8
Working from the Present to the Future: Lessons Learned from Current Practice

SUMMARY

  • Clues emerging from the current research base point to an ideal evidence-based program for the identification, treatment, and prevention of depression among adults would integrate mental and physical health services. For those who are parents, it would strengthen and support parent-child relationships, offer developmentally appropriate treatment and prevention interventions for children, and provide comprehensive resources and referrals for other comorbidities associated with depression in multiple health care settings, including those that engage young children and families. Furthermore, this system of care would utilize more proactive approaches for prevention or early intervention of depression in parents in the context of a two-generation model and would be family-focused, culturally informed, and accessible to vulnerable populations.

  • The existing health care and social services systems are far from implementing the ideal system of care for depressed adults and parents. Early efforts in the adoption, implementation, integration, and dissemination of various components of evidence-based depression care programs offer insight into the future development of key features of such an ideal system.



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8 Working from the Present to the Future: Lessons Learned from Current Practice SUMMARY • Clues emerging from the current research base point to an ideal evidence-based program for the identification, treatment, and pre- vention of depression among adults would integrate mental and physical health services. For those who are parents, it would strengthen and support parent-child relationships, offer develop- mentally appropriate treatment and prevention interventions for children, and provide comprehensive resources and referrals for other comorbidities associated with depression in multiple health care settings, including those that engage young children and fami- lies. Furthermore, this system of care would utilize more proactive approaches for prevention or early intervention of depression in parents in the context of a two-generation model and would be family-focused, culturally informed, and accessible to vulnerable populations. • The existing health care and social services systems are far from implementing the ideal system of care for depressed adults and parents. Early efforts in the adoption, implementation, integra- tion, and dissemination of various components of evidence-based depression care programs offer insight into the future development of key features of such an ideal system. 

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Quality Improvement Interventions • Studies of interventions intended to improve the quality of the de- sign and organization of primary care services for treating adults with depression have resulted in improved outcomes—including quality of care, individual clinical outcomes, cost-effectiveness, and employment status. The implementation of these interventions of- fers important lessons in designing new approaches for depressed parents. Adding a Parent-Child Dimension • Adding a parent-child dimension to adult depression care requires linkages of a range of services and systems integrated across a di- verse range of settings. • Existing exemplary strategies in individual service settings—pri- mary care, home visitation, early childhood and parenting training programs, schools, the criminal justice system, and community- wide programs—offer important lessons regarding the challenges faced in implementing such strategies for depressed parents and their outcomes. Federal-Level Initiatives • Federal efforts in the identification, treatment, and prevention of depression among parents and its effects on children focus primar- ily on maternal depression that occurs during pregnancy or the postpartum period. Current efforts are scattered across several agencies in the U.S. Department of Health and Human Services and include data collection, health education, treatment, prevention, workforce development, and other research activities. State-Level Initiatives • A few state-level initiatives have developed and implemented strate- gies focused on the needs of depressed parents and their children— particularly targeted to women and other vulnerable populations. These initiatives have focused on the training of service providers, expanding access to screening and services, and promoting public awareness to help reduce the stigma associated with mental health disorders.

