Treating Family Members Can Break Depression Cycle, Says Expert

In the 1970s, when Myrna Weissman, Ph.D., was beginning her research on major depression, conventional wisdom held that the disorder occurred primarily in middle-aged and menopausal women but did not occur in children.

In the decades since, the understanding of depression has resoundingly changed. It is widely understood that the disorder can occur in children, and Weissman has spent a great deal of time studying depression within families and how the illness can cycle through the generations. During her session at the APA’s online 2021 Annual Meeting, “Depression in Families: Clinical Opportunities for Breaking the Cycle of Transmission,” Weissman summarized decades of research based on families whom she and her colleagues followed for over 38 years. Weissman is the chief of the Division of Epidemiology at the New York State Psychiatric Institute and The Diane Goldman Kemper Family Professor of Epidemiology and Psychiatry at Columbia University.

Weissman and her colleagues started with two groups of families: Those at high risk for depression and those at low risk. They found that the children in the high-risk families had higher rates of major depression, anxiety disorders, and substance use disorders. Their risk was about two to six times higher than that of children whose parents did not have depression.

By the third generation, however, the rates started to even out, Weissman found. The percentage of grandchildren with a mood disorder hovered around 10% to 15%, regardless of whether the grandchildren had a parent or grandparent with depression. However, if the grandchildren had both a parent and grandparent with depression, the rate of depression was about 30%. This finding suggests that children who have both a parent and grandparent with depression should be targeted for surveillance, Weissman said.

The researchers also found that pediatricians were largely unaware of the psychiatric and behavioral problems of their patients. “Clinically, it’s a good idea to interview the offspring directly,” Weissman said. “Patient information from informants [such as the patient’s pediatrician] is useful, but there’s nothing like direct assessment.”

To determine how treatment of parents influences depression risk in their children, Weissman used data from the Sequenced Treatment Alternatives for the Relief of Depression (STAR*D) study. She and her colleagues found that the children of mothers who went into remission after three to six months of treatment had the most positive outcomes. Regardless of treatment type, the mother’s improvement also benefited the child. “Depression is a family affair,” Weissman said. “If you help the mother, you help the child.”

Yet emphasizing the importance of treating mothers for depression as early as possible raises the complicated question of whether to treat women with antidepressants while pregnant. Weissman and her colleagues teamed up with Jay Gingrich, M.D., Ph.D., to investigate the impact of exposure to selective serotonin reuptake inhibitors (SSRIs) in utero on the offspring’s psychiatric status up to age 14.

They found that children who had been exposed to SSRIs had very high rates of depression by age 14 when compared with the offspring of depressed mothers who had not taken SSRIs during pregnancy. Those who had had no SSRI exposure had much lower rates, Weissman explained.

“This is a controversial topic, because if a woman is depressed while pregnant, that also has a lasting effect on her offspring, and the clinician is put in a very difficult situation of trying to make the best decision as to what to do,” Weissman said. Her colleagues have undertaken three additional studies to try to better understand the effects of SSRIs on the developing fetus.

During the question-and-answer session, an audience member asked Weissman about what to advise patients on the risks or benefits of continuing antidepressants during pregnancy.

“That is a question that should be discussed between the patient and the doctor,” Weissman said. “One of the things we would recommend is to see if it’s possible for the woman to stop medication for a short period of time and to try evidence-based psychotherapy, such as cognitive-behavioral therapy or interpersonal psychotherapy [IPT)]” she said. IPT is an attachment-based therapy that focuses on strengthening interpersonal or social connections that Weissman created with her late husband, Gerald Klerman, M.D. It is now used worldwide (Psychiatric News).

Weissman also emphasized that getting patients’ family psychiatric history can be valuable, though she noted such histories can be difficult to obtain in a clinical setting. She explained that asking patients specifically about symptoms of depression they may have observed in particular family members (such as their mothers or fathers) can yield better results than asking generally about a history.

In response to a question regarding why depression cycles through families, Weissman referenced an editorial she wrote that was published in The American Journal of Psychiatry last year, titled “Is Depression Nature or Nurture? Yes.”

“We cannot, at this time, determine how much is genetic and how much is environmental, because people who are depressed produce environments that can be toxic,” she said. There are large, ongoing studies aimed at answering that question, she noted. “But at the moment, we can’t say which it is, so we’d better treat what we can.” ■