Developing the Sense of Belonging Scale and Understanding Its Relationship to Loneliness, Need to Belong, and General Well-Being Outcomes.

The construct of belonging has played a central role in psychological theories for many years, prompting research that benefits many people. However, there is little consensus for how to measure sense of belonging. We developed an 8-item measure of belonging that is easily adapted to specific contexts. The items capture a sense of being valued, accepted, included/connected, and fitting into a social environment. Study 1 examined candidate items and facilitated item selection. Study 2 demonstrated internal consistency and convergent validity of the scale. Loneliness and belonging were inversely correlated but each made independent contributions predicting general measures of well-being. Together, they fully mediated the effect of positive social contact on three of the four well-being measures. Study 3 experimentally demonstrated the differential sensitivity of specific (belonging at your university) and global (belonging in general) forms of the scale. Participants who wrote about an experience of inclusion relevant to a specific context reported more belonging than participants who wrote about an exclusion experience, but only on the specific, and not global, scale. The measure of belonging reported here is validated in adult samples; it is a flexible tool for research on the sense of belonging, its antecedents, and consequences.

The Role of Latina Peer Mentors in the Implementation of the Alma Program for Women With Perinatal Depression.

This study examines the role that compañeras (peer mentors) play in the implementation of a program, Alma, which was designed to support Latina mothers who are experiencing depression during pregnancy or early parenting and implemented in the rural mountain West of the United States. Drawing from the fields of dissemination and implementation and Latina mujerista (feminist) scholarship, this ethnographic analysis demonstrates how the Alma compañeras facilitate the delivery of Alma by creating and inhabiting intimate mujerista spaces with other mothers and create relationships of mutual and collective healing in the context of relationships de confianza (of trust and confidence). We argue that these Latina women, in their capacity as compañeras, draw upon their cultural funds of knowledge to bring Alma to life in ways that prioritizes flexibility and responsiveness to the community. Shedding light on contextualized processes by which Latina women facilitate the implementation of Alma illustrates how the task-sharing model is well suited to the delivery of mental health services for Latina immigrant mothers and how lay mental health providers can be agents of healing.

Uptake of USPSTF recommendation to refer pregnant individuals for therapy or counseling to prevent perinatal depression.

PURPOSE: Perinatal depression is the most common complication of pregnancy and childbirth, and it is associated with adverse consequences. The United States Preventive Services Task Force (USPSTF) recommends that pregnant and postpartum (i.e., perinatal) individuals at risk for depression be referred for therapy or counseling interventions; however, it is unclear to what extent this recommendation has been implemented. METHODS: Pregnant individuals were recruited via advertisements on a pregnancy app and a separate study on sleep. Respondents completed the initial screening questions to determine their risk for perinatal depression, defined as self-reported history of depression; recent stressors; history of emotional, sexual, or physical abuse; mild depressive symptoms; anxiety symptoms; single; diabetes diagnosis; or unwanted pregnancy. Eligible respondents reported their providers' recommendations for preventing depression, and their utilization of interventions to prevent depression (n = 303). RESULTS: Fewer than 15% of participants reported that a provider referred them for therapy or counseling to prevent depression; recommendations included cognitive behavioral therapy (4%), interpersonal psychotherapy (2.3%), mindfulness-based cognitive therapy (4.3%), or other/unknown (6.6%). Approximately 12% reported that a provider recommended medication to prevent depression. Provider referral rates varied by risk factor, but not by patient demographics. Nearly 20% of participants reported using therapy or counseling to prevent depression, and nearly 13% reported using medication to prevent depression. CONCLUSIONS: We explore potential factors affecting the uptake of the USPSTF recommendation and underscore the importance of preventing perinatal depression.

Temporal pathways of change in two randomized controlled trials for depression and harmful drinking in Goa, India.

