Treatment of maternal depression in urban slums of Karachi, Pakistan: A randomized controlled trial (RCT) of an integrated maternal psychological and early child development intervention

Effectiveness of interpersonal psychotherapy in comparison to other psychological and pharmacological interventions for reducing depressive symptoms in women diagnosed with postpartum depression in low- and middle-income countries: A systematic review

Background

Postpartum depression (PPD) is a condition that can affect any woman regardless of ethnicity, age, party, marital status, income, and type of delivery. This condition is highly prevalent worldwide. PPD, if not treated timely, can affect the maternal-child bond and can have a detrimental impact on the future cognitive, emotional, and behavioral development of the child. Interpersonal psychotherapy (IPT) has been reported as an effective treatment of PPD in previous studies as this focuses on relationship and social support issues. Previous reviews conducted in developed nations have reported the superior efficacy of IPT in comparison to other treatment options. There is no systematic review conducted in low to middle-income countries on the efficacy of IPT on PPD. Therefore it was necessary to undertake a systematic review to assess the effectiveness of IPT in reducing the depression among postpartum women in low and middle-income countries (LMICs).

Objectives

The main aim of this systematic review was to assess the effectiveness of IPT alone or in conjunction with pharmacological therapy and/or other psychological and psychosocial interventions, in reducing depressive symptoms among women diagnosed with PPD residing in LMICs.

Search Methods

The systematic search encompassed several prominent databases and grey literature. Furthermore, experts specializing in the field of IPT were consulted to identify any relevant studies conducted in LMICs that fulfilled the predetermined eligibility criteria. The most recent search update was performed in July 2022.

Selection Criteria

The PICOS criteria were meticulously defined for this review as described. Participants: Postpartum women diagnosed with PPD in LMICs were included. Intervention: IPT either as a standalone treatment or in conjunction with pharmacological therapy was included. Comparison: any form of psychological therapy or pharmacological therapy, whether administered individually or in combination, was considered for comparison. Study designs: experimental and quasi-experimental, factorial designs, and quantitative components (experimental, quasi-experimental, factorial designs) of mixed methods designs were eligible to be included. Studies with single-group study designs and qualitative studies were excluded from the review.

Data Collection and Analysis

Two reviewers from our team conducted a rigorous screening process to determine the eligibility of articles for inclusion. This involved an initial evaluation of titles and abstracts, followed by a comprehensive assessment of the full text of selected articles. In instances where discrepancies arose between the two reviewers, resolution was achieved through discussion or consultation with a third author to establish a consensus. Following the screening process, two team members independently extracted pertinent information and data from the studies that met the inclusion criteria. The treatment effect of the intervention, in comparison to the control group, was subsequently analyzed utilizing the fixed effects model taking into account the small number of studies.

Main Results

A total of 17,588 studies were identified from various databases, and 6493 duplicate studies were removed. Subsequently, 9380 studies underwent independent title and abstract screening resulting in the exclusion of 9040 studies. 345 full texts were thoroughly assessed leading to the exclusion of 341 studies, finally including 4 studies for review. The four included trials were randomized trials and comprised a total sample size of 188 women diagnosed with PPD residing in LMICs. Among these studies, three compared IPT with usual treatment, while one study compared IPT with antidepressant medications (ADMs). In terms of the providers of IPT, in one study, IPT was administered by nurses, while psychologists delivered IPT in another study. In one study, community health workers were responsible for providing IPT. However, in one study, information regarding the specific providers of IPT was not available or reported. The primary outcome measure reported in all four studies was depression, assessed using the Edinburgh Postnatal Depression Scale (EPDS). The geographical distribution of the studies included; one conducted in Zambia, one in Kenya, one in Pakistan, and one in Iran. Out of the four studies, three were included in the meta-analysis, as missing data from one study could not be obtained. Based on the overall treatment effect, it was found that depression scores decreased significantly more in the IPT group compared to other interventions (usual treatment or ADMs) (standardized mean difference [SMD] -0.62, 95% confidence interval [CI] (-1.01, -0.23), Z = 3.13 (p = 0.002), χ 2 = 49.49; df = 2; p < 0.00001; I 2 = 96%; 3 studies, n = 136). Out of the three studies, two studies compared the effectiveness of IPT in reducing depression scores specifically when compared to the usual treatment, and in both studies, depression scores were reduced significantly in the IPT group as compared to the usual treatment group. Only one study directly compared the effectiveness of IPT with ADM, reporting that IPT was more effective than ADM in reducing depression scores among postpartum women. Regarding adverse outcomes, only one study reported suicidal ideation with one participant in the IPT group and two in the ADM group (RR 0.50, 95% CI (0.05, 5.30), p = 0.56, n = 78). The same study reported seven participants in the ADM group had adverse drug reactions as compared to none in the IPT group (RR 15.0, 95% CI (0.89, 254), p = 0.06, n = 78).

Authors' Conclusions

Our comprehensive search yielded a limited number of four studies conducted in such settings. Despite the scarcity of available evidence, the findings collectively suggest that IPT is indeed an effective treatment for reducing PPD when compared to usual treatment and pharmacological therapy. However given the low certainty of evidence, there is a need for further research in the form of well-designed randomized controlled trials with larger sample sizes and a reduced risk of bias. Such studies would greatly contribute to enhancing the strength and reliability of the evidence base regarding the effectiveness of IPT in the context of PPD in LMICs. The knowledge generated from future research endeavors would be highly valuable in guiding the development of more affordable and cost-effective treatment approaches for PPD in resource-limited settings.

Evaluating cognitive behavioral therapy as a solution for postnatal depression in economically disadvantaged regions

PURPOSE

Postnatal depression (PND) impacts numerous women after childbirth, leading to various impairments in their lives. Mental health interventions, such as cognitive behavioral therapy (CBT), need further evaluation in low- and middle-income countries (LMICs) where resources may be scarce. This study aimed to assess the effectiveness of CBT in treating PND in women from LMICs, comparing it to standard care.

METHODS

A systematic review and meta-analysis were conducted following the PRISMA Statement 2020 guidelines. Databases such as PubMed, CINAHL Plus, Cochrane Library, and PsycINFO were searched until September 2022. A modified Delphi process was employed to identify relevant studies. The primary outcome was mean depression scores, measured by the Edinburgh postnatal depression scale at baseline and post-intervention.

