Postpartum Depression Postpartum Depression and Teensand Teens

Rhonda C. Boyd, Ph.D.Rhonda C. Boyd, Ph.D.Children’s Hospital of Philadelphia Children’s Hospital of Philadelphia

& University of Pennsylvania& University of Pennsylvania

October 14, 2008October 14, 2008PPT/Elect Grantees’ Annual MeetingPPT/Elect Grantees’ Annual Meeting

Public Health SignificancePublic Health Significance

Each year close to 750,000 teenage Each year close to 750,000 teenage women (15-19) become pregnant in the women (15-19) become pregnant in the U.S. U.S.

11% of all U.S. births are to teenage 11% of all U.S. births are to teenage women. women.

Major depression is of high prevalence in Major depression is of high prevalence in women of childbearing and child-rearing women of childbearing and child-rearing years. years.

Depression is the highest ranked cause of Depression is the highest ranked cause of disability among all medical conditions disability among all medical conditions found in women.found in women.

AdolescenceAdolescence

Significant developmental and Significant developmental and transitional stage into adulthood.transitional stage into adulthood.

ChangesChanges– HormonalHormonal– CognitiveCognitive– SocialSocial– Psychological Psychological – IdentityIdentity

OverviewOverview Postpartum bluesPostpartum blues

– Highly sensitive period up to 2 weeks after Highly sensitive period up to 2 weeks after birth.birth.

– About 50-85% of women experience this.About 50-85% of women experience this. Postpartum depressionPostpartum depression

– Major depression that lasts for at least 2 Major depression that lasts for at least 2 weeksweeks

– About 10-15% of women develop this.About 10-15% of women develop this. Postpartum PsychosisPostpartum Psychosis

– Severe form of postpartum depressionSevere form of postpartum depression– 1/1,000 women develop this.1/1,000 women develop this.

Major Depressive DisorderMajor Depressive Disorder

5 or more symptoms during same 2 5 or more symptoms during same 2 week periodweek period– Depressed, sad or irritable moodDepressed, sad or irritable mood– Diminished pleasure in activitiesDiminished pleasure in activities– Weight loss or gainWeight loss or gain– Insomnia or hypersomniaInsomnia or hypersomnia

Major Depressive Disorder Major Depressive Disorder (con’t)(con’t)

– Increased or slowness in Increased or slowness in movementmovement

– FatigueFatigue– Feelings of worthlessness; GuiltFeelings of worthlessness; Guilt– Poor concentration; Poor concentration;

IndecisivenessIndecisiveness– Recurrent thoughts of deathRecurrent thoughts of death

2 weeks to 6-12 months 2 weeks to 6-12 months postpartumpostpartum

DysthymicDysthymic DisorderDisorder

Depressed mood for most days of the Depressed mood for most days of the week for 2 years or moreweek for 2 years or more

At least 2 of the symptoms of Major At least 2 of the symptoms of Major Depressive DisorderDepressive Disorder

Little time feeling wellLittle time feeling well

Bipolar DisorderBipolar Disorder Having symptoms of Major Depressive Having symptoms of Major Depressive

Disorder and signs of maniaDisorder and signs of mania Mania includes:Mania includes:

– Increased activityIncreased activity– Talking rapidlyTalking rapidly– Racing thoughtsRacing thoughts– Needing little sleepNeeding little sleep– Thinking you can do anything or have Thinking you can do anything or have

special powersspecial powers– Doing risky thingsDoing risky things

Postpartum PsychosisPostpartum Psychosis

Delusions, hallucinationsDelusions, hallucinations Restlessness, irritabilityRestlessness, irritability Sleep disturbancesSleep disturbances Mood swingsMood swings Risk of suicide and/or infanticideRisk of suicide and/or infanticide Early onset- as early as within 48-Early onset- as early as within 48-

72 hours, usually within the first 2 72 hours, usually within the first 2 weeksweeks

Postpartum AnxietyPostpartum Anxiety

Anxiety can be observed in new Anxiety can be observed in new mothers. mothers.

