Interventions Aim To Prevent Depression in High-Risk Children

Children whose parents have been diagnosed with affective disorders are far more likely to be diagnosed with a mental illness-especially affective disorder-than their peers whose parents do not have mood disorders (Beardslee, 1998; Burge and Hammen, 1991; Downey and Coyne, 1990). Unhappy with these odds, Boston researcher William R. Beardslee, M.D., has developed two promising short-term interventions that aim to prevent depression in this at-risk population.

Both interventions-a two-session psychoeducational lecture series as well as a series of four to eight clinician-centered interventions-have resulted in long-term improvement in family functioning, according to Beardslee, professor of psychiatry at Harvard University and psychiatrist-in-chief at Boston's Children's Hospital and the Judge Baker Children's Center. Specifically, comparisons of detailed parent and child assessments done in randomized, longitudinal studies have indicated increased resilience on the part of at-risk children as well as improved family communication overall. Children in the study reported an increase in coping skills and an improved ability to make sense of their internal and external environments (Beardslee et al., 1998).

Beardslee is confident that changes in family functioning brought about by the interventions have been robust and valuable for families. "Whether this study will demonstrate definitive prevention of depression in kids," he said, "is a separate question." Beardslee added that the next phase of research will focus on achieving a better understanding of the mechanics of the interventions: how they effect change as well as who most benefits from them.

"We see this as very important and promising," said Peter Jensen, M.D., associate director for child and adolescent research at the National Institute for Mental Health. He added, "These are the kinds of tools we need." Jensen said Beardslee's study is the first to compare two behavioral interventions in a specific population with younger children. If these findings are replicated in subsequent studies, such interventions could offer a valuable nonpharmacological alternative to children for whom medication is not effective or acceptable, Jensen said. He added that the next challenge would be to determine when interventions are most valuable for at-risk youngsters.

Over 100 families have been followed in the study, which began in 1989 and was expanded in 1991 with a grant from the NIMH. Children whose families were chosen to participate in the study were between the ages of 8 and 14.

Familial acceptance in the study was contingent upon the absence of frank psychosis, active chemical dependency, and/or active and acrimonious divorce proceedings between the parents. Acceptance criteria for children included the absence of profound mental retardation or a diagnosis of acute depression. All families in the study have had at least one affectively disordered parent.

Beardslee said the idea for the project originated in part from an unrelated research study of patients who had been hospitalized for depression. During clinical interviews, patients spontaneously and repeatedly voiced concern that their children had been irrevocably damaged by their illness. Further, they felt that health care professionals did not take their concerns seriously, something Beardslee believes not only compounded patients' suffering but also led to missed important opportunities to study the relationship between parental affective disorder and child outcome.

"What surprised me is that no one was asking that question and there were no programs to address this issue," said Beardslee, who remembers the days when intake interviews didn't even include questions, much less discussion, about patients' children. At the same time, Beardslee's work with severely depressed and suicidal children in the emergency room of a large city hospital reinforced his sense that early intervention was necessary to foster optimal development and functioning.

Beardslee feels strongly that preventive interventions must be family-based since depression is an illness that can derail marital and parental functioning. Citing statistics asserting that 10% to 20% of adults will experience an episode of depression during their lifetime, Beardslee is concerned that several million children are growing up in families with severe affective illness; this underscores the need for proactive intervention.

Like others in the field, Beardslee believes that the development of affective disorders is likely based on a complex interplay of biological/genetic forces and developmental transactions between children, family members and the outside world (Beardslee, 1998). Some children manage to survive and even flourish under the most difficult circumstances, while others flounder under the same conditions.

Factors such as presence of comorbid diagnoses, chronicity of parental illness and previous history of disorder in a child have been found to be among those factors resulting in poor child outcomes. Conversely, increased resilience has been observed to have significant protective value (Beardslee, 1998).

Beardslee's earlier research on American civil rights workers provided him with important clues about the building blocks of resilience. Interviewees attributed their ability to thrive, despite significant and ongoing adversity, to several core factors. Primary among them were the ability to form strong relationships, an action-oriented outlook, and a keen and cohesive sense of identity.

These characteristics have been observed in subsequent studies of children who had survived cancer or were coping with parental affective disorder. Beardslee has come to believe that these traits are of universal value in terms of individuals' ability to cope with adversity. Beardslee and his colleagues have found that those children of affectively ill parents who had the most promising diagnostic outcomes had a clear understanding that they were not responsible for their parents' illness (Beardslee, 1998). Further, these children had active lives outside the home and a strong sense of self-understanding.

Beardslee said that both interventions have been designed to combat cognitive distortions often held by depressed individuals and their families concerning the symptoms and treatment of their illness. Families also are educated about the risk factors for depression in children and indicators of children's resilience. The psychoeducational lectures attended by parents only are designed to foster an improved understanding of affective illness. Parents are invited to contact program facilitators as the need arises for help with ongoing concerns.

