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Moderate to severe depressive symptoms among adolescent mothers followed four years postpartum
Journal of Adolescent Health 38 (2006) 712–718
Original article
Moderate to severe depressive symptoms among adolescent mothers followed four years postpartum R. Michelle Schmidt, M.D., M.P.H.a,*, Constance M. Wiemann, Ph.D.b, Vaughn I. Rickert, Psy.D.c, and E. O’Brian Smith, Ph.D.d b
a Department of Internal Medicine, Baylor College of Medicine, Houston, Texas Department of Pediatrics, Section of Adolescent and Sports Medicine, Baylor College of Medicine, Houston, Texas c Heilbrunn Department of Population and Family Health, Columbia University, New York, New York d Children’s Nutrition Research Center, Baylor College of Medicine, Houston, Texas Manuscript received February 21, 2005; manuscript accepted May 23, 2005
Abstract
Purpose: To examine race/ethnic differences in depressive symptoms among adolescent mothers during the first four years postpartum. Methods: A prospective study of 623 adolescent mothers, 18 years or younger followed four years after delivery. Depressive symptoms were measured using the Beck Depression Inventory (BDI). These analyses focused on data collected at 3, 12, 24 and 48 months postpartum. Results: Overall, 57% of the sample reported moderate to severe depressive (MSD) symptoms during the four-year period. The steepest increase in the percent reporting new MSD symptoms occurred during the first 12 months after delivery. The prevalence of MSD symptoms was highest at three months (36.7%) and steadily declined through 48 months (21.1%) for all race/ethnic groups with one exception: a slightly higher percentage of African-Americans reported MSD symptoms at 48 (20.0%) than at 24 months (16.9%). Logistic regression analysis used to calculate the relative odds of experiencing MSD symptoms revealed higher odds of depressive symptoms for Caucasians (adjusted odds ratio [AOR] 2.0; 95% confidence interval [CI] 1.2–3.4) at three months, and for Mexican-Americans at both 12 (AOR 2.6; 95% CI 1.4 – 4.8) and 24 (AOR 2.2; 95% CI 1.1– 4.4) months. MSD symptoms at three months were significantly related to MSD symptoms at 48 months for all race/ethnic groups (p ⬍ .001). Conclusions: More than 50% of adolescent mothers experience MSD symptoms during the first postpartum year. As a group, African-American adolescent mothers appear to have the lowest rates of MSD symptoms, but higher rates of recurrence, when compared with Mexican-Americans and Caucasians. © 2006 Society for Adolescent Medicine. All rights reserved.
Keywords:
Adolescent mothers; Depressive symptoms; Prevalence; Race/ethnic differences; Prospective study
Adolescent pregnancy has long-term medical, emotional and economic consequences for mother and child, and is reported to occur more frequently in certain ethnic and racial minorities [1]. Depressive symptoms may occur in the postpartum period of mothers of all ages [2,3]. Rates of depressive symptoms among adolescent mothers have been *Address correspondence to: Dr. Michelle Schmidt, Ben Taub General Hospital, 1504 Taub Loop, Section of General Medicine, Houston, TX 77030. E-mail address: [email protected]
reported to be higher than among nonpregnant/parenting adolescents [4,5] and pregnant or parenting adults [6 –9]. In addition, individuals who experience depressive symptoms as adolescents are more likely to have recurrent episodes of depressive symptoms as adults [10 –12]. Surprisingly little is known about of the history of depressive symptoms in the postpartum period among mothers who begin childbearing as adolescents. Most studies of adolescent mothers suggest higher rates of depressive symptoms soon after delivery, with a decline in symptoms over time [4,13,14]. Yet, how far into the postpartum period
1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2005.05.023
R.M. Schmidt et al. / Journal of Adolescent Health 38 (2006) 712–718
depressive symptoms are maintained, and what percent of young mothers experience recurrent episodes is not well defined. This is because existing studies of pregnant or parenting adolescents have been limited by cross-sectional design [8,15,16]. The few longitudinal studies that have been conducted have employed small, convenience samples [4,13,17,18], making it difficult to generalize results to larger, more heterogeneous populations. As a result, research on race/ethnic differences in the prevalence of depressive symptoms in adolescent mothers remains equivocal. For example, Deal and Holt found associations among depressive symptoms and African-American race, marital status, educational attainment, and socioeconomic status [19]. Another study reported that depressive symptoms were related to perceived social support and stress rather than race/ethnicity [18]. Using a large, multiethnic sample of adolescent mothers, we sought to report the prevalence and course of depressive symptoms during the first four years after delivery. We hypothesized that (a) the prevalence of moderate to severe depressive (MSD) symptoms [20] would be significantly higher at three months postpartum than at 12, 24, and 48 months of follow-up; (b) there would be no race/ethnic differences in the prevalence of MSD symptoms at each point of contact after controlling for economic resources and other covariates; and (c) moderate to severe depressive symptoms at three months would be significantly associated with MSD symptoms at each additional point of contact and for each race/ethnic group. Methods Description of cohort All adolescent mothers through 18 years of age who delivered at the University of Texas Medical Branch (UTMB) at Galveston between December 8, 1993 and February 28, 1996 were eligible to participate if they met the following five criteria: (a) self-identified as Mexican-American, AfricanAmerican, or Caucasian; (b) planned to retain custody of her infant; (c) were able to read and write at a fifth grade level in either English or Spanish; (d) were not diagnosed with major psychiatric disorders; and (e) delivered a healthy infant weighing more than 1500 g. Adolescent mothers from other racial/ethnic groups were excluded from study participation because there were few in each group. There were 1053 adolescent mothers who had live births during the study period and were eligible to participate. Of these, 26 were not approached because of the numerous births on the days they delivered and inadequate personnel to recruit all those eligible. Of the 1027 adolescent mothers invited to participate in the study, 95 refused; the most common reason given was insufficient time to complete the hour-long interview. Demographic comparisons between those who refused to participate and those who were interviewed re-
