Dr Victoria Powell Hi, I’m Dr Vicky  Powell. So I am a Research Associate,   based at the Wolfson Centre for Young People’s  Mental Health at Cardiff University and today,   I’m going to be talking about the effect of  parental depression on child mental health. So,   a bit about me to start. I did my PhD  at Cardiff University a few years ago,   looking at the relationship between ADHD,  attention deficit hyperactivity disorder,   in childhood and depression in life. But,  broadly, I’m quite interested in, kind of,   risk and protective factors for depression in  young people and, also, later on in life, as well. I work mainly from a, kind of, developmental  perspective, looking at different life   stages, across the lifespan, and I  also work, kind of, in a, sort of,   epidemiology-focused type way, as well. So,  at the moment, what I’m working on is mainly   looking at prevention of depression in young  people. So I’m working on a clinical trial   that I will tell you a little bit more  about during the talk today, as well. I’m based in the Cardiff University School of  Medicine, Child and Adolescent Psychiatry Group   for research, and also at the Wolfson Centre,  as I say. So, this is a research centre that   was established with funding from the Wolfson  Foundation, and it’s focused on understanding,   kind of, causes of youth mental health,  thinking about ways we can intervene and help,   focused quite specifically on depression and  anxiety. But we also look at other things,   particularly neurodevelopmental  disorders, as well, such as ADHD. So, what will I be covering today then? The  talk is, kind of, covering three different   sections. So, I’ll start with a, kind of, broader  introduction to depression, parental depression,   and impact on offspring, so a bit of a refresher  of the epidemiology of depression here,   as well. Then I’ll be moving onto talking about  some recent work in the EPAD cohort. So this is   the Early Prediction of Adolescent Depression  study, and I’ll be talking you through some work   I’ve done in this study, which is a cohort of  the offspring of recurrently depressed parents.  And then I’ll be moving onto  talking about my current work,   focused largely on a clinical trial  called the SWELL trial, and this is   a clinical trial aiming to prevent depression,  or reduce depression symptoms, in young people   who are at elevated risk, mainly through  having a parent with a history of depression. This is, kind of, quite a basic, kind of,  introduction, but what is depression? So,   you’ll probably be familiar, I imagine, with  the diagnostic manuals for depression. So,   namely the ICD-11 that we use more over here in  Europe, but also the DSM-5 that’s used in America,   as well. So, these, kind of, lay out a really  useful guideline for how to diagnose depression,   but perhaps don’t capture, kind of, all  the heterogeneity we see in depression   presentation between different people.  And these are the diagnostic manuals I,   kind of, use quite a lot during my  research, so when I refer to, kind of,   research diagnoses of depression later in the  talk, I’ll be using these kinds of frameworks. These frameworks, or diagnostic criteria,  include several symptoms that you’d expect   to see in somebody who has depression. So,  the key one, kind of, being low mood, also,   lack of enjoyment in things previously enjoyed,  as well as a few other symptoms, such as reduced   energy, appetite change, weight change, sleep  problems, suicidal thoughts, plans or attempts,   other symptoms, such as difficulty concentrating  and feelings of worthlessness or guilt. What’s important to note, I suppose, that  depression doesn’t just present as a, kind of,   yes/no, you have the diagnosis, but it’s also  a continuous trait within the population. And,   in fact, those with subthreshold symptoms,  so symptoms that don’t meet the, kind of,   stricter diagnostic criteria for depression,  still are at an increased risk of going on to   have a full-blown disorder later on, and  also experience other adverse outcomes. So, obviously we know that depression is, kind  of, classed under this umbrella of mood disorders.   It, sort of, has a relapsing and  remitting course over time. So,   people might experience several episodes  during their lifetime, but have other times   where they’re feeling perhaps better. And  as I, kind of, briefly mentioned earlier,   it’s a heterogenous disorder, so it’s not  going to look the same from person-to-person,   and this is a really important consideration  to have when doing research in this area. The other thing to note is that, sort of, the  rates of depression increase sharply during   adolescence, and this is particularly true for  girls. So this is when we start to see a gender,   kind of, difference emerging  in the rates of depression. [Pause] And why is depression important? Well,   depression is a leading cause of disability  worldwide, and has a huge burden in terms of,   kind of, days with – lived with disability  over the life course. And, kind of,   moving onto why parental depression is  important then, so I’m based in Wales,   so looking from a Welsh perspective, but this is,  sort of, true to what we see in the UK, as well. So, in Wales, 35% of mothers have a history of  depression and 18% of fathers or stable males,   so a male that was living in the same household,  kind of, for a significant period of the child’s   