Mother-to-mother therapy in India and Pakistan: adaptation and feasibility evaluation of the peer-delivered Thinking Healthy Programme

Addressing Challenges for Psychotherapy Supervision in Global Mental Health: Experiential Learnings From Rural Nepal

Background

As the field of global mental health grows, many psychotherapy trainees will work across cultures in low-resource settings in high-income countries or in low- and middle-income countries. Faculty members and mentors may face several challenges in providing supervision for psychologists in low-resource settings. As such, there is a need to develop best practices for psychotherapy supervision in global mental health.

Methods

We describe the common challenges and potential strategies in psychotherapy supervision based on our research, clinical, and academic partnerships between academic institutions, a nonprofit organization, and the Nepali government.

Results

The strategies and considerations we have found helpful include focusing on therapies with strong behavioral and interpersonal (rather than emotional or cognitive) components and using locally validated therapies or standard manuals that have been endorsed by the WHO for low-resource settings. Other strategies include providing psychotherapy training for local psychiatrists who may be in supervisory roles and gaining competence in navigating different expectations of social structures and family dynamics.

Conclusion

Supervisors face many challenges while supporting trainees and early psychologists in global mental health settings. While ensuring local adaptation, key considerations can be developed into best practices to support psychiatrists, supervisors, and trainees based in low- and middle-income countries.

Rural Friendship Bench: A qualitative study in Zaka district, Zimbabwe

BACKGROUND

We piloted the Friendship Bench-an evidence-based, urban-area task sharing intervention for common mental disorders-in rural Zimbabwe. The intervention combines problem solving therapy with income generating activities. This study sought to understand the intervention's implementation in terms of acceptability, feasibility, and sustainability as well as local attitudes towards mental wellbeing in rural Zimbabwe.

METHODS

Using four separate semi-structured interview guides, we conducted in-depth interviews (N = 32) with patients (n = 9), village health workers (n = 12), nurses (n = 6), and community leaders (n = 5). We analyzed our data using thematic analysis with a diverse coding team using an integrative deductive-inductive approach.

RESULTS

Five themes emerged: 1) explanatory models for mental illness, 2) clinical workflow and emphasis on documentation, 3) positive feedback about the Friendship Bench, 4) accessibility, and 5) feasibility.

CONCLUSION

In its current format, our intervention was acceptable but neither feasible nor sustainable. Sociocultural context is critical in the development of rural task sharing interventions for mental health. We thus recommend a robust pilot and adaptation phase when scaling task sharing interventions in rural sub-Saharan Africa to elevate community voices, leverage existing social structures, and embed interventions as deeply into communities as possible.

Piloting a psychosocial intervention for perinatal depression, the Thinking Healthy Programme-Peer delivered (THPP), in a primary care setting in Lilongwe District, Malawi

Despite the evidence for the effectiveness of psychosocial interventions for perinatal depression, their uptake is low in Low- and Middle-Income Countries. Reasons for this include the lack of contextually adapted interventions and mental health specialists to deliver them. This study aimed to test the acceptability and feasibility of a psychosocial intervention for perinatal depression, the Thinking Healthy Programme-Peer Delivered, adapted for use in rural Malawi. A multi-method evaluation of feasibility and acceptability of the intervention was conducted using a one-group pretest-posttest quasi-experimental design and an exploratory qualitative study. Pre-post intervention change in depression scores (paired t-test) and recruitment, retention and session adherence rates were calculated. Qualitative data were collected through 29 in-depth interviews (22 mothers and 7 peer volunteers) and 1 Focus Group Discussion (18 mothers). Thematic analysis approach was used to analyse qualitative data. Seven (7) out of 8 peer volunteers were successfully trained to deliver the intervention. A total of 31 pregnant women with Edinburgh Postnatal Depression Scale (EPDS) score ≥12 were offered intervention, of whom 24 were enrolled (recruitment rate 77.4%). Out of these 24 women, 22 completed the intervention (retention rate 91.6%). Mean difference between pre- and post-test EPDS scores one week after 8th session was 7.59 (95% CI 4.98 to 10.19), p<0.001. Qualitative evaluation showed that the intervention was acceptable despite some challenges including stigma and issues around incentivization of peer volunteers. The Thinking Healthy Programme-Peer Delivered, adapted for use in Malawi, was feasible to deliver and acceptable to its target population. The intervention may be useful in management of perinatal depression in primary care settings in Malawi. However, definitive trials are needed to evaluate its effectiveness.

Adapting brief problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence in rural Ethiopia

OBJECTIVE

To adapt an evidence-based psychological intervention for pregnant women experiencing depressive symptoms and intimate partner violence (IPV) in rural Ethiopia.

METHOD

We conducted a desk review of contextual factors in Sodo, Ethiopia, followed by qualitative interviews with 16 pregnant women and 12 antenatal care (ANC) providers. We engaged stakeholders through participatory theory of change (ToC) workshops, to select the intervention and articulate a programme theory. We used "ADAPT" guidance to adapt the intervention to the context, before mapping potential harms in a "dark logic model".

RESULTS

Brief problem-solving therapy developed for South Africa was the most contextually relevant model. We adapted the delivery format (participants prioritised confidentiality and brevity) and training and supervision (addressing IPV). Consensus long-term outcomes in our ToC were ANC providers skilled in detecting and responding to emotional difficulties and IPV, women receiving appropriate support, and emotional difficulties improving. Our dark logic model highlighted the risk of more severe IPV and mental health symptoms not being referred appropriately.

CONCLUSION

Although intervention adaptation is recommended, the process is rarely reported in depth. We comprehensively describe how contextual considerations, stakeholder engagement, programme theory, and adaptation can tailor psychological interventions for the target population in a low-income, rural setting.

The Role of Social Support in Perinatal Mental Health and Psychosocial Stimulation

Social support refers to the help someone receives emotionally or instrumentally from their social network. Poor social support in the perinatal period has been associated with increased risk for symptoms of common mental disorders, including depression and posttraumatic stress symptoms (PTS), which may impact parenting behavior. Whether social support impacts parenting behaviors, independent of mental health symptomatology, remains unclear. Among N=309 participants of the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT Trial), a large perinatal depression and anxiety treatment trial, we explored the relations between perceived social support, perinatal depressive and PTS symptoms, and psychosocial stimulation provided by the parent in their home environment. Social support was measured at baseline using the Multidimensional Scale of Perceived Social Support (MSPSS). Perinatal depressive symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS) and PTS symptoms were measured by the Abbreviated PTSD Checklist (PCL-6) at baseline, 3-, and 6-months post-randomization. Psychosocial stimulation was assessed by the Home Observation Measurement of the Environment (HOME) when the infant was between 6 to 24 months. Using stepwise hierarchical regressions, we found: (1) perceived social support at baseline significantly predicted both depressive and PTS symptoms at 3-months post-randomization, even when controlling for baseline depressive and PTS symptoms; and (2) while neither depressive nor PTS symptoms were significantly associated with psychosocial stimulation, perceived social support at baseline was a significant predictor. Clinical implications regarding treatment of perinatal patients are discussed.

The adaptation of a youth mental health intervention to a peer-delivery model utilizing CBPR methods and the ADAPT-ITT framework in Sierra Leone

Low- and middle-income countries (LMICs) carry a significant proportion of the global burden of untreated mental health disorders. Peer-delivered programs offer LMICs with limited mental health professionals an opportunity to increase mental health service access. This study describes the process of adapting a lay-worker-delivered evidence-based youth mental health intervention to a peer-delivery model in Sierra Leone using participatory methods. We convened Youth Community Advisory Boards (YCABs) as partners to develop a peer-delivery model for an evidence-based intervention. In collaboration with YCABs, the Assessment, Decision, Administration, Production, Topical experts, Integration, Training, Testing (ADAPT-ITT) framework was applied to guide the adaptation. The ADAPT-ITT framework is an eight-step process to adapt evidence-based interventions. The ADAPT-ITT framework facilitated the adaptation of the Youth Readiness Intervention (YRI), an evidence-based mental health program intervention that has been delivered by adult lay-workers to the youth peer-delivery platform in Sierra Leone. The YCABs identified program modifications, including the incorporation of storytelling, refinement of metaphors, and alterations to make delivery more accessible to low-literacy youth with particular attention to gender. YCABs also provided recommendations on how to support youth facilitators in providing psychosocial support, emphasizing self-care and boundary setting to ensure high-quality intervention delivery and do-no-harm principles. Study findings suggest that the ADAPT-ITT framework can be feasibly applied to guide the intervention adaptation process in LMICs. The use of participatory methods generated modifications that reflected youth experiences, needs, and concerns as facilitators and participants. Next steps include refinement and pilot testing of the adapted intervention.

