Group problem solving therapy for perinatal depression in primary health care settings in rural Uganda: an intervention cohort study

Background Perinatal depression is of substantial public health importance in low and middle income countries. The study aimed to evaluate the impact of a mental health intervention delivered by non-specialist health workers on symptom severity and disability in women with perinatal depression in Uganda. Methods Pregnant women in the second and third trimester were consecutively screened using the Luganda version of the 9-item Patient Health Questionnaire (PHQ-9). Women who scored ≥5 on the PHQ-9 and who were confirmed to have depression by a midwife were recruited into a treatment cohort and offered a psychological intervention in a stepped care fashion. Women were assessed with PHQ-9 and WHODAS-2.0 at baseline and again at 3 and 6 months after the intervention. Negative regression analysis was done to examine change in PHQ-9 and WHODAS-2.0 scores from baseline to end line. Data were analysed using STATA version 14. Results A total of 2652 pregnant women (98.3%) consented to participate in the study and 153 (5.8%) were diagnosed as depressed. Over a quarter (28.8%) reported having experienced physical interpersonal violence (IPV) while (25.5%) reported sexual IPV in the past year. A third (34.7%) of women diagnosed with depression received 4 or more group PST sessions. There was a mean reduction in PHQ-9 score of 5.13 (95%CI − 6.79 to − 3.47, p < 0.001) and 7.13 (95%CI − 8.68 to − 5.59, p < 0.001) at midline and endline, respectively. WHODAS scores reduced significantly by − 11.78 points (CI 17.64 to − 5.92, p < 0.001) at midline and − 22.92 points (CI 17.64 to − 5.92, p < 0.001) at endline. Clinical response was noted among 69.1% (95%CI 60.4–76.6%) and 93.7% (95%CI 87.8–96.8%) of respondents at midline and endline, respectively. Conclusion An evidence based psychological intervention implemented in primary antenatal care by trained and supervised midwives in a real-world setting may lead to improved outcomes for women with perinatal depression. Future randomised studies are needed to confirm the efficacy of this intervention and possibility for scale up. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04043-6.

You are part of this study because you are the caregiver for a person who is enrolled in the PRIME study. How shall I refer to this person during this interview? (e.g. Your brother, your auntie, Sujit-ji, etc).

Skip when relation (4.18) Not Equal 'Other [77]' OR Skip when participant (3.3) Not Equal 'Caregiver [1]'
Please specify the relationship to __{376541}__ You are part of this study due to problems with Label( cohort (3.2) , Q( cohort (3.2) ,0) ) . How long ago did you MOST RECENTLY start to have these problems? [Enter YEARS ago. If less than 1 year, enter 0] Expects a numeric response (required)

Skip when starty (5.1) Greater Than '0'
How long ago did you MOST RECENTLY start to have these problems? [Enter MONTHS ago. If less than 1 month, enter 0] Expects a numeric response (required)

Skip when startm (5.2) Greater Than '0' OR Skip when starty (5.1) Greater Than '0'
How long ago did you MOST RECENTLY start to have these problems? [Enter number of DAYS ago] Expects a numeric response (required)

Response must be Less Than'31'
Did you seek any help for these problems? By help I mean the kind of support you can get from someone like a traditional healer, community health worker or medical professional. How long ago did you first seek help for this most recent episode? [Enter number of DAYS] Expects a numeric response (required)

Expects a single option response (required)
Did not help at all [0]

Helped a lot [2]
Don't know [888] Have you sought help from any of the following people since the problems with Label( cohort (3.2) , Q( cohort (3.2) ,0) ) most recently started? Also sought help from other (specify): Expects a single line text response (required)

Skip when txseen (5.11) Excludes 'Traditional healer [1]'
How much did the TRADITIONAL HEALER help you? In the past 3 months, did you (or your relative) feel afraid of people for no reason, such as thinking that food is poisoned or someone wants to harm you? Expects a single option response (required) Often [3]

Continupusly [4]
In the past 3 months, did you (or your relative) speak about things and ideas that that other people didnt understand?
Expects a single option response (required)

Continuously [4]
In the past 3 months, did you (or your relative) hear voices that other people did not hear or voices telling you to do things even when other people werent around or did you see things that other people said they could not see? In the past 3 months, have you (your relative) been acting as if you have special powers/abilities, or are a great person in society? 6.6 PANSS6 6.7 PANSS7 6.8 PANNS8 6.9 PANSS9 6.10 PANSS10

PANSS11
In the past 3 months, have you (your relative) felt that people want to follow and hurt you, but other people do not believe you? In the past 3 months, have you (your relative) felt angry often, had thoughts of wanting to hurt people, or threatened other people with violence?
Expects a single option response (required) Often [3]

Continuously [4]
In the past 3 months, have you (your relative) heard from other people that you look distant, unengaged?
Expects a single option response (required) Often [3]

