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A Pilot Study to Reduce Risk for Antepartum Depression Among Women in A Public Health Prenatal Clinic


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This pilot study evaluated the feasibility, effectiveness, and helpfulness of Insight-Plus, a brief culturally-tailored cognitive behavioral intervention for African-American and Caucasian rural low-income women at risk for APD [Edinburgh Postnatal Depression Scale (EPDS) > or = 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 participate. 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 < or = 10). Participants reported that many aspects of the program were helpful and they continued to use the intervention exercises after the sessions ended.
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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:
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
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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.
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.
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?
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
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
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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
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
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
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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Participant Characteristics at Pre-Treatment (n=26)
Total (n=26) Completers (n=17) Drop outs (n=5)
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 (%)
African American 21 (80.7) 15 (88.2) 5 (55.6)
Caucasian 5 (19.2) 2 (11.8) 3 (33.3)
<12 years 13 (50) 9 (52.9) 4 (44.4)
12 years 13 (50) 8 (47.1) 5 (55.6)
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).
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.
Improvement of Depressive Symptoms Scores from Pre-Treatment to Sixth Week of CBI Intervention, and one Month
6th Week of
Intervention n=17
1 Month
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 <
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.
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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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
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
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
Implications for Practice
The preliminary findings of Insight-Plus, a brief, culturally
tailored, relationally focused, and manualized CBI for rural
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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.
American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of
mental disorders (4th ed., text rev.). Washington, DC: Author.
Beck, A. (1967). Depression: Clinical experimental and theoretical aspects.
New York: Harper Row.
Beck, C. T. (2002). Theoretical perspectives of postpartum depression and their
treatment implications. MCN, American Journal of Maternal Child Nursing,
27(5), 282–287.
Beck, C. T. (2008). State of the science on postpartum depression: What nurse
researchers have contributed—part 1. MCN, American Journal of Maternal
Child Nursing,33(2), 121–126.
Beck, R. W.,Jijon, C. R., & Edwards, J. B. (1996). The relationships among gen-
der, perceived financial barriers to care, and health status in a rural population.
The Journal of Rural Health,12, 188–196.
Bennett, H. A., Einarson, A., & Taddio, A. (2004). Prevalence of depression
during pregnancy: Systematic review. Obstetrics and Gynecology,103, 698–
Blanchard, A., Hodgson, J., Gunn, W., Jesse, D. E., & White, M. (2009). Preg-
nancy turns up the volume: Understanding social support and the couple’s
relationship among women with depressive symptoms in pregnancy. Issues
in Mental Health Nursing,30(12), 764–776.
Brand, S. R., & Brennan, P. A. (2009). Impact of antenatal and postpartum
maternal mental illness: How are the children? Clinical Obstetrics and Gy-
necology,52(3), 441–455.
Carroll, K. M., Rounsaville, B. J., Nich, C., Gordon, L. T.,Wirtz, P.W., & Gawin,
F. (1994). One-year follow-up of psychotherapy and pharmacotherapy for
cocaine dependence. Delayed emergence of psychotherapy effects. Archives
of General Psychiatry,51(12), 989–997.
Copeland, M. E., & McKay, M. (2002). The depression workbook—A guide for
living with depression and manic depression. Oakland, CA: New Harbinger
Cox, J. L., Holden, I. M., & Sagovsky, R. (1987). Detection of postnatal de-
pression. Development of the10-item Edinburgh Postnatal Depression Scale.
British Journal of Psychiatry,150, 782–786.
Dennis, C. L., & Ross, L. (2006). The clinical utility of maternal self-
reported personal and familial psychiatric history in identifying women at
risk for postpartum depression. Acta Obstetricia et Gynecologica,85, 1179–
Gaynes, B. N., Gavin, N., Meltzer-Brody, S., Lohr, K. N., Swinson, T.,
Gartlehner, G., Brody, S., & Miller, W. C. (2005). Perinatal depression:
Prevalence, screening accuracy, and screening outcomes. Evidence re-
port/technology assessment no. 119. (Prepared by the RTI-University of North
Carolina Evidence-Based Practice Center, under Contract No. 290-02-0016.)
