Summary description: Thinking Healthy Programme (THP) is a multicomponent cognitive behavioral therapy based intervention that was designed primarily as a task shifted intervention. The standard THP is an evidence-based manualised intervention targeting women with perinatal depression in low socioeconomic settings. It aims to improve health outcomes among mothers and their children through the adaptation and integration of Cognitive Behavior Therapy (CBT) techniques into the routine work of community health workers. Non-specific techniques include active listening, psychoeducation and fostering social support from key family members to support the mother in negotiating the challenges she faces. Owing to its effectiveness and ease of delivery, it was recommended by the World Health Organization as a model intervention and included in the Mental Health GAP Action Programme (mhGAP) for scaling up of mental health services around the world. THP trains non-specialist delivery agents in several evidence-based strategies to improve symptoms of perinatal depression.

The intervention programme comprised of a total of sixteen session.

**Access to the intervention manual: ** Full Open Access

Access to training: Full Open Access

Intended users/ Implementers: Trained and supervised non-specialist provider

Therapeutic strategies: The CBT techniques include challenging unhelpful thoughts, behavioral activation, and problem solving. It includes cognitive behavioral therapy sessions delivered in a simplified form through pictures, illustrations, and activities. The THP illustrates the use of CBT strategies in three simplified steps. By employing guided discovery technique, LHWs use culturally appropriate figures and illustrations to educate the intervention recipients about maladaptive thinking styles and ways to identify them. Intervention recipients are educated about strategies to replace maladaptive thoughts and use alternative healthy strategies. Thereafter, they are educated about the link between thoughts and actions. They are further taught the use of health calendar to monitor their thoughts and behaviors to practice healthy thinking.

Intervention format: The intervention programme comprised of a total of sixteen session. After one or two introductory sessions with the LHW, one session of the THP was delivered weekly for four weeks in the last month of pregnancy. These sessions comprise the module 1 of the THP, called the “preparing for the baby”. This was followed by three sessions in the first month postpartum, collectively termed as module 2, “The baby's arrival”. And then monthly sessions for nine months thereafter, comprising three modules preparing mother for early (2nd to 4th month postnatal), middle (5th to 7th month postnatal) and late (8th to 10th month postnatal) infancy. The timing of the sessions could be adapted according to the convenience of the intervention recipient. Each session lasted between 45 to 60 minutes.

Target population: Perinatal women with depression

Significant effects found on symptoms of: Moderate to large effect sizes noted for Psychological distress, depression, anxiety, social support and functional impairment.

Key innovative or differentiating features of this intervention: THPis open access and available in many languages, this means it can be adapted for different settings. The intervention has been implemented in a number of settings.

Summary of Evidence: The Thinking Healthy Programme (THP) was rigorously evaluated through a high-quality cluster randomized controlled trial involving more than 900 women experiencing perinatal depression in rural Pakistan. The intervention demonstrated substantial effectiveness, yielding an adjusted odds ratio of 0.22 (95% CI: 0.14–0.36), with 77% of participants achieving remission compared to 47% in the enhanced usual care group.

Different populations where the intervention has been used: Perinatal women with depression

Restrictions or requirements for its use: THP is not suitable for people who have a severe impairment related to a mental, neurological or substance use disorder, or are at imminent risk of suicide (e.g. people with a plan to end their life in the near future). Moreover, those with learning disability and psychotic symptoms are excluded.

Requirements / qualifications for trainers and supervisors: Non-specialist health professionals such as community health workers or supervised peers with lived experiences. Ideally this should be a mental health professional thoroughly trained in cognitive behaviour therapy (CBT). See the THP manual for more information.

Examples of implementation outside of RCT contexts: THP has been tested effectively as part of a stepped care package for health workers in Pakistan. It has also been adapted as a digital app, currently the trial is in process of publication; as a universal intervention in Turkey; adapted to target perinatal anxiety. Trial is in progress to test group preventive version of the THP in Pakistan and Turkey. Trial protcol for the app: https://link.springer.com/article/10.1186/s13063-023-07581-w

THP has been pilot tested in India, South Africa, Malawi, Peru and Turkey. Relevant publications: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-04499-6; https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-04499-6; https://pmc.ncbi.nlm.nih.gov/articles/PMC6315282/

Information provided by Ahmed Waqas on 5 December 2024, the co-author of the intervention.