Family Risk Factors in Adolescents with Recurrent Depression

Maternal Mental Health and History of Psychiatric Problems

When a teen receives a diagnosis for major depressive disorder (MDD), one thing they learn is that recovery from depression is a process. Once they receive a referral for and begin treatment, such as outpatient therapy, virtual outpatient therapy, intensive outpatient treatment (IOP), partial hospitalization treatment (PHP), or a residential program (RTC), their progress depends on a variety of factors specific to that teen and their family.

Some teens experience rapid remission of symptoms. After a few outpatient sessions, they understand the scope of their diagnosis and learn practical techniques to manage their symptoms. In most cases, this happens for teens with mild or moderate depression. They’re not cured immediately, or anything like that. They simply get a handle of their symptoms relatively quickly, and find techniques to manage those symptoms that work for them – again, relatively quickly.

For other teens, remission of symptoms takes longer. They may require medication, which, in some cases, can take months of trial and re-trial to find the correct combination of medication, dosage, and timing. For other teens, progress may have nothing to do with medication, but rather, the intensity and level of immersion of their treatment.

For instance, if a teen begins treatment in virtual outpatient therapy or outpatient therapy but shows no treatment progress, they may need to step up to a more immersive level of care, such as an IOP, PHP, or RTC.

And, in some cases, teens find the right level of care, the right combination of therapy, medication, and lifestyle changes. They learn to manage their symptoms, and – in clinical language – their depression goes into remission.

However, that’s not always the end. In some cases, depression returns. This is known as recurrent depression or persistent depressive disorder (PDD). For the purposes of this article, we’ll call it recurrent depression.

New Research: The Role of the Family in Recurrent Depression

The study we’ll discuss today is called “Familial Risk Factors in Relation to Recurrent Depression Among Former Adolescent Psychiatric Inpatients.” To examine what family factors put teens at increased risk of developing recurring depression, researchers examined data from 237 teens diagnosed with major depressive disorder (MDD), 35.4% of whom were later diagnosed with recurrent depression. Here’s how they describe their study:

“We investigated which family environmental factors contribute to differences between recurrent and non-recurrent depression by the young adulthood of the former adolescent inpatients.”

This is an important research effort because identifying risk factors for recurrent depression is the first step toward preventing and/or managing recurring depressive episodes.

To understand the risk factors for recurrent depression, we should first understand the risk factors for adolescent depression, overall. Teen mental health experts identify the following risk factors for depression in teens.

Teen Depression: Risk Factors

  • Family history of depression
    • Family history of depression is a genetic risk factor associated with childhood onset of depression and early-adult/adolescent onset of depression
  • Previous history of mental health disorder
    • Previous diagnosis of a mental health disorder such as anxiety or the presence of an alcohol or substance use disorder increases the risk of depression
  • Major life changes, trauma, stress
  • Major physical illnesses

The next to last bullet point on that list – major life changes, trauma, stress – includes a subset of risk factors known as adverse childhood experiences (ACEs).

Commonly Recognized Adverse Childhood Experiences

  • Physical, emotional, or sexual abuse
  • Physical or emotional neglect
  • Domestic violence
  • Living with a parent or caregiver with a substance use or mental health disorder
  • Living with an individual who was incarcerated or sentenced to be incarcerated
  • Experiencing racism and/or bullying
  • Living in foster homes
  • Living in an unsafe neighborhood
  • Witnessing violence
  • Experiencing economic hardship

Since it appears in both lists above – and since the impact of family on teen depression is a focus of this article – we’ll take a moment to discuss the effect of parental mental health on teenage depression. Research shows that in addition to genetic factors, the presence of a parental mental health disorder can expose a child to negative parenting/relationship patterns and create stressful circumstances in a child’s life. Here’s how researchers describe this phenomenon:

“Long-lasting harmful parenting patterns can negatively affect a child’s developing brain architecture and cause long-lasting effects on a child’s behavior and overall stress response system.”

These changes increase the likelihood of developing adolescent depression, and increase the likelihood that a stressful life events will trigger a depressive episode, and in some cases, precipitate the onset of adolescent depression.

We’re on our way to sharing the risk factors for recurrent depression. But first, we need to define what recurrent depression means.

What is Recurrent Depression?

The study we’re looking at in this article uses a definition of depression and recurrent depression, found in the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10):

“A depressive episode is classified as a minimum of two-week period of almost constantly having two or more of the following symptoms: decreased mood, increased fatigue or decreased interest in previously enjoyable activities. Moreover, a patient has to have one or more of the following symptoms so that the total number of symptoms is four or more: excessive guilt, lowered self-confidence, recurrent thoughts of death, difficulties concentrating, agitation or retardation, changes in eating or in weight, difficulties sleeping, suicidal behavior or attempted suicide.”

And here’s how experts define recurrent depression:

Now let’s look at the previously defined risk factors for recurring depression, before the publication of this new research. Risk factors for recurrent depression:

  • Parental depression
  • High levels of antisocial behavior
  • Persistent negative emotionality
  • Presence of externalizing symptoms: anger, outbursts, tantrums, acting out
  • Childhood physical, sexual, emotional abuse, assault, and maltreatment
  • Persistent absence of positive emotionality
  • High levels of trait – i.e. default – anxiety

In an interesting observation across several studies, researchers report that major stressful life events were strongly associated with initial, but not recurrent, depressive episodes.

