Journal of Adolescence 37 (2014) 1227e1235

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Journal of Adolescence

journal homepage: www.elsevier .com/locate/ jado

A systematic review of perinatal depression interventions foradolescent mothers

Kate Lieberman a, *, Huynh-Nhu Le a, Deborah F. Perry b

a George Washington University, USAb Georgetown University, USA

Keywords:Perinatal depressionInterventionAdolescent

* Corresponding author. George Washington UnivE-mail addresses: Kate_L_L@gwmail.gwu.edu, kl

http://dx.doi.org/10.1016/j.adolescence.2014.08.0040140-1971/© 2014 The Foundation for Professionals

a b s t r a c t

Poor, adolescent, racial/ethnic minority women are at great risk for developing perinataldepression. However, little research has been conducted evaluating interventions for thispopulation. We conducted a systematic review of preventive and treatment interventionsfor perinatal depression tested with adolescents, with a focus on low income, minoritypopulations. Nine research-based articles (including one that reported on two studies)were reviewed systematically, and quality ratings were assigned based on a validatedmeasure assessing randomization, double-blinding, and reporting of participant with-drawals. Two treatment studies were identified, both of which were successful in reducingdepression. Eight prevention studies were located, of which four were more efficaciousthan control conditions in preventing depression. Studies sampled mostly minority, lowsocioeconomic status adolescents. No consistent characteristics across efficacious in-terventions could be identified. This review underscores the need for researchers tofurther investigate and build an evidence base.© 2014 The Foundation for Professionals in Services for Adolescents. Published by Elsevier

Ltd. All rights reserved.

Adolescence is a difficult period of development, marked by hormonal, cognitive, social, and psychological changes thatoften lead to emotional distress, particularly depression ( Stone, Hankin, Gibb, & Abela, 2011; Teunissen et al., 2011). In 2009,409,840 infants were born to adolescent mothers (ages 15e19) in the United States (Hamilton, Martin, & Ventura, 2010). Thisfigure translates into a live birth rate of 39.1 per 1000 adolescents. These statistics are unsettling, given that adolescents arenot fully individuated from their own families and frequently lack the emotional, cognitive, and financial resources necessaryto optimally raise children (Corcoran, Franklin, & Bennet, 2000; Moore & Chase-Lansdale, 2001; Sadler & Catrone, 1983;Thomas & Rickel, 1995). Importantly, the stress from pregnancy in adolescence has been shown to increase the risk fordepression, and perinatal depression (depression occurring during pregnancy through 12 months of delivery) is associatedwith negative consequences inmothers and babies (Barnet, Liu,&DoVoe, 2008;Misri& Joe, 2008). These findings support theneed to develop and test interventions aimed at preventing and treating adolescent perinatal depression. The purpose of thispaper is to examine and evaluate the existing literature on such interventions.

Research has shown that perinatal depression adversely affects both mothers and their infants (Misri & Joe, 2008). Whileliterature regarding the negative consequences of perinatal depression specifically in adolescent populations is limited, re-searchers have shown that adolescent depression (more generally) may result in high risk sexual behavior, substance use, low

ersity, Department of Psychology, 2125 G St. NW, Washington, DC 20052, USA. Tel.: þ1 (917) 699 5548.l2102@gmail.com (K. Lieberman).

in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

K. Lieberman et al. / Journal of Adolescence 37 (2014) 1227e12351228

academic attainment, physical and psychological health problems, and suicide, as well as negative interactions with theirchildren and physical and behavioral problems in their children as infants and toddlers (Barnet et al., 2008; Fletcher, 2008;Franko, Striegel-Moore, Thompson, Schreiber, & Daniels, 2005). Additionally, infants of depressed mothers can experiencedifficulties with emotion regulation and with cognitive, language, and motor development (Murray, 1992).

Research has shown that poor, young, racial or ethnic minority women may be at greatest risk for developing perinataldepression, likely due to a combination of risk factors including life stressors, lack of social support, marital dysfunction,single marital status, low socioeconomic status (SES), and unplanned or unwanted pregnancy (Beck, 2001; Segre, O'Hara, &Stuart, 2007). Rates of postpartum depression as high as 28e56% have been documented in adolescent, low SES, racial orethnic minority mothers (Hodgkinson, Colantuoni, Robers, Berg-Cross, & Belcher, 2010; Ramos-Marcuse et al., 2010).

