Brief Psychotherapy for Maternal Depression: Impact on Mothers and Children.

OBJECTIVE: Two-generation studies demonstrate that treating maternal depression benefits school-age children. Although mothers prefer psychotherapy to medication, little is known about how psychotherapy for maternal depression affects offspring, especially in very high-risk families in which both mothers and children concurrently meet syndromal criteria for psychiatric disorders. This trial evaluated the effects of 2 brief psychotherapies for maternal depression on very high-risk families. METHOD: Mothers with major depressive disorder were randomly assigned to 9 sessions of either brief interpersonal psychotherapy for mothers (IPT-MOMS; n = 85) or brief supportive psychotherapy (BSP; n = 83). Independent assessors evaluated mothers and their children, ages 7 to 18 years, diagnosed with at least 1 internalizing disorder, every 3 months over the course of 1 year. RESULTS: Symptoms and functioning of mothers and children improved significantly over time, with no between-group differences. However, children of mothers assigned to BSP had more outpatient mental health visits and were more likely to receive antidepressant medication. Mothers reported greater satisfaction with IPT-MOMS than BSP. Improvement in mothers' depressive symptoms was associated with improvement in child functioning in time-lagged fashion, with children improving 3 to 6 months after mothers improved. Antidepressant medication use and number of mental health visits received by children did not affect outcomes. CONCLUSION: IPT-MOMS and BSP demonstrated comparable beneficial effects on maternal depression. Children's functioning improved following maternal improvement, independent of youths' treatment. Children of mothers randomized to IPT-MOMS, compared with BSP, achieved comparable outcomes despite less follow-up treatment. Observation of lagged association between maternal improvement and change in child functioning should influence treatment planning for families. Clinical trial registration information-Psychotherapy for Depressed Mothers of Psychiatrically Ill Children; http://clinicaltrials.gov/; NCT00919594.

A Randomized Controlled Trial to Compare Computer-assisted Motivational Intervention with Didactic Educational Counseling to Reduce Unprotected Sex in Female Adolescents.

STUDY OBJECTIVE: To examine a computer-assisted, counselor-guided motivational intervention (CAMI) aimed at reducing the risk of unprotected sexual intercourse. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a 9-month, longitudinal randomized controlled trial with a multisite recruitment strategy including clinic, university, and social referrals, and compared the CAMI with didactic educational counseling in 572 female adolescents with a mean age of 17 years (SD = 2.2 years; range = 13-21 years; 59% African American) who were at risk for pregnancy and sexually transmitted diseases. The primary outcome was the acceptability of the CAMI according to self-reported rating scales. The secondary outcome was the reduction of pregnancy and sexually transmitted disease risk using a 9-month, self-report timeline follow-back calendar of unprotected sex. RESULTS: The CAMI was rated easy to use. Compared with the didactic educational counseling, there was a significant effect of the intervention which suggested that the CAMI helped reduce unprotected sex among participants who completed the study. However, because of the high attrition rate, the intent to treat analysis did not demonstrate a significant effect of the CAMI on reducing the rate of unprotected sex. CONCLUSION: Among those who completed the intervention, the CAMI reduced unprotected sex among an at-risk, predominantly minority sample of female adolescents. Modification of the CAMI to address methodological issues that contributed to a high drop-out rate are needed to make the intervention more acceptable and feasible for use among sexually active predominantly minority, at-risk, female adolescents.

Measuring client perceptions of motivational interviewing: factor analysis of the Client Evaluation of Motivational Interviewing scale.

Motivational interviewing (MI) is an intervention approach that has solid evidence of efficacy with substance use disorders. Research and training have benefitted from the development of observational measures to assess MI fidelity and competence. However, one untapped area of assessment is the client perception of the clinician use of MI. Client perceptions of MI have been found through qualitative interviews to relate to motivation to change, view of the therapist and safety of therapy. The Client Evaluation of MI (CEMI) scale was developed to assess client perception of clinician MI use. This study further evaluated the CEMI through exploratory and confirmatory factor analysis with a sample of 500 individuals with dual diagnosis pre-discharge from an inpatient unit. Participants completed an MI based session prior to completing CEMIs. A two factor (relational and technical) model explained 51.1% of the cumulative variance and was supported through confirmatory factor analysis. Suggestions for revisions are provided as well as potential uses of the CEMI and future directions for research.

