Depression
Conditions
Keywords
HIV, AIDS, Tanzania, depression, perinatal, psychotherapy, task-sharing, problem-solving
Brief summary
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.
Detailed 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
Interventions
BEHAVIORALTask-sharing approach to group therapy
Participants will also identify, select and clarify common concerns/problems; provide orientation to steps in problem-solving; break down identified problems into manageable pieces; choose pieces of problem to address in facilitated discussion of problem solving for implementing solutions; support the sharing of feedback of strategies used in problem-solving and maintaining pleasurable activities. Additionally, the intervention to aim to effect behavior by: explaining the links between problems, negative thoughts, choices made on a day-to-day basis, behaviors, and mood (symptoms of depression); facilitate sharing of practical skills to tackle problems, to change mood-related thoughts, choices and/or behaviors; offer and provide feedback on homework assignments to encourage practice of skills; and help participants attribute reported improvements to the use of new skills during feedback sessions.
BEHAVIORALEnhanced standard of care
Sponsors
National Institute of Mental Health (NIMH)
Harvard Medical School (HMS and HSDM)
Study design
Allocation
RANDOMIZED
Intervention model
SINGLE_GROUP
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
FEMALE
Age
18 Years to 49 Years
Healthy volunteers
No
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
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Depressive disorder and suicidality | Q3 2016 after an average of 1.5 years of follow-up | Using a cut-off score based on the validation study, participants will be classified as having depressive and or suicidality or not. The trial aims to reduce rates of depression and suicidality among participants. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Social support | Q3 2016 after an average of 1.5 years of follow-up | For this measure, the Duke University-University of North Carolina Functional Social Support Questionnaire will be used; this scale has demonstrated positive correlations with other social support scales. A listing of ten items from this of this questionnaire has been used previously in Tanzania, reflecting dimensions of instrumental and emotional support |
| Self-Efficacy | Q3 2016 after an average of 1.5 years of follow-up | The General Self-Efficacy Scale will be used to assess self-efficacy. This scale has demonstrated good internal consistency (Cronbach's alpha ranging from 0.81 to 0.91) and construct validity was shown through positive correlations with optimism and negative correlations with depression and anxiety. |
| HIV-related stigma | Q3 2016 after an average of 1.5 years of follow-up | The HIV Stigma Scale developed by Berger et al. will be used to assess stigma; it has been validated in a diverse sample in the U.S. demonstrated construct validity through factor analysis and internal consistency (Cronbach's alpha of 0.96). A sub-sample of these items also demonstrated construct validity of this scale has also been demonstrated in a resource-limited setting. |
| Intimate partner violence | Q3 2016 after an average of 1.5 years of follow-up | For intimate partner violence (IPV) the WHO Women's Health and Domestic Violence against Women Questionnaire will be used, which assesses emotional, sexual, and physical violence by intimate partners and has demonstrated good internal consistency ranging from 0.66 to 0.81. |
| Infant birthwight | At time of birth | The infant's birth weight will be measured at the time of birth. |
| Gestational Age and Prematurity | At time of birth | The gestational age of the infant at the time of birth will be measured. Premature infants are those whose gestational age is less than 37 weeks. |
| Infant diarrheal disease | Two weeks after infant's birth | The occurrence of diarrheal disease among infants will be assessed during the first two weeks of the infant's life. |
| Weight-for-height | Up to 1.5 years after infant birth | Wight and height will be measured as an outcome for the infant, with low weight-for-height being used to classify infants as wasting (more than two standard deviations below the mean). |
| Height-for-age | Up to 1.5 years after infant's birth | Height and age of infants will be measured at the end of follow-up, and low height-for-age will be used to classify infants as stunted (more than two standard deviations below the mean). |
Countries
Tanzania
Outcome results
None listed