Mom-net: Evaluation of an internet-facilitated cognitive behavioral intervention for low-income depressed mothers

Pre-intervention child maltreatment risks, intervention engagement, and effects on child maltreatment risk within an RCT of MHealth and parenting intervention

Introduction

Evidence-based mental health and parenting support services for mothers postpartum can reduce risk for child maltreatment. However, women suffering economic and cultural stressors disproportionately shoulder the burden of infant caregiving while experiencing profound barriers to accessing mental health and parenting services. This article reports on an MHealth and parenting intervention targeting maternal mood and positive parent practices within a randomized controlled trial, which provided a unique opportunity to view pre-intervention child maltreatment risk, its relationship to subsequent intervention engagement, and intervention engagement effects on pre-post child maltreatment risk reduction.

Method

Principal component factor analysis was conducted to identify a modifiable pre-intervention child maltreatment risk construct within a combined MHealth and parenting intervention sample of 184 primarily Black mothers and their infants. An independent t-test was conducted to compare pre-intervention child maltreatment risk levels between mothers who went on to complete at least two-thirds of the intervention and those who did not. A GLM repeated measures analysis of variance was conducted to determine effects of intervention engagement on child maltreatment risk reduction.

Results

Pre-intervention child maltreatment risk did not differentiate subsequent maternal intervention completion patterns. Mothers who completed two-thirds of the intervention, compared to those who did not, demonstrated significant reductions in pre-post child maltreatment risk.

Discussion

Findings underscore the potential of MHealth parenting interventions to reduce substantial child maltreatment risk through service delivery addressing a range of positive parenting and behavioral health needs postpartum, a particularly vulnerable developmental period for maternal depression and child maltreatment risk.

Promoting Mental Health in Parents of Young Children Using eHealth Interventions: A Systematic Review and Meta-analysis

Parent stress and mental health problems negatively impact early child development. This study aimed to systematically review and meta-analyze the effect of eHealth interventions on parent stress and mental health outcomes, and identify family- and program-level factors that may moderate treatment effects. A search of PsycINFO, Medline, CINAHL, Cochrane and Embase databases was conducted from their inception dates to July 2020. English-language controlled and open trials were included if they reported: (a) administration of an eHealth intervention, and (b) stress or mental health outcomes such as self-report or clinical diagnosis of anxiety and depression, among (c) parents of children who were aged 1–5 years old. Non-human studies, case reports, reviews, editorials, letters, dissertations, and books were excluded. Risk of bias was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Random-effects meta-analyses of standardized mean differences (SMD) were conducted and meta-regressions tested potential moderators. 38 studies were included (N = 4360 parents), from 13 countries (47.4% USA). Meta-analyses indicated eHealth interventions were associated with better self-reported mental health among parents (overall SMD = .368, 95% CI 0.228, 0.509), regardless of study design (k = 30 controlled, k = 8 pre-post) and across most outcomes (k = 17 anxiety, k = 19 depression, k = 12 parenting stress), with small to medium effect sizes. No significant family- or program-level moderators emerged. Despite different types and targets, eHealth interventions offer a promising and accessible option to promote mental health among parents of young children. Further research is needed on moderators and the long-term outcomes of eHealth interventions. Prospero Registration: CRD42020190719.

Brain structural alterations in MDD patients with gastrointestinal symptoms: Evidence from the REST-meta-MDD project

OBJECTIVE

While gastrointestinal (GI) symptoms are very common in patients with major depressive disorder (MDD), few studies have investigated the neural basis behind these symptoms. In this study, we sought to elucidate the neural basis of GI symptoms in MDD patients by analyzing the changes in regional gray matter volume (GMV) and gray matter density (GMD) in brain structure.