life, also have a history of depression, according  to findings that look at routinely collected data   across the population of those registered with  a GP in Wales. And approximately half of young   people diagnosed with depression have a  parent with a history of depression. So,   as you can see, this is actually quite a common  group and an important group to consider. So, in terms of other reasons why parental  depression is important, we know that there   is an increased risk of mental health problems,  particularly mood and anxiety disorders in the   offspring of depressed parents. They are two  to four times more likely to have depression   themselves, and having a parent with depression  also affects the severity and course of disorder   in offspring. So they’re likely to have a, kind  of, more severe presentation of depression. The other reason that parental depression  is important is we know from reviews of   prevention interventions in young people that  prevention techniques that are targeted at high   risk populations tend to be more effective.  And one of these high risk populations,   of course, is the children of depressed parents. So, moving on then to some recent work I led on   in the EPAD study, so just to remind you, that’s  a cohort of the children of depressed parents. So,   I conducted this work, kind of, following the  children of depressed parents from childhood   to adult life, focusing on mood and anxiety  disorders in these children. And the EPAD study   followed the children of depressed parents and  their parents, as well, over a period of around   13 years, so spanning from 2007 to 2020, and  there were four, kind of, waves of assessments. So, at the baseline, there were about 337  families, with a parental history of depression,   who were assessed using, kind of, interviews  and questionnaires, gathering really rich   data on their symptoms and other related  traits. And then they were followed up,   the same families again, about a year after that,  and then, again, another year after that, and then   there was a sort of more adulthood-focused  follow-up around eight years later. So,   we, kind of, have data that covers childhood,  through to adolescence, through to adulthood. So, to give you some background on this work,  the risk of mental health problems, as we know,   is increased in the offspring of depressed  parents, particularly mood and anxiety disorders.   And the transition period from adolescence  to adulthood is a period of vulnerability,   when the rates of psychiatric disorder  increase. And it’s also a time of, kind of,   tumultuous social change for individuals,  so moving from, kind of, the family home   with your parents and becoming independent,  maybe going to university or getting a job. So, this is a really important period to look  at in the offspring of depressed parents,   but we don’t actually have many previous studies  looking at this period in these offspring,   particularly using, kind of, multiple assessment  timepoints to track this transition. So,   the aim of this work was to examine the  prevalence and course of psychopathology,   namely anxiety and depression, from mid-childhood  through to adulthood, so spanning the ages of nine   to 28, in this sample of young people who have  a parent with a history of depression. And we   also wanted to investigate social functioning  in adulthood, so age 18 to 28, and how this,   kind of, related to prior psychiatric disorder,  or current psychiatric disorder, in the offspring. So, how did I go about this then? So, as  I said, we used the EPAD study. So this is   a study of 337 families, so 337 offspring,  aged nine to 17 years old at the baseline,   who were then followed prospectively at four  assessment waves, spanning 13 years in total. We   mainly used, for this study, this measure called  the Child and Adolescent Psychiatric Assessment,   and this is a really detailed clinical  interview, from which you can derive,   sort of, research DSM diagnoses of depression,  anxiety and other mental health conditions. And we   also used questionnaire measures of other things,  particularly the social outcomes in adulthood. So, one thing to note with this study is, as you  can see, there was a wide age range. So offspring   were aged nine to 17 at baseline, so we had a wide  age range at each subsequent wave. But for this   study we wanted to look at developmental  patterns, by developmental stage. So,   what we did was we calculated the prevalence of  disorders, by age group in years, rather than   by wave, and in order to do this, we had to do  something called ‘clustering’ in our analyses. So, clustering on the ID of each participant, to  account for participants that might have occurred   in the same age group at multiple waves. So,  for example, if I wanted to look at childhood,   adolescence, adulthood, etc., there  might be some participants who were   still in that childhood group at waves one  and waves two, because of their age. So,   all analyses, kind of, accounted for that  and clustered people on their ID number. So, this is a very rudimentary diagram of what  the EPAD data looks like. So, we have around   300 families who stayed with us through waves  one to three, ‘cause these happened in quite   quick succession, so there was around a year gap  between each of these. But then, at wave four,   which happened around seven to eight years  later, there was a bit of a drop-off in numbers,   because of this longer time lag, so we have  about 200 families participating by this point. So, when I looked at the data by age and years,  what I ended up with was lots of young people who   had data in, kind of, the late childhood,  early teenage years and then a, sort of,   drop-off in data available later into  adulthood. So, one way of tackling this   is to then group these data into, kind of, age  groups. So, I ended up with a childhood group,   an early adolescence group, a late adolescence  group, transition to adulthood group, that we’re,   kind of, interested in for this research, and  then this mid to late 20s group, as well. So,   you can see the numbers of participants in  each of these age groups at the bottom there. So, moving onto the results of this study.  