Comparing the effectiveness of home visiting paraprofessionals and mental health professionals delivering a postpartum depression preventive intervention: a cluster-randomized non-inferiority clinical trial.

To determine whether pregnant women receiving the Mothers and Babies group-based intervention exhibited greater depressive symptom reductions and fewer new cases of major depression than women receiving usual community-based services, and to examine whether groups run by paraprofessional home visitors and mental health professionals yielded similar depressive symptom reductions and prevention of major depression. Using a cluster-randomized design, 37 home visiting programs were randomized to usual home visiting, Mothers and Babies delivered via home visiting paraprofessionals, or Mothers and Babies delivered via mental health professionals. Baseline assessments were conducted prenatally with follow-up extending to 24 weeks postpartum. Eligibility criteria were ≥ 16 years old, ≤ 33 gestation upon referral, and Spanish/English speaking. Depressive symptoms at 24 weeks postpartum was the primary outcome. Eight hundred seventy-four women were enrolled. Neither intervention arm was superior to usual care in decreasing depressive symptoms across the sample (p = 0.401 home visiting paraprofessional vs. control; p = 0.430 mental health professional vs. control). Post hoc analyses suggest a positive intervention effect for women exhibiting mild depressive symptoms at baseline. We have evidence of non-inferiority, as the model-estimated mean difference in depressive symptoms between intervention arms (0.01 points, 95% CI: -0.79, 0.78) did not surpass our pre-specified margin of non-inferiority of two points. Although we did not find statistically significant differences between intervention and control arms, non-inferiority analyses found paraprofessional home visitors generated similar reductions in depressive symptoms as mental health professionals. Additionally, Mothers and Babies appears to reduce depressive symptoms among women with mild depressive symptoms when delivered by mental health professionals. This trial is registered on ClinicalTrials.gov (initial post: December 1, 2016; identifier: NCT02979444).

Comparing Fidelity Outcomes of Paraprofessional and Professional Delivery of a Perinatal Depression Preventive Intervention.

Mothers and Babies (MB), a perinatal depression preventive intervention, has proven effective in decreasing depressive symptoms and preventing onset of major depression. An ongoing cluster-randomized trial is comparing the effectiveness of the six-session MB group intervention led by paraprofessionals versus mental health professionals. Twenty percent of all audio-recorded intervention sessions were randomly selected for fidelity checks. Analyses assessed mean facilitator adherence and competency overall, by study arm, and by session; and, examined site, facilitator, and client-specific effects. There were no significant differences found between study arms. Findings show paraprofessionals can deliver MB with similar fidelity as mental health professionals.

Four maternal characteristics determine the 12-month course of chronic severe postpartum depressive symptoms.

BACKGROUND: Postpartum depression is a heterogeneous disorder in phenotype and etiology. Characterizing the longitudinal course of depressive symptoms over the first year after birth and identifying variables that predict distinct symptom trajectories will expedite efficient mental health treatment planning. The purpose was to determine 12-month trajectories of postpartum depressive symptoms, identify characteristics that predict the trajectories, and provide a computational algorithm that predicts trajectory membership. METHODS: A prospective cohort of women delivering at an academic medical center (2006-2011) was recruited from an urban women's hospital in Pittsburgh, PA. Women with a postpartum depressive disorder (n = 507) participated and completed symptom severity assessments at 4-8 weeks (intake), 3 months, 6 months, and 12 months. Women were predominantly Caucasian (71.8%), married (53.3%), and college educated (38.7%). Clinician interviews of depressive symptom severity, medical and psychiatric history, assessment of function, obstetric experience, and infant status were conducted. RESULTS: Analyses resulted in identification of three distinct trajectories of depressive symptoms: (1) gradual remission (50.4%), (2) partial improvement (41.8%), and (3) chronic severe (7.8%). Key predictive characteristics of the chronic severe versus gradual remission and partial improvement trajectories included parity, education, and baseline global functioning and depression severity. We were able to predict trajectory membership with 72.8% accuracy from these characteristics. CONCLUSIONS: Four maternal characteristics predicted membership in the chronic severe versus gradual remission and partial improvement trajectories with 72.8% accuracy. The trajectory groups comprise clinically relevant subgroups with the potential for tailored treatments to reduce the disease burden of postpartum depression.

Spatial affect learning restricted in major depression relative to anxiety disorders and healthy controls.

