A Randomised Controlled Trial of Brief Culturally Adapted CBT for Depression in Pakistan

BACKGROUND There is a strong evidence base in favour of the CBT on its role in treating Depression and Anxiety (Embling et. al., 2002; Thase et. al., 2000; Rief. et .al, 2000)). CBT has been shown to be effective for prophylaxis (Shaw, 1989) and for the prevention of depressive relapse (Paykel et al, 1999, Fava et al; 1999). The current evidence suggests that Cognitive Behaviour Therapy (CBT) is as effective as antidepressants for treating depression (DeRubeis, Hollon et al. 1982; Murphy, Simons et al. 1984; Simons, Murphy et al. 1986), and is more effective than antidepressants in preventing relapse (Evans, Hollon et al. 1992; Hollon, DeRubeis et al. 1992). CBT is now included in national treatment guidelines in the USA and the UK (e.g. APA, 2004; NICE, 2004). However, in spite of the large body of the evidence suggesting effectiveness of the CBT for depression in the West, little progress has been made in its delivery in developing countries.

Cognitive behavioral therapy for depression was developed by Beck (Beck et al, 1979). CBT focuses on "how depressed people think and perceive themselves, others and their future". The key aspects of therapy include, taking an educative approach, working in collaboration with the client and develop insights through a Socratic dialogue. The therapist helps the depressed person to learn to recognize his "negative thinking patterns" and to re-evaluate his thinking. Clients are asked to carry out exercises at home to learn new ways of dealing with their problems (called homework). Modern psychotherapies were developed in the west and hence are likely to be underpinned by western values. It is therefore believed that CBT might need modification before it can be used in the non-western cultures because it involves exploration and attempts to modify automatic thoughts and core beliefs (Padesky et al, 1995). A systematic literature search found few studies of cognitive therapy from the non western world. However, the research so far indicates towards effectiveness of this therapy (Sumathipala, 2008, Araya et al, 2003, Wong et al, 2008 & Rahman et al, 2009). We have adapted CBT for depression in Pakistan (Naeem et al, 2009) and a pilot study to evaluate the effectiveness of CBT has shown it to be effective (Naeem et al, 2011).

The focus of the mental health services in Pakistan seem to be in the secondary care. Psychiatric services are available in major cities and patients come to see professionals from around the country. As such it seems only logical that we try to assess the effectiveness of CBT in secondary care. However, given the deficits in resources both human and financial, as well as based on the experience of our team, it will make more sense if we evaluate brief interventions. In this trial we would like to test the applicability of a brief culturally adapted CBT for patients with depression who attend secondary care in Pakistan.

Methodology Objective To assess effectiveness of brief Culturally Sensitive CBT (CS-CBT) for depression against care as usual.

Study design and duration This study is a Randomized Control Trial (RCT) which aims to assess effectiveness of brief Culturally Sensitive CBT (CS-CBT) against care as usual for depression. Study participants will be randomly assigned to two groups the intervention group will receive brief CBT developed and adapted for use in Pakistan using a series of qualitative studies (Naeem et.al 2009).