Maternal and Child Mental Health_Davis

1. feedthechildren.org
Create a world where
no child goes to bed hungry.
Treating Depression to
Increase Behavior
Change & Reduce
Stunting
TomDavis
ChiefProgramOfficer
Linktoonlinenarratedpresentation:
http://bit.ly/IPTG-BehChange

2. Specific vs. General Barriers to Change
Sophia
• Doesn’t excluv. breastfeed.
• Specific barriers.
• Hasn’t heard benefits
• Mother-in-law against it
• Believes child will go
hungry
• Doesn’t understand how
to do it.
• Thinks it’s against God’s
will.
Sonia
 Doesn’t excluv. breastfeed.
 General barriers.
– Has heard benefits, but…
– Abused by husband; depressed
– Stressed by five children
– Little energy for making any change
– Believes child’s growth is matter of luck.
– Doesn’t want to “rock the boat” with
husband.
– Can’t stand to hear child cry
– Fatalistic – believes most things are outside of
her control.

3. Treat people
as whole
people

4. feedthechildren.org
Maternal DepressionAffects the Women and
Children We Serve
• Prevalence of depression in developing countries is between 15-57%.
[Wachs, 2009]
• Women suffer twice as much depression as men; mothers are at even
greater risk.
• Postnatal depression has a significant negative impact on breastfeeding
duration. [Henderson et al, 2003]
• Infants of mothers with depressive symptoms had a 2.17 higher odds of
being stunted (95% CI: 1.24, 3.81; P 1⁄4 0.007) than did infants of
mothers with few symptoms. “Interventions to promote growth in infants
should include prevention or treatment of maternal depressive disorders
and strategies to ensure adequate food security. “ [Black et al, 2009]
• The causal relationship between household food insecurity and
depression is bidirectional. [Huddleston-Casas et al, 2008; Rahman
2013]

5. feedthechildren.org
Maternal Depression and Child Growth
• Maternal depression in the prenatal and postnatal periods predicts poorer growth
and higher risk of diarrhea in a community sample of infants. [Rahman et al, 2004]
• Major depression in the postpartum period and current major depression were
associated with malnutrition in the child. [Anoop et al, 2004]
• Strong associations between maternal depression and higher rates of preterm
birth, LBW, restricted fetal growth (Wachs, 2009).
• 2013 systematic review of 13 clinical trials of structured interventions for perinatal
depression with non-mental health specialists in LMICs showed feasibility and
effectiveness (med-large effect size of -0.38). [Rahman 2013]
• Surkan et al1 found a strong association between maternal depression and
underweight and stunting in children. Elimination of maternal depression
could result in a reduction in stunting of 23-29% (based on the PAR).

6. feedthechildren.org
We can Decrease Maternal Depression
in Developing Countries
• World Vision and researchers (Bolton, Verdeli, et al) did RCTs of
Interpersonal Therapy in Groups (IPT-G) including depressed adults
in South Uganda, and depressed adolescents in refugee camps in
North Uganda (many were child soldiers)
• IPT-G is used to address grief, devastating life changes, issues of
respect in family life
• Community workers – trained for 2 weeks to deliver the intervention
over 4 months
• After 16 weeks, depression decreased:
 86% to 6.5% in the IPT-G intervention group – 92% reduction
 94% to 55% in the control group. (Note: Some depression does
resolve on its own.)
 Significant improvements in functionality in HH tasks

7. feedthechildren.org
Feed the Children’s IPT-G RCT Plan
• Maternal depression  Decreased behavior
change and poor child growth, and
• IPT-G  Decreases depression, but
• Does IPT-G improve behavior change and child
growth?

8. feedthechildren.org
RCT Plan
• Partners: Feed the Children and Columbia University-
Teachers College (Helena Verdelli).
• Country/Region: Malawi
• Short-term goal: Measure the degree to which WASH
and IYCF behavior adoption can be improved through
prior treatment of maternal depression.
• Longer-term goal: Measure the degree to which stunting
can be reduced by treatment of maternal depression.
• Funding source: USG funds.

