Mental Health

Depression. Depression and anxiety are the two most common psychological disorders in youth (Costello et al., 1996). Depression is a costly illness and worldwide is one of the leading causes of morbidity and mortality (Gladstone & Beardslee, 2009).

Parental depression has extensive and serious implications on family members. Depression affects childhood mental health well-being as well as mental health outcomes later on in life ( Solantaus, Paavonen, Toikka, & Punamaki, 2010). Depression in parents often translates to parents who are emotionally distant or unavailable toward their children, and depression in children often stems from depression in parents. Specifically, depres­sion in children whose mothers suffer from depression is significantly greater than rates of depression in children whose mothers do not have depression (Goodman, 2007). Rates of depression in young children and teenagers whose mothers are depressed range between 20% and 41%, with several factors account­ing for the variability. Some of these factors include the level of severity of the mother’s depression, depression levels in fathers, as well as other social and demographic factors (Goodman, 2007).

Suicide is a tragic aspect of depression that people often avoid talking about. Suicide is a complex issue, and risk factors vary by age, race/ethnicity, and family history of mental disorders. Although preventable, in 2007 in the United States, suicide was the 10th lead­ing cause of death among all people (NIMH, 2010). The national average of death by suicide is 11.3 deaths per 100,000 people (NIMH, 2010).

Anxiety. Like depression, family history plays a large part in the development of anxiety and anxiety-related disorders. Anxiety is one of the most common psychological disorders found in youth (Hudson, Dodd, & Bovopoulos, 2011). Because it has become such a common theme among children and

Box 9.3 Another Case of It Happens in Real Life: _ Death by Suicide

While preparing this book chapter for publication, we got word that our former neighbor in a city in which we used to live, Martin, died by suicide. As an electrician by trade, Martin spent several hours at our home over the years helping with repairs. He was a funny man; he made lots of self-deprecat­ing jokes, had everyone around him laughing. He was jovial; he whistled and sang songs while he worked, and talked out loud to himself-and to whatever it was he was trying to fix (something I always found particularly charming). And, most important, he was a partner and a dad. He left his wife and his darling three children. He mustn't have known that in that instant, when he took his life, that he permanently, forever after, increased the risk of his young children's risk for death by suicide.

adolescents, the study of anxiety, its causes, and treatment modalities has increased over the past few years. Although there are still many unanswered questions, the literature points to several issues that have been con­cluded from the research, namely, parental anxiety, parenting styles, and attachment.

Children whose parents have anxiety are seven times more likely to develop an anxiety disorder than are children whose parents do not have anxiety (Turner, Beidel, & Costello, 1987). Similarly, anxious children are more likely to have a parent with anxiety than are nonanxious children (Cooper, Fearn, Willetts, Seabrook, & Parkinson, 2006). Although the diffusion of anxiety from a parent to child is often thought of as a genetic influence, anxiety in children is also attributed to parental mod­eling of anxiety and also parental communica­tion about anxiety (Hudson et al., 2011).

Parents who have anxiety demonstrate high control and low warmth to their children (Hudson et al., 2011; Laraia, Stuart, Frye, Lydiard, & Ballenger, 1994), and these types of behaviors (high control, low warmth) have the potential to lead to broader negative out­comes for children and also influence mental health outcomes when these children become adults. Children whose parents demonstrate high control, or over involvement, typically do so in perceived high anxiety-producing situations. These children, therefore, do not develop strategies for dealing with anxiety, have a fear of anxiety-producing (threatening) situations, and have an increased perception of, and desire to avoid, threatening situations (Hudson et al., 2011). Perhaps along the lines of family environment, and levels of warmth and control, high levels of family conflict have also been linked to childhood anxiety (Barnow, Lucht, & Freyberger, 2001).

Schizophrenia. Just as noted with each of the disorders above, schizophrenia is something that has higher rates of prevalence within families. “First degree, biological relatives” of people with “schizophrenia are 10-times” more likely to develop the disorder than the “general population” (APA, 2000, p. 309). Interestingly, identical twin studies show that environment plays a large role in the onset of schizophrenia. Studies have demonstrated that identical twins raised in the same and dif­ferent environments have different outcomes, illustrating that genetics is not the only factor that leads to schizophrenia.