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.

"They should ask about our feelings": Mongolian women's experiences of postpartum depression

Between 16 and 20% of perinatal women in low- and middle-income countries experience depression. Addressing postpartum depression (PPD) requires an appreciation of how it manifests and is understood in different cultural settings. This study explores postpartum Mongolian women's perceptions and experiences of PPD. We conducted interviews with 35 postpartum women who screened positive for possible depression to examine: (1) personal experiences of pregnancy/childbirth; (2) perceived causes and symptoms of PPD; and (3) strategies for help/support for women experiencing PPD. Unless extreme, depression was not viewed as a disease but rather as a natural condition following childbirth. Differences between a biomedical model of PPD and local idioms of distress could explain why awareness about PPD was low. The most reported PPD symptom was emotional volatility expressed as anger and endorsement of fear- or anxiety-related screening questions, suggesting that these might be especially relevant in the Mongolian context. Psychosocial factors, as opposed to biological, were common perceived causes of PPD, especially interpersonal relationship problems, financial strain, and social isolation. Possible barriers to PPD recognition/treatment included lack of awareness about the range of symptoms, reluctance to initiate discussions with providers about mental health, and lack of PPD screening practices by healthcare providers. We conclude that educational campaigns should be implemented in prenatal/postnatal clinics and pediatric settings to help women and families identify PPD symptoms, and possibly destigmatize PPD. Healthcare providers can also help to identify women with PPD through communication with women and families.

Problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence: A randomised, controlled feasibility trial in rural Ethiopia

Evidence for the feasibility of brief psychological interventions for pregnant women experiencing intimate partner violence (IPV) in rural, low-income country settings is scarce. In rural Ethiopia, the prevalence of antenatal depressive symptoms and lifetime IPV are 29% and 61%, respectively. We aimed to assess the feasibility and related implementation outcomes of brief problem-solving therapy (PST) adapted for pregnant women experiencing IPV (PST-IPV) in rural Ethiopia, and of a randomised, controlled feasibility study design. We recruited 52 pregnant women experiencing depressive symptoms and past-year IPV from two antenatal care (ANC) services. Consenting women were randomised to PST-IPV (n = 25), 'standard' PST (not adapted for women experiencing IPV; n = 12) or enhanced usual care (information about sources of support; n = 15). Masked data collectors conducted outcome assessments nine weeks post-enrolment. Addis Ababa University (#032/19/CDT) and King's College London (#HR-18/19-9230) approved the study. Fidelity to randomisation was impeded by strong cultural norms about what constituted IPV. However, recruitment was feasible (recruitment rate: 1.5 per day; 37% of women screened were eligible). The intervention and trial were acceptable to women (4% declined initial screening, none declined to participate, and 76% attended all four sessions of either active intervention). PST-IPV was acceptable to ANC providers: none dropped out. Sessions lasting up to a mean 52 minutes raised questions about the appropriateness of the model to this context. Competence assessments recommended supplementary communication skills training. Fidelity assessments indicated high adherence, quality, and responsiveness but assessing risks and social networks, and discussing confidentiality needed improvement. Adjustments to optimise a future, fully powered, randomised controlled trial include staggering recruitment in line with therapist availability, more training on the types of IPV and how to discuss them, automating randomisation, a supervision cascade model, and conducting post-intervention outcome assessments immediately and three months postpartum. Registration: Pan African Clinical Trials Registry #PACTR202002513482084 (13/12/2019): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9601.

Improving mental ill-health with psycho-social group interventions in South Asia-A scoping review using a realist lens

This scoping review aimed to synthesise current evidence related to psycho-social groups as part of community-based mental health interventions in South Asia. We used a realist lens to pay attention to the contexts and mechanisms supporting positive outcomes. We included studies published from January 2007 to February 2022 that: were based in communities in South Asia, included a group component, reported on interventions with a clear psychosocial component, targeted adults and were implemented by lay community health workers. Two reviewers extracted data on intervention components, groups and facilitators, participant demographics and enabling contexts, mechanisms and outcomes. Expert reference panels including people with lived experience of psycho-social disability, mental health professionals and policy makers confirmed the validity and relevance of initial review findings. The review examined 15 interventions represented by 42 papers. Only four interventions were solely psycho-social and nearly all included psychoeducation and economic support. Only 8 of the 46 quantitative outcome measures used were developed in South Asia. In a context of social exclusion and limited autonomy for people with psychosocial disability, psychosocial support groups triggered five key mechanisms. Trusted relationships undergirded all mechanisms, and provided a sense of inclusion, social support and of being able to manage mental distress due to improved skills and knowledge. Over time group members felt a sense of belonging and collective strength meaning they were better able to advocate for their own well-being and address upstream social health determinants. This led to outcomes of improved mental health and social participation across the realms of intrapersonal, interpersonal and community. Psychosocial groups merit greater attention as an active ingredient in community interventions and also as an effective, relevant, acceptable and scalable platform that can promote and increase mental health in communities, through facilitation by lay community health workers.

Technology-assisted cognitive-behavior therapy delivered by peers versus standard cognitive behavior therapy delivered by community health workers for perinatal depression: study protocol of a cluster randomized controlled non-inferiority trial

BACKGROUND

The lack of trained mental health professionals is a key barrier to scale-up of evidence-based psychological interventions in low and middle-income countries. We have developed an app that allows a peer with no prior experience of health-care delivery to deliver the cognitive therapy-based intervention for perinatal depression, the Thinking Healthy Programme (THP). This trial aims to assess the effectiveness and cost-effectiveness of this Technology-assisted peer-delivered THP versus standard face-to-face Thinking Healthy Programme delivered by trained health workers.

METHODS

We will employ a non-inferiority stratified cluster randomized controlled trial design comparing the two formats of intervention delivery. A total of 980 women in the second or third trimester of pregnancy with a diagnosis of Major Depressive Episode, evaluated with the Structured Clinical Interview for DSM-V Disorders (SCID), will be recruited into the trial. The unit of randomization will be 70 village clusters randomly allocated in a 1:1 ratio to the intervention and control arms. The primary outcome is defined as remission from major depressive episode at 3 months postnatal measured with the SCID. Data will also be collected on symptoms of anxiety, disability, quality of life, service use and costs, and infant-related outcomes such as exclusive breastfeeding and immunization rates. Data will be collected on the primary outcome and selected secondary outcomes (depression and anxiety scores, exclusive breastfeeding) at 6 months postnatal to evaluate if the improvements are sustained in the longer-term. We are especially interested in sustained improvement (recovery) from major depressive episode.

DISCUSSION

This trial will evaluate the effectiveness and cost-effectiveness of a technology-assisted peer-delivered cognitive behavioral therapy-based intervention in rural Pakistan. If shown to be effective, the novel delivery format could play a role in reducing the treatment gap for perinatal depression and other common mental disorders in LMIC.

TRIAL REGISTRATION

The trial was registered at Clinicaltrials.gov (NCT05353491) on 29 April 2022.

Adverse sequelae of the COVID -19 pandemic on mental health services in Chile

Objective

This study seeks to describe the adverse effects of the COVID-19 pandemic on mental health services in Chile.

Methods

This study is part of ongoing multicountry research known as the Mental Health Care - Adverse Sequelae of COVID-19 study (or the MASC study) that includes seven countries. Chile is the only one in Latin America. This study used a convergent mixed methods design. The quantitative component analyzed data about public mental health care collected between January 2019 and December 2021 from the open-access database at the Ministry of Health. The qualitative component analyzed data collected from focus groups of experts that included professionals in charge of mental health services, policy-makers, service users and caregivers. Finally, the data synthesis was performed by triangulation of both components.

