Prevention of common mental disorders among women in the perinatal period: a critical mixed-methods review and meta-analysis

Interventions to Prevent Relapse or Recurrence of Preconception Anxiety and/or Depression in Perinatal Women: A Systematic Review

OBJECTIVES

Women with preconception anxiety and/or depression experience high rates of relapse or recurrence of the disorders in the perinatal period. This review aimed to identify perinatal interventions that were designed to prevent relapse or recurrence in women with a history of anxiety and/or depression.

METHODS

The review was conducted based on the PRISMA guidelines. Six medical databases were searched with specific search strategies for each. The reference lists of literature reviews retrieved in this search were also screened, as well as the reference lists of reviews identified within these reviews. Additionally, the publications of the first authors of included studies were reviewed for relevant articles.

RESULTS

There were 10 articles eligible for inclusion. These articles described pharmacological or dietary supplement interventions, as well as psychological and/or behavioural interventions. All identified studies focused on the prevention of recurrent depression, comprising four antenatal interventions and six postnatal interventions. No studies reporting interventions for the prevention of recurrent anxiety were identified.

CONCLUSIONS FOR PRACTICE

Several published studies provided evidence supporting the use of prophylactic antidepressants and progesterone to prevent relapse or recurrence of depression, although studies were limited by small sample sizes and the potential for study bias. More recent and higher quality evidence exists for the role of mindfulness and cognitive behavioural therapy in the prevention of depressive relapse. Further exploration of relapse prevention strategies for women with preconception anxiety and/or depression is required, particularly for recurrent anxiety.

Breastfeeding interventions for preventing postpartum depression

BACKGROUND

Postpartum depression is a debilitating mental health disorder, which occurs in approximately 6% to 13% of women who give birth in high-income countries. It is a cause of great suffering for women and can have long-term consequences for child development. Postpartum depression can also negatively influence breastfeeding duration and breastfeeding exclusivity (i.e. feeding the infant only breast milk). However, a positive early, and continued, breastfeeding experience may reduce the risk of having postpartum depression. Breastfeeding interventions that increase the duration and exclusivity of breastfeeding may help prevent or reduce postpartum depressive symptoms.

OBJECTIVES

The primary objective of this review was to assess the effect (benefits and harms) of breastfeeding support interventions, in comparison to standard perinatal care, on maternal postpartum depression. The secondary objective was to assess whether breastfeeding support interventions had an effect on depression symptoms, and whether the effect was dependent on the duration and exclusivity of breastfeeding.

SEARCH METHODS

We searched CENTRAL (Wiley), MEDLINE ALL (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL Complete (Ebsco) and several other bibliographic databases and trial registers. The most recent search was conducted in June 2024.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated educational, psychosocial, pharmacological, alternative (any breastfeeding support intervention that promotes relaxation and reduces stress) or herbal breastfeeding support interventions targeting the prevention or reduction of postpartum depression were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Each title and abstract we identified was screened by two authors independently. Two review authors then independently examined full-text manuscripts to decide if the study met the inclusion criteria. If so, they extracted data from included studies using Covidence software. Two review authors also independently conducted a risk of bias assessment of each study using the RoB 2 tool. We contacted study authors when necessary for more information. We conducted meta-analyses using a random-effects model.

