What works for whom? Mother's psychological distress as a moderator of the effectiveness of a home visiting intervention.

Attachment-based home visiting programs that serve new mothers experiencing psychological distress may advance health equity by helping families systemically exposed to adversity. This study examined whether one such program (Promoting First Relationships/PFR) had particularly beneficial effects on maternal and child relationship outcomes for mothers reporting the greatest psychological distress. A randomized controlled trial of the PFR program included a low-income sample of 252 Spanish- and English-speaking mother-child dyads referred prenatally for mental health concerns. The sample of mothers was 65.5% White, 17.5% Black, and 17.1% multiracial or other racial groups; 47.2% reported Hispanic ethnicity. The moderating variable of psychological distress was measured using maternal-reported screening tools for symptoms of depression, anxiety, anger, post-traumatic stress, and interpersonal sensitivity. Outcomes included observed parenting sensitivity and self-reported understanding of infants/toddlers, caregiving confidence, and child externalizing behavior. Results showed a significant treatment condition by baseline psychological distress interaction for observed parenting sensitivity such that differences in outcomes favoring the PFR condition were greatest among those with high baseline psychological distress (baseline child age 6-12 weeks). In a low-income sample of new mothers, those with the greatest need, as indicated by high psychological distress, showed greater improvements in their sensitive and responsive caregiving if they were randomized to the PFR treatment condition.

Los programas de visita a casa basados en la afectividad que sirven a madres nuevas que experimentan angustia sicológica pudieran mejorar la equidad de salud ayudando a familias sistemáticamente expuestas a circunstancias adversas. Este estudio examinó si uno de tales programas (Promover Primeras Relaciones /PFR) tiene particularmente efectos beneficiosos en los resultados de la relación materna y del niño para madres que reportan la mayor angustia sicológica. Un ensayo controlado al azar sobre el programa PFR incluyó un grupo muestra de bajos recursos económicos de 252 díadas de madre-niño que hablaban español o inglés, referidas prenatalmente por razón de salud mental. El grupo muestra de madres estaba compuesto de 65.5% blancas, 17.5% negras, y 17.1% multirracial o de otros grupos raciales; el 47.2% reportó origen étnico hispano. La variable moderadora de angustia sicológica se midió con herramientas de detección reportadas por las madres para síntomas de depresión, ansiedad, ira, estrés postraumático y sensibilidad interpersonal. Entre los resultados se incluyen la observada sensibilidad de crianza y la auto-reportada comprensión de infantes y niños pequeñitos, la confianza en la prestación de cuidado, así como la conducta de externalización del niño. Los resultados muestran una significativa condición de tratamiento por medio de interacción de angustia sicológica al nivel básico para la observada sensibilidad de crianza, de manera que las diferencias en resultados que favorecen la condición PFR fueron mayores entre quienes presentaban una alta angustia sicológica de base (punto base edad del niño 6 a 12 semanas). En un grupo muestra de madres nuevas de bajos recursos económicos, aquellas con las mayores necesidades, tal como indica la alta angustia sicológica, mostraron mayores logros en su sensibilidad y el cuidado sensible si se les había seleccionado al azar para la condición de tratamiento PFR.

