Department of Pediatrics, Boston Medical Center, Boston, Massachusetts.
Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts.
JAMA Netw Open. 2018 Jun 1;1(2):e180334. doi: 10.1001/jamanetworkopen.2018.0334.
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.
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.
Problem-solving education (n = 111) and usual Head Start services (n = 119).
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.
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).
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.
ClinicalTrials.gov Identifier: NCT01298804.
尽管解决问题一直是成功预防和治疗抑郁症的重要组成部分，但支持解决问题的作用机制的证据却很少。
了解一种有效的抑郁症预防干预措施，即问题解决教育（PSE）的作用机制。
设计、设置和参与者：在一项随机疗效试验（2011 年 2 月 15 日至 2016 年 5 月 9 日）中嵌入了多元路径分析。参与者是来自 6 个 Head Start 机构中的 1 个机构的有抑郁情绪、快感缺失或抑郁病史（但当前没有重度抑郁发作）的母亲。参与者在 12 个月内接受了一系列潜在干预措施中介体和抑郁症状的随访评估。
问题解决教育（n=111）和常规 Head Start 服务（n=119）。
主要结局是抑郁症状加重，每两个月评估一次。评估了 8 种可能的干预中介体：解决问题的能力；掌握；自尊；感知压力；行为激活；以及回避、问题焦点和社会应对。
在 230 名参与者中，有 152 名（66.1%）为西班牙裔；平均（SD）年龄为 31.4（7.3）岁。基于与 PSE 参与或抑郁症状结果的关联，解决问题的能力、感知压力、行为激活和问题焦点应对被纳入一个简约的多元路径模型。在这个模型中，只有感知压力与 PSE 参与和抑郁症状都有关联。PSE 组的参与者感知压力变化的调整标准化分数比对照组低 11%（95%CI，-0.19 至 -0.03），感知压力的改善产生了抑郁症状加重的调整率比（aRR）为 0.42（95%CI，0.33-0.53）。干预组的参与者的行为激活变化评分比对照组高 15%（95%CI，0.01-0.30），问题焦点应对变化评分比对照组高 17%（95%CI，0.03-0.31）；然而，这些结构的变化与抑郁症状加重的差异率无关。PSE 对抑郁症状加重的直接影响（aRR，0.72；95%CI，0.52-0.97）大于感知压力改善解释的中介影响（aRR，0.91；95%CI，0.85-0.98）。
问题解决教育在预防抑郁症状方面是有效的，似乎通过降低感知压力起作用；然而，PSE 对抑郁影响的大部分机制仍未得到解释。这些结果可用于简化干预模型，为有效性测试做准备。
ClinicalTrials.gov 标识符：NCT01298804。