RESULTS

Out of 487 studies identified, five trials were included, totaling 1056 participants (520 in the intervention group and 536 in the comparator group). At baseline, a minor, insignificant positive effect size was found (Cohen's d = 0.1, 95% CI =  - 0.15, 0.35). Post-CBT, the intervention group showed significant improvements in depression scores (Cohen's d =  - 1.9, 95% CI =  - 3.8, 0). When accounting for the influence of one study, (Ngai et al., Psychother Psychosom 84:294-303, 2015), which held substantial weight in the initial analysis, the effect size was adjusted to d = 0.5, highlighting a lesser but still significant difference.

CONCLUSIONS

CBT appears to be effective in improving PND symptoms among women in LMICs and may be considered a first-line treatment for at-risk mothers, including those who are displaced. However, the significant impact of one study on the results emphasizes the need for more rigorous research. The study also highlights the challenges and limitations of providing psychotherapies across LMICs, emphasizing the need for culturally adapted and contextually appropriate interventions to ensure successful implementation and sustainability of mental health care for postnatal women in these settings.

Effectiveness of Learning through Play Plus (LTP Plus) Parenting Intervention on Behaviours of Young Children of Depressed Mothers: A Randomised Controlled Trial

Evidence has shown that parenting intervention programmes improve parental knowledge, attitudes, and practices, which helps in promoting child development. This study aims to examine the effectiveness of parenting intervention in improving child behaviours. This is a secondary analysis of data from a cluster-randomised controlled trial with depressed mothers aged 18-44 years with a child aged 0 to 36 months. This paper reports findings from the dataset of participants with a child aged between 24 and 36 months. Villages (n = 120) were randomised into either of two arms: learning through play plus (LTP Plus) or treatment as usual (TAU). LTP Plus is a 10-session, group parenting intervention integrated with cognitive behaviour therapy, delivered over 3 months. This secondary analysis reports findings on the Eyberg Child Behaviour Inventory (ECBI) and the Home Observation for Measurement of the Environment (HOME). Findings show a significant improvement in child behaviour (ECBI) scores (p < 0.011) and HOME scores (p < 0.001) in the intervention group compared to TAU at 3-month follow-up. In a low-resource setting, low-cost group parenting intervention delivered by community health workers has the potential to improve child behaviours and quality of the home environment. Parenting interventions aimed at improving child behavioural problems can have significant implications for the child, family, and broader societal outcomes. Addressing behavioural problems in early years, parenting interventions can potentially reduce long-term consequences and costs associated with untreated child behavioural issues.

Lived experiences of mothers with postnatal anxiety: a qualitative phenomenology study from Pakistan

OBJECTIVE

The prevalence of postnatal anxiety is high among women during the first year of childbirth globally. Rates are higher in low and middle-income countries (LMICs), that is, 24%. Existing literature on maternal mood and its impact on child development has largely focused on postnatal depression. Postnatal anxiety has been recognised to have significant independent effects similar to those of postnatal depression, including negative effects on various aspects of maternal well-being including quality of life, parent-child interaction and child development. The evidence exploring lived experiences of postnatal anxiety is limited from LMICs. This study explored the lived experiences of anxiety in postnatal mothers in Pakistan.

DESIGN

A phenomenological approach was used for this qualitative study. The audio-recorded interviews were transcribed and analysed using the process of thematic analysis.

SETTINGS

The study was conducted in two community settings in Karachi, Pakistan; the Bin Qasim and Gadap town.

PARTICIPANTS

Women who were 18 years of age or older, had a live childbirth within the previous 12 months and had a score of 10 or higher on the Generalised Anxiety Disorder-7.

RESULTS

In-depth, one-to-one interviews were conducted with 10 participants. The qualitative data comprised of three themes. Theme one: Factors perceived to be associated with postnatal anxiety, Theme two: The perceived impact of postnatal anxiety and Theme three: Support needs. The first theme was further subdivided into two subthemes, that is, Mothers' perception of navigating domestic responsibilities and sociocultural norms of motherhood and financial constraints.

CONCLUSION

Despite the high prevalence of postnatal anxiety in LMICs there is not any published evidence on exploring this phenomenon through in-depth research in Pakistan. Understanding the lived experiences will help health professionals to identify women at risk of developing postnatal anxiety and to develop effective culturally appropriate interventions for women with anxiety during this postnatal period.

Postnatal depression in British mothers of African and Caribbean origin: a randomised controlled trial of learning through play plus culturally adapted cognitive behaviour therapy compared with psychoeducation

Background

One in every three women worldwide experiences postnatal depression after childbirth, with long-term negative consequences on their children. The mainstream mental healthcare provision for British mothers of African/Caribbean origin is mostly unsuccessful due to a lack of culturally appropriate care.

Methods

The study adopts a mixed-methods randomised controlled trial (RCT) design. A 12-session (60 minutes each) of online Learning Through Play plus Culturally adapted Cognitive Behaviour Therapy (LTP+CaCBT) intervention was employed for treating postnatal depression in comparison with psychoeducation (PE). Participants aged 19-53 were screened for depression using the Patient Health Questionnaire (PHQ-9). N=130 participants who scored >5 on PHQ-9 were randomised into LTP+CaCBT (n=65) or PE (n=65) groups. N=12 focus groups (LTP+CaCBT, n=6; PE, n=6) and n=15 individual interviews (LTP+CaCBT, n=8; PE, n=7) were conducted, transcribed verbatim and analysed.

Results

Satisfaction with intervention (LTP+CaCBT, 72.9%; PE, 65.2%); retention rates (LTP+CaCBT, 91%; PE, 71%); reduction in postnatal depression was higher in LTP+CaCBT on PHQ-9 Md=1.00 with z= -4.046; compared to PE, Md=1.00 with z= -1.504. Both groups showed reduced levels of anxiety on GAD-7 with no significant difference. Emerging themes from the qualitative findings showed increased positive moods, reduced worries about parenting difficulties and the facilitative role of remote intervention.

