Since the early 1990s, the burden of depression has been rising and approximately 350,000 Danes were estimated to suffer from depression in 2010 (12-month prevalence: 6.9%) . In 2002, a study showed similar depression rates among US parents and the US adult population (12-month prevalence: 7.2% (Diagnostic and Statistical Manual of Mental Disorders, fourth ed., DSM-IV)) . According to a cohort study including 350 general practices in the UK from 1993 to 2007 , 39% of mothers and 21% of fathers had experienced a depressive episode by the time their children turned 12 years old.
Children of depressed parents have an increased risk of experiencing psycho-social or cognitive impairments during childhood , adolescence  and adult life  and of experiencing somatic diseases (e.g. allergic and cardiovascular conditions) . They often cope by silent adaptation, leaving them alone in a stressful situation [2, 7], and their risk of developing depression in late adolescence is two- to four-fold higher than the risk for offspring of non-depressed parents . The balance between risk and protective factors is important for a successful outcome in adulthood, and social support may promote resilience, i.e., promote a normal life trajectory despite adversity [8, 9]. A negative pathway may be prevented, and a recent study demonstrated that multiple protective factors may reduce mental health problems in adolescents with a parent with depression .
Parents’ reports of a child who internalises problems from two to five years of age may predict internalising in late childhood , and early childhood social withdrawal is a risk factor for depression in young adulthood . Headache and feeling stressed  can also be predictors.
Children of parents with depression are under-recognised in primary care [14, 15]. A British study demonstrated that only 37% of the children who met the criteria for psychiatric disorder were in contact with any service , even if their depressed parents were well-known in general practice.
In Denmark, the local authority’s social services are responsible for supporting these children as necessary; however, we hypothesised that Danish primary care practices have an under-utilised potential for improving the outcomes for children of depressed parents by offering relevant advice to parents in order to promote protective factors [2, 8-10]. Thus, this study aimed to explore Danish general practitioners’ (GPs) professional attention and support to children of parents with depression.
This was a survey study performed among Danish GPs.
Based on a literature study and preliminary GP interviews, a two-page questionnaire was constructed counting 11 main questions related to the respondents’ demographic data, followed by questions about interests, professional attitudes, perceived knowledge, clinical behaviour, interventions related to children of parents with depression, and potential barriers. The questionnaire is available as an appendix .
The questionnaire wording evolved through a process of continuous interaction and refinement with qualitative pilot testing during interviews with seven GPs. The primary quantitative pilot test was performed by mailing the questionnaire to all of the 46 GPs in two small communities. After the relevant clarifications had been made, a second pilot test was carried out among 32 GPs, which revealed no need for further adaptations. The questionnaire was designed to allow optical data recording.
The questionnaire was mailed to a random sample comprising 50% of all Danish GPs. Participants were offered a fee. A reminder was mailed, and in case of incompletion, follow-up was established by telephone or mail. Data from the second pilot test were included in the final dataset.
Statistical analyses were performed using STATA (version 11.2). The representativeness was established by means of information from the census of the general practices in 2011, and standard (Pearson’s) chi-squared tests were used for the analysis. The GPs were asked to estimate the frequencies of specified professional actions on a five-point scale or to give self-assessments on a four-point Likert scale with the categories adequate, fairly adequate, limited and minimal, and these answers were subsequently dichotomised.
Factors affecting the GPs’ awareness of and attention to the children were analysed by logistic regression as no data were normally distributed. First, “assessment of relevance” was analysed as a dependent variable combined with GPs’ gender, age and regional
location. Second, “perceived knowledge about the significance of parental depression” was analysed in relation to gender, age and “assessment of relevance”. Finally, associations between “attention given” and gender, age, knowledge and assessment of relevance were examined. Data on “topics of conversation” and attitude statements were summarised. Analyses were performed on complete data only.
This study was approved by the Danish Data Protection Agency (R.nr. 2010-41-4604). In Denmark, questionnaire surveys do not require ethical approval.
Trial registration: not relevant.
Of the 1,827 GPs invited, 67 GPs were lost due to incorrect addresses, retirement or absence. The response rate was 51%. Of the 890 respondents, 486 (55%) were male GPs. Male GPs account for 59% of the Danish GP population (n = 3,595). Thus, female respondents were slightly overrepresented (p = 0.02).
Male GPs are generally older (66% > 55 years) than female GPs (39% > 55 years; p < 0.01). Male respondents had a mean age of 54.6 (range: 34-73) years. Female respondents’ mean age was 50.9 (range: 37-69) years.
The age groups among female respondents were representative of the age distribution in the female
GP population (p = 0.37). Male respondents were younger than the male GP population (p < 0.01) and, thus, younger males were slightly overrepresented.Follow-up on incomplete answers resulted in missing values ≤ 2% for all variables.
Comparison of early and late respondents showed no group differences .
Attitudes towards and attention given to children of parents with depression
In total, 94% of the respondents found it relevant to give attention to the children when a parent is sick-listed for depression (Table 1)
. Gender differences were evident in the assessment of the relevance of giving attention to 0-1-year-old children and to 15-18-year-old children, as female GPs assessed attention to these age groups to be more relevant than male GPs (Table 1). In total, 68% of the respondents reported asking about the child’s well-being during a consultation with a depressed parent (Table 1). Gender differences were even more marked in the reports of the child as a topic of conversation than they were in the assessment of the relevance of giving attention to the child during the consultation.