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vealed a higher refusal rate among Mexican-American mothers who only spoke Spanish (23%, p ⬍ .001). There were 932 adolescent mothers who completed the delivery interview. During the recruitment period, the Obstetrics service at UTMB-Galveston, the only tertiary care hospital on the island, served adolescents from southeast Texas, the majority of whom lived within a 75-mile radius of Galveston Island. Most patients lived in small towns with populations of fewer than 60,000. Other than hospitals in major urban centers, this was the only hospital in that region accepting patients without private insurance. Data were collected as part of a larger study of substance use among pregnant and parenting adolescents. As part of the larger study, each subject agreed to complete selfadministered surveys at 3, 6, 12, 18, 24, and 48 months postpartum. A more thorough description of the methods can be found in the study by Wiemann et al [21]. A total of 623 participants (182 [29%] Caucasians, 213 [34%] AfricanAmericans, and 228 [37%] Mexican-Americans) returned five of the six follow-up surveys and were considered the analysis sample. Data collection The larger project was presented to potential subjects as a study of the transition into adolescent motherhood. Written consent in English or Spanish was obtained from each participant as well as from a parent or legal guardian for adolescent mothers younger than 18 years who lived at home and were not married. With institutional review board approval, trained female research assistants interviewed each subject privately in English or Spanish in the postpartum ward within 48 hours of delivery. Interviewers who spoke fluent Spanish interviewed all patients who preferred to converse in Spanish. Demographic information was obtained from each adolescent mother during the face-to-face structured interview. All baseline and follow-up survey questions were pilot tested on a group of 20 postpartum adolescent mothers and revised. The questions were translated into Spanish using forward and backward translation; Spanish surveys underwent additional pilot testing. At baseline, all participants completed a face-to-face interview. All follow-up surveys were mailed; if they did not return the packet, telephone interviews were completed. The window for completing the survey included one month before or after the target follow-up date. To maximize survey return, subjects were contacted by telephone to verify survey receipt and to encourage completion. All subjects received $10 for each completed survey up through 24 months and $25 for the 48-month survey. Returned surveys were reviewed so that incomplete or inconsistent reporting could be followed up by contact with specific respondents. Completed baseline
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interviews and surveys were either hand entered or electronically scanned and verified for accuracy. Variable definitions The structured baseline and all follow-up surveys elicited the following information: demographic and reproductive characteristics; social support; depressive symptoms; family violence; intimate partner physical violence toward the adolescent mother; and the use of tobacco and alcohol. Perceived positive support from family members was evaluated by asking subjects to indicate their satisfaction with the support they received from family members using five items such as: “My family helps me with money when I need it.” Participants responded “always true,” “mostly true,” “sometimes true,” “rarely true,” or “never true.” A positive family support score was computed by summing responses to these questions at each point of contact. Internal consistency (Cronbach alpha) for support measures ranged from .80 to .94 depending on the point of follow-up. Economic resources were evaluated by asking the young mother whether she feels she has enough money, food, clothing, to live, coded yes or no [21]. Depressive symptoms were measured using the Beck Depression Inventory, Short Form (BDI). This 13-item instrument, with excellent psychometric properties, is commonly used as a brief screen for depression in primary care settings for adolescents and adults [22]. After obtaining a total score per instructions, depressive symptoms were recoded as a categorical variable. Subjects whose scores ranged from 8 to 39 were coded as having moderate to severe depressive (MSD) symptoms [20]. Chronicity of depressive symptoms was defined as the total number of surveys (out of a possible four surveys mailed at 3, 12, 24, and 48 months) on which adolescent mothers obtained BDI scores in the MSD range. Intimate partner violence (IPV) was defined as having been hit by a boyfriend or husband during an argument or while he was drunk or high or having been hit, slapped, kicked, or physically hurt enough by a current or exboyfriend or ex-husband to cause bruising or bleeding within the preceding six months as answered either yes or no. Family violence was defined as having been hit by a family member (such as parents or siblings) during an argument or while they were high or drunk within the preceding six months either not at all or more than once. Tobacco use or alcohol use by the adolescent mother was confirmed if she reported smoking one or more cigarettes per day or at least more than one sip of alcohol within the last 30 days. Statistical analysis The prevalence of MSD symptoms reported as the proportion of subjects who reported MSD symptoms was calculated at 3, 12, 24, and 48 months postpartum. Compari-
sons across the postpartum period for the entire sample and for each race/ethnic group were made by examining whether there was overlap between pairs of 95% confidence intervals (CI). Additionally, cumulative MSD symptoms were calculated by taking the percentage of young mothers who experienced these symptoms at three months postpartum and adding to it the proportion of subjects who experienced MSD symptoms for the first time at each subsequent point of follow-up [23]. Chi-square tests and 95% CIs were used to compare differences among ethnic groups in prevalence of MSD symptoms at each point of follow-up. Logistic regression was used to calculate the relative odds of experiencing MSD symptoms adjusted for certain covariates. The variables that were taken from the baseline data and added into the model included age at delivery, race, high school graduate by delivery, whether grandmother of the baby had graduated from high school, and language of interview. Parity, financial resources, education level, recent tobacco and alcohol use, recent intimate partner violence, family violence, and family support were added to the model with follow-up data from each survey. Logistic regression was used to calculate the relative odds of experiencing MSD symptoms at 3, 12, 24, and 48 months of follow-up, respectively. These covariates were related to MSD symptoms empirically or through prior studies. Finally, we compared the prevalence of depressive symptoms at each point of contact using the McNemar test [24]. To provide a basis for comparison to prior studies on depression in young mothers, and to provide important information to clinicians on the persistence of MSD symptoms over time, the associations between MSD symptoms experienced at three months postpartum and MSD symptoms experienced at 12, 24, and 48 months were explored. All data were analyzed using SPSS (SPSS 11.0, 2001, Chicago, Illinois).
