Psychosocial interventions for perinatal common mental disorders delivered by providers who are not mental health specialists in low- and middle-income countries: a systematic review and meta-analysis

Cognitive-Behavioural therapy and interpersonal psychotherapy for the treatment of post-natal depression: a narrative review

BACKGROUND

Post-natal Depression (PND) is a depressive disorder that causes significant distress or impairment on different levels in the individual's life and their families. There is already evidence of the efficacy of psychological treatments for PND. We conducted a narrative review and researched the literature for identifying systematic reviews and studies for the best psychological treatments of PND, and examined what parameters made those treatments successful.

METHODS

We searched 4 electronic databases. We included reviews and randomised controlled clinical trials for our research. We excluded other types of studies such as case studies and cohort studies. We followed a specific search strategy with specific terms and a selection process. We identified risk of bias in reviews and studies, and identified their limitations. We synthesized the data based on particular information, including: name of the authors, location, research type, target, population, delivery, outcome measures, participants, control groups, types of intervention, components of treatments, providers, experimental conditions amongst others.

RESULTS

We found 6 reviews and 15 studies which met our inclusion criteria focusing on Cognitive Behavioural Therapy (CBT) for PND. Among the main findings we found that CBT can be delivered on an individual basis or within a group. It can be effective in the short-term, or up to six months post-intervention. CBT can be delivered by professionals or experts, but can also be practiced by non-experts. We found 7 components of CBT, including psychoeducation, cognitive restructuring, and goal setting. We also researched whether virtual reality (VR) has ever been used for the treatment of PND, and found that it has not.

CONCLUSION

From our review, we have concluded that CBT is an effective treatment for PND. We have explored the utility of VR as a possible therapeutic modality for PND and have decided to run a pilot feasibility study as a next step, which will act as the foundational guide for a clinical trial at a later stage.

The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies

Community-based mental health services are emphasized in the World Health Organization’s Mental Health Action Plan, the World Bank’s Disease Control Priorities, and the Action Plan of the World Psychiatric Association. There is increasing evidence for effectiveness of mental health interventions delivered by non-specialists in community platforms in low- and middle-income countries (LMIC). However, the role of community components has yet to be summarized. Our objective was to map community interventions in LMIC, identify competencies for community-based providers, and highlight research gaps. Using a review-of-reviews strategy, we identified 23 reviews for the narrative synthesis. Motivations to employ community components included greater accessibility and acceptability compared to healthcare facilities, greater clinical effectiveness through ongoing contact and use of trusted local providers, family involvement, and economic benefits. Locations included homes, schools, and refugee camps, as well as technology-aided delivery. Activities included awareness raising, psychoeducation, skills training, rehabilitation, and psychological treatments. There was substantial variation in the degree to which community components were integrated with primary care services. Addressing gaps in current practice will require assuring collaboration with service users, utilizing implementation science methods, creating tools to facilitate community services and evaluate competencies of providers, and developing standardized reporting for community-based programs.

Theory of change for the delivery of talking therapies by lay workers to survivors of humanitarian crises in low-income and middle-income countries: protocol of a systematic review

INTRODUCTION

There is a severe shortage of specialist mental healthcare providers in low-income and middle-income countries (LMICs) affected by humanitarian crises. In these settings, talking therapies may be delivered by non-specialists, including lay workers with no tertiary education or formal certification in mental health. This systematic review will synthesise the literature on the implementation and effectiveness of talking therapies delivered by lay workers in LMICs affected by humanitarian crises, in order to develop a Theory of Change (ToC).

