1. Nurturing Families Network Depression Improvement Study The Connecticut Children’s Trust Fund, DSS Center for Social Research, UofH UCONN Health Center, Department of Psychiatry The Cincinnati Children’s Hospital Medical Center Child Health and Development Institute

2. 44.2% are depressed in 1 st year of service 88% do not get mental health treatment Ammerman, Putnam, et al., in press, Child Abuse & Neglect

3. Study Design Screening: EPDS ≥11 44 (26%) out of 167 Eligibility/Pre-treatment Assessment SCID Diagnosis of MDD 19 (45%) out of 42 (2 refusals) IH-CBT (n=12) 15 sessions + booster Ongoing home visitation HVAU (n=7) Community Resources Ongoing home visitation Post-treatment Assessment (n=1) 3 Month Follow-Up Assessment Inclusionary: Participants are ≥16 years old Baby 1<12 months EPDS ≥11 MDD using SCID Exclusionary: Non-NFN participants <16 years old Baby 12 months EPDS <11 No MDD using SCID Substance dependence Psychosis Current suicidality randomization

4. Role of Home Visitor: Our Main Partner   Screen moms using the Edinburgh   Introduce the study   Provide connection/communication to mother/family   Make engaging and identifying this subgroup possible

5. Nurturing Families Network versus Every Child Succeeds  Racial/Ethnic groups  Undocumented families  More variation in geographic location (inner city and rural)

6. What are the signs of depression? (Focus Group Analyses, 2007) “ Well, the signs are lack of interest in things. Because when I first met her she was pregnant, but she was involved in so many different programs. But now she doesn’t do much. She goes to school but she rarely goes even though she lives like in [neighborhood]. She just doesn’t do it. She doesn’t get out much. What I first brought out was like a checklist, like I did it in like a conversation manner to ask her how things were going or did she notice that she had a change in appetite or she was doing things differently. And she did. So I didn’t want to like push the subject every single home visit because then she would stop opening the door.”

7. What are the signs of depression? (Focus Group Analyses, 2007) “ …she is very depressed. She has panic attacks. She was a victim of child abuse. She was sexually abused when she was a child by a relative and then later on by her mother’s boyfriend. She told her mother. Her mother never paid any attention. Her father is not in the picture. She managed to start college.”

8. Experience of Major Depression  Sad, depressed feeling  Loss of interest in activities  Change in appetite  Insomnia; hypersomnia  Psychomotor agitation/retardation  Fatigue/tired, all day, nearly everyday  Feelings of worthlessness or excessive guilt  Difficulty concentrating and/or indecisiveness  Suicidal ideation

9. Individual & Family Context  Past trauma: physical/sexual abuse  Abandonment/rejection by family  Social isolation (i.e., emotional isolation)  Very low sense of worth (often hidden)  Different patterns among subgroups

10. “Ineligible” Mothers  History of depression  Multiple, complex issues  Young-young moms (many changes)  Have emotional support  Stable home situation  Need therapy too

11. Progress in therapy: SUCCESSESS AND CHALLENGES  Moms available for sessions;flexibility of therapists, positive feedback from moms  Moms enjoy learning CBT skills;participate in home practice, i.e. Activity Schedules and Thought Records  Moms responding positively to progress made on “ladder of success”; decrease in BDI II scores  Challenges as in all home visiting: not at home, pre-occupied, interruptions

12. Therapeutic Themes  Lack of entitlement (gender x depression) For help/services For help/services Support/attention from others Support/attention from others Time/Space Time/Space  Ambivalence in general & impact on treatment response/approach to intervention (benefit of motivational strategies, value of assessing “readiness”)  Emerging Typology of Maternal Depression Less severe, high readiness for change, fewer complexities, rapid & dramatic improvement Less severe, high readiness for change, fewer complexities, rapid & dramatic improvement More severe, high complexity, high trauma, intergenerational patterns, slower response to treatment, challenges to engagement More severe, high complexity, high trauma, intergenerational patterns, slower response to treatment, challenges to engagement

13. DISCUSSION  What do you (participating staff) think are successes and challenges so far?  What might be considered for a team model in future?