STARD trial

1
STAR-D trial

• Summary
• The acute remission rates were (only) modest for
  the first two treatment levels (37 for step 1,
  and 31 for step 2)
• Follow-up results indicate that remission at
  entry into follow-up was associated with a better
  prognosis than simple improvement without
  remission
• More treatment steps (regardless of remission
  status) was associated with higher rates of
  relapse shorter average time to relapse
• Those with concurrent medical/psychiatric
  (substance abuse, ADHD, PTSD, OCD) morbidity and
  those with more prolonged/chronic depression
  are less likely to achieve remission with acute
  treatment.

2
STAR-D trial

• Summary
• Cognitive Therapy after unsuccessful treatment
  with medication was as effective as medication
  only
• cognitive therapy alone (Switch group) spared
  side effects of medication
• Major Depressive Disorder treated in primary care
  and outpatient mental health care settings were
  similar in severity, recurrence rates, clinical
  features

3
Psychotherapy

• Types
• Cognitive-Behavioral therapy
• Interpersonal therapy
• Problem-solving therapy
• Psychodynamic therapy
• Client-centered therapy
• Marital/Family therapy
• Eclectic therapy selection of whats valid or
  useful from all models and practices

4
Psychotherapy
Recommendations

• For mild to moderate depression similar
  efficacy to drug therapy
• Combined with drug therapy for
• Severe depression
• Chronic (more than 2 years), recurrent, or
  treatment-resistant depression

5
Psychotherapy

• Issues/barriers
• Stigma associated with mental health care
• Must be a fit between therapist and client
  (variables age, gender, experience, theoretical
  orientation, warmth and style of communication)
• Overcome patients possible perception of being
  rejected or dumped
• Limited third-party coverage for psychotherapy
• copays/family deductibles
• limited visits per year (i.e. 20) physician
  therapist
• Access/availability (especially in rural areas)
• 39 primary care shortage areas in Nebraska
• 95 mental health shortage areas
• (Bureau of Health Professionals, Health
  Resources Service Administration 3/08)
• May require strong motivation and active
  participation in therapy ? limited application to
  patients with severe depression or intellectual
  limitations.

6
Men and Depression

• Paternal Peripartum Depression

7
Ramchandani P., Stein A., Evans J., OConnor,
T.G. Paternal depression in the postnatal period
and child development a prospective population
study Lancet, 2005 Jun 25-Jul 1 365 (9478)
2201-2205
8
Paulson J.F., Dauber S., Leiferman J.A.
Individual and Combined Effects of Postpartum
Depression in Mothers and Fathers on Parenting
Behavior Pediatrics, 2006 Aug 118 (2) 659-668
9
What is the prevalence of paternal peripartum
depression?

• Ramchandani P., Stein A., Evans J., OConnor,
  T.G. Paternal depression in the postnatal period
  and child development a prospective population
  study Lancet, 2005 Jun 25-Jul 1 365 (9478)
  2201-2205
• Depressive symptoms were assessed in mothers
  (n13,351) and fathers (n12,884) 8 weeks after
  birth
• A threshold of 12 on the Edinburgh Postnatal
  Depression Scale (EPDS) was used to classify 10
  of mothers and 4 of fathers in this study as
  depressed

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11
E.P.D.S. Validation in Men

• Matthey S., Barnett B., Kavanagh D., Howie P.
  Validation of the Edinburgh Postnatal Depression
  Scale for men, and comparison of item endorsement
  with their partners Journal of Affective
  Disorders 64 (2001), 175-184
• The only study which has validated the EPDS in
  men
• Mean scores are significantly different for men
  and women the optimum cut-off (best sensitivity
  and specificity) to screen for depression in men
  is 2 points lower than for women
• In this study, a score of 12 on the EPDS had a
  sensitivity of only 42.9 for depression in men
  
• ( 57 of cases would be missed)

