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Screening for Depression in Pregnant Teenagers
J Pediatr Adolesc Gynecol (2001) 14:129-133
Opinions in Pediatric and Adolescent Gynecology Edited by Hatim A. Omar, MD University of Kentucky, Adolescent Medicine & Young Parent Programs, Kentucky Clinic, Lexington, Kentucky
Screening for Depression in Adolescents: Association with Teen Pregnancy Is it depression that leads to teen pregnancy or teen pregnancy that leads to depression? The answer is probably somewhere in between. It is not unusual while interviewing adolescent girls in our clinics to hear the girl say that she might be happier if she had someone who really loved her, someone she could love and take care of. These girls tend to ignore pregnancy protection and are more likely to have high-risk sexual behaviors. On the other hand, many happy girls become depressed once they find out they are pregnant. Depression during pregnancy and postpartum are also common in adolescents. Primary care providers and obstetricians can play a major role in detecting depressive symptoms, which may help in reducing teen pregnancy as well as complications resulting from depression during pregnancy and postpartum depression. To further explore this topic, here are the thoughts of one pediatric and adolescent psychiatrist and one primary care pediatric and adolescent medicine provider.
Screening for Depression in Pregnant Teenagers Catherine Martin, MD Department of Psychiatry, University of Kentucky, Lexington, Kentucky
The utility of a depression screen as part of the health care of the pregnant adolescent is based on several observations. A pre-pregnancy depression screen is warranted as a means of identifying one critical factor that is predictive of risk for becoming pregnant. Clinically it appears that depressed adolescents may engage in unprotected sexual activity and become pregnant as a way to compensate for depressive feelings. Further, © 2001 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
depressed adolescents may be less proactive in insuring that they don’t become pregnant. In a schoolbased study, Miller-Johnson et al1 found that females who are depressed in mid-adolescence were at greater risk to become pregnant in later adolescence. Pregnant adolescents are at risk for depression. Colletta et al.2 reported that over half of adolescent mothers have depressive symptoms and younger, single, and least educated women have the highest rates of depression. Pregnancy has also been identified as a risk factor for adolescent suicide,3 supporting the importance for not only a depression screen, but one with questions regarding suicidal ideation. It is important to examine the complex interrelationships of pregnancy, depression, and possible associated variables. Variables associated with pregnancy and depression include physical abuse and drug and alcohol use. A past history of physical abuse is associated with pregnancy as an adolescent.4 Further, this history of abuse is associated with depression, suicidal thoughts, alcohol and tobacco use, and delinquency.4 As a window into understanding the motivation of the adolescent who becomes pregnant, Rainey et al5 found that sexually abused adolescents, in comparison to their nonabused peers, reported having boyfriends pressuring them to conceive, trying to conceive, and having fears of infertility. Frequent alcohol use is associated with adolescent pregnancy.4 Further, drugabusing adolescent mothers are more depressed than their non–drug-abusing counterparts.6 In our own work, in a teen pregnancy clinic, we found that of 36 adolescents, only 7 reported no major losses. In the remaining 29 cases, major losses included parental divorce; never having known their father (or minimal contact with the father); absent mother; having to leave or being separated from the primary caregiver; murder or death of a parent, close family member, or significant other; and spontaneous or induced abortions.7 Further, the Children’s Depression Inventory (CDI), a well-accepted and clinically useful measure of childhood and adolescent depression,8 significantly correlated with losses (P .05). In addition, alcohol and drug use correlated with losses 1083-3188/01/$20.00 PII S1083-3188(01)00090-0
130
Opinions in Pediatric and Adolescent Gynecology
(P .05) and the CDI (P .01). (Note: The CDI does contain an item regarding suicidality.) It becomes increasingly clear that depression is related to adolescent pregnancy but that depression may be a part of a constellation of socioeconomic, family, environmental, and individual vulnerabilities. A model that considers these complex interactions between depression and adolescent pregnancy is displayed below.
