A 40-year-old single mother of two children from Latin America settles in a large U.S. city where she has come for treatment of a medical condition. The children include a healthy 10-year-old daughter and a 7-year-old son diagnosed with ADHD. Struggling to make ends meet and wrestling with language and other barriers, she falls into a relationship with a man who promises to solve her problems but turns out to be abusive and neglectful. She becomes despondent, angry, and irritable. A primary care physician diagnoses her as depressed and refers her to a psychiatrist.
Is there one patient above? Or are there two, or possibly three?
Typically, the mother in this scenario would be treated by an adult psychiatrist and the son by a child psychiatrist. But a large and growing body of research today indicates that the nonsymptomatic children of depressed parents are at risk for depression themselves, calling for a family-systems approach to treatment that would include the healthy daughter as well as the son.
Moreover, that research also suggests that such a family-based approach can help prevent depression among at-risk children.
Eugene D'Angelo, Ph.D., director of outpatient psychiatry services at Children's Hospital in Boston, told Psychiatric News that in the scenario described above, a family-based prevention intervention developed by Boston psychiatrist William Beardslee, M.D.—a pioneer in research on the prevention of depression in children—was adapted for use with Latino families (see Parental Depression: Let's Talk).
"This was a preventive intervention in which the major focus was on the parent within the family and how the parent impacts the risk for depression and mental illness in the children," he said. "We addressed factors that bore on the mother's own depression, but since this was a preventive intervention, our target was the children.
"In our project [working with Latino families], many of the parents assumed that their children did not know that their parents were depressed," D'Angelo said. "In fact, the children did know and could tell us their parents were depressed. So one of the things we were looking for was to begin to get the family to start to open up lines of communication and to engage in problem-solving activities."
The intervention was described in the June 2009 Family Process.
"Is it the endpoint of the process? No, but it represents a solid beginning," said D'Angelo. "What we are doing is really trying to affect a change in the way the entire family works together that will have lasting beneficial effects for the children."
An intergenerational, family-focused approach to depression in parents—and prevention of depression in children—was the focus of a June 2009 report by the Institute of Medicine (IOM), "Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention."
It stated that "a major challenge to the effective management of parental depression is developing a treatment and prevention strategy that can be introduced within a two-generation framework, conducive for parents and their children."
(An earlier report by the IOM in February 2009, "Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities," stated that preventive interventions in several areas—especially depression, schizophrenia, and violence—are now available and can be implemented on a wide basis [Psychiatric News, April 3, 2009].)
Beardslee, chair of APA's former Corresponding Committee on Prevention of Mental Disorders and Promotion of Mental Health and a member of the IOM committees that produced both reports, said he believes prevention is the future of psychiatry and the rest of medicine.
"Changing the paradigm so that clinicians consider prevention as part of practice is vital," he told Psychiatric News. "Most of medicine has moved to a disease-state-management model rather than an acute-sickness model. For psychiatry, a logical place to start is prevention programs for children of parents who have mental illness."
Also appearing last year in the Journal of the American Medical Association (June 3, 2009) were results of a multicenter, randomized, controlled trial conducted in four U.S. cities showing that a family-based prevention intervention had a significant effect on nonsymptomatic or subsymptomatic children, based on both clinical symptoms and self-reported depressive symptoms, through a nine-month follow-up period.
In the study "Prevention of Depression in Adolescents: A Randomized Control Trial," 316 adolescents whose parents had a current or prior depressive disorder were recruited from August 2003 to February 2006 to participate. Though largely asymptomatic, the adolescents had a history of depression, current elevated but subdiagnostic depressive symptoms, or both. Adolescents were randomly assigned to a prevention program based on cognitive-behavioral therapy or to usual care.
(Usual care consisted of whatever nonstudy mental health services participants sought out in the community.)
The intervention consisted of eight weekly 90-minute sessions followed by six monthly continuation sessions for mixed-sex groups of three to 10 adolescents. Adolescents were taught cognitive restructuring techniques to identify and challenge unrealistic and overly negative thoughts and were taught problem-solving skills. The intervention was developed by Greg Clarke, Ph.D., of Kaiser Permanente Center for Health Research in Portland, Ore.
(The lead author of the report was Judy Garber, Ph.D., of the Department of Psychology at Vanderbilt University, one of the four study sites. Other site leaders were Beardslee; David Brent, M.D., at the University of Pittsburgh; and Clarke.)
Assessments were conducted at baseline, after the eight-week intervention, and after the six-month continuation phase. At follow-up the rate of a probable or definite depressive episode—measured by a depressive symptom rating score of 4 for at least two weeks on the Depression Symptom Rating Scale—was determined.
Results showed that the rate of depressive episodes was lower for those receiving the prevention program than for those in usual care. Adolescents in the prevention program also showed significantly greater improvement in self-reported depressive symptoms than did those in usual care.
Interestingly, if a parent was depressed at baseline, effects of the intervention were tempered.
"We are still in the process of understanding what concurrent parental depression means," Beardslee, a coauthor of the report, told Psychiatric News. "The short-term clinical implication is that we should offer prevention services to children at a time when the parents are not acutely depressed. Therefore, we should be careful to ensure that parents have access to good treatment and that they recover.
"It probably will prove true that combining a treatment for parents who are acutely depressed with a prevention program for their children will be most helpful," he said. "There is evidence that when parents are acutely depressed, youngsters do not do as well in treatment [for their own depression], so we think probably in both instances, a focus on making sure parents get good treatment is needed."
An abstract of "Adaptation of the Preventive Intervention Program for Depression for Use With Predominantly Low-Income Latino Families" is posted at <www3.interscience.wiley.com/journal/122394197/abstract>.
An abstract of "Prevention of Depression in At-Risk Adolescents: A Randomized Controlled Trial" is posted at <http://jama.ama-assn.org/cgi/content/abstract/301/21/2215>.
"Depression in Parents, Parenting and Children: Opportunities to Improve Identification, Treatment, and Prevention" is posted at <www.nap.edu/catalog.php?record_id=12565>.
"Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities" is posted at <http://books.nap.edu/openbook.php?record_id=12480&page5>.