SHARE

South Asian Hub for Advocacy Research and Education on mental health

Brief

Maternal depression is a combined term used for both ante-natal and post-natal depression and is characterised by unhelpful thoughts (such as ‘I am not a good mother’) together with symptoms of fatigue, loss of interest in feeding the child and playing with it, staying aloof and in extreme cases having suicidal tendencies.

The Thinking Healthy Program (THP) was initially designed for maternal health workers by Professor Atif Rahman of the University of Manchester several years ago. It was the largest trial on maternal depression in the developing world, using cognitive behavioural therapy to translate negative thinking into positive thinking and behaviour. This involves using activities such as self-help (listening to music, engaging in exercise, etc), active dialogue within families, asking questions to stimulate new ideas and designing activities around those positive ideas by engaging the mothers.

 

Objectives

To adapt the Thinking Healthy Program for peer-delivery and evaluate its impact on the mothers’ and child’s health

Specific objectives:
  1. Build an evidence base on the role of peers in the delivery of mental health care by developing and evaluating the impact of a peer-led psychological treatment for maternal depression on maternal and child health outcomes
  2. Train researchers and counsellors in adapting the Thinking Healthy Program, an intervention for maternal depression based on Cognitive Behaviour Therapy (CBT) previously evaluated in Pakistan, for delivery by peer counsellors, i.e. lay persons with no prior health training, and to evaluate the intervention in the urban communities of Goa
  3. Involve governmental and non-governmental agencies and user/carer groups in the research process to enhance the translation of research findings and sustainability of the intervention

The work so far

The formative research phase of the project explored the characteristics of women who could become peer counsellors in both countries (see Singla et al, 2014), as well as the adaptations that needed to be made to the Thinking Healthy Programme.Thus a peer was seen to be someone with similar background and experience, good interpersonal skills and a minimum level of education.

The Thinking Healthy Programme Peer-delivered (THPP) was then piloted in a clinical case series in India and Pakistan (Atif et al 2017), with depressed mothers, followed by qualitative interviews and focus groups with mothers and peers on identifying any further changes to the intervention. The main change to the programme was a focus on behavioural activation, in addition to a reduction in the number of sessions, the illness language used, and an increased use of pictures and examples.

The THPP is now being tested for effectiveness and cost effectiveness against enhanced usual care, in two randomised controlled trials in India and Pakistan (Sikander et al, 2015). In India, pregnant mothers indicating moderate to severe depressive symptoms on the Patient Health Questionnaire (PHQ-9) were recruited with informed consent at the antenatal clinics of two local hospitals and a primary health centre. Those in the intervention arm receive 6-14 THPP sessions with a Sakhi, usually at their homes, and are assessed for trial outcomes 3 months and 6 months after the baby is born. In addition to depressive symptoms, mothers are assessed for their functioning, breastfeeding, perceived social support and the infant’s height and weight, as well as healthcare costs.There is also a qualitative sub-study as part of the trial, exploring barriers and facilitators at different levels, with a variety of stakeholders.

Update
While the trial has successfully recruited its targeted sample of 280 pregnant mothers with depressive symptoms and closed its enrollment, the intervention delivery and outcome assessments are continuing. 65% of those ending treatment are meeting treatment completion criteria, and 91% of participants are successfully followed up at the 6-month outcome.

Some achievements:

  • Through SHARE, Sangath has become part of a network of about a dozen research institutions and NGOs in India, Pakistan, Afghanistan, Nepal, Bangladesh and Sri Lanka with a hub at the Public Health Foundation of India in New Delhi
  • The SHARE Hub has had an annual meeting every year, attended by representatives from the research group at Sangath, along with partner organisations
  • The SHARE Hub also contributes to the NIMH Global Hubs meeting every year, updating on the progress of each core component, and learning from other Hubs
  • Publications so far have been listed below
  • The Thinking Healthy manual by Prof Rahman has been adopted by the World Health Organisation for wider use
  • A supplement grant  (with co-investigators: Daisy Singla and Daniela Fuhr, and consultant: Brandon Kohrt) was awarded by NIMH to Sangath to unpack mediating factors in the treatment
  • The qualitative study is also contributing to a shared research question across NIMH Hubs, examining barriers and facilitators to task-shifting in mental health interventions

Next steps

We anticipate completing the trial in June/July 2017, followed by analysis and cost analysis of the data collected.

Publications

Click below to read on:

Click here to download and read research from other SHARE publications and from other research projects at Sangath.