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Issues in Mental Health Nursing, 31:355–364, 2010
Copyright © Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840903427831
A Pilot Study to Reduce Risk for Antepartum Depression
Among Women in A Public Health Prenatal Clinic
D. Elizabeth Jesse, PhD, CNM
East Carolina University, College of Nursing, Greenville, North Carolina, USA
Amy Blanchard, PhD
Antioch University—New England, Keene, New Hampshire, USA
Shelia Bunch, PhD, LCSW
East Carolina University, School of Social Work, Greenville, North Carolina, USA
Christyn Dolbier, PhD
East Carolina University, Department of Psychology, Greenville, North Carolina, USA
Jennifer Hodgson, PhD
East Carolina University, College of Human Ecology, Greenville, North Carolina, USA
Melvin S. Swanson, PhD
East Carolina University, College of Nursing, Greenville, North Carolina, USA
This pilot study evaluated the feasibility, effectiveness, and help-
fulness of Insight-Plus, a brief culturally-tailored cognitive behav-
ioral intervention for African-American and Caucasian rural low-
income women at risk for APD [Edinburgh Postnatal Depression
Scale (EPDS) ≥10]. Forty two percent (63/149) of women in this
non-randomized study were at risk for APD and 41% (26/63) of
women, who met all eligibility criteria, initially agreed to partici-
pate. Seventeen participants completed all six intervention sessions.
Ninety-four percent (16/17) who completed their one-month post-
intervention interviews had an antepartum recovery rate of 81%
(13/16, EPDS ≤10). Participants reported that many aspects of the
program were helpful and they continued to use the intervention
exercises after the sessions ended.
Each year, as many as 50% of pregnant women experience
depressive symptoms (Bennett et al., 2004; Gaynes et al., 2005)
and 11–14.5% meet the diagnostic criteria for antepartum de-
pression (APD), which is defined as a major or minor depressive
This research was supported by a grant from East Carolina Univer-
sity’s Division of Research and Graduate Studies. We thank Dr. John
Morrow, the maternal child health nurses, and other members of the
health department for their collaboration on this project, and we thank
the women who enrolled in our study.
Address correspondence to D. Elizabeth Jesse, East Carolina Uni-
versity, College of Nursing, 3160 Health Sciences Building, Greenville,
NC 27858-4353. E-mail: jessed@ecu.edu
disorder during pregnancy (American Psychiatric Association,
2000; Bennett et al., 2004; Gaynes et al., 2005). Antepartum de-
pression, the most common psychiatric disorder in pregnancy, is
a treatable illness that can result in tremendous personal suffer-
ing, poor self-perception, interpersonal violence, stressful life
events (Jesse & Swanson, 2007), relational stress (Blanchard
et al., 2009), risky behaviors (Linares Scott et al., 2009),
thoughts of harming oneself or the fetus (Lewis et al., 2001),
poor birth outcomes (Li, Liu, & Odouli, 2009), complications
during the present pregnancy (Larsson, Sydsjo, & Josefsson,
2004), development of postpartum depression (Beck, 2008;
Dennis & Ross, 2006), and attachment disorders (Brand & Bren-
nan, 2009).
Low-income and rural women have a higher prevalence of
antepartum depressive symptoms, fewer options for insurance
than middle- or- upper-income women, and experience more
cultural stigma and fears of being labeled a neglectful mother
(Jesse, Dolbier, & Blanchard, 2008; Kermode, Fisher, & Jol-
ley, 2000). Stigma and fear prevent these women from seeking
help until they are in crisis, which can result in more intensive
and expensive interventions (Hauenstein, 2003). Often they are
appropriately reluctant to use medications because of concern
about the potential effects of exposure to antidepressants on the
developing fetus (Moses-Kolko et al., 2005). Some researchers
(Simpson, Krishnan, Kunik, & Ruiz, 2007) report that minor-
ity groups are less or equally likely to suffer from depressive
355
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356 D. E. JESSE ET AL.
symptoms or depression as Caucasians. However, others (Jesse
& Swanson, 2007) found the risk for antepartum depression
was twice as great for African American women than Hispanic
or Caucasian women at this study site. The United States Sur-
geon General (U.S. Department of Health and Human Services,
1999) emphasized the need for interventions with ethnic minor-
ity groups to reduce mental health disparities, yet few are avail-
able generally, and even fewer for minority and low-income and
rural women.
