A 16-year-old girl was brought to the emergency department by her parents because of persistent crying, sadness, apathy, lack of interest and pleasure in activities she formerly enjoyed, social withdrawal, loss of appetite, weight loss of 30 kg, fatigue, headache, poor concentration, hopelessness, and thoughts that it would be better if she were no longer alive. The patient denied any suicidal plans or attempts as well as previous nonsuicidal self-injury. She had not been treated by a psychiatrist previously. Her symptoms had been present for the past 3 months and were causing significant subjective distress and impairment in her daily activities. A neuropediatric examination, an electroencephalogram, and routine laboratory tests, including thyroid hormones, were normal.
The patient lived with her parents and an older sister. Her mother had postpartum depression (PPD) after the birth of the patient and had been in outpatient treatment for a short time. Her mother's episodes of depression recurred several times over more than 7 years, but she often discontinued antidepressant medication and treatment despite encouragement by her husband to continue. taking it. The father had assumed all of the domestic responsibilities of the family, including raising the children. During the patient's childhood the mother did not participate in family activities, usually spent time alone in her bedroom, and was often on sick leave from work. The patient also witnessed verbal conflicts between her parents caused by impaired functioning of her mother. She feared for her mother and her health, and also suffered because of the lack of communication and support from her. The patient did not want to disclose her everyday problems to her mother for fear of overburdening her. Her father described the patient as a sensible and withdrawn child, but she had done well in school and had several friends. However, after moving from a small town to a city at age 13 years, the patient had difficulties adjusting to a new school. She did not have any friends and her grades dropped significantly. After starting high school at age 15 years, her social withdrawal and low self-esteem became more pronounced, and she spent most of her time after school alone at home. Significant weight loss, social isolation, and many missed days of school mandated a referral to a child/adolescent psychiatrist.
She was diagnosed with major depressive disorder (MDD) and treated in the outpatient unit. Treatment involved psychoeducation, individual psychotherapy, medication (fluoxetine at a dose of 20 mg/day), and family therapy. Her mother was encouraged to take her medications and continue with regular psychiatric visits. The patient improved over the next 7 months of regular treatment, and her depressive episode remitted completely. She continued taking her medication for 1 year. She remained in full remission 6 months after discontinuing the medication.
The patient had had sustained emotional problems since her preadolescent years that were not recognized by her parents or school staff. Internalizing problems are often hard to recognize if the child is not expressing any difficulties verbally, and they are usually only detected when severe impairment in functioning occurs.1 Despite the family history of depression in this patient, and especially the PPD of her mother (which is a well-known risk factor for emotional and behavioral problems in offspring), this girl did not receive any screening for her mental health prior to her presentation to the emergency department.2 The decision to refer this patient to a mental health specialist was made by a school psychologist only after noticing her significant weight loss and many missed days of school.
We believe this case is important because PPD is a highly prevalent disorder with a wide range of adverse consequences for the child and the entire family.2,3 Therefore, it is especially important to monitor parent and child outcomes in this patient population. Clinical suspicion of a child's mental health problems should be heightened by recurrent depressive episodes after PPD in the mother and noncompliance with treatment.
In this case, poor mother-infant attachment persisted throughout the patient's childhood. Negative and depressive behavior in the early life of an infant influences the attachment style.2 The children of mothers who are depressed vocalize less and express weaker facial expressions in comparison to children of mothers who are not depressed.2 Mothers who are depressed show less attention and respond less to the needs of their children. They are poor role models for a child on how to regulate negative emotions and deal with problems. The children of mothers who are depressed are more vulnerable, and they have more internalized (depression) and externalized (aggression, destructivity) problems due to impaired mother-child interactions.2
It is also worth noting that the father's support in this case did not mitigate the negative influence of the mother's mental health problems on the emotional development of her daughter. In addition to the negative effects on the offspring, PPD affects the marital relationship as well.3 It causes lack of intimacy and can also cause sexual issues that can disrupt and negatively affect the couple.
Mental health issues of children are often neglected, and referral to appropriate child and adolescent mental health services usually comes late. Early detection and early intervention programs for emotional problems in the adolescent years are scarce in many parts of the world.4 Unrecognized and untreated adolescent depression is associated with substantial present and future morbidity, and it heightens suicide risk.5 Targeted screening of people who are at high-risk, rather than universal screening of the general population, is recommended.6 Despite the known benefits of early identification and treatment, barriers and challenges to identifying and treating adolescent depression persist in many countries.
Given the disability associated with depression in adolescents, prevention or at least delay of onset of the disorder is important.7 Preschool (age 0–5 years) child development programs that aim to provide support, reduce early adversities, enhance early stimulation at home, and improve parenting in high-risk families have been introduced in some countries.4 Such prevention strategies seem to have some immediate and continued positive effects on cognitive ability and antisocial behavior, but consistent evidence with regard to prevention of depressive disorder in adolescents is scarce.
Depression-specific prevention strategies that consist of a combination of psychoeducation and cognitive-behavioral therapy (CBT) strategies applied to children and parents have been developed for high-risk populations (ie, offspring of parents who have had depression, adolescents with subthreshold symptoms of depression, adolescents with a previous depressive episode).7 A group CBT program has been found to reduce the incidence of depression in adolescents after 1 year compared with an untreated group (21.4% vs 32.7%).7 However, the prevention was less effective in those who had a parent with depression. This result, coupled with that of a treatment study of adult depression showing that remission of maternal depression was associated with benefits to their offspring's mental health,8 suggests that effective treatment of parental depression is important for the adolescent with depression.
