Journal of Adolescence 37 (2014) 1227e1235

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A systematic review of perinatal depression interventions for adolescent mothers Kate Lieberman a, *, Huynh-Nhu Le a, Deborah F. Perry b a b

George Washington University, USA Georgetown University, USA

a b s t r a c t Keywords: Perinatal depression Intervention Adolescent

Poor, adolescent, racial/ethnic minority women are at great risk for developing perinatal depression. However, little research has been conducted evaluating interventions for this population. We conducted a systematic review of preventive and treatment interventions for perinatal depression tested with adolescents, with a focus on low income, minority populations. Nine research-based articles (including one that reported on two studies) were reviewed systematically, and quality ratings were assigned based on a validated measure assessing randomization, double-blinding, and reporting of participant withdrawals. Two treatment studies were identified, both of which were successful in reducing depression. Eight prevention studies were located, of which four were more efficacious than control conditions in preventing depression. Studies sampled mostly minority, low socioeconomic status adolescents. No consistent characteristics across efficacious interventions could be identified. This review underscores the need for researchers to further investigate and build an evidence base. © 2014 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

Adolescence is a difficult period of development, marked by hormonal, cognitive, social, and psychological changes that often lead to emotional distress, particularly depression ( Stone, Hankin, Gibb, & Abela, 2011; Teunissen et al., 2011). In 2009, 409,840 infants were born to adolescent mothers (ages 15e19) in the United States (Hamilton, Martin, & Ventura, 2010). This figure translates into a live birth rate of 39.1 per 1000 adolescents. These statistics are unsettling, given that adolescents are not fully individuated from their own families and frequently lack the emotional, cognitive, and financial resources necessary to optimally raise children (Corcoran, Franklin, & Bennet, 2000; Moore & Chase-Lansdale, 2001; Sadler & Catrone, 1983; Thomas & Rickel, 1995). Importantly, the stress from pregnancy in adolescence has been shown to increase the risk for depression, and perinatal depression (depression occurring during pregnancy through 12 months of delivery) is associated with negative consequences in mothers and babies (Barnet, Liu, & DoVoe, 2008; Misri & Joe, 2008). These findings support the need to develop and test interventions aimed at preventing and treating adolescent perinatal depression. The purpose of this paper is to examine and evaluate the existing literature on such interventions. Research has shown that perinatal depression adversely affects both mothers and their infants (Misri & Joe, 2008). While literature regarding the negative consequences of perinatal depression specifically in adolescent populations is limited, researchers have shown that adolescent depression (more generally) may result in high risk sexual behavior, substance use, low

* Corresponding author. George Washington University, Department of Psychology, 2125 G St. NW, Washington, DC 20052, USA. Tel.: þ1 (917) 699 5548. E-mail addresses: [email protected], [email protected] (K. Lieberman). http://dx.doi.org/10.1016/j.adolescence.2014.08.004 0140-1971/© 2014 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

