Problem-Solving Education Prevents Depression Through Stress Reduction

Yaminette Diaz-Linhart, MSW, MPH

Recent research into the mechanisms of preventing depression through problem-solving education (PSE) found that participants’ perceived stress levels were associated with both PSE participation and depressive symptoms.

Study participants in the PSE group had adjusted standardized perceived stress change scores that were 11% lower than those in the control group (95% CI, −0.19 to −0.03).

Additionally, participants in the PSE group 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). These differences, however, were not associated with a different rate of depressive symptoms.

“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,” wrote study authors Michael Silverstein, MD, MPH; Howard Cabral, PhD, MPH; Mark Hegel, PhD; and Yaminette Diaz-Linhart, MSW, MPH, et al.

The study included 230 low-income mothers with depressed mood, anhedonia, or a history of depression, but not in a major depressive episode at the time of the study. This randomized efficacy trial was conducted at 6 different Head Start agencies from 2011 to 2016.

Participating mothers were randomly assigned to problem-solving education in addition to Head Start services (n = 111) or just Head Start services (n = 119), which included family needs assessments, home visitation, parenting groups, referrals to behavioral health services, and assistance with accessing community resources for food, job training, and housing.

PSE participants met one-on-one with trained intervention providers in their homes or at the Head Start center. The full course included 6 instructive sessions, typically 30 to 60 minutes, delivered weekly or biweekly. The authors identified several mediating factors, including problem-solving skills, self-esteem, and coping strategies, and assessed each at baseline, 6 months, and 12 months.

In an invited commentary, David Daniel Ebert, PhD and Pim Cuijpers, PhD applauded Silverstein, et al for investigating the mechanisms of a preventative psychological intervention, an area they say is under-examined.

“It remains unknown through which specific mechanisms such interventions work. Do they mainly work through a reduction of risk factors, or by supporting protective factors, such as mastery and self-efficacy? Asked Ebert and Cuijpers. “They might also be effective simply by enabling individuals to cope with early symptoms of depression and thereby prevent the development of more severe symptoms.”

In discussing the results, the study authors noted that over the course of a year, PSE substantially reduced the rate of symptomatic person-time. “[M]ost of this impact appears to have been a direct effect of PSE on depressive symptoms,” said Silverstein et al. “However, it also appears that a substantial part of PSE’s effect is mediated through a constellation of other factors, most notably the reduction of perceived stress. Although PSE appears to enhance behavioral activation and problem-focused coping, these intervention targets do not appear to be associated with symptom improvement.”

The paper reported that the direct effect of problem-solving education on depressive symptoms was greater than the mediated effect. Silverstein et al described 2 possible interpretations of this finding.

“The first is that our measurement strategy could have underestimated the role of stress as a mediating factor. In this case, the Perceived Stress Scale may have incompletely captured the domains of stress we sought to measure,” the authors wrote. “The second interpretation is that we have yet to fully understand problem solving’s primary mechanism of action; in this case, some of PSE’s purported direct effect may actually be an unmeasured mediated effect.”

The uncertainty highlights a need that the study authors as well as the commentary authors addressed. “More studies are needed to examine the best procedure for prevention as well as relevant mechanisms and moderators of intervention outcome,” said Ebert and Cuijpers.

The study, “Problem-Solving Education to Prevent Depression Among Low-Income Mothers; A Path Mediation Analysis in a Randomized Clinical Trial” was published in JAMA.