Longitudinal study of diagnoses in children of women with unipolar and bipolar affective disorder

Familial risk for major depression: differential white matter alterations in healthy and depressed participants

BACKGROUND

Major depressive disorder (MDD) has been associated with alterations in brain white matter (WM) microstructure. However, diffusion tensor imaging studies in biological relatives have presented contradicting results on WM alterations and their potential as biomarkers for vulnerability or resilience. To shed more light on associations between WM microstructure and resilience to familial risk, analyses including both healthy and depressed relatives of MDD patients are needed.

METHODS

In a 2 (MDD v. healthy controls, HC) × 2 (familial risk yes v. no) design, we investigated fractional anisotropy (FA) via tract-based spatial statistics in a large well-characterised adult sample (N = 528), with additional controls for childhood maltreatment, a potentially confounding proxy for environmental risk.

RESULTS

Analyses revealed a significant main effect of diagnosis on FA in the forceps minor and the left superior longitudinal fasciculus (ptfce-FWE = 0.009). Furthermore, a significant interaction of diagnosis with familial risk emerged (ptfce-FWE = 0.036) Post-hoc pairwise comparisons showed significantly higher FA, mainly in the forceps minor and right inferior fronto-occipital fasciculus, in HC with as compared to HC without familial risk (ptfce-FWE < 0.001), whereas familial risk played no role in MDD patients (ptfce-FWE = 0.797). Adding childhood maltreatment as a covariate, the interaction effect remained stable.

CONCLUSIONS

We found widespread increased FA in HC with familial risk for MDD as compared to a HC low-risk sample. The significant effect of risk on FA was present only in HC, but not in the MDD sample. These alterations might reflect compensatory neural mechanisms in healthy adults at risk for MDD potentially associated with resilience.

Meta-analysis of personal and familial co-occurrence of Attention Deficit/Hyperactivity Disorder and Bipolar Disorder

BACKGROUND

Attention Deficit Disorder / Hyperactivity (ADHD) and Bipolar Disorder (BD) are highly comorbid disorders. Studies have raised the hypothesis of shared genetic, neurobiological, and clinical factors. This would entail an excess risk of co-occurrence of both disorders.

OBJECTIVE

We present the first meta-analysis of individual and familial associations between ADHD and BD.

METHODS

From 2688 references, 59 were included, with a total of 550,379 ADHD patients, 57,799 BD patients and 12,608,137 controls.

RESULTS

Personal history of ADHD increased the risk of BD (OR = 6.06), and conversely individuals with BD had an increased risk of ADHD (OR = 8.94). First-degree relatives of ADHD patients had an increased risk of BD (OR = 1.94). Offspring of individuals with BD had a higher risk for ADHD (OR = 2.33). Finally, first-degree relatives of BD patients had an increased risk of ADHD (OR = 2.71).

CONCLUSION

We show a clear epidemiological overlap between ADHD and BD, as well as a strong familial association which advocates in favor of a more systematic screening.

Trends in depression by glycemic status: Serial cross-sectional analyses of the National Health and Nutrition Examination Surveys, 2005-2016

AIMS

We examined changes in the prevalence of elevated depressive symptoms among US adults with diabetes, prediabetes, and normal glycemic status during 2005-2016.

METHODS

We analyzed data from 32,676 adults in the 2005-2016 National Health and Nutrition Examination Surveys. We defined diabetes as self-reporting a physician diagnosis of diabetes or A1C ≥ 6.5% [48 mmol/mol], and prediabetes as A1C 5.7-6.4% [39-46 mmol/mol]. We used the 9-item Patient Health Questionnaire (PHQ-9) score ≥ 10 or antidepressant use to define 'clinically significant depressive symptoms' (CSDS) and PHQ-9 score ≥ 12 as 'Major Depressive Disorder' (MDD). We calculated prevalence age-standardized to the 2000 US census and used logistic-regression to compute adjusted odds of CSDS and MDD for 2005-2008, 2009-2012, and 2015-2016. We analyzed the prevalence of A1C ≥ 9.0% [75 mmol/mol], systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, non-HDL cholesterol ≥ 130 mg/dL, and current smoking among adults with diagnosed diabetes by depressive status.

RESULTS

The prevalence of CSDS increased among individuals with normal glycemic status from 15.0% (13.5-16.2) to 17.3% (16.0-18.7) (p = 0.03) over 2005-2016. The prevalence of CSDS and MDD remained stable among adults with prediabetes (~ 16% and 1%, respectively) and diabetes (~ 26% and ~3%). After controlling for glycemic, sociodemographic, economic, and self-rated health variables, we found 2-fold greater odds of CSDS among unemployed individuals and 3-fold greater odds among those with fair/poor self-rated health across all survey periods. Cardiometabolic care targets for adults with diagnosed diabetes were stable from 2005 to 2016 and similar across depressive status.

CONCLUSIONS

One-fourth of adults with diabetes have comorbid CSDS; this prevalence remained stable over 2005-2016 with no change in diabetes care. At the population level, depression does not appear to impact diabetes care, but further research could explore subgroups that may be more vulnerable and could benefit from integrated care that addresses both conditions.

Observed Maternal Coping Socialization and Child Internalizing Symptoms: The Roles of Maternal Depressive Symptoms and Peer Stress

Empirical evidence relying primarily on questionnaire reports indicates parent coping socialization messages play an important role in children's psychological functioning. The present study utilized a multi-informant, multi-method design to build on previous coping socialization research in childhood and adolescence. A novel coding system was developed to measure observed parental socialization of coping messages from observations of a discussion-based peer stress task. Questionnaires and direct observations were obtained from mothers with and without a history of depression (N = 116; 50% with a history of depression) and their children (9 to 15 years). Observed maternal coping socialization messages were not significantly correlated with mother or child reports of child internalizing symptoms in bivariate analyses. However, in multiple linear regression analyses, current maternal depressive symptoms and children's level of peer stress emerged as significant moderators of the association between observed maternal coping socialization messages and children's internalizing symptoms. The conceptual and methodological contributions of the current study are discussed, limitations and strengths are noted, and implications for future research are outlined.

Risk Factors for Depression in Adolescents With ADHD: The Impact of Cognitive Biases and Stress

Objective: Youth diagnosed with ADHD are at heightened risk of depression. However, many do not develop depression. Individuals with specific cognitive biases are more likely to develop depression yet it remains untested whether these vulnerability-stress models apply to depression risk in youth with ADHD. Method: We examined whether interpretation and attention biases moderated the relation between stressful life events and depressive symptoms in a sample of adolescents (M_age = 14.42) with ADHD (n = 59) and without ADHD (n = 36). Results: Youth with ADHD experienced more stressful life events compared with those without ADHD. Interpretation biases moderated the association between stress and depressive symptoms in youth with and without ADHD. Attention biases moderated the association between stress and depressive symptoms in the non-ADHD youth only. Conclusion: These results enhance our understanding of vulnerability for depression in adolescence with ADHD and inform targeted prevention and treatment models during this critical developmental juncture.

Early intervention for people at high risk of developing bipolar disorder: a systematic review of clinical trials

Early intervention approaches are built on the premise of preventing disability, burden, and cognitive sequelae caused by bipolar disorder. The objective of this systematic review was to characterise the effectiveness of all the available psychological and pharmacological treatments for early intervention in people at high risk of developing bipolar disorder. The study was registered with PROSPERO (CRD42019133420). We did a systematic search to identify studies published in ten databases up to March 27, 2020. Randomised controlled trials and cohort studies that assessed the effect of pharmacological or psychological interventions in people at high risk of developing bipolar disorder were included. Studies of first episodes of mania were excluded. Eligible papers were assessed for quality and data were extracted. The primary outcomes were change in manic and depressive symptoms from baseline to endpoint. Of the 2856 citations retrieved by our search, 16 studies were included; five evaluated pharmacotherapeutic strategies (three randomised controlled trials and two open-label studies), ten assessed psychotherapeutic strategies (four randomised controlled trials and six open-label studies), and one randomised controlled trial assessed combination therapy; these 16 trials included a total of 755 participants at high risk of developing bipolar disorder. Quality assessment indicated fair to good quality for open-label studies, and a high risk of bias in four randomised controlled trials. Among the pharmacotherapeutic interventions, there is preliminary support for the efficacy of aripiprazole in reducing mood symptoms in people at high risk of developing bipolar disorder. Psychological interventions were effective for various outcomes. There was substantial methodological heterogeneity across studies. This systematic review underscores the need for multicentre, prospective, methodologically homogeneous studies evaluating conversion to bipolar disorder as an outcome measure.

