Psychotherapeutic interventions for depressed, low-income women: a review of the literature

Feasibility and acceptability of the Problem Management for Moms programme for improving maternal mental health in Zambia: an open-label trial

BACKGROUND

Psychological distress is common among mothers in low-income and middle-income countries, limiting their capacity to care for themselves and their children. This study aimed to test the feasibility and acceptability of an adapted psychosocial intervention for distressed mothers in low-resource settings.

METHODS

In this open-label trial, we enrolled women living in Lusaka, Zambia, with high mental distress (>7 score on the 20-item Self-Reporting Questionnaire [SRQ-20]) and children younger than 2 years, who had previously enrolled in the ZamCharts early childhood nutrition trial. We randomly assigned participants (1:1) to the intervention or control group using a random number draw. The intervention was a newly developed Problem Management for Moms (PM4M) programme: a ten-session treatment adapted from Problem Management Plus, which was offered by phone or in person. After randomisation, participants in the intervention group underwent pre-intervention screening, a post-intervention assessment, and a final follow-up assessment 9 months after treatment initiation (ie, final follow-up visit). The control group was assessed at the baseline of ZamCharts and at the final follow-up assessment, and these participants did not receive any intervention. The primary study outcomes were feasibility, acceptability, and participant mental distress measured using the SRQ-20. All primary and secondary outcomes were estimated in the intention-to-treat population, which included all participants who were randomised to the intervention group and attended the final follow-up assessment. Data on ethnicity were not collected. The trial is registered at ClinicalTrials.gov, NCT05627206, and has been completed. Women with lived experience of mental health symptoms were involved in this study.

FINDINGS

Between April 26, and July 14, 2021, 790 women were interviewed in the ZamCharts trial, of whom 265 had high mental distress and were randomly assigned to treatment groups in this trial (134 to the intervention group and 131 to the control group). Of the 134 women in the intervention group, 61 (46%) received the PM4M intervention and 73 (55%) were excluded; 103 in the intervention group and 106 in the control group were successfully interviewed at the final follow-up assessment. The mean age of participants was 27·6 years (SD 7·6) at ZamCharts baseline. PM4M sessions were conducted between Dec 16, 2022, and May 6, 2023. The 61 participants deemed eligible after pre-intervention screening who started the intervention completed a mean of 7·9 (SD 2·9) of ten sessions. 55 (77%) of these 61 participants were somewhat or very satisfied with the intervention. In adjusted intention-to-treat models, the intervention reduced mean SRQ-20 scores by 2·11 points (95% CI -3·50 to -0·63) at the final follow-up, and the adjusted odds ratio of having an SRQ-20 of more than 7 was 0·50 (95% CI 0·27 to 0·93). No serious adverse events were reported.

INTERPRETATION

The results presented here suggest that the PM4M mental health intervention is feasible and has high rates of acceptability. Further research is needed to assess the long-term efficacy of this intervention on women and their children, and its suitability for integration into routine care.

FUNDING

The Eckenstein-Geigy Professorship.

Outcome expectations and working alliance may be more important for patients from rural areas during the transition to college life: An exploratory within-patient analysis

ABSTRACTObjective Research has given limited attention to the distinction between patients from rural and urban areas, especially concerning the frequent overlap between rural living and low socio-economic status (SES). To shed more light on this, we explored the differential treatment processes between patients from rural and urban areas.Method Seven hundred and fourteen patients recruited from a university counseling center in China filled out the questionnaires for Outcome Expectation (OE), Session Alliance Inventory (SAI) and Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) each session. Data was analyzed using the disaggregated cross-lagged panel model and the asymmetric fixed-effect model.Results The findings indicated a reciprocal within-patient relation between OE and SAI for the whole sample. SAI mediated the effect of OE on next-session CORE-OM for patients from rural areas, with a significantly greater indirect effect than for patients from the urban areas. Asymmetric effects were found for OE among patients from urban areas, for whom drops in OE predicted worse next-session CORE-OM more strongly than improvements in OE predicted improved CORE-OM.Conclusion This study provided preliminary evidence for differential OE-alliance-outcome predictions between patients with different SES and affirmed a reciprocal OE-alliance relation in a Chinese sample during the transition period of college.

Are There Biological Correlates of Response to Yoga-Based Interventions in Depression? A Critical Scoping Review

Depression is the most common mental disorder worldwide. Both antidepressants and psychotherapy are effective in treating depression, but the response to these treatments is often incomplete. Yoga-based interventions (YBIs) have been advocated by some researchers as a promising form of alternative treatment for depression. Recent research has attempted to identify the biological mechanisms associated with the antidepressant actions of YBIs. In this scoping review, conducted according to the PRISMA-ScR guidelines, the PubMed and Scopus databases were searched to retrieve research on biomarkers of response to YBIs in patients with depression. These studies were also critically reviewed to evaluate their methodological quality and any sources of bias. Nineteen studies were included in the review. Based on these studies, there is preliminary evidence that YBIs may be associated with increased serum brain-derived neurotrophic factor (BDNF) and reduced serum cortisol and interleukin-6 (IL-6) in patients with depression. However, many of these changes were also observed in the control arms, and the overall quality of the research was low. At present, it cannot be concluded that there are reliable biomarkers of response to YBIs in depression, though there are some potential biological correlates. Further advances in this field will depend critically on improvements in study design, particularly the minimization of sources of bias and the selection of more specific and sensitive biomarkers based on existing evidence from other treatment modalities.

The Importance of Conducting Practice-oriented Research with Underserved Populations

There has been a growing emphasis on dissemination of empirically supported treatments. Dissemination, however, should not be restricted to treatment. It can and, in the spirit of the scientific-practitioner model, should also involve research. Because it focuses on the investigation of clinical routine as it takes place in local settings and because it can involve the collaboration of several stakeholders, practice-oriented research (POR) can be viewed as an optimal research method to be disseminated. POR has the potential of addressing particularly relevant gaps of knowledge and action when implemented in regions of the world that have limited resources for or experiences with empirical research, and/or in clinical settings that are serving clinical populations who are not typically receiving optimal mental care services - specifically, individuals in rural and inner cities that have limited economic and social resources. The establishment and maintenance of POR in such regions and/or settings, however, come with specific obstacles and challenges. Integrating the experiences acquired from research conducted in various continents (Africa, Europe, Latin America, and North America), the goal of this paper is to describe some of these challenges, strategies that have been implemented to address them, as well as new possible directions to facilitate the creation and growth of POR. It also describes how these challenges and ways to deal with them can provide helpful lessons for already existing POR infrastructures.

The association of sociodemographic characteristics with work disability trajectories during and following long-term psychotherapy: a longitudinal register study

PURPOSE

This register-based study examined the trajectories of depression or anxiety disorder-related work disability during and following long-term psychotherapy and identified sociodemographic factors that indicate membership in different trajectory groups.

METHODS

Data were drawn from national registers (Statistics Finland, Social Insurance Institution of Finland). Participants included a random sample of Finnish working-age individuals (18-55 years) who started psychotherapy treatment between 2011 and 2014 and were followed for 5 years: 1 year before and 4 years after the onset of psychotherapy (N = 3 605 individuals; 18 025 person-observations across five time points). Group-based trajectory modeling was applied to assign individuals to work disability trajectories by the number of annual mental health-related work disability months. Multinomial logistic regression was used to examine the associations between trajectory group membership and baseline sociodemographic factors of age, gender, occupational status, and geographical area of residence.