INTERVENTION LITERATURE
The high prevalence and severity of antepartum depressive
symptoms in low-income and rural pregnant women is a signif-
icant problem. Although these women would probably benefit
from early intervention, few receive treatment (Song, Sands,
& Wong, 2004). Cognitive behavioral interventions (CBIs) are
brief interventions that focus on the present, and specific skills
are taught that can reduce risk of depression, even after treatment
is completed (Hollon et al., 2005). CBIs have been successful
in treating depressed non-pregnant adults, but to the best of our
knowledge, researchers have not tested the effectiveness with ru-
ral low-income women enrolled in a local health department’s
prenatal clinic. Two randomized clinical trials (RCTs) used
CBIs in an attempt to prevent postpartum depression (PPD), but
neither had significant results. Zayas, McKee, and Jankowski
(2004) used an eight-session CBI to prevent postpartum depres-
sion in 100 low-income culturally diverse women in an urban
primary care environment. Contrary to expectations, the CBI did
not reduce depressive symptoms significantly at three months
postpartum. Perhaps this was due to challenges in implementa-
tion, issues related to retention of subjects, a poor relationship
with the study site, and student facilitators who changed often.
The second RCT, Mam´
as y Beb´
es/Mothers and Babies (Munoz
et al., 2007) used a 12-session CBI to prevent PPD with 41
urban Spanish or English speaking pregnant women. The in-
tervention was followed by four postpartum booster sessions,
but it did not show significant results. Conversely, a few small
studies (Spinelli & Endicott 2003; Zlotnick, Johnson, Miller,
Pearlstein, & Howard, 2001) have shown more promising re-
sults on the effectiveness of interpersonal therapy (IPT) for re-
ducing the risk of PPD, but risk for antepartum depression was
generally incidental in these studies and those in IPT often meet
more frequently than those in CBIs. For example in Spinelli and
Endicott’s (2003) study the women attended 16 sessions.
STUDY PURPOSE
The pilot study reviewed in this paper looked at a brief,
culturally tailored, relationally focused, and manualized CBI
for rural African-American and Caucasian low-income preg-
nant women at risk for depression. The aims of this study were
to: (1) describe the development of the intervention; (2) test
the feasibility of recruitment, retention, and implementation;
(3) determine the preliminary outcomes; and (4) evaluate the
acceptability and helpfulness to reduce antepartum and post-
partum depressive symptoms within a local health department
(LHD) setting. The researchers sought to answer the research
questions: (1) What is the feasibility of Insight-Plus, an inter-
vention delivered in a local health department setting? (2) Does
the intervention improve depressive symptoms as measured by
the Edinburgh Postnatal Depression Scale (EPDS) and Beck
Depression Inventory II (BDI-II) in the post intervention? (3)
Was the intervention helpful and acceptable to the participants
as measured by postpartum qualitative interviews?
METHOD
Design
This Insight-Plus pilot study used a non-experimental one
group pre-test and post-test design to examine the preliminary
outcomes of the intervention for reducing depressive symptoms
in pregnancy and the postpartum. Descriptive and qualitative
data were collected to examine the feasibility of the intervention
and to evaluate its helpfulness. We intended to run a treatment-
as-usual (TAU) control group but too few women (n=4) were
enrolled to make any statistical comparisons, since most women
we approached chose to take part in the Insight-Plus intervention
rather than the TAU. This study was part of a larger study that
examined biopsychosocial factors and risk for depression in
pregnancy and built on previous research, including a focus
group study and smaller pilot study with women from the study
site.
Setting and Sample
The East Carolina University Institutional Review Board
(IRB) approved our study. A total of 26 women participated
(African-American, n =21 and Caucasian, n =5). These women
were enrolled in the LHD prenatal clinic in Eastern North Car-
olina and were eligible and at risk for APD. Eligibility crite-
ria included pregnancy between 6–30 weeks; age 18 or older;
ability to read at a fourth grade level and to respond to study
questions in English; and an Edinburgh Postnatal Depression
Scale (EPDS) score of ≥10 (Murray & Cox 1990). Exclusion
criteria included cognitive disability as determined by the inter-
viewer’s assessment; inability to attend the sessions; a sponta-
neous abortion before 20 weeks of pregnancy; a diagnosis of
schizophrenia or bipolar disorder with or without psychosis;
taking medication for depression prior to enrollment; currently
receiving other treatment, such as individual, family, or group
psychotherapy; a diagnosis of a high-risk pregnancy, requir-
ing bed rest or hospitalization; and being at risk for suicidal
plans as measured by responses to Question 10 on the EPDS,
Item 9 on the Beck Depression Inventory II (BDI-II), and/or
a evaluation by the social worker at the health department and
confirmed by a clinical diagnosis from a community therapist or
psychiatrist.