There may be anxiety symptoms There may be anxiety symptoms related to caretaking of new infant. related to caretaking of new infant.

There is significant overlap of There is significant overlap of depression and anxiety symptoms in depression and anxiety symptoms in the general population and in the general population and in postpartum mothers.postpartum mothers.

Somatic/ Physical SymptomsSomatic/ Physical Symptoms

There is a significant overlap with There is a significant overlap with postpartum depression & physical postpartum depression & physical symptoms associated with the symptoms associated with the postpartum period: postpartum period: – Sleep difficultiesSleep difficulties– Appetite changesAppetite changes– Weight gainWeight gain– FatigueFatigue

Depression in TeensDepression in Teens

Time frame when most young women are Time frame when most young women are a risk for developing depression.a risk for developing depression.

Depression in adolescent females has Depression in adolescent females has been associated with teenage pregnancy, been associated with teenage pregnancy, increased risk of tobacco use, and increased risk of tobacco use, and increased use of medical services.increased use of medical services.

Depression has been shown to increase Depression has been shown to increase risk of subsequent pregnancy in risk of subsequent pregnancy in adolescent mothers. adolescent mothers.

Bipolar Disorder RiskBipolar Disorder Risk

Adolescence and the late teens are Adolescence and the late teens are also the years in which bipolar also the years in which bipolar disorder will begin to manifest itself disorder will begin to manifest itself in women.in women.

40% of adolescents with major 40% of adolescents with major depressive disorder will develop depressive disorder will develop bipolar disorder later. bipolar disorder later.

Course of DepressionCourse of Depression

Mean length is 7-9 months.Mean length is 7-9 months. There is a 90% remission in 2 years.There is a 90% remission in 2 years. Course of depression symptoms is Course of depression symptoms is

difficult to predict in teens.difficult to predict in teens. Teens with depression have Teens with depression have

increased risk of more episodes in increased risk of more episodes in adulthood. adulthood.

Rates in adolescenceRates in adolescence

15-20% is lifetime prevalence rate in 15-20% is lifetime prevalence rate in adolescents for depression disorders.adolescents for depression disorders.

By 18, it is estimated that 24% of By 18, it is estimated that 24% of youth experience at least 1 clinically youth experience at least 1 clinically significant depression episode.significant depression episode.

1% is lifetime prevalence for bipolar 1% is lifetime prevalence for bipolar disorder in 14-18 year old disorder in 14-18 year old adolescents.adolescents.

Female and Male RatesFemale and Male Rates

Prior to adolescence, females and males Prior to adolescence, females and males have similar rates of major depression.have similar rates of major depression.

During adolescence, females are 2x more During adolescence, females are 2x more likely to have major depression than likely to have major depression than males.males.

This trend continues throughout This trend continues throughout adulthood.adulthood.

Males and females have similar rates of Males and females have similar rates of bipolar disorder.bipolar disorder.

Why are females at a higher Why are females at a higher risk?risk?

Hormonal changes influence the brain.Hormonal changes influence the brain. Structural changes in the brain may Structural changes in the brain may

influence social roles. influence social roles. – Social changes may affect the number Social changes may affect the number

of depression-triggering life events of depression-triggering life events Interactions between hormones and the Interactions between hormones and the

brain’s areas involved in mood influence brain’s areas involved in mood influence behavior and social roles. behavior and social roles. – females may be more vulnerable to females may be more vulnerable to

dysregulation that may make them dysregulation that may make them more sensitive to risk factors of more sensitive to risk factors of depression.depression.

Gender socializationGender socialization

Depression Outcome for TeensDepression Outcome for Teens

Teens with depression may have an Teens with depression may have an increased risk of recurrent depressive increased risk of recurrent depressive episodes in adulthood.episodes in adulthood.