Les programmes de visite à domicile basés sur l'attachement qui servant des nouvelles mères faisant l'expérience de détresse psychologique peuvent faire avancer l'équité en santé en aidant des familles systématiquement exposées à l'adversité. Cette étude a examiné si un tel programme (la Promotion de Premières Relations, soit en anglais Promoting First Relationships/PFR) avait des effets particulièrement bénéfiques sur les résultats de relation maternelle et enfant pour les mères faisant état de la plus grande détresse psychologique. Un essai contrôlé randomisé du programme PFR a inclus un échantillon de 252 dyades mères-enfants de milieu défavorisé, parlant espagnol et anglais, référées avant la naissance pour des problèmes de santé mentale. L'échantillon de mères était 65,5% caucasiennes/blanches, 17,5% noires, and 17,1% multiraciales ou autres groupes raciaux, 47,2% faisant état d'une ethnicité hispanique. La variable modératrice de détresse psychologique a été mesurée en utilisant des outils de dépistage rapportés par la mère de dépression, d'anxiété, de stress post-traumatique, et de sensibilité interpersonnelle. Les résultats ont inclus une sensibilité de parentage observée et une compréhension auto-rapportée des bébés/petits enfants, une confiance de parentage, et un comportement externalisant de l'enfant. Les résultats montrent une condition de traitement importante par l'interaction psychologique de base pour la sensibilité de parentage observée telles que les différences dans les résultats favorisant la condition PFR étaient les plus grandes parmi celles avec la base de détresse psychologique élevée (âge de base de l'enfant 6-12 semaines). Chez un échantillon de nouvelles mères de milieux défavorisés, celles ayant le besoin le plus élevé, indiqué par une haute détresse psychologique, ont fait preuve des plus améliorations dans leur parentage sensible et réactif si elles étaient randomisées pour la condition de traitement PFR.

Change Mechanisms in Brief Interpersonal Psychotherapy for Women With Perinatal Depression: Qualitative Study.

OBJECTIVE: Brief interpersonal psychotherapy (IPT-B) has been shown to be effective in treating perinatal depression and in preventing depressive relapse among socioeconomically disadvantaged women. Yet, it is unclear how IPT-B alleviates depression. Previous research has suggested four possible change mechanisms derived from IPT's interpersonal model: decreasing interpersonal stress, facilitating emotional processing, improving interpersonal skills, and enhancing social support. This study explored how women who received IPT-B or enhanced maternity support services (MSS-Plus) evaluated their respective experiences. METHODS: A qualitative study was conducted with 16 women who had been recruited from public health clinics to participate in a larger, randomized controlled trial of women with major depression or dysthymia and who had been assigned to receive IPT-B or MSS-Plus. The sample was 63% non-Hispanic White, had an average age of 31.6 years, and was balanced in intervention group assignment, posttraumatic stress disorder status, and depression improvement. Telephone interviews included semistructured, open-ended questions eliciting participants' experiences with depression treatment. Predetermined, conceptually derived codes were based on the four postulated IPT change mechanisms. RESULTS: Thematic coded excerpts were collected and discussed. Excerpts lent support to the role of IPT-B in helping women decrease their interpersonal stress; identify, reflect on, and regulate their emotions; and improve their social skills. Evidence for increasing social support was mixed but highlighted the importance of the therapeutic relationship. CONCLUSIONS: Including qualitative findings into training in public health and other clinical settings will help illuminate the role of the provider in facilitating the change mechanisms that may lead to improved mental health among clients.

Benefit-cost analysis of Promoting First Relationships®: Implications of victim benefits assumptions for return on investment.

BACKGROUND: Child abuse and neglect (CAN) cost United States society $136 billion to $428 billion annually. Preventive interventions that reduce CAN may improve people's lives and generate economic benefits to society, but their magnitude is likely to vary greatly with assumptions about victim costs avoided through intervention. OBJECTIVE: We examined the implications of different assumptions about avoided victim costs in a benefit-cost analysis of Promoting First Relationships® (PFR), a 10-session attachment and strengths-based home visiting intervention. PARTICIPANTS AND SETTING: Participants were 247 child protection-involved but intact families in Washington State randomized to receive PFR (n = 124) or resource and referral (n = 123). METHODS: We monetized intervention effects on out-of-home placements and implicit effects on CAN and calculated net present values under three scenarios: (1) benefits from avoided system costs, (2) additional benefits from avoided tangible victim costs, and (3) additional benefits from avoided tangible and intangible quality-of-life victim costs. For scenarios 2 and 3, we varied the CAN effect size and estimated the effect size at which PFR was reliably cost beneficial. RESULTS: PFR's societal net benefit ranged from $1 (scenario 1) to $5514 - $25,562 (scenario 2) and $7004 - $32,072 (scenario 3) (2014 USD). In scenarios 2 and 3, PFR was reliably cost beneficial at a CAN effect size of approximately -0.25. CONCLUSIONS: PFR is cost beneficial assuming tangible victim costs are avoided by PFR. Research into the long-term health and economic consequences of reducing CAN in at-risk populations would contribute to comprehensive, accurate benefits models.