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 WORKING FROM THE PRESENT TO THE FUTURE European Interventions • Several system-wide, collaborative, and interdisciplinary approaches to preventive care in children of the mentally ill—using prevention professionals, master trainers, and family-oriented prevention in- terventions—and often specific to depression have been developed, implemented, and disseminated in a few European countries. ____________________ Supported by the research presented in the previous chapters, the long-term goal should be that evidence-based programs offer services for the identification, treatment, and prevention of depression among adults and would be available in multiple health care settings. These settings would integrate mental and physical health services, and for those who are parents, also strive to strengthen and support parent-child relationships during therapeutic treatment, offer developmentally appropriate treatment and preventive interventions for children and other family members, and provide comprehensive resources and referrals for other comorbidities that might be associated with the parent’s depression (such as substance use, unemployment, unstable housing). Ideally, more proactive approaches to prevention and early intervention in depressed parents would also be avail- able in multiple settings that engage young children and families, such as child care centers, home visitation programs, family support programs, and school-based programs. These treatment, prevention, and proactive approaches would be family-focused, culturally informed, and accessible to vulnerable populations, which often have difficulty in navigating transi- tions among health care, mental health, and community-based programs, and they would help overcome barriers to access to needed care. These interventions would emphasize the importance of treating depression in the context of a two-generation model, helping parents improve their parenting skills while coping with depression, and also offering enhanced supports for children who may be at risk of mental, emotional, and behavioral disorders because of a depressed parent. Existing health care and social services systems are far from achiev- ing this goal and realizing the vision of fully integrated two-generational programs. Yet initial efforts offer important clues in a variety of service settings regarding the nature, scope, quality, and costs of the development of key features of this ideal. These clues provide valuable guidance about the types of models that deserve further support and experimentation in building integrated, comprehensive, and two-generation service strategies to treat and prevent depression among parents and to mitigate its effects on their children.

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN This chapter begins with an overview of selected research studies as- sociated with quality improvement efforts in the treatment of adult depres- sion. Although few of these studies have focused on the parenting aspects of this disorder, they offer important insights into the types of enhance- ments that generate treatment effectiveness and improved outcomes for individual adult patients. Next, the chapter reviews major issues related to the adoption, implementation, integration, and dissemination of evidence- based depression care programs specifically for parents with depression and their children across a wide range of health care and other service settings. The chapter then reviews current federal initiatives intended to bolster the knowledge base to help develop programs and policies that enhance the response to depression among parents and early interventions for children. The final sections of this chapter examine different models of depression interventions for parents that have emerged in selected states as well as Eu- rope. These models offer distinctive approaches to integrating health care and family-focused interventions with an explicit focus on identification, prevention, treatment, and expanded access for vulnerable populations. The chapter concludes with a set of recommendations that could advance the knowledge base associated with the design, experimentation, and imple- mentation of different service models. QUALITY IMPROVEMENT INTERVENTIONS AND THE TREATMENT OF ADULT DEPRESSION A significant body of research has emerged demonstrating that despite the availability of evidence-based interventions and practice guidelines, the outcomes of adult patients with depression remain poor in primary care settings (Schoenbaum et al., 2001). These findings have prompted a search for improvements in the design and organization of primary care services, frequently evaluated through studies of quality improvement (QI), clinical effectiveness, and health care services research. Such studies have shown that certain quality improvement efforts—for example, the Partners in Care (PIC) model, which adds specialized training programs and resources in practice-based settings or the Improving Mood-Promoting Access to Col- laborative Treatment (IMPACT), which includes a collaborative care model using a primary care physician, a care manager, a mental health special- ist, consistent measurement, and stepped care treatment—have resulted in better outcomes as measured by improved quality of care, quality of life, clinical outcomes, and retention in employment over a 1-year follow-up (Schoenbaum et al., 2001; Unützer et al., 2002; Wells et al., 2000). The QI interventions for the PIC model increased health care costs (compared with usual care). Such average increases were $419 for QI- meds and $485 for QI-therapy. However, the societal cost-effectiveness of

