Review
Psychosocial preventive interventions to reduce depressive symptoms in low-SES women at risk: A meta-analysis

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Abstract

Background

Women who have low socioeconomic status (SES) or live in disadvantaged circumstances are a vulnerable group at risk for depression. Little is known about the efficacy of preventive interventions to reduce depressive symptoms in low-SES women. The aim of this study is to provide an overview of controlled outcome studies and to investigate the overall efficacy and moderators of interventions targeted at reducing depressive symptoms in this population.

Methods

A systematic review and meta-analysis were conducted for 14 studies (N = 1396). The effect size of the studies was computed for outcomes assessing changes in depressive symptom levels using the standardized mean difference effect size. Study, target population, and intervention descriptors expected to influence effect size were analyzed using univariate subgroup and metaregression techniques with mixed-effects statistical models.

Results

The estimated overall effect size of 0.31 was significant; study sample characteristics, intervention characteristics and the research design of the studies did not moderate intervention effects.

Limitations

Limitations to this study are the relatively limited number of well controlled studies that could be included in the analyses.

Conclusions

A number of promising programs have been developed specifically for low-SES women, a population at high risk for developing major depression. On average these programs were found to reduce the level of depressive symptoms, with more than half of the studies showing medium to large effect sizes. This indicates that considerable mental health benefits can be gained among disadvantaged women.

Introduction

Depressive disorder is a major mental health problem in the general population, with 12-month prevalence rates of approximately 5 to 7% (Demyttenaere et al., 2004). The presence of depressive symptoms considerably increases the risk of developing a major depression (Cuijpers et al., 2004, Judd et al., 2002). Research has shown that women and people with low socioeconomic status (SES) appear to be especially affected. Incidence and prevalence rates of depressive disorders are higher among women than men, with a sex ratio of about 2:1 (Kuehner, 2003, Seedat et al., 2009). Studies show a similar pattern for low SES (Dohrenwend et al., 1992, Gutierrez-Lobo et al., 2000), with odds ratios (ORs) of 1.81 for depression prevalence and 2.06 for depression persistence in the lowest SES group (Lorant et al., 2003). Thus, women who have low SES or live in disadvantaged circumstances emerge as a particularly vulnerable group at risk for depression (Elliott, 2001, Kuehner, 2003). Compared to women with higher SES, low-SES women seem to have a more than doubled risk for developing depressive symptoms (OR 2.7) (Kahn et al., 2000). Similarly, for single-parent families, often headed by women, an OR of 3.37 has been found for the prevalence of mood disorders in the past 12 months (Bijl et al., 1998).

Numerous factors may contribute to depression in women, including hormonal, genetic, and other biological differences. In the aetiology of depression, stress factors also play an important role (Hauenstein, 1996a). The number and types of stressors as well as the mechanisms for coping with stress may all contribute to an adverse outcome. Chronic stress and daily hassles in particular are considered strong predictors of depressive episodes and symptoms (Hammen, 2003, McConagle and Kessler, 1990). Low-SES women may have the same biological vulnerability for depression as other women, but are more likely to suffer from depression as a result of elevated exposure to stressors, which is socially patterned by socioeconomic status (Denton et al., 2004, Sterk et al., 2006). Disadvantaged women are often exposed to an accumulation of life-event stressors and chronic problems related to their low-SES status, such as poor education, poor labour circumstances and unemployment (Brown et al., 1987, Elliott, 2001), and financial strain, inadequate housing, or neighbourhood violence (Ennis et al., 2000, Peden et al., 2004). The presence of chronic stressors may directly influence psychological distress, but may also indirectly lead to an increase in the number of acute stressors that low-SES women consequently have to deal with (Ennis et al., 2000, Hammen, 2003).

The vulnerability of disadvantaged women to the negative effects of stressful events (e.g. the development of depression), is further increased by their lack of psychological resources to limit the harmful impact of stressful conditions or minimize depressive symptoms. Lower self-esteem and lower perceived control or mastery over their lives are some examples of vulnerabilities that decrease the likelihood that low-SES women will seek and sustain adequate efforts toward solving problems (Ennis et al., 2000, Gallo et al., 2005, Nolen-Hoeksema et al., 1999). The chronicity of major depression, its impairing impact on role functioning, and high rate in disadvantaged women thus create a significant public health problem (Hauenstein, 1996b).

