Postpartum Depression and Teens

1. 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

2. 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.

3. Adolescence • Significant developmental and transitional stage into adulthood. • Changes • Hormonal • Cognitive • Social • Psychological • Identity

4. 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.

5. 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

6. 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

7. DysthymicDisorder • 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

8. 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

9. Postpartum Psychosis • Delusions, hallucinations • Restlessness, irritability • Sleep disturbances • Mood swings • Risk of suicide and/or infanticide • Early onset- as early as within 48-72 hours, usually within the first 2 weeks

10. 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.

11. 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

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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

18. 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

19. 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.

20. Risks for Postpartum Depression • Previous history of depression, especially during pregnancy • Poor social support • Stressful life events • Obstetrical complications • Single • Low-income • Adolescent mother

21. High Risk for Depression • High levels of depression symptoms • Youth of depressed parents • Abused or maltreated youth • Youth exposed to parental conflict

22. 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

23. 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

24. 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

25. Negative Parenting • Depressed mothers have been shown to have: • Difficulties in child management • Inconsistent behaviors and discipline • Unrealistic expectations • Negative interactions with their children • Irritable and angry behavior towards children

26. Negative Parenting (con’t) • Lower levels of parenting self-efficacy • Distracted and preoccupied • Less likely to give infant appropriate stimulation

27. 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.

28. Protective Factors • Positive relationship with parents • Supportive relationship with other family members • Higher level of self-esteem

29. 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

30. 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.

31. 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.

32. 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

33. 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

34. Other Interventions • Multi-component for postpartum teens • Day care, rehabilitation, relaxation therapy, massage therapy & mother-infant 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 non-depressed mothers.

35. 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.