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academic attainment, physical and psychological health problems, and suicide, as well as negative interactions with their children and physical and behavioral problems in their children as infants and toddlers (Barnet et al., 2008; Fletcher, 2008; Franko, Striegel-Moore, Thompson, Schreiber, & Daniels, 2005). Additionally, infants of depressed mothers can experience difficulties with emotion regulation and with cognitive, language, and motor development (Murray, 1992). Research has shown that poor, young, racial or ethnic minority women may be at greatest risk for developing perinatal depression, likely due to a combination of risk factors including life stressors, lack of social support, marital dysfunction, single marital status, low socioeconomic status (SES), and unplanned or unwanted pregnancy (Beck, 2001; Segre, O'Hara, & Stuart, 2007). Rates of postpartum depression as high as 28e56% have been documented in adolescent, low SES, racial or ethnic minority mothers (Hodgkinson, Colantuoni, Robers, Berg-Cross, & Belcher, 2010; Ramos-Marcuse et al., 2010). Because the risk for developing perinatal depression is so high in adolescent, low SES, racial or ethnic minority mothers, it is important for researchers and clinicians to examine risk and resilience factors specific to this population to develop targeted interventions. Research has indicated that adolescents are more likely to experience perinatal depression if they suffer from: low SES, family and/or partner conflict, social isolation, dissatisfaction with social support, low self esteem, low confidence in parenting abilities, or stress (Birkeland, Thompson, & Phares, 2005; Caldwell, Antonucci, & Jackson, 1998; Kalil, Spencer, Spieker, & Gilchrist, 1998; Logsdon, Birkimer, Simpson, & Looney, 2005). On the other hand, positive and supportive family relationships and high self-esteem may protect adolescents from the negative consequences of perinatal depression (Barnet, Joffe, Duggan, Wilson, & Repke, 1996; Caldwell et al., 1998). A growing body of research has documented the efficacy of prevention and treatment programs for perinatal depression in adult mothers. Interventions found to be efficacious generally consist of cognitive-behavioral (CBT) (Chabrol et al., 2002; Le, Perry, & Stuart, 2011; Tandon, Perry, Mendelson, Kemp, & Leis, 2011) and interpersonal therapy (IPT) approaches (Mulchay, Reay, Wilkinson, & Owen, 2010; Zlotnick, Miller, Pearlstein, & Howard, 2001; Zlotnick, Miller, Pearlstein, Howard, & Sweeney, 2006). Unfortunately, little research has been conducted that applies knowledge of the aforementioned risk and protective factors, or research regarding efficacious interventions in adult populations, to the prevention or treatment of perinatal depression in adolescents. The purpose of this paper is to address these gaps by conducting a systematic review of the current preventive and treatment interventions of perinatal depression specifically tested for adolescents, with a focus on low SES, racial or ethnic minority populations. Methods A literature search was conducted using the PsycInfo and PubMed electronic databases. Combinations of the following terms were included: adolescent, teen, depression, postpartum, pregnant, perinatal, intervention, treatment, prevention. Citation index searches were also conducted from the articles identified on the databases. Inclusion criteria for articles were: published within the past 15 years in English; adolescent (teenage) population; and research-based studies testing outcomes of interventions targeting pregnant adolescents or adolescent mothers in improving depression (clinical depression or elevated symptoms), as assessed with a standardized measure. Published dissertations and unpublished documents were not included. The combinations of keywords listed above produced a total of 413 articles. Limiting the results to articles published within the past 15 years yielded 335. Limiting results to articles related to perinatal depression yielded 174. From these, and from a review of their references, 15 studies were found that described interventions targeting perinatal depression. From these, nine articles (including one article, Miller, Gur, Shamok, &Weissman, 2008 , that consisted of two intervention studies, and therefore referred to hereafter as parts a and b, targeted adolescents and adhered fully to inclusion criteria. The interventions included (see Table 1): 1) individual home-based CBT and psycho-education (Ginsburg et al., 2012); 2) group IPT (Miller et al., 2008); 3) home visiting psychoeducation regarding parenting, family planning, substance use prevention, and coping skills (Walkup et al., 2009); 4) home visiting with parenting and adolescent curricula (Barnet et al., 2007); 5) maternal infant massage training (Oswalt, Biassini, Wilson, & Mrug, 2009); 6) maternal massage therapy (Field, Grizzle, Scafidi, & Schanberg, 1996); 7) a motivational interviewing phone-based intervention (Logsdon, Foltz, Stein, Usui, & Josephson, 2010); 8) social support enhancement training (Logsdon, et al., 2005); and 9) a multi-component treatment, with daycare, rehabilitation, relaxation, massage therapy, and mother-infant interaction coaching (Field et al., 2000). Because not all studies were randomized controlled trials (RCTs) and did not calculate effect sizes, we were not able to conduct a meta-analysis. Instead, all studies were reviewed systematically, and quality ratings were assigned to each study based on the Jadad Scale (Jadad et al., 1996). The Jadad Scale is a validated measure assessing randomization, double-blinding, and reporting of participant withdrawals that increases the rigor of a systematic review. It was selected as it was found to demonstrate the best evidence for reliability and validity in a systematic review of 21 scales used to evaluate RCT quality (Olivo et al., 2008). Scores on this measure range from 0 to 5, with higher scores indicating higher quality. One point is awarded for randomization of participants, with an additional point awarded for describing the manner in which participants were randomized. One point is awarded for reporting number of and reasons for participant withdrawals. Two points are awarded to studies that are double-blinded and that describe the process of double-blinding. It should be noted that the Jadad scale has been criticized for its heavy focus on double-blinding, which may not be possible or relevant for some psychological intervention trials, as well as its relative simplicity (it does not, for instance, address issues of statistical analysis, intervention fidelity, treatment adherence, follow-up, and use of sub-group analyses) (Olivo et al., 2008). Therefore, additional qualitative descriptions of intervention quality have been included in this review to

