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A Randomized Controlled Trial of Culturally Relevant, Brief Interpersonal Psychotherapy for Perinatal Depression Nancy K. Grote, Ph.D. Holly A. Swartz, M.D. Sharon L. Geibel, L.C.S.W. Allan Zuckoff, Ph.D. Patricia R. Houck, M.S.H. Ellen Frank, Ph.D. Objectives: Depression during pregnancy is one of the strongest predictors of postpartum depression, which, in turn, has deleterious, lasting effects on infant and child well-being and on the mother’s and father’s mental health. The primary question
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  PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ March 2009 Vol.60 No.3 313   F rom a public health perspec-tive, it is critical to considerthe mental health treatmentneeds of women during the perinatalperiod, particularly those who are so-cioeconomically disadvantaged. Ma-ternal postpartum depression, if notbuffered by protective factors in thefamily, has deleterious, lasting effectson infant and child well-being (1,2)and on the mother’s and father’s sub-sequent mental health (3,4). A meta-analysis (5) indicated that depressionduring pregnancy has been repeated-ly demonstrated to be the most po-tent predictor of postpartum depres-sion. In this article, depression refersto major depressive disorder as de-fined in the DSM-IV  (6), unless oth-erwise indicated.Prevalence rates of antenatal majorand minor depression have been esti-mated in community-based studies torange from 7% to 15% of all pregnan-cies (7,8), but higher rates have beenobserved among women of lower so-cioeconomic status (9–12). Some epi-demiological studies also suggest thatindividuals living in poverty, com-pared with those in the general popu-lation, are at increased risk of majordepression (13) and that women whoare poor, compared with women ingeneral, have higher rates of depres-sive symptoms (14). Pregnancy pro- vides an opportunity to involve women in mental health interven-tions (15) and appears to be a time when women with depression prefer  A Randomized Controlled Trial of Culturally Relevant, Brief InterpersonalPsychotherapy for Perinatal Depression Na   ncy K. Gr    ote, Ph.D.Holly A. Swartz, M.D.Sh    a   r    on L   . G   eibel, L.C.S.W. Alla   n Zuckof    f, Ph.D.Pa   t   r    icia R. Houck, M.S.H.Ellen Fr    a   nk, Ph.D.   Dr. Grote is affiliated with the School of Social Work, University of Washington, CampusBox 354900, 4101 15th Ave. East, Seattle, WA 98105 (e-mail: ngrote@u.washington.edu).Dr. Swartz, Dr. Zuckoff, Ms. Houck, and Dr. Frank are with the Department of Psychia- try and Ms. Geibel is with the Office of Child Development, all at the University of Pitts- burgh. Portions of this article were presented at the Second International Conference onInterpersonal Psychotherapy, November 12–14, 2006, Toronto, Canada, at the 19th Na- tional Institute of Mental Health Research Conference on Mental Health Services, July 23–24, 2007, Washington, D.C., and at the Society for Social Work and Research 12th Annual Conference, “Research That Matters,” January 17–20, 2008, Washington, D.C. Objectives: Depression during pregnancy is one of the strongest predic-tors of postpartum depression, which, in turn, has deleterious, lasting ef-fects on infant and child well-being and on the mother’s and father’s men-tal health. The primary question guiding this randomized controlled trial was, Does culturally relevant, enhanced brief interpersonal psychothera-py (IPT-B) confer greater advantages to low-income, pregnant womenthan those that accrue from enhanced usual care in treating depression inthis population? Enhanced IPT-B is a multicomponent model of care de-signed to treat antenatal depression and consists of an engagement ses-sion, followed by eight acute IPT-B sessions before the birth and mainte-nance IPT up to six months postpartum. IPT-B was specifically enhancedto make it culturally relevant to socioeconomically disadvantaged women.  Methods: Fifty-three non–treatment-seeking, pregnant African-Americanand white patients receiving prenatal services in a large, urban obstetricsand gynecology clinic and meeting criteria for depression on the Edin-burgh Postnatal Depression Scale (score >12 on a scale of 0 to 30) wererandomly assigned to receive either enhanced IPT-B (N=25) or enhancedusual care (N=28), both of which were delivered in the clinic. Participants were assessed before and after treatment on depression diagnoses, de-pressive symptoms, and social functioning.  