Feltz-Cornelis, C. M. V. D., Roijen, L. H., Merecz‐Kot, D., Sinokki, M., Naumanen, P., Shepherd, J., van Krugten, F. C. W., de Mul, M., Staszewska, K., et al. (2022) · Digital Health · doi:10.1177/20552076221131145 · Cited by 13
“There is also a lack of rigorously conducted large-scale RCT using standardized clinical instruments.(18) Additionally, the use of digital technologies to deliver interventions faces high drop-out rates(19) and the problem of identifying participants at risk for mental disorders.”
BackgroundThe evolving landscape of digital mental health: implications for research and practice
Seabrook, E., & Nedeljkovic, M. (2021) · Clinical Psychologist · doi:10.1080/13284207.2021.1977157 · Cited by 12
Svensson, E. M., Osika, W., & Carlbring, P. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100844 · Cited by 12
Metadata
- Authors
- Fu, Z., Burger, H., Arjadi, R., & Bockting, C. L. H.
- Affiliations
- Beijing Normal University (CN)
- University Medical Center Groningen (NL)
- Atma Jaya Catholic University of Indonesia (ID)
- Amsterdam UMC Location University of Amsterdam (NL)
- Corresponding author
- Bockting, Claudi L H
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2020-10
- Volume
- 7
- Issue
- 10
- Pages
- 851-864
- ISSN
- 2215-0366 (ISSN-L)
- PMC
- PMC7455253
- OpenAlex
- W3082767440
- Cited by
- 336
- References
- 49
- Citations by year
- 2026: 39 · 2025: 73 · 2024: 73 · 2023: 57 · 2022: 52 · 2021: 38 · 2020: 4
- FWCI
- 5.94
- Type
- journal article
- Language
- en
- Update notices
- erratum (2021-11-01)
- Open access
- hybrid
- doi.org
- Licence
- Locations
- The Lancet Psychiatry (publishedVersion, other-oa)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (publishedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Pure Amsterdam UMC (submittedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Keywords
- digital psychological interventions, mental illness, low- and middle-income countries, depression, substance abuse, young adults, usual care, cognitive therapy, behavior therapy, intervention effectiveness, usual care comparison, publication bias, quality of evidence, study heterogeneity, GRADE quality assessment, effect size, clinical interview, follow-up duration
- MeSH terms
- Depressive Disorder, Developing Countries, Humans, Psychotherapy, Randomized Controlled Trials as Topic, Outcome Assessment, Health Care, Telemedicine, Substance-Related Disorders
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