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Effectiveness of the Thinking Healthy Programme for perinatal depression delivered through peers: Pooled analysis of two randomized controlled trials in India and Pakistan.

ABSTRACT:

Background

The Thinking Healthy Programme (THP) is recommended to treat perinatal depression in resource-limited settings, but scale-up is hampered by a paucity of community health workers. THP was adapted for peer-delivery (THPP) and evaluated in two randomized controlled trials in India and Pakistan. Our aim was to estimate the effectiveness of THPP on maternal outcomes across these two settings, and evaluate effect-modification by country and other pre-defined covariates.

Methods

Participants were pregnant women aged?18 years with depression (Patient Health Questionnaire (PHQ-9) score?10), randomized to THPP plus enhanced usual care (EUC) or EUC-only. Primary outcomes were symptom severity and remission (PHQ-9 score<5) 6 months post-childbirth. Secondary outcomes included further measures of depression, disability and social support at 3 and 6 months post-childbirth.

Results

Among 850 women (280 India; 570 Pakistan), 704 (83%) attended 6-month follow-up. Participants in the intervention arm had lower symptom severity (PHQ-9 score adjusted mean difference -0.78 (95% confidence interval -1.47,-0.09)) and higher odds of remission (adjusted odds ratio 1.35 (1.02,1.78)) versus EUC-only. There was a greater intervention effect on remission among women with short chronicity of depression, and those primiparous. There were beneficial intervention effects across multiple secondary outcomes.

Limitations

The trials were not powered to assess effect-modifications. 10-20% of participants were missing outcome data.

Conclusions

This pooled analysis demonstrates the effectiveness, acceptability and feasibility of THPP, which can be scaled-up within a stepped-care approach by engaging with the existing health care systems and the communities to address the treatment gap for perinatal depression in resource-limited settings.

SUBMITTER: Vanobberghen F

PROVIDER: S-EPMC7042347 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Effectiveness of the Thinking Healthy Programme for perinatal depression delivered through peers: Pooled analysis of two randomized controlled trials in India and Pakistan.

Vanobberghen Fiona F Weiss Helen A HA Fuhr Daniela C DC Sikander Siham S Afonso Ejma E Ahmad Ikhlaq I Atif Najia N Bibi Amina A Bibi Tayyaba T Bilal Samina S De Sa Aveena A D'Souza Ethel E Joshi Akankasha A Korgaonkar Priya P Krishna Revathi R Lazarus Anisha A Liaqat Rakshanda R Sharif Maria M Weobong Benedict B Zaidi Ahmed A Zuliqar Shaffaq S Patel Vikram V Rahman Atif A

Journal of affective disorders 20191123

<h4>Background</h4>The Thinking Healthy Programme (THP) is recommended to treat perinatal depression in resource-limited settings, but scale-up is hampered by a paucity of community health workers. THP was adapted for peer-delivery (THPP) and evaluated in two randomized controlled trials in India and Pakistan. Our aim was to estimate the effectiveness of THPP on maternal outcomes across these two settings, and evaluate effect-modification by country and other pre-defined covariates.<h4>Methods</ ...[more]

