Depression, Women, and Families: A Generational Challenge
We know a lot about how depression affects women.
For example, women are twice as likely as men to be diagnosed with depression in their lives. This increased prevalence starts in adolescence and extends into older age. Currently, one in 10 women in the United States show symptoms of depression.
Heightened risk factors for women include higher incidences of childhood sexual abuse, intimate partner violence, and high stress induced by persistent gender-based discrimination. In addition, because of the hormonal changes of pregnancy, menstruation, and menopause, women are susceptible to unique types of major depression that men are not.
We also know much about how depression develops through families over time, often passing from parents to their children, starting in youth and adolescence with rates among women and men peaking in their early 20s.
“In the 1970s, the question was, ‘Does childhood depression exist?’” said Dr. Myrna Weissman, Diane Goldman Kemper Family Professor of Epidemiology and Psychiatry at Columbia University and Chief of the Division of Translational Epidemiology at New York State Psychiatric Institute. “The conventional wisdom held that major depression was a disorder primarily of middle-aged and menopausal women and did not happen in children.”
Dr. Weissman, speaking at a Grand Rounds presentation in March sponsored by the Women’s Behavioral Health Division of Yale School of Medicine’s Department of Psychiatry, helped build the body of data that quickly disproved this notion. In detailing some of the work she has led over the last three decades, Dr. Weissman demonstrated the importance of studying women and their families across generations to understand the past and how to improve lives in the present and future.
“Depression is a serious medical condition that significantly affects all aspects of life,” said Dr. Carolyn M. Mazure, Director of Women’s Health Research at Yale, who invited Dr. Weissman to speak. “It is one of the leading causes of disability in the world, and for women, this certainly includes serious symptoms following childbirth or during menopause. In addition, without proper treatment, depression can negatively impact a woman’s entire life. As we can see with Dr. Weissman’s trailblazing work, this can include the whole family.”
The American Psychiatric Association calls for a diagnosis of major depressive disorder (MDD) when someone experiences a “depressed mood or a loss of interest or pleasure in daily activities for more than two weeks” as well as five or more other persistent symptoms that could include loss of sleep or substantial weight loss.
Dr. Weissman received her Ph.D. at Yale and until 1987 served as a Professor of Psychiatry and Epidemiology at Yale School of Medicine and Director of the Depression Research Unit. She began following women with and without depression in the New Haven area 30 years ago and has continued following the same individuals as well as their children, grandchildren, and now, great-grandchildren.
Three decades later, the children of mothers with minor-to-serious depression populated a high-risk group that were three times as likely to develop major depressive disorder themselves, three times as likely to develop an anxiety disorder, and almost three times as likely to develop a substance dependence.
In addition, the second generation of this high-risk group showed a nearly 4 percent incidence of death from suicide, accident, and overdose. The low-risk group, whose mothers were not diagnosed with depression at the outset of the study, experienced no such causes of death.
“This is one of the saddest findings,” Weissman said.
Notably, the researchers found that the rate of mood disorders — which include MDD but also bipolar and other disorders — were highest in children whose parents and grandparents both had MDD.
The researchers also discovered that neither pediatricians nor mothers were often aware of the psychiatric and behavioral problems of the children. For example, Weissman said, 7 percent of children and/or their mothers reported to an independent psychiatric interviewer that the child had made a suicide attempt. In comparison, 60 percent of the children reported suicide attempts that were not reported by the mothers.
Another interesting finding concerns the effect of religion or spirituality on rates of depression. The researchers found that mothers who self-identified as highly religious or spiritual were 81 percent less likely to have depression 10 years after the start of the study. This effect influenced their children as well, who showed a 75 percent lower rate of depression over a 10-year span. Neither frequency of attendance at religious services nor the religious denomination had any impact on the results.
In fact, the importance of religion or spirituality to a parent correlated with a 20-year lower risk of suicidal behavior in their children. This effect was found in boys and girls and was independent of parental depression, divorce, parental suicidal thoughts, and the child’s own religious and spiritual beliefs.
“What does religious importance mean?” Weissman said of a current thread of inquiry she hopes to unravel. “What is it capturing?”
A current survey under analysis reveals that no other question in their long survey predicted depression outcomes like religious and spiritual beliefs.
“I think it has to do with an internal ability to be hopeful,” she said. “And to also feel that you have important values. But I really don’t know.”
Additional studies pointed to even more reasons for hope. For example, when mothers received treatment for depression with medications known as selective serotonin reuptake inhibitors (SSRIs), their children showed better mental health outcomes. And the sooner the mothers showed a remission of their depression, the more positive the results for their children.
“If the mother gets better, the kids get better,” Weissman said. “And if you treat depressed mothers early and to remission, you can help even more.”
Weissman’s team is now studying the risk of future depression in children whose mothers are treated with SSRIs when pregnant. And while she intends to end the longitudinal study of the New Haven-based women and their families after completion of the ongoing 40-year follow-up, she expressed great enthusiasm for the strides her team has made in translating careful research into treatments that meet the needs of the community.
“One of the most rewarding aspects of this research is to work with people who are very skilled in things you don’t know but you know are very important to understanding what you want to learn,” she said. “And that’s something I learned at Yale, where it was very easy to do.”