Mental health resilience in the adolescent offspring of parents with depression: a prospective longitudinal study

Abstract

Background: Young people whose parents have depression have a greatly increased risk of developing a psychiatric disorder, but poor outcomes are not inevitable. Identification of the contributors to mental health resilience in young people at high familial risk is an internationally recognised priority. Our objectives were to identify protective factors that predict sustained good mental health in adolescents with a parent with depression and to test whether these contribute beyond what is explained by parent illness severity.

Methods: The Early Prediction of Adolescent Depression study (EPAD) is a prospective longitudinal study of offspring of parents with recurrent depression. Parents with recurrent major depressive disorder, co-parents, and offspring (aged 9-17 years at baseline) were assessed three times over 4 years in a community setting. Offspring outcomes were operationalised as absence of mental health disorder, subthreshold symptoms, or suicidality on all three study occasions (sustained good mental health); and better than expected mental health (mood and behavioural symptoms at follow-up lower than predicted given severity of parental depression). Family, social, cognitive, and health behaviour predictor variables were assessed using interview and questionnaire measures.

Findings: Between February and June, 2007, we screened 337 families at baseline, of which 331 were eligible. Of these, 262 completed the three assessments and were included in the data for sustained mental health. Adolescent mental health problems were common, but 53 (20%) of the 262 adolescents showed sustained good mental health. Index parent positive expressed emotion (odds ratio 1·91 [95% CI 1·31-2·79]; p=0·001), co-parent support (1·90 [1·38-2·62]; p<0·0001), good-quality social relationships (2·07 [1·35-3·18]; p=0·001), self-efficacy (1·49 [1·05-2·11]; p=0·03), and frequent exercise (2·96 [1·26-6·92]; p=0·01) were associated with sustained good mental health. Analyses accounting for parent depression severity were consistent, but frequent exercise only predicted better than expected mood-related mental health (β=-0·22; p=0·0004) not behavioural mental health, whereas index parents' expression of positive emotions predicted better than expected behavioural mental health (β=-0·16; p=0·01) not mood-related mental health. Multiple protective factors were required for offspring to be free of mental health problems (zero or one protective factor, 4% sustained good mental health; two protective factors, 10%; three protective factors, 13%, four protective factors, 38%; five protective factors, 48%).

Interpretation: Adolescent mental health problems are common, but not inevitable, even when parental depression is severe and recurrent. These findings suggest that prevention programmes will need to enhance multiple protective factors across different domains of functioning.

Funding: Sir Jules Thorn Charitable Trust, Economic and Social Research Council.

Copyright © 2016 Collishaw et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.

Figures

Figure 1

Retention of participants in the Early Prediction of Adolescent Depression study (EPAD) Initial telephone screening identified 469 families. 116 families withdrew before baseline assessment, or were withdrawn for other reasons (incomplete baseline assessments, bipolar diagnosis at baseline assessment; n=16). The baseline eligible sample thus consisted of 337 participants. *Participants were recruited primarily from 62 general practitioner surgeries (263 of 337 of eligible baseline sample), from a database of previously identified adults with recurrent unipolar depression from the community (64 of 337), and via other methods (posters in local health centres, and depression alliance newsletter; 10 of 337). †Numbers vary in main analyses from 209 to 260 due to missing data on individual protective factors.

Figure 2

Cumulative influences on sustained good mental health (n=220) Likelihood of sustained good mental health in offspring according to total number of identified protective factors: positive index parent expressed emotion (high or very high), coparent support (median split; score >3), good-quality social relationships (parent Strengths and Difficulties Questionnaire peer subscale in normal range), adolescent efficacy (median split; General Self Efficacy Scale >28), physical exercise (intense exercise or sport more often than once per week)