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8 Working from the Present to the Future: Lessons Learned from Current Practice SUMMARY â¢ Clues emerging from the current research base point to an ideal evidence-based program for the identification, treatment, and pre- vention of depression among adults would integrate mental and physical health services. For those who are parents, it would strengthen and support parent-child relationships, offer develop- mentally appropriate treatment and prevention interventions for children, and provide comprehensive resources and referrals for other comorbidities associated with depression in multiple health care settings, including those that engage young children and fami- lies. Furthermore, this system of care would utilize more proactive approaches for prevention or early intervention of depression in parents in the context of a two-generation model and would be family-focused, culturally informed, and accessible to vulnerable populations. â¢ The existing health care and social services systems are far from implementing the ideal system of care for depressed adults and parents. Early efforts in the adoption, implementation, integra- tion, and dissemination of various components of evidence-based depression care programs offer insight into the future development of key features of such an ideal system. 343
344 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Quality Improvement Interventions â¢ Studies of interventions intended to improve the quality of the de- sign and organization of primary care services for treating adults with depression have resulted in improved outcomesâincluding quality of care, individual clinical outcomes, cost-effectiveness, and employment status. The implementation of these interventions of- fers important lessons in designing new approaches for depressed parents. Adding a Parent-Child Dimension â¢ Adding a parent-child dimension to adult depression care requires linkages of a range of services and systems integrated across a di- verse range of settings. â¢ Existing exemplary strategies in individual service settingsâpri- mary care, home visitation, early childhood and parenting training programs, schools, the criminal justice system, and community- wide programsâoffer important lessons regarding the challenges faced in implementing such strategies for depressed parents and their outcomes. Federal-Level Initiatives â¢ Federal efforts in the identification, treatment, and prevention of depression among parents and its effects on children focus primar- ily on maternal depression that occurs during pregnancy or the postpartum period. Current efforts are scattered across several agencies in the U.S. Department of Health and Human Services and include data collection, health education, treatment, prevention, workforce development, and other research activities. State-Level Initiatives â¢ A few state-level initiatives have developed and implemented strate- gies focused on the needs of depressed parents and their childrenâ particularly targeted to women and other vulnerable populations. These initiatives have focused on the training of service providers, expanding access to screening and services, and promoting public awareness to help reduce the stigma associated with mental health disorders.
WORKING FROM THE PRESENT TO THE FUTURE 345 European Interventions â¢ Several system-wide, collaborative, and interdisciplinary approaches to preventive care in children of the mentally illâusing prevention professionals, master trainers, and family-oriented prevention in- terventionsâand often specific to depression have been developed, implemented, and disseminated in a few European countries. ____________________ Supported by the research presented in the previous chapters, the long-term goal should be that evidence-based programs offer services for the identification, treatment, and prevention of depression among adults and would be available in multiple health care settings. These settings would integrate mental and physical health services, and for those who are parents, also strive to strengthen and support parent-child relationships during therapeutic treatment, offer developmentally appropriate treatment and preventive interventions for children and other family members, and provide comprehensive resources and referrals for other comorbidities that might be associated with the parentâs depression (such as substance use, unemployment, unstable housing). Ideally, more proactive approaches to prevention and early intervention in depressed parents would also be avail- able in multiple settings that engage young children and families, such as child care centers, home visitation programs, family support programs, and school-based programs. These treatment, prevention, and proactive approaches would be family-focused, culturally informed, and accessible to vulnerable populations, which often have difficulty in navigating transi- tions among health care, mental health, and community-based programs, and they would help overcome barriers to access to needed care. These interventions would emphasize the importance of treating depression in the context of a two-generation model, helping parents improve their parenting skills while coping with depression, and also offering enhanced supports for children who may be at risk of mental, emotional, and behavioral disorders because of a depressed parent. Existing health care and social services systems are far from achiev- ing this goal and realizing the vision of fully integrated two-generational programs. Yet initial efforts offer important clues in a variety of service settings regarding the nature, scope, quality, and costs of the development of key features of this ideal. These clues provide valuable guidance about the types of models that deserve further support and experimentation in building integrated, comprehensive, and two-generation service strategies to treat and prevent depression among parents and to mitigate its effects on their children.
346 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN This chapter begins with an overview of selected research studies as- sociated with quality improvement efforts in the treatment of adult depres- sion. Although few of these studies have focused on the parenting aspects of this disorder, they offer important insights into the types of enhance- ments that generate treatment effectiveness and improved outcomes for individual adult patients. Next, the chapter reviews major issues related to the adoption, implementation, integration, and dissemination of evidence- based depression care programs specifically for parents with depression and their children across a wide range of health care and other service settings. The chapter then reviews current federal initiatives intended to bolster the knowledge base to help develop programs and policies that enhance the response to depression among parents and early interventions for children. The final sections of this chapter examine different models of depression interventions for parents that have emerged in selected states as well as Eu- rope. These models offer distinctive approaches to integrating health care and family-focused interventions with an explicit focus on identification, prevention, treatment, and expanded access for vulnerable populations. The chapter concludes with a set of recommendations that could advance the knowledge base associated with the design, experimentation, and imple- mentation of different service models. QUALITY IMPROVEMENT INTERVENTIONS AND THE TREATMENT OF ADULT DEPRESSION A significant body of research has emerged demonstrating that despite the availability of evidence-based interventions and practice guidelines, the outcomes of adult patients with depression remain poor in primary care settings (Schoenbaum et al., 2001). These findings have prompted a search for improvements in the design and organization of primary care services, frequently evaluated through studies of quality improvement (QI), clinical effectiveness, and health care services research. Such studies have shown that certain quality improvement effortsâfor example, the Partners in Care (PIC) model, which adds specialized training programs and resources in practice-based settings or the Improving Mood-Promoting Access to Col- laborative Treatment (IMPACT), which includes a collaborative care model using a primary care physician, a care manager, a mental health special- ist, consistent measurement, and stepped care treatmentâhave resulted in better outcomes as measured by improved quality of care, quality of life, clinical outcomes, and retention in employment over a 1-year follow-up (Schoenbaum et al., 2001; UnÃ¼tzer et al., 2002; Wells et al., 2000). The QI interventions for the PIC model increased health care costs (compared with usual care). Such average increases were $419 for QI- meds and $485 for QI-therapy. However, the societal cost-effectiveness of
WORKING FROM THE PRESENT TO THE FUTURE 347 such increases was comparable to other accepted medical interventions. The long-term cost-effectiveness of implementing the IMPACT model (for depression care later in life) lowered the mean total health care costs dur- ing 4 years compared with usual care (87 percent probability) (UnÃ¼tzer et al., 2008). The PIC and IMPACT evaluation studies have therefore demonstrated that QI efforts are feasible and cost-effective and can be implemented in ânaturalisticâ practice-based settings. Follow-up studies confirmed these findings for minorities and whites as well as for those with both depressive disorder and subthrehold depression. The QI studies have reported cumulative prevention and treatment benefits beyond the short-term outcomes, especially for minorities. For example, comparison studies with usual care have demonstrated improve- ments in 5-year and 9-year outcomes after a 6-month intervention with the PIC model described above, including improved employment status (Wells et al., 2000); they also reduced stressful life events, equivalent to removing 6â12 deaths of a loved one over a 9-year interval (Sherbourne et al., 2008; Wells et al., 2005). Greater outcome improvements were reported for un- derserved minorities than whites (Miranda et al., 2003). QI programs have also been successfully adapted to a variety of set- tings, populations, and those with co-occurring disorders. For example, the IMPACT model has been implemented in eight different health care systems (e.g., health maintenance organizations, fee for service, inner-city county hospitals, Veterans Administration clinics) and has been tested in African Americans, Latinos, and white patients. It has been tested as well in patients with and without comorbid medical illnesses (like diabetes and cancer) or anxiety disorders and in adults of all ages as well as adolescents (University of Washington, 2009). In all of these settings, populations, and conditions in which IMPACT has been adapted and implemented, it has been shown to be more effective in depression care than usual care (Ell et al., 2008; Grypma et al., 2006; Kinder et al., 2006; Richardson, McCauley, and Katon, 2009). Although these QI programs focus on primary care settings, they should not be viewed as just health care interventions. Starting with patients who are receiving care in primary care settings, they then add a systems approach that often includes mental health specialists or outreach workers who can extend the program beyond primary care. The QI programs also adopt a user-friendly approach, supporting patient education and preferences in the choice of medications or therapeutic interventions, thus increasing the chances that patients will get the intervention they prefer (Dwight-Johnson et al., 2001). It is important to note, however, that the existing QI studies do not differentiate outcomes based on the parental status of the individual adult patient. Nor do they address outcomes beyond those observed in the care