Here's looking at you, kid? Maternal depression and adolescent attention to self- or other-directed emotional faces

BACKGROUND

Maternal depression history represents a significant risk factor for developing psychopathology in children, altered emotional responding may represent a central risk pathway. However, additional research is needed on factors that affect the strength or direction of response alterations in relation to depression-risk in youth. In particular, facial orientation and gaze direction may alter personal relevance, with emotions directed towards an individual heightening motivational salience, compared to emotions directed away.

METHODS

Mother-daughter dyads (N = 56) were recruited based on presence or absence of maternal depression history and absence of youth depression. In line with theoretical perspectives suggesting diminished sensitivity to emotional context in relation to depression risk, we examined three Event-Related Potential (ERP) components in relation to forward versus averted emotional faces in a sample of girls with and without a maternal history of depression: the N200, N400, and Late Positive Potential (LPP).

RESULTS

Results showed a significant maternal depression history by face-orientation effect. Low-risk girls exhibited more negative N200 and N400 amplitudes for straight (M = -3.72, SE = 0.83; M = -3.57, SE = 0.86) versus averted (M = -2.15, SE = 0.76; M = -1.68, SE = 0.81) faces, while girls of mothers with histories of depression showed undifferentiated N200 or N400 responses in relation to face orientation. For LPP amplitudes, low-risk girls exhibited significantly more positive LPP amplitudes than high-risk girls, but only for averted faces (M = 0.69, SE = 0.59 and M = -2.63, SE = 0.74, respectively).

LIMITATIONS

Cross-sectional design and limited sample.

CONCLUSIONS

Results indicate that familial depression risk is associated with altered responsivity to face-orientation, these were interpreted as representing differential sensitivity to the personal-relevance of emotional stimuli.

The Rajarata Pregnancy Cohort (RaPCo): study protocol

Background

Ending preventable maternal deaths remains a global priority and in the later stages of obstetric transition, identifying the social determinants of maternal health outcomes is essential to address stagnating maternal mortality rates. Countries would hardly achieve the Sustainable Development Goal (SGD) targets on maternal health, unless the complex and context-specific socio-economic aetiologies associated with maternal mental health and suicide are identified. The Rajarata Pregnancy Cohort (RaPCo) is a prospective cohort study, designed to explore the interactions between social determinants and maternal mental health in determining pregnancy and new-born outcomes.

Methods

The study will recruit all eligible pregnant women in the maternal care programme of Anuradhapura district, Sri Lanka from July to September 2019. The estimated sample size is 2400. We will assess the socio-demographic and economic status, social capital, gender-based violence and mental health, including a clinical examination and biochemical investigations during the first trimester. Participants will undergo four follow-ups at 2nd and 3rd trimesters, at delivery and in early postpartum. The new-borns will be followed up at birth, neonatal period, at 6 six months and at 1 year. Pregnancy and child outcome data will be collected using direct contact. Qualitative studies will be carried out to understand the complex social factors and behavioural dimensions related to abortion, antenatal depression, maternal deaths and near misses.

Discussion

This is the first reported maternal cohort in Sri Lanka focusing on social determinants and mental health. As a country in stage four of obstetric transition, these findings will provide generalizable evidence on achieving SGD targets in low- and middle-income countries. The study will be conducted in a district with multi-cultural, multi-ethnic and diverse community characteristics; thus, will enable the evidence generated to be applied in many different contexts. The study also possesses the strength of using direct participant contact, data collection, measurement, examination and biochemical testing to minimise errors in routinely collected data. The RaPCo study will be able to generate evidence to strengthen policies to further reduce maternal deaths in the local, regional and global contexts particularly focusing on social factors and mental health, which are not optimally addressed in the global agenda.

Parental bipolar disorder, family environment, and offspring psychiatric disorders: A systematic review

BACKGROUND

Our objective was to systematically review non-experimental studies of parental bipolar disorder (BD), current family environment, and offspring psychiatric disorders to identify characteristics of family environment associated with parental BD and risk for offspring psychiatric disorders.

METHODS

CINAHL, Embase, PsycINFO, and PubMed were searched using MeSH terms to identify studies on offspring of BD parents published through September 2017. We followed PRISMA guidelines and used the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS). We calculated prevalence ratios and 95% confidence intervals to compare offspring psychiatric disorders within and across studies.

RESULTS

Of 10,454 unique documents retrieved, we included 13 studies. The most consistent finding was lower parent-reported cohesion in families with a BD parent versus no parental psychiatric disorders. Family environment did not differ between BD parents and parents with other disorders. Offspring of BD parents had higher prevalence of psychiatric disorders than offspring of parents without psychiatric disorders but did not differ from offspring of parents with other disorders. Families with a BD child had higher conflict than families without a BD child.

LIMITATIONS

Comparisons between studies were qualitative. A single reviewer conducted screening, data extraction, and bias assessment.

CONCLUSIONS

Family environment in families with a BD parent is heterogeneous. The pattern of findings across studies also suggests that family problems may be associated with parental psychiatric illness generally rather than parental BD in particular. Few studies included offspring-reported measures. Given the association of family conflict with offspring mood disorders, further study is merited on children's perceptions of the family environment in the BD high-risk context.

Qualitative evaluation of a preventive intervention for the offspring of parents with a history of depression

BACKGROUND

Meta-analyses of randomised controlled trials suggest that psychological interventions to reduce children's risk of depression are effective. Nevertheless, these effects are modest and diminish over time. The Medical Research Council recommends a mixed-methods approach to the evaluation of complex interventions. By gaining a more thorough understanding of participants' perspectives, qualitative evaluations of preventive interventions could improve their efficacy, longevity and transfer into clinical practice.

METHODS

18 parents and 22 children who had received a 12-session family- and group-based cognitive-behavioural intervention to prevent youth depression as part of a randomised controlled trial took part in semi-structured interviews or a focus group about aspects which had been perceived as helpful, elements they were still using after the intervention had ended, and suggestions they had for improving the intervention.

RESULTS

The chance to openly share and discuss their experiences of depression within and between families was considered helpful by both children and parents. Children benefitted the most from learning coping strategies for dealing with stress and many still used them in everyday life. Parents profited mostly from increasing positive family time, but noted that maintaining new routines after the end of the intervention proved difficult. Participants were generally content with the intervention but commented on how tiring and time consuming it was.

CONCLUSIONS

Managing parents' expectations of family-based interventions in terms of their own mental health needs (versus those of their children) and leaving more room for open discussions may result in interventions which are more appealing to participating families. Increasing intervals between sessions may be one means of improving the longevity of interventions.

TRIAL REGISTRATION

The original RCT this evaluation is a part of was registered under NCT02115880 .

Childbirth and prevention of bipolar disorder: an opportunity for change

The recent conceptualisation of bipolar disorder as a neuroprogressive illness has highlighted the potential importance of prevention and early intervention in high-risk populations. Undiagnosed bipolar disorder early in the disease course is associated with adverse clinical outcomes and impaired functioning for patients, which in turn has economic consequences. Despite the mounting evidence that childbirth is one of the most potent and specific triggers of manic symptoms, studies are not available on the effectiveness of targeted interventions in the prevention of bipolar disorder in women who have recently given birth. In this Personal View, we describe the clinical characteristics of women at risk of developing bipolar disorder after childbirth, before discussing opportunities for prevention and early intervention and outlining challenges in the assessment and management of women at risk of transitioning to bipolar disorder after childbirth. Existing evidence, although scarce, supports a clinical staging model by which at-risk women are managed with a variety of behavioural and pharmacological interventions aimed at preventing bipolar disorder. Close monitoring and early intervention might reduce the risk of hypomanic or manic symptoms in women at risk of developing bipolar disorder after childbirth; however, the potential benefits of early identification and intervention need to be carefully balanced against the additional risks for affected women.