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Table 1 Adolescent perinatal depression intervention study descriptions. Study

Location

Study type

Barnet et al., 2007.

- Baltimore, MD - Recruited from prenatal care sites

Prevention: RCT

Field et al., 1996.

- Inner city area of the United States

Field et al., 2000.

Logsdon et al., 2005.

Sample description

Intervention condition

Intervention provider

Control condition

84

- Pregnant teenagers - Mean age 16.9 - 91% African American, 9% unspecified

- African American women from the community, trained to deliver curricula

- Usual care prenatal site

Prevention: RCT

32

- Trained massage therapists

- Thirty minutes of yoga and/or progressive muscle relaxation on two consecutive days for five weeks

- Location not specified - Recruited from the hospital after delivery

Prevention: RCT

260

- Teenage mothers - Mean age 18.1 - Approx. 71% African American, 29% Latino - Elevated depressive symptoms - Teenage mothers - Mean age 17.3 (depressed group), 18 (nondepressed group) - Approx. 60% African American; 25% Latino; 15% European American

- Home visiting program with parenting and adolescent curricula - Twice per week for one year, once per month for second year - Thirty minute massages on two consecutive days for five weeks

- Not specified

- Not specified

- Location not specified - Recruited from a public school for pregnant and parenting teenagers - Southern, urban area in the United States - Recruited from a adolescent parent program

Prevention: RCT

128

- Three month multicomponent program with day-care, vocational and social education and activities, music mood induction therapy, relaxation therapy, massage therapy, and mother-infant interaction coaching - One-time social support intervention delivered via pamphlet, video, or video plus pamphlet

or

- No intervention

Treatment: Pre-Post

97

- Trained child/ adolescent psychiatric nurse

- No intervention

Miller et al., 2008.

- New York City, NY - Recruited from schools for pregnant and parenting adolescents

Prevention: Pre-Post

14

- Six-month telephone-based depression care program - Motivational interviewing and psychoeducation - Group interpersonal therapy adapted for pregnant adolescents - Twelve weekly sessions of 1 h

- No intervention

Miller et al., 2008.

- New York City, NY - Recruited from public schools for pregnant/ parenting adolescents

Treatment: Pre-Post

11

- Clinical psychologist with seven years of IPT experience and clinical psychologist co-therapist with previous training in IPT - Clinical psychologist with seven years of IPT experience and clinical psychologist co-therapist with previous training in IPT

Oswalt et al., 2009.

- Urban southeast United States

Prevention: RCT

25

Logsdon et al., 2010.

N

- Pregnant teenagers - Mean age 16 - 56% African American, 38% European American - Teenage mothers - Mean age 16.4 - 44% European American, 42% African American

- Pregnant teenagers - Mean age 14.7 - Approx. 71% Latino, 21% African American, 8% African American/Hispanic - Pregnant teenagers - Mean age 16.5 - Approx. 73% African American, 9% Latino, 18% African American/ Hispanic - Clinical depression or adjustment disorder - Teenage mothers - Mean age 16.3

- Group interpersonal therapy adapted for pregnant adolescents - Twelve weekly sessions of 1 h and 15 min

- Pamphlet video

- Not specified

at

- No intervention

- Intervention following (continued on next page)

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Table 1 (continued ) Study

Location

Study type

N

Ginsburg et al., 2012.

- White Mountain Apache Indian reservation

Prevention: RCT

47

Walkup et al., 2009.