Because the risk for developing perinatal depression is so high in adolescent, low SES, racial or ethnic minority mothers, itis important for researchers and clinicians to examine risk and resilience factors specific to this population to develop tar-geted interventions. Research has indicated that adolescents are more likely to experience perinatal depression if they sufferfrom: low SES, family and/or partner conflict, social isolation, dissatisfaction with social support, low self esteem, low con-fidence in parenting abilities, or stress (Birkeland, Thompson, & Phares, 2005; Caldwell, Antonucci, & Jackson, 1998; Kalil,Spencer, Spieker, & Gilchrist, 1998; Logsdon, Birkimer, Simpson, & Looney, 2005). On the other hand, positive and sup-portive family relationships and high self-esteem may protect adolescents from the negative consequences of perinataldepression (Barnet, Joffe, Duggan, Wilson, & Repke, 1996; Caldwell et al., 1998).

A growing body of research has documented the efficacy of prevention and treatment programs for perinatal depression inadult mothers. Interventions found to be efficacious generally consist of cognitive-behavioral (CBT) (Chabrol et al., 2002; Le,Perry, & Stuart, 2011; Tandon, Perry, Mendelson, Kemp, & Leis, 2011) and interpersonal therapy (IPT) approaches (Mulchay,Reay, Wilkinson,& Owen, 2010; Zlotnick, Miller, Pearlstein,& Howard, 2001; Zlotnick, Miller, Pearlstein, Howard,& Sweeney,2006). Unfortunately, little research has been conducted that applies knowledge of the aforementioned risk and protectivefactors, or research regarding efficacious interventions in adult populations, to the prevention or treatment of perinataldepression in adolescents. The purpose of this paper is to address these gaps by conducting a systematic review of the currentpreventive and treatment interventions of perinatal depression specifically tested for adolescents, with a focus on low SES,racial or ethnic minority populations.

Methods

A literature search was conducted using the PsycInfo and PubMed electronic databases. Combinations of the followingterms were included: adolescent, teen, depression, postpartum, pregnant, perinatal, intervention, treatment, prevention. Citationindex searches were also conducted from the articles identified on the databases. Inclusion criteria for articles were: pub-lished within the past 15 years in English; adolescent (teenage) population; and research-based studies testing outcomes ofinterventions targeting pregnant adolescents or adolescent mothers in improving depression (clinical depression or elevatedsymptoms), as assessed with a standardized measure. Published dissertations and unpublished documents were notincluded.

The combinations of keywords listed above produced a total of 413 articles. Limiting the results to articles publishedwithin the past 15 years yielded 335. Limiting results to articles related to perinatal depression yielded 174. From these, andfrom a review of their references, 15 studies were found that described interventions targeting perinatal depression. Fromthese, nine articles (including one article, Miller, Gur, Shamok, &Weissman, 2008 , that consisted of two intervention studies,and therefore referred to hereafter as parts a and b, targeted adolescents and adhered fully to inclusion criteria.

The interventions included (see Table 1): 1) individual home-based CBT and psycho-education (Ginsburg et al., 2012); 2)group IPT (Miller et al., 2008); 3) home visiting psychoeducation regarding parenting, family planning, substance use pre-vention, and coping skills (Walkup et al., 2009); 4) home visitingwith parenting and adolescent curricula (Barnet et al., 2007);5) maternal infant massage training (Oswalt, Biassini, Wilson, & Mrug, 2009); 6) maternal massage therapy (Field, Grizzle,Scafidi, & Schanberg, 1996); 7) a motivational interviewing phone-based intervention (Logsdon, Foltz, Stein, Usui, &Josephson, 2010); 8) social support enhancement training (Logsdon, et al., 2005); and 9) a multi-component treatment,with daycare, rehabilitation, relaxation, massage therapy, and mother-infant interaction coaching (Field et al., 2000).

Because not all studies were randomized controlled trials (RCTs) and did not calculate effect sizes, we were not able toconduct a meta-analysis. Instead, all studies were reviewed systematically, and quality ratings were assigned to each studybased on the Jadad Scale (Jadad et al., 1996). The Jadad Scale is a validatedmeasure assessing randomization, double-blinding,and reporting of participant withdrawals that increases the rigor of a systematic review. It was selected as it was found todemonstrate the best evidence for reliability and validity in a systematic review of 21 scales used to evaluate RCT quality(Olivo et al., 2008). Scores on this measure range from 0 to 5, with higher scores indicating higher quality. One point isawarded for randomization of participants, with an additional point awarded for describing themanner inwhich participantswere randomized. One point is awarded for reporting number of and reasons for participant withdrawals. Two points areawarded to studies that are double-blinded and that describe the process of double-blinding.

