The Thinking Healthy Programme – Intervention

Project Title

Development and Evaluation by Randomized Trial of a Community-Based Early Multi-model Intervention (EMI) for Depressed Mothers and their Infants in Rural Rawalpindi, Pakistan


2004 to 2007


University of Liverpool, UK; University of Manchester, UK; Institute of Psychiatry, Pakistan

Project Information

Depression is the fourth leading cause of disease burden and the largest cause of non-fatal burden, accounting for almost 12% of years lived with disability worldwide. Perinatal depression is associated with poor infant growth and cognitive development, increased rates of infant diarrhea and reduced uptake of immunization.

The treatment of perinatal depression is a public-health priority because of its high prevalence and association with disability and poor infant development. In this project, one of the most effective ‘talking therapy’ for Depression called cognitive behavior therapy was adapted and integrated into the routine work of community-based primary health workers in rural Pakistan; this intervention was called the “Thinking Healthy Programme”.

The intervention was evaluated in one of the largest randomized controlled trials to be conducted in the developing world. In a poor rural community with little access to mental health care, integration of a cognitive behavior therapy-based intervention into the routine work of community health workers more than halved the rates of perinatal depression in the women who received the intervention, compared to those women who did not receive the intervention. In addition, these women had less disability and better overall social functioning. These effects were sustained into the first postnatal year.

Also, as a result of the intervention, the infants had less episodes of diarrhea and were more likely to be immunized; mothers were more likely to use contraception and both the parents reported spending more time playing with their infants. Further analysis of the data showed that the intervention was successful even in women who were very poor and in debt.

Worldwide, the importance of mental health in achieving developmental goals, such as those endorsed by the UN’s Millennium Development project has received increased recognition. However, this recognition is not matched by the development of evidence-based and cost-effective interventions that can be scaled up in resource-poor settings. We believe this project suggests directions such interventions could take to make mental health an important component of public-health programmes. It also high-lights the importance of ‘task-shifting’ strategies to address the treatment gap in mental disorder, i.e., training non-specialists to take on some of the tasks of specialists and deliver these under close supervision.


  1. Rahman A, Sikander, S, Ahmed I, Ahmed M, Tomenson B, Creed F. (2012) Effective treatment of perinatal depression in a low-income country for women in debt and lacking financial empowerment. British Journal of Psychiatry, 201:451-7
  2. Rahman A, Malik A, Sikander S, Roberts C, Creed F. (2008) Cognitive Behaviour Therapy-based intervention by community health-workers for depressed mothers and their infants in rural Pakistan: cluster-randomized controlled trial. Lancet, 372:902-909.
  3. Rahman A (2007) Challenges and opportunities in developing a psychological intervention for perinatal depression in rural Pakistan – a multi-method study (2007) Archives of Women’s Mental Health. 10:211-219
  4. HDRF (2007) Thinking Healthy: Cognitive Behavioural Training for Healthy Mothers and Infants. Training Manual Draft 01-11-2004 (English Version). Human Development Research Foundation, Islamabad, Pakistan.
  5. HDRF (2007) Thinking Healthy: Cognitive Behavioural Training for Healthy Mothers and Infants. Training Manual Draft 01-11-2004 (Urdu Version). Human Development Research Foundation, Islamabad, Pakistan.