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10 J.A. Leis et al.Mediators and moderators related to delivering theintervention which may affect the outcome of the studyshould also be carefully considered. One of the studiesreviewed examined the association between type ofintervention provider and depressive symptoms and surprisingly,found that immediately post-intervention and at9 months postpartum, women who were treated by trainednon-specialist health visitors had a significantly greaterreduction in depressive symptoms than women who weretreated by specialists in the treatments employed (Cooperet al. 2003). These findings have important implicationsfor service delivery and while they need to be replicated,suggest that researchers should examine who can bestdeliver the intervention. In addition, the number of sessionslikely to be needed, how long after the interventionparticipants should be followed, and specifically withrespect to preventive interventions, when the interventionshould be delivered (i.e., during pregnancy, postpartum, oracross both periods), and what level of intervention is mostappropriate to meet the needs of the target populationshould be considered.Research should expand our knowledge base aboutthe effectiveness of empirically-supported interventionsto prevent PPD Only one study we reviewed focused onpreventing PPD (Wiggins et al. 2005), with no preventiveeffects found for the non-directive counseling interventionused by this study. Prevention of mental disorders hasgained increasing attention in recent years, given thatprevalence of common mental illnesses exceeds availabletreatment resources (Muñoz 2001). Moreover, the knownharmful effects of maternal depression on infant socialemotionaldevelopment—as well as on subsequent maternalmental health—make pregnant women and newmothers a critical target for prevention efforts (Mendelsonand Muñoz 2006). Interventions using CBT approaches toprevent PPD have shown promising results in two studiestargeting low-income Latinas in prenatal care settings(Muñoz et al. 2007; Le et al. under review). InterpersonalPsychotherapy (IPT) has also shown promising effects inpreventing PPD in a low-income sample when deliveredin a prenatal medical clinic (Zlotnick et al. 2006). Thesefindings suggest the need to explore whether CBT and IPTapproaches are effective in preventing PPD via homebasedinterventions.Additional research on PPD interventions should focuson high-risk groups, especially low-income, ethnic minoritiesPopulations at highest risk for PPD, such as lowincome,ethnic minorities, are often underrepresented inresearch. Only one of the studies reviewed here reportedinformation on the race or ethnicity of their participants(Wiggins et al. 2005) and only three (Cooper et al. 2003;Holden et al. 1989; Wiggins et al. 2005) providedinformation on socioeconomic status. The single studyfocused on low-income women did not affect PPDsymptoms (Wiggins et al. 2005). It is unclear whether thefailure to achieve desired results in this study wasattributable to the focus on a high-risk population or factorssuch as choice of intervention strategy. However, given thegrowing body of work suggesting that women with fewerfinancial resources and/or who are members of minoritygroups are at elevated risk for PPD (Bennett et al. 2004;Hobfoll et al. 1995; Holzman et al. 2006), and less likely toseek treatment services (Miranda et al. 1998), it isimperative that future interventions focus on addressingthe mental health needs of these populations. Women oflow socioeconomic status often face substantial barriers toobtaining mental health care, including access to healthinsurance, transportation, childcare, and stigma regardinguse of mental health services. Home-based interventionsmay be particularly well-suited to overcoming transportationand childcare barriers for low-income populations.Moreover, embedding mental health services and interventionswithin existing home-based interventions (e.g., homevisiting) may also be perceived as more acceptable and lessstigmatizing.When conducting interventions with low-income womenfrom varied racial and ethnic minority groups,consideration must be given to the cultural norms andvalues that may influence these interventions’ applicabilityand implementation. Interventions developed for andinitially tested with middle or upper class, Whitepopulations often require adaptation to fit the needs andvalues of other groups. Such adaptations must balancecultural adaptation with fidelity to the original interventionmodel (Castro et al. 2004). There is a pressing need forresearchers to document how they adapted manualizedinterventions as they worked with new populations (see,Podorefsky et al. 2001 as an example). Thus, futureresearch on home-based interventions to prevent and treatPPD in low-income women from racial and ethnic minoritygroups should address what aspects of existing evidencebasedinterventions need to be culturally adapted topromote their feasibility and acceptability.Future research should use standardized methodsof reporting findings to improve the quality of publishedexperimental reports The Consolidated Standards ofReporting Trials (CONSORT) statement (Moher et al.2001), which has been widely adopted by the medical fieldfor reporting results of randomized controlled trials, isgaining increased acceptance among social scienceresearchers as well. Future reports of home-based interventionsfor PPD would benefit from including theCONSORT flow diagram, which illustrates participant