Results: Intent-to-treat analy-ses showed that participants in enhanced IPT-B, compared with those inenhanced usual care, displayed significant reductions in depression diag-noses and depressive symptoms before childbirth (three months postbase-line) and at six months postpartum and showed significant improvementsin social functioning at six months postpartum. Conclusions: Findings sug-gest that enhanced IPT-B ameliorates depression during pregnancy andprevents depressive relapse and improves social functioning up to sixmonths postpartum. (  Psychiatric Services 60:313–321, 2009)  psychotherapy to pharmacotherapy (16), because of the potential adverseeffects of medications on the devel-oping fetus and the nursing infant(17). At the same time, however,childbearing and childrearing women with depression, especially those whoare socioeconomically disadvantaged,have proven difficult to engage andretain in adequate mental healthtreatment (11,18,19).Studies have identified a number of practical, psychological, and culturalbarriers to mental health service useby low-income populations, includingcost, inconvenient clinic locations,transportation, limited hours, child-care, stigma, discrimination, previousnegative treatment experiences, bur-den of depression, and the provider’scultural insensitivity (20,21). Women who are poor also more frequently ex-perience threatening and uncontrol-lable life events, exposure to multipleforms of interpersonal and communi-ty violence (that is, emotional, physi-cal, and sexual violence and witness-ing violence), and chronic stressors(12,22). Thus, to be effective fortreating depression among low-in-come, pregnant women, a psy-chotherapeutic intervention needs totake into account the stressful contextof their lives.The primary research questionguiding the study presented here was, Does culturally relevant, en-hanced brief interpersonal psy-chotherapy (IPT-B) for depressionconfer greater advantages to low-in-come, pregnant women than thosethat accrue from enhanced usualcare? Enhanced IPT-B is a multi-component model of care (23) con-sisting of an engagement session, fol-lowed by eight acute IPT-B sessionsbefore the birth and maintenanceIPT up to six months postpartum(24), and it is augmented with modi-fications to make it culturally rele- vant to women who are socioeco-nomically disadvantaged (23). IPT-B was derived from IPT (25), whichhas demonstrated efficacy in treatingacute depression (26–28), in pre- venting depressive relapse throughmaintenance IPT (29), and in treat-ing antenatal and postpartum de-pression (30,31). Enhanced IPT-Bretains the essential theory, targets,and techniques of IPT and has re-ceived empirical support in a num-ber of studies (32–35).In a previous report (36), we pre-sented data showing that non–treat-ment-seeking, pregnant, low-incomeAfrican-American and white partici-pants with depression who receivedenhanced IPT-B in an obstetrics andgynecology clinic had higher rates of engagement (defined as more partic-ipants attending an initial treatmentsession) and higher rates of retention(defined as more treatment sessionsattended) than did those who re-ceived enhanced usual care. Thosein the enhanced usual care group re-ceived depression education materi-als, their social worker received noti-fication (with the patient’s permis-sion) of their elevated depressivesymptoms, and they received a refer-ral to the behavioral health center inthe same obstetrics and gynecology clinic. In the study presented here,using the same sample, we hypothe-sized that treatment with enhancedIPT-B, followed by maintenanceIPT, would result in significant im-provements in psychopathology andfunctioning during pregnancy and atsix months postpartum, compared with enhanced usual care. Methods  Participants and setting  All research procedures were ap-proved by the institutional reviewboard of the University of Pittsburgh.Potential participants were recruitedfrom the public care outpatient ob-stetrics and gynecology clinic of alarge women’s hospital in Pittsburgh,Pennsylvania, where most of the low-income patients were on Medicaid.Pregnant women were referred to thestudy by clinic health care profession-als, the research registry, and clinicflyers. Potential participants weredeemed eligible for inclusion in theprotocol based on the following crite-ria: 18 years or older, ten to 32 weeksgestation, cutoff score >12 on the Ed-inburgh Postnatal Depression Scale(EPDS) (37) (possible scores on theEPDS range from 0 to 30, with high-er scores indicating greater depres-sion severity), English speaking, ac-cess to a telephone, and living in thePittsburgh region. Participants wereexcluded from the study and referredfor appropriate treatment if they metany of the following criteria: sub-stance abuse or dependence withinthe preceding six months; actively suicidal; bipolar disorder, a psychoticdisorder, or an organic mental disor-der; an unstable medical conditionthat could produce symptoms con-founding accurate assessment of mood symptoms (for example, un-treated thyroid disease); severe inti-mate partner violence; and currentreceipt of another form of depressiontreatment (that is, psychotherapy orpharmacotherapy). After receiving acomplete description of the study,participants gave written informedconsent.  