MAIN RESULTS

We included 10 RCTs with 1573 participants in this review. Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) in all studies, where scores range between 0 and 30 (higher scores indicating more depressive symptoms). The studies used a score of over 10 as the cut-off for a diagnosis of depression. Primary outcome It is very uncertain whether psychosocial breastfeeding interventions had any effect on the incidence of postpartum depression immediately post-intervention (RR 0.78, 95% CI 0.23 to 2.70; 1 study, 30 participants), but we found low-certainty evidence that psychosocial breastfeeding interventions may prevent the incidence of postpartum depression in the short term (one to three months) post-intervention (risk ratio (RR) 0.37, 95% confidence interval (CI) 0.14 to 0.93; 1 study, 82 participants). It is very uncertain whether alternative breastfeeding interventions had any effect in preventing the incidence of postpartum depression immediately post-intervention (RR 0.64, 95% CI 0.27 to 1.54; 1 study, 60 participants). The short-term time point was not measured. Secondary outcomes It is very uncertain whether psychosocial breastfeeding interventions had any effect on reducing depressive symptoms immediately post-intervention (mean difference (MD) -0.67, 95% CI -1.63 to 0.28; 4 studies, 512 participants). There is very low-certainty evidence that psychosocial breastfeeding interventions could reduce symptoms of anxiety immediately post-intervention as measured with the Zung Self-rating Anxiety Scale (SAS), where scores between 45 and 59 out of 80 on the SAS indicate mild to moderate anxiety, scores between 60 and 74 marked severe anxiety levels and > 75 extreme anxiety levels (MD -2.30, 95% CI -4.36 to -0.24; 1 study, 100 participants). There was no difference in rates of exclusive breastfeeding immediately post-intervention between those offered a psychosocial breastfeeding intervention and those receiving standard care, but the evidence is very uncertain (RR 1.20, 95% CI 0.96 to 1.51; I2 = 29%; 571 participants; very low-certainty evidence). We found low-certainty evidence that a psychosocial breastfeeding intervention may increase the duration of breastfeeding in the long term (RR 1.64, 95% CI 1.08 to 2.50; 129 participants; low-certainty evidence). For the comparison of alternative breastfeeding intervention versus standard care (which was evaluated in only one study), there was no difference between groups immediately post-intervention in anxiety measured with the State-Trait Anxiety Inventory (STAI); range 20 to 80; higher scores indicate more severe anxiety symptoms (MD 1.80, 95% CI -9.41 to 13.01; 60 participants; very low-certainty evidence), or in stress measured with the Perceived Stress Scale (PSS)-NICE; range 1 to 230, higher scores indicate higher levels of stress (MD 1.90, 95% CI -10.28 to 14.08; 60 participants; very low-certainty evidence), but the evidence is very uncertain. No adverse events connected to the intervention itself were stated in any of the trials, but for most studies, we do not know if this is because there were none or because they were not measured or reported.

AUTHORS' CONCLUSIONS

There is low-certainty evidence that psychosocial breastfeeding interventions may prevent postpartum depression in the short term and increase the duration of breastfeeding in the long-term. The evidence is very uncertain about the effect of psychosocial breastfeeding interventions on other outcomes. The evidence is very uncertain about the effect of alternative breastfeeding interventions on postpartum depression or other outcomes. The included studies did not report any adverse events directly related to the interventions, but it is not clear if this outcome was measured in most studies. Future trials of breastfeeding interventions should be conducted carefully to reduce their risk of bias, and they should be large enough to detect differences between mothers in their mental health.

Co-designing the FOotpaths foR Adolescent MAternal Mental HeAlth (FOR MAMA) intervention for pregnant teens in Malawi

BACKGROUND

This study aimed to gain insights into stakeholders' priorities and preferences for a scalable intervention for common mental problems among perinatal adolescents in Malawi.

METHODS

Participatory stakeholder workshops (n=9) were conducted iteratively according to the principles of the Person-Based Approach. Three stakeholder groups were recruited from one urban and one rural primary health centre in Zomba district, Malawi: perinatal adolescents (n=10), their family members (n=8) and healthcare workers (n=10). Framework analysis was conducted using intervention descriptors from the Template for Intervention Description and Replication checklist.

RESULTS

Participants emphasized the need for information on causes and symptoms of common mental problems and for developing coping strategies: a) those focused on external stressors-problem-solving, financial literacy and interpersonal skills-and b) emotion-focused approach behaviours-behavioural activation, relaxation and anger management. There was a strong preference for healthcare workers as intervention providers. Participants agreed on a brief antenatal intervention delivered weekly using both group and individual formats. There were positive views on both self-help and guided formats. All stakeholder groups felt there was a need for follow-up to ensure that adolescents correctly engaged with the intervention material.

