An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial.

INTRODUCTION: Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings. METHODS AND ANALYSIS: We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness. ETHICS AND DISSEMINATION: Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

Economic evaluations of treatment of depressive disorders in adolescents: Protocol for a scoping review.

AIM: Depressive disorders in adolescents are common and impairing. Evidence-based treatments are available; however, at a cost. In the context of the COVID-19 pandemic, we anticipate increased demand for treatment services for adolescents with depression. We also anticipate that economic resources will be strained. Identifying cost-effective strategies to optimally treat depression in adolescents is imperative. This protocol for a scoping review aims to describe the literature with respect to economic evaluations of treatments for depression in adolescents. METHODS: We will conduct a scoping review using established methods and reporting guidelines. MEDLINE, Embase, PsyclNFO, Econlit, and the International HTA Database will be searched from inception to June 13, 2023, with an update closer to time of manuscript submission, while the NHS Economic Evaluation Database archives will be searched from inception to December 2014. Publications that contain economic evaluations, in the context of a clinical trial or a model-based study, testing a treatment of depression in adolescents will be selected for inclusion. Extracted data items will include: economic evaluation perspectives, health outcome variables and costs used in economic evaluations, types of analyses performed, as well as quality of reporting and methodology. RESULT: A narrative synthesis with summary tables will be used to describe our findings. CONCLUSION: Our findings will help identify gaps in the literature with respect to economic analyses for the treatment of depression such that these gaps can be filled with future research. Policy-makers, funders and administrators may also use our findings to inform their decisions around provision of various treatments for depression in adolescents. REGISTRATION: osf.io/5fteb (note that information on this link will be updated upon acceptance for publication based on reviewer comments).

Public health nurse-delivered cognitive behavioral therapy for postpartum depression: Assessing the effects of maternal treatment on infant emotion regulation.

The effects of maternal postpartum depression (PPD) on offspring emotion regulation (ER) are particularly deleterious as difficulties with ER predict an increased risk of psychopathology. This study examined the impact of maternal participation in a public health nurse (PHN)-delivered group cognitive behavioral therapy (CBT) intervention on infant ER. Mothers/birthing parents were ≥ 18 years old with an Edinburgh Postnatal Depression Scale (EPDS) score ≥ 10, and infants were < 12 months. Between 2017 and 2020, 141 mother-infant dyads were randomized to experimental or control groups. Infant ER was measured at baseline (T1) and nine weeks later (T2) using two neurophysiological measures (frontal alpha asymmetry (FAA) and high-frequency heart rate variability (HF-HRV)), and informant-report of infant temperament. Mothers were a mean of 30.8 years old (SD = 4.7), 92.3% were married/ common-law, and infants were a mean of 5.4 months old (SD = 2.9) and 52.1% were male. A statistically significant group-by-time interaction was found to predict change in HF-HRV between T1 and T2 (F(1,68.3) = 4.04, p = .04), but no significant interaction predicted change in FAA or temperament. Results suggest that PHN-delivered group CBT for PPD may lead to adaptive changes in a neurophysiological marker of infant ER, highlighting the importance of early maternal intervention.

Online peer-delivered group cognitive-behavioral therapy for postpartum depression: A randomized controlled trial.

BACKGROUND: Postpartum depression (PPD) affects up to one in five mothers and birthing parents, yet just 10% receive evidence-based care. This randomized controlled trial aimed to determine if a synchronous online 9-week group cognitive-behavioral therapy (CBT) intervention delivered by mothers who have recovered from postpartum depression (i.e., peers) could effectively improve PPD and its comorbidities. METHODS: Participants (n = 183) in this study lived in Ontario, Canada, were ≥18 years-old, had an infant <12 months, were fluent in English, and scored ≥10 on the Edinburgh Postnatal Depression Scale (EPDS). They were randomized to experimental (received intervention plus treatment as usual (TAU)) or waitlist control (TAU plus the intervention after a 9-week wait) groups. Depression, anxiety, social support, mother-infant bonding, and infant temperament were assessed at baseline and 9 weeks later. Outcomes were assessed in the experimental group 3 months post-intervention to assess stability. RESULTS: Statistically significant reductions were observed in EPDS (B = 5.99; p < 0.001; d = 1.32) and Generalized Anxiety Disorder Questionnaire-7 scores (B = 5.94; p < 0.001; d = 1.22), improvements that remained stable 3 months post-intervention in the experimental group. Maternal social support (p = 0.02; d = 0.40), infant-focused anxiety (p = 0.02; d = 0.54), and infant negative emotionality (p < 0.01; d = 0.23) also improved post-intervention and remained stable 3 months later. CONCLUSION: Online peer-delivered group CBT for PPD can effectively treat PPD and anxiety, and improve social support, infant-focused anxiety, and negative emotionality in infants. This intervention could provide the means to increase access to treatment for those experiencing PPD and improve outcomes for mothers, birthing parents, and families.