Results

By April 2020, mental health service provision had been reduced by 88% in primary care; moreover, secondary and tertiary levels had also reduced their mental health activities by, respectively, 66.3% and 71.3% of pre-COVID levels. Negative sequelae were described at the health systems level, and full recovery had not been achieved by the end of 2021. The pandemic affected the essential characteristics of community-based mental health services, with adverse impacts on the continuity and quality of care, reduced psychosocial and community support, and negative effects on health workers' mental health. Digital solutions were widely implemented to enable remote care, but challenges included the availability of equipment, its quality and the digital divide.

Conclusions

The COVID-19 pandemic has had significant and enduring adverse effects on mental health care. Lessons learned can inform recommendations for good practices for the ongoing and future pandemics and health crises, and highlight the importance of prioritizing the strengthening of mental health services in response to emergencies.

Adaptation and integration of the thinking healthy programme into pregnancy schools in Istanbul, Turkey

BACKGROUND

Perinatal mental health is a major public health concern. In Turkey, public hospitals operate pregnancy schools which provides an opportunity to integrate an evidence-based Thinking Healthy Programme (THP) for perinatal depression. The aim of this study is to adapt the THP for universal use in the group setting and to understand its acceptability and feasibility for integration into the existing antenatal care programme for both face-to-face and online delivery.

METHODS

Following an expert-led adaptation process using the Bernal Framework, field testing was conducted on a group of women and facilitators followed by in-depth interviews (n:8) and group discussions (n = 13). Data were analysed using Thematic Framework Analysis.

RESULTS

Minor but significant adaptations were made to the individually delivered THP for use in the universal group pregnancy schools. Initial findings indicate that the THP-group version was acceptable to its target population and could be integrated into the antenatal care plan for delivery during face-to-face and online group classes.

CONCLUSION

THP is transferable to the Turkish cultural and healthcare context. The THP-group version has the potential to add value to Turkey's existing perinatal healthcare programme.

[Successful Implementation of Peer Support for People with Severe Mental Illness in Germany: a Theory of Change Approach]

OBJECTIVE

Peer support is an established intervention in which people with mental illness receive support by trained peer support workers who have already overcome a mental health crisis. The implementation of peer support is complex due to interacting factors and can be achieved through the participatory Theory of Change method. Aim of this study is to develop a cross-site Theory of Change for the sustainable implementation of UPSIDES peer support in Germany.

METHODS

Based on site-specific Theories of Change workshops from Ulm and Hamburg in which 47 participants took part, a cross-site Theory of Change was designed and verified in three follow-up workshops with 12 participants. Participants' professional and experiential backgrounds were diverse, including peer support workers, hospital directors and managers, mental health professionals (psychiatrists, psychotherapists, nurses), and researchers.

RESULTS

The first pathway of the cross-site Theory of Change focuses on the training of peer support workers, whereas the second pathway emphasizes recognition and integration by mental health institutions and professionals. The third pathway specifies the building of a cross-professional care network to integrate various peer support services. Procedures to approach prospective peer clients are depicted in the fourth pathway. The fifth path addresses the clarification of the role description of peer support workers and the implementation in other institutions through cooperation.

DISCUSSION

Many of the identified implementation steps have been validated in comparable studies. The development of this Theory of Change by bringing together multiple perspectives of key stakeholders is an important basis for the sustainable implementation of UPSIDES peer support. Furthermore, it may serve as a blueprint for the implementation of similar interventions to advance scaling-up of evidence-based user-led and recovery-oriented interventions.

CONCLUSION

The Theory of Change approach is a well-accepted and feasible method, which can be recommended for the implementation of complex interventions such as UPSIDES peer support.

Delivering the Thinking Healthy Programme as a universal group intervention integrated into routine antenatal care: a randomized-controlled pilot study

BACKGROUND

Women with perinatal depression and their children are at increased risk of poor health outcomes. There is a need to implement non-stigmatizing interventions into existing health systems which reduce psychosocial distress during pregnancy and prevent perinatal depression. We adapted the WHO-endorsed Thinking Healthy Programme (THP) to be delivered universally to all women attending routine online pregnancy schools in Istanbul, Turkey. This study aimed to evaluate the feasibility and acceptability of this intervention.

METHODS

This mixed-methods study incorporated a two-arm pilot randomized controlled trial and qualitative evaluation of the feasibility and acceptability of the adapted THP - Brief Group version (THP-BGV) to a range of stakeholders. We recruited pregnant women at 12-30 weeks' gestation through pregnancy schools within the University Hospital's catchment area. Women in the intervention arm received five online sessions of the THP-BGV delivered by antenatal nurses. The intervention employed principles of cognitive behaviour therapy to provide psychoeducation, behaviour activation, problem-solving strategies and group support to participants. In the control arm, women received usual care consisting of routine online educational pregnancy classes aided by the antenatal nurses. The women were assessed for depressive symptoms with the Edinburgh Postnatal Depression Scale at baseline and 4-6 weeks post-intervention and also evaluated for anxiety, perceived social support, partner relationship, level of disability and sleep quality. In-depth interviews were conducted with women and other key stakeholders.

RESULTS

Of the 99 consecutive women referred to the pregnancy schools, 91 (91.9%) were eligible and 88 (88.8%) consented to participate in the study and were randomized. Eighty-two (83%) completed the final assessments. Our main findings were that this preventive group intervention was feasible to be integrated into routine antenatal educational classes and it was valued by the women and delivery-agents. While the study was not powered to detect differences between intervention and control conditions, we found small trends towards reduction in anxiety and depressive symptoms favoring the intervention arm. No serious adverse events were reported.

CONCLUSIONS

Given the paucity of preventive interventions for perinatal depression in low and middle-income countries, a fully powered definitive randomized controlled trial of this feasible and acceptable intervention should be conducted.

TRIAL REGISTRATION

The study was registered at Clinical Trails.gov ( NCT04819711 ) (Registration Date: 29/03/2021).

Enhancing a peer supporter intervention for young mothers living with HIV in Malawi, Tanzania, Uganda, and Zambia: Adaptation and co-development of a psychosocial component

ABSTRACTYoung mothers living with HIV (YMHIV) experience heightened risks to their mental health, as their transition to adulthood is marked by social stigma, health and socioeconomic challenges. Targeted psychosocial interventions may improve the mental health of YMHIV; however, no evidence-based interventions have been developed for this group. Peer support models, more common for youth living with HIV, show promise as a design to reach YMHIV in a non-stigmatising way. This manuscript describes the process of adapting and co-developing an evidence-based psychosocial component (Boost) of a larger intervention called Ask-Boost-Connect-Discuss. Peer supporters in Malawi, Tanzania, Uganda, and Zambia used ABCD to guide group sessions with YMHIV. The research team partnered with an implementing partner, Paediatric-Adolescent Treatment Africa, to undertake this work in three phases: 1) formative research, 2) content adaptation and development, and 3) consultation, refinement, and modification. YMHIV (n = 4), peer supporters (n = 21), and technical advisors (n = 4) were engaged as co-developers, shaping the resulting Boost intervention component at each phase. Peer support models may effectively reach young mothers, and consultation, co-creation, and integration with existing programming can offer rich insights to inform these models. We discuss the implications and promise of this approach.

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.

Gender Transformative Interventions for Perinatal Mental Health in Low and Middle Income Countries-A Scoping Review

Perinatal mental health problems are linked to poor outcomes for mothers, babies and families. In the context of Low and Middle Income Countries (LMIC), a leading risk factor is gender disparity. Addressing gender disparity, by involving fathers, mothers in law and other family members can significantly improve perinatal and maternal healthcare, including risk factors for poor perinatal mental health such as domestic violence and poor social support. This highlights the need to develop and implement gender-transformative (GT) interventions that seek to engage with men and reduce or overcome gender-based constraints. This scoping review aimed to highlight existing gender transformative interventions from LMIC that specifically aimed to address perinatal mental health (partner violence, anxiety or depression and partner support) and identify components of the intervention that were found to be useful and acceptable. This review follows the five-stage Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. Six papers that met the inclusion criteria were included in the review (four from Africa and two from Asia). Common components of gender transformative interventions across studies included couple-based interventions and discussion groups. Gender inequity and related factors are a strong risk for poor perinatal mental health and the dearth of studies highlights the strong need for better evidence of GT interventions in this area.