Continuously [4]
In the past 3 months, have you (your relative) felt like you didnt feel the same way as people around you (e.g. you werent happy at times when they were happy, or you werent sad at times when they were sad? Expects a single option response (required) Often [3]

Continuously [4]
In the past 3 months, have you (your relative) found it difficult to make friends and maintain old friendship OR do you find it difficult to make small talk with people?
Expects a single option response (required) Often [3]

Continuously [4]
In the past 3 months, have you (your relative) had a lack of interest in doing things with other people? 6.12 PANSS12 6.13 PANSS13 6.14 PANSS14 In the past 3 months, have you (your relative) had difficulty understanding familiar sayings, or learning new ideas? In the past 3 months, have you (your relative) been speaking rarely or responded with only yes,no,I dont know to questions? Expects a single option response (required) Often [3]

Continuously [4]
In the past 3 months, have you (your family member) been thinking and talking about the same over and over?

Skip when country (3.1) Equals 'South Africa -Dr KK [4]'
In this section we will ask questions about drinking alcohol. By alcohol I mean drinks like....

Skip when country (3.1) Not Equal 'South Africa -Dr KK [4]'
In this section we will ask questions about drinking alcohol. By alcohol I mean drinks like... [show alcohol chart here-FLASH CARD 1]

Skip when cohort (3.2) Equals 'alcohol [3]'
Have you ever had a drink containing alcohol? Now I am going to ask you some questions about your use of alcoholic beverages during the past THREE months. That is, your use of alcohol beverages since __{377429}__.

Skip when cohort (3.2) Equals 'alcohol [3]'
Have you had a drink containing alcohol in the past three months?

Skip when Total of AUD2 and AUD3 (1.2) Equals '0'
How often during the last 3 months have you found that you were not able to stop drinking once you had started? Here are a number of events that people sometimes experience. Tell me about the frequency of these events in the past THREE months. That is, since __{377429}__.
I have been unhappy because of my drinking.
Expects a single option response (required) One or a few times [1] Once or twice a week [2] Daily or almost daily [3] Because of my drinking, I have not eaten properly.
Expects a single option response (required) One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] I have failed to do what is expected of me because of my drinking.

Expects a single option response (required)
One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] I have felt guilty or ashamed because of my drinking.
Expects a single option response (required) One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] I have taken foolish risks when I have been drinking.

Expects a single option response (required)
One or a few times [1]

Once or twice a week [2]
Daily or almost daily Now answer these questions about things that may have happened to you. During the past 3 months, how much has this happened?
My physical health has been harmed by my drinking.

Expects a single option response (required)
One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] I have had money problems because of my drinking.
Expects a single option response (required) One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] My physical appearance has been harmed by my drinking.
Expects a single option response (required) One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] My family has been hurt by my drinking.
Expects a single option response (required) One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] A friendship or close relationship has been damaged by my drinking.
Expects a single option response (required) One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] My drinking has gotten in the way of my growth as a person.
Expects a single option response (required) One or a few times [1] Once or twice a week [2] My drinking has damaged my social life, popularity, or reputation.
Expects a single option response (required) One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] I have spent too much or lost a lot of money because of my drinking.
Expects a single option response (required) One or a few times [1] Once or twice a week [2] Daily or almost daily [3] Has this happened to you DURING THE PAST 3 MONTHS?
I have had an accident while drinking or intoxicated.
Expects a single option response (required) One or a few times [1]

Once or twice a week [2]
Daily or almost daily [3] Section 9. PHQ9 Now I am asking you some of the problems that may have experienced in the past TWO weeks (that is, since __{393665}__). Please tell me how often have you been bothered by the following problems.

Skip when country (3.1) Not Equal 'South Africa -Dr KK [4]'
Now I am asking you some of the problems that may have experienced in the past TWO weeks (that is, since __{393665}__). [show FLASH CARD 3] Please tell me how often have you been bothered by the following problems.
Little interest or pleasure in doing things.

More than half the days [2]
Nearly every day [3] Feeling down, depressed, or hopeless.

More than half the days [2]
Nearly every day [3] Trouble falling/staying asleep, sleeping too much.

More than half the days [2]
Nearly every day [3] Feeling tired or having little energy.

More than half the days [2]
Nearly every day [3] Poor appetite or overeating.

More than half the days [2]
Nearly every day [3] 9.8 PHQ6 9.9 PHQ7 9.10 PHQ8 9.11 PHQ9 9.12 PHQ10 9.13 Set PHQ total 9.14 phq9end Feeling bad about yourself or that you are a failure or have let yourself or your family down.

More than half the days [2]
Nearly every day [3] Trouble concentrating on things, such as reading the newspaper or watching television.

More than half the days [2]
Nearly every day [3] Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual.

