Children Improve as Mothers’ Depression Remits

The conventional wisdom that a child benefits from improvement in the mother's mental health has been confirmed and quantified in a prospective evaluation of the relationship between a child's clinical state and remission of the mother's depression.

The maternal-child investigation reported in the Journal of the American Medical Association by Myrna Weissman, PhD, and colleagues is an ancillary study of the NIMH-sponsored STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial conducted between December 2001 and April 2004.

Weissman and colleagues¹ found an 11% decrease in rates of diagnosis in children of mothers whose depression remitted after 3 months of antidepressant medication, in contrast to an 8% increase in rates of diagnosis in children of mothers who did not respond to treatment.

“To our knowledge, this is the first published study to document prospectively the relation between remission of a mother's depression and her child's clinical state,” the investigators said.¹

Although childhood-onset psychopathology is likely to have a genetic component, this study supports the strong influence of the environmental factor of remission in maternal depression. Weissman and colleagues acknowledged that their observational study could not establish causality but suggested that “a reduction in stress associated with maternal remission may reverse the long-standing symptoms in children who are likely to be genetically vulnerable.”

Prospectively measuring improvement

Before developing their research protocol as a component of the STAR*D trial, Weissman and colleagues had attempted to identify and treat depression in mothers bringing their children for treatment. The investigators found this to be a problematic strategy, despite identifying a cohort in need of treatment. “It is difficult to engage depressed mothers in treatment for themselves if they come to the clinic to bring their child for treatment of depression,” they noted.²

With few participants and many of their children receiving separate treatment that would confound results, that investigation could only provide a preliminary indication of the relationship between a mother's and her child's conditions. Of 12 mothers who entered the study, 9 completed the study treatment condition of a 12-week course of interpersonal psychotherapy. The investigators found that improvement in maternal depression was associated with improved functioning in their children but not with symptom reduction.

The investigators suggested that the disparate outcomes of improved functioning and unimproved symptoms may have occurred because of a relatively low symptom level at baseline, with some children having received treatment before their mothers entered the study. The investigators also considered the possibility that a longer period than 12 weeks was necessary to measure effect on children's symptoms. Alternatively, they speculated that “at age 14, the offsprings' peer group exerted a greater influence on them than did their mothers.”

To better test their hypothesis, Weissman and colleagues used the STAR*D cohort to identify 151 previously untreated mothers with major depressive disorder who had children aged 7 to 17 years. All the mothers had a baseline score on the 17-item Hamilton Rating Scale for Depression of 14 or higher. About one third of the children had a current psychiatric disorder and nearly half had a lifetime history of psychiatric disorder.³

The STAR*D treatment conditions for the mothers consisted of 5 different antidepressant regimens applied sequentially until remission was achieved, marked by a Hamilton score of 7 or less. The primary outcomes for the children were reduced rates of diagnoses and changes in symptoms assessed with the parent version of the Child Behavior Checklist from baseline to 3 months.

In that period, there was an 11% decrease in the rates of children's diagnoses with remitting maternal depression, from 35% of 24 children to 24%, compared with an 8% increase in children of mothers with continuing depression, from 35% of 71 children to 43%. Symptoms also improved more in the children of improved mothers than in those of mothers with persistent depression. In contrast to the preliminary study, however, there were no significant differences between the groups of children in levels of functioning.

A reduction of at least 50% in maternal depression severity was needed for a decrease in diagnosis and symptom rates to be observed in their children. When maternal depression symptom scores were reduced by 25% or less, there was a 13% increase in the rates of children's diagnoses, and when the mothers' symptoms worsened with treatment, there was an 18% increase in rates of diagnosis in their children.

The improvement in the children of mothers with remitted depression during the relatively short 3-month study period supports intervention for maternal depression to benefit both mother and child, according to the investigators.

“At a time when there are many questions about the appropriate and safe treatment of psychiatric disorders in children,” Weissman and colleagues observed, “these findings suggest that it is important to provide vigorous treatment to mothers if they are depressed.”

References

1. Weissman MM, Pilowsky DJ, Wickramaratne PJ, et al. Remissions in maternal depression and child psychopathology--a STAR*D-child report. JAMA. 2006;295:1389-1398.
2. Verdeli H, Ferro T, Wickramaratne PJ, et al. Treatment of depressed mothers of depressed children: pilot study of feasibility. Depress Anxiety. 2004;19:51-58.
3. Pilowsky DJ, Wickramaratne PJ, Rush AJ, et al. Children of currently depressed mothers: a STAR*D ancillary study. J Clin Psychiatry. 2006;67:126-136.