Early neurodevelopment in the offspring of women enrolled in a randomized controlled trial assessing the effectiveness of a nutrition + exercise intervention on the cognitive development of 12-month-olds.

Experimental data on the effects of lifestyle interventions on fetal neurodevelopment in humans remain scarce. This study assessed the impact of a pregnancy nutrition+exercise intervention on offspring neurodevelopment at 12 months of age. The Be Healthy in Pregnancy (BHIP) randomized controlled trial (RCT) randomly assigned pregnant persons with stratification by site and body mass index (BMI) to bi-weekly nutrition counselling and high dairy protein diet, walking goal of 10,000 steps/day plus usual prenatal care (UPC; intervention group) or UPC alone (control group). This study examined a subset of these mothers (> 18 years, singleton pregnancy, BMI <40 kg/m2, and enrolled by ≤12 weeks gestation) and their infants (intervention = 42, control = 32), assessing cognition, language, motor, social-emotional, and adaptive functioning at 12 months using the Bayley Scales of Infant and Toddler Development third edition (BSID-III) as the outcome measure. We also examined if maternal factors (prepregnancy BMI, gestational weight gain (GWG)) moderated associations. Expressive language (MD = 9.62, 95% CI = (9.05-10.18), p = 0.03, ƞ2p = 0.07) and general adaptive composite (GAC) scores (MD = 103.97, 95% CI = (100.31-107.63), p = 0.04, ƞ2p = 0.06) were higher in infants of mothers in the intervention group. Effect sizes were medium. However, mean cognitive, receptive language, motor, and social-emotional scale scores did not differ between groups. A structured and monitored nutrition+exercise intervention during pregnancy led to improved expressive language and general adaptive behavior in 12-month-olds, but not cognitive, receptive language, motor, or socioemotional functioning. While these experimental data are promising, further research is needed to determine the clinical utility of nutrition+exercise interventions for optimizing infant neurodevelopment.

The impact of peer-delivered cognitive behavioral therapy for postpartum depression on infant emotion regulation.

BACKGROUND: Postpartum depression (PPD) affects up to one in five and negatively affects mothers, birthing parents, and their infants. The impact of PPD exposure on infant emotion regulation (ER) may be particularly harmful given its associations with later psychiatric problems. It remains unclear if treating maternal PPD can improve infant ER. OBJECTIVE: To examine the impact of a nine-week peer-delivered group cognitive behavioral therapy (CBT) intervention on infant ER assessed across physiological and behavioral levels. METHODS: Seventy-three mother-infant dyads were enrolled in a randomized controlled trial from 2018 to 2020. Mothers/birthing parents were randomized to the experimental group or waitlist control group. Measures of infant ER were collected at baseline (T1) and nine weeks later (T2). Infant ER was assessed using two physiological measures (frontal alpha asymmetry (FAA) and High Frequency-Heart Rate Variability (HF-HRV)), and parental-report of infant temperament. RESULTS: Experimental group infants displayed more adaptive changes in both physiological markers of infant ER from T1 to T2 (FAA (F(1,56) = 4.16, p = .046) and HF-HRV (F(1,28.1) = 5.57, p = .03)) than those in the waitlist control group. Despite improvements in maternal PPD, no differences were noted in infant temperament from T1 to T2. LIMITATIONS: A limited sample size, potential lack of generalizability of our results to other populations, and an absence of long-term data collection. CONCLUSIONS: A scalable intervention designed for those with PPD may be capable of adaptively improving infant ER. Replication in larger samples is needed to determine if maternal treatment can help disrupt the transmission of psychiatric risk from mothers/birthing parents to their infants.

