Anxiety disorders are a really common mental health disorder, with a typical onset either before or during early adulthood (Penninx et al., 2021). Anxiety disorders are more common in girls compared to boys (Rutter et al., 2003), associated with lower socio-economic status (Lemstra et al., 2008), and linked to parental internalising problems, such as anxiety and depression (Telman et al., 2018). The likelihood of developing anxiety disorders is shaped by a combination of genetic factors, environmental influences, and their interactions (Penninx et al., 2021).

Parental mental health issues significantly correlate with psychiatric disorders in offspring, with the risk being transmitted through a combination of genetic and environmental factors (Beidel et al., 1997; McLaughlin et al., 2012). Some studies illustrate significant correlations between increased anxiety in children and parental psychopathology when compared to healthy offspring (Breslau et al., 1987; Goodman et al., 1994; Lewinsohn et al., 2000: Telman et al., 2018).

The risks associated with specific anxiety disorders, and whether these risks vary between different parental mood disorder subtypes, remains poorly understood. To address this, Tu and colleagues (2023) aimed to systematically review the existing literature and perform a meta-analysis to investigate the likelihood of anxiety disorders in offspring when their parents are diagnosed with mood disorders, encompassing both bipolar disorder and unipolar depression.

Methods

The researchers conducted a systematic review following PRISMA guidelines.  Studies were eligible if they:

• Were published in peer-reviewed journals
• Included offspring of parents with mood disorders (at-risk group) and offspring of parents without mood disorders (control group)
• Reported a number or percentage of anxiety disorders in offspring
• Reported that both parents and offspring received a diagnosis using clinician-rated diagnostic tools, specifically DMS-3 to 5 and ICD-8 to 10.

Studies were excluded if parents had physical or psychiatric conditions (e.g., cancer) that could influence the risk of offspring developing an anxiety disorder.

Two authors independently reviewed titles and abstracts of all records from the searches of the four databases. Following this, full-text screening was conducted to assess eligibility. The interrater agreement for screening results surpassed 99%.

Study quality was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. 24 studies were rated as ‘fair’ (susceptible to some bias) and 11 studies were rated as ‘good’ (least risk of bias). Studies rated as ‘poor’ (significant risk of bias) were removed.

The random effects model was used for the meta-analysis, which is a statistical method that can account for variability between studies. Overall risk ratios (RRs) were computed for various anxiety disorders, including any anxiety disorder, Social Anxiety Disorder (SAD), Generalised Anxiety Disorder (GAD), social phobia, specific phobia, panic disorder, and agoraphobia. To assess between-study heterogeneity, they employed the Paule-Mandel method.

Subgroup analyses and meta-regression were carried out on predetermined factors, drawing from existing evidence concerning the offspring in our research focus. These factors encompassed parent psychopathology, control condition, parent and offspring gender, offspring age, measures of anxiety disorder, and study design, particularly when there were a minimum of 10 studies.

Results

35 studies were included, comprised of 13 cross-sectional studies, 3 baseline data analyses from cohort studies, and 19 cohort follow-up studies. Studies either recruited children under 19 years old for their analyses, or focused on offspring ranging up to early adulthood. The study populations were predominantly of White ethnicity and located in high-income Western countries.

Main findings

Overall, offspring with parents experiencing mood disorders demonstrated elevated risks across all types of anxiety disorders (RR = 1.82, 95% CI [1.47 to 2.26]). Subgroup analyses indicated no significant difference in anxiety disorder risk when comparing offspring of parents with bipolar disorder to those with unipolar depression.

Lifetime rates of offspring anxiety disorders

Lifetime rates of anxiety disorders were markedly higher among at-risk offspring compared to control offspring. Notably, offspring of parents with mood disorders had a higher prevalence of various anxiety disorders compared to offspring of parents without mood disorders:

• 4% versus 10.0% for Social Anxiety Disorder (SAD)
• 5% versus 7.16% for Generalised Anxiety Disorder (GAD)
• 6% versus 9.32% for social phobia
• 2% versus 12.1% for specific phobia

Risk ratios of offspring anxiety disorders

The combined RRs from all analyses consistently pointed towards an elevated risk of various anxiety disorders in at-risk offspring compared to control offspring, except for agoraphobia:

• SAD: 1.75 (95% CI [1.37 to 2.24])
• GAD: 1.76 (95% CI [1.19 to 2.60])
• Social phobia: 1.51 (95% CI [1.12 to 2.05])
• Specific phobia: 1.44 (95% CI [1.11 to 1.87])
• Panic disorder: 3.07 (95% CI [2.19 to 4.32])
• Agoraphobia: 1.08 (95% CI [0.56 to 2.08])

Risk ratios of offspring anxiety disorders by parental diagnosis

Offspring of parents with bipolar disorder faced increased risks for any anxiety disorder (RR = 1.92, 95% CI [1.40 to 2.64]), SAD (RR = 1.85, 95% CI [1.12 to 3.07]), and panic disorder (RR = 3.27, 95% CI [2.06 to 5.19]).

In contrast, parental unipolar depression elevated risks for any anxiety disorder (RR = 1.54, 95% CI [1.27 to 1.87]), SAD (RR = 2.06, 95% CI [1.11 to 3.83]), specific phobia (RR = 1.41, 95% CI [1.17 to 1.71]), and panic disorder (RR = 3.39, 95% CI [2.18 to 5.25]).

Notably, risk of GAD, social phobia and agoraphobia showed no significant increase for offspring of parents with mood disorders.

