Having a mother or father with depression greatly increases your risk of experiencing the same condition during childhood and adolescence, although the impact of paternal depression has been studied less frequently (see this Mental Elf blog by Jennifer Burgess).
Parental depression also predicts the severity and persistence of depressive symptoms in the offspring, as well as additional health care costs (Ford et al., 2017; Wilkinson et al, 2009; Knapp et al.2015).
Those who experience their first episode in childhood or adolescence have approximately double the risk (compared with their peers) of succumbing to further episodes, as well as poorer long term educational, occupational and social outcomes (Costello and Maughan, 2015).
Given the increasing global burden of depression, prevention among those at increased risk is important (Herrman et al.,), while the children of adults with depression are an easily identified group. I was therefore excited when invited to review this process evaluation of such an intervention, nested within a randomised controlled trial.
This study used qualitative methods to inform the development of the manualised preventive intervention under evaluation, but hoped to generalise to other similar interventions. Participants had all completed a group and family-based programme that involved eight weekly sessions with four monthly boosters. The programme comprised whole group psychoeducation about the nature of depression for three sessions and the boosters, then separate delivery of coping skills for children and parenting strategies for parents for the remaining five sessions. Sessions were two hours long and tasks were set to practice at home between appointments.
Data collection involved semi-structured interviews with parents (n=18), and young people (n=15) from 15 families within 4-13 months, as well as a single focus group (three parents and two children). Nearly all families invited to participate agreed (15/16) and descriptive analysis suggested little difference between the achieved sample and the 80 participants who completed the intervention.
Both the interviews and the focus group followed topic guides that broadly covered what aspects of the intervention participants had found useful, how it could be improved and whether they had been able to apply the knowledge and skills learned after the end of the course.
Most interviews (22/35) and the focus group were successfully recorded and transcribed; the field notes from the remaining interviews were analysed. The analysis used a deductive content analysis approach. A categorisation matrix provided a structure to capture a priori areas of interest, but sub-categories were not constrained. This matrix was used to generate a coding frame, with the final categories developed through consensus after discussion with the research team. Transcripts were then coded using quotes to illustrate each category.
- All parents would recommend the course to others, but both parents and children found the time commitment heavy (n=17).
- Participants welcomed the chance to be with other families facing similar challenges and the opportunity to discuss depression.
- Few children were completely unaware of their parent’s depression, but many reported improved understanding.
- Some parents reported that the information provided was self-evident, and some thought that the intervention was less effective as they were still unwell when they attended.
- Children reported that they had benefitted most from the coping skills, and that they still used them
- Parents welcomed increased positive time as a family, but reported struggling to keep new routines after the end of the intervention.
The authors concluded that managing expectations and leaving more time for discussion might increase the appeal of interventions, while spacing out sessions might increase the longevity of skills and knowledge learned.
Strengths and limitations
The authors discuss reflexivity, which is essential to qualitative work, and go on to say that the most active interviewer was known to some of the families as they were also involved in delivery. Rightly, the potential impact is discussed at length.
Important contextual information about the trial in which this study was nested is missing, although more detail is available via a protocol paper (Platt et al, 2014). For example, prevention can be primary (universal), secondary (targeted) or tertiary (indicated), which is not explicitly stated in the current paper.
How families were recruited as well as how many of those approached for the trial engaged, and the level of attendance at sessions is not documented here, and a brief search did not reveal the definitive trial results. The topic guides are extensive but the interviews ranged from 10-40 minutes and the focus group was only 30 minutes. The authors were concerned that the interview schedule may not have been appropriate for children which suggests insufficient piloting. The inclusion of a single focus group seems rather odd. Studies employing focus group methodology usually run several, as groups vary in what they report. Data saturation is mentioned as a concept, but it is unclear whether the authors thought that new concepts relating to their topics of interest were emerging or not when data collection stopped. Researchers all suffer disasters such as the failure to save audio files reported here, but these interviews could have been excluded as the data quality will inevitably be poorer.
Finally, I am not sure the data provided support the conclusions drawn, and the work raises a number of questions that were not discussed, for example the clinical practice and policy context. The resource implications of such an intensive preventive strategy are huge in a system where a quarter of those referred to mental health services for active intervention (Crenna et al, 2020) are rejected and only 25% of those with mental health contacts are seen (Ford et al, 2007; Mandalia et al, 2018).
Implications for practice
- Participants nearly all saw the intervention as tiring and too time-consuming suggesting the personal costs were perhaps too high given the families current strengths and weaknesses.
- So, could the elements that participants found useful be provided in a less intensive fashion, such as universal coping skills for all children as part of Personal, Social, Health and Economic education?
- Similarly, could advice for adults with depression include encouragement to discuss their condition with family members as well as links to others with the same condition. Indeed, this could be useful and effective not only to parents, but to intimate partners also.
- Would such an intensive programme be more effective and less burdensome when indicated by prior or current depression in two generations of a family?
Statement of interests
No conflicts of interest.
Claus, N., Marzano, L., Loechner, J., Starman, K., Voggt, A., Loy, F., … & Schulte-Koerne, G. (2019). Qualitative evaluation of a preventive intervention for the offspring of parents with a history of depression. BMC psychiatry, 19(1), 1-14.
Burgess, J. (2018). Depression in fathers affects children as much as depression in mothers. The Mental Elf.
Costello, E. J., & Maughan, B. (2015). Annual research review: optimal outcomes of child and adolescent mental illness. Journal of Child Psychology and Psychiatry, 56, 324–341.
Crenna-Jennings, W. & Hutchinson, J. (2020). Access to Child and Adolescent Mental Health Services in 2019. Education Policy Institute: London
Ford, T., Hamilton, H., Meltzer, H., & Goodman, R. (2007). Child Mental Health is Everybody’s Business: The Prevalence of Contact with Public Sector Services by Type of Disorder Among British School Children in a Three‐Year Period. Child and Adolescent Mental Health, 12(1), 13-20.
Ford, T., MacDiarmid, F., Russell, A., Racey, D., & Goodman, R. (2017). The predictors of persistent DSM-IV disorders in three-year follow ups of the British Child and Adolescent Mental Health Surveys 1999 and 2004. Psychological Medicine, 47, 1126–1137.
Herrman, H., Kieling, C., McGorry, P., Horton, R., Sargent, J., & Patel, V. (2019). Reducing the global burden of depression: a Lancet–World Psychiatric Association Commission. The Lancet, 393(10189), e42-e43.
Knapp, M., Snell, T., Healey, A., Guglani, S., Evans-Lacko, S.,Fernandez, J. L., et al. (2015). How do child and adolescent mental health problems influence public sector costs? Inter-individual variations in a nationally representative British sample. Journal of Child Psychology and Psychiatry, 56(6), 667–676
Mandalia D., Ford T., Hill S., Sadler K., Vizard T., Goodman A., Goodman, R. & McManus, S. (2018). Mental Health of Children and Young People in England, 2017; Services, Informal Support and Education. Health and Social Care Information Centre; London.
Platt, B., Pietsch, K., Krick, K., Oort, F., & Schulte-Körne, G. (2014). Study protocol for a randomised controlled trial of a cognitive-behavioural prevention programme for the children of parents with depression: the PRODO trial. BMC psychiatry, 14(1), 263.
Wilkinson, P., Dubicka, B., Kelvin, R., Roberts, C., & Goodyear, I. (2009). Treated depression in adolescents: predictors of outcome at 28 weeks. British Journal of Psychiatry, 194(4), 334–341.