The potential topics of conversation between GPs and parents were assessed by the GPs. The per-centages which GPs reported for their consultations are described in Table 2
. The most frequently addressed topics were general questions about the child’s well-being and recommendations of openness about the depressive disorder, and a seldomly mentioned topic was child complaints relating to physical health. GP agreement about the statements is shown in Table 3
Three statements achieved agreement rates exceeding 90%: Children will be affected by parental depression, and they need help to understand their situation; talking about the children and the parental roles is part of the treatment; GPs wish for a possibility to refer the child to a relevant offer.
Furthermore, two thirds of GPs agreed to the following statement: I would find it desirable if, from now on, we could offer help by talking to the children, and the barrier statement with the highest score was: no more GP time.
Perceived knowledge about the significance of parental depression for the child
In total, poor knowledge of the potential consequences of parental depression for the child was reported by 39% of GPs (Table 1).
Statistically significant gender differences were shown. Female GPs reported sufficient knowledge more frequently than male GPs, as described in Table 1. Regardless of the existing knowledge, 41% reported to be highly interested in learning more about the significance of parental depression for the child. The gender differences were obvious as half of the female GPs and only a third of the male GPs wished to increase their knowledge. Moderate interest was reported by 51% and little interest by 8% of the respondents (Table 1).
The level of perceived knowledge was associated with the GPs’ attention given to the children: GPs with sufficient perceived knowledge addressed the children’s well-being more frequently than GPs with poor perceived knowledge. The strongest association between perceived knowledge and attention given was shown for 15-18-year-old children (Table 4)
In this study, GPs in general assessed that parental depression will affect children and thus found it relevant to give professional attention, but only two thirds of the GPs actually addressed the children during consultations with depressed parents. The GPs wished for better future help to these children.
Poor perceived knowledge of the potential impact of parental depression was often reported, and perceived sufficient GP knowledge was significantly associated with addressing the children during the consultation with the parent. Female GPs reported a significantly higher focus on these children than male GPs.
Strengths and weaknesses
The survey was mailed to 50% of Danish GPs, consti-tuting a large sample. The share of missing values was below 2%, indicating a successful questionnaire construction with well-understood questions.
The individual responses may be biased in more respects: the nature of this survey was subjective, which may predispose respondents to report their ideal intention rather than their actual professional behaviour, i.e., social desirability bias may be present. Recall bias may also be present: respondents were asked to estimate frequencies, but when no routines exist, precise recall is difficult, and both under- and overestimation can be expected. Furthermore, these subjective assessments may vary over time, depending on the prevalence of depressed patients in the consultation.
With responses from 25% of all Danish GPs, the data material is solid. Early respondents and late respondents showed no differences; assuming that there is correspondence between late respondents and non-respondents , this study should be representative of the GP population. However, selection bias is present as female GPs and younger GPs were slightly overrepresented in the study; female GPs gave markedly more professional attention to children of depressed parents than male GPs. Similarly, younger GPs were more aware of the children’s needs than older GPs. In conclusion, this study presumably overestimated the professional attention given to children of depressed parents.
Comparison with existing literature
In our study, GPs assessed that children will be affected by parental depression and will need support to minimise potential impairment. This assumption is in line with findings in other studies [7, 15, 18]. A British study  recommends a possibility for advice from health visitors independently of the children’s age, which is in line with the marked wish in our study for a possibility to refer the child to a relevant offer.
A number of studies [15, 19] have demonstrated a lack of recognition of child and adolescence mental illness and these studies describe a large group of children of parents with depression. This study differs as it focuses on children at risk of developing mental illness.
Our study concentrates on facilitation of support to general protective processes in the children’s everyday lives in order to prevent the development of mental illness.
In our study, the two most important reported barriers were lack of time and perceived poor knowledge, which is in line with the findings in a US study among paediatricians  in which lack of time to identify and treat mental health problems as well as lack of feeling secure and lack of training in treatment of mental health were described as the most important perceived barriers for recognising and treating problems in children of depressed mothers.
In this study, the GPs expressed a marked interest to offer better future support to children of parents with depression, which indicates an individual motivation to improve these children’s situation.
An increased organisational awareness could facilitate the individual, professional GP efforts.
Recommendations for good clinical practice are encompassed in the official clinical guidelines for diagnostics and treatment of depression in general practice . However, the guidelines provide no information about and give no focus to the potential impact of parental depression on a child. Incorporation of the child focus into the guidelines is highly recommendable. Furthermore, distribution of information regarding risk factors and potential support methods for these children should be integrated into medical education at different levels.
The burdens experienced by these children can be reduced by offering them age-appropriate information about depression, by conveying to them that they have no responsibility for the parental depression and by telling them that relevant adults help the parent to overcome the depression .
Given the actual conditions, possibilities for GP support to these children exist. GPs could give information and advice to a parent in order to ease the child’s situation by reducing stress, concern and loneliness and thus improve the child’s well-being .
Social support to these children is of great importance , and GPs can encourage the parents to ask their family network and other adults in the children’s everyday lives to contribute actively to supporting the children and give them the opportunity to maintain their usual activities . Multiple supportive and caring factors in combination (in home, daycare and school) will increase the protection of the child .
This study showed a significant potential for improving the attention given by GPs to children of depressed parents. The overwhelming majority of GPs assessed that giving attention to these children was relevant, while two thirds of the GPs actually addressed the children. Sufficient perceived knowledge of the potential impact of parental depression was crucial for the attention given to the children.
CORRESPONDENCE: Kirsten Hansen. E-mail: firstname.lastname@example.org
ACCEPTED: 14 May 2018
CONFLICTS OF INTEREST: none. Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk
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