It should be noted that the Jadad scale has been criticized for its heavy focus on double-blinding, which may not bepossible or relevant for some psychological intervention trials, as well as its relative simplicity (it does not, for instance,address issues of statistical analysis, intervention fidelity, treatment adherence, follow-up, and use of sub-group analyses)(Olivo et al., 2008). Therefore, additional qualitative descriptions of intervention quality have been included in this review to

Table 1Adolescent perinatal depression intervention study descriptions.

Study Location Study type N Sample description Interventioncondition

Interventionprovider

Control condition

Barnet et al.,2007.

- Baltimore, MD- Recruited fromprenatal caresites

Prevention:RCT

84 - Pregnantteenagers

- Mean age 16.9- 91% AfricanAmerican, 9%unspecified

- Home visitingprogram withparenting andadolescentcurricula

- Twice per weekfor one year, onceper month forsecond year

- African Americanwomen from thecommunity,trained to delivercurricula

- Usual care atprenatal site

Field et al.,1996.

- Inner city area ofthe United States

Prevention:RCT

32 - Teenage mothers- Mean age 18.1- Approx. 71% Afri-can American,29% Latino

- Elevated depres-sive symptoms

- Thirty minutemassages on twoconsecutive daysfor five weeks

- Trained massagetherapists

- Thirty minutes ofyoga and/or pro-gressive musclerelaxation on twoconsecutive daysfor five weeks

Field et al.,2000.

- Location notspecified

- Recruited fromthe hospital afterdelivery

Prevention:RCT

260 - Teenage mothers- Mean age 17.3(depressedgroup), 18 (non-depressed group)

- Approx. 60% Afri-can American;25% Latino; 15%EuropeanAmerican

- Three monthmulti-componentprogram withday-care,vocational andsocial educationand activities,music moodinductiontherapy,relaxationtherapy, massagetherapy, andmother-infantinteractioncoaching

- Not specified - Not specified

Logsdon et al.,2005.

- Location notspecified

- Recruited from apublic school forpregnant andparentingteenagers

Prevention:RCT

128 - Pregnantteenagers

- Mean age 16- 56% AfricanAmerican, 38%EuropeanAmerican

- One-time socialsupport inter-vention deliveredvia pamphlet,video, or videoplus pamphlet

- Pamphlet orvideo

- No intervention

Logsdon et al.,2010.

- Southern, urbanarea in the UnitedStates

- Recruited from aadolescentparent program

Treatment:Pre-Post

97 - Teenage mothers- Mean age 16.4- 44% EuropeanAmerican, 42%African American

- Six-monthtelephone-baseddepression careprogram

- Motivationalinterviewing andpsychoeducation

- Trained child/adolescent psy-chiatric nurse

- No intervention

Miller et al.,2008.

- New York City,NY

- Recruited fromschools for preg-nant andparentingadolescents

Prevention:Pre-Post

14 - Pregnantteenagers

- Mean age 14.7- Approx. 71%Latino, 21% Afri-can American, 8%African Amer-ican/Hispanic

- Group interper-sonal therapyadapted for preg-nant adolescents

- Twelve weeklysessions of 1 h

- Clinical psychol-ogist with sevenyears of IPTexperience andclinical psycholo-gist co-therapistwith previoustraining in IPT

- No intervention

Miller et al.,2008.

- New York City,NY

- Recruited frompublic schools forpregnant/parentingadolescents

Treatment:Pre-Post

11 - Pregnantteenagers

- Mean age 16.5- Approx. 73% Afri-can American, 9%Latino, 18% Afri-can American/Hispanic

- Clinical depres-sion or adjust-ment disorder

- Group interper-sonal therapyadapted for preg-nant adolescents

- Twelve weeklysessions of 1 hand 15 min

- Clinical psychol-ogist with sevenyears of IPTexperience andclinical psycholo-gist co-therapistwith previoustraining in IPT

- No intervention

Oswalt et al.,2009.

- Urban southeastUnited States

Prevention:RCT

25 - Teenage mothers- Mean age 16.3

- Not specified - Interventionfollowing

(continued on next page)

K. Lieberman et al. / Journal of Adolescence 37 (2014) 1227e1235 1229

Table 1 (continued )

Study Location Study type N Sample description Interventioncondition

Interventionprovider

Control condition

- 100% AfricanAmerican

- One-time 30-minlive infantmassage training

completion offollow-upmeasures

Ginsburg et al.,2012.