Randomization Using a permuted block design strat-ified by race, we randomly assignedparticipants to receive either en-hanced IPT-B or enhanced usualcare after an initial screening proce-dure that determined whether par-ticipants met basic inclusion criteriabut before full determination of eligi-bility. This permitted investigators toadminister to those assigned to re-ceive enhanced IPT-B the pretreat-ment engagement session immedi-ately after initial screening, a proce-dure considered essential to address-ing barriers to care in a difficult-to-engage, non–treatment-seeking pop-ulation. A formal diagnostic assess-ment (see below) followed random-ization and the engagement session torule out exclusion criteria.A total of 113 women consentedto screening for inclusion in thestudy from March 2004 through De-cember 2006. Of the 113 women, 42did not meet the initial screeningcriterion (score >12 on the EPDS).Five met this criterion but declinedto participate in a research study. Of the 66 participants randomly as-signed to treatment, three met theinitial screening criterion but didnot meet criteria on the second di-agnostic screening, because of se- vere intimate partner violence(N=1), bipolar disorder (N=1), andcurrent marijuana abuse (N=1). Tenparticipants met the first screeningcriterion but dropped out before thesecond screening; a lack of time was PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ March 2009 Vol.60 No.3 314  given as the most common reason.Thus a total of 53 participants en-tered the study (25 in enhancedIPT-B and 28 in enhanced usualcare).  Assessments Participants were assessed duringpregnancy at baseline, three monthspostbaseline, and six months postpar-tum via valid and reliable assessmenttools. The ten-item EPDS was usedto determine study eligibility (with acutoff score of >12) and to measuredepression severity over time. A cut-off score of 12 or 13 on the EPDS hasshown a sensitivity of 86% and aspecificity of 78% (37). Depressionseverity was also measured with the21-item Beck Depression Inventory (BDI) (38), which has shown a sensi-tivity of 100% and a specificity of 84%in a randomly selected community sample of adults, using a cutoff scoreof 10 (39).Anxiety symptoms were assessed with the 21-item Beck Anxiety Inven-tory (BAI) (40), which has been foundto have a sensitivity of .76 and a speci-ficity of .77 for any anxiety diagnosis when a cutoff score of 5.5 is used(41). Social functioning was meas-ured with the Social and Leisure Do-main of the Social Adjustment Scale(SAS) (42,43), using a cutoff of >2.2to indicate normal functioning in thisdomain. The SAS has successfully measured social functioning in com-munity samples and among persons with schizophrenia, those who havealcoholism, and those who are de-pressed (44). Lifetime and currentmajor depressive disorder was as-signed with the Structured ClinicalInterview for DSM-IV, Clinician Ver-sion (SCID) (45), and other lifetimeand current psychiatric disorders were assigned by using the Diagnos-tic Interview Schedule (DIS), a fully structured interview designed to beadministered by lay interviewers (46).At the six-month postpartum as-sessment, participants were also eval-uated on how well they thought they  were taking care of the new baby, asassessed with the nine-item new baby subscale of the Postpartum Adjust-ment Questionnaire (PPAQ) (47). Inaddition, IPT-B participants complet-ed the EPDS and a four-item treat-ment satisfaction survey (availablefrom the authors) at the beginningand end, respectively, of each treat-ment session. Assessments were ad-ministered by a master’s-level social worker and a doctoral-level psycholo-gist trained and certified in the ad-ministration of the DIS and SCID(according to the standards of theBiometrics Division of the New YorkState Psychiatric Institute). Culturally relevant,enhanced brief interpersonal psychotherapy Participants assigned to culturally rel-evant, enhanced IPT-B were in-formed of their diagnoses, given writ-ten educational materials about de-pression, and referred for depressiontreatment provided in an office in theobstetrics and gynecology clinic where they were receiving prenatalservices. Enhanced IPT-B is a multi-component model of care (23) con-sisting of an engagement session,acute IPT-B, and maintenance IPT(24). It is also augmented with cultur-ally