Results Analyses conducted to compare demographic characteristics of the 623 mothers who comprised the study sample and the 932 who completed the delivery interview revealed no significant differences in age, language use, education, financial resources, intimate partner violence, family violence, substance use, and family support (Table 1). Significant differences between the race/ethnic groups within the analysis sample were observed (Table 1). The prevalence of moderate to severe depressive (MSD) symptoms at the 3-, 12-, 24-, and 48-month points of follow-up is presented in Table 2 as point estimates and 95% confidence limits. As hypothesized, the prevalence of MSD symptoms was highest at three months postpartum and steadily declined over time. Similar patterns were observed across racial/ethnic groups with one exception: a
R.M. Schmidt et al. / Journal of Adolescent Health 38 (2006) 712–718
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Table 1 Selected characteristics of the initial sample and subsample Characteristic
Initial sample (n ⫽ 932) n (%)
Subsample (n ⫽ 623) n (%)
Caucasian (n ⫽ 182) n (%)
African-American (n ⫽ 213) n (%)
Mexican American (n ⫽ 228) n (%)
Age (13–18 years): mean, years (SD) Spanish speaking Graduated high school by delivery Own mother graduated high school Inadequate financial resourcesa ⱖ 1 child at time of index delivery Intimate partner violencea Family/sibling violencea Any tobacco use during pregnancy Any alcohol use during pregnancy Perceived high levels of family support
16.8 (1.17) 93 (10.0) 132 (14.2) 394 (49.1) 223 (28.6) 155 (16.6) 167 (17.9) 127 (13.6) 137 (14.7) 101 (10.8) 715 (76.9)
16.73 (1.18) 53 (8.5) 84 (13.5) 253 (47.5) 167 (28.0) 100 (16.1) 128 (20.5) 85 (13.6) 76 (12.2) 62 (10.0) 478 (77.0)
16.92 (1.11) 1 (0.5) 39 (21.4) 75 (46.6) 37 (21.4) 23 (12.6) 29 (15.9) 28 (15.4) 51 (28.0) 28 (15.4) 152 (84.4)
16.49 (1.28) 0 (0.0) 20 (9.4) 48 (25.5) 60 (29.3) 37 (17.4) 47 (22.1) 32 (15.0) 4 (1.9) 13 (6.1) 171 (80.3)
16.79 (1.11)* 52 (22.8)* 25 (11.0)* 130 (57.1)* 70 (30.7)* 40 (17.5) 52 (22.8)* 25 (11.0) 21 (9.2)* 21 (9.2)* 155 (68.0)*
a
measured at 3 months. * p ⬍ .01 for comparisons among race/ethnic groups.
slightly higher percent of African-Americans reported MSDS at 48 (20.0%) than at 24 months (16.9%). Cumulative depressive symptoms were calculated by taking the percentage of young mothers who experienced MSD symptoms at three months postpartum and adding to it the proportion of subjects who experienced MSD symptoms for the first time at each subsequent point of follow-up. The proportions that are reported are prevalence rates, because new cases of MSD symptoms identified at each follow-up were added to existing cases identified on prior surveys. Overall, 57% of the sample reported MSD symptoms at some point during this four-year period. The steepest increase in the percent reporting new symptoms occurred during the first 12 months after delivery, with half of the total sample reporting these symptoms. Using chi-square analyses, comparisons among racial/ ethnic groups revealed African-Americans were significantly less likely than Caucasians to report MSD symptoms at three months (p ⫽ .048) and significantly less likely than both Caucasians and Mexican-Americans to report MSD symptoms at 24 months (p ⫽ .010). Logistic regression was then used to control for potential covariates (age at delivery, parity, financial resources, language of interview, education level, recent tobacco and alcohol use, family violence, recent intimate partner violence, and family support) at each point of follow-up. At three months postpartum, Caucasians
were 2.0 times (95% CI 1.2–3.4, p ⫽ .012) more likely to report MSD symptoms than African-Americans. At 12 months postpartum, Mexican-Americans were 2.6 times (95% CI 1.4 – 4.8, p ⫽ .003) more likely to report MSD symptoms than African-Americans. Similarly, at 24 months postpartum, Mexican-Americans were 2.2 times (95% CI 1.1– 4.4, p ⫽ .025) more likely to report MSD symptoms than African-Americans. No significant differences in MSD symptoms at 48 months were observed among racial/ethnic groups after controlling for potential covariates. As hypothesized, in the entire subsample and across racial/ethnic groups, MSD symptoms at three months were significantly (McNemar Tests; p ⬍ .05) associated with MSD symptoms at each point of contact and for each race/ethnic group with one exception. Among MexicanAmericans, MSD symptoms at three months postpartum were not related to MSD symptoms at 12 months postpartum (p ⫽ .134). In addition, 48.3% of African-Americans who reported MSD symptoms at three months also reported MSD symptoms at 48 months, versus 39.4% of MexicanAmericans and 27.9% of Caucasians (Figure 1; p ⬍ .01). More than 80% of those who reported MSD symptoms at three months reported similar symptoms on two or more additional surveys. Fifty-five percent of the entire sample reported MSD symptoms on two or more surveys, whereas 15% reported these symptoms at all four points of contact.