Firstly, we wanted to look at the prevalence   of mood and anxiety disorders from childhood  to early adulthood. So, for mood prevalence,   what we found was around 25% of the  offspring, so quite a high number,   met criteria for a current mood disorder, at  least once during the course of the study. And   if you break this down by those age groups that  I derived, you can see that, as we might expect,   this was less common in childhood, kind  of, increasing through adolescence and,   sort of, beginning to peak at the transition to  adulthood and then peaking in the mid to late 20s. And I suppose one thing to note is that at each  age group, these numbers that we were seeing,   for prevalence of mood disorder, were higher  than you’d expect in the general population,   based on reports from the general population.  So, kind of, showing this increased prevalence   of these disorders in these offspring. When I  looked specifically at major depressive disorder,   being the, kind of, most common mood disorder,  we see a similar pattern. So, kind of,   less common in childhood, increasing through  adolescence, and peaking in the mid to late 20s. For anxiety disorders, we saw a slightly  different pattern. So, a third of the offspring   met criteria for a current anxiety disorder  at least once during the study, so, again,   quite a high rate. And we see that these – that  the prevalence is, sort of, higher in childhood,   as we might expect, than mood disorders, and  it, kind of, seems to drop down a little bit   during early adolescence, before rising again  during later adolescence, and peaking, kind of,   maybe a little bit earlier than the mood  disorder, so at the transition to adulthood. When we look at generalised anxiety disorder,  again, as, kind of, being one of the most common   anxiety disorders, we see a pattern that’s more  similar to what we saw with the mood disorders,   I suppose. So, less common in childhood,  before increasing through adolescence,   and then peaking at this transition to adulthood. So, another thing I looked at was breaking down   these results by sex, so looking at males and  females separately, and apologies for all the,   kind of, numbers in the table. But one of the  interesting things to note in this study was   that these, kind of, sharp increases  in prevalence that we were, sort of,   seeing around the transition to adulthood  in mood and anxiety disorder seemed to be   happening slightly later for males than for  females, so I’ve sort of highlighted in bold   for comparison here. But for mood disorders,  for example, we see a sharp increase in the   rate of mood disorders during late adolescence,  as you might expect, but this doesn’t seem to   happen for males, until the transition  to adulthood, so around 18 to 22 years. For anxiety disorder, again, this sharp  increase in anxiety disorder seems to be   happening for females in early adolescence,  whereas it doesn’t seem to happen until late   adolescence for males. And another interesting  point was that, as I touched on earlier,   we know there’s a female preponderance  typically of depression. But in this sample,   what we saw actually that was – once  these rates had increased in males,   they remained similarly quite high in the mid to  late 20s and later on, as they did for females,   so if not even a little bit more prevalent in  males later on in adulthood than for the females. And that brings me onto my next, kind of,  section of results for the EPAD study. So,   we also wanted to look for these mood and  anxiety disorders at the age at which they   were first diagnosed, the, kind of, course they  followed over time, and patterns of comorbidity,   as well, so, like, co-occurrence with  other disorders at the same time. So, with the age at first diagnosis  findings, I guess the key finding   was that it varied really very widely.  So, as you can see, for mood disorders,   the age at first diagnosis within the study  ranged from nine to 26 years old. So a really,   really big age range there and this was seen  similarly for anxiety disorders, as well. And   I guess one thing to note is that some of  these ages at onset were really very young,   compared to what we’d expect from the general  population. So, for example, one child in the   study had their first research diagnosis in this  study of major depressive disorder at only ten   years old. So really, we’re observing quite  young ages at first diagnosis in this sample. And in terms of the course that  these disorders followed over time,   so even though these young people were still  quite young really at the end of the study,   so from 18 to 28 years old at the end of the  study, over 7% of them had had more than one   episode of mood disorder, across the four study  assessment waves. And over 13% of the sample had   met criteria for anxiety disorder at, at least  – at more than one assessment wave, as well. And comorbidity was very, very common.  