Remission of Maternal Depression May Also Benefit Children
March 21, 2006 — Children have less psychopathology if depression in their mothers is successfully treated, according to an assessment of Children whose mothers were enrolled in a multicenter trial, as reported in the March 22/29 issue of JAMA.
"Children of depressed parents have high rates of anxiety, disruptive, and depressive Disorders that begin early, often continue into adulthood, and are impairing," write Myrna M. Weissman, PhD, From Columbia University and the New York State Psychiatric Institute, and colleagues From the Sequenced Treatment Alternatives to Relieve Depression (STAR*D)–Child Team. "Only a few studies of Children of depressed parents have suggested some benefit for Children of reducing parental symptoms, but none of those published have directly treated parental depression in a definitive large sample."
Between December 16, 2001, and April 24, 2004, 151 Children whose depressed mothers were being treated with medication in the multicenter STAR*D trial were assessed by a team of evaluators not involved in maternal treatment and unaware of maternal outcomes. The Study, which is being conducted in 8 primary Care and 11 psychiatric outpatient clinics across 7 regional centers in the United States, is ongoing, and cases are being followed up at 3-month intervals. Children were aged 7 to 17 years.
Primary outcomes include Child diagnoses based on the Kiddie Schedule for Affective Disorders and Schizophrenia; Child symptoms based on the Child Behavior Checklist; and Child functioning based on the Child Global Assessment Scale. Remission of depression in the mothers was defined as a score of 7 or lower on the Hamilton Rating Scale for Depression (HRSD).
Remission of maternal depression after 3 months of treatment was significantly associated with reductions in the Children's diagnoses and symptoms. Children of mothers whose depression remitted had an overall 11% decrease in rates of diagnoses compared with an approximate 8% increase in rates of diagnoses in Children of mothers whose depression did not remit. After controlling for the Child's age, sex, and possible confounding factors, this rate difference remained significant (P = .01).
Of the Children with a diagnosis at baseline, remission occurred in 33% of those whose mothers' depression remitted, and in 12% of those whose mothers' depression did not remit. All Children of mothers whose depression remitted after treatment and who themselves had no baseline diagnosis of depression remained free of psychiatric diagnoses at 3 months. However, 17% of the Children whose mothers remained depressed acquired a psychiatric diagnosis.
Findings were similar when Child symptoms were used as an outcome. A greater level of maternal response was associated with fewer current diagnoses and symptoms in the Children. To detect an improvement in the Child, a maternal response of at least 50% was required.
"Remission of maternal depression has a positive effect on both mothers and their Children, whereas mothers who remain depressed may increase the rates of their Children's Disorders," the authors write. "These findings support the importance of vigorous treatment for depressed mothers in primary Care or psychiatric clinics and suggest the utility of evaluating the Children, especially Children whose mothers continue to be depressed."
Study limitations include lack of experimental design; inability to demonstrate causality or to rule out reverse causation in which Children's improvement had a positive impact on mothers; low rate of women with Children in the overall STAR*D Study; use of a single antidepressant in an open trial design without a placebo control; lack of blinding of Child assessors; inability to account for the impact of the fathers' psychiatric State; and maternal bias in reporting Children's symptoms.
"From a Clinical vantage point, our findings suggest that vigorous treatment of depressed mothers to achieve remission is associated with positive outcomes in their Children as well, whereas failure to treat depressed mothers may increase the burden of illness in their Children," the authors conclude. "At a time when there are many questions about the appropriate and safe treatment of psychiatric Disorders in Children, these findings suggest that it is important to provide vigorous treatment to mothers if they are depressed."
The National Institute of Mental Health supported this Study. Some of the authors have disclosed various relevant financial relationships with Eli Lilly, GlaxoSmithKline, Abbott Laboratories, Lichtwer Pharma GmbH, Lorex Pharmaceuticals, Bayer AG, Compellis, Janssen Pharmaceutica, Knoll Pharmaceutical Co, Lundbeck, Dov Pharmaceuticals, Biovail Pharmaceuticals Inc, BrainCells, Grunenthal GmBH, Sepracor, Somerset Pharmaceuticals, Aspect Medical Systems, AstraZeneca, Bristol-Myers Squibb, Cephalon, J&J Pharmaceuticals, Novartis, Organon Inc, Pharmavite, Pfizer Inc, Roche, Sanofi/Synthelabo, Solvay Pharmaceuticals, Wyeth-Ayerst, Healthcare Technology Systems Inc, Forest Pharmaceuticals, Johnson&Johnson, Cyberonics, National Institutes of Health, National Institute of Mental Health, Predix, Pfizer/Parexel, and Corcept Therapeutics Inc. Forest Laboratories provided citalopram at no cost.
