Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial

Atif Rahman, Abid Malik, Siham Sikander, Christopher Roberts, Francis Creed, Atif Rahman, Abid Malik, Siham Sikander, Christopher Roberts, Francis Creed

Abstract

Background: The treatment of perinatal depression is a public-health priority because of its high prevalence and association with disability and poor infant development. We integrated a cognitive behaviour therapy-based intervention into the routine work of community-based primary health workers in rural Pakistan and assessed the effect of this intervention on maternal depression and infant outcomes.

Methods: We randomly assigned 40 Union Council clusters in rural Rawalpindi, Pakistan, in equal numbers to intervention or control. Married women (aged 16-45 years) in their third trimester of pregnancy with perinatal depression were eligible to participate. In the intervention group, primary health workers were trained to deliver the psychological intervention, whereas in the control group untrained health workers made an equal number of visits to the depressed mothers. The primary outcomes were infant weight and height at 6 months and 12 months, and secondary outcome was maternal depression. The interviewers were unaware of what group the participants were assigned to. Analysis was by intention to treat. The study is registered as ISRCTN65316374.

Findings: The number of clusters per group was 20, with 463 mothers in the intervention group and 440 in the control group. At 6 months, 97 (23%) of 418 and 211 (53%) of 400 mothers in the intervention and control groups, respectively, met the criteria for major depression (adjusted odds ratio (OR) 0.22, 95% CI 0.14 to 0.36, p<0.0001). These effects were sustained at 12 months (111/412 [27%] vs 226/386 [59%], adjusted OR 0.23, 95% CI 0.15 to 0.36, p<0.0001). The differences in weight-for-age and height-for-age Z scores for infants in the two groups were not significant at 6 months (-0.83 vs -0.86, p=0.7 and -2.03 vs -2.16, p=0.3, respectively) or 12 months (-0.64 vs -0.8, p=0.3 and -1.10 vs -1.36, p=0.07, respectively).

Interpretation: This psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in resource-poor settings.

Figures

Figure 1
Figure 1
Trial profile
Figure 2
Figure 2
Rates of depression in women in the control and intervention groups at 6 months and 12 months

References

    1. Lopez A, Mathers C, Ezzati M, Jamison D, Murray C. Global burden of disease and risk factors. World Bank; Washington: 2006.
    1. Mirza I, Jenkins R. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. BMJ. 2004;328:794.
    1. Rahman A, Iqbal Z, Harrington R. Life events, social support and depression in childbirth: perspectives from a rural community in the developing world. Psychol Med. 2003;33:1161–1167.
    1. Rahman A, Iqbal Z, Bunn J, Lovel H, Harrington R. Impact of maternal depression on infant nutritional status and illness: a cohort study. Arch Gen Psychiatry. 2004;61:946–952.
    1. Rahman A, Bunn J, Lovel H, Creed F. Maternal depression increases infant risk of diarrhoeal illness—a cohort study. Arch Dis Child. 2007;92:24–28.
    1. Churchill R, Hunot V, Corney R. A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief psychological treatments for depression. Health Technol Assess. 2001;5:1–173.
    1. Patel V, Araya R, Chatterjee S. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet. 2007;370:991–1005.
    1. Rojas G, Fritsch R, Solis J. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet. 2007;370:1629–1637.
    1. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet. 2007;370:878–889.
    1. Prince M, Patel V, Saxena S. No health without mental health. Lancet. 2007;370:859–877.
    1. Karim S, Saeed K, Rana MH, Mubbashar M, Jenkins R. Pakistan mental health country profile. Int Rev Psychiatry. 2004;16:83–92.
    1. Bhutta ZA, Thaver D, Akram DS, Khan M. A situation and program analysis of malnutrition among women and children in Pakistan: Can we break the time warp? In: Bhutta ZA, editor. Maternal and child health in Pakistan: challenges and opportunities. Oxford University Press; Oxford: 2004. pp. 151–172.
    1. Rahman A. Challenges and opportunities in developing a psychological intervention for perinatal depression in rural Pakistan: a multi-method study. Arch Womens Ment Health. 2007;10:211–219.
    1. Government of Pakistan . District Census Report of Rawalpindi: 1998. Population Census Organization, Government of Pakistan; Islamabad: 1999.
    1. Ministry of Health, Government of Pakistan . National Programme for Family Planning and Primary Health Care. Ministry of Health, Government of Pakistan; 2007.
    1. First MB, Spitzer RL, Gibbon M. Structured Clinical Interview for Axis I DSM-IV Disorders. Biometrics Research; NewYork: 1994.
    1. Gorman LL, O'Hara MW, Figueiredo B. Adaptation of the structured clinical interview for DSM-IV disorders for assessing depression in women during pregnancy and post-partum across countries and cultures. Br J Psychiatry. 2004;46(suppl):s17–s23.
    1. Rahman A, Iqbal Z, Waheed W, Hussain N. Translation and cultural adaptation of health questionnaires. J Pak Med Assoc. 2003;53:142–147.
    1. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56–62.
    1. Husain N, Bevc I, Husain M, Chaudhry IB, Atif N, Rahman A. Prevalence and social correlates of postnatal depression in a low income country. Arch Womens Ment Health. 2006;9:197–202.
    1. VonKorff M, Ustun TB, Ormel J, Kaplan I, Simon G. Self-report disability in an international primary care study of psychological illness. J Clin Epidemiol. 1996;49:297–303.
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 4th edn. APA; Washington, DC: 1994.
    1. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assess. 1988;52:30–41.
    1. WHO . Physical status: the use and interpretation of anthropometry. Technical report series number 854. World Health Organization; Geneva: 1995.
    1. Donner A, Klar N. Design and analysis of cluster randomization trials in health research. Hodder Arnold; London: 2000.
    1. WHO Use and interpretation of anthropometric indicators of nutritional status. Bull World Health Organ. 1986;64:929–941.
    1. Gorstein J, Sullivan K, Yip R. Issues in the assessment of nutritional status using anthropometry. Bull World Health Organ. 1994;72:273–283.
    1. Rahman A, Creed F. Outcome of prenatal depression and risk factors associated with persistence in the first postnatal year: prospective study from Rawalpindi, Pakistan. J Affect Disord. 2007;100:115–121.
    1. Bolton P, Bass J, Neugebauer R. Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA. 2003;289:3117–3124.
    1. Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Organ. 2004;82:866.
    1. Jacob KS, Sharan P, Mirza I. Mental health systems in countries: where are we now? Lancet. 2007;370:1061–1077.
    1. WHO . Community health workers: what do we know about them? World Health Organization; Geneva: 2007.
    1. Chisholm D, Flisher AJ, Lund C. Scale up services for mental disorders: a call for action. Lancet. 2007;370:1241–1252.

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