Healthy Options: Group Psychotherapy for HIV-positive Depressed Perinatal Women.

Harvard Medical School (HMS and HSDM)

Status: Completed

Conditions: Depression

Treatments: Behavioral: Task-sharing approach to group therapy; Behavioral: Enhanced standard of care

Study type: Interventional

Funder types: Other; NIH

Identifiers

NCT02039973

1R01MH100338-01 (U.S. NIH Grant/Contract)

Details and patient eligibility

About

Although there is a significant burden of depression among HIV-positive women in Tanzania, there is a critical gap between the needs of this population and the integration of mental health and PMTCT-plus services. The long-term intent of the research is to bridge this gap with the overall goal to examine the potential for successful integration of enhanced mental health care and brief group interventions among HIV-positive women receiving PMTCT-plus services and to evaluate a combination of evidence-based approaches for treatment of depression in this vulnerable population in Tanzania.

Full description

In resource-limited settings, there has been a significant increase in access to antiretroviral therapy (ART) in recent years. Although there remain serious limitations in access to ART in these settings, for many who have initiated and continue treatment, HIV disease is a chronic condition that needs to be managed over time. There is considerable evidence that individuals with chronic illness have an increased risk of depression, in part related to the challenges in coping and managing their illness. Rates for depression during pregnancy in women living with HIV are estimated to be higher.

Despite this relatively high burden of depression among persons living with HIV/AIDS (PLHA), it has been documented that clinical staff working with PLHA do not routinely identify or treat depression in this setting. This is in contrast to recent revisions in the Tanzanian health policy that emphasize integrating mental health and HIV care at district and lower level health care services. The long-term intent of the research is to bridge this gap between Tanzanian health policy and implementation of integrating mental health care among pre- and post-natal women receiving HIV care. Therefore, the overall goal of the proposed study is to examine the potential for successful integration of enhanced mental health care and group counseling among HIV-positive women receiving preventing mother to child transmission (PMTCT)-plus services and to evaluate a combination of evidence-based approaches in treatment of depression in this vulnerable population in Tanzania.

Specifically this application aims to:

1. Examine the acceptability and feasibility of integrating an enhanced standard of mental health care and group counseling with PMTCT-plus services provided at government-run maternal and child health (MCH) clinics, from the perspectives of: a) facility mental health care focal points and MCH clinic managers, b) perinatal direct care providers; and c) HIV-positive perinatal women;
2. Validate a depression screening tool for major depressive disorder (MDD) and suicidality for use in Tanzania; and
3. Conduct a cluster randomized controlled trial comparing a task-sharing approach (i.e. problem solving and cognitive behavioral therapy components delivered to groups facilitated by lay community based health care workers (CBHWs) versus improved standard

Enrollment: 742 patients

Sex: Female

Ages: 18 to 49 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• pregnant women who access PMTCT-plus services at MCH clinics in Dar es Salaam
• HIV-positive serostatus
• screen positive for depression
• less than 28 weeks of gestation
• confirm they will attend postnatal services at the maternal and child health service they enrolled in for antenatal care for at least two years after they give birth

Exclusion criteria

• any woman less than 18 years of age
• HIV-negative
• screened negative for depression
• screened positive for depression and assessed to be of high suicide risk requiring immediate emergency referral for care
• not able to continue to receive care at the MCH clinic where they were initially enrolled for at least two years after giving birth

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Single Group Assignment

Masking: None (Open label)

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742 participants in 2 patient groups

Task-sharing approach to group therapy

Experimental group

Description:

The intervention will consist of problem-solving therapy as well as cognitive behavioral components. Core problem-solving therapy components will involve lay CBHW facilitated discussions to explore symptoms of depression and how problems are related to depression. Core cognitive behavioral components will include lay CBHW facilitated discussions to explain the purpose of the sessions, as well as effect a number of behavioral changes in participants.

Treatment:

Behavioral: Task-sharing approach to group therapy

Enhanced standard of care

Active Comparator group

Description:

The control condition will promote an enhanced standard of care. Clinicians and nurses at MCH clinics included in the study will receive a structured one day re-orientation training consistent with the World Health Organization (WHO) mh-GAP guidelines for assessment as well as basic psychosocial and drug treatment of moderate to severe depression in primary care settings. The training will be consistent with the standard of care for mental health among HIV-positive populations as outlined in Tanzanian health policy. In addition, clinical staff will be trained to encourage women to invite their male partners to accompany them at clinic visits, where psycho-education on perinatal depression for couples will be offered for those opting to participate.

Treatment:

Behavioral: Enhanced standard of care