12
What is the prevalence of paternal peripartum
depression?

• Paulson J.F., Dauber S., Leiferman J.A.
  Individual and Combined Effects of Postpartum
  Depression in Mothers and Fathers on Parenting
  Behavior Pediatrics, 2006 Aug 118 (2) 659-668
• gt 14,000 births sampled parents interviewed at
  9 months
• Final sample size 5089 two-parent families
• Center for Epidemiologic Studies Depression
  (CES-D) Scale
• 14 of mothers and 10 of fathers had moderate
  
• or severe depressive symptoms
• Neither parent depressed 78.2 , Mother only
  11.5 ,
• Father only 7.4 , Both parents 2.9

13
Does paternal peripartum depression impact the
family?

• Ramchandani P., Stein A., Evans J., OConnor,
  T.G. Paternal depression in the postnatal period
  and child development a prospective population
  study Lancet, 2005 Jun 25-Jul 1 365 (9478)
  2201-2205
• A depressed father at 8 weeks postpartum was
  found to double the risk of behavioral and
  emotional problems in children at 3.5 years of
  age
• (after controlling for maternal peripartum
  depression and later paternal depression)

14
Does paternal peripartum depression impact the
family?

• Paulson J.F., Dauber S., Leiferman J.A.
  Individual and Combined Effects of Postpartum
  Depression in Mothers and Fathers on Parenting
  Behavior Pediatrics, 2006 Aug 118 (2) 659-668
• Findings
• Maternal and Paternal depression each negatively
  impacts
• 1) positive parent-child enrichment activities
  (reading, playing, singing)
• 2) parenting behaviors emphasized in
  anticipatory guidance by pediatricians
• (back to sleep, breastfeeding, putting
  infants to bed drowsy and without a bottle)
• Conclusions
• A depressed parent may negatively impact the well
  parents interaction with their child
• Negative effects on children are exacerbated when
  both parents are depressed
• A well parent may compensate for a depressed
  parent

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Does paternal peripartum depression impact the
family?

• Responsive care provided by the father can buffer
  a child from being negatively influenced by
  maternal peripartum depression during development
• ¹ Hossain Z., Field T., Gonzales J., et. al.
  Infants of depressed mothers interact better with
  their nondepressed fathers. Infant Mental Health
  Journal 1994 15 348-357
• ² Tannenbaum L., Forehand R. Maternal depressive
  mood the role of the father in preventing
  adolescent problem behaviors. Behavior Research
  and Therapy 1994 32 321-325
• ³ Hart S., Field T., del Valle C.,
  Pelaez-Nogureas M. Depressed mothers
  interaction with their one year old infants.
  Infant Behavior and Development 1998 21
  519-525
• ?Murray L. The impact of postnatal depression on
  infant development. Journal of Child Psychology
  and Psychiatry. 1992 33 543-561
• ?Mezulis A.H., Hyde J.S., Clark R. Father
  involvement moderated the effect of maternal
  depression during a childs infancy on child
  behavior problems in kindergarten. Journal of
  Family Psychology 2004 Vol. 18, No. 4, 475-588

16
Does paternal peripartum depression impact the
family?

• Responsive care provided by the father can buffer
  a child from being negatively influenced by
  maternal peripartum depression during development
• 6 Conrad M., Harrem C. Protective and resource
  factors in high- and low-risk children a
  comparison of children with unipolar, bipolar,
  medically ill, and normal mothers. Development
  and Psychopathology 1993 5 593-607
• 7 Hops H., Biglan A., Sherman L. Home
  observations of family interactions of depressed
  women. Journal of Consulting and Clinical
  Psychology. 1987 Jun 55 (3)341-346
• 8 Albertsson-Karlgren U., Graff M., Nettelbaladt
  P. Mental disease postpartum and parent-infant
  interaction evaluation of videotaped sessions.
  Child Abuse Review 2001 10 5-17
• 9 Edhborg M., Lundh W., Seimyr L., Widstrom A.M.
  The parent-child relationship in the context of
  maternal depressive mood. Archives of Womens
  Mental Health 2003 6 211-216

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Does paternal peripartum depression impact the
family?