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 WORKING FROM THE PRESENT TO THE FUTURE such increases was comparable to other accepted medical interventions. The long-term cost-effectiveness of implementing the IMPACT model (for depression care later in life) lowered the mean total health care costs dur- ing 4 years compared with usual care (87 percent probability) (Unützer et al., 2008). The PIC and IMPACT evaluation studies have therefore demonstrated that QI efforts are feasible and cost-effective and can be implemented in “naturalistic” practice-based settings. Follow-up studies confirmed these findings for minorities and whites as well as for those with both depressive disorder and subthrehold depression. The QI studies have reported cumulative prevention and treatment benefits beyond the short-term outcomes, especially for minorities. For example, comparison studies with usual care have demonstrated improve- ments in 5-year and 9-year outcomes after a 6-month intervention with the PIC model described above, including improved employment status (Wells et al., 2000); they also reduced stressful life events, equivalent to removing 6–12 deaths of a loved one over a 9-year interval (Sherbourne et al., 2008; Wells et al., 2005). Greater outcome improvements were reported for un- derserved minorities than whites (Miranda et al., 2003). QI programs have also been successfully adapted to a variety of set- tings, populations, and those with co-occurring disorders. For example, the IMPACT model has been implemented in eight different health care systems (e.g., health maintenance organizations, fee for service, inner-city county hospitals, Veterans Administration clinics) and has been tested in African Americans, Latinos, and white patients. It has been tested as well in patients with and without comorbid medical illnesses (like diabetes and cancer) or anxiety disorders and in adults of all ages as well as adolescents (University of Washington, 2009). In all of these settings, populations, and conditions in which IMPACT has been adapted and implemented, it has been shown to be more effective in depression care than usual care (Ell et al., 2008; Grypma et al., 2006; Kinder et al., 2006; Richardson, McCauley, and Katon, 2009). Although these QI programs focus on primary care settings, they should not be viewed as just health care interventions. Starting with patients who are receiving care in primary care settings, they then add a systems approach that often includes mental health specialists or outreach workers who can extend the program beyond primary care. The QI programs also adopt a user-friendly approach, supporting patient education and preferences in the choice of medications or therapeutic interventions, thus increasing the chances that patients will get the intervention they prefer (Dwight-Johnson et al., 2001). It is important to note, however, that the existing QI studies do not differentiate outcomes based on the parental status of the individual adult patient. Nor do they address outcomes beyond those observed in the care

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN setting or in assessing individual health and employment status. A signifi- cant opportunity exists, therefore, to identify and assess the impact of QI interventions (such as PIC and IMPACT) on adults who are parents of children of various ages. These assessments could examine outcomes as- sociated with QI effects on parenting practices, parent-child relationships, and child outcomes. Such studies would need to disentangle multiple fac- tors, however, such as the changes in parent-child relationships that might be attributable to improved health or improved employment, as well as the interactions among them. ADDING A PARENT-CHILD DIMENSION TO DEPRESSION CARE INTERVENTIONS The research on quality improvement suggests that multiple opportu- nities exist to incorporate evidence-based practices that enhance positive outcomes from the treatment of adult depression. Experience with the implementation of quality improvement interventions thus offers impor- tant lessons in designing new approaches that could focus on strengthen- ing parent-child relationships as well as clinical effectiveness in treatment settings. But adding and implementing an explicit focus on parenting and parent-child relationships to different forms of screening, prevention, and treatment models for adults who struggle with depression (which we collec- tively term as “depression care”) require resolution of multiple challenges. Such interventions need to be multidisciplinary, to be developmentally ori- ented (e.g., pregnant women, first-time parents, parents with multiple chil- dren or blended families), to include a two-generation approach that could include services for children of varying ages, to be culturally appropriate, to have multiple points of access, and to offer patient-centered choices among evidence-based components (such as medication or cognitive-behavioral therapy). Since parental depression frequently occurs in the context of a constellation of comorbid medical and mental health conditions, as well as social and economic risk factors and concurrent circumstances, adjunctive interventions may be required in addition to treatment of the depression and parenting interventions. The committee recognizes that many of the challenges faced in adding and implementing a parent-child dimension to depression care are similar to the challenges faced with the identification, treatment, and prevention of other mental heath and substance use disorders and health care in general as described in the 2006 Institute of Medicine report, Improving Quality of Health Care for Mental and Substance-Use Conditions. However, it is unclear (as well as out of the scope of the committee’s task) if specifically incorporating a two-generation, developmentally oriented model of care for other mental health and substance abuse disorders, other chronic health