In recent years more attention has been paid to the treatment of mental health problems in this group. A brief overview of the literature shows that several effective depression therapies have been developed and adapted to the needs of low-SES women from different cultural backgrounds. For example, a controlled clinical trial offering interpersonal psychotherapy treatment to disadvantaged women with antepartum depression showed significant improvement compared to a parenting education control program. At termination, 60% of those in the IPT group recovered, whereas only 15% of those receiving parent education did so (Spinelli and Endicott, 2003). In addition, Miranda et al. (2003) examined the impact of cognitive-behavioural psychotherapy and antidepressant medication on working poor women. The interventions were modified to be sensitive to low-income women, and separate modest cultural adaptations were made for Latina and African American women. Both the medication intervention and the psychotherapy intervention were effective over and above community care in decreasing depressive symptoms and improving functioning of these women, even after one year follow-up (Miranda et al., 2006). Similarly, Kohn et al. (2002) conducted an evaluation of a CBT intervention adapted to be culturally sensitive in treating depressed low-income African American women. Following treatment, women in the adapted intervention exhibited a larger drop in depressive symptom scores than women treated in a non-adapted intervention. Finally, a study in Santiago, Chile compared the effectiveness of a stepped-care program with usual care in primary-care management of depression in low-income women. The stepped care comprised a 3-month, multi-component intervention including a psychoeducational group intervention, structured follow-up, and drug treatment for patients with severe depression. At six-month follow-up, 70% of the stepped-care group, compared with 30% of the usual-care group, was no longer symptomatic (Araya et al., 2003). Thus in general it seems that well-established psychotherapies such as in Cognitive Behavioral Therapy, Interpersonal Therapy and antidepressant medication are effective for disadvantaged women.

Despite advances in treating depression in low-SES women, the extent to which this group is confronted with depression and their underutilization of mental health services (Katon and Ludman, 2003, Mojtabai, 2005) calls for additional approaches to reduce mental health disparities. One approach to lower the severity and incidence depression among low-SES women would be to shift attention from treatment to prevention. Increasing evidence supports the primary prevention of depression (Dennis, 2005, Mendelson and Muñoz, 2006) and several randomized controlled studies have shown that preventive interventions aimed at participants with an elevated level of depressive symptoms may reduce their risk for developing a depressive disorder (Clarke et al., 2001, Willemse et al., 2004). However, less is known about the efficacy of preventive interventions specifically designed for and targeted at one of the populations most at risk: low-SES women. These interventions are usually adapted to fit the needs, competences and specific risk factors of disadvantaged women and can produce outcomes that enhance their resilience and reduce their vulnerability to depression. Research has found improved outcomes in both treatment and prevention efforts for depression when interventions take participants' social and cultural contexts into account (Podorefsky et al., 2001).

Essential for understanding intervention effects and improving program outcomes is knowledge and comprehension of potential outcome moderators in the study population, characteristics of the intervention and the research design of the studies. Previous meta-analyses (Cuijpers et al., 2008, Jané Llopis et al., 2003) identified outcome moderators for depression prevention interventions. Important moderating variables appeared to be program type and delivery mode, duration and timing of the intervention and type of intervention provider. Study variables that showed a moderating effect were both study quality and type of comparison group. However, it is unclear whether these moderators are also valid for interventions targeted at low-SES women.

This meta-analysis focuses on interventions specially targeting the selective or indicated prevention of depressive symptoms in low-SES women. The first aim is to provide an overview of preventive interventions specifically designed to reduce depressive symptoms in low-SES women and to examine the overall efficacy of these interventions, both immediate and over time. The second aim is to conduct an exploratory moderator analysis to systematically examine possible intervention, research design, and sample characteristics that may be associated with larger effects. By analyzing the effects of specific interventions for this population, this meta-analysis aims to contribute to the primary prevention of depression in low-SES women by identifying potentially influential intervention features.

Section snippets

Search strategy

Relevant studies were identified by searching the PubMed database of the National Library of Medicine, the PsycINFO and ERIC databases, and the Web of Science. The search strategy combined the following three groups of keywords: depress*, depressive symptoms, minor depression, psychological distress; social class, disadvantaged, poverty, socioeconomic status, SES, financial strain; prevent*, intervention, program*, early treatment and mental health services. Searches were specified for both

Characteristics of included studies

Searches of the electronic databases, manual searching and expert contacts identified 4953 titles. After screening of identified titles, 199 abstracts were further inspected to identify potentially eligible studies. Abstracts were screened by the primary author, and the second author independently rated a random sample of 25%. Interrater agreement on inclusion or exclusion of abstracts was 95%. A total of 111 articles were retrieved for further full-text evaluation of the inclusion criteria.

Discussion

This is the first meta-analysis studying the effectiveness of psychosocial interventions on reducing depressive symptoms in low-SES women. Findings from 14 evaluated interventions indicated significant positive effects with an overall effect size of 0.31 (95% CI [0.17; 0.45]). The failsafe N necessary to reduce this finding to a null effect would be six times the number of identified studies in the literature, all reporting negative results. This confirmed confidence in the outcomes of this

Role of funding source

This research was supported by the Dutch Organisation for Health Research and Development (ZonMw), project number 4016.0004. The funding agency has no role in the design, conduct and data analysis of this study.

Conflict of interest

All authors declare to have no conflict of interest.

References1 (91)

  • D.L. Podorefsky et al.

    Adaptation of preventive interventions for a low-income, culturally diverse community

    J. Am. Acad. Child Adolesc. Psychiatry

    (2001)
  • R. Rosenthal

    The "file drawer" problem and tolerance for null results

    Psychol. Bull.

