Authors' objectives: Postnatal depression is more common in British South Asian women than white women in the United Kingdom. Despite empirical evidence suggesting the effectiveness of cognitive–behavioural therapy as a first line of treatment, little evidence is available regarding its applicability to different minority ethnic groups. Determining the clinical and cost-effectiveness of a culturally adapted group psychological intervention (Positive Health Programme) in primary care for British South Asian women with postnatal depression compared with treatment as usual. Postnatal depression (PND) is considered the leading cause of disease burden for women of childbearing age and is a global public health priority. It is often underdiagnosed and under-treated. Low mood, referred to as ‘baby blues’, presents as feeling stressed, weepy, lonely, tired, having mood spells, changes in appetite, and insomnia. It is common for women to experience these feelings following the birth of their baby, but these are usually mild and transient. PND is more severe than the ‘baby blues’ and symptoms usually develop within the first few weeks after giving birth, and can last up to a year after having a baby. PND is defined as a non-psychotic depressive episode meeting standardised diagnostic criteria for a minor, or major, depressive disorder. Literature suggests British South Asian (BSA) women have high rates of PND but are less likely to receive treatment compared to the White British women population. High rates of PND may be due to social isolation, financial problems, discrimination, deprivation, being a migrant, language difficulties and, most importantly, inequity in access to health care. Women of ethnic minority backgrounds are less likely to seek help from a general practitioner (GP) to discuss mental health issues compared to White British, and evidence about perinatal mental illness in the UK, which includes PND, is based largely on research among white women. Cultural sensitivity is required to meet the social, cultural and linguistic needs of patients. Research findings from experiences of PND in BSA women have shown that the women often experience ‘culture clash’, feelings not being understood by healthcare professionals, and there are thus considerable challenges in reporting mental health symptoms. Prajapati and Libeling have cited literature which suggests that, compared to other ethnic groups, GPs are also less likely to recognise mental health difficulties in the South Asian population and, even after recognition, are less likely to refer them to specialist services. Referrals for South Asian primary care patients for talking therapies are also less likely, despite patients reporting a preference for these over psychotropic medications. The National Institute for Health and Care Excellence emphasises the need to improve access to care for ethnic minorities and tailor health services to make them culturally sensitive to people’s cultural identity or heritage. Psychological therapies need to be adapted to improve engagement with people from ethnic minorities. This could facilitate a better understanding of mental health conditions, diverse explanatory models, and idioms of distress, and may improve access and engagement. Failing to understand the implications of ethnicity and culture on mental health can impact the engagement with services with significant cost implications. Research supports psychological interventions such as Cognitive Behavioural Therapy (CBT) as an effective treatment for PND and is recommended as a first-line treatment. A recent meta-analysis and systematic review of systematic reviews reported CBT to be the most effective evidence-based psychological treatment for PND. The CBT-based interventions for PND are grounded in the theory that thoughts are the key to understanding emotional and behavioural responses to certain situations and that thoughts are often based on a person’s previously held experiences and beliefs. Wenzel and Kleiman propose that beliefs, which are manifested through automatic negative thoughts, are activated during stressful periods, including going through transitions or changes and therefore play a key role in the development and maintenance of PND. The access to psychological interventions for ethnic minority patients, remains limited, despite the Improving Access to Psychological Therapies (IAPT) initiative. Systematic reviews demonstrate the potential role of group CBT as an alternate solution to address access barriers, by utilising an approach where a single therapist offers CBT to a group. But there is limited evidence for the effectiveness of this approach in ethnic minority women, and it requires further research. To examine the acceptability of the group intervention from the perspective of BSA women and their families. To explore the views of the GPs about the group psychological intervention and its impact on practice. To explore the perspectives of PHP group facilitators (group psychological intervention deliverers) about training and delivery of the intervention.

Authors' results and conclusions: Seven hundred and thirty-two participants across four study centres were randomised by the Manchester Clinical Trials Unit. At 4 months, almost half of patients in the treatment (Positive Health Programme) group were recovered (138 or 49%), whereas 105 (37%) were recovered in the control (treatment as usual) group. By 12 months, the control (treatment as usual) and treatment (Positive Health Programme) group had over 50% recovery at 140 (54%) and 141 (54%), respectively. For the primary outcome, recovery from postnatal depression at end of intervention, we found a significant effect such that the odds of achieving recovery in the treatment group were almost twice as high compared to the treatment as usual group (odds ratio 1.97, 95% confidence interval 1.26 to 3.10). Between the two groups, there was no significant difference in the odds of recovery at 12 months (odds ratio 1.02, 95% confidence interval 0.62 to 1.66), highlighting a need for more intensive therapies and/or longer-term care plans for this group of patients. The results of this study provide robust evidence that the culturally adapted psychological intervention for postnatal depression in South Asian women is effective at the primary end point and acceptable to women. We consider that the results of this study provide robust evidence that the culturally adapted psychological intervention PHP is clinically effective at the primary end point. The results are promising for the wider field, particularly for learning lessons in engagement with this community. This study has led to multidisciplinary deliberations on a broader level across the UK, focusing on the culturally adapted method of engagement and delivery tailored explicitly for ‘hard-to-reach’ communities. The ethnic minorities community is often labelled as ‘hard-to-reach’ or as ‘easy-to-ignore’ as phrased by one of the community partners. Despite a number of policy initiatives, the services lack the uptake of tailoring their approaches to the community they serve, and the level of cultural engagement is limited. The creative methods of recruitment, engagement and commitment to engage with the community to enhance participation in research can serve as a best-practice example for recruitment in future similar studies. The results suggest that some form of maintenance contact and booster PHP sessions, possibly digital within the 1-year period, could be helpful. The focus of future research should be further development of the PHP intervention and evaluation, with longer-term outcomes. The positive results of transition to remote delivery of PHP observed during the pandemic may be a cost-effective way forward.

Authors' methods: General practices and children’s centres in the North West, East Midlands, Yorkshire, Glasgow and London. British South Asian women meeting the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) depression criteria, aged 16 years or above, with infants up to 12 months. A multicentre randomised controlled trial with an internal pilot and partially nested design to compare treatment as usual plus the Positive Health Programme with treatment as usual in British South Asian women with postnatal depression, with a qualitative study to examine the acceptability and feasibility of the intervention. The study sample limits generalisability with other ethnic minority groups, and the cost-effectiveness analysis did not explore recall bias. Design A multicentre randomised controlled trial (RCT) with a built-in internal pilot and partially nested design to compare TAU-plus-PHP with TAU in BSA women with PND. Participants were randomised via a remote telephone randomisation service, The Manchester Clinical Trials Unit. Nested qualitative studies explored participant, health professional and facilitator perspectives. An additional substudy was incorporated following the pandemic to explore the impact of other associated risk factors related to maternal mental health and specifically in the pandemic’s context. We aimed to increase the understanding of the pandemic-related impact on BSA women, including interpersonal violence (IPV) in their communities. Participants were recruited from general practices and children’s centres in areas of high BSA density in the North West, East Midlands, Yorkshire, Glasgow and London between February 2017 and March 2020.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hta/14/68/08

Year Published: 2025

URL for published report: https://www.journalslibrary.nihr.ac.uk/hta/KKDS6622

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/KKDS6622

Organisation Name: NIHR Health Technology Assessment programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk