Clinical Trials Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatry. Aug 19, 2023; 13(8): 551-562
Published online Aug 19, 2023. doi: 10.5498/wjp.v13.i8.551
Randomized control trial of a culturally adapted behavioral activation therapy for Muslim patients with depression in Pakistan
Saima Dawood, Ghazala Mir, Robert M West
Saima Dawood, Centre for Clinical Psychology, University of the Punjab, Lahore Punjab 54590, Pakistan
Ghazala Mir, Robert M West, Leeds Institute of Health Sciences, School of Medicine, The University of Leeds, Leeds LS2 9JT, West Yorkshire, England, United Kingdom
Author contributions: Dawood S was involved in design of the study, led the data collection and conduct of research on data sites, contributed to analysis and drafted the write-up of results; West RM contributed to the trial design, led statistical analysis and contributed to the writing-up of results and final paper; Mir G developed the concept for the study, contributed to the methodology of the randomized control trial and writing of the final paper and gave final approval of the version to be published; All authors contributed and approved the final manuscript.
Institutional review board statement: This study has been reviewed and approved by the School of Medicine Research and Ethics Committee at the University of Leeds, United Kingdom, No. MERC-19-034; and the National Bioethics Committee, Pakistan, No. NBC-459/20/726.
Clinical trial registration statement: This study is registered at ISRCTN, No. 35418604.
Informed consent statement: All study participants provided informed written consent prior to their inclusion in the current study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Ghazala Mir, PhD, Professor, Leeds Institute of Health Sciences, School of Medicine, The University of Leeds, Clarendon Way, Leeds LS2 9JT, West Yorkshire, England, United Kingdom.
Received: January 22, 2023
Peer-review started: January 22, 2023
First decision: March 1, 2023
Revised: March 10, 2023
Accepted: May 5, 2023
Article in press: May 5, 2023
Published online: August 19, 2023

Behavioral activation therapy (BA) is as effective as cognitive behavior therapy (CBT) in treating depression and can be delivered by practitioners with much less psychological training, making it particularly suitable for low resource settings. BA that is culturally adapted for Muslims (BA-M) is a culturally adapted form of BA that has been found acceptable and feasible for Muslims with depression in the United Kingdom and Turkey; however, this is the first time that its efficacy has been determined through a definitive randomized controlled trial.


To compare the effectiveness of BA-M with CBT for Muslim patients with depression in Pakistan.


One hundred and eight patients were randomized 1:1 to treatment arms in a parallel-group randomized controlled trial in hospital or community sites in Lahore, Pakistan. Recruitment followed self-referral or referrals from clinicians, consultants or relevant professionals at each site. Four measures were recorded by blinded assessors: The patient health questionnaire-9 (PHQ-9); the BA for depression scale short form (BADS-SF); symptom checklist-revised and the World Health Organization Quality-of-Life Brief Scale. All measures were recorded at baseline and post treatment; PHQ-9 and BADS-SF were also recorded at each session and at three month follow up. The primary analysis was to regress the PHQ-9 score after therapy upon the PHQ-9 score before therapy (baseline) and the type of therapy given, that is, analysis of covariance. In addition, analysis using PHQ-9 scores collected at each therapy session was employed in a 2-level regression model.


Patients in the BA-M arm experienced greater improvement in PHQ-9 score of 1.95 units compared to the CBT arm after adjusting for baseline values (P = 0.006) The key reason behind this improvement was that patients were retained in therapy longer under BA-M, in which patients were retained for an average 0.75 sessions more than CBT patients (P = 0.013). Patients also showed significant differences on physical (P < 0.001), psychological (P = 0.004) and social (P = 0.047) domains of Quality of Life (QoL) at post treatment level, indicating an increased QoL in the BA-M group as compared to the treatment as usual group. Some baseline differences were noted in both groups for BA scores and two domains of QoL scale: Physical and environment, which might have influenced the results, though the BA-M group showed more improvement at completion of therapy.


Results proved the efficacy of BA-M in reducing symptoms for depressed patients in Pakistan, indicating BA-M is a promising treatment modality for depression in future, particularly in low resource settings.

Keywords: Culturally adapted therapy, Behavioral activation, Depression, Pakistan, Muslim, Randomized control trial

Core Tip: Behavioral activation therapy that is culturally adapted for Muslims (BA-M) is a more effective treatment for depression in comparison to cognitive behavior therapy (CBT) for Muslim populations within the Pakistani cultural context. Increased engagement with the therapy appears to be the key reason for the significantly lower depression scores of patients receiving BA-M. As this treatment can be delivered by practitioners with much less psychological training than CBT, it is particularly suitable for Muslim patients in low resource settings.