- White MountainApache Indianreservation

Prevention:RCT

47 - Pregnant WhiteMountain ApacheAmerican Indianteenagers

- Mean age 18.15- Baseline depres-sion scores onCES-D � 16

- Psycho-educa-tional and CBTsessions adaptedfor Apacheadolescents

- Eight weekly 30e60 min inehome sessions

- Trained AmericanIndianparaprofessionals

- Perinatal educa-tional support

Walkup et al.,2009.

- Navajo andWhite MountainApache reserva-tions in NM andAZ

- Recruited fromprenatal andschool-basedclinics

Prevention:RCT

167 - Pregnant Amer-ican Indianteenagers

- Median age 18- 65% Navajo, 18%White MountainApache or mixedtribal background

- Prenatal andinfant-careparentinglessons, familyplanning,substance abuseprevention, andproblem-solvingand coping-skillslessons.

- 25, 1 h homevisits

- Trained AmericanIndianparaprofessionals

- Breastfeedingand nutrition ed-ucation program

- 23, 1 hourhome visits

K. Lieberman et al. / Journal of Adolescence 37 (2014) 1227e12351230

supplement the scale, including evaluations of control condition, intervention providers, use of fidelity checks, calculation ofeffect sizes, and utilization of intent-to-treat analyses.

Results

Intervention characteristics

Table 1 provides a description of intervention type, location, sample description, intervention design and dose, inter-vention provider, and control conditions for the articles reviewed. Studies were characterized as treatment or preventionaccording to the definitions utilized by Cuijpers, van Straten, Andersson, and van Oppen (2008). Thus, treatment interventionssought to treat clinical depression, assessed via clinical interviews or measures of clinical depression. Preventive interventionssought to decrease elevated symptoms of depression in the absence of a clinical assessment, or to prevent the onset ofdepressive symptoms or major depressive disorder. According to this operationalization, two of the interventions weretreatment-based (Logsdon et al., 2010; Miller et al., 2008), and eight were prevention-based (Barnet et al., 2007; Field et al.,1996, 2000; Ginsburg et al., 2012; Logsdon et al., 2005; Miller et al., 2008; Oswalt et al., 2009; Walkup et al., 2009).

Intervention outcomesResults are described below. Also summarized below and presented in Table 2 are evaluations of use of fidelity checks,

calculation of effect size, intent-to-treat analysis, randomization, double blinding, reporting of withdrawals, as well as qualityratings based on the Jadad scale.

Treatment studiesBoth treatment studies were effective in reducing depression rates, including a 6-monthmotivational interviewing phone-

based intervention (Logsdon et al., 2010), and a 12-week interpersonal group intervention (Miller et al., 2008).One treatment study assessed the utility of a telephone-based depression care management intervention for adolescent

mothers in reducing depression and increasing therapy utilization (Logsdon et al., 2010). Researchers screened 97 EuropeanAmerican (44%) and African American (42%) adolescent mothers from an adolescent parent program for clinical depression(via the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version, or K-SADS-PL) and elevateddepressive symptomatology (via the Center for Epidemiologic Studies Depression Scale, or CES-D). Twenty-two of themothers had elevated symptom scores, and ten of these met criteria for Major Depressive Disorder. The ten mothers werereferred into the intervention, a 6-month program in which a psychiatric nurse contacted the mothers to provide support,including motivational interviewing (to help the mothers obtain treatment for depression) and psychoeducation. At baseline,intervention group participants had significantly higher depressive symptom scores than the control (non-depressed) group,but by 6 months postpartum, the intervention group's scores had decreased to approximate those of the control group.Whilemental health utilization was low overall (with only four adolescents receiving mental health treatment), the interventiongroup participants hadmoremental health related visits than did the control group (the authors did not indicatewhether this

Table 2Adolescent perinatal depression intervention quality review.

