Title: Evaluating the Impact of Group Interpersonal psychotherapy (IPT) In Lebanon and Kenya on child developmental outcomes, maternal Depression and the mother-child relationship
Funder: Department of Health and Social Care

Abstract: Research Question: Does culturally-adapted group IPT delivered in community settings in Kenya and Lebanon have a greater impact on child developmental outcomes, maternal depression and the mother-child relationship than high quality standard care? Background: Postnatal depression (PND) is a serious, disabling mental health condition affecting between 18-25% of women postnatally in low and middle income countries (LMICs). This is nearly twice the rate in high income countries, yet their needs are under-served. Extensive evidence shows that maternal depression is consistently associated with adverse impacts on caregiving and on children s cognitive and socio-emotional development. Our proposed research programme in Kenya and Lebanon will address the currently limited evidence concerning effective interventions to treat PND in LMICs and test whether a WHO-recommended psychological therapy modified to match local priorities, delivered sustainably with fidelity within existing healthcare systems, can lead to improvements in key measures of early child development alongside improvements in maternal mental health. Aims and objectives: 1) develop a systematic understanding of how local communities perceive postnatal depression, 2) use this learning to work with experienced local practitioners to adjust group IPT to optimise cultural appropriateness, 3) use local clinical and community intelligence and policy support to identify optimal systems for screening women for PND, 4) train local workers to deliver adapted g-IPT, 5) undertake a feasibility RCT to assess the feasibility of critical elements of a trial to evaluate g-IPT, 6) if feasibility is demonstrated, test the effectiveness of g-IPT+ to promote child development and treat maternal depressive symptoms and estimate cost effectiveness, 7) work with communities, practitioners and policy makers to embed sustainable care pathways for postnatal depression and g-IPT+ treatment, and develop a toolkit to support training and implementation in other countries around the globe. Methods: We propose a three-phase study: 1) phase 1 consists of study set up, context mapping and intensive local qualitative research to understand cultural factors related to postnatal depression and its treatment, 2) phase 2 is a feasibility clinical trial alongside qualitative research on protocol suitability, 3) phase 3 is a two-site individually randomised superiority trial of culturally adapted g-IPT+ versus High-Quality Standard Care for women with postnatal depression in Beirut, Lebanon and Nairobi, Kenya (N=412). The population will be women with postnatal depression (PHQ-9) and an infant aged 6-35 weeks. Exclusion criteria include psychotic disorders, severe health conditions and imminent suicide risk. Primary outcome: child cognitive development at 12-month follow-up. Secondary outcomes include: maternal responsive caregiving and depressive symptoms. Timeline: study set up, community engagement, pathway mapping: months 1-4 continuing alongside feasibility trial: months 5-17; full-scale RCT: months 19-42; analysis, final report, dissemination: months 43-48. Anticipated impact & dissemination: The involvement of policy leaders at both sites are anticipated to support impact and sustainability alongside an intensive focus on training of practitioners and researchers as well as a consistent focus on community engagement. The study will complement the existing evidence base for IPT in LMICs and provide an additional application with supporting research and implementation toolkit for both HI and LMICs.

Lay abstract: Depression is the most common mental health issue affecting women of childbearing age. 20%-25% of women in low and middle income countries (LMICs) experience depression during pregnancy or shortly after childbirth. This can be very distressing and affects not only the mother, but also her child. Women with depression often struggle to respond to their children s needs. Research shows that as a result of this children of women with postnatal depression (PND) have poorer learning, or cognitive development, and more emotional and behavior problems as they grow up. This is especially true in LMICs, where families may also be struggling with many other challenges that can affect children s development negatively. Many women in LMICs have very little contact with healthcare services, so antenatal services can be a key opportunity to reach women in need of mental health support. However, currently treatment for PND is rarely available in many LMICs. The World Health Organisation recommends a therapy called interpersonal psychotherapy (IPT) to treat depression. There is research from high income countries showing that IPT is an effective treatment for PND but we do not know whether it works in a LMIC context, or whether it also benefits child development. A team from UCL and Columbia University will work with researchers, policymakers, service users and local community members in Kenya and Lebanon to adapt, deliver and evaluate IPT for PND. In the first phase of the project, local researchers in Kenya and Lebanon will work with the core team to explore how maternal depression is thought about by members of the community, and, with their input and input from service users, adapt a group-based version of IPT to the local culture and setting. We will run a small-scale version of a clinical trial to make sure we know precisely how to run the study and develop solutions to any problems we encounter. We will check we can recruit women efficiently, that women find the treatment acceptable, that enough women stay in the therapy and that the study measures work well. We will then run a full-scale study to test whether this adapted version of IPT improves children s development and tackles the symptoms of depression in their mothers. We hope that this study will not only show that IPT can work, but will also provide us with crucial learning to help Kenya, Lebanon and other countries around the world establish effective and affordable health services for women with depression and their babies. The team includes maternal mental health specialists, the developers of IPT, clinical trial experts, health economists and social anthropologists with a strong track record of establishing research partnerships with local community members, who already have strong links in Kenya and Lebanon.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH;MENTAL HEALTH