The ASHA (Hope) Project: Testing an Integrated Depression Treatment and Economic Strengthening Intervention in Rural Bangladesh: A Pilot Randomized Controlled Trial

Alison Karasz, Shabnam Anne, Jena Derakhshani Hamadani, Fahmida Tofail, Alison Karasz, Shabnam Anne, Jena Derakhshani Hamadani, Fahmida Tofail

Abstract

Depression, a debilitating disorder, is highly prevalent among low-income women in low- and middle-income countries. Standard psychotherapeutic approaches may be helpful, but low treatment uptake, low retention, and transient treatment effects reduce the benefit of therapy. This pilot randomized controlled trial examined the effectiveness and feasibility of an integrated depression treatment/economic strengthening intervention. The study took place in two villages in the Sirajganj district in rural Bangladesh. Forty-eight low-income women with depressive symptoms (Patient Health Questionnaire (PHQ-9) score ≥ 10) were recruited and randomized to intervention or control arms. The intervention included a six-month group-based, fortnightly depression management and financial literacy intervention, which was followed by a cash-transfer of $186 (equivalent to the cost of two goats) at 12 months' follow-up. The cash transfer could be used to purchase a productive asset (e.g., agricultural animals). The control arm received no intervention. Findings showed significant reduction in depression scores in the intervention group. The mean PHQ-9 score decreased from 14.5 to 5.5 (B ± SE, -9.2 ± 0.8 95% CI -10.9, -7.5, p < 0.01) compared to no change in the control group. Most other psycho-social outcomes, including tension, self-esteem, hope, social-support, and participation in household economic decision-making, also improved with intervention. An integrated depression treatment and financial empowerment intervention was found to be highly effective among rural low-income women with depression. Next steps involve formal testing of the model in a larger trial.

Keywords: ASHA; Bangladesh; PHQ-9; asset; cash-transfer; depression; matched savings; poverty; self-esteem; structural interventions; tension.

Conflict of interest statement

The authors declare that they have no competing interests.

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Enrollment.

