Initial findings on preventive intervention for families with parental affective disorders

A family perspective on parental psychosis: An interpretative phenomenological analysis study

OBJECTIVES

While one third of people with a psychotic disorder are a parent, there has been little research to date examining the consequences of this from a whole family perspective. This study investigates families where a parent has experienced an episode of psychosis and compares and contrasts the family members' perspectives.

DESIGN

This study was rooted in phenomenology and data were derived from in-depth semi-structured interviews.

METHODS

Parents with a psychotic disorder who had a child aged between 3 and 11 in a UK NHS Trust were invited to take part in the study. Semi-structured interviews were conducted with these parents, with their child (if they were between the ages of 8 and 11), and with their partner or another close family member. Data were analysed using multiperspectival interpretive phenomenological analysis (m-IPA).

RESULTS

Thirteen participants took part comprising of five parents, four children, three partners and one grandmother. Four themes were developed using m-IPA: (1) Parental psychosis impacts the whole family, (2) Psychosis and my role as a parent, (3) Secrecy and concealment surrounding parental psychosis, and (4) Pressures and vulnerabilities within the family system.

CONCLUSION

Psychosis had a negative impact on all family members and secrecy existed between family members. The children in particular only had partial information about their parent's mental illness, which left them worried and confused. More work is needed to support these families to explain psychosis to the children.

Breaking the silence about illness and death: Potential effects of a pilot study of the family talk intervention when a parent with dependent children receives specialized palliative home care

Objective

The entire family is affected when a parent is severely ill. Parents often need and appreciate professional support when talking to children about illness and death. The family talk intervention (FTI) is family-centered and intends to promote communication about the illness and its consequences, support parenting to enhance family coping and help family members share experiences with each other to create a shared family history. This study aimed to explore potential effects of FTI in specialized palliative home care, as reported by parents.

Method

This pre-post test intervention pilot was conducted in specialized palliative home care. A convergent mixed-method design was used to analyze interview and questionnaire data. Twenty families with dependent children were recruited from two specialized palliative home care units in Stockholm, Sweden.

Results

Parents reported that family communication improved after participation in FTI as family members learned communication strategies that facilitated open sharing of thoughts and feelings. Increased open communication helped family members gain a better understanding of each other's perspectives. Parents reported that relationships with their partner and children had improved as they now shared several strategies for maintaining family relationships. Parents were also less worried following participation in FTI. The ill parents stated that they gained a sense of security and were less worried about the future.

Significance of results

This study adds to the evidence that FTI may be a useful intervention for families with dependent children and an ill parent in a palliative care setting. This trial is registered at ClinicalTrials.gov Identifier NCT03119545.

A Scoping Review of Interventions Designed to Support Parents With Mental Illness That Would Be Appropriate for Parents With Psychosis

The experience of psychosis can present additional difficulties for parents, over and above the normal challenges of parenting. Although there is evidence about parenting interventions specifically targeted at parents with affective disorders, anxiety, and borderline personality disorder, there is currently limited evidence for parents with psychotic disorders. It is not yet known what, if any, interventions exist for this population, or what kinds of evaluations have been conducted. To address this, we conducted a scoping review to determine (1) what parenting interventions have been developed for parents with psychosis (either specifically for, or accessible by, this client group), (2) what components these interventions contain, and (3) what kinds of evaluations have been conducted. The eligibility criteria were broad; we included any report of an intervention for parents with a mental health diagnosis, in which parents with psychosis were eligible to take part, that had been published within the last 20 years. Two reviewers screened reports and extracted the data from the included reports. Thirty-eight studies of 34 interventions were included. The findings show that most interventions have been designed either for parents with any mental illness or parents with severe mental illness, and only two interventions were trialed with a group of parents with psychosis. After noting clusters of intervention components, five groups were formed focused on: (1) talking about parental mental illness, (2) improving parenting skills, (3) long-term tailored support for the whole family, (4) groups for parents with mental illness, and (5) family therapy. Twenty-three quantitative evaluations and 13 qualitative evaluations had been conducted but only eight interventions have or are being evaluated using a randomized controlled trial (RCT). More RCTs of these interventions are needed, in addition to further analysis of the components that are the most effective in changing outcomes for both the parent and their children, in order to support parents with psychosis and their families.

Mental health promotion and prevention interventions in families with parental depression: A randomized controlled trial

BACKGROUND

The transgenerational transmission of affective disorders calls for integrating promotion of child development in the services offered to families with parental depression. The main objective of the present research was to examine the effectiveness and differences in the impact of two relevant interventions in Greece.

METHODS

Thirty families of depressed patients were randomly assigned to the six-to-eight session Family Talk Intervention group and 32 families were included in the lower intensity parent-only two-to-three session Let's Talk about the Children group. Depressed parents and the eldest of their children were assessed prior to the interventions and 4, 10, and 18 months following baseline assessment.

RESULTS

In both groups there were significant improvements in parent's depression, anxiety, perceived social support, parenting and family functioning, as well as improvements in child's depression, anxiety, and child emotional/behavioral problems. Child's prosocial behavior, perceived social support, and health-related quality of life were significantly improved in both groups. All positive effects were evident four months following baseline assessment and could be still documented at 1.5-year follow-up. Mixed linear models showed that family functioning and parenting to a lesser extent were associated with the greatest changes in children's psychosocial outcomes in both interventions..

LIMITATIONS

The lack of data regarding parents that refused to receive the interventions may limit generalizability of results. A further limitation is the lack of a no-intervention control group.