BACKGROUND: The current study explored the temporal pathways of change within two treatments, the Healthy Activity Program (HAP) for depression and the Counselling for Alcohol Problems (CAP) Program for harmful drinking. METHODS: The study took place in the context of two parallel randomized controlled trials in Goa, India. N = 50 random participants who met a priori criteria were selected from each treatment trial and examined for potential direct and mediational pathways. In HAP, we examined the predictive roles of therapy quality and patient-reported activation, assessing whether activation mediated the effects of therapy quality on depression (Patient Health Questionnaire-9) outcomes. In CAP, we examined the predictive roles of therapy quality and patient change- and counter-change-talk, assessing whether change- or counter-change-talk mediated the effects of therapy quality on daily alcohol consumption. RESULTS: In HAP, therapy quality (both general and treatment-specific skills) was associated with patient activation; patient activation but not therapy quality significantly predicted depression outcomes, and patient activation mediated the effects of higher general skills on subsequent clinical outcomes [a × b = -2.555, 95% confidence interval (CI) -5.811 to -0.142]. In CAP, higher treatment-specific skills, but not general skills, were directly associated with drinking outcomes, and reduced levels of counter-change talk both independently predicted, and mediated the effects of higher general skills on, reduced alcohol consumption (a × b = -24.515, 95% CI -41.190 to -11.060). Change talk did not predict alcohol consumption and was not correlated with counter-change talk. CONCLUSION: These findings suggest that therapy quality in early sessions operated through increased patient activation and reduced counter-change talk to reduce depression and harmful drinking respectively.

Treating Anxiety During Pregnancy: Patient Concerns About Pharmaceutical Treatment.

OBJECTIVES: The purpose of the current study was to describe anxious pregnant women's concerns about using pharmacotherapy to treat anxiety symptoms, and the relationship of such concerns to women's willingness to use pharmacotherapy during pregnancy. METHODS: Between April 2011 and May 2012, 148 women who were pregnant and reported elevated anxiety symptoms, as measured by the GAD-2, completed an online survey assessing their concerns about, and willingness to use, pharmacotherapy to treat anxiety symptoms during pregnancy. Qualitative responses were coded, and linear regression was used to assess the relationship between concerns and willingness. RESULTS: Pregnant women with elevated anxiety symptoms reported low willingness to use pharmacotherapy to treat anxiety symptoms during pregnancy. The most common concerns reported were about negative effects on the baby or the self, and a general opposition to taking any medications during pregnancy. These concerns were significantly related to women's willingness to try pharmacotherapy (ps < .016). CONCLUSION: Our findings underscore the importance of a pregnant woman's perceptions of potential side-effects and long-term effects of pharmacotherapy, both for herself and her offspring. These results point to specific factors that may be important to address in communication with patients about pharmacotherapy for anxiety disorders during pregnancy. Such an understanding may help clinicians provide more effective guidance and information about treatment options for anxiety disorders during pregnancy, and increase patients' willingness to engage in those treatments.

The Healthy Activity Program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: a randomised controlled trial.

