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Cited by 993Maternal Mental Health During Pregnancy and PostpartumMental Health Treatment and AccessMaternal and Neonatal Healthcare

Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial

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Rahman, Atif, Malik, Abid, Sikander, Siham, Roberts, Christopher, Creed, Francis·2008·The Lancet
DOI 10.1016/s0140-6736(08)61400-2PMC PMC2603063
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Abstract

Background The treatment of perinatal depression is a public-health priority because of its high prevalence and association with disability and poor infant development. We integrated a cognitive behaviour therapy-based intervention into the routine work of community-based primary health workers in rural Pakistan and assessed the effect of this intervention on maternal depression and infant outcomes.Methods We randomly assigned 40 Union Council clusters in rural Rawalpindi, Pakistan, in equal numbers to intervention or control. Married women (aged 16-45 years) in their third trimester of pregnancy with perinatal depression were eligible to participate. In the intervention group, primary health workers were trained to deliver the psychological intervention, whereas in the control group untrained health workers made an equal number of visits to the depressed mothers. The primary outcomes were infant weight and height at 6 months and 12 months, and secondary outcome was maternal depression. The interviewers were unaware of what group the participants were assigned to. Analysis was by intention to treat. The study is registered as ISRCTN65316374.Findings The number of clusters per group was 20, with 463 mothers in the intervention group and 440 in the control group. At 6 months, 97 (23%) of 418 and 211 (53%) of 400 mothers in the intervention and control groups, respectively, met the criteria for major depression (adjusted odds ratio (OR) 0.22, 95% CI 0.14 to 0.36, p<0.0001). These effects were sustained at 12 months (111/412 [27%] vs 226/386 [59%], adjusted OR 0.23, 95% CI 0.15 to 0.36, p<0.0001). The differences in weight-for-age and height-for-age Z scores for infants in the two groups were not significant at 6 months (-0.83 vs -0.86, p=0.7 and -2.03 vs -2.16, p=0.3, respectively) or 12 months (-0.64 vs -0.8, p=0.3 and -1.10 vs -1.36, p=0.07, respectively).Interpretation This psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in resource-poor settings.

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  • The structured CBT approach has been successfully adapted for use by CHWs to address mental health concerns in perinatal populations in rural Pakistan, showing effective use of CHWs to deliver such interventions in a Muslim population.

    “It has been successfully adapted for use by CHWs to address mental health concerns in perinatal populations in rural Pakistan 23,24 , showing the effective use of CHWs to deliver such interventions in a Muslim population 23,28 .”

    From Addressing Behavioral Health Disparities for Somali Immigrants Through Group Cognitive Behavioral Therapy Led by Community Health Workers (2017) · cites this paper as [24]

    The Introduction describes a structured CBT-based programme adapted for delivery by village health workers in rural Pakistan, and the Discussion reports that it more than halved depression among prenatally depressed women compared with enhanced routine care. Our copy does not identify the participants as a Muslim population, so it does not establish that qualification. (LLM, conf=0.83)

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  • When CBT is delivered by community health workers, it offers great potential to increase access to psychological support in resource-poor settings.

    “The use of CBT in face-to-face or computerized settings, individually or in groups, has been well established 21,22 , and when delivered by community health workers (CHWs) offers great potential to increase access to psychological support in resource-poor settings 23,24 .”

    From Addressing Behavioral Health Disparities for Somali Immigrants Through Group Cognitive Behavioral Therapy Led by Community Health Workers (2017) · cites this paper as [24]

  • Emerging evidence suggests that complexity can be reduced without harmful consequences.

    “emerging evidence indicates that it is possible to reduce complexity without deleterious consequences (e.g., Rahman, Malik, Sikander, Roberts, & Creed, 2008).”

    From User‐centered design for psychosocial intervention development and implementation. (2016) · cites this paper as Rahman, Malik, Sikander, Roberts, & Creed, 2008

  • Maternal depression has been shown to affect child health and growth.

    “but maternal depression has been shown to affect child health47 and growth.48”

    From Effect of psychosocial interventions on social functioning in depression and schizophrenia: meta-analysis (2013) · cites this paper as [47]

  • By moving psychological treatment delivery from specialists to non-specialist community health workers, task-sharing can increase the supply of mental health providers.

    “Task-sharing is a strategy that can expand the availability of mental health providers by shifting delivery of psychological treatments from specialist providers to non-specialist community health workers (Chibanda et al., 2016; Patel et al., 2011; Rahman et al., 2008; Raviola et al., 2019).”

    From Acceptability and feasibility of digital technology for training community health workers to deliver brief psychological treatment for depression in rural India (2019) · cites this paper as Rahman et al., 2008

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Research works printed but not linked: 1

  1. [12]Bhutta ZA Thaver D Akram DS Khan M A situation and program analysis of malnutrition among women and children in Pakistan: Can we break the time warp? Bhutta ZA Maternal and child health in Pakistan: challenges and opportunities 2004 Oxford University Press Oxford 151 172

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Authors
Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F.
Affiliations
  • Human Development Research Foundation (PK)
  • University of Manchester (GB)
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2008-09
Volume
372
Issue
9642
Pages
902-909
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(08)61400-2
PMC
PMC2603063
OpenAlex
W2128974992
Cited by
993
References
33
Citations by year
2026: 45 · 2025: 48 · 2024: 43 · 2023: 65 · 2022: 83 · 2021: 73 · 2020: 60 · 2019: 68 · 2018: 66 · 2017: 56 · 2016: 48 · 2015: 75 · 2014: 64 · 2013: 64 · 2012: 37
FWCI
31.99
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Research Explorer (The University of Manchester) (publishedVersion)
Funders
Wellcome Trust
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Health Sciences › Health Professions › General Health Professions › Maternal and Neonatal Healthcare
Keywords
perinatal depression, maternal depression, cognitive behavioral therapy, community health workers, primary health workers, psychological intervention, infant growth, rural Pakistan, Rawalpindi, third trimester, intervention sustainability, maternal mental health services
MeSH terms
Adolescent, Adult, Birth Weight, Community Health Workers, Depressive Disorder, Female, Humans, Infant, Newborn, Male, Maternal Age, Middle Aged, Pakistan, Pregnancy, Pregnancy Complications, Pregnancy Trimester, Third, Social Class, Social Support, Cognitive Behavioral Therapy, Prevalence, Cluster Analysis, Outcome Assessment, Health Care

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