Lit Review (Results Section)

ORIGINAL ARTICLE

Impact of a preventive intervention for perinatal depression on mood regulation, social support, and coping

Tamar Mendelson & Julie A. Leis & Deborah F. Perry & Elizabeth A. Stuart & S. Darius Tandon

Received: 29 August 2012 /Accepted: 4 February 2013 /Published online: 2 March 2013 # Springer-Verlag Wien 2013

Abstract Perinatal depression prevention trials have rarely examined proximal outcomes that may be relevant for under- standing long-term risk for depression. The Mothers and Babies (MB) Course is a cognitive-behavioral depression prevention intervention, which has been shown to prevent depressive symptoms among at-risk perinatal women of color. This study examined intervention impact on three proximal outcomes that are theoretically linked with the intervention’s model of change and have been empirically linked with risk for depression: mood regulation expectancies, perceived so- cial support, and coping. The study used data from a random- ized intervention trial of the MB Course with 78 low-income, predominantly African-American perinatal women enrolled at one of four home visitation programs in Baltimore City. Mood regulation expectancies, perceived social support, and coping were assessed with self-report instruments at baseline, post- intervention, and 3- and 6-month follow-ups. The intervention group experienced 16 % greater growth in mood regulation from baseline to 6-month follow-up compared to the usual care group, suggesting a prevention effect. The pattern of findings was similar, although not statistically significant, for

social support. Contrary to prediction, the control group expe- rienced less growth in avoidant coping than the intervention group. Findings indicate the MB Course enhances mood reg- ulation, which may facilitate prevention of depression over time. Assessment of intervention effects on proximal outcomes is beneficial for understanding how interventions may enhance protective factors relevant to successful long-term outcomes.

Keywords Perinatal depression . Prevention . Mood regulation expectancy . Social support . Coping . Mothers and Babies Course

Introduction

Psychosocial interventions to reduce or prevent postpartum depression are becoming increasingly popular, and the evi- dence base supporting their efficacy is growing (Muñoz et al. 2012). Both cognitive behavioral and interpersonal strategies have been shown to reduce depressive symptoms and prevent incidence of new cases of major depression in the postpartum period (e.g., Crockett et al. 2008; Muñoz et al. 2012; Tandon et al. 2011; Zlotnick et al. 2006). Studies of perinatal depres- sion prevention interventions have focused primarily on changes in depressive symptoms or disorders. Several studies have also evaluated and reported intervention effects on other proximal outcomes relevant to risk for depression (Brugha et al. 2011; Crockett et al. 2008; Dennis et al. 2009; Elliott et al. 2000); however, most have not done so.

Prevention researchers argue for the importance of con- sidering risk and protective factors both in designing and evaluating interventions (Garber 2006; Ialongo et al. 2006; Sutton 2007). Assessment of intervention impact on proxi- mal factors related to depression risk may be relevant for understanding the likelihood of long-term maintenance of

T. Mendelson (*) : E. A. Stuart : S. D. Tandon Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway/615 N. Wolfe Street, Baltimore, MD, USA e-mail: [email protected]

J. A. Leis : S. D. Tandon Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Baltimore, MD 21287, USA

D. F. Perry Georgetown University Center for Child and Human Development, 3300 Whitehaven Streets, N.W, Washington, DC 20007, USA

Arch Womens Ment Health (2013) 16:211–218 DOI 10.1007/s00737-013-0332-4

intervention effects. Findings have potential to influence further refinements to intervention content or delivery and may also have implications for shaping theories on factors associated with postpartum depression.

The Mothers and Babies Course

The Mothers and Babies (MB) Course is a manualized, cognitive-behavioral intervention designed to reduce risk for perinatal depression among low-income, ethnically di- verse women (Muñoz et al. 2012). Delivered in a group format by trained facilitators, the course teaches women how to modulate negative thoughts, enhance supportive and enjoyable contacts with other people, and increase pleas- ant activities. The mother–baby relationship is emphasized throughout the course, including ways to enhance parenting practices using course skills. Previous research has sup- ported the feasibility of the MB Course and has shown promising effects on depressive symptoms and/or risk for disorder (Le et al. 2011; Muñoz et al. 2012; Tandon et al. 2011). Originally developed for use with Latinas, the course has also been adapted for urban African-American women served by home visitation (HV) programs. Findings from a recent randomized pilot trial indicate that depressive symp- toms in a sample of 78 low-income, predominantly African- American women across four HV programs declined at a significantly greater rate for intervention participants than usual care participants between baseline and 1-week post- intervention, 3-month follow-up, and 6-month follow-up (Tandon et al. under review). At the 6-month follow-up, 11 of 34 (32.4 %) women receiving usual care in this sample were assessed via clinical interview as having a depressive episode compared with 6 of 41 (14.6 %) women receiving the MB Course (Tandon et al. under review). Given these encouraging findings, evaluation of proximal risk and pro- tective factors targeted by the intervention is warranted and may enhance our understanding of intervention mechanisms.