Preliminary findings of emotion regulation in 12-month-old infants of mothers enrolled in a randomized controlled trial assessing a nutrition + exercise intervention.

Improved offspring emotion regulation (ER) has been associated with maternal intake of single nutrients or exercise during pregnancy but has not been examined in randomized trials. We investigated the impact of a maternal nutrition + exercise intervention during pregnancy on offspring ER at 12 months of age. Mothers in the Be Healthy In Pregnancy randomized controlled trial were randomly assigned to an individualized nutrition + exercise intervention plus usual care (UC) or UC alone (control group). A multimethod assessment of infant ER using parasympathetic nervous system function (high frequency heart rate variability [HF-HRV] and root mean square of successive differences [RMSSD]) as well as maternal reports of infant temperament (Infant Behavior Questionnaire- Revised short form) was completed with a subsample of infants of enrolled mothers (intervention = 9, control = 8). The trial was registered at www.clinicaltrials.gov (NCT01689961). We observed greater HF-HRV (M = 4.63, SD = 0.50, p = .04, ƞ2 p  = .25) and RMSSD (M = 24.25, SD = 6.15, p = .04, ƞ2 p  = .25) in infants of mothers in the intervention versus control group. Intervention group infants also had higher maternally rated surgency/extraversion (M = 5.54, SD = 0.38, p = .00, ƞ2 p  = .65) and regulation/orienting (M = 5.46, SD = 0.52, p = .02, ƞ2 p  = .81), and lower negative affectivity (M = 2.70, SD = 0.91, p = .03, ƞ2 p  = .52). These preliminary results suggest that pregnancy nutrition + exercise interventions could improve infant ER but these findings require replication in larger, more diverse samples.

The impact of the COVID-19 pandemic on the mental health of women seeking treatment for postpartum depression.

BACKGROUND: While research has examined the mental health of general population samples of postpartum women during the COVID-19 pandemic, the pandemic's impact on women seeking treatment for postpartum depression (PPD) is not well known. This study compared levels of depression and anxiety, the quality of social relationships, and the temperament of infants of treatment-seeking mothers in Ontario, Canada prior to and during the pandemic. METHODS: Mothers with Edinburgh Postnatal Depression Scale scores ≥10 and seeking treatment for PPD prior to COVID-19 (n = 100) were compared to those who sought treatment during the pandemic (n = 120). Mothers self-reported symptoms of depression, worry/anxiety, partner relationship quality, social support, as well as aspects of the mother-infant relationship and infant temperament. RESULTS: There were no statistically significant differences in symptoms of depression, anxiety, or the quality of social relationships between women seeking treatment for PPD before or during the pandemic. However, mothers reported poorer relationships with their infants, and there was evidence of more negative emotionality in their infants during COVID-19. CONCLUSIONS: The pandemic may not have worsened depression, anxiety, relationships with partners, or social support in mothers seeking treatment for PPD, but appears to have contributed to poorer mother-infant interactions and maternal reports of more negative emotionality in their infants. These findings highlight the importance of identifying women with possible PPD, supporting mother-infant interactions, and monitoring their infants during COVID-19 and beyond.

Peer-Delivered Cognitive-Behavioral Therapy for Postpartum Depression: A Randomized Controlled Trial.

Objective: To determine if a 9-week group cognitive-behavioral therapy (CBT) intervention delivered by women who have recovered from postpartum depression (peers) can effectively reduce symptoms of postpartum depression (PPD) and anxiety and improve social support and the mother-infant relationship.Methods: A sample of 73 mothers living in Ontario, Canada, were randomized into experimental and waitlist control groups between March 2018 and February 2020. Participants were ≥ 18 years of age, had an infant < 12 months old, were fluent in English, and scored ≥ 10 on the Edinburgh Postnatal Depression Scale. The experimental group completed the 9-week group CBT intervention immediately after study enrollment, while the control group did so after a 9-week waiting period. All outcomes were assessed at enrollment (n = 54) and 9 weeks later (n = 38). Outcomes were assessed in the experimental group at 6 months to assess treatment stability.Results: Peer-delivered group CBT for PPD led to clinically and statistically significant improvements in symptoms of depression (F1,47 = 22.52, P < .01) and anxiety (F1,45 = 20.56, P < .05) in the experimental group, and these improvements were stable at the 6-month follow-up. Perceptions of impaired mother-infant bonding (t15 = 3.72, P < .01) and rejection and pathological anger (t15 = 3.01, P < .01) also decreased at the 6-month follow-up in the experimental group.Conclusions: Peer-delivered group CBT for PPD effectively treats symptoms of PPD and anxiety and may lead to improvements in the mother-infant relationship. This intervention is an effective and potentially scalable means by which access to a treatment that meets the needs and wants of mothers with PPD can be increased.Trial Registration: ClinicalTrials.gov Identifier: NCT03285139.