Factors associated with higher risk

Several factors correlated with elevated risks of certain anxiety disorders in offspring, including:

• The absence of anxiety disorders in control parents
• Younger offspring age
• Specific parent/offspring sex.

Conclusions

Overall, this comprehensive analysis highlights the substantial impact of parental mood disorders on the increased risk of anxiety disorders in offspring. The analysis suggests a precise estimate of parental mood disorders on offspring anxiety disorders, while providing information regarding the different types of anxiety disorders. The findings underscore the importance of considering specific anxiety disorders, parental diagnoses, and associated factors in understanding and addressing intergenerational mental health outcomes.

Strengths and limitations

Strengths

• The study addressed a gap in existing literature and built upon previous research, providing evidence for higher risks of nearly all types of anxiety disorders among the offspring of parents with mood disorders.
• The study’s strength lies in its clear inclusion criteria, ensuring a focused examination of the relationships between parental mood disorders and specific anxiety disorders. Clearly defined inclusion criteria narrow down the study’s scope, allowing researchers to examine the research question with precision and controlling confounding variables and without unnecessary variability.
• The researchers used realistic pooling methods with multiple corrections, enhancing the robustness of their findings by incorporating various studies that provide data for different anxiety disorder subtypes, which indeed means we can have more trust in their findings.
• The high interrater reliability for screening results suggests that the reviewers consistently applied the inclusion criteria, enhancing the reliability of the study’s conclusions.

Limitations

• A notable limitation is the predominantly White sample population from high-income Western countries. This limitation raises concerns about the generalisability of the results to a more diverse or global population.
• While the study included numerous studies, it failed to acknowledge the potential impact of small sample sizes on the robustness of the findings. This omission could affect the generalisability and reliability of the results. If the sample size is larger, the review might achieve increased statistical power, potentially leading to more robust and statistically significant findings.
• The inclusion of studies using diagnostic criteria ranging from DSM-III to DSM-5 and ICD-8 to ICD-10, especially for anxiety disorders, introduces inconsistency in the data. Changes in diagnostic criteria over time could influence the comparability of studies and affect the overall coherence of the findings. For example, in the DSM-IV, agoraphobia was typically considered a criterion for diagnosing panic disorder but in the DSM-5, this specific criterion has been dropped, meaning that people may experience panic attacks and agoraphobia independently, leading to a more nuanced understanding of those conditions (Substance Abuse and Mental Health Services Administration, 2016).

Implications

This meta-analysis holds significant relevance for mental health professionals and those involved in delivering mental health interventions. The identified relationship between parental mood disorders and offspring anxiety disorders provides valuable insights that mental health practitioners can integrate into their practice. Understanding these risk factors and underlying mechanisms aids mental health professionals in tailoring treatments and interventions according to the family background and specific needs of their clients.

Practical applications

• Deeper understanding of risk factors: Mental health professionals can use these findings to develop a deeper understanding of the risk factors associated with children’s anxiety disorders in the context of parental mood disorders. This knowledge can guide more targeted and effective interventions.
• Tailored treatment approaches: The study suggests that considering family background, especially parental mood disorders, is crucial in developing treatment strategies. Mental health professionals can use this information to tailor interventions to the specific needs and challenges faced by individuals with a family history of mood disorders.
• Proactive prevention and early identification: The highlighted value of proactive prevention and early identification strategies is essential for mental health practitioners. Armed with this knowledge, they can work towards implementing preventive measures and early identification protocols to reduce the risk of anxiety disorders in children of parents with mood disorders.

Areas for future research

• Generalisability to diverse populations: The study underscores the need for more research to explore the generalisability of the findings to a wider population. Mental health professionals should remain attentive to potential variations in the relationship between parental mood disorders and offspring anxiety disorders in non-White populations and outside Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries.
• Cross-cultural perspectives: Future research could delve into cross-cultural perspectives to assess whether cultural differences impact the observed relationship. Understanding how cultural factors influence mental health outcomes can inform more culturally sensitive interventions.

Statement of interests

None.

Links

Primary paper

Tu, E. N., Manley, H., Saunders, K. E., & Creswell, C. (2023). Systematic review and meta-analysis: risks of anxiety disorders in offspring of parents with mood disorders. Journal of the American Academy of Child & Adolescent Psychiatry.

Other references

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Lewinsohn, P. M., Rohde, P., Seeley, J. R., Klein, D. N., & Gotlib, I.H. (2000). Natural course of adolescent major depressive disorder in a community sample: Predictors of recurrence in young adults. American Journal of Psychiatry, 157, 1584–1591.

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McLaughlin, K., Gadermann, A., Hwang, I., Sampson, N., Al-Hamzawi, A., Andrade, L., . . . Kessler, R. (2012). Parent psychopathology and offspring mental disorders: Results from the WHO World Mental Health Surveys. The British Journal of Psychiatry, 200(4), 290-299.

Rutter, M., Caspi, A., & Moffitt, T. E. (2003). Using sex differences in psychopathology to study causal mechanisms: unifying issues and research strategies. Journal of Child Psychology and Psychiatry, 44(8), 1092-1115.

Substance Abuse and Mental Health Services Administration. (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. Rockville (MD): Substance Abuse and Mental Health Services Administration (US).

Telman, L. G. E., van Steensel, F. J. A., Maric, M., & Bögels, S. M. (2018). What are the odds of anxiety disorders running in families? A family study of anxiety disorders in mothers, fathers, and siblings of children with anxiety disorders. European Child & Adolescent Psychiatry, 27(5), 615–624.

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