Prevention of Depression in At-Risk Adolescents: Moderators of Long-term Response.

In a randomized controlled trial, we found that a cognitive behavioral program (CBP) was significantly more effective than usual care (UC) in preventing the onset of depressive episodes, although not everyone benefitted from the CBP intervention. The present paper explored this heterogeneity of response. Participants were 316 adolescents (M age = 14.8, SD = 1.4) at risk for depression due to having had a prior depressive episode or having current subsyndromal depressive symptoms and having a parent with a history of depression. Using a recursive partitioning approach to baseline characteristics, we (Weersing et al. 2016) previously had identified distinct risk clusters within conditions that predicted depressive episodes through the end of the continuation phase (month 9). The present study used the same risk clusters that had been derived in the CBP group through month 9 to reclassify the UC group and then to examine group differences in depression through month 33. We found that in this overall very high-risk sample, the CBP program was superior to UC among youth in the low-risk cluster (n = 33), characterized by higher functioning, lower anxiety, and parents not depressed at baseline, but not in the middle (n = 95) and high-risk (n = 25) clusters. Across conditions, significantly more depression-free days were found for youth in the low-risk cluster (M = 951.9, SD = 138.8) as compared to youth in the high-risk cluster (M = 800.5, SD = 226.7). Identification of moderators, based on purely prognostic indices, allows for more efficient use of resources and suggests possible prevention targets so as to increase the power of the intervention.

Childhood abuse and lifetime psychopathology in a community sample.

OBJECTIVE: The authors assessed lifetime psychopathology in a general population sample and compared the rates of five psychiatric disorder categories between those who reported a childhood history of either physical or sexual abuse and those who did not. METHOD: A modified version of the Composite International Diagnostic Interview and a self-completed questionnaire on child abuse were administered to a probability sample (N=7,016) of Ontario residents 15 to 64 years of age. RESULTS: Those reporting a history of childhood physical abuse had significantly higher lifetime rates of anxiety disorders, alcohol abuse/dependence, and antisocial behavior and were more likely to have one or more disorders than were those without such a history. Women, but not men, with a history of physical abuse had significantly higher lifetime rates of major depression and illicit drug abuse/dependence than did women with no such history. A history of childhood sexual abuse was also associated with higher rates of all disorders considered in women. In men, the prevalence of disorders tended to be higher among those who reported exposure to sexual abuse, but only the associations with alcohol abuse/dependence and the category of one or more disorders reached statistical significance. The relationship between a childhood history of physical abuse and lifetime psychopathology varied significantly by gender for all categories except for anxiety disorders. Although not statistically significant, a similar relationship was seen between childhood history of sexual abuse and lifetime psychopathology. CONCLUSIONS: A history of abuse in childhood increases the likelihood of lifetime psychopathology; this association appears stronger for women than men.

A developmental and psychobiologic framework for understanding the role of culture in child and adolescent psychiatry.

In summary, despite these widely accepted interdisciplinary perspectives on the role of culture, the DSM framework lacks a culturally meaningful usage. For Kleinman, the changes on culture in the DSM-IV were "too little, too late." The cultural formulation and a glossary of culture-bound syndromes were included in its appendix. The acceptance by the DSM-IV task force of the notion of cultural variations in clinical presentation of disorders may be reflective of changes to come in the future. The current DSM-IV has more of a descriptive psycho-pathologic approach rather than an integrated cross-cultural, psychobiologic, developmental approach, however. The developmental perspective in psychiatry is emerging as a "bridge" for consilience through evidence-based scientific understanding and conciliation through clinical practice. This perspective is unique because it is intrinsic to different aspects of psychiatry. It readily accommodates the descriptive-empirical model by means of concepts borrowed from developmental psychopathology and psychobiology. These concepts include normalcy, life cycle, risk and resilience, and protective mechanisms within a dynamic construction of development that involves an interchange among biology-person-society-culture. The developmental perspective also can make important contributions to a process-oriented approach to measurement beyond a textually defined DSM structure. The developmentally operationalized dimensional constructs offer to expand psychiatry's domains beyond diagnosable conditions and illness boundaries. The developmental perspective argues for early preventive and therapeutic interventions for a broad array of applications based on demonstrated evidence of efficacy. Finally, the developmental perspective with its social and cultural contexts is an intrinsic complement to Kandel's framework for an expanded training of psychiatrists in the neurosciences and the associated innovative technologies for understanding the mechanism of structural and functional changes in the brain in various contexts and categories.

Adaptation of preventive interventions for a low-income, culturally diverse community.