METHODS AND ANALYSIS

Qualitative, quantitative and mixed-methods studies assessing the implementation or effectiveness of lay-delivered talking therapies for common mental disorders provided to adult survivors of humanitarian crises in LMICs will be eligible for inclusion. Studies set in high-income countries will be excluded. No restrictions will be applied to language or year of publication. Unpublished studies will be excluded. Seven electronic databases will be searched: MEDLINE, Embase, PsycINFO, PsycEXTRA, Global Health, Cochrane Library and ClinicalTrials.gov. Contents pages of three peer-reviewed journals will be hand-searched. Sources of grey literature will include resource directories of two online mental health networks (MHPSS.net and MHInnovation.net) and expert consultation. Forward and backward citation searches of included studies will be performed. Two reviewers will independently screen studies for inclusion, extract data and assess study quality. A narrative synthesis will be conducted, following established guidelines. A ToC map will be amended iteratively to take into account the review results and guide the synthesis.

ETHICS AND DISSEMINATION

Findings will be presented in a manuscript for publication in a peer-reviewed journal and disseminated through a coordinated communications strategy targeting knowledge generators, enablers and users.

PROSPERO REGISTRATION NUMBER

CRD42017058287.

Coping strategies of women with postpartum depression symptoms in rural Ethiopia: a cross-sectional community study

BACKGROUND

Most women with postpartum depression (PPD) in low- and middle-income countries remain undiagnosed and untreated, despite evidence for adverse effects on the woman and her child. The aim of this study was to identify the coping strategies used by women with PPD symptoms in rural Ethiopia to inform the development of socio-culturally appropriate interventions.

METHODS

A population-based, cross-sectional study was conducted in a predominantly rural district in southern Ethiopia. All women with live infants between one and 12 months post-partum (n = 3147) were screened for depression symptoms using the validated Patient Health Questionnaire, 9 item version (PHQ-9). Those scoring five or more, 'high PPD symptoms', (n = 385) were included in this study. The Brief Coping with Problems Experienced (COPE-28) scale was used to assess coping strategies. Construct validity of the brief COPE was evaluated using confirmatory factor analysis.

RESULTS

Confirmatory factor analysis of the brief COPE scale supported the previously hypothesized three dimensions of coping (problem-focused, emotion-focused, and dysfunctional). Emotion-focused coping was the most commonly employed coping strategy by women with PPD symptoms. Urban residence was associated positively with all three dimensions of coping. Women who had attended formal education and who attributed their symptoms to a physical cause were more likely to use both problem-focused and emotion-focused coping strategies. Women with better subjective wealth and those who perceived that their husband drank too much alcohol were more likely to use emotion-focused coping. Dysfunctional coping strategies were reported by women who had a poor relationship with their husbands.

CONCLUSIONS

As in high-income countries, women with PPD symptoms were most likely to use emotion-focused and dysfunctional coping strategies. Poverty and the low level of awareness of depression as an illness may additionally impede problem-solving attempts to cope. Prospective studies are needed to understand the prognostic significance of coping styles in this setting and to inform psychosocial intervention development.

Maternal mental health priorities, help-seeking behaviors, and resources in post-conflict settings: a qualitative study in eastern Uganda

BACKGROUND

Limited knowledge exists to inform the selection and introduction of locally relevant, feasible, and effective mental health interventions in diverse socio-cultural contexts and health systems. We examined stakeholders' perspectives on mental health-related priorities, help-seeking behaviors, and existing resources to guide the development of a maternal mental health component for integration into non-specialized care in Soroti, eastern Uganda.

METHODS

We employed rapid ethnographic methods (free listing and ranking; semi-structured interviews; key informant interviews and pile sorting) with community health workers (n = 24), primary health workers (n = 26), perinatal women (n = 24), traditional and religious healers (n = 10), and mental health specialists (n = 9). Interviews were conducted by trained Ateso-speaking interviewers. Two independent teams conducted analyses of interview transcripts following an inductive and thematic approach. Smith's Salience Index was used for analysis of free listing data.

