Effectiveness of the ‘Thinking Healthy Program’ to reduce antenatal depression in pregnant women in a tertiary care hospital: A quasi- experimental study in Pakistan

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The ‘Thinking Healthy Program’ (THP) is an evidence-based intervention specifically designed for addressing perinatal depression. This study aimed to evaluate the effectiveness of THP in reducing perinatal depression among pregnant women in Pakistan. Methods We recruited 220 pregnant women from the obstetrics and gynecology outpatient department of a tertiary care hospital in Lahore, Pakistan. Depression was screened using the Patient Health Questionnaire (PHQ-9), identifying 80 women (36%) with scores indicating depression (PHQ-9 score > 10). Of these, 22 consented to participate in the study. A quasi-experimental design was used to assess the impact of the THP intervention, targeting women aged 18–45 years in their 24–26 week of pregnancy. The intervention included fortnightly psychotherapy sessions aimed at modifying negative thinking patterns and behaviors, particularly in the context of developing mother-child relationships. The effectiveness of the THP sessions was measured using the Student’s t-test. Results A significant reduction in depression scores post-intervention (p < 0.05) demonstrated the intervention’s efficacy. Additional analysis of demographic characteristics also showed significant improvements. Conclusion This study provides evidence that the THP intervention is an effective, low-intensity psychotherapy treatment during the antenatal period, capable of preventing postpartum depression at clinical setting. Pregnancy Antenatal Postpartum Depression Intervention Low-intensity Psychotherapy Figures Figure 1 Figure 2 Figure 3 Background Postpartum depression is a prevalent health condition during pregnancy in female populations from diverse cultures [ 1 ]. However, in low- to middle-income countries (LMICs), postpartum depression is frequently underdiagnosed and untreated. Depression during pregnancy affects 10–37% of pregnancies, while prenatal anxiety affects approximately 27–54% of pregnant women [ 2 ]. In developing countries, the prevalence rate of postpartum depression ranges from being equal to double that of developed countries [ 3 ]. In India, 11% of women suffer from depressive disorders following childbirth [ 4 ], and 24.8% are found in Nigeria [ 5 ]. With 28–63%, Pakistan has the highest prevalence among Asian countries; and more than half of cases is expected to be undiagnosed [ 6 ]. Postpartum depression affects not only mother’s health, but also the child and husband. It can often lead to either maternal death by suicide or infanticide [ 7 ]. Depression during pregnancy is mostly related to operative delivery, low birth weight, preterm birth, anaemia, preeclampsia, diabetes, infant death and congenital malformation [ 8 ]. The most prevalent risk factors for postpartum depression included poor mood during the antenatal period, lack of husband support and poor self-esteem. Being 18 years of age is an independent risk factor for offspring depression. Maternal depression adversely impacts long-term cognitive and socioemotional development in children and has a profound intergenerational impact. Women with prenatal depression were more likely to stop breastfeeding before six months [ 9 ]. Although many other treatment options are available, not all pregnant women are screened for postpartum depression and receive treatment. The recurrent nature of depression and the prenatal period provide a window of opportunity during which preventive techniques can be implemented for at-risk women during their routine antenatal visits to obstetric clinics. Therefore, highlighting the epidemiology of postpartum depression is very important in public health [ 7 ]. The health care community is now facing the unique challenge of perinatal depression because it usually negatively affects innate defence, causes complications of other illnesses and stops patients from taking an active part in their health care due to intrinsic feelings of hopelessness or apathy in depressed patients [ 10 ]. Studies show that in developed countries, psychological and psychosocial interventions are more beneficial for minimizing perinatal depression. Nevertheless, LMICs have inadequate mental health professionals available to meet the population’s needs. Additionally, LMICs are facing challenges such as lack of integration of mental health care services into the primary health care system, limited health infrastructure, inadequate public awareness related to mental health, poverty and social discrimination, a high prevalence of comorbid conditions, and a greater level of stigma and inequalities for people living with mental disorders [ 11 ]. Considering the scarcity of specialized resources in LMICs, it is important to explore alternative delivery strategies. For mood, anxiety and posttraumatic stress disorders, psychological interventions are among the first-line treatments. In low-income countries, a key barrier to sustainable mental health is the scarcity of human resources. A programme promoted by the World Health Organization is the ‘Thinking Healthy Programme’ (THP), a non-specialist-delivered, evidence-based depression intervention that encounters this care gap [ 12 ]. THP is recommended as a low-level intervention to treat depression during pregnancy. The application of modified psychological interventions supervised by non-specialist health workers is a possible solution that is gaining significant importance as part of the global mental health agenda [ 13 ]. The THP intervention was first applied in a community setting that started in the second trimester of pregnancy to avert poor growth in utero and in the postpartum period in Pakistan. However, this intervention has not been tested in urban tertiary care hospital settings as a part of routine screening and treatment for postpartum depression. For that reason, we designed this study to determine the effectiveness of a THP intervention in reducing depressive symptoms in a clinical setting in a tertiary care setting. The findings of this study will be helpful for policymakers to make decisions on the execution of this programme to reduce postpartum depression in tertiary care settings in Pakistan. Methods Study design A quasi-experimental study was conducted by using an intervention called the ‘Thinking Healthy Programme’ (THP), which used the principles of cognitive behaviour therapy techniques of active listening, collaboration with the family, guided discovery (i.e., style of questioning to gently probe family health beliefs and to stimulate alternative ideas), and homework and applied this learning to health workers’ routine practices for maternal and child health education [ 1 ]. The study took approximately seven months to collect data. A structured, standardized modified questionnaire was used for data collection for phase I. In phase II, THP sessions were applied and the data were collected at Sheikh Zayed Hospital Lahore, Pakistan. The study was registered on www.clinicaltrial.gov with the clinical trial number NCT04663243 (9 December 2020) and received an ethical approval from the Institutional Review Board (IRB) ID SZMC/IRB/EXTERNAL/PhD/210/2020. Sample Pregnant women aged 18–45 years who were in the 24th − 26th weeks (second trimester) of pregnancy, had Patient Health Questionnaire (PHQ-9) scores > 10 and were willing to participate were included in the study. Sample size was calculated by using the formula of comparison of two means. Interested participants were given a detailed description of the study. Women who were diagnosed with serious medical conditions and who required inpatient or outpatient treatment, pregnancy-associated illness (except for anaemia), substantial physical or learning disability or other kinds of psychosis were excluded from the study (Fig. 1 ). Data collection The study included a group of women screened in the antenatal period as being at risk of depression with regard to validated interviews. The initial evaluation (E 