OBJECTIVE: To describe essential elements in the adaptation of a prevention approach with a high-risk urban sample, chosen to contrast sharply with the primarily middle-class sample in which it had been originally tested. METHOD: Key elements of a preventive intervention for families with parental depression were adapted for use in the new context. RESULTS: A sequence of alliance-building events was implemented, involving engagement at three levels: community, caregivers, and family. The prevention approach was modified to include an expanded approach to defining depression and resilience; greater flexibility on the part of the clinician; more intensive engagement between clinician and family, with a focus on immediate daily concerns; as well as awareness of cultural issues and responsiveness to the subject's experience of violence. CONCLUSION: Core principles of helping family members to discuss the effects of depression and adversity on family life were affirmed.

Associations of depression, self-esteem, and substance use with sexual risk among adolescents.

BACKGROUND: Adolescents are the population at highest risk for acquiring sexually transmitted diseases (STDs). Previous research has suggested that mental health problems, including depression and low self-esteem, may play an important role in the development and maintenance of sexual risk behaviors. METHODS: National Longitudinal Study of Adolescent Health data from baseline interviews of 7th-12th graders reporting sexual intercourse in the preceding year were analyzed. Using logistic regression, associations of depressive symptoms, self-esteem, and substance use with condom nonuse at last sexual intercourse and with ever having had an STD were explored separately for each gender. RESULTS: Among boys (N = 3,192), depressive symptoms were associated with an increased risk of condom nonuse at last sexual intercourse. The association between depressive symptoms and STD appeared to be mediated by alcohol and marijuana use. For girls (N = 3,391), depressive symptoms were associated with a history of STD, but not with condom nonuse. Self-esteem was not significant in any model that included depressive symptoms. CONCLUSIONS: Adolescents with depressive symptoms are at risk for not using a condom and for having an STD. Further research is needed to elucidate the relationship among depression, substance use, and sexual risk to optimize STD prevention strategies for adolescents.

Prevention of childhood depression: recent findings and future prospects.

Traditionally, research on childhood mood disorders has focused on clinical trials and longitudinal course and outcome studies, rather than on prevention. Recently, however, advances in the design, methodology, and evaluation of prevention approaches and progress in understanding what factors predispose children to depression have made possible the development of theoretically driven, empirically justified approaches to the prevention of depression in youngsters who are at high risk, either because of elevated symptom levels or parental mood disorder. In this review, we outline recent empirical findings on risk factors for depression in nonreferred samples of youngsters and also in children of depressed parents. Additionally, we review three trials of preventive interventions for childhood depression that yield promising initial findings. We emphasize the need to understand both risks for depression and factors that protect youngsters at risk from succumbing to depression in guiding the development of prevention programs. We also argue that consideration of prevention of depression requires addressing broader social adversity influences that lead to poor mental health outcomes in children, even beyond the effects of parental mood disorder. We conclude with an emphasis on the importance of a developmental-transactional perspective that highlights opportunities for intervention at different points across the lifespan.

Increased orbitofrontal cortex levels of choline in depressed adolescents as detected by in vivo proton magnetic resonance spectroscopy.

BACKGROUND: The frontal lobe has been implicated in the pathology of depression in adults. Through the use of magnetic resonance spectroscopy, altered brain choline levels have also been linked to the pathophysiology of affective disorders. METHODS: To identify possible alterations in orbitofrontal cortex levels of cytosolic choline in adolescents with and without depression, 22 depressed and 43 control adolescents were recruited. Of those recruited, usable proton magnetic resonance spectra were acquired from a voxel in the left anterior medial frontal lobe of 17 depressed (mean age 15.8+/-1.6) and 28 healthy adolescents (mean age 14.5+/-1.7). RESULTS: Orbitofrontal cytosolic choline/creatine (Cho/Cr) ratios (p =.032) and cytosolic choline/N-acetyl aspartate (Cho/NAA) ratios (p =.043) were significantly higher in the depressed subjects than in the control subjects. There were no significant differences between depressed and control subjects in gray or white matter content within the voxel. CONCLUSIONS: These findings suggest that brain cytosolic choline may be increased in depressed adolescents in comparison with control subjects and independent of a corresponding structural change. These results are consistent with similar, previously reported findings in adults and suggest that depression in adolescents is associated with alterations in orbitofrontal metabolism.

Implementation of an electronic medical record system in a pediatric psychopharmacology program.

