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.