Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention.

1.Introduction and Magnitude of the Problem

Introduction and Magnitude of the Problem - Depression in Parents, Parenting, and Children - NCBI Bookshelf

Depression is a common, universal, and debilitating public health problem. The Global Burden of Disease study by the Wor...

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概要

この一連の抜粋は、親のうつ病が、罹患した個人とその家族、特に子育てや子供の健康的な発達に及ぼす影響について論じています。 うつ病の発生率、共存症、親のうつ病が子供に及ぼす影響について説明し、うつ病が蔓延しているにもかかわらず、治療が可能なことを強調しています。 さらに、うつ病患者が直面するケアへの障壁と、親のうつ病に対する包括的なケアシステムの必要性を強調しています。 この抜粋では、人種/民族、社会経済的地位、移民の地位における差異を認め、親のうつ病に対する政策対応の必要性を強調しています。 最後に、親のうつ病の影響に対処するための統合的な、家族中心のアプローチの必要性を強調しています。

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目次

親のうつ病、子育て、そして子供：特定、治療、予防を改善するための機会

第 1 章 導入と問題の大きさ

このセクションでは、うつ病の蔓延、親のうつ病の影響、治療における課題など、親のうつ病がもたらす問題の概要を説明します。うつ病は世界中で蔓延しており、特に先進国では深刻な公衆衛生上の問題となっています。この問題の深刻さを強調するために、生涯にわたるうつ病の発生率と、うつ病が個人、家族、社会に与える影響について説明します。

親のうつ病、子育て、子どもの健全な発達に関する委員会

このセクションでは、親のうつ病に対に取り組むために設立された委員会について説明し、その任務と、調査の実施方法、調査範囲について説明します。この委員会は、親のうつ病、子育ての実践、子どもの発達に関する研究をレビューし、親とその子どもに対する効果的な介入を特定し、普及させることを目的としています。

調査の背景

このセクションでは、米国における親と子どもの状況、うつ病の蔓延、格差と脆弱な集団、併存疾患と関連性について、調査の背景を概説します。米国では親の数が多く、その中でうつ病が蔓延していることが強調されています。また、女性、離婚者または死別者、特定の民族的・人種的グループにおける発生率のばらつきについても強調されています。

うつ病の影響

このセクションでは、個人、家族、社会に対するうつ病の影響について説明します。うつ病は、教育の達成度、収入水準、雇用状況、人間関係に悪影響を及ぼし、子育てにも悪影響を及ぼす可能性があります。

ケアの障壁

このセクションでは、うつ病のケアにおける障壁について説明し、地理的、経済的、社会文化的要因、スティグマについて言及しています。地理的な場所、経済状況、社会文化的要因が、うつ病の人々が適切なケアを受けるための大きな障壁となっています。

結論

このセクションでは、親のうつ病に関する重要な調査結果を要約し、将来の研究の必要性を強調しています。親のうつ病は、本人だけでなく、子どもや家族全体に深刻な影響を与える可能性のある、蔓延し、衰弱させる病気です。より多くの研究が必要とされています。

レポートの構成

このセクションでは、レポートの残りの部分の概要を説明し、各章で取り上げるトピックを示しています。このレポートでは、親のうつ病の原因と影響、特定と評価の戦略、治療と予防の戦略、理想的なうつ病ケア介入システム、実装の課題、将来の指示について詳しく考察していきます。

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親のうつ病、子育て、子どもの健康な発達： 識別、治療、予防の機会向上のための学習ガイド

用語集

用語定義

うつ病

気分に影響を与え、興味や喜びの喪失、悲しみ、絶望感、無価値観、罪悪感、集中力や睡眠の変化などを引き起こす一般的な精神疾患。

共存疾患

同時に発生する2つ以上の疾患または状態。うつ病の場合、不安障害や物質乱用などが挙げられる。

有病率

特定の時期または期間における特定の集団における疾患または状態の発生率。

脆弱な集団

社会経済的状況や環境的要因により、身体的、精神的、または社会的に健康状態が悪化するリスクが高い人々。

スティグマ

精神疾患やその他の状態に対する否定的な態度や信念。

証拠に基づく実践

実証的な研究によって有効性が裏付けられている介入やプログラム。

二世代アプローチ

親と子の両方のニーズに対応するうつ病の予防、識別、治療戦略。

社会的決定要因

人々の健康に影響を与える経済的および社会的条件。

短答問題

1. 米国における成人のうつ病の生涯有病率は？ また、うつ病と関連する重要な人口統計学的差異を2つ挙げよ。
2. うつ病の経済的負担は、個人と社会の両方にどのような影響を与えるか、2～3つの例を挙げて説明せよ。
3. うつ病の親を持つ子どもは、どのような生物学的、心理的、行動的、社会的な影響を受ける可能性があるか？
4. うつ病治療へのアクセスと質に影響を与える可能性のある障壁を3つ挙げよ。
5. うつ病の親を持つ子どものアウトカムを予防または軽減するために、どのような二世代アプローチが有効か？
6. うつ病の親の経済的影響を評価する際に考慮すべき重要な要素を3つ挙げよ。
7. うつ病の親が子どもに与える経済的影響を評価する際に、子どもの人的資本と社会資本の両方を考慮することが重要なのはなぜか？
8. うつ病の親を持つ子どもを支援する上で、地域社会環境はどのような役割を果たすか？
9. うつ病の親を持つ家族を支援するための政策やプログラムを開発する際に、文化や言語を考慮することが重要なのはなぜか？
10. うつ病の親に対するスティグマは、どのように治療の妨げになるのか？

短答問題解答

1. 米国における成人のうつ病の生涯有病率は16.2％です。 女性は男性よりもうつ病と診断される可能性が約2倍高く、離婚した、または配偶者を亡くした成人は、結婚している成人よりもうつ病の発生率が高いです。
2. うつ病の経済的負担は、生産性の低下による職場でのコスト、医療費の増加、失業、障害による収入の減少など、個人や社会に大きな影響を与えます。 さらに、うつ病は、他の健康上の問題のリスクを高め、健康管理システムにかかる全体的なコストを増大させる可能性があります。
3. うつ病の親を持つ子どもは、うつ病、不安障害、行動障害などの精神衛生上の問題を発症するリスクが高くなります。 また、認知発達の遅れ、学業成績の低下、社会的および感情的な問題が発生する可能性もあります。
4. うつ病治療へのアクセスと質に影響を与える可能性のある障壁には、精神衛生サービスの利用可能性の低さ、医療費の高いこと、スティグマ、精神疾患やその治療に関する知識不足などがあります。
5. うつ病の親を持つ子どものアウトカムを予防または軽減するために、親のうつ病のスクリーニングと治療、子育て支援プログラム、親と子の両方のメンタルヘルスサービスへのアクセスを提供する二世代アプローチが有効です。
6. うつ病の親の経済的影響を評価する際には、親の雇用状況、収入、教育レベル、家族構成、地域社会の資源へのアクセスなどの要素を考慮する必要があります。
7. 子どもの人的資本（教育、スキル、健康）と社会資本（人間関係、社会的ネットワーク）の両方が、うつ病の親の経済的影響を受ける可能性があります。 うつ病の親は、子どもの教育や社会性の発達を支援するためのリソースやエネルギーが不足している可能性があります。
8. 地域社会環境は、うつ病の親を持つ子どものアウトカムにプラスにもマイナスにも影響を与える可能性があります。 支援的な地域社会は、家族にリソースやサービスを提供し、親のストレスを軽減し、子どもの回復力を促進することができます。
9. 文化や言語は、うつ病の経験、症状の表現、治療への態度に影響を与える可能性があります。 文化的に適切で言語的にアクセスしやすいサービスは、うつ病の親を持つ家族にとって不可欠です。
10. うつ病の親に対するスティグマは、恥や差別への恐れから、助けを求めたり、治療を受けたりすることをためらう原因となる可能性があります。 スティグマはまた、家族が利用できる社会的支援やリソースを制限する可能性もあります。

論文形式の質問

1. うつ病の親を持つ子どもに対する生物学的、心理的、行動的、社会的な影響について論じ、これらの影響を軽減するための介入戦略について考察せよ。
2. うつ病の親を持つ家族に不均衡に影響を与える社会経済的要因について考察し、これらの格差に対処するための政策的示唆を探求せよ。
3. うつ病治療へのアクセスと質に関して、文化的および言語的な障壁の役割について論じ、これらの障壁を克服するための具体的な戦略を提案せよ。
4. うつ病の親とその家族に対するスティグマの影響について考察し、スティグマを減らし、治療を求めることを奨励するためのアプローチを探求せよ。
5. うつ病の親を持つ家族のためのサービスと支援を改善するための、証拠に基づくプログラムと政策の役割について論じ、これらの介入の広範な実装を促進するための課題と機会を特定せよ。