Conclusions

LTP+CaCBT intervention is culturally appropriate and acceptable and reduces postnatal depression in British mothers of African/Caribbean origin. A fully powered RCT is recommended to evaluate the clinical and cost-effectiveness of LTP+CaCBT, including the child's outcomes compared with routine treatment as usual.

Clinical trial registration

www.ClinicalTrials.gov, identifier NCT04820920.

Brain structural and functional outcomes in the offspring of women experiencing psychological distress during pregnancy

In-utero exposure to maternal psychological distress is increasingly linked with disrupted fetal and neonatal brain development and long-term neurobehavioral dysfunction in children and adults. Elevated maternal psychological distress is associated with changes in fetal brain structure and function, including reduced hippocampal and cerebellar volumes, increased cerebral cortical gyrification and sulcal depth, decreased brain metabolites (e.g., choline and creatine levels), and disrupted functional connectivity. After birth, reduced cerebral and cerebellar gray matter volumes, increased cerebral cortical gyrification, altered amygdala and hippocampal volumes, and disturbed brain microstructure and functional connectivity have been reported in the offspring months or even years after exposure to maternal distress during pregnancy. Additionally, adverse child neurodevelopment outcomes such as cognitive, language, learning, memory, social-emotional problems, and neuropsychiatric dysfunction are being increasingly reported after prenatal exposure to maternal distress. The mechanisms by which prenatal maternal psychological distress influences early brain development include but are not limited to impaired placental function, disrupted fetal epigenetic regulation, altered microbiome and inflammation, dysregulated hypothalamic pituitary adrenal axis, altered distribution of the fetal cardiac output to the brain, and disrupted maternal sleep and appetite. This review will appraise the available literature on the brain structural and functional outcomes and neurodevelopmental outcomes in the offspring of pregnant women experiencing elevated psychological distress. In addition, it will also provide an overview of the mechanistic underpinnings of brain development changes in stress response and discuss current treatments for elevated maternal psychological distress, including pharmacotherapy (e.g., selective serotonin reuptake inhibitors) and non-pharmacotherapy (e.g., cognitive-behavior therapy). Finally, it will end with a consideration of future directions in the field.

Efficacy of in-person versus digital mental health interventions for postpartum depression: meta-analysis of randomized controlled trials

AIM

This meta-analysis aimed to compare the efficacy of in-person and digital mental health interventions in addressing Postpartum Depression.

METHODS

Following PRISMA guidelines, the protocol for this meta-analysis was registered at the Open Science Framework (Retrieved from osf.io/wy3s4). This meta analysis included Randomized Controlled Trials (RCTs) conducted between 2013 and 2023. A comprehensive literature search identified 35 eligible RCTs from various electronic databases. Inclusion criteria focused on pregnant women over 18 years old, encompassing antenatal depression and up to two years postpartum. Diagnostic interviews or Edinburgh Postnatal Depression Scale (EPDS) were used to establish PPD. Digital interventions included telephonic, app-based, or internet-based approaches, while in-person interventions involved face-to-face sessions.

RESULTS

The meta-analysis revealed a moderate overall effect size of -0.69, indicating that psychological interventions are effective for PPD. Digital interventions (g = -0.86) exhibited a higher mean effect size than in-person interventions (g = -0.55). Both types of interventions displayed substantial heterogeneity (digital: I2 = 99%, in-person: I2 = 92%), suggesting variability in intervention content, delivery methods, and participant characteristics.

CONCLUSION

Digital mental health interventions show promise in addressing PPD symptoms, with a potentially greater effect size compared to in-person interventions. However, the high heterogeneity observed in both modalities underscores the need for further research to identify key drivers of success and tailor interventions to diverse populations. Additionally, the choice between digital and in-person interventions should consider individual needs and preferences. Ongoing research should further investigate and optimise intervention modalities to better serve pregnant women at risk of PPD.

Comparing the effectiveness of mother-focused interventions to that of mother-child focused interventions in improving maternal postpartum depression outcomes: A systematic review

BACKGROUND

Most empirically researched interventions for postpartum depression (PPD) tend to target mothers' depression alone. Harmful effects of PPD on physical and mental health of both mother and child has led researchers to investigate the impact of interventions on PPD and child outcomes together. So far, the evidence is limited regarding how these interventions compare with those focusing only on mothers' depression. This review compares the effectiveness of PPD-improving interventions focusing only on mothers with those focusing on mother and child together.

METHODS

Nine electronic databases were searched. Thirty-seven studies evaluating mother-focused (n = 30) and mother-child focused interventions (n = 7) were included. Under each category, three theoretical approaches-psychological, psychosocial and mixed-were compared using standardized qualitative procedures. The review's primary outcome was maternal PPD.

RESULTS

A higher proportion of mother-focussed interventions [20/30 (66.7%)] brought significant reduction in PPD outcomes as compared to a lower proportion of mother-child focused interventions [4/7 (57.14%)]. Mother-focused mixed approaches [3/3 (100%)] performed better in improving PPD than psychological [16/24 (67%)] or psychosocial approaches [1/3 (33.3%)] alone. Amongst mother-child focused interventions, psychosocial approaches performed well with two-thirds demonstrating positive effects on PPD.

CONCLUSION

The evidence strongly favors mother-focused interventions for improving PPD with mixed interventions being more effective. Psychosocial approaches performed better with PPD once child-related elements were added, and also seemed best for child outcomes. Psychological approaches were most practiced and effective for PPD, irrespective of the intervention's focus. Further trials are needed to unpack intervention components that improve PPD and increase uptake, especially in lower-and middle-income countries.

Integrating Depression and Alcohol Use Care Into Primary Care in Low- and Middle-Income Countries: A Meta-Analysis

OBJECTIVE

Evaluation of the effectiveness of integration of depression and alcohol use disorder care into primary health care in low- and middle-income countries (LMICs) is limited. The authors aimed to quantify the effectiveness of integrating mental health care into primary care by examining depression and alcohol use disorder outcomes. The study updates a previous systematic review summarizing research on care integration in LMICs.