Study Fidelity checks Effectsizecalculated

Intention-to-treatanalysis

Randomization Doubleblinding

Withdrawalreporting

JadadQualityRatingc

Barnet et al., 2007 Yes Yes No Yes No Yes 2Field et al., 1996. Not reported No No Yes No No 1Field et al., 2000. Not reported No No Yes No No 1Logsdon et al., 2005. Not reported No No Yesb No Yes; reasons not

reported2

Logsdon et al., 2010. Yes No No No No Yes 1Miller et al., 2008 Not reported Yes No No No Yes 1Miller et al., 2008.a Not reported Yes No No No Yes 1Oswalt et al., 2009. Not reported Yes No Yes2 No Yes 3Ginsburg et al., 2012. Yes Yes No Yes2 No Yew 3Walkup et al., 2009. Yes Yes No Yes2 No Yes 3

a Treatment studies. The remaining studies are prevention.b Randomization process was described in the study.c The Jadad Scale rates studies based upon: 1) randomization of participants (one point for randomization; one point for description of randomization

process), 2) reporting of number and reasons for participant withdrawals (one point), and 3) double blinding (one point for double blinding; one point fordescription of double blinding process).

K. Lieberman et al. / Journal of Adolescence 37 (2014) 1227e1235 1231

difference reached statistical significance). Fidelity was assessed insofar as ten percent of interventions were evaluated by twoindependent raters (though fidelity results were not reported).

Another treatment study assessed the effects of group-based IPTon perinatal depressive symptoms and clinical depressionin a sample of 11 pregnant, clinically depressed African American and Hispanic girls (screened and assessed via the K-SADS),attending an after school program at a public high school (Miller et al., 2008). The intervention consisted of 12 weekly groupIPT sessions that aimed to: 1) examine the adolescents' emerging roles as mothers, 2) help the adolescents identify andincrease social and material support, and 3) provide them with practice dealing with conflict and avoiding danger. Post-intervention, eight of the 11 participants no longer met criteria for major depression, and two of the remaining threeshowed reduced severity. Mean Beck Depression Inventory-II (BDI-II) and Hamilton Rating Scale for Depression (HRSD) scoresdecreased, non-significantly, but with large effect sizes (1.19 and .76 for the BDI-II and HRSD, respectively). Mean EdinburghPostnatal Depression Scale (EPDS) scores decreased significantly, with a large effect size (.94). No significant changes wereevident from post intervention to the 20-week follow-up on any of the measures.

Prevention studiesFour of the eight prevention studies were effective in reducing depression incidence compared to control conditions; these

included: a maternal massage program (Field et al., 1996); a multi-component treatment with daycare, relaxation, massage,and mother-infant coaching (Field et al., 2000); a 12-week IPT group intervention (Miller et al., 2008); and a maternal infantmassage program (Oswalt et al., 2009). No significant effects on depressive symptomatology (versus control) were demon-strated in: two home-visiting based psychoeducational interventions (Barnet et al., 2007; Walkup et al., 2009); an individualhome-based CBT intervention (Ginsburg et al., 2012); or a one-time social support enhancement intervention (Logsdon et al.,2005).

Field et al. (1996) conducted a RCT comparing the effects of massage and relaxation therapies on anxiety and depressivesymptoms in adolescent mothers from an inner-city hospital. Thirty-two African American (71%) and Hispanic (29%) ado-lescents with elevated Beck Depression Inventory (BDI) symptom scores (>16) participated in the study. Sixteen wererandomly assigned to receive bi-weekly massages for 5 weeks, and 16 were randomized to the relaxation therapy condition.The massage condition was associated with better outcomes (including decreased depression scores, anxiety scores, andphysiological measures of anxiety), as compared to the relaxation condition. BDI scores and the Profile of Mood States (POMS)depression scale items decreased pre-to-post intervention for the massage group, but not for the relaxation group.

In a different line of study, Field et al. (2000) examined the effects of a three-month comprehensive intervention, includingdaycare, school and vocational activities, mood induction, relaxation, massage therapy, and mother-infant interactioncoaching, on maternal depressive symptoms, biological indicators of stress, mother-infant interactions, and infant outcomes.Adolescent mothers, mostly African American (approximately 60%) and Hispanic (approximately 25%), were recruited fromthe hospital at the time they gave birth; 160 mothers had elevated depressive symptoms at the time of recruitment (BDI-II>12), and 100 mothers had no or minimal symptoms (BDI-II < 9). Thirty-one percent of the participants with elevated BDI-IIscores met the Diagnostic Schedule for Children (DISC) criteria for Dysthymia, while none of the participants with minimalBDI-II symptoms met criteria.