Proximal outcomes

In keeping with the cognitive-behavioral theoretical framework guiding the MB intervention, course modules teach skills for enhancing thoughts, contact with others, and pleasant activities. These skills would be expected to produce improvements in related areas of functioning, including mood regulation expec- tancies, perceived social support, and coping abilities. Each of these proximal outcomes has been associated empirically with risk for—or protection against—depression, suggesting that changes in these factors may contribute to reductions in depres- sion (see Fig. 1).

Mood regulation expectancies refer to belief in one’s ability to modulate negative mood and return to a more positive emotional state. Response expectancy theory (Kirsch 1985)

suggests that mood regulation expectancies influence mood directly via perceived self-efficacy in the context of negative mood, as well as indirectly through the use of coping strategies (Catanzano and Mearns 1990). Data suggest that mood regu- lation expectancies are inversely associated with depressive symptoms (Catanzaro 1993; Catanzano and Mearns 1990; Catanzaro et al. 2000; Drwal 2008; Kassel et al. 2007) and predict future depressive symptoms (Catanzaro et al. 2000; Kassel et al. 2007). We are not aware of studies that have investigated the association of mood regulation expectancies with depression among perinatal samples.

Research has identified significant associations of per- ceived social support with stress, coping, and distress/de- pression; both the absence of positive support and the presence of negative interpersonal influences have been linked with depression (see Coyne and Downey, 1991, for a discussion). Perceived social support is also a significant predictor of mental health during the perinatal period. For instance, low perceived social support from spouses and family during pregnancy and the postpartum period was found to predict major depressive disorder and depressive symptoms (Sheng et al. 2010; Xie et al. 2009).

There is a large theoretical and empirical literature on coping strategies that individuals employ to manage stress in response to situations involving adversity, threat, or loss (Lazarus 1966; Lazarus and Folkman 1984). Research sug- gests that coping approaches aimed at actively addressing a stressful situation are generally effective for maintaining psy- chological well-being, whereas coping strategies involving disengagement or avoidance of the stressor often increase risk for negative outcomes, including depression and anxiety (Littleton et al. 2007; Moskowitz et al. 2009). Some evidence suggests that avoidant, or disengaged, coping strategies are associated with perinatal depressive symptoms, whereas more active coping strategies focused on problem solving may be related to lower perinatal depression scores (Blaney et al. 2004; Edge and Rogers 2005; de Tychey et al. 2005).

The current study

This study examined the impact of the MB Course on mood regulation expectancies, perceived social support, and cop- ing. The study was not designed or powered to test

MB Course

Thoughts

Contact with Others

Pleasant Activities

Proximal Outcomes

Mood Regulation Expectancy

Perceived Social Support

Coping

Distal Outcomes

Depressive Symptoms

Depressive Disorders

Fig. 1 Intervention theory of change

212 T. Mendelson et al.

mediational pathways by which these proximal factors may contribute to intervention impacts on depression. However, measurement of the three proximal outcomes permits a preliminary evaluation of the theory of change guiding the MB intervention. Data for the current study were drawn from the randomized trial of urban, low-income, predomi- nantly African American women in four HV programs described above (n=78). The three proximal outcomes were assessed at baseline, post-intervention, and 3- and 6-month follow-ups. We hypothesized that the intervention would be associated with improved mood regulation expectancies, with higher perceived social support, and with more active and fewer avoidant coping strategies.

Methods

Participants

Pregnant women and women with a child less than 6 months old who were enrolled in one of four Baltimore City home visiting programs were eligible for study participation. Women were contacted by phone and screened for depressive symp- toms using the Center for Epidemiological Studies Depression Scale (CES-D; Radloff 1977) and for depressive disorder using the Maternal Mood Screener (MMS; Le and Muñoz 1998). Women currently experiencing elevated depressive symptoms (CES-D score≥16) and/or who reported a lifetime depressive episode but did not meet criteria for a current depressive episode were invited to join the study. Women meeting criteria for a current depressive episode on the MMS were not eligible to participate; they were referred to the clinical supervisor at the home visiting program who initiated further assessment and referral to mental health treatment.