So, of those who had a mood disorder,   over 70% of them had another psychiatric disorder  that they met criteria for, at the same time,   and for anxiety, this figure was over 60%.  And just to break down, kind of, the types   of comorbidity we saw in the study there, as you  can see, kind of, of the comorbidity types we saw,   mood and anxiety comorbidity was by far  the most common, followed by having,   kind of, more than one type of  anxiety disorder concurrently. And this, sort of, plots the rates of mood  disorder comorbidity over time, or over,   sort of, age group, compared to having  a single mood disorder on its own. So,   as you can see, for mood disorder comorbidity,   this was more common than just having one mood  disorder on its own, across each age group. For anxiety disorder, the pattern was a little  bit different. So, while in, kind of, childhood,   having a single anxiety disorder and no  other concurrent disorder was more common   than having a comorbid presentation. As  we moved into adolescence and adulthood,   comorbidity became the more common presentation. And the final, sort of, section of results for  this work we’re looking at social functioning,   impairment, and risky health behaviours in early  adulthood. Really, I guess, the key takeaway from   this is that poor outcomes in early adulthood,  sort of, socially speaking, for these offspring,   were really very common. So, over half of the  offspring had, sort of, impairment in their daily   functioning by their early adulthood, so age  18 to 28. And nearly 10% had reported a recent   suicide attempt, or deliberate self-harm. Nearly a  third had, kind of, harmful levels of alcohol use.   Nearly a quarter, kind of, reported poor social  support, so they reported only having one person,   or no-one, to rely on for social support. On the other hand, sort of,   education and employment outcomes didn’t look  quite so bad in the offspring of depressed   parents. So, nearly 60% had completed a degree  or were currently in university, while only 15%   were not in education, employment or training. I  suppose it’s important to note that we had that   bit of dropout by wave four in this study, due to,  kind of, the later timepoint of data collection,   and, sort of, parental education was found,  I think, to be associated with that dropout   slightly. So, it might be possible that the more  educated, kind of, families were retained to a,   kind of, greater extent by this timepoint,  so that might be affecting results there. And in terms of how, sort of, prior and current  disorder in the offspring affected these social   outcomes in early adulthood, we found that both  previous and current mood and anxiety disorder   in the offspring were significantly associated  with this impairment in daily functioning in   adulthood. Current mood and anxiety disorder  was also associated with the recent suicide   attempt or deliberate self-harm. Both  previous and current mood disorder or   anxiety disorder were associated with being,  kind of, less likely to complete a degree,   or be currently in university. And only  current mood or anxiety disorders seemed to be   significantly associated with increased likelihood  of being not in education, employment or training. So, moving onto discussing these results  then. Really, one of the key takeaways from,   kind of, looking at the prevalence over  the different age groups was we could see   that the risk period for the onset of  mood and anxiety disorders was really   very prolonged in the offspring of depressed  parents. Extending from childhood all the way   through to adulthood, with prevalence,  sort of, peaking in early adulthood. The transition period from adolescence to  adulthood was a key emerging point for mood   and anxiety disorders, particularly in males.  The age of onset of disorders varied widely,   and comorbidity was very common. And high rates  of poor social outcomes in early adulthood were   observed, some of which were associated with  prior and/or current mood or anxiety disorder. So, some strengths of this particular study  were we had detailed clinical measures,   over multiple assessment waves, spanning  13 years. This cohort, the EPAD cohort,   is the largest cohort that we know of, of the  offspring of parents with major depression.   Some limitations of this study, however, are  the attrition that I referred to earlier,   so the loss of certain participants over time.  We did not have a control group in this study,   as we looked only at the offspring  of depressed parents in this cohort. And, thinking about the implications of  this work then, I suppose we already know   from previous studies, and from, kind of,  policies, including those put forward by the   World Health Organization, that the offspring  of depressed parents should be considered for   prevention and early intervention programmes.  