348 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN setting or in assessing individual health and employment status. A signifi- cant opportunity exists, therefore, to identify and assess the impact of QI interventions (such as PIC and IMPACT) on adults who are parents of children of various ages. These assessments could examine outcomes as- sociated with QI effects on parenting practices, parent-child relationships, and child outcomes. Such studies would need to disentangle multiple fac- tors, however, such as the changes in parent-child relationships that might be attributable to improved health or improved employment, as well as the interactions among them. ADDING A PARENT-CHILD DIMENSION TO DEPRESSION CARE INTERVENTIONS The research on quality improvement suggests that multiple opportu- nities exist to incorporate evidence-based practices that enhance positive outcomes from the treatment of adult depression. Experience with the implementation of quality improvement interventions thus offers impor- tant lessons in designing new approaches that could focus on strengthen- ing parent-child relationships as well as clinical effectiveness in treatment settings. But adding and implementing an explicit focus on parenting and parent-child relationships to different forms of screening, prevention, and treatment models for adults who struggle with depression (which we collec- tively term as âdepression careâ) require resolution of multiple challenges. Such interventions need to be multidisciplinary, to be developmentally ori- ented (e.g., pregnant women, first-time parents, parents with multiple chil- dren or blended families), to include a two-generation approach that could include services for children of varying ages, to be culturally appropriate, to have multiple points of access, and to offer patient-centered choices among evidence-based components (such as medication or cognitive-behavioral therapy). Since parental depression frequently occurs in the context of a constellation of comorbid medical and mental health conditions, as well as social and economic risk factors and concurrent circumstances, adjunctive interventions may be required in addition to treatment of the depression and parenting interventions. The committee recognizes that many of the challenges faced in adding and implementing a parent-child dimension to depression care are similar to the challenges faced with the identification, treatment, and prevention of other mental heath and substance use disorders and health care in general as described in the 2006 Institute of Medicine report, Improving Quality of Health Care for Mental and Substance-Use Conditions. However, it is unclear (as well as out of the scope of the committeeâs task) if specifically incorporating a two-generation, developmentally oriented model of care for other mental health and substance abuse disorders, other chronic health
WORKING FROM THE PRESENT TO THE FUTURE 349 diseases, and health in general is appropriate and requires further explora- tion. Still, potential models of care for parents with depression may need to bridge a range of services and systems and integrate across a diverse range of settings. SPECIAL ISSUES BY SERVICE SETTING Individual service settings offer further insight and important lessons regarding the challenges that deserve systematic attention in implementing innovative strategies to strengthen, identify, treat, and prevent depres- sion and improve parenting practices and parent-child relationships for depressed adults who are parents and their children. This section reviews the experience with exemplary strategies in such settings, including pri- mary care, home visitation, early childhood and parent training programs, schools, the criminal justice system, and community-wide models. Primary Care Primary care practices figure prominently in efforts to improve depres- sion care. Many of the more carefully crafted randomized controlled trials have focused on these practices as an important gateway to care (Dietrich et al., 2004; Katon et al., 2004; Wells et al., 2000). Although the evidence is fairly strong that integrated approaches through primary care can be effective in the management of depression (Gilbody et al., 2003, 2006; Minkovitz et al., 2007), there are many challenges in attempting to scale up these systems. For physicians, time is a major constraint to adopting new roles and responsibilities. A number of studies have shown that practitioners may have difficulty making the time to effectively learn and reliably apply new practices (Horwitz et al., 2007; Olson et al., 2002; Ãstbye et al., 2005; Tai-Seale, McGuire, and Zhang, 2007). Although there is some contrary evidence (Cabana et al., 1999), the possibility of a ubiquitous time crunch is difficult to ignore, particularly as the body of applicable knowledge grows (Jones, 2009). When primary care physicians are asked, for example, to learn and apply new procedures for addressing depression among their patients, it may be hard for them to do so without considering the effect this will have on the overall learning they must do to stay up-to-date and preserve their self-image as a competent clinician as well as their ability to do their job. In primary care settings, where most people encounter the health care system and are an important focus for screening and care for depressed parents, there are many competing demands (Stange et al., 1998). Depres- sion inquiry, counseling, or treatment must compete with multiple clini-
350 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN cian and patient priorities, such as treatment of acute illness, provision of preventive services, and response to patient requests (Klinkman, 1997). These competing demands make individual and organizational learning, as well as incorporation of evidence-based care, more difficult. For example, visits to family physicians typically involve more than three health care problems or conditions, and such visits may involve nearly five for people with chronic diseases (Beasley et al., 2004). Nearly one in five visits also includes concerns or care related to someone other than the primary patient (Flocke, Goodwin, and Stange, 1998). Although family medicineâs capacity for caring for multiple family members is a benefit in dealing with depressed parents and their children, depression care innovations that do not explic- itly take comorbidity and family members into account may be less easily integrated into practice. Financial considerations are also likely to be an inhibitory factor in the assimilation and use of depression care models by primary care physicians, since most of these models appear to add to the gross costs of practice (e.g., for an integrated care manager) (Gilbody, Bower, and Whitty, 2006; Gilbody et al., 2003; Mattke, Seid, and Ma, 2007; Simon et al., 2001). Mental health care has been financially carved out of primary care by many payers over the past 20 years and remains so for many Medicaid programs (Horvitz-Lennon, Kilbourne, and Pincus, 2006). Where they still persist, mental health carve-outs remain a financial barrier to better depression screening and care in primary care by keeping the mental health sector and the general health sector systematically fragmented. The frequent separation of care for adult parents (generally mothers) and their children in primary care settings may make implementation of new policies or tools related to parental depression effects for children more difficult. Some pediatricians do screen mothers for depression, especially in the first few months after delivering a baby. But others may feel that parents are not their patients, or they choose not to screen because they donât know how or have few options for referring parents for treatment. Pediatricians also lack tools for screening children for the effects of depres- sion in parents since no validated tools currently exist. The American Acad- emy of Pediatrics and the American College of Obstetrics and Gynecology encourage obstetricians/gynecologists to screen for maternal depression, particularly in the weeks after delivery (American Academy of Pediatrics and American College of Obstetrics and Gynecology, 2007). However, these providers may not consider infants and children as their patients, or like other primary care providers, may not know that children may need to be evaluated for effects of parental depression. Efforts to implement and disseminate new policies and tools to improve identification and treatment of children affected by parental depression will need to engage clinicians
WORKING FROM THE PRESENT TO THE FUTURE 351 who care for both children and parents and help them understand the role they can play. Although it has not been carefully examined yet as a solution to the problem of getting effective depression care to the people who need it, the conversion of family physician practices into âmedical homesâ for patients is an idea in good currency that might provide a way to reach a large pro- portion of the population who could benefit from such care (Freudenheim, New York Times, July 21, 2008; Sia et al., 2004; Starfield and Shi, 2004). Through this arrangement, a doctor assumes full responsibility for a pa- tientâs medical care, either providing it directly or coordinating access to it. The closer relationship that develops between doctor and patient as a result may increase the likelihood of depression being discussed or symptoms be- ing disclosed (Starfield and Shi, 2004). When physicians receive additional compensation for functioning as a âmedical home,â they may also be able to hire more staff to help manage patient care. Physicians who serve as medical homes may thus develop greater interest and capacity to assimilate and use new developments in depression care. Home Visitation Home visitation programs for young families represent another pos- sible avenue for the identification, treatment, and prevention of depres- sion in parents. A number of home visitation models that serve high-risk populations have been widely implemented. These programs largely serve low-income, young mothers with few resources or social supports, a demo- graphic group that tends not to use center-based services for themselves or their families. These families also experience high levels of associated risk factors, including histories of child maltreatment, domestic violence, and substance abuse. Most home visitation programs include standardized assessments con- ducted by the home visitor for the purposes of determining eligibility for and level of services. Depression screens have been incorporated into routine assessments by several state-based home visiting programs (e.g., Ohio, Connecticut). Most home visitation program models perform some case management functions and rely on referrals to community services to provide specialized forms of care as necessary. Home visitation programs are therefore potentially able to screen and refer associated comorbidities, such as substance abuse, for appropriate services. Home visitation programs are well positioned to address one of the missing elements in services for depressed and at-risk parents: child devel- opment and parenting training. Preliminary studies indicate that successful treatment of maternal depression is not sufficient to improve parenting and child outcomes in depressed mother-child dyads (Forman et al., 2007).
