Addressing Perinatal Depression in Deprived Areas of Istanbul, Turkey

Lead Research Organisation: University of Liverpool
Department Name: Faculty of Health and Life Sciences


Why is it important to address depression in women during pregnancy

Worldwide, depression during pregnancy affects about one in four women. The situation is similar in Turkey. The majority of these women do not receive any treatment. Untreated depression causes great suffering not only to the woman, but also affects the relationship between the mother and infant. It can lead to impaired brain development and poor growth in the infant in the long-term. Timely treatment can prevent these complications.
Perinatal depression be treated effectively with 'talking therapies'. One of the most effective talking therapies, the Thinking Healthy Programme, was developed by Rahman and his team in Pakistan. The programme was adopted by the World Health Organization as its official first-line treatment for perinatal depression. However, the programme was developed for close-knit rural communities and delivered individually to rural women by community health workers. In big cities like Istanbul, rapid migration from rural areas can lead to breakdown of traditional family and community support which may increase the risk of depression. In High Income countries, group therapies have been shown to be effective and deliverable at lower cost. These may also be very useful for communities in which support networks are disrupted. There is currently no group version of the Thinking Healthy Programme.

Objectives of the project

The objectives of this project are two-fold:

Objective 1. To adapt the well-established WHO Thinking Healthy Programme so it can be delivered to groups of women in deprived urban areas of Istanbul and to test the programme in selected antenatal hospitals in deprived districts of the city.

Objective 2. To build capacity of researchers at Marmara University so they can undertake future large-scale studies in this important but neglected area of public health.

How will we address our objectives

The study will be conducted in 6 public hospitals serving low socioeconomic districts in Istanbul. These hospitals run regular antenatal classes for women from very poor backgrounds. We will integrate our intervention in these hospitals.

Objective 1: This will be achieved in two phase. In the formative phase, we will talk to groups of all key stakeholders, including women, their partners and nurses who deliver the intervention. We will hold a workshop with local specialists and experts to adapt the intervention to the group-delivery format. In the feasibility phase, we will compare the adapted 'group' Thinking Healthy programme (intervention) with routine Antenatal classes (control). Both interventions will be delivered to 120 women, randomly divided into intervention and control groups. Our aim is to explore if the new intervention is feasible and acceptable to all our stakeholders, the training and supervision procedures work, and to test the tools required a future large-scale studies. We will use both qualitative and quantitative methods to explore these issues.

Objective 2: Through our previous work in South Asia, we have developed a special course to train new researchers in designing and evaluating interventions for mental health in low and middle income countries. We will conduct two workshops aimed at training researchers at Marmara University in this comprehensive course. The content of the course includes design, implementation, monitoring and evaluation of interventions in low- and middle-income countries.

How we will use the results of our project

We will work closely with the World Health Organization to incorporate our findings into the revised 'group' version of the Thinking Healthy Programme which will be disseminated to all member countries through the WHO's flagship mental health gap action programme. Our partners at Marmara University are ideally placed to scale-up the intervention to other districts in Istanbul. We will publish papers in journals and present at conferences.

Technical Summary

Worldwide, perinatal depression affects about one in four women. The majority do not receive appropriate treatment. Perinatal depression is independently associated with poor infant health and development. The World Health Organization's "Thinking Healthy Programme (THP)" was developed and evaluated by Rahman and colleagues in rural Pakistan to address this treatment gap. The intervention has not been adapted for urban settings. The aim of this project is to adapt and test the feasibility of a group version of THP in socioeconomically deprived areas of urban Istanbul, Turkey. Our second aim is to build capacity at Marmara University to allow future large-scale trials in this area.

The study will be conducted in 6 public hospitals serving low socioeconomic districts in Istanbul in two Phases. In the formative phase, in-depth interviews and focus group discussions of women with depression and service-providers will be conducted to understand the cultural and service-delivery context necessary for adaptation. In the feasibility phase, we will compare the adapted 'group' THP with routine antenatal classes in 120 women with perinatal depression, equally and randomly divided into the two groups. We will use mixed-methods to explore if the new intervention is feasible and acceptable to all our stakeholders and the training and supervision procedures are effective. To build capacity, we will conduct researchers' training workshops at Marmara University in the design, implementation and evaluation of complex interventions in low- and middle-income countries.

Impact and dissemination: We will work with the WHO to incorporate our findings into the revised 'group' version of THP which will be disseminated through the WHO's flagship mental health gap action programme. Our partners at Marmara University plan to scale-up the intervention to other districts in Istanbul. Findings will be published in journals and presented at conferences.

Planned Impact

Our overarching goal is to reduce the treatment gap for perinatal depression in socioeconomically deprived urban areas.

Our Beneficiaries are a) women with perinatal depression, b) health care systems that are responsible for their care and c) organizations that conduct research and evaluation of services.