CONCLUSIONS

The study offers a preliminary evidence base for integrating preventive interventions for child mental health in routine clinical practice with adult depressed patients.

How to support patients with severe mental illness in their parenting role with children aged over 1 year? A systematic review of interventions

PURPOSE

There are well-established risks for parents with severe mental illness (i.e. psychotic and bipolar disorders), both for their children and themselves. Interventions to help parents fulfil their role should therefore be a public health objective, but their implementation needs to be underpinned by research evidence. This systematic review determines what is known about the nature and effectiveness of interventions for parents with severe mental illness.

METHODS

We conducted a narrative synthesis of controlled and uncontrolled studies reporting interventions for this patient group after the post-natal period (i.e. after the child has turned 1 year old).

RESULTS

Eighteen publications reported data from 15 studies. All but two studies were rated as low quality studies. Interventions included home visiting programmes, complex community programmes, residential treatments, and online interventions. Interventions targeted diverse areas, with parenting skills and understanding the impact of mental illness on parenting most frequently addressed. Both parent and child-related outcomes improved, but children were only assessed via observers and follow-up times were short.

CONCLUSIONS

Interventions were diverse with respect to their nature and effectiveness. Future interventions should combine different intervention strategies to target multiple areas in a flexible manner. The addition of positively focussed and resource-oriented components should be investigated. Trials should include direct assessments of both parents and children, outcomes that are relevant from a public health perspective, and establish the long-term effects ideally until children have reached 18 years of age.

Family support programs and adolescent mental health: review of evidence

Family support programs aim to improve parent wellbeing and parenting as well as adolescent mental and behavioral health by addressing the needs of parents of adolescents experiencing or at risk for mental health problems. Family support programs can be part of the treatment for adolescents diagnosed with mental or behavioral health problems, or family support programs can be delivered as prevention programs designed to prevent the onset or escalation of mental or behavioral health problems. This review discusses the rationale for family support programs and describes the range of services provided by family support programs. The primary focus of the review is on evaluating the effectiveness of family support programs as treatments or prevention efforts delivered by clinicians or peers. Two main themes emerged from the review. First, family support programs that included more forms of support evidenced higher levels of effectiveness than family support programs that provided fewer forms of support. Discussion of this theme focuses on individual differences in client needs and program adaptions that may facilitate meeting diverse needs. Second, family support prevention programs appear to be most effective when serving individuals more in need of mental and behavioral health services. Discussion of this theme focuses on the intensity versus breadth of the services provided in prevention programs. More rigorous evaluations of family support programs are needed, especially for peer-delivered family support treatments.

Adverse drug reaction monitoring of antidepressants in the psychiatry outpatients department of a tertiary care teaching hospital

BACKGROUND AND INTRODUCTION

Depression is a prevalent mental disorder and the 4(th) leading cause of disability in the world as per the World Health Organization (WHO). The adverse Drug Reactions (ADRs) to antidepressants are common and they can lead to a non compliance or even a discontinuation of the therapy. This study entitled us to monitor the ADR profile of the antidepressants in a tertiary care teaching hospital.

PATIENTS AND METHODS

A longitudinal, observational study was conducted in the Outpatients Department of Psychiatry in S.C.B. Medical College and Hospital l in collaboration with the I.M.S and SUM Hospital. A total of 160 cases were studied for ADRs by using a predesigned CDSCO form. The patients who were on TCAs, SSRIs and newer antidepressants (SNRIs/NDRIs) were assessed by doing physical examinations, neurological examinations and relevant lab tests. The causalities were assessed by the criteria of the WHO-UMC. The analysis of ADRs was done by using the Chi square test.

RESULTS

Among the 160 patients who took antidepressants, 26.87% reported ADRs, with at least one possible causality.None were labeled as certain, as a rechallenge was not performed.ADRs were mostly observed in polytherapy (14.37%) and with antidepressants like TCAs (58.84%).

CONCLUSIONS

Agitation, anxiety and insomnia were the common ADRs which were associated with the use of antidepressants. This study offers a representative profile of the ADRs which can be expected in the Psychiatry Outpatients Department and due care must be taken to avoid these ADRs.

Family support in prevention programs for children at risk for emotional/behavioral problems

We conducted a review of empirically based prevention programs to identify prevalence and types of family support services within these programs. A total of 238 articles published between 1990 and 2011 that included a family support component were identified; 37 met criteria for inclusion. Following the Institute of Medicine's typology, prevention programs were categorized as universal, selective, or indicated; programs containing more than one prevention level were characterized as multi-level. Family support types included those led by a mental health professional, led by a peer, or team-led. Among the 37 prevention programs reviewed, 27% (n=10) were universal, 41% (n=15) were selective, 16% (n=6) were indicated, and 16% (n=6) were multi-level. The predominant model of family support was professionally led (95%, n=35). Two (n=5%) provided team-led services. None were purely peer-led. In terms of content of family support services, all (100%, n=37) provided instruction/skill build. Information and education was provided by 70% (n=26), followed by emotional support (n=11, 30%) and instrumental or concrete assistance (n=11, 30%). Only 14% (n=5) provided assistance with advocacy. The distribution of models and content of services in prevention studies differ from family support within treatment studies. As family support is likely to be an enduring component of the child and family mental health service continuum, comparative effectiveness studies are needed to inform future development.