BACKGROUND: Although structured psychological treatments are recommended as first-line interventions for depression, only a small fraction of people globally receive these treatments because of poor access in routine primary care. We assessed the effectiveness and cost-effectiveness of a brief psychological treatment (Healthy Activity Program [HAP]) for delivery by lay counsellors to patients with moderately severe to severe depression in primary health-care settings. METHODS: In this randomised controlled trial, we recruited participants aged 18-65 years scoring more than 14 on the Patient Health Questionnaire 9 (PHQ-9) indicating moderately severe to severe depression from ten primary health centres in Goa, India. Pregnant women or patients who needed urgent medical attention or were unable to communicate clearly were not eligible. Participants were randomly allocated (1:1) to enhanced usual care (EUC) alone or EUC combined with HAP in randomly sized blocks (block size four to six [two to four for men]), stratified by primary health centre and sex, and allocation was concealed with use of sequential numbered opaque envelopes. Physicians providing EUC were masked. Primary outcomes were depression symptom severity on the Beck Depression Inventory version II and remission from depression (PHQ-9 score of <10) at 3 months in the intention-to-treat population, assessed by masked field researchers. Secondary outcomes were disability, days unable to work, behavioural activation, suicidal thoughts or attempts, intimate partner violence, and resource use and costs of illness. We assessed serious adverse events in the per-protocol population. This trial is registered with the ISRCTN registry, number ISRCTN95149997. FINDINGS: Between Oct 28, 2013, and July 29, 2015, we enrolled and randomly allocated 495 participants (247 [50%] to the EUC plus HAP group [two of whom were subsequently excluded because of protocol violations] and 248 [50%] to the EUC alone group), of whom 466 (95%) completed the 3 month primary outcome assessment (230 [49%] in the EUC plus HAP group and 236 [51%] in the EUC alone group). Participants in the EUC plus HAP group had significantly lower symptom severity (Beck Depression Inventory version II in EUC plus HAP group 19·99 [SD 15·70] vs 27·52 [13·26] in EUC alone group; adjusted mean difference -7·57 [95% CI -10·27 to -4·86]; p<0·0001) and higher remission (147 [64%] of 230 had a PHQ-9 score of <10 in the HAP plus EUC group vs 91 [39%] of 236 in the EUC alone group; adjusted prevalence ratio 1·61 [1·34-1·93]) than did those in the EUC alone group. EUC plus HAP showed better results than did EUC alone for the secondary outcomes of disability (adjusted mean difference -2·73 [-4·39 to -1·06]; p=0·001), days out of work (-2·29 [-3·84 to -0·73]; p=0·004), intimate partner physical violence in women (0·53 [0·29-0·96]; p=0·04), behavioural activation (2·17 [1·34-3·00]; p<0·0001), and suicidal thoughts or attempts (0·61 [0·45-0·83]; p=0·001). The incremental cost per quality-adjusted life-year gained was $9333 (95% CI 3862-28 169; 2015 international dollars), with an 87% chance of being cost-effective in the study setting. Serious adverse events were infrequent and similar between groups (nine [4%] in the EUC plus HAP group vs ten [4%] in the EUC alone group; p=1·00). INTERPRETATION: HAP delivered by lay counsellors plus EUC was better than EUC alone was for patients with moderately severe to severe depression in routine primary care in Goa, India. HAP was readily accepted by this previously untreated population and was cost-effective in this setting. HAP could be a key strategy to reduce the treatment gap for depressive disorders, the leading mental health disorder worldwide. FUNDING: Wellcome Trust.

Opening windows of opportunities: Evidence for interventions to prevent or treat depression in pregnant women being associated with changes in offspring's developmental trajectories of psychopathology risk.

Although animal models and correlational studies support a model of fetal programming as a mechanism in the transmission of risk for psychopathology from parents to children, the experimental studies that are required to empirically test the model with the human prenatal dyad are scarce. With a systematic review and meta-analysis of the literature, we critically examined the evidence regarding the neurobiological and behavioral changes in infants as a function of randomized clinical trials to prevent or reduce maternal depression during pregnancy, treating randomized clinical trials as experiments testing the fetal programming model. Based on 25 articles that met inclusion criteria, we found support for interventions designed to change maternal prenatal mood being associated with changes in offspring functioning, but with a very small effect size. Effect sizes ranged broadly, and were higher for younger children. The findings enhance understanding of putative mechanisms in the transmission of risk from women's prenatal depression to infants' vulnerabilities to, and early signs of, the development of psychopathology. We note limitations of the literature and suggest solutions to advance understanding of how preventing or treating depression in pregnant women might disrupt the transmission of risk to the infants.

Cross-sectional networks of depressive symptoms before and after antidepressant medication treatment.

