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Postpartum Depression and Teens Rhonda C. Boyd, Ph.D. Children’s Hospital of Philadelphia & University of Pennsylvania October 14, 2008 PPT/Elect Grantees’ Annual Meeting Public Health Significance Each year close to 750,000 teenage women (15-19) become pregnant in the U.S. 11% of all U.S. births are to teenage women. Major depression is of high prevalence in women of childbearing and child-rearing years. Depression is the highest ranked cause of disability among all medical conditions found in women. Adolescence Significant developmental and transitional stage into adulthood. Changes – Hormonal – Cognitive – Social – Psychological – Identity Overview Postpartum blues – Highly sensitive period up to 2 weeks after birth. – About 50-85% of women experience this. Postpartum depression – Major depression that lasts for at least 2 weeks – About 10-15% of women develop this. Postpartum Psychosis – Severe form of postpartum depression – 1/1,000 women develop this. Major Depressive Disorder 5 or more symptoms during same 2 week period –Depressed, sad or irritable mood –Diminished pleasure in activities –Weight loss or gain –Insomnia or hypersomnia Major Depressive Disorder (con’t) –Increased or slowness in movement –Fatigue –Feelings of worthlessness; Guilt –Poor concentration; Indecisiveness –Recurrent thoughts of death 2 weeks to 6-12 months postpartum Dysthymic Disorder Depressed mood for most days of the week for 2 years or more At least 2 of the symptoms of Major Depressive Disorder Little time feeling well Bipolar Disorder Having symptoms of Major Depressive Disorder and signs of mania Mania includes: – Increased activity – Talking rapidly – Racing thoughts – Needing little sleep – Thinking you can do anything or have special powers – Doing risky things Postpartum Psychosis Delusions, hallucinations Restlessness, irritability Sleep disturbances Mood swings Risk of suicide and/or infanticide Early onset- as early as within 4872 hours, usually within the first 2 weeks Postpartum Anxiety Anxiety can be observed in new mothers. There may be anxiety symptoms related to caretaking of new infant. There is significant overlap of depression and anxiety symptoms in the general population and in postpartum mothers. Somatic/ Physical Symptoms There is a significant overlap with postpartum depression & physical symptoms associated with the postpartum period: –Sleep difficulties –Appetite changes –Weight gain –Fatigue Depression in Teens Time frame when most young women are a risk for developing depression. Depression in adolescent females has been associated with teenage pregnancy, increased risk of tobacco use, and increased use of medical services. Depression has been shown to increase risk of subsequent pregnancy in adolescent mothers. Bipolar Disorder Risk Adolescence and the late teens are also the years in which bipolar disorder will begin to manifest itself in women. 40% of adolescents with major depressive disorder will develop bipolar disorder later. Course of Depression Mean length is 7-9 months. There is a 90% remission in 2 years. Course of depression symptoms is difficult to predict in teens. Teens with depression have increased risk of more episodes in adulthood. Rates in adolescence 15-20% is lifetime prevalence rate in adolescents for depression disorders. By 18, it is estimated that 24% of youth experience at least 1 clinically significant depression episode. 1% is lifetime prevalence for bipolar disorder in 14-18 year old adolescents. Female and Male Rates Prior to adolescence, females and males have similar rates of major depression. During adolescence, females are 2x more likely to have major depression than males. This trend continues throughout adulthood. Males and females have similar rates of bipolar disorder. Why are females at a higher risk? Hormonal changes influence the brain. Structural changes in the brain may influence social roles. – Social changes may affect the number of depression-triggering life events Interactions between hormones and the brain’s areas involved in mood influence behavior and social roles. – females may be more vulnerable to dysregulation that may make them more sensitive to risk factors of depression. Gender socialization Depression Outcome for Teens Teens with depression may have an increased risk of recurrent depressive episodes in adulthood. Factors that worsen the outcome of depression in adolescent women: – the presence of a other psychiatric disorder – dysfunctional home life – parental psychiatric disorders Suicidal Behaviors Female teens have higher rates of suicide attempts. Depression is the most common disorder that is associated with youth attempting and completing suicide. Higher rates of suicide completion and attempts as adults. Risks for Postpartum Depression Previous history of depression, especially during pregnancy Poor social support Stressful life events Obstetrical complications Single Low-income Adolescent mother High Risk for Depression High levels of depression symptoms Youth of depressed parents Abused or maltreated youth Youth exposed to parental conflict Interviews with Teen Mothers with Depression Interview Themes: – Suddenly realizing motherhood – Being torn between two realities – Constantly questioning and trying to explain the unexplainable – Feeling alone, betrayed & abandoned by those that you need to love you – Everything is falling down on and around you – You are changing & regrouping; See a different future Impact of Maternal Depression on Infants Specific impact of maternal depression on infants – Feeding problems – Withdrawal – Poor motor and cognitive progress – Less engaged and responsive when interacting – Less exploring by mouth – Less physical growth – More pediatric complications Impact of Maternal Depression on Children Children of depressed mothers are at a increased risk for: – Developmental delays – Behavior problems and disorders – Major Depressive Disorder – Conduct Disorder – Peer difficulties – Substance Problems Negative Parenting Depressed to have: mothers have been shown – Difficulties in child management – Inconsistent behaviors and discipline – Unrealistic expectations – Negative interactions with their children – Irritable and angry behavior towards children Negative Parenting (con’t) Lower levels of parenting selfefficacy Distracted and preoccupied Less likely to give infant appropriate stimulation Social Support With new mothers, social support is needed in many areas (e.g., material, emotional, informational). Teen mothers who have low social support also are more isolated & overwhelmed. Too much social support may make them feel inadequate as parents. Improving social support alone will not likely prevent or reduce depression. Protective Factors Positive relationship with parents Supportive relationship with other family members Higher level of self-esteem Screening for Depression in Teen Mothers Postpartum Depression – Edinburgh Postnatal Depression Scale* Depression in General – Center for Epidemiological Studies* Depression Scale – Beck Depression Inventory* – Reynolds Adolescent Depression Scale Screening Issues Schools are underutilized settings where teens at risk for depression can be identified. Measures used for adults may not be valid for teens. There is still controversy about whether women should be screened for postpartum depression. There is overlap with symptoms associated with postpartum recovery. Treatment for Depression A combination of antidepressant medication and psychotherapy is considered to be the treatment of choice for MDD. Evidence with adolescents is far behind that with adults. Psychotherapy Cognitive behavioral therapy: – Increasing positive behaviors – Replacing negative thought patterns with more positive ones Interpersonal therapy – Improving personal relationships by evaluating interactions and problems with others Medication Selective Serotonin Reuptake Inhibitors (SSRIs) are most commonly used anti-depressants – Prozac*, Zoloft, Paxil*, Celexa, Lexapro, & Luvox* Serotonin and Norinephrine Reuptake Inhibitors (SNRIs) are second most common. – Effexor* & Cymbalta Other Interventions Multi-component for postpartum teens – Day care, rehabilitation, relaxation therapy, massage therapy & motherinfant interaction coaching – Mothers still had higher depression scores than non-depressed mothers. – Mother-child interactions improved. – By 12 months, child outcomes improved and they were similar to children of nondepressed mothers. Other Interventions (con’t) Home visitation for pregnant teens – Parenting curriculum, identify depression & violence, case management, promote health care use & mentoring – Teens in the program had better parenting scores and were more likely to stay in schools. – The program did not have an effect on depression, repeat pregnancy, parenting stress or linkages with primary care.