Research on MI in Equipoise: The Case of Living Organ Donation.

Residual ambivalence prior to live organ donation has been shown to predict worse physical and psychological outcomes for the donor following surgery. We are studying whether MI can help individuals who have agreed to become living organ donors to resolve residual ambivalence about their decision. In this situation, ethical practice demands that the counselor take up a stance of equipoise, equally welcoming of strengthened resolve to donate or a decision not to do so. This paper describes our adaptations of MI for this unique application.

Prevention of poor psychosocial outcomes in living organ donors: from description to theory-driven intervention development and initial feasibility testing.

CONTEXT: Although some living donors experience psychological, somatic, and interpersonal difficulties after donation, interventions to prevent such outcomes have not been developed or evaluated. OBJECTIVE: To (1) summarize empirical evidence on psychosocial outcomes after donation, (2) describe a theoretical framework to guide development of an intervention to prevent poor outcomes, and (3) describe development and initial evaluation of feasibility and acceptability of the intervention. METHODS: Based on a narrative literature review suggesting that individuals ambivalent about donation are at risk for poor psychosocial outcomes after donation, the intervention targeted this risk factor. Intervention structure and content drew on motivational interviewing principles in order to assist prospective donors to resolve ambivalence. Data were collected on donors' characteristics at our institution to determine whether they constituted a representative population in which to evaluate the intervention. Study participants were then recruited to assess the feasibility and acceptability of the intervention. They were required to have scores greater than 0 on the Simmons Ambivalence Scale (indicating at least some ambivalence about donation). RESULTS: Our population was similar to the national living donor population on most demographic and donation-related characteristics. Eight individuals who had been approved to donate either a kidney or liver segment were enrolled for pilot testing of the intervention. All successfully completed the 2-session telephone-based intervention before scheduled donation surgery. Participants' ratings of acceptability and satisfaction were high. Open-ended comments indicated that the intervention addressed participants' thoughts and concerns about the decision to donate. CONCLUSIONS: The intervention is feasible, acceptable, and appears relevant to donor concerns. A clinical trial to evaluate the efficacy of the intervention is warranted.

"Why won't my patients do what's good for them?" Motivational interviewing and treatment adherence.

Limited adherence to healthy habits in adults at risk of lifestyle diseases, some of whom become candidates for bariatric surgery, has been paralleled by high rates of nonadherence to postbariatric surgery behavioral recommendations. This is a specific case of the more general problem of nonadherence to medical treatment of chronic conditions. An adequate understanding of the problem of nonadherence requires an understanding of the motivational factors that influence whether persons implement healthy behavior. Motivational interviewing is an empirically supported counseling style for strengthening a person's own motivation and commitment to change. It offers a model for understanding and intervening with nonadherence to behavioral recommendations that emphasizes the role of clinician communication in both increasing and inadvertently decreasing patient motivation. A conceptual account of patient motivation for healthy change, highlighting the centrality of resolution of patient ambivalence through targeted conversation, is illustrated by thought exercises for the reader and supplemented by references to empirical data. Recommendations for changes in clinical practice to improve patient adherence to behavioral recommendations are also offered.

The efficacy of motivational interviewing versus brief advice for adolescent smoking behavior change.

OBJECTIVE: In this study we sought to evaluate the efficacy of motivational interviewing (MI) compared with structured brief advice (SBA) for adolescent smoking behavior change. METHODS: Participants (N=355) were randomly assigned to 5 sessions of either MI or SBA. The primary outcomes were attempts to reduce and to quit smoking, smoking reduction, and cotinine-validated 7-day point-prevalence smoking abstinence at the end of treatment (week 12) and the 24-week follow-up. RESULTS: White adolescents were ∼80% less likely to attempt to cut back (odds ratio [OR]: 0.21; confidence interval [CI]: 0.08-0.53) and >80% less likely to attempt to quit smoking compared with black adolescents (OR: 0.17 [CI: 0.06-0.46]). Adolescents who were at least planning to cut back or quit smoking at baseline were almost 3 times more likely to attempt to cut back (OR: 2.87 [CI: 1.26-6.52]) and to attempt to quit smoking (OR: 3.13 [CI: 1.19-8.26]). Adolescents who received MI were ∼60% less likely than adolescents who received SBA to try to quit smoking (OR: 0.41 [CI: 0.17-0.97]). However, adolescents who received MI showed a greater reduction in cigarettes smoked per day than adolescents who received SBA (5.3 vs 3.3 fewer cigarettes per day). There were no statistically significant differences between MI and SBA in smoking abstinence (5.7% vs 5.6%, respectively). CONCLUSIONS: The effects of MI on adolescent smoking behavior change are modest, and MI may best fit within a multicomponent smoking cessation treatment approach in which behavior change skills can support and promote smoking behavior change decisions.