Developmental outcomes at age four following maternal antiepileptic drug use

We investigated whether prenatal antiepileptic drug (AED) exposure was associated with adverse outcomes in the Before School Check (B4SC) assessments, particularly the assessments measuring neurodevelopment. Children exposed to AEDs were identified by linking women dispensed AEDs in the Pharmaceutical Collection to births recorded on the National Minimum Dataset (NMDS). Multinomial logistic regression was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) for outcomes of the parent-completed Parental Evaluation of Developmental Status (PEDS) questionnaire and Strengths and Difficulties Questionnaire (SDQ), after adjusting for gender, ethnicity, and socioeconomic deprivation. Between 2012 and 2016, 606 children with a mother who had been dispensed one or more AEDs during pregnancy had taken part in the B4SC. Prenatal exposure to sodium valproate (n = 161) or lamotrigine (n = 149) monotherapy was associated with an increased risk of having an abnormal SDQ - parent-completed (SDQP) score, ≥17 - indicating emotional or behavioral concerns (9.32% of children exposed to sodium valproate monotherapy had an abnormal score; aRR: 2.11; 1.23-3.63; lamotrigine 8.05%; aRR: 2.21; 1.21-4.02). Prenatal exposure to carbamazepine monotherapy (n = 201) was not associated with an increased risk of having an abnormal total SDQP score but was associated with increased risks in the individual domains of the SDQP. Prenatal exposure to AED polytherapy (n = 57) was associated with the highest risk of abnormal SDQP scores (17.54% of children exposed to polytherapy had abnormal scores; aRR: 2.75; 1.25-6.02). Prenatal exposure to sodium valproate and lamotrigine is associated with an increased risk of concerns about emotional and behavioral development being reported by parents in a neurodevelopmental screening program. Additional investigation is required into why significant differences between AEDs were not seen in this study.

A diffusion tensor imaging study of brain microstructural changes related to religion and spirituality in families at high risk for depression

INTRODUCTION

Previously in a three-generation study of families at high risk for depression, we found that belief in the importance of religion/spirituality (R/S) was associated with thicker cortex in bilateral parietal and occipital regions. In the same sample using functional magnetic resonance imaging and electroencephalograph (EEG), we found that offspring at high familial risk had thinner cortices, increased default mode network connectivity, and reduced EEG power. These group differences were significantly diminished in offspring at high risk who reported high importance of R/S beliefs, suggesting a protective effect.

METHODS

This study extends previous work examining brain microstructural differences associated with risk for major depressive disorder (MDD) and tests whether these are normalized in at-risk offspring who report high importance of R/S beliefs. Diffusion tensor imaging (DTI) data were selected from 99 2nd and 3rd generation offspring of 1st generation depressed (high-risk, HR) or nondepressed (low-risk, LR) parents. Whole-brain and region-of-interest analyses were performed, using ellipsoidal area ratio (EAR, an alternative diffusion anisotropy index comparable to fractional anisotropy). We examined microstructural differences associated with familial risk for depression within the groups of high and low importance of R/S beliefs (HI, LI).

RESULTS

In the LI group, HR individuals showed significantly decreased EAR in white matter regions neighboring the precuneus, superior parietal lobe, superior and middle frontal gyrus, and bilateral insula, supplementary motor area, and postcentral gyrus. In the HI group, HR individuals showed reduced EAR in white matter surrounding the left superior, and middle frontal gyrus, left superior parietal lobule, and right supplementary motor area. Microstructural differences associated with familial risk for depression in precuneus, frontal lobe, and temporal lobe were nonsignificant or less significant in the HI group.

CONCLUSION

R/S beliefs may affect microstructure in brain regions associated with R/S, potentially conferring resilience to depression among HR individuals.

At-risk studies and clinical antecedents of psychosis, bipolar disorder and depression: a scoping review in the context of clinical staging

Identifying young people at risk of developing serious mental illness and identifying predictors of onset of illness has been a focus of psychiatric prediction research, particularly in the field of psychosis. Work in this area has facilitated the adoption of the clinical staging model of early clinical phenotypes, ranging from at-risk mental states to chronic and severe mental illness. It has been a topic of debate if these staging models should be conceptualised as disorder-specific or transdiagnostic. In order to inform this debate and facilitate cross-diagnostic discourse, the present scoping review provides a broad overview of the body of literature of (a) longitudinal at-risk approaches and (b) identified antecedents of (homotypic) illness progression across three major mental disorders [psychosis, bipolar disorder (BD) and depression], and places these in the context of clinical staging. Stage 0 at-risk conceptualisations (i.e. familial high-risk approaches) were identified in all three disorders. However, formalised stage 1b conceptualisations (i.e. ultra-high-risk approaches) were only present in psychosis and marginally in BD. The presence of non-specific and overlapping antecedents in the three disorders may support a general staging model, at least in the early stages of severe psychotic or mood disorders.

Differences in Psychopathology between Offspring of Parents with Bipolar I Disorder and Those with Bipolar II Disorder: A Cross-Sectional Study

OBJECTIVE

The aim of this study was to evaluate differences in psychopathology between offspring of parents with bipolar I disorder (BP-I) and those with bipolar II disorder (BP-II).

METHODS

The sample included 201 offspring between 6 and 17 years of age who had at least one parent with BP-I or BP-II. The offspring were diagnostically evaluated using the Korean Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version. Psychopathology and Clinical characteristics were evaluated, including lifetime DSM-5 diagnoses, depression, and childhood trauma. Lifetime DSM-5 diagnoses were also compared between schoolchildren aged 6 to 11 years and adolescents aged 12 to 17 years.

RESULTS

In lifetime DSM-5 diagnoses, offspring of parents with BP-I had significantly increased risk of developing MDD and BP-I than those with BP-II. Regarding clinical characteristics, ADHD rating scale and childhood trauma scale were significantly higher in offspring of parents with BP-I than that in those with BP-II.

CONCLUSION

The present study supports that BP-I may be etiologically distinct from BP-II by a possible genetic liability. Our findings indicate that additional research related to bipolar offspring is needed to enhance understanding of differences between BP-I and BP-II.

Clinical staging model in offspring of parents with bipolar disorder: a systematic review

OBJECTIVE

We sought to systematically review the literature on the psychiatric risk of offspring of parents with bipolar disorder (OPBD) using a developmental psychopathology framework. The review also sought to establish the utility of clinical stage modelling as a framework for identifying precursor disorders to later onset of bipolar disorder (BD) in OPBD.

METHODS

A systematic search was performed using EMBASE, PsychINFO and Medline. Reference lists of included studies and previous reviews were also searched. Studies were included if they reported diagnostic outcomes for child, adolescent and young adult offspring of parents diagnosed with BD.

RESULTS

Twenty-six studies were identified representing 21 individual cohorts. The review identified that OBPD present as a high-risk group for a range of mood and non-mood disorders in childhood, adolescence and young adulthood. The trajectory of risk was from non-mood disorders in childhood via non-bipolar mood disorders in early adolescence towards mania/hypomania in late adolescence and early adulthood. From a clinical staging perspective, childhood anxiety disorders were associated with later onset of BD. Recurrent substance use disorder was identified as a risk in OPBD during late adolescence and early adulthood. Quality ratings indicated that studies were methodologically robust.

CONCLUSIONS

Our review provides evidence for a developmental psychopathology trajectory of precursor risks to BD in OPBD. There is support for clinical stage modelling as a conceptual framework for understanding developmental risk in OPBD and as a tool for developing early and individualized intervention strategies.