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よくある質問：親のうつ病が子供に与える影響

このFAQでは、親のうつ病が子供や家族に与える影響について、よくある質問とその答えを提供します。

質問１： うつ病はどれくらい一般的で、親にどれくらい影響を与えるのですか？

回答： うつ病は世界中で一般的な精神疾患であり、米国では成人の16.2%が生涯のある時点で大うつ病を経験し、さらに4.1%が軽度ではあるものの慢性的なうつ病である気分変調性障害と診断されています。親も例外ではなく、米国では親の約17%が生涯のある時点で大うつ病を経験しており、これは成人全体とほぼ同じ割合です。

質問２： 親のうつ病は子供にどのような影響を与えるのですか？

回答： 親のうつ病は、子供の生物学的、心理的、行動的、社会的な発達に深刻な影響を与える可能性があります。親がうつ病になると、子供への適切なケアや情緒的なサポートが難しくなり、子供の情緒不安定、行動上の問題、学業不振、対人関係の困難などを引き起こす可能性があります。また、親のうつ病は遺伝的な影響もあり、子供が将来うつ病になるリスクを高める可能性も指摘されています。

質問３： 親のうつ病は、特定の社会集団でより一般的ですか？

回答： はい、うつ病の有病率には大きな差が見られます。女性は男性の約2倍うつ病と診断される可能性が高く、独身者や離婚者は既婚者よりもうつ病の割合が高いです。人種や民族によってうつ病の有病率に差があるかどうかは、まだはっきりと解明されていませんが、経済的に困窮している人々、特に女性や若年層ではうつ病の発生率が高いことが分かっています。

質問４： 親のうつ病には、他にどのような問題が併発することがありますか？

回答： うつ病は単独で起こることは少なく、約75%の人がうつ病に加えて、不安障害、物質乱用、行動障害などの他の精神疾患も併発しています。これらの併存疾患は、うつ病の症状を悪化させ、治療を複雑にする可能性があります。

質問５： 親のうつ病は、家族全体にどのような影響を与えるのですか？

回答： 親のうつ病は、家族全体の経済状況、人間関係、社会生活に大きな影響を与える可能性があります。うつ病の親は、仕事に行けなくなったり、生産性が低下したりすることで、経済的な困難に陥りやすくなります。また、子育てや家事の負担が増加し、他の家族にも大きなストレスがかかります。

質問６： 親のうつ病は治療できますか？

回答： はい、うつ病は適切な治療で改善する可能性が高い病気です。精神科医やカウンセラーによる心理療法、抗うつ薬による薬物療法など、さまざまな治療法があります。早期発見・早期治療が重要であり、適切な治療を受けることで、うつ病の症状を軽減し、家族関係を改善することができます。

質問７： 親のうつ病の治療を受ける上で、どのような課題がありますか？

回答： 残念ながら、うつ病の治療を受けられない、あるいは治療を受けたくても受けられない人が多くいます。その理由としては、経済的な問題、治療を受ける時間がない、精神科医やカウンセラーが不足している、うつ病に対する偏見や差別、治療法に関する情報不足などが挙げられます。

質問８： 親のうつ病を予防するために、私たちにできることはありますか？

回答： まず、うつ病に関する正しい知識を持ち、うつ病の兆候に気づくことが重要です。そして、うつ病の疑いがある場合は、早めに専門機関に相談することが大切です。また、地域社会全体で、うつ病に対する理解を深め、偏見や差別をなくしていく努力も必要です。さらに、子育て支援や経済的な支援など、うつ病のリスクを抱える家族へのサポート体制を充実させることも重要です。

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SUMMARY

Prevalence

米国では、成人の16.2％が生涯に大うつ病を報告し、さらに4.1％が軽いが慢性的なうつ病を報告している。 – 性別、年齢、民族性、配偶者の有無など、特定の集団特性によって定義される成人のある部分集団は、うつ病の有病率に格差があることを示している。女性、若年、離婚した成人は、男性、高齢、既婚の成人よりも生涯うつ病の割合が高い。一般に、社会的不利とうつ病有病率との間には、移民第一世代の場合を除き、正の相関が認められている。 – 米国では多くの成人が親である。親（18歳未満の子供が少なくとも1人いる）のうつ病有病率は、米国の成人人口全体と比較して同程度であり、特定の人口特性におけるうつ病有病率の格差も同程度である。 – うつ病は単独で発症することはまれであり、生涯または最近の大うつ病患者の75％は、少なくとも1つの精神保健または薬物乱用の診断も受けていた。

Impact

うつ病は再発を繰り返すため、個人、家族、社会に持続的なコストをもたらす。 – 1,560万人の18歳未満の子供が、過去1年間に大うつ病を発症した大人と同居している。 – 親のうつ病は、生物学的、心理学的、行動学的、社会的に深刻な結果をもたらす可能性があり、特に介護、物質的支援、養育を親に依存している子どもにとっては深刻である。 – このような影響があるにもかかわらず、うつ病はおそらく、発症初期に気づいて治療すれば、最も効果的に治療できる精神疾患のひとつである。

Barriers

うつ病成人のケアへのアクセスや質を低下させる個人レベル、医療提供者レベル、システムレベルの障壁が存在する。これらの制度的、社会文化的、言語的障壁は、既存の格差を引き起こし、維持する原因となっている。文化的、言語的に配慮され、家族の環境、経済的資源、家族、同僚、地域、社会との関係を支援するケアシステムがなければ、このような格差は拡大する可能性がある。医療者と患者・家族のコミュニケーションを改善することは、患者の人種、民族、文化、言語に関連したケアの質の差に対処するための重要な要素である。 – 現在の政策環境は、成人のうつ病患者に対する二世代（すなわち、親、子）の同定、治療、予防戦略を奨励していない。

うつ病は一般的で、普遍的で、衰弱させる公衆衛生上の問題である。世界保健機関(WHO)による世界疾病負担調査(Global Burden of Disease study)では、うつ病が成人期中期の障害に占める割合は、他のどの疾患よりも高いことが明らかにされている(Murray and Lopez, 1996)。事実、大うつ病性障害は、現在、世界的に障害の主な原因となっている(World Health Organization, 2001)。うつ病エピソードを持つ人の中には、うつ病の期間が数週間から数ヵ月で治まる人もいる。しかし、成人の30～50％では、うつ病は再発または慢性化し、完全に治らないと推定されている(例えば、Depue and Monroe, 1986; Judd et al., 1998; Solomon et al., 2000)。皮肉なことに、うつ病はおそらく最も効果的に治療される精神疾患のひとつであり、早期に気づけば予防することができる。

国際的な調査は、うつ病が文化を超えて普遍的であることを証明している。WHOが北米、中南米、ヨーロッパ、アジアの10ヵ国を対象に行った調査（Composite International Diagnostic Interview1による）では、生涯大うつ病の割合は、日本の3％から米国の16％までの幅があることが報告されている（Andrade et al.） より最近では、WHOの世界保健調査（WHO World Health Surveys）は、世界の全地域にわたる60ヵ国、約25万人の参加者からなる国際的な調査であり、うつ病エピソードの1年有病率（疾病および関連保健問題の国際統計分類第10版の基準による）だけでも3.2％と推定されている（Moussavi et al.、2007）。

うつ病は誰にとっても障害となりうるが、その影響の程度は、罹患した本人だけでなく、より広範な家族的背景、特に親に世話や発達の支援を依存しているうつ病患者の子どもにまで及ぶ。このような状況下では、うつ病は多世代にわたる障害となり、特に介護、物質的支援、養育を親に依存している子供にとって、生物学的、心理学的、行動的、社会的に深刻な結果をもたらす可能性がある。したがって、親や養育者のうつ病を軽減または除去することを目的とした効果的な治療は、子どもに対する重要な予防的介入にもなりうる。

純粋に金銭的に表現すれば、うつ病の経済的負担は深刻な世界的公衆衛生問題でもある(Luppa et al., 2007; Moussavi et al., 2007)。米国におけるうつ病に関連する推定費用は、1990年の774億ドルから2000年には831億ドルに、過去10年間で増加した(Greenberg et al., 2003)。2000年の推定総額のうち、直接的治療費は261億ドル、職場コストは515億ドル（欠勤、生産性低下など）、自殺関連コストは54億ドルであった（Greenberg et al.） さらに、うつ病と糖尿病や冠動脈性心疾患などの治療不遵守との間には強い関連があり、うつ病でない病状を持つ患者よりも治療費が高くなる(DiMatteo, Lepper, and Croghan, 2000)。

STUDY CHARGE, APPROACH, AND SCOPE

In May 2006, with support from the Annie E. Casey Foundation, the National Research Council and the Institute of Medicine convened a two-day planning meeting to explore the need for and focus of a future study on maternal depression. Researchers from a variety of disciplines, including pediatrics, policy, and community health, reviewed a small set of studies from the research literature and explored whether the quality of the work was sufficient to support a future comprehensive analysis of the evidence base surrounding maternal depression as well as an exploration of how to improve the application of this knowledge to policy, practice, and program development.