Table 2 Point prevalence of MSD symptoms (unadjusted) at 3, 12, 24 and 48 months postpartum, % (95% confidence interval) Month of follow-up
Total (n ⫽ 623)
Mexican American (n ⫽ 228)
African-American (n ⫽ 213)
Caucasian (n ⫽ 182)
3 (n ⫽ 601) 12 (n ⫽ 592) 24 (n ⫽ 593) 48 (n ⫽ 554)
36.7 (32.9–40.5) 28.4 (24.8–32.0) 23.6 (20.2–27.0) 21.1 (17.7–24.5)
37.0 (33.1–40.9) 32.4 (28.6–36.2) 24.5 (21.0–28.0) 21.3 (17.9–24.7)
30.9 (27.2–34.6) 23.4 (20.0–26.8) 16.9 (13.9–20.0) 20.0 (16.7–23.3)
43.1 (39.1–47.1) 29.3 (25.6–33.0) 30.1 (26.4–33.8) 22.2 (18.7–25.7)
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Figure 1. Proportion (%) of adolescent mothers with MSD symptoms at 3 months who also reported MSD symptoms at 12, 24, and 48 months.
These findings did not differ by race/ethnicity. Finally, of those who experienced MSD symptoms by 48 months of follow-up, 87.9% (312/355) reported these symptoms by the end of the first postpartum year. Discussion In this, the largest published longitudinal study to report depressive symptoms among adolescent mothers from three different race/ethnic groups, more than half of the young mothers reported MSD symptoms over the four-year period. The vast majority of these reported symptom onset within the first postpartum year. As expected [13,25], the prevalence of MSD symptoms was highest at three months postpartum and declined across the four-year period after delivery. Similar patterns were observed across race/ethnic groups, although the decrease in prevalence between 24 and 48 months postpartum was most robust for Caucasian adolescent mothers. Contrary to our expectations and after controlling for significant covariates, Mexican-American and Caucasian adolescent mothers were found to be at higher risk of MSD symptoms than African-Americans, with Mexican-Americans at highest risk overall. The higher rates of MSD symptoms observed among Mexican-Americans as compared with Caucasians and African-Americans in our study are consistent with those previously reported among nonpregnant adolescents by Roberts et al [26]. However, few prior studies have had large enough samples of adolescent mothers from different race/ethnic groups to adequately examine racial/ ethic differences while controlling for important covariates. This study emphasizes that further investigation is needed to understand why these differences exist. In one prior study, differences among race groups were greatly reduced once socioeconomic status had been controlled [19]. In our study, logistic regression analyses revealed differences that had not been identified before the addition of covariates, including economic resources, to the multivariate model. Many adolescent mothers in this study experienced per-
sistent MSD symptoms over four years of follow-up. MSD symptoms reported at three months were significantly associated with MSD symptoms at follow-up, and nearly 90% of those reporting MSD symptoms at 48 months also reported these symptoms within the first postpartum year. This is consistent with literature in adult mothers where almost 90% of those mothers who reported depressive symptoms by four months after delivery had reported onset of these symptoms by the first month postpartum and almost a third of the sample reported persistence of symptoms beyond four months of delivery [27]. Fifty-five percent of the entire sample reported MSD symptoms on two or more surveys, whereas 15% reported these symptoms at all points of contact. Other studies have reported persistence of depressive symptoms in adolescent mothers, adult mothers, and nonparenting adolescents [13,28]. Children of depressed mothers are at increased risk for social, emotional and behavioral problems [29,30]. Thus, these data support the chronic nature of mental health problems in this population and provide evidence of the value of careful and ongoing screening and management. Despite an initial drop in MSD symptoms between 3 and 24 months among all race/ethnic groups, a significant proportion of adolescent mothers who reported MSD symptoms at three months experienced a recurrence of their symptoms at 48 months. This recurrence was highest among African-Americans. This is counterintuitive, as studies commonly report that minority adolescent mothers experience higher levels of family support than Caucasians [31,32]. One study that examined decision making in African-American and Caucasian adolescent mothers found that among African-American adolescent mothers, greater decision-making was associated with increased likelihood of reporting depressive symptoms [33]. Studies in adults have found that racial/ethnic minorities are more likely to report depressed mood and this is associated with their increased likelihood to report difficulty in meeting basic needs [34]. It is possible that shifts in social support associated with entering adulthood, such as moving into an independent living arrangement, precipitated the higher rates of recurrence of depressive symptoms observed among African-Americans in our study. Further examination of this important subgroup is needed to explore possible explanations of this finding. There are limitations to this study. The prepregnancy depressive history in this group of adolescent mothers is unknown. Adolescent mothers with a prior history of major depression or other affective disorders may have been more likely to report MSD symptoms postpartum. Adolescent mothers who were initially interviewed, but failed to return five of six follow-up surveys (n ⫽ 302) were not included in these analyses. It is possible that some of these mothers were severely depressed, and their omission could lead to reduced prevalence estimates.
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Also, it would have been helpful to have collected data from participants at 36 months, although given the trends reported at 24 and 48 months, it is unlikely that findings would have differed significantly from those reported at 48 months. Finally, the Beck Depression Inventory includes somatic criteria that may be part of the normal postpartum physiological process and may be confused with depressive symptoms. Alternative screening tests for postpartum depression have reported lower false positive rates [35]. In summary, owing to improved methodology and a large ethnically diverse sample, our data confirm that the prevalence of depressive symptoms among adolescent mothers, as with older mothers, is elevated after the delivery of a child and, for a subset, persists well into the postpartum period. In fact, more than one out of 10 adolescent mothers appears to have a chronic condition that places both mother and child at risk. The purpose of this article was to provide a solid foundation of the scope of this problem and to examine race/ethnic differences. Future studies are needed to identify predictors of depressive symptoms, in general, and to examine the role of social support. Clinically, our findings have important implications. Our data support the importance of screening for postpartum symptoms among adolescent mothers and to continue screening for several years after delivery. It is important for providers to remember that although symptoms may diminish across time, as these infants age, mothers continue to be at risk for future symptom development.