The design, implementation, and utilization of an electronic medical record system (EMRS) in a pediatric psychopharmacology clinic is described. The EMRS is a relational database with information entered directly by the clinician during a patient visit. It has been used during more than 2590 patient visits with 805 patients. Complete clinical documentation and simultaneous data entry as well as computer generated prescriptions for the patient were accomplished 75% of the time within a 20-min medication management session. One hundred consecutive parents of patients were asked to fill out a five-question survey to begin to assess the impact of the application. Of the 87 parents who responded, all (100%) noted that the doctor paid attention to their concerns. Between 88 and 90% of the parents reported that the use of the computer is a 'good' thing, made it easier to work with the doctor, and that they understood why the computer was being used. The findings support that the development and implementation of an EMRS with direct clinician information entry within pediatric psychopharmacology clinic, is feasible.

A child's experience of parental depression: encouraging relational resilience in families with affective illness.

In this article, we describe an approach that parents with affective illness can use to foster the emotional resilience of their children. Building on current research that emphasizes the need to formulate concepts of risk and resilience in terms of family or relational processes, we propose that affectively ill parents can promote resilience in their children by helping them express the affect they experience as a result of parental illness-related behavior. Risk and resilience are conceptualized in terms of a family's ability to process emotion or affect: a family's need to constrict affect is a risk factor, while the family's ability to elaborate affect encourages relational resilience. An object relations model is used to discuss the ways in which encouraging this elaboration of affect, especially negative affect, contributes to resilience in children. We describe ways in which a preventive intervention helps to increase parents' emotional responsiveness to their children. Using extensive narrative data from followup interviews with families and children, constriction and expansion of emotion in children concerning affectively ill parents are documented, by multiple interviewers, over a span of more than 5 years.

Developmental psychiatry: is there any other kind?

This paper describes the importance of the developmental perspective in psychiatry and addresses the lack of a developmental focus in the DSM-based descriptive empirical model. Although the publication of DSM-III in 1980 represented a "breakthrough" in psychiatry, the revisions of its diagnostic framework over the subsequent two decades have not adapted to the rapidly evolving changes in the field. In this paper we argue that, like once-grand theories, the breakthroughs in the diagnostic framework need to transform. The developmental perspective provides an interdisciplinary and conceptual framework linking facts and theories. It is inherent in different aspects of psychiatry and readily accommodates the descriptive-empirical model by means of inclusive concepts borrowed from developmental psychopathology and psychobiology. It also makes important contributions to a process-oriented approach to measurement. Developmentally operationalized and multidimensional constructs stand to broaden psychiatric domains beyond diagnosable disorders. This argues for preventive and early treatment interventions for a variety of mild, subthreshold, or delayed symptoms of various conditions, based on an understanding of the causal mechanisms and developmental processes involved.

Children of affectively ill parents: a review of the past 10 years.

OBJECTIVE: To review the literature investigating the effects of parental affective illness on children over the past decade. METHOD: A computerized search of articles published over the past 10 years was completed. Articles were reviewed and relevant studies are presented. RESULTS: Over the course of the past 10 years a number of longitudinal studies have confirmed that children of affectively ill parents are at a greater risk for psychiatric disorders than children from homes with non-ill parents. Life table estimates indicate that by the age of 20 a child with an affectively ill parent has a 40% chance of experiencing an episode of major depression. Children from homes with affectively ill parents are more likely to exhibit general difficulties in functioning, increased guilt, and interpersonal difficulties as well as problems with attachment. Marital difficulties, parenting problems, and chronicity and severity of parental affective illness have been associated with the increased rates of disorder observed in these children. CONCLUSION: The presence of depression in parents should alert clinicians to the fact that their children also may be depressed and therefore in need of services. J. Am. Acad. Child Adolesc.

Prevention and the clinical encounter.

Development of an intervention to prevent depression in children of parents with severe affective disorder is described, along with the risk and resilience factors incorporated from prospective longitudinal studies of parents and children at risk. Strategies helpful in bridging the gap between clinical practice and prevention are discussed, and the differences in orientation necessary to include prevention in clinical practice are explored.

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.

Depression in the adolescent patient.

Depression in adolescence is a major public health problem that is associated with significant morbidity and mortality. A large number of clinically depressed adolescents still are unrecognized and untreated. This chapter provides pediatricians with useful guidelines for recognizing and managing adolescent depression in a primary care setting.

Prevalence of child physical and sexual abuse in the community. Results from the Ontario Health Supplement.