A Pilot Study of a Family-Focused Intervention for Children and Families Affected by Maternal Depression

A non-experimental pilot study examined child, mother, and family outcomes of a 10-session multi-family group intervention designed to reduce risk and promote resilience for mothers with depression and their families. Positive changes following the Keeping Families Strong intervention included mother-reported decreases in child behavior and emotional problems, improvements in the quality of family interactions and routines, and improvements in their own well being and support from others. Children (9-16 years) reported decreased internalizing symptoms, improved coping, increased maternal warmth and acceptance, and decreased stressful family events. Attendance and mother-reported satisfaction were high, indicating the perceived value of the intervention.

The Prevention of Depression and Anxiety in a Sample of High-Risk Adolescents: A Randomized Controlled Trial

This study investigated the efficacy of cognitive behavioural therapy (CBT) techniques in preventing depression and anxiety in a group of adolescent high school students with elevated risk for developing emotional disorders. Students were screened using a measure of depression severity and clinical interview. Following screening procedures, students at risk for, but not currently diagnosed with, depression were randomly assigned to one of two intervention groups: a CBT ( n = 25) or an active control group ( n = 21). Assessment measures were administered before treatment, after treatment, and at 3- and 6-month follow-up. Both groups exhibited significant improvements in mood symptomatology and self-esteem outcomes over time. Significant differences between groups were not observed at posttreatment and two follow-up points of assessment. The efficacy of CBT techniques was also examined using a “benchmarking” strategy. The limitations of this study and future research directions are discussed.

Randomized controlled trial of a family cognitive-behavioral preventive intervention for children of depressed parents

A family cognitive-behavioral preventive intervention for parents with a history of depression and their 9-15-year-old children was compared with a self-study written information condition in a randomized clinical trial (n = 111 families). Outcomes were assessed at postintervention (2 months), after completion of 4 monthly booster sessions (6 months), and at 12-month follow-up. Children were assessed by child reports on depressive symptoms, internalizing problems, and externalizing problems; by parent reports on internalizing and externalizing problems; and by child and parent reports on a standardized diagnostic interview. Parent depressive symptoms and parent episodes of major depression also were assessed. Evidence emerged for significant differences favoring the family group intervention on both child and parent outcomes; strongest effects for child outcomes were found at the 12-month assessment with medium effect sizes on most measures. Implications for the prevention of adverse outcomes in children of depressed parents are highlighted.

Review of Interventions for Parental Depression from Toddlerhood to Adolescence

Because of the recurrent course, significant burden, and intergenerational impact of depression, there is a great need for interventions for depressed parents and their children. This article reviews eight interventions that 1) aim to impact the functioning and well-being of 18-month to 18-year old children of depressed parents and 2) have been evaluated in controlled studies. The interventions are described and the empirical evidence of their efficacy is reviewed and critiqued. Existing research points to several promising intervention strategies, such as psychoeducation about parental depression, addressing parenting in adult depression treatment, promoting positive parent-child interactions, and teaching coping skills to children. Common limitations of the research in this area are small sample sizes, homogenous samples, and lack of replication. Implementation problems within the mental healthcare system are highlighted. Multi-component interventions seem to be a promising approach to address the complex impact parental depression has on children and the parent-child relationship. This review illustrates the need for more research on intervention models that can be implemented with children at various developmental levels.

Development of a family-based program to reduce risk and promote resilience among families affected by maternal depression: theoretical basis and program description

Depression is a family matter. It not only diminishes the quality-of-life of the depressed person, but also strains the resources of the family unit and increases the children's risk of developing significant problems that start early and persist into adulthood. Although treatment of a parent's depression is critical, many families also need professional intervention to reduce children's risk. This article reviews the evidence on needs of these families and shows that the theoretical and clinical evidence exists to support the design of interventions for families affected by maternal depression. A preventive intervention developed from this foundation is described, the Keeping Families Strong (KFS) program, that is designed to promote resilience and reduce the risk for psychological disorders in children of parents with depression. The pilot study on the KFS program, conducted in adult mental health outpatient settings, is described. Families participate in 10 meetings 90 min each, with a group for parents and for children (10 years and older) conducted concurrently. The program structure and content are described, the challenges of implementing a family preventive intervention in actual clinical settings are discussed, and a case example is provided, as well as preliminary outcome data on ten families. In sum, we provide a strong rationale for the potential of preventive interventions for families affected by maternal depression.

The therapeutic relationship in secondary mental health care: a conceptual review of measures

OBJECTIVE

The study aimed to determine the conceptual basis of measures of the patient-professional relationship used in routine mental health services research by reviewing their face, content and construct validity.

METHOD

A comprehensive literature search identified measures of the relationship used in mental health services research. The conceptual basis of each identified measure was identified by a review of measures' authors assessments of face, content and construct validity plus item analysis of the measures themselves.

RESULTS

The search identified 15 measures. The seven developed in psychotherapy were likely to be better validated conceptually; most were based on therapeutic alliance models. Measures developed specifically for mental health services were based on a wider range of models including global assessments of the relationship.

CONCLUSION

Most of the better validated measures originate in psychotherapy, but there is limited evidence for their validity in general mental health services. Four measures are recommended.

Interventions for helping people recognise early signs of recurrence in bipolar disorder

BACKGROUND

Recurrence rates for bipolar disorder are high despite effective treatments with mood stabiliser drugs. Self-help treatments and psychological treatments that teach patients to recognise and manage early warning symptoms and signs (EWS) of impending manic or depressive episodes are popular with patients. The main aim of such interventions is to intervene early and prevent bipolar episodes, thereby increasing the time to the next recurrence and preventing hospitalisation.

OBJECTIVES

To compare the effectiveness of an EWS intervention plus treatment as usual (TAU ) versus TAU (involving and not involving a psychological therapy) on time to manic, depressive and all bipolar episodes (the primary outcome), hospitalisation, functioning, depressive and manic symptoms.

