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

Abstract

SummaryBackgroundThe 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.MethodsWe 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.FindingsThe 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).InterpretationThis psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in resource-poor settings.FundingWellcome Trust.

Addressing Behavioral Health Disparities for Somali Immigrants Through Group Cognitive Behavioral Therapy Led by Community Health Workers

“…Cognitive behavioral therapy (CBT) has been widely established as an effective intervention for depression 21,22 . The use of CBT in face-to-face or computerized settings, individually or in groups, has been well established 21,22 , and when delivered by community health workers (CHWs) offers great potential to increase access to psychological support in resource-poor settings 23,24 . In this work we drew on a structured CBT approach 25,26 , which has been established as effective 27 .…”

“…In this work we drew on a structured CBT approach 25,26 , which has been established as effective 27 . It has been successfully adapted for use by CHWs to address mental health concerns in perinatal populations in rural Pakistan 23,24 , showing the effective use of CHWs to deliver such interventions in a Muslim population 23,28 . Task shifting to using CHWs to deliver interventions primarily delivered by behaviorists can be seen as an important aspect of delivering more accessible, efficient, cost-effective services 29,30 .…”

Paid staff or volunteers – does it make a difference? The impact of staffing on child outcomes for children attending community-based programmes in South Africa and Malawi

“…In answer to this lack of specialised skill, many LMIC have adopted task-sharing approaches to service delivery, including the use of non-specialist workers to deliver mental health services [50,51]. There is growing evidence that lay health workers, if specifically trained, can provide some services and care traditionally delivered by mental health professionals [52–56]. However, it has also been noted that staff working with more severe psychological distress require specialised and ongoing training, and supervision [51].…”

Contribution of the Depression in ObaapaVitA and Newhints (DON) Population-based Cohort Study towards Perinatal Depression Epidemiologythe Ghana Model

“…These children and mothers have to be helped using innovative strategies if necessary but without having to re-invent the wheel! Various interventions to tackle perinatal depression have evolved over the years, and evidence appears to be converging on preventive and curative measures using lay community resources particularly in settings with inadequate mental health infrastructure [4][5][6]. Indeed, arguments in favour of scaling up these interventions have been put forward by the new movement for global mental health and the World Health Organisation.…”

“…However, given the dearth of evidence in the use of lay community health workers in improving mental well-being in SSA, plus the fact that only research that is conducted locally is likely to affect awareness and lead to policy change/development [8], we aim to first test the external validity of these interventions in our region. This may require some amount of adaptations to proven and recommended interventions such as the Thinking Healthy Programme [4], or developing workable interventions from scratch. It will also be apt to add value to these interventions by incorporating other interventions that promote child growth and development, which is beginning to gain considerable currency as a public health issue requiring immediate attention.…”