PMID: 32090783

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Project description:BackgroundRates of perinatal depression (antenatal and postnatal depression) in South Asia are among the highest in the world. The delivery of effective psychological treatments for perinatal depression through existing health systems is a challenge due to a lack of human resources. This paper reports on a trial protocol that aims to evaluate the effectiveness and cost-effectiveness of the Thinking Healthy Programme delivered by peers (Thinking Healthy Programme Peer-delivered; THPP), for women with moderate to severe perinatal depression in rural and urban settings in Pakistan and India.Methods/designTHPP is evaluated with two randomised controlled trials: a cluster trial in Rawalpindi, Pakistan, and an individually randomised trial in Goa, India. Trial participants are pregnant women who are registered with the lady health workers in the study area in Pakistan and pregnant women attending outpatient antenatal clinics in India. They will be screened using the patient health questionnaire-9 (PHQ-9) for depression symptoms and will be eligible if their PHQ-9 is equal to or greater than 10 (PHQ-9 ≥ 10). The sample size will be 560 and 280 women in Pakistan and India, respectively. Women in the intervention arm (THPP) will be offered ten individual and four group sessions (Pakistan) or 6-14 individual sessions (India) delivered by a peer (defined as a mother from the same community who is trained and supervised in delivering the intervention). Women in the control arm (enhanced usual care) will receive health care as usual, enhanced by providing the gynaecologist or primary-health facilities with adapted WHO mhGAP guidelines for depression treatment, and providing the woman with her diagnosis and information on how to seek help for herself. The primary outcomes are remission and severity of depression symptoms at the 6-month postnatal follow-up. Secondary outcomes include remission and severity of depression symptoms at the 3-month postnatal follow-up, functional disability, perceived social support, breastfeeding rates, infant height and weight, and costs of health care at the 3- and 6-month postnatal follow-ups. The primary analysis will be intention-to-treat.DiscussionThe trials have the potential to strengthen the evidence on the effectiveness and cost-effectiveness of an evidence-based psychological treatment recommended by the World Health Organisation and delivered by peers for perinatal depression. The trials have the unique opportunity to overcome the shortage of human resources in global mental health and may advance our understanding about the use of peers who work in partnership with the existing health systems in low-resource settings.Trial registrationPakistan Trial: ClinicalTrials.gov Identifier: NCT02111915 (9 April 2014) India Trial: ClinicalTrials.gov Identifier: NCT02104232 (1 April 2014).

Project description:BackgroundPerinatal depression is highly prevalent in South Asia. Although effective and culturally feasible interventions exist, a key bottleneck for scaled-up delivery is lack of trained human resource. The aim of this study was to adapt an evidence-based intervention so that local women from the community (peers) could be trained to deliver it, and to test the adapted intervention for feasibility in India and Pakistan.MethodsThe study was conducted in Rawalpindi, Pakistan and Goa, India. To inform the adaptation process, qualitative data was collected through 7 focus groups (four in Pakistan and three in India) and 61 in-depth interviews (India only). Following adaptation, the intervention was delivered to depressed mothers (20 in Pakistan and 24 in India) for six months through 8 peers in Pakistan and nine in India. Post intervention data was collected from depressed mothers and peers through 41 in-depth interviews (29 in Pakistan and 12 in India) and eight focus groups (one in Pakistan and seven in India). Data was analysed using Framework Analysis approach.ResultsMost mothers perceived the intervention to be acceptable, useful, and viewed the peers as effective delivery-agents. The simple format using vignettes, pictures and everyday terms to describe distress made the intervention easy to understand and deliver. The peers were able to use techniques for behavioural activation with relative ease. Both the mothers and peers found that shared life-experiences and personal characteristics greatly facilitated the intervention-delivery. A minority of mothers had concerns about confidentiality and stigma related to their condition, and some peers felt the role was emotionally challenging.ConclusionsThe study demonstrates the feasibility of using peers to provide interventions for perinatal depression in two South Asian settings. Peers can be a potential resource to deliver evidence-based psychosocial interventions.Trial registrationPakistan Trial: ClinicalTrials.gov Identifier: NCT02111915 (9 April 2014), India Trial: ClinicalTrials.gov Identifier: NCT02104232 (1 April 2014).