Now that we have all our terms defined, we’re finally ready to share the results of the new study.

What the New Research Says About Risk Factors for Teen Recurrent Depression

First, let’s look at the characteristics related to individual adolescents identified in the study:

  • Previous or Co-Occurring Psychiatric Disorders.
    • Among the study group:
      • 77% had mood disorders
      • 37% had substance use disorders
      • 36% had conduct disorders
    • The presence of these disorders did not increase risk of recurrent depression

Next, let’s look at the family-related factors researchers identified in the study. Here are the nine factors the researchers considered:

  1. Income level/socio-economic status
  2. Family size
  3. Presence of one or two parents
  4. Maternal education level
  5. Paternal education level
  6. Parental employment status
  7. Sibling status: youngest, middle, oldest
  8. Presence of parental mental illness
  9. Quality of emotional relationship with parents: close or distant

Of those nine factors, data shows that four  increased risk of recurring depression:

  1. Family size
    • Families of five or more increased risk of recurring depression
  2. Distant relationship with mother
    • This effect was twice as powerful for girls than for boys
  3. Paternal psychiatric issues
    • This effect was more powerful for girls than for boys
  4. Sibling psychiatric issues
    • This effect was more powerful for girls than for boys

We’ll let the study authors summarize these findings:

“These results highlight the importance of including the whole family in the treatment of adolescents with depression. Our findings may also help identifying those youths, who are at risk of developing recurrent depression later in their life. This would allow clinicians to focus more efficiently on preventive measures to help those individuals and their families.”

We concur, one hundred percent. We know the family plays an important role in adolescent depression treatment because we see the impact of family participation every day. We’ll close this article by discussing evidence-based treatment for depression that prioritizes full family engagement in the recovery process.

Treatment for Adolescent Depression: The Role of the Family

When we treat teens with depression, we include the family. The conceptual basis for this approach is derived from and grounded in Family Systems Theory, which proposes the following:

  1. Every child grows up in a system of relationships. Each system may look different, but we call these systems the family.
  2. The specific circumstances in each family play a role in how an individual child grows into an adult.
  3. Therefore, the characteristics the child develops are directly influenced by the system of relationships – i.e. the family – in which the child grew up.

Evidence shows that when families are involved in the treatment process, good things happen:

  • Rates of symptom relapse decrease
  • Time spent in treatment increases
  • Problem behavior, such as aggression and opposition, decreases
  • Symptoms of depression and anxiety decrease
  • Academic performance improves

This is all logical: when family members know what a teen is going through, they’re better equipped to support them as they navigate their treatment journey. And when a family goes above and beyond simply knowing what a teen is going through, and participates in the process themselves, then they’re even better equipped to support their loved one – because they’re right there with them, doing the hard work of therapy and recovery.

Treatment for Adolescent Depression: Dialectical Behavior Therapy (DBT)

In our adolescent DBT programs, we apply a tool created by the inventor of DBT, Dr. Marsha Linehan, which is described in a publication called Finding the Wise Mind. The tool that helps families of adolescents the most – because it was designed specifically for them – is a module called The Middle Path.

The Middle Path borrows concepts originally found in mindfulness practices such as yoga and meditation. Here are the basic concepts applied in the Middle Path Module of DBT.

 

DBT Basics: The Middle Path for Families

During family sessions, a DBT therapist helps adolescents and their families:

  • Accept the world as it exists in the present moment without judgment, and without trying to change it.
  • Understand that every problem or challenge has more than one possible solution.
  • Value the experience and input of all family members in depression treatment
  • Validate the experience, perception, and input of the teen in the depression treatment process
  • Believe that action creates change, and that action based on acceptance and understanding leads to positive, life-affirming outcomes

When teens and their family members participate in this DBT module together, they find that family communication improves. They learn that in many cases, family conflict – including tension that arises when a teen is in treatment – happens when one person or the other holds a rigid position from which they don’t want to move. When teens and parents learnt to take The Middle Path, they can move forward to a space of healing and growth.

How DBT Addresses Recurring Depression

The data in the study we examine above identifies specific family factors associated with recurrent depression. These factors include the closeness of the relationship between the teen and the mother, the size of the family, and the presence of psychiatric issues in siblings or the father.

In a family DBT program, a DBT therapist identifies these risk factors and works with the teen and family to find productive ways to manage the inherent challenges. DBT family workshops can help improve communication, which can enhance and deepen the maternal relationship. DBT skills workshops can help a teen manage the distress caused by the sibling dynamics in a large family. Finally, DBT educational workshops can help teen learn about the psychiatric issues their siblings or parents face, and work with their DBT therapist to create specific coping skills and strategies that support their recovery, while also giving their family members the space, compassion and understanding they need to heal and grow, as well.

In addition, the core of DBT is change through action. A teen in DBT treatment for depression – whether its outpatient, virtual outpatient, intensive outpatient, partial hospitalization, or residential treatment – knows they have to act their way to recovery, rather than think their way to recovery. That means that part of the treatment process is creating durable, practical skills they can use every day. The most important thing about these skills, though, is that they can grown and change over time, as the teen grows and changes. A robust skillset gives a teen the tools to manage their depression for the long-term, and enables them to thrive in recovery, no matter what challenges they face.

Finding Help: Resources

If you’re seeking treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.