9. feedthechildren.org
RCT Plan
Four principal aims:
1. To test whether IPT-G reduces depressive symptoms and
enhances maternal functioning.
2. To investigate effects of reduced maternal depression on
behavior change, care-seeking that promotes child growth,
and improved food security, nutrition, and child health
outcomes;
3. To explore ROI of treating depression in increasing
effectiveness of development food aid programs; and
4. To develop a replicable model for treatment of depression in
FS and CS projects.

10. feedthechildren.org
RCT Plan
Two components:
1. Two-armed cluster RCT of the effectiveness of IPT-G;
2. Care Group health promotion strategy to see if women
who experience substantial reductions in depressive
symptoms in the IPT-G arm exhibit improved uptake of
IYCF and WASH behaviors.
Participants: Depressed pregnant women and those with
at least one child under two residing in selected villages in
Malawi (est. pop. = 30K).

11. feedthechildren.org
RCT Plan
Sample size:
• 3,600 mothers assessed for depression =
• 900 depressed mothers (25% of sample).
• Assuming 15% decline to participate = 765 depressed
women,
• Half (383) recruited into the RCT for depression.
Of those:
• 192 in intervention: IPT-G and then behavior promotion
via Care Groups;
• 192 in comparison arm: Beh promotion via CGs only

12. feedthechildren.org
RCT Plan
Primary Outcomes:
• Depression symptoms (via Hopkins Symptom
Checklist)
• Functional impairment will be measured with a
gender-specific 9-item questionnaire.
• Behavior change: Using standard KPC questions on
three WASH nutrition-related behaviors, three
nutrition behaviors, and one care-seeking behavior.

13. feedthechildren.org
RCT Plan
Selected Secondary Outcomes:
• Care Group attendance
• Neighbor Women group attendance
• Assessment of stunting, underweight and
wasting
• IPT-G providers adherence to the manual

14. feedthechildren.org
RCT Plan
1. Promoters initiate identification of potentially study-eligible subjects.
2. Promoters organize meetings of pregnant women / mothers for
individual and confidential screening for depression and impaired
social functioning.
3. Study participants are selected. Promoters provide all women
screened with psychoeducation in a group setting (what depression
is, how it affects lives, not your fault, etc.).
4. Consenting women assessed for level of depressive symptoms and
social functioning at baseline.
5. Depressed women randomized into intervention or comparison
arms (1:1) with cluster unit being the Care Group coverage area.

15. feedthechildren.org
RCT Plan
6. Two Study Arms:
• IPT-G + CG Arm:
• Assessed for depression, IYCF and WASH behaviors, and
functional impairment;
• Receive IPT-G for 12 weeks, 90 mins/week.
• Reassessment for depression; and then
• reached by CGVs with behavior promotion for five months.
• Re-assessment of depression, behaviors, and functional
impairment.
• Assess + CG Arm:
• Assessed for same things.
• After 12 weeks wait time, reassessed, then reached by CGVs
with behavior promotion for 5m.
• Reassessment for same things.
7. Referral of severely depressed/suicidal women.

16. feedthechildren.org
RCT Plan
8. Analysis: Logistic regression and t-tests.
9. Follow-up, longer-term study looking at stunting in both groups.
10. Expected results: Participation in IPT-G will lead to decreased depression,
better functionality, and higher adoption of IYCF, WASH, and care-seeking
behaviors of depressed women in the IPT-G + CG Arm. Also we will
determine if changes in depression scores are attributable to the IPT-G
intervention or whether Care Groups alone had an impact on depression
symptoms.
11. Key deliverables: A study report, peer-reviewed paper, modified IPT-G
manual, IPT-G training at baseline for other FS implementers in Malawi, a
one-day lessons learned conference, and a cadre of FS implementers
trained in IPT-G.
12. Expected costs: $200,000

17. feedthechildren.org
Collaborators Needed
• Steal this plan!
• Feed the Children and Columbia are committed to
testing of this new intervention (in as many sites as
possible) given it’s potential for revolutionizing results in
improving behavior change (especially amongst
depressed women) and reducing stunting.
• To contact Helena Verdelli about IPT-G:
VERDELIH@nyspi.columbia.edu
• We are committed to peer-to-peer, lateral scale-up of
good program models. Let us know how to help you!