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REDUCING RISK FOR ANTEPARTUM DEPRESSION 357
Intervention and Workbook Development
Insight-Plus was adapted from Insight, an existing manual-
ized CBI for non-pregnant women (Gordon, 1999, 2002). In-
sight was based on Beck’s (1967) cognitive model and was
reported to be effective for treating 18- to 24-year-old under-
graduate college women and low-income non-pregnant single
mothers with depressive symptoms (Peden, Rayens, Hall, &
Beebe, 2001; Peden, Rayens, Hall, & Grant, 2004). A number
of steps were taken to develop the Insight-Plus intervention and
workbook. First, a psychiatric nurse practitioner who facilitated
Insight groups in a nearby city trained the multidisciplinary
team, which included the Principal Investigator (PI), a nurse-
midwife, and the facilitators who were marriage and family
therapists, medical family therapy doctoral students, a licensed
clinical social worker, and a rehabilitation studies master’s stu-
dent. Second, we incorporated themes from our focus group
study (Jesse, Dolbier, & Blanchard, 2008) that elicited informa-
tion about what pregnant women wanted in an intervention if
they were at risk for depression at this study site. The themes
included facilitating trust, reducing stigma, overcoming barriers,
and incorporating effective ways to reduce stress and depressive
symptoms; the facilitators were sensitive to sociocultural, so-
cioeconomic, and interpersonal issues.
Because Gordon’s workbook was written for non-pregnant
women who read at a college reading level, it was not appro-
priate for this population. With permission from Gordon (per-
sonal communication, March 23, 2009), we took a number of
steps to develop a workbook tailored for minority and rural
low-income pregnant women. First, the study team included
pregnancy specific information developed by the first author, a
nurse-midwife, such as how to determine depressive symptoms
from physical and emotional changes in pregnancy. We also in-
cluded information on postpartum depression and adapted the
program to be used by individuals or groups. Next, we rewrote
the content for a fourth grade reading level using the 2003
and 2007 Microsoft Word Flesch-Kincaid Reading Level pro-
gram. Third, we included many colorful and attractive graphics,
brief homework assignments, and real world examples. Fourth,
we included a guided visualization CD (Menzies, Taylor, &
Bourguignon, 2006) with permission of the author and a audio
tape with inspirational literature/affirmations by Iyania Vanzant
(2003) suggested by the women in the focus groups. Next, we
included thought stopping activities that were described in Pe-
den et al.’s (2004) study of Insight, derived from the Depression
Workbook (Copeland & McKay, 2002).
Finally, before the current study began, the research team de-
veloped and tested the Insight-Plus workbook, in a pilot with five
African-American and Caucasian pregnant women at risk for
depression at the local health department (LHD). We solicited
feedback about the workbook and the sessions from the study
participants as well as members of the research team, includ-
ing the group facilitators, one of whom is an expert on cultural
competency and mental health issues with African-American
women. After IRB approval, we included the recommended
changes. Dr. Gordon reviewed the final workbook for appropri-
ateness of content and her feedback was included.
Recruitment and Procedures
Recruitment for this study was from the Local Health Depart-
ment. We used the LHD’s screening process to identify women
eligible for this study, described in more detail elsewhere (Jesse
et al., 2009). Women at risk for depression (EPDS ≥10) who
were interested in the study filled out and signed an agreement
to be contacted by a member of the research team and pro-
vided contact information and their next prenatal appointment
date. Women at the LHD with suicidal plans or those with other
mood disorder, such as bipolar disorder, were referred to the
Regional Perinatal Center for further evaluation and care and
they were not eligible for enrollment in the study.
Women who were interested in the study were contacted
by one of the RAs. The RAs were students in the marriage
and family therapy program or in the master’s of public health
graduate program, including an RN. After obtaining informed
consent, in the first baseline interview (Time 1; T1), sociode-
mographic information, including age, ethnicity/race, type of
insurance (Medicaid or none), education, gravida/para, history
of depression, partner status, and measures of depression symp-
tom severity (EPDS and BDI-II) were obtained. If the women
did not have time to complete the interview before or after their
prenatal visit, another time was scheduled. Next, the second in-
terview (Time 2; T2) occurred at the end of the last intervention
session; the third interview (Time 3; T3) occurred at one-month
post-intervention. The interval from the T1–T3 interviews was
approximately ten weeks. The final interviews occurred at four
weeks (Time 4; T4) and eight weeks (Time 5; T5) postpartum to
determine the participants PPD symptoms, aspects of the CBI
that were most helpful, and what activities they continued to use.