Acknowledgment This project was sponsored by grants DA09636 and DA08404 (Dr. Wiemann) from the National Institute on Drug Abuse, Rockville, MD, and by The Hogg Foundation for Mental Health, Austin, Tex (Dr. Wiemann). The findings presented herein do not reflect the views of these granting organizations. We are indebted to the many adolescent participants who shared their experiences with us and to the interviewers who spent hundreds of hours collecting this information. Dr. Wiemann’s time was partially supported by a grant from the Health Resources and Services Administration (T71MC00011).
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Original article
Moderate to severe depressive symptoms among adolescent mothers followed four years postpartum R. Michelle Schmidt, M.D., M.P.H.a,*, Constance M. Wiemann, Ph.D.b, Vaughn I. Rickert, Psy.D.c, and E. O’Brian Smith, Ph.D.d b
a Department of Internal Medicine, Baylor College of Medicine, Houston, Texas Department of Pediatrics, Section of Adolescent and Sports Medicine, Baylor College of Medicine, Houston, Texas c Heilbrunn Department of Population and Family Health, Columbia University, New York, New York d Children’s Nutrition Research Center, Baylor College of Medicine, Houston, Texas Manuscript received February 21, 2005; manuscript accepted May 23, 2005
Abstract
Purpose: To examine race/ethnic differences in depressive symptoms among adolescent mothers during the first four years postpartum. Methods: A prospective study of 623 adolescent mothers, 18 years or younger followed four years after delivery. Depressive symptoms were measured using the Beck Depression Inventory (BDI). These analyses focused on data collected at 3, 12, 24 and 48 months postpartum. Results: Overall, 57% of the sample reported moderate to severe depressive (MSD) symptoms during the four-year period. The steepest increase in the percent reporting new MSD symptoms occurred during the first 12 months after delivery. The prevalence of MSD symptoms was highest at three months (36.7%) and steadily declined through 48 months (21.1%) for all race/ethnic groups with one exception: a slightly higher percentage of African-Americans reported MSD symptoms at 48 (20.0%) than at 24 months (16.9%). Logistic regression analysis used to calculate the relative odds of experiencing MSD symptoms revealed higher odds of depressive symptoms for Caucasians (adjusted odds ratio [AOR] 2.0; 95% confidence interval [CI] 1.2–3.4) at three months, and for Mexican-Americans at both 12 (AOR 2.6; 95% CI 1.4 – 4.8) and 24 (AOR 2.2; 95% CI 1.1– 4.4) months. MSD symptoms at three months were significantly related to MSD symptoms at 48 months for all race/ethnic groups (p ⬍ .001). Conclusions: More than 50% of adolescent mothers experience MSD symptoms during the first postpartum year. As a group, African-American adolescent mothers appear to have the lowest rates of MSD symptoms, but higher rates of recurrence, when compared with Mexican-Americans and Caucasians. © 2006 Society for Adolescent Medicine. All rights reserved.
Keywords:
Adolescent mothers; Depressive symptoms; Prevalence; Race/ethnic differences; Prospective study
Adolescent pregnancy has long-term medical, emotional and economic consequences for mother and child, and is reported to occur more frequently in certain ethnic and racial minorities [1]. Depressive symptoms may occur in the postpartum period of mothers of all ages [2,3]. Rates of depressive symptoms among adolescent mothers have been *Address correspondence to: Dr. Michelle Schmidt, Ben Taub General Hospital, 1504 Taub Loop, Section of General Medicine, Houston, TX 77030. E-mail address: [email protected]
reported to be higher than among nonpregnant/parenting adolescents [4,5] and pregnant or parenting adults [6 –9]. In addition, individuals who experience depressive symptoms as adolescents are more likely to have recurrent episodes of depressive symptoms as adults [10 –12]. Surprisingly little is known about of the history of depressive symptoms in the postpartum period among mothers who begin childbearing as adolescents. Most studies of adolescent mothers suggest higher rates of depressive symptoms soon after delivery, with a decline in symptoms over time [4,13,14]. Yet, how far into the postpartum period
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depressive symptoms are maintained, and what percent of young mothers experience recurrent episodes is not well defined. This is because existing studies of pregnant or parenting adolescents have been limited by cross-sectional design [8,15,16]. The few longitudinal studies that have been conducted have employed small, convenience samples [4,13,17,18], making it difficult to generalize results to larger, more heterogeneous populations. As a result, research on race/ethnic differences in the prevalence of depressive symptoms in adolescent mothers remains equivocal. For example, Deal and Holt found associations among depressive symptoms and African-American race, marital status, educational attainment, and socioeconomic status [19]. Another study reported that depressive symptoms were related to perceived social support and stress rather than race/ethnicity [18]. Using a large, multiethnic sample of adolescent mothers, we sought to report the prevalence and course of depressive symptoms during the first four years after delivery. We hypothesized that (a) the prevalence of moderate to severe depressive (MSD) symptoms [20] would be significantly higher at three months postpartum than at 12, 24, and 48 months of follow-up; (b) there would be no race/ethnic differences in the prevalence of MSD symptoms at each point of contact after controlling for economic resources and other covariates; and (c) moderate to severe depressive symptoms at three months would be significantly associated with MSD symptoms at each additional point of contact and for each race/ethnic group. Methods Description of cohort All adolescent mothers through 18 years of age who delivered at the University of Texas Medical Branch (UTMB) at Galveston between December 8, 1993 and February 28, 1996 were eligible to participate if they met the following five criteria: (a) self-identified as Mexican-American, AfricanAmerican, or Caucasian; (b) planned to retain custody of her infant; (c) were able to read and write at a fifth grade level in either English or Spanish; (d) were not diagnosed with major psychiatric disorders; and (e) delivered a healthy infant weighing more than 1500 g. Adolescent mothers from other racial/ethnic groups were excluded from study participation because there were few in each group. There were 1053 adolescent mothers who had live births during the study period and were eligible to participate. Of these, 26 were not approached because of the numerous births on the days they delivered and inadequate personnel to recruit all those eligible. Of the 1027 adolescent mothers invited to participate in the study, 95 refused; the most common reason given was insufficient time to complete the hour-long interview. Demographic comparisons between those who refused to participate and those who were interviewed re-
