Randomized control trial of a culturally adapted behavioral activation therapy for Muslim patients with depression in Pakistan

Table 1 Baseline characteristics of patients stratified by therapy arm

Characteristics		BA-M		TAU		P value
		Mean or count	SD or %	Mean or count	SD or %
Age		32.3	9.6	33.8	11.5	0.437
Gender	Men	17	30%	24	42%	0.242
	Women	40	70%	33	58%
Data site	CCP	18	34%	22	39%	0.880
	PIMH	21	40%	21	37%
	Mayo	14	26%	14	25%
Education	Below primary	6	11%	6	11%	0.300
	Matric	11	20%	14	25%
	FA/A Level	9	16%	12	21%
	Other	24	43%	14	25%
	Middle/secondary	6	11%	11	19%
Marital status	Married	27	47%	19	33%	0.039
	Sep/divorced/widowed	5	9%	15	26%
	Unmarried	25	44%	23	40%
Family system	Nuclear	32	56%	31	54%	0.999
	Joint	25	44%	26	46%
Working status	Yes	25	45%	21	37%	0.514
	No	31	55%	36	63%
SES	Lower class	14	25%	21	37%	0.247
	Middle or upper class	42	75%	36	63%
PHQ (Pre)		19.5	4.9	20.1	4.1	0.487
BADS (Pre)		20.2	8.4	15.6	6.3	0.001
SCL-R (Dep)		41.9	9.9	43.1	8.2	0.506
D1 (Pre)	Physical health	17.9	4.9	14.7	4.8	0.001
D2 (Pre)	Psychological health	12.3	3.3	11.7	3.3	0.333
D3 (Pre)	Social relationships	8.4	2.6	7.9	2.6	0.298
D4 (Pre)	Environment	22.4	5.2	20.0	5.1	0.014

BA-M: Behavioral activation therapy that is culturally adapted for Muslims; TAU: Treatment as usual; CCP: Centre for Clinical Psychology, Lahore; PIMH: Punjab Institute of Mental Health, Lahore; FA/A: Upper secondary level education; PHQ: Patient health questionnaire; BADS: Behavioral activation for depression scale short form; SCL-R: Symptom checklist-revised; D: Domain; Dep: Depression.

Table 2 Characteristics of lost and retained patients

Characteristics		Lost to follow up (n = 11)	Retained (n = 103)	P value
Age, mean (SD)		35.27 (13.94)	32.83 (10.19)	0.469
Gender	Men	9 (82%)	32 (31%)	0.003
	Women	2 (18%)	71 (69%)
Education	Below primary	1 (10%)	11 (11%)
	Matric	3 (30%)	22 (21%)
	FA/A Level	1 (10%)	20 (19%)	0.915
	Other	3 (30%)	35 (34%)
	Middle/secondary	2 (20%)	15 (15%)
Marital status	Married	3 (27%)	43 (42%)	0.617
	Sep/divorced/widowed	2 (18%)	18 (18%)
	Unmarried	6 (55%)	42 (41%)
Family system	Nuclear	10 (91%)	53 (52%)	0.029
	Joint	1 (9%)	50 (49%)
Working status	Yes	5 (46%)	41 (40%)	0.989
	No	6 (55%)	61 (60%)
SES	Lower class	6 (55%)	29 (28%)	0.151
	Middle or upper class	5 (46%)	73 (72%)
PHQ Pre		20.18 (2.82)	19.79 (4.71)	0.786
BADS Pre		14.09 (4.11)	18.34 (7.90)	0.082
SCL-R (Dep)		36.91 (9.61)	43.14 (8.88)	0.030
D1 (Pre)	Physical health	16.64 (2.94)	16.33 (5.26)	0.850
D2 (Pre)	Psychological health	12.18 (3.06)	11.94 (3.31)	0.818
D3 (Pre)	Social relationships	8.00 (1.41)	8.17 (2.70)	0.842
D4 (Pre)	Environment	20.18 (3.06)	21.31 (5.44)	0.501

SES: Socioeconomic status; FA/A: Upper secondary level education; PHQ: Patient health questionnaire; BADS: Behavioral activation for depression scale short form; SCL-R: Symptom checklist-revised; D: Domain; Dep: Depression