PURPOSE: Recent reviews have questioned the efficacy of selective serotonin reuptake inhibitors (SSRIs) above placebo response, and their working mechanisms remain unclear. New approaches to understanding the effects of SSRIs are necessary to enhance their efficacy. The aim of this study was to explore the possibilities of using cross-sectional network analysis to increase our understanding of symptom connectivity before and after SSRI treatment. METHODS: In two randomized controlled trials (total N = 178), we estimated Gaussian graphical models among 20 symptoms of the Beck Depression Inventory-II before and after 8 weeks of treatment with the SSRI paroxetine. Networks were compared on connectivity, community structure, predictability (proportion explained variance), and strength centrality (i.e., connectedness to other symptoms in the network). RESULTS: Symptom severity for all individual BDI-II symptoms significantly decreased over 8 weeks of SSRI treatment, whereas interconnectivity and predictability of the symptoms significantly increased. At baseline, three communities were detected; five communities were detected at week 8. CONCLUSIONS: Findings suggest the effects of SSRIs can be studied using the network approach. The increased connectivity, predictability, and communities at week 8 may be explained by the decrease in depressive symptoms rather than specific effects of SSRIs. Future studies with larger samples and placebo controls are needed to offer insight into the effects of SSRIs. TRIAL REGISTRATION: The trials described in this manuscript were funded by the NIMH. Pennsylvania/Vanderbilt study: 5 R10 MH55877 ( https://projectreporter.nih.gov/project_info_description.cfm?aid=6186633&icde=28344168&ddparam=&ddvalue=&ddsub=&cr=1&csb=default&cs=ASC&MMOpt= ). Washington study: R01 MH55502 ( https://projectreporter.nih.gov/project_info_description.cfm?aid=2034618&icde=28344217&ddparam=&ddvalue=&ddsub=&cr=5&csb=default&cs=ASC ).

Psychotherapeutic Treatments for Depression During Pregnancy.

Depression during pregnancy is a significant public health problem that is associated with adverse consequences for women and children. Despite the availability of treatment options, depression during pregnancy is often undertreated. Most pregnant women prefer nonpharmacological interventions over antidepressant medications. We review the evidence base for psychotherapeutic treatment approaches to depression during pregnancy. Treatments reviewed include interpersonal therapy, cognitive-behavioral therapy, behavioral activation, and mindfulness-based cognitive therapy. We review both traditional face-to-face delivery and digital interventions. We conclude with recommendations for treatment preferences, collaborative decision-making, and strategies to improve uptake of such services among prenatal women.

Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme, a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial.

BACKGROUND: The Healthy Activity Programme (HAP), a brief behavioural intervention delivered by lay counsellors, enhanced remission over 3 months among primary care attendees with depression in peri-urban and rural settings in India. We evaluated the sustainability of the effects after treatment termination, the cost-effectiveness of HAP over 12 months, and the effects of the hypothesized mediator of activation on clinical outcomes. METHODS AND FINDINGS: Primary care attendees aged 18-65 years screened with moderately severe to severe depression on the Patient Health Questionnaire 9 (PHQ-9) were randomised to either HAP plus enhanced usual care (EUC) (n = 247) or EUC alone (n = 248), of whom 95% completed assessments at 3 months, and 91% at 12 months. Primary outcomes were severity on the Beck Depression Inventory-II (BDI-II) and remission on the PHQ-9. HAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up (difference in mean BDI-II score between 3 and 12 months = -0.34; 95% CI -2.37, 1.69; p = 0.74), with lower symptom severity scores than participants who received EUC alone (adjusted mean difference in BDI-II score = -4.45; 95% CI -7.26, -1.63; p = 0.002) and higher rates of remission (adjusted prevalence ratio [aPR] = 1.36; 95% CI 1.15, 1.61; p < 0.009). They also fared better on most secondary outcomes, including recovery (aPR = 1.98; 95% CI 1.29, 3.03; p = 0.002), any response over time (aPR = 1.45; 95% CI 1.27, 1.66; p < 0.001), higher likelihood of reporting a minimal clinically important difference (aPR = 1.42; 95% CI 1.17, 1.71; p < 0.001), and lower likelihood of reporting suicidal behaviour (aPR = 0.71; 95% CI 0.51, 1.01; p = 0.06). HAP plus EUC also had a marginal effect on WHO Disability Assessment Schedule score at 12 months (aPR = -1.58; 95% CI -3.33, 0.17; p = 0.08); other outcomes (days unable to work, intimate partner violence toward females) did not statistically significantly differ between the two arms. Economic analyses indicated that HAP plus EUC was dominant over EUC alone, with lower costs and better outcomes; uncertainty analysis showed that from this health system perspective there was a 95% chance of HAP being cost-effective, given a willingness to pay threshold of Intl$16,060-equivalent to GDP per capita in Goa-per quality-adjusted life year gained. Patient-reported behavioural activation level at 3 months mediated the effect of the HAP intervention on the 12-month depression score (ß = -2.62; 95% CI -3.28, -1.97; p < 0.001). Serious adverse events were infrequent, and prevalence was similar by arm. We were unable to assess possible episodes of remission and relapse that may have occurred between our outcome assessment time points of 3 and 12 months after randomisation. We did not account for or evaluate the effect of mediators other than behavioural activation. CONCLUSIONS: HAP's superiority over EUC at the end of treatment was largely stable over time and was mediated by patient activation. HAP provides better outcomes at lower costs from a perspective covering publicly funded healthcare services and productivity impacts on patients and their families. TRIAL REGISTRATION: ISRCTN registry ISRCTN95149997.