relevant modifications. One doc-toral-level clinician and one master’s-level clinician, both of whom had su-pervised training and experience inenhanced IPT-B, served as therapists,followed detailed treatment manuals,and received weekly supervision by an expert (NG or HS). Engagementand IPT-B sessions were audiotaped,and 77% were reviewed for fidelity tothe model.Briefly, the engagement session,described elsewhere (36,48), is basedon principles of motivational inter- viewing and ethnographic interview-ing and is designed to promote en-gagement by building trust and ad-dressing the practical, psychological,and cultural barriers to care experi-enced by individuals who are socio-economically disadvantaged. Morespecifically, during engagement, theinterviewer elicits each participant’sunique barriers to care and engagesin collaborative problem solving toameliorate each barrier. For exam-ple, if a participant doubts the rele- vance of treatment to her prob-lems—specifically whether en-hanced IPT-B could reduce her de-pression triggered by losing her job—the interviewer would informher that this treatment can assist herin finding a new job or job training, inaddition to helping her manage theinterpersonal difficulties resultingfrom the job loss. In addition, the in-terviewer approaches the participantin a culturally sensitive manner con-sistent with the principles of ethno-graphic interviewing: the intervieweradopts a one-down position as alearner; tries to understand the cul-tural perspectives and values of the woman without bias; inquires aboutthe woman’s view of depression,health-related beliefs, and copingpractices (for example, the impor-tance of spirituality or familismo inher life); and asks what the woman would like in a therapist, includingthe importance of race-ethnicity.IPT-B, similar to IPT, is designedto treat depression by helping pa-tients resolve one of four interper-sonal problem areas (that is, roletransition, role dispute, grief, and in-terpersonal deficits) related to theonset or maintenance of a depressiveepisode, but it differs from IPT in anumber of ways (23,Swartz HA,Grote NK, Frank E, et al., unpub-lished treatment manual, 2003). Forexample, to reduce treatment burdenand activate change in the partici-pant, the format of IPT-B treatmentis restructured into eight rather than16 sessions, a focus on the long-termproblem area of interpersonaldeficits is avoided, and between-ses-sion behavioral activation strategiesthat have an interpersonal focus areencouraged (23).Given the considerable body of ev-idence that major depression is achronic condition in which recur-rence is expected (49), we providedbiweekly or monthly maintenanceIPT sessions up to six months post-partum to prevent depressive relapseby helping participants deal effective-ly with the social and interpersonalstressors associated with remission(24). Because the goal of mainte-nance IPT is to maintain recovery, thepatient is encouraged to be watchfulfor the appearance of early somatic,affective, or cognitive symptoms re-lated to prior depressive episodes andto practice skills learned in IPT-B toprevent relapse. Maintenance IPTalso differs from IPT-B in that the pa-tient can focus on more than one in- PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ March 2009 Vol.60 No.3 315  terpersonal problem area while she isin remission.Finally, a number of culturally rel-evant additions (23) of a pragmaticnature were integrated into IPT-B,including free bus passes, childcare,and the facilitation of access to need-ed social services (that is, food, jobtraining, housing, and free baby sup-plies), similar to the case manage-ment component added to cognitive-behavioral therapy in a previous de-pression treatment study with low-income women (50). Engagementand IPT-B sessions were delivered inan office in the large obstetrics andgynecology clinic to make treatmentmore accessible and less stigmatiz-ing. At times when participantscould not attend treatment, the ses-sion was conducted on the phone tomaintain continuity, a practice foundto be effective in the delivery of psy-chotherapy and pharmacotherapy for depression (51).Further, as described previously (52), we enhanced IPT-B in waysthat reflected seven out of the eightcomponents delineated in the cul-turally centered framework of Bernal and colleagues (53): persons,metaphors, concepts, content, goals,methods, and contexts. For example, we addressed the component of per-sons by employing therapists who were trained in cultural competenceand had considerable experience working with persons of racial-ethnicminority groups who were living inpoverty. We also utilized the compo-nent of metaphors by displaying cul-turally relevant pictures