“When A Parent Is Depressed – How Can We Help?”

Presentation by

William R. Beardslee, MD

Department of Psychiatry

Boston Children’s Hospital and Harvard Medical School

“The child is the bearer of whatever the futureshall be … At this center … his incomparable tendernessto experience, his malleability, the almost unimaginable

nakedness and defenselessness of this wondrousfive-windowed nerve and core.”

James Agee, “Let Us Now Praise Famous Men”

 

“The pediatrician can regard the family as carrying the ‘chromosomes’ that perpetuate the culture and also

form the cornerstone of emotional development.”

Beardslee & Richmond, “Mental Health of the Young: An Overview”

“If you always do what you’ve always done, you’ll always get what you’ve always got.”

~ Albert Einstein

Health care reform must challenge existing paradigms and develop new

paradigms.

Envisioning the Future

What should a heath care system look like that fully meets the needs of families , incorporates prevention and treatment, and reflects cultural competence and cultural humility?

IOM 2009

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Outline

1. Overview

2. Prevention of mental illness

3. Parental depression

4. Resilience

5. Preventive interventions – Family Talk

6. Recent work

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Prevention of Mental Illness

Family-centered care

Prevention of mental illness and problem behavior

Population level impact Implementation and dissemination

Chronology of International Collaboration I – The Beginning

2000World Mental Health Association and the Carter Center – first combined meeting on mental health prevention. Many countries already have program components underway. Ongoing work of COPMI in Australia.

2001-PresentEffective Family Programme in Finland, Dr. Tytti Solantaus.

2002WMHA (London) – International group focus on children of the mentally ill formed including Australian representatives.

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Chronology of International Collaboration II

2002-OnwardNumerous programs for children of the mentally ill in Holland, Sweden, Norway, Finland, Denmark, and other countries.

Numerous conferences and meetings within countries, at the Nordic Forum, and in other places internationally.

2009Second bi-annual meeting of international COPMI organization – Adelaide, Australia. Development of extensive collaborations between Drs. Beardslee and Solantaus, Australian COPMI and Australian psychiatrists on interventions. Australian COPMI release of key training website materials.

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Chronology of International Collaboration III – 2012 to 2014

2012Vancouver, British Columbia. Third bi-annual COPMI meeting

2014Fourth biannual meeting of the COPMI group, Berkeley, California.

Conference in Malmo, Sweden.

Preventive OpportunitiesEarly in Life

Early onset (¾ of adult disorders had onset by age 24; ½ by age 14)

First symptoms occur 2-4 years prior to diagnosable disorder

Common risk factors for multiple problems and disorders

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Mental Health PromotionAims to:

Enhance individuals’– ability to achieve developmentally

appropriate tasks (developmental competence)

– positive sense of self-esteem, mastery, well-being, and social inclusion

Strengthen their ability to cope with adversity

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Preventive Intervention Opportunities

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A Central Theme

“The scientific foundation has been created for the nation to begin to create a society in which young people arrive at adulthood with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships with others.”

Depression Is . . .

a family calamity, often profoundly misunderstood.

a rearrangement of neurotransmitter function.

a chronic smoldering illness. often the result of social injustice and

adversity. a DSM-V diagnosis.

A series of recent meta-analyses demonstrate that in both adults and

children, a significant number of episodes of major depression

can be prevented.

Preventive InterventionsPromising preventive intervention strategies exist. They include, for the most part:

• Treating the parents• Providing help with parenting• Using a two-generational approach

Some also directly involve children.

Depression Prevention Examples: IOM Report

1. Family Talk - Beardslee, et al., 2009

2. Prevention of depression - Garber, et al., 2009 –moderated by acute parental depression

3. Parent/Child Coping Session - Compas and colleagues

4. Mothers’ and babies’ program - Munoz

IOM 2009 18

Emerging Findings from the POD Study

We demonstrated in a sample of over 310 youth significant prevention of episodes of

major depression using a cognitive behavioral group intervention at 9 months, 33 months,

and, most recently, at 60 months.

Across both reports and in a variety of different risk situations, very strong

evidence exists for the valueof parenting programs.

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How do we see resilience in individuals?

How do we see resilience in families?

Characteristics of Resilience in Civil Rights Workers

Capacity for anger and continuous working Capacity to have a vision for the future and also

to work actively in the present Deep commitment to human relationships Self- and shared understanding

Family Talk Component Studies

1979 - 1985: Risk Assessment - Children of Parents with Mood Disorders

1983 - 1987: Resiliency Studies and Intervention Development

1989 - 1991: Pilot Comparison of Public Health Interventions

1991 - 2000: Randomized Trial Comparing Psychoeducational Family Interventions for Depression

1997 - 1999: Family CORE in Dorchester

1998: Narrative Reconstruction

2000: Efficacy to Effectiveness – Countrywide programs in Finland and at least five other places; Project

FOCUS with the Navy; Family Connections

Characteristics of Resilient Youth

Activities - Intense Involvement in Age Appropriate Developmental Challenges - in School, Work, Community, Religion, and Culture

Relationships - Deep Commitment to Interpersonal Relationships - Family, Peers, and Adults Outside the Family