RESULTS

Four mental health-related work disability trajectories were identified: stable very low (72%), decrease (11%), persistent low (9%) and persistent high (7%). Those with older age, female gender, lower occupational status, and living in sparsely populated geographical areas were more likely to belong to the most unfavorable trajectory group of persistent high work disability. The presence of multiple risk characteristics substantially increased the probability of belonging to the most adverse trajectory group.

CONCLUSIONS

Sociodemographic factors were associated with the course of mental health-related work disability in association with psychotherapy. Rehabilitative psychotherapy does not function as an equal support resource for work ability in all parts of the population.

Group Interpersonal Psychotherapy for minoritized Head Start mothers with depressive symptoms: A mixed method study

This study explores minoritized mothers' experiences in group interpersonal psychotherapy (IPT-G) and relates their experiences to treatment outcomes. Quantitative and qualitative data were gathered from 26 Latinx and Black mothers who participated in IPT-G. Mothers were divided into three groups: (1) not depressed at follow-up, (2) depressed at follow-up, and (3) those with subclinical symptoms throughout the intervention, and similarities and differences across groups were examined. Results showed that mothers not depressed at follow-up reported high levels of emotional safety in IPT-G, facilitating emotional processing. Mothers depressed at follow-up referenced the impact of stigma and had greater difficulty sharing their feelings and also reported lower socioeconomic status and higher levels of trauma. It appears that high levels of environmental stressors and difficulty developing trusting therapeutic relationships were related to experiencing depression at the conclusion of treatment. Alternatively, for many mothers, IPT-G provided within head start was an effective therapeutic option.

Sociodemographic Factors as Predictors of the Duration of Long-term Psychotherapy: Evidence from a Finnish Nationwide Register Study

OBJECTIVE

The role of sociodemographic factors in determining psychotherapy duration has been largely unexplored despite their known association with treatment use. We examined the association between sociodemographic factors and rehabilitative psychotherapy treatment duration, as well as any changes in duration over time.

METHOD

We used three register-based nationally representative cohorts. Participants included employed Finnish individuals (n = 5572, 77% women, mean age = 37) who started psychotherapy treatment in 2011, 2013 or 2016 and were followed until 2019. We used negative binomial regression to examine the association between sociodemographic factors (age, gender, education, occupational status, income, geographical area of residence, and onset year of treatment) with treatment duration.

RESULTS

The mean treatment duration was 27 months (with a standard deviation of 12 months). Several sociodemographic factors were associated with treatment duration. Gender and education were found to have the largest impact on treatment duration, with females having a longer duration (IRR 1.08, 95% CI 1.04-1.11) and those with low education having a shorter duration (IRR 0.91, 95% CI 0.85-0.97), resulting in a difference of 2-3 months. Treatment duration also increased in later years, which suggests potentially increasing differences in treatment implementation. At largest, the combined effect of all factors corresponded to a 10-month difference in treatment duration.

CONCLUSIONS

The duration of long-term psychotherapy varied across the sociodemographic groups and increased in all studied groups in the 2010s.

Implementation of caregiver depression screening in an urban, community-based asthma clinic: a quality improvement project

OBJECTIVE

Caregiver depressive symptoms are prevalent among children with asthma and associated with greater asthma morbidity. Identifying caregivers with depression and connecting them to appropriate treatment may reduce child asthma morbidity. The goal of this project was to implement a workflow for caregiver depression screening and treatment referral in an urban, community-based, asthma clinic serving under-resourced children.

METHODS

The Model for Improvement with weekly Plan-Do-Study-Act cycles was utilized. A two-item depression screening tool (Patient Health Questionnaire-2; PHQ-2) and an acceptability question using a 5-point Likert scale were added to an existing social needs screening checklist administered to all caregivers during the child's clinic visit. Caregivers with a positive PHQ-2 score (≥3) received the PHQ-9. Positive screens on the PHQ-9 (≥5) received information and referrals by level of risk. PHQ-9 positive caregivers received a follow-up phone call two weeks post-visit to assess connection to support, improvement in depressive symptoms, and satisfaction with resources provided.

RESULTS

The PHQ-2 was completed by 84.4% of caregivers (233/276). Caregivers had a mean age of 33.8 years (SD = 8.3; Range: 18-68) and were predominately female (86.4%), Black (80.4%), and non-Hispanic (78.4%). The majority (72.3%) found the screening acceptable (agree/strongly agree). Nearly one in six caregivers (37/233, 15.9%) reported depressive symptoms (PHQ-2 ≥ 3); 11.6% (27/233) had clinically significant symptoms (PHQ-9 score ≥ 10); and 2.1% (5/233) reported suicidal thoughts. Of those with depressive symptoms, 70.3% (26/37) participated in the follow-up phone call. While 50% (13/26) reported the resources given in clinic were "extremely helpful," no caregivers contacted or used them.

CONCLUSIONS

Caregiver depression screening was successfully integrated into a pediatric asthma clinic serving under-resourced children. While caregivers found screening to be acceptable, it did not facilitate short-term connection to treatment among those with depressive symptoms.

Effectiveness of mHealth consultation services for preventing postpartum depressive symptoms: a randomized clinical trial

BACKGROUND

Although many conventional healthcare services to prevent postpartum depression are provided face-to-face, physical and psychosocial barriers remain. These barriers may be overcome by using mobile health services (mHealth). To examine the effectiveness of mHealth professional consultation services in preventing postpartum depressive symptoms in real-world settings, we conducted this randomized controlled trial in Japan, where universal free face-to-face perinatal care is available.

METHODS

This study included 734 pregnant women living in Yokohama city who could communicate in Japanese, recruited at public offices and childcare support facilities. The participants were randomized to the mHealth group (intervention, n = 365), where they could use a free app-based mHealth consultation service with gynecologists/obstetricians, pediatricians, and midwives whenever and as many times as they wanted between 6 p.m. and 10 p.m. on weekdays throughout their pregnancy and postpartum periods (funded by the City of Yokohama government) or the usual care group (control, n = 369). The primary outcome was the risk of elevated postpartum depressive symptoms, defined as Edinburgh Postnatal Depression Scale score ≥ 9. Secondary outcomes were self-efficacy, loneliness, perceived barriers to healthcare access, number of clinic visits, and ambulance usage. All outcomes were collected three months post-delivery. We also conducted subgroup analyses assessing the differences in the treatment effect by sociodemographic status.

RESULTS

Most women completed all questionnaires (n = 639 of 734, response rate: 87%). The mean baseline age was 32.9 ± 4.2 years, and 62% were primipara. Three months post-delivery, women in the mHealth group had a lower risk of elevated postpartum depressive symptoms (47/310 [15.2%]) compared to the usual care group (75/329 [22.8%], risk ratio: 0.67 [95% confidence interval: 0.48-0.93]). Compared with the usual care group, women in the mHealth group had higher self-efficacy, less loneliness, and fewer perceived barriers to healthcare access. No differences were observed in the frequency of clinic visits or ambulance usage. Furthermore, in the subgroup analyses, we did not find differences in the treatment effect by sociodemographic status.

CONCLUSIONS

Local government-funded mHealth consultation services have a preventive effect on postpartum depressive symptoms, removing physical and psychological barriers to healthcare access in real-world settings.

TRIAL REGISTRATION

UMIN-CTR identifier: UMIN000041611. Registered 31 August 2021.