Other contributors to these complex interactions include school problems, low self-esteem, and conflict in the home.9 Depression screening should continue after the infant is born. In adults, depression has been reported to be more prevalent in women with children compared to those with no children in the home,9 and the younger the mother, the greater the risk for depression.10 At first examination it might appear that screening for depression in the pregnant adolescent is like opening Pandora’s box. While there is validity in the concern that identifying a problem for which there is no available intervention does little good, there are logical steps clinicians can take. First, it may help to reframe the issue of identification and treatment of adolescent depression in the pregnant adolescent as a window of opportunity. Clinically, it appears that pregnancy in adolescence can be a nodal point where the pregnant adolescent may first have the opportunity to have access to her “own” caregiver, one with whom she can share her concerns. In addition, adolescents who have always been concerned with their parents’ wishes may have the opportunity to begin to mobilize resources for the baby and themselves in a proactive way. Depression in the pregnant adolescent may be difficult to assess in the clinical setting. An effective strategy that is time and resource efficient is administration of brief, focused questionnaires. It is not uncommon for adolescents to share more information on questionnaires than face to face. The Children’s Depression Inventory is simple and easy to use. Given the complexity of the interactions of depression, adolescent pregnancy, and other behaviors, several questions investigating high-risk behaviors should accompany a depression screen. Such questions could include: 1. Have you ever been abused by anyone? _____ physically _____ sexually _____ emotionally 2. Do you smoke cigarettes? _____ Yes _____ No Do you drink alcohol? _____ Yes _____ No
Do you smoke marijuana? Any other drugs?
_____ Yes _____ No _____ Yes _____ No
Once depressive symptomatology has been identified, the clinician must perform a type of triage.11 Depending on the severity of depression, the presence or absence of suicidal thoughts and behaviors, and the presence or absence of co-morbid high-risk behaviors such as substance use, the clinician will need to make appropriate referrals. The clinician must first be aware of what services are available in the adolescent’s community. The spectrum of services that could be considered include psychiatric inpatient services (if a severe depression and suicidality are identified), psychiatric outpatient care (including individual counseling and support for the family), and specific therapies to address substance use and physical abuse issues. Public health nursing early intervention programs,12 school-based programs,13 and home health nursing visits14 have all impacted on improved outcome for the adolescent and her infant. Clinicians would be well served to have their staff identify local resources that are in place for pregnant adolescents. In fact, an argument can be made for the advocacy role of the clinician, who takes an active role in development of services.15 If symptoms are less severe, the clinician may deal directly with the pregnant adolescent and her family. It is interesting to note that general practices with female doctors, young doctors, or more nurse time had lower teenage pregnancy rates.16 This may imply that taking time with adolescents and their concerns may be a sound investment in preventing unplanned outcomes. In summary, for those providing care for adolescents, a measure of depression may assist in identification of adolescent females at risk for becoming pregnant, depressed pregnant adolescents, and depressed adolescent mothers. The measurement of depression should occur in the context of understanding the personal and environmental vulnerabilities of the pregnant adolescent. Further, clinicians need to become aware of a spectrum of services that can be mobilized to help the pregnant adolescent and her unborn child.
Acknowledgments: This study was supported in part by NIDA grants no. DA 05312 and 1 K08 DA00333.