METHODS

Following PRISMA guidelines, the authors included studies from the previous review and studies published from 2017 to 2020 that included adults with alcohol use disorder or depression. Studies were evaluated for type of integration model with the typology developed previously. A meta-analysis using a random-effects model to assess effectiveness of integrated interventions was conducted. Meta-regression analyses to examine the impact of study characteristics on depression and alcohol use disorder outcomes were conducted.

RESULTS

In total, 49 new articles were identified, and 74 articles from the previous and current studies met inclusion criteria for the meta-analysis. Overall random effect sizes were 0.28 (95% CI=0.22-0.35) and 0.17 (95% CI=0.11-0.24) for studies targeting care integration for depression or for alcohol use disorder, respectively, into primary care in LMICs. High heterogeneity within and among studies was observed. No significant association was found between country income level and depression and alcohol use outcomes. However, differences in effect sizes between types of integration model were statistically significant (p<0.001).

CONCLUSIONS

Integration of mental health care into primary health care in LMICs was found to improve depression and alcohol use disorder outcomes. This evidence should be considered when designing interventions to improve mental health screening and treatment in LMICs.

Integrated Moving on After Breast Cancer and Culturally Adapted Cognitive Behavior Therapy intervention for depression and anxiety among Pakistani women with breast cancer: Protocol of a randomized controlled trial

Objective

The diagnosis and treatment of breast cancer is associated with significant distress that has huge impact on survivors' quality of life. The objective of this study is to assess the effectiveness of an integrated intervention "Moving on After Breast Cancer (ABC) Plus culturally adapted Cognitive Behavior Therapy" (Moving on ABC Plus).

Method

This is a randomized controlled trial that aims to recruit 354 breast cancer survivors from the inpatient and outpatient oncology departments in public and private hospitals in Karachi, Hyderabad, Lahore, Multan, and Rawalpindi in Pakistan. Patients scoring 10 or above on either the Patient Health Questionnaire-9 and/or the Generalized Anxiety Disorder scale (GAD-7) will be recruited. Baseline assessments will include Functional Assessment of Cancer Therapy-Breast; EuroQol-5D; Multidimensional Scale for Perceived Social Support; Intrusive Thoughts Scale; and Rosenberg Self-Esteem Scale. Participants randomized into intervention arm, Moving on ABC Plus, will receive 12 individual therapy sessions over 4 months. Follow-up will be completed at 4- and 6-month post-randomization, using all baseline instruments along with the Client Satisfaction Questionnaire (CSQ-8). We will also explore the participants', their family members', and the therapists' experiences of the trial and intervention.

Results

We will be assessing the effectiveness of intervention in reducing depression and anxiety in breast cancer survivors as a primary outcome of the trial. The secondary outcomes will include effectiveness of intervention in terms of reduction in intrusive thoughts and improvement in health-related quality of life, self-esteem, and perceived social support.

Conclusion

The results of the study will inform the design of a future larger randomized control trial with long-term follow-up.

Supporting Depressed Mothers of Young Children with Intellectual Disability: Feasibility of an Integrated Parenting Intervention in a Low-Income Setting

As a lifelong condition, intellectual disability (ID) remains a public health priority. Parents caring for children with ID experience serious challenges to their wellbeing, including depression, anxiety, stress and health-related quality of life. Integrated parenting interventions, which have been well evidenced for depressed mothers, may also effectively support depressed parents with a child with ID in low-resource settings such as Pakistan, and in turn optimise child outcomes. We conducted a mixed-method rater-blind feasibility randomised controlled trial, which assessed the feasibility and acceptability of the Learning Through Play in My Own Way Plus (LTP-IMOW Plus) intervention. Mothers who screened positive for depression (n = 26) with a young child (age 3-6 years) with ID were recruited from two low-resource community settings. Participants in the intervention arm (n = 13) received 12 group sessions of LTP-IMOW Plus and others (n = 13) received routine care. The intervention was feasible and acceptable with 100% retention and 100% session attendance. The intervention improved depression, anxiety, parenting stress and child socialisation score outcomes relative to the routine care arm. The framework utilised to analyse the qualitative interviews with seven participants at pre-intervention identified a range of struggles experienced by the mothers, and at post-intervention, found improved knowledge of child development and practices, improved mother-child relationships, recommendations for the intervention and perceived practical barriers and facilitators. The findings highlight the prospects for a clinical and cost-effective trial of an integrated parenting intervention to manage long-term parental mental health needs and improve child outcomes.

Culturally adapted motivational interviewing with cognitive behavior therapy and mindfulness-based relapse prevention for substance use disorder in Pakistan (CAMAIB): protocol for a feasibility factorial randomised controlled trial

BACKGROUND

The use of psychoactive substances significantly impacts the health, social and economic aspects of families, communities and nations. There is a need to develop and test psychological interventions aimed for individuals with substance use disorder (SUD) in lower- and middle-income countries (LMICs), such as in Pakistan. The aim of this exploratory trial is to test the feasibility and acceptability of two culturally adapted psychological interventions in a factorial randomised controlled trial (RCT).

METHODS

The proposed project will be conducted in three phases. The first phase of the study will focus on cultural adaptation of the interventions through qualitative interviews with key stakeholders. The second phase will be to refine and produce manually assisted interventions. Third and last stage would be to assess the feasibility of the culturally adapted interventions through a factorial RCT. The study will be carried out in Karachi, Hyderabad, Peshawar, Lahore and Rawalpindi, Pakistan. Recruitment of participants will take place from primary care and volunteer organisations/drug rehabilitation centres. A total of 260 individuals diagnosed with SUD (n = 65) in each of the four arms will be recruited. The intervention will be delivered weekly over a period of 12 weeks in both individual and group settings. Assessments will be carried out at baseline, at 12th week (after completion of intervention) and 24th week post-randomisation. The analysis will determine the feasibility of recruitment, randomisation, retention and intervention delivery. Acceptability of intervention will be determined in terms of adherence to intervention, i.e. the mean number of sessions attended, number of home assignments completed, attrition rates, as well as through process evaluation to understand the implementation process, context, participants' satisfaction, and impact of the study intervention. The health resource use and impact on the quality of life will be established through health economic data.

DISCUSSION

This study will provide evidence for feasibility and acceptability of culturally adapted manually assisted psychological interventions for individuals with SUD in the context of Pakistan. The study will have clinical implications if intervention is proven feasible and acceptable.