METHOD

Subjects were recruited from 13 clinical centers and categorized into three groups, each of which is based on the presence or absence of GI symptoms: the GI symptoms group (MDD patients with at least one GI symptom), the non-GI symptoms group (MDD patients without any GI symptoms), and the healthy control group (HCs). Structural magnetic resonance images (MRI) were collected of 335 patients in the GI symptoms group, 149 patients in the non-GI symptoms group, and 446 patients in the healthy control group. The 17-item Hamilton Depression Rating Scale (HAMD-17) was administered to all patients. Correlation analysis and logistic regression analysis were used to determine if there was a correlation between the altered brain regions and the clinical symptoms.

RESULTS

There were significantly higher HAMD-17 scores in the GI symptoms group than that of the non-GI symptoms group (P < 0.001). Both GMV and GMD were significant different among the three groups for the bilateral superior temporal gyrus, bilateral middle temporal gyrus, left lingual gyrus, bilateral caudate nucleus, right Fusiform gyrus and bilateral Thalamus (GRF correction, cluster-P < 0.01, voxel-P < 0.001). Compared to the HC group, the GI symptoms group demonstrated increased GMV and GMD in the bilateral superior temporal gyrus, and the non-GI symptoms group demonstrated an increased GMV and GMD in the right superior temporal gyrus, right fusiform gyrus and decreased GMV in the right Caudate nucleus (GRF correction, cluster-P < 0.01, voxel-P < 0.001). Compared to the non-GI symptoms group, the GI symptoms group demonstrated significantly increased GMV and GMD in the bilateral thalamus, as well as decreased GMV in the bilateral superior temporal gyrus and bilateral insula lobe (GRF correction, cluster-P < 0.01, voxel-P < 0.001). While these changed brain areas had significantly association with GI symptoms (P < 0.001), they were not correlated with depressive symptoms (P > 0.05). Risk factors for gastrointestinal symptoms in MDD patients (p < 0.05) included age, increased GMD in the right thalamus, and decreased GMV in the bilateral superior temporal gyrus and left Insula lobe.

CONCLUSION

MDD patients with GI symptoms have more severe depressive symptoms. MDD patients with GI symptoms exhibited larger GMV and GMD in the bilateral thalamus, and smaller GMV in the bilateral superior temporal gyrus and bilateral insula lobe that were correlated with GI symptoms, and some of them and age may contribute to the presence of GI symptoms in MDD patients.

Optimizing Social-Emotional-Communication Development in Infants of Mothers With Depression: Protocol for a Randomized Controlled Trial of a Mobile Intervention Targeting Depression and Responsive Parenting

BACKGROUND

Postpartum depression interferes with maternal engagement in interventions that are effective in improving infant social-emotional and social-communication outcomes. There is an absence of integrated interventions with demonstrated effectiveness in both reducing maternal depression and promoting parent-mediated practices that optimize infant social-emotional and social-communication competencies. Interventions targeting maternal depression are often separate from parent-mediated interventions. To address the life course needs of depressed mothers and their infants, we need brief, accessible, and integrated interventions that target both maternal depression and specific parent practices shown to improve infant social-emotional and social-communication trajectories.

OBJECTIVE

The aim of this study is to evaluate the efficacy of a mobile internet intervention, Mom and Baby Net, with remote coaching to improve maternal mood and promote parent practices that optimize infant social-emotional and social-communication development.

METHODS

This is a two-arm, randomized controlled intent-to-treat trial. Primary outcomes include maternal depression symptoms and observed parent and infant behaviors. Outcomes are measured via direct observational assessments and standardized questionnaires. The sample is being recruited from the urban core of a large southern city in the United States. Study enrollment was initiated in 2017 and concluded in 2020. Participants are biological mothers with elevated depression symptoms, aged 18 years or older, and who have custody of an infant less than 12 months of age. Exclusion criteria at the time of screening include maternal homelessness or shelter residence, inpatient mental health or substance abuse treatment, or maternal or infant treatment of a major mental or physical illness that would hinder meaningful study participation.

RESULTS

The start date of this grant-funded randomized controlled trial (RCT) was September 1, 2016. Data collection is ongoing. Following the institutional review board (IRB)-approved pilot work, the RCT was approved by the IRB on November 17, 2017. Recruitment was initiated immediately following IRB approval. Between February 15, 2018, and March 11, 2021, we successfully recruited a sample of 184 women and their infants into the RCT. The sample is predominantly African American and socioeconomically disadvantaged.

