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Children of parents with depression are at high risk for various negative outcomes, including major depressive disorder (MDD) (with an approximately 40% cumulative risk for MDD by age 20 years) and other emotional and behavioural disorders (1–3). One study also reports high suicide rates and poor home and school functioning (4). Families with marital discord, parenting problems, and chronic and severe parental affective illness are at greatest risk for negative outcomes (3,5). Further, parental depression is associated with other risk factors for child maladjustment (for example, financial hardship, parental unemployment, and marital discord) and with lowered social support (6,7). While these associations are well documented, the causal mechanisms involving genes, child cognition, and environmental factors are just beginning to be elucidated (8,9). Parental depression also negatively influences parent–child relationships, leading to insecure attachment in young children, reduced maternal responsiveness, reduced sensitivity to interactions initiated by infants, reduced overall maternal–infant interactions, and a more negative relationship tone (10,11). These interactional patterns are bidirectional. For instance, mothers with depression and their infants matched negative behavioural states more often and positive behavioural states less often than did dyads without depression (12), and mothers with depression behaved differently toward symptomatic children than toward their nonsymptomatic siblings (13). Overall, the findings suggest that negative interactional patterns arising in parent–child dyads are key to the development of child problems in families with a parent suffering from depression. Further study is needed to document specific maladaptive patterns and to evaluate interventions targeted at these maladaptive interactions. Earlier work with affected families showed that child disturbance increases with the child’s increasing age (3). Therefore, prevention strategies directed at children should be most efficient if they target older children and adolescents. A recent trial, for example, tested the preventive effects of cognitive therapy in symptomatic (but not showing a disorder) adolescent offspring of parents with depression. Adolescents receiving the group intervention were significantly less likely to experience a depressive episode over 12-month follow-up (9.3% and 28.8% in the experimental group and usual-treatment control subjects, respectively) (14). However, it is also appropriate to target families with infants, preschool, and preadolescent children. The most extensive study to date compared family psychoeducation with a didactic presentation. After 18 months, those receiving the family program were functioning significantly better than those randomized to the lecture series (15). At 3-year follow-up, the family intervention led to improved family communication, less parental guilt, better understanding of the parent’s illness by the child, fewer depressive symptoms, and better child adaptive functioning (16). The program was designed to treat a single family at a time and was implemented by experienced clinicians. Perhaps owing to these factors, it has not been widely disseminated. We have developed a group program targeted at parents with depression and their partners. The aim is to increase knowledge about depression’s effect on the family and to enhance family functioning, thereby reducing risk to the children. The program is structured, manualized, and designed to be administered by clinicians without a high level of psychotherapeutic expertise. Thus, it should be easily transferable to other settings if shown to be effective. At this stage, there is no direct child involvement, although this would be a necessary component of any comprehensive program addressing the varied needs of affected families. This pilot study assessed the intervention’s feasibility and acceptability and obtained preliminary evidence of its effectiveness in enhancing parental knowledge and functioning. Description of the InterventionThe program is based on family psychoeducation and parent-training models. Family psychoeducation was developed to provide information and to foster communication, as well as family problem-solving and coping skills, in families with a member affected by schizophrenia (17,18). The parent-training model was developed specifically for families with children suffering from behaviour disorders. It incorporates concepts and methods derived from social-learning theory (specifically, coping-modelling procedures), parent-education theory (specifically, cognitive strategies and contingency-management techniques), and family-systems theory (specifically, family problem solving, collaborative approaches to management, and supportive communication) (19). The group program borrowed from each of these models with the aims of increasing the parents’ knowledge about depression and its impact on the family, of increasing spousal support, of increasing positive communication, and of enhancing positive parenting strategies directed at child problems common to these families. The program comprised 8 weekly, 2-hour sessions with 8 to 12 parent participants (alone or with their partner or a family member). The sessions included a socialization opportunity, a review of minutes from the previous session, didactic information sharing, viewing and group critique of video analogues portraying difficult parenting situations, the group leader’s summary of the session, and a group discussion to set a homework task. Each session focused on a specific issue confronting families with a parent suffering from depression (for example, a child’s withdrawal from peers) and on parenting strategies relevant to the issue. Free on-site child care was provided to facilitate the attendance of parents with young children. There is overlap with the previously evaluated family program (15), but the intervention also differs in important ways. It is a parent-group intervention, and children are not present. The focus is broader, in that general communication and problem-solving methods are covered along with the enhancement of specific parenting strategies, with an emphasis on understanding and reversing depression’s negative impact on parenting. The rationale is that improved parenting will strengthen parent–child relationships over the longer term and reduce negative child outcomes. Study Design and HypothesesThe pilot study was a controlled trial with participants randomized to the parent group or to a wait-list control group. The main outcomes, measured posttreatment and at 3-month follow-up, were knowledge of depression, parenting practices, sense of parenting competence, family relationships and functioning, and depressive symptoms. Secondary outcomes concerned child functioning. The goal was to assess whether participation in the experimental group led to immediate positive changes in targeted areas of family functioning. Because the study was exploratory, rather than confirmatory, we did not test specific hypotheses. However, a priori, preliminary evidence of effectiveness was taken to be demonstrated if the experimental group scored higher at posttreatment and follow-up on knowledge of depression, parenting, and family relationship measures, with standardized ES > 0.5. MethodsParticipants Table 1 provides baseline descriptive statistics. The proband mean age
was 41 years, and there were more women than men (only 4 men were included
as probands). A sizeable minority were single parents (33%). Most probands
in both groups had postsecondary education and were working full- or part-time.
Partners reported higher rates of postsecondary education, and almost all
were employed full-time. Although all probands met the inclusion criteria
(MDD in the past 12 months, according to the referring clinician), not
all met DSM-IV MDD criteria as assessed by the Composite International
Diagnostic Interview (CIDI) (76% and 83% in experimental and control groups,
respectively). Of the partners, 7 (25%) met MDD criteria, based on the
CIDI interview. Among probands, the mean Centre for Epidemiologic Studies-Depression
(CES-D) self-report score was above the recommended clinical cutoff (>
16), the mean number of lifetime MDD episodes was 7, and the mean number
of previous psychiatric hospitalizations was 3. Almost all the probands
(95%) were currently receiving medication for depression, and most were
seeing a psychiatrist or family doctor. Probands with depression described
more depressive symptoms in the index child than did their partner and
child. Overall, these statistics describe a sample with moderate-to-severe
depressive disorders.
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