2006年5月、アニー・E・ケーシー財団の支援により、全米研究会議と医学研究所は、母親のうつ病に関する将来の研究の必要性と焦点を探るために、2日間の計画会議を開催した。小児科、政策、地域保健を含む様々な分野の研究者が、研究文献から少数の研究を検討し、その研究の質が、政策、実践、プログラム開発へのこの知識の適用を改善する方法の検討と同様に、母親のうつ病を取り巻く証拠基盤の将来の包括的分析を支援するのに十分であるかどうかを検討した。

The presentations and discussion resulted in a few key conclusions. The research literature on the treatment and prevention of depression among adults and children is rich with findings about effective interventions. More importantly, there exists a sound knowledge base about the effects of depression in families, the mechanisms of transmission of illness, and the risk and protective factors that either trigger or prevent onset or reduce severity of the disorder. The last 10 years have witnessed an increase in evidence-based prevention in general and the development of promising approaches specific to the identification, treatment, and prevention of depression in families. Aside from presenting and assessing the existing evidence, the meeting also shed light on serious gaps in the synthesis and application of extant findings and interventions in the family setting because of the diffuse and disjointed nature of the prevention, identification, and treatment literatures. Specifically, there exists a need to identify approaches that can highlight ways to translate research knowledge into effective interventions in a broad range of parental support and child health and development strategies.

発表と討論の結果、いくつかの重要な結論が得られた。成人および小児のうつ病の治療と予防に関する研究文献は、効果的な介入に関する知見に富んでいる。さらに重要なことは、家族におけるうつ病の影響、病気の伝播メカニズム、発症の引き金となる、あるいは発症を予防する、あるいは重症度を軽減する危険因子と防御因子に関する確かな知識基盤が存在することである。この10年間で、一般的にエビデンスに基づく予防が増加し、家族におけるうつ病の特定、治療、予防に特化した有望なアプローチが開発された。既存のエビデンスを提示し評価するだけでなく、予防、同定、治療に関する文献が拡散しバラバラであるため、現存する知見の統合と応用、家族への介入における深刻なギャップにも光が当てられた。具体的には、親支援と子どもの健康と発達に関する幅広い戦略において、研究知識を効果的な介入に結びつける方法を明らかにするアプローチが必要である。

Study Charge

Concerned about these complex issues, the National Academies’ Board on Children, Youth, and Families formed the Committee on Depression, Parenting Practices, and the Healthy Development of Children, with funding from the Robert Wood Johnson Foundation, the Annie E. Casey Foundation, The California Endowment, and the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services. The National Research Council and the Institute of Medicine appointed the 17-member committee in October 2007 to review the relevant research literature on the identification, prevention, and treatment of parental depression, its interaction with parenting practices, and its effects on children and families. The committee was asked to1.clarify what is known about interactions among depression and its co-occurring conditions, parenting practices, and child health and development;2.identify the findings, strengths, and limitations of the evidentiary base that support assessment, treatment, and prevention interventions for depressed parents and their children;3.highlight disparities in the prevalence, prevention, treatment, and outcomes of parental depression among different sociodemographic populations (e.g., race/ethnicity, socioeconomic status);4.examine strategies for widespread implementation of best practice and promising practice programs, given the large numbers of depressed parents; and5.identify strategies that can foster the use of effective interventions in different service settings for diverse populations of children and families.

全米アカデミーの子ども・青少年・家族委員会は、このような複雑な問題を懸念し、ロバート・ウッド・ジョンソン財団、アニー・E・ケーシー財団、カリフォルニア基金、米国保健社会福祉省の薬物乱用・精神保健サービス局および保健資源・サービス局からの資金提供を受けて、「うつ病、子育て実践、子どもの健全な成長に関する委員会」を結成した。米国学術会議（National Research Council）と医学研究所（Institute of Medicine）は、親のうつ病の特定、予防、治療、子育ての実践との相互作用、子どもと家族への影響に関する関連研究文献を検討するため、2007年10月に17人の委員からなる委員会を任命した。

1.うつ病とその併発状態、子育ての実践、子どもの健康と発達の相互作用について知られていることを明らかにすること、2.うつ病の親とその子どもに対する評価、治療、予防の介入を支持する証拠となる知見、長所、限界を明らかにすること、3.異なる社会人口統計学的集団（人種／民族、社会経済的地位など）における親のうつ病の有病率、予防、治療、転帰における格差を明らかにすること、4.うつ病の親の数が多いことから、ベストプラクティスや有望な実践プログラムを広く実施するための戦略を検討すること、5.異なる社会人口統計学的集団における効果的な介入の使用を促進することができる戦略を明らかにすること、 うつ病の親の数が多いことから、ベストプラクティスや有望な実践プログラムを広く実施するための戦略を検討する。

Study Approach

A variety of sources informed the committee’s work. Five formal committee meetings and one public workshop were held during the course of the study. The workshop explored innovative strategies and models that integrate mental health services for depression, parenting, and child development services within various settings for diverse populations of children and families; explored strategies that insure interventions are appropriate for diverse populations; and explored existing opportunities for interventions as well as existing barriers to implementation or replication of promising programs or best practices at regional, state, multi-state, or national levels in a variety of settings.

さまざまな情報源から、委員会の作業は進められた。調査期間中、5回の正式な委員会会議と1回の公開ワークショップが開催された。ワークショップでは、多様な子どもと家族のために、うつ病、子育て、子どもの発達のためのメンタルヘルスサービスをさまざまな環境の中で統合する革新的な戦略とモデルを探求し、介入が多様な集団に適切であることを保証する戦略を探求し、介入のための既存の機会と、地域、州、複数州、または国のレベルで、有望なプログラムやベストプラクティスをさまざまな環境で実施または再現するための既存の障壁を探求した。

The committee also reviewed literature from a range of disciplines and sources. Technical reviews were commissioned by experts on a variety of topics including: genetics and the environment; integration and implementation of services and models of care; the economic burden of depression; public-health policy; and vulnerable populations. Data and research on depression in adults, specifically parents, were analyzed. The committee considered research on the causes, comorbidities, and consequences of depression in adults (including parenting and child health outcomes), various health and support services for depression care, the features of interventions and implementation strategies for depression care in diverse populations, and public policies related to implementing promising interventions.

委員会はまた、さまざまな分野や情報源からの文献を検討した。遺伝と環境、サービスやケアモデルの統合と実施、うつ病の経済的負担、公衆衛生政策、脆弱な集団など、さまざまなトピックについて専門家に技術的レビューを依頼した。成人、特に両親のうつ病に関するデータと研究が分析された。委員会は、成人におけるうつ病の原因、併存疾患、結果（子育てと子どもの健康アウトカムを含む）、うつ病ケアのためのさまざまな保健・支援サービス、多様な集団におけるうつ病ケアのための介入と実施戦略の特徴、有望な介入の実施に関連する公共政策に関する研究を検討した。

Additionally, the committee visited programs focused on providing mental health services in substance abuse settings to underserviced populations. The limited evaluation of these programs and the lack of a standard against which to study them make it impossible to designate any of them as exemplary models of care. However, these visits provided examples of health services being delivered specifically to vulnerable and underserviced parents, and they helped the committee gain insight into various services, partnerships, approaches, and care models that are used. The sites visited were Entre Familia Program of the Boston Public Health Commission and PROTOTYPES Women’s Center in Pomona, California. Both visits encompassed a tour of the program site and meetings with leaders of the sponsoring institution and other staff and partnering programs.

さらに委員会は、薬物乱用の環境において、十分なサービスを受けていない人々に精神保健サービスを提供することに重点を置いたプログラムを視察した。これらのプログラムの評価は限られており、またそれらを研究する基準がないため、どのプログラムも模範的なケアモデルとして指定することは不可能である。しかし、これらの訪問は、特に社会的弱者や十分なサービスを受けていない親に医療サービスが提供されている例を示すものであり、委員会が様々なサービス、パートナーシップ、アプローチ、ケアモデルについて見識を深めるのに役立った。訪問先は、ボストン公衆衛生委員会のEntre Familia Programと、カリフォルニア州ポモナのPROTOTYPES Women’s Centerであった。どちらの視察も、プログラムの現場を見学し、主催機関のリーダーや他のスタッフ、提携プログラムとのミーティングを行った。

Study Scope

The committee was charged broadly with an examination of depression in parents and its effects on parenting practices and child development. However, the charge did not specify what “depression” or “parents” should encompass. Therefore, one of the committee’s early tasks was to reach consensus on how to define these terms in reviewing the literature.

Defining Depression

The available literature on depression in adults—and, more specifically, on parents and its effects on parenting practices and children and families—has not measured depression in a consistent manner; it is therefore important to consider these varied approaches. In general, there is continual debate on how to define mental disorders, and specifically for depression there are many tools used in the literature to assess adults for depression.