Effectiveness and implementation outcomes for peer-delivered mental health interventions in low- and middle-income countries: a mixed-methods systematic review

PURPOSE

This review aimed to evaluate interventions led by peer counselors (PCs) for adults with common mental disorders in low- and middle-income countries (LMICs) along indices of overall effectiveness and key implementation outcomes (acceptability, feasibility, cost, fidelity, sustainability).

METHODS

This review followed a mixed-methods systematic review design. MEDLINE/PubMed, Embase, PsycINFO, and Global Health databases were searched for PC-led interventions for adults in LMICs targeting depressive and/or anxiety disorders or PTSD. Quantitative data was narratively synthesized, and qualitative data was thematically synthesized separately. The results from the qualitative and quantitative syntheses were then combined in a cross-study synthesis.

RESULTS

Twenty-four papers describing thirteen PC-led interventions were included for review. Narrative synthesis results indicated mixed effectiveness of PC-led interventions in reducing depressive, anxiety, PTSD symptoms and high PC competency. Thematic synthesis revealed five descriptive themes: (1) Preferred PC characteristics; (2) Incentives and motivation for PCs; (3) Barriers to PC-led intervention implementation; (4) Helpful supervision/training practices; and (5) Overall high acceptability of PC-led interventions. Cross-study synthesis revealed high acceptability, feasibility, and fidelity, but cost and sustainability outcomes were underreported in included papers.

CONCLUSION

PC-led interventions seem to show initial promise in terms of effectiveness, acceptability, feasibility, cost, fidelity, and sustainability. Future research should focus on standardizing measurements of implementation outcomes to facilitate cross-study analysis. Additional empirical attention should be paid to underrepresented implementation outcomes (e.g., cost, sustainability). Finally, researchers should adopt a participatory approach that elevates the perspectives of PCs throughout all stages of the implementation process.

Technology-assisted peer therapy: a new way of delivering evidence-based psychological interventions

In low-income settings, ninety percent of individuals with clinical depression have no access to evidence-based psychological interventions. Reasons include lack of funds for specialist services, scarcity of trained mental health professionals, and the stigma attached to mental illness. In recent years there have been many studies demonstrating effective delivery of psychological interventions through a variety of non-specialists. While these interventions are cost-effective and less stigmatising, efforts to scale-up are hampered by issues of quality-control, and what has been described by implementation scientists as ‘voltage-drop’ and ‘programme-drift.’ Using principles of Human Centred Design in a rural setting in Pakistan, we worked with potential users to co-design a Tablet or Smartphone-based App that can assist a lay-person deliver the Thinking Healthy Programme, a World Health Organization-endorsed evidence-based intervention for perinatal depression. The active ingredients of this cognitive-therapy based intervention are delivered by a virtual ‘avatar’ therapist incorporated into the App which is operated by a ‘peer’ (a woman from the neighbourhood with no prior experience of healthcare delivery). Using automated cues from the App, the peer reinforces key therapeutic messages, helps with problem-solving and provides the non-specific but essential therapeutic elements of empathy and support. The peer and App therefore act as co-therapists in delivery of the intervention. The peer can deliver the intervention with good fidelity after brief automated in-built training. This approach has the potential to be applied to other areas of mental health and help bridge the treatment gap, especially in resource-poor settings. This paper describes the process of co-development with end-users and key features of the App.

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

Perinatal depression is highly prevalent in low- and middle-income countries (LMICs) and is associated with adverse maternal and child health consequences. Task-shared psychological and psychosocial interventions for perinatal depression have demonstrated clinical and cost-effectiveness when delivered on a large scale. However, task-sharing approaches, especially in LMICs, require an effective mechanism, whereby clients who are not likely to benefit from such interventions are identified from the outset so that they can benefit from higher intensity treatments. Such a stratified approach can ensure that limited resources are utilized appropriately and effectively. The use of standardized and easy-to-implement algorithmic devices (e.g., nomograms) could help with such targeted dissemination of interventions. The present investigation posits a prognostic model and a nomogram to predict the prognosis of perinatal depression among women in rural Pakistan. The nomogram was developed to deliver stratified model of care in primary care settings by identifying those women who respond well to a non-specialist delivered intervention and those requiring specialist care. This secondary analysis utilized data from 903 pregnant women with depression who participated in a cluster randomized, controlled trial that tested the effectiveness of the Thinking Healthy Program in rural Rawalpindi, Pakistan. The participants were recruited from 40 union councils in two sub-districts of Rawalpindi and randomly assigned to intervention and enhanced usual care. Sixteen sessions of the THP intervention were delivered by trained community health workers to women with depression over pregnancy and the postnatal period. A trained assessment team used the Structured Clinical Interview for DSM-IV current major depressive episode module to diagnose major depressive disorder at baseline and post-intervention. The intervention received by the participants emerged as the most significant predictor in the prognostic model. Among clinical factors, baseline severity of core-emotional symptoms emerged as an essential predictor, followed by atypical symptoms and insomnia. Higher severity of these symptoms was associated with a poorer prognosis. Other important predictors of a favorable prognosis included support from one’s mother or mother-in-law, financial empowerment, higher socioeconomic class, and living in a joint family system. This prognostic model yielded acceptable discrimination (c-statistic = 0.75) and calibration to aid in personalized delivery of the intervention.

Exploring the cultural appropriateness of a psychosocial intervention, the Thinking Healthy Programme-Peer delivered (THPP), for perinatal depression in Lilongwe, Malawi

Background

Perinatal depression is a common and disabling mental health problem in Malawi and other Low- and middle-income countries. There is evidence for effective psychosocial interventions for perinatal depression, but no such intervention has been developed for use in Malawi. The broad aim of this study was to explore the cultural appropriateness of a psychosocial intervention for perinatal depression called the Thinking Healthy Programme-Peer delivered for adaptation and use in Lilongwe, Malawi.

Methods

A qualitative exploratory design was used. Data were collected through conducting five Focus Group Discussions, involving thirty-eight purposefully selected participants including pregnant women, community volunteers and their supervisors, the Health Surveillance Assistants and maternal health care workers at implementation and policy level following observations of video recorded role plays of the Thinking Healthy Programme-Peer delivered sessions in theatre testing. A content analysis approach was used to analyse data.

Results

Six main themes were generated regarding the appropriateness of the content and delivery of the Thinking Healthy Programme-Peer delivered intervention, including: 1) Focus of the intervention; 2) Cultural appropriateness of the content; 3) Language used; 4) Context; 5) Provider of the intervention; and 6) Flexibility in the delivery of the intervention. The Thinking Healthy Programme-Peer delivered intervention was deemed appropriate for the target population, though with recommendations to: review illustrations to enhance clarity, use culturally appropriate stories and idioms, use daily spoken language, and adapt the number and duration of sessions to meet the needs of individual clients.

Conclusions

These findings highlight important areas to inform adaptation of the Thinking Healthy Programme-Peer delivered and add to the growing evidence of cultural adaptation of psychosocial interventions for perinatal depression.

Maternal mental health of adolescent mothers: a cross-sectional mixed-method study protocol to determine cultural and social factors and mental health needs in Lilongwe, Malawi

INTRODUCTION

Adolescence marks a transition of life from childhood to adulthood. Becoming a mother during adolescence presents unique challenges that have a significant mental and physical burden and may increase the likelihood of developing common mental disorders (CMDs). Untreated CMDs have serious effects on both the mother and her child. Culture constitutes an important context for most experiences, and affects how individuals seek help. However, there is limited research that has investigated how culture and social factors influence the adolescent mother's mental health during the postpartum period in Malawi.

