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High- versus low-intensity interventions for perinatal depression delivered by non-specialist primary maternal care providers in Nigeria: cluster randomised controlled trial (the EXPONATE trial)

  • Oye Gureje (a1), Bibilola D. Oladeji (a2), Alan A. Montgomery (a3), Ricardo Araya (a4), Toyin Bello (a5), Dan Chisholm (a6), Danielle Groleau (a7), Laurence J. Kirmayer (a8), Lola Kola (a9), Lydia B. Olley (a10), Wei Tan (a11) and Phyllis Zelkowitz (a12)...

Abstract

Background

Contextually appropriate interventions delivered by primary maternal care providers (PMCPs) might be effective in reducing the treatment gap for perinatal depression.

Aim

To compare high-intensity treatment (HIT) with low-intensity treatment (LIT) for perinatal depression.

Method

Cluster randomised clinical trial, conducted in Ibadan, Nigeria between 18 June 2013 and 11 December 2015 in 29 maternal care clinics allocated by computed-generated random sequence (15 HIT; 14 LIT). Interventions were delivered individually to antenatal women with DSM-IV (1994) major depression by trained PMCPs. LIT consisted of the basic psychosocial treatment specifications in the World Health Organization Mental Health Gap Action Programme – Intervention Guide. HIT comprised LIT plus eight weekly problem-solving therapy sessions with possible additional sessions determined by scores on the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome was remission of depression at 6 months postpartum (EPDS < 6).

Results

There were 686 participants; 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed remission rates of 70% with HIT and 66% with LIT: risk difference 4% (95% CI −4.1%, 12.0%), adjusted odds ratio 1.12 (95% CI 0.73, 1.72). HIT was more effective for severe depression (odds ratio 2.29; 95% CI 1.01, 5.20; P = 0.047) and resulted in a higher rate of exclusive breastfeeding. Infant outcomes, cost-effectiveness and adverse events were similar.

Conclusions

Except among severely depressed perinatal women, we found no strong evidence to recommend high-intensity in preference to low-intensity psychological intervention in routine primary maternal care.

Declaration of interests

None.

Copyright

Corresponding author

Correspondence: Oye Gureje, World Health Organization Collaborating Center for Research and Training in Mental Health, Neuroscience and Substance Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria. Email: ogureje@comui.edu.ng