SEARCH STRATEGY

Relevant studies identified by searching Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References - searched on 20/10/2005), supplemented with hand searching the journal Bipolar Disorders, searching the UK National Research Register, checking reference lists of included studies and contacting authors.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) were included. Participants were adults with a diagnosis of bipolar disorder based on standardised psychiatric criteria.

DATA COLLECTION AND ANALYSIS

Two reviewers independently rated trials for inclusion. Data were extracted from included trials by reviewers using a data extraction sheet. Authors of all the included studies were contacted for any additional information required. Time to recurrence data was summarised as log hazard ratios, dichotomous data as relative risk and continuous data as weighted mean difference, using random effects models to calculate effect size only when there was heterogeneity in the data.

MAIN RESULTS

Eleven RCTs were identified, but only six provided primary outcome data. All six RCTs were of high quality. Time to first recurrence of any type (RE, hazards ratio 0.57, 95% CI 0.39 to 0.82), time to manic/hypomanic episode, time to depressive episode, and percentage of people hospitalised and functioning favoured the intervention group. Neither depressive nor hypomanic symptoms differed between intervention and control groups.

AUTHORS' CONCLUSIONS

This review shows a beneficial effect of EWS in time to recurrence, percentage of people hospitalised and functioning in people with bipolar disorder. However, the absence of data on the primary outcome measure in so many included studies is a source of concern and a potential source of bias. Mental health services should consider routinely providing EWS interventions to adults with bipolar disorder, as they appear to reduce hospitalisation and therefore may be cost-effective.

Pharmacological treatment of adolescent major depression

Antidepressant agents are widely prescribed for adolescents, although specific data regarding their efficacy in this age range are limited. The aims of the present article are to review research findings regarding the use of antidepressant drugs for adolescent depression and to discuss the main results in light of our clinical experience. Only 13 controlled trials on the use of antidepressant drugs for adolescent major depression are available in the literature. Six studies evaluated the efficacy of tricyclic antidepressants, yet they only included 196 adolescents altogether. Seven studies, including a total of 1,403 patients, evaluated the efficacy of three specific serotonin reuptake inhibitors: fluoxetine, paroxetine, and sertraline. Based on published data, serotonin reuptake inhibitors appear to be the first-line psychopharmacologic treatment for adolescent depression, as three compounds (fluoxetine, paroxetine, and sertraline) appeared to be effective in this indication. Conversely, all published studies failed to demonstrate that the tricyclic antidepressants were superior to placebo. Several questions remain open and are discussed: How should we use available scientific data in clinical practice? Are there nonspecific factors implicated in treatment response? Is there a serotonin hypothesis for juvenile depression? What are the priorities for future research?

A family-based approach to the prevention of depressive symptoms in children at risk: evidence of parental and child change

OBJECTIVE

Depression in parents is a prevalent and impairing illness that is encountered frequently in medical practice. Children of depressed parents are at risk for psychopathology and other difficulties. A series of recent national reports have recommended the development of prevention efforts targeting children of depressed parents. Yet, to date, few controlled prevention studies of depression in children and adolescents have been conducted. In this study, we report the evaluation of 2 preventive intervention strategies that target children living in homes with depressed parents. Both are public health approaches that were designed to be used by a wide range of practitioners from a variety of disciplines, including pediatricians, internists, school counselors, nurses, and mental health practitioners. We adopted a developmental perspective and intervened with families when children were entering the age of highest risk for depression onset (ie, adolescence). We chose a family-based approach to prevention and sought to reduce risk factors and enhance protective factors for early adolescents by increasing positive interactions between parents and children, and by increasing understanding of the illness for everyone in the family. Our prevention approaches were designed to provide information about mood disorders to parents, to equip parents with the skills they need to communicate information to their children, and to open a dialogue with their children about the effects of parental depression. We hypothesized that participation in these prevention programs would result in parental change in child-related behaviors and attitudes about depression and its impact on the family. In addition, we hypothesized that this parental change would produce change in children's self-understanding, and in children's depressive symptomatology.

METHODS

We conducted a large-scale efficacy trial of 2 manual-based preventive intervention programs that were designed to be used widely in public health settings. These interventions target the relatively healthy children (ages 8-15) of parents with mood disorder. Ninety-three families (88.5% of our initial sample), including 121 children, participated in this study through the fourth assessment point. These families were assigned randomly to either a lecture or a clinician-facilitated intervention. Both interventions were specified in manuals. The lecture condition consisted of 2 separate meetings delivered in a group format without children present. The clinician-facilitated condition consisted of 6 to 11 sessions, including separate meetings with parents and children, and a family meeting in which the parents led a discussion of the illness and of positive steps that can be taken to promote healthy functioning in the children. In addition, telephone contacts or refresher meetings were conducted at 6- to 9-month intervals. In both conditions, psychoeducational material about mood disorders, risk, and resilience was presented and efforts were made to decrease feelings of guilt and blame in children. Parents were helped to build resilience in their children through encouraging their friendships, their success outside of the home, and their understanding of parental illness and of themselves. In addition, in the clinician-facilitated condition, efforts were made to link the psychoeducational material presented to the family's own unique illness experience. To address directly how their lives had changed, all family members in both conditions were assessed for psychopathology and for overall functioning at intake, and for psychopathology, functioning, and response to intervention immediately postintervention, approximately 1 year postintervention, and again approximately 2.5 years postintervention.