Using Motivational Interviewing to Enhance Treatment Outcome in People With Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is a leading cause of health-related disability. There are two evidence-based treatments for OCD, pharmacotherapy and cognitive-behavioral therapy consisting of exposure and response prevention (EX/RP). Although effective, outcome from both treatments is often limited by patient lack of adherence to the treatment procedures. In this article, we present the rationale for using motivational interviewing (MI) to increase EX/RP adherence. We then review two published studies that used MI in different ways to foster EX/RP participation. Finally, we describe 6 cases in which we explored whether MI could help ready OCD patients who had refused or failed prior evidence-based treatment of any kind. Together, these data illustrate the promise and obstacles of employing MI to promote treatment adherence in OCD. We conclude by discussing future directions for researchers and for clinicians when using MI in this population.

Challenges using motivational interviewing as an adjunct to exposure therapy for obsessive-compulsive disorder.

Exposure and response prevention (EX/RP) is an efficacious treatment for obsessive-compulsive disorder (OCD). However, patients often do not adhere fully to EX/RP procedures. Motivational interviewing (MI) has been shown to improve treatment adherence in other disorders. This pilot study used a randomized controlled design to examine whether MI can be successfully added to EX/RP and whether this intervention (EX/RP+MI) could improve patient adherence to between-session EX/RP procedures relative to EX/RP alone. Thirty adults with OCD were randomized to 18 sessions of EX/RP or EX/RP+MI. Therapists rated patient adherence at each exposure session. Independent evaluators assessed change in OCD and depressive symptoms, and patients completed self-report measures of readiness for change and quality of life. The two treatment conditions differed in degree of congruence with MI but not in conduct of EX/RP procedures. Both groups experienced clinically significant improvement in OCD symptoms, without significant group differences in patient adherence. There are several possible reasons why EX/RP+MI had no effect on patient adherence compared to standard EX/RP, each of which has important implications for the design of future MI studies in OCD. We recommend that MI be further evaluated in OCD by exploring alternative modes of delivery and by focusing on patients less ready for change than the current sample.

Associations between religiosity and sexual and contraceptive behaviors.

STUDY OBJECTIVE: To determine associations between religiosity and female adolescents' sexual and contraceptive behaviors. DESIGN: We conducted a secondary analysis on data from a randomized controlled trial comparing interventions designed to prevent pregnancy and sexually transmitted diseases (STDs). Multivariable modeling assessed the association between a religiosity index consisting of items related to religious behaviors and impact of religious beliefs on decisions and sexual outcomes. PARTICIPANTS: 572 female adolescents aged 13 to 21, recruited via a hospital-based adolescent clinic and community-wide advertisements. MAIN OUTCOME MEASURES: Sexual experience, pregnancy, STDs, number of lifetime partners, frequency of sexual activity, previous contraceptive use, and planned contraceptive use. RESULTS: Mean participant age was 17.4 +/- 2.2 years and 68% had been sexually active. Most (74.1%) had a religious affiliation and over half (52.8%) reported that their religious beliefs impact their decision to have sex at least "somewhat." Multivariate analyses showed that, compared with those with low religiosity, those with high religiosity were less likely to have had sexual intercourse (OR = 0.23, 95% CI = 0.14, 0.39). Among sexually active participants, those with high religiosity were less likely to have been pregnant (OR = 0.46, 95% CI = 0.22, 0.97), to have had an STD (OR = 0.42, 95% CI = 0.22, 0.81), or to have had multiple (>or=4) lifetime partners (OR = 0.38, 95% CI = 0.21, 0.68) compared to those with low religiosity. Levels of religiosity were not significantly associated with frequency of intercourse, contraception use at last intercourse, or planned contraceptive use. CONCLUSION: In this cohort, religiosity appeared to be a protective factor rather than a risk factor with regard to sexual behavior and was not associated with contraception use.