RESULTS

When asked about common reasons for visiting health clinics, the most salient responses were malaria, general postnatal care, and husbands being absent. Amongst the free listed items that were identified as mental health problems, the three highest ranked concerns were adeka na aomisio (sickness of thoughts); ipum (epilepsy), and emalaria (malaria). The terms epilepsy and malaria were used in ways that reflected both biomedical and cultural concepts of distress. Sickness of thoughts appeared to overlap substantially with major depression as described in international classification, and was perceived to be caused by unsupportive husbands, intimate partner violence, chronic poverty, and physical illnesses. Reported help-seeking for sickness of thoughts included turning to family and community members for support and consultation, followed by traditional or religious healers and health centers if the problem persisted.

CONCLUSION

Our findings add to existing literature that describes 'thinking too much' idioms as cultural concepts of distress with roots in social adversity. In addition to making feasible and effective treatment available, our findings indicate the importance of prevention strategies that address the social determinants of psychological distress for perinatal women in post-conflict low-resource contexts.

A process evaluation exploring the lay counsellor experience of delivering a task shared psycho-social intervention for perinatal depression in Khayelitsha, South Africa

BACKGROUND

Task sharing of psycho-social interventions for perinatal depression has been shown to be feasible, acceptable and effective in low and middle-income countries. This study conducted a process evaluation exploring the perceptions of counsellors who delivered a task shared psycho-social counselling intervention for perinatal depression in Khayelitsha, Cape Town together with independent fidelity ratings.

METHODS

Post intervention qualitative semi-structured interviews were conducted with six counsellors from the AFrica Focus on Intervention Research for Mental health (AFFIRM-SA) randomised controlled trial on their perceptions of delivering a task shared psycho-social intervention for perinatal depression. Themes were identified using the framework approach and were coded and analysed using Nvivo v11. These interviews were supplemented with fidelity ratings for each counsellor and supervision notes.

RESULTS

Facilitating factors in the delivery of the intervention included intervention related factors such as: the content of the intervention, ongoing training and supervision, using a counselling manual, conducting counselling sessions in the local language (isiXhosa) and fidelity to the manual; counsellor factors included counsellors' confidence and motivation to conduct the sessions; participant factors included older age, commitment and a desire to be helped. Barriers included contextual factors such as poverty, crime and lack of space to conduct counselling sessions and participant factors such as the nature of the participant's problem, young age, and avoidance of contact with counsellors. Fidelity ratings and dropout rates varied substantially between counsellors.

CONCLUSION

These findings show that a variety of intervention, counsellor, participant and contextual factors need to be considered in the delivery of task sharing counselling interventions. Careful attention needs to be paid to ongoing supervision and quality of care if lay counsellors are to deliver good quality task shared counselling interventions in under-resourced communities.

TRIAL REGISTRATION

Clinical Trials: NCT01977326 , registered on 24/10/2013; Pan African Clinical Trials Registry: PACTR201403000676264 , registered on 11/10/2013.

Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries

Common mental disorders, including depression, anxiety, and posttraumatic stress, are leading causes of disability worldwide. Treatment for these disorders is limited in low- and middle-income countries. This systematic review synthesizes the implementation processes and examines the effectiveness of psychological treatments for common mental disorders in adults delivered by nonspecialist providers in low- and middle-income countries. In total, 27 trials met the eligibility criteria; most treatments targeted depression or posttraumatic stress. Treatments were commonly delivered by community health workers or peers in primary care or community settings; they usually were delivered with fewer than 10 sessions over 2-3 months in an individual, face-to-face format. Treatments included common elements, such as nonspecific engagement and specific domains of behavioral, interpersonal, emotional, and cognitive elements. The pooled effect size was 0.49 (95% confidence interval = 0.36-0.62), favoring intervention conditions. Our review demonstrates that psychological treatments-comprising a parsimonious set of common elements and delivered by a low-cost, widely available human resource-have moderate to strong effects in reducing the burden of common mental disorders.