- Navajo and White Mountain Apache reservations in NM and AZ - Recruited from prenatal and school-based clinics

Prevention: RCT

167

Sample description

Intervention condition

- 100% African American

- One-time 30-min live infant massage training - Psycho-educational and CBT sessions adapted for Apache adolescents - Eight weekly 30 e60 min in ehome sessions - Prenatal and infant-care parenting lessons, family planning, substance abuse prevention, and problem-solving and coping-skills lessons. - 25, 1 h home visits

- Pregnant White Mountain Apache American Indian teenagers - Mean age 18.15 - Baseline depression scores on CES-D  16 - Pregnant American Indian teenagers - Median age 18 - 65% Navajo, 18% White Mountain Apache or mixed tribal background

Intervention provider

- Trained American Indian paraprofessionals

- Trained American Indian paraprofessionals

Control condition completion of follow-up measures - Perinatal educational support

- Breastfeeding and nutrition education program - 23, 1 hour home visits

supplement the scale, including evaluations of control condition, intervention providers, use of fidelity checks, calculation of effect sizes, and utilization of intent-to-treat analyses.

Results Intervention characteristics Table 1 provides a description of intervention type, location, sample description, intervention design and dose, intervention provider, and control conditions for the articles reviewed. Studies were characterized as treatment or prevention according to the definitions utilized by Cuijpers, van Straten, Andersson, and van Oppen (2008). Thus, treatment interventions sought to treat clinical depression, assessed via clinical interviews or measures of clinical depression. Preventive interventions sought to decrease elevated symptoms of depression in the absence of a clinical assessment, or to prevent the onset of depressive symptoms or major depressive disorder. According to this operationalization, two of the interventions were treatment-based (Logsdon et al., 2010; Miller et al., 2008), and eight were prevention-based (Barnet et al., 2007; Field et al., 1996, 2000; Ginsburg et al., 2012; Logsdon et al., 2005; Miller et al., 2008; Oswalt et al., 2009; Walkup et al., 2009). Intervention outcomes Results are described below. Also summarized below and presented in Table 2 are evaluations of use of fidelity checks, calculation of effect size, intent-to-treat analysis, randomization, double blinding, reporting of withdrawals, as well as quality ratings based on the Jadad scale. Treatment studies Both treatment studies were effective in reducing depression rates, including a 6-month motivational interviewing phonebased intervention (Logsdon et al., 2010), and a 12-week interpersonal group intervention (Miller et al., 2008). One treatment study assessed the utility of a telephone-based depression care management intervention for adolescent mothers in reducing depression and increasing therapy utilization (Logsdon et al., 2010). Researchers screened 97 European American (44%) and African American (42%) adolescent mothers from an adolescent parent program for clinical depression (via the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version, or K-SADS-PL) and elevated depressive symptomatology (via the Center for Epidemiologic Studies Depression Scale, or CES-D). Twenty-two of the mothers had elevated symptom scores, and ten of these met criteria for Major Depressive Disorder. The ten mothers were referred into the intervention, a 6-month program in which a psychiatric nurse contacted the mothers to provide support, including motivational interviewing (to help the mothers obtain treatment for depression) and psychoeducation. At baseline, intervention group participants had significantly higher depressive symptom scores than the control (non-depressed) group, but by 6 months postpartum, the intervention group's scores had decreased to approximate those of the control group. While mental health utilization was low overall (with only four adolescents receiving mental health treatment), the intervention group participants had more mental health related visits than did the control group (the authors did not indicate whether this

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Table 2 Adolescent perinatal depression intervention quality review. Study

Fidelity checks

Effect size calculated

Intention-to-treat analysis

Randomization

Double blinding

Withdrawal reporting

Jadad Quality Ratingc

Barnet et al., 2007 Field et al., 1996. Field et al., 2000. Logsdon et al., 2005.

Yes Not reported Not reported Not reported

Yes No No No

No No No No

Yes Yes Yes Yesb

No No No No

2 1 1 2

Logsdon et al., 2010. Miller et al., 2008 Miller et al., 2008.a Oswalt et al., 2009. Ginsburg et al., 2012. Walkup et al., 2009.

