title: Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial.
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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  This psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in resource-poor settings.
authors.affiliation: School of Population, Community, and Behavioural Sciences, University of Liverpool, Liverpool, UK.
authors.forename: Atif
authors.initials: A
authors.lastname: Rahman
authors.forename: Abid
authors.initials: A
authors.lastname: Malik
authors.forename: Siham
authors.initials: S
authors.lastname: Sikander
authors.forename: Christopher
authors.initials: C
authors.lastname: Roberts
authors.forename: Francis
authors.initials: F
authors.lastname: Creed
mesh_terms: D000293:Adolescent; D000328:Adult; D001724:Birth Weight; D016000:Cluster Analysis; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003150:Community Health Workers; D003866:Depressive Disorder / Q000628:therapy*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008423:Maternal Age; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010154:Pakistan / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000523:psychology* / Q000628:therapy*; D011263:Pregnancy Trimester, Third / Q000523:psychology*; D015995:Prevalence; D012923:Social Class; D012944:Social Support
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