RAs wrote comments verbatim and final responses were read
back to the participants for clarification. Finally, to understand
the context of each woman’s risk for depression, group facilita-
tors kept a log to record the participants’ health risk behaviors
and crises that could affect the intervention’s efficacy, and their
general observations were included for descriptive purposes.
Addressing Recruitment Barriers
To address recruitment barriers, transportation and child care
were provided if needed; we had flexible scheduling, one-on-
one, as well as group meetings, incentives, reminders, and addi-
tional support to enhance follow-up phone call responses. The
study coordinator kept a table listing dates and times partici-
pants were called and their responses. Sessions were held in a
private room at the LHD and each group was closed to new par-
ticipants after the initial session. To enhance retention, stigma
was addressed and facilitators built rapport and trust with the
participants and contact with the participants was maintained.
We requested that they call us when they delivered their baby so
we could send them a congratulation card. Participants were
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358 D. E. JESSE ET AL.
compensated for their time ($50 after six sessions and $10
and $15 for the four- and eight-week postpartum interviews)
and they had a light meal with their support person in Session
Four.
Intervention
The Insight-Plus program consisted of six two-hour group or
individual sessions in which women learned to set goals, break
tasks into smaller components, recognize and prioritize life’s
problems, manage stress, and solve problems to alleviate de-
pression. Women were given the Insight-Plus Workbook during
their first session and the facilitator introduced the program, de-
scribed group member responsibilities, symptoms of depression
in pregnancy, goal setting, distorted thinking, and thoughts, feel-
ings, and behaviors. These concepts were reviewed after each
session and homework was assigned. Session Two focused on
coping and relaxation, and women received the guided imagery
CD. In Session Three, the facilitator discussed significant other
relationships and domestic violence, and the participants were
asked to invite a partner/support person to Session Four. After
signing a research/treatment informed consent form in Session
Four, the support persons met concurrently to learn more about
Insight-Plus, signs and symptoms of antepartum depression,
communication skills, and the CBI techniques. One of the mem-
bers of the research team facilitated the support group session,
which met concurrently with the participants’ session. Sugges-
tions were offered on how to elicit open communication in their
relationships, what helps women at risk for prenatal depression,
and the signs and symptoms for PPD. In the last 40 minutes, the
support persons joined the women for shared group activities,
including eating a pre-ordered meal together and watching and
discussing a DVD on APD. In Session Five participants dis-
cussed grief and loss and spirituality and said their goodbyes.
In Session Six they reviewed the signs and symptoms of post-
partum depression and the completed the depression screening
scales.
Measures
Edinburgh Postnatal Depression Scale (EPDS)
The EPDS is a 10-item self-report questionnaire that has been
used widely in clinical and research work to measure antepartum
(Murray & Cox, 1990) and postpartum depressive symptoms
(Cox et al., 1987). Questions on the EPDS are framed within
the past seven days, and the response format is frequency based.
Each item is rated on a four-point scale (0–3); the scale takes
less than five minutes to administer. Responses are summed to
obtain a score; the minimum and maximum scores are 0 and
30, respectively. Large community surveys have shown that the
EPDS has strong validity and reliability for use in pregnancy
(Bennett et al., 2004; Murray & Cox, 1990). Recommended
EPDS cut-off scores for perinatal depression range from 9 to 13
(Gaynes et al., 2005). A cut-off score of 12–13 identified women
who are most likely to be experiencing postpartum depression
in Cox et al.’s (1987) study. A lower threshold score of 10
for risk of APD is more sensitive and misses fewer cases of
major antepartum depression (Gaynes et al., 2005). Therefore,
we used a cut-off score of 10 or greater for risk of APD and
12 or greater for PPD to identify a positive response of risk for
depression.
Beck Depression Inventory-II (BDI-II)
The BDI-II (Beck et al., 1996), a 21-item self-report inven-
tory, was also chosen to measure depressive symptoms because
it has been widely used in clinical research, validated for use in
pregnancy with low-income and minority women, and required
only approximately 5–10 minutes to complete. Affective, cog-
nitive, motivational, and vegetative symptoms of depression are
measured on a four-point scale ranging from 0–3, with summed
scores ranging from 0–63. The BDI-II uses two weeks as the
time frame for symptoms. Based on previous studies, a cut-off
score of >16 was used to identify risk for antepartum depres-
sion in pregnancy. Because of small sample size, reliability of
the EPDS and BDI-II cannot be assumed. However, Cronbach’s
alpha coefficients for the BDI-II scale were .92 for Caucasians
and .88 for African American women in the PI’s latest study
with a similar sample of women (Jesse & Swanson 2007); cron-
bach’s alpha coefficients for the EPDS scale were .88 in a sample
of adolescent mothers in a southern, urban area of the United
States (Logsdon, 2009).