1, baseline) took place at the 24th to 26th week of pregnancy. The assessments were performed by an experienced researcher who was trained to administer the PHQ-9, which is used as a screening tool for depression for non-specialists [ 14 ] and is widely used in cross-cultural epidemiological and treatment studies of antenatal and postnatal depression. The follow-up evaluation (E 2 ) was performed after delivery within 6 weeks of the postpartum period. Pre- and post-intervention data were collected to evaluate the effectiveness of the intervention (Fig. 2 ). Intervention The intervention consisted of four sessions delivered fortnightly to ensure that expectant women could receive the maximum therapy in the middle of their pregnancy. In addition, two booster sessions were delivered aiming to revise the previous sessions and reinforce their key health messages. The core sessions focused on (1) psychoeducation and stress management, (2) personal wellbeing, (3) social support and (4) mother-infant bonding. Booster sessions were delivered during the expectant women’s routine antenatal visits to the hospital as fifth and sixth sessions. Each session consisted of an interactive exchange of information (60%) and practical exercises (40%). The sessions were carried out in the outpatient department to ensure maximum participation during the planned follow-up visit. The sessions lasted between 45 and 90 minutes. Family members were invited to attend the first, third and sixth sessions. Each session consisted of two or more specific objectives that moved toward progressive steps, along with exercises for reasoning with somatic symptoms and the child delivery model (Table 1 ). Table 1 Description of intervention sessions Sessions Active ingredient Timing of session delivery Recipients 1) Psycho-education and stress management Psycho-education (Knowledge about depressive disorders and stress management skills) Fortnightly 22 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 3) Social support Thought challenging and behavior activation (Strategies for improving interpersonal relationship and social support). Fortnightly All participants recruited into the intervention and their family members 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 5) Booster sessions (depending on time of enrolment) Behavior activation and problem management skills Booster sessions were coordinated with the recipients’ routine antenatal visits All participants recruited into the intervention 6) Preparing for the baby and early postnatal period Addressing fear of child-birth (strategies for planning for baby’s arrival). Psycho-education (coping with early post pregnancy challenges) Late pregnancy All participants recruited into the intervention arm and their family members. Pregnant women were considered to be at psychosocial risk via the following factors: socioeconomic background (husbands with low-wage employment, unemployment, with or without financial support), limited social contact (migrants or those living alone), nutritional deficiency and the risk of depression (validated interview). The Urdu version of the questionnaire and the THP were used for the convenience of participants. Withdrawal and lost to follow-up Participants were free to withdraw from the study at any time upon request. The investigator discontinued or withdrew a participant from the study for the following reasons: Death of participants Loss of pregnancy Participants moved away from the study area Acute, chronic, or long-term physical or psychiatric illness led to inpatient hospitalization during the study Any clinical adverse event, laboratory abnormality, or other medical condition or situation occurs such that continued participation in the study would not be in the best interest of the participant Disease progression that required discontinuation of the intervention Refusal to continue the study as a family/husband did not allow for participation in the study. The reasons for participant termination or withdrawal from the study were recorded. Subjects who provided consent to participate and who received the study intervention but subsequently withdrew or discontinued the study were excluded. A participant was considered lost to follow-up if he or she failed to return to the endpoint assessment (i.e., 6 weeks postpartum) and/or was unable to be contacted. Mobile messages were sent to participants to remind them of their visits and the session’s home work. The following actions were taken if a participant failed to return to the clinic for a required study visit: The researcher attempted to contact the participant, reschedule the missed visit in a subsequent week, counsel the participant on the importance of maintaining the assigned visit schedule, and ascertain whether the participant wished to and/or could continue in the study. These contact attempts were documented in the participants’ study files. If the participant continued to be unreachable before the final 6-week postpartum visit, she was considered withdrawn from the study and lost to follow-up. Before a participant was deemed lost to follow-up, the investigator made every effort to regain contact with the participant (where possible, three telephone calls and a call to any designated family friends for whom the participant was provided a contact phone number in case of loss to follow-up, and if necessary). Data analysis Data were analyzed with SPSS. Descriptive and bivariate analyses were conducted. We calculated means (including standard deviations [SD)] and mean differences (pre- and post-intervention) for PHQ-9 and performed stratified analyses according to the independent variables in terms of demographic characteristics. The effectiveness of the THP sessions was measured using the Student’s t-test. A p-value less than 0.05 was considered to be statistically significant. Results The demographics of the THP patients before and after the intervention are shown in Table 2 . A significant difference was found in the depression scores according to age, education level of the participant, education level of the husband, employment status of the participant, employment status of the husband, and age of the partner. Table 2 shows that depression scores in relation to monthly income were significant in the 31,000–45,999 Rupees category. Figure 3 shows the comparison of depression scores between pre-intervention screening and post-intervention screening and revealed a significant difference in the reduction of depression after intervention. Table 2 Pre- and post-depression scores in relation to demographic characteristics Depression on PHQ-9 score Mean difference p-value Before intervention Mean ± SD After intervention Mean ± SD Age (in years) 18–25 18.00 ± 2.00 6.80 ± 2.38 11.20 0.003 26–30 16.62 ± 3.30 6.85 ± 5.06 9.76 < 0.001 31–35 15.00 ± 3.16 9.25 ± 4.57 5.75 0.225 Participant’s education Primary 17.00 2.00 - - Secondary 16.75 ± 2.75 4.00 ± 2.44 12.75 0.008 Higher 16.59 ± 3.29 8.35 ± 4.35 8.23 < 0.001 Participant’s employment Not employed 16.94 ± 3.03 7.11 ± 4.52 9.83 < 0.001 Employed 15.25 ± 3.20 8.00 ± 4.54 7.25 0.080 Husband’s education Secondary 15.50 ± 3.53 10.00 ± 7.07 5.50 0.597 Higher 16.75 ± 3.09 7.00 ± 4.26 9.75 < 0.001 Husband’s employment Employed 17.06 ± 3.03 6.72 ± 4.18 10.33 < 0.001 Business 14.75 ± 2.75 9.75 ± 5.31 5.00 0.159 Partner age difference (in years) ≤ 1 15.50 ± 1.91 7.75 ± 4.92 7.75 0.045 2–3 16.00 ± 3.08 10.40 ± 4.50 5.60 0.164 4–6 17.25 ± 4.16 6.25 ± 4.86 11.00 0.005 7–9 19.00 ± 1.41 3.50 ± 2.12 15.50 0.102 ≥ 10 16.00 ± 1.00 6.67 ± 0.57 9.33 0.009 Monthly income (in Rupees) 60,000 17.00 ± 3.46 5.75 ± 2.21 11.25 0.003 Changes were significant in younger age groups, but not in women aged 31–35 years. Women and their husbands who had higher education levels showed greater compliance with the intervention than did those who had lower education levels. Participants who were not employed (housewives) and whose husbands were doing jobs and whose age difference was > 10 years were more likely to benefit from the intervention in reducing antenatal depressive symptoms. Pregnant mothers who had a