Mental Health is a Family Matter: Treating Depressed Mothers of Kids with Psychiatric Disorders

Transcription

1 Mental Health is a Family Matter: Treating Depressed Mothers of Kids with Psychiatric Disorders Holly A. Swartz, MD Associate Professor of Psychiatry Stacy Martin, MSEd, NCC, LPC Research Coordinator Western Psychiatric Institute and Clinic University of Pittsburgh School of Medicine

2 OVERVIEW Why focus on depressed mothers and their offspring? Interpersonal Psychotherapy (IPT) for Depressed Mothers: description of IPT-MOMS IPT-MOMS for Depressed Mothers of Children with Psychiatric Illness Summary and Future Directions

3 Why Focus on Depressed Mothers? 20% women experience an episode of depression 1 2/3 are parents 2 Off-spring of depressed parents are at increased risk (2- to 5-fold) for both internalizing and externalizing disorders 3, 4 1 Kessler et al., 1993; 2 Nicholson et al., 2001; 3 Weissman et al.1997; Gotlib & Lee, 1996; 4 Weissman et al.1984

4 Why Focus on Depressed Mothers (Cont.) Exposure to a depressed parent in childhood Enduring negative consequences 1 Exacerbates child s course of illness 2 Interferes with child s treatment 3 Interferes with prevention of depression in high risk adolescents 4 1 Weissman et al., 2006; 2 Hammen et al., 1991; 3 Brent et al., 1998; 4 Garber et al., 2009

5 However.. treatment of maternal depression is associated with better outcomes in children 1,2,3 1 Weissman et al. 2006, 2 Wickramaratne et al. 2011; 3 Swartz et al. 2008

6 Impact of Maternal Treatment on Offspring 1 Maternal Remission Status Remitted (n=34) Baseline 3 Months n (%) n (%) 12 (34%) 8 (24 %) Unremitted (n=71) 25 (35%) 30 (43%) 1 Weissman et al., 2006

7 Maternal and Child Psychiatric Illness Contributing Factors Genetic Factors 15-35% 1 Environmental Factors Maternal (but not paternal) depression is an environmental risk factor for MDD and disruptive disorders in adopted adolescents 2 Assisted conception families show mixed effects of heredity and environment 3 Girls may be more sensitive to the negative effects of maternal depression symptoms than boys 3 Reciprocal pathways of influence 4 ill mothers ill children 1 Kendler KS, Baker JH Psychol Med Tully EC et al. Am J Psychiatry Lewis G et al. J Am Acad Child Adolesc Psychiatry Hammen C et al., J Consult Clin Psychol 2004

8 Mother Blame

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10 Challenges in the Treatment of Depressed Mothers Depressed mothers of children in MH treatment are notoriously difficult to engage and retain in their own MH health treatment 1, 2 Women may prefer psychosocial interventions to medication 3 Targeted psychosocial strategies may have more enduring impact on family system 4 1 Swartz et al., 2005; 2 Ferro et al. 2000; 3 Alvidrez & Azocar, 1999; 4 Cook & Steigman, 2000

11 Barriers to Treatment for Depressed Mothers Stigma 1 Custody issues 2 Fragmentation of maternal/child mental health care services 3 Non-treatment seeking 4 Limited resources: time and money 1 Nicholson et al., 1996; 2 Hearle et al., 1999; 3 Blanch et al., 1994; 4 Swartz et al. 2005

12 Supermarket Psychotherapy Supermarket large store conveniently located free child care (ages 3-12) 16 weeks of psychotherapy Psychotherapy administered in conference room behind meat packing section Subjects given grocery vouchers upon completion of research assessments Swartz HA et al., Psych Services, 2002

13 Supermarket Psychotherapy: Results 12 subjects Completers (n=6) Non-Completers (n=6) Treatment visits over 4 months mean=5.8 (entire sample) mean=8.7 (completers only) Swartz et al., Psych Services, 2002

14 [A]ttempts have been made to shorten the duration of analyses. Such endeavors required no justification; they could claim to be based on the strongest considerations of reason and expediency. -Freud, 1937

15 Components of IPT-MOMS Pre-treatment Engagement Session (1 session) 1 Brief Interpersonal Psychotherapy (IPT-B; 8 sessions) 2 Specific set of strategies directed toward addressing core issues facing depressed mothers 1 Swartz et al., Prof Psychol Res Prac, 2007; 2 Swartz et al., Psych Services, 2004