Assessing a change mechanism in a randomized home-visiting trial: Reducing disrupted maternal communication decreases infant disorganization

Although randomized interventions trials have been shown to reduce the incidence of disorganized attachment, no studies to date have identified the mechanisms of change responsible for such reductions. Maternal sensitivity has been assessed in various studies and shown to change with intervention, but in the only study to formally assess mediation, changes in maternal sensitivity did not mediate changes in infant security of attachment (Cicchetti, Rogosch, & Toth, 2006). Primary aims of the current randomized controlled intervention trial in a high-risk population were to fill gaps in the literature by assessing whether the intervention (a) reduced disorganization, (b) reduced disrupted maternal communication, and (c) whether reductions in disrupted maternal communication mediated changes in infant disorganization. The results indicated that, compared to controls (n= 52), both infant disorganization and disrupted maternal communication were significantly reduced in the intervention group (n= 65) that received regular home-visiting during pregnancy and the first year of life. Furthermore, reductions in disrupted maternal communication partially accounted for the observed reductions in infant disorganization compared to randomized controls. The results are discussed in relation to the societal cost effectiveness of early attachment-informed interventions for mothers and infants, as well as the importance of formally assessing underlying mechanisms of change in order to improve and appropriately target preventive interventions.

Alcohol consumption, smoking, and drug use in pregnancy: Prevalence and risk factors in Southern Thailand

INTRODUCTION

Substance use during pregnancy contributes to the risk of adverse health outcomes in mothers and children-in utero and during later development. In this study, we investigated the prevalence of substance use and associated factors in pregnant women receiving antenatal care in public hospitals in Thailand.

METHODS

Women (3578) attending 7 antenatal care clinics in Songkhla for the first time during their current pregnancy were interviewed with a structured questionnaire focusing on demographic data, obstetric history, use of alcohol, tobacco, and other substances, and the General Health Questionnaire was administered. The use of substances was confirmed with the ultrarapid version of the Alcohol, Smoking, and Substance Involvement Screening Test and urine tests, which were also administered to 1 in 5 to 10 randomly selected women whose screening results were negative.

RESULTS

Based on self-reports and General Health Questionnaire results, the weighted prevalence of alcohol, tobacco, or illicit substance use and that of "mental health problems" were 5.6% (95% confidence interval [CI], 4.9-6.4) and 29.2% (95% CI, 27.5-30.9), respectively. On the basis of the ultrarapid version of the Alcohol, Smoking, and Substance Involvement Screening Test and urine tests, the prevalence of likely substance use disorder during the 3 months prior to assessment was 1.2% (95% CI, 0.8-1.5) and 7.7% (95% CI, 4.6-10.7), respectively. Factors associated with substance use were religion, unmarried status, unplanned pregnancy, previous abortion, and current mental health problem.

DISCUSSION

Our results emphasize the need for identification of substance use and mental health problems, with the help of questionnaires and biological markers, followed by early intervention.

Treatment gap and help-seeking for postpartum depression in a rural African setting

BACKGROUND

Postpartum depression (PPD) affects more than one in ten women and is associated with adverse consequences for mother, child and family. Integrating mental health care into maternal health care platforms is proposed as a means of improving access to effective care and reducing the 'treatment gap' in low- and middle-income countries. This study aimed to determine the proportion of women with PPD who sought help form a health facility and the associated factors.

METHODS

A community based, cross-sectional survey was conducted in southern Ethiopia. A total of 3147 women who were between one and 12 months postpartum were screened for depressive symptoms in their home using a culturally validated version of the Patient Health Questionnaire (PHQ-9). Women scoring five or more (indicating potential depressive disorder) (n = 385) were interviewed regarding help-seeking behavior. Multiple logistic regression was used to identify factors associated independently with help-seeking from health services.