This study, sort of, adds to that and, also,   highlights that such interventions may need to be  delivered or considered over sustained periods,   and the need for prolonged vigilance in this  group of the offspring of depressed parents. So, that brings me onto the next section of my  talk. So, currently, what I’m working on is a   clinical trial of a preventative intervention in  young people who have a parent with a history of   depression. So, this trial is called the SWELL  trial, that stands of the Skills for Adolescent   WELLbeing, and I’m going to talk you through,  sort of, what we plan to do in this trial. So, this trial sits under a workstream at  the Wolfson Centre called Interventions and   Adolescence at High Familial Risk. And the core  aim of this workstream is to develop and test   intervention to support young people, and their  families, where a parent suffers from depression. To give you some background on this work, in the  children of parents with a history of depression,   we know from the previous parts of my presentation  that they’re at increased risk of depression,   and CBT-based depression prevention  approaches appear to be promising in this   group. One programme that’s shown particular  benefit is the Coping with Stress programme,   and this is a group-based cognitive  behavioural therapy, or CBT, programme. And Garber and colleagues, who ran a large  randomised controlled trial over in the US,   back in 2009, found that this intervention was  effective in preventing the onset of depression,   but not when the young person’s parent was  currently depressed at the start of the study.   So it seemed to be less effective for young  people whose parent was currently depressed,   though all of the young people in the study  had a parent who had a history of depression. So, with this in mind, we made a few updates to  the intervention for the SWELL trial. Firstly,   we’ve added this parent depression  treatment optimisation phase,   for parents who are depressed at the start of the  study, prior to the young person being randomised   to the preventative intervention. And this is  to address that finding from the Garber study,   where they found that current depression in the  parent modified the effects of the intervention   for the young people. And really, we’re aiming  to get the parent into the best possible place   we can, before the young person starts their  intervention, and we hope that this means it will   work better for the young person. But the parent  will still remain in the study, and their child,   regardless of whether they recover or not  at the end of this optimisation phase. And we’ve also adapted the trial, adapted the  trial intervention, for scalability within a,   kind of, modern, UK, NHS context. So,  it’s been shortened from eight months   to five months overall. It’s also been – it’s  also going to be delivered online, sort of,   over a Zoom-like platform, rather than in person. So, to give you an overview of the  SWELL intervention and what it, kind of,   involves. It’s a psychoeducational group,  CBT, delivered, as I say, over Zoom. It will   involve groups of six to eight young people  being, sort of, guided through sessions by a   trained Therapist. There will be eight lots of  weekly sessions that are 90 minutes in length,   covering, kind of, various cognitive restructuring  type skills, and this will be followed by three   lots of monthly continuation sessions. So these  will allow an opportunity to consolidate what   they’ve learned in the weekly sessions and, kind  of, troubleshoot any issues they’ve been having. So, the first sessions provide  an overview of depression,   its relationship to stressful situations, and  then introduce the group members to each other,   of course. And then the sessions move  onto focusing on training and cognitive   restructuring skills, sort of, focused on  techniques for modifying negative thoughts. And so, the aims of this study then, are to test  the effectiveness of this SWELL intervention for   the prevention of depression episodes in young  people at an increased risk for depression.   And we also want to test the effect of  the intervention on secondary outcomes,   such as symptoms of depression and anxiety.  And if the intervention works we want to know,   you know, why it works and how it  works, so we will also be exploring   potential mechanisms through which the  intervention might have its effect and,   sort of, factors affecting, kind of,  implementation of the intervention. In terms of, kind of, who we want in the study  and who we’re looking to recruit, our inclusion   criteria are young people aged 13 to 17 years,  who have subthreshold depressive symptoms at   the moment, or have a history of depression in  the past, and this is because we’re looking to,   kind of, prevent depression rather than treat  an active depressive episode. They also need   to have a parent with a history of recurrent  depression, so at least two previous episodes,   who’s willing to engage with the  study in a depression treatment plan. And in terms of, kind of, exclusion criteria,  if the young person meets diagnostic criteria   for depression currently they can’t be  involved, as this is a preventative study,   as I mention. Similarly, if they’re currently on  antidepressants, or have previously completed CBT,   they will be excluded. And another exclusion  criteria is, kind of, the child having other,   sort of, mental health difficulties  that would mean that this intervention   wouldn’t be the right fit for them. So, for  example, generalised learning difficulties,   bipolar disorder, schizophrenia, eating  