Impact of a home visiting program on sleep problems among young children experiencing adversity.

BACKGROUND: Adversity may negatively impact young children's sleep but receiving home visitation services could buffer children from this potential consequence of adversity. OBJECTIVE: This study examined whether young children's adverse experiences increased their risk for sleep problems and if Promoting First Relationships® (PFR), a home visitation program, reduced children's risk for sleep problems both directly and indirectly through increased parenting sensitivity. PARTICIPANTS AND SETTING: Participants were 247 parents and their 10- to 24-month-old child recruited from Child Protective Services offices. METHODS: A secondary analysis of a randomized controlled trial comparing PFR to a resource and referral control condition was conducted. Four time points of data were collected from baseline to 6 months post-intervention. Parenting sensitivity was measured at all time points using a parent-child interaction tool. Children's adversities were measured at various time points using caregiver report tools and official state records. Children's sleep problems were reported by parents at 6 months post-intervention. RESULTS: The likelihood of having a sleep problem increased as children's adversities increased (ß = .23, SE = .08, p = .005). There was no effect (direct or indirect) of treatment assignment on children's sleep problems (ps > .05). Post hoc analyses showed a treatment assignment by adversity interaction such that children's odds of having a sleep problem increased as their adversities increased, but only among children in the control condition (b = -0.37, SE = 0.17, p = .030). CONCLUSIONS: Experiencing more adversities associated with a greater risk for sleep problems, but PFR buffered children from this risk.

An intervention that increases parental sensitivity in families referred to Child Protective Services also changes toddlers' parasympathetic regulation.

Experiencing maltreatment in early childhood predicts poor parasympathetic regulation, characterized by low baseline parasympathetic activity and strong withdrawal of parasympathetic influence in response to tasks. The Promoting First Relationships® (PFR) program improves parental sensitivity toward young children in families identified as maltreating. Using a subsample from a randomized control trial, we examined whether parental participation in PFR had lasting effects on toddlers' parasympathetic regulation, as measured by respiratory sinus arrhythmia (RSA), relative to a resource and referral control condition. In addition, we examined whether parental sensitive and responsive behavior mediated or moderated associations between parent treatment group and children's RSA. More than 6 months after completing treatment, 29 families in the PFR condition and 30 families in the control condition were visited at home, and toddlers' RSA was assessed at baseline and during five moderately challenging tasks. Groups did not differ in baseline RSA, but differed in RSA reactivity to the tasks. Across tasks, toddlers of parents in the control condition manifested significantly larger RSA decreases than toddlers of parents in the PFR condition. Parental behavior showed divergent associations with RSA change for toddlers of parents in the PFR versus control condition, with PFR treatment predicting RSA change ranging from small decreases to increases in toddlers of parents who showed the most sensitive, responsive behavior in the 6 months following treatment. This preliminary study showed that the same intervention that improved parenting also improved toddlers' parasympathetic regulation in response to everyday activities, warranting further experimental investigation.

Does Parents' Own History of Child Abuse Moderate the Effectiveness of the Promoting First Relationships® Intervention in Child Welfare?

To better understand how and for whom parenting intervention may improve family outcomes in child welfare services, we examined whether parents' own history of child abuse moderated the indirect effects of the Promoting First Relationships® (PFR) intervention on toddlers' secure base behavior via parental sensitivity. Parents ( N = 247) and their toddlers (10-24 months) involved with child protective services were randomized to PFR or a control intervention. Results showed that the PFR group demonstrated greater parental sensitivity at postintervention than the control group, which in turn led to higher levels of toddler secure base behavior at 6-month follow-up. Findings from a moderated mediation model indicated that these intervention effects were only evident for parents who experienced physical abuse in their childhood. Parents' history of sexual or emotional abuse did not significantly moderate outcomes. These results provide evidence for a key mechanism of change in PFR informed by attachment theory and suggest that PFR intervention effects may be stronger in parents at higher risk of the intergenerational transmission of abuse.