TRIAL REGISTRATION

Name of the registry: ClinicalTrials.gov, Trial registration number: NCT04885569 , Date of registration: 25th April 2021.

Psychological treatment of perinatal depression: a meta-analysis

BACKGROUND

Depression during pregnancy and after the birth of a child is highly prevalent and an important public health problem. Psychological interventions are the first-line treatment and, although a considerable number of randomized trials have been conducted, no recent comprehensive meta-analysis has evaluated treatment effects.

METHODS

We used an existing database of randomized controlled trials of psychotherapies for adult depression and included studies aimed at perinatal depression. Random effects models were used in all analyses. We examined the effects of the interventions in the short and long term, and also examined secondary outcomes.

RESULTS

Forty-three studies with 49 comparisons and 6270 participants between an intervention and control group were included. The overall effect size was g = 0.67 [95% confidence interval (CI) 0.45~0.89; numbers needed-to-be-treated = 4.39] with high heterogeneity (I² = 80%; 95% CI 75~85). This effect size remained largely unchanged and significant in a series of sensitivity analyses, although some publication bias was found. The effects remained significant at 6-12 months follow-up. Significant effects were also found for social support, anxiety, functional limitations, parental stress and marital stress, although the number of studies for each outcome was low. All results should be considered with caution because of the high levels of heterogeneity in most analyses.

CONCLUSIONS

Psychological interventions are probably effective in the treatment of perinatal depression, with effects that last at least up to 6-12 months and probably also have effects on social support, anxiety, functional impairment, parental stress, and marital stress.

Effect of psychotherapy for adult depression on self-esteem: A systematic review and meta-analysis

BACKGROUND

There is emerging evidence to suggest that Cognitive Behavioral Therapy for depression may have a secondary effect on self-esteem, but less is known about non-CBT based interventions. To examine this, we had two main aims; (1) to meta-analyze psychotherapy effects on (i) depression and (ii) self-esteem, and (2) to investigate the relationship between reductions in depression symptoms and improvements in self-esteem.

DESIGN

A systematic review and meta-analysis.

METHODS

Following the PRISMA guidelines, we conducted a meta-analysis of randomized control trials of psychotherapy for adult depression, which included a self-esteem outcome at post-treatment. Nineteen studies with a total of 3423 participants met the inclusion criteria. For each comparison between psychotherapy and a control condition, we calculated Hedges' g both for depression and self-esteem and pooled them in two separate meta-analyses. Furthermore, meta-regression was used to explore the association between the effect of psychotherapy for depression and its effect on self-esteem.

RESULTS

The effects on depression were large and significant (Hedges' g = -0.95; [95 % CI: -1.27, -0.63]). We found evidence of smaller, albeit still moderate, effects on self-esteem (Hedges'g = 0.63; [95 % CI:0.32, 0.93]), with sustained effects at 6-12 months (Hedges'g = 0.70; [95 % CI: -0.03, 1.43]). We also found a strong inverse association between the effects of psychotherapy for depression and self-esteem (β = -0.60, p < 0.001).

LIMITATIONS

Heterogeneity was very high (I² = 97 %), and out of 19 trials, only 6 trials were rated as having a low risk of bias.

CONCLUSIONS

The results suggest that psychotherapy for depression may improve self-esteem to a moderate degree.

Scaling up community-delivered mental health support and care: A landscape analysis

Introduction

The mental health crisis has caused widespread suffering and has been further exacerbated by the COVID-19 pandemic. Marginalized groups are especially affected, with many concerns rooted in social determinants of mental health. To stem this tide of suffering, consideration of approaches outside the traditional biomedical model will be necessary. Drawing from task-sharing models of mental health care that have been pioneered in low-resource settings, community-initiated care (CIC) represents a potentially promising collection of approaches. This landscape analysis seeks to identify examples of CIC that have been implemented outside of the research context, with the aim of identifying barriers and facilitators of scale up.

Methods

A narrative review approach was used for this landscape analysis in which the PubMed database was searched and further supplemented with Google Scholar. Promising programs were then discussed over multiple rounds of meetings with the research team, consisting of collaborators with varied experiences in mental health. Using the selection criteria and feedback derived from group meetings, a final list of programs was identified and summarized according to common characteristics and features.

Results

The initial PubMed search yielded 16 results, supplemented by review of the first 100 entries in Google Scholar. Through 5 follow-up meetings among team members, consensus was reached on a final list of 9 programs, which were grouped into three categories based on similar themes and topics: (1) approaches for the delivery of psychosocial interventions; (2) public health and integrative approaches to mental health; and (3) approaches for addressing youth mental health. Key facilitators to scale up included the importance of sustainable financing and human resources, addressing social determinants and stigma, engaging diverse stakeholders, leveraging existing health infrastructure, using sustainable training models, ensuring cultural relevance and appropriateness, and leveraging digital technologies.

Discussion

This landscape analysis, though not an exhaustive summary of the literature, describes promising examples of efforts to scale up CIC outside of the research context. Going forward, it will be necessary to mobilize stakeholders at the community, health system, and government levels to effectively promote CIC.

Healthcare-Based Interventions to Improve Parenting Outcomes in LMICs: A Systematic Review and Meta-Analysis

OBJECTIVES

Although a number of early childhood development (ECD) interventions in healthcare settings in low- and middle-income countries (LMICs) have been developed to improve parent-directed outcomes and support ECD, their impact have yet to be established. This review assesses the effectiveness of healthcare-based ECD interventions in LMICs on the following key evidence-informed parenting outcomes affecting ECD: (1) responsive caregiving (2) cognitive stimulation and (3) parental mental health. Impacts on parental knowledge regarding ECD and parenting stress were also assessed.

METHODS

PubMed, PsycINFO, Scopus, CINAHL and Embase were searched. We included randomized controlled trials reporting effects of healthcare-based ECD interventions in LMICs on parent-directed outcomes in the first five years of life. Data extraction included study characteristics, design, sample size, participant characteristics, settings, intervention descriptions, and outcomes. Meta-analyses were conducted using random effects models.

