This investigation examined the effect of comorbid maternal depressive and anxiety disorders on maternal depression severity, kinship support, and child behavioral problems among African American families. A high frequency of comorbid anxiety disorders was found in our sample of African American mothers with depression. Specifically, we found that 58% of the mothers had comorbid depressive and anxiety disorders. This rate was slightly higher than rates of comorbid anxiety disorders found among asample of mothers with depression (43%) and a sample of African American mothers with depression (38%) in an epidemiological study in the United States [3
]. Similarly, in an Australian population-based survey, 37.9% of mothers reported high levels of both depression and anxiety [50
]. However, our rate is similar to the 60% rate of comorbid depressive and anxiety disorders in a sample of Chinese women [51
]. Clearly, comorbid anxiety is a prevalent condition that needs to be examined among African American mothers with depression.
Comorbid PTSD was the most common anxiety disorder, with a third of our sample of depressed mothers meeting criteria for a diagnosis. The frequency found in the present study is higher than rates in epidemiological studies ranging from 9.7-10.1% among women [52
]. It is not clear if race may account for the higher rate of PTSD in our sample compared to the epidemiological studies. For example, in one U.S. national study, PTSD diagnoses were more frequent among African Americans compared to other racial/ethnic groups [54
]; however, another U.S. national study did not find race differences for African Americans [55
]. The high frequency of comorbid PTSD suggests that the sample is vulnerable and high risk.
Additionally, our study showed that comorbid PTSD was associated with increased maternal depression severity. Similarly, it has been found that mothers with a history of trauma and victimization have been shown to exhibit more depression symptoms [56
]. The research literature shows some support for maternal PTSD impacting more than mother's presentation of psychiatric symptoms. For example, studies have linked parental PTSD with increased anxiety, depression, and maladjustment in children [57
]. It has been proposed that maternal history of victimization impacts child functioning through mediation of maternal depression [59
]. Although we did not find an association with comorbid PTSD and child behavior problems, future research should explore the potential impact of comorbid depression and PTSD on child functioning. It is possible that PTSD may impact child behavior through maternal depression severity and maternal depression severity acts as a mediator instead of a moderator in the transmission process.
PTSD was also associated with less kinship support. This is consistent with the research literature on social support in general. In a meta-analysis, perceived social support was negatively associated with posttraumatic stress symptoms [60
]. In a traumatized sample of individuals in motor vehicle accidents, social support was also negatively associated with PTSD numbing symptoms [61
]. Depression reinforces social isolation that leaves a mother feeling alone with few people, including extended family members, to turn to for support, encouragement, and help. Comorbid PTSD and depression likely exacerbates feelings of social isolation. Similarly, within our sample, maternal depression severity was negatively correlated with kinship support. These findings suggest a potential direct positive effect of kinship support on maternal functioning. This extends current research on social support for individuals with depression and/or PTSD.
A major finding showed that of all the comorbid anxiety disorders, two increased the risk of child internalizing behavior problems. Children of mothers with comorbid depression and OCD were more likely to have greater internalizing behavior problems than children of depressed mothers without comorbid OCD. This is a significant finding because there has been sparse investigation on the impact of maternal depression and OCD on child outcomes. One study that specifically tested for maternal depression and comorbid OCD did not find any effect on child psychiatric diagnoses [21
]. Overall, there are few studies examining maternal OCD and its impact on children; however, findings suggest that there are increased internalizing problems reported in children compared to mothers without psychopathology [62
]. Clearly, this is an understudied area which needs further research with a larger sample.
The other maternal comorbid anxiety disorder that was associated with increased child internalizing behavior problems was the diagnostic category including PD and Agoraphobia, although it was marginally significant. In accordance with this finding, a few studies have shown increased mood disorders among children of mothers with comorbid depression and PD with Agoraphobia [20
]. In one well-designed study, Bierderman et al. [64
] examined child outcomes among parents with comorbid depression and PD compared to depression only, PD only, and no psychiatric diagnosis. They found few differences in child outcomes among the parental psychiatric groups. Nonetheless, comorbid parental depression and PD was associated with increased occurrence of Separation Anxiety Disorder and multiple anxiety disorders in children. Another study demonstrated that children of mothers with comorbid depression and PD, compared to children with mothers with only depression or only anxiety disorders, are more likely to exhibit behavioral inhibition, a precursor to anxiety disorders [65
]. There is growing evidence of the negative consequence of comorbid depression and PD on child functioning.
The number of maternal comorbid anxiety disorders was correlated with maternal factors. The greater the number of anxiety disorders exhibited among depressed African American mothers, the more severe her depression and the less perceived kinship support. This is consistent with a United Kingdom study of mothers with recurrent depression that found that the number of co-occurring problems, including anxiety, was associated with increased maternal depression, as well as new onset child psychiatric problems [66
]. It is possible that depressed mothers with a greater number of anxiety disorders have more impairment and psychopathology that affects psychiatric and social functioning. Empirical evidence shows that psychiatric comorbidity is associated with increased severity of disorders [2
]. This is particularly relevant to African Americans, as the presentation of MDD has been demonstrated to be more severe and disabling for African Americans compared with European Americans [29
]. Additionally, our results indicate that comorbid Social Phobia increases maternal depression severity. In a sample of adults, it has been shown that comorbid Social Phobia, OCD and Panic Disorder with depression are associated with earlier onset of disorder, more hospitalizations, and more suicide attempts compared to only MDD alone [69
]. These specific psychiatric outcomes represent severity of disorder in a compelling manner with the demonstration of societal and personal costs. Future studies could benefit from examining severity of disorder by multiple indices.