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ORIGINAL ARTICLE
PREPP: postpartum depression prevention through
the mother–infant dyad
Elizabeth A. Werner
1
&Hanna C. Gustafsson
1
&Seonjoo Lee
3,4
&
Tianshu Feng
3
&Nan Jiang
1
&Preeya Desai
1
&Catherine Monk
1,2
Received: 2 March 2015 /Accepted: 5 July 2015
#Springer-Verlag Wien 2015
Abstract Most interventions to prevent postpartum depres-
sion (PPD) focus on the mother rather than the mother–infant
dyad. As strong relationships between infant sleep and cry
behavior and maternal postpartum mood have been demon-
strated by previous research, interventions targeted at the dyad
may reduce symptoms of PPD. The goal of the current study
was to examine the effectiveness of Practical Resources for
Effective Postpartum Parenting (PREPP). PREPP is a new
PPD prevention protocol that aims to treat women at risk for
PPD by promoting maternally mediated behavioral changes in
their infants, while also including mother-focused skills.
Results of this randomized control trial (RCT) (n=54) indicate
that this novel, brief intervention was well tolerated and effec-
tive in reducing maternal symptoms of anxiety and depres-
sion, particularly at 6 weeks postpartum. Additionally, this
study found that infants of mothers enrolled in PREPP had
fewer bouts of fussing and crying at 6 weeks postpartum than
those infants whose mothers were in the Enhanced TAU
group. These preliminary results indicate that PREPP has the
potential to reduce the incidence of PPD in women at risk and
to directly impact the developing mother–child relationship,
the mother’s view of her child, and child outcomes.
Keywords Pregnancy .Postpartum depression .Anxiety .
Randomized control trial .Infant fuss and cry
Of the over 4 million live births each year in the USA, nearly
800,000—or 20 %—of these mothers will develop major or
minor depression within the first 3 months postpartum. These
numbers dwarf prevalence rates for gestational diabetes (2–5%)
and preterm birth (12.7 %) (Dabelea et al. 2005; Saigal and
Doyle 2008). Postpartum Depression (PPD) affects the mother
and her infant. It is associated with marital discord and impaired
occupational and social functioning, particularly with respect to
maternal–infant interactions that are characterized by disengage-
ment, hostility, and intrusion (Burke 2003;Lovejoyetal.2000;
Martins and Gaffan 2000;Murrayetal.1995). Child outcomes
include poor cognitive functioning, as well as emotional and
behavioral problems such as increased risk for externalizing
disorders and future psychopathology (Cicchetti et al. 1998;
Grace et al. 2003; Kurstjens and Wolke 2001). These deleterious
effects on child developmental trajectories have been shown
even when controlling for family SES and subsequent maternal
mental illness, indicating the importance of preventing PPD
during this critical period in development (Hay et al. 2001).
Existing clinical treatments for the prevention of PPD use
standard approaches that focus solely on the mother, e.g.,
pharmacologic and psychological interventions to reduce
women’s symptoms. Given the complex genetic, biological,
and environmental etiology of depression, there is a need for
an array of intervention and treatment options; given the spe-
cific context in which PPD occurs, it is logical to exploit the
unique dyadic orientation of this period when designing new
treatment strategies. It also is important to consider the reasons
Hanna C. Gustafsson is co-first author.
*Elizabeth A. Werner
ew150@cumc.columbia.edu
1
Division of Behavioral Medicine, Department of Psychiatry,
Columbia University Medical Center, 622 West 168th Street,
PH1540-E, New York, NY 10032, USA
2
New York State Psychiatric Institute, New York, NY, USA
3
Division of Biostatistics, New York State Psychiatric Institute, New
York, NY, USA
4
Department of Biostatistics and Psychiatry, Columbia University,
New York, NY, USA
Arch Womens Ment Health
DOI 10.1007/s00737-015-0549-5
that PPD is significantly undertreated when developing a new
prevention protocol (Werner et al. 2014), e.g., time constraints
during the postpartum period and reluctance to take psycho-
tropic medications when breastfeeding (Ballestrem et al.
2005; Boath et al. 2004; Whitton et al. 1996).
This report describes a small, randomized control trial
(RCT) of a novel, brief, preventive intervention for PPD
called PREPP, Practical Resources for Effective Postpartum
Parenting, which aims to determine if a behavioral interven-
tion primarily targeting maternal caregiving of young infants
can increase infant sleep and reduce fuss/cry behavior, and
thereby reduce the incidence and/or severity of postpartum
maternal depression. PREPP integrates emerging, evidence-
based caregiving techniques, traditional psychotherapy ap-
proaches, psycho-education, as well as mindfulness medita-
tion training to treat at-risk women by promoting maternally
mediated behavioral changes in their infants.
Risks for PPD, including infant behaviors
Established risk factors for PPD include prenatal depres-
sion and anxiety, low social support, and a history of psy-
chopathology (O’Hara and Swain 1996; Beck 1996;
Seguin et al. 1999). Emerging data shows strong associa-
tions between infant behavior and maternal mood dysreg-
ulation. In several papers, greater infant fuss/cry and poor
sleep behavior were associated with maternal depression
(Armstrong et al. 1998; Bayer et al. 2007;Dennisand
Ross 2005; Hiscock and Wake 2001;Maxtedetal.2005;
Radesky et al. 2013;Viketal.2009). More specifically, in
a study of 55 dyads, infant crying at 3 months (based on
maternal report and laboratory observation) accounted for
30 % of the variance in PPD symptoms; the effect was
direct, and indirect, through the mediation of reducing
levels of parenting self-efficacy (Cutrona and Troutman
1986). In a prospective study of 180 women at risk for
PPD, objectively assessed neonatal irritability and poor
motor function predicted PPD at 2 months (estimated con-
tribution to log odds were 1.37 and 1.18, respectively,
p<0.0005); as these infant behaviors improved, so did ma-
ternal depression scores (Murray et al. 1996). Barr et al.