RESULTS

8 articles were included. Summary standardized mean differences demonstrated significant benefits of healthcare-based interventions in LMICs for improving: (1) cognitive stimulation (n = 4; SMD = 0.32; 95% CI: 0.08 to 0.56) and (2) ECD knowledge (n = 4; SMD = 0.44; 95% CI: 0.27 to 0.60). No significant effects were seen on maternal depression and parenting stress; only one study assessed parent-child interactions in the context of responsiveness. Limitations included small number of studies for moderation analysis, high heterogeneity, variability in measures used for outcomes and timing of assessments.

CONCLUSIONS FOR PRACTICE

Our results demonstrate statistically significant effects of healthcare-based interventions in LMICs on improving key evidence-based parenting outcomes and offers one promising strategy to support children reach their full developmental potential.

The silent burden: a landscape analysis of common perinatal mental disorders in low- and middle-income countries

Background

Mental health has long fallen behind physical health in attention, funding, and action—especially in low- and middle-income countries (LMICs). It has been conspicuously absent from global reproductive, maternal, newborn, child, and adolescent health (MNCAH) programming, despite increasing awareness of the intergenerational impact of common perinatal mental disorders (CPMDs). However, the universal health coverage (UHC) movement and COVID-19 have brought mental health to the forefront, and the MNCAH community is looking to understand how to provide women effective, sustainable care at scale. To address this, MOMENTUM Country and Global Leadership (MCGL) commissioned a landscape analysis in December 2020 to assess the state of CPMDs and identify what is being done to address the burden in LMICs.

Methods

The landscape analysis (LA) used a multitiered approach. First, reviewers chose a scoping review methodology to search literature in PubMed, Google Scholar, PsychInfo, and Scopus. Titles and abstracts were reviewed before a multidisciplinary team conducted data extraction and analysis on relevant articles. Second, 44 key informant interviews and two focus group discussions were conducted with mental health, MNCAH, humanitarian, nutrition, gender-based violence (GBV), advocacy, and implementation research experts. Finally, reviewers completed a document analysis of relevant mental health policies from 19 countries.

Results

The LA identified risk factors for CPMDs, maternal mental health interventions and implementation strategies, and remaining knowledge gaps. Risk factors included social determinants, such as economic or gender inequality, and individual experiences, such as stillbirth. Core components identified in successful perinatal mental health (PMH) interventions at community level included stepped care, detailed context assessments, task-sharing models, and talk therapy; at health facility level, they included pre-service training on mental health, trained and supervised providers, referral and assessment processes, mental health support for providers, provision of respectful care, and linkages with GBV services. Yet, significant gaps remain in understanding how to address CPMDs.

Conclusion

These findings illuminate an urgent need to provide CPMD prevention and care to women in LMICs. The time is long overdue to take perinatal mental health seriously. Efforts should strive to generate better evidence while implementing successful approaches to help millions of women “suffering in silence.”

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04589-z.

Cultural adaptation of cognitive behaviour therapy for depression: a qualitative study exploring views of patients and practitioners from India

Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, culture can influence engagement and treatment efficacy of CBT. Several attempts have been made in Asian countries to develop a culturally adapted CBT for depression. However, research in the Indian context documenting the views on cultural influence of CBT is limited. The present study is an attempt to explore the views of patients and therapists in India by following an evidence-based approach that focuses on three areas for adaptation: (1) awareness of relevant cultural issues and preparation for therapy; (2) assessment and engagement; and (3) adjustments in therapy techniques. Semi-structured interviews with three consultant clinical psychologists/therapists, a focused group discussion with six clinical psychologists, and two patients undergoing CBT for depression were conducted. The data were analysed using a thematic framework analysis by identifying emerging themes and categories. The results highlight therapists’ experiences, problems faced, and recommendations in all three areas of adaptation. The findings highlight the need for adaptation with understanding and acknowledging the culture differences and clinical presentation. Culturally sensitive assessment and formulation with minor adaptation in clinical practice was recommended. Therapists emphasised the use of proverbs, local stories and simplified terminologies in therapy. The findings will aid in providing culturally sensitive treatment to patients with depression in India.

Key learning aims

(1)

Building Resilience Against ViolencE (BRAVE): protocol of a parenting intervention for mothers and fathers with post-traumatic stress disorder in Pakistan

BACKGROUND

Prevalence of post-traumatic stress disorder (PTSD) is high in Pakistan both due to natural disasters and ongoing conflicts. Offspring of trauma survivors are at increased risk for mental and physical illnesses. Parental PTSD has been linked to troubled parent-child relationships, behaviour problems, trauma symptoms, and depression in children. This study aims to explore the acceptability, feasibility and indications of the effectiveness of group learning through play plus trauma-focused cognitive behaviour therapy (LTP Plus TF-CBT) for parents experiencing PTSD.

METHODS/DESIGN

This is a two-arm pilot cluster randomised controlled trial (RCT). We aim to recruit 300 parents with a diagnosis of PTSD. The screening will be done using the Impact of Event Scale-Revised. Diagnosis of PTSD will be confirmed using the Clinician-Administered PTSD Scale-5 (CAPS-5). Union Councils from Peshawar and Karachi will be randomised into either group LTP Plus TF CBT arm or treatment as usual (TAU). The intervention includes 12 sessions of LTP Plus TF-CBT delivered weekly in the first 2 months and then fortnightly in a group setting by trained psychologists. The groups will be co-facilitated by the community health workers (CHWs). Parents will be assessed at baseline and 4th month (end of the intervention), using the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder (GAD-7) Scale, Client Service Receipt Inventory (CSRI), and Ages and Stages Questionnaire (ASQ-3).

DISCUSSION

This trial would help build an understanding of the acceptability, feasibility and indications of the effectiveness of a low-cost parenting intervention.

Stigma of postpartum depression: The role of lady health workers in health care-A qualitative study

The researchers explore the stigma of postpartum depression and role of lady health workers in bringing the women to the health facility and following up on their treatment. In-depth interviews were conducted from the registered patients (n = 22), Lady Health Visitors (n = 2) and Lady Health Workers (LHWs) (n = 2) in a public primary and tertiary healthcare facility in peri-urban areas of district Rawalpindi, Pakistan. Stigma of depression and lack of awareness was perceived as one of the major reasons for women to struggle with the label of postpartum depression and seeking medical treatment. Lady health workers played a significant role in health education and bringing them to the health facility. The services rendered by LHWs can be enhanced through comprehensive training as they can play an effective role in spreading awareness and educating the patients of postpartum depression in peri-urban areas and their families, consequently, ensuring their treatment and its follow-up.

