Depression, Postpartum Clinical Trial
Official title:
Decreasing Stunting by Reducing Maternal Depression in Uganda - A Cluster Randomized Controlled Trial (CRCT) for Improved Nutrition Outcomes
The project seeks to test the integration of Interpersonal Psychotherapy for Groups within Care Group projects and investigate whether the treatment of maternal depression with Interpersonal Psychotherapy for Groups improves the adoption of nutrition-related behaviors that can reduce stunting in the Kitgum District in northern Uganda. A secondary aim is to examine whether the participation in the care groups will also result in remission of depression as a non-specific therapeutic effect although it may not be intended as an antidepressant treatment.
Over the past two decades there has been a growing global momentum and commitment to address
malnutrition. The most recent indication of this is reflected in goal #2 of the Sustainable
Development Goals, "end hunger, achieve food security and improved nutrition and promote
sustainable agriculture." However, great challenges remain. Today, over 165 million children
under five are chronically malnourished or stunted, and once a child is stunted, it is nearly
impossible to regain their cognitive and physical potential. In addition, it is estimated
that malnutrition contributes to more than one-third of all child deaths under the age of
five.
Through research and fieldwork, key evidence-based interventions and target populations have
been identified. It has been found that the most critical time to prevent chronic
malnutrition is from conception up through the child's second birthday, known as the "first
1,000 days." Improving household behaviors related to maternal and child health and nutrition
such as improved water, sanitation, and hygiene practices, proper infant and young child
feeding practices, optimal maternal nutrition and antenatal care, and others can reduce child
malnutrition and prevent up to 57% of deaths of children under five years of age.
However, despite the gains in reducing stunting in children, there has been no program
implemented at scale that has come close to normalizing child growth. There is a need for new
tools and interventions that focus on other causes of malnutrition aside from poor water,
sanitation, and hygiene, infant and young child feeding, home management/care seeking for
sick children, maternal nutrition/antenatal care, and use of preventive services (e.g.,
immunizations). One promising new intervention is the treatment of maternal depression, an
underlying cause of malnutrition. The potential global impact of adding community-based
treatment of maternal depression to the investigator's toolbox of interventions to reduce
child stunting could be significant: A recent meta-analysis found that stunting could be
reduced globally by about 27% by eliminating maternal depression (Surkan, J, Kennedy C,
Hurley, B, and Black, M., 2011). As such, the investigators believe that treatment of
maternal depression could result in improved nutrition behavior change in mothers, leading to
significant reductions in child stunting and helping to end hunger.
An effective, low-cost, short-duration community-based method for decreasing depression has
been established that was first rigorously tested in Uganda: Interpersonal Psychotherapy for
Groups. Several Private Voluntary Organizations in Africa have used this low-cost,
short-duration, community-based group psychosocial approach and found it to be a
culturally-sensitive, acceptable, and feasible approach to address depression. A cluster
randomized controlled trial of this approach in depressed adults in southern Ugandan rural
communities yielded a 93% decline in diagnosable depression (vs. a 45% decline in controls),
as well as significantly higher functionality in household tasks, including those associated
with child nutrition and health (Bass et al, 2006). However, this study did not measure
changes in maternal adoption of behaviors that affect child nutritional status and the
possible effect of treatment of maternal depression on improved child growth. Demonstrating
that Interpersonal Psychotherapy for Groups works for increasing maternal adoption of
behaviors that affect child nutritional status could have a profound effect on how
malnutrition is prevented worldwide, and save children and their mothers from a lot of
unnecessary suffering.
Therefore, Food for the Hungry in partnership with the team at the Global Mental Health Lab
at Teachers College, Columbia University is proposing a 33 month project which will test how
to integrate Interpersonal Psychotherapy for Groups within Care Group projects and whether
the treatment of maternal depression with Interpersonal Psychotherapy for Groups improves the
adoption of maternal behaviors that can reduce stunting in Kitgum District in northern
Uganda. Using a cluster randomized controlled trial design, Food for the Hungry will test
whether adding Interpersonal Psychotherapy for Groups for half of the women identified with
depression improves the adoption of household health and nutrition behaviors known to improve
child linear growth.
Pregnant women and mothers with a child born after 3 April 2016 (who will be under 18 months
of age by the time health promotion begins on 4 October 2017) will be assessed for
depression, and half of those who meet a cutoff for depression will be randomly assigned to
IPT-G. Following the three-month implementation of Interpersonal Psychotherapy for Groups,
all pregnant women and women with children under two years of age in the project area will
participate in Care Groups, an evidence-based community nutrition promotion model to improve
maternal and child health and nutrition behaviors. A recent set of papers summarized the
history of Care Groups and the outcomes achieved with the model on children under two years
of age in many countries around the world (Perry et al, 2015), and how projects using Care
Groups are achieving on average more than double the behavior change of other models on
maternal behaviors that affect the growth of children 0-23m (George et al, 2015). Through
Care Groups, women will learn about proper water, sanitation, and hygiene behaviors; Infant
and Young Child Feeding practices; management of childhood illnesses; home management,
referral and care seeking for sick children; family planning; and use of preventive services
available at health facilities (e.g., growth monitoring, deworming, vitamin A
supplementation). All children under five years of age will also be screened for acute
malnutrition by the Care Group Volunteers, and receive deworming medication and vitamin A
supplementation twice a year through the Ministry of Health and Community Health Workers as
part of national campaigns. Care group experts report improvement of depression as a result
of these focus groups, due to the connection, social support and problem-solving among the
group members. At the conclusion of this project, a Lessons Learned conference will be held
in Uganda and an online dissemination event will be held in order to facilitate the sharing
of project results. Results will also be disseminated through peer-reviewed papers and
communities of practice.
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