Research report
Maternal care and paternal protection influence response to psychotherapy treatment for adult depression

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Abstract

Background

Adverse childhood experiences of neglect, overprotection and abuse, well-recognized risk factors for the development of adult psychopathology, were examined as predictors of response to psychotherapy treatment for adults with depression.

Methods

Outpatients in a randomized clinical trial of interpersonal psychotherapy (IPT) or cognitive-behavioral therapy (CBT) completed the parental bonding instrument (PBI) at baseline to establish levels of care and protection. Childhood abuse was asked about using clinical interviews. The PBI variables were examined in tertiles while the abuse variables were categorized as “none,” “some,” and “severe.” Associations between these childhood adversities and treatment response were examined in those who completed the trial.

Results

Of 177 outpatients with depression who were randomized, 159 completed an adequate trial of therapy. Within these 159 patients, 57% were categorized as responders to treatment. The mean percentage improvement on the MADRS was 57.7% (±31.4). Across both treatments, patients reporting intermediate levels of maternal care had the best response to treatment. Also across both treatments, the interaction effects of maternal care and paternal protection by treatment were statistically significant. Examining the two therapies independently, maternal care and paternal protection were associated with a differential response to IPT but not CBT. Reports of abuse, whether physical, emotional or sexual, did not impact treatment response.

Limitations

This study examined patients who completed treatment, which may have attenuated the findings. Two categories of childhood adversity were measured although a range of other adverse childhood experiences exist. The results were from exploratory analyses and require replication.

Conclusions

Maternal care, demonstrating a robust main effect across treatments, appears to be the childhood variable most strongly associated with response to psychotherapy in this sample. In addition, maternal care and paternal protection were associated with a differential response to treatment. These results suggest that the quality of on-going intra-familial relationships has a greater impact on treatment response than experiences of abuse. The findings may aid clinicians in selecting which psychotherapy to use, depending on a patient's childhood history.

Introduction

A well-established link exists between adverse childhood experiences of abuse and neglect and the development of depression in adulthood (Chapman et al., 2004, Heim et al., 2008, Oakley-Browne et al., 1995, Parker, 1979). Abuse in childhood, whether physical, emotional or sexual in nature, has been associated with a range of adult psychopathology including anxiety and suicidal ideation (Anda et al., 2006, Enns et al., 2002, Hill et al., 2001). Childhood neglect, or the absence of sufficient care and attention, has been linked to posttraumatic stress disorder symptoms and adult obesity (Pederson and Wilson, 2009). Similarly, parental overprotection has been associated with a range of psychological problems such as anxiety and personality disorder as well as chronic physical illness (Yoshida et al., 2005, Agostini et al., 2010, Gao et al., 2010). In two large studies involving more than 60,000 people in 22 countries, exposure to childhood adversity was estimated to account for between 25% and 44% of mental health disorders, depending on age of onset measured (Green et al., 2010, Kessler et al., 2010).

Despite the established links between childhood adversity and the experience of later life depression, a limited number of studies examine the predictive nature of childhood adversity in terms of its impact on treatment response for adult depression. In one study by Klein et al., 808 patients with chronic major depressive disorder were enrolled in an open-label trial of algorithm-guided pharmacotherapy and asked about childhood experiences at baseline (Klein et al., 2009). Childhood adversities including maternal overcontrol, paternal abuse, paternal indifference and sexual abuse predicted a lower probability of remission. In addition, maternal abuse, maternal indifference and paternal overcontrol predicted duration of illness. In another study, 681 chronically depressed patients were treated with antidepressant medication, cognitive behavioral analysis system of psychotherapy or a combination of the two (Nemeroff et al., 2003). Those reporting childhood adversity responded better to psychotherapy by itself than to an antidepressant alone, while the combined treatment was only marginally better than the psychotherapy alone. In another trial which compared two antidepressants, those reporting maternal overprotection in childhood did worse in all three outcomes studied, while those reporting paternal neglect were less likely to complete treatment (Johnstone et al., 2009). Finally, another study incorporated data from four clinical trials of patients with a variety of psychological diagnoses, using the PBI as a predictor for outcome in individual and group psychotherapy (Ryum et al., 2008). Results were varied, with high paternal care associated with better and worse outcomes, depending on treatment. Additionally, high maternal care was associated with worse outcomes and high maternal protection better outcomes, depending on treatment.

