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

Abstract

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.

Psychological and social interventions for mental health issues and disorders in Southeast Asia: a systematic review

“…One was conducted in Indonesia [68], Timor-Leste [69] and Sri Lanka [70]. One study was conducted in Pakistan and India and their results were pooled [71]. Furthermore, two studies presented different parts of their results in different publications: [44,[61][62][63].…”

“…[40] over 12 months, found that a collaborative stepped care intervention resulted in significantly faster recovery rates for anxiety and depressive disorders in public health care patients. THP [41,71] and HAP [49], two promising peer led interventions were both found to reduce levels of depression and depressive remission in India and Pakistan, with HAP also reducing suicidal thoughts or attempts over 12 months in a medium sized RCT in Nepal [64]. A group based peer led life skills intervention [57], a lay counselling intervention [65] and an online behavioural activation programme with peer support [25] were also found to reduce depressive and/or anxiety symptoms at 3, 6 and 12 months.…”

“…The Thinking Health programme (THP) is a peer delivered programme for perinatal depression which was evaluated by Fuhr et al [41] and Vanobberghen et al [71]. THP is based on: behavioural activation, active listening, collaboration with the patient's family, guided discovery and homework.…”

“…In a study in India, Fuhr et al [41] found that THP intervention plus enhanced usual care versus enhanced usual care significantly improved depressive symptoms (P = 0.01) at 6 months, however rates of remission (P = 0.16) were not significantly different between the groups at 6 months. Vanobberghen et al [71] pooled the results from Fuhr et al [41] with another RCT from Pakistan (N = 530) and found that THP was effective at reducing levels of depression (P = 0.03) and remission from depression (P = 0.04) at 6 months. The main difference between the Pakistan versus India delivery was that in Pakistan the intervention was delivered in a mixture of group and individual sessions.…”

A systematic review of the concept 'male involvement in maternal health' by natural language processing and descriptive analysis.

“…The low number of studies on psychosocial health in Africa in our review showed that the relationship between perinatal depression/psychosocial health and the role of the male partner is poorly studied in Africa. While some have argued that many low income countries have more pressing issues within maternal health than addressing perinatal depression (such as severe maternal morbidity and mortality)(2), other studies have shown there is reasonable evidence for the benefits and effectiveness of psychological interventions in LMIC(44,47). The low availability of mental health services in LMICs is one of the main challenges for addressing mental health problems, but some recent studies have shown that training and organising lay mental health care workers to address mental health care problems are a feasible and effective approach to combatting mental health disorders(48).…”