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9 WORKING FROM THE PRESENT TO THE FUTURE diseases, and health in general is appropriate and requires further explora- tion. Still, potential models of care for parents with depression may need to bridge a range of services and systems and integrate across a diverse range of settings. SPECIAL ISSUES BY SERVICE SETTING Individual service settings offer further insight and important lessons regarding the challenges that deserve systematic attention in implementing innovative strategies to strengthen, identify, treat, and prevent depres- sion and improve parenting practices and parent-child relationships for depressed adults who are parents and their children. This section reviews the experience with exemplary strategies in such settings, including pri- mary care, home visitation, early childhood and parent training programs, schools, the criminal justice system, and community-wide models. Primary Care Primary care practices figure prominently in efforts to improve depres- sion care. Many of the more carefully crafted randomized controlled trials have focused on these practices as an important gateway to care (Dietrich et al., 2004; Katon et al., 2004; Wells et al., 2000). Although the evidence is fairly strong that integrated approaches through primary care can be effective in the management of depression (Gilbody et al., 2003, 2006; Minkovitz et al., 2007), there are many challenges in attempting to scale up these systems. For physicians, time is a major constraint to adopting new roles and responsibilities. A number of studies have shown that practitioners may have difficulty making the time to effectively learn and reliably apply new practices (Horwitz et al., 2007; Olson et al., 2002; Østbye et al., 2005; Tai-Seale, McGuire, and Zhang, 2007). Although there is some contrary evidence (Cabana et al., 1999), the possibility of a ubiquitous time crunch is difficult to ignore, particularly as the body of applicable knowledge grows (Jones, 2009). When primary care physicians are asked, for example, to learn and apply new procedures for addressing depression among their patients, it may be hard for them to do so without considering the effect this will have on the overall learning they must do to stay up-to-date and preserve their self-image as a competent clinician as well as their ability to do their job. In primary care settings, where most people encounter the health care system and are an important focus for screening and care for depressed parents, there are many competing demands (Stange et al., 1998). Depres- sion inquiry, counseling, or treatment must compete with multiple clini-

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0 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN cian and patient priorities, such as treatment of acute illness, provision of preventive services, and response to patient requests (Klinkman, 1997). These competing demands make individual and organizational learning, as well as incorporation of evidence-based care, more difficult. For example, visits to family physicians typically involve more than three health care problems or conditions, and such visits may involve nearly five for people with chronic diseases (Beasley et al., 2004). Nearly one in five visits also includes concerns or care related to someone other than the primary patient (Flocke, Goodwin, and Stange, 1998). Although family medicine’s capacity for caring for multiple family members is a benefit in dealing with depressed parents and their children, depression care innovations that do not explic- itly take comorbidity and family members into account may be less easily integrated into practice. Financial considerations are also likely to be an inhibitory factor in the assimilation and use of depression care models by primary care physicians, since most of these models appear to add to the gross costs of practice (e.g., for an integrated care manager) (Gilbody, Bower, and Whitty, 2006; Gilbody et al., 2003; Mattke, Seid, and Ma, 2007; Simon et al., 2001). Mental health care has been financially carved out of primary care by many payers over the past 20 years and remains so for many Medicaid programs (Horvitz-Lennon, Kilbourne, and Pincus, 2006). Where they still persist, mental health carve-outs remain a financial barrier to better depression screening and care in primary care by keeping the mental health sector and the general health sector systematically fragmented. The frequent separation of care for adult parents (generally mothers) and their children in primary care settings may make implementation of new policies or tools related to parental depression effects for children more difficult. Some pediatricians do screen mothers for depression, especially in the first few months after delivering a baby. But others may feel that parents are not their patients, or they choose not to screen because they don’t know how or have few options for referring parents for treatment. Pediatricians also lack tools for screening children for the effects of depres- sion in parents since no validated tools currently exist. The American Acad- emy of Pediatrics and the American College of Obstetrics and Gynecology encourage obstetricians/gynecologists to screen for maternal depression, particularly in the weeks after delivery (American Academy of Pediatrics and American College of Obstetrics and Gynecology, 2007). However, these providers may not consider infants and children as their patients, or like other primary care providers, may not know that children may need to be evaluated for effects of parental depression. Efforts to implement and disseminate new policies and tools to improve identification and treatment of children affected by parental depression will need to engage clinicians