RESULTS

Only 4.2 % of women (n = 16) with high PPD symptoms had obtained mental health care and only 12.7 % of women (n = 49) had been in contact with any health service since the onset of their symptoms. In the multivariable analysis, urban residence, adjusted odds ratio (aOR): 4.39 (95 % confidence interval (CI) 1.23, 15.68); strong social support, aOR: 2.44 (95 % CI 1.30, 4.56); perceived physical cause, aOR: 6.61 (95 % CI 1.76, 24.80); perceived higher severity aOR: 2.28 (95 % CI 1.41, 5.47); perceived need for treatment aOR: 1.46 (95 % CI 1.57, 18.99); PHQ score, aOR: 1.14 (95 % CI 1.04, 1.25); and disability, aOR: 1.06 (95 % CI 1.01, 1.15) were associated significantly with help-seeking from health services. More than half of the women with high levels of PPD symptoms (n = 231; 60.0  %) attributed their symptoms to a psychosocial cause and 269 (69.9 %) perceived a need for treatment. Equal proportions endorsed biomedical treatment and traditional or religious healing as the appropriate intervention.

CONCLUSION

In the absence of an accessible maternal mental health service the treatment gap was very high. There is a need to create public awareness about PPD, its causes and consequences, and the need for help seeking. However, symptom attributions and help-seeking preferences indicate potential acceptability of interventions located in maternal health care services within primary care.

Women's Preferences for Treatment of Perinatal Depression and Anxiety: A Discrete Choice Experiment

Perinatal depression and anxiety (PNDA) are an international healthcare priority, associated with significant short- and long-term problems for women, their children and families. Effective treatment is available but uptake is suboptimal: some women go untreated whilst others choose treatments without strong evidence of efficacy. Better understanding of women’s preferences for treatment is needed to facilitate uptake of effective treatment. To address this issue, a discrete choice experiment (DCE) was administered to 217 pregnant or postnatal women in Australia, who were recruited through an online research company and had similar sociodemographic characteristics to Australian data for perinatal women. The DCE investigated preferences regarding cost, treatment type, availability of childcare, modality and efficacy. Data were analysed using logit-based models accounting for preference and scale heterogeneity. Predicted probability analysis was used to explore relative attribute importance and policy change scenarios, including how these differed by women’s sociodemographic characteristics. Cost and treatment type had the greatest impact on choice, such that a policy of subsidising effective treatments was predicted to double their uptake compared with the base case. There were differences in predicted uptake associated with certain sociodemographic characteristics: for example, women with higher educational attainment were more likely to choose effective treatment. The findings suggest policy directions for decision makers whose goal is to reduce the burden of PNDA on women, their children and families.

Maternal mental health in primary care in five low- and middle-income countries: a situational analysis

BACKGROUND

The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care.

METHODS

The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness.

RESULTS

Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3-50 %) and alcohol consumption during pregnancy (5-51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community.

CONCLUSIONS

It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.

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

BACKGROUND

Rates of perinatal depression (antenatal and postnatal depression) in South Asia are among the highest in the world. The delivery of effective psychological treatments for perinatal depression through existing health systems is a challenge due to a lack of human resources. This paper reports on a trial protocol that aims to evaluate the effectiveness and cost-effectiveness of the Thinking Healthy Programme delivered by peers (Thinking Healthy Programme Peer-delivered; THPP), for women with moderate to severe perinatal depression in rural and urban settings in Pakistan and India.