Yes Not reported Not reported Not reported Yes Yes

No Yes Yes Yes Yes Yes

No No No No No No

No No No Yes2 Yes2 Yes2

No No No No No No

Yes No No Yes; reasons not reported Yes Yes Yes Yes Yew Yes

1 1 1 3 3 3

a

Treatment studies. The remaining studies are prevention. Randomization process was described in the study. c The Jadad Scale rates studies based upon: 1) randomization of participants (one point for randomization; one point for description of randomization process), 2) reporting of number and reasons for participant withdrawals (one point), and 3) double blinding (one point for double blinding; one point for description of double blinding process). b

difference reached statistical significance). Fidelity was assessed insofar as ten percent of interventions were evaluated by two independent raters (though fidelity results were not reported). Another treatment study assessed the effects of group-based IPT on perinatal depressive symptoms and clinical depression in a sample of 11 pregnant, clinically depressed African American and Hispanic girls (screened and assessed via the K-SADS), attending an after school program at a public high school (Miller et al., 2008). The intervention consisted of 12 weekly group IPT sessions that aimed to: 1) examine the adolescents' emerging roles as mothers, 2) help the adolescents identify and increase social and material support, and 3) provide them with practice dealing with conflict and avoiding danger. Postintervention, eight of the 11 participants no longer met criteria for major depression, and two of the remaining three showed reduced severity. Mean Beck Depression Inventory-II (BDI-II) and Hamilton Rating Scale for Depression (HRSD) scores decreased, non-significantly, but with large effect sizes (1.19 and .76 for the BDI-II and HRSD, respectively). Mean Edinburgh Postnatal Depression Scale (EPDS) scores decreased significantly, with a large effect size (.94). No significant changes were evident from post intervention to the 20-week follow-up on any of the measures. Prevention studies Four of the eight prevention studies were effective in reducing depression incidence compared to control conditions; these included: a maternal massage program (Field et al., 1996); a multi-component treatment with daycare, relaxation, massage, and mother-infant coaching (Field et al., 2000); a 12-week IPT group intervention (Miller et al., 2008); and a maternal infant massage program (Oswalt et al., 2009). No significant effects on depressive symptomatology (versus control) were demonstrated in: two home-visiting based psychoeducational interventions (Barnet et al., 2007; Walkup et al., 2009); an individual home-based CBT intervention (Ginsburg et al., 2012); or a one-time social support enhancement intervention (Logsdon et al., 2005). Field et al. (1996) conducted a RCT comparing the effects of massage and relaxation therapies on anxiety and depressive symptoms in adolescent mothers from an inner-city hospital. Thirty-two African American (71%) and Hispanic (29%) adolescents with elevated Beck Depression Inventory (BDI) symptom scores (>16) participated in the study. Sixteen were randomly assigned to receive bi-weekly massages for 5 weeks, and 16 were randomized to the relaxation therapy condition. The massage condition was associated with better outcomes (including decreased depression scores, anxiety scores, and physiological measures of anxiety), as compared to the relaxation condition. BDI scores and the Profile of Mood States (POMS) depression scale items decreased pre-to-post intervention for the massage group, but not for the relaxation group. In a different line of study, Field et al. (2000) examined the effects of a three-month comprehensive intervention, including daycare, school and vocational activities, mood induction, relaxation, massage therapy, and mother-infant interaction coaching, on maternal depressive symptoms, biological indicators of stress, mother-infant interactions, and infant outcomes. Adolescent mothers, mostly African American (approximately 60%) and Hispanic (approximately 25%), were recruited from the hospital at the time they gave birth; 160 mothers had elevated depressive symptoms at the time of recruitment (BDI-II> 12), and 100 mothers had no or minimal symptoms (BDI-II < 9). Thirty-one percent of the participants with elevated BDI-II scores met the Diagnostic Schedule for Children (DISC) criteria for Dysthymia, while none of the participants with minimal BDI-II symptoms met criteria. Participants with elevated depressive symptoms were randomized to the intervention or control group at 3 months postpartum, while participants without elevated depression scores comprised a “non-depressed” group. At six months postpartum, mothers in the intervention group had significantly lower BDI scores and incidence of major depression measured on the DISC as compared to control group participants, but their scores and incidence were higher than those of the