Risk Factors for Depression: An Autobiographical Review

I have been given a priceless opportunity to reflect on my career in the remarkably productive field of risk factors for depression. Psychological research on depression exploded in the early years of my work. I try to give an account of the choices and challenges, and reflect on the influences, some calculated and some serendipitous, that determined the paths I have followed. I focus mostly on the robust depression risk factors that have influenced my research, including dysfunctional cognitions, stressful life events and circumstances, parental depression, interpersonal dysfunction, and being female, and I cover some of what I did but also the influential work of others. This is a selective review of depression research in the past 40 or so years, noting some of the big developments that set the stage for the remarkable activity that continues today. In the conclusion, there is a brief statement of aspirations for future developments in our field.

Offspring of depressed and anxious patients: Help-seeking after first onset of a mood and/or anxiety disorder

BACKGROUND

Offspring of patients with depressive and/or anxiety disorders are at high risk of developing a similar disorder themselves. Early recognition and treatment may have substantial effects on prognosis. The main aim of this study was to examine the time to initial help-seeking and its determinants in offspring after the first onset of a mood and/or anxiety disorder.

METHODS

Data are presented of 215 offspring with a mood and/or anxiety disorder participating in a cohort study with 10 year follow-up. We determined age of disorder onset and age of initial help-seeking. Offspring characteristics (gender, IQ, age of onset, disorder type, suicidal ideation) and family characteristics (socioeconomic status, family functioning) were investigated as potential predictors of the time to initial help-seeking.

RESULTS

The estimated overall proportion of offspring of depressed/anxious patients who eventually seek help after onset of a mood and/or anxiety disorder was 91.9%. The time to initial help-seeking was more than two years in 39.6% of the offspring. Being female, having a mood disorder or comorbid mood and anxiety disorder (relative to anxiety) and a disorder onset in adolescence or adulthood (relative to childhood) predicted a shorter time to initial help-seeking.

LIMITATIONS

Baseline information relied on retrospective reports. Age of onsets and age of initial help-seeking may therefore be subject to recall bias.

CONCLUSION

Although most offspring eventually seek help after onset of a mood/anxiety disorder, delays in help-seeking were common, especially in specific subgroups of patients. This information may help to develop targeted strategies to reduce help-seeking delays.

What can we learn from offspring studies in bipolar disorder?

We offer a contemporary review of studies of the offspring of parents with bipolar disorder and explore the clinical characteristics of these populations. We discuss how different methodological approaches may influence study findings and may explain some of the heterogeneity in the results reported. We also highlight some of the environmental risk factors that may increase the likelihood of transition from an ‘at-risk’ or high-risk state to bipolar disorder. Last, we briefly discuss the implications of study findings for early intervention strategies and comment on such issues as genetic counselling and primary and early secondary prevention programmes.

Depression: point-prevalence and risk factors in a North Cyprus household adult cross-sectional study

BACKGROUND

Depression is one of the most common diagnosed psychiatric disorders in the world. Besides individual risk factors, it is also found that environment and socio-cultural factors are the other main risk factors for depression. In this article, the results of the 2016 national household survey of depression in North Cyprus (NC) are presented. The aim of the study is to determine the prevalence and possible risk factors of depression in NC households.

METHODS

The study was conducted between April and June 2016, the sample consisting of Turkish-speaking individuals between 18 and 88 years of age living permanently in NC. A multi-stage stratified (randomized) quota was used in the survey, and 978 people were selected according to the 2011 census. A 21 item questionnaire prepared by the researchers and a Turkish version of the Beck Depression Inventory scales were used for obtaining data.

RESULTS

This cross-sectional study found a point prevalence of 23.4% for relatively high BDI scores (≥17) suggesting clinical depression. Being female, a widow, unemployed, having a limited education and low income level, having a physical illness, living alone, and using illicit substances were defined as possible risk factors for depression.

CONCLUSIONS

When we consider the world prevalence, NC has one of the higher depression prevalence. NC has environmental and socio-cultural characteristics such as a history of war, migration and colonization, high unemployment rates, socioeconomic problems, similar to other extremely high prevalence depression countries and regions, which give a strong indication of the importance of socio-cultural factors on depression.

Time-Frequency Reward-Related Delta Prospectively Predicts the Development of Adolescent-Onset Depression

BACKGROUND

A blunted reward positivity (RewP), an event-related potential elicited by feedback indicating monetary gain relative to loss, was recently shown to prospectively predict the development of adolescent-onset depression. Time-frequency-based representations of this activity (e.g., reward-related delta) have also been associated with depression. This study is a reanalysis of the time-domain RewP investigation to examine the incremental value of time-frequency indices in the prediction of adolescent-onset depression.

METHODS

The sample included 444 13- to 15-year-old girls with no lifetime history of a depressive disorder. At baseline, adolescents completed a monetary guessing task, and both time-domain and time-frequency analyses were conducted on the event-related potential response to gain and loss feedback. Lifetime psychiatric history in the adolescent and a biological parent were evaluated with diagnostic interviews, and adolescents' current depressive symptoms were assessed using a self-report questionnaire. Adolescents were interviewed again approximately 18 months later to identify first-onset depressive disorder.

RESULTS

Blunted reward-related delta predicted first-onset depressive disorder 18 months later, independent of the time-domain RewP and psychosocial risk factors (i.e., adolescent baseline depressive symptoms, adolescent and parental psychiatric history). In contrast, loss-related theta did not predict the development of depression. Reward-related delta increased sensitivity (73.8% to 82.8%) and positive predictive value (45.0% to 70.9%) for first-onset depressive disorder when applied in parallel and in series, respectively, with baseline depressive symptoms and the time-domain RewP.

CONCLUSIONS

This study provides evidence that frequency-based representations of event-related potentials provide incremental value in the prediction of psychiatric disorders.

Transgenerational impairment of hippocampal Akt-mTOR signaling and behavioral deficits in the offspring of mice that experience postpartum depression-like illness

Postpartum depression (PPD) has adverse effects on offspring and increases their vulnerability to psychiatric disorders such as depression. Akt-mTOR signaling in the hippocampus is implicated in depression but its role in the behavioral deficits in PPD offspring remains unknown. By using a prepregnancy stress model of PPD in which Balb/c females that experience chronic stress before pregnancy show long-lasting PPD-like behaviors, we tested depression-like behaviors in PPD offspring (PPD-F1) at juvenile and adult ages as well as in the second generation (PPD-F2) produced by cross of male PPD-F1 with naïve females. Hippocampal Akt-mTOR signaling was examined in the F1 and F2 generations of PPD, as well as in PPD-F1 mice treated with a single dose of the antidepressant ketamine. PPD-F1 showed depression-like behaviors at juvenile and adult stages, evidenced by reduced sucrose preference (SP), increased immobility time in the forced swim test (FST), and a longer latency to feed and reduced food consumption in the novelty suppressed feeding (NSF) test. PPD-F1 mice showed Akt-mTOR signaling deficiency in the hippocampus, with down-regulated expression of p-Akt, p-mTOR and p-p70S6K. A single dose of ketamine reversed the behavior deficits and the impairment in Akt-mTOR signaling in PPD-F1. Furthermore, the PPD-F2 mice remained deficient in the SP and NSF test and hippocampal Akt-mTOR signaling, although the performance in FST was normal. The present study demonstrated both long-term and transgenerational effects of PPD on the depression-like behaviors of offspring, and suggested impaired Akt-mTOR signaling may play a part.

Pilot Randomized Controlled Trial of Omega-3 and Individual-Family Psychoeducational Psychotherapy for Children and Adolescents With Depression

The goal of this study is to evaluate feasibility and estimate effect sizes of omega-3 fatty acids (Ω3), individual-family psychoeducational psychotherapy (PEP), their combination, and moderating effects of maternal depression and psychosocial stressors in youth with depression. In a pilot 2 × 2 randomized controlled trial, 72 youth (ages 7-14; 57% Caucasian, 57% male) with major depression, dysthymia, or depression not otherwise specified were randomized to 12 weeks of Ω3, PEP+placebo, Ω3+PEP, or placebo. Ω3 versus placebo was double-masked. Evaluators masked to condition assessed depressive severity at baseline (randomization) and at 2, 4, 6, 9, and 12 weeks using the Children's Depression Rating Scale-Revised. Side effects were either absent or mild. PEP was administered with 74% fidelity. Remission was 77%, Ω3+PEP; 61%, PEP+placebo; 44%, Ω3; 56%, placebo. Intent-to-treat analyses found small to medium effects of combined treatment (d = .29) and Ω3 monotherapy (d = .42), but negligible effect for PEP+placebo (d < .10), all compared to placebo alone. Relative to placebo, youth with fewer social stressors responded better to Ω3 (p = .04), PEP (p = .028), and their combination (p = .035), and those with maternal depression responded better to PEP (p = .020) than did those without maternal depression. Remission rates were favorable compared to other studies of psychotherapy and comparable to an existing randomized controlled trial of Ω3; results warrant further evaluation in a larger sample. Ω3 was well tolerated. Active treatments show significantly more placebo-controlled depression improvement in the context of maternal depression and fewer stressors, suggesting that they may benefit depression with a more endogenous than environmental origin.