CONCLUSIONS

Findings informed the design of a brief multicomponent guided intervention for adolescents in the antenatal period.

Integrating WHO thinking healthy programme for maternal mental health into routine antenatal care in China: a randomized-controlled pilot trial

Background

Women with perinatal depression and their children are at increased risk of poor health outcomes. Integrating evidence based non-stigmatizing interventions within existing health systems is crucial to reducing psychosocial distress during pregnancy and preventing perinatal depression. This study aimed to evaluate the feasibility of the World Health Organization (WHO) endorsed cognitive-behavior therapy-based Thinking Healthy Programme (THP), delivered by antenatal nurses in China.

Methods

A two-arm pilot randomized controlled pilot trial was conducted to assess the feasibility and of the adapted Chinese version of the Thinking Healthy Programme (THP) among various stakeholders. We recruited pregnant women between 25- and 34-weeks' gestation from two pregnancy schools within the two public sector Hospitals in Xian. Participants in the intervention group attended five face to face sessions of THP facilitated by antenatal nurses. This intervention used cognitive behavior therapy principles to offer psychoeducation, behavioral activation, problem-solving strategies, and social support. In the control group, participants received standard care, which included routine pregnancy education classes led by antenatal nurses. We assessed depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9) at baseline, after the intervention and 4-6 weeks post-intervention, along with evaluations of anxiety, perceived social support, and health-related quality of life.

Results

Among the 737 pregnant women screened, 267 (30.26%) scored ≥5 on the PHQ-9. Out of these, 85 were eligible and consented to participate, with 42 assigned to the intervention group and 43 to the control group. Eighty participants (94.1%) completed the final assessments. Our primary findings indicated that this nurse-delivered intervention was feasible to integrate into routine antenatal care and was well-received by both the women and the delivery agents. Although the study was not designed to detect differences between the intervention and control groups, we observed positive trends towards reductions in anxiety and depressive symptoms favoring the intervention arm. No serious adverse events were reported. This trial is registered in the Chinese Clinical Trial Registry with the registration number ChiCTR1900028114.

Conclusions

We conclude that this intervention, grounded in the well-established WHO Thinking Healthy Programme, is both feasible and acceptable to stakeholders. It merits a definitive randomized trial to assess its effectiveness and cost-effectiveness across various settings.

Clinical Trial Registration

ChiCTR1900028114.

Multiple mediation analysis of a task-shared psychosocial intervention for perinatal anxiety: Exploratory findings from a randomized controlled trial in Pakistan

BACKGROUND

The "Healthy Mother Healthy Baby" (HMHB) study is a phase three, single-blind randomized clinical trial conducted at Holy Family Hospital (HFH) in association with Rawalpindi Medical University (RMU). We aimed to examine the mediators of a specialized psychosocial approach based on Cognitive Behavioural Therapy principles, targeting pregnant women experiencing anxiety. The HMHB intervention was effective in treating perinatal anxiety symptoms and preventing future depressive episodes.

METHODS

The trial randomized participants into two arms: the HMHB intervention or Enhanced Usual Care (EUC), following World Health Organization guidelines. The HMHB intervention comprised strategies to strengthen social support networks, improving mother-baby bonding and strategies to deal with interpersonal conflicts, economic challenges, and societal gender preferences using cognitive and behavioural techniques and culturally resonant illustrations. Participants underwent rigorous data collection at three pivotal timepoints: baseline, third trimester, and 6-weeks postnatal. The primary outcome was anxiety symptom severity scores using the Hospital Anxiety and Depression Scale (HADS) at 6-weeks post-childbirth. Four potential mediators - social support, behavioural activation, perceived stress, and pregnancy experience - were assessed in the third trimester of pregnancy.