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vealed a higher refusal rate among Mexican-American mothers who only spoke Spanish (23%, p ⬍ .001). There were 932 adolescent mothers who completed the delivery interview. During the recruitment period, the Obstetrics service at UTMB-Galveston, the only tertiary care hospital on the island, served adolescents from southeast Texas, the majority of whom lived within a 75-mile radius of Galveston Island. Most patients lived in small towns with populations of fewer than 60,000. Other than hospitals in major urban centers, this was the only hospital in that region accepting patients without private insurance. Data were collected as part of a larger study of substance use among pregnant and parenting adolescents. As part of the larger study, each subject agreed to complete selfadministered surveys at 3, 6, 12, 18, 24, and 48 months postpartum. A more thorough description of the methods can be found in the study by Wiemann et al [21]. A total of 623 participants (182 [29%] Caucasians, 213 [34%] AfricanAmericans, and 228 [37%] Mexican-Americans) returned five of the six follow-up surveys and were considered the analysis sample. Data collection The larger project was presented to potential subjects as a study of the transition into adolescent motherhood. Written consent in English or Spanish was obtained from each participant as well as from a parent or legal guardian for adolescent mothers younger than 18 years who lived at home and were not married. With institutional review board approval, trained female research assistants interviewed each subject privately in English or Spanish in the postpartum ward within 48 hours of delivery. Interviewers who spoke fluent Spanish interviewed all patients who preferred to converse in Spanish. Demographic information was obtained from each adolescent mother during the face-to-face structured interview. All baseline and follow-up survey questions were pilot tested on a group of 20 postpartum adolescent mothers and revised. The questions were translated into Spanish using forward and backward translation; Spanish surveys underwent additional pilot testing. At baseline, all participants completed a face-to-face interview. All follow-up surveys were mailed; if they did not return the packet, telephone interviews were completed. The window for completing the survey included one month before or after the target follow-up date. To maximize survey return, subjects were contacted by telephone to verify survey receipt and to encourage completion. All subjects received $10 for each completed survey up through 24 months and $25 for the 48-month survey. Returned surveys were reviewed so that incomplete or inconsistent reporting could be followed up by contact with specific respondents. Completed baseline
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interviews and surveys were either hand entered or electronically scanned and verified for accuracy. Variable definitions The structured baseline and all follow-up surveys elicited the following information: demographic and reproductive characteristics; social support; depressive symptoms; family violence; intimate partner physical violence toward the adolescent mother; and the use of tobacco and alcohol. Perceived positive support from family members was evaluated by asking subjects to indicate their satisfaction with the support they received from family members using five items such as: “My family helps me with money when I need it.” Participants responded “always true,” “mostly true,” “sometimes true,” “rarely true,” or “never true.” A positive family support score was computed by summing responses to these questions at each point of contact. Internal consistency (Cronbach alpha) for support measures ranged from .80 to .94 depending on the point of follow-up. Economic resources were evaluated by asking the young mother whether she feels she has enough money, food, clothing, to live, coded yes or no [21]. Depressive symptoms were measured using the Beck Depression Inventory, Short Form (BDI). This 13-item instrument, with excellent psychometric properties, is commonly used as a brief screen for depression in primary care settings for adolescents and adults [22]. After obtaining a total score per instructions, depressive symptoms were recoded as a categorical variable. Subjects whose scores ranged from 8 to 39 were coded as having moderate to severe depressive (MSD) symptoms [20]. Chronicity of depressive symptoms was defined as the total number of surveys (out of a possible four surveys mailed at 3, 12, 24, and 48 months) on which adolescent mothers obtained BDI scores in the MSD range. Intimate partner violence (IPV) was defined as having been hit by a boyfriend or husband during an argument or while he was drunk or high or having been hit, slapped, kicked, or physically hurt enough by a current or exboyfriend or ex-husband to cause bruising or bleeding within the preceding six months as answered either yes or no. Family violence was defined as having been hit by a family member (such as parents or siblings) during an argument or while they were high or drunk within the preceding six months either not at all or more than once. Tobacco use or alcohol use by the adolescent mother was confirmed if she reported smoking one or more cigarettes per day or at least more than one sip of alcohol within the last 30 days. Statistical analysis The prevalence of MSD symptoms reported as the proportion of subjects who reported MSD symptoms was calculated at 3, 12, 24, and 48 months postpartum. Compari-
sons across the postpartum period for the entire sample and for each race/ethnic group were made by examining whether there was overlap between pairs of 95% confidence intervals (CI). Additionally, cumulative MSD symptoms were calculated by taking the percentage of young mothers who experienced these symptoms at three months postpartum and adding to it the proportion of subjects who experienced MSD symptoms for the first time at each subsequent point of follow-up [23]. Chi-square tests and 95% CIs were used to compare differences among ethnic groups in prevalence of MSD symptoms at each point of follow-up. Logistic regression was used to calculate the relative odds of experiencing MSD symptoms adjusted for certain covariates. The variables that were taken from the baseline data and added into the model included age at delivery, race, high school graduate by delivery, whether grandmother of the baby had graduated from high school, and language of interview. Parity, financial resources, education level, recent tobacco and alcohol use, recent intimate partner violence, family violence, and family support were added to the model with follow-up data from each survey. Logistic regression was used to calculate the relative odds of experiencing MSD symptoms at 3, 12, 24, and 48 months of follow-up, respectively. These covariates were related to MSD symptoms empirically or through prior studies. Finally, we compared the prevalence of depressive symptoms at each point of contact using the McNemar test [24]. To provide a basis for comparison to prior studies on depression in young mothers, and to provide important information to clinicians on the persistence of MSD symptoms over time, the associations between MSD symptoms experienced at three months postpartum and MSD symptoms experienced at 12, 24, and 48 months were explored. All data were analyzed using SPSS (SPSS 11.0, 2001, Chicago, Illinois).