Challenges and developments in research of the early stages of bipolar disorder

Recently, attention in the field of bipolar disorder (BD) has focused on prevention, including early detection and intervention, as these strategies have the potential to delay, lessen the severity, or even prevent full-blown episodes of BD. Although knowledge of the neurobiology of BD has advanced substantially in the last two decades, most research was conducted with chronic patients. The objective of this paper is to comprehensively review the literature regarding the early stages of BD, to explore recent discoveries on the neurobiology of these stages, and to discuss implications for research and clinical care. The following databases were searched: PubMed, PsycINFO, Cochrane Library, and SciELO. Articles published in English from inception to December 2015 were retrieved. Several research approaches were used, including examination of offspring studies, retrospective studies, prospective studies of clinical high-risk populations, and exploration of the progression after the first manic episode. Investigations with neuroimaging, cognition assessments, and biomarkers provide promising (although not definitive) evidence of alterations in the neural substrate during the at-risk stage. Research on BD should be expanded to encompass at-risk states and aligned with recent methodological progress in neuroscience.

Attachment Status Affects Heart Rate Responses to Experimental Ostracism in Inpatients with Depression

Depression is assumed to be both a risk factor for rejection and a result of it, and as such constitutes an important factor in rejection research. Attachment theory has been applied to understand psychological disorders, such as depression, and can explain individual differences in responses to rejection. Research on autonomic nervous system activity to rejection experiences has been contradictory, with opposing strings of argumentation (activating vs. numbing). We investigated autonomic nervous system-mediated peripheral physiological responses (heart rate) to experimentally manipulated ostracism (Cyberball) in 97 depressed patients with organized (n = 52) and disorganized attachment status (n = 45). Controlling for baseline mean heart rate levels, depressed patients with disorganized attachment status responded to ostracism with significantly higher increases in heart rate than depressed patients with organized attachment status (p = .029; ηp2 = .051). These results suggest that attachment status may be a useful indicator of autonomic responses to perceived social threat, which in turn may affect the therapeutic process and the patient-therapist relationship.

The Specific Role of Relationship Life Events in the Onset of Depression during Pregnancy and the Postpartum

BACKGROUND

The precipitating role of life events in the onset of depression is well-established. The present study sought to examine whether life events hypothesised to be personally salient would be more strongly associated with depression than other life events. In a sample of women making the first transition to parenthood, we hypothesised that negative events related to the partner relationship would be particularly salient and thus more strongly predictive of depression than other events.

METHODS

A community-based sample of 316 first-time mothers stratified by psychosocial risk completed interviews at 32 weeks gestation and 29 weeks postpartum to assess dated occurrence of life events and depression onsets from conception to 29 weeks postpartum. Complete data was available from 273 (86.4%). Cox proportional hazards regression was used to examine risk for onset of depression in the 6 months following a relationship event versus other events, after accounting for past history of depression and other potential confounders.

RESULTS

52 women (19.0%) experienced an onset of depression between conception and 6 months postpartum. Both relationship events (Hazard Ratio = 2.1, p = .001) and other life events (Hazard Ratio = 1.3, p = .020) were associated with increased risk for depression onset; however, relationship events showed a significantly greater risk for depression than did other life events (p = .044).

CONCLUSIONS

The results are consistent with the hypothesis that personally salient events are more predictive of depression onset than other events. Further, they indicate the clinical significance of events related to the partner relationship during pregnancy and the postpartum.

Parental history of psychiatric diagnoses and unipolar depression: a Danish National Register-based cohort study

BACKGROUND

Depression is known to run in families, but the effects of parental history of other psychiatric diagnoses on depression rates are less well studied. Few studies have examined the impact of parental psychopathology on depression rates in older age groups.

METHOD

We established a population-based cohort including all individuals born in Denmark after 1954 and alive on their 10th birthday (N = 29 76 264). Exposure variables were maternal and paternal history of schizophrenia, bipolar disorder, depression, anxiety or 'other' psychiatric diagnoses. Incidence rate ratios (IRRs) were estimated using Poisson regressions.

RESULTS

Parental history of any psychiatric diagnosis increased incidence rates of outpatient (maternal: IRR 1.88, p < 0.0001; paternal: IRR 1.68, p < 0.0001) and inpatient (maternal: IRR 1.99, p < 0.0001; paternal: IRR 1.83, p < 0.0001) depression relative to no parental history. IRRs for parental history of non-affective disorders remained relatively stable across age groups, while IRRs for parental affective disorders (unipolar or bipolar) decreased with age from 2.29-3.96 in the youngest age group to 1.53-1.90 in the oldest group. IRR estimates for all parental diagnoses were similar among individuals aged ⩾41 years (IRR range 1.51-1.90).

CONCLUSIONS

Parental history of any psychiatric diagnosis is associated with increased incidence rates of unipolar depression. In younger age groups, parental history of affective diagnoses is more strongly associated with rates of unipolar depression than non-affective diagnoses; however, this distinction disappears after age 40, suggesting that parental psychopathology in general, rather than any one disorder, confers risk for depression in middle life.

The Next Big Thing in Child and Adolescent Psychiatry: Interventions to Prevent and Intervene Early in Psychiatric Illnesses

The last two decades have marked tremendous progress in our ability to prevent and intervene early in psychiatric illnesses. The interventions described in this article range from established, empirically-supported treatments to creative interventions early in their development and deployment. Some of these interventions are low-technology programs delivered in social settings (such as schools), and some rely on sophisticated emerging technologies such as neuroimaging. This article reviews 4 preventative interventions: 1) The use of structural brain imaging to identify children at risk for familial depression who are most likely to benefit from preventative cognitive behavioral therapy 2) The Good Behavior Game, a school based program that, when implemented in 1st grade classrooms, cut the incidence of substance use disorders in students in half when those students were 19 years old, 3) The SPARX video game, which has the potential to be an accessible, appealing, and cost-effective treatment for the thousands of teens affected by mild to moderate depressive disorders, and 4) Intensive psychosocial treatments which can reduce the progression of from the ultra high risk state to the first episode psychosis by 50% over 12 months. All of these interventions have tremendous potential to reduce the suffering and disability caused by psychiatric illness to both children and adults.

Treatment of maternal depression in a medication clinical trial and its effect on children

OBJECTIVE

Observational studies show that when a depressed mother's symptoms remit, her children's psychiatric symptoms decrease. Using randomized treatment assignment, the authors sought to determine the differential effects of a depressed mother's treatment on her child.

METHOD

The study was a randomized double-blind 12-week trial of escitalopram, bupropion, or the combination of the two in depressed mothers (N=76), with independent assessment of their children (N=135; ages 7-17 years).

RESULTS

There were no significant treatment differences in mothers' depressive symptoms or remission. Children's depressive symptoms and functioning improved significantly among those whose mothers were in the escitalopram group (compared with those whose mothers were in the bupropion and combination treatment groups). Only in the escitalopram group was significant improvement of mother's depression associated with improvement in the child's symptoms. Exploratory analyses suggested that this may be due to changes in parental functioning: Mothers in the escitalopram group reported significantly greater improvement, compared with the other groups, in their ability to listen and talk to their children, who as a group reported that their mothers were more caring over the 12 weeks. Maternal baseline negative affectivity appeared to moderate the effect of maternal treatment on children, although the effect was not statistically significant. Children of mothers with low negative affectivity improved in all treatment groups. Children of mothers with high negative affectivity improved significantly only for those whose mothers were in the escitalopram group.

