Cross-situational coping with peer and family stressors in adolescent offspring of depressed parents

Offspring of depressed parents are faced with significant interpersonal stress both within their families and in peer relationships. The present study examined parent and self-reports of adolescents' coping in response to family and peer stressors in 73 adolescent children of parents with a history of depression. Correlational analyses indicated that adolescents were moderately consistent in the coping strategies used with peer stress and family stress. Mean levels of coping were similar across situations, as adolescents reported greater use of secondary control coping (i.e., acceptance, distraction) than primary control coping (i.e., problem solving, emotional expression) or disengagement coping (i.e., avoidance) with both types of stress. Regression analyses indicated that fewer symptoms of self-reported anxiety/depression and aggression were related to using secondary control coping strategies in response to family stress and primary control coping in response to peer stress. Implications for understanding the characteristics of effective coping with stress related to living with a depressed parent are highlighted.     

A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents.

BACKGROUND: Adolescent offspring of depressed parents are at high risk for development of depression. Cognitive restructuring therapy holds promise for preventing progression to depressive episodes. METHODS: A randomized, controlled trial was conducted to prevent depressive episodes in at-risk offspring (aged 13-18 years) of adults treated for depression in a health maintenance organization (HMO). Potential adult cases were found by reviewing the HMO pharmacy records for dispensation of antidepressant medication and the mental health appointment system. Medical charts were reviewed for a depression diagnosis. Recruitment letters signed by treating physicians were mailed to adults. Eligible offspring had subdiagnostic depressive symptoms insufficient to meet full DSM-III-R criteria for affective disorder and/or a past mood disorder. These youth were randomized to usual HMO care (n = 49) or usual care plus a 15-session group cognitive therapy prevention program (n = 45). RESULTS: We detected significant treatment-by-time (program) effects for the Center for Epidemiological Studies Depression Scale (P=.005) and the Global Assessment of Functioning scores (P =.04). Survival analysis of incident major depressive episodes during a median 15-month follow-up found a significant advantage (P =.003) for the experimental condition (9.3% cumulative major depression incidence) compared with the usual-care control condition (28.8%). CONCLUSION: A brief, group cognitive therapy prevention program can reduce the risk for depression in the adolescent offspring of parents with a history of depression.     

Impact of comorbidity on a cognitive-behavioral group treatment for adolescent depression.

OBJECTIVE: Examine hypotheses concerning the negative impact of lifetime psychiatric comorbidity on participation in, and benefit from, a cognitive-behavioral group treatment for depression in adolescents (e.g., greater severity at intake, less recovery and more recurrence, less participation in treatment). METHOD: Across two previous studies conducted between 1986 and 1993, 151 depressed adolescents (aged 14-18) were randomly assigned to one of three treatment conditions (two active treatments and a waitlist control) and followed for 24 months posttreatment. Forty percent of participants had one or more lifetime comorbid diagnoses at intake. RESULTS: Comorbid anxiety disorders were associated with higher depression measure scores at intake and greater decrease in depression scores by posttreatment. Overall lifetime comorbidity was unrelated to diagnostic recovery, but lifetime substance abuse/dependence was associated with slower time to recovery. Participants with attention-deficit and disruptive behavior disorders were more likely to experience depression recurrence posttreatment. Associations between comorbidity and participation or therapy process measures were nonsignificant. CONCLUSIONS: Although some outcomes were worse for some comorbid diagnoses, the reassuring overall conclusion is that the presence of psychiatric comorbidity is generally not a contraindication for the use of structured group cognitive-behavioral interventions for depressed adolescents.     

Five-year prospective outcome of psychopathology in the adolescent offspring of bipolar parents

OBJECTIVE: For nearly 5 years a prospective high risk cohort study was carried out in the Netherlands among adolescent offspring of parents with bipolar disorder (BD). The purpose of this study was to determine the prevalence of psychopathology, specifically mood disorders, in adolescents and young adults with a bipolar parent. METHOD: At first and second measurement 140 and 132 children of bipolar parents, respectively, were psychiatrically evaluated with a semi-structured psychiatric interview (K-SADS-PL). At follow up (third measurement), nearly 5 years later, lifetime DSM IV diagnoses were obtained from the SCID interview for 129 subjects (aged 16--26 years). RESULTS: Compared with the first measurement, the lifetime prevalence of BD increased from 3 to 10% at follow up. In addition, the lifetime prevalence of overall mood disorders increased to 40% and of overall psychopathology to 59%. All subjects except for one with BD, debuted with a unipolar mood disorder with a mean of 4.9 (SD 3.4) years prior to the first (hypo)manic episode. CONCLUSION: At follow up, we noticed an increase in BD onset, while a further increase could be expected. In addition, we found that a unipolar depression in bipolar offspring is a risk factor for, and at the same time the first sign of, the development of BD.     