found that at 6 weeks postpartum, mother-reported infant
cry/fuss duration and frequency were positively associated
with postpartum distress (r(88)=0.45 and 0.28, p<0.01,
respectively) (Miller et al. 1993). Distress levels increased
pre- to postpartum in women whose infants met clinical
criteria for Bcolic^(Miller et al. 1993). There also is an
association between infant sleeping problems and PPD,
which may be mediated via disruption in women’s sleep
(Armstrong et al. 1998; Bayer et al. 2007;DennisandRoss
2005; Hiscock and Wake 2001). To date, including the
treatment of infant behaviors in PPD interventions is only
beginning (Hiscock and Wake 2002; Hiscock et al. 2014).
Prevention of PPD
There have been many RCTs of psychological preventive in-
terventions for PPD. In a recent systematic review, Werner and
colleagues (2014) identified 37 psychological and psychoso-
cial intervention RCTs of which 17 were found to be effective.
Of these 17 effective RCTs, 13 were conducted with at-risk
populations, suggesting the importance of utilizing known
PPD risk factors as inclusion criteria when targeting women
for PDD preventive treatment. These authors (Werner et al.
2014) and others (Boath et al. 2004; Whitton et al. 1996;
Ballestrem et al. 2005) highlight several reasons that treat-
ments to prevent PPD may not be effective, including (1)
non-validated approaches to measure risk for PPD (Werner
et al. 2014), (2) emphasis on pharmacology when women
are breast feeding (Boath et al. 2004; Whitton et al. 1996),
and (3) high rates of attrition (Werner et al. 2014), which
may result from (a) stigma associated with receiving mental
health care (McIntosh 1993), (b) lack of accessibility, includ-
ing difficulty attending appointments with a new baby
(Ballestrem et al. 2005), and (c) a sole focus on the moth-
er—which overlooks the child-centered orientation of the
perinatal period and the salience of maternal–infant interac-
tions to maternal well-being (Kochanska et al. 2000,2001,
2009; Kochanska and Aksan 2006; Feldman and Eidelman
2006;Feldman2007). Addressing these limitations is crucial
to developing successful PPD preventive interventions
(Werner et al. 2014).
Infant sleep and cry interventions
Largely independent of PPD interventions, several caregiving
techniques have been shown to positively affect infant sleep
and fuss/cry behavior (Meyer and Erler 2011; Pinilla and
Birch 1993; St. James-Roberts and Gillham 2001;Van
Sleuwen et al. 2007). For example, Pinilla and Birch (1993)
found that their intervention program was highly effective in
changing parent behavior and improving infant sleep duration
when delivered to parents in the home over multiple sessions
up to 8 weeks post-delivery, though parents were less compli-
ant with the same protocol when given instructions for it dur-
ing a 1× home visit within 8–14 days post-birth, and there was
little effect on infant sleep (St. James-Roberts and Gillham
2001). In Pinilla and Birch’s study of 26 first-time parents,
13 were assigned to a behavioral intervention, which, by
4 weeks postpartum, resulted in 38 % of infants sleeping
through the night (defined as sleeping without signaling for
attention between 12 and 5 A.M. for several consecutive nights)
compared to 7 % for the control group; by 8 weeks postpar-
tum, 100 % of the intervention group slept through the night
compared to 23 % (Pinilla and Birch 1993). This intervention
protocol encompassed several infant behavioral techniques to
increase nighttime sleeping in infants, including providing a
E.A. Werner et al.
focal feeding to the infant between 10 P. M . and midnight, ac-
centuating differences between day and night by providing
higher levels of stimulation during the day, and lengthening
the latency to feeding time in the middle of the night by en-
gaging in other attentive activities such as walking with the
baby and diapering, thereby extinguishing the association be-
tween night time waking and feeding (Pinilla and Birch 1993;
St. James-Roberts and Gillham 2001). In other research,
swaddling has been identified as a tool that can promote sleep
continuity, fewer awakenings, and more quiet sleep as evi-
denced in both laboratory and descriptive studies (Van
Sleuwen et al. 2007). In an RCT conducted in Germany
(Meyer and Erler 2011) of 85 healthy infants studied in a sleep
laboratory, swaddling was found to reduce the rate of sponta-
neous awakening, the number of sleep stage changes, and the
amount of time spent awake. It also was found to promote
quiet sleep and sleep efficiency (Meyer and Erler 2011).
There are other behavioral techniques to reduce infant
fussing and crying behavior. Barr et al. conducted a random-
ized controlled trial on the effects of increased carrying on
infant fuss/cry behavior (Hunziker and Barr 1986). At 3 weeks
postpartum, 99 dyads were randomly assigned to increased
carrying or no intervention; by 6 weeks post-delivery, the peak
age for crying, infants in the intervention group cried and
fussed 43 % less overall and 51 % less during 4 P.M .tomid-
night; similar but smaller differences were found at 4, 8, and
12 weeks (Hunziker and Barr 1986). However, these results
have not been consistently replicated. For example, when the
carrying intervention was taught to women in the hospital in
Britain immediately following birth, there were no effects of
increased carrying on infant cry/fuss behavior (St. James-
Roberts et al. 1995).