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non-depressed group. These results were maintained at the 12 months postpartum follow-up. Thus, intervention group participants continued to have lower depressive symptoms and rates of depression, though these remained higher than the non-depressed group. In a pilot study, Miller et al. (2008) analyzed the effects on depressive symptoms of group IPT for pregnant teenagers attending a New York public school for pregnant and parenting girls. Participants included 14 pregnant African American and Hispanic adolescents enrolled in a health class at the specialized school; all girls who were enrolled in the health class were invited to participate. The intervention consisted of 12 weekly group IPT sessions that aimed to: 1) examine the adolescents' emerging roles as mothers, 2) help them identify and increase social and material support, and 3) provide them with practice dealing with conflict and avoiding danger. Thirteen out of the 14 girls showed significant reduction in depressive symptoms (assessed via the BDI-II and the EPDS) from pre-to-post intervention, with large and significant effect sizes (.86 and .89 for the BDI-II and EPDS, respectively). A post-hoc quasi-experimental control group of 13 pregnant adolescents who took the health class but who did not participate in the group had significantly higher BDI-II and EPDS scores at the 12-week mark than the adolescents who underwent the intervention. Oswalt et al. (2009) tested the effects of maternal infant massage on adolescents' depression, confidence, parenting stress, and feelings about relationships with their infants. Twenty-five African American adolescents were recruited from an educational and vocational parental training program at a public school. Mothers were randomly assigned, using a random numbers table, to the massage intervention (one-time infant massage training) or control (no intervention) group. Mothers were assessed at baseline (four weeks postpartum) and two months post intervention. Intervention group participants reported significantly lower depressive symptom (BDI-II) scores after the intervention, with a large effect size of .91. The other four prevention studies did not demonstrate significant impacts on depression scores. Barnet et al. (2007) tested the effects of a home visiting program for pregnant and parenting adolescents on depressive symptoms, parenting, school status, and repeat pregnancy. The sample consisted of 84 adolescents (91% African American) receiving care from one of three prenatal care sites in Baltimore. Forty-four adolescents were randomized to the home visiting program, and 40 were randomized to the usual care condition, and participants were followed for two years. The home visiting program began in the third trimester, and consisted of two visits per week from trained paraprofessionals through one year postpartum and one visit per month through the second year. The parenting curriculum focused on improving knowledge of child development, increasing parenting attitudes and skills, and encouraging the use of health care. The adolescent curriculum taught safe sex practices and promoting school attendance and completion. Home visitors rated their adherence to program standards via standardized forms. Baseline depression symptom scores, assessed via the CES-D, were elevated in 34.5% of the sample. The home visiting program did not impact depression scores; however, the program was associated with significant increases in parenting attitude scores (with a medium effect size of .49) and with increased odds of school continuation. In another psychoeducational home-visiting based study, Walkup et al. (2009) enrolled pregnant American Indian (Navajo and White Mountain Apache) adolescents to test the efficacy of a culturally adapted intervention (Family Spirit Intervention) in improving a variety of perinatal outcomes, including depression. Participants included 167 pregnant Navajo and White Mountain Apache adolescents and young adults (aged 12e22), recruited from reservation-based prenatal and school-based clinics, and randomized to either the Family Spirit Intervention or a breastfeeding and nutrition education program. The Family Spirit Intervention consisted of 25 home-based, paraprofessional-delivered sessions, culturally designed for American Indian adolescents, focusing on prenatal and infant care, family planning, substance abuse prevention, and instruction in coping skills and problem solving. This intervention utilized structured manuals and assessed fidelity through random checking of intervention adherence (of audiotaped sessions) and weekly supervision of interventionists. Participants were assessed at baseline and at 2, 6, and 12 months postpartum. No between or within group differences were found in change in depressive symptom (CES-D) scores between any time-points. Another preventive intervention targeting American Indian adolescents assessed the efficacy of a culturally adapted home-based CBT program in reducing perinatal depressive symptoms and preventing the onset of postpartum depression (Ginsburg et al., 2012). Participants included 47 pregnant Apache American Indian teenagers with elevated depressive symptom scores (CES-D score of 16 or greater), who did not meet criteria for current MDD (as assessed via clinical interviews). The adolescents were randomly assigned to either the intervention (Living in Harmony) or control (Education-Support) condition. The Living in Harmony program consisted of an eight-week home-visiting based CBT intervention, culturally adapted such that language and concepts cohered with participants' life experiences. The Education-Support condition was a home-visiting based perinatal educational support program, which did not address coping skills for depression. Participants were assessed immediately post intervention, and at 4, 12, and 24 weeks postpartum. Fidelity was assessed via periodic direct observation of interventionists and evaluators, as well as daily and weekly supervision. Participants from both conditions decreased in severity of depressive symptoms (assessed via the CES-D and EPDS) from pre to post intervention and follow ups, with effect sizes ranging from .05 to .22 for the CES-D and from .03 to .22 for the EPDS; however, no differences in depression measures emerged between conditions. Rates of major depression were low across groups, with only two participants (from the control group) meeting criteria at any time point post intervention. Finally, Logsdon and colleagues (2005) tested the efficacy of a one-time social support intervention in decreasing depressive symptoms among adolescent mothers. One hundred twenty-eight mostly African American (56%) and European American (38%) students taking a childbirth education class from a public school for pregnant and parenting adolescents were recruited. Students were randomly assigned, using a random numbers table, to receive pamphlet, video, or pamphlet plus