AHRQ Publication No. 05-E006-2. Rockville, MD: Agency for Healthcare
Research and Quality.
Gordon, V. C., & Tobin, M. (1991; 2002). INSIGHT: A cognitive enhancement
program for women. University of Minnesota, Minneapolis, MN. Retrieved
February 1, 2009, from
Grote, N. K., Bledsoe, S. E., Swartz, H., & Frank, E. (2004). Feasibility of
providing culturally relevant, brief interpersonal psychotherapy for antenatal
depression in an obstetrics clinic: A pilot study. Research on Social Work
Practice,14, 397–406.
Hart, R., & McMahon, C. A. (2006). Mood state and psychological ad-
justment to pregnancy. Archives of Women’s Mental Health,9, 329–
Hauenstein, E. (2003). No comfort in the rural south: Women living depressed.
Archives of Psychiatric Nursing,17(1), 3–11.
Hollon, S. D., Jarrett, R. B., Nierenberg, A. A., Thase, M. E., Trived, J. M.,
& Rush, A. J. (2005). Psychotherapy and medication in the treatment of
adult and geriatric depression: Which monotherapy or combined treatment?
Journal of Clinical Psychiatry,66(4), 455–468.
Jesse, D. E., Dolbier, C., & Blanchard, A., (2008). Barriers to seeking help
and treatment suggestions for prenatal depressive symptoms: Focus groups
with rural low-income women. Issues in Mental Health Nursing,29,3
Jesse, D. E., Morrow, J., Dennis, T., Herring, D., & Laster, B. M. (2009).
Translating research to preventantenatal depression in a public health prenatal
clinic: A model approach. Journal of Public Health Management & Practice,
15(2), 160–166.
Jesse, D. E., & Swanson, M. (2007). Risks and resources associated with an-
tepartum risk for depression among rural southern women. Nursing Research,
56(6), 378–386.
Kermode, M., Fisher, J., & Jolley, D. (2000). Health insurance status and
mood during pregnancy and following birth: A longitudinal study of multi-
parous women. Australian and New Zealand Journal of Psychiatry,34, 664–
Larsson, C., Sydsjo, G., & Josefsson, A. (2004). Health, sociodemographic data,
and pregnancy outcome in women with antepartum depressive symptoms.
Obstetrics & Gynecology,104(3), 459–466.
Lewis, G., Drife, J., Botting, B., Carson, C., Cooper, G., Hall, M., McCormick,
C., Neilson, J., Oates, M., Shaw, R., de Swiet, M., Millward-Sadler, H.,
Thomas, T., Thompson, W., Willats, S. (2001). Why mothers die 1997–1999:
the fifth report of the confidential enquiries into maternal deaths in the United
Kingdom. London, UK: Royal College of Obstetricians and Gynaecologists
Li, D., Liu, L., & Odouli, R. (2009). Presence of depressive symptoms during
early pregnancy and the risk of preterm delivery: A prospective cohort study.
Human Reproduction (Oxford, England),24(1), 146–153.
Linares Scott, T. J., Heil, S. H., Higgins, S. T., Badger, G. J., & Bernstein,
I. M. (2009). Depressive symptoms predict smoking status among pregnant
women. Addictive Behaviors,34(8), 705–708.
Logsdon, C. M., Usui, W. M., & Nering, M. (2009). Validation of Edinburgh
Postnatal Depression Scale for adolescent mothers. Archives of Women’s
Mental Health,12, 433–440.
Menzies, V., Taylor, A. G., & Bourguignon, C. (2006). Effects of guided im-
agery on outcomes of pain, functional status, and self-efficacy in persons
diagnosed with fibromyalgia. Journal of Alternative and Complementary
Medicine,12(1), 23–30.
Issues Ment Health Nurs Downloaded from by East Carolina University on 09/27/10
For personal use only.