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 WORKING FROM THE PRESENT TO THE FUTURE who care for both children and parents and help them understand the role they can play. Although it has not been carefully examined yet as a solution to the problem of getting effective depression care to the people who need it, the conversion of family physician practices into “medical homes” for patients is an idea in good currency that might provide a way to reach a large pro- portion of the population who could benefit from such care (Freudenheim, New York Times, July 21, 2008; Sia et al., 2004; Starfield and Shi, 2004). Through this arrangement, a doctor assumes full responsibility for a pa- tient’s medical care, either providing it directly or coordinating access to it. The closer relationship that develops between doctor and patient as a result may increase the likelihood of depression being discussed or symptoms be- ing disclosed (Starfield and Shi, 2004). When physicians receive additional compensation for functioning as a “medical home,” they may also be able to hire more staff to help manage patient care. Physicians who serve as medical homes may thus develop greater interest and capacity to assimilate and use new developments in depression care. Home Visitation Home visitation programs for young families represent another pos- sible avenue for the identification, treatment, and prevention of depres- sion in parents. A number of home visitation models that serve high-risk populations have been widely implemented. These programs largely serve low-income, young mothers with few resources or social supports, a demo- graphic group that tends not to use center-based services for themselves or their families. These families also experience high levels of associated risk factors, including histories of child maltreatment, domestic violence, and substance abuse. Most home visitation programs include standardized assessments con- ducted by the home visitor for the purposes of determining eligibility for and level of services. Depression screens have been incorporated into routine assessments by several state-based home visiting programs (e.g., Ohio, Connecticut). Most home visitation program models perform some case management functions and rely on referrals to community services to provide specialized forms of care as necessary. Home visitation programs are therefore potentially able to screen and refer associated comorbidities, such as substance abuse, for appropriate services. Home visitation programs are well positioned to address one of the missing elements in services for depressed and at-risk parents: child devel- opment and parenting training. Preliminary studies indicate that successful treatment of maternal depression is not sufficient to improve parenting and child outcomes in depressed mother-child dyads (Forman et al., 2007).

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN However, a small, randomized trial of a home visiting–based parenting in- tervention for depressed mothers demonstrated significant improvements in attachment security (as measured by the Attachment Q-Set), maternal sensi- tivity, and child socioemotional competence (van Doesum et al., 2008). The Nurse-Family Partnership (NFP) has drawn a significant amount of attention and support owing to the high quality and persuasiveness of the evidence for its effectiveness on the basis of three, well-designed, randomized controlled trials and long-term findings (Isaacs, 2007; Karoly, Kilburn, and Cannon, 2005; Partnership for America’s Economic Success, 2008). In this program, nurse home visitors are trained to screen first-time mothers for depression and to make appropriate referrals for treatment. Louisiana was one of the early adopters of the NFP model and has tested a supplemented version that couples nurse visitor teams with an infant mental health specialist, usually a social worker, to help identify and treat parental, mostly maternal, mental health issues (Boris et al., 2006). A consortium of local agencies in the Cincinnati area called Every Child Succeeds, which operates both the Nurse-Family Partnership and another home visiting program, Healthy Families America, have tested, with some success, the use of cognitive behavioral therapy with participating mothers diagnosed with depression (Ammerman et al., 2005). Early Childhood and Parent Training Programs A system with enormous potential for reaching parents with or at risk of depression is the array of programs and services that have taken shape to support the early development of children and parenting. By far the largest and most prominent of these programs is Head Start. Like many early childhood interventions, Head Start is designed to address the needs of children and, to some extent, their parents. In recent years, federal per- formance standards for Head Start have heavily emphasized the program’s responsibility for readying children for school, with relatively less weight given to the program’s role in helping and engaging parents. This has been counterbalanced to some extent by the emergence of Early Head Start, a program for children from birth to age 3 years and their families. Early Head Start is actually a set of program options from which local Head Start agencies may choose: center-based care for children, home visiting for children and their families, or a combination of the two. Al- though initial findings from the 17-site randomized trial of Early Head Start did not show any impact on parental depression, more recent evidence sug- gests that the program may have had a delayed inoculatory effect (Chazan- Cohen et al., 2007). The downstream incidence of depression (i.e., delaying the impact on maternal depression) among parents in the treatment group has been significantly lower than those in the control condition.

