In this Papers Podcast, Dr. Katie Burkhouse discusses her co-authored JCPP Annual Research Review paper ‘Annual Research Review: Emotion processing in offspring of mothers with depression diagnoses – a systematic review of neural and physiological research’ (https://doi.org/10.1111/jcpp.13734).
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- How health care professionals can impact the ‘vulnerability process’ to help alter the outcomes for offspring of depressed mothers.
- Targeted interventions in the pre-conception period.
- Suggestions for women and birthing people, who have a history of mental health conditions and are considering having a baby, to promote healthier emotional development of their offspring.
- Potential biological markers that may be used to inform early targeted prevention efforts for high-risk populations and the forms of interventions.
- What needs to change within the current provision of health care to see a reduction in disruptions in emotion processing patterns amongst high-risk offspring.
- Paternal depression and the limited research currently available.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Katie Burkhouse, PhD, is an Assistant Professor of Psychiatry and a Clinical Psychologist at Nationwide Children’s Hospital. She received her PhD in Clinical Psychology from Binghamton University (SUNY) and completed her Clinical Internship at UIC. Her program of research broadly focuses on identifying behavioral-brain risk phenotypes and preventive interventions for youth depressive disorders. Much of this work focuses on utilizing multiple levels of analysis (i.e., behavioral, EEG, pupil dilation, fMRI) to identify cognitive-affective processing styles involved in the transmission of depression from parents to their offspring. A second focus of her research involves applying this mechanism-based work to prevention and intervention efforts for youth at high risk for depression. The ultimate goal of this work is to improve the identification and prevention of internalizing disorders in children and adolescents. (Bio from Nationwide Children’s Hospital).
Transcript
[00:00:09.990] Caroline Priscott: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Caroline Priscott, a Midwife, by background, with 20 years’ experience in the field, including six years as a Team Leader, caring for women and birthing people with significant vulnerabilities such as mental health conditions.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known has CAMH, and JCPP Advances.
Today, I am interviewing Dr. Katie Burkhouse, Assistant Professor of Psychiatry and Behavioural Health, Children’s Hospital and the Ohio State University. Katie is the author of the Annual Research Review Paper “Emotion Processing in Offspring of Mothers with Depression Diagnosis – a Systematic Review of Neural and Physiological Research,” recently published in the Journal of Child Psychology and Psychiatry.
If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with the rating or review, and do share with friends and colleagues.
Thank you so much for joining us today to discuss what is truly a fascinating piece of research. Can we start with an introduction about who you are and what you do?
[00:01:31.150] Dr. Katie Burkhouse: Yes, of course, and thank you for having me today. So, I also want to mention that this work was co-led by my colleague Dr. Autumn Kujawa at Vanderbilt University. So, as you mentioned, I’m an Assistant Professor of Psychiatry and Behavioural Health at Nationwide Children’s Hospital and also the Ohio State University. So, I’m a Clinical Researcher and my programme of research has two main areas of focus. The first involves studying risk factors for youth depression from a biological lens, and the second involves applying this mechanism-informed work to the development of novel prevention or intervention efforts to reduce youth depression risk.
[00:02:09.300] Caroline Priscott: Thank you, Katie. Let’s turn to your paper; can you give us a brief overview to set the scene?
[00:02:15.170] Dr. Katie Burkhouse: Sure. So, in general, we know that one of the most potent predictors of depression risk is a family history of depression. That is if you have a mother with a history of major depression, you are two-to-three times more likely to experience depression by early adulthood, relative to youth of mothers that have no depression history. So, we also know that these offspring are also prone to exhibit other forms of psychopathology, such as anxiety disorders or behaviour problems. So, why is this?
Well, we know that there are environmental and genetic contributions that go into this risk. In addition, there’s also a significant wealth of research suggesting that alterations in the processing of emotion may be one mechanism driving these elevated rates of psychopathology among these kids of depressed mothers. So, by emotion processing, we simply mean how we react and regulate our emotions. So, when presented with something that evokes an emotion, something that’s angry or fearful or sad in nature, individuals can differ in how they react and respond to these emotions.
They also can differ in how they regulate their responses. So, using different strategies to perhaps reduce our negative emotion such as sadness, or even using different strategies to enhance some of our positive emotions such as happiness. And we think that these individual differences in emotion processing may be one way through which maternal depression results in future forms of psychopathology, such as depression in the offspring.
So, in our review, we essentially wanted to investigate this possibility and to synthesise evidence for associations between a clinical diagnosis of depression in mothers and offspring’s emotion processing abilities at the biological level. We also wanted to focus on biological measures, within our review paper, as these types of measures tend to offer unique insight into emotional reactivity and regulation across development, even beginning in early infancy, without relying on child or parent reports which can sometimes be susceptible to biases based on mood state. And this approach also offers insight into the underlying neurobiological processes associated with emotion processing disturbances and subsequent depression risk.