Review of studies of child and adolescent offspring of bipolar parents

Objective: The authors reviewed studies of child and adolescent offspring of bipolar (BP) parents. Findings from these studies are critically discussed with respect to methodological issues that can inform future designs.

Methods: A Medline search was performed to identify studies that examined child and adolescent offspring of BP parents. Publications were excluded if they did not separate offspring of BP parents from offspring of major depressive disorder or schizoaffective parents (‘affective offspring’) or did not separately analyze data from child‐ and adolescent‐age versus adult offspring.

Results: Seventeen studies fit these review criteria. Rates of mood disorders in child and adolescent offspring of BP parents ranged from 5 to 67% compared with rates in offspring of healthy volunteers of 0–38%. Rates of non‐mood disordered psychopathology ranged from 5 to 52% in offspring of BP parents and from 0 to 25% in offspring of healthy volunteers. Rates of mood disorders and of other psychopathology were increased in offspring of BP parents compared with offspring of healthy volunteers in all of the eight studies that included a comparison group of offspring of healthy volunteers.

Conclusions: Studies suggest that children (≤21 years) of BP parents are at increased risk for developing mood and other disorders (e.g., disruptive, anxiety). Therefore, additional investigations are clearly warranted. In the context of current research on diagnosis, assessment, longitudinal course and comorbidity of childhood mania, the following suggestions for the design of future studies should be considered: 1) Phenotypic specification of bipolar manifestations (e.g., BP‐I, BP‐II, BP‐NOS) in child/adolescent offspring and in bipolar parents themselves. 2) Control groups that are pediatric‐age relevant and thus include attention‐deficit hyperactivity disorder. 3) Assessments that include items for prepubertal mania and for onsets and offsets of all occurrences of symptoms and of environmental factors (e.g., life events) in offspring and in parents so that trajectories of overlap and sequence between child and parental mania can be investigated. 4) These detailed onsets and offsets of symptoms are also necessary to investigate prodromal manifestations of mania in the offspring. 5) Unaffected offspring present a unique opportunity to study pre‐ and postmorbid cognitive and physiological endophenotypes and structural and functional brain abnormalities. Findings from offspring studies will be crucial to inform research on the development of early intervention and prevention strategies.     

The evolution of psychiatric services in a health maintenance organization

The authors describe a prepaid mental health service program in which outpatients referrals were 34.7 per 1,000 members per month, the hospital admission rate was .80 admissions per 1,000 members per year, and the average length of hospital stay was 5.03 days. They offer several explanations for their finding that the costs for mental health services in this program appear lower than those in fee-for-service programs.     

Teaching psychiatry in the health maintenance organization

Psychiatric residents training in a health maintenance organization (HMO) rapidly encounter the conflict between high demand for services and limited supply of time. In one HMO setting, the Harvard Community Health Plan, supervisors assist trainees in managing their practices to recognize their avoidances and conflicts and to respond therapeutically in keeping with the setting.     

Predicting school dropout and adolescent sexual behavior in offspring of depressed and nondepressed mothers

OBJECTIVE: To examine predictors of school dropout and adolescent sexual behavior in offspring of depressed and nondepressed mothers. Possible moderators of the relation between maternal depression and these outcomes also were explored. METHOD: Participants were 240 mothers and adolescents assessed annually from 6th through 12th grade. Interviews and questionnaires measured the chronicity and severity of the mother's depressive episodes, the mother's educational attainment, socioeconomic status, the presence of a father, the adolescent's IQ, externalizing behaviors, and substance use disorders. RESULTS: Substance use disorders before ninth grade significantly predicted higher rates of both school dropout and adolescent sexual behavior. Lower levels of mother's educational attainment and higher rates of adolescent's externalizing behaviors in grades 6 through 8 predicted higher school dropout. Higher IQ was associated with a lower likelihood of dropping out among offspring of never or moderately depressed mothers, but not for offspring of chronic/severely depressed mothers. Among offspring of never or moderately depressed mothers, the presence of a male head of household was associated with lower rates of adolescent sexual behavior, but not among offspring of chronically/severely depressed mothers. CONCLUSIONS: These findings have implications for the development of programs aimed at preventing behavior problems in high-risk adolescents.     