Self-Understanding - Self-Reflection and Understanding in Action

Resilience in Parents

Commitment to parenting

Openness to self-reflection

Commitment to family connections and growth of shared understanding

Core Elements of the Intervention

1. Assessment of all family members

2. Presentation of psychoeducational material (e.g., affective disorder, child risk, and child resilience)

3. Linkage of psychoeducational material to the family’s life experience

4. Decreasing feelings of guilt and blame in the children

5. Helping the children develop relationships (inside and outside the family) to facilitate independent functioning in school and in activities outside the home

Seven Modules

1. Taking a history2. Psychoeducation and the family’s

story3. Seeing the children4. Planning the family meeting5. Holding the family meeting6. One week follow-up, check-in7. Long-term follow-up

Six Principles for a Successful Family Meeting

1. Pay attention to the timing of the meeting.

2. Gain commitment to the process from the entire family.

3. Begin by identifying specific major concerns and addressing them.

4. Bring together and reknit the family history.

5. Plan to talk more than once.

6. Draw on all the available resources to get through depression.

Narrative Project for FamiliesWho Sustained Changes – Self-Reflection

Over Time

1. The emergence of the healer within

2. The need to understand depression anew across development

• Children’s growth• Vicissitudes of parental illness

Different Implementations of the Family Talk Approach

1. Randomized trial pilot – Dorchester for single parent families of color

2. Out of the Darkened Room – a book for families about how to overcome parental depression

3. Development of a program for Latino families

4. Large scale approaches – collaborations in Finland, Holland, and Australia

5. Head Start – Program for parental adversity / depression

6. Blackfeet Nation – Head Start – Family Connections

Different Implementations of the Family Talk Approach

(continued)

6. Costa Rica

7. Collaboration with other investigators in new preventive interventions – Project Focus; Chicago city-wide training; family-strengthening intervention in Rwanda; web-based training – FamPod.org

8. International collaborations – COPMI

9. Urban Institute Project – policy interventions for depression among young poor mothers

Latino Team

Latino Adaptation Familismo

Allocentric orientation

Kinds of separation in immigrant families

Differing involvement of parents and children in the mainstream culture

Immigration narrative

What helps parents cope with depression?

Focus on the children Visualizations. Envisioning a better future Prayer, songs, religion, church community, spiritual healing Support groups Helping others, sharing information Focusing in the present: “viviendo de dia a dia” (living day to day) Not giving up: “seguir la lucha” Alternative medicine Humor: “al mal tiempo buena cara” “yo no lloro, yo me rio”

FAMpod Home Page

http://fampod.org

FAMpod Collaborations

Primary Care Implications Screening and referral are useful when

available referral sources have been identified.

Attention to the system in which primary care occurs and its ability to deal effectively with depressed parents are as important as any particular intervention.

A primary care physician is in the best position to provide family-centered preventive care for depression and to facilitate treatment.

Clinical Implications

Working with parents who are depressed as parents first is essential.

Elicit the parents’ concerns both about himself/herself and about the children.

Brief parenting interventions and referral of children for evaluation are also helpful.

Follow-up is essential.

Importance of Narrative

Attention to the family narrative and what has been disrupted is important in helping the family get back on track in re-establishing rituals and having regular conversations.

Key Ongoing Themesfrom IOM Work

Major depression can be prevented

How to ameliorate the effects of poverty

Encouragement of nurturing environments

How to incorporate family prevention

perspectives under the ACA

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IOM Forum on Promoting Children’s Cognitive, Affective

and Behavioral Health

A focus on implementation and disseminationof health promotion and prevention strategies.

The first forum dealt with effectiveparenting interventions.

Co-chairs:

Dr. C. Hendricks BrownDr. William R. Beardslee

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http://www.iom.edu/Reports/2014/Strategies-for-Scaling-Effective-Family-Focused-Preventive-Interventions.aspx

Core Principles Across Projects

Self-understanding and shared understanding

Individual and shared narratives.

Self care and shared support

Long-term commitment to long-term partnerships - several years at a minimum

Shared values

In all these projects, families have become our partners and our guides. We are deeply grateful to them and thank them for their extraordinary courage in

confronting adversity and for their willingness to help usco-construct these interventions.

Thank You … For more information, please contact:

william.beardslee@childrens.harvard.edu

Materials for Head Start parents and teachers about resilience and depression available at www.childrenshospital.org/familyconnections

Web-based training in Family Talk and other resources available at www.fampod.org

Perry DF, Miranda J, Ammerman RT, and Beardslee WR. Depression in mothers: More Than the Blues – A Toolkit for Family Service Providers. 2014, Washington, DC. Substance Abuse and Mental Health Services Administration. [On-line] http://store.samhsa.gov/product/SMA14-4878

References 1. Beardslee WR. When a parent is depressed: How to protect

your children from the effects of depression in the family. Originally published in hardcover under the title, Out of the darkened room: When a parent is depressed: Protecting the children and strengthening the family, by Little, Brown and Company, 2002. First paperback edition, 2003.