RESULTS

We examined the outcomes of child understanding and internalizing symptomatology, and a number of predictor variables, using repeated measures analyses with generalized estimating equations. We found that parents in both conditions reported significant change in child-related behaviors and and attitudes, and that the amount of change reported increased over time from time 3 to time 4 (chi2(1) = 18.1). Moreover, relative to parents in the lecture program (mean number of changes = 6.3), parents in the clinician-facilitated program reported more change in child-related behaviors and attitudes (mean number of changes = 9.8). Children in both conditions reported increased understanding of parental illness attributable to participation in our intervention programs. There was a positive association between the amount of change children reported in their understanding of parental illness and the number of changes couples reported in child-related behaviors/attitudes (chi2(1) = 37.3; ie, parents who had changed the most in response to intervention had children who also changed the most). Finally, internalizing scores for all children decreased with increased time since intervention (chi2(1) = 7.3). In addition, females had higher internalizing scores than males (chi2(1) = 5.3). There was no significant effect of group on children's change in internalizing symptomatology (chi2(1) = 0.2).

CONCLUSIONS

We enrolled families with relatively healthy children, administered carefully designed preventive interventions that are manual-based and relatively brief, and found that these programs do have long-standing positive effects in how families problem solve around parental illness. Our results show significant benefits from both interventions. Moreover, changes in parents' perceptions translated directly into changes in children's own understanding of parental illness. Parental behavior and attitude changes and their connection to child changes in understanding identify an important mediating variable: family change. By increasing children's understanding of parental mood disorder, our interventions were found to promote resilience-related qualities in these children at risk. This presentation represents the first and only longitudinal primary prevention study of relatively healthy children at risk for psychopathology attributable to parental mood disorder and demonstrates a significant reduction in risk factors and increase in protective factors in these families over a long time interval--2(1/2) years. Our results provide support for a family-based approach to preventive intervention.

Use of a computer-based application in a pediatric hemodialysis unit: a pilot study

This report describes preliminary efforts to implement a computer-based application, called Zora, in a pediatric hemodialysis unit. The feasibility and safety of establishing a virtual community in the hemodialysis unit are explored. Zora allows users to design and inhabit a graphical virtual city where they create characters, stories and spaces while communicating in real-time. Over a 5-month period, 7 hemodialysis patients and 4 unit staff found Zora enjoyable and safe. The results support the premise that computational environments may offer an opportunity for pediatric patients and their caregivers to participate in virtual communities that promote coping with chronic physical illnesses.

A pilot study of a parent-education group for families affected by depression

OBJECTIVE

This study assessed the feasibility and efficacy of a parent-education group for families with young children and a parent with depression. We designed the program to be readily disseminated if shown to be effective.

METHOD

We recruited 44 parents with depression from clinics and family doctors in Hamilton, Ontario, and randomly assigned them to receive the parenting program or to a wait-list control group. The outcomes measured included knowledge of depression, parenting, family relationships, depression symptoms, child depressive symptoms, and functioning. We used analysis of covariance to test for posttreatment differences between experimental and control groups.

RESULTS

Of the treatment group, 27% dropped out at posttreatment, and 43% by follow-up. Those who dropped out had more severe depression at baseline than did those who completed the program, and there was selective loss of parents with more severe depression in the experimental group. In intention-to-treat analyses at posttreatment, probands in the experimental group reported more improvements on family functioning, parenting sense of competence, and family and parent conflict than did control subjects. Standardized effect sizes (ES) were medium (0.4 to 0.6). When baseline depressive symptom scores were controlled in the analyses, the between-group differences were reduced, showing that selective loss of participants may have influenced the findings.

CONCLUSIONS

On balance, the results are encouraging and support the further development and evaluation of the group intervention. However, the study does not provide unequivocal evidence in support of the program. Before it is transferred to other settings, the program needs further modification to improve participation by parents with more severe depression and further evaluation of its effectiveness.

Phenomenology, psychosocial correlates, and treatment seeking in major depression and dysthymia of adolescence

OBJECTIVE

To compare phenomenology, psychosocial correlates, and treatment seeking in DSM-Itt-R major depression and dysthymia among adolescents diagnosed as cases in a community-based study.

METHOD

A self-report questionnaire, including psychosocial data, life events, eating behaviors, depressive symptoms, substance use, pathological behaviors, and family and school functioning was administered to a nonselected sample (N = 3,287, 93.2% of targeted population) of adolescents aged 11 to 20 years from several Haute-Marne communities in France in 1988-1989. Subgroups of subjects (n = 205, 84.7% of eligible subjects) were interviewed with a structured diagnostic schedule, and adolescents with major depression (n = 49), dysthymia (n = 21) and controls (n = 135) were compared.

RESULTS

Nearly 30% of controls had at least one current symptom of depression. Patterns of affective symptoms were similar in major depression and dysthymia, but significant differences emerged in comorbid conditions (more anxiety disorders, suicidal behaviors, and alcohol intoxications associated with major depression) and stressor at onset (more severe in major depression). Experiences of loss during the prior 12 months were associated with both forms of affective disorder, while poor family relationships were specific correlates of dysthymia. In contrast, peer relationships and pathological behaviors did not differ between depressed subjects and controls. Although psychosocial functioning was significantly impaired in both groups of depressed adolescents, treatment seeking was limited to 34.7% for major depressive subjects and 23.8% for dysthymic subjects.

CONCLUSION

The results provide evidence that major depression and dysthymia in adolescence are equally severe but may have distinct patterns in associated factors. Despite free access to health care, the rate of treatment seeking for mood disorders in France is similar to that reported in U.S. studies.