References

    1. Karimli L., Ssewamala F.M., Neilands T.B., Wells C.R., Bermudez L.G. Poverty, economic strengthening, and mental health among AIDS orphaned children in Uganda: Mediation model in a randomized clinical trial. Soc. Sci. Med. 2019;228:17–24. doi: 10.1016/j.socscimed.2019.03.003.
    1. Heflin C.M., Iceland J. Poverty, Material Hardship and Depression. Soc. Sci. Q. 2009;90:1051–1071. doi: 10.1111/j.1540-6237.2009.00645.x.
    1. Goulding A.N., Rosenblum K.L., Miller A.L., Peterson K.E., Chen Y.P., Kaciroti N., Lumeng J.C. Associations between maternal depressive symptoms and child feeding practices in a cross-sectional study of low-income mothers and their young children. Int. J. Behav. Nutr. Phys. Act. 2014;11:75. doi: 10.1186/1479-5868-11-75.
    1. Levy L.B., O’Hara M.W. Psychotherapeutic interventions for depressed, low-income women: A review of the literature. Clin. Psychol. Rev. 2010;30:934–950. doi: 10.1016/j.cpr.2010.06.006.
    1. Miranda J., Green B.L. The need for mental health services research focusing on poor young women. J. Ment. Health Policy Econ. 1999;2:73–80. doi: 10.1002/(SICI)1099-176X(199906)2:2<73::AID-MHP40>;2-3.
    1. Patel V., Rodrigues M., DeSouza N. Gender, Poverty, and Postnatal Depression: A Study of Mothers in Goa, India. Am. J. Psychiatry. 2002;159:43–47. doi: 10.1176/appi.ajp.159.1.43.
    1. Goldman L.S., Nielsen N.H., Champion H.C. Awareness, diagnosis, and treatment of depression. J. Gen. Intern. Med. 1999;14:569–580. doi: 10.1046/j.1525-1497.1999.03478.x.
    1. Ferrari A.J., Charlson F.J., Norman R.E., Patten S.B., Freedman G.D., Murray C.J., Vos T., Whiteford H.A. Burden of Depressive Disorders by Country, Sex, Age, and Year: Findings from the Global Burden of Disease Study 2010. PLoS Med. 2013;10:e1001547. doi: 10.1371/journal.pmed.1001547.
    1. Üstün T.B., Ayuso-Mateos J.L., Chatterji S., Mathers C., Murray C.J.L. Global burden of depressive disorders in the year 2000. Br. J. Psychiatry. 2004;184:386–392. doi: 10.1192/bjp.184.5.386.
    1. Lerman S. The syndemogenesis of depression: Concepts and examples. Med. Anthr. Theory Open Access J. Anthr. Health Illn. Med. 2018;5:56–85. doi: 10.17157/mat.5.4.549.
    1. Sharma A. Syndemics: Health in context. Lancet. 2017;389:881.
    1. Global Gender Gap Report World Economic Forum. World Economic Forum; Geneva, Switzerland: 2015.
    1. Hyde J.S., Mezulis A.H., Abramson L.Y. The ABCs of depression: Integrating affective, biological, and cognitive models to explain the emergence of the gender difference in depression. Psychol Rev. 2008;115:291–313. doi: 10.1037/0033-295X.115.2.291.
    1. Mumford D.B., Saeed K., Ahmad I., Latif S., Mubbashar M.H. Stress and psychiatric disorder in rural Punjab. A community survey. Br. J. Psychiatry J. Ment. Sci. 1997;170:473–478. doi: 10.1192/bjp.170.5.473.
    1. Ogbo F.A., Mathsyaraja S., Koti R.K., Perz J., Page A. The burden of depressive disorders in South Asia, 1990–2016: Findings from the global burden of disease study. BMC Psychiatry. 2018;18:1–11. doi: 10.1186/s12888-018-1918-1.
    1. Buckshee K. Impact of roles of women on health in India. Int. J. Gynecol. Obs. 1997;58:35–42. doi: 10.1016/S0020-7292(97)02887-7.
    1. Jambunathan J. Sociocultural factors in depression in Asian Indian women. Health Care Women Int. 1992;13:261–270. doi: 10.1080/07399339209516001.
    1. Rani M., Bonu S. Rural Indian women’s care-seeking behavior and choice of provider for gynecological symptoms 1334. Stud. Fam. Plan. 2003;34:173–185. doi: 10.1111/j.1728-4465.2003.00173.x.
    1. Rodrigues M., Patel V., Jaswal S., De Souza N. Listening to mothers: Qualitative studies on motherhood and depression from Goa, India. Soc. Sci. Med. 2003;57:1797–1806. doi: 10.1016/S0277-9536(03)00062-5.
    1. Ulrich H. A study of change and depression among Hanik Brahmin women in a South Indian village. Cult. Med. Psychiatry. 1987;11:261–287. doi: 10.1007/BF00048516.
    1. Karasz A. Marriage, Depression and Illness: Sociosomatic Models in a South Asian Immigrant Community. Psychol. Dev. Soc. 2005;17:161–180. doi: 10.1177/097133360501700205.
    1. Slomian J., Honvo G., Emonts P., Reginster J.-Y., Bruyere O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Women’s Health. 2019;15 doi: 10.1177/1745506519844044.
    1. Harpham T., Huttly S., De Silva M.J., Abramsky T. Maternal mental health and child nutritional status in four developing countries. J. Epidemiol. Community Health. 2005;59:1060–1064. doi: 10.1136/jech.2005.039180.
    1. Patel V., Prince M. Global mental health: A new global health field comes of age. JAMA. 2010;303:1976–1977. doi: 10.1001/jama.2010.616.