Detecting and learning the location of unpleasant or pleasant scenarios, or spatial affect learning, is an essential skill that safeguards well-being (Crawford & Cacioppo, 2002). Potentially altered by psychiatric illness, this skill has yet to be measured in adults with and without major depressive disorder (MDD) and anxiety disorders (AD). This study enrolled 199 adults diagnosed with MDD and AD (n=53), MDD (n=47), AD (n=54), and no disorders (n=45). Measures included clinical interviews, self-reports, and a validated spatial affect task using affective pictures (IAPS; Lang, Bradley, & Cuthbert, 2005). Participants with MDD showed impaired spatial affect learning of negative stimuli and irrelevant learning of pleasant pictures compared with non-depressed adults. Adults with MDD may use a "GOOD is UP" heuristic reflected by their impaired learning of the opposite correlation (i.e., "BAD is UP") and performance in the pleasant version of the task.

The negativity bias: conceptualization, quantification, and individual differences.

There is an extensive literature on the negativity bias, including its conceptualization, measurement, temporal stability (individual differences), and neural and genetic associations. Hibbing et al. posit that the difference across individuals in the negativity bias is a key factor in determining political predisposition. The measures and paradigms developed in this literature provide a means of testing this hypothesis.

What are the clinical implications of new onset or worsening anxiety during the first two weeks of SSRI treatment for depression?

OBJECTIVE: To evaluate the prevalence of new onset or worsening of anxiety symptoms, as well as their clinical implications, during the first 2 weeks of Selective Serotonin Reuptake Inhibitor (SSRI) pharmacotherapy for depression. METHOD: Adult outpatients with nonpsychotic major depressive disorder were enrolled in an 8-week acute phase SSRI treatment trial at 15 clinical sites across the United States. Worsening anxiety was defined as a greater than 2-point increase on the Beck Anxiety Inventory (BAI) between baseline and Week 2. New onset of anxiety symptoms was ascribed when the BAI baseline rating was 0 and the Week 2 value was greater or equal to 2 points on the BAI. RESULTS: Overall, after 2 weeks of treatment, 48.8% (98 of 201 participants) reported improvement in anxiety symptoms, 36.3% (73 of 201) reported minimal symptom change, and 14.9% (30 of 201) reported worsening of anxiety symptoms. No association was found between change in anxiety symptoms within the first 2 weeks and change in depressive symptoms or remission at the end of 8 weeks of treatment. For participants with clinically meaningful anxiety symptoms at baseline, however, worsening of anxiety during the first 2 weeks of treatment was associated with worsening depressive symptoms by 8 weeks (P = .054). CONCLUSIONS: The trajectory of anxiety symptom change early in SSRI treatment is an important indicator of eventual outcome for outpatients with major depression and baseline anxiety symptoms.

The use of psychosocial stress scales in preterm birth research.

Psychosocial stress has been identified as a potential risk factor for preterm birth. However, an association has not been found consistently, and a consensus on the extent to which stress and preterm birth are linked is still lacking. A literature search was performed with a combination of keywords and MeSH terms to detect studies of psychosocial stress and preterm birth. Studies were included in the review if psychosocial stress was measured with a standardized, validated instrument and if the outcomes included either preterm birth or low birthweight. Within the 138 studies that met inclusion criteria, 85 different instruments were used. Measures that had been designed specifically for pregnancy were used infrequently, although scales were sometimes modified for the pregnant population. The many different measures that have been used may be a factor that accounts for the inconsistent associations that have been observed.

Perceptual bias of patients with schizophrenia in morphed facial expression.

Limited research has specifically examined the nature of the dysfunction in emotion categorization representation in schizophrenia. The current study aimed to investigate the perception bias of morphed facial expression in subjects with schizophrenia and healthy controls in the emotion continua. Twenty-eight patients with schizophrenia and thirty-one healthy controls took part in this study. They were administered a standardized set of morphed photographs of facial expressions with varying emotional intensities between 0% and 100% of the emotion, in 10% increments to provide a range of intensities from pleasant to unpleasant and approach to withdraw. Shift points, indicating the time point that the subjects' emotion identification begins to change, and response slopes, indicating how rapidly these changes have happened at the shift points in the emotion continuum, were measured. Patients exhibited a significantly greater response slope (i.e., patients' perception changed more rapidly) and greater shift point (i.e., patients still perceived mild expressions of anger as happy faces) with increasing emotion signal compared with healthy controls when the facial expression morphed from happy to angry. Furthermore, patients with schizophrenia still perceived mild expressions of fear as angry faces(a greater shift point) and were less discriminative from angry to fearful emotion(a flatter response slope). They were sensitive to sadness (a smaller shift point) and the perception changed rapidly (a sharper response slope) as compared with healthy controls in the emotion continuum of happy to sad. In conclusion, patients with schizophrenia demonstrated impaired categorical perception of facial expressions, with generally 'rapid' but 'late' discrimination towards social threat-related stimuli such as angry facial expression. Compared with healthy controls, these patients have a sharper discrimination perception pattern in the emotion continua from positive valence to negative valence.

