Effectiveness of the Thinking Healthy Programme for Perinatal Depression Delivered Through Peers: Pooled Analysis of Two Randomized Controlled Trials in India and Pakistan

Overview

Journal J Affect Disord

Date 2020 Feb 25

PMID 32090783

Citations 16

Authors

Fiona Vanobberghen

Helen A Weiss

Daniela C Fuhr

Siham Sikander

Ejma Afonso

Ikhlaq Ahmad

Najia Atif

Amina Bibi

Tayyaba Bibi

Samina Bilal

Aveena De Sa

Ethel Dsouza

Akankasha Joshi

Priya Korgaonkar

Revathi Krishna

Anisha Lazarus

Rakshanda Liaqat

Maria Sharif

Benedict Weobong

Ahmed Zaidi

Shaffaq Zuliqar

Vikram Patel

Atif Rahman

Affiliations

Soon will be listed here.

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.

Citing Articles

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References

Rahman A, Fisher J, Bower P, Luchters S, Tran T, Yasamy M . 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(8):593-601I. PMC: 3738304. DOI: 10.2471/BLT.12.109819. View

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(5):211-9. PMC: 2424205. DOI: 10.1007/s00737-007-0193-9. View

Posternak M, Miller I . Untreated short-term course of major depression: a meta-analysis of outcomes from studies using wait-list control groups. J Affect Disord. 2001; 66(2-3):139-46. DOI: 10.1016/s0165-0327(00)00304-9. View

Sikander S, Lazarus A, Bangash O, Fuhr D, Weobong B, Krishna R . The effectiveness and cost-effectiveness of the peer-delivered Thinking Healthy Programme for perinatal depression in Pakistan and India: the SHARE study protocol for randomised controlled trials. Trials. 2015; 16:534. PMC: 4659202. DOI: 10.1186/s13063-015-1063-9. View

Fisher J, de Mello M, Patel V, Rahman A, Tran T, Holton S . Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012; 90(2):139G-149G. PMC: 3302553. DOI: 10.2471/BLT.11.091850. View

Singla D, Lazarus A, Atif N, Sikander S, Bhatia U, Ahmad I . "Someone like us": delivering maternal mental health through peers in two South Asian contexts. J Affect Disord. 2014; 168:452-8. PMC: 4157588. DOI: 10.1016/j.jad.2014.07.017. View

Friedrich M . Depression Is the Leading Cause of Disability Around the World. JAMA. 2017; 317(15):1517. DOI: 10.1001/jama.2017.3826. View

Singla D, Weobong B, Nadkarni A, Chowdhary N, Shinde S, Anand A . Improving the scalability of psychological treatments in developing countries: an evaluation of peer-led therapy quality assessment in Goa, India. Behav Res Ther. 2014; 60:53-9. PMC: 4148587. DOI: 10.1016/j.brat.2014.06.006. View

Rojas G, Fritsch R, Solis J, Jadresic E, Castillo C, Gonzalez M . Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet. 2007; 370(9599):1629-37. DOI: 10.1016/S0140-6736(07)61685-7. View

10.

Gelaye B, Kajeepeta S, Williams M . Suicidal ideation in pregnancy: an epidemiologic review. Arch Womens Ment Health. 2016; 19(5):741-51. PMC: 5023474. DOI: 10.1007/s00737-016-0646-0. View

11.

Atif N, Krishna R, Sikander S, Lazarus A, Nisar A, Ahmad I . Mother-to-mother therapy in India and Pakistan: adaptation and feasibility evaluation of the peer-delivered Thinking Healthy Programme. BMC Psychiatry. 2017; 17(1):79. PMC: 5324237. DOI: 10.1186/s12888-017-1244-z. View

12.

Jaskiewicz W, Tulenko K . Increasing community health worker productivity and effectiveness: a review of the influence of the work environment. Hum Resour Health. 2012; 10:38. PMC: 3472248. DOI: 10.1186/1478-4491-10-38. View

13.

Chowdhary N, Sikander S, Atif N, Singh N, Ahmad I, Fuhr D . The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle income countries: a systematic review. Best Pract Res Clin Obstet Gynaecol. 2013; 28(1):113-33. PMC: 3893480. DOI: 10.1016/j.bpobgyn.2013.08.013. View

14.

Singla D, MacKinnon D, Fuhr D, Sikander S, Rahman A, Patel V . Multiple mediation analysis of the peer-delivered Thinking Healthy Programme for perinatal depression: findings from two parallel, randomised controlled trials. Br J Psychiatry. 2019; 218(3):143-150. DOI: 10.1192/bjp.2019.184. View

15.

Haq Z, Iqbal Z, Rahman A . Job stress among community health workers: a multi-method study from Pakistan. Int J Ment Health Syst. 2008; 2(1):15. PMC: 2584063. DOI: 10.1186/1752-4458-2-15. View

16.

Austin M, Frilingos M, Lumley J, Hadzi-Pavlovic D, Roncolato W, Acland S . Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomised controlled trial. J Affect Disord. 2007; 105(1-3):35-44. DOI: 10.1016/j.jad.2007.04.001. View

17.

Field T, Diego M, Hernandez-Reif M . Prenatal depression effects on the fetus and newborn: a review. Infant Behav Dev. 2006; 29(3):445-55. DOI: 10.1016/j.infbeh.2006.03.003. View

18.

Whiteford H, Harris M, McKeon G, Baxter A, Pennell C, Barendregt J . Estimating remission from untreated major depression: a systematic review and meta-analysis. Psychol Med. 2012; 43(8):1569-85. DOI: 10.1017/S0033291712001717. View

19.

Kakuma R, Minas H, van Ginneken N, Dal Poz M, Desiraju K, Morris J . Human resources for mental health care: current situation and strategies for action. Lancet. 2011; 378(9803):1654-63. DOI: 10.1016/S0140-6736(11)61093-3. View

20.

Hendrick V, Altshuler L, Cohen L, Stowe Z . Evaluation of mental health and depression during pregnancy: position paper. Psychopharmacol Bull. 1998; 34(3):297-9. View