• Having two depressed parents is associated with
  worse social and emotional adjustment for
  children than having only a depressed mother
• ¹ Goodman S.H., Brogan D., Lynch M.E., Fielding
  B. Social and emotional competence in children
  of depressed mothers. Child Development 1993
  64 516-531
• ² Burke L. The impact of maternal depression on
  familial relationships. International Review of
  Psychiatry 2003 15 243-255
• ? Carro M.G., Grant K.E., Gotlieb I.H., Compass
  B.E. Postpartum depression and child
  development An investigation of mothers and
  fathers of sources of risk and resilience.
  Development and Psychopathology 1993 5 567-579
• ? Paulson J.F., Dauber S., Leiferman J.A.
  Individual and combined effects of postpartum
  depression in mothers and fathers on parenting
  behavior. Pediatrics 2006 118(2) 659-669

18
Does paternal peripartum depression impact the
family?

• Having two depressed parents is associated with
  worse social and emotional adjustment for
  children than having only a depressed mother
• 5 Marchand J.F., Hock E. The relation of problem
  behavior in preschool to depressive symptoms in
  mothers and fathers. The Journal of Genetic
  Psychology 1998 159 353-366
• 6 Weissman M., Prusoff B., Gammon G., Merikangas
  K., Leckman J., Kidd K. Psychopathology in the
  children (ages 6-18) of depressed and normal
  parents. Journal of the American Academy of
  Child Psychiatry 1984 23 78-84

19
What factors contribute to paternal depression?

• Lack of a good role model
• Inexperience with infant care? distress
• Fathers may desire more involvement with child
  care than allowed
• Cultural beliefs supporting rigid gender
  parenting roles
• Efficiency or quality (things are done faster or
  better if mother does it)
• Sympathy or admiration (hes done enough)
• Anger a result of marital conflict ? restricted
  contact

20
What factors contribute to paternal depression?

• Child additional financial responsibility
• ? a dilemma between Dad the breadwinner and Dad
  the caring/nurturing/involved parent
• Lack of paternity work leave

21
The cost of child rearing

• According to the U.S. Department of Agricultures
  report Expenditures on Children by Families in
  2007 a two-parent family is likely to spend the
  following to raise one child from birth to age
  17

assumes an average annual inflation rate of 3.1

• Does not include
• health and lifestyle costs of pregnancy and
  prenatal preparation
• cost of college tuition
• the cost of a break in ones working career to
  be a stay-at-home parent

22
What factors contribute to paternal depression?

• Maternal depression
• Fathers whose partners are depressed have a 2.5
  times higher risk of depression at 6 weeks
  postpartum¹
• (vs. fathers whose partners are not
  depressed)
• 24-50 of men whose partners experience
  postpartum depression were also depressed (during
  first postpartum year)²

¹ Matthey S, et. al. Paternal and maternal
depressed mood during the transition to
parenthood. J Affect Dis 2000 60 (2)75-85 ²
Goodman JH. Paternal postpartum depression, its
relationship to maternal postpartum depression,
and implications for family health. J Adv Nurs
2004 Jan 45(1) 26-35
23
What factors contribute to paternal depression?

• Same factors as for mothers
• Lack of sleep/fatigue
• Complications of pregnancy or loss (miscarriage,
  stillbirth, abortion)
• Recent negative life events (unemployment,
  financial problems)
• Poor social support (from family/friends/coworkers
  )
• Marital instability (including mother-in-law
  conflicts)
• Lifestyle changes less time with friends, more
  time with in-laws, less freedom/spontaneity, need
  for larger home, having to work more (men tend to
  process these sacrifices as a loss)

24
What factors contribute to paternal depression?

• Men in step families or partners of single
  mothers tend to have higher levels of depressive
  symptoms than men in traditional families

25
Men and Depression