As indicated, few studies have examined whether these
caregiving techniques have an impact on maternal depressive
symptoms. In the first of its kind, Hiscock et al. (2014)pro-
vided 781 mother–infant dyads with written materials and an
educational DVD that presented information about infant
sleep cycles and crying patterns, strategies to promote inde-
pendent settling (e.g., swaddling), and information about self-
care for parents. Mothers in the intervention group were sig-
nificantly less likely to meet criteria for possible depression
(>9 on the Edinburgh Postnatal Depression Scale) when their
infant was 6 months old, though there were no differences
between the intervention and control groups at 4 months post-
partum. These caregiving techniques also were effective in
reducing daytime sleep and crying problems, but only for a
subset of their participants who they characterized as
Bfrequent feeders^by caregiver report. These findings provide
promising evidence that behavioral techniques targeting ma-
ternal care can be a useful component of PPD intervention
programs, though they require replication, and several ques-
tions remain. For example, maternal depressive symptoms
were studied at 4 and 6 months postpartum, yet the
Diagnostic and Statistical Manual of Mental Disorders (5th
ed.; American Psychiatric Association, 2013) specifies that
PPD has an onset within the first 4 weeks after birth. Given
the significance of this early developmental period for chil-
dren’s long-term functioning (e.g., Hay et al. 2001), examin-
ing maternal depressive symptoms earlier in development is
critical. Second, Hiscock et al.’s intervention program recruit-
ed women 7–10 days postpartum, potentially after mothers
already had started to become symptomatic. It remains unclear
if intervening earlier (i.e., during pregnancy) would help to
prevent these symptoms from developing, resulting in differ-
ences in maternal well-being that are observable earlier in the
child’s life. Third, these authors—and most other PPD preven-
tion studies (Werner et al. 2014)—only focused on maternal
depressive symptoms when assessing postpartum mood.
However, there is evidence that women with PDD often have
severe anxiety and even panic attacks (Miller et al. 2006). The
extent to which these caregiving techniques also may improve
maternal anxiety in the postnatal period has been not been
studied.
Other tools for maternal mood intervention postpartum
The use of psychoeducation about the hormonal and psycho-
social changes that occur during the postpartum period has
been shown to be effective in the reduction of postpartum
depressive symptoms (Elliott et al. 2000; Matthey et al.
2004). In addition, programs like the Period of PURPLE cry-
ing (Barr et al. 2009) have been effective in improving mater-
nal knowledge about infant crying and developing coping
mechanisms to deal with the maternal upset caused by incon-
solable crying. Mindfulness meditation is another strategy that
can help women to cope better when their babies are distress-
ed and/or unsoothable. The success of a recent trial of a
mindfulness-based therapy for the prevention of perinatal de-
pressive relapse/recurrence suggests that the use of these types
of techniques may contribute to the prevention of PPD
(Dimidjian et al. 2014). To date, these therapeutic tools that
are aimed directly at helping the mother (e.g., mindfulness
meditation, psychoeducation about perinatal biological and
emotional changes) have not been added to an intervention
protocol focused on caregiving techniques.
The current study
The goal of the current study was to examine the effectiveness
of PREPP, a new PPD preventionprotocol that aims to treat at-
risk women by promoting maternally mediated behavioral
changes in their infants, while also including mother-focused
skills. In a sample of 54 dyads, we sought to test if PREPP
compared to an enhanced treatment as usual (ETAU) group
(1) reduces depression and anxiety symptoms during the early
postnatal period, (2) decreases infant fuss and cry behavior,
PREPP: postpartum depression prevention
and (3) has high rates of treatment compliance given the brief
number of sessions that are timed to perinatal medical sessions
and the description of the intervention as coaching.
Methods
Overview
Figure 1provides a schedule of participants’assessment and
PREPP sessions. Women were recruited and screened for
study eligibility by telephone (including PPD risk using the
Predictive Index of Postnatal Depression, Cooper et al. 1996)
in their third trimester of pregnancy. Between 34 and
38 weeks’gestation, potential participants came to the labora-
tory to provide informed consent and complete mood ques-
tionnaires by self-report and interviewer administration
(Assessment 1). They also met with the clinical psychologist
who informed them of their treatment group assignment as
dictated by a computer-generated random assignment sched-
ule. Participants who were assigned to the PREPP group re-
ceived their first session of PREPP, while those in the ETAU
group were provided with an information session about PPD,
a brief clinical mood assessment, and a referral for treatment if
warranted or requested by the participant. Between 18 and
36 h after giving birth, all participants were visited by a re-
search assistant who collected medical information about their
delivery. Those in the PREPP intervention received their sec-
ond treatment session with the psychologist. At 2 weeks post-
partum, participants in the PREPP group received a check-in
telephone call from the psychologist with whom they had
been working. Those in the ETAU group received a brief
check-in call from the research assistant. At 6 weeks postpar-
tum, all participants returned to the laboratory to complete
mood assessments and meet with the psychologist
(Assessment 2). Women in the PREPP group received their
final PREPP session, while those in the ETAU group were
again given information about PPD and were clinically
assessed and referred to treatment when appropriate. At
10 weeks postpartum, participants were contacted by tele-
phone and completed the mood questionnaires via telephone
(Assessment 3). At 16 weeks postpartum, these questionnaires
were administered in person in the laboratory (Assessment 4).
Participants
Pregnant women ages 18–45 in their second or third trimester
of pregnancy were recruited through the Department of
Obstetrics and Gynecology at Columbia University Medical
Center (CUMC) and via flyers posted at CUMC. Women who
reported smoking tobacco or using recreational drugs, lacking
fluency in English, currently receiving psychological/
psychiatric treatment, taking medication, having a medically
complicated pregnancy, or carrying a non-singleton pregnan-
cy were not eligible for enrollment in this study. This trial was
registered with clinicaltrials.gov: NCT01379781. All study
procedures were approved by the Institutional Review Board
of the New York State Psychiatric Institute/CUMC.