Initial severity of depression and efficacy of cognitive-behavioural therapy: individual-participant data meta-analysis of pill-placebo-controlled trials.

BackgroundThe influence of baseline severity has been examined for antidepressant medications but has not been studied properly for cognitive-behavioural therapy (CBT) in comparison with pill placebo.AimsTo synthesise evidence regarding the influence of initial severity on efficacy of CBT from all randomised controlled trials (RCTs) in which CBT, in face-to-face individual or group format, was compared with pill-placebo control in adults with major depression.MethodA systematic review and an individual-participant data meta-analysis using mixed models that included trial effects as random effects. We used multiple imputation to handle missing data.ResultsWe identified five RCTs, and we were given access to individual-level data (n = 509) for all five. The analyses revealed that the difference in changes in Hamilton Rating Scale for Depression between CBT and pill placebo was not influenced by baseline severity (interaction P = 0.43). Removing the non-significant interaction term from the model, the difference between CBT and pill placebo was a standardised mean difference of -0.22 (95% CI -0.42 to -0.02, P = 0.03, I2 = 0%).ConclusionsPatients suffering from major depression can expect as much benefit from CBT across the wide range of baseline severity. This finding can help inform individualised treatment decisions by patients and their clinicians.

Melancholic and atypical depression as predictor and moderator of outcome in cognitive behavior therapy and pharmacotherapy for adult depression.

BACKGROUND: Melancholic and atypical depression are widely thought to moderate or predict outcome of pharmacological and psychological treatments of adult depression, but that has not yet been established. This study uses the data from four earlier trials comparing cognitive behavior therapy (CBT) versus antidepressant medications (ADMs; and pill placebo when available) to examine the extent to which melancholic and atypical depression moderate or predict outcome in an "individual patient data" meta-analysis. METHODS: We conducted a systematic search for studies directly comparing CBT versus ADM, contacted the researchers, integrated the resulting datasets from these studies into one big dataset, and selected the studies that included melancholic or atypical depressive subtyping according to DSM-IV criteria at baseline (n = 4, with 805 patients). After multiple imputation of missing data at posttest, mixed models were used to conduct the main analyses. RESULTS: In none of the analyses was melancholic or atypical depression found to significantly moderate outcome (indicating a better or worse outcome of these patients in CBT compared to ADM; i.e., an interaction), predict outcome independent of treatment group (i.e., a main effect), or predict outcome within a given modality. The outcome differences between patients with melancholia or atypical depression versus those without were consistently very small (all effect sizes g < 0.10). CONCLUSIONS: We found no indication that melancholic or atypical depressions are significant or relevant moderators or predictors of outcome of CBT and ADM.

Lessons learned from training peer-leaders to conduct Body Project workshops.

The Body Project is a cognitive-dissonance intervention that is effective in improving body satisfaction for high school and college aged women. The Body Project can be implemented by trained peers, thus increasing its potential for broad and cost-effective dissemination. Little is known, however, about peer-leaders' perceptions of their training needs and preferences to deliver prevention programs. This qualitative study explored the perceptions of training strengths and areas of improvement among 14 Body Project peer-leaders at a college campus through a series of focus groups. Recommendations are made to inform training for the Body Project as well as peer-led prevention and treatment interventions more broadly.

