Discussion
depression
The treatment response rate among Ugandan PWLWH receiving depression care using an evidence-based collaborative care model was high overall, consistent with other studies, (Patel, et al., Nearly all (96%) participants who were identified as having depression received treatment, and over three-quarters of treated participants responded to PST or ADT. This encouraging result is consistent with existing literature on the effectiveness of psychological interventions such as PST for people living with HIV (van Luenen, et al., The finding that the treatment response rate was higher among those receiving PST (83.3%), compared to those receiving ADT (66.7%), deserves future study. One potential explanation is that more participants had severe depression symptoms at the start of treatment in the ADT group (29%) than the PST group (5%). Both groups were receiving support through the Family Support Group program (see Online Supplement for description of this multi-session group program to support PMTCT and pregnancy management instituted by the Ugandan Ministry of Health) as part of usual care, but perhaps the PST sessions, which could be tailored to address the specific problems facing the patient, better equipped patients with skills to manage their depression and related stressors (Malouff, et al., For participants who did not respond to their initial treatment modality, providers made few changes to management (i.e., they were not “stepped up” in therapy intensity). In particular, of the 22 participants (10 on PST, 12 on ADT) who never responded to treatment, only five were switched (n = 1) or had another treatment modality added (n = 4) to improve response, although eight of these participants (four on each modality) prematurely discontinued treatment, thus having less time to experience a change in treatment. While PST could be intensified by adding sessions, there were no dosage increases among participants receiving ADT. These results suggest a need to strengthen the provision of supportive supervision and consider refresher trainings for providers, as prior studies have documented the importance of these supports for maintaining skills over time and ensuring fidelity to treatment protocols (Murray, et al., Limited research exists on factors influencing response to depression treatment in this population. However, our observations that greater social support and less intimate partner violence were associated with greater likelihood of treatment response are consistent with a prior Ugandan study (Atuhaire, et al., This study has limitations. We do not have data on decision-making around selection of initial depression treatment modality, nor fidelity to interventions (e.g., adherence to ADT, engagement in PST sessions), which could affect treatment response. In addition, due to sample size, we could not examine differential effectiveness of treatment modalities by depression severity. Lastly, the treatment efficacy data presented reflect response to open treatment; the comparison to usual care is presented elsewhere in the context of intervention effects on PMTCT outcomes, for which depression outcomes were a mediator (Wagner et al., submitted).These results highlight that non-mental health experts, specifically nurses and lay persons, can effectively identify depression and implement both psychological and pharmacologic evidence-based depression treatment with training and supervision by specialists. Nearly all participants who needed treatment received the treatment of their choice (predominantly PST), and nearly three-quarters responded to treatment, which is at least equivalent to response rates in the literature. Our data also demonstrate the importance of screening for social support and IPV to identify PWLWH at risk for or in need of treatment for perinatal depression. These findings will help inform efforts to strengthen the provision of evidence-based, individualized perinatal depression care to PWLWH in Uganda and other low resource settings.