of racially and ethnically diverse infants in thetherapist’s office and by using storiesfrom the participants’ cultural back-ground to reinforce treatment goals.To address the component of con-cepts, therapists provided educationabout depression in a way that wascongruent with the participant’s cul-ture and used the word “stressed” in-stead of the word “depressed,” if aparticipant so desired, to minimizeher perceived stigma of depression.The component of content was ad-dressed by exploring what copingmechanisms and cultural resources,such as spirituality or familismo, hadhelped participants through adversi-ty in the past and by building onthese resources during treatment.Therapists helped clients developtreatment goals that were personally and culturally relevant to them.Methods were addressed by intensiveoutreach and shortening treatment toreduce participant burden. Contexts were addressed by the pragmaticad-ditions described above, such as fa-cilitation of access to needed socialservices.  Enhanced usual care Participants assigned to enhancedusual care were informed of their di-agnoses, given written educationalmaterials about depression, and werestrongly encouraged to seek treat-ment at the behavioral health centerlocated in the obstetrics and gynecol-ogy clinic where they were receivingprenatal services (or at the neighbor-hood mental health center, if they preferred). Enhanced usual care par-ticipants were provided the same ad- vantages as the IPT-B group to helpthem overcome practical barriers—easy access to depression treatmentin the obstetrics and gynecology clin-ic, familiarity with the setting, de-creased stigma, childcare, and freebus passes. In addition, participantsin the enhanced usual care group re-ceived more monitoring of their de-pression severity and diagnostic statusthan they typically received in theclinic, inasmuch as research staff con-tacted them every three weeks to as-sess their mood and to encouragethem to enter treatment, as indicated. With the participant’s permission, anote was placed in her medical recordindicating the presence of major de-pression and her social worker wascontacted to reinforce the treatmentreferral. True usual care for de-pressed pregnant or postpartum women would risk human subjectsconcerns for these women and theirfamilies.  Data analysis Participants in enhanced IPT-B(N=25) and enhanced usual care(N=28) were compared at baselineon demographic and clinical charac-teristics by using chi square tests andanalysis of variance, as appropriate.Overall study attrition rate was low(N=7, 13%) for this diverse sample(18) and equivalent across treatmentgroups. The amount of missing datafor our primary outcome measure,the Edinburgh Postnatal DepressionScale, was 8% (N=4 out of 53) beforechildbirth (three months postbase-line [time 2]) and 13% (N=7 out of 53) at six months postpartum (time3) and was equivalent across groupsat each time point. By examiningreasons for dropout, we concludedthat the data were likely missing atrandom. Thus mixed-effects modelsusing maximum likelihood proce-dures were employed to conduct in-tent-to-treat analyses to assesschange in clinical and functioning variables from baseline to time 2 andtime 3 (54). Typically, a 50% reduc-tion in symptom score (an indicationof treatment response) has been anaccepted measurement of clinicalimprovement in randomized trialsevaluating treatment for depression(55–57). To detect 50% improve-ment in depressive symptoms on theEPDS, we used mixed-effects mod-els to impute the missing scores andthen conducted chi square analyses.To detect improvement in depres-sion diagnostic status at times 2 and3, a likely indicator of remission, weconducted chi square analyses. Con- ventional alpha levels (p<.05) wereused to determine statistically signif-icant differences. Effect sizes, ap-propriate to each type of analysis, were also calculated (58). In the Re-sults section, we refer to enhancedIPT-B and enhanced usual care asIPT-B and usual care, respectively. Results  Baseline demographic and clinical characteristics Demographic and clinical informa-tion for each group is summarized inTable 1. Analyses show that partici-pants in the IPT-B and usual caregroups did not differ significantly onany of these baseline demographicor clinical characteristics. Similar tothe patient population at the obstet-rics and gynecology clinic, a majori-ty of our sample was African Ameri-can (N=33, 62%); not married (N=43, 81%); had a high school degree,GED, vocational training, or somecollege (N=41, 77%); were current-ly unemployed (N=34, 64%); and PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ March 2009 Vol.60 No.3 316
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