The Impact of a Health Empowerment Program on Self-Care Enablement and Mental Health among Low-Income Families: Evidence from a 5 Year Cohort Study in Hong Kong

Health empowerment can be an effective way to reduce health inequities. This prospective cohort study evaluated the 5 year impact of a health empowerment program (HEP) on health outcomes among adults from low-income families. The Patient Enablement Instrument version 2 (PEI-2), Depression, Anxiety and Stress Scale 21 (DASS-21), and 12 item Short-Form Health Survey version 2 (SF-12v2) were administered at baseline and follow-up for both intervention and comparison groups. A total of 289 participants (n = 162 for intervention group, n = 127 for comparison group) were included in the analysis. Most of the participants were female (72.32%), and aged from 26 to 66 years old (M = 41.63, SD = 6.91). Linear regressions weighted by inverse probability weighting using the propensity score showed that, after follow-up of 5 years, the intervention group demonstrated significantly greater increases in all items and total scores for the PEI-2 (all B > 0.59, p < 0.001), greater decreases in the DASS depression score (B = -1.98 p = 0.001), and greater increases in the Mental Component Summary score of the SF-12v2 (B = 2.99, p = 0.027) than the comparison group. The HEP may be an effective intervention enabling adults from low-income families to manage their health-related issues and improve their mental health, as evidenced by our study.

The mastery lifestyle intervention to reduce biopsychosocial risks for pregnant Latinas and African Americans and their infants: protocol for a randomized controlled trial

BACKGROUND

Pregnant Mexican Americans (hereafter called Latinas) and Black/African American women are at increased risk for psychological distress, contributing to preterm birth and low birthweight; acculturative stress combined with perceived stress elevates depressive symptoms in Latinas. Based on our prior research using a psychoneuroimmunology framework, we identified psychological and neuroendocrine risk factors as predictors of preterm birth in Latina women that are also identified as risk factors for Black/African American women.

METHODS/DESIGN

In this prospective, randomized controlled trial with parallel group design we will explore psychosocial, neuroendocrine, and birth outcome effects of the Mastery Lifestyle Intervention (MLI). The MLI is a culturally relevant, manualized, psychosocial, group intervention integrating two cognitive behavioral therapies for both pregnant Latinas and Black/African American women (total n = 221). Study inclusion criteria are: women with current pregnancy at 14-20 weeks gestation, ability to read and speak English or Spanish, self-identify as Latina of Mexican heritage or Black/African American, 18-45 years old, born in the US or Mexico, and currently living in the US. Participants must receive Medicaid or other government-supported insurance, and meet screening criteria for anxiety, depressive symptoms, or stress. Participants are randomly assigned to either the intervention (MLI) or usual care group (UCG) in groups of 6-8 participants that occur over 6 consecutive weeks. Data are collected at 3 time points: enrollment (14-20 weeks gestation), following treatment (20-26 weeks), and 6 weeks after treatment (32-36 weeks gestation). Additional outcome, mediating, and moderating data are collected from the electronic health record during pregnancy and at birth. Analyses will primarily use generalized linear mixed modeling (GLMM) to evaluate the relationships between predictors and outcomes.

DISCUSSION

This RCT will test the efficacy of two combined third generation cognitive behavioral therapies (the MLI), given in a group format over 6 sessions, as compared to a usual prenatal care group, for both Latina and African American pregnant women. If efficacious, it may be provided as an adjunct to routine prenatal care and improve mental health, as well as babies being born too small and too soon.

TRIAL REGISTRATION

The trial was retrospectively registered at ClinicalTrials.gov . Bethesda (MD): National Library of Medicine. Identifier NCT05012072 , Reducing Pregnancy Risks: The Mastery Lifestyle Intervention (MLI); August 19, 2021. The trial is currently recruiting participants.

Lifestyle, Demographic and Socio-Economic Determinants of Mental Health Disorders of Employees in the European Countries

Ensuring the health and well-being of workers should be a top priority for employers and governments. The aim of the article is to evaluate and rank the importance of mental health determinants: lifestyle, demographic factors and socio-economic status. The research study is based on EHIS 2013-2015 data for a sample of N = 140,791 employees from 30 European countries. The results obtained using machine learning techniques such as gradient-boosted trees and SHAPley values show that the mental health of European employees is strongly determined by the BMI, age and social support from close people. The next vital features are alcohol consumption, an unmet need for health care and sports activity, followed by the affordability of medicine or treatment, income and occupation. The wide range of variables clearly indicates that there is an important role for governments to play in order to minimize the risk of mental disorders across various socio-economic groups. It is also a signal for businesses to help boost the mental health of their employees by creating holistic, mentally friendly working conditions, such as offering time-management training, implementing morning briefings, offering quiet areas, making employees feel valued, educating them about depression and burnout symptoms, and promoting a healthy lifestyle.

Improving Maternal Mental Health as a Pathway to Economic Mobility in the TANF System

OBJECTIVE

The authors sought to evaluate the acceptability, feasibility, and initial outcomes of the delivery of a group cognitive-behavioral therapy (CBT) mental health intervention for mothers in the Temporary Assistance for Needy Families (TANF) program.

METHODS

An 8-week group CBT program was made available to parenting women (N=40) in a large, urban TANF system from April to August 2019. Participants completed baseline and endpoint measures to assess depressive symptoms, perceived stress, social support, employment, and program acceptability. TANF administrative data were examined to assess TANF engagement.

RESULTS

TANF staff were successfully trained to deliver CBT. The participants reported significantly reduced depressive symptoms and perceived stress; perceived social support significantly increased from the beginning to the end of the intervention.

CONCLUSIONS

A model that fully embedded CBT delivery in a TANF system was acceptable to low-income parenting women and TANF staff and reduced depressive symptoms among the women. The scalability of interventions to address maternal depression among low-income women has presented a challenge. Delivering mental health interventions in the U.S. TANF system may offer a scalable method to reduce depression and increase employment in a population bearing a high mental health burden.

Gender differences in the mental health impact of the COVID-19 lockdown: Longitudinal evidence from the Netherlands

Recent contributions highlighted gender differences in the mental health consequences of COVID-19 lockdowns. However, their cross-sectional designs cannot differentiate between pre-existing gender differences and differences induced by lockdowns. Estimating fixed-effects models using longitudinal data from the Lifelines biobank and cohort study with repeated mental health measurements throughout the lockdown, we overcome this caveat. Significant gender differences in mental health during the lockdown were found, where women experienced more depression symptoms and disorders and men experienced more anxiety symptoms and disorders stemming from the lockdown. Policymakers need to keep in mind that the COVID-19 lockdowns have different effects on mental health for men and women.

Drawing on Dialogues in Arts-Based Dynamic Interpersonal Therapy (ADIT) for Complex Depression: A Complex Intervention Development Study Using the Medical Research Council (UK) Phased Guidance

Aim: The aim of this paper is to present the development and evaluation of an art psychotherapy brief treatment method for complex depression for patients referred to mental health services.

Background: Art Psychotherapy literature describes a range of processes of relational change through the use of arts focused and relationship focused interventions. Complex depression has a prevalence of 3% of the population in the West and it is recorded that in 2016 only 28% of that population were receiving psychological treatment. This study was developed to test the hypothesis of whether an accessible and acceptable approach to the treatment of complex depression could be developed in relation to existing evidence-based practice within mental health services.

Method: The United Kingdom Medical Research Council phased guidance for complex intervention development was used (Phases I and II) to develop the intervention. The process included producing a literature overview, systematic description of clinical practice, including a logic model and a clinical protocol. The art psychotherapy protocol described an arts-based dynamic interpersonal therapy approach (ADIT), offered 1:1 over 24 sessions. Further to this the intervention was tested for referrer acceptability. The intervention is in the early stages of evaluation, using changes to the patient's depression and anxiety measured pre- and post-treatment with a follow-up measure at 3 months following completion of treatment.