family income of 31,000–45,999f Rupees showed significant improvements following the intervention (Mean ± SD = 3.75 ± 2.36; mean difference: 15.00, p = 0.007). The results of the THP psychotherapy intervention were highly significant in reducing depression symptoms in pregnant women. Women who had depression scores > 10 at the baseline screening level (mean ± SD = 16.27 ± 2.60) had substantially reduced depression symptoms after the THP intervention (mean ± SD = 7.27 ± 4.43), and a significant effect (mean difference: 9.00, p < 0.001) of the intervention was found during the antenatal period. Discussion The THP is a psychological intervention designed to address moderate to moderately severe perinatal depression. This intervention was carried out in urban clinical settings of a tertiary care hospital in Lahore, Pakistan. Administered by a trained non-specialist researcher to pregnant women in their second trimester, the primary goal was to mitigate the risk of postpartum depression. This study investigated demographic factors including age, participants’ and their husbands’ education level, employment status, and the age difference between partners. Notably, the intervention significantly alleviated depression symptoms among participants. Similar studies have highlighted the adaptability of such interventions. For instance, research in India suggested that THP is particularly beneficial for women with a shorter history of depression, improving their perceived social support and reducing disability [ 15 ]. This aligns with global evidence indicating that non-specialist laywomen can effectively deliver primary psychological care in low-resource settings. In this trial, the PHQ-9, an Urdu version validated for reliability and simplicity, was employed to screen for depressive symptoms before and after the intervention. The tool’s effectiveness is well-documented across several low-resource middle-income countries [ 16 – 18 ]. Our findings are consistent with broader research showing that psychological therapies can be effectively managed by lay workers in low-resource environments. Demographic insights from our study revealed that participants and their spouses, being better educated and residing in urban areas, were more receptive to understanding and benefiting from the therapy. In Pakistan, where the majority of households are joint families with more than eight members and one to two dependents, family significantly influences the daily lives and mental health of pregnant women. These women, often preoccupied with family duties and predominantly overseen by their mothers-in-law, receive limited emotional support from their partners to discuss personal and health issues, potentially exacerbating depressive symptoms. The psychotherapy sessions offered a crucial opportunity for them to voice concerns about their health and family dynamics. Interestingly, a contrasting study in India found that this intervention did not yield enhanced benefits in similar well-educated and resourced environments [ 15 ], suggesting the influence of other contextual factors on the efficacy of the treatment. A comparative study conducted in a rural community setting in Pakistan found that 93% of the pregnant women in the intervention group were homemakers, aligning with our findings where most women were similarly not employed. Notably, the intervention demonstrated a more significant effect in these non-working women. However, it was found that most mothers benefiting from the intervention had lower or secondary education [ 19 ]. In our study, a considerable number of participants possessed secondary or higher education and exhibited a positive response to the treatment. The THP employs behavioral activation techniques and is facilitated by lay workers. It has proven to be an effective, low-cost approach not only in reducing symptoms of perinatal depression but also in fostering recovery post-delivery. Additionally, it enhances social support and improves functional outcomes, thus contributing positively to public health [ 20 ]. Another study based on THP conducted in a rural community demonstrated significantly enhanced outcomes within three months postpartum, a critical period for maternal involvement in child healthcare [ 19 ]. This timing is crucial as it aligns with heightened demands on mothers’ mental and physical health. The findings advocate for the expansion of mental health services in clinical settings, even those lacking specialized mental health professionals. THP, which employs basic cognitive behavioral therapy techniques such as active listening, empathy, and non-judgmental support, can be effectively administered as front-line therapy for perinatal depression. These foundational skills facilitate the detection and modification of negative thoughts, pivotal in behavioral activation. Given its efficacy, THP should be tailored to meet individual needs and integrated into the health system through a collaborative care model, thus potentially enabling a broader recovery during the antenatal period and beyond [ 21 ]. Limitations Our research was conducted at a tertiary care hospital in an urban, developed city characterized by a high literacy rate. However, the generalizability and acceptability of our psychological treatment findings may vary among populations in socioeconomically poorer regions with different healthcare systems. This study was self-funded and limited to a single institution, which restricted our sample size. Consequently, broader conclusions are constrained, and the results would benefit from a more extensive participant base. High dropout rates were noted, primarily due to challenges in obtaining permission from husbands or in-laws for women to discuss their personal and family issues. Additionally, our limited resources prevented long-term follow-up and the implementation of randomized controlled trials, which could have enhanced the robustness of our findings. Future research should focus on incorporating randomized trials to improve the generalizability and validity of the results. Conclusions The THP intervention proved to be an effective low-level psychotherapy treatment for preventing postpartum depression during the antenatal period in a tertiary care hospital setting. This cost-effective, short-duration preventive approach can be seamlessly integrated with the collaboration of gynecological and obstetric units in hospitals, reaching hundreds of women during routine antenatal visits. Moreover, by mitigating depression, this intervention supports not only the psychological well-being of mothers but also benefits the entire family, contributing significantly to the enhancement of public health outcomes for women and children. Abbreviations LMIC Low- to middle-income countries PHQ Patient Health Questionnaire SD Standard deviation THP Thinking Healthy Program Declarations Ethics approval and consent to participate This study received an ethical approval from the Institutional Review Board at the University of the Punjab(ID SZMC/IRB/EXTERNAL/PhD/210/2020). All procedures were conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent before participating in this study. Consent for publication Not applicable. Availability of data and materials Data is available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions QA: conceptualization, methodology, data curation, formal analysis, writing – original draft preparation; JS: conceptualization methodology, data curation, validation, supervision; AM: conceptualization methodology, data curation, validation, supervision; KS: data analysis, writing – original draft preparation; RZ: formal analysis, writing – reviewing and editing; MN: formal analysis, data curation, writing – reviewing and editing; GMJB: formal analysis, data curation, writing – reviewing and editing; FF: writing – reviewing and editing, supervision. All authors approved the final version of the manuscript to be published. Acknowledgements We would like to express our gratitude to the participants and staff of Sheikh Zyed Hospital, Lahore and the University of Punjab Lahore. References Rahman A, Malik A, Sikander S, Roberts C, Creed F. 