Mood and anxiety disorders are common among women of reproductive age (between puberty and menopause, ages 15–44)1 and midlife (ages 45–64) 2–4. Both age groups mark a significant period of transition for women. During the reproductive years, women go through milestones of menstrual cycle, pregnancy, birth, maternity and parenting5. Midlife spans from the natural cessation of reproductive capacity (menopause) until retirement, and is accompanied by a range of family, work and physiological changes that can impact various aspects of a woman's life6. Changes among both age groups, therefore, often include shifts in family structure and dynamics, work responsibilities and satisfaction, relationship dynamics, redistribution of body weight, changes in sexual functioning ,and the emergence of new responsibilities 7–11 .
Nevertheless, research suggests women show increased risk for depression and anxiety during midlife ages relative to reproductive years12. For instance, women during the menopause transition period that typically lasts anywhere from a few months to several years,are at higher risk for anxiety symptoms relative to premenopausal women3,4, particularly women showing low anxiety before menopause2. Women entering the menopause transition period are also twice as likely to develop significant depressive symptoms than women before menopause4, 13–15 although these differences seem to diminish post-menopause14.
Cognitive behavioral therapy (CBT) is considered the “gold standard” non-pharmaceutical intervention for anxiety and depression16. Numerous studies have shown CBT efficacy during various life transitions and challenges including premenstrual dysphoria, postpartum depression, menopause related distress, trauma and grief 17–21.
CBT interventions use various methods (e.g., exposure, cognitive restructuring, behavioral experiments) to challenge maladaptive beliefs and appraisals of internal (e.g., physical sensations, thoughts, feelings, emotions) and external events (e.g., conflict at work, economic crisis)16. In the context of midlife, for instance, CBT interventions may target maladaptive beliefs about aging (e.g., “Aging means I’ll be abandoned”) or menopause (e.g., “Menopause symptoms are shameful”)22,23.
Despite the evidence for its efficacy, several barriers may hinder women from seeking CBT treatment for mental health conditions.These include high cost of face-to-face CBT therapy, limited access to care (particularly for women living in rural or remote areas), transportation or scheduling conflicts (e.g., between work and child rearing commitments) that make it difficult to attend in-person appointments and embarrassment or fear of being stigmatized (e.g. when discussing postpartum depression or menopause-related issues)24,25.
Digital technologies help overcome some of these barriers by providing easily accessible, continuous (24 hours a day), CBT-based interventions from anywhere (with internet connection), at a lower cost than face-to-face interventions that can often be provided anonymously26. Moreover, such interventions often include personalisation capacities and game-like interactive elements27,28) making them attractive to a wide range of audiences. Digital interventions, therefore, have the potential to improve the delivery of evidence-based care to women in need of mental health assistance, thereby narrowing the disparity between the number of individuals who require psychological treatment and those who actually receive it29–31.
Indeed, a substantial body of evidence suggests the efficacy of digital interventions such as computerized and internet-based CBT in treating anxiety and depression symptoms32–34. Studies have demonstrated that online CBT interventions for these disorders are equally effective as traditional face-to-face CBT treatments35. More recent findings support the efficacy and effectiveness of CBT-based mobile health (mHealth) digital technologies in reducing various mental health symptoms36.
“OCD.app, Anxiety, Mood & Sleep'' (ocd.app) is a mobile app on the GGtude platform that includes brief CBT-based daily exercises targeting maladaptive beliefs associated with various mental health symptoms. Eight randomized controlled trials (RCTs)37–44 in various countries (e.g., US, Italy, Spain, Turkey, Israel), as well as real world data analyses 45,46 have consistently linked training on the GGtude platform with significant reductions in a variety of mental health symptoms.
For instance, in a recent fully remote crossover RCT in the USA, Ben-Zeev and colleagues40 have shown that people with serious mental illness (SMI; n = 315) training daily with the GGtude platform for 30 days show reductions in self-reported depression, disability and anxiety as well as an increase in positive recovery attitudes and self-esteem. The waitlist control group participants showed comparable changes in outcome measures after cross over. Evaluating the effectiveness of training with the GGtude platform on participants high in COVID-19 related distress, Akin-Sari and colleagues39 showed app use was associated with reductions in COVID-19 related distress, depression symptoms and associated maladaptive beliefs.
The depression and anxiety modules of ocd.app target maladaptive beliefs that are commonly associated with anxiety and depression symptoms. These beliefs include but are not limited to, beliefs in change, over-monitoring of physical sensations, catastrophization of physical sensations and psychological experiences, overestimation of threat, helplessness and hopelessness, self-criticism, perfectionism and fear of being abandoned. Users engage in a comprehensive program consisting of brief daily exercises lasting only 3 minutes. By discarding anxiety and depression related cognitions (swiping them up) and embracing more adaptive statements (pulling them towards themselves), users increase accessibility of adaptive over maladaptive cognitions and learn to challenge their maladaptive beliefs. Systematically targeting different anxiety and depression related cognitions, in turn, is expected to reduce users’ maladaptive beliefs and related symptoms.
Training on the GGtude platform has been suggested to decrease users' mental health symptoms by altering the balance between adaptive and maladaptive cognitions45. Users' ability to produce and retrieve adaptive self-statements may increase through repeated exposure to such self-statements. Prompting users with maladaptive beliefs while exposing them to unexpected competing cognitions may expedite their reflective processing to adjust their maladaptive beliefs47.
Physical movements involved in the daily categorization exercises (i.e., swiping up or down of cognitions) may also lead to more distinct signals regarding the congruity of adaptive versus maladaptive cognitions to their mental health goals (i.e., embodied cognition)48. In addition, self-statements pairing self-referential pronouns with positive action words may enhance users' implicit positive self-concept49. Finally, brief psychoeducation scripts, such as "The world can feel dangerous. However, constantly searching for danger increases our fears and anxieties. Let's learn to reduce this tendency" may help users understand and reinforce basic principles of cognitive-behavioral therapy50.
The reproductive and midlife periods include many life transitions that may activate maladaptive cognitions and increase the risk for depression and anxiety. Maladaptive cognitions are often associated with the various psychological experiences, physical sensations, potential threats and self-criticism which are integral part of women’s lives during these ages. We hypothesize that brief training exercises targeting maladaptive beliefs and cognitions will be feasible in reducing depression and anxiety symptoms among women in both these significant developmental periods. Despite different trajectories along the way both age groups we expect using the anxiety and depression modules of ocd.app would be associated with reductions in GAD-7 and PHQ-9 scores at both T1 and T-Final assessment points. Stronger effects are expected for women completing all levels of the corresponding modules as they trained longer and increased the activation of adaptive relative to maladaptive cognitions facilitating their retrieval as well as having learned to challenge a greater number of different maladaptive beliefs 45,47.