Participants were compensated for their assessment sessions,
and the travel to and from the meetings, but not for interven-
tion sessions.
Assessment measures
Predictive index of PPD
When women were 28–38 weeks pregnant, potential partici-
pants were screened via telephone for their risk for PPD. PPD
risk was defined as scoring above 24 on the Predictive Index
of Postnatal Depression (Cooper et al. 1996). This 17-item
questionnaire asks women about factors that may predispose
them to PPD (e.g., BHave you felt particularly depressed or
miserable over the last few weeks?^BAfter any previous de-
livery were you particularly miserable or depressed at any
time during the following year?^BHas this pregnancy been
a positive experience for you?^). This widely used measure
has been shown to have adequate sensitivity and specificity
(Cooper et al. 1996).
Hamilton rating scales of depression and anxiety
Maternal depressive symptoms were measured by a trained
interviewer blind to the participants’group assignment
using the Hamilton Rating Scale for Depression (HRSD),
a15–20-min rater-administered measure that indexes de-
pressive symptoms over the previous 2 weeks (Williams
1988). The HRSD values of 8–13 indicate mild depression,
Fig. 1 Assessment and treatment session schedule
E.A. Werner et al.
14–18 indicate moderate depression, and 19–22 indicate
severe depression (Hamilton 1960). Maternal symptoms
of anxiety were measured using the 10–15-min Hamilton
Anxiety Rating Scale (HAM-A, Hamilton 1959), which
also indexes symptomatology over the previous 2 weeks.
Values less than 17 on this scale indicate mild severity, 18–
24 indicates mild to moderate anxiety, and 25–30 indicates
moderate to severe anxiety (Hamilton 1959). The validity
and reliability of the HRSD and HAM-A is well established
(Maier et al. 1988; Ramos-Brieva and Cordero-Villafafila
1988;Trajkovićet al. 2011).
Patient health questionnaire
Maternal depressive symptoms also were assessed using
the depression module of the patient health questionnaire
(PHQ-9; Kroenke and Spitzer 2002), a nine-item self-re-
port measure that assesses the DSM-IV diagnostic criteria
for depression (αranged from 0.72 to 0.77 at the various
assessment time points). Respondents are asked to rate on
a 3-point Likert-type scale (where 0=not at all and 3=
nearly every day) how frequently they were bothered by
specific symptoms over the past 2 weeks. An example
item reads Bfeeling down, depressed, or hopeless.^
Scores of 0–4 on this scale indicate minimal depression,
5–9 indicates mild depression, 10–14 indicates moderate
depression, 15–19 indicates moderately severe depression,
and 20–27 indicates severe depression (Kroenke et al.
2001).
Infant fuss/cry episodes
Data about infant fussing and crying were obtained using
the Baby’sDayDiary(Barr 1985). Over four 24-h pe-
riods, mothers recorded the duration and frequency of
seven infant behavioral states: awake, alert, fussing, cry-
ing, inconsolable crying, feeding, and sleeping. Mothers
also recorded the duration and frequency of body contact
with their infants. A number of variables are produced
from these diaries, including the total number of episodes
during which the infant was fussing or crying. Following
previously published reports using this measure (e.g.,
Wol k e et al. 1994), the total number of episodes during
which the infant was fussing or crying was averaged over
the 4 days to arrive at an average daily frequency of fuss/
cry episodes. This measure has been well validated, as
evidenced by high correlations between its metrics and
audio recordings of fussing and crying (e.g., agreements
around 0.9) (Barr et al. 1988; St. James-Roberts et al.
1993). Importantly, previous research has found that the
quality of reporting using this measure is not biased by
caregiver depressive symptoms (Miller et al. 1993).
Intervention: PREPP and ETAU
PREPP
PREPP comprised a number of infant behavioral interven-
tions and targeted psychotherapy techniques. The partici-
pants in the PREPP arm of the study received three consec-
utive in-person sessions with a Ph.D.-level psychologist.
These sessions were described to the participants as
Bcoaching^sessions to minimize stigma that many women
associate with receiving mental healthcare during the peri-
natal period (Dennis and Chung-Lee 2006). The psycholo-
gist also contacted participants by telephone at 2 weeks
postpartum and, using motivational interviewing tech-
niques, encouraged the use of PREPP skills and answered
specific participant questions. To increase accessibility for
patients, the three in-person sessions were scheduled to
coincide with standard medical visits: (1) 34–38 weeks
(third trimester ultrasound), (2) in the hospital post-
delivery (delivery), and (3) 6 weeks postpartum (6-week
well baby visit). Although this was a standardized protocol,
the instructional visits were personalized and varied in re-
sponse to women’s needs and concerns.