16 Pre-Treatment Engagement Session (Swartz et al., 2007; Grote et al., 2007) Based on principles of Motivational Interviewing and Ethnographic Interviewing We ask about: Her perception of her depression experience, including stigma Acute and chronic stressors linked with her depression Her strengths and coping mechanisms, especially spirituality Previous negative experiences with mental health care What she wants out of a therapist does race or gender matter? Practical barriers transportation, child care, scheduling We provide: Psychoeducation, problem solving, affirmation, and hope

17 What is Interpersonal Psychotherapy (IPT)? Goals: symptom alleviation & improved social functioning Builds on empirical findings that interpersonal (IP) issues are linked to depressed mood & that depression impairs IP functioning MOOD Interpersonal Events

18 HISTORY OF IPT Roots in Interpersonal School: Adolf Meyer & Harry Stack Sullivan Codified in the 1970 s: Gerald Klerman & Myrna Weissman the kind of psychotherapy people do in real life Expansion from research trials to clinical settings Expansion from depression to other disorders

19 CHARACTERISTICS OF IPT Focuses on the Here and Now Non-neutral, active therapist Facilitates a positive transference but does not interpret it Concentrates on an affectively meaningful problem area Medical model of illness Links mood to life events

20 The Four Problem Areas Role Transition Role Dispute Grief (complicated bereavement) Interpersonal Deficits Klerman et al., 1984; Weissman et al. 2000

21 Structure of Brief IPT (IPT-B) 1 (8 vs. 16 sessions) Initial Phase (2 sessions) Psychiatric assessment and abbreviated interpersonal inventory Provisional and final case formulation Middle Phase (5 sessions) Choose only one interpersonal problem area: Role transition, role dispute, grief Exclude interpersonal deficits Build on existing strengths Choose a problem that is manageable in 8 sessions Explicit interpersonal homework assignments (designed to engage patient in change process) Termination (1 session) Support and underscore self-efficacy 1 Swartz et al., Psych Services, 2004

22 IPT-MOMS 1 Define a new IPT problem area Parenting an Ill Child Sub-type of Role Transition Goals Mourn the old role (parenting a normal child) Normalize ambivalent feelings associated with new role (parenting an ill child) Enhance mastery of new role Address and alleviate maternal guilt 1 Swartz et al., unpublished manual

23 IPT-MOMS Strategies Help mothers to Interface more effectively with child s health care providers Prioritize self-care Build social support Find new ways to positively connect with child Tolerate uncertainties associated with child s course and prognosis (uncouple child course from maternal course)

24 IPT-MOMS: Study Design and Subject Flow 1 1 Swartz et al., AJP, 2008.

25 Outcome: Maternal Symptoms Time IPT-MOMS TAU ANCOVA or t-test Instrument n Mean (SD) n Mean (SD) t or F; df; p BDI base (8.3) (8.3) 1.10; 45; ns 3M (6.5) (6.7) 7.46; 1,37; M (7.8) (9.6) 4.03; 1,320; HRSD-17 base (4.4) (4.2) 1.36, 45, ns 3M (4.0) (6.6) 6.36; 1,39; <0.02 9M (3.9) (7.0) 8.36; 1,35; BAI base (11.3) (9.5) 0.66; 44; ns 3M (4.7) (6.1) 5.57; 1,36; <0.03 9M (9.7) (10.4) 0.12; 1,32; ns

26 Outcome: Maternal Global Severity and Functioning Time IPT-MOMS TAU ANCOVA or t-test Instrument n Median (SD) n Median (SD) t or F; df; p CGI- Severity base (0.6) (0.5) 1.78; 45; ns 3M (1.1) (1.2) 9.64; 1,39;.004 9M (1.0) (1.3) 6.2; 1,35; <0.02 GAF base (4.5) (5.0) -1.20; 45; ns 3M (9.0) (11.0) 5.57; 1,39; <0.03 9M (8.8) (10.9) 7.28; 1,35; <0.02