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Cite Share Download PDF Status: Published Journal Publication published 18 Apr, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 20 Jun, 2024 Editor assigned by journal 20 Jun, 2024 Submission checks completed at journal 20 Jun, 2024 First submitted to journal 01 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Fischer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIie2PsWrDMBCGrwis5YxXmxb3Fa4IDIVCXkXGq2kDXTIEIgg4W2c/jovAWdy9hVKSxXPAUFoIoZKbTnE8d9A36H5O+jgdgMPxD+Erc0gblgDMVAwATSE49k9BfbyywSpXkeoVGlf6UP0qd1RZBUYUxurdZv4OyPm2m84+UKxfnrvZdB8Dz6phxctKWbcmoLgsm0dMmvssaogEYDs4ZmJegvS0DR7zC4nJK1KkiFIV5jQ8xSoHbQJvmX+QKEoU30ZZqPBhd1ZJC6tAwnwlkUJM7BQJYX5mfS+D9EljvwvWEsMmT24ViZsC2+GP8aW++PrUMQbrbYdzOQlWjXhT+/g64NlmcMyfetryxt47HA6HY5QfsvhOLaVQ1DcAAAAASUVORK5CYII=","orcid":"","institution":"Charité – Universitätsmedizin Berlin","correspondingAuthor":true,"prefix":"","firstName":"Florian","middleName":"","lastName":"Fischer","suffix":""}],"badges":[],"createdAt":"2024-06-01 13:41:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4513865/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4513865/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-026-09129-7","type":"published","date":"2026-04-18T15:59:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60602831,"identity":"3cdb5b39-1d5e-4de2-bfb9-f944891f83e2","added_by":"auto","created_at":"2024-07-18 16:18:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":102573,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram for the eligibility screening\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4513865/v1/c535886c856b66654f4e05ea.png"},{"id":60602162,"identity":"177c4c3d-2af1-42b2-a461-eda315c5fd98","added_by":"auto","created_at":"2024-07-18 16:10:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55385,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT flow diagram for sample selection\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4513865/v1/eb7532f0d2498960ab3dd0eb.png"},{"id":60602160,"identity":"575d1068-0152-4576-ac26-92fb0a3e6425","added_by":"auto","created_at":"2024-07-18 16:10:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":66509,"visible":true,"origin":"","legend":"\u003cp\u003eDepression reduction before and after screening\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4513865/v1/f76ddc09c183f90dc9119fcc.png"},{"id":107351350,"identity":"36b75650-1820-495b-bc5e-c8f11626d74e","added_by":"auto","created_at":"2026-04-20 16:10:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":634796,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4513865/v1/a2bc48cf-9189-4980-a156-3a6073829523.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of the ‘Thinking Healthy Program’ to reduce antenatal depression in pregnant women in a tertiary care hospital: A quasi- experimental study in Pakistan","fulltext":[{"header":"Background","content":"\u003cp\u003ePostpartum depression is a prevalent health condition during pregnancy in female populations from diverse cultures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, in low- to middle-income countries (LMICs), postpartum depression is frequently underdiagnosed and untreated. Depression during pregnancy affects 10\u0026ndash;37% of pregnancies, while prenatal anxiety affects approximately 27\u0026ndash;54% of pregnant women [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In developing countries, the prevalence rate of postpartum depression ranges from being equal to double that of developed countries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In India, 11% of women suffer from depressive disorders following childbirth [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and 24.8% are found in Nigeria [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. With 28\u0026ndash;63%, Pakistan has the highest prevalence among Asian countries; and more than half of cases is expected to be undiagnosed [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePostpartum depression affects not only mother\u0026rsquo;s health, but also the child and husband. It can often lead to either maternal death by suicide or infanticide [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Depression during pregnancy is mostly related to operative delivery, low birth weight, preterm birth, anaemia, preeclampsia, diabetes, infant death and congenital malformation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The most prevalent risk factors for postpartum depression included poor mood during the antenatal period, lack of husband support and poor self-esteem. Being 18 years of age is an independent risk factor for offspring depression. Maternal depression adversely impacts long-term cognitive and socioemotional development in children and has a profound intergenerational impact. Women with prenatal depression were more likely to stop breastfeeding before six months [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although many other treatment options are available, not all pregnant women are screened for postpartum depression and receive treatment. The recurrent nature of depression and the prenatal period provide a window of opportunity during which preventive techniques can be implemented for at-risk women during their routine antenatal visits to obstetric clinics. Therefore, highlighting the epidemiology of postpartum depression is very important in public health [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe health care community is now facing the unique challenge of perinatal depression because it usually negatively affects innate defence, causes complications of other illnesses and stops patients from taking an active part in their health care due to intrinsic feelings of hopelessness or apathy in depressed patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Studies show that in developed countries, psychological and psychosocial interventions are more beneficial for minimizing perinatal depression. Nevertheless, LMICs have inadequate mental health professionals available to meet the population\u0026rsquo;s needs. Additionally, LMICs are facing challenges such as lack of integration of mental health care services into the primary health care system, limited health infrastructure, inadequate public awareness related to mental health, poverty and social discrimination, a high prevalence of comorbid conditions, and a greater level of stigma and inequalities for people living with mental disorders [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Considering the scarcity of specialized resources in LMICs, it is important to explore alternative delivery strategies.\u003c/p\u003e \u003cp\u003eFor mood, anxiety and posttraumatic stress disorders, psychological interventions are among the first-line treatments. In low-income countries, a key barrier to sustainable mental health is the scarcity of human resources. A programme promoted by the World Health Organization is the \u0026lsquo;Thinking Healthy Programme\u0026rsquo; (THP), a non-specialist-delivered, evidence-based depression intervention that encounters this care gap [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. THP is recommended as a low-level intervention to treat depression during pregnancy. The application of modified psychological interventions supervised by non-specialist health workers is a possible solution that is gaining significant importance as part of the global mental health agenda [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The THP intervention was first applied in a community setting that started in the second trimester of pregnancy to avert poor growth in utero and in the postpartum period in Pakistan. However, this intervention has not been tested in urban tertiary care hospital settings as a part of routine screening and treatment for postpartum depression. For that reason, we designed this study to determine the effectiveness of a THP intervention in reducing depressive symptoms in a clinical setting in a tertiary care setting. The findings of this study will be helpful for policymakers to make decisions on the execution of this programme to reduce postpartum depression in tertiary care settings in Pakistan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eA quasi-experimental study was conducted by using an intervention called the \u0026lsquo;Thinking Healthy Programme\u0026rsquo; (THP), which used the principles of cognitive behaviour therapy techniques of active listening, collaboration with the family, guided discovery (i.e., style of questioning to gently probe family health beliefs and to stimulate alternative ideas), and homework and applied this learning to health workers\u0026rsquo; routine practices for maternal and child health education [\u003cspan\u003e1\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eThe study took approximately seven months to collect data. A structured, standardized modified questionnaire was used for data collection for phase I. In phase II, THP sessions were applied and the data were collected at Sheikh Zayed Hospital Lahore, Pakistan.