PARENTAL CHILDHOOD ADVERSITY, DEPRESSIVE SYMPTOMS, AND PARENTING QUALITY: EFFECTS ON TODDLER SELF-REGULATION IN CHILD WELFARE SERVICES INVOLVED FAMILIES.

Parents who are involved with child welfare services (CWSI) often have a history of childhood adversity and depressive symptoms. Both affect parenting quality, which in turn influences child adaptive functioning. We tested a model of the relations between parental depression and child regulatory outcomes first proposed by K. Lyons-Ruth, R. Wolfe, A. Lyubchik, and R. Steingard (2002). We hypothesized that both parental depression and parenting quality mediate the effects of parental early adversity on offspring regulatory outcomes. Participants were 123 CWSI parents and their toddlers assessed three times over a period of 6 months. At Time 1, parents reported on their childhood adversity and current depressive symptoms. At Time 2, parents' sensitivity to their child's distress and nondistress cues was rated from a videotaped teaching task. At Time 3, observers rated children's emotional regulation, orientation/engagement, and secure base behavior. The results of a path model partly supported the hypotheses. Parent childhood adversity was associated with current depressive symptoms, which in turn related to parent sensitivity to child distress, but not nondistress. Sensitivity to distress also predicted secure base behavior. Depression directly predicted orientation/engagement, also predicted by sensitivity to nondistress. Sensitivity to distress predicted emotion regulation and orientation/engagement. Results are discussed in terms of intervention approaches for CWSI families.

Ensuring Implementation Fidelity of a 10-Week Home Visiting Program in Two Randomized Clinical Trials.

Introduction Implementation fidelity is a challenge for the adoption of evidence-based programs within social service broadly and child welfare specifically. However, implementation fidelity is critical for maintaining the integrity of clinical trials and for ensuring successful delivery of services in public health settings. Methods Promoting First Relationships ® (PFR), a 10-week home visiting parenting intervention, was evaluated in two randomized clinical trials with populations of families in child welfare. Seven providers from community agencies participated in the trials and administered PFR. Fidelity data collected included observational measures of provider behavior, provider records, and input from clients to assess training uptake, adherence to content, quality of delivery, program dosage, and participant satisfaction. Results In mock cases to assess training uptake, providers demonstrated an increase in PFR verbalization strategies and a decrease non-PFR verbalizations from pre to post PFR training, and overall this was maintained a year later (Mann-Whitney U's = 0, p's < .01). Adherence to content in actual cases was high, with M = 97% of the program elements completed. Quality of delivery varied across providers, indicated by PFR consultation strategies (Wilks' Lambda F = 18.24, df = 15, p < .001) and global ratings (F = 13.35, df = 5, p < .001). Program dosage was high in both trials (71 and 86% receiving 10 sessions), and participant satisfaction was high (M = 3.9, SD = 0.2; 4 = greater satisfaction). Discussion This system of training and monitoring provides an example of procedures that can be used effectively to achieve implementation fidelity with evidence-based programs in social service practice.

Assessing Variations in Developmental Outcomes Among Teenage Offspring of Teen Mothers: Maternal Life Course Correlates.

This study investigated potential heterogeneity in development among offspring (age 17) of teen mothers and maternal life course as correlates of variation. Using latent class analysis, subgroups of developmental outcomes were identified. Maternal standing in two life course realms (i.e., socioeconomic and domestic) was considered as a potential explanation for heterogeneity in offspring's development. Offspring reported on measures assessing their psychological, academic, and behavioral development. Teen mothers reported on measures of life course realms. Three subgroups of developmental outcomes were identified: on track (52%), at risk (37%), and troubled (11%). Findings suggest that economic hardship and number of pregnancies among teen mothers distinguish developmental patterns among teenage offspring, whereas teen mothers' educational attainment and marital status do not.

Incremental Benefit-Cost of MOMCare: Collaborative Care for Perinatal Depression Among Economically Disadvantaged Women.