Maternal and Infant Performance on the Face-to-Face Still-Face Task following Maternal Cognitive Behavioral Therapy for Postpartum Depression.

OBJECTIVE: This study examined the impact of treating postpartum depression (PPD) with cognitive-behavioral therapy (CBT) on mother and infant behavior on the face-to-face still-face (FFSF) paradigm. METHODS: Data from 68 mothers and their infants, 35 women with PPD within 12 months of delivery, and 33 healthy control dyads matched on infant age, sex and familial socioeconomic status were examined. Women with PPD received nine weeks of group CBT and were compared with healthy control dyads with at three timepoints on changes in mother-infant performance on the FFSF. RESULTS: A significant group x FFSF phase x visit interaction was observed for infant withdrawn behavior at the three months post-treatment (p=0.006). Infants of mothers with PPD displayed significantly less withdrawn behavior after treatment, normalizing to levels of control infants. LIMITATIONS: A relatively small sample consisting predominantly of Caucasian mother-infant dyads and the presence of comorbid anxiety in the PPD group. CONCLUSION: Three months after group CBT for PPD, infants' withdrawn behavior appears to normalize to levels seen in the infants of healthy controls. Future studies should investigate whether treatments focused on the mother-infant dyad have distinctive effects on mothers and their infants' behaviors.

Public health nurses' experiences learning and delivering a group cognitive behavioral therapy intervention for postpartum depression.

OBJECTIVES: Public Health Nurses (PHNs) often provide support to women with postpartum depression (PPD) in the absence of specialized training. The objective of this study was to explore the experiences of six PHNs who were trained to deliver a group cognitive behavioral therapy (CBT) intervention for PPD in the public health setting, and to describe how learning and delivering this intervention affected their professional roles and personal lives. DESIGN: This qualitative study employed a phenomenological approach. SAMPLE: Six PHNs who completed the CBT training program and delivered at least one CBT group in their community. MEASUREMENTS: Individual in-depth interviews were conducted and transcribed verbatim. Transcripts were analyzed according to thematic derivation procedures. RESULTS: The themes that emerged from the interviews with the PHNs included: (a) components of the CBT training program that nurses most valued, (b) benefits of training for their professional role as a PHN, (c) implications for practice, and (d) using CBT skills in their personal lives. CONCLUSIONS: The provision of CBT training to PHNs may not only positively impact their work with clients with mental illness, but may also have the potential to provide broader clinical and professional benefits for these skilled professionals and their other clients.

Right frontal brain activity at rest in the early 20s predicts threat-related bias ten years later among extremely low birth weight survivors.

Exposure to early adversity is known to shape brain-behavior relations, which in turn can lead to hypersensitivity to threat and an increased risk of developing a range of psychopathologies. To date, much of the work in this area has considered exposure to negative post-natal events (e.g., maltreatment) in shaping these relations in humans. Here we examined the influence of prenatal adversity in the form of a suboptimal intra-uterine environment (i.e., being born at extremely low birth weight; [ELBW i.e., < 1000 g]). ELBW babies are the tiniest and most at-risk infants and are known to be at risk for internalizing problems (e.g., depression and anxiety) from childhood through early adulthood. However, we know relatively little about the mechanism(s) underlying this risk. Using the oldest known prospectively followed cohort of ELBW survivors, we examined associations among birth weight status, individual differences in frontal brain electrical activity (EEG) at rest (a marker of affective style) at age 22-26 years, and threat-related biases to angry faces (using the dot probe task) at 30-35 years of age. We found that among ELBW adults, those displaying greater relative right frontal EEG activity at rest exhibited greater vigilance to angry faces than those exhibiting greater relative left frontal EEG activity (n = 34, r = -0.40, p = .02). This pattern was not observed among normal birth weight (NBW) control participants (n = 47, r = .08, p > .05). As well, the relation between frontal EEG asymmetry and vigilance to angry faces was stronger for the ELBW group versus the NBW group (z = -2.21, p =  .03). These findings suggest that exposure to significant prenatal adversity may have long-term programming effects on biological and cognitive systems associated with emotion regulatory processes in the fourth decade of life. We speculate that these vulnerabilities may contribute to making some ELBW survivors susceptible to psychopathology.