Recruitment took place between October 2009 and March 2010. Details regarding participant eligibility, ran- domization, and flow are reported elsewhere (Tandon et al. under review). One hundred and twenty women were eligi- ble for the study and randomized. Of the 61 women assigned to the intervention group, 41 enrolled in the study while among the 59 who were assigned to the control group, 37 enrolled. There were no statistically significant differ- ences in maternal age, pregnancy status, or race/ethnicity between randomized women who enrolled and did not en- roll in the study for either the intervention or control groups.

Procedures

Women were randomized to receive standard home visiting services plus a modified, 6-week version of the MB Course or standard home visiting services plus information on perinatal depression. Participants were surveyed at four time points: pre-intervention, post-intervention, and at 3 and 6 months

follow-up. Mood regulation expectancies, social support, and coping were assessed at each time point. Study partici- pants were compensated $20 cash for each completed survey. The Johns Hopkins University School ofMedicine Institutional Review Board approved all study procedures. Written consent was obtained from participants prior to completion of the baseline assessment.

Intervention

Our version of the MB intervention, adapted to ensure cultural and contextual appropriateness for low-income, ur- ban women, consisted of six 2-h intervention sessions de- livered weekly in a group format by either a licensed clinical social worker or clinical psychologist. The six sessions were divided into three two-session modules that mapped onto core cognitive behavioral concepts: pleasant activities, thoughts, and contact with others. Each session contained didactic instruction on core content, as well as activities and group discussion. Booster sessions, which reviewed the main course concepts, were held at 3 and 6 months post- intervention. In addition to the group sessions, intervention participants received one-on-one home visitor reinforcement of group material. Reinforcements took place after each of the first five intervention sessions during home visitors’ regularly scheduled visits with all clients who were inter- vention participants. Of the 41 women in the intervention group, 40 (98 %) completed the 1-week post-intervention as- sessment, and all 41 completed the 3- and 6-month post- intervention assessments. Women in the intervention group attended a mean of 4.5 sessions (SD=1.36, range=1–6), and 71 % received weekly reinforcements from their home visitor; 78 % attended one booster session, and 51 % attended both. Of the 37women in the control group, all 37 completed the 1-week post-intervention assessment, 35 (95%) completed the 3-month assessment, and 34 (92 %) completed the 6-month assessment. Additional details about the intervention content and study procedures can be found in Tandon et al. (2011).

Measures

Mood regulation was measured using the Negative Mood Regulation Scale (Catanzaro and Mearns 1990), which evalu- ates an individual’s expectancy that she will be able to regulate a negative mood. The scale consists of 30 items such as “When I’m upset, I believe that I can do something to feel better” and “When I’m upset, I believe that it won’t be long before I can calm myself down.” Items are rated on a 5-point scale ranging from “strong disagreement” to “strong agreement.” Scores can range from 30–150; higher scores indicate a stronger belief in one’s ability to improve a negative mood state. Internal consis- tency of the scale was good; Cronbach’s alpha ranged from 0.84–0.91.

Impact of a perinatal preventive intervention 213

Perceived availability of social support was measured using the Interpersonal Support Evaluation List (ISEL; Cohen and Hoberman 1983). We used a 30-item version of the ISEL, which evaluates perceived availability of ap- praisal support, belonging support, and tangible support with items such as “There are several people that I trust to help solve my problems” and “I often meet or talk with family or friends.” Items are rated on a 4-point scale ranging from “definitely false” to “definitely true.” Scores can range from 0–120; higher scores indicate greater perceived sup- port. Internal consistency in this sample was acceptable; Cronbach’s alpha ranged from 0.73–0.92.