Changes in depressive symptoms and social functioning in the sequenced treatment alternatives to relieve depression study.

Major depressive disorder (MDD) profoundly affects social functioning, including the ability to enjoy social activities with peers, friends, and family members. We sought to compare changes in social functioning and depressive symptoms in the first level of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Adult outpatients (N = 2876) with diagnoses of MDD were treated using flexible doses of citalopram for up to 14 weeks. We compared the change over the course of treatment in the social activities item of the Work and Social Adjustment Scale to the change in individual items of the Quick Inventory of Depressive Symptoms-Self-Rated (QIDS-SR). Improvement in social functioning was modestly positively correlated with improvement in sad mood, concentration/decision making, involvement, and energy/fatigability. Only 16% to 22% of the variance in the change in social functioning was accounted for by these symptoms, and only 32% was accounted for by the total QIDS-SR score. In this large real-world sample of outpatients treated using citalopram, changes in depressive symptoms do not entirely explain improvements in social functioning.

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression.

This study followed treatment responders from a randomized controlled trial of adults with major depression. Patients treated with medication but withdrawn onto pill-placebo had more relapse through 1 year of follow-up compared to patients who received prior behavioral activation, prior cognitive therapy, or continued medication. Prior psychotherapy was also superior to medication withdrawal in the prevention of recurrence across the 2nd year of follow-up. Specific comparisons indicated that patients previously exposed to cognitive therapy were significantly less likely to relapse following treatment termination than patients withdrawn from medication, and patients previously exposed to behavioral activation did almost as well relative to patients withdrawn from medication, although the difference was not significantly different. Differences between behavioral activation and cognitive therapy were small in magnitude and not significantly different across the full 2-year follow-up, and each therapy was at least as efficacious as the continuation of medication. These findings suggest that behavioral activation may be nearly as enduring as cognitive therapy and that both psychotherapies are less expensive and longer lasting alternatives to medication in the treatment of depression.

Remitted depression moderates self-injurious behavior in personality-disordered research volunteers.

The moderating effects of depression on self-injurious behavior among personality-disordered individuals (N=40) were examined. Self-injurious behavior (SIB) was assessed using a well-validated laboratory measure. Remitted depression was associated with greater sensitivity to self-aggressive cues, indicating that remitted depression may be a risk factor for SIB.

Identifying differences in biased affective information processing in major depression.

This study investigates the extent to which participants with major depression differ from healthy comparison participants in the irregularities in affective information processing, characterized by deficits in facial expression recognition, intensity categorization, and reaction time to identifying emotionally salient and neutral information. Data on diagnoses, symptom severity, and affective information processing using a facial recognition task were collected from 66 participants, male and female between ages 18 and 54 years, grouped by major depressive disorder (N=37) or healthy non-psychiatric (N=29) status. Findings from MANCOVAs revealed that major depression was associated with a significantly longer reaction time to sad facial expressions compared with healthy status. Also, depressed participants demonstrated a negative bias towards interpreting neutral facial expressions as sad significantly more often than healthy participants. In turn, healthy participants interpreted neutral faces as happy significantly more often than depressed participants. No group differences were observed for facial expression recognition and intensity categorization. The observed effects suggest that depression has significant effects on the perception of the intensity of negative affective stimuli, delayed speed of processing sad affective information, and biases towards interpreting neutral faces as sad.

A qualitative exploration of depression in emerging adulthood: disorder, development, and social context.

OBJECTIVE: One in four emerging adults will experience a depressive episode between the ages of 18-25. We examined the lived experience of emerging adults with a focus on their treatment seeking, development and the social context of their illness. METHOD: In-depth interviews were conducted with 15 participants with major or minor depression. Interviews were recorded, transcribed verbatim and analyzed using established qualitative methods. RESULTS: Emerging adults reported dynamic and complex interactions within and between thematic areas including identification as an individual with depression, interactions with the healthcare system, relationships with friends and family, and role transitions from childhood to adulthood. Depressed mood, concerns about self-identifying one's self as being depressed, the complexity of seeking care often without insurance or financial support, alienation from peers and family, and a sense of failure to achieve expected developmental milestones appeared to interact and exacerbate functional impairment. CONCLUSIONS: Further research is needed to better understand and intervene upon pathways that lead to poor outcomes such as delayed milestones among emerging adults with depression. Health care providers should be conscious of the unique vulnerabilities posed by depressive disorders in this age group.