OBJECTIVE: Effectiveness of collaborative care for perinatal depression has been demonstrated for MOMCare, from early pregnancy up to 15 months postpartum, for Medicaid enrollees in a public health system. MOMCare had a greater impact on reducing depression and improving functioning for women with comorbid posttraumatic stress disorder (PTSD) than for those without PTSD. This study estimated the incremental benefit and cost and the net benefit of MOMCare for women with major depression and PTSD. METHODS: A randomized trial (September 2009 to December 2014) compared the MOMCare collaborative care depression intervention (choice of brief interpersonal psychotherapy or pharmacotherapy or both) with enhanced maternity support services (MSS-Plus) in the public health system of Seattle-King County. Among pregnant women with a probable diagnosis of major depression or dysthymia (N=164), two-thirds (N=106) met criteria for probable PTSD. Blinded assessments at three, six, 12, and 18 months postbaseline included the Symptom Checklist-20 depression scale and the Cornell Services Index. Analyses of covariance estimated gain in depression free days (DFDs) by intervention and PTSD status. RESULTS: When the analysis controlled for baseline depression severity, women with probable depression and PTSD in MOMCare had 68 more depression-free days over 18 months than those in MSS-Plus (p<.05). The additional depression care cost per MOMCare participant with comorbid PTSD was $1,312. The incremental net benefit of MOMCare was positive if a DFD was valued at ≥$20. CONCLUSIONS: For women with probable major depression and PTSD, MOMCare had significant clinical benefit over MSS-Plus, with only a moderate increase in health services cost.

Collaborative Care for Perinatal Depression Among Socioeconomically Disadvantaged Women: Adverse Neonatal Birth Events and Treatment Response.

OBJECTIVE: The study examined the effectiveness of a perinatal collaborative care intervention in moderating the effects of adverse neonatal birth events on risks of postpartum depressive symptoms and impaired functioning among women of lower socioeconomic status with antenatal depression. METHODS: A randomized controlled trial with blinded outcome assessments was conducted in ten public health centers, comparing MOMCare (choice of brief interpersonal psychotherapy, pharmacotherapy, or both) with intensive maternity support services (MSS-Plus). Participants had probable diagnoses of major depressive disorder or dysthymia during pregnancy. Generalized estimating equations estimated differences in depression and functioning measures between groups with and without adverse birth events within the treatment arms. A total of 160 women, 43% of whom experienced at least one adverse birth event, were included in the analyses. RESULTS: For women who received MOMCare, postpartum depression scores (measured with the Symptom Checklist-20) did not differ by whether or not they experienced an adverse birth event (mean±SD scores of .86±.51 for mothers with an adverse birth event and .83±.56 for mothers with no event; p=.78). For women who received MSS-Plus, having an adverse birth event was associated with persisting depression in the postpartum period (mean scores of 1.20±.0.61 for mothers with an adverse birth event and .93±.52 for mothers without adverse birth event; p=.04). Similar results were seen for depression response rates and functioning. CONCLUSIONS: MOMCare mitigated the risk of postpartum depressive symptoms and impaired functioning among women of low socioeconomic status who had antenatal depression and who experienced adverse birth events.

Promoting First Relationships®: Randomized Trial of a 10-Week Home Visiting Program With Families Referred to Child Protective Services.

We conducted a community-based randomized control trial with intent-to-treat analysis on Promoting First Relationships® (PFR), a 10-week home visiting program. The study included 247 families with 10- to 24-month-old children who had a recent, open child protective services investigation of child maltreatment. Families were randomly assigned to receive either the 10-week home visiting PFR service or a telephone-based, three-call resource and referral (R&R) service. Across postintervention time points, parents in the PFR condition scored higher than families in the R&R condition in parent understanding of toddlers' social emotional needs ( d = .35) and observed parental sensitivity ( d = .20). Children in the PFR condition scored lower than children in the comparison condition on an observational measure of atypical affective communication ( d = .19) and were less likely than children in the comparison group to be placed into foster care through 1-year postintervention (6% vs. 13%, p = .042). No significant differences were found on measures of parenting stress or child social-emotional competence, behavior problems, or secure base behavior. Overall, the results show support for the promise of PFR as an intervention for enhancing parent sensitivity and preventing child removals for families in the child welfare system.

