The Bi-Directional Relationship Between Parent–Child Conflict and Treatment Outcome in Treatment-Resistant Adolescent Depression

doi:10.1016/j.jaac.2013.01.012

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 52, Issue 4, April 2013, Pages 370-377

https://doi.org/10.1016/j.jaac.2013.01.012 Get rights and content

Objective

To examine the bidirectional relationship between parent–child discord and treatment outcome for adolescent treatment-resistant depression.

Method

Depressed youth who had not responded to an adequate course of a selective serotonin reuptake inhibitor (SSRI) were randomized to either a switch to another SSRI or venlafaxine, with or without the addition of cognitive behavior therapy (CBT) in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study. The Conflict Behavior Questionnaire was used to assess adolescent (CBQ-A) and parent-reported (CBQ-P) parent–child discord. The impact of remission on parent–child conflict, and the differential impact of medication and CBT on the CBQ-A and CBQ-P, were assessed using generalized linear models.

Results

Although there were no differential treatment effects on parent or adolescent-report of conflict, remission was associated with improvement in the CBQ-P. In general, intake family conflict did not predict remission, except in the sub-group of participants whose parents reported clinically significant parent–child conflict at intake, for whom high levels of parent-reported conflict predicted a lower likelihood of remission. Conflict also did not moderate treatment response.

Conclusions

Remission of depression may be sufficient to reduce parent-reported parent–child conflict. However, higher parent-reported conflict, in the clinically significant range, predicts a lower likelihood of remission from depression. Clinical trial registration information—Treatment of SSRI-Resistant Depression in Adolescents (TORDIA); http://clinicaltrials.gov/; NCT00018902.

Section snippets

Participants

Participants consisted of 334 adolescents between 12 and 18 years of age enrolled in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study. The participants had to have a clinical diagnosis of major depressive disorder (MDD) or dysthymia by DSM-IV criteria,²⁷ moderate-to-severe depressive symptoms, (≥40 on the Children’s Depression Rating Scale–Revised [CDRS-R],²⁸ and ≥4 on the Clinical Global Impression–Severity Subscale [CGI-S]28, 29) which persisted despite an 8-week trial

Range and Correlates of the CBQ

At entry, participants’ scores on the CBQ-A ranged from 0 to 20 (mean = 8.92, standard deviation [SD] = 6.21), with 50.5% in the clinically significant range (≥9). The CBQ-A was positively correlated with a number of indicators of clinical severity, including global severity (CGI-S), depression (CDRS-R, BDI), hopelessness (BHS), self-harm (SIQ, past attempt, non-suicidal self-harm), and comorbid conditions (alcohol/drug use, disruptive behavior disorders) (TABLE 1, TABLE 2). Of these, only the

Discussion

In this article, we have examined the extent to which adolescent and parent-reported parent–child conflict predicted or moderated treatment response and, conversely, the degree to which treatments for depression affected parent–child conflict. We found that treatment effects were relatively unaffected by parent–child conflict, as reported by either parent or adolescent. Adolescent-reported parent–child conflict at baseline did predict a lower likelihood of remission, but not after controlling

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: This work was supported by National Institute of Mental Health grants MH61835, MH61958, MH61869, MH61856, MH61864, MH62014, MH66371, and MH18951.

: Dr. Brent and Ms. Porta served as the statistical experts for this research.

: The authors thank: the study co-investigators (Anthony Spirito, Ph.D., and Henrietta Leonard, M.D. (deceased) of Brown University; Betsy Kennard, Psy.D., of the University of Texas, Southwestern Medical Center–Dallas; Satish Iyengar, Ph.D., of the University of Pittsburgh; Lynn DeBar, Ph.D., and Frances Lynch, Ph.D., of Kaiser Permanente–Portland; James McCracken, M.D., Michael Strober, Ph.D., and Robert Suddath, M.D., of the University of California–Los Angeles; and Benedetto Vitiello, M.D., of NIMH. The authors also thank Robin Martin, B.A., and Mary Carter, Ph.D., of the Western Psychiatric Institute and Clinic for manuscript preparation and editorial assistance, and the staff, participants, and families who made this project possible.

: Disclosure: Dr. Emslie has received research support from Biobehavioral Diagnostics, Eli Lilly and Co., Forest Laboratories, GlaxoSmithKline, and Somerset. He has served as a consultant for Biobehavioral Diagnostics, Eli Lilly and Co., Forest Laboratories, GlaxoSmithKline, Pfizer, and Wyeth Pharmaceuticals. Dr. Wagner has received research support from NIMH and has served on an advisory board for Forest Laboratories. Dr. Keller has served as a consultant to or has received honoraria from Abbott, CENEREX, Cephalon, Cypress Bioscience, Cyberonics, Forest Laboratories, Janssen, JDS, Medtronic, Organon, Novartis, Pfizer, Roche, Solvay, Wyeth, and Sierra Neuropharmaceuticals; has received grant or research support from Pfizer; and has served on advisory boards for Abbott Laboratories, Bristol-Myers Squibb, CENEREX, Cyberonics, Cypress Bioscience, Forest Laboratories, Janssen, Neuronetics, Novartis, Organon, and Pfizer. Dr. Birmaher has received research funding from the NIMH, and has received or will receive royalties for publications from Random House, Inc. (New Hope for Children and Teens with Bipolar Disorder) and Lippincott Williams and Wilkins (Treating Child and Adolescent Depression). Dr. Asarnow has served as a consultant on cognitive behavior therapy, depression treatment quality improvement, and on an unrestricted grant from Pfizer; and has received unrestricted funding from Philip Morris. Dr. Brent has received research support from NIMH, royalties from Guilford Press, and royalties from the electronic self-rated version of the Columbia Suicide Severity Rating Scale (C-SSRS) from ERT, Inc.; and has served as an UpToDate Psychiatry Editor. Drs. Clarke, Shamseddeen, and Ryan, Mr. Rengasamy, Mr. Mansoor, Mr. Hilton, Ms. Porta, Ms. He, and Ms. Mayes report no biomedical financial interests or potential conflicts of interest.

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New ResearchThe Bi-Directional Relationship Between Parent–Child Conflict and Treatment Outcome in Treatment-Resistant Adolescent Depression

Objective

Method

Results

Conclusions

Section snippets

Participants

Range and Correlates of the CBQ

Discussion

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Affect Disord

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Clin Psychol Rev

J Am Acad Child Adolesc Psychiatry

Addict Behav

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Clin Psychol Rev

J Am Acad Child Adolesc Psychiatry

Parental communication deviance in childhood onset schizophrenia spectrum and depressive disorders

J Child Psychol Psychiatry

Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder

Arch Gen Psychiatry

Stress generation in depression: reflections on origins, research, and future directions

J Clin Psychol

Adolescent depression: stressful interpersonal contexts and risk for recurrence

Curr Dir Psychol Sci

Cognitive and family therapies for adolescent depression: treatment specificity, mediation, and moderation

J Consult Clin Psychol

Psychosocial functioning in prepubertal major depressive disorders. II. Interpersonal relationships after sustained recovery from affective episode

Arch Gen Psychiatry

Psychosocial functioning in prepubertal major depressive disorders. I. Interpersonal relationships during the depressive episode

Arch Gen Psychiatry

Treatment effects on the social adjustment of depressed patients

Arch Gen Psychiatry

New Research
The Bi-Directional Relationship Between Parent–Child Conflict and Treatment Outcome in Treatment-Resistant Adolescent Depression