Participants with elevated depressive symptoms were randomized to the intervention or control group at 3 monthspostpartum, while participants without elevated depression scores comprised a “non-depressed” group. At six monthspostpartum, mothers in the intervention group had significantly lower BDI scores and incidence of major depressionmeasured on the DISC as compared to control group participants, but their scores and incidencewere higher than those of the

K. Lieberman et al. / Journal of Adolescence 37 (2014) 1227e12351232

non-depressed group. These results were maintained at the 12 months postpartum follow-up. Thus, intervention groupparticipants continued to have lower depressive symptoms and rates of depression, though these remained higher than thenon-depressed group.

In a pilot study, Miller et al. (2008) analyzed the effects on depressive symptoms of group IPT for pregnant teenagersattending a New York public school for pregnant and parenting girls. Participants included 14 pregnant African American andHispanic adolescents enrolled in a health class at the specialized school; all girls who were enrolled in the health class wereinvited to participate. The intervention consisted of 12 weekly group IPT sessions that aimed to: 1) examine the adolescents'emerging roles as mothers, 2) help them identify and increase social and material support, and 3) provide themwith practicedealing with conflict and avoiding danger. Thirteen out of the 14 girls showed significant reduction in depressive symptoms(assessed via the BDI-II and the EPDS) from pre-to-post intervention, with large and significant effect sizes (.86 and .89 for theBDI-II and EPDS, respectively). A post-hoc quasi-experimental control group of 13 pregnant adolescents who took the healthclass but who did not participate in the group had significantly higher BDI-II and EPDS scores at the 12-week mark than theadolescents who underwent the intervention.

Oswalt et al. (2009) tested the effects of maternal infant massage on adolescents' depression, confidence, parenting stress,and feelings about relationships with their infants. Twenty-five African American adolescents were recruited from aneducational and vocational parental training program at a public school. Mothers were randomly assigned, using a randomnumbers table, to the massage intervention (one-time infant massage training) or control (no intervention) group. Motherswere assessed at baseline (four weeks postpartum) and two months post intervention. Intervention group participants re-ported significantly lower depressive symptom (BDI-II) scores after the intervention, with a large effect size of .91.

The other four prevention studies did not demonstrate significant impacts on depression scores. Barnet et al. (2007)tested the effects of a home visiting program for pregnant and parenting adolescents on depressive symptoms,parenting, school status, and repeat pregnancy. The sample consisted of 84 adolescents (91% African American) receivingcare from one of three prenatal care sites in Baltimore. Forty-four adolescents were randomized to the home visitingprogram, and 40 were randomized to the usual care condition, and participants were followed for two years. The homevisiting program began in the third trimester, and consisted of two visits per week from trained paraprofessionals throughone year postpartum and one visit per month through the second year. The parenting curriculum focused on improvingknowledge of child development, increasing parenting attitudes and skills, and encouraging the use of health care. Theadolescent curriculum taught safe sex practices and promoting school attendance and completion. Home visitors ratedtheir adherence to program standards via standardized forms. Baseline depression symptom scores, assessed via the CES-D,were elevated in 34.5% of the sample. The home visiting program did not impact depression scores; however, the programwas associated with significant increases in parenting attitude scores (with a medium effect size of .49) and with increasedodds of school continuation.

In another psychoeducational home-visiting based study, Walkup et al. (2009) enrolled pregnant American Indian (Navajoand White Mountain Apache) adolescents to test the efficacy of a culturally adapted intervention (Family Spirit Intervention)in improving a variety of perinatal outcomes, including depression. Participants included 167 pregnant Navajo and WhiteMountain Apache adolescents and young adults (aged 12e22), recruited from reservation-based prenatal and school-basedclinics, and randomized to either the Family Spirit Intervention or a breastfeeding and nutrition education program. TheFamily Spirit Intervention consisted of 25 home-based, paraprofessional-delivered sessions, culturally designed for AmericanIndian adolescents, focusing on prenatal and infant care, family planning, substance abuse prevention, and instruction incoping skills and problem solving. This intervention utilized structured manuals and assessed fidelity through randomchecking of intervention adherence (of audiotaped sessions) and weekly supervision of interventionists. Participants wereassessed at baseline and at 2, 6, and 12 months postpartum. No between or within group differences were found in change indepressive symptom (CES-D) scores between any time-points.