A randomized controlled trial of culturally relevant, brief interpersonal psychotherapy for perinatal depression.

OBJECTIVES: Depression during pregnancy is one of the strongest predictors of postpartum depression, which, in turn, has deleterious, lasting effects on infant and child well-being and on the mother's and father's mental health. The primary question guiding this randomized controlled trial was, Does culturally relevant, enhanced brief interpersonal psychotherapy (IPT-B) confer greater advantages to low-income, pregnant women than those that accrue from enhanced usual care in treating depression in this population? Enhanced IPT-B is a multicomponent model of care designed to treat antenatal depression and consists of an engagement session, followed by eight acute IPT-B sessions before the birth and maintenance IPT up to six months postpartum. IPT-B was specifically enhanced to make it culturally relevant to socioeconomically disadvantaged women. METHODS: Fifty-three non-treatment-seeking, pregnant African-American and white patients receiving prenatal services in a large, urban obstetrics and gynecology clinic and meeting criteria for depression on the Edinburgh Postnatal Depression Scale (score >12 on a scale of 0 to 30) were randomly assigned to receive either enhanced IPT-B (N=25) or enhanced usual care (N=28), both of which were delivered in the clinic. Participants were assessed before and after treatment on depression diagnoses, depressive symptoms, and social functioning. RESULTS: Intent-to-treat analyses showed that participants in enhanced IPT-B, compared with those in enhanced usual care, displayed significant reductions in depression diagnoses and depressive symptoms before childbirth (three months postbaseline) and at six months postpartum and showed significant improvements in social functioning at six months postpartum. CONCLUSIONS: Findings suggest that enhanced IPT-B ameliorates depression during pregnancy and prevents depressive relapse and improves social functioning up to six months postpartum.

Brief interpersonal psychotherapy for depressed mothers whose children are receiving psychiatric treatment.

OBJECTIVE: Depressed mothers of children with psychiatric illness struggle with both their own psychiatric disorder and the demands of caring for ill children. When maternal depression remains untreated, mothers suffer, and psychiatric illness in their offspring is less likely to improve. This randomized, controlled trial compared the interpersonal psychotherapy for depressed mothers (IPT-MOMS), a nine-session intervention based on standard interpersonal psychotherapy, to treatment as usual for depressed mothers with psychiatrically ill offspring. METHOD: Forty-seven mothers meeting DSM-IV criteria for major depression were recruited from a pediatric mental health clinic where their school-age children were receiving psychiatric treatment and randomly assigned to IPT-MOMS (N=26) or treatment as usual (N=21). Mother-child pairs were assessed at three time points: baseline, 3-month follow-up, and 9-month follow-up. Child treatment was not determined by the study. RESULTS: Compared to subjects assigned to treatment as usual, subjects assigned to IPT-MOMS showed significantly lower levels of depression symptoms, as measured by the Hamilton Depression Rating Scale, and higher levels of functioning, as measured by the Global Assessment of Functioning, at 3-month and 9-month follow-ups. Compared to the offspring of mothers receiving treatment as usual, the offspring of mothers assigned to IPT-MOMS showed significantly lower levels of depression as measured by the Children's Depressive Inventory at the 9-month follow-up. CONCLUSIONS: Assignment to IPT-MOMS was associated with reduced levels of maternal symptoms and improved functioning at the 3- and 9-month follow-ups compared to treatment as usual. Maternal improvement preceded improvement in offspring, suggesting that maternal changes may mediate child outcomes.

Adding motivational interviewing to exposure and ritual prevention for obsessive-compulsive disorder: an open pilot trial.

Exposure and ritual prevention (EX/RP) is an efficacious treatment for obsessive-compulsive disorder (OCD), but high dropout rates and variable treatment adherence limit its effectiveness. Motivational interviewing (MI) has shown promise as an adjunct to symptom-focused treatments for improving treatment adherence and outcomes. The authors developed a manual integrating MI with EX/RP, consisting of three information-gathering/motivational enhancement sessions and 15 EX/RP sessions with an optional MI module to be used as needed. Six patients with moderate to severe OCD symptoms (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score> or =16) underwent treatment. Five showed a decrease in their baseline Y-BOCS scores and an increase in their quality of life, with three achieving an excellent response (i.e. Y-BOCS< or =12 at Session 18). The authors briefly describe the motivational strategies used in the six cases and suggest that integrating MI with standard EX/RP is a promising method to increase and sustain patient engagement with EX/RP. Challenges in combining these treatments and maintaining the integrity of each as well as limitations of the study are discussed.