Illness-related concerns of mothers of children with congenital heart disease

OBJECTIVE

This study examined concerns expressed by mothers of children with congenital heart disease (CHD). The relationships among mothers' concerns, medical severity, and mother's emotional state were examined at two points in time.

METHOD

Thirty-eight mothers of children with CHD aged 3 to 16 completed semistructured interviews and rating scales during hospitalization and 2 to 4 weeks after discharge. Mothers rated their distress about illness-related concerns, as well as their own depressed mood and anxiety. Mothers and two cardiologists rated the medical severity of each child's disease.

RESULTS

Mothers' concerns were reliably grouped into five categories: medical prognosis, quality of life, psychosocial functioning, effects on family, and financial issues. During hospitalization, mothers were most concerned about medical prognosis. Distress about most concerns decreased postdischarge, as did mother's anxiety and depressed mood. Mothers' perceptions of medical severity were associated with distress about psychosocial issues postdischarge. Mother's anxiety was not associated with number of concerns reported, or with distress about those concerns. Maternal depressed mood was associated with fewer illness-related concerns, but greater distress about those concerns.

CONCLUSIONS

Illness-related concerns can be meaningfully categorized and are not necessarily a function of disease severity or mother's emotional state. An awareness of common concerns will improve clinical care by enabling practitioners to anticipate and address concerns in a proactive way. The results may inform the development of supportive mental health interventions for families of children with CHD.

Depression in youth: psychosocial interventions

Witnessed over the past 20 years are major advances in knowledge regarding depression in children and adolescents. Although additional research is needed, clinicians can now turn to treatment strategies with demonstrated efficacy. In this article we review the literature on psychosocial interventions for depression in youth and offer a working model to guide the treatment of depressed youth. We begin with a brief overview of the model, followed by a review of the treatment efficacy and prevention literatures. We offer some caveats that impact the ability to move from this treatment literature to the real world of clinical practice. We conclude by considering how extant research can inform treatment decisions and highlight critical questions that need to be addressed through future research.

Preventive interventions for youth suicide: a risk factor-based approach

OBJECTIVE

This review draws on current knowledge of risk for youth suicide to categorize strategies for intervention. Its goal is to identify areas of 'research need' and to provide an evidence base to identify 'best buy' preventive interventions for youth suicide.

METHOD

The design, development, implementation and evaluation of prevention strategies ranging from clinical interventions to population-based universal approaches are considered within five risk factor domains: individual, family, community, school and peer.

RESULTS

There is a paucity of evidence on the effects of interventions targeting depression and suicidal behaviour. Nevertheless, there are effective indicated, selective and universal interventions for important risk factors for depression and suicidal behaviour. Little evidence has emerged to support the efficacy of some traditional approaches to suicide prevention, such as school based suicide education programs and telephone hotlines.

CONCLUSIONS

Youth suicide prevention strategies in Australia have generally employed traditional approaches that focus on clinical interventions for self-harmers, restricting access to lethal means, providing services to high risk groups and enhancing general practitioner responses. Both program development and research evaluation of interventions for many important risk and protective factors for suicide have been neglected.

The experience journal: a computer-based intervention for families facing congenital heart disease

OBJECTIVE

To test the feasibility and safety of a computer-based application designed to facilitate the healthy coping of children and their families who must contend with significant congenital heart disease (CHD). The application, called the Experience Journal (EJ), is a psychoeducational intervention based on a narrative model involving the sharing of personal stories about an illness.

METHOD

Testing was conducted in 2 phases. In phase 1, 9 parents of children with CHD and 1 adult with CHD were asked to use the EJ. After utilization, semistructured interviews assessed EJ usability and safety. In phase 2, 40 mothers of children with CHD used the EJ during a hospitalization. Assessment of feasibility and safety was measured through the use of semistructured interviews prior to EJ utilization and 2 to 4 weeks after hospital discharge.

RESULTS

Results revealed that the EJ was safe and useful for decreasing social isolation, increasing understanding of familial feelings about cardiac illness, and fostering positive reactions in mothers.

CONCLUSIONS

Computer-based interventions that present psychoeducational and medical information closely connected to "one's own story" may open up new possibilities for families facing pediatric illnesses.

From cognitive information to shared meaning: healing principles in prevention intervention

Families with parental affective disorder participated in a large-scale longitudinal study which involved participation in a standardized, short-term, psychoeducational preventive intervention. These families were followed for at least 3 years. An analysis of clinical material from the first 12 families to complete the intervention identified specific healing principles that contributed to positive changes in behavior and attitude. The healing elements of the intervention included demystification of the illness, modulation of shame and guilt, increase in the capacity for perspective taking, and development of a hopeful perspective and belief in one's own competence. Therapeutic effectiveness evolved in a process that linked cognitive information and presented depression as an illness that could be understood with the acknowledgement of family members' individual and collective experience. In this way, families developed a shared understanding of the illness that was useful over time. This article discusses the ways in which the healing principles promoted changes in family members' behavior and attitude, which, in turn, enhanced resiliency in children.

Characteristics of adolescent girls with depressive symptoms in a so-called "normal' sample

OBJECTIVE

Forty-four percent of adolescent girls who had been screened for absence of psychiatric disorder reported depressive symptoms on a structured interview. Girls reporting symptoms were assigned to a depression group and compared to those who were free of depressive symptoms on behavioral and neuropsychological measures to determine if there were meaningful differences in cognition, behavior and motivation/self-perception between groups.

