Mood disorders and symptoms during pregnancy and the postpartum period are not uncommon and affect women across the world.  In spite of relatively high rates of depression among childbearing women, there are often inadequate resources for treatment, particularly in poorer countries. In countries lacking resources, health care is often managed by community health workers or individuals with basic health care training who provide care to difficult-to-reach populations. There are often few mental health professionals, leaving many women without adequate treatment. In an attempt to provide treatment to a greater number of women, some investigators are attempting to train community health workers to provide some psychotherapy as part of their standard duties.

In a recent paper published in the Lancet, Rahman and colleagues report on the success of using cognitive behavioral therapy (CBT) techniques delivered by community health workers to treat maternal depression and improve infant outcomes among women and children living in rural Pakistan. CBT is a short-term, skills-focused form of talk therapy that focuses on the interaction between thoughts, feelings, and behaviors. In a previous study, Rahman and colleagues developed a modified version of CBT that was acceptable to both depressed Pakistani women and Pakistani health care workers. This version of CBT utilized techniques such as active listening, “guided discovery,” and opportunities to practice new skills through homework. The purpose of this study was to examine how effective it was in alleviating depression and improving various infant outcomes, such as infant growth and rates of immunization.

In the study, 903 pregnant women with depression were recruited from health centers in rural Pakistan were randomly assigned to one of two groups: the “Thinking Healthy” intervention, or enhanced routine care. Both groups received an equal number of health care worker visits, but participants who were assigned to the “Thinking Healthy” group also received the modified version of CBT delivered by their community health worker. Participants were assessed at six and 12 months after enrollment. Compared to women in the enhanced routine care group, women who received the “Thinking Healthy” intervention had significantly lower depression scores (as measured by the Hamilton Depression Rating Scale) at both assessments. In addition, these women had lower disability scores, greater perception of social support, and better overall functioning than women who received enhanced standard of care alone. There were also some significant differences with respect to infant outcomes between the control and treatment group. For example, infants of mothers who received the “Thinking Healthy” intervention were more likely to have received their recommended immunizations by the 12 month assessment.

The results of this study suggest that CBT delivered by health care workers can significantly reduce depressive symptomatology among postpartum women living in rural areas. Furthermore, treating depression in mothers may also result in improved infant outcomes. Additional studies of this kind are required in order to determine how to best provide quality mental health care to women where mental health professionals are not readily available.

Christina Psaros, PhD

Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F. (2008). Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet, 372, 902-909.

To learn more:

Rahman, A. (2007). Challenges and opportunities in developing a psychological intervention for perinatal depression in rural Pakistan: A multi-method study. Archives of Women’s Mental Health, 10, 211-219.

Rojas, G., Fritsch, R., Solis, J., et al. (2007). Treatment of postnatal depression in low-income mothers in primary care clinics in Santiago, Chile: A randomised comtrolled trial. Lancet, 370, 1629-1637.

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