More than half the days [2]
Nearly every day [3] Thoughts that you would be better off dead or of hurting yourself in some way.

More than half the days [2]
Nearly every day [3] How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Expects a single option response (required) Operator This field is not displayed on the handset, Operator: Set( TotalPHQ (1.18) , Sum of ( q37418) , q374189 , q374190 , q374191 , q374192 , q374193 , q374194 , q374195 , q374196 ) )

Section Prerequisites Skip when participant (3.3) Equals'Caregiver [1]'
The next questions are about feelings and events that may have occurred in the past THREE months. That is, since __{377429}__.
Have you thought of taking your life in the past 3 months?
Expects a single option response (required)

If response Equals 'No [0]' then skip to endofsuicidality (10.11)
Did you make a plan for taking your own life at any time in the past 3 months?
Expects a single option response (required)

If response Equals 'No [0]' then skip to endofsuicidality (10.11)
Have you attempted to take your own life in the past 3 months?
Expects a single option response (required)

Did it require medical attention?
Expects a single option response (required) In the past 3 months, have you spoken to anyone about thinking about or attempting to take your own life?
Expects a single option response (required)

Response must be Not Equal'1'
Prerequisites Skip when epilasty (11.1) Greater Than '1' How long ago did you last experience a seizure? [Enter 0-23 MONTHS ago. If <1 month, enter 0] Expects a numeric response (required)

Skip when epilastm (11.2) Greater Than '0'
How long ago did you last experience a seizure? [Enter number of DAYS ago] Expects a numeric response (required)

Response must be between'0' and '31'
How many seizures did you have in the past 30 days? That is, since __{377317}__.  During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions (infections) after birth?
Expects a single option response (required)

Skip when tetinj (12.7) Not Equal 'Yes [1]'
During this pregnancy, how many times did you get this tetanus injection?
Expects a numeric response (required) The next part of this interview is about difficulties people have because of health conditions. [Fieldworker: Hand flashcard to respondent] By health condition I mean diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems and problems with alcohol or drugs.  How much of a problem did you have in joining community activities (for example, festivities, religious or other activities) in the same way as anyone else can? Overall, in the past 30 days, how many days were these difficulties present?
Expects a numeric response (required)

Response must be Less Than or Equal'30'
In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
Expects a numeric response (required)

Response must be Less Than or Equal'30'
In the past 30 days, not counting the days you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?  -proxy (1.4) Equals'3'

Skip when country (3.1) Not Equal 'Uganda -Kamuli [5]'
[These question must be answered by the caregiver on behalf of the patient -the following questions refer to the patient's health care.] I would now like to know about your recent experiences with obtaining health care. Following questions will be about your inpatient care which you have taken in the last year In the last year, have you ever stayed overnight in a hospital? That is, since __{377431}__.
Expects a single option response (required)

If response Equals 'No [0]' then skip to outpatient instruction (16.2)
How many times have you been admitted into a hospital in the last year?
Expects a numeric response (required) How many of those visits occurred in the past 3 months? That is, since __{377429}__.

Skip when country (3.1) Not Equal 'Uganda -Kamuli [5]'
[These question must be answered by the caregiver on behalf of the patient -the following questions refer to the patient's health care.] Excluding those times you may have been admitted for inpatient care, I want to know how many times you met any of the following health care providers in the past THREE months. That is, since __{377429}__. Any other mental health professionals (e.g. non-counselor, non-psychiatrist, non-psychiatric nurse) Expects a numeric response (required)

Skip when omhno (16.14) Equals '0'
Please specify the other mental health provider: In the last 3 months you have visited health providers __{374182}__ time(s). I will now ask you questions about each of these visits. We will start with your MOST RECENT visit.

Alcohol problems [7]
Other mental health problems [8] Other chronic disease (e.g. heart, diabetes) [9] Other To whom did you get a referral? Brief narrative about the content of the treatment, including the number of previous and future visits.

Expects a single line text response (required)
How satisfied are you with the treatment you received from the Label( opdwho (17.1) , Q( opdwho (17.1) ,0) ) ?

Very dissatisfied [5]
Don't know [888] How long did it take you to travel to the Label( opdwho ( How much did you, your family or friends have to pay for the consultation with the Label( opdwho (17.1) , Q( opdwho (17.1) ,0)  Staying healthy can be difficult when you have Label( cohort (3.2) , Q( cohort (3.2) ,0) ) . I would like to learn about the type of help you get from health workers for Label( cohort (3.2) , Q( cohort (3.2) ,0) ) . This might include a health extension worker in a health post, a nurse or health officer in a health centre or a doctor in the hospital. Label( cohort (3.2) , Q( cohort (3.2) ,0) ) In the past 3 months, have you received any health care for problems with Label( cohort (3.2) , Q( cohort (3.2) ,0) ) ?
Expects a single option response (required)

Skip when country (3.1) Not Equal 'South Africa -Dr KK [4]'
Over the past 3 months (since __{377429}__), when you received care for Label( cohort (3.2) , Q( cohort (3.2) ,0) ) how often were you... [Show FLASH CARD 6] How often were you... Satisfied that your care was well organized, for example, that there was good coordination between different providers involved with your care?