CONTEXT: Although child maltreatment is considered common, few community surveys have examined the prevalence of more than 1 type of maltreatment among both males and females. OBJECTIVE: To determine the prevalence of a history of physical and sexual abuse during childhood among the general population. DESIGN: General population survey. SETTING: Household dwellings in the province of Ontario, Canada. PARTICIPANTS: A random sample (N=9953) of residents aged 15 years and older participated in the Ontario Health Supplement. MAIN OUTCOME MEASURE: Self-administered questionnaire about a history of physical and sexual abuse in childhood. RESULTS: A history of child physical abuse was reported more often by males (31.2%) than females (21.1%), while sexual abuse during childhood was more commonly reported by females (12.8%) than males (4.3%). Severe physical abuse was reported by similar proportions of males (10.7%) and females (9.2%). A greater percentage of females reported a history of severe sexual abuse (11.1%) compared with males (3.9%). Age of the respondent was not significantly associated with childhood abuse within any category for males. However, for females, the reported prevalence in childhood of sexual abuse, co-occurrence of physical and sexual abuse, and both categories of severe abuse decreased with increasing age of the respondent. CONCLUSIONS: A history of childhood maltreatment among Ontario residents is common. Child abuse may be more prevalent in younger women compared with older women, or there may be a greater willingness among younger women to report abuse.

Sustained change in parents receiving preventive interventions for families with depression.

OBJECTIVE: The purpose of this study was to compare the sustained effects of two cognitive, psychoeducational preventive interventions for families in which a parent had an affective disorder. METHOD: Thirty-seven families, in which there was a child between the ages of 8 and 15 years (mean = 11.5 years) and at least one parent who had experienced a recent episode of affective disorder according to the Research Diagnostic Criteria, were studied 1.5 years after enrollment in the study. The families were randomly assigned to one of two interventions, clinician-facilitated or lecture. The two interventions were similar in content but differed in the degree of involvement of the children and the linking of information to the families' life experiences. Nineteen families participated in the clinician-facilitated intervention, which consisted of six to 10 sessions. Eighteen families were assigned to the lecture condition, which consisted of two lectures attended only by parents. Family members were interviewed both before and after the interventions with diagnostic interviews and semistructured measures designed to assess response to the interventions. RESULTS: Sustained effects of the interventions were reported 1.5 years after enrollment. The clinician-facilitated intervention was associated with more positive self-reported and assessor-rated changes than the lecture intervention. CONCLUSIONS: These short-term preventive interventions, particularly the clinician-facilitated one, have long-term benefits for families with parental affective disorder.

Examination of children's responses to two preventive intervention strategies over time.

OBJECTIVE: To examine long-term effects of two forms of preventive intervention designed to increase families' understanding of parental affective disorder and to prevent depression in children. METHOD: Thirty-six families who had a nondepressed child between ages 8 and 15 years and a parent who had experienced affective disorder were enrolled and randomly assigned to either a clinician-facilitated intervention or a lecture discussion group. Each parent and child were assessed prior to randomization, after intervention, and approximately 1 1/2 years after enrollment. Assessments included standard diagnostic interviews, measures of child and family functioning, and interviews about experience of parental affective disorder and intervention effects. RESULTS: Children in the clinician-facilitated group reported greater understanding of parental affective disorder, as rated by self-report, rater-generated scales, and parent report, and had better adaptive functioning after intervention. Parents in the clinician-facilitated intervention group reported significantly more change. CONCLUSION: Findings from both interventions support the value of a future-oriented resiliency-based approach. The greater effects of the clinician-facilitated intervention support the need for linking cognitive information to families' life experience and involving children directly in order to achieve long-term effects.

Examination of preventive interventions for families with depression: evidence of change.

Thirty-seven families who had a child between the ages of 8 and 15 (mean age = 12.0 years) and had at least one parent, who had experienced a recent episode of affective disorder were assigned randomly to one of two psychoeducational interventions. The interventions (clinician-facilitated or lecture-group discussion) were designed to prevent childhood depression and related problems through decreasing the impact of related risk factors and encouraging resiliency-promoting behaviors and attitudes. They were similar in content but differed in the level of the children's involvement and the degree to which the families' individual life experiences were linked to the educational material. Assessments included standard diagnostic and social functioning instruments and interviews designed specifically for this project to assess behavior and attitude change. Each parent and child was individually assessed by separate assessors who were blind to information about the other family members. Parent participants in both groups reported being satisfied with the intervention. Clinician group participants reported a significantly larger number of overall changes, as well as higher levels of change regarding communications about the illness with their children and increased understanding by the children of their illness. Significantly more children in the clinician group also reported they gained a better understanding of parental affective illness as a result of their participation in the project.

"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.