High- versus low-intensity interventions for perinatal depression delivered by non-specialist primary maternal care providers in Nigeria: cluster randomised controlled trial (the EXPONATE trial)

Abstract

BackgroundContextually appropriate interventions delivered by primary maternal care providers (PMCPs) might be effective in reducing the treatment gap for perinatal depression.AimTo compare high-intensity treatment (HIT) with low-intensity treatment (LIT) for perinatal depression.MethodCluster randomised clinical trial, conducted in Ibadan, Nigeria between 18 June 2013 and 11 December 2015 in 29 maternal care clinics allocated by computed-generated random sequence (15 HIT; 14 LIT). Interventions were delivered individually to antenatal women with DSM-IV (1994) major depression by trained PMCPs. LIT consisted of the basic psychosocial treatment specifications in the World Health Organization Mental Health Gap Action Programme – Intervention Guide. HIT comprised LIT plus eight weekly problem-solving therapy sessions with possible additional sessions determined by scores on the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome was remission of depression at 6 months postpartum (EPDS < 6).ResultsThere were 686 participants; 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed remission rates of 70% with HIT and 66% with LIT: risk difference 4% (95% CI −4.1%, 12.0%), adjusted odds ratio 1.12 (95% CI 0.73, 1.72). HIT was more effective for severe depression (odds ratio 2.29; 95% CI 1.01, 5.20; P = 0.047) and resulted in a higher rate of exclusive breastfeeding. Infant outcomes, cost-effectiveness and adverse events were similar.ConclusionsExcept among severely depressed perinatal women, we found no strong evidence to recommend high-intensity in preference to low-intensity psychological intervention in routine primary maternal care.Declaration of interestsNone.

Stigma and utilization of treatment for adolescent perinatal depression in Ibadan Nigeria

“…We did a total of 6 Focus Group Discussions (FGDs) with three mothers groups (n=17), and three primary care providers groups (n=25) between 6 th March and 29 th April 2018. In the RCT, our team trained non-specialist maternal and child health clinicians (MCHC) to deliver psychosocial interventions for perinatal depression using the Nigerian adapted WHO mhGAP intervention guide (mhGAP-IG) (Gureje et al, 2019). The 17 mothers who were adolescents when the RCT was conducted, were no longer adolescents at the time of the FGDs.…”

“…The occurrence of PD among adolescents complicates their unique ageand development-related challenges and thus demands services attuned to the unique needs of this age group. Evidence from Nigeria suggests that children of adolescent mothers with depression have poorer outcomes (Oladeji et al, 2019). However, Nigeria, like other low resource nations of the region, lacks adequate numbers of trained care providers as well as appropriate infrastructure to support high quality primary maternity care for adolescents (WHO, 2018).…”

Responding to the challenge of Adolescent Perinatal Depression (RAPiD): protocol for a cluster randomized hybrid trial of psychosocial intervention in primary maternal care

“…In a recently concluded cluster randomized controlled trial of interventions for perinatal depression in primary care in Oyo State, Nigeria [15], we had a chance to do some explorations of what an appropriate intervention for adolescents with perinatal depression might consist of in order for it to meet the complex and unique needs of this group of mothers. In that trial, 772 teenage adolescents (aged ≤ 19 years; mean age 18 years) were among the entire sample of 9352 persons screened for perinatal depression in the second or third trimester (that is, 8.3% of the entire sample).…”

“…Following the meetings, key informant interviews were held with frontline maternal care providers and with adolescent mothers. The key informants were selected from among providers and adolescent trial participants in our previously concluded RCT [15]. In the interviews with providers, we explored facility manpower and workload issues; experience with the delivery of treatment during the RCT, in particular engagement with the adolescents; and facility organizational issues, including those relating to the scheduling of clinic appointments for trial participants.…”

“…The primary outcome considered in calculating the sample size is the level of depressive symptoms as assessed with the EPDS total score at 6 months postpartum. Based on the results of our recently concluded cluster randomized controlled trial of interventions for perinatal depression in primary care in Nigeria (EXPONATE) [15] showing a standard deviation (SD) for the EPDS score of 4.5, we estimate that a mean difference of 2.0 in the EPDS score between the two arms at 6-month postnatal follow-up will represent a clinically significant difference in depression symptoms, giving a target effect size of 0.44. About 6 months into recruitment to the current trial, there was an imbalance in the ratio of participants recruited to the trial of about 1.5 in favor of the intervention arm.…”