\u003c/p\u003e\n \u003cp\u003eThe study was registered on \u003cspan\u003e\u003cspan\u003ewww.clinicaltrial.gov\u003c/span\u003e\u003c/span\u003e with the clinical trial number NCT04663243 (9 December 2020) and received an ethical approval from the Institutional Review Board (IRB) ID SZMC/IRB/EXTERNAL/PhD/210/2020.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003eSample\u003c/h2\u003e\n \u003cp\u003ePregnant women aged 18\u0026ndash;45 years who were in the 24th \u0026minus;\u0026thinsp;26th weeks (second trimester) of pregnancy, had Patient Health Questionnaire (PHQ-9) scores\u0026thinsp;\u0026gt;\u0026thinsp;10 and were willing to participate were included in the study. Sample size was calculated by using the formula of comparison of two means. Interested participants were given a detailed description of the study. Women who were diagnosed with serious medical conditions and who required inpatient or outpatient treatment, pregnancy-associated illness (except for anaemia), substantial physical or learning disability or other kinds of psychosis were excluded from the study (Fig.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003eData collection\u003c/h2\u003e\n \u003cp\u003eThe study included a group of women screened in the antenatal period as being at risk of depression with regard to validated interviews. The initial evaluation (E\u003csub\u003e1,\u003c/sub\u003e baseline) took place at the 24th to 26th week of pregnancy. The assessments were performed by an experienced researcher who was trained to administer the PHQ-9, which is used as a screening tool for depression for non-specialists [\u003cspan\u003e14\u003c/span\u003e] and is widely used in cross-cultural epidemiological and treatment studies of antenatal and postnatal depression. The follow-up evaluation (E\u003csub\u003e2\u003c/sub\u003e) was performed after delivery within 6 weeks of the postpartum period. Pre- and post-intervention data were collected to evaluate the effectiveness of the intervention (Fig.\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003eIntervention\u003c/h2\u003e\n \u003cp\u003eThe intervention consisted of four sessions delivered fortnightly to ensure that expectant women could receive the maximum therapy in the middle of their pregnancy. In addition, two booster sessions were delivered aiming to revise the previous sessions and reinforce their key health messages. The core sessions focused on (1) psychoeducation and stress management, (2) personal wellbeing, (3) social support and (4) mother-infant bonding. Booster sessions were delivered during the expectant women\u0026rsquo;s routine antenatal visits to the hospital as fifth and sixth sessions. Each session consisted of an interactive exchange of information (60%) and practical exercises (40%).\u003c/p\u003e\n \u003cp\u003eThe sessions were carried out in the outpatient department to ensure maximum participation during the planned follow-up visit. The sessions lasted between 45 and 90 minutes. Family members were invited to attend the first, third and sixth sessions. Each session consisted of two or more specific objectives that moved toward progressive steps, along with exercises for reasoning with somatic symptoms and the child delivery model (Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eDescription of intervention sessions\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSessions\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eActive ingredient\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTiming of session delivery\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRecipients\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1) Psycho-education and stress management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePsycho-education (Knowledge about depressive disorders and stress management skills)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFortnightly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2) Personal wellbeing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThought challenging and behavior activation (Strategies for improving overall wellbeing, including diet, rest, relaxation, sleep, and managing common complaints during pregnancy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFortnightly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3) Social support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThought challenging and behavior activation (Strategies for improving interpersonal relationship and social support).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFortnightly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll participants recruited into the intervention and their family members\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4) Bonding with the infant during pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThought challenging and behavior activation (Strategies for improving bonding with the infant during pregnancy). Addressing fear of child-birth (knowledge and planning of safe delivery).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFortnightly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll participants recruited into the intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5) Booster sessions (depending on time of enrolment)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBehavior activation and problem management skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBooster sessions were coordinated with the recipients\u0026rsquo; routine antenatal visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll participants recruited into the intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6) Preparing for the baby and early postnatal period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAddressing fear of child-birth (strategies for planning for baby\u0026rsquo;s arrival). Psycho-education (coping with early post pregnancy challenges)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLate pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll participants recruited into the intervention arm and their family members.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003ePregnant women were considered to be at psychosocial risk via the following factors: socioeconomic background (husbands with low-wage employment, unemployment, with or without financial support), limited social contact (migrants or those living alone), nutritional deficiency and the risk of depression (validated interview). The Urdu version of the questionnaire and the THP were used for the convenience of participants.