A peer-facilitated psychological group intervention for perinatal women living with HIV and depression in Tanzania-Healthy Options: A cluster-randomized controlled trial

Abstract

Background Perinatal women living with HIV (PWLH) have a greater risk of depression compared to other women; however, there are limited specialized mental health services available to them. We aimed to determine whether a stepped-care intervention facilitated by trained lay providers can improve mental health outcomes postpartum for PWLH. Methods and findings Healthy Options is a cluster-randomized controlled study conducted in 16 government-managed antenatal care clinics that provided HIV care for pregnant women in urban Tanzania. Recruitment occurred from May 2015 through April 2016, with the final round of data collection completed in October 2017. Participants included a consecutive sample of pregnant women under 30 weeks of gestation, living with HIV and depression, and attending the study clinics. Control sites received enhanced usual care for depression (EUDC). Intervention sites received EUDC plus the Healthy Options intervention, which includes prenatal group sessions of problem-solving therapy (PST) plus cognitive behavioral therapy (CBT) sessions for individuals showing depressive symptoms at 6 weeks postdelivery. We assessed depressive symptoms comparable to major depressive disorder (MDD) using the Patient Health Questionnaire-9 (PHQ-9) with a locally validated cutoff at 9 months and 6 weeks postpartum. The primary time point is 9 months postpartum. We examined differences in outcomes using an intent-to-treat analysis with a complete case approach, meaning those with data at the relevant time point were included in the analysis. We used generalized estimating equations accounting for clustering. Of 818 women screened using the PHQ-9, 742 were determined eligible and enrolled (395 intervention; 347 control); 649 women (87.5%) participated in the first follow-up and 641 women (86.4%) in the second. A majority (270, 74.6%) of women in the intervention arm attended 5 or more PST sessions. Women enrolled in Healthy Options demonstrated a 67% (RR 0.33; 95% CI: 0.22, 0.51; p-value: <0.001; corresponding to a 25.7% difference in absolute risk) lower likelihood of depressive symptoms than women in control clusters at 6 weeks postpartum. At 9 months postpartum, women enrolled in Healthy Options demonstrated a nonsignificant 26% (RR 0.74; 95% CI: 0.42, 1.3; p-value: 0.281; corresponding to a 3.2% difference in absolute risk) lower likelihood of depressive symptoms than women in control clusters. Study limitations include not using diagnostic interviews to measure depression and not blinding data collectors to intervention status during follow-up. Conclusions The Healthy Options intervention did not demonstrate reduction in depressive symptoms at 9 months postpartum, the primary outcome. Significant reductions were seen in depression symptoms at 6 weeks postpartum, the secondary outcome. Stepped-care interventions may be relevant for improving outcomes in the critical early postpartum window. Trial registration Clinical Trial registration number (closed to new participants) NCT02039973

When less is more: The way forward for mental health interventions during the perinatal period

“…Utilising community-based health workers trained in problem solving and cognitive behaviour therapy for women screened for depression risk. While the Healthy Options intervention showed no benefit for a reduction in depressive symptoms at 9 months postpartum (primary outcome), there was a benefit for depressive symptoms at 6 weeks postpartum [3].This is an important study adding to the growing evidence base of interventions for improving mental health in the perinatal period in LMICs. Having said this, there are a number of key areas that we believe bear discussion in thinking about the way forward for the design and evaluation of perinatal mental health interventions such as this one.…”

“…Screening in LMIC countries must ensure high specificity, as the costs of diverting large numbers of “false positive” women into care is problematic [ 6 , 7 ]. Kaaya and colleagues [ 3 ] expected that the lower rates of post-birth depression reflected remission of depression. Yet, there are few longitudinal studies from LMICs showing rates of depression remission postnatally.…”

“…The argument of Kaaya and colleagues [ 3 ] about how women living with HIV require specialised mental health services, punctuates this need. Given the stigma and added burden of living with a chronic infectious disease, providing a tailored intervention to all women living with HIV may appear at first blush to be a good approach.…”

“…In addition, depression is a leading cause of disability globally, but despite these high levels, data for low- and middle-income countries (LMICs) is limited—particularly in the context of HIV [ 2 ]. Given this context, the work of Kaaya and colleagues [ 3 ] describing a peer-facilitated psychological group intervention (Healthy Option) for perinatal women living with HIV and receiving ART is welcome. The study was a cluster randomised controlled trial conducted in urban districts of Dar es Salaam.…”

“…Utilising community-based health workers trained in problem solving and cognitive behaviour therapy for women screened for depression risk. While the Healthy Options intervention showed no benefit for a reduction in depressive symptoms at 9 months postpartum (primary outcome), there was a benefit for depressive symptoms at 6 weeks postpartum [ 3 ].…”