A review by Frank and Glied (2006) on mental health policy in the United States describes three ways in which epidemiologists generally define who has a mental disorder: (1) those who have symptoms and signs of a particular disorder, (2) those who have mental health-related impairment in daily life, and (3) those who have sought treatment for a mental health condition. A combination of these three is generally preferred over a single one because each selects a distinct subgroup of the population, usually with small overlap. In addition, experts continue to argue about the specific combination of signs and symptoms on which diagnoses should be based.

A variety of methods are used to screen for or diagnose depression, which is reflected in the literature that the committee reviewed. The use of diverse methods for defining depression is a result of restrictions on time and cost, study populations’ sociodemographic characteristics (e.g., race/ethnicity, socioeconomic status), and differences in provider training. Research that defines parental depression by symptoms is more common in the literature than a clinical diagnosis. Literature that discusses effects of depression on parenting practices is based mostly on depressive symptoms or “distress.” In addition, defining depression using symptoms may be more efficient overall from the provider’s perspective but may complicate detection in a person also experiencing conditions resulting from substance use or trauma. For example, substance abuse greatly influences symptoms of mental illness and vice versa. Further, using methods that define depression by symptoms may lead to higher rates among one group over another, for example women compared to men.

The problem with using a clinical definition of parental depression is that it generally identifies only those who are active in the mental health system; people who are isolated or who are disadvantaged are less likely to have access to mental health services and hence are more likely to go undiagnosed. And methods used for clinical diagnosis may vary by type of provider. Generalist physicians provide most of the depression screening and care to the general population, whereas the limited number of available specialty mental health providers (i.e., those with advanced mental health training) may see a more severely ill population.

Given these considerations, in describing this literature on depression in adults who are parents and its effects on parenting practices, children, and families, the committee chose to use both symptoms and a clinical diagnosis of depression whenever the data were available. However, due to the concerns described above, it may be important to distinguish the use of methods that use self-report symptoms compared to clinician-rated depression diagnosis because the method could highlight different outcomes seen across studies of depression, parenting, and child outcomes.

Defining Parents and the Family Unit

Family composition is marked by increased diversity and change. It has been estimated that less than 50 percent of children in the United States live in traditional nuclear families, in which two biological parents are married to each other with full siblings (Brandon and Bumpass, 2001). Instead, children’s living arrangements increasingly include unmarried parents, step-families, foster parents, and multigenerational households. For example, the proportion of cohabitating same-sex and opposite-sex couples who have children is increasing (Bengtson et al., 2005). In addition, the number of grandparents who are raising their grandchildren has increased dramatically over the past few decades (Casper and Bryson, 1998). However a family unit is composed, it still holds true that 70 percent of children under the age of 18 live in two-parent households (Federal Interagency Forum on Child and Family Statistics, 2007).

The committee focused its search of the impact and prevalence of depression, interventions, and strategies of implementation on depression in parents on all individuals who take care of a child or children in a variety of family structures. This definition of a parent allows discussion to include a variety of caregivers of children. However, having decided to focus the study on a variety of caregivers in a variety of family structures, we found limited literature specifically on parents with depression and even more limited information regarding specific groups of caregivers, including fathers and grandparents. The little information that is available for these other caregivers is highlighted throughout the report when available.

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STUDY CONTEXT

Parents and Their Children

In 2004, it was estimated that approximately 148.8 million parents live in the United States (U.S. Census Bureau, 2005a, 2005b). The Current Population Survey, through its household survey data, helps to track the number of mothers, fathers, and other caregivers who take care of children under the age of 18 in the United States. In 2007, it was estimated that there were 36.5 million married parents, single fathers, and single mothers (i.e., households) who care for their own children under the age of 18—that is, approximately 47 percent of households (U.S. Census Bureau, 2008b). Together, these parents take care of approximately 96 percent of almost 74 million children under age 18 in the United States. The remaining 3 percent of children (2.5 million) do not live with either of their parents, but with a grandparent, other relative, or nonrelative or are in the foster care system (U.S. Census Bureau, 2008a).

Prevalence of Depression

In the United States, the 2001 National Comorbidity Survey-Replication (NCS-R) revealed that the prevalence of major depression (defined by syndrome features, impairment, and duration of at least two weeks) in adults in their lifetime was 16.2 percent (over 3 million adults), while another 4.1 percent met the diagnostic criteria for dysthymic disorder, a milder but chronic form of depression (The ESEMeD/MHEDEA 2000 Investigators, 2004; Kessler et al., 2003). Overall, both international and national data support the universal nature of depression. While many studies do not specifically investigate parental depression or even note parental status among their samples, a few national surveys help give insight into the prevalence of depression among adults who are also parents in the United States. For example, a subsample of the National Comorbidity Survey Replication in 2002 reported that 17 percent of parents (with at least one child) had major or severe depression in their lifetime, a prevalence similar to that of the entire U.S. population of 16.2 percent (see Table 1-1). Examining rates of parental depression in the past year, the NCS-R found that approximately 7 percent of parents (with at least one child) had major or severe depression in the last 12 months and did not differ by the age of the child (see Table 1-1). The Pregnancy Risk Assessment Monitoring System (PRAMS), another national data set that collects self-reported data, offers further insight on the scope of depression, specifically in postpartum women. The survey found that 11 to 20 percent of new mothers were affected by depressive symptoms following childbirth (Centers for Disease Control and Prevention, 2008). One important longitudinal study in the United Kingdom of parents and child outcomes, the Avon Longitudinal Study of Parents and Children, was used to do secondary analyses of paternal peripartum depression (Ramchandani et al., 2008). Father’s depression correlated strongly with maternal depression scores, suggesting that, when fathers are depressed, there may be a high prevalence of both parents being depressed.

TABLE 1-1

Prevalence of Major Depressive Disorder with Hierarchy for Adults with at Least One Child Under the Age of 18 Years, 2002.

Disparities and Vulnerable Populations

Despite its prevalence across cultures, sexes, income strata, and age groups, tremendous differences in depression rates in particular sociodemo graphic categories is noteworthy. For example, women are about twice as likely to be diagnosed with depression as men in nearly all cultures (Andrade et al., 2003; Kessler, 2003; Riolo et al., 2005). Among adults overall, rates of depression are higher among single or divorced people than among their married counterparts (e.g., The ESEMeD/MHEDEA 2000 Investigators, 2004; Kessler et al., 2003). Stratified by age, depression is more common among teenagers and younger adults than among older adults, with apparently increasing rates in more recently born cohorts (e.g., Cross-National Collaborative Group, 1992; The ESEMeD/MHEDEA 2000 Investigators, 2004; Kessler et al., 2005). Similarly, a subsample of the NCS-R reports significant differences in lifetime and past year major depression prevalence rates among parents by gender, marital status, if English was their primary language while they were growing up, if they were born in the United States, and by race/ethnicity (see Tables 1-2 and 1-3). Mothers have almost double the prevalence of lifetime major depression than fathers. Parents overall and especially mothers who were divorced, widowed, or separated reported higher lifetime prevalence of major depression than those who were married or never married. Also, parents and mothers born in the United States and raised with English as their primary language report lifetime major depression significantly more than those who were not born in the United States or if English was not their primary language. Unlike the general population of parents and mothers, fathers reported significant differences in lifetime depression rates by current work status. Fathers not in the workforce at all have almost double the prevalence of lifetime depression than fathers who are employed or currently unemployed. Among the general population of parents, poverty status, and educational attainment did not significantly affect the prevalence of lifetime major depression. Although differences in rates by gender and marital status were similar as for prevalence of lifetime major depression, reports of major depression in the past year also found additional differences by current work status. Parents, and in particular fathers, who were employed had approximately half of the prevalence of major depression in the past year compared with parents who were unemployed or not in the workforce (see Table 1-3). Finally, similar to the general adult population and specific to the parent population, the Medical Expenditure Panel Survey in 2004 found gender disparities in the prevalence of poor mental health. A total of 4.5 percent of households reported that the mother was the only adult with fair or poor mental health, compared with 2.6 percent of households who reported that the father was the only adult affected. Around 1 percent of households report that both adults (mother and father) had fair or poor mental health (personal communication, Stephen Petterson, Robert Graham Center, February 13, 2008).

TABLE 1-2

Lifetime Prevalence of Major Depression with Hierarchy^a by Selected Demographic Characteristics forAdults with at Least One Child Under the Age of 18 Years, 2002 (taking into account weighting and complex survey design).

TABLE 1-3

12-Month Prevalence of Major Depression with Hierarchy by Selected Demographic Characteristics for Adults with at Least One Child Under the Age of 18 Years, 2002 (taking into account weighting and complex survey design).