Results: Phase I of the study provided a good basis for developing a logic model and protocol. The authors found that there was good clinical consensus about the use of a structured clinical art psychotherapy method (ADIT) and the literature overview was used to support specific examples of good practice. The verification of clinical coherence was represented by a logic model and clinical protocol for delivering the intervention. The acceptability study demonstrated very high levels of acceptability for referrers reporting that (i) ADIT was acceptable for patients with complex/major depression, (ii) that they were likely to refer to ADIT in the future (iii) that the use of arts was likely to improve accessibility (iv) the use of arts was likely to improve outcomes and (v) that offering ADIT was an effective use of mental health resources.

Discussion: Phase I of this intervention development study (following MRC guidance) demonstrated theoretical and practice coherence resulting in a clinical protocol and logic model. Whilst Phase II of this study showed promising results, Phase II would need to be sufficiently scaled up to a full trial to further test the intervention and protocol.

Sociodemographic factors associated with routine outcome monitoring: a historical cohort study of 28,382 young people accessing child and adolescent mental health services

BACKGROUND

Patient-reported outcome measures (PROMs) are important tools to inform patients, clinicians and policy-makers about clinical need and the effectiveness of any given treatment. Consistent PROM use can promote early symptom detection, help identify unexpected treatment responses and improve therapeutic engagement. Very few studies have examined associations between patient characteristics and PROM data collection.

METHODS

We used the electronic mental health records for 28,382 children and young people (aged 4-17 years) accessing Child and Adolescent Mental Health Services (CAMHS) across four South London boroughs between the 1st of January 2008 to the 1st of October 2017. We examined the completion rates of the caregiver Strengths and Difficulties Questionnaire (SDQ), a ubiquitous PROM for CAMHS at baseline and 6-month follow-up.

RESULTS AND CONCLUSIONS

SDQs were present for approximately 40% (n = 11,212) of the sample at baseline, and from these, only 8% (n = 928) had a follow-up SDQ. Patterns of unequal PROM collection by sociodemographic factors were identified: males were more likely (aOR 1.07, 95% CI 1.01-1.13), whilst older age (aOR 0.87, 95% CI 0.87-0.88), Black (aOR 0.79 95% CI 0.74-0.84) and Asian ethnicity (aOR 0.75 95% CI 0.66-0.86) relative to White ethnicity, and residence within the most deprived neighbourhood (aOR 0.87 95% CI 0.80-0.94) were less likely to have a record of baseline SDQ. Similar results were found in the sub-group (n = 11,212) with follow-up SDQ collection. Our findings indicate systematic differences in the currently available PROMS data and highlights which groups require increased focus if we are to gain equitable PROM collection. We need to ensure representative PROM collection for all individuals accessing treatment, regardless of ethnic or socioeconomic background; biased data have adverse ramifications for policy and service level decision-making.

The ASHA (Hope) Project: Testing an Integrated Depression Treatment and Economic Strengthening Intervention in Rural Bangladesh: A Pilot Randomized Controlled Trial

Depression, a debilitating disorder, is highly prevalent among low-income women in low- and middle-income countries. Standard psychotherapeutic approaches may be helpful, but low treatment uptake, low retention, and transient treatment effects reduce the benefit of therapy. This pilot randomized controlled trial examined the effectiveness and feasibility of an integrated depression treatment/economic strengthening intervention. The study took place in two villages in the Sirajganj district in rural Bangladesh. Forty-eight low-income women with depressive symptoms (Patient Health Questionnaire (PHQ-9) score ≥ 10) were recruited and randomized to intervention or control arms. The intervention included a six-month group-based, fortnightly depression management and financial literacy intervention, which was followed by a cash-transfer of $186 (equivalent to the cost of two goats) at 12 months' follow-up. The cash transfer could be used to purchase a productive asset (e.g., agricultural animals). The control arm received no intervention. Findings showed significant reduction in depression scores in the intervention group. The mean PHQ-9 score decreased from 14.5 to 5.5 (B ± SE, -9.2 ± 0.8 95% CI -10.9, -7.5, p < 0.01) compared to no change in the control group. Most other psycho-social outcomes, including tension, self-esteem, hope, social-support, and participation in household economic decision-making, also improved with intervention. An integrated depression treatment and financial empowerment intervention was found to be highly effective among rural low-income women with depression. Next steps involve formal testing of the model in a larger trial.

Assessment of risk for food insecurity among African American urban households: utilizing cumulative risk indices and latent class analysis to examine accumulation of risk factors

African American caregivers in low-income, urban communities have high rates of food insecurity. Unemployment, education, smoking, stress, and depressive symptoms are associated with household food insecurity. A cumulative risk model suggests that accumulation of risk may compound food insecurity risk, and certain risk factors are more likely to co-occur. This study utilizes two approaches to examine food insecurity risk among African American caregivers with an adolescent daughter-a cumulative risk index to examine accumulation of risk and food insecurity risk; latent class analysis (LCA) to determine if certain risk profiles exist and their relation to food insecurity risk. Caregivers completed surveys including demographic, psychosocial, and behavioral questions (to create a cumulative risk index) and a validated 2-item food insecurity screen. LCA was used to identify risk profiles. Logistic regression was used to examine relations between cumulative risk, risk profiles, and food insecurity risk. Each additional cumulative risk index factor was associated with a 54% increase in odds of risk of food insecurity. LCA identified three subgroups: high stress/depression (class #1), low education/low stress and depression (class #2), and low risk overall (class #3). Odds of food insecurity risk were 4.7 times higher for class #1, and 1.5 times higher for class #2 compared with class #3. This study contributes to understanding of how food insecurity risk relates to cumulative risk and risk profiles. Findings can be used to improve food insecurity risk screening in clinical settings, enhancing intervention/referral for food security risk and mental health among African American caregivers and their households.

Poverty and Food Insecurity Predict Mealtime Structure: Mediating Pathways of Parent Disciplinary Practices and Depressive Symptoms

OBJECTIVE

Structured, well-organized mealtime routines can provide many physical and mental health benefits for children. Poverty and food insecurity (FI) are socioeconomic risk factors for less effective mealtime routines. However, the specific mechanisms by which these social factors may negatively impact mealtime structure are not well-understood. We test whether poverty and FI are associated with parenting factors (mental health and parent disciplinary practices), and whether these parenting factors in turn associate with less mealtime structure.

METHODS

Low-income families (N = 270), recruited when children were approximately 6-years-old (wave 1), were followed for 2 years (wave 2). Socioeconomic and parenting factors were assessed at W1 via parent-report. Associations of poverty and FI with two measures of mealtime structure (parent-reported and observed mealtime structure at wave 1 and wave 2), mediated by parent factors (depressive symptoms, lax and overreactive parent disciplinary practices) were assessed in separate path analyses.

RESULTS

The association between higher depth of poverty and less mealtime structure in early childhood was mediated by greater parent depressive symptoms. FI was associated with less mealtime structure in early childhood, mediated by overreactive parenting, and with less mealtime structure in early and mid-childhood, mediated by lax parenting.

CONCLUSION

Poverty and food insecurity may contribute to suboptimal parent disciplinary practices and poor parent mental health, which may reduce mealtime structure for children. Addressing parent mental health and parent disciplinary practices in the context of socioeconomic adversity may be one way in which interventions can improve mealtime structure for low-income families.