Depression is an interpersonal illness that directly affects parenting and all family relationships.3 Treatment of PPD, although helpful in reducing maternal depressive symptoms, may not affect “mothering” behaviors.9 Therefore, a family-based approach to prevention of depression in offspring of mothers with PPD is necessary, which implies interventions that support families' engagement with mental health services.10 Parenting programs11 and relationship-focused interventions that target the mother-child unit, rather than just the mother, and aim to increase responsiveness of mothers who are depressed to their children12 have been developed for mothers with PPD.
Identifying depression in adolescents is complex and crucial for both primary health care and mental health care providers.6 Comprehensive treatment is essential for patient recovery. Interventions aimed at improving parenting to help mothers engage optimally with their infants, as well as overall family functioning, should be considered, especially in depressed offspring of mothers who had PPD and recurrent depressive episodes.10–12 Finally, PPD prevention, screening, and intervention is known to be the strongest predictor of a child's optimal psychosocial outcome, so the most effective way to prevent patients from enduring experiences such as adolescent depression is psychiatric intervention and effective treatment of maternal mental health issues.8,13 In high-risk contexts, where depression is more likely to be prolonged or recurrent, such as in this case, it is important that long-term monitoring takes place so that support for both mothers and children can be provided responsively and on an ongoing basis.2,8
Professionals who work with families in various settings need to proactively develop an integrated and comprehensive strategy for prevention of mental health problems in children of mothers with depression.14 Collaboration across professions (obstetricians, pediatricians, general practitioners, adult psychiatrist, child and adolescent psychiatrist, psychotherapists, social workers) is needed to provide targeted interventions in the multiple settings in which mothers with depression and their children seek out care.14 The millions of children affected by maternal depression worldwide deserve nothing less.
- Ryan SM, Jorm AF, Toumbourou JW, Lubman DI. Parent and family factors associated with service use by young people with mental health problems: a systematic review. Early Interv Psychiatry. 2015;9(6):433–446. doi:. doi:10.1111/eip.12211 [CrossRef]
- Murray L, Halligan S, Cooper P. Effects of postnatal depression on mother-infant interactions and child development. In: Wachs T, Bremner G, eds. Handbook of Infant Development. 2nd ed. Hoboken, NJ: Wiley-Blackwell; 2010:192–220.
- Letourneau NL, Dennis CL, Benzies K, et al. Postpartum depression is a family affair: addressing the impact on mothers, fathers, and children. Issues Ment Health Nurs.2012;33(7):445–457. doi:. doi:10.3109/01612840.2012.673054 [CrossRef]
- Patel V, Fisher AJ, Hetrick S, McGorry P. Mental health of young people: a global public-health challenge. Lancet. 2007;369:1302–1313. doi:10.1016/S0140-6736(07)60368-7 [CrossRef].
- Copeland WE, Shanahan L, Costello J, Angold A. Childhood and adolescent psychiatric disorders as predictors of young adult disorders. Arch Gen Psychiatry. 2009;66:764–772. doi:. doi:10.1001/archgenpsychiatry.2009.85 [CrossRef]
- Thapar A, Collishaw S, Pine DS, Thapar AK. Depression in adolescence. Lancet. 2012;379(9820):1056–1067. doi:. doi:10.1016/S0140-6736(11)60871-4 [CrossRef]
- Garber J, Clarke GN, Weersing VR, et al. Prevention of depression in at-risk adolescents: a randomized controlled trial. JAMA. 2009;301:2215–2224. doi:. doi:10.1001/jama.2009.788 [CrossRef]
- Foster CE, Webster MC, Weissman MM, et al. Remission of maternal depression: relations to family functioning and youth internalizing and externalizing symptoms. J Clin Child Adolesc Psychol. 2008;37:714–724. doi:. doi:10.1080/15374410802359726 [CrossRef]
- Logsdon M, Wisner K, Hanusa BH. Does maternal role functioning improve with antidepressant treatment in women with postpartum depression?J Womens Health (Larchmt). 2009;18(1):85–90. doi:. doi:10.1089/jwh.2007.0635 [CrossRef]
- Olin SS, Hoagwood KE, Rodriguez J, et al. The application of behavior change theory to family-based services: improving parent empowerment in children's mental health. J Child Fam Stud. 2010;19:462–470. doi:. doi:10.1007/s10826-009-9317-3 [CrossRef]
- Barlow J, Coren E. Parenting-training programmes for improving maternal psychosocial health. Cochrane Database Syst Rev. 2004;(1):CD002020. doi:10.1002/14651858.CD002020.pub2 [CrossRef].
- Tsivos ZL, Calam R, Sanders MR, Wittkowski A. Interventions for postnatal depression assessing the mother–infant relationship and child developmental outcomes: a systematic review. Int J Womens Health. 2015;7:429–447. doi:10.2147/IJWH.S75311 [CrossRef].
- Battle CL, Zlotnick C. Prevention of postpartum depression. Psychiatr Ann. 2005;35:590–598. doi:10.3928/0048-5713-20050701-17 [CrossRef]
- Rishel CW. Pathways to prevention for children of depressed mothers: a review of the literature and recommendations for practice. Depression Res Treat. 2012;313689. doi:10.1155/2012/313689 [CrossRef].