Treatment of Depression in Adults Should Consider Children, Say Researchers

NRC/IOM Report Urges Physicians to Focus on Family

By David Mitchell
7/1/2009

Physicians and other health care professionals who treat adults with depression also should consider the effects of the illness on their patients' children, according to a new report from the National Research Council and the Institute of Medicine.

One in five adults suffers from a major depressive disorder during his or her lifetime, and far more suffer from mild depression, said Mareasa Isaacs, Ph.D., executive director of the Washington, D.C.-based National Alliance of Multi-Ethnic Behavioral Health Associations.

Isaacs, a member of the committee that developed the study report, said during a June 10 news conference announcing the report's release that 7.5 million American parents suffer from depression each year, and nearly 16 million children live with those parents.

"Depression interferes with quality of parenting and puts children of all age levels at risk for poor health and development," she said. "The message is that it's really important to look at depression as something that affects not only the individual, but the children and other members of the family."

Isaacs said that 75 percent of adults who suffer from depression have comorbid conditions, including other mental health and substance use issues. Two-thirds of adults with depression are not treated for the condition because of lack of insurance, inability to access care and other factors, she said.

Mary Jane England, M.D., president of Regis College, Weston, Mass., and past president of the American Psychiatric Association, served as chair of the committee that wrote the report. She said during the news conference that 2 percent to 4 percent of children born to parents with depression themselves suffer from depression as young children; as many as 40 percent of adolescents living with parents suffering from depression also have depression.

Although numerous factors influence child development, England said adolescents in this group also are at a higher risk for substance abuse.

Perceived Stigma Barrier to Teen Treatment

A study in the June issue of Medical Care reports that although adolescent depression is common, only a small percentage of teens with depression receive treatment.

The study involved 184 teens with depression and a control group of 184 teens who were not depressed recruited from seven primary care practices, along with 338 of their parents. It found that teens with depression were much more likely than nondepressed teens to perceive barriers to care, including perceived stigma about being diagnosed with or treated for depression, as well as concern about family members' reactions to their condition.

The study also considered other barriers, including costs, time constraints and availability of care. It noted, however, that parents were less likely than their children to report barriers to care, and the researchers suggest that primary care physicians elicit information from both adolescents and parents to improve treatment.

William Beardslee, M.D., academic chair of the department of psychiatry at Children’s Hospital, Boston, and Gardner/Monks Professor of Child Psychiatry at Harvard Medical School, Cambridge, Mass., said during the news conference that there are effective screening tools available to identify adults with depression in primary care settings, but the screening programs do not take into consideration whether the patient is a parent or how that individual's condition affects his or her family or ability to function as a parent.

Acknowledging that most treatment options available currently focus on the individual, the report advocates a two-generation approach to benefit the family as a whole.

Allen Dietrich, M.D., of Lebanon, N.H., professor in the department of community and family medicine at Dartmouth Medical School, Hanover, N.H., and co-chair of the MacArthur Foundation Initiative on Depression and Primary Care at Dartmouth and Duke University, Durham, N.C., was not part of the committee, but he told AAFP News Now that he agrees with its findings.

"In our ability to care for families across generations, we, as family physicians, are in an ideal position," said Dietrich, who also is president of the North American Primary Care Research Group and a member of the U.S. Preventive Services Task Force. "As this report makes clear, the well-child visit provides an opportunity to recognize depression in a parent and take steps to initiate treatment for the depressed parent and to ensure that the needs of the child and others in the family are addressed."

According to the report, emerging preventive interventions or adaptations of existing evidence-based parenting and child development interventions for families with parents who are depressed show promise for improving outcomes by

preventing or improving depression in parents;
targeting the vulnerability of children of depressed parents; and
improving parent-child relationships.

Frank Putnam, M.D., director of the Mayerson Center for Safe and Healthy Children and professor of pediatrics and child psychiatry at Cincinnati Children’s Hospital Medical Center, said during the June 10 news conference that the health care system needs to address the nation's lack of primary care physicians and mental health providers, as well as the need for training models to help primary care physicians diagnose and treat depression.

England agreed.

"The amount of information that's available today on the effectiveness of treatment for depression is wonderful," she said, "but it's not shared or known by many primary care providers, whether they're doctors, nurses or others. We need to find a way to improve education so that when a parent presents (him- or herself) to the pediatrician, OB-Gyn or other primary care physician, depression is recognized."

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