Results Analyses conducted to compare demographic characteristics of the 623 mothers who comprised the study sample and the 932 who completed the delivery interview revealed no significant differences in age, language use, education, financial resources, intimate partner violence, family violence, substance use, and family support (Table 1). Significant differences between the race/ethnic groups within the analysis sample were observed (Table 1). The prevalence of moderate to severe depressive (MSD) symptoms at the 3-, 12-, 24-, and 48-month points of follow-up is presented in Table 2 as point estimates and 95% confidence limits. As hypothesized, the prevalence of MSD symptoms was highest at three months postpartum and steadily declined over time. Similar patterns were observed across racial/ethnic groups with one exception: a
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Table 1 Selected characteristics of the initial sample and subsample Characteristic
Initial sample (n ⫽ 932) n (%)
Subsample (n ⫽ 623) n (%)
Caucasian (n ⫽ 182) n (%)
African-American (n ⫽ 213) n (%)
Mexican American (n ⫽ 228) n (%)
Age (13–18 years): mean, years (SD) Spanish speaking Graduated high school by delivery Own mother graduated high school Inadequate financial resourcesa ⱖ 1 child at time of index delivery Intimate partner violencea Family/sibling violencea Any tobacco use during pregnancy Any alcohol use during pregnancy Perceived high levels of family support
16.8 (1.17) 93 (10.0) 132 (14.2) 394 (49.1) 223 (28.6) 155 (16.6) 167 (17.9) 127 (13.6) 137 (14.7) 101 (10.8) 715 (76.9)
16.73 (1.18) 53 (8.5) 84 (13.5) 253 (47.5) 167 (28.0) 100 (16.1) 128 (20.5) 85 (13.6) 76 (12.2) 62 (10.0) 478 (77.0)
16.92 (1.11) 1 (0.5) 39 (21.4) 75 (46.6) 37 (21.4) 23 (12.6) 29 (15.9) 28 (15.4) 51 (28.0) 28 (15.4) 152 (84.4)
16.49 (1.28) 0 (0.0) 20 (9.4) 48 (25.5) 60 (29.3) 37 (17.4) 47 (22.1) 32 (15.0) 4 (1.9) 13 (6.1) 171 (80.3)
16.79 (1.11)* 52 (22.8)* 25 (11.0)* 130 (57.1)* 70 (30.7)* 40 (17.5) 52 (22.8)* 25 (11.0) 21 (9.2)* 21 (9.2)* 155 (68.0)*
a
measured at 3 months. * p ⬍ .01 for comparisons among race/ethnic groups.
slightly higher percent of African-Americans reported MSDS at 48 (20.0%) than at 24 months (16.9%). Cumulative depressive symptoms were calculated by taking the percentage of young mothers who experienced MSD symptoms at three months postpartum and adding to it the proportion of subjects who experienced MSD symptoms for the first time at each subsequent point of follow-up. The proportions that are reported are prevalence rates, because new cases of MSD symptoms identified at each follow-up were added to existing cases identified on prior surveys. Overall, 57% of the sample reported MSD symptoms at some point during this four-year period. The steepest increase in the percent reporting new symptoms occurred during the first 12 months after delivery, with half of the total sample reporting these symptoms. Using chi-square analyses, comparisons among racial/ ethnic groups revealed African-Americans were significantly less likely than Caucasians to report MSD symptoms at three months (p ⫽ .048) and significantly less likely than both Caucasians and Mexican-Americans to report MSD symptoms at 24 months (p ⫽ .010). Logistic regression was then used to control for potential covariates (age at delivery, parity, financial resources, language of interview, education level, recent tobacco and alcohol use, family violence, recent intimate partner violence, and family support) at each point of follow-up. At three months postpartum, Caucasians
were 2.0 times (95% CI 1.2–3.4, p ⫽ .012) more likely to report MSD symptoms than African-Americans. At 12 months postpartum, Mexican-Americans were 2.6 times (95% CI 1.4 – 4.8, p ⫽ .003) more likely to report MSD symptoms than African-Americans. Similarly, at 24 months postpartum, Mexican-Americans were 2.2 times (95% CI 1.1– 4.4, p ⫽ .025) more likely to report MSD symptoms than African-Americans. No significant differences in MSD symptoms at 48 months were observed among racial/ethnic groups after controlling for potential covariates. As hypothesized, in the entire subsample and across racial/ethnic groups, MSD symptoms at three months were significantly (McNemar Tests; p ⬍ .05) associated with MSD symptoms at each point of contact and for each race/ethnic group with one exception. Among MexicanAmericans, MSD symptoms at three months postpartum were not related to MSD symptoms at 12 months postpartum (p ⫽ .134). In addition, 48.3% of African-Americans who reported MSD symptoms at three months also reported MSD symptoms at 48 months, versus 39.4% of MexicanAmericans and 27.9% of Caucasians (Figure 1; p ⬍ .01). More than 80% of those who reported MSD symptoms at three months reported similar symptoms on two or more additional surveys. Fifty-five percent of the entire sample reported MSD symptoms on two or more surveys, whereas 15% reported these symptoms at all four points of contact.