It is not clear whether certain subgroups of the population are disproportionately affected by depression. For example, differences in (particu larly chronic) depression are reported along the lines of race and ethnicity. However, there seem to be some inconsistencies about whether the prevalence rates for depression in the general adult as well as in the parent population in racial/ethnic minority groups is higher or lower than their white counterparts. Existing national surveys² report lower rates in life-time prevalence for adults in these racial/ethnic minority groups (e.g., Asian Americans, African Americans) and similar prevalence rates in a given year to that of non-Hispanic whites (Takeuchi et al., 2007; Williams et al., 2007). The limited available evidence suggests the need for research on this topic (Jackson and Williams, 2006). The subsample of the NCS-R specific to parents shows the highest rates of lifetime and past year major depression specifically among parents who are black immigrants from the Caribbean (about 30 percent), followed by non-Hispanic whites (around 20 percent), African Americans (around 12 percent), non-Mexican Hispanics (around 15 percent), and Mexicans (10 percent). Asians report the lowest prevalence (around 9 percent) (see Tables 1-2 and 1-3).

A number of studies have examined depression among groups that are disadvantaged for a variety of reasons, such as poverty. While these studies differ in terms of design, sample size, and specific findings, they all document the same trend: a positive association between depression and social disadvantage, except in the case of first generation immigrants. For example, studies of low-income women found depression rates nearly double those in the general population, ranging between 12 and 27 percent for current (Bassuk et al., 1998; Jesse et al., 2005; Lanzi et al., 1999 ) and 43 percent for lifetime prevalence (Bassuk et al., 1998). A longitudinal population study showed a clear relationship between worsening socioeconomic circumstances and depression, and a meta-analysis of 51 studies found compelling evidence for socioeconomic inequality in depression (Lorant et al., 2003, 2007). Among women participating in state welfare-to-work programs, Siefert and colleagues (2000) recorded current depression among more than a quarter of them. A national survey found homeless women with lifetime prevalence rates of depression around 45 percent and current (i.e., past month) prevalence rates of roughly 10 percent (Bassuk et al., 1998). In their research with incarcerated women, Bloom and colleagues found that 13.7 percent of their sample had been diagnosed with a current episode of depression (Bloom et al., 2003). Research indicates that immigrants from Mexico, the Caribbean, and Africa have lower rates of mental health disorders than their U.S.-born counterparts (Miranda et al., 2005; Vega et al., 1998); however, recent surveys also indicate the mental health status of immigrant populations has been found to deteriorate with the time of tenure in the United States (Grant et al., 2004; Vega et al., 1998).

The scientific literature classifies many of these groups as “vulnerable populations.” The notion of vulnerability is based on the epidemiological concept of risk, which is used to quantify the probability that an individual will become ill or suffer adversity in a given period of time. According to this definition, vulnerable populations are comprised of individuals who have a higher probability of experiencing poor physical, psychological, or social health than others at any point in time due to shared sociodemographic or environmental circumstances (Aday, 1994). Social vulnerability affects health in general and depression specifically via several pathways. For example, such factors as limited access to knowledge and resources as well as increased exposure to such social stressors as marginal neighborhoods, community violence, and discrimination directly affect the genesis, progression, and treatment of depression. In addition, the stigma associated with belonging to a disadvantaged group may increase individuals’ isolation, thus causing or exacerbating depressive symptoms, and it may affect their treatment-seeking behaviors. More generally, the stigma of having a diagnosis of depression among certain disadvantaged and cultural groups may impede depression-related research endeavors (U.S. Surgeon General, 1999).

The concept of vulnerability has important research and policy implications for two main reasons. First, risks may accumulate additively or multiplicatively, depending on the number of high-risk groups to which an individual or family belongs. Second, compared with their normative counterparts, vulnerable populations may require additional medical and social services to meet their multiple, coinciding physical and mental health needs, as well as their children’s developmental needs.

Bearing in mind such vulnerability-related considerations is of particular importance in the context of depression because it is precisely those social environments and characteristics in which depression most commonly occurs—such as poverty, marital status, or disadvantage due to gender, race and ethnicity—that are themselves factors likely to exacerbate or prolong depression. Because of their typically stressful and enduring nature, these conditions may create a constellation of vulnerabilities that overwhelm the person’s coping capabilities and diminish the effectiveness of treatments that have proven successful under less challenging circumstances. Moreover, given the disproportionate incidence of depression among women, particularly those who are poor and single, as well as those who are young and in their prime childbearing and child rearing years, depression poses a concern because of its potential for impairing parenting.

The data from the NCS-R specific to parents reveal similar prevalence rates of depression compared with adults in general, including disparities in gender, race/ethnicity, and marital status, and employment status for fathers. Other demographic disparities that are generally considered a contributor to depression, i.e., income level, was not seen to significantly contribute to depression in parents in this particular subsample of one study (although a difference is still seen). More longitudinal and cross-sectional data are needed to further document and clarify the prevalence, incidence, disparities, causes, and consequences of depression in adults who are parents.

Comorbidities and Correlates of Depression

According to the National Comorbidity Survey, approximately 75 percent of individuals who had lifetime or recent depression also had at least one additional mental health or substance abuse diagnosis (Kessler et al., 2005), as did 60–65 percent of those with current major depression, as reported in both U.S. and international studies (e.g., De Graaf et al., 2002; Rush et al., 2005). Often the depression occurs in part because of difficulties caused by the other disorders, principally substance abuse, anxiety disorders, and conduct and antisocial disorders. In addition, depression is often comorbid with other chronic medical conditions, such as diabetes, hypertension, and arthritis, and can worsen their associated health outcomes (Ciechanowski, Katon, and Russo, 2000; Katon, 1998, 2003; Moussavi et al., 2007). Individuals who are depressed are more likely to amplify physical symptoms and to develop catastrophic ideas about the causes and consequences of their symptoms (Barsky, 1979; Edwards et al., 2006). The social and physical functioning of depressed individuals often is poor, and they are hospitalized more frequently than people with other major chronic medical problems. Such comorbid conditions may greatly complicate the severity, duration, and recurrence of depression and diminish the effectiveness of treatments for it. The reverse is also true: depression may impede individuals’ efforts to find effective treatments or coping strategies for dealing with their co-occurring disorders.

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IMPACT OF DEPRESSION

Adding to the problem that depression rarely occurs alone, a further complication is the recurrent nature of depression as well as its impact on individuals, their families, and society. Although depressed mood or sadness are normal human experiences associated with loss of treasured relationships, disappointments, and failures, most people who experience such states recover quickly within hours or a few days. However, clinically significant depression not only persists but also has detrimental effects on intellectual processes and attitudes about the self, the world, and the future; impedes adaptive behaviors and family and social interactions; erodes en ergy; and disrupts bodily processes—in addition to its effect on mood and emotions.

Individual

The National Institute of Mental Health Collaborative Health Program on the Psychobiology of Depression found that, over a 5-year period, depressed persons had lower educational achievement, lower income levels, fewer periods of employment, and decreased occupational status than nondepressed persons matched for age and gender (Coryell, Endicott, and Keller, 1990). The multisite WHO study on the effects of depression on social functioning found that, after 10 years, 25 percent of depressed patients showed poor functioning and about 40 percent exhibited moderate impairment (Thornicroft and Sartorius, 1993). Even with appropriate treatment, depression has the tendency to be episodic and recurrent; that is, after a person has been depressed once and recovers, he or she is likely to experience one or more subsequent episodes; single episodes of depression are the exception (Andrews, 2001; Solomon et al., 2000). This recurrent pattern of illness leads to sustained individual, family, and societal costs.

Consequently, individuals with depression often cannot function in optimal ways in their close relationships or in work, social, and leisure activities. Thus, depression is associated with decrements in work attendance, work quality, and productivity (Kessler et al., 2006; Wang et al., 2004); with unresponsive, harsh, or rejecting parenting (Cummings and Davies, 1999; Goodman and Gotlib, 1999); with dissatisfaction or conflict in close relationships (Kessler, Walters, and Forthofer, 1998; Whisman, 2001); and with medical problems due both to poor self-care and to the effects of depression on neurobiological and immune functioning (Evans et al., 2005; Katon, 2003). Even depression that is considered “subclinical” in severity may, if sufficiently enduring, predict impaired functioning in important roles or disproportionate use of services (Johnson, Weissman, and Klerman, 1992; Wells et al., 1989).

Family and Society

Addressing the charge to the committee, this report describes a large number of traditional clinical and epidemiological approaches documenting the negative impact of depression in parents on parenting and children’s health and development. Using the prevalence data presented above, the number of children under the age of 18 in each household from the NCS-R (i.e., 2.07172), and applying it to U.S. Census data from 2001, the committee estimates that 15.6 million children under 18 years of age are living with an adult who had major depression in the past year (note: the NCS-R public use data does not provide data on depression diagnosis on both parents in a household, so this may be an underestimate of the number of these children). Yet few opportunities currently exist to identify this vulnerable population or to offer prevention and treatment services that can also enhance the parenting practices of a depressed parent in a framework that also offers services for children.

But the focus of the current research literature primarily on symptoms and diagnosis of depression in an adult does not do justice to the larger possible impacts on family development. It is essential to consider both in terms of either difficulties or opportunities for prevention, not just the individuals in the family but the family as a whole. A much broader definition of effects on the family is needed, which the committee introduces here in this report.