Coping was assessed using the Brief COPE (Carver 1997), a 28-item measure that includes 14 subscales assess- ing different coping reactions. The measure is designed to assess coping reactions in response to a specific stressor. The instructions were adapted in this study so as to be relevant for pregnancy-related stress: “These items deal with ways you’ve been coping with the stress in your life since you found out you were pregnant. There are many ways to try to deal with things. These items ask what you’ve been doing to cope with your pregnancy.” Items such as “I’ve been taking action to try to make the situation better” and “I’ve been refusing to believe that it has happened” measure both adaptive and problematic reactions and are rated on a 4-point scale ranging from “I haven’t been doing this at all” to “I’ve been doing this a lot.” The Brief COPE was not designed to yield a single coping index. Following the author’s recommendations, we subjected the 14 subscales to factor analysis to create higher-order factors. Using prin- cipal components analysis with varimax rotation we identi- fied two factors that explained 57 % of the variance. Factor 1, active coping, included the following subscales: self- distraction, active coping, using emotional support, using instrumental support, positive reframing, planning, accep- tance, and religion. Possible scores on this factor ranged from 16 to 64 with higher scores indicating better, more active coping. Cronbach’s alpha for this factor ranged from 0.80–0.89. Factor 2, avoidant coping, included the subscales measuring denial, substance use, behavioral disengagement, venting, and self blame. Possible scores on this factor ranged from 10 to 40; lower scores indicated better, less avoidant coping. Cronbach’s alpha for this factor ranged from 0.72–0.77. One subscale, humor, was not retained. Additional detail regarding the factor analysis is available upon request.

Statistical analyses

Differences between participants in the intervention and usual care groups at baseline were determined using inde- pendent sample t tests for continuous variables, Fisher’s exact test for categorical variables with small cell sizes,

and χ2 tests for categorical variables without small cell sizes. The effect of the intervention on the proximal outcomes was estimated using multilevel linear regression. A separate re- gression model was fit for each outcome. Each model includ- ed fixed effects for condition (intervention versus usual care), time, the condition by time interaction, and site (i.e., home visiting program), and a random effect for participant to account for the non-independence of measures for the same participant over time. To allow for flexible trends over time, the time variable in the model was coded as a factor, with an indicator variable for each time point (baseline [omitted cate- gory], post-intervention, 3-month follow-up, and 6-month follow-up). The distributions of mood regulation and avoidant coping scores were skewed and were log transformed before running the outcome models. All analyses were conducted using Stata version 11 (StataCorp 2009), with the xtmixed command used to run the multilevel (mixed effects) models.

Results

Sample characteristics

At baseline, participants ranged in age from 14 to 41 with a mean age of 24.1 (SD=6.1) years. Most women in the sample were African American (83.1 %), single (78.2 %), and were not currently working (72.4 %). Over half had a high school degree or GED (59.7 %). Approximately one third (28.2 %) of the sample was pregnant; the remaining women (71.8 %) were postpartum. The current child was the first child for 27.6 % of women. There were no significant differences between partic- ipants in the intervention and usual care groups at baseline on any demographic characteristics (Table 1).

Intervention impact on proximal outcomes

Results of the multilevel linear regression models are shown in Table 2, and the means showing the trends in each outcome over time by group are displayed in Fig. 2.

Mood regulation No significant differences in mood regu- lation were found between the groups at baseline, and growth in mood regulation did not differ by group from baseline to post-intervention or 3 months post-intervention. However, the groups differed in growth in mood regulation from baseline to 6-month follow-up; the intervention group experienced 16 % greater growth in mood regulation from baseline to 6-month follow-up compared to the usual care group (β=0.16, SE=0.03, p<0.001).

Social support A similar pattern emerged for perceived social support although the finding was not statistically significant at the 0.05 level: the growth in perceived social

214 T. Mendelson et al.

support from baseline to 6-month follow-up was 6.67 points larger among participants in the intervention group than par- ticipants in the usual care group (β=6.67, SE=0.03, p<0.10).

Coping There was no statistically significant difference in active coping between the groups over time. Surprisingly, for avoidant coping, participants in the intervention group had a 14 % larger increase in avoidant coping strategies between baseline and the 6-month post-intervention follow- up compared to participants in the usual care group (β= 0.14, SE=0.07, p<0.05).

Discussion

This study assessed the impact of the 6-week MB Course on proximal outcomes of mood regulation expectancies, per- ceived social support, and coping among pregnant women and new mothers. As predicted, women in the intervention group displayed greater growth in mood regulation expec- tancies between baseline and the 6-month follow-up com- pared with women in the control group. This finding suggests that the intervention enhances a cognitive factor with potential to protect against depression and promote

positive mental health. The pattern was similar but not statistically significant for perceived social support. The MB Course did not significantly impact active coping, and

Table 1 Participant demographic characteristics at baseline by inter- vention group

Characteristic Intervention (n=41)

Usual care (n=37)

p value

Age, mean (SD) 24.4 (6.4) 23.8 (5.9) 0.65

Race, no. (%)

African American 33 (82.5) 31 (83.8) 0.99

Caucasian 5 (12.5) 4 (10.8)