364 D. E. JESSE ET AL.
Moses-Kolko, E. L., Bogen, D., Perel, J., Bregar, A., Uhl, K., Levin, B., &
Wisner, K. L. (2005). Neonatal signs after late in utero exposure to serotonin
reuptake inhibitors: Literature review and implications for clinical appli-
cations. Journal of the American Medical Association, 18,293(19), 2372–
noz, R. F., Le, H. N., Ghosh, I. C., Ippen, C., Diaz, M. A., Urizar, G. G.,
Soto, J., Mendelson, T., Delucchi, K., & Lieberman, A. F. (2007). Prevention
of postpartum depression in low-income women: Development of the Mam´
es/Mothers and Babies Course. Cognitive & Behavioral Practice,14,
Murray, D., & Cox, J. (1990). Screening for depression during pregnancy with
the Edinburgh Postnatal Depression Scale (EPDS). Journal of Reproductive
and Infant Psychology,8, 99–107.
Peden, A. R., Rayens, M. K., Hall, L. A., & Beebe, L. H. (2001). Preventing
depression in high-risk college women: A report of an 18-month follow-up.
Journal of American College Health,49, 299–306.
Peden, A. R., Rayens, M. K., Hall, L. A., & Grant, E. (2004). Negative thinking
and the mental health of low-income single mothers. Journal of Nursing
Scholarship,36(4), 337–344.
Simpson, S. M., Krishnan, L. L., Kunik, M. E., & Ruiz, P. (2007). Racial
disparities in diagnosis and treatment of depression: A literature review. The
Psychiatric Quarterly,78(1), 3–14.
Song, D., Sands, R. G., & Wong, Y. L. (2004). Utilization of mental
health services by low-income pregnant and postpartum women on medical
assistance. Women and Health,39, 1–24. Retrieved March 17, 2009, from papers/28/
Spinelli, M.G., & Endicott, J. (2003). Controlled clinical trial of interpersonal
psychotherapy versus parenting education program for depressed pregnant
women. Am J Psychiatry,160, 555–562.
Stemler, S. (2001). An overview of content analysis. Practical Assess-
ment, Research & Evaluation,7(17). Retrieved from
U.S. Department of Health and Human Services (1999). Mental Health: A Re-
port of the Surgeon General. Rockville, MD: U.S. Department of Health
and Human Services, Substance Abuse and Mental Health Services Admin-
istration, Center for Mental Health Services, National Institutes of Health,
National Institute of Mental Health.
US Department of Health and Human Services. (2003). Health Re-
sources and Services Administration, Office of Rural Health Policy,
Rural Mental Health in the WICHE West: Meeting workforce de-
mands through regional partnership. Retrieved April 19, 2008, from,
Vanzant, I. (2003). Acts of Faith: Daily Meditations for People of Color
(audio tape). Available at:
Zayas, L. H., McKee, M. D., & Jankowski, K. R. (2004) Adapting psychosocial
intervention research to urban primary care environments: A case example.
Annals of Family Medicine.,2(5), 504–508.
Zlotnick, C., Johnson, S. L., Miller, I. W., Pearlstein, T., & Howard, M. (2001).
Postpartum depression in women receiving public assistance: Pilot study of
an interpersonal therapy-oriented group intervention. American Journal of
Psychiatry,58, 638–640.
Issues Ment Health Nurs Downloaded from by East Carolina University on 09/27/10
For personal use only.
... Most studies required women to have elevated symptoms of depression (Crockett, Zlotnick, Davis, Payne, & Washington, 2008;Grote et al., 2009;Jesse et al., 2015.;Le, Perry, & Stuart, 2011;Muñoz et al., 2007;Sampson, Villarreal, & Rubin, 2016) or meet a clinically significant cut-off for depression (Field et al., 2013a;Jesse et al., 2010;Lenze & Potts, 2017;McKee, Zayas, Fletcher, Boyd, & Nam, 2006). None of the 13 eligible studies required women to meet any anxiety symptom cut-off. ...
... A variety of psychological interventions to reduce perinatal depressive symptoms among Black women and Latinas emerged as part of this review. The most common treatment modality was CBT (El-Mohandes et al., 2008;Jesse et al., 2010;Jesse et al., 2015;Le et al., 2011;Muñoz et al., 2007;Sampson et al., 2016), followed by IPT (Crockett et al., 2008;Field et al., 2013a;Grote et al., 2009;Lenze & Potts, 2017). CBT+ social support (McKee et al., 2006), behavioral activation (Kieffer et al., 2013), and mindfulness (Zhang & Emory, 2015) were also examined. ...
... Interventionists were primarily master's or PhD level therapists (Crockett et al., 2008;El-Mohades et al., 2008;Field et al., 2013a;Grote et al., 2009;Jesse et al., 2010;Jesse et al., 2015;Lenze & Potts, 2018;McKee et al., 2006;Muñoz et al., 2007;Zhang & Emory, 2015), followed by community health workers (Kieffer et al., 2013) or community caseworkers (Sampson et al., 2016). ...
Black women and Latinas have more symptoms of depression and anxiety during pregnancy than do their non‐Latina White counterparts. While effective interventions targeting internalizing disorders in pregnancy are available, they are primarily tested with White women. This article reviews randomized controlled trials and non‐randomized studies to better understand the effectiveness of psychological interventions for anxiety and depression during pregnancy in Latinas and Black women. Additionally, this review summarizes important characteristics of interventions such as intervention format, treatment modality, and the use of cultural adaptations. Literature searches of relevant research citation databases produced 68 studies, 13 of which were included in the final review. Most studies were excluded because their samples were not majority Latina or Black women, or because they did not test an intervention. Of the included studies, three interventions outperformed a control group condition and showed statistically significant reductions in depressive symptoms. An additional two studies showed reductions in depressive symptoms from pre to post‐treatment using non‐controlled designs. The remaining eight studies (seven randomized and one non‐randomized) did not show significant intervention effects. Cognitive behavioral therapy was the modality with most evidence for reducing depressive symptoms in pregnant Black and Latina women. No intervention was found to reduce anxiety symptoms, although only two of the 13 measured anxiety as an outcome. Five studies made cultural adaptations to their treatment protocols. Future studies should strive to better understand the importance of cultural modifications to improve engagement and clinical outcomes with pregnant women receiving treatment for anxiety and depression.
... The Insight-Plus, culturally tailored, cognitive-behavioral manualized intervention for rural and minority, pregnant low-income women is summarized in Table 1 and described in more detail in a previous study. 44 The intervention was adapted from Insight, a manualized program for nonpregnant women who read at a college reading level. 45, 46 Beck's cognitive-behavioral model [47][48][49][50] and Jesse's bio-psychosocialspiritual theory 1,51 provided the theoretical framework for the intervention. ...
... All chapters were written at a fourth-grade reading level and were piloted in the earlier study. 44 The manual was translated and back translated into Spanish for Spanish-speaking participants. ...
... Based on the focus group themes 52 and pilot findings, 44 we reduced barriers to women attending the cognitive-behavioral intervention by providing transportation, child care, brief ice-breaker games, prizes, humorous and fun activities, and snacks. We also encouraged the women to develop hobbies; to journal; and to listen to relaxing, motivational, and positive music. ...
Full-text available
Introduction: Cognitive-behavioral group interventions have been shown to improve depressive symptoms in adult populations. This article details the feasibility and efficacy of a 6-week, culturally tailored, cognitive-behavioral intervention offered to rural, minority, low-income women at risk for antepartum depression. Methods: A total of 146 pregnant women were stratified by high risk for antepartum depression (Edinburgh Postnatal Depression Scale [EPDS] score of 10 or higher) or by low-moderate risk (EPDS score of 4-9) and randomized to a cognitive-behavioral intervention or treatment as usual. Differences in mean change of EPDS and Beck Depression Inventory (BDI)-II scores for low-moderate and high-risk women in the cognitive-behavioral intervention and treatment as usual for the full sample were assessed from baseline (T1), posttreatment (T2), and one-month follow-up (T3), and for African American women in the subsample. Results: Both the cognitive-behavioral intervention and treatment-as-usual groups had significant reductions in the EPDS scores from T1 to T2 and T1 to T3. In women at high risk for depression (n = 62), there was no significant treatment effect from T1 to T2 or T3 for the EPDS. However, in low-moderate risk women, there was a significantly greater mean change in the BDI-II scores from significant decrease in the BDI-II scores from T1 to T2 (4.92 vs 0.59, P = .018) and T1 to T3 (5.67 vs 1.51, P = .04). Also, the cognitive-behavioral intervention significantly reduced EPDS scores for African American women at high risk (n = 43) from T1 to T2 (5.59 vs 2.18, P = .02) and from T1 to T3 (6.32 vs 3.14, P = .04). Discussion: A cognitive-behavioral intervention integrated within prenatal clinics is feasible in this sample, although attrition rates were high. Compared to treatment as usual, the cognitive-behavioral intervention reduced depressive symptoms for African American women at high risk for antepartum depression and for the full sample of women at low-moderate risk for antepartum depression. These promising findings need to be replicated in a larger controlled clinical trial that incorporates methods to maintain greater participant engagement.
... Previous studies have shown low engagement and high dropout rates of psychological treatment among ethnic minority populations in HICs compared to the native population which suggests that current treatment options lack cultural relevance or appropriateness [14,16]. Therefore, cultural beliefs, values and traditions are essential in intervention planning and execution for addressing maternal depression [25,26,33,35,[41][42][43][44]. In the Grote et al. 's [41] study using an RCT design, culturally relevant and enhanced brief Interpersonal Psychotherapy (IPT-B) had a greater effect on treating depression in low-income pregnant women compared to those receiving enhanced usual care. ...
Full-text available
Background Maternal depression is a leading cause of disease burden for women worldwide; however, there are ethnic inequalities in access to psychological interventions in high-income countries (HICs). Culturally appropriate interventions might prove beneficial for African and Caribbean women living in HICs as ethnic minorities. Methods The review strategy was formulated using the PICo (Population, phenomenon of Interest, and Context) framework with Boolean operators (AND/OR/NOT) to ensure rigour in the use of search terms (“postpartum depression”, “maternal depression”, “postnatal depression”, “perinatal depression” “mental health”, “psychotherapy” “intervention”, “treatment”, “black Caribbean”, “black African”, “mothers” and “women”). Five databases, including Scopus, PsycINFO, Applied Social Science Index and Abstracts (ASSIA), ProQuest Central and Web of Science, were searched for published articles between 2000 and July 2020. 13 studies met the inclusion criteria, and the relevant data extracted were synthesised and thematically analysed. Results Data syntheses and analyses of included studies produced four themes, including (1) enhance parenting confidence and self-care; (2) effective mother–child interpersonal relationship; (3) culturally appropriate maternal care; and (4) internet-mediated care for maternal depression. Conclusion In the quest to address maternal mental health disparities among mothers of African and Caribbean origin in HICs, the authors recommend culturally adapted psychological interventions to be tested in randomised control trials.
... Pilot study with 17 women at risk of antepartum depression (Jesse et al., 2010) (Kanter et al., 2015), RCT Literature review Some experiences during treatment development suggested necessary alterations at the level of technique, such as a simplified treatment rationale, and less reliance on written homework assignments. Pilot case reports and other studies informed the evaluation of the current Case report , Case study , Open trial (Kanter et al., 2010) manual. ...
Background: There is current debate about the effectiveness and generalizability of evidence-based psychological therapies in treatment of depression for diverse ethno-cultural groups. This has led to increasing interest in culturally adapted psychotherapies (CAPs). Methods: Studies on CAPs for face-to-face treatment of depressed adults were identified using nine electronic database searches. Data on the process of adaptation was analysed using thematic analysis and treatment efficacy was assessed through meta-analysis of Randomized Controlled Trials. Results: Fifteen studies were included in the review, of which eight were included in a meta-analysis. Cognitive Behavioural Therapy and Behavioural Activation were commonly selected approaches for CAPs, mainly based on their strong evidence base for effectiveness. Twelve studies reported the adaptation process that follows all or some phases recommended by the Medical Research Council Framework for developing complex interventions. A meta-analysis of 16 RCTs, which included eight studies from the current review and eight studies from an earlier review (Chowdhary et al. (2014), demonstrated a statistically significant benefit in favour of CAPs, reducing symptom burden [standardized mean difference -0.63, 95% confidence interval -0.87 to -0.39]. Subgroup analysis showed a larger effect when the intervention was for the majority ethnic group in a population, rather than a minority group. Limitations: Some studies did not report all relevant information, and in the subgroup analysis only three studies were of minority groups. Conclusions: CAPs were confirmed to be more efficacious than control treatments. This supports the continued development and evaluation of culturally adapted psychotherapies for depression.
Background: Women are predisposed to maternal depression due to childbirth difficulties and parenting responsibilities, leading to long-term negative consequences on their children. The uptake of mental healthcare by British mothers of African/Caribbean origin is low due to the lack of access to culturally appropriate care. Methods: A mixed-methods randomised controlled feasibility trial was adopted to test the appropriateness and acceptability of Learning Through Play plus Culturally adapted Cognitive Behaviour Therapy (LTP+CaCBT) for treating maternal depression compared with Psychoeducation (PE). Mothers (N=26) aged 20-55 were screened for depression using the Patient Health Questionnaire (PHQ-9). Those who scored >5 on PHQ-9 were further interviewed using the Revised Clinical Interview Schedule to confirm the diagnosis and randomised into LTP+CaCBT (n=13) or Psychoeducation (n=13) groups. Assessments were carried out at baseline, end of the intervention at 3-months and 6-months post-randomisation. N=2 focus groups (LTP+CaCBT, n=12; PE, n=7) and N=8 individual interviews were conducted (LTP+CaCBT, n=4; PE, n=4). Results: The LTP+CaCBT showed higher acceptability, feasibility and satisfaction levels than the PE group. Participants experienced the intervention as beneficial to their parenting skills with reduced depression and anxiety in the LTP+CaCBT compared to the PE group. Conclusions: This is the first feasibility trial of an integrated online parenting intervention for British African and Caribbean mothers. The results indicated that culturally adapted LTP+CaCBT is acceptable and feasible. There is a need to study the clinical and cost-effectiveness of LTP+CaCBT in an appropriately powered randomised control trial and include the child's outcomes.
Intergenerational trauma (IGT) explains why populations subjected to long-term, mass trauma show a higher prevalence of disease even several generations after the original events. Residential schools and other legacies of colonization continue to impact Aboriginal populations, who have higher rates of mental health concerns. Poor maternal mental health during pregnancy can have serious health consequences for the mother, the baby, and the whole family; these include impacting the cognitive, emotional and behavioural development of children and youth. This paper has the following objectives: 1) To define intergenerational trauma and contextualize it in understanding the mental health of pregnant and parenting Aboriginal women; 2) To summarize individual-level and population-level approaches to promoting mental health, and examine their congruence with the needs of Aboriginal populations; 3) To discuss the importance of targeting IGT in both individual-level and population-level interventions for pregnant Aboriginal women . Various scholars have suggested that healing from IGT is best achieved through a combination of mainstream psychotherapies and culturally-entrenched healing practices, conducted in culturally safe settings. Pregnancy has been argued to be a particularly meaningful intervention point to break the cycle of IGT transmission. Given the importance of pregnant women’s mental health to both maternal and child health outcomes, including mental health trajectories for children and youth, it is clear that interventions, programs and services for pregnant Aboriginal women need to be designed to explicitly facilitate healing from IGT. In this regard, further empirical research on IGT and on healing are warranted, to permit an evidence-based approach.
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Background: Evaluating child growth is, in practice, performed by measuring the development of a child’s weight, height, and body composition in comparison to averages observed among a reference population. Objective: To describe the nutritional status of children of low income families who live in urban region in northeastern Brazil. Methods: This study is a population case series with a transversal and observational design. The study population consisted of 257 children, aged 5 to10 years, who were enrolled in a public school to children of low income families. We used the cutoff point for short stature of -2 Z scores for age, and underweight, overweight, and obese were classified as the 5th, 85th, and 95th percentiles, respectively, of the body mass index (BMI) for age, with both classifications in accordance with the Center for Disease Control and Prevention (CDC 2000). Comparisons by gender were performed for the measures of the central tendency and the frequency of diagnoses, in addition to the tendency of the evolution of BMI by age. Results: The prevalence of short stature was 3.5% (95% CI: 1.9 – 6.5). In the evaluation of BMI for age, the prevalences found for underweight, overweight, and obese were 5.8% (95% CI: 3.6 –9.4), 4.7% (95% CI: 2.7 – 8.0), and 2.3% (95% CI: 1.1 – 5.0), respectively. We found a significant trend in the reduction of BMI with the increase in age. Conclusions: According to CDC references, the prevalences of underweight and short stature were higher than expected and for the overweight and obesity were lower than expected, indicating that the nutritional transition had still not reached, as commonly is described, these low income children from the urban outskirts of the Northeast region. Key words: Nutrition assessment, anthropometry, nutritional transition, school health.
Depression during pregnancy is a significant public health problem that is associated with adverse consequences for women and children. Despite the availability of treatment options, depression during pregnancy is often undertreated. Most pregnant women prefer nonpharmacological interventions over antidepressant medications. We review the evidence base for psychotherapeutic treatment approaches to depression during pregnancy. Treatments reviewed include interpersonal therapy, cognitive-behavioral therapy, behavioral activation, and mindfulness-based cognitive therapy. We review both traditional face-to-face delivery and digital interventions. We conclude with recommendations for treatment preferences, collaborative decision-making, and strategies to improve uptake of such services among prenatal women.
Intergenerational trauma explains why populations subjected to long-term and mass trauma show a higher prevalence of disease, even several generations after the original events. Residential schools and other legacies of colonization continue to impact Aboriginal populations, who have higher rates of mental health concerns. Poor maternal mental health during pregnancy can have serious health consequences for the mother, the baby, and the whole family; these include impacting the cognitive, emotional, and behavioural development of children and youth. This paper has the following objectives: to define intergenerational trauma and contextualize it in understanding the mental health of pregnant and parenting Aboriginal women; to summarize individual-level and population-level approaches to promoting mental health and examine their congruence with the needs of Aboriginal populations; and to discuss the importance of targeting intergenerational trauma in both individual-level and population-level interventions for pregnant Aboriginal women. Various scholars have suggested that healing from intergenerational trauma is best achieved through a combination of mainstream psychotherapies and culturally-entrenched healing practices, conducted in culturally safe settings. Pregnancy has been argued to be a particularly meaningful intervention point to break the cycle of intergenerational trauma transmission. Given the importance of pregnant women’s mental health to both maternal and child health outcomes, including mental health trajectories for children and youth, it is clear that interventions, programs, and services for pregnant Aboriginal women need to be designed to explicitly facilitate healing from intergenerational trauma. In this regard, further empirical research on intergenerational trauma and on healing are warranted, to permit an evidence-based approach.
Background: Antenatal psychological distress is a pivotal issue critically associated with postpartum health disorders in mothers and the progeny, of which pluses Cesarean section-induced anxiolytic and stressful responses may produce potential remarkable sequelae to maternal and infant wellbeings. Preoperative psychological preparation is preferably suggested for alleviating psychological troubles to premedications, while its accurate effect in this context is not well defined. The aim of this study was to test the hypothesis that preoperative psychological visiting by trained expert theater nurses using specially designed psycho-leaflets could reduce prior Cesarean stress and anxiolytic levels, and improve maternal and infant outcomes. Methods: After approval by the institutional review board and patient's consent, 146 parturients with American Society of Anesthesiologists (ASA) physical status class I or II were randomly allocated to a "psychological visiting" or "non-psychological visiting" group. The interventional information given by trained expert theater nurses mainly focused on dealing with the complications, inadequate anesthesia and postoperative analgesia, post-surgical rehabilitation, breathing and relaxation training, mental control, and postpartum care. The endpoints of the study included the scorings rated using patient self-rating anxiety scale (SAS) and depression scale (SDS), salivary cortisol, and maternal and infant outcomes. The association between maternal demographic variables and anxiety levels was assessed through multivariate logistic regression. Results: The median visiting time of the psychological group was 53 min, but 21 min in the non-psychological group (p = 0.008), while preoperative psychoprophylactic visiting produced considerable effect on anxiolytic level alleviation and cortisol reduction, but not depressive level, in women undergoing Cesarean section than those without psychological intervention. Women received psychological intervention had an earlier onset of lactation, superior postoperative analgesia, less adverse events and shorter urinary indwelling catheterization than those of the comparison. No significant difference was observed in infant outcomes between both the groups. Maternal demographic data were strongly associated with the anxiolytic level. Conclusions: These results indicate preoperative psychoprophylactic preparation for Cesarean patients alleviates maternal anxiolytic and stressful levels, improves maternal outcomes, and increases overall satisfaction with Cesarean experience.