This conceptualization considers broadly the environment, economic resources, and relationships with family, coworkers, the community, and society (see Figure 1-1³). The community environment may either contribute to the impacts of parental depression in a family or help to mitigate them. Costs to families are much greater than individual economic costs for the depressed person. The burden of suffering is large for the depressed individual and frequently for other family members as well. The community environment is also likely to directly influence child outcomes. And a family’s current characteristics and financial resources are likely to affect the economic impact of a depressive episode on the family. Once depressed, parents have an effect on their own potential human capital (i.e., decreased employment, earnings, productivity), social capital (i.e., skills, abilities, knowledge, relationships), and their decisions on allocating their resources (i.e., time, money). These characteristics and decisions affect the well-being of family members in both the short term and the long term. They can include the maintenance and development of their children’s physical and mental health (e.g., they cannot take them to the doctor for well-child visits), their development of human capital (e.g., their child dropping out of school, achieving poorer academic performance), and their development of social capital (e.g., their child’s impairment in marital and work relationships). Taking a developmental approach that addresses long-term possible negative consequences of parental depression emphasizes both the magnitude of the costs and the need for action.

FIGURE 1-1

Conceptual model of the economic impact of depressed parents on children. NOTES: Employment = unemployment, reduced productivity; Environment = physical—housing quality, rural versus urban; social—crime rates, racial/ethnic representation, (more…)

A parent is central to the family’s functioning. His or her impairments can have dramatic effects on their children and the family. These patterns of impairment in depressed parents and the risks to their families offer natural targets for preventive and treatment interventions at various levels, includ ing, for example, making sure that families with depression have health insurance or recognizing that, with depression, parents will need additional support to get tasks done.

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BARRIERS TO CARE

Like a variety of other health services, access to care for depression may be influenced by geographic, physical, financial, sociocultural, and temporal barriers. Such barriers include transportation issues, physical disabilities, language barriers, cultural customs and beliefs, and health insurance coverage. Furthermore, an individual’s ability to access and use care may be affected by demographic characteristics (i.e., age, gender, education level, occupation, race/ethnicity), need (i.e., perceived health) and enabling characteristics (i.e., language, income, convenience, transportation, health system characteristics like infrastructure, linkages to a variety of providers). Stigma is a major barrier to seeking mental health treatment. Both self-stigma (people’s own responses to depression and help-seeking) and perceived stigma (perceptions of others’ negative responses) partially account for people’s reluctance to seek treatment (Barney et al., 2006; Halter, 2004). Many people are not familiar with treatment options, there is stigma associated with mental health treatments, and many providers are not aware of their patients’ preferences (Dwight-Johnson et al., 2000; Givens et al., 2007; Jaycox et al., 2006).

A number of institutional and sociocultural barriers are responsible for causing and maintaining existing disparities in access to and quality of mental health services received by minority groups. A succinct summary of the complex constellation of barriers is that “disparities result from ongoing interactions among factors at the levels of the health care environment, health care organization, community, provider, and person throughout the course of the depression development and treatment-seeking process” (Chin et al., 2007; Van Voorhees et al., 2007, p. 1617). Social marginalization, which has played a key role in rendering some populations disproportionately vulnerable to and affected by incidence of depression, extends its adverse impact by limiting the engagement of and treatment in historically underserved communities (Aguilar-Gaxiola et al., 2008). These groups’ isolation from mainstream society because of linguistic barriers, geographic isolation, a history of oppression, racism, discrimination, poverty, and immigration status plays a key role in creating and perpetuating many of the barriers to treatment.

In addition to individual and provider barriers to care specific to depression in adults, a body of literature continues to document the system-level limitations in mental health care generally. As described in a 2006 Institute of Medicine report entitled Improving the Quality of Health Care for Mental and Substance-Use Conditions, the “inadequacy of [mental health and substance use] health care is a dimension of the poor quality of all health care” (Institute of Medicine, 2006, p. 8). However, it also points out that care for mental health and substance use problems is also distinct from health care generally. The distinctive features they describe include greater stigma associated with diagnoses, a less developed infrastructure for measuring and improving the quality of care, a need for a greater number of linkages among multiple clinicians, organizations and systems providing care to patients with mental health conditions, less widespread use of information technology, a more educationally diverse workforce, and a differently structured marketplace for the purchase of mental health and substance use health care (Institute of Medicine, 2006). With this in mind, the report recommended using the strategy set forth by another Institute of Medicine report (2001), Crossing the Quality Chasm, as a basic framework to achieve substantial improvements in quality of care, but to tailor it to the distinctive features of mental health and substance use care.

Depression presents a fundamental paradox: it is one of the most prevalent of psychiatric conditions but also one that is highly amenable to treatment, at least in the acute phase. The U.S. Surgeon General, the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, and many others continue to document advances in the understanding of depression, the identification and assessment of depressed individuals, and the development of efficacious treatments, as well as strategies for delivering these interventions effectively. Yet despite recent scientific advances, in 2007, only 64 percent of adults in the United States who had a major depressive episode in the past year received some form of treatment (Office of Applied Studies, 2008). Only approximately 30 percent of depressed adults in community samples reportedly will receive any treatment (Simon et al., 2004). Further, depression in adults is typically discussed as an isolated problem. The focus is rarely on how depression affects parenting and child outcomes; how often it occurs in combination with other parental risks, like substance abuse and trauma; or what kinds of strategies can help to identify, treat, and prevent these negative consequences for parents and their children (Knitzer, Theberge, and Johnson, 2008). The current policy environment does not encourage an identification and treatment strategy with this kind of two-generation developmental lens, nor does it support the dissemination or implementation of the growing body of knowledge about effective interventions.

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CONCLUSION

National surveys exist that describe the rates of depression in adults and indicate disparities as defined by selected population characteristics. A subsample of one such survey specifically identified the parental status of these adults. Parents (with at least one child under age 18) have similar rates of depression compared to the entire U.S. adult population, including similar disparities in depression rates for selected population characteristics such as sex, age, and marital status. In general, social disadvantage has been positively associated with higher prevalence rates of depression in adults except in the case of newly arrived immigrants. Further, a majority of individuals with major depression also had at least one additional mental health or substance abuse diagnosis. Thus, comorbidity between mental disorders tends to be the norm rather than the exception.

Depression, due to its recurrent nature, leads to sustained individual, family, and societal costs. Furthermore, depression in parents or other caregivers can have serious biological, psychological, behavioral, and social consequences especially for children. More longitudinal and cross-sectional data are needed to further document and clarify the prevalence, incidence, disparities, causes, and consequences of depression in adults who are parents. Individual-, provider-, and system-level barriers exist that decrease the access to and quality of care for depressed adults. These institutional and sociocultural barriers are responsible for causing and maintaining existing disparities. Without a system of care that supports a family’s environment, economic resources and relationships with family, coworkers, the community, and society, such disparities may increase.

Ultimately depression is a good and effectively identified indicator of a problem that could trigger a system of care (if it is in place) that intervenes not only by treating depression in the parent but also by enhancing parenting skills and alleviating other stresses, co-occurring conditions, and social contexts, as well as identifying children at risk.

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ORGANIZATION OF THE REPORT

Following this introduction, Chapter 2 describes new approaches to tackling parental depression as well as issues and standards in evaluating this literature. Chapter 3 reviews the causes of depression, and Chapter 4 reviews the effects of depression on parenting and child health and psychological functioning. Chapter 5 reviews strategies to identify and assess depression, and Chapter 6 reviews strategies for the treatment of depression in parents and their families. Chapter 7 reviews strategies for preventing depression in parents, with a special emphasis on the prevention or reduction of adverse outcomes in children of parents who are depressed. Chapter 8 describes an ideal vision of a depression care intervention system, highlighting important components of this system that are emerging in selected service settings as well as through state and European initiatives, and reviewing federal-level initiatives that have supported this knowledge base. Chapter 9 describes systemic, workforce, and fiscal policy challenges that have emerged from current initiatives associated with implementing innovative evidence-based strategies in addressing depression in parents and its impact on children. Chapter 10 describes next steps that can be taken to help contribute to the design and implementation of the ideal prevention and depression system for parental depression, which includes knowledge development and the creation of an organizational culture receptive to new research. To aid the reader, the committee’s summary of the literature is presented at the beginning of the chapter and the conclusions, research gaps, and committee’s recommendations are presented at the end of each chapter, where appropriate. Finally, the role of culture, language, and social determinants of health were identified across the chapters when literature was available when describing vulnerable populations who experience mental health disparities. A list of acronyms is provided in Appendix A. The agenda and participants of the committee’s public workshop are listed in Appendix B, and biographical sketches of the committee members and staff are provided in Appendix C.