Factors that worsen the outcome of Factors that worsen the outcome of depression in adolescent women:depression in adolescent women:– the presence of a other psychiatric the presence of a other psychiatric

disorderdisorder– dysfunctional home lifedysfunctional home life– parental psychiatric disordersparental psychiatric disorders

Suicidal BehaviorsSuicidal Behaviors

Female teens have higher rates of Female teens have higher rates of suicide attempts.suicide attempts.

Depression is the most common Depression is the most common disorder that is associated with youth disorder that is associated with youth attempting and completing suicide.attempting and completing suicide.

Higher rates of suicide completion Higher rates of suicide completion and attempts as adults.and attempts as adults.

Risks for Postpartum Risks for Postpartum DepressionDepression

Previous history of depression, Previous history of depression, especially during pregnancyespecially during pregnancy

Poor social supportPoor social support Stressful life eventsStressful life events Obstetrical complicationsObstetrical complications SingleSingle Low-incomeLow-income Adolescent motherAdolescent mother

High Risk for DepressionHigh Risk for Depression

High levels of depression symptomsHigh levels of depression symptoms Youth of depressed parentsYouth of depressed parents Abused or maltreated youthAbused or maltreated youth Youth exposed to parental conflictYouth exposed to parental conflict

Interviews with Teen Mothers Interviews with Teen Mothers with Depressionwith Depression

Interview Themes:Interview Themes:– Suddenly realizing motherhoodSuddenly realizing motherhood– Being torn between two realitiesBeing torn between two realities– Constantly questioning and trying to Constantly questioning and trying to

explain the unexplainableexplain the unexplainable– Feeling alone, betrayed & abandoned by Feeling alone, betrayed & abandoned by

those that you need to love youthose that you need to love you– Everything is falling down on and Everything is falling down on and

around youaround you– You are changing & regrouping; You are changing & regrouping; See a different futureSee a different future

Impact of Maternal Depression Impact of Maternal Depression on Infantson Infants

Specific impact of maternal Specific impact of maternal depression on infantsdepression on infants– Feeding problemsFeeding problems– WithdrawalWithdrawal– Poor motor and cognitive progressPoor motor and cognitive progress– Less engaged and responsive when Less engaged and responsive when

interactinginteracting– Less exploring by mouthLess exploring by mouth– Less physical growthLess physical growth– More pediatric complicationsMore pediatric complications

Impact of Maternal Depression Impact of Maternal Depression on Childrenon Children

Children of depressed mothers are at Children of depressed mothers are at a increased risk for:a increased risk for:– Developmental delaysDevelopmental delays– Behavior problems and disordersBehavior problems and disorders– Major Depressive DisorderMajor Depressive Disorder– Conduct DisorderConduct Disorder– Peer difficultiesPeer difficulties– Substance ProblemsSubstance Problems

Negative ParentingNegative Parenting Depressed mothers have been shown Depressed mothers have been shown

to have:to have:– Difficulties in child managementDifficulties in child management– Inconsistent behaviors and disciplineInconsistent behaviors and discipline– Unrealistic expectationsUnrealistic expectations– Negative interactions with their Negative interactions with their

childrenchildren– Irritable and angry behavior towards Irritable and angry behavior towards

childrenchildren

Negative Parenting (con’t)Negative Parenting (con’t)

Lower levels of parenting self-Lower levels of parenting self-efficacyefficacy

Distracted and preoccupiedDistracted and preoccupied Less likely to give infant appropriate Less likely to give infant appropriate

stimulationstimulation

Social SupportSocial Support

With new mothers, social support is With new mothers, social support is needed in many areas (e.g., material, needed in many areas (e.g., material, emotional, informational).emotional, informational).

Teen mothers who have low social support Teen mothers who have low social support also are more isolated & overwhelmed.also are more isolated & overwhelmed.

Too much social support may make them Too much social support may make them feel inadequate as parents.feel inadequate as parents.

