Mood disorders during pregnancy and the postpartum period are potentially devastating conditions that affect a significant number of women and their offspring. Research suggests that 80–85% of expectant mothers will develop a mild mood disturbance (blues) during or after their gestational period and 8–15% will experience a major depressive disorder (MDD; Gotlib et al. 1989
; Kumar et al. 1984
; O'Hara and Swain 1996
; O'Hara et al. 1990
; Reck et al. 2008
). Hallmark symptoms of these disorders include loss of interest in previously pleasurable activities, feelings of guilt, worthlessness, helplessness and hopelessness that are severe and impairing and last for at least 2 weeks. Among adolescents, this rate is even higher, with estimates of antenatal depression ranging between 16 and 44%, almost twice as high as among adult pregnant women and non-pregnant adolescents (Gross et al. 2002
; Figueiredo et al. 2007
; Miller 1998
). Moreover, prospective studies indicate that elevated levels of postnatal depression are preceded by high levels of prenatal depressive symptoms (Heron et al. 2004
). This research suggests an advantage of intervening during pregnancy to reduce morbidity associated with depression.
In light of the prevalence and consequences of prenatal and postpartum depression, there is a critical need for both treatment and preventive interventions. Preventive interventions in particular hold the promise of decreasing the likelihood that expectant mothers will experience MDD during pregnancy and postpartum, minimize the need for costly treatment, and ultimately decrease the long-term impact of depression on both the mother and child. Unfortunately, there are few published studies examining the efficacy of preventive interventions during pregnancy using randomized controlled designs; even fewer have been conducted with adolescents, and none have focused on American Indian (AI) populations.
Although findings have not been uniformly positive (e.g., Logsdon and Gennaro 2005
; Crockett et al. 2008
; Reid et al. 2002
), results from several studies suggest that psychosocial interventions, namely interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) may reduce depressive symptoms during pregnancy as well as postpartum. For instance, in a pilot study, Zlotnick et al. (2001)
evaluated the effectiveness of a four session IPT-oriented intervention with pregnant women (N
= 37) receiving public assistance. The authors found that at three months postpartum none of the women in the intervention group, compared to 33% in the control group (treatment as usual; TAU), met criteria for MDD. Similar findings were reported in a larger study (Zlotnick et al. 2006
). Elliott et al. (2000)
randomly assigned “vulnerable” pregnant adults (N
= 99) to an 11-session group intervention (based on a combination of strategies such as psychoeducation, changing negative attributions, and increasing social support) or TAU. Among first time mothers, depression scores on the Edinburgh Postpartum Depression Scale (EPDS) and rates of depressive disorders were significantly lower in the intervention (19%) compared to TAU (39%) group at a 3 month follow up. While these findings are encouraging, more data are needed to determine the usefulness of preventive interventions for postpartum depression, particularly among vulnerable populations.
The current study was designed to extend this literature and to address the needs of one of the most vulnerable populations in the United States, reservation-based expectant AI adolescents and young adults. Reservation-based pregnant White Mountain Apaches were targeted for this study because they are at high risk for the development of depressive symptoms and disorders (Ginsburg et al. 2008
). AI adolescents in general have the poorest health status among adolescents in the US, as measured by rates of premature mortality and morbidity and high rates of mental illness (e.g., Whitbeck et al. 2006
). AI adolescents also have significant demographic risk factors for depression such as poverty, high substance use and school drop-out rates, and residential instability, that compound normal stressors for pregnant teenagers (Blum et al. 1992
; US DHHS 2004
). These health and demographic disparities are related to both historical and contemporary factors that impact the lives of AI youth and their families. First, a long history of federal policies relating to land subjugation and tribal community relocation has resulted in the loss of tribal territories, degradation of Indian political and economic systems, languages, traditions and cultures; in essence, the destruction of the social fabric of Indian communities, which are now being rebuilt. Second, but not unrelated, day-to-day life for AI families is difficult. AI youth grow up in communities with serious problems of unemployment, poverty, challenged educational systems, and stressful home lives plagued by broken nuclear and extended family networks. Consequently, the needs of this population are significant.
The goal of the intervention, entitled Living in Harmony
(LIH), was to reduce depressive symptoms during pregnancy and prevent the onset of MDD postpartum. The intervention was theoretically-derived, based on a cognitive behavioral therapeutic (CBT) approach, culturally adapted, and delivered by AI paraprofessionals. The preliminary effectiveness of LIH was evaluated using a randomized controlled trial comparing LIH to an eight lesson education-support comparison condition (ES). Both interventions were comprised of 8 lessons and were delivered during pregnancy (initiated prior to 29 weeks gestation). Assessments were conducted at pre and post-intervention and at 4, 12, and 24 weeks postpartum. Our primary hypothesis was that LIH would result in greater reductions in depressive symptoms and fewer women diagnosed with MDD. In addition, because social support has been linked to lower levels of depressive symptoms (e.g., Margolin 2006
) enhancing social support was targeted in the LIH intervention. Thus, we hypothesized that women in LIH, relative to ES, would report greater improvement in social support. Finally, consistent with previous research examining the impact of treatments for depression (e.g., TADS 2004), we hypothesized that women in LIH, relative to ES, would report superior functioning as a result of the CBT skills they learned.