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 WORKING FROM THE PRESENT TO THE FUTURE Head Start, because of its size and sustained support and dissemina- tion, would appear to be an attractive vehicle for reaching a large number of disadvantaged parents, but there are questions about the capability of local Head Start agencies to take on more responsibility. Even though Head Start is striving to improve the quality of local agency staff, the overall level of education and experience remains relatively low and turnover can be a problem (consistent with the general experience in early childhood education) (Barnett, 2002; Bryant et al., 1994; Currie and Neidell, 2007; Early et al., 2007; Gallagher and Clifford, 2000; Pai-Samant et al., 2005). Nor are the effects of staff quality on outcomes entirely clear (Currie and Niedell, 2007). Nonetheless, Head Start’s 40 years of durability—a remark- able feat among nonentitlement social programs—makes it a credible target of opportunity for extending the reach of effective depression care. Beardslee and colleagues (in press-a) have developed an adaptation of programs generally used in Head Start centers called Family Connections. Given that the rate of depression in parents of children attending these centers is high and in one Early Head Start study was 48 percent, Beardlee’s approach is to provide education about depression and work closely in a staff development approach to increase teachers’ competence in dealing with depression and related mental health difficulties in parents and chil- dren (Knitzer, Theberge, and Johnson, 2008). This approach was chosen because of the very high rates of depression noted in studies of parents in Head Start and Early Head Start. Given the high prevalence, Head Start and Early Head Start teachers encounter depression daily in the parents of children they deal with and undoubtedly also see the effects of depression in the children (Beardslee et al., in press-a). The core approach was to combine trainings in which all of the staff participated around key issues in mental health, such as how to engage difficult parents, how to build resilience in youngsters, and how to understand depression with onsite consultation over a 3-year period. The central goal of the program was to increase teach- ers’ self-reflection and shared reflection and their understandings of how to take care of themselves. It also aimed to promote self-reflection and self care in parents. This approach was developed in partnership with Head Start providers in the Boston area, particularly Action for Boston Com- munity Development. Working in a single site over 3 years, the investiga- tors showed that the trainings were well received, as was the consultation model, and that in qualitative interviews with teachers and staff and asses- sor observation, substantial teacher growth occurred. Through this work, they have advanced the thesis that it is necessary to consider depression’s impact at four levels: the individual level, the family level, the caregiving system level, and the community level. Correspondingly, it is necessary to identify resilience and strength and ways to cope with depression at each of these four levels.

