The intervention did not produce any significant change in infant growth indices but had other benefits—ie, infants had less episodes of diarrhoea and were more likely to be immunised than those in the control group; mothers were more likely to use contraception (birth spacing is an important factor in reducing infant morbidity), and both parents reported spending more time playing with their infants. In a poor rural community with little access to mental health care, integration of a cognitive behaviour therapy-based intervention into the routine work of community health workers more than halved the rate of depression in prenatally depressed women compared with those receiving enhanced routine care. In addition to symptomatic relief, the women receiving the intervention had less disability and better overall and social functioning, and these effects were sustained after 1 year.
This community-based trial had a high response and follow-up rate. Assessments were done by trained and experienced researchers who were from the same cultural background as the depressed women, and all instruments were culturally adapted. The cluster design ensured that the risk of contamination was negligible. Although cluster-randomised trials are susceptible to bias, the baseline characteristics in the two groups were similar, and efforts were made to ensure that the assessors remained unaware of the allocation. The trial did not capture mothers who were not depressed in pregnancy and developed a depressive episode postnatally. However, our previous study in the same area showed that in more than 90% of the women, postnatal depression was a continuation of a depressive episode during pregnancy3
and therefore targeting women for intervention during pregnancy was the correct strategy.
The rate of stunting in infants in the intervention group was non-significantly less than that in the control group. Height for age is more responsive to repeated or longer term adverse conditions (such as maternal depression) than is weight for age, which responds to acute adversity.27
Growth is likely to be affected by complex interactions between maternal, child, and environmental variables. The benefits of improved maternal mental health on infant nutrition, possibly mediated through improved stimulation, care, and responsive feeding are likely to be cumulative and develop during time. A longer follow-up might have shown significant effects of the intervention. The finding that infants whose mothers did not respond to treatment had poor growth, even after controlling for sociodemographic factors, strengthens the argument for an important role of maternal depression in infant undernutrition. Thus, earlier interventions (before depression becomes chronic), and development of secondary-care and tertiary-care facilities for depressed women who do not respond to primary care, might be necessary.
Of note, our comparisons were not between intervention and treatment as usual but intervention and enhanced routine care. The rate of recovery from depression in the control group at 6 months (47%) was greater than the rate of spontaneous remission without treatment we reported in our previous observational study in the same area (24%).28
We did not assess whether the Lady Health Workers in the control group took action to treat the mothers' depression (other than monitoring their visits). Even regular, monitored visits by experienced health workers could have had therapeutic benefits, which could have diluted the effects of our intervention on our primary outcome. Such treatment effects with control groups have been reported in other trials in developing countries.29
Even in high-income countries, more than 50% of people in the community with major depression are not treated because access to mental health care is absent.30
In low-income countries, this value is 70–100%.31
This intervention has the potential of providing mental health care at the doorstep to a very high proportion of women with this highly prevalent and disabling mental disorder in Pakistan and other low-income countries. This programme is not vertical (ie, focusing solely on depression); it is dependent on a separate mental-health workforce. On the contrary, the integrated cognitive behaviour therapy-approach eases the routine work of health workers with women who are otherwise socially excluded and difficult to access, and has added benefits, such as improvement of infant health outcomes. Indeed, the intervention led to an increased rate of immunisation and uptake of contraception, the two key tasks for Lady Health Workers. These effects, combined with the high prevalence of maternal depression, should make this intervention of interest to policy makers.
The intervention was designed to be integrated into the routine work of the Lady Health Workers, and feedback from the 40 trained women showed that almost all of them thought it was relevant to their day-to-day work and none of them considered it an extra burden.13
The training was short (2 days followed by a 1 day refresher after 4 months) and therefore feasible on a large scale. However, an important component of the training process was the monthly half-day group supervision, which, for this study, was provided by experienced members of the research team.13
Regular and reliable training and supervision are essential for the success of community health worker-based programmes.32
Working with depressed individuals and their families in very poor settings can be stressful for the health workers; therefore, strong supervisory mechanisms need to be in place when scaling up a programme of this nature. This supervision could be in the form of peer groups in which health workers from each locality meet on a regular basis to discuss the families they are caring for. In our experience, such meetings in which health workers brainstorm for solutions and discuss their successes and failures in a supportive environment can be a sustainable model for supervision in places without resources to employ trained supervisors.13
Guidelines for such peer supervision would need to be incorporated into training.
Worldwide, the importance of mental health in achieving developmental goals, such as those endorsed by the UN's Millennium Development project has received increased recognition.33
However, this recognition is not matched by the development of an evidence-base for cost-effective interventions that can be scaled up in resource-poor settings. We believe this study suggests directions such interventions could take to make mental health an important component of public-health programmes.