In earlier analyses of this trial comparing interpersonal psychotherapy (IPT) with cognitive behavioral therapy (CBT) for depression, severity of illness and patient characteristics were associated with a differential response to treatment (Luty et al., 2007, Joyce et al., 2007, Carter et al., 2010). While there was no overall difference between the two psychotherapies in the whole sample, patients with severe depression responded better to CBT (Luty et al., 2007). Differential predictors of treatment response, with poorer outcomes associated with IPT, were found for comorbid personality disorder and certain temperament and character features (Joyce et al., 2007). Other predictors of treatment response were recurrent depression, the belief in the therapy's logicalness and citing childhood experiences as a reason for depression (Carter et al., 2010).

Sellman et al. (1997), in a sample of men with alcohol dependence treated with three weeks of a therapeutic inpatient program, showed that the personality trait of persistence predicted sustained remission from alcohol dependence. Unpublished data from this study also found that the highest remission rates occurred in those reporting intermediate levels of maternal care on the PBI (Sellman, 1993). This finding raised the possibility of non-linear relationships for PBI variables in relation to treatment outcomes.

In this paper, we examined the predictive potential of childhood adversity on a patient's response to psychotherapy for adult depression. Given the well-established risk between childhood adversity in its many forms and developing depression in adulthood, many might suggest that experiencing abuse and neglect in childhood would lead to worse treatment outcomes in adulthood. However, the limited studies available on treatment response suggest a variable and somewhat counter intuitive response to treatment depending on the childhood adversities experienced. This paper was an exploration of the impact of neglect, overprotection and abuse on treatment response in IPT and CBT for adults with depressive disorder.

Section snippets

Sample

Outpatients (177) with a major depressive episode (Association, 1994) were recruited from a number of outpatient sources and randomized to either IPT (Klerman et al., 1984) or CBT (Beck, 1995, Beck et al., 1979). Of the 177 outpatients, 159 completed an adequate trial of psychotherapy and were included in the analyses. Patients were free from any psychotropic medication aside from oral contraceptives and the occasional hypnotic for a minimum of two weeks prior to study participation. Patients'

Descriptive characteristics of 159 treatment completers

Of the 177 patients randomized to psychotherapy, 159 completed at least eight psychotherapy sessions. Of the 91 patients randomized to IPT, 8 (9%) did not complete the minimum number of weekly therapy sessions. Among the 86 patients randomized to CBT, 10 (12%) did not complete minimum number of weekly therapy sessions. The difference between treatment drop-out was not significant. Table 1 presents the descriptive characteristics of these patients, the treatment to which they were randomized,

Discussion

In this paper we reported that the childhood experiences of maternal care and paternal protection predicted treatment response to psychotherapy for adults with depression. Our analyses demonstrate three positive findings: a main effect across both treatments for maternal care; a treatment-specific response with IPT for maternal care and paternal protection, as well as an interaction effect by therapy when the outcome measure is categorical. The main effect of maternal care was non-linear,

Role of funding source

The study was funded by grants from the Health Research Council of New Zealand. The Clinical Research Unit of the Department of Psychological Medicine, Christchurch, is supported by the University of Otago, and the Mental Health Division of Canterbury Health. Jeanette Johnstone is supported by a scholarship from the University of Otago.

Conflict of interest

The authors report no competing interests with respect to this research.

Acknowledgment

This research was funded by grants from the Health Research Council of New Zealand. We thank, in particular, the researchers, therapists and clinicians who worked on this study, and a special thanks to all those who participated in the study.

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