Development and process evaluation of a primary care internet-based intervention to prevent depression in emerging adults.

BACKGROUND: Primary care is a potential setting for implementation of depression prevention interventions using cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). The purpose of this study was to develop and conduct a process evaluation of a primary care/ Internet-based intervention that addresses key dissemination barriers in a community setting. METHOD: We used an interdisciplinary team of investigators in a multistep intervention development process among a sample of primary care patients (aged 18 to 24 years). The intervention included an initial primary care motivational interview to engage the participant, 11 Internet-based modules based on CBT (to counter pessimistic thinking) and IPT (to activate social networks and strengthen relationship skills), and a follow-up motivational interview in primary care to enhance behavior change. Each component of the intervention was rated with regard to dissemination barriers of (1) fidelity, (2) motivation, (3) dose, (4) perceived helpfulness (rated on a Likert scale), and (5) potential costs. The study was conducted from April through June of 2004. RESULTS: Fidelity checklist and serial reviews were satisfactory (100% core concepts translated into intervention). Key motivations for participation included (1) risk reduction, (2) intervention effectiveness, (3) "resiliency," and (4) altruism. In terms of dose, 13 of 14 participants engaged the Internet-based components, completing a mean of 7.2 modules (SD = 3.9). The 2 primary care interviews and the self-assessment and resiliency modules received the highest helpfulness ratings. The duration of the 2 motivational interviews was approximately 17-18 minutes, which is similar to a typical primary care visit. CONCLUSIONS: By using multidisciplinary teams and incorporating the opinions of potential users, complex preventive mental health interventions can be translated into primary care settings with adequate fidelity, motivation, dose, and perceived helpfulness, and at a reasonably low cost.

Generating an efficient version of the Edinburgh Postnatal Depression Scale in an urban obstetrical population.

BACKGROUND: Postpartum depression incurs significant burden and suffering. METHODS: We investigated the latent structure of the most commonly used screening measure, the Edinburgh Postnatal Depression Scale (EPDS) in women (N=15,172) and tested its predictive validity for the diagnosis of depression as determined with a structured clinical interview. Exploratory and confirmatory factor analyses, Receiver Operating Characteristic curves, and logistic regression analyses were conducted. RESULTS: A seven-item one factor scale (items 1, 2, 6, 7, 8, 9, 10) emerged with a Goodness of Index Fit Index (GFI) =.96, relative to the ten-item two factor version of the EPDS (GFI =.94). The seven-item EPDS achieved good sensitivity and specificity in predicting the 10-item EPDS, with a cut point score of 4 on the seven item EPDS to predict a 10-item EPDS score of 10 or more (sensitivity =95%, specificity =91%). The seven and 10-item EPDS showed a similar ability to predict a diagnoses of depression (area under the ROC curve=.795 for the 10-item, .770 for the seven-item EPDS). Logistic regression analyses showed similar predictive ability between the seven- and 10-item scales in predicting scores higher than 18 on the clinical interview LIMITATIONS: The sample represents women from one Midwest medical center and the EPDS was measured via phone. CONCLUSION: The seven-item one factor version of the EPDS is an efficient and effective measure of depression severity on par with the two factor 10-item version of the EPDS.

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression.

Antidepressant medication is considered the current standard for severe depression, and cognitive therapy is the most widely investigated psychosocial treatment for depression. However, not all patients want to take medication, and cognitive therapy has not demonstrated consistent efficacy across trials. Moreover, dismantling designs have suggested that behavioral components may account for the efficacy of cognitive therapy. The present study tested the efficacy of behavioral activation by comparing it with cognitive therapy and antidepressant medication in a randomized placebo-controlled design in adults with major depressive disorder (N = 241). In addition, it examined the importance of initial severity as a moderator of treatment outcome. Among more severely depressed patients, behavioral activation was comparable to antidepressant medication, and both significantly outperformed cognitive therapy. The implications of these findings for the evaluation of current treatment guidelines and dissemination are discussed.

Twice the negativity bias and half the positivity offset: Evaluative responses to emotional information in depression.

