Optimizing outcomes in children of depressed parents: Identification of modifiable promoters of sustained mental health resilience.
Children and Young People’s Mental Health PhD Scholarship 2020 - University of Cardiff
Supervisors: Stephan Collishaw, Frances Rice, Gemma Hammerton
Over 1 million children in the UK live with a parent with depression. They are at high risk of depression and other mental health problems. These can have a profound and long-lasting impact on young people’s education, relationships and future health. However, whilst some develop serious mental health difficulties, others are surprisingly resilient. Very little is known about why this is. This project focuses on protective factors that help promote good mental health in studies that track the development of children of depressed parents into adult life. Previous work has pointed to important modifiable child, family, social and lifestyle factors that could be targeted by mental health intervention to forestall future mental health difficulties. However, the long-term benefits of these protective factors remain unclear. The scholarship will involve new research examining predictors of long-term mental health resilience in children of depressed parents in high-risk and unselected population cohorts. These children are now in their 20s. Young adulthood is a particularly important time, when mental health problems often first emerge and when young people often face major challenges in their lives – leaving home, going to University, gaining employment or starting a family of their own.
The objectives of the study are to 1) identify modifiable predictors of mental health resilience; 2) understand why, when and how protective factors have beneficial effects on mental health; and 3) work with affected families to develop new guidelines for promoting mental health in young people at risk for depression.
Aims are to
1) identify modifiable child, family, social and lifestyle factors that predict sustained mental health resilience in children of depressed mothers using high-risk and population cohorts followed into adulthood;
2) use longitudinal methods to examine the timing at which identified protective effects have their greatest effect, rule out alternative explanations such as reverse causation, and test whether protective mechanisms vary by gender and by child mental health outcome; and
3) collaborate with stakeholders (young people, families, schools) to refine the objectives of the studentship at the outset, inform ongoing development of school- and health based depression prevention, and develop guidelines for future practice based on the study findings.
Research Student: Eglė Padaigaitė
Hi, my name is Eglė, and I am due to start my PhD in October 2020 at the MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University. I feel very fortunate to have been appointed to this post sponsored by MHRUK studentship and be given the opportunity to further develop my research skills while investigating factors promoting good mental health outcomes in young individuals at high risk for psychopathology.
I previously attained my undergraduate degree in Psychology at Vilnius University (Lithuania) and research master’s degree in Clinical and Cognitive Neuroscience with specialization in Psychopathology at Maastricht University (Netherlands). For my master’s thesis, I worked on Cambridge Ultrasound Sibling and Parent Study (CUSP) at the Autism Research Centre, University of Cambridge. My master’s thesis project investigated differential fetal growth trajectories in children exposed to the suboptimal intrauterine environment (i.e. androgen excess during pregnancy), and its association with autism likelihood in a child. Based on my thesis results, I am currently preparing a manuscript for publication.
Prior to my placement at the Autism Research Centre, I worked as a student assistant on Addenbrooke’s Cognitive Examination (ACE-R) adaptation and standardization project at Vilnius University and as a research assistant on a ‘Feigning: A cognitive dissonance analysis’ study at Maastricht University. As an undergraduate psychology student, I also interned at primary school, gymnasium, house of correction, and mental health centre. Outside of studying and research, I worked as a simulated patient for undergraduate Psychiatric Anamnesis course at Maastricht University and as an INSPIRE conference assistant at Amsterdam, Netherlands.
Progress report Year 3, 2023
I spent the third year of my PhD finalising the first two empirical chapters for publication and developing an analysis plan for my PhD's third and final empirical chapter. The first thesis chapter examined protective factors for mental health resilience in a high-risk cohort known as the Early Prediction of Adolescent Depression (EPAD) study. This study demonstrated that resilience in young adulthood is rare, with only about 1 in 10 individuals not developing mental health problems while transitioning from adolescence into adulthood; well-established adolescent protective factors are developmental-stage specific and does not seem to have a long-lasting effect; treatment of parental depression and comorbid conditions could be an alternative approach to improve mental health outcomes in this population. The second results chapter – a systematic review – summarised 59 articles (i.e., 60 studies) examining protective factors for mental health resilience across development. Most included studies (88%) examined protective factors in toddlerhood, childhood or adolescence and were conducted in high-earning countries (97%). Most protective factors were examined only once and varied by developmental stage, complicating the strength of evidence evaluation. Overall, the most strongly supported factors were a supportive spouse (to the mother), co-parent support (to the child), positive parenting, and inhibitory control.
