Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Effects of an App-Based Mindfulness Intervention during Pregnancy on the Infant's Prenatal Androgen Exposure: A Randomized Controlled Pilot Trial

Prenatal androgen exposure modulates the development of the brain, with lasting effects on its function and behavior over the infant's life span. Environmental factors during pregnancy, in particular maternal stress, have been shown to influence the androgen load of the unborn child. We here addressed the research gap on whether a mindfulness intervention or a pregnancy education administered to pregnant women more affects the androgen exposure of the unborn child (quantified by the proxies of second-to-fourth digit length ratio (2D:4D) and anogenital distance assessed one year after delivery and at delivery, respectively). Moreover, we tested the mindfulness intervention's effects on maternal perceived stress, anxiety, depressiveness, and mindfulness. Pregnant women (gestation weeks 8-14) were randomized to a 15-week app-based mindfulness-oriented intervention (N = 72) or a pregnancy education intervention (control condition; N = 74). The mindfulness-oriented group did not significantly differ from the pregnancy education group in infants' 2D:4D or anogenital distance (partial η2 ≤ 0.01) or in maternal stress, anxiety, depressiveness, or mindfulness. However, the descriptive results indicate that across pregnancy, stress and anxiety decreased and mindfulness increased in both groups. Overall, this study did not show that the mindfulness intervention (relative to the pregnancy education) reduced the prenatal androgen exposure of the unborn children or improved the maternal outcomes significantly.

The effect of cognitive behavioral counseling on anxiety and worry level of women with intermediate risk during first trimester screening for down syndrome: a randomized controlled trial: a randomized controlled trial

BACKGROUND

Anxiety related to prenatal screening programs negatively affects maternal and child health.

OBJECTIVE

The study aimed to determine the effect of Cognitive Behavioral Counseling on the anxiety and worry levels of women with intermediate risk during first-trimester screening for Down Syndrome.

METHODS

The study was a randomized controlled trial conducted on 52 pregnant women with intermediate risk (1: 51 - 1:1500) during first-trimester screening for Down Syndrome and without additional structural anomalies that referred to three cities of Zanjan province in 2021. The eligible women were randomly assigned to intervention and control groups, with a block size of four. The intervention group received CBC in four sessions of 120 min two times a week by phone. Data were collected using Vandenberg Anxiety Questionnaire, and Cambridge Worry Questionnaire in three phases baseline, after the intervention, and 6 weeks follow-ups. Data were analyzed using independent t-test, chi-square, and repeated measures ANOVA at a 95% confidence level. (P < 0.05).

RESULTS

In the counselling group, the mean (SD) of a total score of anxiety before the intervention was 67.11 (20.68) which decreased to 32.50 (13.58) in six weeks after the intervention. Furthermore, the mean (SD) of a total score of worry before the intervention was 56.19 (16.76) which decreased to 32.96 (8.89) six weeks after the intervention. Based on the repeated measures ANOVA test, the mean total score of anxiety and worry were statistically significant 6 weeks after the intervention compared with the control group(p < 0.001).

CONCLUSION

Based on the study results, CBC can reduce the anxiety and worry levels of women with intermediate risk during first trimester screening for Down Syndrome.

TRIAL REGISTRATION

The study was registered at the Iranian Registry of Clinical Trials website under the code IRCT20160608028352N8, ( https://en.irct.ir/trial/49998 ). The first trial registration date was (29/08/2020).

The Effect of Digital Mindfulness Interventions on Depressive, Anxiety, and Stress Symptoms in Pregnant Women: A Systematic Review and Meta-Analysis

Introduction. Pregnancy is a unique time in a woman's life that can be both exciting and challenging. It is also a period that can be associated with significant stress, anxiety, and depression, which can have negative consequences for both the mother and the baby. Mindfulness interventions are known to be a well-suited treatment and prevention method for psychiatric symptoms in pregnancy, and web-based applications have been explored. We here present an up-to-date systematic review and meta-analysis of randomized-controlled trials to investigate the effect of digital-based mindfulness interventions on depressive, anxiety, and stress symptoms during pregnancy. Methods. The systematic literature search and data extraction was performed by two independent raters. It resulted in 13 eligible studies overall comprising 1373 participants. We conducted random-effects meta-analyses for depressive, anxiety, and stress symptoms after completion of a digital mindfulness intervention (compared to a control group). Results. Digital mindfulness intervention methods were significantly able to reduce depression (g = -0.47, 95% CI [-0.9; -0.09]) and anxiety symptoms (g = -0.41, 95% CI [-0.77; -0.05]), but not stress symptoms. These effects were moderated by the attrition rate (βDepression = 0.025, pDepression < 0.01; βAnxiety = 0.022, pAnxiety < 0.01; βStress = 0.022, pStress < 0.01). Primiparity also had a significant influence on the intervention effect regarding depression symptoms (β = 0.033, p = 0.024). Conclusions. Digital mindfulness interventions are a promising method to reduce mental health symptoms in pregnant women. We identified certain parameters moderating this effect, for example, primiparity and the attrition rate.

