Depression is too often a family affair and ought to be viewed that way,
but the unsystematic nature of the U.S. health care system serves as a major
block to identifying and treating millions of parents whose depression may
affect their children's future, according to a report from the National
Research Council and the Institute of Medicine.
"[P]arental depression is prevalent, but a comprehensive strategy to
treat the depressed adults and prevent problems in the children in their care
is absent," said the report from a task force chaired by Mary Jane
England, M.D., president of Regis College in Weston, Mass., and a former
president of APA. She spoke at a press conference in Washington, D.C., last
month announcing the study's results.
The report estimates that there are 7.5 million parents with depression in
the United States caring for 16 million children under age 18.
Depression is usually addressed as a disorder in individuals, but when that
individual is a parent, it can affect other family members as well. Parental
depression can result in a withdrawn, detached parenting style that interferes
with attachment and harms the child's physical, psychological, and social
development. It can also disrupt the structure and routine that provide a
framework for young lives and is associated with poorer physical health in
children. Depression is often accompanied by other physical or psychological
comorbidities, most prominently anxiety or substance abuse, often worsening
outcomes for affected families, said England.
"We need to think about depressed parents as parents first and then
as depressed people," added panel member William Beardslee, M.D.,
academic chair in the Department of Psychiatry at Children's Hospital Boston
and the Gardner/Monks Professor of Child Psychiatry at Harvard Medical School.
Current approaches to depression focus too narrowly on symptoms and diagnoses
in individuals while ignoring broader effects on families. Existing screening,
treatment, and research protocols, for instance, do not take into account the
possibility that the patient is a parent.
The problem has received less attention than it should because it falls
along the boundaries of professional and policy domains, from research to
payment for services.
"There is remarkably little systematic examination of depression in
parents," said the report. Research and attention usually focus on
mothers, with little data available on fathers. Women are screened during
pregnancy and shortly following birth, but seldom beyond that point, due to
inadequate guidelines or insurance limitations involving cut-off points for
reimbursing the physician. Numerous barriers to care stand in the way of
screening, access, treatment, and reimbursement.
The remedy lies in comprehensive, multigenerational, family-centered care
that will not only identify and treat parents with depression,
but also help them
improve their parenting skills, and provide support for their children,
For a start, the U.S. Surgeon General should encourage federal health
agencies to increase their recognition of depression in parents and its
effects on children's development, along with collaborative research into risk
and protective factors and, ultimately, demonstration projects to evaluate
The Substance Abuse and Mental Health Services Administration and the
Health Resources and Services Administration should develop collaborative
training programs for primary, mental health, and substance abuse
professionals to break down the silos that isolate professional groups.
Payment rules for both public and private payers should be changed to
permit care in nonclinical settings (such as home visits or community centers)
and eliminate current restrictions in Medicaid that prohibit same-day visits
for mental health and primary care services.
Impeding use of Medicaid for this group are "low reimbursement rates,
lack of benefit coverage to assess for maternal depression, prohibitions
against pediatricians assess[ing] parents, and a restricted range of eligible
The prospect of achieving such widespread change is daunting, even for
members of the IOM committee. "We know what we should do, but we don't
know how to implement it," said Beardslee in a follow-up interview."
We need a broad public-health approach. However, there will be a real
payoff because medical outcomes are worse in people with depression, so there
ought to be an incentive to identify and treat family members."
"Depression in Parents, Parenting, and Children: Opportunities
to Improve Identification, Treatment, and Prevention" is posted at<www.bocyf.org/parental_depression_brief.pdf>.▪