CONCLUSIONS

Data collection is scheduled to be concluded in March 2022. We anticipate that relative to the attention control condition, which is focused on education around maternal depression and infant developmental milestones with matching technology and coaching structure, mothers in the Mom and Baby Net intervention will experience greater reductions in depression and gains in sensitive and responsive parent practices and that their infants will demonstrate greater gains in social-emotional and social-communication behavior.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03464630; https://clinicaltrials.gov/ct2/show/NCT03464630.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/31072.

Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): A systematic review and meta-analysis

OBJECTIVES

Perinatal depression (PND) is a prevalent and disabling problem both during pregnancy and the postpartum period. The legacy screening measure has been the Edinburgh Postnatal Depression Scale (EPDS). This systematic review examines the validity of the PHQ-9 as a screener for PND.

METHODS

The following databases were searched from January 2001 (when the PHQ-9 was first published) through June 2020: MEDLINE, Embase, and PsychInfo. Studies that compared the PHQ-9 to a criterion standard psychiatric interview were used to determine the operating characteristics of sensitivity, specificity and area under the curve (AUC). Studies comparing the PHQ-9 to the EPDS and other depression scales evaluated convergent validity.

RESULTS

A total of 35 articles were eligible for criterion (n = 10) or convergent (n = 25) validity. Meta-analysis of the 7 criterion validity studies using the standard PHQ-9 cut point ≥10 showed a pooled sensitivity, specificity and AUC of 0.84, 0.81 and 0.89, respectively. Operating characteristics of the PHQ-9 and EPDS were nearly identical in head-to-head comparison studies. The median correlation between the PHQ-9 and EPDS was 0.59, and categorical agreement was moderate.

CONCLUSIONS

The PHQ-9 appears to be a viable option for perinatal depression screening with operating characteristics similar to the legacy EPDS.

Brain structural and functional alterations in MDD patient with gastrointestinal symptoms: A resting-state MRI study

OBJECTIVE

It is common for major depressive disorder (MDD) to be accompanied by gastrointestinal (GI) symptoms, which are known to negatively impact the course and severity of the disease. Although previous studies have attempted to explore the neuropathology of MDD, few studies have focused on the pathogenesis of GI symptoms in MDD. In this study, we investigated the changes in regional gray matter volume (GMV) and regional homogeneity (ReHo) present in MDD accompanied by GI symptoms.

METHOD

The following images were obtained and analyzed: Structural and functional magnetic resonance images (MRI) of 36 patients with MDD accompanied by GI symptoms (GI symptoms group), 22 patients without GI symptoms (Non-GI symptoms group), and 27 healthy controls (HC. The 24-item Hamilton Depression Rating Scale (HAMD) was administered. A correlation analysis was used to identify the possible associations between altered regional GMV, ReHo symptoms, GI symptoms, and depressive symptoms.

RESULTS

The total scores from the HAMD-24 in the GI symptoms group were significantly higher than in the Non-GI symptoms group (P<0.05). Significant differences in both GMV and ReHo were observed among the three groups for the right parahippocampal gyrus, left precentral gyrus, left middle frontal gyrus, right superior frontal gyrus, right middle frontal gyrus, and left inferior orbitofrontal gyrus (AlphaSim correction, P <0.001). The GI symptoms group exhibited significantly decreased GMV and ReHo in the left middle frontal gyrus, precentral gyrus, right superior frontal gyrus, and middle frontal gyrus. Additionally, the GI symptoms group exhibited increased ReHo in the left superior temporal gyrus at a higher level than the non-GI symptoms group. (AlphaSim correction, P <0.001). These altered brain areas were correlated with GI symptoms (P<0.001) but not depressive symptoms (P>0.05).

