Globally the prevalence of mental health and psychosocial problems is high during pregnancy and after birth. It is reported that almost one in four women in developing countries suffers from anxiety/depression around the period of childbirth, which can lead to a chronic or recurring depressive course throughout life. A literature review of 143 research studies undertaken in 40 countries around the world reported that the prevalence of postpartum depression (PPD) in Asian countries ranged from 11 percent to 60.8 percent. The mean overall prevalence of anxiety and depressive disorders in the Pakistani population has been reported to be 34 percent with higher rates in women than in men. A prevalence of 30 percent has been reported among women of reproductive age group in a semi-urban community of Karachi. Studies done in urban tertiary care settings in Pakistan have reported figures ranging from 24 percent to 42 percent. Other community-based studies from rural Pakistan have reported prevalence ranging from 28 percent to 36 percent in postpartum women. A cohort study from rural Pakistan has reported persistent postpartum depression in 56 percent of those who developed PPD. Depression after childbirth affects the health of the mother as well as the health, growth and development of the child. Studies have revealed that perinatal depression is associated with poor growth, high risk of diarrhoea and reduced uptake of immunisation. Currently the detection and treatment of depression after childbirth is less than satisfactory and many women are reluctant to take pharmacotherapy for fear of excretion of drugs into their breast milk. Studies from high income countries have reported that psychotherapeutic approaches, such as cognitive behaviour therapy, interpersonal therapy or problem solving therapy are effective treatments for depression. A few randomised trials from low income and middle income countries have also reported similar findings. Substantial decrease in depressive symptoms in women after miscarriage has been reported after six sessions of interpersonal counselling. A randomised controlled study conducted in a poor rural community in Pakistan has shown that integration of cognitive behaviour therapy (CBT) into routine work of community health workers more than halved the rate of depression in prenatally depressed women compared with those receiving routine care only. In addition to symptomatic relief, the intervention group had less disability, better overall social functioning and the benefit persisted after one year. It has been reported that patients treated with either pharmacotherapy or cognitive therapy showed similar results. No published findings to date suggest that antidepressant medication reduces future risk of depressive episodes after discontinuation, whereas cognitive therapy has been shown to provide protection against relapse and possible recurrence. Higher percentages of relapses and recurrences have been reported among patients who were on pharmacotherapy than on cognitive therapy. In a randomised controlled trial, significant improvement was found in women of reproductive age who were suffering from anxiety and depression after eight weekly counselling sessions by minimally trained community women. Based on this experience, this study was conducted to assess the benefits of counselling from minimally trained community health workers working with anxious and depressed women during the first two and a half years after childbirth, and to assess the rate of recurrence and the interval preceding recurrence of anxiety/depression after counselling.
SELECTION AND TRAINING: Women aged 18 years and above residing at the study sites, able to read and write Urdu and willing to be trained were identified. They were trained in administration of the screening instrument, the Aga Khan University Anxiety and Depression Scale (AKUADS), and other study questionnaires. They were also trained to provide counselling to mothers who were found to be anxious and depressed.