My first thesis chapter is currently being revised following review and will be submitted to the Journal of the American Academy of Child and Adolescent Psychiatry. Following best scientific practices, along with the manuscript, we will also publish supplements with a directed acyclic graph (DAG) explaining potential pathways that could lead to bias in our analyses, multiple imputation steps that we followed while performing analyses, and multiple imputation code that is freely available on the GitHub: https://github.com/padaigaitee/EPAD-mental-health-resilience. I have also finalised the systematic review manuscript that is currently being reviewed and revised by co-authors and will be shortly submitted to the Lancet Psychiatry.
I have also developed an analysis plan for my final thesis chapter. In this chapter, I will examine the protective role of lifestyle factors using the Avon Longitudinal Study of Parents and Children (ALSPAC) – a population cohort study designed to determine the role of environmental and genetic factors in human health and development. To obtain data access, I have submitted a research proposal to the ALSPAC Executive Committee and the list of variables of interest. I have also presented the analysis plan internally to the Child and Adolescent Psychiatry Team and PhD appraisal panel and revised it accordingly.
First, I will compare the offspring of depressed and non-depressed parents on lifestyle factors of interest. Then, I will use the Structural Equation Modelling (SEM) multi-group models approach to model depression trajectories between ages 13 and 25 years and compare them between the offspring of depressed and non-depressed parents. Finally, I will examine the protective role of diet (e.g., diet quality and exclusion of processed foods), exercise (e.g., total physical activity and time spent at different physical activity intensities), and sleep (e.g., sleep deviation and efficiency, social jetlag, and sleep behaviours) in relation to depressive symptoms trajectories in offspring exposed and unexposed to parental depression. DAGs will be used to determine potential causal pathways and to decide which variables should be included in the models. I have started deriving variables for analyses but will prioritise this chapter from September onwards. During the final year of my PhD, I plan to work on the third chapter of my thesis and finalise the thesis introduction and methods so that I will have my first PhD thesis draft by spring and plenty of time for revisions before the final submission deadline in September 2024.
Finally, this year I also successfully applied for the divisional ECR Travel and Development Award (TADA), allowing me to present my PhD results at the 23rd WPA World Congress of Psychiatry – an international conference held in Vienna, Austria, this September. I felt incredibly honoured and grateful to be selected for a short oral presentation at this conference and divisional travel award.
Progress report Year 2, 2022
During the second year of my PhD, along with other tasks, I continued working on the systematic review. To get external feedback on the protocol, we submitted it for publication. Unfortunately, due to Covid-19, manuscript revision took longer than anticipated (9 months for the first round of edits), resulting in delays. Nevertheless, the protocol successfully went through two rounds of revisions already. Hopefully, it will soon be published in the Systematic Reviews journal.
In our systematic review, we screened 5250 abstracts and 196 full texts. We identified 78 studies as eligible for inclusion (71 observational and 7 randomised controlled trials) – way more than expected, making it hard to manage and highly time-consuming. Nevertheless, another PhD student and I are currently performing independent data extraction and risk of bias assessments that we plan to finish in the next couple of months.
Our preliminary findings show that many factors have been identified by at least one published research study as having a protective effect. Individual (e.g., self-perception and regulation, cognition, personality, and biological), external (e.g., social, lifestyle, school, neighbourhood), and family factors (e.g., parental depression characteristics, family climate, parenting behaviours, and parent-child relationships) were of importance. Most protective factors were studied in children or adolescents rather than young adults and examined only in one study, making it hard to determine their robustness in buffering parental depression effects.
I also worked on the first empirical chapter of my thesis. Using the Early Prediction of Adolescence Depression (EPAD) cohort, we tested if well-known protective factors associated with mental health resilience in adolescence have long-term benefits for mental health in adulthood. Considering input from the youth advisory group we did last year, we used different conceptual and operational definitions of mental health resilience. We also tested some individual and cognitive factors that may explain why some individuals develop mental health problems while others don’t.