METHODS/DESIGN

THPP is evaluated with two randomised controlled trials: a cluster trial in Rawalpindi, Pakistan, and an individually randomised trial in Goa, India. Trial participants are pregnant women who are registered with the lady health workers in the study area in Pakistan and pregnant women attending outpatient antenatal clinics in India. They will be screened using the patient health questionnaire-9 (PHQ-9) for depression symptoms and will be eligible if their PHQ-9 is equal to or greater than 10 (PHQ-9 ≥ 10). The sample size will be 560 and 280 women in Pakistan and India, respectively. Women in the intervention arm (THPP) will be offered ten individual and four group sessions (Pakistan) or 6-14 individual sessions (India) delivered by a peer (defined as a mother from the same community who is trained and supervised in delivering the intervention). Women in the control arm (enhanced usual care) will receive health care as usual, enhanced by providing the gynaecologist or primary-health facilities with adapted WHO mhGAP guidelines for depression treatment, and providing the woman with her diagnosis and information on how to seek help for herself. The primary outcomes are remission and severity of depression symptoms at the 6-month postnatal follow-up. Secondary outcomes include remission and severity of depression symptoms at the 3-month postnatal follow-up, functional disability, perceived social support, breastfeeding rates, infant height and weight, and costs of health care at the 3- and 6-month postnatal follow-ups. The primary analysis will be intention-to-treat.

DISCUSSION

The trials have the potential to strengthen the evidence on the effectiveness and cost-effectiveness of an evidence-based psychological treatment recommended by the World Health Organisation and delivered by peers for perinatal depression. The trials have the unique opportunity to overcome the shortage of human resources in global mental health and may advance our understanding about the use of peers who work in partnership with the existing health systems in low-resource settings.

TRIAL REGISTRATION

Pakistan Trial: ClinicalTrials.gov Identifier: NCT02111915 (9 April 2014) India Trial: ClinicalTrials.gov Identifier: NCT02104232 (1 April 2014).

Perinatal distress and depression in Malawi: an exploratory qualitative study of stressors, supports and symptoms

Quantitative studies have demonstrated that depression and anxiety in the perinatal period are common amongst women in low- and middle-income countries and are associated with a range of psychosocial and health-related stressors. In this exploratory qualitative study conducted in southern Malawi, we investigated the thoughts and emotions experienced by women in pregnancy and the postnatal period, their expectations of support from husband and others, problems and difficulties faced and the impact of these on psychological wellbeing. We conducted 11 focus group discussions with a total of 98 parous women. A thematic analysis approach was used. Three major themes were identified: pregnancy as a time of uncertainty, the husband (and others) as support and stressor, and the impact of stressors on mental health. Pregnancy was seen as bringing uncertainty about the survival and wellbeing of both mother and unborn child. Poverty, lack of support, HIV, witchcraft and child illness were identified as causes of worry in the perinatal period. Husbands were expected to provide emotional, financial and practical support, with wider family and friends having a lesser role. Infidelity, abuse and abandonment were seen as key stressors in the perinatal period. Exposure to stressors was understood to lead to altered mental states, the symptoms of which are consistent with the concept of common perinatal mental disorder. This study confirms and expands on evidence from quantitative studies and provides formative data for the development of a psychosocial intervention for common perinatal mental disorder in Malawi.

Non-psychotic mental disorders in the perinatal period

Mental disorders are among the most common morbidities of pregnancy and the postnatal period, and can have adverse effects on the mother, her child, and family. This Series paper summarises the evidence about epidemiology, risk factors, identification, and interventions for non-psychotic mental disorders. Although the phenomenology and risk factors for perinatal mental disorders are largely similar to those for the disorders at other times, treatment considerations differ during pregnancy and breastfeeding. Most randomised controlled trials have examined psychosocial and psychological interventions for postnatal depression, with evidence for effectiveness in treating and preventing the disorder. Few high-quality studies exist on the effectiveness or safety of pharmacological treatments in the perinatal period, despite quite high prescription rates. General principles of prescribing of drugs in the perinatal period are provided, but individual risk-benefit analyses are needed for decisions about treatment.

Impact of a participatory intervention with women's groups on psychological distress among mothers in rural Bangladesh: secondary analysis of a cluster-randomised controlled trial

Background

Perinatal common mental disorders (PCMDs) are a major cause of disability among women and disproportionately affect lower income countries. Interventions to address PCMDs are urgently needed in these settings, and group-based and peer-led approaches are potential strategies to increase access to mental health interventions. Participatory women’s health groups led by local women previously reduced postpartum psychological distress in eastern India. We assessed the effect of a similar intervention on postpartum psychological distress in rural Bangladesh.