RESULTS

A total of 1200 participants were randomized to the HMHB and EUC arms. In the six-week follow-up time point, 379 participants remained in the EUC group, and 387 continued in the HMHB group. Post-intervention, HMHB participants displayed significant improvements in postnatal anxiety and depression scores. Mediation analyses revealed social support and pregnancy hassles as significant mediators of the intervention's effect on postnatal anxiety outcomes, while only social support emerged as a significant mediator for depression outcomes.

CONCLUSION

The HMHB intervention showed promising results in improving anxiety and depression scores among pregnant women. Significant mediation effects suggest the importance of targeting social support and managing pregnancy-related hassles for optimal intervention effectiveness.

World Psychiatric Association-Asian Journal of Psychiatry Commission on Public Mental Health

Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health remains overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative overview of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.

Effects of digital health interventions on the psychological outcomes of perinatal women: umbrella review of systematic reviews and meta-analyses

Evidence about the effects of digital health interventions (DHIs) on the psychological outcomes of perinatal women is increasing but remains inconsistent. An umbrella review was conducted to (1) assess the effect of DHIs on depressive, anxiety and stress symptoms and (2) compare the effects of DHIs on different digital platforms and population natures. Ten databases were searched from inception until December 23, 2022. The Hartung-Knapp-Sidik-Jonkman random-effects meta-analyses were utilised. Methodological quality was evaluated using the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2). Twenty-four systematic reviews with 41 meta-analyses involving 45,509 perinatal women from 264 primary studies were included. The credibility of the evidence of meta-analyses was rated as highly suggestive (4.88%), suggestive (26.83%), weak (51.22%) or non-significant (17.07%) according to AMSTAR-2. Our findings suggest that DHIs are beneficial for reducing stress symptoms. However, conflicting effects were found on anxiety symptoms. Subgroup and meta-regression analyses suggested that DHIs effectively improve depressive symptoms in postnatal women, and DHIs using the website platform are highly effective in stress reduction. DHIs can be implemented adjuvant to usual obstetric care to improve depressive and stress symptoms. Additional well-designed RCTs with long-term follow-up are warranted.

Anxiety-focused cognitive behavioral therapy delivered by non-specialists to prevent postnatal depression: a randomized, phase 3 trial

Anxiety experienced by women during pregnancy is highly prevalent, especially in resource-poor settings and strongly predicts postnatal common mental disorders (CMDs), anxiety and depression. We evaluated the effectiveness of an anxiety-focused early prenatal intervention on preventing postnatal CMDs. This study was a phase 3, two-arm, single-blind, randomized controlled trial conducted in Pakistan with women who were ≤22 weeks pregnant and had at least mild anxiety without clinical depression. Participants were randomized to the Happy Mother-Healthy Baby program, based on cognitive behavioral therapy, consisting of six one-on-one intervention sessions in pregnancy delivered by non-specialist providers, or to enhanced care alone. The primary outcome was major depression, generalized anxiety disorder or both at 6 weeks after delivery. Overall, 755 women completed postnatal assessments (380 (50.3%), intervention arm; 375 (49.7%) enhanced-care arm). The primary outcomes were met. Examined jointly, we found 81% reduced odds of having either a major depressive episode (MDE) or moderate-to-severe anxiety for women randomized to the intervention (adjusted odds ratio (aOR) = 0.19, 95% CI 0.14-0.28). Overall, 12% of women in the intervention group developed MDE at 6 weeks postpartum, versus 41% in the control group. We found reductions of 81% and 74% in the odds of postnatal MDE (aOR = 0.19, 95% CI 0.13-0.28) and of moderate-to-severe anxiety (aOR = 0.26, 95% CI 0.17-0.40), respectively. The Happy Mother-Healthy Baby program early prenatal intervention focusing on anxiety symptoms reduced postpartum CMDs. ClinicalTrials.gov identifier NCT03880032 .