27 Maternal Depressive Symptoms (HRSD-17) 25 H R S D S c o r e Baseline 3M 9M IPT-MOMS TAU remitted

28 Maternal Global Functioning (Global Assessment of Functioning) 80 G A S S c o re IPT-MOMS TAU 50 Baseline 3M 9M

29 Outcome: Child Depression Scores and Functioning Time IPT-MOMS TAU ANCOVA or t-test Instrument n Median (SD) n Median (SD) t or F; df; p CDI (t-scores) base (11.9) (14.4) 1.49; 44; ns 3M (11.2) (14.0) 0.00; 1,30; ns 9M (4.9) (10.2) 14.61; 1,24; CIS base (7.4) (9.0) 1.19; 44; ns 3M (10) (10.3) 0.17; 1,30; ns 9M (8.1) (7.7) 5.25; 1,24;.003

30 Psychotherapy for Depressed Mothers of Psychiatrically Ill Children R01 MH (Swartz, P.I.) Mothers: current episode of major depressive disorder (SCID), HRSD Children: Age 7-18, current or recent internalizing disorder (KSADS), receiving or referred for MH treatment N=210 mother/child dyads IPT-MOMS v. Brief Supportive Psychotherapy Acute treatment (moms only): 9 sessions over 3 months Follow-up: 6, 9, and 12 months

31 Non-Specific Strategies to Engage Depressed Mothers- I Collect multiple contacts ( , cellphone, landline, alternate phone numbers) Use of /texts/cellphones/letters to schedule/contact moms Reminder prompts prior to visits Child-friendly clinic (play room, staff attitudes, welcoming to kids with special needs)

32 Non-Specific Strategies to Engage Depressed Mothers- II Flexible scheduling Meet mothers face-to-face at their child s appointment Home visits Phone sessions (up to 2/3 of sessions) Avoid using the word depressed (substitute overwhelmed ) Collaboration with child providers to locate MIA moms

33 Non-Specific Strategies to Engage Depressed Mothers- III Compensate mothers and child at assessment visits Offer bus, parking, and food vouchers on visit days Provide assistance accessing services for children who are not currently receiving care

34 Child Clinical Data Symptoms Functioning Child Depression Inventory (n=62) Strengths and Difficulties Questionnaire (n=61) Columbia Impairment Scale (n=62) Mean Min Max

35 Child Clinical Data-Current Diagnoses Diagnoses (n=61) n Percent Mood Disorders 79 Major Depressive Disorder Bipolar Disorders 3 5 Other Mood Disorders 8 13 Anxiety Disorders 55 Simple Phobia Anxiety Disorder NOS 7 11 PTSD 6 10 Panic Disorder 3 5 OCD 5 8 Separation Anxiety Disorder 3 5 Attention Deficit Disorder Oppositional Defiant D/O 4 7 No diagnosis 2 3

36 Mother (n=65) Demographic Data n percent Race Asian Black White Annual Household Income $50, $20-50, <$20, Marital Status Married/Living as Married Past 4 weeks without permanent address Divorced/Separated/Never Married/Widowed Yes 9 14

37 Mothers (n=65) Demographic Data Education n percent Less than High School 3 5 High School More than High School Employment Disabled 1 2 Unemployed Part-time Homemaker 6 9 Full-time Age, mean years (range) 44.0 ( )

38 Mothers (n=65) Demographic Data Depression (n=65) Childhood Trauma Questionnaire-SF (n=54) Mean Min Max Prevalence HRSD HRSD Emotional Abuse (59%) Emotional Neglect (67%) Physical Abuse (33%) Physical Neglect (41%) Sexual Abuse (24%)

39 Summary High risk-high yield population Difficult to recruit/engage/retain Active outreach in multiple domains required Baseline demographics suggest heterogeneity: perhaps different strategies will be required for different families leading to a personalized approach to care

40 Taking care of children can be very demanding. Researchers at the University of Pittsburgh are currently recruiting participants for a study to learn about depression in mothers and how it affects their children. We are looking for mothers who: Are currently experiencing distress and hopelessness Are interested in participating in talk therapy sessions Have a child (age 7-18) in need of mental health treatment or currently in treatment Regardless of eligibility, the MOMS Study Team is here to help and will provide referral sources for mother and child. If you or someone you know might benefit from this program, please call or momsstudy@upmc.edu

41 This presentation may not be reproduced without written permission from the author. All rights reserved, 2012