Lessons learned from a pilot randomized controlled trial of dyadic interpersonal psychotherapy for perinatal depression in a low-income population

BACKGROUND

Perinatal depression is a public health burden impacting mothers and their offspring. This study extended brief-Interpersonal Psychotherapy delivered during pregnancy by incorporating a postpartum attachment based dyadic-component to maintain mother's treatment gains and enhance the mother-infant relationship (called IPT-Dyad). The current report presents data from a pilot randomized controlled trial comparing IPT-Dyad to Enhanced Treatment as Usual (ETAU).

METHODS

Women, ages 18 and older, between 12-30 weeks gestation meeting criteria for a depressive disorder were eligible. Participants were randomized to either IPT-Dyad (n = 21) or ETAU (n = 21). Maternal and infant outcomes were assessed through one-year postpartum.

RESULTS

Participants were primarily African American (77%), single (80%), with low-incomes. Attrition was high in both groups (IPT-Dyad 30%; ETAU 40%). Depression scores improved from baseline in both groups and remained improved over the 12 month follow-up. There were no between group differences on measures of parenting stress, mother-infant interactions, and infant socioemotional functioning.

LIMITATIONS

The small sample size of this study was further reduced by attrition, despite efforts to maintain engagement. Reliance on self-report outcome measures is also a limitation.

CONCLUSIONS

IPT-Dyad may be a promising intervention for perinatal depression with potential benefit for mothers and babies. Treatment engagement and management of psychosocial needs were persistent challenges throughout the postpartum period. Further refinement of intervention content and schedule to better meet the needs and values of under-resourced mothers is needed. Earlier screening; better integration of care within OB settings; and delivering care in conjunction with social service resources may also improve outcomes.

Work Status, Financial Stress, Family Problems, and Gender Differences in the Prevalence of Depression in Chile

INTRODUCTION

It is widely known that women have a higher prevalence of depression than men. These differences may be explained by social differences between women and men due to gender roles. In Chile, as elsewhere, women have greater household responsibilities, lower job incomes, and especially low labor market participation. However, the incidence of these gender differences on the higher prevalence of depression in women requires further study in the Chilean context.

OBJECTIVE

To identify main social differences between women and men associated with gender differences in the prevalence of depression in middle-aged Chilean men and women.

DATA SOURCE

Data comes from the second Chilean National Health Survey (2009-2010), a cross-sectional, nationally representative sample (n = 2771) composed of 1103 men and 1668 women (39.8 and 60.2%, respectively), whose age range goes from 25 to 55 years old. This study was approved by the Ethics Committee of Pontificia Universidad Católica de Chile.

METHODS

Prevalence ratios were calculated through Poisson regression models to estimate associations between the prevalence of past episodes of depression and social stressful life events variables for men and women separately. Gender prevalence ratios of depression (Gender PR) adjusted for age and subsequently adjusted by the social and stressful life events variables. The analyses considered factors such as age, educational level, per-capita household income, work status, role as the head of household, marital status, events of violence, family problems, personal health problems or accidents, and self-reported financial stress.

RESULTS

This study finds that doing housework, reporting a serious family problem and having high financial stress were associated with a higher prevalence of depression in both genders. Whereas, health problems were only associated with prevalence in men. The age-adjusted gender PR was 2.84 [confidence interval (CI): 2.0-4.1], and when all selected variables were included attenuated to a PR of 1.86 (CI 1.3-2.7). The variable most strongly associated with depression in the fully-adjusted model was housework (PR: 5.3; CI: 1.3-21.0).

CONCLUSION

In conclusion, this study finds that depression in in Chile is associated with social factors such as participation in housework, family problems, and financial stress, all of which are more common in women. To make further progress in the study of this public health problem in Chile, it is essential to incorporate more detailed characterization of gender roles in surveys and other studies. Likewise, social policies and interventions that contribute to reduce gender social inequalities in the exposure to adverse life circumstances can contribute to reduce unnecessary and avoidable gender disparities in health.

Psychological interventions for depression and anxiety in pregnant Latina and Black women in the United States: A systematic review

Black women and Latinas have more symptoms of depression and anxiety during pregnancy than do their non-Latina White counterparts. Although effective interventions targeting internalizing disorders in pregnancy are available, they are primarily tested with White women. This article reviews randomized controlled trials and non-randomized studies to better understand the effectiveness of psychological interventions for anxiety and depression during pregnancy in Latinas and Black women. Additionally, this review summarizes important characteristics of interventions such as intervention format, treatment modality, and the use of cultural adaptations. Literature searches of relevant research citation databases produced 68 studies; 13 of which were included in the final review. Most studies were excluded because their samples were not majority Latina or Black women or because they did not test an intervention. Of the included studies, three interventions outperformed a control group condition and showed statistically significant reductions in depressive symptoms. An additional two studies showed reductions in depressive symptoms from pretreatment to post-treatment using non-controlled designs. The remaining eight studies (seven randomized and one non-randomized) did not show significant intervention effects. Cognitive behavioral therapy was the modality with most evidence for reducing depressive symptoms in pregnant Black and Latina women. No intervention was found to reduce anxiety symptoms, although only two of the 13 measured anxiety as an outcome. Five studies made cultural adaptations to their treatment protocols. Future studies should strive to better understand the importance of cultural modifications to improve engagement and clinical outcomes with pregnant women receiving treatment for anxiety and depression.

Perinatal Depression in Low-Income Women: A Literature Review and Innovative Screening Approach

PURPOSE OF REVIEW

This paper reviews literature on perinatal depression prevalence, consequences, and screening among low-income women and women of color. We introduce the Warm Connections program's innovative perinatal depression screening protocol and explore perinatal depression patterns among WIC participants.

RECENT FINDINGS

Perinatal depression negatively impacts maternal and child outcomes. Research shows mixed findings of perinatal depression prevalence rates among low-income women and women of color. The Warm Connections program supports the ability of WIC staff to administer the EPDS to WIC participants. Perinatal depression rates appeared lower in the Warm Connections program than in studies using less specific perinatal depression screening instruments with similar samples. Future research should continue to explore perinatal depression patterns among low-income women and women of color. Partnering with community-based settings such as WIC provides innovative opportunities to provide screening, referral, and treatment for low income women and women of color.

Resilience in the midst of chaos: Socioecological model applied to women with depressive symptoms and socioeconomic disadvantage

Socioeconomic disadvantage is extremely common among women with depressive symptoms presenting for women's health care. While social stressors related to socioeconomic disadvantage can contribute to depression, health care tends to focus on patients' symptoms in isolation of context. Health care providers may be more effective by addressing issues related to socioeconomic disadvantage. It is imperative to identify common challenges related to socioeconomic disadvantage, as well as sources of resilience. In this qualitative study, we interviewed 20 women's health patients experiencing depressive symptoms and socioeconomic disadvantage about their views of their mental health, the impact of social stressors, and their resources and skills. A Consensual Qualitative Research approach was used to identify domains consisting of challenges and resiliencies. We applied the socioecological model when coding the data and identified cross-cutting themes of chaos and distress, as well as resilience. These findings suggest the importance of incorporating context in the health care of women with depression and socioeconomic disadvantage.

A Group-Based Online Intervention to Prevent Postpartum Depression (Sunnyside): Feasibility Randomized Controlled Trial

BACKGROUND

Postpartum depression (PPD) has a 20% 3-month prevalence rate. The consequences of PPD are significant for the mother, infant, and the family. There is a need for preventive interventions for PPD, which are effective and accessible; however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the issues pertaining to access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group might create an intervention with the scalability and cost-effectiveness of an individual intervention and the better outcomes typically found in supported interventions.