Another preventive intervention targeting American Indian adolescents assessed the efficacy of a culturally adaptedhome-based CBT program in reducing perinatal depressive symptoms and preventing the onset of postpartum depression(Ginsburg et al., 2012). Participants included 47 pregnant Apache American Indian teenagers with elevated depressivesymptom scores (CES-D score of 16 or greater), who did notmeet criteria for currentMDD (as assessed via clinical interviews).The adolescents were randomly assigned to either the intervention (Living in Harmony) or control (Education-Support)condition. The Living in Harmony program consisted of an eight-week home-visiting based CBT intervention, culturallyadapted such that language and concepts cohered with participants' life experiences. The Education-Support conditionwas ahome-visiting based perinatal educational support program, which did not address coping skills for depression. Participantswere assessed immediately post intervention, and at 4,12, and 24weeks postpartum. Fidelity was assessed via periodic directobservation of interventionists and evaluators, as well as daily and weekly supervision.

Participants from both conditions decreased in severity of depressive symptoms (assessed via the CES-D and EPDS) frompre to post intervention and follow ups, with effect sizes ranging from .05 to .22 for the CES-D and from .03 to .22 for the EPDS;however, no differences in depression measures emerged between conditions. Rates of major depression were low acrossgroups, with only two participants (from the control group) meeting criteria at any time point post intervention.

Finally, Logsdon and colleagues (2005) tested the efficacy of a one-time social support intervention in decreasingdepressive symptoms among adolescent mothers. One hundred twenty-eight mostly African American (56%) and EuropeanAmerican (38%) students taking a childbirth education class from a public school for pregnant and parenting adolescents wererecruited. Students were randomly assigned, using a random numbers table, to receive pamphlet, video, or pamphlet plus

K. Lieberman et al. / Journal of Adolescence 37 (2014) 1227e1235 1233

video social support coaching, or to the control group. The intervention emphasized: identifying the need for support,deciding what kind of help to ask for, whom to ask for help, how to ask for help, and how to return favors. Participants wereassessed via the CES-D. Fifty-six percent of participants demonstrated mild depression symptom scores at baseline. Post-intervention, at six weeks postpartum, no significant differences were found on any measures between groups; however,depressive symptoms decreased (significantly) from pregnancy to the postpartum follow-up across groups.

Discussion

The purpose of this paper was to evaluate the current state of research regarding interventions to treat or prevent perinataldepression in pregnant and parenting adolescents, using a validated system to rate the quality of the intervention trials. Ninearticles (reporting on 10 studies) examining outcomes of interventions for pregnant adolescents or adolescent mothers inimproving depression were evaluated, including two treatment and eight prevention studies.

Both of the treatment studies, a group IPT treatment (Miller et al., 2008) and a motivational interviewing intervention(Logsdon et al., 2010), were successful in reducing rates of major depression. These studies had strengths of enrolling ethnicminority samples in mostly urban, underserved settings. Despite these strengths and the evidence for the utility of thesetreatments, the rigor of these studies was limited. Neither was a randomized controlled trial, and neither had a specifiedactive control condition (their control conditions consisted of treatment as usual). Only one utilized fidelity checks (Logsdonet al., 2010), only one reported effect sizes (Miller et al., 2008b), and neither utilized intent-to-treat analyses. Additionally,neither study utilized double blinding, though this process can be difficult to implement in intervention research. Regardingquality ratings, both studies received one out of five possible points, for reporting number of and reasons for participantwithdrawals. The lack of fidelity checks, effect size reporting, and utilization of intent-to-treat indicate the need for moremethodologically rigorous research in this area.

A substantially greater number of prevention studies than treatment studies were identified. The comparative number ofprevention studies is promising for the direction of this literature, as preventive interventions are designed to decrease theincidence of disorder, as well as subsequent negative sequelae. Of the eight prevention interventions, four were more suc-cessful than control conditions in preventing perinatal depression: a maternal massage program (Field et al., 1996); a multi-component treatment (Field et al., 2000); a 12-week IPT group intervention (Miller et al., 2008); and a maternal infantmassage program (Oswalt et al., 2009). Four of the eight studies demonstrated no significant effects on depressive symp-tomatology versus a control condition: two home-visiting based psychoeducational interventions (Barnet et al., 2007;Walkup et al., 2009); an individual home-based CBT intervention (Ginsburg et al., 2012); and a one-time social supportenhancement intervention (Logsdon et al., 2005). While the home-based CBT program resulted in decreased depressionscores post-versus pre-intervention, the program performed no better than the usual care, perinatal educational controlcondition (Ginsburg et al., 2012).