References 1. Miller-Johnson S, Winn DM, Coie J, et al: Motherhood during the teen years: a developmental perspective on risk factors for childbearing. Dev Psychopathol 1999; 11:85 2. Colletta ND: At risk for depression: A study of young mothers. J Genet Psychol 1983; 142:301
Opinions in Pediatric and Adolescent Gynecology 3. Hoberman HM, Garfinkel BD: Completed suicide in youth. Can J Psychiatry 1988; 33:494 4. Adams JA, East PL: Past physical abuse is significantly correlated with pregnancy as an adolescent. J Pediatr Adolesc Gynecol 1999; 12:1383 5. Rainey DY, Stevens-Simon C, Kaplan DW: Are adolescents who report prior sexual abuse at higher risk for pregnancy? Child Abuse Negl 1995; 19:1283 6. Scafidi FA, Field T, Prodromidis M, et al: Psychosocial stressor of drug-abusing disadvantaged adolescent mothers. Adolescence 1997; 32:93 7. Martin CA, Hill KK, Welsh R: Adolescent pregnancy, a stressful life event: Cause and consequence. In: Children of Trauma Stressful Life Events and Their Effects on Children and Adolescents. Edited by Thomas Miller. Madison, International Universities Press, Inc., 1998, pp. 141–160 8. Kovacs M: The Children’s Depression Inventory: A SelfRated Depression Scale for School-Aged Youngsters. San Antonio, Psychological Corporation, 1992 9. Zuckerman B, Amaro H, Beardslee W: Mental health of adolescent mothers: The implications of depression and drug use. JDBP 1987; 8:111 10. McGee R, Williams S, Kashan TH, et al: Prevalence of selfreported depressive symptoms and associated social factors in mothers in Dunedin. Br J Psychiatry 1983; 143:473 11. Dryfoos JG: Medical clinics in junior high school: changing the model to meet demands. J Adolesc Health 1994; 15:549 12. Koniak-Griffin D, Anderson NL, Verzemnieks I, Brecht ML: A public health nursing early intervention program for adolescent mothers: outcomes from pregnancy through 6 weeks postpartum. Nurs Res 2000; 49:130 13. Meadows M, Sadler LS, Reitmeyer GD: School-based support for urban adolescent mothers. J Pediatr Health Care 2000; 14:221 14. Kitzman H, Olds DL, Hanks C, et al: Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial. JAMA 1997; 27:644 15. Jennings RH: The patient advocate. Am J Obstet Gynecol 1997; 177:251 16. Hippisley-Cox J, Allen J, Pringle M, et al: Association between teenage pregnancy rates and the age and sex of general practitioners: cross sectional survey in Trent 1994–7. BMJ 2000; 15:11
Screening of Adolescent Females for Depression Before, During, and After Pregnancy Darby McElderry, MD Department of Pediatrics, University of Kentucky Medical Center, Lexington, Kentucky
Pregnancy and childbirth are known to have major physiologic and psychological effects on women. The rate of major depression in pregnant women is generally quoted in medical literature as approximately
131
10%, much the same as depression in nonpregnant women.1 Of major public health concern is the morbidity associated with postpartum depression, as well as perinatal outcomes associated with depressed mood during pregnancy. We also know that depressed adolescent females are at greater risk to become pregnant than are their nondepressed peers.2 Therefore, it seems that screening for depression may identify adolescent females at risk for becoming pregnant, adolescent mothers with depressed mood, and depressed pregnant teenagers. Depressed female adolescents may engage in sexual activity and become pregnant as a way to compensate for their depression. They perceive that they then have someone to love, someone who loves them unconditionally, and someone who depends on them for care. One study has shown that depressed females in mid-adolescence were at greatest risk for becoming pregnant in later adolescence.2 History of physical and sexual abuse, drug and alcohol use, and delinquent behaviors are also all associated with pregnancy in adolescent females.3 Given the higher risk of pregnancy associated with being depressed as an adolescent, screening teenagers routinely for depression seems a logical potential prevention measure. Despite a large amount of literature regarding postpartum mood disorders, there is relatively scarce information available on depressed mood during pregnancy itself. This is perhaps explained by the fact that information available to date mostly utilizes selfadministered questionnaires, which lack standardization or validation of use in the adolescent population. Some commonly used questionnaires are the Beck Depression Inventory (BDI), the Children’s Depression Inventory (CDI), and the Center for Epidemiologic Studies Depression Scale (CES-D). Of debate in current literature is the scoring of such questionnaires. Some suggest a higher cut-off value during pregnancy to avoid false positives resulting from common somatic complaints associated with both pregnancy and depression.4,5 One study of adolescent mothers showed significant correlation between the BDI and CES-D scores.6 Other authors have suggested that data using these inventories are difficult to interpret, because they use symptoms of depression such as fatigue and changes in sleep or appetite that are also common pregnancy-related somatic experiences.4,7 Emerging research and clinical studies have yielded data to indicate that maternal stress and depression may have adverse physical effects on the newborn. Steer et al8 found that increased risks of low birth weight, preterm delivery, and small-for-gestational-age infants were associated with maternal depressive symptoms as measured by the BDI. Kurki et al9 linked depression and anxiety in early pregnancy with risk for subsequent preeclampsia. Higher trait
Opinions in Pediatric and Adolescent Gynecology Edited by Hatim A. Omar, MD University of Kentucky, Adolescent Medicine & Young Parent Programs, Kentucky Clinic, Lexington, Kentucky
Screening for Depression in Adolescents: Association with Teen Pregnancy Is it depression that leads to teen pregnancy or teen pregnancy that leads to depression? The answer is probably somewhere in between. It is not unusual while interviewing adolescent girls in our clinics to hear the girl say that she might be happier if she had someone who really loved her, someone she could love and take care of. These girls tend to ignore pregnancy protection and are more likely to have high-risk sexual behaviors. On the other hand, many happy girls become depressed once they find out they are pregnant. Depression during pregnancy and postpartum are also common in adolescents. Primary care providers and obstetricians can play a major role in detecting depressive symptoms, which may help in reducing teen pregnancy as well as complications resulting from depression during pregnancy and postpartum depression. To further explore this topic, here are the thoughts of one pediatric and adolescent psychiatrist and one primary care pediatric and adolescent medicine provider.
