Randomised evaluation of a preventive intervention for postnatal depression in high-risk populations in Pakistan and Turkey: PREVENT-PND

Postnatal depression, or depression after childbirth, affects one in five women worldwide. The majority live in low- and middle-income countries (LMICs). The condition causes suffering not only to the mother, but has negative effects on the growth and development of the new-born. It is therefore vitally important to prevent postnatal depression. Building on our preparatory work conducted in Pakistan and Turkey, we aim to conduct a large study of about 650 women in the two countries to test a 'talking therapy' delivered to groups of women during pregnancy. The therapy is based on established principles of cognitive behaviour therapy and helps the mothers recognise symptoms of depression early, undertake activities that help keep such symptoms in check, and offers support to deal with commonly encountered challenges during pregnancy and after childbirth. We will compare randomly assigned women who receive the therapy with women who attend routine pregnancy 'educational' groups, assessing them for symptoms of depression and other well-being and childcare measures after they have given birth. We will repeat these assessments 6 months after birth to see if any positive effects are sustained. We will evaluate the costs of delivering the intervention versus its benefits. We will explore how the therapy works, so that we can improve such interventions in the future. If our proposed intervention is successful in preventing depression, it will be the first time such an intervention has been evaluated in low- and middle-income countries. The World Health Organization recommends interventions to prevent postnatal depression but recognises the lack of research in LMICs. Our study will show the way in which such interventions can be incorporated into programmes for women's health, and achieve real benefits for women and their new-borns not only in Pakistan and Turkey, but across the world. Our project will also assist in developing capacity in the two countries to conduct more sophisticated research that can assist with the scale-up of such interventions.

Postnatal depression affects one in five women worldwide and has huge economic and societal costs. There are no preventive interventions tested in low and middle-income countries (LMICs). We have conducted a feasibility study of a brief 5-session intervention based on principles of cognitive behaviour therapy in Turkey. We now aim to conduct a definitive Randomised Controlled Trial (RCT) in two diverse settings (peri-urban Pakistan and urban Istanbul), using two different formats (face-to-face in Pakistan and online in Turkey). Our objectives are to evaluate the effectiveness and cost-effectiveness of the intervention and understand how the effects are mediated. Six hundred and sixty four women from both sites with sub-clinical symptoms of anxiety and/or depression will randomly receive either the 5-session group intervention or enhanced usual care consisting of an equal number of group sessions consisting of information about pregnancy, psychoeducation and sign-posting. We will evaluate the women 6-8 weeks after giving birth for a depressive episode using a validated questionnaire. We will also evaluate them for secondary outcomes including anxiety, functioning, quality of life, mother-Infant relationship, health related behaviours and costs associated with the interventions. We will measure potential mediators of effect, including activation, problem-solving and cognitive restructuring. The outcomes will be repeated at 6-months postnatal to evaluate if the benefits are sustained. We will also conduct a qualitative process evaluation to understand the issues involved in both receiving and delivering the intervention, and challenges involved in integrating the intervention to health systems in the two settings. If our intervention is effective, we will work with the World Health Organization to disseminate it globally. We will build capacity of researchers to conduct further implementation and scale-up studies in LMIC.