Promoting Birth Parents' Relationships with their Toddlers upon Reunification: Results from Promoting First Relationships® Home Visiting Program.

Birth parents, once reunified with their child after a foster care placement, are in need of in-home support services to prevent reoccurrence of maltreatment and reentry into foster care, establish a strong relationship with their child, and enhance child well-being. Few studies have addressed the efficacy of home visiting services for reunified birth parents of toddlers. This study reports on the findings from a randomized control trial of a 10-week home visiting program, Promoting First Relationships® (Kelly, Sandoval, Zuckerman, & Buehlman, 2008), for a subsample of 43 reunified birth parents that were part of the larger trial. We describe how the elements of the intervention align with the needs of parents and children in child welfare. Although the sample size was small and most of the estimates of intervention effects were not statistically significant, the effect sizes and the pattern of results suggest that the intervention may have improved both observed parenting sensitivity and observed child behaviors as well as decreased parent report of child behavior problems. Implications are that providing in-home services soon after a reunification may be efficacious in strengthening birth parents' capacity to respond sensitively to their children as well as improving child social and emotional outcomes and well-being.

A Randomized Trial of Collaborative Care for Perinatal Depression in Socioeconomically Disadvantaged Women: The Impact of Comorbid Posttraumatic Stress Disorder.

OBJECTIVE: The comorbidity of posttraumatic stress disorder (PTSD) with antenatal depression poses increased risks for postpartum depression and may delay or diminish response to evidence-based depression care. In a secondary analysis of an 18-month study of collaborative care for perinatal depression, the authors hypothesized that pregnant, depressed, socioeconomically disadvantaged women with comorbid PTSD would show more improvement in the MOMCare intervention providing Brief Interpersonal Psychotherapy and/or antidepressants, compared to intensive public health Maternity Support Services (MSS-Plus). METHODS: A multisite randomized controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System, July 2009-January 2014. Pregnant women were recruited who met criteria for a probable diagnosis of major depressive disorder (MDD) on the Patient Health Questionnaire-9 and/or dysthymia on the MINI-International Neuropsychiatric Interview (5.0.0). The primary outcome was depression severity at 3-, 6-, 12-and 18-month follow-ups; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression care. RESULTS: Sixty-five percent of the sample of 164 met criteria for probable comorbid PTSD. The treatment effect was significantly associated with PTSD status in a group-by-PTSD severity interaction, controlling for baseline depression severity (Wald χ²1 = 4.52, P = .03). Over the 18-month follow-up, those with comorbid PTSD in MOMCare (n = 48), versus MSS-Plus (n = 58), showed greater improvement in depression severity (Wald χ²1 = 8.51, P < .004), PTSD severity (Wald χ²1 = 5.55, P < .02), and functioning (Wald χ²1 = 4.40, P < .04); higher rates of depression response (Wald χ²1 = 4.13, P < .04) and remission (Wald χ²1 = 5.17, P < .02); and increased use of mental health services (Wald χ²1 = 39.87, P < .0001) and antidepressant medication (Wald χ²1 = 8.07, P < .005). Participants without comorbid PTSD in MOMCare (n = 33) and MSS-Plus (n = 25) showed equivalent improvement on these outcomes. CONCLUSIONS: Collaborative depression care had a greater impact on perinatal depressive outcomes for socioeconomically disadvantaged women with comorbid PTSD than for those without PTSD. Findings suggest that a stepped care treatment model for high-risk pregnant women with both MDD and PTSD could be integrated into public health systems in the United States. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01045655.

COLLABORATIVE CARE FOR PERINATAL DEPRESSION IN SOCIOECONOMICALLY DISADVANTAGED WOMEN: A RANDOMIZED TRIAL.

