Preventing Anxiety and Depression in Pregnancy: A Landmark Trial from Pakistan
For many pregnant women in Pakistan, anxiety is an unseen burden. Nearly half of pregnant women in the country experience anxiety, yet most never receive support. For years, this silence felt inevitable.
A groundbreaking prenatal mental health initiative led by Pamela Surkan, ScD, PhD, MS demonstrates that it is possible and scalable to prevent postpartum anxiety and depression by addressing anxiety early in pregnancy. Supported by the National Institute of Mental Health (NIMH), the project “An anxiety-focused early prenatal intervention for the prevention of common mental disorders in Pakistan” marks a major milestone for global maternal mental health research and innovation.
What began as a collaboration seed planted during the Grand Challenges in Global Mental Health meeting in Washington, DC in 2012 evolved into a multi-year, multi-institution research partnership spanning Pakistan, the University of Liverpool, Johns Hopkins University, and collaborators across public health, psychology, psychiatry and obstetrics. The approach was bold in its simplicity: offer cognitive behavioral therapy early in pregnancy, delivered not by mental health specialists, but by trained non-specialist counselors so it could reach everyone. The program focused on the treatment of symptoms of anxiety during pregnancy, with a main goal of preventing postpartum depression.
Why this project matters
Common mental disorders (CMDs) such as anxiety and depression are pervasive during pregnancy, particularly in low- and middle-income countries. In Pakistan, up to 49% of pregnant women experience anxiety, yet access to mental health care remains severely limited. Prenatal anxiety is rarely addressed in public health systems, despite the long-term consequences for mothers and their children.
The project team set out to close this gap through prevention. Their mission was clear: develop a low-cost, sustainable intervention that reduces anxiety early in pregnancy — and improves both maternal and child outcomes.
What was done
The research team designed and tested a culturally adapted cognitive behavioral therapy (CBT) program delivered by non-specialist health providers in a public hospital in Rawalpindi. 1,200 pregnant women were randomized to receive either the intervention or usual care. Outcomes included postpartum mental health disorders, fetal and newborn growth, cost-effectiveness, and psychosocial mechanisms of change.
The approach was intentionally scalable: accessible, low-cost, and designed for health systems without specialist clinicians.
Breakthrough results
In March 2024, findings from the main trial were published in Nature Medicine, marking one of the most influential contributions to maternal mental health research to date.
Key findings from the trial include:
- Women receiving the intervention had 81% lower odds of postpartum depression or moderate-to-severe anxiety compared to those receiving usual care.
- Only 12% of women in the intervention group developed postpartum depression, versus 41% in the control group.
- Among women who attended five or more sessions, the risk of low birthweight and small-for-gestational-age births decreased by 39% and 32%, respectively.
Beyond clinical outcomes, findings showed that improved social support, reduced stress, and fewer pregnancy-related hassles played a significant role in producing positive mental health outcomes.
A research legacy already reshaping the field
To date, 29 peer-reviewed articles have been published, with multiple manuscripts in review and additional papers in preparation. The project has:
- Established one of the world’s largest datasets on prenatal anxiety in LMICs
- Developed a manualized intervention ready for dissemination
- Contributed evidence on intimate partner violence, maternal-infant bonding, breastfeeding, biological mechanisms of anxiety, and infant developmental outcomes
Notably, the intervention has already been highlighted in a research feature in Nature and selected by NIMH for a featured press release, highlighting its global relevance and potential for scale.
What’s next
The research team is now focused on scaling, with proposals submitted to test the intervention in new contexts and plans to make the intervention manual publicly available through the Center for Global Mental Health.
With strong partnerships in Pakistan and shared commitment across the global mental health community, this work has paved the way for a paradigm shift: preventing postpartum depression by treating anxiety early, and doing so through accessible, non-specialist care.
“We hope this research doesn’t end with evidence, but with implementation. Every pregnant woman deserves the chance to thrive, and mental health must be recognized as a core part of maternal health everywhere.” - Pamela Surkan, ScD, PhD, MS
About the study
- Project title: An anxiety-focused early prenatal intervention for the prevention of common mental disorders in Pakistan
- Funder: National Institute of Mental Health (RO1 MH111859)
- PI: Dr. Pamela Surkan
- Years: 2017–2024
- Primary partners: University of Liverpool, Human Development Research Foundation Pakistan, Johns Hopkins Bloomberg School of Public Health, and collaborators across Pakistan and the U.S.