    (1979)
  • Y.D. Senturia et al.

    Successful techniques for retention of study participants in an inner-city population

    Control. Clin. Trials

    (1998)
  • A. Tezel et al.

    Comparison of effects of nursing care to problem solving training on levels of depressive symptoms in post- partum women

    Patient Educ. Couns.

    (2006)
  • B.S. Ali et al.

    The effectiveness of counseling on anxiety and depression by mimimally trained counselors: a randomized controlled trial

    Am. J. Psychother.

    (2003)
  • F. Azocar et al.

    Treatment of depression in disadvantaged women

    Women Ther.

    (1996)
  • M.J. Bakermans-Kranenburg et al.

    Less is more: meta-analyses of sensitivity and attachment interventions in early childhood

    Psychol. Bull.

    (2003)
  • E.L. Bassuk et al.

    Prevalence of mental health and substance use disorders among homeless and low-income housed mothers

    Am. J. Psychiatry

    (1998)
  • A. Baxter et al.

    Social support, needs and stress in urban families with children enrolled in an early intervention program

    Infant Toddler Intervention

    (1999)
  • L.S. Beeber et al.

    In-home intervention for depressive symptoms with low- income mothers of infants and toddlers in the United States

    Health Care Women Int.

    (2004)
  • Bhuiga, A., Chowdhury, M., 2002. Beneficial effects of a woman-focused development programme on child survival:...
  • R.V. Bijl et al.

    Prevalence of psychiatric disorder in the general population: results of the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

    Soc. Psychiatry Psychiatr. Epidemiol.

    (1998)
  • G.W. Brown et al.

    Life events, vulnerability and onset of depression: some refinements

    Br. J. Psychiatry

    (1987)
  • L.F. Bullock et al.

    Telephone support for pregnant women: outcome in late pregnancy

    N. Z. Med. J.

    (1995)
  • G.N. Clarke et al.

    A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents

    Arch. Gen. Psychiatry

    (2001)
  • J. Cohen

    Statistical Power Analysis for the Behavioural Sciences

    (1988)
  • K. Crockett et al.

    A depression preventive intervention for rural low-income African-American pregnant women at risk for postpartum depression

    Arch. Womens Ment. Health

    (2008)
  • P. Cuijpers et al.

    Characteristics of effective psychological treatments of depression: a metaregression analysis

    Psychother. Res.

    (2008)
  • E.J. D'Angelo et al.

    Adaptation of the preventive intervention program for depression for use with predominantly low-income Latino families

    Fam. Process

    (2009)
  • K. Demyttenaere et al.

    Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys

    JAMA

    (2004)
  • P.C.A.M. Den Boer et al.

    Paraprofessionals for anxiety and depressive disorders

    Cochrane Database Syst Rev

    (2005)
  • C.L. Dennis

    Psychosocial and psychological interventions for prevention of postnatal depression: systematic review

    Br. Med. J.

    (2005)
  • B.P. Dohrenwend et al.

    Socioeconomic status and psychiatric disorders. The causation-selection issue

    Science

    (1992)
  • M. Egger et al.

    Bias in meta-analysis detected by a simple, graphical test

    Br. Med. J.

    (1997)
  • M. Elliott

    Gender differences in causes of depression

    Women Health

    (2001)
  • N.E. Ennis et al.

    Money doesn't talk, it swears: how economic stress and resistance resources impact inner-city women's depressive mood

    Am. J. Community Psychol.

    (2000)
  • L. Falconnier et al.

    Adressing economic stress in the treatment of depression

    Am. J. Orthopsychiatry

    (2008)
  • L.C. Gallo et al.

    Socioeconomic status, resources, psychological experiences, and emotional responses: a test of the reserve capacity model

    J. Pers. Soc. Psychol.

    (2005)
  • L.J. Gleser et al.

    Stochastically dependent effect sizes

  • Greenberg, M.T., Domitrovich, C., Bumbarger, B., 2001. The prevention of mental disorders in school-aged children:...
  • K. Gutierrez-Lobo et al.

    The gender gap in depression reconsidered: the influence of marital and employment status on the female/male ratio of treated incidence rates

    Soc. Psychiatry Psychiatr. Epidemiol.

    (2000)
  • E.J. Hauenstein

    Testing innovative nursing care: home intervention with depressed rural women

    Issues Ment. Health Nurs.

    (1996)
  • L.V. Hedges et al.

    Statistical Methods for Meta-analysis

    (1985)
  • J.P. Higgins et al.

    Measuring inconsistency in meta-analyses

    Br. Med. J.

    (2003)
  • J.L. Horowitz et al.

    The prevention of depressive symptoms in children and adolescents: a meta-analytic review

    J. Consult. Clin. Psychol.

    (2006)
  • Cited by (0)

    1

    References marked with an asterisk indicate studies included in the meta-analysis.

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