The context of family makes up a large part of the environment for an individual liv­ing with schizophrenia. Although, for many years, the study of schizophrenia focused on the strong biological foundation, more recent efforts have turned attention to the impor­tance of family and social support. Family behaviors relate to the course and treatment of schizophrenia (Lopez et al., 2004). Families’ reactions to an individual with schizophrenia posthospitalization have implications for recov­ery and relapse (Butzlaff & Hooley, 1998). Specifically, patients who enter an environment with families who demonstrate high levels of hostility, emotional overinvolvement, and criticism on discharge are more likely to relapse than patients who enter an environment with families who demonstrate low levels of hostil­ity, emotional overinvolvement, and criticism (Butzlaff & Hooley, 1998). Additional research found that the level of warmth displayed within an environment is directly related to relapse as well. Patients, posthospitalization, who return to an environment that displays high levels of warmth are less likely to relapse than patients who return to an environment that displays low levels of warmth (Ivanovic, Vuletic, & Bebbington, 1994).

Substance Abuse and Dependence. Family environment and familial relationships each have a robust connection to the onset and continuation of substance abuse among ado­lescents. “Specific aspects of family life and family relationships have strong and consistent connections to the initiation, exacerbation, and relapse of drug problems” (Rowe & Liddle, 2003, p. 97). Regardless of culture, numerous familial factors consistently predict adolescent substance abuse over time (Rowe & Liddle, 2003). Familial relationship factors such as poor parent-child relationships predict adolescent substance abuse (Brook, Brook, Arencibia-Mireles, Richter, & Whiteman, 2001), while parenting styles that encompass low levels of monitoring and poor parent-child communication are predictive of substance abuse initiation and continuation by adoles­cents (Liddle, Rowe, Dakof, & Lyke, 1998).

Existing mental health disorders also play a role in adolescent substance abuse. People who have two mental health diagnoses are considered to have “dual diagnosis,” and people with three or more diagnoses are con­sidered to have “multiple diagnosis disorder.” Mood disorders (depression) and anxiety dis­orders are commonly diagnosed as a dual diagnosis, with the other diagnosis being substance abuse (Greydanus & Patel, 2005). Not surprisingly, a review of the literature by Hawkins, Catalano, and Miller (1992) demonstrated that many of the same environ­mental and familial characteristics that lead to depression, anxiety, and even the relapse of schizophrenia are also linked to the onset and continued use of substances. Some of these factors include parenting styles that are too permissive, overly critical, inconsistent with expectations, fail to monitor behavior, and lack of maternal warmth; high levels of family conflict; and low parent involvement in child engagements and low parental warmth.

In summary, there is a great deal of overlap among the mental health disorders addressed in this chapter. One commonality is that each of these disorders can be viewed from the BMD meaning that biology, parenting, communication, marital discord, culture, and levels of stress, and environment each play a role in the process of these disorders. No one area can be labeled as the cause of a given mental health disorder, and we have seen how culture plays a role in the way people experi­ence, communicate, and even define mental ill­ness. A second commonality is that substance abuse and dependence is often a co-occurring disorder in people struggling with mood dis­orders (e.g., depression), anxiety-related disor­ders, and schizophrenia. A third commonality among these disorders is that family members often do not know how to support an indi­vidual with mental illness. They do not know how to effectively communicate with the individual who is ill; they do not know how to communicate with providers about their observations and fears; and they are often at a loss for ways to demonstrate support. A fourth commonality among these disorders is that family matters. In some cases, we have seen that parenting styles and family violence lead to maladaptive behaviors for children as they enter adulthood (high levels of depres­sion and anxiety). We have also seen that high levels of hostility, emotional overinvolvement, and criticism by family members have a direct impact on the recovery process for someone with schizophrenia. Additionally, evidence suggests that higher levels of warmth displayed by family members also have a posi­tive impact by reducing the chances of relapse for someone with schizophrenia. It seems, then, that sometimes family environment can shape the outcome of the onset of some types of mental illness, as well as be a critical part of the recovery process. The next section will address another way that families can affect the role of mental illness: prevention and treatment.