352 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN However, a small, randomized trial of a home visitingâbased parenting in- tervention for depressed mothers demonstrated significant improvements in attachment security (as measured by the Attachment Q-Set), maternal sensi- tivity, and child socioemotional competence (van Doesum et al., 2008). The Nurse-Family Partnership (NFP) has drawn a significant amount of attention and support owing to the high quality and persuasiveness of the evidence for its effectiveness on the basis of three, well-designed, randomized controlled trials and long-term findings (Isaacs, 2007; Karoly, Kilburn, and Cannon, 2005; Partnership for Americaâs Economic Success, 2008). In this program, nurse home visitors are trained to screen first-time mothers for depression and to make appropriate referrals for treatment. Louisiana was one of the early adopters of the NFP model and has tested a supplemented version that couples nurse visitor teams with an infant mental health specialist, usually a social worker, to help identify and treat parental, mostly maternal, mental health issues (Boris et al., 2006). A consortium of local agencies in the Cincinnati area called Every Child Succeeds, which operates both the Nurse-Family Partnership and another home visiting program, Healthy Families America, have tested, with some success, the use of cognitive behavioral therapy with participating mothers diagnosed with depression (Ammerman et al., 2005). Early Childhood and Parent Training Programs A system with enormous potential for reaching parents with or at risk of depression is the array of programs and services that have taken shape to support the early development of children and parenting. By far the largest and most prominent of these programs is Head Start. Like many early childhood interventions, Head Start is designed to address the needs of children and, to some extent, their parents. In recent years, federal per- formance standards for Head Start have heavily emphasized the programâs responsibility for readying children for school, with relatively less weight given to the programâs role in helping and engaging parents. This has been counterbalanced to some extent by the emergence of Early Head Start, a program for children from birth to age 3 years and their families. Early Head Start is actually a set of program options from which local Head Start agencies may choose: center-based care for children, home visiting for children and their families, or a combination of the two. Al- though initial findings from the 17-site randomized trial of Early Head Start did not show any impact on parental depression, more recent evidence sug- gests that the program may have had a delayed inoculatory effect (Chazan- Cohen et al., 2007). The downstream incidence of depression (i.e., delaying the impact on maternal depression) among parents in the treatment group has been significantly lower than those in the control condition.
WORKING FROM THE PRESENT TO THE FUTURE 353 Head Start, because of its size and sustained support and dissemina- tion, would appear to be an attractive vehicle for reaching a large number of disadvantaged parents, but there are questions about the capability of local Head Start agencies to take on more responsibility. Even though Head Start is striving to improve the quality of local agency staff, the overall level of education and experience remains relatively low and turnover can be a problem (consistent with the general experience in early childhood education) (Barnett, 2002; Bryant et al., 1994; Currie and Neidell, 2007; Early et al., 2007; Gallagher and Clifford, 2000; Pai-Samant et al., 2005). Nor are the effects of staff quality on outcomes entirely clear (Currie and Niedell, 2007). Nonetheless, Head Startâs 40 years of durabilityâa remark- able feat among nonentitlement social programsâmakes it a credible target of opportunity for extending the reach of effective depression care. Beardslee and colleagues (in press-a) have developed an adaptation of programs generally used in Head Start centers called Family Connections. Given that the rate of depression in parents of children attending these centers is high and in one Early Head Start study was 48 percent, Beardleeâs approach is to provide education about depression and work closely in a staff development approach to increase teachersâ competence in dealing with depression and related mental health difficulties in parents and chil- dren (Knitzer, Theberge, and Johnson, 2008). This approach was chosen because of the very high rates of depression noted in studies of parents in Head Start and Early Head Start. Given the high prevalence, Head Start and Early Head Start teachers encounter depression daily in the parents of children they deal with and undoubtedly also see the effects of depression in the children (Beardslee et al., in press-a). The core approach was to combine trainings in which all of the staff participated around key issues in mental health, such as how to engage difficult parents, how to build resilience in youngsters, and how to understand depression with onsite consultation over a 3-year period. The central goal of the program was to increase teach- ersâ self-reflection and shared reflection and their understandings of how to take care of themselves. It also aimed to promote self-reflection and self care in parents. This approach was developed in partnership with Head Start providers in the Boston area, particularly Action for Boston Com- munity Development. Working in a single site over 3 years, the investiga- tors showed that the trainings were well received, as was the consultation model, and that in qualitative interviews with teachers and staff and asses- sor observation, substantial teacher growth occurred. Through this work, they have advanced the thesis that it is necessary to consider depressionâs impact at four levels: the individual level, the family level, the caregiving system level, and the community level. Correspondingly, it is necessary to identify resilience and strength and ways to cope with depression at each of these four levels.
354 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Family Connections provides a consultant who works with teachers, children, and parents, with a primary focus on teachersâ concerns to address depression and related adversities. This consultation is paired with staff group trainings about key issues in mental health: how to build resilience in the face of depression, what is depression, how to engage difficult parents, how to build resilience in parents and children in the face of depression, and the importance of self-reflection both for parents and teachers. The trainings are conducted by the consultant, who works in the center and is therefore able to address any concerns that a parent, teacher, or child may have and to apply the content of the trainings to everyday challenges. A set of materials for parents, teachers, and workshop leaders has been developed and includes brief documents for parents and teachers about the key issues as well as a workshop leaderâs guide to how to conduct trainings and les- sons learned. These materials are available on the Head Start website to all Head Start centers (Avery et al., 2008). Initial evaluation of the approach shows that teachers value the training and consultation and report that it influences their practice; parents also report positive responses (Beardslee et al., in press-a). In addition to Head Start, a variety of other evidence-based, family- focused programs have slowly been gaining wider application and are able to connect directly with vulnerable parents. Investigations show that well- designed parent training programs can reduce parental depression while also improving parenting skills (DeGarmo, Patterson, and Forgatch, 2004; Kaminski et al., 2008), at least for a period of time (Barlow, Coren, and Stewart-Brown, 2003). Even when such programs do not directly affect depression, they may still enable gains in parenting knowledge and abil- ity (Baydar, Reid, and Webster-Stratton, 2003; Olds et al., 2003). Parent training is also part of the responsibility of the public child welfare system at the state and local levels. However, the quality of the training programs used by child welfare agencies varies widely, and there is little evidence on how effective even the higher quality programs are in practice (Barth et al., 2005). School-Based Services Schools offer the potential to provide integrated parent-child depres- sion services, especially for teenage parents. Many schools have school nurses or nurse aids who could be trained to screen for depression (Centers for Disease Control and Prevention, 2006), but these and other school employees (i.e., school counselors) have a range of other duties. However, only a minority of schools have a school-based health clinic where addi- tional capacity might be situated to deal with a range of identified mental health needs. Less than a fifth of these clinics report offering mental health
WORKING FROM THE PRESENT TO THE FUTURE 355 services (Brener et al., 2007). By and large, schools do not actively engage in detecting, attempting to treat, or making efforts to prevent depression (Foster et al., 2005). Their approaches tend to be passive and reactive, and, to the extent that they respond to mental health situations, an orientation to short-term, crisis intervention appears to predominate (Foster et al., 2005). Schools are a challenging environment for depression care for at least three reasons. First, schools are semi-closed systems, meaning that they are to a degree designed to be impervious to external influence (Ringeisen, Henderson, and Hoagwood, 2003). And they are not organized to address two-generation depression issues. Second, the work cultures of schools and mental health providers differ; the words and concepts they use and the out- comes on which they focus, while sharing some points of intersection, differ enough to make communication and collaboration difficult (Hoagwood and Johnson, 2003; Kutash, Duchnowski, and Lynn, 2006). Third, even when cultural differences can be reconciled, trying to add work or change practices inside schools has been shown to require time-con- suming and careful planning and extensive and often expensive support, to integrate new activities with the old (Gottfredson and Gottfredson, 2002). Programs and practices to improve mental health that cannot be readily integrated into the curriculum and what goes on in classroomsâthat is, cannot be amalgamated with the core technology of schoolsâmay stand little chance of broad and effective use (Hawkins et al., 1999; Hoagwood et al., 2007). Even when integration is possible, limited headway may be made without strong and consistent support from the school principal (Kam, Greenberg, and Walls, 2003; Ringwalt et al., 2003). Criminal Justice System Another possibility to consider involves organizations in the criminal justice system, given the disproportionate representation of persons with mental illness in county and state jails and prisons and the especially high rates of depression among incarcerated women (Kane-Mallik and Visher, 2008). The opportunity to infuse improvements in depression care into this system would seem beneficial for a couple of reasons. One is the slow but growing use of programs to divert low-risk and youthful offenders, including those with mental health problems, from incarceration into treat- ment programs (Steadman and Naples, 2005). Mental health courts have emerged in some jurisdictions to facilitate and support diversion (Boothroyd et al., 2005; Grudzinskas et al., 2005). In some cases, both mental health and regular courts have diverted youth into evidence-based treatments, such as multisystem therapy, functional family therapy, and treatment foster care (Cuellar, McReynolds, and Wasserman, 2006).