And then I’ll just end by saying that one of the main motivations for this review paper, in terms of identifying these specific mechanisms, is that the hope is that they can elucidate different targets for prevention and intervention efforts to reduce the detrimental effects of maternal depression on offspring’s mental and physical health across development.
[00:04:51.150] Caroline Priscott: Can you tell us a little bit more about the methodology used?
[00:04:55.120] Dr. Katie Burkhouse: Yeah, so essentially, we conducted a systematic review that was in accordance with PRIMSA guidelines, and we searched for articles in PubMed and PsycINFO for studies in which the sample included mothers that had a DSM-defined depressive disorder that was assessed via a diagnostic interview or a clinical assessment. And the studies also had to include a measure of offspring emotional reactivity or regulation, assessed at the biological level, between birth to 18 years of age.
Our review focussed on biological measures and some of these included autonomic psychophysiology, electroencephalography, or EEG, MEG, event-related potentials and then also structural and functional base neuroimaging. So, this search strategy returned over 6,000 articles, and we reviewed all of these to ensure that they met all of the requirements for our inclusion and exclusion criteria. And the final number of studies that we landed on for this review paper was 64.
[00:05:55.650] Caroline Priscott: Thank you, and what were the key findings? What were the things that stood out for you?
[00:06:01.280] Dr. Katie Burkhouse: So, in our paper, we focused our discussion on findings that were observed across two or more studies. So first, we found some pretty consistent evidence that youth of depressed mothers were observed to exhibit increased or heightened activation in the amygdala, which is a brain region involved in salience detection. And this increased response was found for different forms of negative stimuli such as in response to seeing threatening or sad faces.
We also found pretty consistent evidence with neuroimaging and EEG studies that these high-risk youth were prone to exhibit reduced brain activation responses to positive and rewarding stimuli, such as happy faces or in response to winning a reward. We also found that several resting-state brain networks also differentiated these offspring of depressed versus non-depressed mothers, such that infants and youth of depressed mothers exhibited altered patterns of connectivity within several different brain networks that support adaptive emotion regulation, such as the cognitive control network and also the salience emotional network.
And one interesting thing from our review was that across some of our measures, we found that some of these alterations in emotion processing were only apparent among youth of depressed mothers who were exposed to negative environmental contact, such as higher levels of childhood maltreatment or exhibiting current emotional problems, such as higher levels of sadness or irritability. So, we think that there might be some specific subgroups of offspring of depressed mothers that are particularly at elevated risk for experiencing these emotion processing patterns at the biological level.
And then the last thing I’ll say is that several of these patterns that we detected in the current review of altered emotion processing styles, we found that they were detected as early as infancy and early childhood. Suggesting a potentially early emerging vulnerability factor that may be used to predict the later emergence of psychopathology in these high‑risk offspring.
[00:08:02.819] Caroline Priscott: Thank you. So, you highlight a large body of work showing that difficulties in emotion processing are central to the development and maintenance of many forms of psychopathology. And there is further evidence, from longitudinal studies, showing that alterations in emotion processing prospectively predict later psychopathology among offspring of depressed mothers, potentially reflecting a vulnerability process. As healthcare professionals, how can we impact this process to help alter the outcome?
[00:08:33.600] Dr. Katie Burkhouse: Yeah, so this is such a great question. I think, in general, as healthcare professionals, the first thing that comes to mind is that it’s important to continue to screen for depression in mothers and not just assessing current depression, which is common practice. But also assessing for a prior history of depression as well, as many of the studies that we included in the current review included mothers, with a past history of depression, and they were not current. So, we’re seeing these alterations in emotion processing in these offspring of mothers with a past history of depression. So, if we’re only screening current depression, we might be missing families that are at highest risk.
And so, as healthcare professionals, we can continue to promote positive health behaviours in these mothers and also educate on the potential risks to offspring when depression and stress are particularly high and severe. So, we still have a ways to go in terms of translating this work to prevention and intervention efforts.
I think ideally we would have a system where after we do our screening, as professionals, we can then determine, okay, which offspring are at greatest risk for experiencing depression and emotion processing abnormalities. And we could offer potential solutions for prevention and intervention efforts that might be the most useful in terms of improving emotion regulation skills in these families to mitigate this risk for depression.
[00:09:57.860] Caroline Priscott: Your paper identifies certain aspects, for example, elevated cortisol and how this can alter foetal physiology, development and growth. What are your thoughts on targeted interventions in the preconception period to prevent or limit the impact of this occurring?