A Supported Online Resilience-Enhancing Intervention for Pregnant Women: A Non-Randomized Pilot Study

A 28-week supported online intervention for pregnant women, informed by the Behavior Change Wheel Framework, was developed. The intervention included exercises, group sessions and a peer support platform. The aim of this study was to examine the potential effectiveness of the intervention in enhancing resilience and promoting maternal mental health. Using a quasi-experimental design, assessments were conducted at baseline, postintervention and follow-ups at six and 12 months after childbirth. Resilience, resilience attributes, and maternal mental health were measured using standardised scales. The intervention group received the intervention (N = 70), while the control group (N = 32) received care-as-usual. A repeated-measures ANOVA was used to determine within- and between-group changes. Results showed no significant differences between groups regarding resilience and maternal mental health. However, the intervention group demonstrated stable resilience (p = 0.320) compared to a significant decrease in the control group (p = 0.004). Within the intervention group, perceived social support remained stable during the intervention, but decreased significantly at the first follow-up (p = 0.012). All participants faced additional stress from the COVID-19 pandemic alongside the challenges of parenthood. This study contributes to maternal mental health literature with an innovative, supported online intervention. The intervention consists of different deployable components, designed to be offered online, and the current pilot data are promising. Further research is warranted to explore its full potential in clinical practice.

The effect of digital health interventions on postpartum depression or anxiety: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to examine the effect of digital health interventions compared with treatment as usual on preventing and treating postpartum depression and postpartum anxiety.

DATA SOURCES

Searches were conducted in Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov.

STUDY ELIGIBILITY REQUIREMENTS

The systematic review included full-text randomized controlled trials comparing digital health interventions with treatment as usual for preventing or treating postpartum depression and postpartum anxiety.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened all abstracts for eligibility and independently reviewed all potentially eligible full-text articles for inclusion. A third author screened abstracts and full-text articles as needed to determine eligibility in cases of discrepancy. The primary outcome was the score on the first ascertainment of postpartum depression or postpartum anxiety symptoms after the intervention. Secondary outcomes included screening positive for postpartum depression or postpartum anxiety --as defined in the primary study --and loss to follow-up, defined as the proportion of participants who completed the final study assessment compared with the number of initially randomized participants. For continuous outcomes, the Hedges method was used to obtain standardized mean differences when the studies used different psychometric scales, and weighted mean differences were calculated when studies used the same psychometric scales. For categorical outcomes, pooled relative risks were estimated.

RESULTS

Of 921 studies originally identified, 31 randomized controlled trials-corresponding to 5532 participants randomized to digital health intervention and 5492 participants randomized to treatment as usual-were included. Compared with treatment as usual, digital health interventions significantly reduced mean scores ascertaining postpartum depression symptoms (29 studies: standardized mean difference, -0.64 [95% confidence interval, -0.88 to -0.40]; I2=94.4%) and postpartum anxiety symptoms (17 studies: standardized mean difference, -0.49 [95% confidence interval, -0.72 to -0.25]; I2=84.6%). In the few studies that assessed screen-positive rates for postpartum depression (n=4) or postpartum anxiety (n=1), there were no significant differences between those randomized to digital health intervention and treatment as usual. Overall, those randomized to digital health intervention had 38% increased risk of not completing the final study assessment compared with those randomized to treatment as usual (pooled relative risk, 1.38 [95% confidence interval, 1.18-1.62]), but those randomized to app-based digital health intervention had similar loss-to-follow-up rates as those randomized to treatment as usual (relative risk, 1.04 [95% confidence interval, 0.91-1.19]).

CONCLUSION

Digital health interventions modestly, but significantly, reduced scores assessing postpartum depression and postpartum anxiety symptoms. More research is needed to identify digital health interventions that effectively prevent or treat postpartum depression and postpartum anxiety but encourage ongoing engagement throughout the study period.