The intervention protocol encompassed the following five
specific infant behavioral techniques, supported by emerging
research and aimed at reducing infant fuss/cry behavior and
promoting sleep (Barr et al. 2009; Meyer and Erler 2011;
Pinilla and Birch 1993; St. James-Roberts and Gillham
2001; Van Sleuwen et al. 2007): (1) feeding the infant between
10 P.M. and midnight, even if s/he must be awakened (Bafocal
feed^) (Pinilla and Birch 1993; St. James-Roberts and
Gillham 2001); (2) accentuating differences between day
and night by providing higher levels of stimulation during
the day (Pinilla and Birch 1993; St. James-Roberts and
Gillham 2001); (3) lengthening the latency to feeding time
in the middle of the night by engaging in other attentive ac-
tivities such as walking with the baby and diapering, thereby
extinguishing the association between night time waking and
feeding (Pinilla and Birch 1993; St. James-Roberts and
Gillham 2001); (4) carrying infants for a minimum of 3 h a
day, throughout the day, in addition to the carrying that occurs
in response to crying and feeding (Barr et al. 2009); and (5)
learning to swaddle the baby (Van Sleuwen et al. 2007). As
part of the intervention, women also were provided with (1)
supportive psychological interviewing that encourages reflec-
tion on their own childhood and how it will inform the devel-
opment of their parental identity, (2) psychoeducation about
the postpartum period (e.g., hormone levels, Baby Blues, in-
fant cry behavior/patterns based on materials from the Period
of Purple Crying campaign; Barr et al. 2009), and (3) various
mindfulness techniques aimed at (a) helping them to cope
better when their babies are distressed and/or unsoothable
and (b) aiding them to return to sleep after tending to their
PREPP: postpartum depression prevention
babies during the nighttime. In the first visit, participants are
given a carrier and a swaddling blanket to use with their
babies.
Enhanced TAU
Participants in the ETAU condition met with a Ph.D.-level
clinical psychologist on two occasions: (1) 34–38 weeks’ges-
tation and (2) 6 weeks postpartum. During these visits, the
psychologist discussed PPD symptoms with participants and
offered referrals for mental health care. The psychologist pro-
vided suitable referrals and clinical follow-up for all partici-
pants who reported symptoms of depression or anxiety or if
the participant expressed interest in such a referral.
Participants also were provided with printed educational ma-
terials about the symptoms of PPD and supportive services in
the community.
Analytic strategy
A series of linear mixed effects models (McCulloch and
Neuhaus 2001) were used to assess the effect of the PREPP
intervention on participants’psychiatric symptomatology.
Specifically, three linear mixed effects models were conducted,
one for each of the maternal mood measures (i.e., HRSD,
HAM-A, and PHQ-9). In each of these models, the partici-
pant’s intervention status (0=ETAU, 1 = PREPP) was entered
as a predictor of change in maternal mood over time. Linear
mixed effects models can accommodate missing data, and
therefore no participants were excluded from analyses due to
missing data. A univariate analysis of variance (ANOVA) was
used to test whether women in the PREPP and ETAU groups
differed in their report of infant fuss/cry behaviors. All analyses
were conducted using SPSS version 22.0 (IBM Corporation,
Armonk, NY) and adhered to intention-to-treat principles with
one exception: one participant who was randomized to the
PREPP condition was immediately referred to intensive psy-
chiatric treatment during the first intervention session and sub-
sequently attended twice-weekly treatment throughout the du-
ration of the study. As current mental health treatment was an
exclusion criterion for the study (and in an effort not to overes-
timate the effectiveness of the study treatments), we made an a
priori decision to exclude her from analyses.
Results
Recruitment and enrollment
Of the 619 individuals who were screened for this study
between July 2011 and December 2013, 95 (15 %) were
eligible to enroll. The majority of individuals who were
deemed ineligible did not score high enough on the
Predictive Index of Postnatal Depression to be considered
at risk for PPD (n=261); other common reasons for ineli-
gibility were if they were having a medically complicated
pregnancy (n=54), if they delivered their child prior to
being screened for the study (n=52), and if they were not
interested in participating in research (n=50). Of the 95
women who were eligible for the current study, 54 (57 %)
were enrolled and randomized to either the PREPP (n=27)
or ETAU (n=27) condition. The majority of women who
were eligible but did not enroll were lost to follow-up (n=
22) or did not show to their consent appointment (n=13).
More detailed information about screening, eligibility, and
enrollment can be found in Fig. 2.
Demographics and baseline mood measures
Demographic information about the sample appears in
Tab le 1. The groups did not differ significantly from one an-
other on any of these variables.
Treatment adherence and assessment attrition
All participants who were randomized to the PREPP interven-
tion condition received the entire treatment. That is, they all
attended and completed the prenatal, newborn, and 6-week
postpartum treatment sessions and had a phone session with
the psychologist at 2 weeks postpartum. With respect to as-
sessment sessions, there are missing data.
Of the 54 participants who were randomized to either the
PREPP or the ETAU conditions, all completed the first assess-
ment. The participant (described above) who was randomized
to the PREPP condition but who was immediately referred to
intensive psychiatric treatment discontinued participation at
this session. Eight individuals did not complete the 6-week
postpartum session, 13 did not complete the 10-week postpar-
tum session, and 18 did not complete the 4-month postpartum
session. Individuals who did or did not participate in these
assessments did not differ from one another on any of the
demographic or pre-randomization mood variables, with one
exception: participants who did not complete the 6-week as-
sessment (n=8), on average, had lower Predictive Index of
Postnatal Depression scores at screening (m=27, SD=2.5)
than those who did participate (m=30.7, SD=2.5), p<0.05.
Figure 2presents more detailed information about participant
attrition for assessment sessions.
Treatment effects
Clinical relevance of average maternal mood by group
at each session
Participant scores on the Predictive Index of Postnatal
Depression at screening and descriptive information (i.e.,
E.A. Werner et al.
means, standard deviations, range) about women’s HRSD,
HAM-A, and PHQ-9 scores prior to randomization (at 36–
38 gestational weeks) and at the various assessment time
points appear in Table 2. At the pre-randomization assess-
ment, participants (n=53), on average, scored in the
Bmoderate depression^range on the HRSD (m=16.11, SD=
11.86), in the Bmild anxiety^range on the HAM-A (m=16.45,
SD= 12.26), and in the Bmild depression^range on the PHQ-9
(m=7.12, SD=3.97). The PREPP and ETAU groups did not
differ statistically from one another on any of these variables
at study entry, although the mean of the PREPP group fell in
the Bmoderate depression^range and the ETAU group’smean
was in the Bmild depression^range.