Other 2 (5.0) 2 (5.4)

Marital status, no. (%)

Single 31 (75.6) 31 (83.8) 0.37

Married 10 (24.4) 6 (16.2)

Employment status, no. (%)

Unemployed 28 (70.0) 27 (75.0) 0.25

Working full-time 5 (12.5) 7 (19.4)

Working part-time 7 (17.5) 2 (5.6)

Educational attainment, no. (%)

<High school degree 15 (37.5) 16 (43.2) 0.10

High school degree/GED 9 (22.5) 14 (37.8)

>High school degree/GED 16 (40.0) 7 (18.9)

Pregnancy status

Prenatal, no. (%) 12 (29.3) 10 (27.0) 0.83

Postpartum, no. (%) 29 (70.7) 27 (73.0)

p values were calculated using independent sample t tests for contin- uous variables, Fisher’s exact test for categorical variables with small cell sizes, and χ2 tests for categorical variables without small cell sizes

Table 2 Results of the random intercept multilevel model for second- ary outcomes

Coefficient (SE) z value

Mood regulation expectanciesa

Condition (intervention vs usual care)

0.01 (0.03) 0.38

1 week post-intervention −0.02 (0.02) −0.76

3 months post-intervention 0.02 (0.02) 0.92

6 months post-intervention −0.11 (0.02) −4.55***

Condition*1 week post-intervention

0.04 (0.03) 1.28

Condition*3 months post-intervention

0.06 (0.03) 1.86

Condition*6 months post-intervention

0.16 (0.03) 4.83***

Social support

Condition (intervention vs usual care)

3.89 (3.13) 1.24

1 week post-intervention 0.85 (2.54) 0.33

3 months post-intervention 1.78 (2.57) 0.69

6 months post-intervention −4.70 (2.61) −1.80‡

Condition*1 week post-intervention

−0.62 (3.52) −0.18

Condition*3 months post-intervention

−0.76 (3.50) −0.22

Condition*6 months post-intervention

6.67 (3.53) 1.89‡

Active coping

Condition (intervention vs usual care)

−1.18 (2.32) −0.51

1 week post-intervention −0.05 (1.74) −0.03

3 months post-intervention −2.86 (1.77) −1.62

6 months post-intervention −1.82 (1.78) −1.02

Condition*1 week post-intervention

0.35 (2.43) 0.14

Condition*3 months post-intervention

3.41 (2.43) 1.40

Condition*6 months post-intervention

3.30 (2.45) 1.35

Avoidant copinga

Condition (intervention vs usual care)

−0.01 (0.07) −0.09

1 week post-intervention 0.05 (0.05) 1.01

3 months post-intervention −0.01 (0.05) −0.02

6 months post-intervention −0.14 (0.05) −2.63**

Condition*1 week post-intervention

−0.08 (0.07) −1.17

Condition*3 months post-intervention

−0.03 (0.07) −0.35

Condition*6 months post-intervention

0.14 (0.07) 2.01*

‡ p<0.10; *p<0.05; **p<0.01; ***p<0.001 a Outcome was transformed by taking the log

Impact of a perinatal preventive intervention 215

contrary to predictions, was associated with a trajectory of increased avoidant coping among the intervention as com- pared with control participants.

Our analyses indicated that significant group differences in mood regulation expectancies emerged only at the 6- month follow up and were not evident at the post- intervention or 3-month follow up. As shown in Fig. 2, mood regulation expectancies remained relatively constant among intervention participants, whereas control group par- ticipants reported a decrease in positive expectancies be- tween the 3 and 6 month follow ups. This pattern of findings suggests a preventive intervention effect, in which intervention participants were buffered against feelings of lowered self-efficacy in regulating mood over the postpar- tum period. Demands of caretaking for an infant may have had a more negative effect on women’s mood regulation expectancies in the control group because they had not been exposed to specialized skills training through the interven- tion. Research using qualitative methods to explore experi- ences among postpartum women would be beneficial for better understanding this trajectory.

The pattern of findings for perceived social support, al- though not significant, also suggests that the control group may have experienced a trend toward reduced perceptions of social support from the 3- to 6-month follow-up. Findings may also reflect the fact that women in the control group were less likely than intervention participants to have experienced con- sistent supportive contact and information sharing with other at-risk pregnant women and new mothers, including the two booster sessions at follow-ups. This study was not powered to detect differences in perceived social support, but the effect size obtained in this study can inform the design of future trials

in which social support is assessed. In addition, we will con- sider whether additional emphasis in the intervention and booster sessions on increasing sources of social support—and identifying existing supports—may be beneficial.