356 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Another reason is the recently elevated policy interest in community reentry of offenders who have completed their sentences (e.g., P.L. 110-199, the Second Chance Act of 2007) (Conway and Hutson, 2007; Re-entry Pol- icy Council, 2005). No actual system exists yet for this purpose. However, through mostly federal and philanthropic support, several reentry programs have been or are being tested. One notable, recently completed demonstra- tion involved the use of small and medium-sized urban churches in part- nership with local juvenile justice authorities and social service agencies (Bauldry, 2006; Bauldry and Hartmann, 2004; Branch, 2002). Although the churches were highly committed, they lacked the formal structures, staffing capabilities, and discipline needed to be effective without substantial and sustained amounts of training and technical assistance from outside experts. Interestingly enough, this research found that mentoring seemed to prevent depression among participating youth, although there were doubts that it would be as effective with already depressed youth (Bauldry, 2006). It may be worth noting that the criminal justice system has been one of the more active arenas for the implementation of evidence-based practices and programs (Aos, Miller, and Drake, 2006; National Research Council, 2007). Research indicates that prisons may be more likely than jails and probation and parole offices to use evidence-based practices (Henderson, Taxman, and Young, 2008). And community-based organizations may be more likely than either prisons or jails to implement programs and practices of known effectiveness (Friedmann, Taxman, and Henderson, 2007). In all cases, the experiences and beliefs of administrators have emerged as an important moderating factor (Friedmann, Taxman, and Henderson, 2007; Henderson, Taxman, and Young, 2008). There is also evidence that criminal justice organizations tend to implement clusters of complemen- tary practices rather than one practice at a time (Henderson, Taxman, and Young, 2008). However, among evidence-based practices, developmentally appropriate and research-supported forms of treatment appear to be the least likely for criminal justice entities to use (Henderson, Taxman, and Young, 2008), perhaps because these do not fit neatly into their core so- cial technology, namely, incarceration (Thompson, 1967). Evidently, most jails provide some form of mental health screening and are equipped to administer psychotropic medications (Soloman et al., 2008). Slightly under half offer mental health counseling, but only about a fourth help offenders find mental health services after they have been released (Soloman et al., 2008).
WORKING FROM THE PRESENT TO THE FUTURE 357 Community-Level Models Although not specific to depression care, the Communities That Care model of local collaboration may turn out to be an effective means of mobilizing and sustaining support for evidence-based interventions. In this risk and protective factors approach, stakeholders come together to review data about youth problems in the community and then to select available evidence-based programs to address the problems they determine to be most salient (Hawkins, Catalano, and Associates, 1992). Early results from an ongoing randomized clinical trial show that communities using the model are experiencing greater reductions in youth problem behavior (Hawkins et al., 2008). Evaluation of implementation suggests some of the reasons why participating communities may be doing better than nonparticipating ones, but the methods used have not been robust or precise enough to link implementation activities causally to outcomes (Brown et al., 2007; Fagan et al., 2008). Nor has the cost-effectiveness of the Communities That Care approach been determined. Surveys of community primary care and mental health providers have found that concurrent treatment of depressed patients is common in the community, but these treatments are less interactive and collaborative than the treatment models proven effective in randomized controlled trials. Researchers think that colocation of these providers would improve the collaboration and effectiveness (Valenstein et al., 1999). There are good real-world models of colocation and collaboration that work well (Druss et al., 2001); however, disseminating such models more broadly would re- quire organizational and financial integration, as well as removal of policy barriers (Horvitz-Lennon, Kilbourne, and Pincus, 2006). Collaboration seems applicable to the variety of integrated depression care models that have been evaluated. The evidence, though favorable, may be less persuasive because it is derived from clinical trial experience rather than real-world performance. Effect sizes demonstrate that collaborative care is significantly better than usual practice, but effects may be too nar- rowly targeted or may not rise to the level needed to compel adoption, other than among a minority of practitioners or organizations (Mattke, Seid, and Ma, 2007; Pfeffer and Sutton, 2006). Often with multisite trials, evidence is aggregated across sites, raising questions about whether some sites did notably better than others and thus leading to the possibility that unidenti- fied factors may lie behind good performance (Rosenheck, 2001). Data on costs may be missing or incomplete or based on studies using samples that are not large enough to ensure validity (Briggs and Gray, 1998; Gardiner, Sirbu, and Rahbar, 2004; Sturm, UnÃ¼tzer, and Katon, 1999).
358 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN FEDERAL-LEVEL INITIATIVES Federal efforts in the United States to treat and prevent depression among parents and to mitigate the effects of a parentâs depression on chil- dren currently include data collection; health education; treatment, preven- tion, and workforce development; and research activities. These activities, currently scattered across several agencies in the U.S. Department of Health and Human Services, provide a basis for the development of more inten- sive and collaborative programs and policies to enhance state-based and professional responses to depression in parents and early interventions for children whose parents may be affected by this disorder. At present, federal efforts focus primarily on maternal depression that occurs during pregnancy or the postpartum period. Although one of the strategic goals of the U.S. Department of Health and Human Services is to âpromote and encourage preventative health care, including mental health, lifelong healthy behav- iors, and recoveryâ (U.S. Department of Health and Human Services, n.d.), efforts to coordinate programmatic, policy, and research efforts targeted to depression in parents have not emerged as a national priority. Agency for Healthcare Research and Quality A 2005 report for the Agency for Healthcare Research and Qual- ity (AHRQ), Perinatal Depression: Prevalence, Screening, Accuracy, and Screening Outcomes (Gaynes et al., 2005), observed that depression is as common in women during pregnancy as it is after they give birth. The report defined perinatal depression as a condition that encompasses major and minor depressive episodes that occur either during pregnancy or within the first 12 months after delivery, noting that this disorder may affect as many as 5 to 25 percent of new mothers. The AHRQ report indicates that these repercussions are of significant public health concern and concludes that perinatal depression is the leading cause of disease-related disability among women, resulting in depressive episodes and negatively affecting their children and families. To assist health care providers and community planners, AHRQ has also developed a guide to adopting innovations that provides generic advice on the issues and steps that potential adopters should consider and whether or not a given innovation will address their needs and is feasible (Brach et al., 2008). Further details of this report are provided in Chapter 10. Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) initiated the Pregnancy Risk Assessment Monitoring System (PRAMS) in 1987. The
WORKING FROM THE PRESENT TO THE FUTURE 359 program âidentifies and monitors selected maternal experiences and be- haviors before, during, and after pregnancy.â This effort surveys indicators associated with the incidence of infant mortality and low birth weight, and includes self-reports (by mothers) regarding postpartum depression. CDC does not specifically collect data regarding the incidence or severity of de- pression during other stages of parenting, the identification of paternal de- pression, or the impact of parental depression on children; however one of the leading health indicatorsâmental healthâidentified in Healthy People 2010 led to a number of objectives including âincrease the proportion of adults with recognized depression who receive treatmentâ and âincrease the proportion of persons with co-occurring substance abuse and mental disor- ders who receive treatment for both disorders.â It also contains objectives intended to increase access to quality health services, with topics including insurance, preventive and behavioral services, and competencies as well as racial and ethnic disparities for health providers (U.S. Department of Health and Human Services, 2000). Health Resources and Services Administration The Health Resources and Service Administration (HRSA) has created a public education website that provides comprehensive information related to maternal and peripartum depression. The Maternal and Child Health Bureau (MCHB) in HRSA has produced a free booklet that describes com- mon concerns of peripartum women and offers guidance (including recom- mendations and information about other relevant organizations) about how best to deal with the symptoms of depression that may occur during pregnancy. A related website includes the same content with accompanying hyperlinks. Publications include Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends (Health Resources and Services Administration, 2006). HRSA officials have sought to incor- porate findings from the 2005 AHRQ report noted above into state-based planning and professional development efforts, through such activities as the DataSpeak web conference series organized by the Maternal and Child Health Information Resource Center (see, for example, http://mchb.hrsa. gov/mchirc/dataspeak/events/june_05/index.htm). Healthy Start is another HRSA-funded program that draws on evidence- based interventions in community-based contexts, striving to reduce the infant mortality rateâespecially among women who are statistically more likely to have infants die prematurely. Women enrolled in Healthy Start are linked to a medical home from the moment of conception until 2 years post- partum. Health providers routinely screen for signs of perinatal depression and other mental and physical challenges that prenatal women may face. HRSA and MCHB also support research to explore health service sys-
