Problem-Solving Education to Prevent Depression Among Low-Income Mothers: A Path Mediation Analysis in a Randomized Clinical Trial

Michael Silverstein, Howard Cabral, Mark Hegel, Yaminette Diaz-Linhart, William Beardslee, Caroline J Kistin, Emily Feinberg, Michael Silverstein, Howard Cabral, Mark Hegel, Yaminette Diaz-Linhart, William Beardslee, Caroline J Kistin, Emily Feinberg

Abstract

Importance: Although problem solving has been an important component of successful depression prevention and treatment interventions, evidence to support problem solving's mechanism of action is sparse.

Objective: To understand the mechanism of an efficacious depression prevention intervention, problem-solving education (PSE).

Design, setting, and participants: A multivariate path analysis was embedded within a randomized efficacy trial (February 15, 2011, to May 9, 2016). Participants were mothers with depressed mood, anhedonia, or depression history (but not in current major depressive episode) at 1 of 6 Head Start agencies. Participants were followed up for 12 months with serial assessments of potential intervention mediators and depressive symptoms.

Interventions: Problem-solving education (n = 111) and usual Head Start services (n = 119).

Main outcomes and measures: Primary outcomes were depressive symptom elevations, which were measured bimonthly. Eight plausible intervention mediators were assessed: problem-solving ability; mastery; self-esteem; perceived stress; behavioral activation; and avoidant, problem-focused, and social coping.

Results: Among 230 participants, 152 (66.1%) were Hispanic; mean (SD) age was 31.4 (7.3) years. Based on associations with either PSE participation or depressive symptom outcomes, problem-solving ability, perceived stress, behavioral activation, and problem-focused coping were included in a parsimonious, multivariate path model. In this model, only perceived stress was associated with both PSE participation and depressive symptoms. Participants in the PSE group had adjusted standardized perceived stress change scores that were 11% lower than controls (95% CI, -0.19 to -0.03), and improvement in perceived stress generated an adjusted rate ratio (aRR) of 0.42 (95% CI, 0.33-0.53) for depressive symptom elevations. Participants in the intervention group also had standardized behavioral activation change scores 15% greater than controls (95% CI, 0.01-0.30) and problem-focused coping change scores 17% greater than controls (95% CI, 0.03-0.31); however, changes in these constructs were not associated with a differential rate of depressive symptom elevations. The direct effect of PSE on depressive symptom elevations (aRR, 0.72; 95% CI, 0.52-0.97) was greater than the mediated effect explained by improvement in perceived stress (aRR, 0.91; 95% CI, 0.85-0.98).

Conclusions and relevance: Problem-solving education is efficacious in preventing depressive symptoms and appears to work by decreasing perceived stress; however, the mechanism for much of PSE's impact on depression remains unexplained. These results can be used to simplify the intervention model in preparation for effectiveness testing.

Trial registration: ClinicalTrials.gov Identifier: NCT01298804.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Silverstein reported grants from the National Institutes of Health during the conduct of the study. Dr Cabral reported grants from the National Institute of Mental Health during the conduct of the study. Dr Diaz-Linhart reported grants from Boston Medical Center during the conduct of the study. Dr Beardslee reported grants from Boston University during the conduct of the study. Dr Kistin reported grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. CONSORT Diagram
Figure 1.. CONSORT Diagram
From Silverstein et al. MDE indicates major depressive episode; PSE, problem-solving education.
Figure 2.. Full Multivariate Model
Figure 2.. Full Multivariate Model
Coefficients linking problem-solving education (PSE) to mediators convey the adjusted difference in percentage of a standard deviation of change between those receiving PSE and those not receiving PSE. The values shown in parentheses are 95% confidence intervals. For perceived stress and avoidant coping, a negative value conveys a more positive outcome; for all other mediators, a positive value conveys a more positive outcome. Estimates shown linking mediators to depressive symptom elevations convey the adjusted rate of depressive symptom elevations associated with an incremental 1 SD change mediator score.
Figure 3.. Parsimonious Multivariate Path Model
Figure 3.. Parsimonious Multivariate Path Model
Coefficients linking problem-solving education (PSE) to mediators convey the adjusted difference in percentage of a standard deviation of change between those receiving PSE and those not receiving PSE. The values shown in parentheses are 95% confidence intervals. For perceived stress, a negative value conveys a more positive outcome; for all other mediators, a positive value conveys a more positive outcome. Estimates shown linking mediators to depressive symptom elevations convey the adjusted rate of depressive symptom elevations associated with an incremental 1 SD change mediator score.

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