1. Depression Improvement Study Center for Social Research The CT Children’s Trust Fund, DSS The University of Connecticut Health Center, Department of Psychiatry The Cincinnati Children’s Hospital Medical Center Funded through a grant from the US Department of Health and Human Services. Additional support is provided by the Children’s Fund of Connecticut.

2. Study Team Marcia Hughes, Center for Social Research Morella Mora, Center for Social Research Linda Harris, The CT Children’s Trust Fund Karen Steinberg, University of CT Health Center Kathy Novak, University of CT Health Center

3. Home Visitor’s Guide to the Research Process Your guide is divided into four parts: Part One overall aims of the study. Part Two the role of the home visitor Part Three the research process and the role of the researchers Appendix contains sample scripts and the study forms

4. Part One: Why This Study Is Important and What We Aim to Achieve Why Treat Maternal Depression? Both national research and focus groups with home visitors in CT show that depression is a serious problem for mothers and their children. In addition, it potentially interferes with the effectiveness of home visitation programs.

5. Depressive Symptoms in the 1 st year of Service Highly prevalent Persistent even with home visitation services Often goes untreated Mothers are often unresponsive to home visitors Detrimental to Home Visiting

6. 88% do not get mental health treatment 44.2% are depressed in 1 st year of service Ammerman, Putnam, et al., in press, Child Abuse & Neglect

7. Barriers for Mothers Treatment may be unavailable in their community Lack of transportation Scheduling conflicts Lack of childcare Concerns about stigma May not receive a sufficient number of sessions for the treatment to be most effective

8. Home Visitor challenges Greater difficulty forming a relationship with the depressed mothers Mothers are less responsive to their advice Home visitors are not trained to diagnose major depression Home visitors are unprepared to deal with mothers crying and negative thought patterns Added worries about risks to the child

9. Benefits of IH-CBT Home Visitors are trained to screen mothers for depressive symptoms Therapists are trained to deal with mother’s crying and negative thought patterns Mothers are more likely to receive sufficient number of sessions and benefit from the treatment Therapists and Home Visitors work together as a team to help the mother Mothers are more receptive to the home visitor Effectively treating mother’s depression improves her parenting

10. Study Objectives 1) Compare the effectiveness of In-Home Cognitive Behavior Therapy (IH-CBT) in contrast to “typical” home visitation (THV) 2) Examine if there are different effects of IH-CBT on two home visitation models: Ohio’s Early Childhood Succeeds and Connecticut’s Nurturing Families Network (NFN) program 3) Examine the impact of effective treatment of depression on child functioning.

11. Part Two: The Role of the Home Visitor 1) Identify mothers who may be eligible 2) Introduce them into the Study 3) Make Referrals to the Study Research Team

12. STEP ONE: Identify Mothers who may be Eligible First-time mothers (cannot have more than one child), at least 16 years of age, and have a diagnosis of major depression. To screen your mothers for symptoms of Depression, ask them to complete the Edinburgh Postnatal Depression Scale (EPDS) at one to 12 months postnatal. Total up their responses using the score sheet (this involves simple math).

13. Review Edinburgh results If score is 2 or higher on item # 10, immediately contact your Supervisor to discuss appropriate intervention If their score is 11 or over, review the results with your supervisor and discuss how and when to introduce the study to the mother. If their score falls below 11, screen again every 2 months (no later than 12 months postnatal).

14. STEP TWO: Introduce the Study Explain the program using script as a guide Give Program Brochure to the mother Call us with any questions

15. Script to introduce the study “I would like to let you know about the Depression Improvement Study, for which you may be eligible. At Nurturing Families Network we are always trying to find ways to make our program better so that we can provide the best services to moms and their babies. I know you want your child to be happy and achieve the most out of his/her life. If you have been feeling blue (negative, beaten down, down and out, unhappy, sad) and are worried about your relationship with your child, this study may be able to help you and your child….(script continues)”

16. STEP THREE: Complete the Referral and Contact Information Form If the mother is interested in joining the study: Complete parts A, B, and C of the form and ask for the mother’s signature on part C. Fax the completed form and call us to let us know. If the mother is not interested in joining the study Fill out parts A and B of the form fax the form to us

17. STEP FOUR: Mail the Edinburgh Results Mail to us monthly along with your other NFN data (i.e. specifically by the 10 th of each month). Make sure that the Family Identification Number and your name is on each form before sending it to us.

18. Part Three: The research process

19. STEP ONE: Consenting Process Explain to the mother her involvement in the study and that it is voluntary Ask her to sign a written consent form granting permission to conduct the pre-assessment and enroll her in the study if eligible. For mothers who are under age 18, the researchers will have to obtain parental consent.

20. STEP TWO: Interview to Determine Eligibility (Pre-Assessment) Researchers will conduct a semi-structured interview (using the Structured Clinical Interview for DSM IV Axis I Disorders, SCID) (First, M. et. 1992). The mother will fill out self report forms on depressive symptoms, her social support and social network, any history of trauma, and other symptom dimensions (i.e. psychopathology). If any red flags (e.g. current bipolar disorder, chronic drug abuse, psychosis) which would make the mother ineligible for the study, the interview will be stopped.

21. STEP THREE: Random Assignment of Eligible Mothers Total of 100 mothers in the study Half of the mothers will receive In-home cognitive behavior therapy treatment (IH-CBT) and the other half will receive the typical home visitation (THV) with referrals to treatment in the community. Ensure equal representation for African Americans, Hispanics, and Caucasians/Other races within the two groups.

22. STEP FOUR: Notification to Mother Mothers who are Ineligible The mother and home visitor are notified by phone. A letter will be sent to the mom with information from the pre-assessment which they can use to get help in the community. The home visitor and the mother will discuss referral options for receiving treatment in the community.

23. Notification cont. Mothers who are Eligible The mother and home visitor are notified Informed of which group THV Group or IH-CBT THV mothers will discuss with their home visitor treatment options and referrals in the community. IH-CBT mothers are informed that their information will be passed along to the therapist Therapist receives a case summary based on the pre-assessment and contacts the mother to schedule their first therapy session.

24. STEP FIVE: Scheduling of Ongoing Assessments and Therapy Sessions THV Group: A brief 15 minute screen for identifying symptoms of depression will be given in weeks six and twelve by the researcher. –reminder call when the date approaches.

25. Scheduling cont. IH-CBT Group: There will be a total of 15 sessions and one booster session. A brief 15 minute screen for identifying symptoms of depression will be given at each session.

26. STEP SIX: Post Assessments Around 4 1/2 to 5 months after the first interview. Conducted by independent evaluators, who are trained Ph.D. students. They will be accompanied by a researcher. The independent evaluators are not told which group the mother was assigned to.

27. STEP SEVEN: Booster Session for Mothers in therapy Additional therapy session one month after session 15.

28. STEP EIGHT: Three Month Follow-Up Assessment This will be conducted by the independent evaluators. Mothers will be given a reminder call in advance of the scheduled date.

29. STEP NINE: 12 Month Child Outcome Interview Researchers will administer the Infant and Toddler Social- Emotional Assessment Questionnaire (ITSEA) when the child is twelve months old.

30. Appendix Script for administering the Edinburgh Script to introduce the study Referral and Contact Information Form Edinburgh Scale Edinburgh Score Sheet