360 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN tem factors that may contribute to perinatal depression. One such study explores how the health-seeking and resilient behaviors of recent immi- grants coping with maternal depression compare with the experiences of the majority population (Huang, 2007). This study will also use national survey data to explore the role of selected social influences as moderators or mediators of maternal depression. MCHB is addressing the need to increase the number of individuals trained to provide mental health services for people with depression, and in particular peripartum depression, by means of investigators and programs that purport to achieve that goal. For example, a grant was awarded to a program administered by the School of Public Health at the University of California, Berkeley that aimed to increase the capacity to screen, assess, and treat mental health disorders in peripartum women. The program or- ganized convening activities of relevant leaders and stakeholders to develop and evaluate a continuing educational curriculum to be offered to rel- evant health professionals (Guendelman, 2008). MCHB has also awarded grants to institutions that increase the competence of physicians to render depression-related services to all adults, regardless of gender (Bureau of Health Professions, n.d.). National Institutes of Health Several institutes of the National Institutes of Health (NIH), most notably the National Institute of Mental Health, sponsor research studies investigating biological and environmental factors associated with mater- nal, postpartum, and generalized forms of adult depression. A noteworthy example, as described in Chapter 7, includes an analysis of the STAR*D findings, which reported in 2006 that when women treated for depression become symptom-free, their children are less likely to be diagnosed with de- pression (Weissman et al., 2006). The study alerts health professionals and patients to the need for vigorous identification and treatment of depressed mothers as well as the evaluation of their children for symptoms. At present, no systematic effort is available to coordinate the findings from NIH studies about parental depression or to integrate these research findings into programmatic and state-based programs in HRSA, AHRQ, CDC, or the Substance Abuse and Mental Health Services Administration (SAMHSA). Substance Abuse and Mental Health Services Administration SAMHSA is tasked with setting national mental health policy, con- ducting translational research, and delivering mental health services. Its National Mental Health Information Center provides access to multiple
WORKING FROM THE PRESENT TO THE FUTURE 361 public and private resources focused on maternal depression as well as highlighting the impact of parental depression on children (Substance Abuse and Mental Health Services Administration, 2000). These publications and online resources offer links to governmental centers and nongovernmental organizations that offer assistance to women dealing with mental illness. SAMHSA also coordinates and provides a National Registry of Evidence- based Programs and Practices. This self-nominating, peer-reviewed, and rated registry is a searchable database of interventions for the prevention and treatment of mental and substances use disorders. It aims to improve access to information on tested programs and practices that can be readily disseminated by individuals, agencies, and organizations in their communi- ties (Substance Abuse and Mental Health Services Administration, 2009). In addition, the SAMHSA Center for Mental Health Services (CMHS) has for 35 years provided financial support for people who are ethnic minorities to pursue mental health professionsârelated careers (Substance Abuse and Mental Health Services Administration, 2008). This mission helps to address the need to increase the number of individuals trained to provide mental health services to people with depression. The CMHS center in SAMHSA also includes the Child, Adolescent, and Family Branch (CAFB). This branch promotes and ensures that the mental health needs of children and their families are addressed by a âcommunity- based system of care.â The systems of care framework highlights the im- portance of meeting the mental health needs of children, adolescents, and their families in their home, school, and community environments. The framework also rests on the principles of being child-centered, family- driven, strength-based, and culturally competent and involving interagency collaboration. CAFB has launched several major initiatives that provide a basis for extending its work with a more explicit focus on parental depression. These include â¢ Caring for Every Childâs Mental Health Campaign â¢ Child and Adolescent Mental Health and Substance Abuse State Infrastructure Grants â¢ Circles of Care â¢ Comprehensive Community Mental Health Services Program for Children and Their Families â¢ Council on Coordination and Collaboration â¢ Partnerships for Youth Transition â¢ Statewide Family Network Grant Program â See http://mentalhealth.samhsa.gov/publications/allpubs/KEN95-0016/default.asp.
362 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Office of the Surgeon General The Office of the Surgeon General (OSG) identifies priority areas of focus in addressing public health concerns. Currently, these include dis- ease prevention, eliminating health disparities, public health preparedness, and improving health literacy. Those specifically related to improving the quality of care for depressed parents and their children include eliminat- ing health disparities and public health preparedness. To help eliminate health disparities the OSG is expanding programs like Community Health Centers and the State Childrenâs Health Insurance Program, helping to increase public awareness and outreach, as well as conducting additional research to help inform policy and activities to increase the access to health information, health insurance, and health services. To improve the public health preparedness of the nation, one of the OSGâs priorities is mental health and resilience. Specifically, it has been targeting parents, teachers, and emergency relief workers to provide guidance on coping with fear and anxiety as a result of trauma and disaster. Past efforts of the OSG included the publications that asserted that mental health is a public health problem and that striking disparities in access, quality, and availability of mental health services exist for racial and ethnic minorities in the United States (U.S. Surgeon General, 1999, 2001). Office of Womenâs Health The Office of Womenâs Health (OWH) has a Womenâs Mental Health Initiative, which strives to provide an understanding of mental health in physical health care, promoting awareness of mental health, and advising health providers and consumers. This office has convened stakeholders (including decision makers, advocates, and consumers) following a 2005 workshop on womenâs mental health organized by the Office of the U.S. Surgeon General. OWH has published several reports to enhance public education and consumer-directed initiatives, but such publications do not address parenting roles, nor do they examine the impact of depression among women on their children. STATE-LEVEL INITIATIVES A few states have made significant attempts to develop system-wide strategies that are focused on the needs of depressed parents and their chil- dren. Current state policy strategies are relatively limited and have not been systematically evaluated. However, they provide insight into the opportuni- ties and barriers that emerge in developing more integrated, comprehensive, community-based, and multigenerational approaches in meeting the needs of vulnerable populations.
WORKING FROM THE PRESENT TO THE FUTURE 363 Two strategies have emerged that deserve attention. First, several states have developed comprehensive initiatives that typically combine profes- sional training of service providers (i.e., to educate them about prevalence, causes, and consequences) with access to expanded screening and services in nontraditional settings. These multipronged efforts are state-initiated and rely primarily on state funds. Some states have successfully expanded their use of Medicaid funds, particularly to pay for maternal screening and other preventive services. Second, several states have adopted state legisla- tion (and funding) to reduce the stigma of mental health disorders and to promote public awareness, particularly focused on perinatal depression. These state policy reforms are especially important in reducing barriers to seeking care and providing services among vulnerable populations that may be unable to afford private services or are reluctant to engage with community programs. State-Led Comprehensive Initiatives Illinois Illinois has several initiatives that are primarily directed at improving outcomes for pregnant women and young children. These include â¢ The Perinatal Mental Health Consultation Service, operated by the University of Illinois at Chicago and the state, in partnership with the Illinois Chapter of the Academy of Pediatrics and the Acad- emy of Family Physicians, offers provider consultative services and education and training to clinicians across disciplines to develop competencies in assessment and treatment of maternal depression. The education and quality improvement initiatives also include a pilot to develop a stepped care model; it includes self-care kits to be disseminated statewide that provide information on when and where to access resources. The state is also piloting a tool to assess risk at the preconception and interconception stages. The initiative also includes support for postpartum depression crisis intervention through hotlines. â¢ Through a contract with its managed care organizations and its primary care case management network, Illinois requires prenatal and postpartum depression screening using an approved, validated, â The state agencies involved are the Department of Human Services, the Department of Healthcare and Family Services, the Department of Public Health, the Department of Financial and Professional Regulation, and the Medical Licensing Board.
