Effectiveness of Thinking Healthy Program for Prevention of Antenatal Depression to Improve Maternal Health, Pakistan
Phase: NA
Conditions: Post Partum Depression
Sponsor: University of the Punjab

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Effectiveness 
of 
Thinking 
Healthy 
Program 
for 
prevention of antenatal depression to improve maternal 
health, Pakistan 
Background of Study: 
 
Postpartum depression is a major health issue for many women from diverse 
cultures, yet it remains underdiagnosed and undertreated, especially in low 
income countries. The prevalence rate of developing countries ranges from being 
equal to double from that of the developed world (Cooper et al., 2009). Pakistan 
has the highest prevalence amongst Asian countries that is 28%- 63%. More than 
half of the cases in Pakistan go unrecognized (Tikmani, Soomro, Tikmani, 
Zulfiqar, & Bhutto, 2016). Antenatal depression may complicate up to 10–37 % 
of pregnancies, while as many as 27–54 % of pregnancies are complicated by 
antenatal anxiety. Depression in pregnancy and postpartum is associated with 
significant morbidity (Williams et al., 2016). 
Statement of the problem: 
 
In 2015, approximately 5,500,000 babies were born in Pakistan, or around 
14,900 every day. Among young women (aged 20-24), 8 percent gave birth by 
age 18 years. Approximately 671 babies will die each day before reaching their 
first month, about 665 stillbirths occur every day. In Pakistan, the main causes of 
neonatal deaths in 2015 were prematurity (39.3 percent) (Unicef, 2015). Mood 
disorders in pregnancy and post-partum period are common and considered as a 
public health issue. Out of the meager health budget of Pakistan, only 0.4% is 
allocated to mental health (World Health Organization, 2009). 
Preterm birth, a primary obstacle to the World Health Organization’s Sustainable 
Development Goal 4, which is to reduce childhood mortality. The aim of the 

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present study is to test the intervention in targeted group of pregnant women. We 
will hypothesize that primary care attendees can provide intervention that would 
show greater reductions in symptoms of depression, post-traumatic stress, and 
functional impairment and reduced symptoms of depressive disorder after 
treatment and at 3-month follow-up compared with base scores. 
 
 
Aim & Objectives of the Study: 
 
 

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Objectives 
Methodology 
Objectives 
Methodology 
Study design: 
 
 
 
 
 
 
 
 
 
 
Screening 
pregnant 
women 
for 
depression 
during 24th -26th weeks of 
pregnancy. 
To explore the social & 
demographic 
factors 
responsible for antenatal 
and postnatal depression. 
Study Design: Screening 
of patients 
Place: 
Sheikh 
Zyed 
Hospital, Lahore 
Sample size:20 
Before and after assessment to 
find the effectiveness of THP 
(Thinking 
healthy 
program) 
intervention in improving the 
mental 
health 
to 
reduce 
antenatal and postpartum (PPD) 
depression. 
Study Design: Quasi 
experimental study 
Sampling: 
Techniques: Purposive 
sampling technique 
Sample Size: 20 
 
 
 
 
 
 
 
 
 
 
 
Phase – 
I 
Phase – II 

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Study Period: 
 
The present study will take about six months in data collection. 
 
Inclusion criteria: 
 
The eligibility criterion will be women who will deliver a baby with age 18-45 years, and will in 
the 24th -26th months of pregnancy. Interested participants will be given detailed information 
about the study. Informed consent will be obtained to participate in the study. 
Exclusion criteria: 
 
Women will be diagnosed serious medical condition requiring inpatient or outpatient treatment, 
pregnancy-related illness (except for common conditions, such as anaemia), substantial physical 
or learning disability or other form of psychosis will be excluded from study. Women younger 
than 18 and greater than 45 years will also be excluded. 
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Schema: 
 