CONCLUSIONS

The effects of the depressed mother's improvement on her children may depend on her type of treatment. Depressed mothers with high anxious distress and irritability may require medications that reduce these symptoms in order to show the effect of her remission on her children.

Five women’s recollections and reflections on being raised by a mother with psychosis

This qualitative research project explored the recollections and reflections of women who were raised by mothers suffering with psychosis. Existing research has documented the mostly negative effects of maternal psychopathology on offspring; they are exposed to both the genetic and environmental effects of such illness. Very few qualitative studies exist in this research area. The mother–daughter perspective was taken to explore the ways that daughters felt maternal psychosis might have affected this primary relationship. Five participants comprised the purposive, snowball sample. The semi-structured interview method was used for data collection. The data was analysed using thematic content analysis. Nine themes and two sub-themes emerged from the interview data; these were (1) resilience and survival (with two sub-themes: (1.1) extreme self-sufficiency and (1.2) low self-esteem and the need for approval); (2) memories of maternal psychotic episodes; (3) mother–daughter bond; (4) importance of father; (5) sibling sounding boards and responsibilities; (6) silent family storms; (7) significant others; (8) stigma, shame, and secrecy; and (9) maternal psychosis, motherhood, and feminine identity. All participants believe that maternal psychosis had affected them profoundly, both in childhood and adulthood. They felt that it had influenced their personality development in various ways, including the formation of feminine identity.

A familial risk enriched cohort as a platform for testing early interventions to prevent severe mental illness

BACKGROUND

Severe mental illness (SMI), including schizophrenia, bipolar disorder and severe depression, is responsible for a substantial proportion of disability in the population. This article describes the aims and design of a research study that takes a novel approach to targeted prevention of SMI. It is based on the rationale that early developmental antecedents to SMI are likely to be more malleable than fully developed mood or psychotic disorders and that low-risk interventions targeting antecedents may reduce the risk of SMI.

METHODS/DESIGN

Families Overcoming Risks and Building Opportunities for Well-being (FORBOW) is an accelerated cohort study that includes a large proportion of offspring of parents with SMI and embeds intervention trials in a cohort multiple randomized controlled trial (cmRCT) design. Antecedents are conditions of the individual that are distressing but not severely impairing, predict SMI with moderate-to-large effect sizes and precede the onset of SMI by at least several years. FORBOW focuses on the following antecedents: affective lability, anxiety, psychotic-like experiences, basic symptoms, sleep problems, somatic symptoms, cannabis use and cognitive delay. Enrolment of offspring over a broad age range (0 to 21 years) will allow researchers to draw conclusions on a longer developmental period from a study of shorter duration. Annual assessments cover a full range of psychopathology, cognitive abilities, eligibility criteria for interventions and outcomes. Pre-emptive early interventions (PEI) will include skill training for parents of younger children and courses in emotional well-being skills based on cognitive behavioural therapy for older children and youth. A sample enriched for familial risk of SMI will enhance statistical power for testing the efficacy of PEI.

DISCUSSION

FORBOW offers a platform for efficient and unbiased testing of interventions selected according to best available evidence. Since few differences exist between familial and 'sporadic' SMI, the same interventions are likely to be effective in the general population. Comparison of short-term efficacy of PEI on antecedents and the long term efficacy for preventing the onset of SMI will provide an experimental test of the etiological role of antecedents in the development of SMI.

The effects of parental mood on reports of their children's psychopathology

OBJECTIVE

In this study, we aimed to assess whether current mood state (depressed or manic/hypomanic) among parents with a mood disorder would affect their reports of their offspring's psychopathology.

METHOD

Sixty-five parents with current depression, 42 parents with current mania/hypomania, 181 parents with mood disorder in remission, and their offspring (n = 479, aged 6-18 years) completed assessments of offspring psychopathology as part of the Pittsburgh Bipolar Offspring Study (BIOS). We compared rates of offspring psychopathology assessed using the following: a clinician-administered semi-structured interview with parent and child using the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS); parent-reported Child Behavior Checklist (CBCL); offspring self-reported Youth Self Reports (YSR) for those 11 years and older (n = 250); and teachers' reports when available (n = 209).

RESULTS

There were no between-group differences in rates of psychopathology yielded from the K-SADS, except for more depressive disorders in offspring of parents with current mania/hypomania compared to offspring of parents in remission. Conversely, using the CBCL and comparing with parents who were in remission, parents with current depression reported significantly more externalizing psychopathology in offspring, whereas parents with current mania/hypomania reported more externalizing and internalizing psychopathology in their offspring. On the YSR, offspring of parents with current mania/hypomania had more internalizing psychopathology compared to offspring of parents in remission. Teacher's reports showed no between-group differences in rates of any psychopathology.

CONCLUSION

Parental active mood symptomatology, especially during a manic/hypomanic episode, significantly affects their reports of their offspring's psychopathology. Trained interviewers reduce potential report bias. Clinicians and studies assessing children's psychopathology should take into account parental current mood state.

A meta-analysis of the risk of major affective disorder in relatives of individuals affected by major depressive disorder or bipolar disorder

BACKGROUND

To conduct a meta-analysis to estimate the incidence of major depressive disorder (MDD) and bipolar disorder (BD) in first-degree relatives (FDRs) of probands affected by MDD or BD. The risk for MDD in FDR of BD probands and vice versa is also investigated.

METHODS

A systematic review of case-control and cohort studies, which were published between 1977 and 2012; reported relative risks (RR) or odd ratios (OR) or equivalent raw data; made an explicit distinction between MDD and BD; used operational diagnostic criteria; and reported systematic proband recruitment and ascertainment of relatives. Studies were obtained by electronic MEDLINE and EMBASE searches and hand-searching. Estimates were derived from pooled data using random effects methods.

RESULTS

Of an initial sample of 241 articles, 22 were eligible for inclusion. For FDRs of one proband with MDD compared to healthy control probands, estimates for MDD were OR=2.14 (95% CI 1.72-2.67), increasing to OR=3.23 (95% CI 2.11-4.94) for two MDD probands. For FDRs of one BD proband compared to healthy control probands, estimates for BD were OR=7.92 (95% CI 2.45-25.61), and OR=6.58 (95% CI 2.64-16.43) for FDRs of two BD probands.

CONCLUSIONS

These findings support previously published data indicating strong familiality for both MDD and BD. Data will be useful in providing individuals with a family history of MDD or BPD with tailored risk estimates.

Dynamic temporal relations between anxious and depressive symptoms across adolescence

Symptoms of anxiety and depression are prevalent among adolescents and associated with impairment in multiple domains of functioning. Moreover, anxiety and depression frequently co-occur, with estimated comorbidity rates as high as 75%. Whereas previous research has shown that anxiety symptoms predict increased depressive symptoms over time, the relation between depressive symptoms and later anxiety symptoms has been inconsistent. The present study examined dynamic relations between anxiety and depressive symptoms across adolescence and explored whether these longitudinal relations were moderated by maternal history of anxiety, family relationship quality, or children's attributional style. Participants included 240 children (M age = 11.86 years; 53.9% female) and their mothers, who were assessed annually for 6 years. Children reported on their depressive symptoms and mothers reported on their child's anxiety symptoms. Dynamic latent change score models indicated that anxiety symptoms predicted subsequent elevations in depressive symptoms over time. Depressive symptoms predicted subsequent elevations in anxiety symptoms among children who had mothers with a history of anxiety, reported low family relationship quality, or had high levels of negative attributions. Thus, whereas anxiety symptoms were a robust predictor of later depressive symptoms during adolescence, contextual and individual factors may be important to consider when examining relations between depressive symptoms and subsequent change in anxiety symptoms.

A comparison of the emotional and behavioral problems of children of patients with cancer or a mental disorder and their association with parental quality of life

OBJECTIVE

To compare the emotional and behavioral problems of children of patients suffering from cancer or a mental disorder and their association with parental quality of life.