METHOD

Adolescent girls were randomly selected from local schools to participate in a study of neuropsychological development in adolescence. Those who volunteered and whose parents reported them to be free of psychiatric disorders were enrolled and completed a battery of behavioral, neuropsychological and motivation/self-perception measures.

RESULTS

The depressed group showed more behavioral problems, evaluated themselves as less competent, showed more extrinsic motivational orientation, had lower IQ and differed on a measure of visual spatial perception.

CONCLUSION

The frequency of subclinical depression is high in adolescent girls, even when parents report no psychiatric/emotional problems. The increase in problem behaviors and extrinsic motivation, as well as the decrease in feelings of self-worth suggest that this group may benefit from intervention. Poorer performance on a measure of visual spatial perception needs further investigation to confirm its association with depression and understand its relationship to depressive symptoms.

"Speech after long silence": the use of narrative therapy in a preventive intervention for children of parents with affective disorder

This article is an attempt to explain why the stories of those who suffer from affective disorder have gone unspoken, and to describe how the Preventive Intervention Project (PIP) helps to elaborate a narrative process within families. The PIP is a short-term, psychoeducational intervention focused on enhancing family understanding of affective disorder, and on building resiliency in children. Detailed descriptions of interventions with two families are used to demonstrate how the PIP works with parents and children: to move the narrative process from private to shared meaning. We discuss how cultural "canons" regarding affective illness reinforce a tendency to keep that experience private. We then show how the PIP provides an alternative, "schematic base" of understanding that facilitates a family's ability to begin a dialogue about their illness. We hope to demonstrate how this modernist, psychoeducational framework can be integrated with a more open-ended, postmodern construction of meaning.

A high-risk pilot study of the children of adults with social phobia

OBJECTIVE

Children of patients with social phobia were studied to estimate their rates of psychiatric disorder.

METHOD

Twenty-six social-phobic outpatients who had at least one child between the ages of 4 and 18 years participated in the study. Information was collected from parents on all 47 children and from the children between 12 and 18 years of age. Diagnoses in the children were made based on DSM-III-R and were done by a best-estimate method, using parent and child reports from a modified Anxiety Disorders Interview Schedule for Children, the Survey Diagnostic Instrument, the Current Self-Report Childhood Inhibition Scale, and the Alcohol Dependence Survey.

RESULTS

Of the 47 children, 49% had at least one lifetime anxiety disorder diagnosis. The most common diagnoses were overanxious disorder (30%), social phobia (23%), and separation anxiety disorder (19%). Sixty-five percent had more than one anxiety disorder diagnosis. Lifetime major depression was found, in 8.5% of the children. Parents whose children met criteria for an anxiety disorder had a greater mean number of comorbid diagnoses than did the parents of unaffected children.

CONCLUSION

This pilot study suggests that children of social-phobic parents may have increased rates of psychiatric disorder. Further studies incorporating a control group are needed.

Dissociative mothers' subjective experience of parenting

This study examined to what extent the symptoms of dissociative mothers interfered with their parenting and their subjective experiences of mothering. A group of 54 dissociative inpatient or day-patient mothers, 20 nondissociative inpatient mothers, and 20 hospital staff mothers were screened for Dissociative Disorders using the Structured Clinical Interview for Dissociative Disorders (SCID-D). They were then asked to fill out a self-report questionnaire on various aspects of mothering. This questionnaire, the Subjective Experiences of Parenting Scale (SEPS), examined 14 parenting characteristics: parenting partner support; relative support; abusiveness towards the child; extent to which symptoms interfered with parenting; constructive parenting traits; supportive versus hurtful discipline; extent of showing affection; ability to express affection; attachment behaviors; cognitive distortions; regulation of anger; self versus mother in parenting; subjective experience of mothering; and actions to promote the developmental growth of the child Dissociatives presented significantly more negative parenting behavior and related attributes than staff controls on 13 of the 14 parenting characteristics. Compared to nondissociative patients, the dissociative cohort presented poorer parenting behavior and related attributes on 9 of the 14 characteristics. Overall, the dissociatives experienced more problems with parenting attitudes and behaviors than either comparison group. Dissociative mothers manifested affective, behavioral, and cognitive difficulties in parenting.

Response of families to two preventive intervention strategies: long-term differences in behavior and attitude change

OBJECTIVE

To explore the long-term impact of two forms of preventive intervention designed to diminish risk to children in families in which one or both parents suffered from affective disorder.

METHOD

Fifty-four parents in 18 families were initially assessed and randomly assigned to one of two interventions--a clinician-facilitated, manual-based, psychoeducational preventive intervention or a standardized lecture-group discussion in which similar educational information was presented. Assessments included standard diagnostic interviews, child behavior scales, and semistructured interviews with parents about the effects of the intervention. Follow-up assessments were conducted three times over the 3-year follow-up interval.

RESULTS

No harmful effects were reported for either intervention, and ratings of degree of upset about reported concerns declined across time for both conditions. Families receiving the clinician-facilitated intervention reported more behavior and attitude changes than did lecture-group families when assessed after intervention. The difference between the two groups was sustained at further follow-up assessments.

CONCLUSION

Although both preventive interventions produced changes in behaviors and attitudes, parents in the clinician-facilitated intervention reported more benefit. These data support the hypothesis that linking cognitive information to the family's life experience produces long-term changes.

Affective language between depressed mothers and their children: the potential impact of psychotherapy

OBJECTIVE

To determine whether depressed mothers who had had psychotherapy were more able to communicate accurately about emotions than depressed mothers who had not had treatment.