We found that protective factors do not have long-lasting benefits for mental health in young adulthood and seem to postpone rather than predict or help to recover from mental health problems. Therefore, our study shows that early intervention might not be enough to prevent or ease mental health recovery in children of depressed parents, and individuals at risk may need continuous support. I was lucky enough for my abstract to be accepted by the Life History Research Society Conference, where I made a poster presentation (see my poster below).
I have also presented preliminary findings from the systematic review, focus group and longitudinal analyses to the Child and Adolescent Psychiatry Team and researchers at the Division of Psychological Medicine and Clinical Neurosciences. Additionally, I have attended multiple training courses, including Causal Inference and Mediation courses at Bristol Medical School that will be extremely helpful during the third PhD year. Finally, I gained teaching experience while designing and delivering a Student Selected Component Practical Research Experience (research elective) to the first-year undergraduate medical students, which I immensely enjoyed.
During the third year of my PhD, I plan to finalise the systematic review and EPAD results and submit them for publication. I will also use the Avon Longitudinal Study of Parents and Children cohort to examine the potential protective effects of lifestyle and genetic factors.
Progress report Year 1, 2021
My PhD project aims to identify which factors could explain why some young individuals raised by depressed parents do not develop mental health difficulties despite being at high familial risk for depression. I have started my research by conducting a systematic literature review. In addition to reviewing the literature on child, family, and social protective factors, this systematic literature will also aim to see if improvement in parent depression acts as a modifiable protective factor for child’s mental health. I have written the systematic review protocol, registered it in The International Database of Prospectively Registered Systematic Reviews (PROSPERO) and submitted the protocol manuscript for publication. I have also established a collaboration with another researcher who acts as a second reviewer. We have already finished screening 5250 research paper titles and abstracts. Only about 4% of studies will be included in the next full-text screening stage. Besides laying a solid foundation for my PhD project analyses, it helped me improve my data search and synthesis skills, which will be invaluable for my future career in research.
To bring in the perspective of young individuals raised by depressed parents, we also set up a youth advisory group at the Wolfson Centre for Young People’s Mental Health, where I had the opportunity to hear their opinions about mental health resilience and the most important factors that could explain why some individuals face mental health struggles while others do not. I was astonished by young people’s sense of responsibility for their mental health and determination to create a better environment for themselves. It also made me realise that young individuals believe that resilience starts from within, and they are very keen to learn how to improve their mental health. The picture below shows how young adults ranked key categories for mental health resilience in order of importance (from interactive presentation software Mentimeter).
Currently, I am preparing an analysis plan for the first empirical thesis chapter. Working with one of the largest studies of children of depressed parents followed up on four occasions for over a decade (the Early Prediction of Adolescent Depression study), I will use a multifactorial approach to test if an individual (e.g., genetic predisposition, neurobiology, physical health, cognition, and coping skills), family (e.g., conflict and cohesion, parental control, and emotional support), and external support factors (e.g., friendships, social network, community belonging) during adolescence can predict sustained good mental health in young adulthood. Next, I will test if observed associations are causal and identify potential underlying mechanisms. My PhD project will aim to provide a more complete picture of mental health resilience and modifiable factors that could be targeted to improve the lives of depressed parents and their children.
Furthermore, I enrolled in various statistical training courses to learn about qualitative research methods and ways to deal with missing data in observational studies. I also presented my research ideas and study progress to the Child and Adolescence Psychiatry team, and made new connections with other postgraduate researchers while co-organising the student-led research conference at Cardiff University. In my free time, I explore Cardiff and Wales's breath-taking nature and get to meet lovely people while doing so.
Finally, I would like to thank Mental Health Research UK for giving me the opportunity to work on this fascinating and very important topic. I am also very grateful to my supervisors and the Child and Adolescence Psychiatry team for such a warm, welcoming, and supportive research environment that gives me the freedom to follow my research interests, learn new things, and maintain a healthy work-life balance.