Helping depressed adolescents: a menu of cognitive-behavioral procedures for primary care

Depression among adolescents has received recognition as a significant psychiatric problem that requires prompt intervention. This article will help primary care providers to understand the significance of adolescent depression, recognize its prevalence in primary care, cite the evidence supporting cognitive-behavioral therapy (CBT) as a treatment for depressed adolescents, recognize the challenges of using CBT in primary care, and use 7 different CBT approaches with their patients. Psychiatric diagnoses may be present in 38% of adolescents who see a primary care physician, and among that number, depression is the most common diagnosis. Cognitive-behavioral therapy provides a scientifically proven tool for those physicians who want to provide their young depressed patients an effective counseling approach. Cognitive-behavioral therapy enhances self-control, perceptions of personal efficacy, rational problem-solving skills, social skills, and participation in activities and physical exercise that bring the adolescent a sense of pleasure or mastery. CBT has been proven to be effective when delivered by physicians who have received significant instructions. Unfortunately, CBT techniques can at first seem overly abstract, overwhelming in number, and difficult to teach in the 15-minute visit. However, CBT techniques can be made clear and accessible for a busy physician. The case of a depressed 14-year-old male high school student who comes to his physician for a pre-participation sports physical is presented to illustrate the application of CBT in primary care.     

High levels of cortisol among adolescent offspring of parents with bipolar disorder: a pilot study

The hypothalamic-pituitary-adrenal (HPA) axis is compromised at several levels in major depressive and bipolar disorder (BD). However, it is not known whether HPA abnormalities predate the onset of these disorders. We conducted a pilot study comparing salivary cortisol levels of 10 adolescent offspring of parents with BD and 10 offspring of parents with no mental disorder (NMD). For two days, samples were collected at awakening and during the day in the adolescents' natural environment. The offspring of parents with BD had higher mean cortisol levels in the mornings and afternoons than the offspring of parents with NMD. When controlling for age, group differences in cortisol persisted in the afternoon, but not morning samples. None of the adolescents met diagnostic criteria for anxiety, affective, attention-deficit, or conduct disorders. Although preliminary, the results suggest that there is an early abnormality in the HPA system of the offspring of parents with BD.     

Benzodiazepine use in older adults enrolled in a health maintenance organization.

OBJECTIVES: The authors examined patterns of benzodiazepine use in older adults. Specifically, they describe prevalence and incidence of benzodiazepine use during the index year, describe persistence and intensity of benzodiazepine use over a 4-year period; and examine factors associated with benzodiazepine use in the upcoming year. METHODS: Authors performed a secondary analysis of data collected as part of a health promotion intervention trial conducted from 1986 to 1992 in older health maintenance organization enrollees (N=1,505). Benzodiazepine use was ascertained from computerized pharmacy records. Demographic characteristics, health status, and health behaviors were ascertained from mailed questionnaires. RESULTS: During the index year, the prevalence and incidence of benzodiazepine use was 12.3% and 6.6%, respectively. Of those using during the index year, 16% of new users and 63% of previous users continued to use for the following 3 years. The factors significantly associated with benzodiazepine use in the following year were female gender, high school education, higher chronic disease score, higher levels of self-reported pain and stress, low-to-normal body mass index (BMI), and self-reported nervous disorder. CONCLUSIONS: New users had low intensity of use and a low probability of continuing use over the following 3 years. A very small percentage of this sample had evidence of daily use for 4 years. Of concern, benzodiazepines were used by the segment of the sample that were at greatest risk for hip fractures (women with normal/low BMI). Clinicians should assess the need for continued benzodiazepine use at regular intervals.