Exploring Heterogeneity in perinatal depression: a comprehensive review

Perinatal depression (PND) is a significant contributor to maternal morbidity globally. Recognized as a major cause of poor infant development, epidemiological and interventional research on it has increased over the last decade. Recently, studies have pointed out that PND is a heterogeneous condition, with variability in its phenotypes, rather than a homogenous latent entity and a concrete diagnosis, as previously conceptualized in psychometric literature and diagnostic systems. Therefore, it is pertinent that researchers recognize this to progress in elucidating its aetiology and developing efficacious interventions.This systematic review is conducted in accordance with the Meta-analysis of observational studies in epidemiology (MOOSE). It aims to provide an updated and comprehensive account of research on heterogeneity in phenotypes of PND and its implications in research, public health, and clinical practice. It provides a synthesis and quality assessment of studies reporting heterogeneity in PND using cutting-edge statistical techniques and machine learning algorithms. After reporting the phenotypes of PND, based on heterogeneous trajectories and symptom profiles, it also elucidates the risk factors associated with severe forms of PND, followed by robust evidence for adverse child outcomes. Furthermore, recommendations are made to improve public health and clinical practice in screening, diagnosis, and treatment of PND.

Adaptation and integration of the thinking healthy programme into pregnancy schools in Istanbul, Turkey

BACKGROUND

Perinatal mental health is a major public health concern. In Turkey, public hospitals operate pregnancy schools which provides an opportunity to integrate an evidence-based Thinking Healthy Programme (THP) for perinatal depression. The aim of this study is to adapt the THP for universal use in the group setting and to understand its acceptability and feasibility for integration into the existing antenatal care programme for both face-to-face and online delivery.

METHODS

Following an expert-led adaptation process using the Bernal Framework, field testing was conducted on a group of women and facilitators followed by in-depth interviews (n:8) and group discussions (n = 13). Data were analysed using Thematic Framework Analysis.

RESULTS

Minor but significant adaptations were made to the individually delivered THP for use in the universal group pregnancy schools. Initial findings indicate that the THP-group version was acceptable to its target population and could be integrated into the antenatal care plan for delivery during face-to-face and online group classes.

CONCLUSION

THP is transferable to the Turkish cultural and healthcare context. The THP-group version has the potential to add value to Turkey's existing perinatal healthcare programme.

Optimizing cognitive and behavioral approaches for perinatal depression: A systematic review and meta-regression analysis

Cognitive behavioral therapies (CBT) have been demonstrated efficacious in treating perinatal depression (PND). This has been demonstrated in several meta-analyses of randomized controlled trials and quasi-experimental studies. However, there is a need for up-to-date meta-analytical evidence providing reliable estimates for CBT's effectiveness in treating and preventing PND. Furthermore, with the world moving toward precision medicine, approaches require a critical synthesis of psychotherapies, especially to unpack their mechanisms of action and to understand what approaches work best for whom. Therefore, the present systematic review and meta-regression analyses aim to answer these research questions. We searched six academic databases through February 2022 and identified 56 studies for an in-depth review. Using pretested data extraction sheets, we extracted patient-level and intervention-level characteristics and effect size data from each study. Random-effects meta-analyses and mixed-effect subgroup analyses were run to delineate the effectiveness and moderators of CBT interventions for PND, respectively. CBT-based interventions yielded a strong effect size (SMD = -0.74, 95% confidence interval [CI]: -0.91 to -0.56, n = 9,722) in alleviating depressive symptoms. These interventions were effective across different delivery formats (individual, group, and electronic) and could be delivered effectively by specialists and nonspecialists. Longer duration CBT interventions may not necessarily be more effective than shorter ones. Moreover, CBT-based interventions should consider including various behavioral ingredients to maximize intervention benefits.