ENROLMENT AND DATA COLLECTION: A field office was established at Qayumabad and the counsellors visited each house in Qayumabad and adjacent sectors of Manzoor Colony, and inquired about the date of the last menstrual period from women in the reproductive age group. Those found to be pregnant were informed of the objectives of the study and were invited to participate in the study after childbirth and written consent was obtained. This process of identification of pregnant women was carried on for the first two years of the study. The expected date of delivery was calculated from the date of the last menstrual period and the counsellors started weekly home visits when the participant woman had reached the 36th week of pregnancy, and this continued until childbirth. Consent was again obtained from mothers of live births before enrolling them in the study. The socio-demographic, home environment, family relationship and newborn postnatal questionnaires were administered within seven to 10 days of childbirth by the counsellors. Routine follow-ups were scheduled after one, two, six, 12, 18, 24 and 30 months of childbirth for screening of anxiety/depression among mothers and monitoring of child growth/development. Verbal consent was obtained each time before administering AKUADS. Women with AKUADS scores of 17 or above were interviewed by the clinical psychologist for confirmation of anxiety/depression. A total of 102 women were found to be anxious and depressed at least once during the study period. Among them 84 had only one episode, 16 had two episodes and two women suffered three episodes giving a total of 122 episodes. The number of episodes of anxiety/depression at one month, two months, six months, 12 months, 18 months, 24 months and 30 months were 14, 14, 27, 35, 18, 12 and two, respectively. All women found to be anxious/depressed by the clinical psychologist or who scored 19 or above on AKUADS were offered weekly one-hour counselling sessions for eight weeks. Only 62 accepted; main reasons for refusal were objection from their husbands and in-laws and the social stigma attached to the diagnosis of a mental illness. Very basic cognitive behavioural therapy, supportive and problem-solving counselling was provided. Sessions were conducted at the client’s residence on the day and time of her convenience. The counsellors kept notes of their sessions and discussed these with the clinical psychologist on a daily basis initially, and once weekly as they became better trained and more confident. They also had easy access to the other members of the training team throughout the study period. All identified women whether they had agreed to counselling or not were requested to take the AKUADS at four and eight weeks after being diagnosed. Those women whose AKUADS scores after eight weeks of counselling were 16 and below were considered to have recovered and those with a score of 17 or above were interviewed by the clinical psychologist for the confirmation of persistence of anxiety/depression. Only five of them (three counselled; two non-counselled) did not recover after eight weeks of identification and were advised to seek pharmacological treatment. Those who had recovered from anxiety and depression were then followed regularly according to the study protocol for recurrence during the study period. Recurrence was considered when, at any follow-up visit the AKUADS score was found to be 17 and above, and confirmation was also obtained from the psychologist. Two suicidal patients were referred for treatment and were not included in the study. All women enrolled in the programme, irrespective of whether they were anxious/depressed or not or whether they were being counselled or not, were instructed in healthy child rearing practices and the growth and development of their indexed child was monitored.
RESULTS: Out of the 420 women enrolled, 102 women were found to be anxious and or depressed with a total of 122 episodes, based on the AKUADS score and supplemented by the clinical psychologist’s interview. AKUADS scores after four and eight weeks were only available for 71 women – 59 from the counselled and 12 from the not counselled group. The association of different characteristics by counselling status was observed. No significant differences were found for variables such as age, level of education, past history of anxiety and depression, husband’s education, religion, mother tongue, migrant status, ownership of house, total number of rooms, total number of persons per household, gravidity, past history of still birth, satisfaction with current life, domestic violence, gender of the newborn, qualification of the birth attendant and place of birth. The characteristics having a significant association were difficulty in breast feeding and study area. The average AKUADS score at the time of diagnosis was significantly higher in those who had refused counselling as compared to those who had agreed to and received counselling. Repeated analyses of variance of AKUADS scores of anxious/depressed women after the fourth and eighth weeks of identification showed significant effects of time, interaction between time and counselling status, and counselling status. Pair-wise comparisons of mean AKUADS scores using Bonferroni method were made for all time points (when identified after fourth and eighth weeks of identification) and were found significant for all time points pairs. Similarly, pair-wise comparisons for counselling status at each time point were made and mean AKUADS scores at the time of identification and after fourth week of identification were found to be significant. During the overall study period from February 1, 2004 to January 31, 2007, post-test data were available for 71 women diagnosed as anxious and depressed at induction in the study (59 counselled; 12 non-counselled). Out of them 54 women had recovered after four weeks (49 counselled; five non-counselled) and 66 women after eight weeks. (56 counselled; 10 non-counselled). During the regular follow-up, recurrence of anxiety and depression was observed in seven women among the counselled group and in four women among the non-counselled group. The earliest recurrence time in the counselled group was nine months and the latest was 26 months as compared to the not counselled in which the earliest recurrence occurred at three months and the latest at 12 months. No significant difference was observed in the mean recurrence time between the counselled and not counselled group.