Resilience-enhancing interventions for antepartum depressive symptoms: systematic review

BACKGROUND

Antepartum depressive symptoms (ADS) are highly prevalent and may affect the mother and child. Cognitive-behavioural therapy and interpersonal therapy are effective psychological interventions for depression. However, low adherence and high attrition rates in studies of prevention and treatment of antepartum depression suggest that these approaches might not be entirely suitable for women with mild/moderate ADS. Considering the protective association between resilience and ADS, women with ADS might benefit more from interventions focusing on promotion of mental well-being and resilience.

AIMS

We aimed to provide an overview of studies evaluating the effectiveness of antepartum resilience-enhancing interventions targeting the improvement of ante- and postpartum depressive symptoms. We also investigated whether these interventions improve resilience and resilience factors in the peripartum period.

METHOD

We conducted a systematic review, using PRISMA guidelines. Studies were eligible for inclusion when they utilised a randomised controlled trial or quasi-experimental design, studied pregnant women with ADS, and implemented psychological interventions that (a) aimed to reduce maternal ADS and/or prevent peripartum major depression, and (b) addressed one or more psychological resilience factors.

RESULTS

Five of the six included cognitive-behavioural therapy interventions and all four mindfulness-based interventions were effective in reducing peripartum depressive symptoms and/or the incidence of depression. However, the methodological quality of most of the included studies was low to moderate. Only three studies assessed change in resilience factors.

CONCLUSIONS

Resilience-enhancing interventions might be beneficial for mental well-being of pregnant women with ADS, although more rigorously designed intervention studies are needed.

Motherhood and Me (Mom-Me): The Development of an Acceptance-Based Group for Women with Postpartum Mood and Anxiety Symptoms

Untreated postpartum mood and anxiety disorders (PMADs) place women and their families at risk for negative biopsychosocial sequelae. Innovative and tailored treatments are needed to address potential disruptions in maternal functioning. Third-wave cognitive-behavioral approaches, including acceptance and commitment therapy (ACT) and dialectical behavioral therapy (DBT), hold promise for optimizing functioning given the focus on values-based living, rather than symptom reduction.

PURPOSE

The purpose of this paper is to describe the development of an innovative psychotherapy group for women with symptoms of PMADs.

METHODS

This seven-session group, Motherhood and Me (Mom-Me), includes selected skills training from ACT, DBT, and Emotion-Centered Problem-Solving Therapy.

RESULTS

Mom-Me group sessions are described, and an outline of key information (session goals, content, and homework assignments) is provided to facilitate practical implementation.

CONCLUSION

In line with third-wave approaches, this group was developed to enhance maternal functioning, which, in turn, may help women cope with psychological distress during the transition to motherhood.

Effect of acceptance and commitment therapy on mood, sleep quality and quality of life in menopausal women: a randomized controlled trial

BACKGROUND

One of the most critical periods in a woman's life is menopause. During menopause, depression and anxiety are among the most common mood changes. Sleep disorders also increase during menopause, which leads to quality of life disorders. Different methods such as medication, psychotherapy, or a combination of them are used to treat these disorders. Acceptance and commitment-based therapy is one of the newest methods in psychotherapy that recently has been used a lot. Therefore, this study was conducted to determine the effect of acceptance and commitment therapy (ACT) on mood (primary outcome), sleep quality, and quality of life (secondary outcomes) of menopausal women.

METHODS

This randomized controlled trial was performed on 86 menopausal women in Tabriz, Iran in 2021. Using the blocking method, participants were randomly assigned into the intervention and control groups. The intervention group received counseling based on ACT approach in 8 sessions of 60 to 90 min. The control group received only routine health care. Depression, Anxiety, Stress Scale-21 (DASS 21), Menopause Quality of Life (MENQOL), and Pittsburgh Sleep Quality Index (PSQI) questionnaires were completed before intervention and immediately after the intervention. Independent t-test and Mann-Whitney U test were used to compare the outcomes between the two groups.

RESULTS

In terms of sociodemographic characteristics and baseline values of the studied variables, there was no statistically significant difference between the study groups before the intervention. At the end of the intervention, the mean (SD: standard deviation) scores of anxiety, stress, and depression in the counseling group were 2.66 (1.28), 2.91 (1.62), and 1.98 (1.59) and in the control group were 4.19 (1.85), 5.61 (1.49) and 3.59 (1.91). In the intervention group, the mean score of all three variables was significantly lower than the control group (P < 0.001). After the intervention, the mean (SD) of the total sleep quality score was 4.04 (2.52) in the counseling group and 4.13 (2.63) in the control group. In addition, the mean (SD) of the total quality of life score was 23.47 (20.13) in the counseling group and 23.14 (17.76) in the control group. Between the study groups, there were no statistically significant differences in the mean of the overall score of sleep quality (P = 0.867) and the overall score of quality of life (P = 0.759).