364 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN standardized tool, referral, and treatment, as well as ongoing monitoring and tracking for enrollees. A complementary state law requires that women and their families be educated about perinatal mental health disorders in prenatal and labor and delivery settings, and that women be invited to take an assessment questionnaire in prenatal, postnatal, and pediatric care settings. â¢ Screening for perinatal depression using an approved instrument is reimbursable for women enrolled in health care and family ser- vices, from pregnancy through 1 year after delivery. If women are screened by a provider during their infantâs well-child and episodic visits, the screening can be reimbursed through the infantâs cover- age. Infants and toddlers of mothers with mental health diagnoses (including depression) are automatically eligible for the early inter- vention program. Iowa In Iowa, the Department of Public Health is working to improve pro- vider knowledge and capacity as well as consumer knowledge and ease of access. â¢ In collaboration with three other state departments, a statewide advocacy organization and the University of Iowa sponsor a state- wide train-the-trainer program that to date has trained an esti- mated 100 trainers. The program trains program staff in early childhood, maternal health, case management, and mental health programs, as well as Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), nursing, and home visiting staff. It includes a mentorship component, requires agency-level commitment to screening, and reimburses agencies for staff time. â¢ In collaboration with the University of Iowa, the state has devel- oped a web-based training for physicians known as STEP, Support and Train to Enhance Primary Care. It contains a consultation com- ponent and is designed to enhance the stateâs capacity in primary care to appropriately identify and treat perinatal depression. â¢ The state also produced a pocket guide for health care profession- als, that is, a reference book that includes information on treat- ment, coding, and billing. It is anticipated that this will be widely distributed through the major health care provider associations. â¢ Iowa also established a provider and consumer website providing â Depression Screening Tools: Use in Perinatal Populations, see http://www.psych.uic.edu/ research/perinatalmentalhealth/pdf/screening_assessment.pdf.
WORKING FROM THE PRESENT TO THE FUTURE 365 referral information that identifies mental health providers in all 99 counties, including details of their payment requirements and their specific training in perinatal depression. Primary care provid- ers who access this service can also get free consultation with a University of Iowaâbased mental health clinician. To improve screening, the state added two depression screening ques- tions (from the Patient Health Questionnaire, a standardized assessment) to the Department of Human Servicesâapproved Prenatal Risk Assessment tool required for all providers. The state funds a toll-free telephone resource and referral information line. New Jersey The New Jersey initiative focuses on a legislatively mandated perinatal care network and the use of state dollars to pay for treatment for those who would otherwise not have access (Cooper, 2008). The development of the perinatal care network has also facilitated improved data collection and accountability. Through the stateâs e-birth certificate program, mandated screenings for maternal depression can be tracked (between 80â85 percent of the screenings are now in the database). The other components include â¢ Six grants to private, nonprofit, maternal and child health consor- tia whose geographic reach extends across the state. Each regional consortium customizes its approach to providing family support activities. â¢ State subsidy for treatment of postpartum depression through com- munity behavioral health services, providing a crucial access point irrespective of insurance status. New Jersey also recently awarded a grant to a pediatric entity to work with pediatricians to improve screening and referral capacity, and the state sup- ports a crisis hotline for providers. North Carolina In North Carolina the state effort has focused on creating a supportive Medicaid fiscal framework to support expanded screening and treatment of depression for both children and women. â¢ State Medicaid policy requires that pediatric practices use a formal, standardized developmental screening tool during well-child visits
366 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN and that parents be screened for depression by the childâs primary care provider. â¢ The state has expanded Medicaid coverage to reimburse for up to 26 mental health visits for children, 6 of which can be used by the parents to see primary care providers, social workers, and psychologists. Ohio The Ohio Departments of Health and Mental Health have launched a statewide, county-based home visitation program. This program, titled Help-Me-Grow, includes an emphasis on screening and referrals for paren- tal depression among the participating mothers in collaboration with local mental health agencies. â¢ Help-Me-Grow home visitors administer the Edinburgh Postnatal Depression Scale (EPDS) to new mothers with infants ages 4 to 20 weeks. EPDS scores and demographic data are entered into a web-based data system that prompts the home visitor to make a referral for mothers who score above selected cut-off points. The clientâs score and pertinent referral information are made available to the local mental health agency, and the program database auto- matically prompts a monitor to review client interactions with the mental health agency to see if appointments were made and kept. Currently operating in 17 Ohio counties, the program is scheduled to increase to 40 counties in 2010. Unpublished results indicate that 20 percent of screened mothers met the EPDS clinical thresh- old, 68 percent of positive screens accepted mental health referral offers, and 37 percent of referred mothers kept their mental health appointments at 30 days after referral. No data are collected on treatment outcomes. Rhode Island In Rhode Island, a specific initiative targets a subpopulation, those receiving public assistance. â¢ The Work Towards Wellness Program, a telephone care manage- ment strategy to address depression, has demonstrated early signs of success among individuals with depression in the Temporary Assistance for Needy Families Program. Nearly 98 percent of the largely female participants with depression have children, and one- third of the children are under age 5. The telephone care manage-
WORKING FROM THE PRESENT TO THE FUTURE 367 ment strategy is modeled after a quality initiative for depression in primary care. To date, more than 75 percent of the participants enrolled in the treatment component of the study experienced a reduction in symptoms, and, among two-fifths of these individuals with depression, symptoms were reduced by more than 50 percent (Bloom et al., 2007). This effort, however, is linked with and builds on other work that Rhode Island has carried out through the Department of Public Health to reduce the impact of high-risk parental conditions on young children. State-Led Specific Public Awareness Activities In addition to the more comprehensive initiatives highlighted above, several states also have made efforts to promote public awareness and to reduce the stigma attached to parental depression. In both Washington and New Jersey, Speak Up When You Are Down is a multilingual public education campaign to increase awareness of post- partum depression funded through a legislative appropriation. In Iowa, an extensive public information and antistigma campaign was launched by the state that included fact sheets on maternal depression and infant mental health for legislators, a display board and booth at the state fair, and articles in the local media. In Minnesota, state legislation passed in 2005 requires that all hospitals and health care providers provide parents and families of newborns with information about postpartum depression. Providers are also required to make available information about postpartum depression to pregnant women and their families. The state developed multilingual fact sheets and brochures on postpartum depression and information on best practices for care management. There is, however, no research on the effectiveness of these campaigns, particularly when they are not linked to further supports for providers or improved access to treatment. It should also be noted that, through a variety of special, often foundation-funded initiatives, such as the Assuring Better Child Health and Development (ABCD) project supported by the Commonwealth Fund (Pelletier and Abrams, 2003), states are engaging in strategic analysis and fiscal planning to improve their use of Medicaid and other federal dollars to improve developmentally appropriate health care and better support for positive social and emotional outcomes in young children. This major effort, through several different cohorts, now involves close to half of the states. Finally, as an indication of the sustainability of program implemen- tation, Project THRIVE at the National Center for Children in Poverty has documented the progress of states implementing the Early Childhood
368 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Comprehensive Systemsâa program targeting early intervention for young children at risk of developmental delays and serious emotional disturbances and their familiesâto develop policy commitments and relationships be- tween the state agencies and the local service delivery systems (Johnson and Theberge, 2007a, 2007b; Johnson et al., 2008). These demonstration grants, supported by federal agencies, have also found that states vary in their ability to make commitments and sustain them over time. EUROPEAN PREVENTIVE INTERVENTIONS WITH PARENTS AND CHILDREN Several European countries have developed useful and novel approaches to preventive work with children of the mentally ill, often with a specific focus on depression (Beardslee et al., in press-b). The work in these Euro- pean countries goes far beyond the state-level initiatives described above by focusing on experimentation with system-wide approaches as well as collaborative interdisciplinary efforts. None of these multisectoral strategies has been rigorously evaluated; however, they demonstrate strong interest among care providers in collaborating with new service models that focus on the complex dimensions and family relationships that are an integral part of responding to the needs of children and parents who are coping with depression in their household. These examples further demonstrate how a national health policy that explicitly focuses on prevention as well as treatment can stimulate and enhance the formation of provider training pro- grams, multiple partnerships, and innovative efforts in local communities. The Netherlands In the 1970s the Netherlands began to develop a network of prevention and health promotion teams that were located in multiple service sectors (public health services, mental health services, addiction clinics, and several others) supported by prevention-oriented national institutes and research centers. Preventionists have a specific role and title, and many have been educated in Dutch academic and training programs that feature a particular focus on prevention, health education, and health promotion. The work is part of a national health policy, and about 5â10 percent of the budgets of community mental health centers are spent on prevention of mental disor- ders, much of it to support the work of prevention experts, although it also supports the part-time involvement of mental health professionals. Five main priorities of prevention have been identified: (1) depression, (2) stress in the workplace, (3) child abuse, (4) children of mentally ill parents, and (5) chronically mentally ill patients and their networks. The approach is to make the care of children of mentally ill parents a regular