Like the treatment studies, the prevention studies recruited mostly minority samples from underserved urban areas.However, compared to the treatment studies, some of the prevention studies were more methodologically rigorous. Eachutilized a randomized controlled design, and all but two (Field et al., 1996, 2000) reported on participant retention. Threereported effect sizes (Barnet et al., 2007; Ginsburg et al., 2012; Oswalt et al., 2009), and three utilized intent-to-treat analysisand fidelity checks (Barnet et al., 2007; Ginsburg et al., 2012;Walkup et al., 2009). However, quality ratings ranged from one tothree out of five points. Therefore, there remains room for increased rigor in these studies. For instance, only one of theprevention studies had an active control condition (Walkup et al., 2009), and five did not utilize intent-to-treat analyses,fidelity checks, or double blinding (Field et al., 1996; Logsdon et al., 2005; Miller et al., 2008; Oswalt et al., 2009). In sum,additional research utilizing rigorous methodology is needed to identify preventive interventions that successfully reducedepression in perinatal adolescents.

Taking the treatment and prevention studies together, it is difficult to identify a pattern in the types of interventions thatproved efficacious. Efficacious interventions varied in terms of their approach, length, and type of providers. This suggeststhat a variety of approaches may be warranted, given the diversity of adolescent risk and resilience factors at play in thispopulation. None of the studies reported on subgroups who did or did not benefit, leaving room for future researchers toinvestigate and identify for what works for distinct populations of adolescents.

Future directions

To address the need for increased rigor, future studies should include full descriptions of samples, interventions, inter-vention providers, and control conditions. Interventions should be delivered by trained interveners with the competence toact flexibly, accurately assess and diagnose, and develop and implement treatment goals (American Psychological Association,2006). Control conditions should consist of active placebo interventions or evidence-based alternatives. Intervention fidelityshould be assessed and reported, and participant retention should likewise be described. Effect sizes should be calculated, andanalyses should be based on intent-to-treat.

Since psychological disorders may manifest differently across cultures and individuals (APA, 2006), testing interventionsacross populations is necessary to demonstrate that the intervention is generalizable. Indeed, the studies reviewed in thisarticle included sizable racial and ethnic minority samples, a considerable strength of this body of work. Studies should alsoaddress the ways in which interventions may be adequately adapted to fit the needs and preferences of their target

K. Lieberman et al. / Journal of Adolescence 37 (2014) 1227e12351234

populations. This type of cultural sensitivity was demonstrated in two of the studies reviewed in this paper, which addressedthe effects of interventions specifically targeting American Indian adolescents, by reflecting local native practices and beliefs(Ginsburg et al., 2012;Walkup et al., 2009). Interventions that are successfully culturally adapted are better able to: effectuallyengage participants in terms of recruitment, enrollment, attendance, and intervention satisfaction; and change negativeclinical outcomes, including both universal and culturally specific problems (Barrera & Castro, 2006).

Researchers and clinicians interested in targeting depression in perinatal adolescents may benefit from adapting in-terventions deemed evidence based and successful for perinatal adult depression, and adapting evidence based interventionsthat successfully address general depression in adolescents. CBT has been shown to be successful in the treatment (Bledsoe&Grote, 2006) and prevention (Mu~noz et al., 2007) of perinatal depression in adults. Group CBT has also been demonstrated asefficacious in preventing and treating depression in adolescents (David-Ferdon & Kaslow, 2008). In particular, the “Copingwith Depression-Adolescent” course was found to decrease the odds of major depression in adolescent children of depressedadults (Clarke et al., 2001) and in adolescents with elevated depressive symptom scores (Clarke, Hawkins, Sheeber,Lewinsohn, & Seeley, 1995); and it was found to successfully treat depression in adolescents who met criteria for the clin-ical disorder (Rhode, Clarke, Mace, Jorgensen,& Seeley, 2004). However, as demonstrated in this review, researchers have notyet successfully adapted CBT interventions for use with perinatal adolescents. Such an adaptation would be an importantdirection for future research.

Given the current state of the literature on interventions designed to treat and prevent adolescent perinatal depression,preliminary evidence has been found for the efficacy of a small number of treatment and a larger number of preventiveinterventions. However, this body of work is less than complete. Given the well-documented negative sequelae of perinataldepression on maternal and child outcomes, more research is needed to develop efficacious and effective interventions.Interventions that successfully treat or prevent adolescent perinatal depression can positively impact two generations (bothmother and baby), and improve the odds of long-term well-being for adolescents and their children.

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