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN during pregnancy and the postpartum period and have not been coordi- nated across the agencies. Finally, selected states form the vanguard for demonstration efforts by revising programs and policies to introduce more comprehensive and family-focused interventions for parents with depression. These efforts seek to raise the professional training of care providers as well as educate the public about the causes and consequences of depression, striving to reduce stigma associated with this disorder and to improve child outcomes. Such efforts are especially laudable in calling attention to the multidimensional nature of depression and highlighting approaches that require innovative strategies and collaborative efforts. In addition, a number of European countries have developed extensive national programs and mental health prevention teams. Children of mentally ill parents often routinely qual- ify for services. Prevention professionals, the use of master trainers, and family-oriented prevention interventions are important components in these system-wide, collaborative, interdisciplinary programs. RECOMMENDATIONS This chapter describes the components of an ideal evidence-based pro- gram for the care of depressed adults who are parents. Although the current system of care is far from being ready to implement this ideal, a variety of initiatives for improving the quality of services for depressed parents and their children have emerged at the community, state, and federal level, as well as internationally in a variety of service settings. Based on the opportu- nities (and challenges) that have emerged in implementing these initiatives, the committee makes three recommendations intended to build on them and to improve the outreach and delivery of services in different settings for diverse populations of children and families. Improve Awareness and Understanding Recommendation 1: The Office of the U.S. Surgeon General should identify depression in parents and its effects on the healthy develop- ment of children as part of its public health priorities focused on mental health and eliminating health disparities. To implement this recommendation, the U.S. Surgeon General should encourage individual agencies, particularly the National Institutes of Health, HRSA, CDC, and SAMHSA, to support the Healthy People 2020 overarch- ing goal of achieving health equity and eliminating health disparities by including the importance of identification, treatment, and prevention of depression and its potential impact on the healthy development of children

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 WORKING FROM THE PRESENT TO THE FUTURE of depressed parents. These agencies should pay particular attention to groups and populations that have historically and currently experience bar- riers in receiving quality health care, including for behavioral health. Efforts should be made to ensure that effective strategies are employed to increase the participation and engagement of these vulnerable populations in critical research studies and clinical trials. New research methods and innovative models that partner with vulnerable communities should be supported. Particular focus should be directed at prevention and early intervention ef- forts that are community based and culturally appropriate so that the high burden of disability currently associated with depression in populations experiencing health disparities can be reduced. Recommendation 2: The Secretary of the U.S. Department of Health and Human Services, in coordination with state governors, should launch a national effort to further document the magnitude of the problem of depression in adults who are parents, prevent adverse ef- fects on children, and develop activities and materials to foster public education and awareness. To implement this recommendation, first, the Secretary of the U.S. Department of Health and Human Services should encourage individual agencies, particularly the National Institute of Mental Health, HRSA, CDC, and AHRQ, to identify the parental status of adults and add reliable and valid measures of depression to ongoing longitudinal and cross-sectional studies of parents and children and national health surveys, in ways that will support analyses of prevalence, incidence, disparities, causes, and con- sequences. Second, CDC should develop guidelines to assist the states in their efforts to collect data on the incidence and prevalence of the number of depressed adults who are parents and the number of children at risk to adverse health and psychological outcomes. Finally, using this information, the U.S. Department of Health and Human Services should encourage agen- cies, most notably HRSA, to develop a series of public education activities and materials highlighting what is known about the impact of depression in parents. These activities and materials should specifically target the public and individuals who make decisions about care for a diverse population of depressed parents and their children in a variety of settings (e.g., state and county leadership, state health directors, state mental health agencies, and state maternal and child health services). Support Innovative Strategies Recommendation 3: Congress should authorize the creation of a new national demonstration program in the U.S. Department of Health and

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Human Services that supports innovative efforts to design and evaluate strategies in a wide range of settings and populations to identify, treat, and prevent depression in parents and its adverse outcomes in their children. Such efforts should use a combination of components—in- cluding screening and treating the adult, identifying that the adult is a parent, enhancing parenting practices, and preventing adverse out- comes in the children. The results of the new demonstration program should be evaluated and, if warranted, Congress should subsequently fund a coordinated initiative to introduce these strategies in a variety of settings. To implement this recommendation, agencies in the U.S. Department of Health and Human Services should prepare a request for proposals for community-level demonstration projects. Such demonstration projects • should test ways to reduce barriers to care by using one or more empirically based strategies to identify, treat, and prevent depres- sion in parents in heterogeneous populations (i.e., race/ethnicity, income level), those in whom depression is typically underidenti- fied, and those with risk factors and co-occurring conditions (e.g., trauma, anxiety disorders, substance use disorders); • should call attention to effective interventions in which screening and assessment are linked to needed care of parents with depres- sion, that support training in positive parenting, and that encour- age strategies to prevent adverse outcomes in their children; • could identify multiple opportunities to engage parents who are depressed as well as to identify children (at all ages) who are at risk because their parents are depressed; • could include the Healthy Start Program, the Head Start Program, the Nurse-Family Partnership, home visiting, schools, primary care, mental health and substance abuse treatment settings, and other programs that offer early childhood interventions; • would ideally use more than one strategy and could use funds to test state-based efforts that experiment with different service strate- gies and service settings and to strengthen the relationship between mental health services and parental support programs; • could test ways to reduce the stigma and biases frequently as- sociated with depression, address cultural and racial barriers and disparities in the mental health services system, and explore op- portunities to strengthen formal and informal supports for families that are consistent with cultural traditions and resources; and • should include state mental health agencies and local government (e.g., counties), at least in an advisory capacity.