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REFERENCES

• Aday, L.A. (1994). Health status of vulnerable populations. Annual Review of Public Health 15, 487–509. [PubMed]
• Aguilar-Gaxiola, S., Elliott, K., Debb-Sossa, N., King, R.T., Magaña, C.G., Miller, E., Sala, M., Sribney, W.M., and Breslau, J. (2008). Engaging the Underserved: Personal Accounts of Communities on Mental Health Needs for Prevention and Early Intervention Strategies . Monograph #1, UC Davis Center for Reducing Health Disparities. Sacramento: UC Davis.
• Andrade, L., Caraveo-Anduaga, J.J., Berglund, P., Bijl, R.V., De Graaf, R., Vollebergh, W., Dragomirecka, E., Kohn, R., Keller, M., Kessler, R.C., Kawakami, N., Kilic, C., Offord, D., Ustun, T.B., and Wittchen, H.U. (2003). The epidemiology of major depressive episodes: Results from the International Consortium of Psychiatric Epidemiology (ICPE) Surveys. International Journal of Methods in Psychiatric Research, 12, 3–21. [PMC free article] [PubMed]
• Andrews, G. (2001). Should depression be managed as a chronic disease? British Medical Journal, 322, 419–421. [PMC free article] [PubMed]
• Barney, L.J., Griffiths, K.M., Jorm, A.F., and Christensen, H. (2006). Stigma about depression and its impact on help-seeking intentions. Australian and New Zealand Journal of Psychiatry, 40, 51–54. [PubMed]
• Barsky, A.J. (1979). Patients who amplify bodily sensations. Annals of Internal Medicine, 91, 63–70. [PubMed]
• Bassuk, E.L., Buckner, J.C., Perloff, J.N., and Bassuk, S.S. (1998). Prevalence of mental health and substance use disorders among homeless and low-income housed mothers. American Journal of Psychiatry, 155, 1561–1564. [PubMed]
• Bengtson, V.L., Acock, A.C., Allen, K.R., Dilworth-Anderson, P., and Klein, D.M. (2005). Sourcebook of Family Theory and Research . Thousand Oaks, CA: Sage.
• Bloom, B., Owen, B., Covington, S., and Raeder, M. (2003). Gender-Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders . Washington, DC: National Institute of Corrections, U.S. Department of Justice.
• Brandon, P.D., and Bumpass, L. (2001). Children’s living arrangement, coresidence of unmarried fathers, and welfare receipt. Journal of Family Issues, 22, 3–26.
• Casper, L.M., and Bryson, K.R. (1998). CoResident Grandparents and Their Grandchildren: Grandparent Maintained Families . (Current Population Report). Washington, DC: U.S. Bureau of the Census.
• Centers for Disease Control and Prevention. (2008). Prevalence of self-reported postpartum depressive symptoms—17 states, 2004–2005. Morbidity and Mortality Weekly Report, 57, 361–366. [PubMed]
• Chin, M.H., Walters, A.E., Cook, S.C., and Huang, E.S. (2007). Interventions to reduce racial and ethnic disparities in health care. Medical Care Research and Review, 64, 7S–28S. [PMC free article] [PubMed]
• Ciechanowski, P.S., Katon, W.J., and Russo, J.E. (2000). Depression and diabetes: Impact of depressive symptoms on adherence, function, and costs. Archives of Internal Medicine, 160, 3278–3285. [PubMed]
• Coryell, W., Endicott, J., and Keller, M.B. (1990). Outcome of patients with chronic affective disorder: A five-year follow-up. American Journal of Psychiatry, 147, 1627–1633. [PubMed]
• Cross-National Collaborative Group. (1992). The changing rate of major depression: Cross-national comparisons. Journal of the American Medical Association, 268, 3098–3105. [PubMed]
• Cummings, E.M., and Davies, P.T. (1999). Depressed parents and family functioning: Interpersonal effects and children’s functioning and development. In T.E. Joiner, editor; and J.C. Coyne, editor. (Eds.), The Interactional Nature of Depression: Advances in Interpersonal Approaches (pp. 299–327). Washington, DC: American Psychological Association.
• De Graaf, R., Bijl, R.V., Smith, F., Vollebergh, W.A.M., and Spijker, J. (2002). Risk factors for 12-month comorbidity of mood, anxiety, and substance use disorders: Findings from the Netherlands Mental Health Survey and Incidence Study. American Journal of Psychiatry, 159, 620–629. [PubMed]
• Depue, R.A., and Monroe, S.M. (1986). Conceptualization and measurement of human disorder and life stress research: The problem of chronic disturbance. Psychological Bulletin, 99, 36–51. [PubMed]
• DiMatteo, M.R., Lepper, H.S., and Croghan, T.W. (2000). Depression is a risk factor for non-compliance with medical treatment. Archives of Internal Medicine, 160, 2101–2107. [PubMed]
• Dwight-Johnson, M., Sherbourne, C.D., Liao, D., and Wells, K.B. (2000). Treatment preferences among depressed primary care patients. Journal of General Internal Medicine, 15, 527–534. [PMC free article] [PubMed]
• Edwards, R.R., Bingham, C.O. 3rd, Bathon, J., and Haythornewaite, J.A. (2006). Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases. Arthritis and Rheumatism, 55, 325–332. [PubMed]
• The ESEMeD/MHEDEA 2000 Investigators. (2004). Prevalence of mental disorders in Europe: Results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica, 109, 21–27. [PubMed]
• Evans, D.L., Charney, D.S., Lewis, L., Golden, R.N., Gorman, J.M., Krishnan, K.R.R., Nemeroff, C.B., Bremner, J.D., Carney, R.M., Coyne, J.C., Delong, M.R., Frasure-Smith, N., Glassman, A.H., Gold, P.W., Grant, I., Gwyther, L., Ironson, G., Johnson, R.L., Kanner, A.M., Katon, W.J., Kaufmann, P.G., Keefe, F.J., Ketter, T., Laughren, T.P., Leserman, J., Lyketsos, C.G., McDonald, W.M., McEwen, B.S., Miller, A.H., Mussleman, D., O’Connor, C., Petitto, J.M., Pollock, B.G., Robinson, R.G., Roose, S.P., Rowland, J., Sheline, Y., Sheps, D.S., Simon, G., Spiegel, D., Stunkard, A., Sunderland, T., Tibbits, P., Jr., and Valvo, W.J. (2005). Mood disorders in the medically ill: Scientific review and recommendations. Biological Psychiatry, 58, 175–189. [PubMed]
• Federal Interagency Forum on Child and Family Statistics. (2007). America’s Children: Key National Indicators of Well-Being, 2007 . Washington, DC: U.S. Government Printing Office.
• Frank, R.G., and Glied, S. (2006). The population with mental illness. In R.G. Frank, editor; ., S. Glied, editor; , and R. Carter, editor. (Eds.), Better But Not Well: Mental Health Policy in the United States Since 1950 (pp. 8–25). Baltimore, MD: Johns Hopkins University Press.
• Givens, J.L., Katz, I.R., Bellamy, S., and Holmes, W.C. (2007). Stigma and the acceptability of depression treatments among African Americans and whites. Journal of General Medicine, 22, 1292–1297. [PMC free article] [PubMed]
• Goodman, S., and Gotlib, I. (1999). Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychological Review, 106, 458–490. [PubMed]
• Grant, B.F., Stinson, F.S., Hasin, D.S., Dawson, D.A., Chou, S.P., and Anderson, K. (2004). Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States. Archives of General Psychiatry, 61, 1226–1233. [PubMed]
• Greenberg, P.E., Kessler, R.C., Birnbaum, H.C., Leong, S.A., Lowe, S.W., Berglund, P.A., and Corey-Lisle, P.K. (2003). The economic burden of depression in the United States: How did it change between 1990 and 2000? Journal of Clinical Psychiatry, 64, 1465–1475. [PubMed]
• Halter, M.J. (2004). The stigma of seeking care and depression. Archives of Psychiatric Nursing, 18, 178–184. [PubMed]
• Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century . Washington, DC: National Academy Press. [PubMed]
• Institute of Medicine. (2006). Improving the Quality of Health Care for Mental and Substance-Use Conditions . Washington, DC: The National Academies Press.
• Jackson, P.B., and Williams, D.R. (2006). Culture, race/ethnicity, and depression. In C.L.M. Keyes, editor; and S.H. Goodman, editor. (Eds.), Women and Depression: A Handbook for the Social, Behavioral, and Biomedical Sciences (pp. 328–359). New York: Cambridge University Press.
• Jaycox, L.H., Asarnow, J.R., Sherbourne, C.D. Rea, M.M., LaBorde, A.P., and Wells, K.B. (2006). Adolescent primary care patients’ preferences for depression treatment. Administration and Policy in Mental Health, 33, 198–207. [PubMed]
• Jesse, D.E., Walcott-McQuigg, J., Mariella, A., and Swanson, M.S. (2005). Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy. Journal of Midwifery and Women’s Health, 50, 405–410. [PubMed]
• Johnson, J., Weissman, M.M., and Klerman, G. (1992). Service utilization and social morbidity associated with depressive symptoms in the community. Journal of the American Medical Association, 267, 1478–1483. [PubMed]
