Brief Culturally adapted CBT (CaCBT) for depression: A randomized controlled trial from Pakistan

Abstract

Objectives

To determine the efficacy of brief Culturally adapted CBT (CaCBT) for depression when added to Treatment As usual (TAU)—delivered by trained therapists using a manual compared with alone TAU.

Methods

This was an assessor-blinded, randomised controlled clinical trial. Particpants with a diagnosis of depression, attending psychiatry departments of three teaching hospitals in Lahore, Pakistan, were included in the study. We screened a total of 280 patients and randomly allocated 137 of them to CaCBT plus Treatment As Usual (TAU) [Treatment group] or to TAU alone [Control group]. Assessments were completed at baseline, at 3 months and at 9 months after baseline. Reduction in depression score (Hospital Anxiety and Depression-Depression Subscale) at 3 months was primary outcome measure. The secondary outcome measures included anxiety scores (Hospital Anxiety and Depression-Anxiety Subscale), somatic symptoms (Bradford Somatic Inventory), disability (Brief Disability Questionnaire) and satisfaction with the treatment.

Findings

A total of 69 participants were randomised to Treatment group and 68 to Control group. Participants in Treatment group showed statistically significant improvement in depression (p=0.000), anxiety (p=0.000), somatic symptoms (p=0.005) and disability (p=0.000). This effect was sustained at 9 months after baseline (Except for disability). Participants in Treatment group also reported higher satisfaction with treatment compared with those in Control group.

Conclusion

Brief CaCBT can be effective in improving depressive symptoms, when compared with treatment as usual. This is the first report of a trial of Culturally adapted CBT from South Asia and further studies are needed to generalise these findings.

Introduction

CBT is now recommended as a treatment option in National Treatment Guidelines in the US and UK (National Institute of Clinical Excellence, 2009, American Psychiatric Association, 1993). There is a robust evidence base for the effectiveness of Cognitive Behaviour Therapy (CBT) in treatment, prophylaxis and prevention of relapse of depression and anxiety (Embling, 2002, Fava et al., 1998, Paykel et al., 1999, Thase, 1997). However, despite this evidence in the West, limited progress has been made in evaluating the effectiveness of CBT in low and middle income countries.

Modern psychotherapies were developed in the West and hence are underpinned by the Western values. Cultural factors heavily influence delivery of evidence based therapies (Bhugra and Bhui, 1998, Bhui and Morgan, 2007, Bhui, 2010). It is therefore believed that CBT might need modification before it can be used in the NonWestern cultures because it involves exploration and attempts to modify automatic thoughts and core beliefs (Padesky and Greenberger, 1995). The limited research so far points towards effectiveness of treatment manuals based on basic CBT principles (Husain et al., 2013, Rahman et al., 2008, Sumathipala et al., 2008) (Araya et al., 2003). We are not aware of a published trial that reported CBT delivered by trained therapists for patients attending secondary care. We adapted CBT for depression in Pakistan and a pilot study to evaluate the effectiveness of CBT has shown it to be effective in primary care (Naeem et al., 2011).

The standard CBT for depression consists of 10–20 sessions (Bond and Dryden, 2005). It is not feasible to deliver this in a LAMI country setting in view of pressure of competing demands on clinician׳s time and meagre resources for care of psychiatric patients, so it was our understanding, on the basis of our previous work, that brief interventions will be more acceptable (18). Therefore we adapted the therapy and developed a brief intervention. This paper reports the efficacy of brief Culturally adapted CBT (CaCBT) for depression when added to Treatment As usual (TAU)—delivered by trained therapists using a manual compared with TAU alone.