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Peer-reviewedCC BY-NC-ND 4.0JAMA Network Open

RELAX Perinatal Digital Intervention to Prevent Increasing Anxiety

  • Colette R. Hirsch1,2
  • Brittannia Volkmer1,3
  • Yogini Sawjani1
  • Nathalie Towner1
  • Mary Newburn1
  • Jo Bennett1,4
  • Laura Bridle2,5,6
  • Megan McGovern7,8
  • Louise MacGregor7,8
  • Laura McCabe4
  • Katherine Clark9
  • Sophie Webster5
8 more authors
  • Alison Hylton-Potts10
  • Omar Campbell11
  • Michele Misgalla11
  • Gertrude Seneviratne2
  • Jill Newby12,13
  • Frances Meeten1,2
  • Kimberley Goldsmith7,8
  • Michelle L. Moulds13
13 affiliations
  1. 1Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
  2. 2South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, United Kingdom
  3. 3Faculty of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
  4. 4Department of Women’s and Children’s Health, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, United Kingdom
  5. 5Women’s Health, Kings College Hospital NHS Foundation Trust, London, United Kingdom
  6. 6Oxleas NHS Foundation Trust, Queen Mary’s Hospital, London, United Kingdom
  7. 7Department of Biostatistics & Health Informatics, King’s College London, London, United Kingdom
  8. 8King’s Clinical Trials Unit, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
  9. 9Department of Women and Children’s Health, King’s College London, Weston Education Centre, London, United Kingdom
  10. 10Women’s Health, Epsom and St Helier University Hospitals NHS Trust, London, United Kingdom
  11. 11King’s College Denmark Hill Maternity and Neonatal Voices Partnership, London, United Kingdom
  12. 12Black Dog Institute, Randwick, New South Wales, Australia
  13. 13School of Psychology, Faculty of Science, University of New South Wales, Sydney, Kensington, New South Wales, Australia
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Abstract

Importance: Anxiety disorders affect 1 in 5 pregnant women and birthing people. Cognitive bias modification for interpretation reduces anxiety and repetitive negative thinking (RNT; a risk factor for anxiety) among nonpregnant samples.

Objective: To evaluate whether adding pregnancy-tailored cognitive bias modification for interpretation to usual maternity care (UC) prevents increased anxiety during pregnancy; reduces anxiety, depression, and RNT before and after birth; and improves functioning before and after birth compared with UC.

Design, Setting, and Participants: The RELAX (Reducing Levels of Anxiety) 2-arm, parallel-group, multisite, superiority, phase 2b randomized clinical trial recruited participants from June 2023 to July 2024, with final assessment in April 2025. Participants included pregnant individuals in the UK at 16 to 28 weeks’ gestation, with high RNT and up to moderate anxiety, recruited via antenatal clinics or self-referral.

Intervention: Participants were randomized to the self-led digital intervention (RELAX plus UC), involving twelve 17-minute sessions over 4 weeks, or to UC.

Main Outcomes and Measures: Assessments took place at baseline before randomization (T0) and 4 weeks (T1), 8 weeks (T2), and 36 weeks (T3; 12-24 weeks after birth) after randomization. The primary outcome was anxiety, as assessed by the 7-item Generalized Anxiety Disorder scale (GAD-7) at T2 and as a secondary outcome at T3. Secondary outcomes included RNT (assessed by the 10-item trait version of the Repetitive Thinking Questionnaire [RTQ-10]), depression (general and perinatal, assessed by the Patient Health Questionnaire–9 [PHQ-9] and Edinburgh Postnatal Depression Scale [EPDS]), perinatal anxiety (assessed by the Perinatal Anxiety Screening Scale [PASS]), worry (assessed by the Penn State Worry Questionnaire [PSWQ]), and functioning (assessed by the Work and Social Adjustment Scale [WSAS]). Interpretation bias at T1 was the hypothesized mechanism. Analysis was performed using a modified intention-to-treat approach.