BACKGROUND: Both antenatal and postpartum depression have adverse, lasting effects on maternal and child well-being. Socioeconomically disadvantaged women are at increased risk for perinatal depression and have experienced difficulty accessing evidence-based depression care. The authors evaluated whether "MOMCare,"a culturally relevant, collaborative care intervention, providing a choice of brief interpersonal psychotherapy and/or antidepressants, is associated with improved quality of care and depressive outcomes compared to intensive public health Maternity Support Services (MSS-Plus). METHODS: A randomized multisite controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System. From January 2010 to July 2012, pregnant women were recruited who met criteria for probable major depression and/or dysthymia, English-speaking, had telephone access, and ≥18 years old. The primary outcome was depression severity at 3-, 6-, 12-, 18-month postbaseline assessments; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression care. RESULTS: All participants were on Medicaid and 27 years old on average; 58% were non-White; 71% were unmarried; and 65% had probable PTSD. From before birth to 18 months postbaseline, MOMCare (n = 83) compared to MSS-Plus participants (n = 85) attained significantly lower levels of depression severity (Wald's χ(2) = 6.09, df = 1, P = .01) and PTSD severity (Wald's χ(2) = 4.61, df = 1, P = .04), higher rates of depression remission (Wald's χ(2) = 3.67, df = 1, P = .05), and had a greater likelihood of receiving ≥4 mental health visits (Wald's χ(2) = 58.23, df = 1, P < .0001) and of adhering to antidepressants in the prior month (Wald's χ(2) = 10.00, df = 1, P < .01). CONCLUSION: Compared to MSS-Plus, MOMCare showed significant improvement in quality of care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women. Findings suggest that evidence-based perinatal depression care can be integrated into the services of a county public health system in the United States. CLINICAL TRIAL REGISTRATION: ClinicalTrials.govNCT01045655.

Culturally relevant treatment services for perinatal depression in socio-economically disadvantaged women: the design of the MOMCare study.

BACKGROUND: Depression during pregnancy has been demonstrated to be predictive of low birthweight, prematurity, and postpartum depression. These adverse outcomes potentially have lasting effects on maternal and child well-being. Socio-economically disadvantaged women are twice as likely as middle-class women to meet diagnostic criteria for antenatal major depression (MDD), but have proven difficult to engage and retain in treatment. Collaborative care treatment models for depression have not been evaluated for racially/ethnically diverse, pregnant women on Medicaid receiving care in a public health system. This paper describes the design, methodology, culturally relevant enhancements, and implementation of a randomized controlled trial of depression care management compared to public health Maternity Support Services (MSS). METHODS: Pregnant, public health patients, >18 years with a likely diagnosis of MDD or dysthymia, measured respectively by the Patient Health Questionnaire-9 (PHQ-9) or the Mini-International Neuropsychiatric Interview (MINI), were randomized to the intervention or to public health MSS. The primary outcome was reduction in depression severity from baseline during pregnancy to 18-months post-baseline (one-year postpartum). BASELINE RESULTS: 168 women with likely MDD (96.4%) and/or dysthymia (24.4%) were randomized. Average age was 27.6 years and gestational age was 22.4 weeks; 58.3% racial/ethnic minority; 71.4% unmarried; 22% no high school degree/GED; 65.3% unemployed; 42.1% making <$10,000 annually; 80.4% having recurrent depression; 64.6% PTSD, and 72% unplanned pregnancy. CONCLUSIONS: A collaborative care team, including a psychiatrist, psychologist, project manager, and 3 social workers, met weekly, collaborated with the patients' obstetrics providers, and monitored depression severity using an electronic tracking system. Potential sustainability of the intervention within a public health system requires further study.

Impact of childhood trauma on the outcomes of a perinatal depression trial.