DISCUSSION AND CONCLUSIONS: The findings of this study suggest that after four and eight weeks the scores of AKUADS, both the counselled and not counselled groups, showed a significant decline from the initial scores, but the counselled group fared better than the not counselled. It has been reported that integration of a cognitive-behaviour-therapy-based intervention by community health workers had substantially reduced the rate of depression in prenatally depressed women compared with those receiving routine care. It has also been reported that cognitive therapy can be as effective as medications in the initial treatment of moderate to severe major depression. Lack of autonomy is one of the known vulnerability factors for anxiety/depression and our results support this finding as the AKUADS scores at the time of identification were higher among the group that could not be counselled because of lack of permission from the family. The significant decline in the not counselled group suggests several possibilities such as the fact that lapse of time since delivery itself tends to reduce anxiety/depression in women, or that it reflects the natural history of anxiety/depression that waxes and wanes. It could also be the result of enhanced social support because of regular visits from counsellors, monitoring of growth and development of the indexed child and learning healthy child-rearing practices by all mothers. The later possibility also makes it difficult to ascertain the decline in scores of the counselled group as resulting from purely counselling to the actual or perceived social support experienced by the group. A meta-analysis published in the Cochrane Database of Systemic Reviews 2007 suggests that psychosocial and psychological interventions are both effective treatment options for postpartum depression; our results also suggest that probably psycho-social support alone and in combination with counselling could benefit postpartum women with anxiety and depression, the separate contribution of each one cannot be determined as the data is from an action research programme and not a randomised controlled trial. More recently, a randomised controlled study has suggested that interpersonal psychotherapy ameliorates depression during pregnancy and prevents depressive relapse and improves social functioning up to six months postpartum. Varying recurrence rates have been reported for various types of psychotherapy, from 26 percent to 67 percent. It has been reported that CBT resulted in a significantly lower relapse rate (40 percent) at a six-year follow-up than pharmacological management (90 percent). In our study, which was conducted over a period of 30 months, we found an overall recurrence rate of 16.4 percent, with a marginally significant difference between the counselled (12.3 percent) and the non-counselled groups (28.6 percent). The recurrence rate in the counselled group is lower than that mentioned in the studies referred above, as probably our study population had mild to moderate depression due to the fact that suicidal patients and those who had not responded to eight sessions of counselling were referred for treatment; for ethical reasons these patients had continued to be counselled but were not included in the analysis. In our study we also observed that minimum time interval before recurrence was longer in the counselled, that is nine months as compared to the not counselled in which it was three months. Cognitive therapy has demonstrated an enduring effect that prevents the return of symptoms after successful treatment. It has been reported that cognitive therapy has an enduring effect and is a less expensive and longer-lasting alternative to medications. A consistently encouraging response has been found to counselling by minimally trained community women in underprivileged communities. One of the limitations of our study was that the ethics committee of the AKU declined to approve a randomised controlled trial, as one of our investigators had earlier established the benefit from counselling by minimally trained counsellors in the same community. Another limitation is that a majority of the non-counselled group refused to take the AKUADS after four and eight weeks of initial identification, leaving us with small numbers for comparison. The third limitation is that those women who were enrolled towards the end of the study could not be followed for a longer period of time. This could also possibly be a reason for a lower recurrence rate (16.4 percent). The fourth limitation is that the interviewers were not blind to the counselling status of the women interviewed at fourth and eighth weeks follow-up as they themselves were the counsellors. In addition, this study was conducted in two underprivileged urban communities; hence, the study participants may not completely represent the city population. RECOMMENDATIONS: Depression after childbirth is of great concern to primary and mental healthcare professionals. In most developing countries primary care practitioners neither have the time nor the skill to counsel patients; and certified psychologists/counsellors are very few. They are mostly restricted to big cities and are inaccessible and unaffordable for most of the population. Moreover, these countries cannot afford the luxury of developing a special cadre of community health workers taking care of mental health problems only. Therefore, it is recommended that minimal skills for identification and counselling of anxiety/depression should be incorporated in the training of community health workers to improve the mental health of women with anxiety and depression in resource-strained countries. Above all, there is widespread stigma and scepticism attached to conventional psychiatric services which act as barriers for use even when available. Hence community-based counselling services, besides being accessible and affordable, would probably be more acceptable.
Extracted from the research article ‘Effectiveness of counselling for anxiety and depression in mothers of children ages 0-30 months by community workers in Karachi, Pakistan: a quasi experimental study’ authored by Niloufer S Ali, Badar S Ali, Iqbal S Azam and Ali K Khuwaja