Results: A total of 268 participants were randomized (mean [SD] age 33.7 [3.9] years; 174 [64.9%] married). Anxiety was significantly lower for RELAX participants vs UC (mean GAD-7 difference, –1.5; 95% CI, −2.4 to −0.6; P = .001). Depression (mean PHQ-9 difference, –0.8; 95% CI –1.5 to –0.1; and mean EPDS difference, –1.1; 95% CI, –2.0 to –0.2), RNT (mean RTQ-10 difference, –2.7; 95% CI, –4.5 to –0.9), worry (mean PSWQ difference, –3.6; 95% CI, –5.9 to –1.3), and perinatal anxiety (mean PASS difference, –5.5; 95% CI, –8.2 to –2.8) were significantly lower at T2. Effects on general anxiety (mean GAD-7 difference, –1.0; 95% CI, –1.9 to –0.1), postnatal depression (mean EPDS difference, –1.3; 95% CI, –2.4 to –0.2), and RNT (mean RTQ-10 difference, –2.4; 95% CI, –4.6 to –0.2) were sustained at T3. RELAX promoted more positive interpretations vs UC (mean difference, 2.1; 95% CI, 1.8-2.3) that did not mediate effects at T2 (indirect effect on GAD-7, –0.2; percentile bootstrap 95% CI, –0.4 to 0.1). Functioning did not differ at T2 (mean WSAS difference, –1.0; 95% CI, –2.5 to 0.5) or T3 (mean WSAS difference, –0.8; 95% CI, –2.7 to 1.2), nor did perinatal anxiety (mean PASS difference, –2.1; 95% CI, –5.5 to 1.4), general depression (mean PHQ-9 difference, –0.2; 95% CI, –1.2 to 0.9), or worry (mean PSWQ difference, –1.4; 95% CI, –4.1 to 1.3) at T3.

Conclusions and Relevance: In this randomized clinical trial, anxiety was lower during pregnancy and postnatally for RELAX plus UC participants compared with those receiving UC. Integrating RELAX into maternity care for those at risk of increased anxiety has potential to improve maternal mental health.