At the 6-week postpartum session, participants in the
PREPP group, on average, scored in the Bmild depression^
range on the HRSD (m= 12.09, SD= 7.31), whereas those in
the ETAU group scored in the Bmoderate depression^range
(m=17.17, SD=9.81). As can be seen in Table 2,bothgroups,
on average, scored in the Bmild depression^range at the 10-
and 16-week postpartum sessions. At 10 weeks postpartum,
the average PHQ-9 score for the PREPP group indicated
Bmild depression^; the average score was at the Bmoderate
Fig. 2 Consort diagram
PREPP: postpartum depression prevention
Tabl e 1 Participant demographic
information and mood variables
prior to randomization
PREPP Enhanced TAU
Mean (SD) or % nMean (SD) or % n
Maternal age (years) 30.87 (6.51) 26 29.60 (5.67) 27
Relationship status
Living together 34.60 % 9 33.33 % 9
Married 38.50 % 10 29.63 % 8
Not living together 7.69 % 2 11.11 % 3
Single 15.40 % 4 18.52 % 5
Divorced 0.00 % 0 7.41 % 2
Race
Asian 7.70 % 2 7.41 % 2
Black/African American 15.40 % 4 22.22 % 6
White/Caucasian 15.40 % 4 7.41 % 2
Biracial 3.80 % 1 0.00 % 0
Other 53.80 % 14 62.96 % 17
Ethnicity
Hispanic 57.70 % 15 59.26 % 16
Not Hispanic 38.50 % 10 37.04 % 10
Maternal education (years) 15.94 (4.19) 25 14.82 (2.53) 27
Number of other children 0.44 (0.65) 25 0.67 (.83) 27
Employment status
Not working outside of home 38.50 % 10 48.15 % 13
Full time 38.50 % 10 25.93 % 7
Part time 19.20 % 5 25.93 % 7
Paternal age (years) 35.25 (8.41) 24 31.15 (6.71) 27
Tabl e 2 Means and standard deviations of maternal mood variables
PREPP intervention Enhanced TAU
Mean (SD) Range Severity Mean (SD) Range Severity
Predictive index of postnatal depression
28–38 weeks GA 31.19 (6.09) 25–47 29.07 (2.81) 25–35
HRSD
36–38 weeks GA 18.48 (12.82) 0–48 Moderate 13.83 (10.64) 1–44 Mild
6 weeks postpartum 12.09 (7.31) 1–24 Mild 17.17 (9.81) 2–35 Moderate
10 weeks postpartum 11.48 (8.45) 0–27 Mild 13.44 (10.48) 0–40 Mild
16 weeks postpartum 10.48 (10.31) 0–33 Mild 11.12 (9.43) 0–30 Mild
HAM-A
36–38 weeks GA 19.35 (13.79) 1–44 Mild/moderate 13.67 (10.11) 1–36 Mild
6 weeks postpartum 11.73 (8.20) 1–26 Mild 14.17 (8.49) 3–31 Mild
10 weeks postpartum 11.07 (8.22) 0–28 Mild 12.00 (8.96) 1–33 Mild
16 weeks postpartum 9.33 (9.77) 0–33 Mild 11.53 (9.10) 0–33 Mild
PHQ-9
36–38 weeks GA 6.45 (3.57) 0–15 Mild 7.79 (4.31) 1–18 Mild
6 weeks postpartum 7.16 (4.39) 0–14 Mild 10.08 (5.03) 1–16 Moderate
10 weeks postpartum 7.06 (5.04) 1–21 Mild 8.29 (4.06) 1–17 Mild
16 weeks postpartum 4.00 (3.30) 0–11 Minimal 7.22 (4.13) 0–17 Mild
E.A. Werner et al.
depression^level for the ETAU group; at 16 weeks, PHQ
results showed the PREPP participants at the Bminimal level^
of depression, while those in the ETAU sample had an average
score that remained in the Bmild^range.
Change in maternal mood by treatment group
Results from the mixed effects models that were used to test
whether the PREPP intervention had an effect on maternal
symptoms of depression or anxiety are presented in Table 3.
Consistent with expectation, these results indicate that women
who underwent PREPP compared to those who received the
ETAU differed significantly from one another in their change
in symptomatology over time.
Specifically, HRSD and HAM-A results show women who
received the PREPP intervention decreased significantly in their
HRSD-rated depressive symptoms (B=−6.54, p=0.01) between
the pre-randomization assessment (i.e., at 36–38 weeks’gesta-
tion) and the 6-week postpartum session. In contrast, women in
the ETAU group had no significant change between the prenatal
and 6-week postpartum assessment (B=3.02, p=0.22). The re-
sults for anxiety are consistent with those for depression, such
that women in PREPP decreased significantly in their HAM-A-
rated symptoms of anxiety between the pre-randomization as-
sessment and 6 weeks postpartum (B=−7.84, p<0.01), whereas
those in the ETAU group did not change significantly over this
period of time (B=0.24, p=0.94). These PREPP effects
remained marginally significant (p<0.10) at the 10-week as-
sessment for both HRSD and HAM-A findings and were statis-
tically significant for HAM-A scores at 16 weeks postpartum
(p<0.05). As a complement to the results from these mixed
effects models, Figs. 3and 4present the average change scores
(presented separately by treatment condition) for HRSD and
HAM-A scores, respectively.
For the PHQ-9, results from the mixed effects model were as
follows. The PREPP group did not change significantly be-
tween the prenatal and 6-week postpartum session (B=0.61,
p=0.58). The ETAU group, however, reported significantly
more depressive symptoms at the 6-week postpartum session,
relative to the pre-randomization assessment (B= 2.44, p=
0.02). Figure 5presents the average change scores for the
PHQ-9 scores, presented separately by treatment condition.