Data Analysis
The pre-treatment characteristics assessed included sociode-
mographic factors, and a consort flow analysis was maintained
to assess the feasibility of study recruitment and retention (num-
bers refused, dropped, lost to follow-up [LTF], withdrawal rates,
and reasons given). Summary statistics for antepartum and post-
partum risk for depression are presented as means and standard
deviations for continuous variables and as percentages for dis-
crete variables. Differences in pre- and post-intervention EPDS
and BDI-II mean scores were analyzed using paired t-tests to
determine the change in antepartum scores (T1–T3). SPSS 16.0
for Windows was used for all quantitative data analyses. We
defined statistical significance as (p<.05).
Finally, content analysis of the women’s responses to open-
ended questions was used to analyze the data (Stemler, 2001).
A pair of researchers categorized the data using the coding
scheme, and inter-coder reliability was established with inter-
coder agreement of 0.9. The participants’ responses were read
and discussed until 100% agreement was reached on numbers
and percentages of answers to the following open-ended ques-
tions: “Which aspects of Insight-Plus were most helpful to you?”
Which Insight-Plus activities have you continued to use?” Par-
ticipant answers were sorted into categories and themes and
conclusions were drawn. Descriptive analysis was performed
for the frequency of the answers for each question.
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REDUCING RISK FOR ANTEPARTUM DEPRESSION 359
TABLE 1
Participant Characteristics at Pre-Treatment (n=26)
Total (n=26) Completers (n=17) Drop outs (n=5)
Other∗(n=4)
Characteristics of the Participants Mean (SD) Mean (SD) Mean (SD)
Age (years) 24.69 ±5.33 25.12 ±5.87 23.89 ±4.30
Gravida 2.50 ±2.04 2.56 ±2.50 2.38 ±1.69
Para 1.21 ±1.91 1.38 ±2.16 .88 ±1.36
n (%) n (%) n (%)
Race
African American 21 (80.7) 15 (88.2) 5 (55.6)
Caucasian 5 (19.2) 2 (11.8) 3 (33.3)
Education
<12 years 13 (50) 9 (52.9) 4 (44.4)
≥12 years 13 (50) 8 (47.1) 5 (55.6)
Insurance
Medicare/Medicaid 21 (80.8) 15 (88.2) 6 (66.7)
None 2 (7.7) 1 (5.9) 1 (22.2)
Private 3 (11.5) 1 (5.9) 2 (11.1)
History of Depression
Yes 8 (3 0 .8) 4 (23.5) 4 (42.9)
No 15 (57.7)(3 missing) 12 (70.6)(1 missing) 3 (57.1)
Partner Status
Has a partner 10 (38.4) 11(64.7) 4 (44.7)
Does not have a Partner 16 (64.0) 6 (35.3) 5 (55.6)
∗Participants revealed a preexisting psychiatric disorder after they entered the study, that would have excluded them at intake (treatment for
substance abuse and anxiety disorder (n=1); bipolar disorder (n=2); schizophrenia (n=1).
RESULTS
Sample Description
Table 1 describes the sociodemographic characteristics of
the participants who completed the intervention and those who
dropped out or revealed a preexisting psychiatric condition after
enrollment. The participants, on the average, were 25 years old;
most had been pregnant two or more times and had at least
one child. The majority were African-American and received
Medicaid insurance; half had less than a high school education,
a third were single without a supportive partner, and 23% had a
history of depression.
Recruitment and Retention Results
Forty-two percent (63/149) of the women interviewed at
baseline were at risk for APD (EPDS ≥10) and met all eli-
gibility criteria. Forty-one percent (26/63) of those women ini-
tially agreed to participate in the intervention. The most frequent
reasons for nonparticipation included lack of interest, moving,
illness, not maintaining telephone contact, and ineligibility due
to advancing gestational age or giving birth prematurely while
waiting for an intervention group to form. Five of the 26 par-
ticipants (19%) who were initially interested in the interven-
tion and signed the informed consent form dropped out either
after the initial EPDS screening, before completing the TI in-
terviews, or before the intervention began. Another four of the
26 participants (15%) who were initially interested failed the
eligibility criteria after enrollment because of a preexisting psy-
chiatric condition, such as schizophrenia or bipolar disorder. All
of these women were referred for psychiatric care and treatment.