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003eWithdrawal and lost to follow-up\u003c/h2\u003e\n \u003cp\u003eParticipants were free to withdraw from the study at any time upon request. The investigator discontinued or withdrew a participant from the study for the following reasons:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eDeath of participants\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eLoss of pregnancy\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eParticipants moved away from the study area\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eAcute, chronic, or long-term physical or psychiatric illness led to inpatient hospitalization during the study\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eAny clinical adverse event, laboratory abnormality, or other medical condition or situation occurs such that continued participation in the study would not be in the best interest of the participant\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eDisease progression that required discontinuation of the intervention\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eRefusal to continue the study as a family/husband did not allow for participation in the study.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eThe reasons for participant termination or withdrawal from the study were recorded. Subjects who provided consent to participate and who received the study intervention but subsequently withdrew or discontinued the study were excluded.\u003c/p\u003e\n \u003cp\u003eA participant was considered lost to follow-up if he or she failed to return to the endpoint assessment (i.e., 6 weeks postpartum) and/or was unable to be contacted. Mobile messages were sent to participants to remind them of their visits and the session\u0026rsquo;s home work.\u003c/p\u003e\n \u003cp\u003eThe following actions were taken if a participant failed to return to the clinic for a required study visit:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eThe researcher attempted to contact the participant, reschedule the missed visit in a subsequent week, counsel the participant on the importance of maintaining the assigned visit schedule, and ascertain whether the participant wished to and/or could continue in the study. These contact attempts were documented in the participants\u0026rsquo; study files.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eIf the participant continued to be unreachable before the final 6-week postpartum visit, she was considered withdrawn from the study and lost to follow-up.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eBefore a participant was deemed lost to follow-up, the investigator made every effort to regain contact with the participant (where possible, three telephone calls and a call to any designated family friends for whom the participant was provided a contact phone number in case of loss to follow-up, and if necessary).\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eData analysis\u003c/h2\u003e\n \u003cp\u003eData were analyzed with SPSS. Descriptive and bivariate analyses were conducted. We calculated means (including standard deviations [SD)] and mean differences (pre- and post-intervention) for PHQ-9 and performed stratified analyses according to the independent variables in terms of demographic characteristics. The effectiveness of the THP sessions was measured using the Student\u0026rsquo;s t-test. A p-value less than 0.05 was considered to be statistically significant.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographics of the THP patients before and after the intervention are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. A significant difference was found in the depression scores according to age, education level of the participant, education level of the husband, employment status of the participant, employment status of the husband, and age of the partner. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that depression scores in relation to monthly income were significant in the 31,000\u0026ndash;45,999 Rupees category. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the comparison of depression scores between pre-intervention screening and post-intervention screening and revealed a significant difference in the reduction of depression after intervention.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePre- and post-depression scores in relation to demographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eDepression on PHQ-9 score\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eMean difference\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eBefore intervention\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eAfter intervention\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAge (in years)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.85\u0026thinsp;\u0026plusmn;\u0026thinsp;5.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParticipant\u0026rsquo;s education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.75\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.59\u0026thinsp;\u0026plusmn;\u0026thinsp;3.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParticipant\u0026rsquo;s employment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.11\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHusband\u0026rsquo;s education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.50\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;7.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.597\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHusband\u0026rsquo;s employment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.75\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.75\u0026thinsp;\u0026plusmn;\u0026thinsp;5.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePartner age difference (in years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.40\u0026thinsp;\u0026plusmn;\u0026thinsp;4.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.164\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly income (in Rupees)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;16,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16,000\u0026ndash;30,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.75\u0026thinsp;\u0026plusmn;\u0026thinsp;5.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31,000\u0026ndash;45,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.75\u0026thinsp;\u0026plusmn;\u0026thinsp;2.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46,000\u0026ndash;60,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.75\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eChanges were significant in younger age groups, but not in women aged 31\u0026ndash;35 years. Women and their husbands who had higher education levels showed greater compliance with the intervention than did those who had lower education levels.\u003c/p\u003e \u003cp\u003eParticipants who were not employed (housewives) and whose husbands were doing jobs and whose age difference was \u0026gt;\u0026thinsp;10 years were more likely to benefit from the intervention in reducing antenatal depressive symptoms. Pregnant mothers who had a family income of 31,000\u0026ndash;45,999f Rupees showed significant improvements following the intervention (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;3.75\u0026thinsp;\u0026plusmn;\u0026thinsp;2.36; mean difference: 15.00, p\u0026thinsp;=\u0026thinsp;0.007).\u003c/p\u003e \u003cp\u003eThe results of the THP psychotherapy intervention were highly significant in reducing depression symptoms in pregnant women. Women who had depression scores\u0026thinsp;\u0026gt;\u0026thinsp;10 at the baseline screening level (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;16.27\u0026thinsp;\u0026plusmn;\u0026thinsp;2.60) had substantially reduced depression symptoms after the THP intervention (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;7.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.43), and a significant effect (mean difference: 9.00, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) of the intervention was found during the antenatal period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe THP is a psychological intervention designed to address moderate to moderately severe perinatal depression. This intervention was carried out in urban clinical settings of a tertiary care hospital in Lahore, Pakistan. Administered by a trained non-specialist researcher to pregnant women in their second trimester, the primary goal was to mitigate the risk of postpartum depression. This study investigated demographic factors including age, participants\u0026rsquo; and their husbands\u0026rsquo; education level, employment status, and the age difference between partners. Notably, the intervention significantly alleviated depression symptoms among participants.