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
Research background

Depression is the largest cause of disability worldwide and can strongly impact on families and society as well as individuals. Culturally appropriate, accessible and cost-effective treatments are needed in low resource settings such as Pakistan. This study is the first randomized control trial globally of behavioral activation (BA) therapy that is culturally adapted for Muslim patients (BA-M).

Research motivation

The main focus was to explore whether BA-M, as a culturally adapted therapy, would achieve better results than cognitive behavior therapy (CBT), a standard treatment developed in a Western context. BA can be delivered by practitioners with much less psychological training than CBT, making it particularly suitable for low resource settings. This research has great significance for future studies on how to reduce depression and increase access to treatment for Muslim communities worldwide.

Research objectives

The purpose of the study was to compare the effectiveness of BA-M with CBT for Muslim patients in Pakistan.

Research methods

Clinical data were analyzed for 108 patients in a parallel-group randomized controlled trial in hospital or community sites in Lahore, Pakistan. 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 WHOQOL-BREF quality of life (QoL) 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. In addition, analysis using PHQ-9 scores collected at each therapy session was employed in a 2-level regression model.

Research results

Patients in the BA-M arm experienced greater improvement in PHQ-9 score compared to the CBT arm and were retained in therapy longer than those receiving CBT after adjusting for baseline values. BA-M patients also showed significant differences on physical, psychological and social domains of QoL at post treatment level, indicating an increased QoL in the BA-M group as compared to the CBT group.

Research conclusions

BA-M is a culturally appropriate treatment for depression that achieves better results than CBT, which is current standard treatment in Pakistan. BA-M can be delivered by practitioners with much less psychological training than CBT and is a promising treatment modality for depression in Muslim communities, particularly in low resource settings.

Research perspectives

Future research should evaluate acceptability and effectiveness of BA-M in other Muslim populations, including where these constitute minorities, and issues related to implementation and scale-up.