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

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Summary Background Little is known about how to scale up care for depression in settings where non-physician lay workers constitute the bulk of frontline providers. We aimed to compare a stepped-care intervention package for depression with usual care enhanced by use of the WHO Mental Health Gap Action Programme intervention guide (mhGAP-IG). Methods We did a cluster-randomised trial in primary care clinics in Ibadan, Nigeria. Eligible clinics were those with adequate staffing to provide various 24-h clinical services and with regular physician supervision. Clinics (clusters), anonymised and stratified by local government area, were randomly allocated (1:1) with a computer-generated random number sequence to one of two groups: an intervention group in which patients received a stepped-care intervention (eight sessions of individual problem-solving therapy, with an extra two to four sessions if needed) plus enhanced usual care, and a control group in which patients received enhanced usual care only. Patients from enrolled clinics could participate if they were aged 18 years or older, not pregnant, and had moderate to severe depression (scoring ≥11 on the nine-item patient health questionnaire [PHQ-9]). The primary outcome was the proportion of patients with remission of depression at 12 months (a score of ≤6 on the PHQ-9, with assessors masked to group allocation) in the intention-to-treat population. This trial is registered with the International Standard Randomised Controlled Trials Number registry (ISRCTN46754188) and is completed. Findings 35 of 97 clinics approached were eligible and agreed to participate, of which 18 were allocated to the intervention group and 17 to the control group. 1178 patients (631 [54%] in the intervention group and 547 [46%] in the control group) were recruited between Dec 2, 2013, and June 29, 2015, among whom 976 (83%) were female and baseline mean PHQ-9 score was 13·7 (SD 2·6). Of the 562 (89%) patients in the intervention group and 473 (86%) in the control group who completed 12-month follow-up, similar proportions in each group had remission of depression (425 [76%] in the intervention group vs 366 [77%] in the control group; adjusted odds ratio 1·0 [95% CI 0·70–1·40]). At 12 months, 17 (3%) deaths, one (<1%) psychotic illness, and one (<1%) case of bipolar disorder in the intervention group, and 16 deaths (3%) and one (<1%) case of bipolar disorder in the control group were recorded. No adverse events were judged to be related to the study procedures. Interpretation For patients with moderate to severe depression receiving care from non-physician primary health-care workers in Nigeria, a stepped-care, problem-solving intervention combined with enhanced usual care is similarly effective to enhanced usual care alone. Enhancing usual care with mhGAP-IG might provide simple and affordable approach to scaling up depression care in sub-Sahara...

The findings confirm the low incidence of dementia in this population, as previously reported. The condition is nevertheless associated with higher risk of mortality. Along with some features of social disadvantage, proxies of lower cognitive reserve were risk factors for incident dementia.

Objective: The effect of deliriumon stroke outcome has not been quantified in sub-Saharan Africa. We investigated the prevalence of delirium occurring within one week of stroke in Nigerian survivors and its association with dementia and mortality at 3 months. Methods: Delirium was ascertained after repeated assessments within one week of stroke using the Confusion Assessment Method. Demographic and clinical characteristics, stroke severity, current and pre-morbid cognitive functioning were also assessed. Participants were then followed up for 3 months using culturally-validated neuropsychological tools. Probable dementia was ascertained according to the National Institute of Neurological Disorders and Stroke (NINDS-AIREN) criteria. Associations were investigated using both binomial and multinomial logistic regression analyses and presented as odds ratios (O.R) and relative risk ratios (RRR). Results: Of 101 consenting stroke survivors, 99 had two assessments for delirium within one week of the stroke. Delirium was present in 33.3% of stroke survivors (65.6% hypoactive, 21.9% hyperactive, and 12.1% mixed type). Having a severe stroke was associated with delirium (O.R=6.2, 95% C.I=1.1–13.8) after adjusting for age, gender, education and economic status, lifestyle factors, multimorbidities and laterality. At follow-up, those with severe stroke had a stronger association between delirium and dementia (RRR=4.3, 95% C.I=1.2–15.6) or death (RRR= 3.7, 95% C.I = 1.1–12.1). Conclusion: Delirium, in this sub-Saharan African sample, was already present in about one-third of survivors within one week of stroke. Survivors of severe stroke are at higher risk of delirium and its complications, and could be important target for delirium preventive interventions.

