Abstract
Home visiting is a child abuse prevention strategy that seeks to optimize child development by providing mothers with support, training, and parenting information. Research has consistently found high rates of depression in mothers participating in home visiting programs and low levels of obtaining mental health treatment in the community. Successful treatment of depressed mothers in home visiting programs holds the potential to improve maternal and child outcomes. In-Home Cognitive-Behavioral Therapy (IH-CBT) is an adapted treatment for depressed mothers, which is provided alongside home visiting and seeks to optimize engagement and impact through delivery in the home setting; a focus on issues important to young, low-income mothers; and a strong collaborative relationship between therapists and home visitors. This study examined predictors of depression status at posttreatment in 60 mothers who received IH-CBT and concurrent home visiting. Variables considered included demographics, illness history, severity, and numbers of treatment sessions and home visits. Results indicated that young maternal age, fewer episodes of major depressive disorder, lower depression severity at pretreatment, lower levels of symptoms of personality disorders, and more treatment sessions and home visits predicted asymptomatic status at posttreatment.
Home visiting is a child abuse prevention strategy that targets new mothers and their children who are at demographic risk for adverse parenting outcomes. Such programs typically seek to enroll mothers prenatally or during the first months after the child’s birth, provide a trained visitor who provides services in the home setting, deliver a developmentally aligned curriculum that focuses on positive child development and meeting maternal and child needs, and link families to other resources in the community (Boller & Strong, 2010). The overarching objective of home visiting is to optimize child development and maternal life course by providing intensive services and support during the critical early years of the child’s life.
By seeing mothers in the home, a frequent barrier to services is overcome. As a result, home visiting programs are an ideal setting in which to identify and intervene with depressed mothers who might otherwise fail to receive adequate care (National Research Council and Institute of Medicine, 2009). Depression is commonly reported in mothers enrolled in home visiting programs. Indeed, most mothers in home visiting programs display characteristics associated with elevated risk for depression, including being unmarried, socially isolated, young, living in poverty, and victims of violence (Segre, O’Hara, Arndt, & Stuart, 2007). For example, Ammerman et al. (2009) found that 45.3% of mothers participating in a regional home visiting program had elevated levels of depressive symptoms using the Beck Depression Inventory–II (BDI-II) at two time points in the 1st year of service. This study also reported that 74.1% of mothers experienced childhood trauma and violence prior to enrollment. Depression in mothers in home visiting is associated with greater impairments in parenting, increased parenting stress, and social isolation relative to nondepressed mothers (Ammerman, Shenk, et al., 2011). Research has consistently demonstrated that (a) depressed mothers in home visiting rarely obtain mental health treatment in the community and (b) home visiting by itself yields little benefit to maternal depressive symptoms over the course of services (Ammerman, Putnam, Bosse, Teeters, & Van Ginkel, 2010). Because maternal depression can mitigate the benefits of home visiting and prolonged exposure to depressed mothers can contribute to poor outcomes in children (Hay, Pawlby, Waters, Perra, & Sharp, 2010), it is important to provide effective treatment to this population.
In response to this need, Ammerman, Bodley, et al. (2007) systematically adapted cognitive-behavioral therapy (CBT) for use with depressed mothers receiving home visitation. Implemented by trained therapists and delivered concurrently with home visiting, In-Home Cognitive-Behavioral Therapy (IH-CBT) combines the principles and strategies of CBT (J. S. Beck, 2011) with a set of procedures and approaches that promotes engagement, makes content relevant to the needs of young mothers, permits implementation in the home setting, and forges a strong collaborative relationship between the therapist and home visitor to smoothly coordinate services and optimize outcomes. Adaptations include identifying suitable areas for conducting therapy in homes that are often small, crowded, and unkempt; addressing the unique issues of socially isolated, low-income mothers who are raising a new baby; and creating close working relationships between home visitors and therapists. IH-CBT is a focused treatment that emphasizes the reduction of maternal depressive symptoms and recovery from major depressive disorder (MDD), thereby allowing home visitors to attend to issues related to parenting, maternal functioning, and child development. IH-CBT is delivered in 15 weekly sessions and a 1-month booster that are in addition to visits provided by home visitors. There is regular contact between the therapist and home visitor over the course of treatment, and home visitors attend the 15th session to review treatment impacts and facilitate home visitor support of mothers following termination (Ammerman, Putnam, Stevens, et al., 2011).
Preliminary evidence suggests that IH-CBT is efficacious in the treatment of depressed mothers in home visiting. Ammerman, Putnam, Stevens, et al. (2011) provided IH-CBT to 64 mothers aged 18 years and older who were participating in a home visiting program, obtained scores of ≥20 on the BDI-II, and met criteria for MDD using the Primary Care Evaluation of Mental Disorders (PRIME-MD; Spitzer et al., 1994). Pre–post comparisons revealed that 46.9% of mothers were partially remitted in terms of MDD diagnosis and 32.8% were fully remitted at the end of treatment. Mothers also reported decreased depressive symptoms, and improvements in social support, relationships, coping, and satisfaction with motherhood. A subsequent comparison of the 64 mothers to 241 mothers who had similarly elevated BDI-II scores at enrollment in home visiting showed a large reduction (M difference = 7.8 points, p < .01) in the treatment group relative to untreated mothers. Group comparisons were not moderated by maternal age, race, education, or home visitation model, suggesting that the adaptations made in IH-CBT were successful in impacting the diverse populations served by home visiting. Yet, it is not known what characteristics or other variables are most predictive of improvement of maternal depression in those receiving IH-CBT.
Identifying predictors of outcome among individuals who receive treatment is a useful way to determine who is most likely to benefit from a specific intervention. Such prognostic information can be used to refine treatments to better address the needs of those who respond less optimally (Driessen & Hollon, 2010), and to determine at the start of treatment to what extent individuals might benefit based on pretreatment characteristics. Several reviews have summarized research examining predictors of outcomes in CBT for adult depression (Driessen & Hollon, 2010; Haby, Donnelly, Corry, & Vos, 2006; Hamilton & Dobson, 2002). These efforts have identified demographic, clinical, and treatment process variables that are associated with favorable or poor outcomes. In terms of demographics, unmarried status and older age have been found to predict poorer response to CBT in depressed adults (e.g., Fournier et al., 2009). There is also a consistent and robust relationship between illness severity and outcomes. Chronic depression, pretreatment depression severity, earlier onset of MDD, and comorbid personality disorders have been found to be predictive of poorer response. Duration of CBT is also important, with better outcomes associated with more sessions. Such information is unavailable for IH-CBT and depressed mothers in home visiting.
Delineating pretreatment variables that predict response to IH-CBT is an important area for research for two reasons. First, depressed mothers in home visiting display many of the characteristics associated with poorer response, including unmarried status and significant morbidity (Ammerman, Putnam, Chard, Stevens, & Van Ginkel, 2011). Second, such information can guide modifications to IH-CBT that will lead to more effective treatment for this high-risk population. The unique features of IH-CBT (provided in home setting, integral collaboration between therapists and home visitors) may yield different predictors than what has been found in studies that rely primarily on adult clients of varied age, include males, report on treatments provided in center-based settings, and without regard to parenting status.
The purpose of this study was to determine predictors of depression outcome in a sample of depressed mothers who received concurrent home visiting and IH-CBT. Mothers were enrolled in treatment between 2 and 10 months postpartum and assessed at pretreatment and posttreatment. At posttreatment, mothers were categorized as asymptomatic or still symptomatic based on obtaining a score of ≤8 on the BDI-II (Keller, 2003). These groups were contrasted on demographic, clinical, and treatment process variables. As the theoretical foundation of IH-CBT relies heavily on the close relationship between therapy and home visiting, number of home visits was examined to determine its potential contribution to predicting outcome. It was hypothesized that, relative to mothers who are symptomatic at posttreatment, asymptomatic mothers would be younger, have less severe clinical indicators of depression at pretreatment, and receive more IH-CBT sessions and home visits.
Method
Participants
Participants consisted of 60 new mothers aged 16 or older who participated in a home visiting program, were diagnosed with MDD, enrolled between 2 and 10 months postpartum, and received IH-CBT as part of a clinical trial (Ammerman, Putnam, Altaye, Stevens, & Van Ginkel, 2012). Mothers were enrolled in Every Child Succeeds, a regional home visiting program serving new mothers in Southwestern Ohio and Northern Kentucky. The geographic area covered by the program included urban and rural areas. Two national models of home visitation were utilized: Nurse–Family Partnership (NFP; Olds, 2010) and Healthy Families America (HFA; Holton & Harding, 2007). Participating mothers had at least one of four sociodemographic risk characteristics needed for eligibility: unmarried, low income, age < 18 years, and inadequate prenatal care. Mothers were enrolled in home visiting prior to 28 weeks gestation in NFP as per model parameters and from 20 weeks gestation through the child reaching 3 months of age for HFA. In the NFP, home visits were provided by nurses, whereas in HFA, home visits were provided by social workers, related professionals, and paraprofessionals. The goals of home visitation are to (a) improve pregnancy outcomes through nutrition education and substance use reduction; (b) support parents in providing children with a safe, nurturing, and stimulating home environment; (c) optimize child health and development; (d) link families to health care and other needed services; and (e) promote economic self-sufficiency (Ammerman, Putnam, et al., 2007).
Table 1 presents the demographic characteristics of the treated group. For the sample as a whole, mothers were young (M = 22.4, SD = 5.0), predominantly Caucasian (61.6%) and African American (33.3%), unmarried (86.7%), and low income (75.0% < US$20,000 annual household income). In terms of home visitation model, 54 mothers were in the HFA model and 6 in the NFP model. Fifty-three mothers were primiparous and 7 (HFA only) had more than one child.
Demographic Characteristics of Sample (n = 60)
Using the Structured Clinical Interview for DSM-IV (SCID) at pretreatment assessment, the breakdown of MDD severity was mild = 20.0%, moderate = 50.0%, and severe = 30.0%. Onset of the presenting episode during postpartum (within 6 weeks after birth) was found in 26.7% of participants. Recurrent depression was reported by 78.3% of mothers (M number of episodes = 2.9 [SD = 1.7], M age of first episode = 14.7 years [SD = 5.7]). Comorbidity was high, with 76.3% of participants meeting criteria for other psychiatric disorders.
Procedures
Mothers were recruited in a two-step process as part of a clinical trial of IH-CBT. First, home visitors administered the Edinburgh Postnatal Depression Scale (Cox, Holden, & Sagovsky, 1987) to mothers at 3 months postpartum. Mothers who screened positive were approached to participate in the trial. Interested mothers then received a pretreatment and eligibility assessment. Inclusion criteria were age ≥16 years and current diagnosis of MDD. Exclusion criteria were bipolar disorder, current substance dependence, psychosis, mental retardation, suicidality or homicidality requiring acute intervention, or current use of psychotropic medications or psychotherapy. Data are presented from the pretreatment and posttreatment assessments. The sample included mothers originally assigned to IH-CBT (n = 47) and those assigned to the control condition who subsequently crossed over to IH-CBT (n = 13) at posttreatment based on continued diagnosis of MDD. Nine mothers were lost to posttreatment follow-up but were included in analyses.
Home Visiting and IH-CBT
All mothers received ongoing services from home visitors as per the HFA and NFP model directives while participating in IH-CBT. Both models call for regular home visits during the intervals covered during the trial, and home visitors are given discretion to increase frequency of visits if needed. Curricula for both models are distinct, but each addresses child health and development, nurturing mother–child relationship, maternal health and self-sufficiency, and linkage to other community services.
IH-CBT was delivered in the home by two licensed, master’s level social workers. Treatment consisted of 15 sessions that were scheduled weekly and lasted 60 min plus a booster session 1 month posttreatment. Adaptations to CBT were made to address setting, population, and context. These adaptations were made based on a review of the literature, consultation with home visitors, and input from mothers in home visitation. First, IH-CBT was delivered in the home. Creative solutions and accommodations were made to ensure treatment delivery in home environments where privacy was sometimes difficult to ensure, the child was present, and unexpected interruptions occurred. However, providing treatment in the home offered advantages in that many of the clinical issues that were addressed in treatment occurred in the home setting, and the therapist was able to observe elements of the home that may have been contributory to the clinical presentation. The second adaptation involved addressing the primary concerns of young, low income, new mothers who were socially isolated (Levy & O’Hara, 2010). Treatment content focused on issues relevant to this population, such as transition to adult roles, stress management, parenting challenges, and family relationships. The third adaptation sought to facilitate close collaboration (Zwarenstein, Goldman, & Reeves, 2009) with home visitors. Collaboration occurred through weekly written communication between therapist and home visitor utilizing a shared web-based documentation system, and/or telephone contact as needed. In addition, the home visitor attended the 15th session with the mother and therapist. Weekly supervision was provided by two doctoral level clinicians.
Measures
SCID Axis I Disorders (SCID-I)
The SCID (January 2007 version; Spitzer, Williams, Gibbon, & First, 1992) is a semistructured psychiatric interview that is widely used in research and clinical practice. It is used to diagnose 14 common psychiatric disorders, including MDD. Interrater reliability is generally high, ranging from 0.57 to 1.00 (Zanarini & Frankenburg, 2001), and validity is well established (Shear et al., 2000). Interviews were audio-recorded and 25% were rated by a second rater yielding a kappa coefficient = .89. The SCID was used to determine MDD diagnosis, comorbidities, and clinical features of MDD, including age of onset and number of episodes.
BDI-II
The BDI-II (A. T. Beck, Steer, & Brown, 1996) is one of the most widely used self-report screens of depressive symptomatology, with strong reliability and validity properties. It consists of 21 items in which mothers indicated presence and severity of depressive symptoms over the past 2 weeks by endorsing one of four statements reflecting degree of severity, yielding a total score. The BDI-II was administered at pretreatment and posttreatment. Participants were categorized as asymptomatic (BDI-II ≤ 8) or symptomatic (BDI-II ≥ 9) at posttreatment (Keller, 2003).
Childhood Trauma Questionnaire (CTQ)
The CTQ (Bernstein et al., 2003) is a 28-item version of the larger CTQ. Items describe maltreatment experiences in childhood and are endorsed on a 5-item Likert-type scale reflecting how true they are. Scores reflect physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect. The CTQ has excellent internal reliability (α = .61-.94 in clinical and community samples) and correlates highly with determinations of maltreatment (Scher, Stein, Asmundson, McCreary, & Forde, 2001). The CTQ was analyzed using the total raw score.
Iowa Personality Disorder Screen (IPDS)
The IPDS (Langbehn et al., 1999) is a brief, 11-item screen for symptoms of personality disorders. It is administered as an interview, and each item is endorsed as yes/no based on reports consistent with symptoms suggestive of personality disorders (e.g., “feels uncomfortable in situations where he or she is not the center of attention”). A total score is derived reflecting the number of items rated as “yes.” The IPDS has acceptable psychometric characteristics, including adequate sensitivity and specificity (Trull & Amdur, 2001).
Results
Overview of Analyses
Based on the number of mothers available for posttreatment assessment, asymptomatic (n = 33, 64.7%) and symptomatic (n = 18, 35.3%) groups were formed using the BDI-II ≤ 8 as the criterion. Missing data were handled via maximum likelihood estimation with a saturated correlates model (Enders, 2010). Handling missing data via maximum likelihood estimation assumes that these data are missing at random (MAR), meaning the missing data are related to the variables included in the analysis model. There is no formal test for MAR, but increasing the number of variables in the analysis model tends to make the MAR assumption more plausible. A saturated correlates model allows additional variables to be added to the analysis model without biasing parameter estimates of interest. Accordingly, selected demographics were added to the analysis model as additional correlates of missing data. Asymptomatic and symptomatic groups were contrasted using MANOVA and Wald Z values with accompanying Cohen’s d effect size estimates. Next, a hierarchical linear regression was conducted to determine the relative contributions of previously identified determinants of endpoint symptom status to reduction in BDI-II scores from pre- to posttreatment. All analyses were conducted using Mplus version 6.12 (Muthen & Muthen, 2010).
Table 2 presents contrasts for the asymptomatic and symptomatic groups using a maximum likelihood estimation with saturated correlates model for the full sample (n = 60). Maternal demographics, pretreatment and historical clinical characteristics, and intervention parameters (number of IH-CBT sessions and number of home visits) were examined. Race, income, and marital status were added as missing data correlates to improve the accuracy of the estimates. Marital status was not considered given that most of the sample was unmarried. MANOVA revealed six variables that were statistically significant and differentiated asymptomatic and symptomatic groups. In contrast with mothers who still had clinically elevated levels of depression at posttreatment, asymptomatic mothers were younger, had fewer lifetime episodes of MDD, had lower BDI-II scores at pretreatment, had lower levels of symptoms suggesting a personality disorder, and received more IH-CBT sessions and home visits during the treatment interval. Effect sizes were medium to large in size, with particularly noteworthy effect sizes emerging for number of treatment sessions and number of home visits. Taken together, a variety of participant characteristics and service parameters separately contributed to predicting a low level of depressive symptoms at posttreatment.
Means and SDs for Asymptomatic and Symptomatic Groups and Results From Comparisons Using MANOVA
Note: CI = confidence interval; CTQ = Childhood Trauma Questionnaire; MDD = major depressive disorder; BDI-II = Beck Depression Inventory–II; IPDS = Iowa Personality Disorder Screen; IH-CBT = In-Home Cognitive-Behavioral Therapy.
p < .05. **p < .01 based on Wald Z values > ±1.645; 95% CI’s based on 1,000 bootstrap samples.
Regarding number of home visits, follow-up analyses indicated that this effect was particularly evident during the first half of treatment. Although asymptomatic mothers received more home visits than their symptomatic counterparts during the first half (t = 4.32, p < .001) and second half (t = 2.11, p < .05) of treatment, the gap was most evident during the first half (M home visits = 8.20 [SD = 3.44] vs. 4.54 [SD = 2.41]; Cohen’s d effect size estimate = 2.08) than the second half (M home visits = 6.52 [SD = 3.28] vs. 4.58 [SD = 3.16]; Cohen’s d effect size estimate = 1.08). Thus, although increased home visits were observed throughout the treatment interval, mothers who were asymptomatic at posttreatment received almost twice as many home visits in the first half of treatment than those who ended in the symptomatic category. The inverse relationship between number of home visits and posttreatment BDI-II scores is further elucidated in Figure 1 which shows the scatterplot with fitted trend line for number of home visits and endpoint BDI-II scores.
Scatterplot showing association between number of home visits and posttreatment BDI-II scores
A hierarchical linear regression was next conducted to identify predictors of posttreatment BDI-II scores while considering the demographic, clinical, and intervention process variables that emerged from the group contrasts. Pretreatment BDI-II scores and number of home visits received prior to commencement of IH-CBT were also included. Table 3 presents results of the regression (F = 5.87, p < .001, R2 = .446). Two variables emerged as statistically significant (p < .05) predictors in the full model: number of home visits and symptoms of personality disorders as measured by the IPDS. Number of IH-CBT sessions approached (p = .08) but did not reach statistical significance. Despite this, results from the regression indicate that number of IH-CBT sessions and home visits contribute uniquely to positive depression outcomes.
Results of Hierarchical Linear Regression Predicting Posttreatment BDI-II Scores
Note: CI = confidence interval; BDI-II = Beck Depression Inventory–II; IPDS = Iowa Personality Disorder Screen; MDD = major depressive disorder; IH-DBT = In-Home Cognitive-Behavioral Therapy.
p < .05. 95% CIs computed based on 1,000 bootstrap samples.
Discussion
This study identified predictors of treatment outcome in depressed mothers who received IH-CBT and concurrent home visiting. IH-CBT is unique in that it is an adapted treatment that was designed to be engaging, relevant, and effective for new mothers participating in home visiting programs. Results showed that 64.7% of treated mothers obtained a posttreatment BDI-II score of ≤8 indicative of asymptomatic status, a pattern consistent with other effective treatments for perinatal depression (Sockol, Epperson, & Barber, 2011). Delineating predictors of reaching a clinical threshold indicative of positive treatment response is important to refining and improving IH-CBT. In addition, predictors can be used a priori to develop treatment plans for mothers who may be expected to respond more or less robustly to IH-CBT. As hypothesized, a number of variables emerged as predictive of treatment outcome involving demographic, clinical, and intervention process factors.
Consistent with hypotheses, number of IH-CBT sessions was predictive of better depression outcomes. Yet, the most robust predictor was number of home visits. Mothers who received increased home visits during treatment were more likely to be asymptomatic at posttreatment than those with fewer home visits even when controlling for frequency of home visits prior to treatment and other predictor variables (including number of IH-CBT sessions). IH-CBT is distinctive in that it is designed to be implemented alongside home visiting. A close working relationship between therapists and home visitors is posited to be essential to optimal outcomes. Number of home visits is a reasonable proxy of the strength of this collaborative effort. As such, results suggest that the active involvement of home visitors with mothers during the treatment interval, and particularly during the first half of treatment, propels mothers toward lower depression severity at posttreatment. It is possible that the increased frequency of home visits works synergistically with treatment to bring about better outcomes, which would be consistent with the theoretical foundation of IH-CBT. An alternative explanation is that mothers who are on a trajectory toward improvement are more engaged in home visiting and seek additional contact with home visitors. However, home visitors may be drawn to mothers who are emerging from a depressive state. They may capitalize on mothers’ increased energy and interest by increasing home visit frequency. There may also be an unknown variable that is associated with increased home visits and IH-CBT treatment sessions that contributes to better outcomes. Although home visitors strive to follow a schedule of visits as dictated by home visiting models, there is substantial variability in intensity of service due to maternal willingness and availability and perceived need. Findings from this study suggest that, for depressed mothers who receive IH-CBT treatment, consistent and regular contact by home visitors is associated with more robust decreases in depressive symptoms.
Other variables also predicted posttreatment depression. Younger mothers were more likely to be asymptomatic than their older counterparts. In the larger literature on adults treated for MDD with psychotherapy (including CBT) or medications, findings have been mixed (Driessen & Hollon, 2010). Most recently, Fournier et al. (2009) found that younger adults were more responsive to CBT than older adults. Similarly, the Treatment for Adolescents With Depression Study (TADS; Curry et al., 2006) found that younger adolescents had superior outcomes following treatment than older peers. It is not clear why younger age is associated with improved outcomes, and this finding warrants continued research. It is possible that less experience with depression improves responsiveness to IH-CBT treatment. To this end, it is noteworthy that age was not a significant contributor to posttreatment BDI-II scores when considered alongside other predictors, such as number of MDD episodes.
Severity emerged as a predictor of posttreatment depression, at least in the form of number of MDD episodes and symptoms of personality disorders. Depression chronicity, reflected in part by number of episodes, has been consistently found to be associated with less improvement in CBT treatment. Chronicity may reflect a more recalcitrant form of depression. Likewise, there is evidence that repeated episodes increase susceptibility to subsequent depression (Monroe & Harkness, 2011), which may in turn diminish treatment effectiveness. Baseline severity was also associated with a less robust response to treatment. For mothers who have higher pretreatment levels of depression and more episodes, they may require additional treatment. Age of onset, a variable reflecting illness severity that has been found to be related to treatment outcome in other adult populations, was not a significant predictor of posttreatment depressive levels in mothers receiving IH-CBT. In this population of young, low income, new mothers it is not a useful indicator of treatment response. In contrast, increased symptoms of personality disorders predicted less improvement, and this variable was significant even after controlling for other predictors in a regression model. Personality disorders, particularly those reflecting a submissive personality style, are associated with chronicity of depression (Cain et al., 2011). Although CBT treatment specifically focused on adults with personality disorders has been found to be efficacious (Matusiewicz, Hopwood, Banducci, & Lejuez, 2010), the co-occurrence of MDD and personality disorders has been found to be detrimental to outcomes in adults receiving depression-focused CBT (Fournier et al., 2008). As with chronicity, additional IH-CBT sessions or a more direct focus on personality disorder mechanisms may be needed to boost outcomes for mothers in home visiting programs. Finally, in contrast, history of childhood trauma (which was widely represented in the sample) did not predict differential levels of posttreatment depression.
This is the first study to examine predictors of outcomes in IH-CBT, and one of the few efforts that focused on depressed mothers who were young, had low income, and were new parents. The study had a number of strengths. First, an array of theoretically meaningful predictors was examined reflecting demographic, clinical, and intervention process variables. Second, multiple measurement strategies were used, including self-report and clinical interview. Third, maximum likelihood estimation with a saturated correlates model was used to address missing data and take advantage of the full sample. Fourth, two widely disseminated models of home visitation were represented in the sample thereby facilitating generalizability of findings.
There are also several limitations that warrant caution in interpreting findings. First, the sample size was relatively small, limiting statistical power. Second, determination of asymptomatic versus symptomatic status at posttreatment is one of several ways that treatment response can be described. Others include recovery or remission (Keller, 2003), both of which require an extended interval during which depressive symptoms remain below a preestablished level of clinical significance. The predictors found in the current study may not necessarily emerge under different definitions of treatment response. Third, although the IPDS is a psychometrically acceptable screen for symptoms of personality disorders, it is not a substitute for more comprehensive clinical interviews that more definitively diagnose specific personality disorders. Fourth, although number of IH-CBT sessions and home visits were considered, quality of services was not addressed.
Findings from this study have important implications for clinical practice in the treatment depression in new mothers participating in home visiting programs. A high rate of IH-CBT treatment sessions and home visits, administered concurrently, are likely to bring about the most robust reductions in depressive symptoms. As IH-CBT explicitly promotes and facilitates collaboration between therapists and home visitors, it is better able to create this synergistic effect than other treatments. Depression treatment received in the community is less likely to produce the close working relationship between clinicians and home visitors, given structural and logistical barriers. Several pretreatment and historical features of depression (e.g., personality disorder symptoms, number of MDD episodes) may indicate a need for additional treatment, although this is an empirical question that awaits additional research. Results from this study underscore the need to conduct research on new mothers participating in home visiting programs separately given that findings from studies of other adult populations may not be generalizable to this population.
Footnotes
Acknowledgements
Authors’ Note
Frank W. Putnam is now at the Department of Psychiatry, University of North Carolina School of Medicine.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Grant R34MH073867 from the National Institute of Mental Health.