OBJECTIVES

This study aimed to describe the development of a cognitive behavioral therapy (CBT) internet intervention with peer support to prevent PPD and examine preliminary depression and site usage outcomes.

METHODS

User-centered design groups were used to develop the internet intervention. Once the intervention was developed, women who were 20 to 28 weeks pregnant with symptoms of depression (Patient Health Questionnaire-8 scores of 5-14) but who had no major depression diagnosis were enrolled in a randomized controlled trial (RCT) to compare 8 weeks of a CBT-based internet intervention with peer support to an individual internet intervention designed to prevent PPD. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), and then 4 weeks and 6 weeks postpartum.

RESULTS

A total of 25 women were randomized. Of these, 24 women completed the RCT. Patient Health Questionnaire-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only 4% (1/24) met the criteria for PPD. There was no difference between groups in adherence to the intervention, with an average of 14.55 log-ins over the course of treatment.

CONCLUSIONS

Results suggest women were responsive to both peer support and individual internet interventions to prevent PPD and that peer support may be a useful feature to keep participants adherent.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02121015; https://clinicaltrials.gov/ct2/show/NCT02121015 (archived by WebCite at http://www.webcitation.org/765a7qBKy).

Education and mental health: Do psychosocial resources matter?

Prevalence rates for mental health problems are higher when an individual's socioeconomic status (SES) is low, but the underlying mechanisms are not clearly understood. We investigated associations between education as indicator for SES and depressive symptoms as well as positive mental health (PMH). Moreover, we hypothesized that low education is associated with a lack of psychosocial resources and more daily hassles, which in turn mediate the relationships between education and mental health. In a German representative sample (N = 7937), we cross-sectionally first examined whether a person's educational level was associated with depressive symptoms and PMH. Educational level was defined as the highest academic qualification achieved. Second, we investigated whether also sense of control, resilience, delay of gratification, cultural activity and daily hassles followed gradients along the educational level. Third, we investigated whether they mediated the relationship between education and mental health. Results showed that depressive symptoms measured by items from the DASS-42 depression subscale were more prevalent for persons with a low educational level, PMH operationalized by the Positive Mental Health Scale was equally distributed, and all psychosocial characteristics followed the gradient of educational level. In addition, the group with a high school diploma was particularly burdened. Structural equation modeling indicated that the associations between education and mental health were mediated by all psychosocial characteristics and daily hassles, apart from the delay of gratification. In the group with the lowest educational level the model fit indices for depressive symptoms and PMH were acceptable (χ2 = 10007.243 (627), CFI = 0.869, RMSEA = 0.04 (90% CI [0.04, 0.04], SRMR = 0.05; and χ2 = 12779.968 (741), CFI = 0.86, RMSEA = 0.05 (90% CI [0.05, 0.05], SRMR = 0.05), respectively). The effect size Pm refers to the proportion of the total effect that is mediated by one or more variables ("M"), and the effect size of all indirect effects in the model for depressive symptoms was Pm = .80 and for PMH it was Pm = .68. The results support our hypotheses that low education is associated with less psychosocial resources, which in turn serve together with daily hassles as pathways between education and depressive symptoms as well as PMH. Building on these findings, longitudinal studies are necessary to investigate causality.

Treatment of Maternal Depression With In-Home Cognitive Behavioral Therapy Augmented by a Parenting Enhancement: A Case Report

Depression is prevalent among mothers who participate in home visitation programs. This case study describes In-Home Cognitive Behavior Therapy (IH-CBT), an empirically based treatment for depressed mothers that is strongly integrated with ongoing home visitation. The use of a Parenting Enhancement for Maternal Depression (PEMD) module was added to address parenting difficulties in a depressed mother. This case describes issues and challenges encountered in delivering treatment in the home with low-income, depressed mothers. Issues involving engagement, adaptation to the setting, responding to the unique needs of low-income mothers, and partnership with concurrent home visiting to optimize outcomes are considered. Long-term follow-up (18 months after the end of treatment) permits examination of sustainability of gains. Implications for treating this high-risk population are discussed.

Shape of change in internet based behavioral activation treatment for depression

Shape of change, sudden gains and depression spikes were examined in an online 12-session Behavioral Activation (BA) treatment for depression. Client and therapist factors related to sudden gains were examined to investigate processes associated with outcome.

METHODS

Participants were postpartum Women with Major Depressive Disorder (n=42) who received online BA supported in 30-minute telephone sessions by a mental health worker. Depression symptoms were assessed at each session and number of sessions completed were recorded by the online program. Therapist records were rated for client stressful life event and therapist concrete focus. A quadratic pattern provided the best fit with the data; a cubic pattern was a poor fit. Sudden gains, but not depression spikes, predicted lower depression scores at 17-week outcome. Women who had higher baseline social functioning, did not experience a stressful life event during therapy, and completed more online modules, but not more telephone sessions, were more likely to have a sudden gain. A concrete therapist focus was associated with sudden gains. These results extend research on trajectories of change and sudden gains to an online BA treatment and to postpartum depression, and suggest important client and therapist factors associated with sudden gains.

Brief Interpersonal Psychotherapy for depression during pregnancy in a low-income population: A randomized controlled trial

BACKGROUND

Depression is common in low-income pregnant women, and treatments need to be fitted to meet their needs. We conducted a randomized controlled trial comparing brief Interpersonal Psychotherapy (brief-IPT) to enhanced treatment as usual (ETAU) for perinatal depression in low-income women. The brief-IPT model is designed to better engage low-income women by utilizing an engagement session, providing flexible delivery of sessions, and pragmatic case management.

METHODS

Pregnant women, aged ≥18, between 12 and 30 weeks gestation were recruited from an urban prenatal clinic. Women scoring ≥10 on the Edinburgh Depression Scale and meeting depressive disorder criteria were randomized to either brief-IPT (n=21) or ETAU (n=21). We assessed treatment outcomes, acceptability, and feasibility of the intervention (measured by session attendance).

RESULTS

Depression scores significantly decreased in both brief-IPT and ETAU. Brief-IPT participants reported significant improvements in social support satisfaction as compared to ETAU participants, even after controlling for concurrent depressive symptoms. Brief-IPT participants reported high satisfaction with the program. However, many participants did not participate in the full 9-session course of treatment (average sessions attended =6, range 0-17).

LIMITATIONS

Small sample size, use of self-report measures, and lack of an active psychotherapy control group limits interpretation of study results.

CONCLUSIONS

Brief-IPT for perinatal depression is acceptable to low-income women and is helpful for improving depressive symptoms and social support. However, feasibility of the treatment was limited by relatively low session attendance in spite of efforts to maximize treatment engagement. Additional modifications to meet the needs of low-income women are discussed.

Depression Treatment by Non-Mental-Health Providers: Incremental Evidence for the Effectiveness of Listening Visits

Maternal depression is a prevalent public health problem, particularly for low-income mothers of young children. Intervention development efforts, which often focus on surmounting instrumental barriers to care, have not successfully engaged and retained women in treatment. Task-sharing approaches like Listening Visits (LV) could overcome key instrumental and psychological barriers by leveraging the access of trusted, community caregivers to deliver treatment. A recent randomized controlled trial (RCT) demonstrated the efficacy of LV delivered by non-mental-health providers as compared to usual care. The present report presents results from a follow-up phase of that RCT during which participants who had completed LV were followed for an additional 8 weeks and completed measures of depression and quality of life. In addition, participants who were initially randomized to the wait-list control group received LV and were assessed. Treatment gains previously observed in participants completing LV were enhanced during the 8-week follow-up period. Participants receiving LV during the follow-up period experienced significant improvement in depressive symptoms. Results demonstrate the sustainability of LV delivered by non-mental-health providers, and provide preliminary evidence for the replicability of this approach in a sample of predominately low-income pregnant women and mothers of young children.