Screening for Depression in Pregnant Teenagers Catherine Martin, MD Department of Psychiatry, University of Kentucky, Lexington, Kentucky
The utility of a depression screen as part of the health care of the pregnant adolescent is based on several observations. A pre-pregnancy depression screen is warranted as a means of identifying one critical factor that is predictive of risk for becoming pregnant. Clinically it appears that depressed adolescents may engage in unprotected sexual activity and become pregnant as a way to compensate for depressive feelings. Further, © 2001 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
depressed adolescents may be less proactive in insuring that they don’t become pregnant. In a schoolbased study, Miller-Johnson et al1 found that females who are depressed in mid-adolescence were at greater risk to become pregnant in later adolescence. Pregnant adolescents are at risk for depression. Colletta et al.2 reported that over half of adolescent mothers have depressive symptoms and younger, single, and least educated women have the highest rates of depression. Pregnancy has also been identified as a risk factor for adolescent suicide,3 supporting the importance for not only a depression screen, but one with questions regarding suicidal ideation. It is important to examine the complex interrelationships of pregnancy, depression, and possible associated variables. Variables associated with pregnancy and depression include physical abuse and drug and alcohol use. A past history of physical abuse is associated with pregnancy as an adolescent.4 Further, this history of abuse is associated with depression, suicidal thoughts, alcohol and tobacco use, and delinquency.4 As a window into understanding the motivation of the adolescent who becomes pregnant, Rainey et al5 found that sexually abused adolescents, in comparison to their nonabused peers, reported having boyfriends pressuring them to conceive, trying to conceive, and having fears of infertility. Frequent alcohol use is associated with adolescent pregnancy.4 Further, drugabusing adolescent mothers are more depressed than their non–drug-abusing counterparts.6 In our own work, in a teen pregnancy clinic, we found that of 36 adolescents, only 7 reported no major losses. In the remaining 29 cases, major losses included parental divorce; never having known their father (or minimal contact with the father); absent mother; having to leave or being separated from the primary caregiver; murder or death of a parent, close family member, or significant other; and spontaneous or induced abortions.7 Further, the Children’s Depression Inventory (CDI), a well-accepted and clinically useful measure of childhood and adolescent depression,8 significantly correlated with losses (P .05). In addition, alcohol and drug use correlated with losses 1083-3188/01/$20.00 PII S1083-3188(01)00090-0
130
Opinions in Pediatric and Adolescent Gynecology
(P .05) and the CDI (P .01). (Note: The CDI does contain an item regarding suicidality.) It becomes increasingly clear that depression is related to adolescent pregnancy but that depression may be a part of a constellation of socioeconomic, family, environmental, and individual vulnerabilities. A model that considers these complex interactions between depression and adolescent pregnancy is displayed below.