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 WORKING FROM THE PRESENT TO THE FUTURE Finally SAMSHA should promote interagency collaboration with other U.S. Department of Health and Human Services agencies—CDC, HRSA, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, the National Institute of Mental Health, the National Institute on Nursing Research, and the National Institute of Child Health and Human Development—to develop coordinated strategies that support the design and evaluation of these demonstration projects. SAMHSA could identify an interagency committee to pool information about programs that are affected by parents with depression, programs that offer opportunities to engage parents and children in the treatment and prevention of this dis- order, and research and evaluation studies that offer insight into effective interventions. SAMHSA could develop opportunities to introduce effective interventions in both community-based systems of care frameworks and in integrated behavioral and mental health services in a variety of settings, including primary care and substance abuse treatment settings. REFERENCES American Academy of Pediatrics and American College of Obstetrics and Gynecology. (2007). Guidelines for Perinatal Care (6th ed.). Elk Grove Village, IL: American Academy of Pediatrics. Ammerman, R.T., Putnam, F.W., Stevens, J., Holleb, L.J., Novak, A.L., and Van Ginkel, J.B. (2005). In-home cognitive behavior therapy for depression: An adapted treatment for first-time mothers in home visitation. Best Practices in Mental Health, , 1–14. Aos, S., Miller, M., and Drake, E. (2006). Evidence-Based Public Policy Options to Reduce Future Prison Construction, Criminal Justice Costs, and Crime Rates. Olympia: Wash- ington State Institute for Public Policy. Avery, M.R., Beardslee, W.R., Ayoub, C.C., and Watts, C.L. (2008). Family Connections Materials: A Comprehensive Approach in Dealing with Parental Depression and Re- lated Adversities. Available: http://eclkc.ohs.acf.hhs.gov/hslc/ecdh/Mental%20Health/ Resources%20and%20Support%20for%20Families/Parent%20Support%20and%20R esources/FamilyConnection.htm#TrainingModules [accessed April 24, 2009]. Barlow, J., Coren, E., and Stewart-Brown, S.S.B. (2003). Parent-training programmes for improving maternal psychosocial health. Cochrane Database of Systematic Reviews, (4) Art. no. CD002020. Barnett, W.S. (2002). Early childhood education. In A. Molnar (Ed.), School Reform Propos- als: The Research Evidence (pp. 1–26). Greenwich, CT: Information Age. Barth, R.P., Landsverk, J. Chamberlain, P., Reid, J.B., Rolls, J.A., Hurlburt, M.S., Farmer, E.M.Z., James, S., McCabe, K.M., and Kohl, P.L. (2005). Parent-training programs in child welfare services: Planning for a more evidence-based approach to serving biological parents. Research on Social Work Practice, , 353–371. Bauldry, S. (2006). Positive Support: Mentoring and Depression among High-Risk Youth. Philadelphia: Public/Private Ventures. Bauldry, S.G., and Hartmann, T.A. (2004). The Promise and Challenge of Mentoring High- Risk Youth: Findings from the National Faith-Based Initiative. Philadelphia: Public/Pri- vate Ventures.

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