CONCLUSION

Patients with MDD accompanied by GI symptoms have more severe depressive symptoms. The structural and functional changes of the brain may be the pathogenesis for the GI symptoms in patients with MDD.

Advancing mental health equality: a mapping review of interventions, economic evaluations and barriers and facilitators

BACKGROUND

This work aimed to identify studies of interventions seeking to address mental health inequalities, studies assessing the economic impact of such interventions and factors which act as barriers and those that can facilitate interventions to address inequalities in mental health care.

METHODS

A systematic mapping method was chosen. Studies were included if they: (1) focused on a population with: (a) mental health disorders, (b) protected or other characteristics putting them at risk of experiencing mental health inequalities; (2) addressed an intervention focused on addressing mental health inequalities; and (3) met criteria for one or more of three research questions: (i) primary research studies (any study design) or systematic reviews reporting effectiveness findings for an intervention or interventions, (ii) studies reporting economic evaluation findings, (iii) primary research studies (any study design) or systematic reviews identifying or describing, potential barriers or facilitators to interventions. A bibliographic search of MEDLINE, HMIC, ASSIA, Social Policy & Practice, Sociological Abstracts, Social Services Abstracts and PsycINFO spanned January 2008 to December 2018. Study selection was performed according to inclusion criteria. Data were extracted and tabulated to map studies and summarise published research on mental health inequalities. A visual representation of the mapping review (a mapping diagram) is included.

RESULTS

Overall, 128 studies met inclusion criteria: 115 primary studies and 13 systematic reviews. Of those, 94 looked at interventions, 6 at cost-effectiveness and 36 at barriers and facilitators. An existing taxonomy of disparities interventions was used and modified to categorise interventions by type and strategy. Most of the identified interventions focused on addressing socioeconomic factors, race disparities and age-related issues. The most frequently used intervention strategy was providing psychological support. Barriers and associated facilitators were categorised into groups including (not limited to) access to care, communication issues and financial constraints.

CONCLUSIONS

The mapping review was useful in assessing the spread of literature and identifying highly researched areas versus prominent gaps. The findings are useful for clinicians, commissioners and service providers seeking to understand strategies to support the advancement of mental health equality for different populations and could be used to inform further research and support local decision-making.

SYSTEMATIC REVIEW REGISTRATION

Not applicable.

Ecological contributions to maternal-infant functioning: Differences between rural and urban family contexts

AIMS

This study considered urban-rural differences in maternal-infant interactions (sensitivity/responsiveness and synchrony/reciprocity), infant temperament, and parenting stress, for samples similar in socioeconomic and racial composition. Higher sensitivity/responsiveness and synchrony/reciprocity were hypothesized for urban dyads, with more challenging temperament profiles predicted for rural infants. Rural mothers were expected to report more parenting-role stress.

METHODS

Urban (n = 68; San Francisco Bay) and rural (n = 120; inland Pacific Northwest) mothers of infants provided ratings of temperament and parenting stress. Parental sensitivity/responsiveness and synchrony/reciprocity were coded from mother-infant play observations. Groups were compared via analyses of covariance.

RESULTS

Urban mothers demonstrated significantly more sensitivity/responsiveness and synchrony/reciprocity compared to their rural counterparts. Rural mothers rated their infants significantly higher in negative affectivity and distress in response to limitations.

CONCLUSION

Although socioeconomic status is traditionally implicated in rural and urban population differences, our results suggest other factors (e.g., isolation, access to resources) warrant further exploration. Rural ecology appears to present risk that should be examined more closely in maternal-infant interactions and child social-emotional development. The variability of risk within urban and rural classifications (e.g., suburban, inner-city) also requires consideration.