CONCLUSION

Using ACT-based counseling can improve the mood of menopausal women. However, further randomized clinical trials are needed before making a definitive conclusions.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT): IRCT20120718010324N65. Date of registration: 2/19/2021. Date of first registration: 2/19/2021. URL: https://en.irct.ir/user/trial/53544/view; Date of recruitment start date: 2/22/2021.

The Effect of Solution-Oriented Counseling on Coping Strategies in Mental Health Issues in Women with Gestational Diabetes

This study aimed to investigate the effectiveness of solution-oriented intervention in patients with gestational diabetes, stress and anxiety on using coping strategies. This study was a randomized clinical trial with a control group. The population consisted of 56 diabetic women under treatment with insulin, who obtained higher score in one of the psychological disorders using DASS-21 (Depression, anxiety, stress scale). The participants were randomly assigned in two interventional (n = 28) and control (n = 28) groups after signing the written informed consent forms. The solution-oriented interventional program was conducted in six 60-min sessions for 6 weeks. Immediately after the final session and 6-8 weeks after the first session of the intervention, both groups completed coping inventory for stressful situations. The analytical statistic of t-test, chi-square, and variance analysis with repeated measurements using SPSS were used to analyze the data. solution-oriented counseling increased the problem-solving coping strategy in the intervention group (P = 0.001); the scores obtained by the subjects in the interventional group after adjusting the score before the intervention increased 2.68 units immediately after the intervention, which was not statistically significant (p-value = 0.44). However, it increased 11.5 scores six weeks after the intervention, which was statistically significant (P = 0.00). But, emotional and avoidance coping strategies were not significantly different between the two groups. This technique can be easily trained to all clients, and since it is focused on finding various solutions for psychological problems by clients, it can be used to reduce stress and anxiety in other chronic diseases as well.IRCT code: The code of this clinical trial study is IRCT20200202046339N1.

Psychological, educational, and alternative interventions for reducing fear of childbirth in pregnant women: A systematic review

OBJECTIVE

This review aims to identify non-medical interventions that may reduce the fear of childbirth, directly or indirectly (through its factors).

METHODS

This review followed the PRISMA guidance and a rigorous protocol that was registered in PROSPERO. Searches were done in ProQuest, the International Clinical Trials Registry Platform, and Google Scholar. All RCTs published in the last 5 years, in English or Spanish, regarding women with a low-risk pregnancy and without mental disorders were included.

RESULTS

From 5147 articles found, only 69 were full-text assessed. Finally, 18 studies were included suggesting that prenatal education, psychoeducation, and counseling might be effective, whereas cognitive-behavioral therapy and some alternative therapies require more research. The results of relaxation techniques were contradictory. Results also suggest that social support and exposure (through education) might have an important role in the efficacy of interventions.

CONCLUSIONS

More appropriately randomized and blinded trials are necessary that use a prespecified definition of fear of childbirth and comprehensive measurement tools specific for pregnant women.

The Effect of ACT on Self-Esteem and Self-efficacy of Women with Breast Cancer in Iran

Background:

Today, breast cancer is the second major cause of cancer deaths in women.

Objective:

The present study aimed to determine the effect of acceptance and commitment therapy (ACT) on self-esteem and self-efficacy of cancer adaptation behaviors in women.

Methods:

The present study was a randomized educational trial (IRCT Registration number: IRCT2016100430140N1) based on intervention and control groups including 30 patients with breast cancer who were referred to Cancer comprehensive center of Imam Khomeini Hospital in Sari 2017. The intervention group participated in ACT sessions for 8 weeks held as 8 sessions. In the control group, there was no intervention and only chemotherapy was carried out. Self-esteem and self-efficacy of cancer adaptation behaviors were assessed using Rosenberg Self-esteem Scale and Cancer Behavior Inventory before and after the intervention and one month later. Data analysis was tested by repeated measurement, ANOVA and Tukey post-hoc tests.

Results:

The mean of self-esteem before and after intervention and one month later was 13.46 ± 1.12, 16.86 ± 0.91, 15.86 ± 0.99 in ACT group, and 14 ± 1, 14.40 ± 0.98, 14.20 ± 1.08 in the control group, respectively (F(2,27)=11.90, P=0.001). The mean of self-efficacy of cancer adjustment behaviors before and after the intervention and one month later was 104.40 ± 20.19, 218.20 ± 15.32, 214.86 ± 16.97 in ACT group, and 96.86 ± 15.04, 97.06 ± 18.61, 94.53 ± 14.69 in the control group, respectively (F(2,27)=8.26, P=0.001).

Conclusion:

This counseling approach can be used as an easy, non-invasive and helpful method to increase self-esteem and self-efficacy among patients for adaptation to cancer.