JAMA. 2006;295:1389-1395
Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:
"Children of depressed parents have high rates of anxiety, disruptive, and depressive Disorders that begin early, often continue into adulthood, and are impairing," write Myrna M. Weissman, PhD, From Columbia University and the New York State Psychiatric Institute, and colleagues From the Sequenced Treatment Alternatives to Relieve Depression (STAR*D)–Child Team. "Only a few studies of Children of depressed parents have suggested some benefit for Children of reducing parental symptoms, but none of those published have directly treated parental depression in a definitive large sample."
Between December 16, 2001, and April 24, 2004, 151 Children whose depressed mothers were being treated with medication in the multicenter STAR*D trial were assessed by a team of evaluators not involved in maternal treatment and unaware of maternal outcomes. The Study, which is being conducted in 8 primary Care and 11 psychiatric outpatient clinics across 7 regional centers in the United States, is ongoing, and cases are being followed up at 3-month intervals. Children were aged 7 to 17 years.
Primary outcomes include Child diagnoses based on the Kiddie Schedule for Affective Disorders and Schizophrenia; Child symptoms based on the Child Behavior Checklist; and Child functioning based on the Child Global Assessment Scale. Remission of depression in the mothers was defined as a score of 7 or lower on the Hamilton Rating Scale for Depression (HRSD).
Remission of maternal depression after 3 months of treatment was significantly associated with reductions in the Children's diagnoses and symptoms. Children of mothers whose depression remitted had an overall 11% decrease in rates of diagnoses compared with an approximate 8% increase in rates of diagnoses in Children of mothers whose depression did not remit. After controlling for the Child's age, sex, and possible confounding factors, this rate difference remained significant (P = .01).
Of the Children with a diagnosis at baseline, remission occurred in 33% of those whose mothers' depression remitted, and in 12% of those whose mothers' depression did not remit. All Children of mothers whose depression remitted after treatment and who themselves had no baseline diagnosis of depression remained free of psychiatric diagnoses at 3 months. However, 17% of the Children whose mothers remained depressed acquired a psychiatric diagnosis.
Findings were similar when Child symptoms were used as an outcome. A greater level of maternal response was associated with fewer current diagnoses and symptoms in the Children. To detect an improvement in the Child, a maternal response of at least 50% was required.
"Remission of maternal depression has a positive effect on both mothers and their Children, whereas mothers who remain depressed may increase the rates of their Children's Disorders," the authors write. "These findings support the importance of vigorous treatment for depressed mothers in primary Care or psychiatric clinics and suggest the utility of evaluating the Children, especially Children whose mothers continue to be depressed."
Study limitations include lack of experimental design; inability to demonstrate causality or to rule out reverse causation in which Children's improvement had a positive impact on mothers; low rate of women with Children in the overall STAR*D Study; use of a single antidepressant in an open trial design without a placebo control; lack of blinding of Child assessors; inability to account for the impact of the fathers' psychiatric State; and maternal bias in reporting Children's symptoms.
"From a Clinical vantage point, our findings suggest that vigorous treatment of depressed mothers to achieve remission is associated with positive outcomes in their Children as well, whereas failure to treat depressed mothers may increase the burden of illness in their Children," the authors conclude. "At a time when there are many questions about the appropriate and safe treatment of psychiatric Disorders in Children, these findings suggest that it is important to provide vigorous treatment to mothers if they are depressed."
The National Institute of Mental Health supported this Study. Some of the authors have disclosed various relevant financial relationships with Eli Lilly, GlaxoSmithKline, Abbott Laboratories, Lichtwer Pharma GmbH, Lorex Pharmaceuticals, Bayer AG, Compellis, Janssen Pharmaceutica, Knoll Pharmaceutical Co, Lundbeck, Dov Pharmaceuticals, Biovail Pharmaceuticals Inc, BrainCells, Grunenthal GmBH, Sepracor, Somerset Pharmaceuticals, Aspect Medical Systems, AstraZeneca, Bristol-Myers Squibb, Cephalon, J&J Pharmaceuticals, Novartis, Organon Inc, Pharmavite, Pfizer Inc, Roche, Sanofi/Synthelabo, Solvay Pharmaceuticals, Wyeth-Ayerst, Healthcare Technology Systems Inc, Forest Pharmaceuticals, Johnson&Johnson, Cyberonics, National Institutes of Health, National Institute of Mental Health, Predix, Pfizer/Parexel, and Corcept Therapeutics Inc. Forest Laboratories provided citalopram at no cost.
