Interventions Aim To Prevent Depression in High-Risk Children

"Dr. Beardslee's project is one of the most ambitious and encouraging in terms of a nonpharmacological intervention for children," said David Mrazek, M.D., chair of the department of psychiatry and behavioral sciences at the George Washington University Medical Center. "You have a much better chance of putting the child back into a normal developmental trajectory" with early and sustained intervention, Mrazek said.

Unfortunately, according to Mrazek and others in the field, a commitment to prevention, particularly in the area of mental health, is not high on the list of the managed care industry's priorities. "It's a slight peculiarity in our health system," said a sardonic Mrazek, referring to what he believes is a myopic approach to care.

Despite the potentially enormous savings in public health expenditures, Mrazek believes that the unwillingness of managed care to invest in early and sustained interventions is based on the fact that preventive program outcomes are often hard to quantify and can take years to manifest. Mrazek recalled a conversation with a managed care executive during which the latter remarked, "Our average subscriber is with us for two years. We want to prevent something imminent."

University of Washington researcher Geraldine Dawson, Ph.D., is among those who share Mrazek's sense of urgency about the need for better understanding of the link between parental depression and increased risk of morbidity in their children. In two different studies, Dawson and her colleagues have found that infants of depressed mothers exhibited atypical frontal brain activity (Dawson et al., 1997). Specifically, these infants exhibited reduced activity in the left frontal region-the area associated with joy, interest and other emotions linked to approach toward the environment. In several other studies, infants of depressed mothers displayed increased activity in the right frontal region-the area linked to sadness, disgust and other withdrawal emotions (Dawson et al., 1997).

The continued lack of a systemic perspective in the treatment of depression is another obstacle to preventive interventions, according to Simon H. Budman, Ph.D., president and founder of Innovative Training Systems Inc., which develops health promotion strategies. "People can understand it, but there's no way that people, mental health clinicians included, think a lot about the children of their depressed patients," he said. Budman was also the director of mental health research and mental health training at Harvard Community Health Plan.

"It's probably not dissimilar to a cardiologist who sees a person in their 30s or 40s with a heart attack and is not particularly focused on their children or families," Budman added. "Clinicians are trained to think about the particular patient in their office and are not taught to think in a systemic wayýthe training of clinicians is so pathology-focused and so little focused on the broader issues."

There is little time to be lost for Beardslee and others in the field, as depression continues to impose staggering human and financial costs. In 1990, depression was the fourth leading cause of disease-burden in the world, according to the Global Burden of Disease project, a worldwide collaboration of more than 100 doctors and epidemiologists sponsored by the World Health Organization and the World Bank. Researchers define disease-burden as the measure used to gauge both the number of years lost to premature death as well as the number of years lived with a disability. By 2020, depression is expected to become the single leading cause of disease-burden worldwide. "Depression is rising and each successive decade is getting worse," said NIMH's Jensen. "We better get a handle on this thing."