METHODS/DESIGN

A cross-sectional sequential mixed methods design will be carried out in four phases. Phase one will include the preparatory phase and scoping review. The second phase will comprise a survey with adolescent mothers. The sample for the survey consists of adolescent postpartum mothers aged 14-19 years (with infants of up to 6 months of age) who have the capacity to consent for the study. Phase three will be a qualitative study in which in-depth interviews and focus group discussions will be employed to collect data from health workers and informal healthcare providers in the community (eg, traditional healers, traditional birth attendants). The fourth phase will involve developing recommendations for policy and practice ETHICS AND DISSEMINATION: This study will provide an understanding of the impact of culture and social factors that influence adolescent mother's mental health and well-being, including the identification of potential risk and protective factors. The findings will inform recommendations for an appropriate, culturally accepted spectrum of interventions, including universal, selective and indicated prevention strategies. The findings will be disseminated to stakeholders working in maternal health in Malawi. Ethical approval was received from the Curtin University Human Research Ethics Committee (HRE2021-0223) and (P.05/21/575) Malawian Ethics Board National Committee on Research Ethics in the Social Sciences and Humanities.

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."

Factors affecting the implementation of task-sharing interventions for perinatal depression in low- and middle-income countries: A systematic review and qualitative metasynthesis

Background The vast majority of women with perinatal depression (PND) live in low- and middle-income countries (LMICs). Task sharing is an alternative delivery strategy to implement PND services. However, the exploration of influencing factors for task sharing in PND services is poor. Therefore, this study aimed to identify factors affecting LMICs to implement PND task-sharing interventions from the perspective of stakeholders and weigh their levels of evidence. Methods A comprehensive literature search was carried out through six English and Chinese databases on qualitative data. We used Critical Appraisal Skills Programme (CASP)/Meta Quality Appraisal Tool (MetaQAT) to appraise included studies, extracted data according to the Consolidated Framework for Implementation Research (CFIR), and assigned levels of confidence in the factors through Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). Results 17 studies met the eligibility criteria, factors identified with high levels of evidence were coded to the CFIR constructs, including "Knowledge and Attitudes of Those Served by the Organization", "Available Resources", "Compatibility", "Access to knowledge and information", "Resources of Those Served by the Organization" and "Alignment". Conclusion This metasynthesis highlights task sharing in PND interventions is influenced by multiple factors. We synthesized and developed implementation recommendations for practice. Strategies must be actively developed to enable women and their families to enjoy the benefits of good perinatal mental health.

Mapping the role of patient and public involvement during the different stages of healthcare innovation: A scoping review

BACKGROUND

Patient and public involvement (PPI) has become increasingly important in the development, delivery and improvement of healthcare. PPI is used in healthcare innovation; yet, how it is used has been under-reported. The aim of this scoping review is to identify and map the current available empirical evidence on the role of PPI during different stages of healthcare innovation.

METHODS

The scoping review was conducted in accordance with PRISMAScR and included any study published in a peer-reviewed journal between 2004 and 2021 that reported on PPI in healthcare innovation within any healthcare setting or context in any country. The following databases were searched: Medline, EMBASE, CINAHL, PsycInfo, HMIC and Google Scholar. We included any study type, including quantitative, qualitative and mixed-method studies. We excluded theoretical frameworks, conceptual, scientific or grey literature as well as discussion and opinion papers.

RESULTS

Of the 87 included studies, 81 (93%) focused on or were conducted by authors in developed countries. A wide range of conditions were considered, with more studies focusing on mental health (n = 18, 21%) and cancer care (n = 8, 9%). The vast majority of the studies focused on process and service innovations (n = 62, 71%). Seven studies focused on technological and clinical innovations (8%), while 12 looked at both technological and service innovations (14%). Only five studies examined systems innovation (5%) and one study looked across all types of innovations (1%). PPI is more common in the earlier stages of innovation, particularly problem identification and invention, in comparison to adoption and diffusion.

CONCLUSION

Healthcare innovation tends to be a lengthy process. Yet, our study highlights that PPI is more common across earlier stages of innovation and focuses mostly on service innovation. Stronger PPI in later stages could support the adoption and diffusion of innovation.

PATIENT OR PUBLIC CONTRIBUTION

One of the coauthors of the paper (S. S.) is a service user with extensive experience in PPI research. S. S. supported the analysis and writing up of the paper.

Effect of a lay counselor delivered integrated maternal mental health and early childhood development group-based intervention in Siaya County, Kenya: A quasi-experimental longitudinal study

BACKGROUND

Maternal mental health is linked to early childhood development; yet there is a gap in evidence-based interventions for low-resource settings. This study estimates the impact of 'Integrated Mothers and Babies Course and Early Childhood Development' (iMBC/ECD), a cognitive-behavioral, group-based intervention, on maternal depression and early childhood social-emotional development in Siaya County, Kenya.

METHODS

This quasi-experimental study enrolled 417 pregnant women and mothers of children under age 2 across two sub-counties in Siaya County. The intervention area had 193 women in 23 groups implementing iMBC/ECD and the control area had 224 women in 30 groups exposed to ECD only content. Mother/index child dyads were followed for two years. To estimate the causal treatment effect from the non-randomized design, we implemented the propensity score weighting method with inverse probability weights.

RESULTS

At baseline, 10.2% of participants endorsed moderate/severe depressive symptoms. At 14-months post-intervention, 7.4% endorsed moderate/severe depression. Overall, iMBC/ECD intervention did not have a significant impact on reducing maternal depression or improving children's social and emotional development. However, sub-group analyses revealed that iMBC/ECD was associated with lowered depressive symptoms among women with no/low education, four or more children and/or no experience of intimate partner violence in the past year. Women with high program attendance (more than half of 14 sessions) also experienced consistently fewer depressive symptoms compared to those with lower attendance.

LIMITATIONS

Non-randomized study, sub-group analyses are exploratory.

CONCLUSIONS

The iMBC/ECD program may have the potential to improve maternal mental health and early child development for more targeted vulnerable populations.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Contemporary management of unipolar depression in the perinatal period

Introduction: There is increasing recognition that antenatal depression and postpartum depression are highly prevalent and have significant impact on maternal and child health.Areas Covered: In the initial part of the manuscript, the authors review the epidemiology of antenatal and postpartum depression and its impact on maternal and child health. The later part of the manuscript reviews the current status of the medical management and psychosocial interventions targeting perinatal depression.Expert Opinion: Perinatal depression is the focus of several studies with increasing interest in developing effective interventions. While several psychosocial interventions targeting maternal depressive symptoms during pregnancy and postpartum are available, more studies are needed to address the need for safe and efficacious strategies for the use of antidepressant medication during pregnancy and in the postpartum period.

Multiple mediation analysis of the peer-delivered Thinking Healthy Programme for perinatal depression: findings from two parallel, randomised controlled trials

BACKGROUND

Low-intensity psychosocial interventions have been effective in targeting perinatal depression, but relevant mechanisms of change remain unknown.

AIMS

To examine three theoretically informed mediators of the Thinking Healthy Programme Peer-delivered (THPP), an evidence-based psychosocial intervention for perinatal depression, on symptom severity in two parallel, randomised controlled trials in Goa, India and Rawalpindi, Pakistan.

METHOD

Participants included pregnant women aged ≥18 years with moderate to severe depression, as defined by a Patient Health Questionnaire 9 (PHQ-9) score ≥10, and were randomised to either THPP or enhanced usual care. We examine whether three prespecified variables (patient activation, social support and mother-child attachment) at 3 months post-childbirth mediated the effects of THPP interventions of perinatal depressive symptom severity (PHQ-9) at the primary end-point of 6 months post-childbirth. We first examined individual mediation within each trial (n = 280 in India and n = 570 in Pakistan), followed by a pooled analysis across both trials (N = 850).

RESULTS

In both site-specific and pooled analyses, patient activation and support at 3 months independently mediated the intervention effects on depressive symptom severity at 6 months, accounting for 23.6 and 18.2% of the total effect of THPP, respectively. The intervention had no effect on mother-child attachment scores, thus there was no evidence that this factor mediated the intervention effect.

CONCLUSIONS

The effects of the psychosocial intervention on depression outcomes in mothers were mediated by the same two factors in both contexts, suggesting that such interventions seeking to alleviate perinatal depression should target both social support and patient activation levels.

DECLARATION OF INTEREST

None.