Project description:BackgroundThe negative effects of perinatal depression on the mother and child start early and persist throughout the lifecourse (Lancet 369(9556):145-57, 2007; Am J Psychiatry 159(1):43-7, 2002; Arch Dis Child 77(2):99-101, 1997; J Pak Med Assoc 60(4):329; J Psychosoma Res 49(3):207-16, 2000; Clin Child Fam Psychol Rev 14(1):1-27, 2011). Given that 10-35 % of children worldwide are exposed to perinatal depression in their first year of life (Int Rev Psychiatry 8(1):37-54, 1996), mitigating this intergenerational risk is a global public health priority (Perspect Public Health 129(5):221-7, 2009; Trop Med Int Health 13(4):579-83, 2008; Br Med Bull 101(1):57-79, 2012). However, it is not clear whether intervention with depressed women can have long-term benefits for the mother and/or her child. We describe a study of the effectiveness of a peer-delivered depression intervention delivered through 36 postnatal months, the Thinking Healthy Program Peer-delivered PLUS (THPP+) for women and their children in rural Pakistan.Methods/designThe THPP+ study aims are: (1) to evaluate the effects of an extended 36-month perinatal depression intervention on maternal and index child outcomes using a cluster randomized controlled trial (c-RCT) and (2) to determine whether outcomes among index children of perinatally depressed women in the intervention arm converge with those of index children born to perinatally nondepressed women. The trial is designed to recruit 560 pregnant women who screened positive for perinatal depression (PHQ-9 score ≥10) from 40 village clusters, of which 20 receive the THPP+ intervention. An additional reference group consists of 560 perinatally nondepressed women from the same 40 clusters as the THPP+ trial. The women in the nondepressed group are not targeted to receive the THPP+ intervention; but, by recruiting pregnant women from both intervention and control clusters, we are able to evaluate any carryover effects of the THPP+ intervention on the women and their children. Perinatally depressed women in the THPP+ intervention arm receive bimonthly group-based sessions. Primary outcomes are 3-year maternal depression and 3-year child development indicators. Analyses are intention-to-treat and account for the clustered design.DiscussionThis trial, together with the reference group, has the potential to further our understanding of the early developmental lifecourse of children of both perinatally depressed and perinatally nondepressed women in rural Pakistan and to determine whether intervening with women's depression in the perinatal period can mitigate the negative effects of maternal depression on 36-month child development.Trial registrationTHPP-P ClinicalTrials.gov Identifier: NCT02111915 (registered on 9 April 2014). THPP+ ClinicalTrials.gov Identifier: NCT02658994 (registered on 21 January 2016).SponsorHuman Development Research Foundation (HDRF).

Project description:BackgroundMothers-in-law often provide key childcare support to daughters-in-law during the perinatal period that may enhance maternal mental health. Yet, poor mother-in-law/daughter-in-law relationships may be associated with maternal depression. The extent to which mother-in-law childcare involvement affects perinatal depression may differ across contexts of family conflict.ObjectiveWe explored the relationship between mother-in-law childcare and daughter-in-law perinatal depression in rural Pakistan across contexts of family conflict.MethodsData on 783 women came from the Bachpan Cohort, a birth cohort in Pakistan. Maternally-reported mother-in-law childcare was assessed at 3 and 12 months postpartum using a 24-h recall and categorized into no, low, and high involvement. Major depression was captured at 3 and 12 months using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV. Family conflict was captured using three items from the Life Events Checklist. Log-Poisson models were used to estimate cross-sectional associations between mother-in-law childcare and perinatal depression, stratified by family conflict.ResultsMother-in-law childcare was common in the first year postpartum. The association between mother-in-law childcare and perinatal depression differed by the presence of family conflict and postpartum timing. At 3 months postpartum, low and high mother-in-law childcare (vs no involvement) were associated with a lower prevalence of depression regardless of family conflict. At 12 months postpartum, among families with no conflict, low mother-in-law childcare (vs no involvement) was associated with lower perinatal depression; however, among families with conflict, high mother-in-law childcare was associated with increased perinatal depression.ConclusionOur findings highlight the complexities of associations between mother-in-law childcare support and perinatal depression in the first year after birth. Mother-in-law childcare in the immediate postpartum period was beneficial for mothers. Understanding the source, amount, timing, and context of social support is necessary to inform research and interventions that aim to improve maternal mental health.

Project description:BackgroundThe lack of trained mental health professionals is a key barrier to scale-up of evidence-based psychological interventions in low and middle-income countries. We have developed an app that allows a peer with no prior experience of health-care delivery to deliver the cognitive therapy-based intervention for perinatal depression, the Thinking Healthy Programme (THP). This trial aims to assess the effectiveness and cost-effectiveness of this Technology-assisted peer-delivered THP versus standard face-to-face Thinking Healthy Programme delivered by trained health workers.MethodsWe will employ a non-inferiority stratified cluster randomized controlled trial design comparing the two formats of intervention delivery. A total of 980 women in the second or third trimester of pregnancy with a diagnosis of Major Depressive Episode, evaluated with the Structured Clinical Interview for DSM-V Disorders (SCID), will be recruited into the trial. The unit of randomization will be 70 village clusters randomly allocated in a 1:1 ratio to the intervention and control arms. The primary outcome is defined as remission from major depressive episode at 3 months postnatal measured with the SCID. Data will also be collected on symptoms of anxiety, disability, quality of life, service use and costs, and infant-related outcomes such as exclusive breastfeeding and immunization rates. Data will be collected on the primary outcome and selected secondary outcomes (depression and anxiety scores, exclusive breastfeeding) at 6 months postnatal to evaluate if the improvements are sustained in the longer-term. We are especially interested in sustained improvement (recovery) from major depressive episode.DiscussionThis trial will evaluate the effectiveness and cost-effectiveness of a technology-assisted peer-delivered cognitive behavioral therapy-based intervention in rural Pakistan. If shown to be effective, the novel delivery format could play a role in reducing the treatment gap for perinatal depression and other common mental disorders in LMIC.Trial registrationThe trial was registered at Clinicaltrials.gov (NCT05353491) on 29 April 2022.