Improving social support alone will not Improving social support alone will not likely prevent or reduce depression. likely prevent or reduce depression.

Protective FactorsProtective Factors

Positive relationship with parentsPositive relationship with parents Supportive relationship with other Supportive relationship with other

family membersfamily members Higher level of self-esteemHigher level of self-esteem

Screening for Depression in Screening for Depression in Teen MothersTeen Mothers

Postpartum DepressionPostpartum Depression– Edinburgh Postnatal Depression Scale* Edinburgh Postnatal Depression Scale*

Depression in GeneralDepression in General– Center for Epidemiological Studies* Center for Epidemiological Studies*

Depression Scale Depression Scale – Beck Depression Inventory* Beck Depression Inventory* – Reynolds Adolescent Depression ScaleReynolds Adolescent Depression Scale

Screening IssuesScreening Issues

Schools are underutilized settings where Schools are underutilized settings where teens at risk for depression can be teens at risk for depression can be identified.identified.

Measures used for adults may not be valid Measures used for adults may not be valid for teens.for teens.

There is still controversy about whether There is still controversy about whether women should be screened for postpartum women should be screened for postpartum depression.depression.

There is overlap with symptoms associated There is overlap with symptoms associated with postpartum recovery.with postpartum recovery.

Treatment for DepressionTreatment for Depression

A combination of antidepressant A combination of antidepressant medication and psychotherapy is medication and psychotherapy is considered to be the treatment of considered to be the treatment of choice for MDD. choice for MDD.

Evidence with adolescents is far Evidence with adolescents is far behind that with adults.behind that with adults.

PsychotherapyPsychotherapy

Cognitive behavioral therapy: Cognitive behavioral therapy: – Increasing positive behaviorsIncreasing positive behaviors– Replacing negative thought patterns Replacing negative thought patterns

with more positive oneswith more positive ones Interpersonal therapyInterpersonal therapy

– Improving personal relationships by Improving personal relationships by evaluating interactions and problems evaluating interactions and problems with otherswith others

MedicationMedication

Selective Serotonin Reuptake Selective Serotonin Reuptake Inhibitors (SSRIs) are most commonly Inhibitors (SSRIs) are most commonly used anti-depressantsused anti-depressants– Prozac*, Zoloft, Paxil*, Celexa, Lexapro, Prozac*, Zoloft, Paxil*, Celexa, Lexapro,

& Luvox*& Luvox* Serotonin and Norinephrine Reuptake Serotonin and Norinephrine Reuptake

Inhibitors (SNRIs) are second most Inhibitors (SNRIs) are second most common.common.– Effexor* & CymbaltaEffexor* & Cymbalta

Other InterventionsOther Interventions Multi-component for postpartum teensMulti-component for postpartum teens

– Day care, rehabilitation, relaxation Day care, rehabilitation, relaxation therapy, massage therapy & mother-therapy, massage therapy & mother-infant interaction coachinginfant interaction coaching

– Mothers still had higher depression scores Mothers still had higher depression scores than non-depressed mothers.than non-depressed mothers.

– Mother-child interactions improved.Mother-child interactions improved.– By 12 months, child outcomes improved By 12 months, child outcomes improved

and they were similar to children of non-and they were similar to children of non-depressed mothers.depressed mothers.

Other Interventions (con’t)Other Interventions (con’t)

Home visitation for pregnant teensHome visitation for pregnant teens– Parenting curriculum, identify Parenting curriculum, identify

depression & violence, case depression & violence, case management, promote health care use management, promote health care use & mentoring& mentoring

– Teens in the program had better Teens in the program had better parenting scores and were more likely parenting scores and were more likely to stay in schools.to stay in schools.

– The program did not have an effect on The program did not have an effect on depression, repeat pregnancy, depression, repeat pregnancy, parenting stress or linkages with parenting stress or linkages with primary care. primary care.