Improving access to psychosocial interventions for perinatal depression in low- and middle-income countries: lessons from the field

Over 90% women with perinatal depression in low and middle-income countries do not receive treatment. Scale-up of evidence-based psychosocial interventions is a key challenge. We developed the Thinking Healthy Programme (THP), a psychosocial intervention that can be delivered by non-specialist providers such as community health workers in primary and secondary care settings. Our research showed that three out of 4 women with perinatal depression who received the programme recovered, and there were beneficial effects on infant outcomes. In over a decade since the original research, policy and practice uptake of the programme globally has been promising. We describe factors contributing to this: the programme is relatively inexpensive and culturally transferable; the intervention can be integrated with existing maternal and child health programmes; the programme is amenable to 'task-sharing' via peers, nurses, community health-workers and other frontline workers; cascaded models of training and supervision, and the use of technology for training and delivery provide exciting future avenues for scaled-up implementation. These innovations are relevant to the neglected field of public mental health, especially in the post COVID19 era when rates of anxiety and depression are likely to rise globally.

A systematic review of mental health literacy in Pakistan

Individual mental health has become a primary global concern. In Pakistan, the prevalence of mental health issues is still unclear, as not many studies have assessed the level of mental health literacy (MHL) in the country. This systematic review aims to bridge this gap by encouraging the early detection of mental disorders, lessening stigma, and improving help-seeking behavior. Nine electronic databases were searched to identify empirical literature in this area. Only studies that evaluated MHL efficacy and those published in English were selected. Non-peer reviewed articles and gray literature were excluded. From 613 studies retrieved, 59 studies met the inclusion criteria and were reviewed. Forty-three of the included studies mentioned mental health outcome measures (of which only four mentioned reliability indices), 13 discussed stigma, 18 examined help-seeking approaches to mental illness treatments, and 47 discussed mental health knowledge. Additionally, the outcome of the MHL measures had considerable heterogeneity and limited validity. Meta-analysis was not conducted due to a lack of MHL operationalization. Besides, the measurement tools in the studies lacked consistency and standardization. This review compiled the available studies on MHL to assist researchers currently studying the various dimensions of MHL, as well as those designing new studies or investigating effective methods to increase MHL. This review highlights the need for well-designed controlled intervention studies. Further implications for researchers, practitioners, and policymakers are mentioned.

Why we heal: The evolution of psychological healing and implications for global mental health

Why do humans heal one another? Evolutionary psychology has advanced our understanding of why humans suffer psychological distress and mental illness. However, to date, the evolutionary origins of what drives humans to alleviate the suffering of others has received limited attention. Therefore, we draw upon evolutionary theory to assess why humans psychologically support one another, focusing on the interpersonal regulation of emotions that shapes how humans heal and console one another when in psychosocial distress. To understand why we engage in psychological healing, we review the evolution of cooperation among social species and the roles of emotional contagion, empathy, and self-regulation. We discuss key aspects of human biocultural evolution that have contributed to healing behaviors: symbolic logic including language, complex social networks, and the long period of childhood that necessitates identifying and responding to others in distress. However, both biological and cultural evolution also have led to social context when empathy and consoling are impeded. Ultimately, by understanding the evolutionary processes shaping why humans psychologically do or do not heal one another, we can improve our current approaches in global mental health and uncover new opportunities to improve the treatment of mental illness across cultures and context around the world.

Common factors in psychological treatments delivered by non-specialists in low- and middle-income countries: Manual review of competencies

Delivery of psychological and psychosocial treatments by non-specialists in low-and middle-income countries (LMIC) is a growing strategy to address the global mental health treatment gap. However, little is known about which competencies are essential for non-specialists to effectively deliver treatment. Psychotherapy research in high-income countries suggests that effective treatment requires competency in common factors. Therefore, our objective was to identify how common factors are described in evidence-supported non-specialist interventions in LMICs. To meet this objective, we identified and coded common factors by reviewing 16 evidence-supported manuals for psychological treatments delivered by non-specialists in LMICs. World Health Organization (WHO) manuals and other non-proprietary manuals, with positive randomized control outcomes, were included in the review. Fifteen common factors were identified and described in most manuals: 'promoting hope and realistic expectancy of change' and 'confidentiality' were described in 15 manuals (94%), followed by 'giving praise' and 'psychoeducation' (88% of manuals), and 'rapport building' (81% of manuals). Descriptions of common factors were similar across manuals, suggesting that training and competency evaluation approaches can be harmonized across interventions. Compiling these descriptions from the manuals can inform foundational training in common factors for diverse cadres of non-specialists around the world.

"A Woman Is a Puppet." Women's Disempowerment and Prenatal Anxiety in Pakistan: A Qualitative Study of Sources, Mitigators, and Coping Strategies for Anxiety in Pregnancy

Common mental disorders are highly prevalent among pregnant women in low- and middle-income countries, yet prenatal anxiety remains poorly understood, particularly in the sociocultural context of South Asia. Our study explored sources, mitigators, and coping strategies for anxiety among symptomatic pregnant women in Pakistan, particularly in relation to autonomy in decision-making and social support. We interviewed 19 pregnant married women aged 18-37 years recruited from 2017-2018 at a public hospital in Rawalpindi who screened positive for anxiety. Thematic analysis was based on both inductive emergent codes and deductive a priori constructs of pregnancy-related empowerment. Gender norms emerged as an important dimension of Pakistani women's social environment in both constraining pregnancy-related agency and contributing to prenatal anxiety. Women's avenues of self-advocacy were largely limited to indirect means such as appeals to the husband for intercession or return to her natal home. The levels of autonomy during pregnancy depended on the area of decision-making, and peer/family support was a critical protective factor and enabling resource for maternal mental health. Women's disempowerment is a key contextual factor in the sociocultural experience of prenatal maternal anxiety in South Asia, and further examination of the intersections between empowerment and perinatal mental illness might help inform the development of more context-specific preventive approaches.

Implementation outcomes of cognitive behavioural therapy delivered by non-specialists for common mental disorders and substance-use disorders in low- and middle-income countries: a systematic review

Due to severe shortages of specialist mental health personnel in low- and middle-income countries (LMICs), psychological therapies are increasingly being delivered by non-specialist health workers (NSHWs). Previous reviews have investigated the effectiveness of NSHW-delivered psychological therapies, including cognitive behavioural therapy (CBT), in LMIC settings. This systematic review aims to synthesise findings on the implementation outcomes of NSHW-delivered CBT interventions addressing common mental disorders and substance-use disorders in LMICs. Four databases were searched, yielding 3211 records, 18 of which met all inclusion criteria. We extracted and synthesised qualitative and quantitative data across eight implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration and sustainability. Findings suggest that delivery of CBT-based interventions by NSHWs can be acceptable, appropriate and feasible in LMIC settings. However, more research is needed to better evaluate these and other under-reported implementation outcomes.

Brief Report: Preliminary Outcomes of a Peer Counselling Program for Parents of Children with Autism in the South Asian Community

Peer volunteers have been found to be effective in delivering psychosocial interventions when they come from the same culture and share similar experiences as participants. We examined the clinical utility (feasibility and preliminary effectiveness) of a community-based, manualized, peer-delivered group counselling program to address the need for culturally responsive counselling for parents of children with autism in the South Asian community. Sixty-three parents (M_age = 43.7 years, 68% mothers) participated in the program, and reported high stable program satisfaction across sessions. Further, parents reported improved mental health and quality of life following involvement in the program, with changes noted even after the first session. Further research is warranted to assess the efficacy of this kind of parent support intervention.

Effectiveness of the Thinking Healthy Programme for perinatal depression delivered through peers: Pooled analysis of two randomized controlled trials in India and Pakistan

BACKGROUND

The Thinking Healthy Programme (THP) is recommended to treat perinatal depression in resource-limited settings, but scale-up is hampered by a paucity of community health workers. THP was adapted for peer-delivery (THPP) and evaluated in two randomized controlled trials in India and Pakistan. Our aim was to estimate the effectiveness of THPP on maternal outcomes across these two settings, and evaluate effect-modification by country and other pre-defined covariates.

METHODS

Participants were pregnant women aged≥18 years with depression (Patient Health Questionnaire (PHQ-9) score≥10), randomized to THPP plus enhanced usual care (EUC) or EUC-only. Primary outcomes were symptom severity and remission (PHQ-9 score<5) 6 months post-childbirth. Secondary outcomes included further measures of depression, disability and social support at 3 and 6 months post-childbirth.

