Effects of an intensive depression-focused intervention for smoking cessation in pregnancy.

Recent data (CDC, 2006) reports an overall smoking rate of 11%–12% among women during pregnancy. Low socioeconomic status (SES) and depression have been found to be independent risk factors for continued smoking during pregnancy (Solomon & Quinn, 2004) (Ludman et al., 2000; Pritchard, 1994; Solomon et al., 2006; Zhu & Valbo, 2002) as well as post-partum relapse (Solomon et al., 2007). There is evidence that depression clusters with SES and other risk factors for persistent smoking during pregnancy, and that the clustering of such factors predicts smoking in a gradient fashion (Kahn, Certain, & Whitaker, 2002). That depression co-occurs with low SES is not surprising. Children who grow up with low SES parents are at two to three times greater risk for developing major depressive disorder (MDD) than those who grow up with parents of higher SES, even when parental MDD status is controlled (Ritsher, Warner, Johnson, & Dohrenwend, 2001; Gilman, Kawachi, Fitzmaurice, & Buka, 2002). Because persistent smoking during pregnancy is increasingly concentrated among low SES women, it might be assumed that the prevalence of MDD and depressive symptoms would be high in pregnant smokers. Evidence for this prediction comes from studies utilizing both epidemiological and clinical samples. In nationally representative samples of pregnant women, rates of depressive disorders have been estimated to be 11.4% in current tobacco users without nicotine dependence and 41% in women with DSM-IV nicotine dependence (Goodwin, Keyes, & Simuro, 2007); and the percentage of women above the Centers for Epidemiological Studies Depression Scale (CES-D) cutoff for depression has been found to be 37.5% (Zhu & Valbo, 2002). In a population based sample of low-income women, 9% met criteria for MDD within the past year (Flick et al., 2006). In a sample of women being screened for participation in a low intensity smoking cessation intervention trial, 46.1% of women met criteria for MDD, dysthymia or minor depression (Blalock, Fouladi, Wetter, & Cinciripini, 2005). Very few studies have examined the impact of depression on smoking cessation in pregnant women. One study found that baseline depressive symptoms failed to predict smoking cessation during late pregnancy among pregnant women participating in a telephone counseling smoking cessation intervention trial. (Ludman et al., 2000) However, the overall severity of depressive symptoms was low in the study sample, and this may have reduced the likelihood of detecting a significant relationship. Higher levels of depressive symptoms at end of pregnancy were found to predict relapse at 6 months postpartum in one study (Solomon et al., 2007). In a sample of pregnant smokers who were participating in a low intensity (videos) smoking cessation intervention (Blalock, Robinson, Wetter, & Cinciripini, 2006), we found that women with dysthymia or minor depression at baseline were less likely to be abstinent than women without current depressive disorders, although the effect for depressive disorder was marginal (OR = 6.3, 95% CI = [.757, 52.17], p = .076). Despite the lack of data on the impact of depression on smoking outcome in pregnant smokers, it seems likely that high levels of depression may pose barriers to cessation in this population and that the relative ineffectiveness of smoking cessation interventions for pregnant smokers may be due in part to lack of attention to such symptoms. While meta-analytic reviews indicate that psychosocial interventions are more effective for smoking cessation than usual care in pregnant smokers (Fiore et al., 2008; Lumley, Oliver, & Waters, 2000), the overall prenatal abstinence rates remain low with an average of 7.6% in control conditions and 13.3% in experimental conditions. More intensive interventions (e.g., greater than 90 minutes of therapist contact::Dornelas et al., 2006) or more frequent visits (e.g., up to 8::Albrecht et al., 2006), have been associated with higher abstinence rates during pregnancy; 28% at end of pregnancy and 39% at 8-weeks post—randomization, respectively. However, abstinence rates decline during the postpartum period and in most studies, perinatal differences between experimental and control conditions are no longer significant at postpartum follow-ups (Fiore et al., 2008; Melvin & Gaffney, 2004). The current study was designed to evaluate whether adding an intensive depression-focused treatment component to standard smoking cessation counseling would improve abstinence and depression outcomes in pregnant smokers. We evaluated Cognitive Behavioral Analysis System of Psychotherapy (CBASP), which is a learning-theory based approach that specifically targets interpersonal skills and coping deficits of the chronically depressed individual (McCullough, 2000). Given its interpersonal focus, CBASP appeared especially relevant for addressing a spectrum of psychosocial concerns among pregnant smokers, particularly those with high levels of depressive symptoms. In the current study, a combined smoking cessation and CBASP intervention was compared to a time and intensity matched smoking cessation and Health and Wellness (HW) educational control. Based on previous studies indicating that depression treatment components improve abstinence outcomes among those with more severe forms of depressive disorders and/or symptoms, but not among those with less severe forms of depression and/or symptoms (Brown et al., 2001; Haas, Munoz, Humfleet, Reus, & Hall, 2004; Patten, Drews, Myers, Martin, & Wolter, 2002), we hypothesized that only those with higher levels of baseline depressive symptoms would derive more benefit from the CBASP treatment, in terms of abstinence and symptom reduction, in comparison to HW. Those without such symptoms were expected to fare equally well with CBASP or HW treatments. Treatment effectiveness irrespective of symptoms of depression was not expected to vary.