Our Constituencies (organisations or networks that will help our work create impact) include: a) at the national level, the Marmara University; b) at the regional level, the South Asian Hub for Advocacy, Research and Education in mental health (SHARE), and c) at the global level, the World Health Organization.
Pathways to Impact

We will work with these constituencies through a number of channels to maximise the impact of our work.

A) In Istanbul, Turkey, Marmara University develops and provides training programmes for health professionals working in affiliated public hospitals in this deprived district of Istanbul. If found to be feasible, training in the group intervention will be provided to all public hospitals affiliated with Marmara University. By building capacity in conducting randomised trials at Marmara University, we will be in a position to apply for further research funding, which can contribute to further impact by addressing important effectiveness, implementation and scale-up questions.

B) In Asia, PI Rahman leads the South Asian Hub for Advocacy, Research and Education in mental health (SHARE) which has partners in non-governmental sectors and academia from all South Asian countries. SHARE has been working to build regional capacity and awareness for mental health since 2012. SHARE's network now extends beyond the region and includes China and the Middle East. SHARE works closely with over a dozen organizations and academic institutions engaged in maternal and child mental health in their respective countries. The team will engage closely with researchers and implementers from the SHARE network who will learn from the project and apply the innovations to their own settings. SHARE will also disseminate the findings to other partners countries (India, China and the Middle-East) to maximise impact.

C) Globally, the Thinking Healthy Programme is part of the World Health Organization's mental health GAP action programme (mhGAP). The manual is freely downloadable from the WHO website and has been downloaded over 10,000 times in 3 years. Rahman is tasked with carrying out revisions to the WHO Thinking Healthy Programme as more research is conducted on it globally. The findings from the project will directly feed into this revision process. The group version of the Thinking Healthy Programme will be adopted by the WHO mhGAP programme and disseminated to all countries in the world through this platform. WHO also supports countries in training in mhGAP and this will provide further channels for dissemination.
Description We have completed our pilot study successfully despite challenges arising from the COVID pandemic and ODA funding cuts.
We were able to recruit 91 pregnant women into the study who were randomised to intervention or control arms. In the control arms. We used a mixture of qualitative and quantitative methods to test study feasibility. Women completed questionnaires for depression, anxiety, perceived social support, level of disability and sleep when they were enrolled and then after 4-6 weeks of completion of the intervention. Of the women recruited, 83% completed final assessments. Overall, 36.4% women attended all classes, and 14.8% of women never attended the sessions. Service users and suppliers valued and supported the intervention. No serious adverse events were reported. Results showed a reduction at 4-6 weeks in mean Edinburgh Postnatal Depression Scale (EPDS) scores from pre to post intervention for the intervention group, while mean EPDS scores for the control group did not change from pre to post intervention. There were no significant group differences in EPDS scores between intervention and control group, though there was a positive trend for the intervention subjects toward lower depressive symptoms. The findings from this pilot study suggest that the intervention, and the measures used, were well received and easily integrated into existing pregnancy schools. Our findings support trial feasibility and can be used to undertake an adequately powered future trial.
Exploitation Route Marmara University plays a pivotal role in national health policy and research, with the University Hospital being a Turkish Ministry of Health affiliate institution. Lack of services for mental health is well-recognised and the project findings will provide impetus for further effort in this neglected area.
Sectors Healthcare