Non-specialist-delivered psychosocial intervention for prenatal anxiety in a tertiary care setting in Pakistan: a qualitative process evaluation

OBJECTIVES

A manualised cognitive-behavioural therapy-based psychosocial intervention for prenatal anxiety called Happy Mother Healthy Baby is being tested for its effectiveness through a randomised control trial in Pakistan. The aim of this study was to evaluate the intervention delivery process and the research process.

DESIGN

Qualitative methods were used to explore in depth the intervention delivery and research process.

SETTING

This process evaluation was embedded within a randomised control trial conducted in a tertiary care facility in Rawalpindi, Pakistan.

PARTICIPANTS

Data were collected through in-depth interviews (n=35) with the trial participants and focus group discussions (n=3) with the research staff. Transcripts were analysed using a Framework Analysis.

RESULTS

The evaluation of the intervention delivery process indicated that it can be effectively delivered by non-specialist providers trained and supervised by a specialist. The intervention was perceived to be culturally acceptable and appropriately addressing problems related to prenatal anxiety. Lack of awareness of 'talking' therapies and poor family support were potential barriers to participant engagement. The evaluation of the research process highlighted that culturally appropriate consent procedures facilitated recruitment of participants, while incentivisation and family involvement facilitated sustained engagement and retention. Lack of women's empowerment and mental health stigma were potential barriers to implementation of the programme.

CONCLUSION

We conclude that non-specialists can feasibly deliver an evidence-based intervention integrated into routine antenatal care in a tertiary hospital. Non-specialist providers are likely to be more cost effective and less stigmatising. Inclusion of family is key for participant recruitment, retention and engagement with the intervention.

TRIAL REGISTRATION NUMBER

NCT03880032.

Delivering the Thinking Healthy Programme as a universal group intervention integrated into routine antenatal care: a randomized-controlled pilot study

BACKGROUND

Women with perinatal depression and their children are at increased risk of poor health outcomes. There is a need to implement non-stigmatizing interventions into existing health systems which reduce psychosocial distress during pregnancy and prevent perinatal depression. We adapted the WHO-endorsed Thinking Healthy Programme (THP) to be delivered universally to all women attending routine online pregnancy schools in Istanbul, Turkey. This study aimed to evaluate the feasibility and acceptability of this intervention.

METHODS

This mixed-methods study incorporated a two-arm pilot randomized controlled trial and qualitative evaluation of the feasibility and acceptability of the adapted THP - Brief Group version (THP-BGV) to a range of stakeholders. We recruited pregnant women at 12-30 weeks' gestation through pregnancy schools within the University Hospital's catchment area. Women in the intervention arm received five online sessions of the THP-BGV delivered by antenatal nurses. The intervention employed principles of cognitive behaviour therapy to provide psychoeducation, behaviour activation, problem-solving strategies and group support to participants. In the control arm, women received usual care consisting of routine online educational pregnancy classes aided by the antenatal nurses. The women were assessed for depressive symptoms with the Edinburgh Postnatal Depression Scale at baseline and 4-6 weeks post-intervention and also evaluated for anxiety, perceived social support, partner relationship, level of disability and sleep quality. In-depth interviews were conducted with women and other key stakeholders.

RESULTS

Of the 99 consecutive women referred to the pregnancy schools, 91 (91.9%) were eligible and 88 (88.8%) consented to participate in the study and were randomized. Eighty-two (83%) completed the final assessments. Our main findings were that this preventive group intervention was feasible to be integrated into routine antenatal educational classes and it was valued by the women and delivery-agents. While the study was not powered to detect differences between intervention and control conditions, we found small trends towards reduction in anxiety and depressive symptoms favoring the intervention arm. No serious adverse events were reported.

CONCLUSIONS

Given the paucity of preventive interventions for perinatal depression in low and middle-income countries, a fully powered definitive randomized controlled trial of this feasible and acceptable intervention should be conducted.

TRIAL REGISTRATION

The study was registered at Clinical Trails.gov ( NCT04819711 ) (Registration Date: 29/03/2021).