Table 3 Summary of outcome after therapy

Characteristics	BA-M	TAU	P value
n	57	57
Drop Out	4 (7%)	7 (12%)	0.526
Retained	53 (93%)	50 (88%)
PHQ (Post), mean (SD)	4.19 (3.42)	6.18 (3.85)	0.006
BADS (Post)	34.34 (7.32)	27.90 (8.53)	< 0.001
SCL-R (Dep)	16.00 (8.08)	19.96 (7.74)	0.013
D1 Physical Health (Post)	25.85 (2.91)	22.84 (3.35)	< 0.001
D2 Psychological Health (Post)	19.74 (3.08)	17.88 (3.26)	0.004
D3 Social Relationships (Post)	10.45 (1.96)	9.64 (2.15)	0.047
D4 Environment (Post)	27.83 (4.91)	26.48 (4.44)	0.147
Number of Sessions	9.00 (1.77)	8.25 (1.39)	0.013

BA: Behavioral activation therapy; BA-M: Behavioral activation therapy that is culturally adapted for Muslims; TAU: Treatment as usual; PHQ: Patient health questionnaire; BADS: Behavioral activation for depression scale short form; SCL-R: Symptom checklist-revised; D: Domain; Dep: Depression.

Table 4 Coefficients for the regression of the patient health questionnaire-9 post-therapy measurement on baseline and therapy arm

Characteristics	Estimate	95%CI	P value
Intercept	1.205	(-1.887, 4.298)	0.441
TAU Arm	1.946	(0.545, 3.347)	0.007
Baseline PHQ	0.152	(0.002, 0.301)	0.046

TAU: Treatment as usual; PHQ: Patient health questionnaire.

Table 5 Coefficients from the regression for secondary outcomes from analysis of covariance models

Characteristics	Estimate	95%CI	P value
BADS
Intercept	36.332	(31.629, 41.035)	< 0.001
Arm TAU	-6.854	(-10.076, -3.631)	< 0.001
Baseline BADS	-0.098	(-0.302, 0.107)	0.346
SCL-R (Dep)
Intercept	0.455	(-6.723, 7.633)	0.900
Arm TAU	3.802	(0.960, 6.644)	0.009
Baseline SCL-R (Dep)	-0.098	(-0.302, 0.107)	0.346
WHOQOL (D1: Physical)
Intercept	22.948	(20.662, 25.235)	< 0.001
Arm TAU	-2.489	(-3.737, -1.241)	< 0.001
Baseline (D1: Physical)	0.162	(0.043, 0.281)	0.008
WHOQOL (D2: Psychological)
Intercept	16.097	(13.71, 25.235)	< 0.001
Arm TAU	-1.614	(-2.809, -0.420)	0.009
Baseline (D2: Psychological)	0.295	(0.133, 0.476)	0.002
WHOQOL (D3: Social)
Intercept	7.836	(6.583, 9.089)	< 0.001
Arm TAU	-0.688	(-1.424, 0.048)	0.066
Baseline (D3: Social)	0.313	(0.176, 0.450)	< 0.001
WHOQOL (D4: Environment)
Intercept	18.072	(14.496, 21.648)	< 0.001
Arm TAU	-0.328	(-1.967, 1.312)	0.693
Baseline (D4: Environment)	0.435	(0.283, 0.586)	< 0.001

BADS: Behavioral activation for depression scale short form; SCL-R: Symptom checklist-revised; WHOQOL: World Health Organization quality of life; D: Domain; Dep: Depression; TAU: Treatment as usual; PHQ: Patient health questionnaire.

Table 6 Coefficients for the fixed effects of the longitudinal model for patient health questionnaire-9

Characteristics	Estimate	95%CI	P value
Overall Intercept	21.536	(20.549, 22.524)	< 0.001
TAU Arm	0.396	(-1.010, 1.800)	0.582
Session	-2.260	(-2.363, -2.156)	< 0.001
TAU-session interaction	0.10203	(-0.058, 0.261)	0.210

TAU: Treatment as usual.