Trial Registration: https://www.isrctn.com/ISRCTN12754931

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Cite

BibTeXRIS
BibTeX
@article{hirsch2026relax,
  title = {{RELAX Perinatal Digital Intervention to Prevent Increasing Anxiety}},
  author = {Colette R. Hirsch and Brittannia Volkmer and Yogini Sawjani and Nathalie Towner and Mary Newburn and Jo Bennett and Laura Bridle and Megan McGovern and Louise MacGregor and Laura McCabe and Katherine Clark and Sophie Webster and Alison Hylton-Potts and Omar Campbell and Michele Misgalla and Gertrude Seneviratne and Jill Newby and Frances Meeten and Kimberley Goldsmith and Michelle L. Moulds},
  journal = {JAMA Network Open},
  year = {2026},
  month = nov,
  doi = {10.1001/jamanetworkopen.2026.40518},
  url = {https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2856249},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - RELAX Perinatal Digital Intervention to Prevent Increasing Anxiety
AU  - Colette R. Hirsch
AU  - Brittannia Volkmer
AU  - Yogini Sawjani
AU  - Nathalie Towner
AU  - Mary Newburn
AU  - Jo Bennett
AU  - Laura Bridle
AU  - Megan McGovern
AU  - Louise MacGregor
AU  - Laura McCabe
AU  - Katherine Clark
AU  - Sophie Webster
AU  - Alison Hylton-Potts
AU  - Omar Campbell
AU  - Michele Misgalla
AU  - Gertrude Seneviratne
AU  - Jill Newby
AU  - Frances Meeten
AU  - Kimberley Goldsmith
AU  - Michelle L. Moulds
PY  - 2026
DA  - 2026/11/04
JO  - JAMA Network Open
DO  - 10.1001/jamanetworkopen.2026.40518
UR  - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2856249
AB  - Importance: Anxiety disorders affect 1 in 5 pregnant women and birthing people. Cognitive bias modification for interpretation reduces anxiety and repetitive negative thinking (RNT; a risk factor for anxiety) among nonpregnant samples.  Objective: To evaluate whether adding pregnancy-tailored cognitive bias modification for interpretation to usual maternity care (UC) prevents increased anxiety during pregnancy; reduces anxiety, depression, and RNT before and after birth; and improves functioning before and after birth compared with UC.  Design, Setting, and Participants: The RELAX (Reducing Levels of Anxiety) 2-arm, parallel-group, multisite, superiority, phase 2b randomized clinical trial recruited participants from June 2023 to July 2024, with final assessment in April 2025. Participants included pregnant individuals in the UK at 16 to 28 weeks’ gestation, with high RNT and up to moderate anxiety, recruited via antenatal clinics or self-referral.  Intervention: Participants were randomized to the self-led digital intervention (RELAX plus UC), involving twelve 17-minute sessions over 4 weeks, or to UC.  Main Outcomes and Measures: Assessments took place at baseline before randomization (T0) and 4 weeks (T1), 8 weeks (T2), and 36 weeks (T3; 12-24 weeks after birth) after randomization. The primary outcome was anxiety, as assessed by the 7-item Generalized Anxiety Disorder scale (GAD-7) at T2 and as a secondary outcome at T3. Secondary outcomes included RNT (assessed by the 10-item trait version of the Repetitive Thinking Questionnaire [RTQ-10]), depression (general and perinatal, assessed by the Patient Health Questionnaire–9 [PHQ-9] and Edinburgh Postnatal Depression Scale [EPDS]), perinatal anxiety (assessed by the Perinatal Anxiety Screening Scale [PASS]), worry (assessed by the Penn State Worry Questionnaire [PSWQ]), and functioning (assessed by the Work and Social Adjustment Scale [WSAS]). Interpretation bias at T1 was the hypothesized mechanism. Analysis was performed using a modified intention-to-treat approach.  Results: A total of 268 participants were randomized (mean [SD] age 33.7 [3.9] years; 174 [64.9%] married). Anxiety was significantly lower for RELAX participants vs UC (mean GAD-7 difference, –1.5; 95% CI, −2.4 to −0.6; P = .001). Depression (mean PHQ-9 difference, –0.8; 95% CI –1.5 to –0.1; and mean EPDS difference, –1.1; 95% CI, –2.0 to –0.2), RNT (mean RTQ-10 difference, –2.7; 95% CI, –4.5 to –0.9), worry (mean PSWQ difference, –3.6; 95% CI, –5.9 to –1.3), and perinatal anxiety (mean PASS difference, –5.5; 95% CI, –8.2 to –2.8) were significantly lower at T2. Effects on general anxiety (mean GAD-7 difference, –1.0; 95% CI, –1.9 to –0.1), postnatal depression (mean EPDS difference, –1.3; 95% CI, –2.4 to –0.2), and RNT (mean RTQ-10 difference, –2.4; 95% CI, –4.6 to –0.2) were sustained at T3. RELAX promoted more positive interpretations vs UC (mean difference, 2.1; 95% CI, 1.8-2.3) that did not mediate effects at T2 (indirect effect on GAD-7, –0.2; percentile bootstrap 95% CI, –0.4 to 0.1). Functioning did not differ at T2 (mean WSAS difference, –1.0; 95% CI, –2.5 to 0.5) or T3 (mean WSAS difference, –0.8; 95% CI, –2.7 to 1.2), nor did perinatal anxiety (mean PASS difference, –2.1; 95% CI, –5.5 to 1.4), general depression (mean PHQ-9 difference, –0.2; 95% CI, –1.2 to 0.9), or worry (mean PSWQ difference, –1.4; 95% CI, –4.1 to 1.3) at T3.  Conclusions and Relevance: In this randomized clinical trial, anxiety was lower during pregnancy and postnatally for RELAX plus UC participants compared with those receiving UC. Integrating RELAX into maternity care for those at risk of increased anxiety has potential to improve maternal mental health.  Trial Registration: https://www.isrctn.com/ISRCTN12754931
SN  - 2574-3805
ER  -