Enhancing Interpersonal Psychotherapy for Mothers and Expectant Mothers on Low Incomes: Adaptations and Additions.

Intervening with depressed women during their childbearing years, especially with those on low incomes, is critically important. Not only do mothers and expectant mothers suffer unnecessarily, but their untreated depression has critical negative consequences for their families. Despite this, these women have proven especially difficult to engage in psychotherapy. In this paper we describe several adaptations and additions we have made to a brief form of Interpersonal Psychotherapy (IPT) to meet the needs of mothers and expectant mothers living on low incomes in the community who suffer from depression, but face significant practical, psychological, and cultural barriers to engaging in and staying in treatment. In addition, we present some preliminary data on the extent to which our enhanced, brief IPT approach promotes improvements in treatment engagement and retention relative to usual care for expectant mothers on low incomes.

Engaging women who are depressed and economically disadvantaged in mental health treatment.

Women disadvantaged by poverty, as well as racial or ethnic minority status, are more likely to experience depression than the rest of the U.S. population. At the same time, they are less likely to seek or remain in treatment for depression in traditional mental health settings. This article explores a therapeutic, psychosocial engagement strategy developed to address the barriers to treatment engagement and the application of this strategy to a special population--women of color and white women who are depressed and living on low incomes. The conceptual foundations of this intervention-ethnographic and motivational interviewing--as well as its key techniques and structure are reviewed. Finally, a case example description and promising pilot data demonstrate the usefulness of this strategy.

An open-label trial of enhanced brief interpersonal psychotherapy in depressed mothers whose children are receiving psychiatric treatment.

Major depression affects one out of five women during her lifetime. Depressed mothers with psychiatrically ill children represent an especially vulnerable population. Challenged by the demands of caring for ill children, these mothers often put their own needs last; consequently, their depressions remain untreated. This population is especially difficult to engage in treatment. We have developed a nine-session intervention, an engagement session followed by eight sessions of brief interpersonal psychotherapy designed to increase maternal participation in their own psychotherapy, resolve symptoms of maternal depression, and enhance relationships (IPT-MOMS). This open-label trial assesses the feasibility and acceptability of providing this treatment to depressed mothers. Thirteen mothers meeting DSM-IV criteria for major depression were recruited from a pediatric mental health clinic where their school-age children were receiving psychiatric treatment. Subjects (mothers) were treated openly with IPT-MOMS. Eighty-five percent (11/13) completed the study. Subjects were evaluated with the Hamilton Rating Scale for Depression, and completed self-report measures of quality of life and functioning at three time points: baseline, after treatment completion, and 6-months posttreatment. A signed rank test was used to compare measurement changes between assessment time points. Subjects showed significant improvement from baseline to posttreatment on measures of maternal symptoms and functioning. These gains were maintained at 6-month follow-up. Therapy was well tolerated and accepted by depressed mothers, who are typically difficult to engage in treatment. A high proportion of subjects completed treatment and experienced improvements in functioning. Future randomized clinical trials are needed to establish the efficacy of this approach.

Treating complicated grief and substance use disorders: a pilot study.

Empirically supported treatments for co-occurring substance use disorders (SUDs) and grief problems are lacking, despite the salience of grief pathology in substance abusers. Identification of a syndrome of complicated grief, distinct from bereavement-related depression and anxiety, led to the development of a targeted treatment, but this treatment has not been tried with persons with SUDs. We recruited 16 adults with complicated grief and substance dependence or abuse into an open pilot study of a manualized 24-session treatment, incorporating motivational interviewing and emotion coping and communication skills into our efficacious complicated grief treatment. Completer and intent-to-treat analyses showed significant reductions in Inventory of Complicated Grief and Beck Depression Inventory scores, with large effect sizes. Timeline Followback percent days abstinent increased significantly in both analyses, with medium to large effect sizes, and cravings declined significantly. Study limitations notwithstanding, complicated grief and substance use treatment appears to be a promising intervention that merits further research.