Background: Depression is common among women in the perinatal period. Although pregnancy and motherhood among adolescents are global public health issues, little is known about how adolescents differ from adults in the occurrence and correlates of perinatal depression.Methods: Data were derived from a cluster randomized controlled trial of psychosocial interventions for perinatal depression in primary maternal care in Nigeria (the Expanding Care for Perinatal Women with Depression trial). Adolescents and adult participants recruited during pregnancy and followed up till 6-month postpartum were compared: proportions with depression [screening positive to depression on the Edinburgh Postnatal Depression Scale (score ≥ 12) and meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria using the short form of the Composite International Diagnostic Interview]; adjustment and attitude to pregnancy and motherhood (using the Maternal Adjustment and Maternal Attitudes scale); and parenting skills (measured on Infant–Toddler version of the Home Inventory for Measurement of the Environment). Infant and fetal growth were assessed by measures of weight and head circumference at birth and upper mid-upper arm circumference (MUAC) at 6 months.Results: Of 8,580 adults screened, 6.9% had major depression compared with 17.7% of 772 screened adolescents (p < 0.001). Adolescents had significantly poorer adjustment and attitudes to pregnancy, lower mean fetal gestational age at birth, and a smaller mean baby’s birth weight. At 6-month postpartum, there were no significant differences in the rates of remission from depression between adolescent and adult women (Edinburgh Postnatal Depression Scale score <6). Adolescent mothers continued to have poorer maternal attitudes and parenting skills indicated by significantly lower scores on the Infant–Toddler version of the Home Inventory for Measurement of the Environment responsivity and involvement subscales. Infants of adolescent mothers had a higher rate of undernutrition (defined as MUAC < 12.5 cm) compared with those of adult mothers: 14.8 and 6.3%, respectively (p = 0.008), with the mean MUAC remaining significantly lower for infants of adolescent mothers after adjusting for their lower birth weight (p = 0.04).Conclusion: Perinatal depression is more common and is associated with poorer maternal attitudes and parenting skills in adolescents compared with those in adults. Evidence from this exploratory study suggests that in improving outcomes in infants of adolescent mothers with perinatal depression, depression treatment may need to be supplemented with specific approaches to improve parenting skills.

PurposeWorking on the hypothesis that the social and economic factors associated with onset of late-life depression operate differently for men and women, we investigated the impact of current social relationships and lifetime occupational attainment on incident major depressive disorder (MDD) assessed in three follow-up waves over a period of 5 years.MethodsParticipants were part of a household multistage probability sample of 2149 Nigerians who were aged 65 years and above. The presence of current and lifetime MDD was assessed using the World Health Organization (WHO) Composite International Diagnostic Interview. Participants’ highest occupational attainment was categorised based on the International Standard Classification of Occupations, while socio-economic positions were estimated using asset-based measures relevant to low-income settings. Current social contacts and participation were assessed using items from the WHO Disability Assessment Schedule.ResultsWe found an incidence rate of 120.9 per 1000 persons years (95% CI = 110.4–132.5) among 1394 persons who were free of lifetime MDD and dementia at baseline. Incidence rates were 94.7 (95% CI = 82.5–108.7) and 153.8 (136.3–173.6) per 1000 person years, in men and women respectively. In analyses comparing gender and adjusting for the effect of age, we found that while a lifetime of unskilled occupation (trade: HR = 1.4, 95% CI = 1.0–2.0, and elementary occupations: HR = 1.5, 95% CI = 1.1–2.1) was significantly associated with incident MDD in men (but not in women), living in a rural location (HR = 1.3, 95% CI = 1.0–1.7) and having no regular contact with family (HR = 2.2, 95% CI = 1.0–4.7) at baseline significantly predicted subsequent onset of MDD in women.ConclusionThere was a gender differential in the association of social and economic factors with incident MDD in this sample. These findings have implications for the design of early prevention strategies for late-life depression in sub-Saharan Africa.Electronic supplementary materialThe online version of this article (10.1007/s00127-018-1500-7) contains supplementary material, which is available to authorized users.

Objectives Few studies in Africa have investigated the risk profile and course of loneliness in old age. This study examined the risk factors for onset and chronicity, as well as the predictors of recovery from loneliness in a large representative sample of community dwelling older Africans. Methods/Design A household multistage probability sample of Nigerians who were 65 years or older was drawn from a geographical area with approximately 25 million population. Loneliness was measured using the 3‐item University of California (UCLA) scale in 2007 and annually in 2008 and 2009. Social engagement, social network, and depression were evaluated using the WHO Composite International Diagnostic Interview. Respondents were also administered the 30‐item Geriatric Depression Scale. Multivariate logistic regression models were used to explore for risk factors. Estimates of adjusted hazard ratios (HR) for recovery were derived with the discrete time version of the Cox regression model for time invariant explanatory variables. Results Of 1704 respondents, 1525 were free of loneliness, using the UCLA scale, in 2007. A total of 209 (18.8%) persons developed new onset of loneliness in 2008 and 2009. Depression (O.R = 2.9, 95% C.I = 1.3–6.7), unmarried status (OR = 2.1, 95% C.I = 1.2–3.9) and social isolation (OR = 1.8, 95% CI = 1.0–3.2) independently predicted loneliness onset. Baseline demographic, health, social, and lifestyle factors were not associated with a chronic course of loneliness. The overall recovery rate estimated over two years was 89.5% (95% CI = 75.3–106.4). Being male (HR = 1.3, 95% C.I = 1.0–1.6), ≥80 years (HR = 1.4, 95% CI = 1.2–1.8) and having good social engagement at baseline (HR = 1.5, 95% C. = 1.1–2.0) independently predicted recovery from loneliness. Conclusions Over a 2‐year period, nearly one in five community‐dwelling Africans developed new onset loneliness in old age, with a similar proportion having a chronic course of the emotional experience. While depression and indices of social isolation at baseline were associated with onset, good social engagement predicted recovery from loneliness.