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video social support coaching, or to the control group. The intervention emphasized: identifying the need for support, deciding what kind of help to ask for, whom to ask for help, how to ask for help, and how to return favors. Participants were assessed via the CES-D. Fifty-six percent of participants demonstrated mild depression symptom scores at baseline. Postintervention, at six weeks postpartum, no significant differences were found on any measures between groups; however, depressive symptoms decreased (significantly) from pregnancy to the postpartum follow-up across groups. Discussion The purpose of this paper was to evaluate the current state of research regarding interventions to treat or prevent perinatal depression in pregnant and parenting adolescents, using a validated system to rate the quality of the intervention trials. Nine articles (reporting on 10 studies) examining outcomes of interventions for pregnant adolescents or adolescent mothers in improving depression were evaluated, including two treatment and eight prevention studies. Both of the treatment studies, a group IPT treatment (Miller et al., 2008) and a motivational interviewing intervention (Logsdon et al., 2010), were successful in reducing rates of major depression. These studies had strengths of enrolling ethnic minority samples in mostly urban, underserved settings. Despite these strengths and the evidence for the utility of these treatments, the rigor of these studies was limited. Neither was a randomized controlled trial, and neither had a specified active control condition (their control conditions consisted of treatment as usual). Only one utilized fidelity checks (Logsdon et al., 2010), only one reported effect sizes (Miller et al., 2008b), and neither utilized intent-to-treat analyses. Additionally, neither study utilized double blinding, though this process can be difficult to implement in intervention research. Regarding quality ratings, both studies received one out of five possible points, for reporting number of and reasons for participant withdrawals. The lack of fidelity checks, effect size reporting, and utilization of intent-to-treat indicate the need for more methodologically rigorous research in this area. A substantially greater number of prevention studies than treatment studies were identified. The comparative number of prevention studies is promising for the direction of this literature, as preventive interventions are designed to decrease the incidence of disorder, as well as subsequent negative sequelae. Of the eight prevention interventions, four were more successful than control conditions in preventing perinatal depression: a maternal massage program (Field et al., 1996); a multicomponent treatment (Field et al., 2000); a 12-week IPT group intervention (Miller et al., 2008); and a maternal infant massage program (Oswalt et al., 2009). Four of the eight studies demonstrated no significant effects on depressive symptomatology versus a control condition: two home-visiting based psychoeducational interventions (Barnet et al., 2007; Walkup et al., 2009); an individual home-based CBT intervention (Ginsburg et al., 2012); and a one-time social support enhancement intervention (Logsdon et al., 2005). While the home-based CBT program resulted in decreased depression scores post-versus pre-intervention, the program performed no better than the usual care, perinatal educational control condition (Ginsburg et al., 2012). Like the treatment studies, the prevention studies recruited mostly minority samples from underserved urban areas. However, compared to the treatment studies, some of the prevention studies were more methodologically rigorous. Each utilized a randomized controlled design, and all but two (Field et al., 1996, 2000) reported on participant retention. Three reported effect sizes (Barnet et al., 2007; Ginsburg et al., 2012; Oswalt et al., 2009), and three utilized intent-to-treat analysis and fidelity checks (Barnet et al., 2007; Ginsburg et al., 2012; Walkup et al., 2009). However, quality ratings ranged from one to three out of five points. Therefore, there remains room for increased rigor in these studies. For instance, only one of the prevention studies had an active control condition (Walkup et al., 2009), and five did not utilize intent-to-treat analyses, fidelity checks, or double blinding (Field et al., 1996; Logsdon et al., 2005; Miller et al., 2008; Oswalt et al., 2009). In sum, additional research utilizing rigorous methodology is needed to identify preventive interventions that successfully reduce depression in perinatal adolescents. Taking the treatment and prevention studies together, it is difficult to identify a pattern in the types of interventions that proved efficacious. Efficacious interventions varied in terms of their approach, length, and type of providers. This suggests that a variety of approaches may be warranted, given the diversity of adolescent risk and resilience factors at play in this population. None of the studies reported on subgroups who did or did not benefit, leaving room for future researchers to investigate and identify for what works for distinct populations of adolescents. Future directions To address the need for increased rigor, future studies should include full descriptions of samples, interventions, intervention providers, and control conditions. Interventions should be delivered by trained interveners with the competence to act flexibly, accurately assess and diagnose, and develop and implement treatment goals (American Psychological Association, 2006). Control conditions should consist of active placebo interventions or evidence-based alternatives. Intervention fidelity should be assessed and reported, and participant retention should likewise be described. Effect sizes should be calculated, and analyses should be based on intent-to-treat. Since psychological disorders may manifest differently across cultures and individuals (APA, 2006), testing interventions across populations is necessary to demonstrate that the intervention is generalizable. Indeed, the studies reviewed in this article included sizable racial and ethnic minority samples, a considerable strength of this body of work. Studies should also address the ways in which interventions may be adequately adapted to fit the needs and preferences of their target

