Improving access to psychological therapies for perinatal depression in low and middle-income countries

Perinatal depression affects one in four women in low and middle income countries with over 90% not receiving any treatment for this condition. This has devastating consequences such as increased disability and suicide as well as the infants of depressed mothers being at a higher risk of poor physical, cognitive and emotional development. Researchers from the University of Liverpool published the Thinking Healthy Programme (THP), becoming the first fully manualised psychological intervention to be adopted by the World Health Organization for global dissemination. Training has been implemented in 90 countries with over 90,000 community health workers being trained in Pakistan alone.

The Challenge

Perinatal depression (depression in pregnancy, around childbirth or within the first year post‐partum) affects one in four women in low and middle income countries. This has huge economic and societal costs as infants of depressed mothers are at a higher risk of poor physical, cognitive and emotional development. Sadly, over 90% women in low-income countries do not receive any treatment for this condition.

The research approach

In 2008 Professor Rahman’s group published a landmark Lancet paper describing the ‘Thinking Healthy’ trial in Pakistan. In 2013-14, the group was commissioned by the WHO to adapt the 'Thinking Healthy Programme' (THP) to a global audience. In 2015, the adapted version was incorporated into the WHO’s Mental Health Gap Action Programme (mhGAP) and published on the WHO website in 6 major languages. This was followed in 2017 with the trial of an App for training and supervision of THP and in 2018, with two randomised controlled trials of THP, delivered by peers in India and Pakistan, extending the evidence-base for THP.

Currently, they are undertaking a long-term follow-up of the 2018 trial participants in Pakistan.

Working in partnership

The WHO’s strategy to reduce the treatment gap for common mental disorder such as perinatal depression was launched in 2008, and had ‘task-shifting’ (process of delegation whereby tasks are moved, where appropriate or from highly specialised workforce to less specialised health workers) as its cornerstone. The first edition of the WHO Mental Health Gap Action Programme (mhGAP) intervention guide published in 2010, provided guidelines for management of priority conditions such as perinatal depression but lacked detailed manualised programmes that would allow ‘task-shifting’ to be feasibly employed.

Around the time the mhGAP programme was released in 2008, the group published their landmark trial of the Thinking Healthy Programme. The WHO’s mental health team visited the programme in Pakistan and commissioned Professor Rahman to adapt the programme for its mhGAP programme. Working with the mhGAP team and a group of international experts, Professor Rahman concluded this work in 2015. The WHO Thinking Healthy Programme became the first completely manualised evidence-based intervention, with step-by-step instructions for implementation by non-specialist, to be incorporated in the WHO’s global mhGAP programme.  In 2016, it was incorporated into the second edition of the mhGAP intervention guide.

Outputs and outcomes

The WHO, through its head office in Geneva and its 6 Regional Offices around the world, is mandated to provide technical assistance to all member countries for training and dissemination of the mhGAP programme. According to WHO sources, the training has been implemented in 90 countries and although figures are unavaible for the number of health professionals trained, the potential reach of the programe is huge. This is evident in Pakistan where it was included in the President's Plan to Promote Mental Health of Pakistanis which has mandated that all 90,000 community health works in Pakistan be trained in THP by 2024.

The Thinking Healthy Programme is also now freely available on the WHO website in 6 languages (Spanish, Italian, French, Turkish, Chinese and Urdu) and has been downloaded over 20,000 times since its launch in May 2020. The influential Lancet Commission on Global Mental Health cited the programme as a ‘case-study’ of exemplary programmes to reduce the mental health treatment gap. Additionally, THP has been included in the WHO’s Eastern Mediterranean Region’s Framework for Mental Health as a ‘Best Buy’, which serves as a guide to policy-makers for investments in mental health. The Framework has been ratified by all 22 member countries.

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