Maternal Pregnancy Diet Quality Is Directly Associated with Autonomic Nervous System Function in 6-Month-Old Offspring.

BACKGROUND: Many pregnant women are consuming diets of poor overall quality. Although many studies have linked poor prenatal diet quality to an increased risk of specific diseases in offspring, it is not known if exposure to poor prenatal diet affects core neurophysiological regulatory systems in offspring known to lie upstream of multiple diseases. OBJECTIVE: We aimed to examine the association between prenatal diet quality and autonomic nervous system (ANS) function in infants at 6 mo of age. METHODS: Data from 400 women (aged >18 y, with uncomplicated pregnancies) and their infants participating in the Maternal-Infant Research on Environmental Chemicals-Infant Development cohort were used to investigate links between prenatal diet quality and infant ANS function at 6 mo of age. Prenatal diet quality was assessed using the Healthy Eating Index (2010), calculated from a validated FFQ completed by women during the first trimester. Infant ANS function was measured using 2 assessments of heart rate variability (HRV) including root mean square of successive differences (RMSSD) and SD of N-N intervals (SDNN). Associations were analyzed before and after adjustment for socioeconomic status, maternal depression symptoms, maternal cardiometabolic dysfunction, breastfeeding, and prenatal smoking. RESULTS: Poorer prenatal diet quality was associated with lower infant HRV assessed using RMSSD (B: 0.07; 95% CI: 0.01, 0.13; R2 = 0.013) and SDNN (B: 0.18; 95% CI: 0.02, 0.35; R2 = 0.011). These associations remained significant after adjustment for confounding variables [RMSSD: B: 0.09; 95% CI: 0.003, 0.18; squared semipartial correlation (sp2) = 0.14 and SDNN B: 0.24; 95% CI: 0.0, 0.49; sp2 = 0.13]. CONCLUSIONS: In a large cohort study, poorer prenatal diet quality was associated with lower offspring HRV, a marker of decreased capacity of the ANS to respond adaptively to challenge. Therefore, poor prenatal diet may play a significant role in the programming of multiple organ systems and could increase general susceptibility to disease in offspring.

Exposure to caring parenting and adult mental health in extremely low birthweight survivors.

AIM: Individuals born at extremely low birthweight (ELBW; <1000 g) are exposed to early adversities that increase the risk of mental health problems in later life. Caring parenting has been shown to offset the negative effects of early adversity in general population samples. However, the long-term impact of caring parenting on the mental health of preterm survivors in adulthood is not known. METHODS: Using data from the world's oldest longitudinally followed cohort of ELBW survivors (n = 179) and matched normal birthweight (NBW) control participants (n = 145), we examined if caring parenting moderated the link between preterm birth and mental health at 30-35 years of age. Participants reported on the parenting they received from their mothers using the parental bonding instrument. Self-esteem and internalising problems (i.e. depression, anxiety) were self-reported at 30-35 years of age using the Coopersmith Self-Esteem Inventory and Young Adult Self-Report questionnaire, respectively. RESULTS: A statistically significant interaction was found between birthweight status and caring maternal parenting on self-esteem and internalising psychopathology in adulthood. Stratified analyses demonstrated that caring parenting was associated with better self-esteem (P < 0.001) and lower levels of internalising symptoms (P = 0.001), but in NBW participants only. CONCLUSIONS: While the receipt of caring maternal parenting promoted mental health in adults born at NBW, it did not have the same protective effect on ELBW survivors. More research is needed to elucidate the aspects of parenting and the family environment that promote the long-term mental health of preterm survivors.