Mediation analyses of Internet-facilitated cognitive behavioral intervention for maternal depression

This study evaluated the putative mediating mechanisms of an Internet-facilitated cognitive-behavioral therapy (CBT) intervention for depression tailored to economically disadvantaged mothers of preschool-age children. The CBT mediators were tested across two previously published randomized controlled trials which included the same measures of behavioral activation, negative thinking, and savoring of positive events. Trial 1 included 70 mothers with elevated depressive symptoms who were randomized to either the eight-session, Internet-facilitated intervention (Mom-Net) or to treatment as usual. Trial 2 included 266 mothers with elevated depressive symptoms who were randomized to either Mom-Net or to a motivational interviewing and referral to services condition. Simple mediation models tested each putative mediator independently followed by tests of multiple mediation that simultaneously included all three mediators in the model to assess the salient contributions of each mediator. The pattern of results for the mediating effects were systematically replicated across the two trials and suggest that behavioral activation and negative thinking are salient mediators of the Mom-Net intervention; significant mediating effects for savoring were obtained only in the simple mediation models and were not obtained in the multiple mediation models.

Dissemination of computer-assisted cognitive-behavior therapy for depression in primary care

Computer-assisted cognitive-behavior therapy (CCBT) for depression in primary care will be evaluated in a trial with 240 patients randomly assigned to CCBT or treatment as usual (TAU). The study will disseminate a therapy method found to be effective in psychiatric settings into primary care - a setting in which there have been significant problems in the delivery of adequate, evidence-based treatment for depression. The study will include a high percentage of disadvantaged (low-income) patients - a population that has been largely ignored in previous research in CCBT. There have been no previous studies of CCBT for depression in primary care that have enrolled large numbers of disadvantaged patients. The form of CCBT used in this study is designed to increase access to effective therapy, provide a cost-effective method, and be a sustainable model for wide-spread use in primary care. In order to deliver therapy in a practical manner that can be replicated in other primary care practices, patients with significant symptoms of depression will receive treatment with an empirically supported computer program that builds cognitive-behavior therapy skills. Support for CCBT will be provided by telephone and/or e-mail contact with a care coordinator (CC) instead of face-to-face treatment with a cognitive-behavior therapist. Outcome will be assessed by measuring CCBT completion rate, comprehension of CBT concepts, and satisfaction with treatment, in addition to ratings of depressive symptoms, negative thoughts, and quality of life. The cost-effectiveness analysis and exploration of possible predictors of outcome should help clinicians, health care organizations, and others plan further dissemination of CCBT in primary care.

The prognosis and changes of regional brain gray matter volume in MDD with gastrointestinal symptoms

Objective: It is common that major depressive disorder (MDD) is accompanied by gastrointestinal (GI) symptoms. However, few studies have focused on the clinical characteristics and its possible mechanism, while brain gray matter (GM) structure is important in the pathogenesis of GI symptoms. In this study, we aimed to investigate the basic clinical characteristics and regional GM volume changes in MDD accompanied by GI symptoms. Method: Patients with MDD (n=49) and age, gender, and educational level-matched healthy controls (n=30) were recruited. Patients with MDD were divided into two groups based on the GI status: MDD with (n=27) and without (n=22) GI symptoms. The 24-item Hamilton Depression Rating Scale (HAMD) was administered. T1-weighted anatomical images were obtained and analyzed. Correlation analysis was used to identify the possible associations between changed regional GM volume and GI symptoms and depressive symptoms. Results: The HAMD reductive ratio for 2 weeks of treatment in the GI symptoms group was significantly higher than the non-GI symptoms group (P<0.05). The regional GM volume showed significant differences among the three groups (Gaussian Random Field [GRF] correction, voxel-P<0.01, cluster-P <0.05). Compared with non-GI symptoms group, GI symptoms group exhibited significantly increased GM volume in the left hippocampus, left parahippocampal gyrus, right parahippocampal gyrus; and decreased GM volume in the right middle frontal gyrus, right precentral gyrus, right cuneus, right precuneus, right superior occipital gyrus (GRF correction, voxel-P <0.01, cluster-P <0.05). These altered brain areas were correlated with the GI symptoms, not depressive symptoms. Conclusion: The changed regional brain GM volume in GI-MDD group may be the pathogenesis for the GI symptoms. In addition, the GI symptoms may predict the prognosis of MDD.