    1. Patel V., Collins P.Y., Copeland J.R.M., Kakuma R., Katontoka S., Lamichhane J., Naik S., Skeen S. The Movement for Global Mental Health. Br. J. Psychiatry. 2011;198:88–90. doi: 10.1192/bjp.bp.109.074518.
    1. Cuijpers P., Karyotaki E., Reijnders M., Purgato M., Barbui C. Psychotherapies for depression in low- and middle-income countries: A meta-analysis. World Psychiatry. 2018;17:90–101. doi: 10.1002/wps.20493.
    1. Patel V., Weiss H.A., Chowdhary N., Naik S., Pednekar S., Chatterjee S. The effectiveness of a lay health worker led intervention for depressive and anxiety disorders in primary care: The MANAS cluster randomized trial in Goa, India. Lancet. 2010;376:2086. doi: 10.1016/S0140-6736(10)61508-5.
    1. Shidhaye R., Baron E., Murhar V., Rathod S., Khan A., Singh A., Shrivastava S., Muke S., Shrivastava R., Lund C., et al. Community, facility and individual level impact of integrating mental health screening and treatment into the primary healthcare system in Sehore district, Madhya Pradesh, India. BMJ Glob. Health. 2019;4:e001344. doi: 10.1136/bmjgh-2018-001344.
    1. Clark J. Medicalization of global health 1: Has the global health agenda become too medicalized? Glob. Health Action. 2014;7:23998. doi: 10.3402/gha.v7.23998.
    1. Summerfield D. How scientifically valid is the knowledge base of global mental health? BMJ. 2008;336:992–994. doi: 10.1136/.
    1. Rahman A., Malik A., Sikander S., Roberts C., Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: A cluster-randomised controlled trial. Lancet. 2008;372:902–909. doi: 10.1016/S0140-6736(08)61400-2.
    1. Brown G.W., Harris T.O., Kendrick T., Chatwin J., Craig T.K.J., Kelly V., Mander H., Ring A., Wallace V., Uher R. Antidepressants, social adversity and outcome of depression in general practice. J. Affect. Disord. 2010;121:239–246. doi: 10.1016/j.jad.2009.06.004.
    1. Warden D., Rush A.J., Wisniewski S.R., Lesser I.M., Thase M.E., Balasubramani G.K. Income and attrition in the treatment of depression: A STAR*D report. Depress Anxiety. 2009;26:622–633. doi: 10.1002/da.20541.
    1. Jakubovski E., Bloch M.H. Prognostic Subgroups for Citalopram Response in the STAR*D Trial. J. Clin. Psychiatry. 2014;75:738–747. doi: 10.4088/JCP.13m08727.
    1. Falconnier L. Socioeconomic status in the treatment of depression. Am. J. Orthopsychiatry. 2009;79:148–158. doi: 10.1037/a0015469.
    1. Jain F.A., Hunter A.M., Brooks J.O., 3rd, Leuchter A.F. Predictive socioeconomic and clinical profiles of antidepressant response and remission. Depress Anxiety. 2013;30:624–630. doi: 10.1002/da.22045.
    1. Westen D., Novotny C.M., Thompson-Brenner H. The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and Reporting in Controlled Clinical Trials. Psychol. Bull. 2004;130:631–663. doi: 10.1037/0033-2909.130.4.631.
    1. Rahman A., Fisher J., Bower P., Luchters S., Tran T., Yasamy M.T., Saxena S., Waheed W. Interventions for common perinatal mental disorders in women in low- and middle-income countries: A systematic review and meta-analysis. Bull. World Health Organ. 2013;91:593–601I. doi: 10.2471/BLT.12.109819.
    1. Haushofer J., Mudida R., Shapiro J. The Comparative Impact of Cash Transfers and Psychotherapy on Psychological and Economic Well-Being. Springer; Berlin/Heidelberg, Germany: 2019.
    1. Steinert C., Hofmann M., Kruse J., Leichsenring F. Relapse rates after psychotherapy for depression—Stable long-term effects? A meta-analysis. J. Affect. Disord. 2014;168:107–118. doi: 10.1016/j.jad.2014.06.043.
    1. Karasz A. The development of valid subtypes for depression in primary care settings: A preliminary study using an explanatory model approach. J. Nerv. Ment. Dis. 2008;196:289–296. doi: 10.1097/NMD.0b013e31816a496e.
    1. Karasz A. Cultural differences in conceptual models of depression. Soc. Sci. Med. 2005;60:1625–1635. doi: 10.1016/j.socscimed.2004.08.011.
    1. Karasz A., Dempsey K. Health Seeking for Ambiguous Symptoms in Two Cultural Groups: A Comparative Study. Transcult. Psychiatry. 2008;45:415–438. doi: 10.1177/1363461508094674.
    1. Karasz A., Garcia N., Ferri L. Conceptual Models of Depression in Primary Care Patients: A Comparative Study. J. Cross Cult. Psychol. 2009;40:1041–1059. doi: 10.1177/0022022109348782.
    1. Karasz A., Sacajiu G., Garcia N. Conceptual models of psychological distress among low-income patients in an inner-city primary care clinic. J. Gen. Intern. Med. 2003;18:475–477. doi: 10.1046/j.1525-1497.2003.20636.x.
    1. Karasz A., Watkins L. Conceptual Models of Treatment in Depressed Hispanic Patients. Ann. Fam. Med. 2006;4:527–533. doi: 10.1370/afm.579.