The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: systematic development and randomised evaluation.

BACKGROUND: Reducing the global treatment gap for mental disorders requires treatments that are economical, effective and culturally appropriate. AIMS: To describe a systematic approach to the development of a brief psychological treatment for patients with severe depression delivered by lay counsellors in primary healthcare. METHOD: The treatment was developed in three stages using a variety of methods: (a) identifying potential strategies; (b) developing a theoretical framework; and (c) evaluating the acceptability, feasibility and effectiveness of the psychological treatment. RESULTS: The Healthy Activity Program (HAP) is delivered over 6-8 sessions and consists of behavioral activation as the core psychological framework with added emphasis on strategies such as problem-solving and activation of social networks. Key elements to improve acceptability and feasibility are also included. In an intention-to-treat analysis of a pilot randomised controlled trial (55 participants), the prevalence of depression (Beck Depression Inventory II ⩾19) after 2 months was lower in the HAP than the control arm (adjusted risk ratio = 0.55, 95% CI 0.32-0.94,P= 0.01). CONCLUSIONS: Our systematic approach to the development of psychological treatments could be extended to other mental disorders. HAP is an acceptable and effective brief psychological treatment for severe depression delivered by lay counsellors in primary care.

Role of self-compassion in psychological well-being among perinatal women.

Self-compassion is associated with depression and anxiety in general samples. Although recent research indicates that dysfunctional maternal attitudes predict the development of perinatal depression and anxiety symptoms, no research to date has examined the construct of self-compassion and its relationship with psychological well-being in perinatal women. Pregnant and postpartum women (N = 189) completed self-report measures of depression and anxiety history, current depression and anxiety symptom severity, and self-compassion. Women with higher depression and anxiety symptom severity had significantly lower self-compassion. Additionally, women with self-reported prior history of depression or anxiety had significantly lower self-compassion even while controlling for current depression or anxiety symptom severity, respectively. Our results suggest that self-compassion warrants further attention in the study of the development, maintenance, and treatment of perinatal mood and anxiety disorders.

The Adolescent Behavioral Activation Program: Adapting Behavioral Activation as a Treatment for Depression in Adolescence.

This study aimed to examine implementation feasibility and initial treatment outcomes of a behavioral activation (BA) based treatment for adolescent depression, the Adolescent Behavioral Activation Program (A-BAP). A randomized, controlled trial was conducted with 60 clinically referred adolescents with a depressive disorder who were randomized to receive either 14 sessions of A-BAP or uncontrolled evidenced-based practice for depression. The urban sample was 64% female, predominantly Non-Hispanic White (67%), and had an average age of 14.9 years. Measures of depression, global functioning, activation, and avoidance were obtained through clinical interviews and/or through parent and adolescent self-report at preintervention and end of intervention. Intent-to-treat linear mixed effects modeling and logistic regression analysis revealed that both conditions produced statistically significant improvement from pretreatment to end of treatment in depression, global functioning, and activation and avoidance. There were no significant differences across treatment conditions. These findings provide the first step in establishing the efficacy of BA as a treatment for adolescent depression and support the need for ongoing research on BA as a way to enhance the strategies available for treatment of depression in this population.

An open trial of mindfulness-based cognitive therapy for the prevention of perinatal depressive relapse/recurrence.