Method

We conducted a secondary analysis of data from a cluster-randomised controlled trial with 18 clusters and an estimated population of 532,996. Nine clusters received an intervention comprising monthly meetings during which women’s groups worked through a participatory learning and action cycle to develop strategies for improving women’s and children’s health. There was one group for every 309 individuals in the population, 810 groups in total. Mothers in nine control clusters had access to usual perinatal care. Postpartum psychological distress was measured with the 20-item Self Reporting Questionnaire (SRQ-20) between six and 52 weeks after delivery, during the months of January to April, in 2010 and 2011.

Results

We analysed outcomes for 6275 mothers. Although the cluster mean SRQ-20 score was lower in the intervention arm (mean 5.2, standard deviation 1.8) compared to control (5.3, 1.2), the difference was not significant (β 1.44, 95% CI 0.28, 3.08).

Conclusions

Despite promising results in India, participatory women’s groups focused on women’s and children’s health had no significant effect on postpartum psychological distress in rural Bangladesh.

Antenatal depression case finding by community health workers in South Africa: feasibility of a mobile phone application

Randomized controlled trials conducted in resource-limited settings have shown that once women with depressed mood are evaluated by specialists and referred for treatment, lay health workers can be trained to effectively administer psychological treatments. We sought to determine the extent to which community health workers could also be trained to conduct case finding using short and ultrashort screening instruments programmed into mobile phones. Pregnant, Xhosa-speaking women were recruited independently in two cross-sectional studies (N = 1,144 and N = 361) conducted in Khayelitsha, South Africa and assessed for antenatal depression. In the smaller study, community health workers with no training in human subject research were trained to administer the Edinburgh Postnatal Depression Scale (EPDS) during the routine course of their community-based outreach. We compared the operating characteristics of four short and ultrashort versions of the EPDS with the criterion standard of probable depression, defined as an EPDS-10 ≥ 13. The prevalence of probable depression (475/1144 [42 %] and 165/361 [46 %]) was consistent across both samples. The 2-item subscale demonstrated poor internal consistency (Cronbach's α ranged from 0.55 to 0.58). All four subscales demonstrated excellent discrimination, with area under the receiver operating characteristic curve (AUC) values ranging from 0.91 to 0.99. Maximal discrimination was observed for the 7-item depressive symptoms subscale: at the conventional screening threshold of ≥10, it had 0.97 sensitivity and 0.76 specificity for detecting probable antenatal depression. The comparability of the findings across the two studies suggests that it is feasible to use community health workers to conduct case finding for antenatal depression.

Innovative strategies for closing the mental health treatment gap globally

PURPOSE OF REVIEW

In the field of global mental health, an enormous gap between what we know and what we do exists in the delivery of clinical care. Creative and effective strategies that surmount the barriers to provision of mental healthcare are essential to improve the lives of millions affected by mental illness. This article provides a review of three classes of innovative strategies currently being developed and implemented to diminish the mental health treatment gap globally.

RECENT FINDINGS

This review provides recent evidence related to the feasibility of implementation and efficacy for the following three classes of innovation that show promise for building clinical capacity and expanding mental health coverage: integration of mental health services into primary care; expansion of human capacity through task sharing and training of nonspecialists; and innovative use of technological platforms to enhance access, cut costs, and reduce stigma.

SUMMARY

The strategies outlined in this review hold great potential for enhancing mental health treatment services, and address some of the major barriers globally to accessing mental healthcare, such as scarcity of resources (infrastructure, capacity, and funding) and stigma. Despite much evidence supporting the efficacy of these models, thorough studies that test their feasibility, acceptability, utility, and effectiveness in various contexts, including low-income and middle-income countries, are required. Moreover, these innovations require social support and political will in order to be successfully implemented and scaled-up such that they have a meaningful impact on the burden of disease associated with mental illness worldwide.