    1. Grote N.K., Zuckoff A., Swartz H.A., Bledsoe S.E., Geibel S. Engaging women who are depressed and economically disadvantaged in mental health treatment. Soc. Work. 2007;52:295–308. doi: 10.1093/sw/52.4.295.
    1. Anderson C.M., Robins C.S., Greeno C.G., Cahalane H., Copeland V.C., Andrews R.M. Why Lower Income Mothers Do Not Engage With the Formal Mental Health Care System: Perceived Barriers to Care. Qual. Health Res. 2006;16:926–943. doi: 10.1177/1049732306289224.
    1. Schraufnagel T.J., Wagner A.W., Miranda J., Roy-Byrne P.P. Treating minority patients with depression and anxiety: What does the evidence tell us? Gen. Hosp. Psychiatry. 2006;28:27–36. doi: 10.1016/j.genhosppsych.2005.07.002.
    1. Boshara R. Seven Surprising Findings from the Asset-Building Field. Federal Reserve Bank of St. Louis; St. Louis, MO, USA: 2011.
    1. Bynner J., Paxton W. The Asset-Effect: Institute for Public Policy Research. Institute for Public Policy Research; Newcastle, UK: 2001.
    1. Angeles G., de Hoop J., Handa S., Kilburn K., Milazzo A., Peterman A. Government of Malawi’s unconditional cash transfer improves youth mental health. Soc. Sci. Med. 2019;225:108–119. doi: 10.1016/j.socscimed.2019.01.037.
    1. Haushofer J., Shapiro J. The Short-term Impact of Unconditional Cash Transfers to the Poor: Experimental Evidence from Kenya*. Q. J. Econ. 2016;131:1973–2042. doi: 10.1093/qje/qjw025.
    1. Banerjee A., Duflo E., Goldberg N., Karlan D., Osei R., Parienté W. A multifaceted program causes lasting progress for the very poor: Evidence from six countries. Science. 2015;348:1260799. doi: 10.1126/science.1260799.
    1. Karasz A., Raghavan S., Patel V., Zaman M., Akhter L., Kabita M. ASHA: Using Participatory Methods to Develop an Asset-building Mental Health Intervention for Bangladeshi Immigrant Women. J. Epidemiol. Community Health. 2015;9:501–512.
    1. Werner D., Bower W. Helping Health Workers Learn: A Book of Methods, Aids and Ideas for Workers at the Village Level. Hesperian; Berkeley, CA, USA: 1982.
    1. Spitzer R.L., Kroenke K., Williams J.B. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282:1737–1744. doi: 10.1001/jama.282.18.1737.
    1. Chowdhury A.K., Alam M.N., Ali S.M. Dasherkandi project studies. Demography, morbidity and mortality in a rural community of Bangladesh. Bangladesh Med Res. Counc. Bull. 1981;7:22–39.
    1. Islam M., Ali M., Ferroni P., Underwood P., Alam F. Prevalence of psychiatric disorders in an urban community in Bangladesh. Gen. Hosp. Psychiatry. 2003;25:353–357. doi: 10.1016/S0163-8343(03)00067-7.
    1. Roy T., Lloyd C.E., Parvin M., Mohiuddin K.G.B., Rahman M. Prevalence of co-morbid depression in out-patients with type 2 diabetes mellitus in Bangladesh. BMC Psychiatry. 2012;12:123. doi: 10.1186/1471-244X-12-123.
    1. Karasz A., Patel V.V., Kabita M., Shimu P. “Tension” in South Asian women: Developing a measure of common mental disorder using participatory methods. Prog. Community Health Partnersh. Res. Educ. Action. 2013;7:429–441. doi: 10.1353/cpr.2013.0046.
    1. Sherbourne C.D., Stewart A.L. The MOS social support survey. Soc. Sci. Med. 1991;32:705–714. doi: 10.1016/0277-9536(91)90150-B.
    1. Mason K., Smith H. Women’s Empowerment and Social Context: Resutls from Five Asian Countries. World Bank; Washington, DC, USA: 2003.
    1. Beck A.T., Weissman A., Lester D., Trexler L. The measurement of pessimism: The Hopelessness Scale. J. Consult. Clin. Psychol. 1974;42:861–865. doi: 10.1037/h0037562.
    1. Rosenberg M. Society and the Adolescent Self-Image. Princeton University Press; Princeton, NJ, USA: 1965.
    1. Baum F., Fisher M. Why behavioural health promotion endures despite its failure to reduce health inequities. Sociol Health Illn. 2014;36:213–225. doi: 10.1111/1467-9566.12112.
    1. Holman D., Lynch R., Reeves A. How do health behaviour interventions take account of social context? A literature trend and co-citation analysis. Health. 2018;22:389–410. doi: 10.1177/1363459317695630.
    1. Golden S.D., Earp J.A. Social ecological approaches to individuals and their contexts: Twenty years of health education & behavior health promotion interventions. Health education & behavior: The official publication of the Society for Public Health Education. Health Educ. Behav. 2012;39:364–372.
    1. Blattman C., Jamison J., Sheridan M. Reducing crime and violence: Experimental evidence from cognitive behavioral therapy in Liberia. Am. Econ. Rev. 2015;107:1165–1206. doi: 10.1257/aer.20150503.

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