\u003c/p\u003e \u003cp\u003eSimilar studies have highlighted the adaptability of such interventions. For instance, research in India suggested that THP is particularly beneficial for women with a shorter history of depression, improving their perceived social support and reducing disability [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This aligns with global evidence indicating that non-specialist laywomen can effectively deliver primary psychological care in low-resource settings.\u003c/p\u003e \u003cp\u003eIn this trial, the PHQ-9, an Urdu version validated for reliability and simplicity, was employed to screen for depressive symptoms before and after the intervention. The tool\u0026rsquo;s effectiveness is well-documented across several low-resource middle-income countries [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our findings are consistent with broader research showing that psychological therapies can be effectively managed by lay workers in low-resource environments.\u003c/p\u003e \u003cp\u003e Demographic insights from our study revealed that participants and their spouses, being better educated and residing in urban areas, were more receptive to understanding and benefiting from the therapy. In Pakistan, where the majority of households are joint families with more than eight members and one to two dependents, family significantly influences the daily lives and mental health of pregnant women. These women, often preoccupied with family duties and predominantly overseen by their mothers-in-law, receive limited emotional support from their partners to discuss personal and health issues, potentially exacerbating depressive symptoms. The psychotherapy sessions offered a crucial opportunity for them to voice concerns about their health and family dynamics. Interestingly, a contrasting study in India found that this intervention did not yield enhanced benefits in similar well-educated and resourced environments [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], suggesting the influence of other contextual factors on the efficacy of the treatment.\u003c/p\u003e \u003cp\u003eA comparative study conducted in a rural community setting in Pakistan found that 93% of the pregnant women in the intervention group were homemakers, aligning with our findings where most women were similarly not employed. Notably, the intervention demonstrated a more significant effect in these non-working women. However, it was found that most mothers benefiting from the intervention had lower or secondary education [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our study, a considerable number of participants possessed secondary or higher education and exhibited a positive response to the treatment. The THP employs behavioral activation techniques and is facilitated by lay workers. It has proven to be an effective, low-cost approach not only in reducing symptoms of perinatal depression but also in fostering recovery post-delivery. Additionally, it enhances social support and improves functional outcomes, thus contributing positively to public health [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother study based on THP conducted in a rural community demonstrated significantly enhanced outcomes within three months postpartum, a critical period for maternal involvement in child healthcare [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This timing is crucial as it aligns with heightened demands on mothers\u0026rsquo; mental and physical health. The findings advocate for the expansion of mental health services in clinical settings, even those lacking specialized mental health professionals. THP, which employs basic cognitive behavioral therapy techniques such as active listening, empathy, and non-judgmental support, can be effectively administered as front-line therapy for perinatal depression. These foundational skills facilitate the detection and modification of negative thoughts, pivotal in behavioral activation. Given its efficacy, THP should be tailored to meet individual needs and integrated into the health system through a collaborative care model, thus potentially enabling a broader recovery during the antenatal period and beyond [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003e Our research was conducted at a tertiary care hospital in an urban, developed city characterized by a high literacy rate. However, the generalizability and acceptability of our psychological treatment findings may vary among populations in socioeconomically poorer regions with different healthcare systems. This study was self-funded and limited to a single institution, which restricted our sample size. Consequently, broader conclusions are constrained, and the results would benefit from a more extensive participant base. High dropout rates were noted, primarily due to challenges in obtaining permission from husbands or in-laws for women to discuss their personal and family issues. Additionally, our limited resources prevented long-term follow-up and the implementation of randomized controlled trials, which could have enhanced the robustness of our findings. Future research should focus on incorporating randomized trials to improve the generalizability and validity of the results.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe THP intervention proved to be an effective low-level psychotherapy treatment for preventing postpartum depression during the antenatal period in a tertiary care hospital setting. This cost-effective, short-duration preventive approach can be seamlessly integrated with the collaboration of gynecological and obstetric units in hospitals, reaching hundreds of women during routine antenatal visits. Moreover, by mitigating depression, this intervention supports not only the psychological well-being of mothers but also benefits the entire family, contributing significantly to the enhancement of public health outcomes for women and children.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLMIC\u0026nbsp;\u0026nbsp; Low- to middle-income countries\u003c/p\u003e\n\u003cp\u003ePHQ\u0026nbsp; \u0026nbsp;\u0026nbsp;Patient Health Questionnaire\u003c/p\u003e\n\u003cp\u003eSD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Standard deviation\u003c/p\u003e\n\u003cp\u003eTHP \u0026nbsp; \u0026nbsp; \u0026nbsp;Thinking Healthy Program\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received an ethical approval from the Institutional Review Board at the University of the Punjab(ID SZMC/IRB/EXTERNAL/PhD/210/2020). All procedures were conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent before participating in this study.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQA: conceptualization, methodology, data curation, formal analysis, writing \u0026ndash; original draft preparation; JS: conceptualization methodology, data curation, validation, supervision; AM: conceptualization methodology, data curation, validation, supervision; KS: data analysis, writing \u0026ndash; original draft preparation; RZ: formal analysis, writing \u0026ndash; reviewing and editing; MN: formal analysis, data curation, writing \u0026ndash; reviewing and editing; GMJB: formal analysis, data curation, writing \u0026ndash; reviewing and editing; FF: writing \u0026ndash; reviewing and editing, supervision. All authors approved the final version of the manuscript to be published.\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to the participants and staff of Sheikh Zyed Hospital, Lahore and the University of Punjab Lahore.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet. 2008;372(9642):902\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eWilliams JA, Romero VC, Clinton CM, Vazquez DM, Marcus SM, Chilimigras JL, et al. Vitamin D levels and perinatal depressive symptoms in women at risk: A secondary analysis of the mothers, omega-3, and mental health study. BMC Pregnancy Childbirth. 