Description • The Thinking Healthy Programme- Brief Group Version (THP-BGV) was evalauted in this feasibility study. The intervention is designed to implement in low-resource settings to empower pregnant women as a preventive approach for good mental well-being. • Most women exposed to THP-BGV found the intervention useful for their mental well-being. • The intervention was acceptable to the women because it supported maternal self-efficacy, promotion of healthy life habits, sharing of feelings and thoughts with others, and normalization of feelings. • Since the intervention was delivered in a group format, it also promoted networking and peer support. • The study addressed the following sustainable developmental goals: ending poverty, good health and well-being, decent work and economic growth, gender equality, reduced inequalities, climate action, life below water, life on land, and partnership for the goals. o THP-BGV is designed to prevent perinatal depression and thus prevent future hospital admissions and resource use for the treatment of perinatal depression. Family supplies are supported by preventing potential expenses that would be required for the treatment of perinatal depression. With the prevention of perinatal depression, the potential burden on mental health services will also be decreased. It is also expected to reduce the national economic cost of not preventing the disorder. o With the THP-BVG, good health and well-being are supported by teaching women how to manage unhelpful thoughts. Besides the intervention promotes healthy lifestyle habits. Increased psychosocial well-being is reported by the participating women since bonding with the baby, marital relationship, and social support are addressed. Women reported increase in their knowledge and felt better equipped for providing care to their babies. Positive effects were expected to persist beyond the pregnancy, and even have lifecourse positive outcomes both for the woman and the baby. o The program is designed to support and empower mothers. Mothers' awareness about mental health and healthy lifestyles is increased. Mothers were also taught how to self-manage their unhealthy thoughts to promote their well-being. o Decent work and economic growth are addressed by preventing perinatal depression. The productivity of the women is expected to be increased by protecting them from perinatal depression thus returning to the work after maternity leave. o The THP-BVG is designed for all women from all kinds of socioeconomic levels. Women in lower socioeconomic groups may less likely to reach mental health services. Since the program is delivered in routine antenatal pregnancy school classes run in public hospitals from the Ministery of Health in Turkey, all women can equally access the intervention. Inequalities are expected to be reduced by the promotion of the involvement of socioeconomically deprived women to the classes. o Perinatal depression is known to reduce postpartum breastfeeding rates. Breastmilk is the most beneficial food for babies. It is clean, does not require energy to produce, and thus is environmentally friendly. By contrast formula, feeding causes waste production and consumption of water and energy. Preventing perinatal depression by the THP-BVG can increase breastfeeding rates and thus support climate action, life below water and on land. o Partnership for the goal of preventing perinatal depression was possible by building collaboration between institutions from UK and Turkey. • The original THP was developed for the treatment of postpartum depression but the THP-BGV was delivered to the expecting mothers as a preventive measure. • Diversity was ensured by offering the study participation to all women willing to attend antenatal pregnancy school classes regardless of their cultural or socioeconomic status. • Maternal well-being and women were prioritized in the THP-BGV. Male engagement was encouraged but was not acceptable by the mothers due to privacy issues. Secondary gains for men are expected to be achieved since family well-being is supported by the empowerment of women. Some women reported the intervention not only benefitting them but also their family members. Many participants reported improved relationship with their husbands and in-laws. They attributed this to their improved confidence and better communication.
First Year Of Impact 2021
Sector Healthcare
Impact Types Societal

Description Presentation to the Early Childhood Development Civil Society Organisations Platform in Turkey.
Geographic Reach National 
Policy Influence Type Contribution to a national consultation/review
Impact The integration of maternal mental health interventions in routine antenatal care was discussed with policy-makers. The research findings helped make the case for this. Discussions are ongoing.
Description Capacity Building 
Organisation Human Development Research Foundation
Country Pakistan 
Sector Charity/Non Profit 
PI Contribution Capacity building in a young Pakistani female researcher, Ms Anum Nisar, based at the collaborating institution (HDRF).
Collaborator Contribution Partners assisted with development and evaluation of the intervention being tested.
Impact The junior researcher is a co-author on the main publication from this project (Boran et al, BMC Psychiatry 2022)
Start Year 2020
Description Marmara University, Istanbul, Turkey 
Organisation Marmara University
Country Turkey 
Sector Academic/University 
PI Contribution The PI from University of Liverpool, Rahman, spearheads the Institute's Global Mental Health programme. He has developed and evaluated several interventions for depression, anxiety, and child developmental disorders, conducting over a dozen major RCTs in South Asia and sub Saharan Africa. Rahman and his team at Liverpool have contributed to all aspects of the work, capacity building, training and governance related to research.
Collaborator Contribution Marmara University with more than 3000 faculty members and a student body reaching 60,000 has been a leading institutions of higher education in Turkey for 124 years. The Department of Social Paediatrics is housed within the Marmara University, School of Medicine and the PhD programme on Social Pediatrics is offered within the Institute of Health Sciences and both are led by co-PI Prof Perran Boran. The University hospital has close relationship with the other 5 public hospitals where the trial is to be conducted.Boran translated and adapted the official WHO version of the Thinking Healthy Programme in Turkish. Her faculty have been trained in the programme and apply it to their clinical practice. Boran wlll be responsible for day-to-day supervision of the project. Co-I Donmez is based at the Department of Psychiatry, Marmara University, School of Medicine. She is an early career researcher specialising in women's mental health. Collaborators from Marmara University, School of Medicine include Dilsad Save, public health specialist, who will assist with randomization procedures and qualitative analyses; Seyhan Hidiroglu, public health specialist, who will assist with data management and qualitative analyses; Volkan Topçuoglu, psychiatrist, who will be responsible for the management of psychiatric emergencies, consultation of participants who have severe depression and other referral-related issues, and; from the Public Hospital Union, administrative organisation of the Public Hospitals Engin Ersin Simsek, family physician, who will be responsible for the administrative organization of 5 pregnancy schools.
Impact None.
Start Year 2020
Description Engagement with policy makers 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Profs Boran and Rahman presented the findings at this Conference on 18th Nov 2021: International Early Childhood Development Civil Society Organizations Platform Congress: From Science to Policy, 18-21th Nov 2021. Online Congress, Turkey. The congress was attended by Health Ministry officials, representatives of Non-Governmental Organizations, academics and practitioners. The talked raised awareness of the importance of maternal mental health for child health.
Year(s) Of Engagement Activity 2021