[00:10:13.600] Dr. Katie Burkhouse: So, this is the really exciting and developing area right now. So, there are many new studies happening, you know, in this arena, testing if interventions that are aimed at improving maternal depressive symptoms prenatally may be useful in promoting healthy emotional development in offspring. So, for instance, I know of one study that’s occurring at the University of Denver where they’re using a randomised control trial to evaluate whether interpersonal therapy reduces depressive symptoms among pregnant mothers. And, in doing so, has an impact on offspring’s emotion processing vulnerabilities across different units of analysis. So, cortisol activity, utilising neuroimaging assessments across development, and then seeing if these changes in emotion processing styles result in reductions in emotional and behavioural problems across development in these offspring.
And others have done similar type of studies with cognitive behavioural therapy in mothers and showing some promising effects on infants’ brain structure and development after birth. So, I think this type of work has the potential to inform our mechanistic understanding of intergenerational risk patterns, while also offering solutions for early psychopathology prevention, you know, beginning in infancy, among these high-risk offspring.
[00:11:32.730] Caroline Priscott: So, Katie, what would you suggest to those women and birthing people who have a history of mental health conditions and are considering having a baby in order to promote healthy emotional development of their offspring?
[00:11:43.910] Dr. Katie Burkhouse: So, yes, this is a great question. I think that the main thing I would suggest is to talk with your medical care professional, so whether this is your OBGYN, your Primary Care Physician, and your Therapist or Psychiatrist and discussing your history of mental health conditions. In general, many women with depression may resist treatment whenever they are pregnant because they overestimate the risks of depression medication, for example, and underestimate the risks of untreated mental illness. So, I think Clinicians can help address this potential dilemma and provide optimum care to pregnant mothers by collaborating with patients on a treatment plan and informing them about the risks of potential untreated depression.
And especially in the case of severe depression, we know that it’s important for a Clinician to discuss how certain meds like SSRIs and other forms of psychotropic medications are the appropriate form of care, even if a woman is pregnant or breastfeeding. And so after pregnancy, I think, as mothers too, it’s also important, when possible, to continue to seek support if you are suffering with postpartum depression.
We know that it’s not just depression prenatally that impacts these emotion processing alterations and also depression risk in offspring, but also the postnatal period is especially salient for shaping healthy emotional development in offspring. So, as mothers, things that we can do are, you know, promoting appropriate emotion socialisation, such as talking to our children about our emotions or their emotions when they’re struggling or when we’re struggling. And modelling good responses to emotional events can be really impactful in shaping the way our children learn and develop healthy emotion processing skills.
[00:13:28.779] Caroline Priscott: You highlight potential biological markers that may be used to inform early targeted prevention efforts for this high-risk population. Can you tell us more about the biological markers and what forms of interventions you are referring to?
[00:13:41.470] Dr. Katie Burkhouse: Yes, so first an important next step is for studies to actually test whether or not these alterations in emotion processing styles observed among offspring of depressed mothers in our review are actually longitudinally prospective predictors of future emotional and behaviour problems. And if that is the case, we can start to use the term ‘biological markers’.
So, for instance, in our review, we saw pretty consistent evidence that kids of depressed mothers exhibited reduced brain activation to positive or reward-relevant stimuli. So this might be a potential biological marker of future depression risk. And, in fact, others have shown in the literature, with community samples, that a blunted reward response, at the biological level, does predict future depressive trajectories in youth. And so preventive – preventative interventions that are aimed at enhancing positive affect or a reward response in this population come to mind.
And my colleague Autumn Kujawa and I, we have actually been working to develop a positive affect prevention programme for depressed mothers and their offspring that aims to enhance positive affect and reward response at the dyadic and individual level among families. And we have some preliminary evidence, from this small pilot study, that this type of prevention programme is effective in enhancing positive affect in our offspring of depressed mothers and also preventing the emergence of broad psychopathologies sometimes in these at-risk youth. So, we think that this type of experimental therapeutics approach, in which we develop interventions that directly target core mechanisms or biological markers of the disorder, will ultimately prove to be the most impactful in preventing the emergence of early forms of psychopathology, such as depression in this case.
[00:15:32.589 ] Caroline Priscott: So, what do you think needs to change within the current provision of healthcare in order to see a reduction in disruptions in emotion processing patterns amongst high-risk offspring and, in turn, reducing the potential risk of child emotional and behavioural problems?
[00:15:46.490] Dr. Katie Burkhouse: Yes, so a great question, loaded question. I think, in general, early intervention is key. So, as healthcare professionals, as I’ve mentioned, I think we can do a better job of screening for depression among the mothers’, both current and past, histories, to determine which infants are at highest risk for potential adverse outcomes. But then the larger and more difficult question is, “Okay, so we’ve flagged this mother that’s at high risk and this offspring, now what?”