Beardslee said that gains were particularly strong and long-lived in the clinician-centered intervention, which includes separate meetings for parents and children as well as family sessions. A core feature of this intervention is the active discussion of affective disorder as it relates to the specific functioning of the family. This process, said Beardslee, gives family members permission to openly discuss parental illness and can serve as an important model for families with generalized communication problems. Clinicians contact families periodically to check on their progress following the conclusion of the program. In addition, participants in both interventions receive detailed assessments over the course of the study.

"If you've undergone terrible adversity in your family and it's not discussed and you're part of it, finding a way to discuss it safely lets people make sense of it and move on," Beardslee said. The Boston researcher said comparisons of longitudinal assessments indicate that this can be an especially powerful and corrective intervention for children, whose insight broadens and deepens as they move into adolescence and beyond. "The understanding that worked for them when they were 12 doesn't work for them when they're 19," he added.

As for those children who do develop depression, Beardslee believes that the interventions will sensitize families to the importance of early diagnosis and treatment. He said that manual-based interventions could be used by pediatricians and primary care physicians as easily and as effectively as by mental health professionals.

"Dr. Beardslee's project is one of the most ambitious and encouraging in terms of a nonpharmacological intervention for children," said David Mrazek, M.D., chair of the department of psychiatry and behavioral sciences at the George Washington University Medical Center. "You have a much better chance of putting the child back into a normal developmental trajectory" with early and sustained intervention, Mrazek said.

Unfortunately, according to Mrazek and others in the field, a commitment to prevention, particularly in the area of mental health, is not high on the list of the managed care industry's priorities. "It's a slight peculiarity in our health system," said a sardonic Mrazek, referring to what he believes is a myopic approach to care.

Despite the potentially enormous savings in public health expenditures, Mrazek believes that the unwillingness of managed care to invest in early and sustained interventions is based on the fact that preventive program outcomes are often hard to quantify and can take years to manifest. Mrazek recalled a conversation with a managed care executive during which the latter remarked, "Our average subscriber is with us for two years. We want to prevent something imminent."

University of Washington researcher Geraldine Dawson, Ph.D., is among those who share Mrazek's sense of urgency about the need for better understanding of the link between parental depression and increased risk of morbidity in their children. In two different studies, Dawson and her colleagues have found that infants of depressed mothers exhibited atypical frontal brain activity (Dawson et al., 1997). Specifically, these infants exhibited reduced activity in the left frontal region-the area associated with joy, interest and other emotions linked to approach toward the environment. In several other studies, infants of depressed mothers displayed increased activity in the right frontal region-the area linked to sadness, disgust and other withdrawal emotions (Dawson et al., 1997).

The continued lack of a systemic perspective in the treatment of depression is another obstacle to preventive interventions, according to Simon H. Budman, Ph.D., president and founder of Innovative Training Systems Inc., which develops health promotion strategies. "People can understand it, but there's no way that people, mental health clinicians included, think a lot about the children of their depressed patients," he said. Budman was also the director of mental health research and mental health training at Harvard Community Health Plan.

"It's probably not dissimilar to a cardiologist who sees a person in their 30s or 40s with a heart attack and is not particularly focused on their children or families," Budman added. "Clinicians are trained to think about the particular patient in their office and are not taught to think in a systemic waythe training of clinicians is so pathology-focused and so little focused on the broader issues."

There is little time to be lost for Beardslee and others in the field, as depression continues to impose staggering human and financial costs. In 1990, depression was the fourth leading cause of disease-burden in the world, according to the Global Burden of Disease project, a worldwide collaboration of more than 100 doctors and epidemiologists sponsored by the World Health Organization and the World Bank. Researchers define disease-burden as the measure used to gauge both the number of years lost to premature death as well as the number of years lived with a disability. By 2020, depression is expected to become the single leading cause of disease-burden worldwide. "Depression is rising and each successive decade is getting worse," said NIMH's Jensen. "We better get a handle on this thing."

References:

References

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Burge D, Hammen C (1991), Maternal communication: predictors of outcome at follow-up in a sample of children at high and low risk for depression. J Abnorm Psychol 100(2):174-180.

Dawson G, Frey K, Panagiotides H et al. (1997), Infants of depressed mothers exhibit atypical frontal brain activity: a replication and extension of previous findings. J Child Psychol Psychiatry 38(2):179-186.

Downey D, Coyne J (1990), Children of depressed parents: an integrative review. Psychol Bull 108(1):50-76.

Murray CJ, Lopez AD eds. (1996), The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020, Vol. 1. Cambridge, Mass.: Harvard School of Public Health on behalf of the World Health Organization and the World Bank.