BACKGROUND AND OBJECTIVES: Humans have the dual capacity to assign a slightly pleasant valence to neutral stimuli (the positivity offset) to encourage approach behaviors, as well as to assign a higher negative valence to unpleasant images relative to the positive valence to equally arousing and extreme pleasant images (the negativity bias) to facilitate defensive strategies. We conducted an experimental psychopathology study to examine the extent to which the negativity bias and the positivity offset differ in participants with and without major depression.. METHOD: Forty-one depressed and thirty-six healthy participants were evaluated using a structured clinical interview for DSM-IV Axis I disorders, questionnaires, and a computerized task designed to measure implicit affective responses to unpleasant, neutral, and pleasant stimuli. RESULTS: The negativity bias was significantly higher and the positivity offset was significantly lower in depressed relative to healthy participants.. LIMITATIONS: Entry criteria enrolling medication-free participants with minimal DSM-IV comorbidity may limit generalizability of the findings. CONCLUSIONS: This study advances our understanding of the positive and negative valence systems in depression, highlighting the irregularities in the positive valence system..

The negativity bias predicts response rate to Behavioral Activation for depression.

BACKGROUND AND OBJECTIVES: This treatment study investigated the extent to which asymmetric dimensions of affective responding, specifically the positivity offset and the negativity bias, at pretreatment altered the rate of response to Behavioral Activation treatment for depression. METHOD: Forty-one depressed participants were enrolled into 16 weekly sessions of BA. An additional 36 lifetime healthy participants were evaluated prospectively for 16 weeks to compare affective responding between healthy and remitted patients at post-treatment. All participants were assessed at Weeks 0, 8 and 16 using repeated measures, involving a structured clinical interview for DSM-IV Axis I disorders, questionnaires, and a computerized task designed to measure affective responses to unpleasant, neutral, and pleasant images. RESULTS: The negativity bias at pre-treatment predicted the rate of response to BA, while the positivity offset did not. LIMITATIONS: Only one treatment condition was used in this study and untreated depressed participants were not enrolled, limiting our ability to compare the effect of BA. CONCLUSIONS: Baseline negativity bias may serve as a signal for patients to engage in and benefit from the goal-directed BA strategies, thereby accelerating rate of response.

Reduced striatal activation in females with major depression during the processing of affective stimuli.

The extent to which affective reactivity and associated neural underpinnings are altered by depression remains equivocal. This study assessed striatal activation in fifty-one unmedicated female participants meeting DSM-IV criteria for Major Depressive Disorder (MDD) and 61 age-matched healthy females (HC) aged 17-63 years. Participants completed an affective reactivity functional magnetic resonance imaging task. Data were preprocessed using SPM8, and region-of-interest analyses were completed using MarsBaR to extract caudate, putamen, and nucleus accumbens (NAcc) activation. General linear repeated measure ANOVAs were used to assess group differences and correlational analyses were used to measure the association between activation, depression severity, and anhedonia. Main effects of hemisphere, valence, and group status were observed, with MDD participants demonstrating decreased striatal activation compared with HC. Across groups and valence types, the left hemisphere demonstrated greater activation than the right hemisphere in the putamen and nucleus accumbens, whereas the right hemisphere demonstrated greater activation than the left in the caudate. Additionally, unpleasant stimuli elicited greater activation than pleasant and neutral stimuli in the caudate and putamen, and unpleasant stimuli elicited greater activation than neutral stimuli in the NAcc. There were no significant associations between activation, depression severity, and anhedonia. Overall, depression was characterized by reduced affective reactivity in the striatum, regardless of stimuli valence, supporting the emotion context insensitivity model of depression.

Differences in the neural correlates of affective responses in depressed and healthy women.

We aimed to characterize the extent to which there were differences in neural activation between female participants who were diagnosed with or without depression while viewing negative and neutral imagery. The study enrolled 105 medication-free, right-handed female participants between 17 and 63 years who met criteria for current Major Depressive Disorder (n=47) or no prior psychiatric diagnoses (n=58). All participants completed a clinical assessment and underwent a functional Magnetic Resonance Imaging (fMRI) scan while responding to an implicit affect task that required them to identify the location of ideographs embedded in one of four corners of each valenced image. When unpleasant (termed negative) stimuli were presented, depressed relative to healthy participants showed significantly decreased activation of the left amygdala and right Inferior Parietal Lobe (IPL). When activation was assessed during the negative versus neutral condition, depressed relative to healthy participants showed significantly increased activation in the Anterior Cingulate Cortex (ACC) and the left IPL. Notably, within-group analyses of healthy participants under the negative condition showed that depressive severity was positively correlated with activation in the left amygdala and left IPL. Our findings suggest that depression influences bottom-up and top-down processing of unpleasant information.