METHOD

Three groups of mother-child pairs were studied: mothers without psychiatric diagnosis or treatment (n = 31), depressed mothers without treatment (n = 10), and depressed mothers with psychotherapy (n = 43). Photographs of infants expressing emotions were viewed and discussed by the mother-child pair and were rated independently.

RESULTS

A comparison by analysis of variance and Duncan procedures revealed significant differences between groups in both mothers' and children's accuracy scores. Mothers who had had psychotherapy were more able to interpret emotional expression with accuracy (p < .05), particularly about negative emotions such as anger and sadness (p < .01), than were the mothers of the depressed no treatment group. Depressed mothers without treatment were more inaccurate (for example, sadness interpreted as anger).

CONCLUSIONS

Psychotherapy may contribute to the depressed mother's achievement of accuracy in speaking with her child about emotions. The depressed mother whose depressive illness goes untreated is more inclined to be inaccurate and may pass these inclinations on to her child. The generality of the psychotherapy variable makes these findings preliminary.

Interviews with psychiatric inpatients about professional intervention with regard to their children

A description of mentally ill parents' experience and points of view concerning professional intervention in relation to their young children is presented in this paper. The results are from an interview survey designed with the purpose of improving the basis for cooperation between mentally ill patients and professionals, when intervention in relation to these patients' children is needed. Fifty consecutively admitted psychiatric inpatients with children 0-10 years old were interviewed by child psychiatrists and their information constitutes the study material. Data concerning the family situations and children have been published previously. One quarter of the patients had experienced having children placed in institutions or with foster families. Forty per cent had never received professional help related to their children. One third of the patients expressed a need for support, which was not presently received. A large group of patients did not know where to go for help related to children or would not be comfortable doing so. When making a global assessment of the childrens' situation based on the study material the child psychiatrists found reason for concern in regard to approximately 80% of the children. In most cases their views were in accordance with those of the mentally ill parents. Clinical implications concerning planning of intervention in regard to children of mentally ill parents are discussed.

Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: a randomized trial of a group cognitive intervention

OBJECTIVES

This investigation attempted to prevent unipolar depressive episodes in a sample of high school adolescents with an elevated risk of depressive disorder.

METHOD

Adolescents at risk for future depressive disorder by virtue of having elevated depressive symptomatology were selected with a two-stage case-finding procedure. The Center for Epidemiologic Studies-Depression Scale (CES-D) was administered to 1,652 students; adolescents with elevated CES-D scores were interviewed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Subjects with current affective diagnoses were referred to nonexperimental services. The remaining 150 consenting subjects were considered at risk for future depression and randomized to either a 15-session cognitive group prevention intervention or an "usual care" control condition. Subjects were reassessed for DSM-III-R diagnostic status after the intervention and at 6- and 12-month follow-up points.

RESULTS

Survival analyses indicated a significant 12-month advantage for the prevention program, with affective disorder total incidence rates of 14.5% for the active intervention, versus 25.7% for the control condition. No differences were detected for nonaffective disorders across the study period.

CONCLUSION

Depressive disorder can be successfully prevented among adolescents with an elevated future risk.

Psychopathology in the families of inpatient affective disordered adolescents

The purpose of this study was to examine the rates of psychiatric disorders in the parents of affective disordered adolescent inpatients, and to examine characteristics of the adolescent patients' illnesses and hospital stays for effects of having a concurrently depressed mother. Twenty-three percent of the depressed probands (N = 33), 20% of the bipolar group (N = 10), and 9% of the psychiatric control group (N = 11) had mothers who reported major depression (MD) at the time of hospitalization. Concurrent maternal depression did not have prominent effects on the course of the adolescents' hospitalizations.

The impact of parental affective disorder on depression in offspring: a longitudinal follow-up in a nonreferred sample

OBJECTIVE

This study explored the effects of parental affective disorder on offspring in a nonreferred health maintenance organization 4 years after initial examination.

METHOD

The sample, average age 18.5 years, included 91% of the 153 youngsters initially studied. The main instruments were structured diagnostic interviews scored according to criterion systems for both parents and children; assessment of the youngsters was blind to the previous assessment.

RESULTS

Rates of major depressive disorder were higher in the children of parents with affective disorder (26%) compared with those whose parents had no disorder (10%).

CONCLUSION

Depression and other parental affective disorders, as they occur in the community in parents who often are neither recognized nor treated, are associated with serious affective disorder in offspring. Clinical and preventive approaches for these offspring are needed and should be targeted to all families in which there is serious parental affective disorder, not just those who present for psychiatric treatment.

Comparison of preventive interventions for families with parental affective disorder

Twenty families participated in a random assignment trial of two cognitive psychoeducational preventive interventions for families with parental affective disorder. Twelve families were assigned to a clinician-based intervention and eight to a lecture-based intervention, with assessment prior to intervention and an average of 18 weeks following intervention. Both groups were satisfied and believed they received help from the intervention. The clinician-based group was significantly more satisfied overall, and reported significantly more changes in both behaviors and attitudes about their illness from pre- to postintervention. Both groups showed significant decrease in degree of upset over issues of concern from pre- to postintervention. The clinician-based group reported receiving significantly more help with their primary concern. The implications of these findings are discussed.

Preventive intervention with the children of depressed parents. A case study

Children of parents with depression are at significant risk for impairment, but little is known about preventive intervention strategies prior to the onset of illness in the children. This paper discusses a preventive approach to assisting families in helping children cope with parental affective disorder. A case study is presented which demonstrates the compatibility of this family-based intervention with psychoanalytically oriented treatment for the parent. Key aspects of this work include the enhancement of self-understanding and resiliency in children.