METHODS

A total of 223 children from 136 families and their 160 parents were investigated from multiple perspectives in a cross-sectional study. The consistency of different adjustment reports between family members was examined. Through mixed models, the differences between parental HRQoL and the children's symptomatology were studied with regard to the type of parental illness. The prediction of children's adjustment through parental HRQoL was further examined. Additionally, gender and age of the children were considered.

RESULTS

Half of the children exhibited psychosocial problems. Gender and age differences were independent of the type of parental disease. In families with parental cancer, the reports of children's adjustment were more consistent between family members than in families where a parental mental disorder was present. We found differences in HRQoL between families with mentally ill parents and those with parental cancer patients. Specifically, the healthy partners of mentally ill parents showed worse HRQoL compared with healthy partners of cancer patients. Healthy parents' reduced HRQoL was associated with worse adjustment in their children, regardless of the type of parental illness, but this result was not found for ill parents.

CONCLUSION

Family members confronted with parental cancer or mental disorders are more burdened compared with those from the "normal" population, independently of the type of disease. Our results indicate that the type of a parental disease has no direct effect on children's adjustment. However, there are disease-specific effects on parental HRQoL, which are associated with children's adjustment.

Discriminating risk and resilience endophenotypes from lifetime illness effects in familial major depressive disorder

IMPORTANCE

The neural systems that confer risk or vulnerability for developing familial depression, and those that protect against or confer resilience to becoming ill, can be disentangled from the effects of prior illness by comparing brain imaging measures in previously ill and never ill persons who have either a high or low familial risk for depression.

OBJECTIVE

To distinguish risk and resilience endophenotypes for major depression from the effects of prior lifetime illness.

DESIGN, SETTING, AND PARTICIPANTS

We used functional magnetic resonance imaging to measure and compare brain function during performance of an attentional, self-regulatory task across a large sample of multigenerational families ascertained specifically to be at either high or low risk for developing major depression. Study procedures were performed in a university setting. A total of 143 community participants were followed up prospectively for more than 20 years in a university setting. The sample was enriched with persons who were at higher or lower familial risk for developing depression based on being biological offspring of either a clinical sample of persons with major depression or a community control sample of persons with no discernible lifetime illness.

MAIN OUTCOMES AND MEASURES

Task-related change in blood oxygen level-dependent functional magnetic resonance imaging signal.

RESULTS

A risk endophenotype included greater activation of cortical attention circuits. A resilience endophenotype included greater activation of the dorsal anterior cingulate cortex. The effects of prior lifetime illness were common to both risk groups and included greater deactivation of default-mode circuits.

CONCLUSIONS AND RELEVANCE

These findings identify neural systems that increase risk for depression, those that protect from illness, and those that endure following illness onset, and they suggest circuits to target for developing novel preventive and therapeutic interventions.

Hypomania spectrum disorder in adolescence: a 15-year follow-up of non-mood morbidity in adulthood

BACKGROUND

We investigated whether adolescents with hypomania spectrum episodes have an excess risk of mental and physical morbidity in adulthood, as compared with adolescents exclusively reporting major depressive disorder (MDD) and controls without a history of adolescent mood disorders.

METHODS

A community sample of adolescents (N = 2 300) in the town of Uppsala, Sweden, was screened for depressive symptoms. Both participants with positive screening and matched controls (in total 631) were diagnostically interviewed. Ninety participants reported hypomania spectrum episodes (40 full-syndromal, 18 with brief episode, and 32 subsyndromal), while another 197 fulfilled the criteria for MDD without a history of a hypomania spectrum episode. A follow up after 15 years included a blinded diagnostic interview, a self-assessment of personality disorders, and national register data on prescription drugs and health services use. The participation rate at the follow-up interview was 71% (64/90) for the hypomania spectrum group, and 65.9% (130/197) for the MDD group. Multiple imputation was used to handle missing data.

RESULTS

The outcomes of the hypomania spectrum group and the MDD group were similar regarding subsequent non-mood Axis I disorders in adulthood (present in 53 vs. 57%). A personality disorder was reported by 29% of the hypomania spectrum group and by 20% of the MDD group, but a statistically significant difference was reached only for obsessive-compulsive personality disorder (24 vs. 14%). In both groups, the risk of Axis I disorders and personality disorders in adulthood correlated with continuation of mood disorder. Prescription drugs and health service use in adulthood was similar in the two groups. Compared with adolescents without mood disorders, both groups had a higher subsequent risk of psychiatric morbidity, used more mental health care, and received more psychotropic drugs.

CONCLUSIONS

Although adolescents with hypomania spectrum episodes and adolescents with MDD do not differ substantially in health outcomes, both groups are at increased risk for subsequent mental health problems. Thus, it is important to identify and treat children and adolescents with mood disorders, and carefully follow the continuing course.

Transdiagnostic and disorder-specific models of intergenerational transmission of internalizing pathology

BACKGROUND

Numerous studies have supported an association between maternal depression and child psychiatric outcomes, but few have controlled for the confounding effects of both maternal and offspring co-morbidity. Thus, it remains unclear whether the correspondence between maternal and offspring depressive and anxiety disorders is better explained by associations between shared features of maternal and offspring internalizing disorders or by specific effects exerted by unique aspects of individual disorders.

METHOD

Pairs of mothers and offspring overselected for maternal depression (n = 815) were assessed at offspring age 15 years for anxiety and depressive disorders; 705 completed a follow-up at offspring age 20 years. For both mothers and offspring, structural equation modeling was used to distinguish transdiagnostic internalizing pathology--representing the overlap among all depressive and anxiety disorders--from diagnosis-specific forms of pathology. To discriminate between general versus specific pathways of intergenerational transmission of psychopathology, we examined (a) the general association between the maternal and offspring internalizing factors and (b) the correlations between maternal and offspring diagnosis-specific pathology for each disorder.

RESULTS

For mothers and offspring, a unidimensional latent variable model provided the best fit to the correlations among depressive and anxiety disorders. The maternal transdiagnostic internalizing factor strongly predicted the corresponding factor among offspring. In addition, the unique component of post-traumatic stress disorder among offspring was significantly related to the analogous unique component among mothers, but specific components of other maternal disorders, including depression, did not predict corresponding offspring pathology.

CONCLUSIONS

Results suggest that intergenerational transmission of internalizing disorders is largely non-specific.

Neuropsychological and behavioral profiles in attention-deficit hyperactivity disorder children of parents with a history of mood disorders: a pilot study

OBJECTIVE

We aimed to investigate the neurocognitive and behavioral endophenotypes of premorbid mood disorder. We compared intelligence, neuropsychological functioning, and behavioral problems among three groups: 1) a high-risk group [attention-deficit hyperactivity disorder (ADHD) children of parents with a history of a mood disorder], 2) a low-risk group (ADHD children of parents without a history of a mood disorder), and 3) normal comparison subjects.

METHODS

We used the Korean Educational Development Institute Wechsler Intelligence Scale for Children-Revised (KEDI-WISC-R), the Stroop Color Word Interference Test (Stroop), the Wisconsin Card Sorting Test (WCST), and the Rey-Osterrieth Complex Figure Test (RCFT) as neurocognitive measures, and we used the Child Behavior Checklist (CBCL) as a behavioral measure. Performance on these neuropsychological tests and score on the CBCL of 18 high-risk children were compared to those of 20 low-risk children and 24 healthy children. We also assessed the children's current mood state and familial functioning to control for the confounding effects of these variables.

RESULTS

Compared to low-risk and healthy children, high-risk children were impaired on the Picture Completion and Stroop Word subtest and showed higher scores on the CBCL subscales representing internalizing symptoms. These significant group differences persisted even after adjustment for the children's current mood state and familial functioning.

CONCLUSION

Neuropsychological deficits in the offspring of parents with a mood disorder may be associated with the current mood state rather than with innate characteristics, while their internalizing symptoms may partially stem from innate characteristics that are endophenotypes of a premorbid mood disorder.