The unexpected finding for avoidant coping merits in- vestigation in future studies on the MB Course. Similar to the pattern for the mood regulation outcome, the finding was driven by changes among control group women between the 3- and 6-month follow-ups; intervention group women remained relatively constant in levels of avoidant coping, whereas control group women decreased. We view this finding with caution because we are not confident that the Brief COPE scale adequately assessed coping strategies relevant for our study sample. As noted above, the measure is intended to assess coping reactions in response to a specific stressor, rather than more general coping strategies used regularly for coping with daily stresses. Instructions were adapted so as to target “stress in your life since you found out you were pregnant;” however, these instructions were not altered for the post-intervention and follow-up assessments and thus may not have adequately captured the sorts of stressors occurring during the postpartum peri- od. In future studies on the efficacy of the MB Course, it may be beneficial to develop a coping scale that evaluates more explicitly the coping skills targeted in the intervention, such as cognitive restructuring and pleasant activities. Given the pervasive and chronic nature of stress in our target population, it may also be more appropriate to assess the use of day-to-day coping strategies, rather than strategies used in response to a specific stress domain.

Several other perinatal depression prevention trials have evaluated and reported on proximal outcomes related to

a

b

BASE POST 3 MO 6 MO

BASE POST 3 MO 6 MO BASE POST 3 MO 6 MO

BASE POST 3 MO 6 MO

c

d

Fig. 2 Means showing trends in each outcome over time by group. a Mood regulation, b social support, c active coping, d avoidant coping. The means were obtained from multilevel linear regression models accounting for correlations within participants over time but do not account for site (i.e., home visiting program). These means are almost identical to those obtained in analyses accounting for site

216 T. Mendelson et al.

depression risk. These outcomes include anxiety (Dennis et al. 2009; Elliott et al. 2000), social support/loneliness (Brugha et al. 2011; Dennis et al. 2009; Elliott et al. 2000), coping (Brugha et al. 2011), and parental stress and adjustment (Crockett et al. 2008). Among those studies reporting significant intervention effects (Crockett et al. 2008; Dennis et al. 2009; Elliott et al. 2000), some degree of improvement was also found in anxiety (Dennis et al. 2009), social support (Elliott et al. 2000), and postpartum adjustment (Crockett et al. 2008). Ours is the only study of which we are aware to evaluate and report improve- ments in mood regulation expectancies. Taken together, these findings suggest that effective perinatal depression prevention programs may have positive impacts on depression-related risks and protective factors. Elliott and colleagues reported that higher ratings of marital and close relationships among intervention as compared with control participants did not mediate the effect of the intervention on depression (Elliott et al. 2000), whereas other studies did not include evaluation of mediation.

Limitations of the present study include the fact that the intervention trial was powered to detect group differences in depressive symptoms, not in the proximal outcomes assessed in this study. The relatively small sample size may have limited our ability to detect small effects, for example in perceived social support, and did not permit us to evaluate whether the proximal factors mediated intervention impacts on depression. Our Brief COPE measure, as noted above, was also potentially not an adequate index of coping strategies targeted in the intervention. This study also has notable strengths, including a randomized controlled design and lon- gitudinal assessments with 3- and 6-month follow-ups. It is one of the few intervention trials aimed at prevention of postpartum depression that incorporated and reported on mul- tiple measures of risk and protective factors.

Conclusion

In sum, the MB Course shows promise in preventing post- partum declines in women’s perceived ability to regulate their negative mood states effectively. This effect may serve a protective function with respect to prevention of perinatal depression, given evidence for concurrent and prospective associations of mood regulation expectancies with depres- sive symptoms (e.g., Catanzaro et al. 2000; Kassel et al. 2007). Evaluation of risk and protective factors as secondary outcomes in depression prevention trials is a potentially valuable way to better understand long-term intervention benefits. Next steps in the field of perinatal depression prevention include the implementation of larger-scale ran- domized controlled trials that are adequately powered to assess mediational pathways.

Acknowledgments The study was funded by the Johns Hopkins Institute for Clinical and Translational Research (1U54RR023561- 01A1) and The Abell Foundation. We gratefully acknowledge Karen Edwards for her assistance with recruitment, assessments, and other aspects of the study. We would also like to thank the four home visiting programs and their program participants for their strong support of this project.

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