Evidence-Based Interventions for Depressed Mothers and Their Young Children

Depression in mothers is a significant risk factor for the development of maladjustment in children. This article focuses on modifiable risk processes linking depression in mothers and adaptation in their young children (i.e., infancy through preschool age). First, the authors present evidence of the efficacy of interventions for reducing the primary source of risk: maternal depression. Second, they describe a central mechanism-parenting behaviors-underlying the relation between maternal depression and children's adjustment. Third, the authors recommend two different integrated interventions that successfully treat mothers' depression and enhance parenting skills with infants and young children. Finally, the authors note the possible need for supplementary interventions to address severity and comorbidity of mothers' depression, barriers to engaging in treatment, and the sustainability of program benefits.

Improving Mental Health Access for Low-Income Children and Families in the Primary Care Setting

Poverty is a common experience for many children and families in the United States. Children <18 years old are disproportionately affected by poverty, making up 33% of all people in poverty. Living in a poor or low-income household has been linked to poor health and increased risk for mental health problems in both children and adults that can persist across the life span. Despite their high need for mental health services, children and families living in poverty are least likely to be connected with high-quality mental health care. Pediatric primary care providers are in a unique position to take a leading role in addressing disparities in access to mental health care, because many low-income families come to them first to address mental health concerns. In this report, we discuss the impact of poverty on mental health, barriers to care, and integrated behavioral health care models that show promise in improving access and outcomes for children and families residing in the contexts of poverty. We also offer practice recommendations, relevant to providers in the primary care setting, that can help improve access to mental health care in this population.

Nurse-Patient Interaction as a Treatment for Antepartum Depression: A Mixed-Methods Analysis [Formula: see text]

BACKGROUND

The U.S. Preventative Services Task Force guidelines recommend pregnant women be screened for depression and adequate systems be in place to treat this condition.

OBJECTIVE

This study examines a nurse-delivered telephone support intervention provided to low-income, pregnant women living in rural settings.

DESIGN

This study had a complementary mixed-methods design, using secondary data. Peplau's theory of interpersonal relations was used as a framework to guide the study.

RESULTS

The phases of Peplau's theory of interpersonal relations were evident in the interactions. Underserved women at high risk for depression appreciated this type of support, with the women at highest risk for depression utilizing more of the nursing support provided. On average, Mental Health Index-5 scores improved from 45 to 66.

CONCLUSION

A nurse-delivered telephone support intervention, modeled around Peplau's theory of interpersonal relations, may be an effective way of providing support to underserved women and has the potential to treat or offset antepartum depression.

Depression treatment delivered at the point-of-care: a qualitative assessment of the views of low-income US mothers

BACKGROUND/OBJECTIVE

Within the first months of childbirth, clinically significant depressive symptoms are experienced by 19% of mothers in the US, and are even more prevalent among low-income and ethnic-minority women. Paradoxically, low-income and ethnic-minority mothers are faced with unique barriers that make them less likely to receive professional mental health care. To find ways to remove these barriers, a recent US trial extended use of a United Kingdom intervention, Listening Visits (LV), an evidence-based treatment delivered by home visitors/office nursing staff.

METHODS

A qualitative content analysis was conducted with participants' (N=19 in an open trial and N=49 in a randomized controlled trial) responses to a post-treatment semi-structured interview assessing their views of LV. The percentage of participants endorsing each thematic code is presented.

RESULTS

When the provider first introduced the LV intervention, 77.9% of women retrospectively reported having positive views of trying this new approach. Recipients most frequently mentioned as helpful two aspects of LV: empathic listening/support and the collaborative style of the LV provider. Half of the women (50%) did not suggest changes to how LV were delivered. Among those who suggested changes, the most frequent (42.6%) suggestion was to increase the number/duration of sessions.

CONCLUSION

Listening Visits is an acceptable depression treatment approach, as perceived by low-income, ethnic-minority mothers, which health and social service providers who serve this population can use.

Mental health treatment seeking patterns and preferences of Appalachian women with depression

This qualitative study explored social-cultural factors that shape treatment seeking behaviors among depressed rural, low-income women in Appalachia-a region with high rates of depression and a shortage of mental health services. Recent research shows that increasingly rural women are receiving some form of treatment and identifying their symptoms as depression. Using purposive sampling, investigators recruited 28 depressed low-income women living in Appalachian Kentucky and conducted semistructured interviews on participants' perceptions of depression and treatment seeking. Even in this sample of women with diverse treatment behaviors (half reported current treatment), participants expressed ambivalence about treatment and its potential to promote recovery. Participants stressed that poor treatment quality-not merely access-limited their engagement in treatment and at times reinforced their depression. While women acknowledged the stigma of depression, they indicated that their resistance to seek help for their depression was influenced by the expectation of women's self-reliance in the rural setting and the gendered taboo against negative thinking. Ambivalence and stigma led women to try to cope independently, resulting in further isolation. This study's findings reiterate the need for improved quality and increased availability of depression treatment in rural areas. In addition, culturally appropriate depression interventions must acknowledge rural cultural values of self-reliance and barriers to obtaining social support that lead many women to endure depression in isolation. (PsycINFO Database Record

A systematic review of depression psychotherapies among Latinos

For decades, the literature has reported persistent treatment disparities among depressed Latinos. Fortunately, treatment development and evaluation in this underserved population has expanded in recent years. This review summarizes outcomes across 36 unique depression treatment studies that reported treatment outcomes for Latinos. Results indicated that there was significant variability in the quality of RCT and type/number of cultural adaptations. The review suggested that there might a relation between cultural adaptations with treatment outcomes; future studies are warranted to confirm this association. Cognitive Behavioral Therapy was the most evaluated treatment (CBT; n=18, 50% of all evaluations), followed by Problem Solving Therapy (PST; n=4), Interpersonal Therapy (IPT; n=4), and Behavioral Activation (BA; n=3). CBT seems to fare better when compared to usual care, but not when compared to a contact-time matched control condition or active treatment. There is growing support for PST and IPT as efficacious depression interventions among Latinos. IPT shows particularly positive results for perinatal depression. BA warrants additional examination in RCT. Although scarce, telephone and in-home counseling have shown efficacy in reducing depression and increasing retention. Promotora-assisted trials require formal assessment. Limitations and future directions of the depression psychotherapy research among Latinos are discussed.

Child Maltreatment History and Response to CBT Treatment in Depressed Mothers Participating in Home Visiting

Child maltreatment contributes to depression in adults. Evidence indicates that such experiences are associated with poorer outcomes in treatment. Mothers in home visiting programs display high rates of depression and child maltreatment histories. In-Home Cognitive Behavioral Therapy (IH-CBT) was developed to treat maternal depression in home visiting. The purpose of this study was to examine the moderating effects of child maltreatment history on depression, social functioning, and parenting in mothers participating in a clinical trial of IH-CBT. Ninety-three depressed mothers in home visiting between 2 and 10 months postpartum were randomly assigned to IH-CBT (n = 47) plus home visiting or standard home visiting (SHV; n = 46). Mothers were identified via screening and then confirmation of major depressive disorder diagnosis. Measures of child maltreatment history, depression, social functioning, and parenting were administered at pre-treatment, post-treatment, and 3-month follow-up. Results indicated high rates of maltreatment in both conditions relative to the general population. Mixed model analyses found a number of main effects in which experiences of different types of trauma were associated with poorer functioning regardless of treatment condition. Evidence of a moderating effect of maltreatment on treatment outcomes was found for physical abuse and parenting and emotional abuse and social network size. Future research should focus on increasing the effectiveness of IH-CBT with depressed mothers who have experienced child maltreatment.