disorder, and alcohol or drug dependence. And, similarly, if the parent has  other difficulties that would mean   the study’s not quite the right fit, so bipolar  disorder, schizophrenia, personality disorder,   or post-traumatic stress disorder. And there  are other, kind of, more bureaucratic type   inclusion/exclusion criteria, as well. So, for  example, as the parent will be going into this   treatment optimisation phase if they’re  currently depressed, we need our trial   Psychiatrist to be their treating Psychiatrist,  so the parent can’t be currently in secondary   services. Okay, and we’re aiming to recruit  400 young people and their parent as well. So, in terms of how this study’s, sort of, set  up and how the participants will flow through the   study. So, as I mentioned, this is a randomised  controlled intervention trial. It includes a   treatment optimisation phase for parents who  are currently depressed at the screening stage,   and I’ll go into more about what that involves  shortly. If the parent’s currently depressed,   they will enter this stage for 12 weeks,  before the parent and the young person then   completes some baseline assessments about  their mental health and related factors,   before then being randomised immediately  after baseline. So, the young person will   be randomised either to a, kind of, treatment as  usual group, where they just carry on with any   usual treatment they’d be receiving, or they’re  allocated to our SWELL intervention group CBT. Then we follow-up with both the young person  and the parent three months and nine months   after they are randomised. And there’s also some  qualitative data collection going on, as well,   we want to collect, kind of, the parent’s  and young person’s feedback about, sort of,   what they found helpful in the intervention, and  this will help us to explore mechanisms, as well. Okay, so in terms of what the parent treatment  optimisation involves. Parents who are currently   depressed at the screening stage will be referred  into this parent treatment optimisation stage,   if they’re eligible for the study. So, it will  involve an initial consultation with a Consultant   Psychiatrist, working with us on the trial.  And they will, sort of, consider the parent’s   current depressive symptoms, whether there needs  to be a change to any medication, initiation of   new medication, kind of, making some lifestyle,  sort of, change advice, if needed, and there’s   also an opportunity to, kind of – for the parent  to be initiated onto an internet CBT programme. This treatment phase will last 12 weeks in  total, and there will be check-ins every two   weeks with other members of the treatment team,  including the Psychiatrists or other workers   we have in the team who are supporting this  treatment optimisation phase. And this is all,   sort of, based on the NICE guidelines  for management of adult depression.  And the outcomes we are looking at for this  study. So, primarily, we are testing whether   a depression episode occurs in the young person  during the nine month follow-up period, using a,   sort of, time-to-event approach. So, we want  to see whether this intervention can increase   the time to onset of a depressive episode  in young people, so helping to prevent it. And we also want to look at secondary  outcomes, such as whether the intervention   reduces depression symptoms, reduces a  risk score we’re developing for depression,   does it reduce their anxiety symptoms,  irritability symptoms? Whether it improves   their quality of life, developmental competency,  and whether it reduces impairment, as well. And to note, as well, that we are currently  recruiting for this study. So, we are looking for   parents with a history of depression, and a  child aged 13 to 17 for recruitment, and we’ll   go through a, kind of, more detailed screening  phase with them once they’re in the study. And   we’re recruiting young people and their parents,  via the parent, through four main routes. So, a   pre-existing cohort of people who’ve participated  in, kind of, mental health research before, so at   the National Centre for Mental Health. We’re also  recruiting through primary care in South Wales,   in the UK, and we’re recruiting through primary  mental health services in South Wales, as well,   and via social media. And this study is open, you  know, through social media to any family in the   UK, who – you know, where there’s a parent with a  history of depression and a child aged 13 to 17. And of course, it’s quite an exciting study,  ‘cause there’s an opportunity for parents to   access, sort of, a consultation with a  trial Psychiatrist if they’re currently   experiencing high depression symptoms. And  there’s also an opportunity for young people   to potentially be a part of this preventative  CBT group, teaching those skills for wellbeing. Okay, so, to sum up then. Today, I’ve, kind of,  of given a brief overview of depression and,   sort of, parental depression and why  they are important. I’ve looked at,   sort of, some recent work we’ve done in the EPAD  study, so this cohort of offspring of recurrently   depressed parents. And then finished  up by talking about this SWELL trial,   so a clinical trial looking to prevent  depression in young people who are   at increased risk through having a  parent with a history of depression. So, with that, I’ll wrap up, and  thank you very much for listening.