Other contributors to these complex interactions include school problems, low self-esteem, and conflict in the home.9 Depression screening should continue after the infant is born. In adults, depression has been reported to be more prevalent in women with children compared to those with no children in the home,9 and the younger the mother, the greater the risk for depression.10 At first examination it might appear that screening for depression in the pregnant adolescent is like opening Pandora’s box. While there is validity in the concern that identifying a problem for which there is no available intervention does little good, there are logical steps clinicians can take. First, it may help to reframe the issue of identification and treatment of adolescent depression in the pregnant adolescent as a window of opportunity. Clinically, it appears that pregnancy in adolescence can be a nodal point where the pregnant adolescent may first have the opportunity to have access to her “own” caregiver, one with whom she can share her concerns. In addition, adolescents who have always been concerned with their parents’ wishes may have the opportunity to begin to mobilize resources for the baby and themselves in a proactive way. Depression in the pregnant adolescent may be difficult to assess in the clinical setting. An effective strategy that is time and resource efficient is administration of brief, focused questionnaires. It is not uncommon for adolescents to share more information on questionnaires than face to face. The Children’s Depression Inventory is simple and easy to use. Given the complexity of the interactions of depression, adolescent pregnancy, and other behaviors, several questions investigating high-risk behaviors should accompany a depression screen. Such questions could include: 1. Have you ever been abused by anyone? _____ physically _____ sexually _____ emotionally 2. Do you smoke cigarettes? _____ Yes _____ No Do you drink alcohol? _____ Yes _____ No
Do you smoke marijuana? Any other drugs?
_____ Yes _____ No _____ Yes _____ No
Once depressive symptomatology has been identified, the clinician must perform a type of triage.11 Depending on the severity of depression, the presence or absence of suicidal thoughts and behaviors, and the presence or absence of co-morbid high-risk behaviors such as substance use, the clinician will need to make appropriate referrals. The clinician must first be aware of what services are available in the adolescent’s community. The spectrum of services that could be considered include psychiatric inpatient services (if a severe depression and suicidality are identified), psychiatric outpatient care (including individual counseling and support for the family), and specific therapies to address substance use and physical abuse issues. Public health nursing early intervention programs,12 school-based programs,13 and home health nursing visits14 have all impacted on improved outcome for the adolescent and her infant. Clinicians would be well served to have their staff identify local resources that are in place for pregnant adolescents. In fact, an argument can be made for the advocacy role of the clinician, who takes an active role in development of services.15 If symptoms are less severe, the clinician may deal directly with the pregnant adolescent and her family. It is interesting to note that general practices with female doctors, young doctors, or more nurse time had lower teenage pregnancy rates.16 This may imply that taking time with adolescents and their concerns may be a sound investment in preventing unplanned outcomes. In summary, for those providing care for adolescents, a measure of depression may assist in identification of adolescent females at risk for becoming pregnant, depressed pregnant adolescents, and depressed adolescent mothers. The measurement of depression should occur in the context of understanding the personal and environmental vulnerabilities of the pregnant adolescent. Further, clinicians need to become aware of a spectrum of services that can be mobilized to help the pregnant adolescent and her unborn child.
Acknowledgments: This study was supported in part by NIDA grants no. DA 05312 and 1 K08 DA00333.