None of the time [1]
A little of the time [2]

Most of the time [4]
Always [5] How often were you... Encouraged by providers to take more care of your condition, for example, shown how any actions that you have taken to take care of yourself has improved your condition?

Most of the time [4]
Always [5] How often were you... Helped to set specific goals to improve your condition, e.g., getting active, acting on a problem, joining a support group?
Expects a single option response (required)

None of the time [1]
A little of the time  ( cohort (3.2) , Q( cohort (3.2) ,0) ) and whether the treatment/interventions recommended were in alignment with your values, beliefs and traditions? Expects a single option response (required)

Most of the time [4]
Always [5] How often were you... Provided skills to help you to deal with your condition even when under great stress or hard times? Expects a single option response (required)

None of the time [1]
A little of the time [2]

Most of the time [4]
Always [5] How often were you... Encouraged to attend programs in the community that could help you?

None of the time [1]
A little of the time [2]

Most of the time [4]
Always [5] How often were you... Asked how your visits with other providers were going?

None of the time [1]
A little of the time [2]

Skip when country (3.1) Not Equal 'Uganda -Kamuli [5]'
[These question must be answered by the caregiver on behalf of the patient -the following questions refer to the patient's medication.] [Instruction for country teams: List all known psychotropic medications being used in any PRIME country and list them for use in Question 2. Nonpsychotropic will fall under Other (specify)=77] In the past THREE months (since __{377429}__), how many new or continuing medications have you been prescribed for ANY health condition?

Skip when rxname (20.1) Not Equal 'Other medication [77]'
[This drug is not a psychotropic. Skip ahead.] Expects a single option response (optional)
Expects a single option response (required)
Expects a single option response (required) Don't know/Can't remember [88] [End of this medication] Section 21. Covert Medication
Expects a single option response (required)

All the time [1]
Most of the time (>3 of the last 4 weeks) [2] Sometimes (at least 2-3/4 weeks) [3] Took the medicine occasionally (<2 of the last 8 weeks) [4] Did not take any medicine at all [5] Sometimes when a relative is unwell or is unwilling to take their medication, family members give the medication without the relatives knowledge. For example by putting the medication into the relatives food. Have you or anyone in your family ever given Q ptname (4.17) medication without their knowledge?
Expects a single option response (required) Section 22. CGI -Community Group Interventions

Section Prerequisites Skip when participant (3.3) Equals'Caregiver [1]' OR Skip when country (3.1) Equals'South Africa -Dr KK [4]'
For treatment of Label( cohort (3.2) , Q( cohort (3.2) ,0) ) in the past THREE months, have you been involved in any of the following: Tell me yes or no as I list the options. In this section, I'm going to ask you a few more questions about the care you have received over the past THREE months, that is since __{377429}__, for your problems with Label( cohort (3.2) , Q( cohort (3.2) ) ) specifically.
Expects a single option response (required)

Skip when visit (3.7) Not Equal 'Endline [3]'
Are you aware that you were identified with problems of Label( cohort (3.2) , Q( cohort (3.2) ) ) one year ago? Expects a single option response (required) Did you visit the health centre for this problem?
Expects a single option response (required)

Skip when hcenter (35.4) Equals 'No [0]'
How many times did you visit the health centre for this problem? [Ask for an estimate]

Expects a numeric response (required)
What treatment did you receive for this problem?

Home-based care from FCHVs/HBCWs [4]
Home-based care from counselors [ About how many hours did you work in the past 4 weeks (28 days)?
Expects a numeric response (required)

Skip when country (3.1) Equals 'South Africa -Dr KK [4]'
Families can have a lot of different experiences when one of its members has psychiatric problems. Can you please tell me whether any of the following things have happened-not at all, sometimes, often or a lot in the past SIX months.

Skip when country (3.1) Not Equal 'South Africa -Dr KK [4]'
Families can have a lot of different experiences when one of its members has psychiatric problems. Can you please tell me whether any of the following things have happened-not at all, sometimes, often or a lot in the past SIX months. [Show FLASH CARD 7] You worried that your neighbours would treat you differently Now I would like to ask some specific questions about your own involvement with __{376541}__ and the involvement of other family members over the past SIX months.
Would you say that you are the family member that __{376541}__ depends on the most? Expects a single option response (required)

No [0]
Yes [1] Overall, how much have you been involved in helping __{376541}__ when he/she has had psychiatric problems?

Some [2]
A lot [3] I would now like to ask you some questions about how __{376541}__'s problems may have affected your life in the past or might in the future.