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 Postpartum depression Postpartum Psychosis
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. 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

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 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 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: Interpersonal 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.