Novel Approach Prevents Depression in High-Risk Mothers

Pam Harrison

June 16, 2017

A simple problem-solving intervention significantly curbs full-blown depression in at-risk mothers with depressive symptoms, results from a randomized trial suggest.

"This wasn't a treatment project, it was a prevention project where we worked with mothers who had low-level symptoms of depression, and our goal was to prevent the emergence of high-level symptoms that would be consistent with a diagnosis of depression," Michael Silverstein, MD, MPH, Boston Medical Center, Massachusetts told Medscape Medical News.

"The success of the project blew us away because we were able to demonstrate that the project cut the incidence rate of high-level depressive symptoms by 40%.

"This is a simple intervention for which we can train nonlicensed providers in 2- to 3-day sessions and then have them deliver this program with high fidelity in the community," Dr Silverstein added.

The study was published online June 14 in JAMA Psychiatry.

Benefits May Extend to Children

The Head Start program is an overall wellness program initiated during the Kennedy era to serve low-income children and families nationwide.

"The idea is that by giving disadvantaged children a high-quality, early learning experience before they hit kindergarten, they'll hit kindergarten more ready to learn," said Dr Silverstein.

Head Start is not purely a preschool program, nor is it a designed to deliver mental health services to mothers as they make their often difficult way through life.

Knowing that depression and depressive symptoms are extremely common among low-income mothers, the investigators developed a problem-solving education (PSE) program consisting of six sessions centered on cognitive behavioral tasks.

Problem-solving sessions lasted 30 to 60 minutes and were conducted as home visits or in Head Start centers for 6 to 8 weeks.

The researchers trained 15 intervention providers ― who were not licensed mental health clinicians ― to offer PSE sessions to mothers. The sessions were conducted mostly in the mothers' homes, although sessions could be held wherever the providers and the mothers could meet, including park benches during mothers' lunch breaks.

Dr Silverstein noted that problem-solving has long been used as a treatment to help people with major depression.

Often used in conjunction with medication, problem-solving sessions are usually administered by highly trained psychologists or social workers, not nonlicensed, community care–based providers, which makes the PSE program offered within the Head Start program exceptional.

Of the 230 mothers who participated in the project, 111 were assigned to the PSE group. The remaining mothers received typical Head Start services.

"Of a possible 6 PSE sessions, the mean number completed was 4.64," the investigators note. Slightly more than half of the PSE group (58.6%) completed the full course.

At the end of the 12-month follow-up, in the PSE group, the mean number of moderately severe elevations in symptoms was 0.84, compared to 1.12 for the usual-service Head Start group.

"This difference produced an adjusted incident rate ratio (aIRR) of 0.60...in favour of PSE," the researchers report.

The researchers stratified participating mothers into two groups on the basis of whether they had a baseline score of 11 or greater on the Quick Inventory of Depressive Symptoms (QIDS). Higher scores indicate a higher burden of depressive symptoms.

Among those whose score was below the threshold, PSE exerted a preventive effect on symptom elevation (aIRR, 0.39).

In contrast, mothers with QIDS scores above the baseline level of 11 derived no benefit from the PSE program.

In accounting for this difference, the study authors suggest that PSE is not intense enough to alleviate more clinically significant depressive symptoms, although there may be other explanations.

"We know without a shadow of a doubt that a child growing up with a mother who suffers from depression is at a disadvantage — socially, cognitively, in every which way," said Dr Silverstein.

"That's no fault of the mother, but it's a big component of the child's environment, particularly in the early years of life. If we are able to prevent that, we feel that it will not only benefit the mother, but the child stands to benefit as well," he added.

Promising Indicators

Commenting on the findings for Medscape Medical News, Shanna Shulman, PhD, senior program officer, the Richard and Susan Smith Foundation, Newton, Massachusetts, said she found a number of promising indicators emerging from this study.

"First of all, it's an upstream intervention, which means we have a chance to have a positive impact on the lives of vulnerable families before illness contributes to a compromised quality of life," Dr Shulman noted.

Being a prevention program, the PSE initiative that was implemented in the study is also a highly cost-effective solution because it is administered by nonlicensed community care workers in an upstream context, she added.

She also applauded the use of nonlicensed individuals in and of itself, because these people are already deeply embedded in their community. As such, they are rooted in the culture of the community and are trusted by the young mothers who see the Head Start program as a community of their own.

Lastly, the PSE program is easy for low-income mothers to access. "Certainly here in the US, we have tremendous challenges to provide adequate access to behavioral health services for vulnerable families," Dr Shulman said.

"So the fact that these people were able to find a way to use the Head Start program, which is already a very effective conduit into these families' lives, is quite promising," she added.

The Richard and Susan Smith Family Foundation works to improve the lives of disadvantaged families in the greater Boston area.

The study was supported by the National Institute of Mental Health. The study authors and Dr Shulman have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online June 14, 2017. Full text

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