BACKGROUND: Childhood abuse and neglect have been linked with increased risks of adverse mental health outcomes in adulthood and may moderate or predict response to depression treatment. In a small randomized controlled trial treating depression in a diverse sample of nontreatment-seeking, pregnant, low-income women, we hypothesized that childhood trauma exposure would moderate changes in symptoms and functioning over time for women assigned to usual care (UC), but not to brief interpersonal psychotherapy (IPT-B) followed by maintenance IPT. Second, we predicted that trauma exposure would be negatively associated with treatment response over time and at the two follow-up time points for women within UC, but not for those within IPT-B who were expected to show remission in depression severity and other outcomes, regardless of trauma exposure. METHODS: Fifty-three pregnant low-income women were randomly assigned to IPT-B (n = 25) or UC (n = 28). Inclusion criteria included ≥ 18 years, >12 on the Edinburgh Postnatal Depression Scale, 10-32 weeks gestation, English speaking, and access to a phone. Participants were evaluated for childhood trauma, depressive symptoms/diagnoses, anxiety symptoms, social functioning, and interpersonal problems. RESULTS: Regression and mixed effects repeated measures analyses revealed that trauma exposure did not moderate changes in symptoms and functioning over time for women in UC versus IPT-B. Analyses of covariance showed that within the IPT-B group, women with more versus less trauma exposure had greater depression severity and poorer outcomes at 3-month postbaseline. At 6-month postpartum, they had outcomes indicating remission in depression and functioning, but also had more residual depressive symptoms than those with less trauma exposure. CONCLUSIONS: Childhood trauma did not predict poorer outcomes in the IPT-B group at 6-month postpartum, as it did at 3-month postbaseline, suggesting that IPT including maintenance sessions is a reasonable approach to treating depression in this population. Since women with more trauma exposure had more residual depressive symptoms at 6-month postpartum, they might require longer maintenance treatment to prevent depressive relapse.

The prevalence and correlates of depressive symptoms among adolescent mothers: results from a 17-year longitudinal study.

The objective of the authors in this study was to examine the prevalence and correlates of elevated depressive symptoms in a 17-year cohort study of 173 women who were unmarried, pregnant adolescents between June 1988 and January 1990. Multiple logistic regression was used to estimate the associations between correlates and elevated depressive symptoms during five distinct developmental periods of the life course. Depressive symptoms were measured by the Brief Symptom Inventory depression subscale. The prevalence of elevated depressive symptoms in adolescent mothers significantly increased over the 17 years of the study from 19.8% to 35.2%. In adjusted analyses, antenatal depressive symptoms were positively and significantly associated with elevated depressive symptoms at every developmental period. Intimate partner violence was positively and significantly associated with elevated depressive symptoms during all but one developmental period. Other significant correlates of elevated depressive symptoms included welfare receipt, smoking, and parity, all of which were significant at some, but not other, developmental periods. Antenatal depressive symptoms and intimate partner violence were positively and significantly associated with elevated depressive symptoms. Given the public health consequences associated with maternal depression, clinical and community-based interventions should be developed to identify and to treat adolescent mothers at-risk for antenatal depression and intimate partner violence.

Young mothers' decisions to use marijuana: a test of an expanded Theory of Planned Behaviour.

The current study examines the Theory of Planned Behaviour's (TPB) ability to predict marijuana use among young women who experienced a premarital pregnancy before the age of 18 years, using longitudinal data. The validity of the TPB assumption that all other variables work through TPB constructs is also tested. Indicators of four constructs that have been shown in the literature to be predictive of marijuana use-persistent environmental adversity, emotional distress, adolescent marijuana use and drug use in the social network-were tested as predictors of attitudes, norms and self-efficacy, in a structural equation modelling framework. All paths from distal predictors were through the mediating TPB constructs, in accordance with the tenets of the model. Implications of these findings for the TPB model and for understanding factors that lead to marijuana use are discussed.

Predicting Markers of Adulthood among Adolescent Mothers.

This prospective longitudinal study examines the antecedents of adolescent mothers' transition into adulthood and their attainment of multiple adult statuses in their early 30s in a nonclinical sample. The distribution, timing, and impact of factors in adolescence (education, employment, marriage, economic status, criminal involvement, and others) are shown relative to their impact on the transition into adulthood and attainment of typical markers of adulthood (employment, economic status, marriage, postsecondary education, and family formation). Descriptive data of demographic variables for adolescent mothers are reported from birth of child at average age 16 through 16 years postpartum at average age 32. Logistic regression results indicate that of all the factors examined in adolescence, on-time graduation from high school or receipt of a GED (by age 19) influenced the attainment of multiple markers of adulthood. Implications for intervention and policy with regard to completion of basic education are discussed.