References

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1Gelaye, B, Rondon, M, Araya, R, Williams, M. Epidemiology of maternal depression, risk factors, and child outcomes in low- and middle-income countries. Lancet Psychiatry 2016; 3: 973–82.
2Aderibigbe, YA, Gureje, O, Omigbodun, O. Postnatal emotional disorders in Nigerian women: a study of antecedents and associations. Br J Psychiatry 1993; 163: 645–50.
3Uwakwe, R, Okonkwo, JE. Affective (depressive) morbidity in puerperal Nigerian women: validation of the Edinburgh Postnatal Depression Scale. Acta Psychiatr Scand 2003; 107: 251–9.
4Bonari, L, Pinto, N, Ahn, E, Einarson, A, Steiner, M, Koren, G. Perinatal risks of untreated depression during pregnancy. Can J Psychiatry 2004; 49: 726–35.
5Grote, NK, Bridge, JA, Gavin, AR, Melville, JL, Iyengar, S, Katon, WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry 2010; 67: 1012–24.
6Field, T. Prenatal depression effects on early development: a review. Infant Behav Dev 2011; 34: 114.
7Stein, A, Pearson, RM, Goodman, SH, Rapa, E, Rahman, A, McCallum, M, et al. Effects of perinatal mental disorders on the fetus and child. Lancet 2014; 384: 1800–19.
8Prince, M, Patel, V, Saxena, S, Maj, M, Maselko, J, Phillips, MR, et al. No health without mental health. Lancet 2007; 370: 859–77.
9Hearn, G, Iliff, A, Jones, I, Kirby, A, Ormiston, P, Parr, P, et al. Postnatal depression in the community. Br J Gen Pract 1998; 48: 1064–6.
10Dennis, CI, Ross, IE, Grigoriadis, S. Psychosocial and psychological interventions for treating antenatal depression. Cochrane Database Syst Rev 2007; 3: CD006309.
11Clarke, K, King, M, Prost, A. Psychosocial interventions for perinatal common mental disorders delivered by providers who are not mental health specialists in low- and middle-income countries: a systematic review and meta-analysis. PLoS Med 2013; 10: e1001541.
12Rahman, A, Fisher, J, Bower, P, Luchters, S, Tran, T, Yasamy, MT, et al. Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis. Bull World Health Organ 2013; 91: 593601.
13Gureje, O, Oladeji, B, Araya, M, Montgomery, AA, Kola, L, Kirmayer, L, et al. Expanding care for perinatal women with depression (EXPONATE): study protocol for a randomized controlled trial of an intervention package for perinatal depression in primary care. BMC Psychiatry 2015; 15: 136.
14Cox, J, Holden, J, Sagovsky, R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: 782–6.
15Kessler, RC, Calabrese, JR, Farley, PA, Gruber, MJ, Jewell, MA, Katon, W, et al. Composite International Diagnostic Interview screening scales for DSM-IV anxiety and mood disorders. Psychol Med 2013; 43: 1625–37.
16Oladeji, BD, Kola, L, Abiona, T, Montgomery, AA, Araya, R, Gureje, O. A pilot randomized controlled trial of a stepped care intervention package for depression in primary care in Nigeria. BMC Psychiatry 2015; 15: 96.
17World Health Organization. WHO Disability Assessment Schedule II. World Health Organization, 1999.
18Kumar, R, Robson, K, Smith, A. Development of a self-administered questionnaire to measure maternal adjustment and attitudes during pregnancy and after delivery. J Psychosom Res 1984; 28: 4351.
19Caldwell, BM, Bradley, RH. HOME Inventory Administration Manual: Comprehensive Edition. University of Arkansas for Mediacl Sciences and University of Arkansa at Little Rock, 2003.
20Lasalvia, A, Zoppei, S, Van Bortel, T, Bonetto, C, Cristofalo, D, Wahlbeck, K, et al. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. Lancet 2013; 381: 5562.
21Chisholm, D, Conroy, S, Glangeaud-Freudenthal, N, Oates, MR, Asten, P, Barry, S, et al. Health services research into postnatal depression: results from a preliminary cross-cultural study. Br J Psychiatry Suppl 2004; 46: s4552.
22Rahman, A, Malik, A, Sikander, S, Roberts, C, Creed, F. Cognitive behavior therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomized controlled trial. Lancet 2008; 372: 902–9.
23Rojas, G, Fritsch, R, Solis, J, Jadresic, E, Castillo, C, González, M, et al. Treatment of postnatal depression in low-income mothers in primary care clinics in Santiago, Chile: a randomized controlled trial. Lancet 2007; 370: 1629–37.
24Eldridge, SM, Ashby, D, Kerry, S. Sample size for cluster randomized trials: effect of coefficient of variation of cluster size and analysis method. Int J Epidemiol 2006; 35: 1292–300.
25Adeponle, A, Groleau, D, Kola, L, Kirmayer, L, Gureje, O. Perinatal depression in Nigeria: perspectives of women, family caregivers and health care providers. Int J Ment Health Syst 2017; 11: 27.
26Chowdhary, N, Sikander, S, Atif, N, Singh, N, Ahmad, I, Fuhr, DC, et al. The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle income countries: a systematic review. Best Pract Research Clin Obstetr and Gynaecol 2014; 28: 113–33.
27Adewuya, AO, Ola, BA, Dada, AO, Fasoto, OO. Validation of the Edinburgh Postnatal Depression Scale as a screening tool for depression in late pregnancy among Nigerian women. J Psychosom Obstet Gynaecol 2006; 27: 267–72.
28Tan, W, Gureje, O, Montgomery, A, Hepburn, T, Oladeji, B, Araya, R, et al. Investigating recruitment imbalance in EXPONATE, a cluster randomised trial. Trials 2017; 18: 190.
29Gureje, O, Odejide, AO, Olatawura, MO, Ikuesan, BA, Acha, RA, Bamidele, RW, et al. Results from the Ibadan Centre. In Mental illness across the world in General Health Care: An international study (eds Ustün, TB, Sartorius, N): 157–73. John Wiley & Sons, 1995.
30Gureje, O, Lasebikan, VO, Kola, L, Makanjuola, VA. Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of Mental Health and Well-Being. Br J Psychiatry 2006; 188: 465–71.
31Gureje, O, Olowosegun, O, Adebayo, K, Stein, DJ. The prevalence of non-affective psychosis in the Nigerian Survey of mental Health and Wellbeing. World Psychiatry 2010; 9: 50–5.

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High- versus low-intensity interventions for perinatal depression delivered by non-specialist primary maternal care providers in Nigeria: cluster randomised controlled trial (the EXPONATE trial)

  • Oye Gureje (a1), Bibilola D. Oladeji (a2), Alan A. Montgomery (a3), Ricardo Araya (a4), Toyin Bello (a5), Dan Chisholm (a6), Danielle Groleau (a7), Laurence J. Kirmayer (a8), Lola Kola (a9), Lydia B. Olley (a10), Wei Tan (a11) and Phyllis Zelkowitz (a12)...
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