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Create a world where no child goes to bed hungry.

Treating Depression to Increase Behavior Change & Reduce Stunting

Tom Davis Chief Program Officer Link to online narrated presentation: http://bit.ly/IPTG-BehChange

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.

Treat people as whole people

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Maternal Depression Affects 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]

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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).

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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

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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?

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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.

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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.

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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).

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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

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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.

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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

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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.

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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.

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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

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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!