This is where more research needs to come into play to really test which interventions will be most impactful in preventing these emotion processing alterations and subsequent depression risk. And you may wonder what type of interventions would be useful here. Well, I’ve already touched on a few examples, but I’ll highlight just a few more. So, you know, as I’ve said before, treating depression in the mother during pregnancy with psychotherapy or meds is important to see how it impacts the infant long-term.
I think in an ideal world, we would have insurances that would cover different forms of preventative interventions that have shown promise in changing outcomes for offspring. Typically, our insurances will usually only cover active interventions for individuals that are currently experiencing psychopathology.
One example, though, is a family-group-based cognitive behavioural therapy programme that was developed by Bruce Compas at Vanderbilt University for depressed mothers and their offspring. And part of the programme works with the parents on increasing positive parenting skills that may impact offspring’s emotion processing styles and subsequent depression risk. And then other parts of the prevention programme involve teaching offspring adaptive emotion regulation skills to use in their daily lives, whether that be for handling stress within the family, in the mother, or just stress within their everyday lives.
And in this trial, the intervention has shown promise in improving emotion regulation skills and also decreasing rates of psychopathology in high-risk offspring. And so, this type of approach, I think that if we could get insurances to cover prevention programmes like these, this would go a long way in preventing the emergence of several different forms of psychopathology, not just depression, but anxiety disorders, and behaviour problems as well.
This is just one example, but I think it gives an idea of where I think we need to move this work long-term from research to clinical practice.
[00:18:07.390] Caroline Priscott: That sounds really exciting. So, are you planning some follow-up research or is there anything else in the pipeline that you’d like to share with us? I was particularly drawn to paternal depression and the limited research there is currently, despite this being associated with a range of emotional and behavioural outcomes in offspring.
[00:18:24.400] Dr. Katie Burkhouse: Yeah, so, you know, of course, but that’s always the question, right? We do not have any active studies right now with fathers, but we know fathers are important and we know that paternal depression is also associated with a range of psychopathology symptoms in our offspring. So we are hoping to extend this work in the near future to include fathers and, you know, investigate these questions further with this population.
I will talk about one study that we are getting ready to start in the next few months, which is the NIH-funded grant to continue exploring how alterations in emotion processing, at the biological level, are implicated not only in the development of depression in these high-risk offspring, but also the course of depression. So, much of the work that we reviewed in our paper was limited by a single assessment point of emotion processing. So, unfortunately, we know very little about what happens to these emotion processing styles or patterns, once depression emerges in these high-risk offspring.
So, we suspect that as depression worsens or becomes amplified, these emotion processing alterations also become worse and/or amplified. And so, in this new grant, we are planning to assess emotion processing with neuroimaging and EEG every 12 months for two years in our offspring of depressed and non‑depressed mothers. And we think that this type of approach may lead to the discovery of novel treatment targets for depression that could be aimed at improving emotion regulation abilities, at the behavioural or brain level, to decrease depression risk in our offspring.
And within this project as well, we are also investigating whether or not there are certain subgroups of youth that are most vulnerable to experiencing these alterations in emotion processing. So, an additional limitation of prior work in this area that we discuss in the review is that most studies did not include a diverse sample of offspring in terms of gender, race and age, for example. And, in fact, we did see some evidence, in our review, that age did impact some of the patterns of findings, though, again, many of these studies were underpowered to really understand the magnitude of the true effect.
So in this new study, we are hoping to include a larger diverse sample of youth in the Columbus region to evaluate whether or not there are certain subgroups of youth, so perhaps post-pubertal girls, that are at highest risk for experiencing depression through these pathways in emotion processing.
[00:20:49.540] Caroline Priscott: We look forward to reading that when you have that paper. So, finally, what is your take-home message for our listeners?
[00:20:56.200] Dr. Katie Burkhouse: The take-home message, from our review paper, is that although we have made significant progress in the past decade or so, in terms of understanding why these offspring of depressed mothers are at heightened risk for experiencing depression, and in this case, with our review, highlighting the role of altered emotion processing styles, we still have a ways to go, both in terms of researching clinical efforts. I think one main takeaway, though, is that many of these patterns that were detected in our offspring of depressed mothers were observed as early on as infancy.
This highlights significant potential, both research-wise and clinically, to use this information to inform early detection for psychopathology and potentially early prevention programmes. And I’m very excited for new research happening in this area, using some of the biological markers that we discussed today to inform novel prevention efforts for these at-risk youth, and then continuing to advocate for professionals to screen for maternal depression and educate on the importance of reducing stress and depressive levels during pregnancy, to ultimately protect the mother and the offspring.
[00:22:01.750] Caroline Priscott: Thank you ever so much, Katie, that was really interesting. For more details on Katie Burkhouse, please visit the ACAMH website, www.acamh.org and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and please do share with friends and colleagues.