Effects on infant fuss/cry behavior
Data from the Baby’s Day Diary was available on a subset of
participants enrolled in the current study (n=30);this subsam-
ple did not differ significantly from the complete sample on
any of the demographic variables, but did differ significantly
on their score on the PHQ-9 prior to randomization, with the
respondents scoring higher than the non-respondents. Results
from the ANOVA used to test whether infants in the PREPP
versus ETAU conditions differed from one another in the fre-
quency of their fuss/cry behavior are visually depicted in
Fig. 6. Consistent with expectation, mothers who received
the PREPP intervention reported fewer bouts of fuss/cry be-
havior (m=4.07, SD= 2.50) than those in the ETAU condition
(m=6.30, SD=2.63), F(1, 28)=5.68, p=0.02.
Discussion
The current study provides preliminary evidence in support of
the effectiveness of PREPP in preventing the development of
Tabl e 3 Results of linear mixed effects models
HRSD HAM-A PHQ-9
Va r i ab l e BSE BB SE BB SE B
Intercept 14.21** 2.00 14.01** 1.95 7.78** 0.84
Main effects
Intervention group
a
4.27 2.87 5.34†2.79 −1.26 1.18
Time
b
6 weeks postpartum 3.02 2.46 0.24 2.41 2.44* 1.05
10 weeks postpartum −1.06 2.53 −2.10 2.47 0.41 1.07
16 weeks postpartum −3.42 2.43 −2.43 2.67 −0.82 1.18
Interaction effects
Intervention group× time 6 weeks postpartum −9.56** 3.51 −8.07* 3.44 −1.83* 1.52
10 weeks postpartum −6.17†3.47 −6.67†3.60 −0.11 1.55
16 weeks postpartum −4.11 3.94 −7.69* 3.60 −2.20 1.75
HRSD Hamilton Rating Scales for Depression, HAM-A Hamilton Rating Scales for Anxiety, PHQ-9 Patient Health Questionnaire
*p<0.05, **p<0.01, †p<0.10
a
0= Enhanced Treatment as Usual, 1= PREPP
b
The reference group for all time effects is 36–38 weeks’gestation (prior to randomization)
PREPP: postpartum depression prevention
PPD symptoms. These effects were most consistently observed
at 6 weeks postpartum; given that the DSM-V specifies that
symptoms of PPD must first occur within the first 4 weeks post-
partum, these findings indicate that PREPP is a useful tool
consistent with the clinical focus on this time period for mothers,
as well as their infants. In addition, the study also found that
mothers who received PREPP reported having infants who
fussed and cried fewer times per day at 6 weeks postpartum than
Note: Change scores are calculated with respect to the previous assessment timepoint.
The mood assessment at 36-38 weeks gestation occurred prior to randomization.
Fig. 3 Hamilton rating scales for
depression change scores: ETAU
versus PREPP
Note: Change scores are calculated with respect to the previous assessment timepoint.
The mood assessment at 36-38 weeks gestation occurred prior to randomization.
Fig. 4 Hamilton rating scales for
anxiety change scores: ETAU
versus PREPP
E.A. Werner et al.
infants of the ETAU mothers. These data, along with the 0 %
attrition rate for PREPP treatment sessions, suggest that PREPP
is a well-tolerated intervention, and one with promising results
for preventing PPD in those at risk for it.
Specifically, we found that women at risk for PPD who re-
ceived the dyadically oriented preventive intervention, on aver-
age, reduced symptoms of depression and anxiety judged by
blinded, clinician report (HRSD, HRSA) at 6 weeks postpartum,
while those at-risk women who were assigned to the ETAU
group did not. Additionally, there was a significant increase in
self-reported depression in the ETAU group and no change in the
PREPP intervention group on this index. PREPP’seffectson
blind-clinician ratings of maternal depression approached signif-
icance at the 10-week assessment. Blind-clinician ratings of anx-
iety approached significance at the 10-week assessment and were
significantly lower than baseline at 16 weeks postpartum.
Despite having robust findings at the 6-week assessment,
the current study did not consistently observe statistically sig-
nificant long-term effects on the clinician-rated and self-report
measures administered at 10 and 16 weeks postpartum. These
less consistent results may be due to several factors. First, this
is a small pilot study, so our analyses may have been under-
powered. Additionally, as indicated, not all participants com-
pleted all assessment sessions, which may have contributed
further to issues of power. Second, post hoc analyses revealed
that there was differential attrition for the ETAU group only,
such that participants in this group who did not complete the
16-week assessment had significantly higher HRSD scores
pre-randomization. This may have created an artificial appear-
ance of improvement in the symptomatology of the ETAU
group, thereby reducing our ability to detect an effect at this
later time point. Third, previous research by Hiscock et al.
(2014) found that their treatment to prevent infant sleep and
cry problems had effects on maternal report of depression
symptoms at 6 months but not on these symptoms at 4 months
postpartum. Perhaps, if we had followed our sample for an
additional 2 months, we, too, may have seen PREPP having a
sustained effect on maternal mood 6 months postpartum even
though we saw no 16-week effect. If, in future studies, we
confirm a lack of effect at these later postpartum assessments,
Note: Change scores are calculated with respect to the previous assessment timepoint.
The mood assessment at 36-38 weeks gestation occurred prior to randomization.