Project description:Background:Perinatal depression is associated with negative effects on child behavioural, cognitive and emotional development, birth outcomes, and physical growth. In India, increased priority accorded to mental health programs mean it is now possible to reduce the population-level burden of perinatal depression. In this secondary analysis of two studies, we aimed to describe the epidemiological features of depression among community- and facility-based samples of perinatal women from rural central India, and to describe the help-seeking behaviours from those women who screened positive for depression. Methods:The Community Study was a multi-round population-based cross-sectional survey (n?=?6087). The Facility Study was a multi-round facility-based cross-sectional survey (n?=?1577). Both studies were conducted in Sehore District, Madhya Pradesh between 2013 and 2017. Field workers conducted structured interviews with perinatal women. The questionnaire had sections relating to sociodemographic characteristics, depression screening using the Patient's Health Questionnaire (PHQ9), treatment seeking for depression-related symptoms, and disability. Using data pooled from both studies, we tested each characteristic for association with the total screening score and with screening positive for depression. Results:We identified 224 perinatal women from the Community Study and 130 perinatal women from the Facility Study, of whom 8.8% and 18.5% screened positive for depression, respectively. For the continuous PHQ9 score, there was evidence of a "U" shaped association with age, and positive associations with pregnancy, disability score, suicidality and being a health facility attendee. For the binary PHQ9 score, there was evidence of positive associations with pregnancy, disability score, suicidality and being a health facility attendee. Conclusions:This study highlights where the largest population-level variations in perinatal depression symptoms are present in this Indian sample, for which mental health service provision should be made a priority. Epidemiological evidence generated by this study, as well as new evidence on peer-delivered interventions for perinatal depression, must be utilized by policy-makers to prioritize mental health services for mothers along with maternal and child health services.

Project description:BackgroundPerinatal mental health (PMH) is a worldwide public health issue crossing cultural boundaries. However, the prevalence of PMH conditions vary considerably. These disparities stem in part from poor understanding and stigma surrounding PMH which hinder pregnant women from seeking mental health care and may exacerbate their conditions. Bangladesh, India and Pakistan are South Asian countries with a higher burden of PMH conditions than in the Global North-West and very different social and cultural norms around gender and mental health. The aim of this systematic review (PROSPERO Ref: CRD42020167903) was to identify, synthesise and appraise the available literature on perceptions and attitudes of perinatal (pregnant and postpartum) women, their families and healthcare providers surrounding PMH in Bangladesh, India and Pakistan.MethodsFive electronic databases, MEDLINE, Embase, PsycINFO, Scopus and Web of science, and grey literature were searched using predefined search terms. Qualitative or quantitative articles with a qualitative component reporting perceptions and attitudes surrounding PMH in Bangladesh, India and Pakistan were eligible for inclusion, if published in English between January 2000 and January 2021. The Critical Appraisal Skills Programme Qualitative Research Checklist and Newcastle-Ottawa Scale for cross-sectional studies were used to assess study quality. Findings were synthesised using thematic synthesis, as described by Thomas and Harden 2008.ResultsEight studies were included. Five overarching themes comprising 17 sub-categories were identified. These descriptive themes were: perceived causes of PMH, perceived symptoms of PMH, perceptions of motherhood, accessing PMH care and emotional sharing and coping strategies. Sociocultural expectations underpin many of the themes identified in this review including the importance of familial and societal causes of PMH, emphasis on physical symptoms, sacredness of motherhood, lack of awareness, stigma, shame, limited resources allocated for mental health and lack of emotional sharing.ConclusionsThere is a complex range of perceptions and attitudes around PMH which influence women's experiences and access to PMH care. These findings will inform policy and practice through targeted interventions to tackle stigmatising attitudes and increasing education and training for healthcare providers.