Post-traumatic Stress Disorder Symptoms and Mental Health over Time among Low-Income Women at Increased Risk of HIV in the U.S

Women living in poverty suffer more post-traumatic stress disorder (PTSD) symptoms than do members of the general population; however we know little about factors associated with changes in their PTSD symptoms over time. Using data from HPTN 064, a cohort of women from low-income, high-HIV-prevalence communities across six eastern states (n=1,860), we assessed the prevalence of and changes in PTSD symptoms over 12 months and the effect of potential predictors on symptom acquisition and remission (via the Primary Care-PTSD symptoms scale). Forty-three percent screened positive for PTSD symptoms. Those reporting food insecurity, ongoing abuse, depressive symptoms, or binge drinking were more likely to acquire PTSD symptoms. Those with ongoing abuse or depressive symptoms were less likely to experience PTSD symptom remission. Findings suggest a need to integrate programs to reduce abuse, depression, and economic hardship with those that address sexual health risks among women living in low-income, high-HIV-prevalence neighborhoods.

The COMPASS pilot study: a total worker Health™ intervention for home care workers

OBJECTIVE

To develop a team-based Total Worker Health™ (injury prevention + health promotion) intervention for home care workers and estimate intervention effects on workers' well-being and health and safety behaviors.

METHODS

Home care workers (n = 16) met monthly in teams for education and social support using a scripted, peer-led approach. Meeting process measures and pre-/postintervention outcome measures were collected.

RESULTS

Knowledge gains averaged 18.7% (standard deviation = 0.04), and 62.0% (standard deviation = 0.13) of participants reported making safety or health changes between meetings. Workers' well-being improved significantly (life satisfaction, d = 0.65, P < 0.05; negative affect, d = 0.64, P < 0.05), and the majority of other safety and health outcomes changed in expected directions.

CONCLUSIONS

COMPASS is a feasible intervention model for simultaneously preventing injuries and promoting health among home care workers.

An Application of Behavioral Activation Therapy for Major Depressive Disorder in the Context of Complicated Grief, Low Social-Economic Status, and Ethnic Minority Status

Behavioral activation (BA) has been shown to be an effective treatment for depression, especially for severe and/or chronic depression; however, there is little empirical guidance on how BA can be effectively utilized to treat chronic Major Depressive Disorder (MDD) in the context of complicated grief, low socioeconomic status, and ethnic minority status. This case study focuses on the treatment of Ms. X, a 51-year-old African American woman with chronic depression that was exacerbated by complicated grief. This case describes an effective course of a standard BA protocol for MDD in the context of complicated grief, low socioeconomic status, and ethnic minority status and illustrates how a BA protocol can be applied while incorporating important cultural considerations.

Depression improvement and parenting in low-income mothers in home visiting

Research on older children and high-resource families demonstrates that maternal improvement in depression often leads to parallel changes in parenting and child adjustment. It is unclear if this association extends to younger children and low-income mothers. This study examined if In-Home Cognitive Behavioral Therapy (IH-CBT), a treatment for depressed mothers participating in home visiting programs, contributes to improvements in parenting and child adjustment. Ninety-three depressed mothers in home visiting between 2 and 10 months postpartum were randomly assigned to IH-CBT (n = 47) plus home visiting or standard home visiting (SHV; n = 46). Mothers were identified via screening and subsequent diagnosis of major depressive disorder (MDD). Measures of depression, parenting stress, nurturing parenting, and child adjustment were administered at pre-treatment, post-treatment, and 3 months follow-up. Results indicated that there were no differences between IH-CBT and controls on parenting and child adjustment. Low levels of depression were associated with decreased parenting stress and increased nurturing parenting. Improvement in depression was related to changes in parenting in low-income mothers participating in home visiting programs. IH-CBT was not independently associated with these improvements, although to the extent that treatment facilitated improvement; there were corresponding benefits to parenting. Child adjustment was not associated with maternal depression, a finding possibly attributed to the benefits of concurrent home visiting or measurement limitations. Future research should focus on longer-term follow-up, implications of relapse, and child adjustment in later years.

Intersection of race-ethnicity and gender in depression care: screening, access, and minimally adequate treatment

OBJECTIVES

This study examined the interaction of race-ethnicity and gender in depression screening, receipt of any mental health care, and receipt of adequate care.

METHODS

Data from electronic health records (2010-2012) of adult primary care patients from a New England urban health care system were used (N=65,079). Multivariate logit regression models were estimated to assess associations between race-ethnicity, gender, and other covariates and depression screening, any depression care among those with a positive screen, and adequate depression care. To measure disparities in utilization, we controlled for need variables but not for non-need variables, including insurance, marital status, and socioeconomic status.

RESULTS

Among males and females, blacks and Asians were less likely and Latinos were more likely to be screened for depression compared with whites. Among those with moderate or severe depression, black males and females, Latino males, and Asian males and females were less likely than whites to receive any mental health care. The disparity in screening between blacks and whites was greater among females compared with males. The disparity between Latinos and whites in receipt of any mental health care and of adequate care was greater among males than females.

CONCLUSIONS

This approach underscored the importance of identifying disparities at each step of depression care by both race-ethnicity and gender. Targeting certain groups in specific stages of care, for example, screening of black females or providing any mental health care and adequate care for Latino males, would be more effective than a blanket approach to disparities reduction.

Feasibility and Perception of Using Text Messages as an Adjunct Therapy for Low-Income, Minority Mothers With Postpartum Depression

BACKGROUND

Postpartum depression (PPD) is the most common medical problem among new mothers that can have a negative impact on infant health. Traditional treatments are often difficult for low-income mothers to complete, particularly given the numerous barriers families face.

OBJECTIVE

Among low-income, primarily racial, and ethnic minority mothers with postpartum depression, our aim was to evaluate (1) the feasibility of sending supportive text messages, and (2) the perception of receiving private, supportive text messages for postpartum depression.

METHODS

Mothers found to be at risk for postpartum depression received supportive text messages four times weekly for 6 months in addition to receiving access to traditional counseling services based within an academic pediatric office. Feasibility was evaluated along with cellular and text messaging use, access, and perception of the message protocol. Perception of the message protocol was evaluated at study completion via a Likert scale questionnaire and open-ended qualitative survey.

RESULTS

In total, 4158/4790 (86.81%) text messages were successfully delivered to 54 mothers over a 6-month period at a low cost (US $777.60). Among the 96 scripted messages, 37 unique messages (38.54%) allowed for a response. Of all sent messages that allowed for responses, 7.30% (118/1616) were responded to, and 66.1% of those responses requested a call back; 46% (25/54) of mothers responded at least once to a text message. Mothers felt that messages were easily received and read (25/28, 89%) and relevant to them personally (23/28, 82%). Most shared texts with others (21/28, 75%).

CONCLUSIONS

Text messaging is feasible, well-accepted, and may serve as a simple, inexpensive adjunct therapy well-suited to cross socioeconomic boundaries and provide private support for at-risk mothers suffering from postpartum depression.