JAMA. 2006;295:1389-1395
Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:
- Describe the prevalence and consequences of psychiatric illness during childhood.
- Identify the psychiatric outcomes among Children of mothers with controlled depression.
Clinical Context
The risk for psychiatric illness is increased by a factor of 2 to 3 among Children whose parents have a diagnosis of depression, and psychiatric symptoms are usually present in such children prior to the advent of puberty. While psychiatric illness places children at increased risk for social and occupational dysfunction as well as some medical problems, the best treatment of children with psychiatric illness is often controversial and based on relatively few clinical trials.
No large trials have examined whether treatment of parental depression can reduce the risk for psychiatric illness in children. The authors of the current study examine a mother-child cohort from a depression research project, STAR*D, which was described in an article by Rush and colleagues in the February 2003 issue of the American Journal of Psychiatry. The authors sought to determine if remission of maternal depression had a significant psychiatric impact on their children.
Study Highlights
- Women were drawn into the current study from the STAR*D study, which examined the most effective treatment of major depression. All participants were between the ages of 25 and 60 years and had children between 7 and 17 years of age. Women had a diagnosis of major depression with a HRSD score of 14 or more.
- All women were treated with citalopram, which was followed by other therapy for nonresponders. Maternal remission was defined by an HRSD score of 7 or less, while response was defined as a reduction in the baseline HRSD score by 50% or more.
- Children were examined at baseline and 3 months using validated surveys for psychiatric illness, psychiatric symptoms, and global functioning.
- The main study outcome was the relationship between maternal remission from depression and the change in psychiatric diagnoses and symptoms among children.
- 151 mother-child pairs were recruited into the study, and 75% completed the 3-month assessment. 33% of women met remission criteria within 3 months, and the overall response rate to treatment was 47%. Women whose depression was not significantly improved were more likely to be economically disadvantaged vs responders, and they also had more severe baseline depression and higher rates of comorbid anxiety disorders.
- No difference in child baseline demographic or clinical characteristics based on mothers' response or nonresponse to treatment existed. The prevalence of anxiety, depression, or disruptive behavior disorders in children was 16%, 10%, and 22%, respectively. Approximately half of the children had a previous diagnosis of psychiatric illness.
- During the 3-month study period, an 11% decrease in the rates of diagnosis of psychiatric illness among children with a mother exhibiting remission of depression occurred. Conversely, an 8% increase in the rates of psychiatric illness among children of mothers with continuing depression occurred. This difference remained significant after multivariate analysis.
- Baseline psychiatric illness resolved in 33% vs 12% of children of mothers with and without remission, respectively. No child of a mother with depression in remission developed new or relapsing psychiatric illness, although 17% of children of mothers with continuing depression experienced new or relapsing psychiatric illness.
- Symptoms of depression and disruptive behavior decreased from baseline among children of mothers with depression in remission, while these symptoms increased along with anxiety symptoms among children whose mothers' depression did not improve.
- Children's level of functioning was not affected by maternal remission status.
- A linear relationship was found between maternal response level to treatment and the change in rates of children's psychiatric diagnoses. A maternal response of at least 50% was associated with significantly improved outcomes in children.
- The study's main results were unchanged when controlling for children receiving psychiatric treatment.
Pearls for Practice
- Parental depression increases the risk for psychiatric illness in children, but a dearth of research exists regarding the treatment of psychiatric illness in children or the effects of treatment of parental depression on children.
- The current study demonstrates that maternal remission of depression can improve the rates of psychiatric diagnoses in children, the incidence of new cases of psychiatric illness in children, and symptoms of depression and disruptive behaviors in children. However, maternal remission did not affect children's global functioning.
Saludos afectuosos
Dr. José Manuel Ferrer Guerra
posted by Klip7 at
2:20 PM