2. Beardslee WR. Commitment and Endurance: Common themes in the life histories of civil rights workers who stayed. Am J Orthopsychiatry, 1983, 53(1), 34-42.

References (continued)3. Beardslee WR, Ayoub C, Avery MW, Watts CI, and O’Carroll KL.

Family Connections: An approach for strengthening early care systems in facing depression and adversity. Am J Orthopsychiatry. 2010, 80(4), 482-95.

4. Beardslee WR, Brent DA, Weersing VR, Clarke GN, Porta G, Hollon SD, Gladstone TRG, Gallop R, Lynch FL, Iyengar S, DeBar L, and Garber J. Prevention of depression in at-risk adolescents: Longer-term effects. JAMA Psychiatry, 2013, 70(11), 1161-1170. doi: 10.1001/jamapsychiatry.2013.295. Available on-line in PubMed PMCID: PMC 3978119.

References (continued)

5. Beardslee WR, Solantaus TS, Morgan BS, Gladstone TR, and Kowalenko NM. Preventive interventions for children of parents with depression: International perspectives. MJA, 2012, Open 1 Suppl 1, 23-27.

6. Beardslee WR, Gladstone TRG, and O’Connor E. Transmission and prevention of mood disorders among children of affectively ill parents: A review. JAACAP, 2011, 50, 1098-1109. {On-line] www.jaacap.org.

7. Beardslee WR, Lester P, Klosinski L, Saltzman W, Woodward K, Nash W, Mogil C, Koffman R, and Leskin G. Family-centered preventive intervention for military families: Implications for implementation science. Prev Sci, 2011. DOI: 10.1007/s11121-011-0234-S. [On-line] Open source publication: http://www.springerlink.com/content/8265h1k18u4x77nr/fulltext.pdf

References (continued)

8. Biglan A, Flay BR, Embry DD, and Sandler IN. The critical role of nurturing environments for promoting human well-being. Am Psychol. 2012. 257-271.

9. Cuijpers P, Beckman ATF and Reynolds III C. Preventing Depression: A Global Priority. JAMA, 2012, 1033-1034.

10. Cuijpers P, von Straten A, Smit F, Miahlopoulos C, and Beckman A. Preventing the onset of depressive disorders: a meta-analytic review of psychological interventions. Am J Psychiatry, 2008, 165(10), 1271-80.

11. D’Angelo EJ, Llerena-Quinn R, Shapiro R, Colon F, Gallagher K, and Beardslee WR. Adaptation of the preventive intervention program for depression for use with Latino families. Fam Process, 2009, 48(2), 269-291.

References (continued)

12. Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent DA, Gladstone TRG, DeBar LL, Lynch FL, D’Angelo E, Hollon SD, Shamseddeen W, and Iyengar S. Prevention of depression in at-risk adolescents: A randomized controlled trial. JAMA, 2009, 301(21), 2215-2224. [On-line] http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2737625.

13. Golden O, Hawkins A, and Beardslee WR. Home visiting and maternal depression: Seizing the opportunities to help mothers and young children. Urban Institute. 2011.

14. Howell E, Golden O, and Beardslee W. Emerging opportunities for addressing maternal depression under Medicaid. Urban Institute. 2013 [On-line] http://www.urban.org.

References (continued)

15. Merry SN, Herrick SE, Cox GR, Brudevole-Iversen T, Bir JJ, McDowell H. Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD003380. DOI: 10.1002/14651858.CD003380.pub3.

16. Munoz RF, Beardslee WR, and Leykin Y. Major depression can be prevented. Am Psychol. 2012. 67(4). 285-295.

17. Podorefsky DL, McDonald-Dowdell M, & Beardslee WR. Adaptation of preventive interventions for a low-income, culturally diverse community. JAACAP, 2001, 40:8: 879-886.

18.

References (continued)

18. National Research Council and Institute of Medicine. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Committee on Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions. Mary Ellen O’Connell, Thomas Boat, and Kenneth E. Warner, Editors. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. 2009. [On line] http://www.nap.edu/catalog.php?record_id=12480.

19. National Research Council and Institute of Medicine. Depression in parents, parenting and children: Opportunities to improve identification, treatment, and prevention efforts. Washington, DC: The National Academies Press. 2009. [On line] http://www.nap.edu/catalog.php?record_id=12565.

References (continued)

20. Perrino T, Beardslee W, Bernal G, Brincks A, Cruden G, Howe G, Murry V, Pantin H, Prado G, Sandler I, and Hendricks Brown C. Towards scientific equity for the prevention of depression and internalizing symptoms in vulnerable youth. Prev Sci. 10/2014; DOI: 10.1007/s11121-014-0518-7.

21. Perry DF, Miranda J, Ammerman RT, and Beardslee WR. Depression in Mothers: More Than the Blues—A Toolkit for Family Service Providers. 2014, Washington, DC: Substance Abuse and Mental Health Services Administration. [On-line] http://store.samhsa.gov/product/SMA14-4878.

22. Yoshikawa H, Aber JL, and Beardslee WR. The effects of poverty on the mental, emotional and behavioral health of children and youth: Implications for prevention. Am Psychol. 67(4).2012, 272-284.