• Judd, L.L., Akiskal, H.S., Maser, J.D., Zeller, P.J., Endicott, J., Coryell, W., Paulus, M.P., Kunovac, J.L., Leon, A.C., Mueller, T.I., Rice, J.A., and Keller, M.B. (1998). A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. Archives of General Psychiatry, 55, 694–700. [PubMed]
• Katon, W. (1998). The effect of major depression on chronic medical illness. Seminars in Clinical Neuropsychiatry, 3, 82–86. [PubMed]
• Katon, W.J. (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry, 54, 216–226. [PubMed]
• Kessler, R.C. (2003). Epidemiology of women and depression. Journal of Affective Disorders, 74, 5–13. [PubMed]
• Kessler, R.C., Akiskal, H.S., Ames, M., Birnbaum, H., Greenberg, P., Hirschfeld, R.M.A., Jin, R., Merikangas, K.R., Simon, G.E., and Wang, P.S. (2006). Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers. American Journal of Psychiatry, 163(9), 1561–1568. [PMC free article] [PubMed]
• Kessler, R.C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K.R., Rush, A.J., Walters, E.E., and Wang, P.S. (2003). The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). Journal of the American Medical Association, 289, 3095–3105. [PubMed]
• Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., and Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602. [PubMed]
• Kessler, R.C., Walters, E.E., and Forthofer, M.S. (1998). The social consequences of psychiatric disorders, III: Probability of marital stability. American Journal of Psychiatry, 155, 1092–1096. [PubMed]
• Knitzer, J., Theberge, S., and Johnson, K. (2008). Reducing Maternal Depression and Its Impact on Young Children: Toward a Responsive Early Childhood Policy Framework . New York: National Center for Children in Poverty.
• Lanzi, R.G., Pascoe J.M., Keltner B., and Ramey, S.L. (1999). Correlates of maternal depressive symptoms in a National Head Start Program sample. Archives of Pediatrics and Adolescent Medicine, 153(8), 801–807. [PubMed]
• Lorant, V., Croux, C., Weich, S., Deliege, D., Mackenbach, J., and Ansseau, M. (2007). Depression and socioeconomic risk factors: 7-year longitudinal population study. British Journal of Psychiatry, 190, 293–298. [PubMed]
• Lorant, V., Deliege, D., Eaton, W., Robert, A., Philippot, P., and Ansseau, M. (2003). Socioeconomic inequalities in depression: A meta-analysis. American Journal of Epidemiology, 157, 98–112. [PubMed]
• Luppa, M., Heinrich, S., Angermeyer, M.C., König, H.H., and Riedel-Heller, S.G. (2007). Cost-of-illness studies of depression: A systematic review. Journal of Affective Disorders, 98, 29–43. [PubMed]
• Miranda, J., Siddique, J., Belin, T.R., and Kohn, L.P. (2005). Depression prevalence in disadvantaged young black women. African and Caribbean immigrants compared to U.S.-born African Americans. Social Psychiatry and Psychiatric Epidemiology, 40, 253–258. [PubMed]
• Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., and Ustun, B. (2007). Depression, chronic diseases, and decrements in health: Results from the World Health Surveys. The Lancet, 370, 851–858. [PubMed]
• Muñoz, S.S. (2003). Cost to treat a depression case falls. The Wall Street Journal, December 31, p. D2.
• Murray, C.J., and Lopez, A.D. (1996). The Global Burden of Disease . Cambridge. MA: Harvard University Press.
• Office of Applied Studies. (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings . (DHHS Pub No. SMA 08-4343). Rockville, MD: Substance Abuse and Mental Health Services Administration.
• Ramchandani, P.G., Stein, A., O’Connor, T.G., Heron, J., Murray, L., and Evans, J. (2008). Depression in men in the postnatal period and later child psychopathology: A population cohort study. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 390–398. [PMC free article] [PubMed]
• Riolo, S.A., Nguyen, T.A., Greden, J.F., and King, C.A. (2005). Prevalence of depression by race/ethnicity: Findings from the National Health and Nutrition Examination Survey III. American Journal of Public Health, 95, 998–1000. [PMC free article] [PubMed]
• Rush, A.J., Zimmerman, M., Wisniewski, S.R., Fava, M., Hollon, S.D., Warden, D., Biggs, M.M., Shores-Wilson, K., Shelton, R.C., Luther, J.F., Thomas, B., and Trivedi, M.H. (2005). Comorbid psychiatric disorders in depressed outpatients: Demographic and clinical features. Journal of Affective Disorders, 87, 43–55. [PubMed]
• Siefert, K., Bowman, P.J., Heflin, C.M., Danzger, S., and Williams, D.R. (2000). Social and environmental predictors of maternal depression in current and recent welfare recipients. American Journal of Orthopsychiatry, 70, 510–522. [PubMed]
• Simon, G.E., Fleck, M., Lucas, R., Bushnell, D.M., and the LIDO Group. (2004). Prevalence and predictors of depression treatment in an international primary care study. American Journal of Psychiatry, 161, 1626–1634. [PubMed]
• Solomon, D.A., Keller, M.B., Leon, A.C., Mueller, T.I., Lavori, P.W., Shea, M.T., Coryell, W., Warshaw, M., Turvey, C., Maser, J.D., and Endicott, J. (2000). Multiple recurrences of major depressive disorder. American Journal of Psychiatry, 157, 229–233. [PubMed]
• Takeuchi, D.T., Zane, N., Hong, S., Chae, D.H., Gong, F., Gee, G.C., Walton, E., Sue, S., and Alegria, M. (2007). Immigration-related factors and mental disorders among Asian Americans. American Journal of Public Health, 97, 84–90. [PMC free article] [PubMed]
• Thornicroft, G., and Sartorius, N. (1993). The course and outcome of depression in different cultures: 10-year follow-up of the WHO Collaborative Study on the Assessment of Depressive Disorders. Psychological Medicine, 23, 1023–1032. [PubMed]
• U.S. Census Bureau. (2005. a). Facts for Features. Father’s Day: June 19, 2005 . Available: http://www​.census.gov​/Press-Release/www/releases​/archives/cb05ff-08.pdf [accessed February 4, 2009].
• U.S. Census Bureau. (2005. b). Facts for Features. Mother’s Day: May 8, 2005 . Available: http://www​.census.gov​/Press-Release/www/releases​/archives/cb05-ff.05-2.pdf [accessed February 4, 2009].
• U.S. Census Bureau. (2008. a). C2. Household Relationship and Living Arrangements of Children/1 Under 18 Years, by Age and Sex: 2007 . Available: http://www​.census.gov​/population/socdemo​/hh-fam/cps2007/tabC2-all.xls [accessed October 29, 2008].
• U.S. Census Bureau. (2008. b). Table F1. Family Households/1, by Type, Age of Own Children, Age of Family Members, and Age, Race and Hispanic Origin/2 of Householder: 2007 . Available: http://www​.census.gov​/population/socdemo​/hh-fam/cps2007/tabF1-all.xls [accessed October 29, 2008].
• U.S. Surgeon General. (1999). Mental Health: A Report of the Surgeon General . Washington, DC: U.S. Department of Health and Human Services.
• Van Voorhees, B.W., Walters, A.E., Prochaska, M., and Quinn, M.T. (2007). Reducing health disparities in depressive disorders outcomes between non-Hispanic whites and ethnic minorities: A call for pragmatic strategies over the life course. Medical Care Research Review, 64, 157s-194s. [PubMed]
• Vega, W.A., Kolody, B., Aguilar-Gaxiola, S., Alderete, E., Catalano, R., and Caraveo-Anduaga, J. (1998). Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Archives of General Psychiatry, 55, 771–778. [PubMed]
• Wang, P.S., Beck, A.L., Berglund, P., McKenas, D.K., Pronk, N.P., Simon, G.E., and Kessler, R.C. (2004). Effects of major depression on moment-in-time work performance. American Journal of Psychiatry, 161, 1885–1891. [PubMed]
• Wells, K.B., Stewart, A., Hays, R.D., Burnam, A., Rogers, W., Daniels, M., Berry, S., Greenfield, S., and Ware, J. (1989). The functioning and well-being of depressed patients. Journal of the American Medical Association, 262, 914–919. [PubMed]
• Whisman, M.A. (2001). The association between depression and marital dissatisfaction. In S.R.H. Beach, editor. (Ed.), Marital and Family Processes in Depression: A Scientific Foundation for Clinical Practice. Washington, DC: American Psychological Association.
• Williams, D.R., Gonzalez, H.M., Neighbors, H., Nesse, R., Abelson, J.M., Sweetman, J., and Jackson, J.S. (2007). Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: Results from the National Survey of American Life. Archives of General Psychiatry, 64, 305–315. [PubMed]
• World Health Organization. (2001). The Global Burden of Disease . Available: http://files​.dcp2.org/pdf/GBD/GBD01.pdf [accessed December 2008].