This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Cognitive behavioural therapy (CBT) is recommended for women with postnatal depression. But there is limited evidence for the effectiveness of this talking therapy in minority ethnic groups.
Researchers developed culturally-adapted therapy. They found that it helped British women from South Asian backgrounds (Pakistani, Indian, Bangladeshi and Sri Lankan) to recover from postnatal depression faster than usual care alone.
The researchers hope their findings will encourage further development and commissioning of culturally-adapted CBT for postnatal depression.
More information about postnatal depression can be found on the NHS website.
The issue: is standard therapy for postnatal depression suitable for everyone?
More than 1 in 10 women experience postnatal depression (depression within a year of giving birth, usually starting in the few weeks after birth). A child’s first years (conception to age 2) provide the foundation for a healthy life. Untreated postnatal depression is linked with childhood difficulties (for example, reduced growth, and intellectual, social and emotional development and behavioural problems).
Postnatal depression is estimated to cost around £75,000 per mother and child over the course of their lifetime (2012/2013 prices) through poor mental health, loss of productivity and unpaid care. Most costs (£53,000; 70%) are for the child.
The National Institute for Health and Care Excellence (NICE) recommends cognitive behavioural therapy (CBT) for women with postnatal depression who typically have persistent symptoms that impact daily life (such as sadness, low energy, loss of interest in daily activities). However, fewer than half the women with these symptoms seek or access treatment. People from British ethnic minorities are less likely than others to engage with NHS talking therapies. Further, there is little evidence to show the effectiveness and acceptability of standard CBT among minority ethnic groups. Stigma, language and cultural barriers can be barriers to both diagnosis and treatment.
Researchers adapted group CBT for British women of South Asian backgrounds. Their Positive Health Programme provides education about depression, tailored for women from a British South Asian background. It addresses issues such as a lack of confidence, alongside the positive role of religion and spirituality in mental health. The programme was delivered by NHS researchers with backgrounds in psychology but little experience of delivering psychological therapies.
The study compared the impact of this programme with usual care among women from South Asian backgrounds.
What’s new?
Researchers invited 732 British South Asian women with infants younger than 1 year to take part in the study. About half (55%) were Pakistani, others were Indian (24%), Bangladeshi (18%) or Sri Lankan (3%). On average, they were 32 years old with a 24-week-old baby on entry to the study.
The study was carried out between 2017 and 2020 in 5 UK centres (including GP surgeries and community settings). All women received usual care (which included GP care, referral to talking therapies and antidepressant medication as needed). Half the women (368) were assigned by chance to receive the adapted therapy in addition. The adapted therapy was given as 12 group sessions in 4 months. Each session lasted 60-90 minutes and was delivered in the languages participants preferred.
Researchers assessed depression (using the Hamilton Depression Rating Scale) at the start of the study, at 4 months and at 12 months. The main outcome was recovery from depression at 4 months. Group sessions were delivered in person in community venues, and online during the COVID-19 pandemic.
Overall, at 4 months, from 562 responses, more women in the adapted therapy group (49%) had recovered from depression than in the usual care group (37%). The researchers accounted for depression score at the beginning of the study, number of other children and education level. After these adjustments, women in the adapted therapy group were almost twice as likely to have recovered as those in the usual care group.
At 12 months, women in both groups were similarly likely to have recovered from depression (54% for both groups).
Women who received the adapted therapy showed significant improvement over usual care in the participants’ sense of parenting competence at 12 months, but not at 4 months.
Why is this important?
Among women from British South Asian backgrounds, culturally-adapted group therapy could lead to faster recovery from postnatal depression, compared with usual care. This could protect mothers and their children from subsequent problems, and in turn reduce the future societal costs linked with postnatal depression.
The intervention does not address domestic violence and abuse; interviews found this to be a major cause of postnatal depression. The researchers suggest that further research into interventions for postnatal depression incorporates strategies to tackle domestic violence and abuse.
The findings might not be generalisable to other minority ethnic groups, the researchers caution.
How was the study carried out?
The researchers’ strategies for gathering participants included:
- community engagement; researchers attended community children’s groups, sought to involve faith leaders and participants’ families and arranged regular drop-in sessions over tea that were open to the community
- use of relevant languages (such as Urdu or Bengali; participants were asked what language they would prefer for group sessions)
- staff training in cultural competence, including ethical considerations
- appropriate use of social media
- full ethical approval that was obtained through the usual process and adapted to ensure respect for participants’ cultural background (for example, some participants wanted family engagement and consent to be a shared decision to respect the cultural household dynamics).
Senior CBT therapists provided appropriate training and supervision to ensure the safety of participants and session facilitators.
What’s next?
Further research could explore strategies for scale-up and consider how to sustain the treatment benefit. The researchers are trialling a brief version of the programme (4 sessions only) which could offer a cost-effective alternative; this study indicated that 4 sessions could be helpful. The team is also planning to test a fully remote version.
You may be interested to read
This is a summary of: Husain N, and others. Efficacy of a culturally adapted, cognitive behavioural therapy-based intervention for postnatal depression in British south Asian women (ROSHNI-2): a multicentre, randomised controlled trial. Lancet 2024; 404: 1430 – 1443.
Press release from the University of Nottingham: https://www.nottingham.ac.uk/news/study-on-british-south-asian-maternal-health
Further detail about the programme: Husain N, and others. Exploratory RCT of a group psychological intervention for postnatal depression in British mothers of South Asian origin - ROSHNI-D. Acta Psychologica 2023; 238: 103974.
Funding: This study was funded by the NIHR Health Technology Assessment.
Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the original paper.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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