Predictors of psychological distress among postnatal mothers in rural Nepal: a cross-sectional community-based study

BACKGROUND

Perinatal common mental disorders are a major cause of disability among women and have consequences for children's growth and development. We aimed to identify factors associated with psychological distress, a proxy for common mental disorders, among mothers in rural Dhanusha, Nepal.

METHODS

We used data from 9078 mothers who were screened for distress using the 12-item General Health Questionnaire (GHQ-12) around six weeks after delivery. We assessed the association between GHQ-12 score and socioeconomic, gender-based, cultural and reproductive health factors using a hierarchical analytical framework and multilevel linear regression models.

RESULTS

Using a threshold GHQ-12 score of ≥6 to indicate caseness, the prevalence of distress was 9.8% (886/9078). Factors that predicted distress were severe food insecurity (β 2.21 (95% confidence interval 1.43, 3.40)), having a multiple birth (2.28 (1.27, 4.10)), caesarean section (1.70 (0.29, 2.24)), perinatal health problems (1.58 (1.23, 2.02)), no schooling (1.37 (1.08, 1.73)), fewer assets (1.33 (1.10, 1.60)), five or more children (1.33 (1.09, 1.61)), poor or no antenatal care (1.31 (1.15, 1.48) p<0.001), having never had a son (1.31 (1.14, 1.49)), not staying in the parental home in the postnatal period (1.15 (1.02, 1.30)), having a husband with no schooling (1.17 (0.96, 1.43)) and lower maternal age (0.99 (0.97, 1.00)).

LIMITATIONS

The study was cross-sectional and we were therefore unable to infer causality. Because data were not collected for some established predictors, including infant death, domestic violence and history of mental illness, we could not assess their associations with distress.

CONCLUSIONS

Socioeconomic disadvantage, gender inequality and poor reproductive health predict distress among mothers in Dhanusha. Maternal and child health programmes, as well as poverty-alleviation and educational interventions, may be beneficial for maternal mental health.

Reliability and validity of instruments for assessing perinatal depression in African settings: systematic review and meta-analysis

BACKGROUND

A major barrier to improving perinatal mental health in Africa is the lack of locally validated tools for identifying probable cases of perinatal depression or for measuring changes in depression symptom severity. We systematically reviewed the evidence on the reliability and validity of instruments to assess perinatal depression in African settings.

METHODS AND FINDINGS

Of 1,027 records identified through searching 7 electronic databases, we reviewed 126 full-text reports. We included 25 unique studies, which were disseminated in 26 journal articles and 1 doctoral dissertation. These enrolled 12,544 women living in nine different North and sub-Saharan African countries. Only three studies (12%) used instruments developed specifically for use in a given cultural setting. Most studies provided evidence of criterion-related validity (20 [80%]) or reliability (15 [60%]), while fewer studies provided evidence of construct validity, content validity, or internal structure. The Edinburgh postnatal depression scale (EPDS), assessed in 16 studies (64%), was the most frequently used instrument in our sample. Ten studies estimated the internal consistency of the EPDS (median estimated coefficient alpha, 0.84; interquartile range, 0.71-0.87). For the 14 studies that estimated sensitivity and specificity for the EPDS, we constructed 2 x 2 tables for each cut-off score. Using a bivariate random-effects model, we estimated a pooled sensitivity of 0.94 (95% confidence interval [CI], 0.68-0.99) and a pooled specificity of 0.77 (95% CI, 0.59-0.88) at a cut-off score of ≥ 9, with higher cut-off scores yielding greater specificity at the cost of lower sensitivity.

CONCLUSIONS

The EPDS can reliably and validly measure perinatal depression symptom severity or screen for probable postnatal depression in African countries, but more validation studies on other instruments are needed. In addition, more qualitative research is needed to adequately characterize local understandings of perinatal depression-like syndromes in different African contexts.