Pregnant women with histories of depression are at high risk of depressive relapse/recurrence during the perinatal period, and options for relapse/recurrence prevention are limited. Mindfulness-based cognitive therapy (MBCT) has strong evidence among general populations but has not been studied among at-risk pregnant women to prevent depression. We examined the feasibility, acceptability, and clinical outcomes of depression symptom severity and relapse/recurrence associated with MBCT adapted for perinatal women (MBCT-PD). Pregnant women with depression histories were recruited from obstetrics clinics in a large health maintenance organization at two sites and enrolled in MBCT-PD (N = 49). Self-reported depressive symptoms and interview-based assessments of depression relapse/recurrence status were measured at baseline, during MBCT-PD, and through 6-months postpartum. Pregnant women reported interest, engagement, and satisfaction with the program. Retention rates were high, as were rates of completion of daily homework practices. Intent to treat analyses indicated a significant improvement in depression symptom levels and an 18 % rate of relapse/recurrence through 6 months postpartum. MBCT-PD shows promise as an acceptable, feasible, and clinically beneficial brief psychosocial prevention option for pregnant women with histories of depression. Randomized controlled trials are needed to examine the efficacy of MBCT-PD for the prevention of depressive relapse/recurrence during pregnancy and postpartum.

Breastfeeding Support and Messaging: A Call to Integrate Public Health and Psychological Perspectives.

INTRODUCTION: Appropriate attention to maternal mental health is missing in many public health breastfeeding promotion efforts. Although there are many benefits to breastfeeding for both mom and infant, the relationship between maternal mental health and breastfeeding is complex. Breastfeeding may not be the most effective or feasible option for all mothers. METHODS: We highlight a key international breastfeeding promotion program and argue that consideration for maternal mental health could be further incorporated into the initiative. We provide examples of how this could be done and also state that further guidance on the best alternative feeding practices to ensure the healthy development of infants is needed. RESULTS AND CONCLUSION: There is an opportunity to enhance public health breastfeeding initiatives by integrating a perinatal mental health perspective into their guidelines and accompanying resources.

Disseminating behavioural activation for depression via online training: preliminary steps.

BACKGROUND: Despite the availability of evidence-based treatments for depression, large gaps exist between empirical research and clinical practice. AIMS: To make preliminary steps toward the dissemination of Behavioural Activation (BA) via online training by examining clinicians' interest in learning BA via online training and the effects of a preliminary version of BA online training. METHOD: In study 1, practising clinicians (n = 540) completed a survey that assessed attitudes towards learning BA using an online training format. In study 2, we conducted a small, pilot randomized controlled trial (n = 46) to examine preliminary efficacy of teaching BA principles and treatment strategies with a precursor version of BA online training. RESULTS: Study findings suggest that clinicians have interest in learning about BA via online training and that clinicians participating in BA online training evidence high satisfaction and significant gains in self-efficacy using BA and knowledge of BA terms and concepts. CONCLUSIONS: These results support the importance of efforts to disseminate BA and the viability of online training as an easily accessible and affordable training option.

Gender as predictor and moderator of outcome in cognitive behavior therapy and pharmacotherapy for adult depression: an "individual patient data" meta-analysis.

BACKGROUND: It has yet to be established whether gender moderates or predicts outcome of psychological and pharmacological treatments for adult depression because: (1) individual randomized trials typically lack sufficient statistical power to detect moderators and predictors and (2) meta-analyses cannot examine such associations directly. METHODS: We conducted an "individual patient data" meta-analysis with the primary data of 1,766 patients from 14 eligible randomized trials comparing cognitive behavior therapy (CBT) with pharmacotherapy. Five studies also compared CBT and pharmacotherapy with pill placebo. We examined the extent to which gender moderates or predicts outcome, using the Hamilton Rating Scale for Depression-17-item (HAM-D-17), with mixed effects models. RESULTS: Despite the high statistical power, we did not find any indication (P > 0.05) that gender moderates outcome (i.e., no indication that either men or women respond better or worse to CBT than to pharmacotherapy or vice versa). Gender was neither a nonspecific predictor (indicating whether gender is related to improvement, regardless of comparison or control groups), nor a specific predictor (predicting outcome of CBT and pharmacotherapy compared to pill placebo). The average differences between men and women within three conditions (CBT, pharmacotherapy, and pill placebo) were less than one point on the HAM-D-17. CONCLUSIONS: The lack of predictive relations in a this good sized sample suggests that gender does not moderate differential response to CBT versus medication treatment and that it neither predicts nonspecific response across the treatments nor the specificity of response for either treatment with respect to pill placebo.