SCREENING FOR ELIGIBILITY OR EXCLUSION AND BASELINE ASSESSEMENTS 
 
All women who attend 
Gynae/Obs OPD - Antenatal desk 
 
PHQ-9 
score of ≥ 
10 
depression 
Refer for Antenatal 
check up 
 
ELIGIBILE 
Excluded 
Psychiatric illness: 
Refer to IoP 
Exclude: 
PHQ-9 score 
<10, PHQ-9 
> 20 
Step 1: Screening 
for eligibility (Time 
point 1) Age ≥ 18 
Pregnancy ≥ 24 
weeks ≤20 Km 
can understand 
Urdu 
Step 2: Consent 
and Eligibility 
according to 
inclusion criteria 
Step 3: Screening for eligibility Personal 
Health Questionnaire (PHQ-9) 

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Intervention at weeks24th -26th weeks 
20% non-response rate/rejection 
(n=20) 
N=1
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6 weeks’ postpartum-end-point assessment 
(E2 = after delivery assessment) Patient Health Questionnaire 9 items 
Analysi 
 
Follow 
up 
5.4.1 CONSORT flow diagram: 
 
 
 
 
 
 

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Primary outcome of this study is to evaluate the impact of a novel psychosomatic antenatal 
programme THP, meant to decrease symptoms of depression in the fourth week after childbirth. 
Secondary outcome is to assess the perceived level of social support, problems for which the 
person seeks help and women empowerment after intervention. 
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Table: 
Description of intervention sessions 
 
 
Sessions 
Active ingredient 
Timing of session 
delivery 
Recipients 
Session 1: Psycho- 
education and Stress 
Management 
Psycho-education 
(Knowledge 
about 
anxiety disorders and 
stress 
 management 
skills) 
Fortnightly 
All 
participants 
recruited 
into 
the 
intervention and their 
family members 
Session 2: Personal 
Wellbeing 
Thought 
challenging 
and behavior activation 
(Strategies 
for 
improving 
overall 
wellbeing, 
including 
diet, 
rest, 
relaxation, 
sleep, 
and 
managing 
common 
complaints 
during pregnancy) 
Fortnightly 
All participants 
Session 3: Social Thought 
challenging 
and behavior activation 
Fortnightly 
All 
participants 
recruited 
 into 
the 

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Support 
(Strategies 
for 
improving interpersonal 
relationship and social 
support). 
intervention and their 
family members 
Session 4: Bonding 
with 
the 
infant 
during pregnancy 
Thought 
challenging 
and behavior activation 
(Strategies 
 for 
improving bonding with 
the 
infant 
during 
pregnancy). Addressing 
fear 
of 
child-birth 
(knowledge 
and 
planning 
of 
safe 
delivery). 
Fortnightly 
All 
participants 
recruited 
into 
the 
intervention 
Booster 
sessions 
(depending on time 
of enrollment) 
Behavior activation and 
problem 
management 
skills 
Booster 
sessions 
will be coordinated 
with the recipients’ 
routine 
antenatal 
visits 
All 
participants 
recruited 
into 
the 
intervention 
Session 
6: 
Preparing for  the 
baby 
and 
early 
Addressing 
fear 
of 
child-birth 
(strategies 
for planning for baby’s 
Late pregnancy 
All participants 
recruited into the 
intervention arm and 
their family members. 
postnatal period 
arrival). 
Psycho- 
education (coping with 
early post pregnancy 
challenges) 

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Statistical analysis: 
 
Quantitative data were analyzed with SPSS 21. Statistics will be compiled for the interventional 
group on EPDS, social support, stress, couple relationship and postpartum variables (women’s 
somatic symptoms, childbirth outcomes). Group differences in baseline characteristics will be 
examined using chi-square tests, the Mann–Whitney test or the Kolmogorov-Smirnov test. 
Categorical data of principal variables will be presented as percentages and comparisons made 
by chi-square tests. Univariate analysis used average and standard deviation by 95% confidence 
interval. Analysis of secondary variables paired sample student t test will be applied.