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Objective: To minimize barriers to care, ameliorate antenatal depression, and prevent postpartum depression, we conducted a pilot study to assess the feasibility of providing brief interpersonal psychotherapy (IPT-B) to depressed, pregnant patients on low incomes in an obstetrics and gynecological (OB/GYN) clinic. Method: Twelve pregnant, depressed women were recruited as a convenience sample from the clinic and were offered a pretreatment engagement interview and eight sessions of IPT-B, followed by monthly maintenance IPT sessions up to 6-months postpartum. Results: Nine of these 12 patients (75%) completed eight sessions of IPT-B. Paired t tests showed that completers of IPT-B displayed significant improvement at posttreatment and 6-months postpartum on three measures of depression, a measure of anxiety, and some aspects of social functioning. Conclusions: These preliminary results suggest that providing depression screening and treatment to this sample in an OB/GYN clinic was feasible and accompanied by high rates of clinical and functional improvement.
Studied 100 women who were between 28 and 34 wks gestation and were attending a maternity hospital antenatal clinic. The validity of the Edinburgh Postnatal Depression Scale (EPDS) developed by J. L. Cox et al (see record 1988-25195-001) was examined. Ss were also interviewed using the Standardized Psychiatric Interview (D. P. Goldberg et al, 1970). EPDS scores were compared with the Research Diagnostic Criteria (RDC) diagnosis of major and minor depression and with total weighted scores derived from the interview. The EPDS identified all Ss with RDC major depression but was less effective in detecting those with RDC minor depression. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study examined the relationships among gender, perceived financial barriers to health care, and selected health status indicators in a randomly selected rural Appalachian sample. The data were gathered through the Johnson County Health Survey. The survey was conducted through personal interviews with 207 females and 178 males representing 197 households. The Duke Health Profile was used to measure the perceived health of the respondents. Analysis of variance, t tests, and descriptive statistics were used to analyze the data. Analysis of the data revealed that women perceive financial barriers to health care significantly more than men (P<0.01), even when living in the same household; women had significantly poorer health than men (P<0.01); and both women and men with perceived financial barriers experienced poorer health (P<0.01) than those who did not perceive such barriers. Conclusions from the study suggest that in this rural sample women were the most compromised by both gender and health status, and that they perceived that their health care needs were not being adequately met.
A prenatal intervention designed to prevent the onset of major depressive episodes (MDEs) during pregnancy and postpartum was pilot tested at a public sector women’s clinic. The Mamás y Bebés/Mothers and Babies Course is an intervention developed in Spanish and English that uses a cognitive-behavioral mood management framework, and incorporates social learning concepts, attachment theory, and socio-cultural issues. The four goals of this project were to develop the intervention, assess its acceptability, test the feasibility of conducting a randomized trial with public sector patients, and obtain estimates of its effect size. Forty-one pregnant women at high risk for developing MDEs were randomized to the Mothers and Babies Course (n = 21) or a comparison condition (n = 20). Assessments occurred during pregnancy and at 1, 3, 6, and 12 months postpartum. Differences in terms of depression symptom levels or incidence of MDEs between the two groups did not reach statistical significance in this pilot trial. However, the MDE incidence rates of 14% for the intervention condition versus 25% for the comparison condition represent a small effect size (h = 0.28) that will be further examined in a larger scale study. The intervention was well received by the participants and implementation of a randomized trial appeared quite feasible as indicated by our follow-up rate of 91% at 12 months. Implications for the continuing development of preventive interventions for perinatal depression are discussed.