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populations. This type of cultural sensitivity was demonstrated in two of the studies reviewed in this paper, which addressed the effects of interventions specifically targeting American Indian adolescents, by reflecting local native practices and beliefs (Ginsburg et al., 2012; Walkup et al., 2009). Interventions that are successfully culturally adapted are better able to: effectually engage participants in terms of recruitment, enrollment, attendance, and intervention satisfaction; and change negative clinical outcomes, including both universal and culturally specific problems (Barrera & Castro, 2006). Researchers and clinicians interested in targeting depression in perinatal adolescents may benefit from adapting interventions deemed evidence based and successful for perinatal adult depression, and adapting evidence based interventions that successfully address general depression in adolescents. CBT has been shown to be successful in the treatment (Bledsoe & ~ oz et al., 2007) of perinatal depression in adults. Group CBT has also been demonstrated as Grote, 2006) and prevention (Mun efficacious in preventing and treating depression in adolescents (David-Ferdon & Kaslow, 2008). In particular, the “Coping with Depression-Adolescent” course was found to decrease the odds of major depression in adolescent children of depressed adults (Clarke et al., 2001) and in adolescents with elevated depressive symptom scores (Clarke, Hawkins, Sheeber, Lewinsohn, & Seeley, 1995); and it was found to successfully treat depression in adolescents who met criteria for the clinical disorder (Rhode, Clarke, Mace, Jorgensen, & Seeley, 2004). However, as demonstrated in this review, researchers have not yet successfully adapted CBT interventions for use with perinatal adolescents. Such an adaptation would be an important direction for future research. Given the current state of the literature on interventions designed to treat and prevent adolescent perinatal depression, preliminary evidence has been found for the efficacy of a small number of treatment and a larger number of preventive interventions. However, this body of work is less than complete. Given the well-documented negative sequelae of perinatal depression on maternal and child outcomes, more research is needed to develop efficacious and effective interventions. Interventions that successfully treat or prevent adolescent perinatal depression can positively impact two generations (both mother and baby), and improve the odds of long-term well-being for adolescents and their children.

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A systematic review of perinatal depression interventions for adolescent mothers.

Poor, adolescent, racial/ethnic minority women are at great risk for developing perinatal depression. However, little research has been conducted eval...
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