The remaining 17 of the eligible participants completed all six
intervention sessions: 94% (16/17) completed their T3 interview
(one-month post-intervention), 68% (11/16) completed their T4
interview (four weeks postpartum) and 50% (8/16) completed
their T5 interview (eight weeks postpartum).
Intervention Results
As can be seen in Table 2, there was a significant sharp
decline in the participants’ depressive symptoms from T1 to
T2 that declined even more dramatically at T3; compared to
pretreatment, participants had a 65% rate of “recovery” (11/17,
EPDS <10) in the sixth intervention week and an 81% rate
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360 D. E. JESSE ET AL.
TABLE 2
Improvement of Depressive Symptoms Scores from Pre-Treatment to Sixth Week of CBI Intervention, and one Month
Post-Intervention
Pre-Treatment
n=17
6th Week of
Intervention n=17
1 Month
Post-Intervention
n=16 Participants with Improved Score
T1 T2 T3 T1–T3
Measure n(%) n(%) n(%) n(%)
EPDS ≥10 17 (100) 6 (35.3) 3 (18.8) 14 (81.2)
EPDS <10 0 11 (64.7) 13 (81.3) —
BDI-II ≥16 16 (100) 5 (29.4) 7 (41.2) 9 (58.8)
BDI-II <16 0 12 (70.6) 9 (56.3) —
Mean (SD) Mean (SD) Mean (SD) Eta squared statistic
EPDS 15.12 ±3.22 9.76 ±5.22∗∗ 6.81 ±4.29∗∗∗ .82
large effect size
BDI-II 28.41 ±9.17 14.24 ±11.81∗∗ 13.94 ±7.08∗∗∗ .53
large effect size
∗significant p<0.05; ∗∗significant p<0.01; ∗∗∗ significant p<0.001.
of “recovery” at one-month post-intervention (13/16 EPDS <
10). The paired t-test was used to compare mean change in
EPDS and BDI-II scores from pre-treatment to one-month post-
intervention. At four weeks postpartum 91% (10/11) had EPDS
scores indicating “recovery” (EPDS <12) and at eight weeks
75% (6/8) had EPDS scores indicating “recovery” (EPDS <
12).
Contextual Factors and Health Risk Behaviors Results
Based on the log book information from facilitators, it was
noted that many women were single and most struggled with
multiple stressors and crises that surfaced during the Insight-
Plus sessions. For example, one participant was in jail for a short
period of time; other participants experienced interpersonal vi-
olence (IPV), either with their partner or through witnessing
of IPV in their family; and still others experienced deaths in
their family, substance use, relationship problems, divorce, rel-
atives or partners in jail, and loss of housing. Six participants
reported experiencing IPV within the last year and three expe-
rienced IPV during pregnancy. Consequently, the intervention
topics were rearranged depending on the women’s needs. For
example, if women revealed domestic violence issues in Ses-
sion Two, the facilitator would discuss it then instead of waiting
until the scheduled time in Session Four. Several of the women
created a safety plan and moved in with a relative or in a shelter,
leaving their partners, or the woman and her partner moved in
together with their in-laws, which protected the women from
further IPV. One facilitator noted that women frequently wore
sweat pants or non-descript clothing in the first several sessions,
whereas by the third session participants began dressing up for
the group or wearing make-up. Another woman left a crime
filled neighborhood with support of other women in the group.
Most women invited a close girlfriend or their mothers to the
support group session rather than the father of the baby (FOB).
Despite encouragement several women did not invite anyone,
because they thought no one would be interested in coming.
Helpfulness and Evaluation of the Intervention
As noted in Table 3, the participants reported many aspects
of Insight-Plus that were helpful and they continued to use the
intervention exercises after the sessions ended. In order of fre-
quency, they reported that the most helpful aspects were related
to general mental health/self-esteem (n=7), stress reduction
(n=6), problem-solving (n=2), affirmations/facilitator (n=
4), and group format (n=2). Activities they continued to use
included stress reduction (n=11), positive affirmations (n=
9), thought-stopping (n=3), I-statements and journaling (n=
2). Many participants made positive affirmations a part of their
daily routine. For example, one participant posted a reminder
on her bathroom mirror and shared that when she looked in the
mirror she was reminded of her affirmations; she believed her
self-worth has increased as a result. Others stated that when
things got stressful they would stop and breathe, a technique
used several times throughout the intervention.
DISCUSSION
This study described the development, feasibility, and out-
comes of Insight-Plus, a brief manualized six-session CBI devel-
oped for African-American and Caucasian low-income women
at risk for antepartum depression as recruited through a LHD.
