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Friday, March 24, 2006

Remission of Maternal Depression May Also Benefit Children

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.



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