RESULTS

Among 850 women (280 India; 570 Pakistan), 704 (83%) attended 6-month follow-up. Participants in the intervention arm had lower symptom severity (PHQ-9 score adjusted mean difference -0.78 (95% confidence interval -1.47,-0.09)) and higher odds of remission (adjusted odds ratio 1.35 (1.02,1.78)) versus EUC-only. There was a greater intervention effect on remission among women with short chronicity of depression, and those primiparous. There were beneficial intervention effects across multiple secondary outcomes.

LIMITATIONS

The trials were not powered to assess effect-modifications. 10-20% of participants were missing outcome data.

CONCLUSIONS

This pooled analysis demonstrates the effectiveness, acceptability and feasibility of THPP, which can be scaled-up within a stepped-care approach by engaging with the existing health care systems and the communities to address the treatment gap for perinatal depression in resource-limited settings.

Implementation outcomes and strategies for depression interventions in low- and middle-income countries: a systematic review

BACKGROUND

We systematically reviewed implementation research targeting depression interventions in low- and middle-income countries (LMICs) to assess gaps in methodological coverage.

METHODS

PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of depression interventions in LMICs reporting at least one implementation outcome published through March 2019.

RESULTS

A total of 8714 studies were screened, 759 were assessed for eligibility, and 79 studies met inclusion criteria. Common implementation outcomes reported were acceptability (n = 50; 63.3%), feasibility (n = 28; 35.4%), and fidelity (n = 18; 22.8%). Only four studies (5.1%) reported adoption or penetration, and three (3.8%) reported sustainability. The Sub-Saharan Africa region (n = 29; 36.7%) had the most studies. The majority of studies (n = 59; 74.7%) reported outcomes for a depression intervention implemented in pilot researcher-controlled settings. Studies commonly focused on Hybrid Type-1 effectiveness-implementation designs (n = 53; 67.1), followed by Hybrid Type-3 (n = 16; 20.3%). Only 21 studies (26.6%) tested an implementation strategy, with the most common being revising professional roles (n = 10; 47.6%). The most common intervention modality was individual psychotherapy (n = 30; 38.0%). Common study designs were mixed methods (n = 27; 34.2%), quasi-experimental uncontrolled pre-post (n = 17; 21.5%), and individual randomized trials (n = 16; 20.3).

CONCLUSIONS

Existing research has focused on early-stage implementation outcomes. Most studies have utilized Hybrid Type-1 designs, with the primary aim to test intervention effectiveness delivered in researcher-controlled settings. Future research should focus on testing and optimizing implementation strategies to promote scale-up of evidence-based depression interventions in routine care. These studies should use high-quality pragmatic designs and focus on later-stage implementation outcomes such as cost, penetration, and sustainability.

Measuring the implementation strength of a perinatal mental health intervention delivered by peer volunteers in rural Pakistan

The South Asian region, including Pakistan, reports one of the highest rates of perinatal depression. Effective task-shifting perinatal mental health interventions exist and are gaining attention of policy makers, as a potential solution to bridge the existing treatment gap. However, no specific indicators are available to gauge the level of implementation for such interventions in the South Asian region. The Thinking Healthy Programme Peer-delivered (THPP) is a perinatal mental health intervention delivered, at scale, by peer volunteers (PVs). An effectiveness trial for THPP based on 570 depressed pregnant women was conducted in rural Rawalpindi, Pakistan. In addition, we also examined the implementation processes of THPP in order to develop an index to gauge implementation strength of this intervention. The key components of this index are based on four important intervention processes related to service provision which include; i) the competence of PVs, ii) supervisions attended by PVs and iii) number and iv) duration of THPP sessions. We attempt to inform an implementation strength index which best correlates with reduced perinatal depression and disability at 6 months post childbirth. Knowledge of such an implementation strength index for a task-shifted perinatal depression intervention carries implications for scale up strategies.

Development of a Psychological Intervention to Address Anxiety During Pregnancy in a Low-Income Country

Background: One in five women suffer from anxiety during pregnancy. Untreated anxiety is a risk factor for postnatal depression and is associated with adverse birth outcomes. Despite the high prevalence of prenatal anxiety in low- and middle-income countries (LMICs), efforts to develop and evaluate context-specific interventions in these settings are lacking. We aimed to develop a culturally appropriate, feasible, and acceptable psychological intervention for perinatal anxiety in the context of a low-income population in Pakistan. Methods: We conducted this research in Rawalpindi District at the Obstetrics Department of the Holy Family Hospital, Rawalpindi Medical University a government facility catering to a mixture of low-income urban, peri-urban, and rural populations. We used a mixture of research methods to: a) investigate the clinical, cultural, and health-service delivery context of perinatal anxiety; b) select an evidence-based approach that suited the population and health-delivery system; c) develop an intervention with extensive reference documentation/manuals; and d) examine issues involved in its implementation. Qualitative data were collected through in-depth interviews and focus group discussions, and analyzed using framework analysis. Results: Informed by the qualitative findings and review of existing evidence-based practices, we developed the "Happy Mother, Healthy Baby" intervention, which was based on principles of cognitive behavior therapy. Its evidence-based elements included: developing an empathetic relationship, challenging thoughts, behavior activation, problem solving, and involving family. These elements were applied using a three-step approach: 1) learning to identify unhealthy or unhelpful thinking and behavior; 2) learning to replace unhealthy or unhelpful thinking and behavior with helpful thinking and behavior; and 3) practicing thinking and acting healthy. Delivered by non-specialist providers, the intervention used culturally appropriate illustrations and examples of healthy activities to set tasks in collaboration with the women to encourage engagement in helpful behaviors. Feedback from the non-specialist providers indicated that the intervention was acceptable, feasible, and perceived to be helpful by the women receiving it. Conclusion: This new psychosocial intervention for perinatal anxiety, based on principles of cognitive behavior therapy and delivered by non-specialists, has the potential to address this important but neglected condition in LMICs.

Lay counselors: Thoughts on the crossing of ecological frameworks and the use of lay counselors in the scale up of early infant mental health interventions

The recent call for the scale-up of evidence-based early childhood development interventions, in lower and middle-income countries and for minority groups in high-income countries, has seen numerous suggestions to train greater numbers of lay mental health workers to fulfill these functions. While studies have found that concepts from developed country settings, such as attachment, parental sensitivity, and containment, find purchase and relevance within developing settings, the management of contextual and cultural factors and the tensions of cultural interfacing in the rollout of these programs in developing country settings require consideration. Drawing on the experiences of two successful South African mother-infant home-visiting programs as examples, this article discusses some of the challenges in provision of attachment-based infant mental health programs and highlights the need for careful consideration of a number of factors pertaining to the recruitment, supervision, and management of lay mental health workers before large-scale rollout is conducted.

"Passing through difficult times": Perceptions of perinatal depression and treatment needs in Malawi - A qualitative study to inform the development of a culturally sensitive intervention

PURPOSE

This study was conducted to explore the perceptions of perinatal women and key maternal care health workers about perinatal depression and the health service needs required to inform development of a culturally sensitive and acceptable psychosocial intervention.

METHODS

This qualitative study used a descriptive exploratory design; it is the first phase of a larger mixed methods study aimed at adapting a psychosocial intervention for perinatal depression. We conducted in-depth interviews with 22 women who screened positive for depression using a locally validated Chichewa version of the Edinburgh Postnatal Depression Scale at antenatal and postnatal clinics in 1 rural and 1 urban health care setting in Lilongwe District, Malawi. We also conducted 10 key informant interviews with maternal care health workers. Informed consent was obtained from all participants. An interview guide was used to guide enquiry about perceptions of perinatal depression and health service needs. Interviews were transcribed, translated and analysed using content analysis approach.

RESULTS

Perinatal depression was recognized as a common mental health problem that affected self-care activities and functioning of women in the perinatal period. Financial difficulties, relationship problems (polygamy, lack of support, neglect, and infidelity), traumatic events (intimate partner violence and loss) and fear of birth outcomes were identified as causes of depression. All study participants acknowledged the need for support and an intervention that will address the identified challenges. Additionally, they viewed strengthening the health delivery system as crucial to effectively address their needs and gaps identified in the system.

