Efficacy of a Maternal Depression Prevention Strategy
in Head Start
A Randomized Clinical Trial
Michael Silverstein, MD, MPH; Yaminette Diaz-Linhart, MSW, MPH; Howard Cabral, PhD, MPH; William Beardslee, MD;
Mark Hegel, PhD; Winta Haile, BA; Jenna Sander, MPH; Gregory Patts, MPH; Emily Feinberg, ScD
IMPORTANCE Low-income and minority mothers experience a disproportionate incidence of
depression and lack access to treatment services. Development of prevention strategies in
accessible community-based venues is a potentially important public health strategy.
OBJECTIVE To determine the efficacy of a depression prevention strategy embedded in
DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was performed from
February 15, 2011, through May 9, 2016, at 6 Head Start agencies serving families at or below
the federal poverty level. Participants included mothers with depressed mood, anhedonia, or
depression history but who were not in a current major depressive episode. Participants were
followed up for 12 months with masked outcome assessments. Final follow-up was
completed on May 9, 2016.
INTERVENTIONS Participants were randomized to a problem-solving education (PSE)
intervention (n = 111) or usual Head Start services (n = 119).
MAIN OUTCOMES AND MEASURES Primary outcomes were problem-solving skills and
depressive symptoms. To capture the chronicity and intensity of symptoms, the Quick
Inventory of Depressive Symptoms was administered bimonthly, and rates of clinically
significant symptom elevations were compared across groups. Secondarily, the presence of
a major depressive episode was assessed using the Structured Clinical Interview for DSM-IV
Axis I Disorders.
RESULTS Among the 230 participants, 152 (66.1%) were Hispanic, with a mean (SD) age of
31.4 (7.3) years. An intention-to-treat analysis among 223 participants contributing follow-up
data found no differences in problem-solving skills across groups. The mean (SD) number of
depressive symptom elevations among the PSE participants was 0.84 (1.39) compared with
1.12 (1.47) among the usual service participants (adjusted incident rate ratio [aIRR], 0.60; 95%
CI, 0.41-0.90). In analyses stratified according to baseline depressive symptoms, PSE exerted
a preventive effect among those with lower-level baseline symptoms, with a mean (SD) of
0.39 (0.84) elevations among PSE participants compared with 0.88 (1.37) among usual
service participants (aIRR, 0.39; 95% CI, 0.21-0.75). However, no difference was observed
among those with higher-level baseline symptoms (mean [SD] elevations, 2.06 [1.92] for PSE
and 2.00 [1.91] for usual service; aIRR, 1.10; 95% CI, 0.67-1.80). Analysis of symptom scores
followed the same pattern, with an adjusted mean reduction of 1.33 (95% CI, 0.36-2.29)
among participants with lower-level baseline symptoms.
CONCLUSIONS AND RELEVANCE The PSE intervention is efficacious in preventing depressive
symptom episodes and performs optimally among those with initial low-level symptoms.
Additional effectiveness studies in Head Start are necessary to develop meaningful public
TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01298804
JAMA Psychiatry. doi:10.1001/jamapsychiatry.2017.1001
Published online June 14, 2017.
Author Affiliations: Author
affiliations are listed at the end of this
Corresponding Author: Michael
Silverstein, MD, MPH, Department of
Pediatrics, Boston Medical Center,
One Boston Medical Center Place,
Vose Hall, 3rd Floor, Boston, MA 02118
JAMA Psychiatry | Original Investigation
© 2017 American Medical Association. All rights reserved.