Associations between parent-adolescent attachment relationship quality, negative life events and mental health

Purpose

The aim of this study was to examine the association of negative life events and parent-adolescent attachment relationship quality with mental health problems and to explore an interaction between the parent-adolescent attachment relationship and one or multiple negative life events on the mental health of adolescents.

Methods

A two-year longitudinal study was conducted among first-year secondary school students (N = 3181). The occurrence of life events and the quality of parent-adolescent attachment were assessed at baseline and mental health status at two-year follow-up by means of self-report questionnaires. Binary logistic regression analyses were conducted to assess associations between life events, parent-adolescent attachment and mental health problems. Relative Excess Risk due to Interaction techniques were used to determine the interaction effects on the additive scale.

Results

Life events were related to mental health status, as was parent-adolescent attachment. The combined effect of an unfavourable parent-adolescent attachment with life events on mental health was larger than the sum of the two individual effects. Among adolescents with one life event or multiple life events, an unfavourable parent-adolescent attachment increased the risk of mental health problems at follow-up compared to the group without life events.

Conclusion

Results supported an interaction effect between parent-adolescent attachment and negative life events on mental health. Especially adolescents with one or multiple life events and an unfavourable parent-adolescent attachment seems to be a vulnerable group for mental health problems. Implications for further research are discussed.

Familial transmission of parental mood disorders: unipolar and bipolar disorders in offspring

OBJECTIVES

Offspring of depressed parents are at increased risk for psychiatric disorders. Although bipolar disorder (BD) and major depressive disorder (MDD) are both found in the same families, it is not clear whether transmission to offspring of BD or MDD tends to occur from parents with the same mood disorder subtype. Our primary hypothesis was that the offspring of parents with BD would be at increased risk for BD and other comorbid disorders common to BD, such as anxiety and substance use, relative to the offspring of parents with MDD. The offspring of parents with BD versus those with MDD were also hypothesized to be at greater risk for externalizing disorders (i.e., conduct disorder, attention-deficit hyperactivity disorder, or antisocial personality disorder).

METHODS

Parents (n = 320) with mood disorders and their offspring (n = 679) were studied. Adult offspring were administered the Structured Clinical Interview for DSM-IV Axis I Disorders to establish the presence of psychopathology. Offspring aged 10-18 years were assessed using the School Aged Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version, and parents of children under the age of ten completed the Child Behavioral Checklist. Data were examined using Cox proportional hazard regression.

RESULTS

There was no difference in hazard of mood disorders in the offspring of parents with BD as compared to the offspring of parents with MDD. However, a number of other parent and offspring characteristics increased the risk of mood, anxiety, externalizing, and substance use disorders in the offspring, including self-reported childhood abuse in the parent or offspring, offspring impulsive aggression, and the age at onset of parental mood disorder.

CONCLUSIONS

Mood disorders are highly familial, a finding that appears independent of whether the parent's condition is unipolar or bipolar, suggesting considerable overlap in the heritability of MDD and BD. Although parental characteristics had a limited influence on the risk of offspring psychopathology, reported childhood adversity, be it in the parent or child, is a harbinger of negative outcomes. These risk factors extend previous findings, and are consistent with diathesis-stress conceptualizations.

Using the high-risk family design to identify biomarkers for major depression

The familial nature of major depressive disorder (MDD) is now well recognized. We followed children and grandchildren of probands with and without MDD to examine transmission of depression over generations, and to identify early vulnerability markers prior to the onset of disease. The study now includes three generations and five completed assessment waves spanning 25 years, with a sixth wave underway. Beginning with the fourth wave, we collected measures of brain structure (magnetic resonance imaging, MRI) and physiology (electroencephalography, EEG) and DNA in order to examine at a biological level why the offspring of depressed parents were at higher risk. In this paper, we provide an overview of the study design, the main findings, including new data, and the role of the high-risk design in translational research. We demonstrate that offspring of depressed parents ('high-risk'), when compared with those of non-depressed parents ('low-risk'), were at increased risk for depressive and anxiety disorders, with anxiety appearing earlier and being a predisposing factor for MDD. Offspring with two generations previously affected were at greatest risk. Thinning of the cortical mantle (MRI) and reduced resting-state activity (EEG) within the right parieto-temporal hemisphere differentiated high- from low-risk offspring, regardless of whether the offspring had MDD, suggesting that these measures might serve as familial trait markers for depression and related syndromes. The high- and low-risk offspring also differed by serotonin transporter promoter length polymorphism genotypes, even though the same genotypes were not associated with the presence of MDD. The high-risk epidemiological design appears to be a particularly valuable asset in translational research as it allows targeting of biological processes that emerge prior to the onset of disease, and identifies individuals at high risk for the disorder who may carry the trait or marker but not yet be affected.

The significance of at-risk or prodromal symptoms for bipolar I disorder in children and adolescents

While in the early identification and intervention of psychosis-specific instruments and risk criteria have been generated and validated, research into indicated preventive strategies for bipolar I disorder (BD I) has only recently gained momentum. As the first signs of BD I often start before adulthood, such efforts are especially important in the vulnerable pediatric population. Data are summarized regarding the presence and nature of potentially prodromal, that is, subsyndromal, symptoms prior to BD I, defined by first-episode mania, focusing on pediatric patients. Research indicates the possibility of early identification of youth at clinical high risk for BD. Support for this proposition comes from retrospective studies of BD I patients, as well as prospective studies of community samples, offspring of BD I subjects, youth with depressive disorders, and patients at high risk for psychosis or with bipolar spectrum disorders without lifetime history of mania. These data provide essential insight into potential signs and symptoms that may enable presyndromal identification of BD I in youth. However, except for offspring studies, broader prospective approaches that focus on youth at clinical high risk for BD I and on developing specific interviews and (or) rating scales and risk criteria are mostly missing, or in their early stage. More work is needed to determine valid and sufficiently specific clinical high-risk criteria, to distinguish risk factors, endophenotypes, and comorbidities from prodromal symptomatology, and to develop phase-specific interventions that titrate the risk of intervention to the risk of transition to mania and to functional impairment or distress. Moreover, studies are needed that determine potential differences in prodromal symptoms and trajectories between children, adolescents, and adults, and the best phase-specific interventions.

Parents with bipolar disorder: Are disease characteristics good predictors of psychopathology in offspring?

Purpose

To investigate rates of psychopathology in the offspring of subjects with bipolar disorder (BP-offspring) compared to the offspring of healthy subjects (HC-offspring) in a Spanish sample and to study possible predictors of psychopathology in BP-offspring.

Subjects

Fifty BP-offspring from 36 families and 25 HC-offspring from 25 families.

Methods

Psychopathology was compared in BP-offspring and HC-offspring. Factors associated with DSM-IV axis I disorders in BP-offspring were analyzed using logistic regression.

Results

Half of BP-offspring fulfilled the diagnostic criteria for at least one axis I disorder with attention-deficit/hyperactivity disorder (30%), anxiety disorders (14%) and affective disorders (10%) as the most frequent. After controlling for having more than one sibling in the study, the odds ratio for BP-offspring presenting an axis I disorder was 15.02 when a biological parent had bipolar disorder with a lifetime history of psychotic symptoms and 3.34 when one parent had bipolar II disorder. Moreover, a higher Global Assessment of Functioning score in the biological co-parent was associated with a significantly lower frequency of axis I disorders in BP-offspring.

Discussion and conclusions

Psychopathology in BP-offspring should be routinely assessed, with special emphasis on children from parents with specific disease characteristics (psychosis, BP II disorder) in order to establish an early diagnosis and appropriate interventions.

Targeting parental psychopathology in child anxiety

The increased risk of anxiety in children of parents with psychopathology is a significant public health problem, as early-onset is associated with a variety of difficulties later in life. The aim of this article is to determine if treating parents is associated with improvements in child anxiety through the review of both top-down (parent identified for treatment) and family-focused child anxiety treatment studies. The authors present conclusions based on the state of the current literature, discuss implications for research and clinical practice, and propose utilizing a family-based model for treating parental psychopathology, parental behavior, and child anxiety.