CONCLUSION

The results of this study support plans to develop a family focused intervention for perinatal depression in Malawi addressing relationship, psychosocial and economic issues. It also highlights the importance of strengthening the health delivery system especially at primary care level where the majority of women access care in Malawi and across Sub-Saharan Africa.

Women's circles as a culturally safe psychosocial intervention in Guatemalan indigenous communities: a community-led pilot randomised trial

BACKGROUND

Indigenous Maya women in Guatemala show some of the worst maternal health indicators worldwide. Our objective was to test acceptability, feasibility and impact of a co-designed group psychosocial intervention (Women's Circles) in a population with significant need but no access to mental health services.

METHODS

A parallel group pilot randomised study was undertaken in five rural Mam and three periurban K'iche' communities. Participants included 84 women (12 per community, in seven of the communities) randomly allocated to intervention and 71 to control groups; all were pregnant and/or within 2 years postpartum. The intervention consisted of 10 sessions co-designed with and facilitated by 16 circle leaders. Main outcome measures were: maternal psychosocial distress (HSCL-25), wellbeing (MHC-SF), self-efficacy and engagement in early infant stimulation activities. In-depth interviews also assessed acceptability and feasibility.

RESULTS

The intervention proved feasible and well accepted by circle leaders and participating women. 1-month post-intervention, wellbeing scores (p-value 0.008) and self-care self-efficacy (0.049) scores were higher among intervention compared to control women. Those women who attended more sessions had higher wellbeing (0.007), self-care and infant-care self-efficacy (0.014 and 0.043, respectively), and early infant stimulation (0.019) scores.

CONCLUSIONS

The pilot demonstrated acceptability, feasibility and potential efficacy to justify a future definitive randomised controlled trial. Co-designed women's groups provide a safe space where indigenous women can collectively improve their functioning and wellbeing.

TRIAL REGISTRATION

ISRCTN13964819 . Registered 26 June 2018, retrospectively registered.

Delivering the Thinking Healthy Programme for perinatal depression through peers: an individually randomised controlled trial in India

BACKGROUND

The Thinking Healthy Programme (THP) is a psychological intervention recommended for the treatment of perinatal depression. However, efforts to integrate the intervention at scale into the routines of community health workers who delivered the THP when it was first evaluated were compromised by the competing responsibilities of community health workers. We aimed to assess the effectiveness and cost-effectiveness of THP peer-delivered (THPP) in Goa, India.

METHODS

In this single-blind, individually randomised controlled trial, we recruited pregnant women aged 18 years or older who scored at least 10 on the Patient Health Questionnaire-9 (PHQ-9) from antenatal clinics in Goa. Participants were randomly allocated (1:1) to receive enhanced usual care (EUC; so-called because, in India, perinatal depression is not typically treated) only (control group) or THPP in addition to EUC (intervention group) in randomly sized blocks that were stratified by area of residence (urban or rural). Group allocations were concealed from participants and researchers before assignments were made by use of sequentially numbered opaque envelopes. The primary outcomes were the severity of depressive symptoms (assessed by PHQ-9 score) and the prevalence of remission (defined as a PHQ-9 score of less than 5) in participants with available data 6 months after childbirth, which was assessed by researchers who were masked to treatment allocations. We analysed outcomes by intention to treat, adjusting for covariates that were defined a priori or that showed imbalance at baseline. The trial is registered with ClinicalTrials.gov, number NCT02104232.

FINDINGS

Between Oct 24, 2014, and June 24, 2016, we assessed 118 260 women for their eligibility for screening, of whom 111 851 (94·6%) women were ineligible. 6409 (5·4%) women were eligible for screening and 6369 (99·4%) of these women consented to be screened with the PHQ-9 (40 women did not consent), of whom 333 (5·2%) screened positive for depression (defined as a PHQ-9 score of at least 10). We enrolled 280 (84·1%) women with perinatal depression; 140 women were assigned to the THPP and EUC group and 140 women to the EUC only group. The final treatment was given on May 27, 2017. The final 6-month outcome assessment was completed on June 9, 2017. At 6 months after birth, 122 (87%) women in the THPP and EUC group and 129 (92%) women in the EUC only group were assessed for the primary outcome. There was a higher prevalence of remission at 6 months after birth in the THPP and EUC group compared with the EUC only group (89 [73%] women in the intervention group vs 77 [60%] women in the control group; prevalence ratio 1·21, 95% CI 1·01 to 1·45; p=0·04), but there was no evidence of a difference in symptom severity between the groups (mean PHQ-9 score 3·47 [SD 4·49] in the intervention group vs 4·48 [5·11] in the control group; standardised mean difference -0·18, 95% CI -0·43 to 0·07; p=0·16). There was no evidence of significant differences in serious adverse events between the groups.

INTERPRETATION

THPP had a moderate effect on remission from perinatal depression over the 6-month postnatal period. THPP is relatively cheap to deliver and is cost-saving through reduced health-care, time and productivity costs.

FUNDING

National Institute of Mental Health (USA).

Delivering the Thinking Healthy Programme for perinatal depression through volunteer peers: a cluster randomised controlled trial in Pakistan

BACKGROUND

The Thinking Healthy Programme (THP), which is endorsed by WHO, is an evidence-based intervention for perinatal depression. We adapted THP for delivery by volunteer peers (laywomen from the community) to address the human resource needs in bridging the treatment gap, and we aimed to assess its effectiveness and cost-effectiveness in Rawalpindi, Pakistan.

METHODS

In this cluster randomised controlled trial, we randomly assigned 40 village clusters (1:1) to provide either THP peer-delivered (THPP) and enhanced usual care (EUC; intervention group) or EUC only (control group) to the participants within clusters. These villages were randomly selected from eligible villages by an independent researcher. The participants were pregnant women aged 18 years or older who had scored at least 10 on the Patient Health Questionnaire-9 (PHQ-9), who we recruited from households within communities in Rawalpindi, Pakistan. The research teams who were responsible for recruiting trial participants were masked to treatment allocations. Participants attended follow-up visits at 3 and 6 months after childbirth. The primary outcomes were the severity of depressive symptoms (assessed by PHQ-9 score) and the prevalence of remission (defined as a PHQ-9 score of less than 5) in participants with available data 6 months after childbirth, which was assessed by researchers who were masked to treatment allocations. We analysed outcomes by intention to treat, adjusting for covariates that were defined a priori or that showed imbalance at baseline. The trial was registered with ClinicalTrials.gov, number NCT02111915.

FINDINGS

Between April 15 and July 30, 2014, we randomly selected 40 of 46 eligible village clusters for assessment, as per sample size calculations. Between Oct 15, 2014, and Feb 25, 2016, we identified and screened 971 women from 20 village clusters that had been randomly assigned to the THPP and EUC group and 939 women from 20 village clusters that had been randomly assigned to the EUC only group. In the intervention group, 79 women were ineligible for inclusion, 11 women refused screening, 597 women screened negative on the PHQ-9, and one woman did not consent to participate. In the control group, 75 women were ineligible for inclusion, 14 women refused screening, 562 women screened negative on the PHQ-9, and one woman did not consent to participate. We enrolled 283 (29%) women in the intervention group and 287 (31%) women in the control group. At 6 months after childbirth, 227 (80%) women in the THPP and EUC group and 226 (79%) women in the EUC only group were assessed for the primary outcome. The severity of depression (assessed by PHQ-9 scores; standardised mean difference -0·13, 95% CI -0·31 to 0·06; p=0·07) and prevalence of remission (49% in the intervention group vs 45% in the control group; prevalence ratio 1·12, 95% CI 0·95 to 1·29; p=0·14) did not significantly differ between the groups 6 months after childbirth. There was no evidence of significant differences in serious adverse events between the groups.

INTERPRETATION

THPP had no effect on symptom severity or remission from perinatal depression at 6 months after childbirth, but we found that it was beneficial on some other metrics of severity and disability and that it was cost-effective. THPP could be a step towards use of an unused human resource to address the treatment gap in perinatal depression.

FUNDING

National Institute of Mental Health (USA).