2016;16:203. \u003c/li\u003e\n\u003cli\u003eCooper PJ, Tomlinson M, Swartz L, Landman M, Molteno C, Stein A, et al. Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. BMJ. 2009;338:b974. \u003c/li\u003e\n\u003cli\u003eShriraam, Shah PB, Rani MA, Sathiyasekaran BWC. A community-based study of postpartum depression in rural Southern India. Indian J Soc Psychiatry. 2019;35(1):64.\u003c/li\u003e\n\u003cli\u003eBakare MO, Okoye JO, Obindo JT. Introducing depression and developmental screenings into the national programme on immunization (NPI) in southeast Nigeria: an experimental cross-sectional assessment. Gen Hosp Psychiatry. 2014;36(1):105\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eTikmani SS, Soomro T, Tikmani P, Zulfiqar S, Bhutto A. Prevalence and determinants of postpartum depression in a tertiary care hospital. Austin J Obs Gynecol. 2016;3(2):1\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eThe American College of Obstetricians and Gynecologist. Screening for Perinatal Depression. Replace Comm Opin. 2018;132(757):208\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eGrigoriadis S, Graves L, Peer M, Mamisashvili L, Tomlinson G, Vigod SN, et al. Maternal anxiety during pregnancy and the association with adverse perinatal outcomes. J Clin Psychiatry. 2018;79(5): 17r12011.\u003c/li\u003e\n\u003cli\u003eBelay YA, Moges NA, Hiksa FF, Arado KK, Liben ML. Prevalence of antenatal depression and associated factors among pregnant women attending antenatal care at Dubti hospital: A case of pastoralist region in Northeast Ethiopia. Depress Res Treat. 2018;2018: 1659089.\u003c/li\u003e\n\u003cli\u003eStraub H, Adams M, Kim JJ, Silver RK. Antenatal depressive symptoms increase the likelihood of preterm birth. Am J Obstet Gynecol. 2012;207(4):329.e1\u0026ndash;e4. \u003c/li\u003e\n\u003cli\u003eWainberg ML, Scorza P, Shultz JM, Helpman L, Mootz JJ, Johnson KA, et al. Challenges and opportunities in global mental health: a research-to-practice perspective. Curr Psychiatry Rep. 2017;19:28.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Thinking healthy: A manual for psychosocial management of perinatal depression. Geneva: World Health Organization; 2015. \u003c/li\u003e\n\u003cli\u003eRahman A, Khan MN, Hamdani SU, Chiumento A, Akhtar P, Nazir H, et al. Effectiveness of a brief group psychological intervention for women in a post-conflict setting in Pakistan: a single-blind, cluster, randomised controlled trial. Lancet. 2019;6736(10182):17333\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eGallis JA, Maselko J, O\u0026rsquo;Donnell K, Song K, Saqib K, Turner EL, et al. Criterion-related validity and reliability of the Urdu version of the patient health questionnaire in a sample of community-based pregnant women in Pakistan. PeerJ. 2018;6:e5185.\u003c/li\u003e\n\u003cli\u003eFuhr DC, Weobong B, Lazarus A, Vanobberghen F, Weiss HA, Singla DR et al. Delivering the Thinking Health Programme for perinatal depression through peers: an individually randomised controlled trial in India. Lancet Psychiatry. 2019;6(2):115\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eBitew T, Hanlon C, Medhin G, Fekadu A. Antenatal predictors of incident and persistent postnatal depressive symptoms in rural Ethiopia: a population-based prospective study. Reprod Health. 2019;16(1):28.\u003c/li\u003e\n\u003cli\u003eAhmad S, Hussain S, Akhtar F, Shah FS. Urdu translation and validation of PHQ-9, a reliable identification, severity and treatment outcome tool for depression. J Pak Med Assoc. 2018;68(6):1166\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003ePoongothai S, Pradeepa R, Ganesan A, Mohan V. Reliability and validity of a modified PHQ-9 item inventory (PHQ-12) as a screening instrument for assessing depression in Asian Indians (CURES-65). J Assoc Physicians India. 2009;57:147\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eSikander S, Ahmad I, Atif N, Zaidi A, Vanovverghen F, Weiss HA, et al. Delivering the Thinking Healthy Programme for perinatal depression through volunteer peers: a cluster randomised controlled trial in Pakistan. Lancet Psychiatry. 2019;6(2):128\u0026ndash;139.\u003c/li\u003e\n\u003cli\u003eAtif N, Krishna RN, Sikandar S, Lazarus A, Nisar A, Ahmad I, et al. Mother-to-mother therapy in India and Pakistan: adaptation and feasibility evaluation of the peer-delivered Thinking Healthy Programme. BMC Psychiatry. 2017;17:79.\u003c/li\u003e\n\u003cli\u003eEappen BS, Aguilar M, Ramos K, Contreras C, Prom MC, Scorza P, et al. Preparing to launch the \u0026lsquo;Thinking Healthy Programme\u0026rsquo;\u0026apos; perinatal depression intervention in Urban Lima, Peru: experiences from the field. Glob Ment Health. 2018;5:e41.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pregnancy, Antenatal, Postpartum, Depression, Intervention, Low-intensity Psychotherapy","lastPublishedDoi":"10.21203/rs.3.rs-4513865/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4513865/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn developing countries, the prevalence of postpartum depression can range from being comparable to that of developed nations to twice as high. The \u0026lsquo;Thinking Healthy Program\u0026rsquo; (THP) is an evidence-based intervention specifically designed for addressing perinatal depression. This study aimed to evaluate the effectiveness of THP in reducing perinatal depression among pregnant women in Pakistan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe recruited 220 pregnant women from the obstetrics and gynecology outpatient department of a tertiary care hospital in Lahore, Pakistan. Depression was screened using the Patient Health Questionnaire (PHQ-9), identifying 80 women (36%) with scores indicating depression (PHQ-9 score\u0026thinsp;\u0026gt;\u0026thinsp;10). Of these, 22 consented to participate in the study. A quasi-experimental design was used to assess the impact of the THP intervention, targeting women aged 18\u0026ndash;45 years in their 24\u0026ndash;26 week of pregnancy. The intervention included fortnightly psychotherapy sessions aimed at modifying negative thinking patterns and behaviors, particularly in the context of developing mother-child relationships. The effectiveness of the THP sessions was measured using the Student\u0026rsquo;s t-test.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA significant reduction in depression scores post-intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) demonstrated the intervention\u0026rsquo;s efficacy. Additional analysis of demographic characteristics also showed significant improvements.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study provides evidence that the THP intervention is an effective, low-intensity psychotherapy treatment during the antenatal period, capable of preventing postpartum depression at clinical setting.\u003c/p\u003e","manuscriptTitle":"Effectiveness of the ‘Thinking Healthy Program’ to reduce antenatal depression in pregnant women in a tertiary care hospital: A quasi- experimental study in Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 16:10:34","doi":"10.21203/rs.3.rs-4513865/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-20T19:05:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-20T05:02:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-20T05:01:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-06-01T13:39:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6a2f8b23-0c75-4990-acfe-f12742a2bb3d","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:08:13+00:00","versionOfRecord":{"articleIdentity":"rs-4513865","link":"https://doi.org/10.1186/s12884-026-09129-7","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2026-04-18 15:59:31","publishedOnDateReadable":"April 18th, 2026"},"versionCreatedAt":"2024-07-18 16:10:34","video":"","vorDoi":"10.1186/s12884-026-09129-7","vorDoiUrl":"https://doi.org/10.1186/s12884-026-09129-7","workflowStages":[]},"version":"v1","identity":"rs-4513865","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4513865","identity":"rs-4513865","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}