Project description:Rates of perinatal depression in low and middle income countries are reported to be very high. Perinatal depression not only has profound impact on women's health, disability and functioning, it is associated with poor child health outcomes such as pre-term birth, under-nutrition and stunting, which ultimately have an adverse trans-generational impact. There is strong evidence in the medical literature that perinatal depression can be effectively managed with psychological treatments delivered by non-specialists. Our previous research in Pakistan led to the development of a successful perinatal depression intervention, the Thinking Healthy Program (THP). The THP is a psychological treatment delivered by community health workers. The burden of perinatal depression can be reduced through scale-up of this proven intervention; however, training of health workers at scale is a major barrier. To enhance access to such interventions there is a need to look at technological solutions to training and supervision.This is a non-inferiority, single-blinded randomized controlled trial. Eighty community health workers called Lady Health Workers (LHWs) working in a post-conflict rural area in Pakistan (Swat) will be recruited through the LHW program. LHWs will be randomly allocated to Technology-assisted Cascade Training and Supervision (TACTS) or to specialist-delivered training (40 in each group). The TACTS group will receive training in THP through LHW supervisors using a tablet-based training package, whereas the comparison group will receive training directly from mental health specialists. Our hypothesis is that both groups will achieve equal competence. Primary outcome measure will be competence of health workers at delivering THP using a modified ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale immediately post training and after 3 months of supervision. Independent assessors will be blinded to the LHW allocation status.Women living in post-conflict areas are at higher risk of depression compared to the general population. Implementation of evidence-based interventions for depression in such situations is a challenge because health systems are weak and human resources are scarce. The key innovation to be tested in this trial is a Technology-assisted Cascade Training and Supervision system to assist scale-up of the THP.Registered with ClinicalTrials.gov as GCC-THP-TACTS-2015, Identifier: NCT02644902 .

Project description:BackgroundPerinatal mental health issues affect approximately 10% of women in high-income countries and 30% in low- or middle-income countries. This review aims to determine the prevalence of perinatal depression among mothers and fathers in Pakistan and identify associated risk factors.MethodsWe conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We included quantitative studies on the prevalence or incidence of maternal and paternal perinatal depression, including antenatal or postnatal depression in Pakistan, with or without associated risk factors. We performed an electronic search, dual-title/abstract and full-text screening, and data extraction. Analysis was conducted on Revman and JBI SUMARI software. The quality of the included studies was assessed with the NHLBI tool. This review updated a previously published review that included 43 studies, with the last search date of 31st May 2019, now extended to literature published up to June 30, 2023.ResultsConsistent with the previous review, our analysis of 61 studies indicated a pooled prevalence of 37% (95% confidence interval (CI): 30.6-43.6) for maternal antenatal depression. Postnatal depression at different time points, revealed rates of 34.2% (95% CI: 22.7-46.7), 40.9% (95% CI: 0-97.4), and 43.1% (95% CI: 24.4-62.9) at 3, 6 and 12 months, respectively. Paternal postnatal depression was observed at 40.5% (95% CI: 14.9-69) based on two studies. Risk factors for maternal perinatal depression include multiparity, contraceptive failure, inadequate antenatal care, pregnancy-induced hypertension, previous psychiatric illness, passive smoking, drug abuse, low socio-economic status, marital problems, family hardships, recent bereavement, housing difficulties, food insecurity, husband's illiteracy, his unemployment, and being blamed for child disability.ConclusionThe findings reveal a high prevalence of perinatal depression among mothers with very limited evidence of fathers residing in Pakistan, emphasising the need for prospective studies addressing mental health challenges.RegistrationThis review is registered on PROSPERO (CRD42023442581).

Dataset Information

Effectiveness of the Thinking Healthy Programme for perinatal depression delivered through peers: Pooled analysis of two randomized controlled trials in India and Pakistan.

Background

Methods

Results

Limitations

Conclusions

Publications

Effectiveness of the Thinking Healthy Programme for perinatal depression delivered through peers: Pooled analysis of two randomized controlled trials in India and Pakistan.

Similar Datasets

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