An integrated parenting intervention for maternal depression and child development in a low-resource setting: Cluster randomized controlled trial

BACKGROUND

Rates of depression among Pakistani mothers are high, leading to poor developmental outcomes in their children. This study tested the effectiveness of a manualized integrated parenting program; Learning through Play Plus (LTP+) for maternal depression in Karachi, Pakistan.

METHODS

A cluster randomized control trial conducted from January 2014 to December 2015 across 120 villages in Karachi. A total of 774 depressed mothers aged 18-44 years with children aged 0-30 months old, were included. Villages were randomized to receive LTP+ added to treatment as usual (TAU) or TAU alone. Primary outcomes were severity of maternal depression at 3 and 6 months measured by the Edinburgh Postnatal Depression Scale and child socio-emotional development at 6 months measured by the Ages and Stages Questionnaire (ASQ). Secondary outcomes included maternal anxiety, quality of life, social support, parenting competence, and knowledge about child development.

RESULTS

Mothers in the LTP+ group reported significantly lower depression scores compared to those in the TAU group (6.6 vs. 13.8, effect size [ES]: -7.2; 95% confidence interval [CI]: -8.2, -6.1) at 3 and 6 months (7.2 vs. 12.00; ES: -4.6; 95% CI: -5.9, -3.4). Child socio-emotional development at 6 months was significantly better in the LTP+ group on all domains of the ASQ. There were also statistically significant improvements on all secondary outcomes at 3- and 6-month follow-up.

CONCLUSION

In low-resource settings like Pakistan, low-cost integrated parenting interventions delivered by lay health workers can provide effective treatment for depressed mothers, leading to improvements in child development.

Caught Between External Pressures and Internal Battles: Psychosocial Factors Affecting Gestational Weight Gain - A Scoping Review

Many physical factors (including maternal comorbidities) affecting gestational weight gain (GWG) have been widely studied; however, the psychosocial aspects pertaining to this need to be put under the microscope, especially in countries characterized by low indicators of socioeconomic development. Gaining and maintaining an adequate amount of weight during pregnancy is important to prevent premature deliveries, fetal demise, fetal macrosomia, shoulder dystocia during delivery, emergency cesarean sections, postpartum weight retention, childhood obesity, etc. A scoping review of the articles published in the last five years has revealed that perinatal outcomes like gestational weight are influenced by certain psychosocial factors, including, but not limited to, intimate partner violence, lack of social support and recognition, financial distress, household food insecurity, chronic stress and depression related to pregnancy, eating pathologies, and low self-esteem. Employing a multi-disciplinary approach, which involves seeking the help of psychiatrists/psychologists, obstetricians, nutritionists, and public health specialists, can help us mitigate undesirable outcomes related to inadequate and excessive weight gain during pregnancy. More intervention-based research focusing on psychosocial factors relating to GWG is needed in regions like South Asia, which is associated with low indicators of socioeconomic development.

A Group Parenting Intervention for Depressed Fathers (LTP + Dads): A Feasibility Study from Pakistan

BACKGROUND

Globally, paternal depression is a neglected and under-researched area.

AIMS

To feasibility test Learning Through Play Plus Dads (LTP+ Dads), a group parenting psychoeducation program adapted for depressed Pakistani fathers of children under 3 years of age.

METHODS

Fathers with depression were recruited in Karachi, Pakistan, for a pre-post feasibility study. Ten sessions of group LTP+ Dads were offered over three months. Clinical assessments were administered at baseline, three (end of intervention), and six (follow-up) months and included the Edinburgh Postnatal Depression Scale, 17-item Hamilton Depression Rating Scale, Brief Disability Questionnaire, Multidimensional Scale of Perceived Social Support, Euro-Qol-5 Dimensions, Rosenberg Self-esteem Scale, Parenting Stress Index, and Knowledge, Attitude and Practices questionnaire.

RESULTS

Of the 78 fathers approached, 34 consented to screening and 18 were eligible to participate. Participants had a mean age of 33 years, with a mean of 3.61 children. Most were unemployed and were from low-income households with low education backgrounds. The intervention was feasible and acceptable based on a recruitment rate of 100% of eligible participants and a 100% attendance rate for five of the 10 sessions. Fathers showed, on average, a reduction in depressive symptoms, an increase in most areas of knowledge, and positive attitudes about child development. Perceived social support, self-esteem, and functioning scores also increased.

CONCLUSIONS

A low-cost, culturally adapted group intervention was found to be feasible and acceptable. Changes in depression, parenting-related, and other outcomes are promising and inform a future larger trial.

TRIAL REGISTRATION

The trial was registered on Clinicaltrials.gov on 9 December 2020 (identifier: NCT04660253).

Efficacy of learning through play plus intervention to reduce maternal depression in women with malnourished children: A randomized controlled trial from Pakistan✰

BACKGROUND

The risk factors and adverse outcomes related to maternal depression and child malnutrition are a leading cause of morbidity and mortality in low and middle-income countries (LMIC) including Pakistan. Above 25% of women suffer from maternal depression. Up to 50% children are under-nourished which contributes to 35% of all under-5 deaths in the country.

AIM

To determine the efficacy of Learning through Play Plus Thinking Healthy Program (LTP Plus) intervention to reduce maternal depression in mothers with undernourished children.

METHODS

In this randomised controlled trial, all eligible mothers presenting to the paediatric departments were invited to participate in the study. Out of the total 256 mothers screened, 107 were included, 54 of those were randomly allocated to LTP Plus group and 53 to treatment as usual (TAU). Edinburgh Postnatal Depression Scale (EPDS) was used to screen for depression. Hamilton Depression Rating Scale (HDRS), Maternal Attachment Inventory (MAI), Social Support Scale (OSLO-3) and the Euro-QoL (EQ-5D) were used to measure the severity of depression, mother-child attachment, level of support and health related quality of life dimensions. Assessments were completed at baseline, end of intervention (3 months from baseline) and at 6 months from baseline.