The results of the pilot study answered research question one,
suggesting that it is feasible to recruit pregnant women at risk for
depression for a brief CBI integrated in a LHD with promising
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REDUCING RISK FOR ANTEPARTUM DEPRESSION 361
TABLE 3
Helpful Aspects of Insight-Plus Cognitive Behavioral Intervention and Activities Participants Continued to use at Four and Eight
Weeks Postpartum
Question: Which aspects of CBI have been helpful to you?
Themes Participants’ Statements
General Mental
Health/Self-Esteem
•Thinking about my needs, not being a pushover, putting myself and baby
first (n=1)
•An outlet to focus on self and mental health (n=1)
•That I am better (n=1)
•Can trust people (n=1)
•Don’t have to hide (n=1)
•Treating myself with respect (n=1)
•Knowing everyone’s not perfect (n=1)
Stress-Reduction •Sitting and reading, relaxation techniques (n=2)
•Learning how to handle stress and communication (n=2)
•Learning to calm down (n=1)
Problem-Solving •How to overcome problems (n=1)
•Having ways to deal with problems that I can’t control (n=1)
Affirmations/Facilitator •Every aspect, enjoyed talking to [facilitator] (n=1)
•Affirmations, I statements (n=3)
Group Format •Groups (n=1)
•Groups, screenings, everything (n=1)
Question: Which Insight-Plus activities have you continued to use?
Stress-Reduction •Learned to calm down (n=1)
•Not to get stressed out (n=1)
•Overcome and breathe and relax (n=1)
•Relaxation (n=1)
•CDs (guided visualization) (n=4)
•Breathing techniques (n=1)
•None–difficult to relax (n=2)
Positive Affirmations •Tapes [affirmations] (n=1)
•Affirmations (n=4)
•Say something positive (n=1)
•Think of positive (n=1)
•Read affirmations on sticky notes (n=1)
Thought-Stopping •Block out of mind (n=1)
•Thought stopping (n=2)
I Statements and •I statements (n=1)
Journaling •Journaling (n=1)
results. In response to research questions two and three, women
in the CBI had significantly lower depressive symptoms, main-
tained their improvement over time, reported that the program
was helpful and acceptable, and reported activities they con-
tinued to use after the intervention ended. These are unique
findings in need of further study.
As previously described, no study could be found that tested a
CBI with rural low-income and minority pregnant women. Two
other published studies (Munoz et al., 2007; Zayas et al., 2004)
tested a CBI to prevent PPD with urban and Hispanic women,
but neither demonstrated a statistically significant decrease in
the women’s depressive symptoms in the postpartum period. Za-
yas et al. (2004) reported that the non-significant findings were
likely a result of their implementation challenges. This study
overcame many of these implementation challenges by collab-
orating with the LHD staff to develop a coordinated system for
the study and to review study progress and making adjustments
as necessary. We integrated culturally appropriate themes from
the focus groups and built trust with the pregnant women and
their support persons. For example, each session began with
an ice breaker activity that was fun and positive. Each trained
mental health provider facilitated all of the six sessions for each
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362 D. E. JESSE ET AL.
group. While three facilitators were Caucasian and one was
African-American, we found that race did not prevent women
from sharing and improving. Even if the facilitator was of an-
other race, the participants freely shared aspects of their culture
with the facilitator, who was attuned to the women’s culture
and had established trust. Interestingly, more African-American
women (88%) showed interest in Insight-Plus than Caucasian
women (12%). This finding is similar to what we learned in a
previous focus group study (Jesse et al., 2008). In that study,
“not wanting help” was expressed more by Caucasian women
(66%) than African-American women (33%).
One of the biggest challenges for recruitment was engag-
ing the women’s initial interest in the study. Interviewers es-
tablished therapeutic interaction, engagement interviews were
established, and the intervention was readily available. How-
ever, often the women reporting being tired after a long day at
the clinic and did not want to take time to complete the inter-
view. There were also time and transportation challenges, and
there were stressors preventing some women from enrolling.
After IRB approval, we adjusted our protocol to meet these
challenges, such as improving ways to maintain current phone
numbers and addresses, which changed frequently.
