Does One Treatment Fit All? Effectiveness of a Multicomponent Cognitive Behavioral Therapy Program in Data-Driven Subtypes of Perinatal Depression

Abstract

Background: Current diagnostic systems of mental disorders are criticized for their poor validity and reliability, owing to the within disorder heterogeneity and between disorder homogeneity. The issue is important if treatments for mental disorders are to be tailored to individual needs. There is little information in this area on perinatal depression (PND), a highly prevalent condition globally.Aims: i) Quantify heterogeneity attributable to the polythetic diagnostic framework for PND and, ii) present evidence for the effectiveness of a multicomponent and low-intensity cognitive behavioral Thinking Healthy Programme (THP) across the heterogeneous presentations of PND.Methods: This investigation presents secondary analyses of a cluster randomized controlled trial, conducted in Kallar Syedan, Pakistan. A total of 903 pregnant women were randomized to an intervention group receiving the THP intervention or control group receiving enhanced usual care. Principal component analyses and clustering algorithm were utilized to identify heterogenous subtypes of PND. Linear mixed effects models were used to assess effectiveness of the intervention across the identified subtypes of PND.Results: Four different clusters of PND were identified: mixed anxiety-depression, somatic depression, mild depression, and atypical depression. All clinical phenotypes responded well to the THP intervention. Compared to their counterparts in the control group, mothers with mild depression in the treatment group yielded lowest risk ratios 0.24 (95% CI: 0.15 to 0.37), followed by mothers with anxiety-depression 0.50 (95% CI: 0.37 to 0.68), atypical depression 0.51 (95% CI: 0.27 to 0.99) and somatic depression 0.59 (95% CI: 0.42 to 0.83).Conclusion: The Thinking Healthy Programme was found to be effective in reducing severity of depressive symptoms and disability across the four subtypes of PND.

Predicting Remission among Perinatal Women with Depression in Rural Pakistan: A Prognostic Model for Task-Shared Interventions in Primary Care Settings

“…It also yielded a c-statistic of 0.75, which is in the range of 0.60 to 0.85 for models predicting depression onset, treatment outcome, and relapse [ 20 , 21 , 23 , 43 ]. Our findings build upon previous research where the concept of heterogeneity in depression has been leveraged to predict treatment outcomes accurately [ 29 ]. Besides accounting for heterogeneity in the clinical presentation for PND, this model also incorporates short and easy-to-measure constructs of sources of social support, relationship status and empowerment, and socioeconomic class.…”

“…In this context, previous research has shown that depressive disorders are highly heterogeneous, with varying clinical presentations [ 1 , 45 , 46 ]. Our previous work [ 29 ] noted that for PND, the symptoms of HDRS clustered together into 365 different combinations. Research on heterogeneity in PND and its link with maternal morbidity, child outcomes, and treatment considerations are lacking.…”

“…We developed this prognostic model using data from a large-scale cluster randomized, controlled trial (cRCT) of the THP program delivered by community health workers in rural subdistricts of Gujar Khan and Kallar Syedan in Rawalpindi, Pakistan. Details of the study design have been presented in our previous publications [ 29 , 30 ]. The primary study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of The University of Manchester, UK.…”

“…We also included the allocation of trial participants to either the THP intervention or enhanced care as usual group as a variable. Briefly, the THP [ 29 , 30 ] is a task-shared psychosocial intervention underpinned by cognitive-behavioral approaches, including cognitive restructuring, behavioral activation, and problem solving. It is an evidence-based manualized intervention endorsed by the World Health Organization as a low-intensity treatment for perinatal depression.…”

“…We instead favored scores on symptom dimensions obtained after dimension reduction techniques to avoid multicollinearity in model building. Detailed analyses on the development of these symptom dimensions have been reported elsewhere [ 29 ]. Briefly, by applying dimension reduction and cluster analyses on individual items of the clinician rated HDRS, we elucidated four symptom dimensions for PND: Core emotional symptoms: depressed mood, anhedonia, loss of appetite, psychic anxiety, and somatic anxiety.…”