RESULTS

Mothers in the LTP Plus group significantly showed improvements in depression (p<0.001), social support (p = 0.02) and quality of life (p<0.001) at the end of the intervention (LTP Plus), as compared to the TAU group, which were sustained up to 6 months after baseline.

CONCLUSION

The outcomes of LTP Plus intervention for mothers of malnourished children show promising results in reducing maternal depression and improving child outcomes. A full trial with longer-term outcomes and cost-effectiveness needs to be conducted.

Postpartum Depression: Prevalence and Associated Risk Factors Among Women in Sindh, Pakistan

Introduction

Postpartum depression (PPD) is defined as the onset of depressive symptoms within six weeks of childbirth. PPD is more common in resource-constrained countries as compared to developed countries. The study aimed to evaluate the factors associated with PPD among women in Sindh, Pakistan.

Methods

A multi-centre, cross-sectional study was conducted at three major tertiary care setups in Sindh, Pakistan. All women presenting to the outpatient department within six weeks of giving live birth were eligible to participate. All women who had stillbirths, abortions, or were treated for a past psychiatric illness or neurological disease were excluded from the study. The Edinburgh postpartum depression scale (EPDS) was used as a screening tool. All socio-demographic factors were documented in a predefined pro forma. The data was analyzed using Statistical Package for Social Sciences (SPSS, Version 26, IBM, Chicago, IL).

Results

According to the Edinburgh postpartum depression scale (EPDS), the incidence of postpartum depression in the current study population was 19.3%. Of these, 12 (3.3%) women had persistently thought about self-harming. Over 100 women did not receive any formal education, constituting the majority of the study population. Formula milk feeding of the newborn was significantly associated with an increased frequency of postpartum depression (p= 0.0001).

Conclusion

The current study highlights the significant burden of postpartum depression in Pakistan. However, the present study failed to find any significant risk factors associated with postpartum depression. Only formula milk feeding was significantly associated with a higher frequency of PPD among study patients.

A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression

No network meta-analysis has examined the relative effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression, while this is a very important clinical issue. We conducted systematic searches in bibliographical databases to identify randomized trials in which a psychotherapy and a pharmacotherapy for the acute or long-term treatment of depression were compared with each other, or in which the combination of a psychotherapy and a pharmacotherapy was compared with either one alone. The main outcome was treatment response (50% improvement between baseline and endpoint). Remission and acceptability (defined as study drop-out for any reason) were also examined. Possible moderators that were assessed included chronic and treatment-resistant depression and baseline severity of depression. Data were pooled as relative risk (RR) using a random-effects model. A total of 101 studies with 11,910 patients were included. Depression in most studies was moderate to severe. In the network meta-analysis, combined treatment was more effective than psychotherapy alone (RR=1.27; 95% CI: 1.14-1.39) and pharmacotherapy alone (RR=1.25; 95% CI: 1.14-1.37) in achieving response at the end of treatment. No significant difference was found between psychotherapy alone and pharmacotherapy alone (RR=0.99; 95% CI: 0.92-1.08). Similar results were found for remission. Combined treatment (RR=1.23; 95% CI: 1.05-1.45) and psychotherapy alone (RR=1.17; 95% CI: 1.02-1.32) were more acceptable than pharmacotherapy. Results were similar for chronic and treatment-resistant depression. The combination of psychotherapy and pharmacotherapy seems to be the best choice for patients with moderate depression. More research is needed on long-term effects of treatments (including cost-effectiveness), on the impact of specific pharmacological and non-pharmacological approaches, and on the effects in specific populations of patients.

Don’t abandon RCTs in IVF. We don’t even understand them

The conclusion of the Human Fertilisation and Embryology Authority that ‘add-on’ therapies in IVF are not supported by high-quality evidence has prompted new questions regarding the role of the randomized controlled trial (RCT) in evaluating infertility treatments. Critics argue that trials are cumbersome tools that provide irrelevant answers. Instead, they argue that greater emphasis should be placed on large observational databases, which can be analysed using powerful algorithms to determine which treatments work and for whom. Although the validity of these arguments rests upon the sciences of statistics and epidemiology, the discussion to date has largely been conducted without reference to these fields. We aim to remedy this omission, by evaluating the arguments against RCTs in IVF from a primarily methodological perspective. We suggest that, while criticism of the status quo is warranted, a retreat from RCTs is more likely to make things worse for patients and clinicians.

Culturally-adapted cognitive behavioural therapy based intervention for maternal depression: a mixed-methods feasibility study

BACKGROUND

British Pakistanis are one of the largest ethnic minority groups living in the UK, with high rates of maternal depression being reported in this population. Evidence suggests that culturally-adapted Cognitive Behavioural Therapy (CBT)-based interventions for depression, may improve clinical outcomes and patient satisfaction. This study was conducted to develop and test the feasibility and acceptability of a culturally-adapted, CBT-based, manual-assisted intervention in British Pakistani mothers experiencing maternal depression.

METHODS

A mixed-method feasibility study that included qualitative interviews followed by the development of a CBT-based intervention for mothers with mild to moderate depression. Following the qualitative interviews, a CBT-based intervention called the Positive Health Program (PHP) was developed and delivered consisting of 12-weekly sessions. A before and after design was used to explore the feasibility and acceptability of the Positive Health Programme.

RESULTS

A culturally-adapted CBT-based group intervention (PHP) was acceptable to this group and improvements were reported in depression and health-related quality of life. The women's understanding of 'depression' as a general consensus was in physical terms, but with an onset triggered by psychosocial causes. The most commonly reported factors contributing to depression were marital disharmony, lack of social support, and financial difficulties. Past help offered was primarily antidepressants, which were not welcomed by most of the women. A lack of availability of culturally sensitive interventions and the limited cultural sensitivity of NHS staff was also reported.

CONCLUSION

This study provides preliminary evidence for the feasibility and acceptability of a CBT-based culturally-adapted group psychological intervention for British Pakistani mothers.

TRIAL REGISTRATION

Study ethics registration number: 10/H1005/62 (University of Manchester).