WORKING FROM THE PRESENT TO THE FUTURE 369 part of the systems of care, not an isolated activity. If someone comes in for care for an adult mental illness, they are routinely asked if they have children. If children are present, the family automatically qualifies for ser- vices. Informal home visits and an array of prevention services from which parents and children can choose are offered. Over the past 15 years, a comprehensive array of services for chil- dren of mentally ill parents have been developed, including play and talk groups, information support groups, online work websites, brochures, vid- eos, school-based education, and a buddy system for children and for par- ents, home-based mother-baby interventions, parent training, and others. This is accompanied by extensive postgraduate training. Using the existing network of preventionists in community health centers, over 80 prevention- ists have been trained in the use of the Family Talk Intervention devised by Beardslee and colleagues and has used it in their regular practice. In the Netherlands, a group of professionals also has been certified to do preventive care. It allows for the adoption and dissemination of related evidence-based programs when they become available. The preventionists are subject to continuous improvement and modification. They have a net- work in which they collaborate with research institutes, and the structure of support is thought to be essential to making preventive intervention a regular part of care. They have emphasized that it is important to consider preventive care for children of the mentally ill as an integral part of the mental health and primary health care system. They have also emphasized that adequate support for time and the development of services is required as new services become available, with a need for a constant interplay be- tween research and practice (Beardslee et al., in press-a). Finland In Finland, starting in 2001 under the leadership of Tytti Solantaus, a nationwide program has been developed effectively in a stepwise fashion. The Finnish Child Welfare Act states that, if a parent is identified as receiv- ing treatment, the needs of children should be addressed. The aim of the Efficient Family Program is to build care of patientsâ children into routine practice, with every parent receiving support. This was deliberately con- ceived as a change from an individual and treatment-centered program to a family and prevention-centered one. Mass media campaigns, national and local conferences, and seminars were offered, and the clinicsâ leadership and the clinicians were eager to learn. Training began with extensive training of master trainers, who then trained many others. Initially, over a 2-year period, over 40 master trainers were trained. Two master trainers from each site were trained with a commitment from the clinic leadership that they would return to their original sites and be able to use the preventive services
370 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN and train others in their clinics (Beardslee et al., in press-b; Solantaus and Toikka, 2006; Toikka and Solantaus, 2006). The program involves a family of interventions, including the Family Talk Intervention, a 1- to 2-session intervention using a book for parents, the Letâs Talk About Children discussion, peer groups, and a group inter- vention. Thus, in thinking of large-scale public health interventions, having multiple vehicles to deliver the same content is important. In addition, a network meeting was introduced in which either clinicians or parents in- volved with either the care of children or in their own care could call for a meeting of all professionals involved in the care of a child and devise a coordinated plan. This network meeting was also an attempt to address the long-standing lack of integration between services for children and services for adults. The groups served by the intervention have been expanded to include families with serious medical illness, families facing substance abuse problems, and families with court-related matters. The program is now being used in all of the health districts in Finland. Over 80 master trainers and over 700 clinicians have been trained. A ran- domized trial comparing the Family Talk Intervention with the Letâs Talk About Children discussion is under way. Initial findings from parents are that both interventions are safe and feasible in the Finnish setting, with a greater effect for the more intensive Family Talk Intervention. From a public health point of view, the idea that every professional working with mentally ill parents is responsible for initiating child preven- tive services is an important contribution. The program has shown that nurses, doctors, psychologists, social workers, and therapists can master the Letâs Talk About Children discussion and that a countrywide strategy can be successful. There are many advantages to proceeding first by training those who can train others and then in a stepwise fashion over a number of years, ensure the dissemination of a program. The program has demon- strated that flexibility in the delivery of these strategies and their application to the kinds of conditions beyond depression with which parents wrestle are valuable. It is also important to note that, in contrast to the Dutch system, the program does not use special preventionists, but rather all clinicians have responsibility for preventive services. Investigators in Finland, Iceland, Norway, Sweden, and Denmark have formed a coalition named the Nordic Forum. A 3-day meeting is held an- nually in which those countries developing programs for children of the mentally ill meet together in mutual support. Iceland, Norway, and Sweden have chosen to include the Family Talk Intervention as part of their regular array of services, and both Norway and Sweden are in the process of de- veloping national programs.
WORKING FROM THE PRESENT TO THE FUTURE 371 RESEARCH GAPS While evidence is emerging about ways to improve and strengthen the quality of treatment programs for depressed adults, little is known about the extent to which these quality improvement efforts apply to the par- ticular needs of adults who are parents or to their children. Furthermore, research presented in the preceding chapters suggests that children are directly affected by a parentâs depression. Their needs are not addressed in a care system that focuses solely on improving treatment effectiveness without regard for the vulnerable persons (especially very young children) whose care and relationships may be disrupted by the disorder. Research is therefore needed to examine how quality improvement ef- forts contribute to enhancing the relationships and outcomes of parents and their children when compared with the general population of nonparenting adults who participate in treatment programs, and it should incorporate three major principlesârecognition and treatment of parental depression, enhancement and support for parenting, and a focus on the developmen- tal outcomes of children. Research resources should be dedicated to un- derstanding common as well as unique problems in designing treatment services for parents with children at different stages of development, includ- ing infants, toddlers, school-age children, and adolescents. Once optimal strategies are identified, research is needed for the dissemination of these programs into the care settings that match these developmental stages. Further, many individuals who screen positive for depression decline mental health services. For widespread implementation of programs that are shown to be effective for families with depression, there is a need for more work on issues of engagement and barriers to access to services as most families with depressed parents do not receive adequate intervention. Research on depression care models should therefore identify characteris- tics of individuals who accept services and individuals who decline them to determine how well a given model fits with the cultural and socioeco- nomic characteristics of the relevant community. Research opportunities may exist to engage individuals in treatment that is directly relevant to distinct stages of parenting, such as those noted above: preconception, pre- natal, postpartum, and later stages, as well as comparing the outcomes of first-time parents with those who are raising older children or children in blended families The comparative effectiveness of treatment strategies that are targeted on these developmental stages deserves to be tested in design- ing future quality improvement research studies. Interventions centered on parenting are particularly compelling because engagement is a crucial step to effectively intervening in families with depression. Programs that address parenting needs offer great promise as a highly effective way to engage par- ents and, when needed, trigger services that can address their depression,
372 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN parenting, and prevention of adverse outcomes in children. Trials are also needed of specific ways to offer additional identification, outreach, engage- ment, and treatment and prevention services to those vulnerable families who face multiple risks. Finally, families with depressed parents are most likely to be recognized in a variety of settings. As described in Chapter 7, targeted intervention approaches are likely to be most promising. Therefore, in addition to interventions for parents who present with depression for mental health services, research is needed on how best to identify parental depression and provide services within a range of settings in which families at high risk for depression seek services (such as Head Start, WIC, preschool). Thus, resources need to be available in these settings to identify parental depres- sion and to assist families in getting treatment and prevention services. This is most relevant to low-income and ethnic-minority populations given that they are at increased risk for depression but are less likely to seek mental health services. CONCLUSION The size of the problem and the enormous number of families at risk of the effects of parental depression ideally call for experimentation with interventions that can be implemented at multiple sites in existing systems and deployed with planned variations on regional levels and for culturally diverse populations. A wide range of settings are now available for identi- fying, treating, and preventing depression in parents and its consequences for children. Existing strategies and evidence suggest opportunities in pri- mary care, home visitation programs, early childhood care and educa- tion programs, schools, the criminal justice system, and community-based programs. Primary care, home visitation, and early childhood settings, in particular, offer valuable opportunities for identification of depression in parents and its outcomes, the encouragement of sustained relationships and high levels of trust, and reduction of barriers for low-income populations at higher risk of parental depression. Each setting, however, requires differ- ent implementation approaches that frequently involve innovative service strategies to address complex interactions between depression, parenting practices, and parent and child engagement with services. It is important to note as well that each setting frequently has difficulty in establishing strong linkages with mental health services. Some of the most successful depression care programs have been imple- mented in quality improvement efforts in primary care settings. However, physicians in particular face competing demands for their time and atten- tion, as the average office visit requires them to address multiple health care problems and complaints. Mental health carve-outs as well as the