Fig. 5 Patient health
questionnaire change scores:
ETAU versus PREPP
0
1
2
3
4
5
6
7
8
Average Daily Frequency of
Fuss/Cry Episodes
PREPP Enhanced
TAU
*p< .05
Fig. 6 Infants of mothers in the PREPP fuss/cry significantly fewer times
per day than those in the ETAU condition
PREPP: postpartum depression prevention
it may suggest that PREPP would be enhanced by providing
infant behavioral interventions that are focused on the care-
giving of older babies.
This study also found that the PREPP intervention was
effective in reducing the number of episodes of infant fuss/
cry behavior by maternal report. On average, women who
received PREPP reported over two fewer bouts of fuss/cry
per day. These results add support to previous findings that
demonstrated that the use of specific infant care techniques is
effective at reducing infant fuss/cry behavior (Hunziker and
Barr 1986; Hiscock et al. 2014). Unlike Hiscock et al. (2014),
who found that their intervention reduced crying problems
only in babies classified as Bfrequent feeders,^the current
study found that the effects on maternal report of cry behavior
were not limited to a subset of infants. However, it is impor-
tant to note that our infants actually may represent a subset
because we only recruited women at risk for PPD for this
study. Although this study did not have the power to test
whether reductions in infant crying is the mechanism through
which maternal mood was improved, the fact that reductions
in distressed mood and in infant fuss/cry behaviors both oc-
curred at 6 weeks supports our theoretical prediction of the
dyadic influence of mother and infant behavior.
In addition to finding that this treatment can affect maternal
mood and infant fuss/cry behavior, we also found that PREPP
is a well-tolerated and accessible treatment for PPD. All par-
ticipants who were randomized to the PREPP condition com-
pleted all treatment sessions, yielding a 0 % attrition rate. This
rate is much lower than those reported by many other PPD
prevention programs (Stamp et al. 1995; Brugha et al. 2000;
Le Strat et al. 2011), some of which describe attrition rates
over 50 % (e.g., Lara et al. 2010). We attribute our 0 % attri-
tion rate to our careful attention to the barriers to PPD treat-
ment, including calling our intervention Bcoaching sessions^
to address the stigma associated with receiving mental health
care (McIntosh 1993) and improving the accessibility of this
treatment by offering it at the same time women are receiving
routine medical care. In addition, we hypothesize that
targeting the dyad and teaching infant care techniques in ad-
dition to the use of traditional psychotherapeutic techniques
may have increased engagement in the treatment.
Strengths
There were several methodological strengths of this study. For
example, we utilized both blind, clinician-rated assessments
and self-report measures of maternal mood. In addition, this
study also benefits from assessing both symptoms of depres-
sion and anxiety as outcome measures. As PPD often encom-
passes symptoms of anxiety as well as depression (Miller et al.
2006), the inclusion of anxiety assessment is essential when
determining the effectivity of a preventive PPD intervention.
Limitations
This study also had a number of limitations. Most notably, this
pilot study had a small sample size, which may have reduced
our ability to detect certain findings. Despite its small sample
size, the current study reports several statistically significant
findings, a fact that may reflect the robust nature of these ef-
fects. We also had a differential attrition rate for the assessment
sessions in the ETAU group, such that the most depressed
(those with highest HRSD scores pre-randomization) dropped
out of the study, which artificially reduced the severity of the
mood scores in the ETAU group over time. As described above,
thismayhaveprovidedanoverlyconservativeassessmentof
the effectiveness of PREPP over time. However, there still were
trends at 10 weeks postpartum for the HRSD and HAM-A, and
a significant result for the HAM-A at 16 weeks postpartum.
Future research with a larger sample may provide further sup-
port for the effectiveness of PREPP in reducing symptoms over
time. Another weakness of this study is that crying and fussing
bouts were assessed by maternal report. However, they were
assessed using the Baby’sDayDiary(Barr 1985), a widely used
tool that has been shown to be highly reliable and valid (St.
James-Roberts and Gillham 2001). Further, as Radesky et al.
recently suggested (2013), because we are aiming to reduce
maternal depression/anxiety symptoms by reducing fussing/
crying behavior in infants, an alteration in maternal perception
of these infant behaviors, a Bdyadic measure,^may be effective
on its own in improving maternal mood via improvement in
self-efficacy. Last, the current study did not include a self-report
measure of anxiety and only relied on a clinician rating, despite
the fact that anxiety symptoms are a major feature of PPD.
However, clinician assessments are often considered a more
valid assessment of symptomatology than self-report measures.
Summary and conclusions
Building on developmental data showing the profound bi-
directionality of emotional and behavioral influences between
mother and infant (Kochanska et al. 2000,2001,2009;
Kochanska and Aksan 2006; Feldman and Eidelman 2006;
Feldman 2007), PREPP takes a dyadic behavioral approach
to the prevention of PPD. The current pilot study indicates that
this novel, brief intervention, which also includes
psychoeducation and mindfulness skills, was well tolerated
and effective in reducing maternal symptoms of anxiety and
depression, particularly at 6 weeks postpartum. Additionally,
this study found that infants of mothers enrolled in PREPP had
fewer bouts of fussing and crying at 6 weeks postpartum than
those infants whose mothers were in the Enhanced TAU
group. Significantly, reports show that remission from PPD
using standard treatment does not improve women’sratingsof
their children’s behavior, nor child outcomes (Forman et al.
E.A. Werner et al.
2007). These preliminary results indicate that PREPP has the
potential to reduce the incidence of PPD in women at risk and
to directly impact the developing mother–child relationship,
the mother’s view of her child, and child outcomes.
Acknowledgements This study was supported by the National Institute
of Mental Health (R21MH092665), the Robin Hood Foundation, and by
a postdoctoral fellowship in behavioral medicine awarded by the Herbert
H.andRuthS.Reinerfellowshipfund.
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