References 1. Miller-Johnson S, Winn DM, Coie J, et al: Motherhood during the teen years: a developmental perspective on risk factors for childbearing. Dev Psychopathol 1999; 11:85 2. Colletta ND: At risk for depression: A study of young mothers. J Genet Psychol 1983; 142:301
Opinions in Pediatric and Adolescent Gynecology 3. Hoberman HM, Garfinkel BD: Completed suicide in youth. Can J Psychiatry 1988; 33:494 4. Adams JA, East PL: Past physical abuse is significantly correlated with pregnancy as an adolescent. J Pediatr Adolesc Gynecol 1999; 12:1383 5. Rainey DY, Stevens-Simon C, Kaplan DW: Are adolescents who report prior sexual abuse at higher risk for pregnancy? Child Abuse Negl 1995; 19:1283 6. Scafidi FA, Field T, Prodromidis M, et al: Psychosocial stressor of drug-abusing disadvantaged adolescent mothers. Adolescence 1997; 32:93 7. Martin CA, Hill KK, Welsh R: Adolescent pregnancy, a stressful life event: Cause and consequence. In: Children of Trauma Stressful Life Events and Their Effects on Children and Adolescents. Edited by Thomas Miller. Madison, International Universities Press, Inc., 1998, pp. 141–160 8. Kovacs M: The Children’s Depression Inventory: A SelfRated Depression Scale for School-Aged Youngsters. San Antonio, Psychological Corporation, 1992 9. Zuckerman B, Amaro H, Beardslee W: Mental health of adolescent mothers: The implications of depression and drug use. JDBP 1987; 8:111 10. McGee R, Williams S, Kashan TH, et al: Prevalence of selfreported depressive symptoms and associated social factors in mothers in Dunedin. Br J Psychiatry 1983; 143:473 11. Dryfoos JG: Medical clinics in junior high school: changing the model to meet demands. J Adolesc Health 1994; 15:549 12. Koniak-Griffin D, Anderson NL, Verzemnieks I, Brecht ML: A public health nursing early intervention program for adolescent mothers: outcomes from pregnancy through 6 weeks postpartum. Nurs Res 2000; 49:130 13. Meadows M, Sadler LS, Reitmeyer GD: School-based support for urban adolescent mothers. J Pediatr Health Care 2000; 14:221 14. Kitzman H, Olds DL, Hanks C, et al: Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial. JAMA 1997; 27:644 15. Jennings RH: The patient advocate. Am J Obstet Gynecol 1997; 177:251 16. Hippisley-Cox J, Allen J, Pringle M, et al: Association between teenage pregnancy rates and the age and sex of general practitioners: cross sectional survey in Trent 1994–7. BMJ 2000; 15:11
Screening of Adolescent Females for Depression Before, During, and After Pregnancy Darby McElderry, MD Department of Pediatrics, University of Kentucky Medical Center, Lexington, Kentucky
Pregnancy and childbirth are known to have major physiologic and psychological effects on women. The rate of major depression in pregnant women is generally quoted in medical literature as approximately
131
10%, much the same as depression in nonpregnant women.1 Of major public health concern is the morbidity associated with postpartum depression, as well as perinatal outcomes associated with depressed mood during pregnancy. We also know that depressed adolescent females are at greater risk to become pregnant than are their nondepressed peers.2 Therefore, it seems that screening for depression may identify adolescent females at risk for becoming pregnant, adolescent mothers with depressed mood, and depressed pregnant teenagers. Depressed female adolescents may engage in sexual activity and become pregnant as a way to compensate for their depression. They perceive that they then have someone to love, someone who loves them unconditionally, and someone who depends on them for care. One study has shown that depressed females in mid-adolescence were at greatest risk for becoming pregnant in later adolescence.2 History of physical and sexual abuse, drug and alcohol use, and delinquent behaviors are also all associated with pregnancy in adolescent females.3 Given the higher risk of pregnancy associated with being depressed as an adolescent, screening teenagers routinely for depression seems a logical potential prevention measure. Despite a large amount of literature regarding postpartum mood disorders, there is relatively scarce information available on depressed mood during pregnancy itself. This is perhaps explained by the fact that information available to date mostly utilizes selfadministered questionnaires, which lack standardization or validation of use in the adolescent population. Some commonly used questionnaires are the Beck Depression Inventory (BDI), the Children’s Depression Inventory (CDI), and the Center for Epidemiologic Studies Depression Scale (CES-D). Of debate in current literature is the scoring of such questionnaires. Some suggest a higher cut-off value during pregnancy to avoid false positives resulting from common somatic complaints associated with both pregnancy and depression.4,5 One study of adolescent mothers showed significant correlation between the BDI and CES-D scores.6 Other authors have suggested that data using these inventories are difficult to interpret, because they use symptoms of depression such as fatigue and changes in sleep or appetite that are also common pregnancy-related somatic experiences.4,7 Emerging research and clinical studies have yielded data to indicate that maternal stress and depression may have adverse physical effects on the newborn. Steer et al8 found that increased risks of low birth weight, preterm delivery, and small-for-gestational-age infants were associated with maternal depressive symptoms as measured by the BDI. Kurki et al9 linked depression and anxiety in early pregnancy with risk for subsequent preeclampsia. Higher trait