What works and for whom in treating depression in older adults in deprived communities in Brazil: Findings from a causal mediation analyses of the PROACTIVE trial that overlapped with the COVID-19 pandemic (preprint)

Background: The PROACTIVE trial was a task-shared, collaborative care, psychosocial intervention that was highly effective at improving recovery from depression in older adults in Brazil that overlapped with the COVID-19 pandemic. Here we investigate mediators of the interventions effectiveness. Methods: Causal mediation analysis using interventional indirect effects, decomposed the total effect of PROACTIVE on recovery from depression (PHQ-9 less than 10), into multiple indirect effects including: dose of intervention (number of sessions and number of activities completed); social support measured through Luben Social Network Scale; perceived loneliness through the three-item UCLA questionnaire; conditions associated with frailty; and extra sessions offered to participants who did not respond to the intervention. Findings: Of the interventions total effect (difference in probability of recovery from depression between the intervention and control arms 0.211 [bias-corrected 95% CI: 0.139, 0.274]): 14% was mediated through improved conditions associated with frailty 0.030 [0.003, 0.065]); 6% through reduced loneliness (0.013 [0.001, 0.028]); and 20% through attending extra sessions for participants who did not respond to the intervention (0.042 [0.007, 0.105]). Interpretation: Our findings emphasise the importance of a home-based intervention to improve depression outcomes where participants are encouraged to self-select activities to mitigate against loneliness and are referred to primary care to manage health issues relating to frailty. Importantly, our findings suggest that offering extra sessions to participants who did not respond to the intervention shows promise in ensuring a sustained recovery from depression.

­­The Impact of a National Cash Transfer Programme on Reducing Suicide: A Study Using the 100 Million Brazilian Cohort (preprint)

Background: Socio-economic factors have been consistently associated with suicide, and economic recessions are linked to rising suicide rates. This study investigates the effect of the world`s largest conditional cash transfer (CCT) programme on suicide rates in a cohort of half the Brazilian population. Methods: We used data from the 100 Million Brazilian Cohort, covering a 12-year period (2004 to 2015). It comprises socio-economic and demographic information on 114,008,317 individuals, linked to the “Bolsa Família” programme (BFP) payroll database, and nationwide death registration data. We fitted Poisson models to estimate the incidence rate ratios for suicide, associated with exposure to the BFP and Propensity Score (PS) to group BFP beneficiaries and non-beneficiaries. We estimated the PS through multiple logistic regression using baseline socio-demographic and economic characteristics and year of registration, and ran Kernel matching analysis and several sensitivity tests. Results: In the main analysis, 33,281 suicide cases occurred among the 69,707,312 individuals followed for 305,229,883 person-years at risk. Suicide rates among beneficiaries and non-beneficiaries were 5.5 (95%CI=5.44, 5.61) and 11.1 (95%CI=10.41, 11.81) in the matched cohort and 5.4 (95%CI=5.32, 5.47) and 10.7 (95%CI=10.51, 10.87) per 100,000 individuals, in the original cohorts. BFP beneficiaries had a 61% lower suicide rate than non-beneficiaries (IRR=0.39, 95%CI=0.37,0.41) in the main analysis and similar results in all sensitivity analyses. This effect was higher among women (IRR=0.35, 95%IC=0.31,0.39), and younger individuals (IRR=0.40, 95%IC=0.37,0.44). Interpretation: CCT programs play an important role in poverty reduction and well-being improvement for beneficiaries. We have also demonstrated that it contributes towards reduced suicide rates. Targeting social determinants, using cash transfer programmes, could be important tools to limit suicide, predicted to rise in the aftermath of the economic recession, consequent to the Covid-19 pandemic.Funding Statement: The authors received no direct financial support for this article. During the study DBM held a research associate scholarship from Wellcome Trust (202912/Z/16/Z) and CIDACS has received support from the Department of Science and Technology, from the Brazilian Ministry of Health; National Research Council (CNPq), Brazil; Bill and Melinda Gates Foundation (CHAMADA MCTI/CNPq/MS/SCTIE/Decit/Fundação Bill e Melinda Gates N o 47/2014); Health Surveillance Secretariat, Ministry of Health, Brazil; Fundação de Apoio a Pesquisa do Estado da Bahia (FAPESB); Financiadora de Estudos e Projetos (FINEP); Secretaria de Ciência e Tecnologia do Estado da Bahia (SECTI), and Wellcome Trust.Declaration of Interests: All authors have no competing interests.Ethics Approval Statement: This study was approved by the two research ethics committees of the: (i) Federal University of Bahia (application number: 1023107) and (ii) London School of Hygiene & Tropical Medicine (application number: 11581).