WORKING FROM THE PRESENT TO THE FUTURE 373 potential increase in gross costs present financial barriers to adoption for many primary care practices. Medical homes, however, offer an attractive environment with potential remuneration and improved physician-patient rapport, which should facilitate screening and interventions for parental depression. Home visitation programs provide a service setting in which high-risk parents and families can be readily screened for depression in the comfort of their own homes. In addition to screening and mental health referrals, home visitors can provide parenting interventions to depressed parents and screen for developmental delays and emotional problems in their children. Early childhood and parent training programs also offer ready access to high-risk families and the opportunity to provide services to both parents and children. Schools provide another venue in which to engage both parents and children, although their semiclosed nature and absence of a mental health orientation present significant challenges. Criminal justice systems, while often overlooked, may provide important opportunities to reach individuals with high rates of depression and mental illness. The criminal justice system as a whole has been in the forefront of adopting evidence-based practices. However, a variety of institutional and legal constraints limit the ability to research the success of these efforts. Communities interested in developing comprehensive integrated de- pression care screening, prevention, or treatment components in one or more the settings will need to wrestle with the complexity inherent to coordination and communication among multidisciplinary, multisystem components. Getting started in one or two settings, such as a primary care clinic or a Head Start program, may offer more opportunity and be easier to initiate than launching a comprehensive community effort. But an innova- tive parental depression program will have to compete with other routine demands in selected service settings. It will require a passionate leader and team members who can organize group commitment and find resources for treatment or treatment referral options for identified parents and children. It will also require new forms of data collection to monitor client character- istics, services, and outcomes. The experience with single-setting programs can reveal the scope of the problem and offer treatment success stories that could lead to more comprehensive community efforts for treating parental depression with a two-generation lens in settings particular to diverse and vulnerable populations. Multiple agencies scattered across the U.S. Department of Health and Human Services are working to provide a basis for the development of programs and policies to enhance responses to depression among parents through data collection, health education, workforce development, and other research activities. Most of these efforts focus on maternal depression
374 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN during pregnancy and the postpartum period and have not been coordi- nated across the agencies. Finally, selected states form the vanguard for demonstration efforts by revising programs and policies to introduce more comprehensive and family-focused interventions for parents with depression. These efforts seek to raise the professional training of care providers as well as educate the public about the causes and consequences of depression, striving to reduce stigma associated with this disorder and to improve child outcomes. Such efforts are especially laudable in calling attention to the multidimensional nature of depression and highlighting approaches that require innovative strategies and collaborative efforts. In addition, a number of European countries have developed extensive national programs and mental health prevention teams. Children of mentally ill parents often routinely qual- ify for services. Prevention professionals, the use of master trainers, and family-oriented prevention interventions are important components in these system-wide, collaborative, interdisciplinary programs. RECOMMENDATIONS This chapter describes the components of an ideal evidence-based pro- gram for the care of depressed adults who are parents. Although the current system of care is far from being ready to implement this ideal, a variety of initiatives for improving the quality of services for depressed parents and their children have emerged at the community, state, and federal level, as well as internationally in a variety of service settings. Based on the opportu- nities (and challenges) that have emerged in implementing these initiatives, the committee makes three recommendations intended to build on them and to improve the outreach and delivery of services in different settings for diverse populations of children and families. Improve Awareness and Understanding Recommendation 1: The Office of the U.S. Surgeon General should identify depression in parents and its effects on the healthy develop- ment of children as part of its public health priorities focused on mental health and eliminating health disparities. To implement this recommendation, the U.S. Surgeon General should encourage individual agencies, particularly the National Institutes of Health, HRSA, CDC, and SAMHSA, to support the Healthy People 2020 overarch- ing goal of achieving health equity and eliminating health disparities by including the importance of identification, treatment, and prevention of depression and its potential impact on the healthy development of children
WORKING FROM THE PRESENT TO THE FUTURE 375 of depressed parents. These agencies should pay particular attention to groups and populations that have historically and currently experience bar- riers in receiving quality health care, including for behavioral health. Efforts should be made to ensure that effective strategies are employed to increase the participation and engagement of these vulnerable populations in critical research studies and clinical trials. New research methods and innovative models that partner with vulnerable communities should be supported. Particular focus should be directed at prevention and early intervention ef- forts that are community based and culturally appropriate so that the high burden of disability currently associated with depression in populations experiencing health disparities can be reduced. Recommendation 2: The Secretary of the U.S. Department of Health and Human Services, in coordination with state governors, should launch a national effort to further document the magnitude of the problem of depression in adults who are parents, prevent adverse ef- fects on children, and develop activities and materials to foster public education and awareness. To implement this recommendation, first, the Secretary of the U.S. Department of Health and Human Services should encourage individual agencies, particularly the National Institute of Mental Health, HRSA, CDC, and AHRQ, to identify the parental status of adults and add reliable and valid measures of depression to ongoing longitudinal and cross-sectional studies of parents and children and national health surveys, in ways that will support analyses of prevalence, incidence, disparities, causes, and con- sequences. Second, CDC should develop guidelines to assist the states in their efforts to collect data on the incidence and prevalence of the number of depressed adults who are parents and the number of children at risk to adverse health and psychological outcomes. Finally, using this information, the U.S. Department of Health and Human Services should encourage agen- cies, most notably HRSA, to develop a series of public education activities and materials highlighting what is known about the impact of depression in parents. These activities and materials should specifically target the public and individuals who make decisions about care for a diverse population of depressed parents and their children in a variety of settings (e.g., state and county leadership, state health directors, state mental health agencies, and state maternal and child health services). Support Innovative Strategies Recommendation 3: Congress should authorize the creation of a new national demonstration program in the U.S. Department of Health and
376 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Human Services that supports innovative efforts to design and evaluate strategies in a wide range of settings and populations to identify, treat, and prevent depression in parents and its adverse outcomes in their children. Such efforts should use a combination of componentsâin- cluding screening and treating the adult, identifying that the adult is a parent, enhancing parenting practices, and preventing adverse out- comes in the children. The results of the new demonstration program should be evaluated and, if warranted, Congress should subsequently fund a coordinated initiative to introduce these strategies in a variety of settings. To implement this recommendation, agencies in the U.S. Department of Health and Human Services should prepare a request for proposals for community-level demonstration projects. Such demonstration projects â¢ should test ways to reduce barriers to care by using one or more empirically based strategies to identify, treat, and prevent depres- sion in parents in heterogeneous populations (i.e., race/ethnicity, income level), those in whom depression is typically underidenti- fied, and those with risk factors and co-occurring conditions (e.g., trauma, anxiety disorders, substance use disorders); â¢ should call attention to effective interventions in which screening and assessment are linked to needed care of parents with depres- sion, that support training in positive parenting, and that encour- age strategies to prevent adverse outcomes in their children; â¢ could identify multiple opportunities to engage parents who are depressed as well as to identify children (at all ages) who are at risk because their parents are depressed; â¢ could include the Healthy Start Program, the Head Start Program, the Nurse-Family Partnership, home visiting, schools, primary care, mental health and substance abuse treatment settings, and other programs that offer early childhood interventions; â¢ would ideally use more than one strategy and could use funds to test state-based efforts that experiment with different service strate- gies and service settings and to strengthen the relationship between mental health services and parental support programs; â¢ could test ways to reduce the stigma and biases frequently as- sociated with depression, address cultural and racial barriers and disparities in the mental health services system, and explore op- portunities to strengthen formal and informal supports for families that are consistent with cultural traditions and resources; and â¢ should include state mental health agencies and local government (e.g., counties), at least in an advisory capacity.
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