Home-based interventions for postpartum depression 11progress through the phases of a randomized trial, andelements of the CONSORT checklist such as recruitmentand follow-up procedures, method and implementation ofrandomization, baseline participant demographic and clinicalcharacteristics, sample size determination, and statisticalmethods used for analyses (Moher et al. 2001).Quality of future published studies can also be improved byproviding sufficient detail about the intervention that wouldallow it to be replicated with fidelity and reportingstatistical information needed to calculate effect sizes.Finally, to bring home-based PPD intervention research tothe attention of policy makers and increase the likelihood ofits wider adoption, future studies would benefit fromreporting cost data and cost-effectiveness analyses.While this review represents the first synthesis of thearray of home-based interventions aimed at preventing andtreating PPD, there are several limitations that must benoted. First, we were not able to conduct a meta-analysis ofthe studies in our review, as only three of the six studiesprovided sufficient information to permit effect sizecalculation (Chabrol et al. 2002; Cooper et al. 2003;Prendergast and Austin 2001). Second, it is unclear whetherinterventions that showed more immediate benefits intreating PPD continue to benefit women subsequently.Previous research has documented that among adults whorecover from depression, 25% experience a recurrence ofdisorder within the first year and 60% within 5 years(Solomon et al. 2000). Only three (Cooper et al. 2003;Prendergast and Austin 2001; Wiggins et al. 2005) ofthesix studies followed participants post-intervention and inthe one study that showed an effect of the interventionand followed participants over time, the effects were notmaintained (Cooper et al. 2003). Third, differences acrossthe studies in intervention duration and content, interventionproviders, depression measures, assessment timeframes, and study samples create challenges for comparingfindings across studies. For instance, interventionsranged in duration from six weekly sessions (Prendergastand Austin 2001) to 1 year of monthly sessions (Wigginset al. 2005) and only three studies used trained therapistsor intervention specialists (Appleby et al. 1997; Chabrol etal. 2002; Cooper et al. 2003). Furthermore, study sitesincluded settings in England, France, Scotland, Australia,and Sweden, therefore encompassing women of variedcultural norms and diverse environmental stressors. As aresult, the generalizability of these study findings to othersettings may be limited. Fourth, there were methodologicallimitations among the studies reviewed, including highattrition levels (Appleby et al. 1997), inclusion of womentaking antidepressants without accounting for the effectsof those medications (Holden et al. 1989; Prendergast andAustin 2001), and failure to report intent-to-treat analyses(Wickberg and Hwang 1996). In addition, only half of thestudies used a manualized intervention (Chabrol et al.2002; Holden et al. 1989; Prendergast and Austin 2001),conducted independent assessments (Appleby et al. 1997;Cooper et al. 2003; Holden et al. 1989), and took steps toensure adherence to the intervention protocol (Chabrolet al. 2002; Cooperetal.2003; Prendergast and Austin2001). These methodological limitations require that theresults of these studies be interpreted with caution. Finally,our review only included studies that used a RCT design.Promising findings have emerged from other home-basedinterventions to treat PPD, including the work of Ammermanet al. (2005) who used an adapted form of CBT to treat PPDamong women enrolled in paraprofessional and nurse homevisitation programs.In spite of these limitations, we believe this reviewaddresses an important gap in our knowledge about theopportunities to reduce the burden of postpartum depressionin women and their families. We see the growth ofhome-visiting programs—especially those targeted atpopulations with increased risk for depression anddisproportionate rates of untreated depression—as a wayto decrease disparities in access to evidence-based mentalheath prevention and treatment services. Partnerships withmental health professionals may offer an important tool tohome-visiting programs seeking to demonstrate their ownvalue and effectiveness. The evidence-based interventionsdelivered in the homes of pregnant and recently postpartumwomen reviewed here show promise. We hope ourrecommendations for future work in this area willencourage more high-quality studies to elucidate thefactors associated with positive outcomes for women atrisk for postpartum depression.Acknowledgements Support for this research was provided by theFamily League of Baltimore City, Inc., and the Maryland Governor’sOffice for Children.ReferencesAdministration for Children & Families (2006) Research to Practice:Depression in the lives of early head start families. U.S.Department of Health and Human Services, Washington, DCAmerican Psychiatric Association (1994) Diagnostic and statisticalmanual of mental disorders, 4th edn. American PsychiatricAssociation, WashingtonAmmerman RT, Putnam FW, Stevens J, Holleb LJ, Novak AL, VanGinkel JB (2005) In-home cognitive-behavior therapy fordepression: an adapted treatment for first-time mothers in homevisitation. Best Pract Ment Health 1:1–14Appleby L, Warner R, Whitton A, Faragher F (1997) A controlledstudy of fluoxetine and cognitive-behavioural counseling in thetreatment of postnatal depression. Br Med J 314:932–936Armstrong KL, Fraser JA, Dadds MR, Morris J (1999) A randomized,controlled trial of nurse home visiting to vulnerable families withnewborns. J Paediatr Child Health 35:247–244
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