The greatest challenge to retention was maintaining con-
tact over time. The participants’ phone numbers often changed
from week to week or their phones were disconnected; phone
numbers of their friends or emergency contacts did not always
work. Despite this, we had a high rate of retention in the in-
tervention once women enrolled. Participants were given a $50
incentive after completing six sessions (average $8 per visit)
and transportation and child care were offered, although only
a small percentage of the women requested child care and ap-
proximately a third of the women needed transportation. These
incentives cannot explain the high rate of retention since other
studies with low-income pregnant women at risk for depression
had a higher rate of attrition, despite offering $20 incentives
for transportation and child care for each of eight visits (Grote,
Bledsoe, Swartz, & Frank, 2004). All of the women who came
to the first intervention session completed the six-session in-
tervention; only one woman was lost to follow-up one-month
later (T3) (94% rate of retention) but it was more difficult to
maintain contact over an extended time, that is, at four and eight
weeks postpartum. Near the end of the study, we discovered
that we lost fewer women to follow-up if we offered a small
incentive to participants who informed us of their new contact
information.
Because all of the pregnant women in our study were at risk
for APD and many had complex stressors, it was even more
remarkable that they consistently attended. As noted earlier, in
addition to being pregnant and at risk for depression, many ex-
perienced or witnessed IPV, had inadequate or unstable housing,
and lacked support and many were single parents and/or were
in stressful relationships with the father of the baby. These find-
ings are similar to those described in a previous study (Jesse &
Swanson, 2007). In that study, women at risk for depression were
more likely to have suffered abuse, experienced more stress, and
reported low self-esteem, less spirituality, and less support from
family and friends. Because of the additional risks that the facili-
tators described, we began to consider improvement-recovery of
the women in a broader sense. For example, as a consequence
of the intervention, several women exposed to IPV created a
safety plan, moved in with a family member, enrolled in case
management, and with the social workers’ help, obtained a pro-
tective order against their partner. Although they may not have
improved as much on their depressive symptoms, it may be that
these women needed to establish a safe environment before their
depressive symptoms could improve. Most importantly, women
described feeling empowered to leave bad situations and were
feeling better after harmful situations changed. These findings
highlight the importance of addressing depressive symptoms
holistically and the importance of cultural sensitivity and build-
ing trust with participants.
Compared to pretreatment, participants in our study had a
65% rate of “recovery” in the sixth intervention week and an
81% rate of “recovery” at one-month post-intervention. This
delay in the effect suggests that CBI homework and the women’s
insights may take more time than expected to integrate. This
would be important to evaluate in future studies.
As described in Table 3, the women found Insight-Plus to be
helpful and they used many aspects of the homework assign-
ments and activities after it ended. As one participant explained,
“I learned to calm down, not to get stressed out, and when I
heard negative thoughts, I blocked it and breathed to relax and
thought of something positive.” Munoz and colleagues (2007)
also found that participants reported generally high ratings for
their sessions, but did not describe which activities were most
helpful for the participants.
The limitations of this study are related to a small pilot study
with a focus on feasibility of recruitment and retention of low-
income and minority women at risk for APD rather than the
efficacy of the intervention. Thus, findings should be generalized
with caution. Despite lacking a control or comparison group
with random assignment, our findings can form the basis for a
future randomized controlled trial (RCT) that includes current
staff from the LHD so that the program could be sustained.
While there was not a psychiatric nurse-practitioner available
to facilitate the groups, the original program was developed by
a psychiatric nurse. Clinical depression was not evaluated in
this study; in future studies, it would be important to include a
structured clinical interview to determine depressive symptoms
versus clinical depression. Although Hispanic/Latina women at
risk for depression were not included in this study, the workbook
has been translated into Spanish and back-translated for future
research.
Implications for Practice
The preliminary findings of Insight-Plus, a brief, culturally
tailored, relationally focused, and manualized CBI for rural
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REDUCING RISK FOR ANTEPARTUM DEPRESSION 363
African-American and Caucasian low-income at risk for an-
tepartum depression suggest that it was feasible, had promising
results, and was helpful. A program such as this may be es-
pecially promising for public health settings, because so many
rural low-income women and African-American women expe-
rience significant depressive symptoms during pregnancy, but
are less likely than other women to seek care for depression;
when they finally do seek care, their symptoms are far worse. If
women who suffer from antepartum depression or depressive
symptoms are to be identified, it is essential that nurses univer-
sally screen for risk of depression and for mental health pro-
fessionals to build rapport and trusting relationships so women
can overcome barriers and receive help. Women in this pilot
study only attended group for six weeks, yet they reported skills
and techniques that benefited them after the group ended. For
example, problem solving, guided relaxation, thought stopping,
and affirmations were noted by the participants as particularly
useful and are recommended.
Declaration of interest: The authors report no declaration of
interest. The authors alone are responsible for the content and
writing of the paper.
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