Table 2 Point prevalence of MSD symptoms (unadjusted) at 3, 12, 24 and 48 months postpartum, % (95% confidence interval) Month of follow-up
Total (n ⫽ 623)
Mexican American (n ⫽ 228)
African-American (n ⫽ 213)
Caucasian (n ⫽ 182)
3 (n ⫽ 601) 12 (n ⫽ 592) 24 (n ⫽ 593) 48 (n ⫽ 554)
36.7 (32.9–40.5) 28.4 (24.8–32.0) 23.6 (20.2–27.0) 21.1 (17.7–24.5)
37.0 (33.1–40.9) 32.4 (28.6–36.2) 24.5 (21.0–28.0) 21.3 (17.9–24.7)
30.9 (27.2–34.6) 23.4 (20.0–26.8) 16.9 (13.9–20.0) 20.0 (16.7–23.3)
43.1 (39.1–47.1) 29.3 (25.6–33.0) 30.1 (26.4–33.8) 22.2 (18.7–25.7)
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Figure 1. Proportion (%) of adolescent mothers with MSD symptoms at 3 months who also reported MSD symptoms at 12, 24, and 48 months.
These findings did not differ by race/ethnicity. Finally, of those who experienced MSD symptoms by 48 months of follow-up, 87.9% (312/355) reported these symptoms by the end of the first postpartum year. Discussion In this, the largest published longitudinal study to report depressive symptoms among adolescent mothers from three different race/ethnic groups, more than half of the young mothers reported MSD symptoms over the four-year period. The vast majority of these reported symptom onset within the first postpartum year. As expected [13,25], the prevalence of MSD symptoms was highest at three months postpartum and declined across the four-year period after delivery. Similar patterns were observed across race/ethnic groups, although the decrease in prevalence between 24 and 48 months postpartum was most robust for Caucasian adolescent mothers. Contrary to our expectations and after controlling for significant covariates, Mexican-American and Caucasian adolescent mothers were found to be at higher risk of MSD symptoms than African-Americans, with Mexican-Americans at highest risk overall. The higher rates of MSD symptoms observed among Mexican-Americans as compared with Caucasians and African-Americans in our study are consistent with those previously reported among nonpregnant adolescents by Roberts et al [26]. However, few prior studies have had large enough samples of adolescent mothers from different race/ethnic groups to adequately examine racial/ ethic differences while controlling for important covariates. This study emphasizes that further investigation is needed to understand why these differences exist. In one prior study, differences among race groups were greatly reduced once socioeconomic status had been controlled [19]. In our study, logistic regression analyses revealed differences that had not been identified before the addition of covariates, including economic resources, to the multivariate model. Many adolescent mothers in this study experienced per-
sistent MSD symptoms over four years of follow-up. MSD symptoms reported at three months were significantly associated with MSD symptoms at follow-up, and nearly 90% of those reporting MSD symptoms at 48 months also reported these symptoms within the first postpartum year. This is consistent with literature in adult mothers where almost 90% of those mothers who reported depressive symptoms by four months after delivery had reported onset of these symptoms by the first month postpartum and almost a third of the sample reported persistence of symptoms beyond four months of delivery [27]. Fifty-five percent of the entire sample reported MSD symptoms on two or more surveys, whereas 15% reported these symptoms at all points of contact. Other studies have reported persistence of depressive symptoms in adolescent mothers, adult mothers, and nonparenting adolescents [13,28]. Children of depressed mothers are at increased risk for social, emotional and behavioral problems [29,30]. Thus, these data support the chronic nature of mental health problems in this population and provide evidence of the value of careful and ongoing screening and management. Despite an initial drop in MSD symptoms between 3 and 24 months among all race/ethnic groups, a significant proportion of adolescent mothers who reported MSD symptoms at three months experienced a recurrence of their symptoms at 48 months. This recurrence was highest among African-Americans. This is counterintuitive, as studies commonly report that minority adolescent mothers experience higher levels of family support than Caucasians [31,32]. One study that examined decision making in African-American and Caucasian adolescent mothers found that among African-American adolescent mothers, greater decision-making was associated with increased likelihood of reporting depressive symptoms [33]. Studies in adults have found that racial/ethnic minorities are more likely to report depressed mood and this is associated with their increased likelihood to report difficulty in meeting basic needs [34]. It is possible that shifts in social support associated with entering adulthood, such as moving into an independent living arrangement, precipitated the higher rates of recurrence of depressive symptoms observed among African-Americans in our study. Further examination of this important subgroup is needed to explore possible explanations of this finding. There are limitations to this study. The prepregnancy depressive history in this group of adolescent mothers is unknown. Adolescent mothers with a prior history of major depression or other affective disorders may have been more likely to report MSD symptoms postpartum. Adolescent mothers who were initially interviewed, but failed to return five of six follow-up surveys (n ⫽ 302) were not included in these analyses. It is possible that some of these mothers were severely depressed, and their omission could lead to reduced prevalence estimates.
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Also, it would have been helpful to have collected data from participants at 36 months, although given the trends reported at 24 and 48 months, it is unlikely that findings would have differed significantly from those reported at 48 months. Finally, the Beck Depression Inventory includes somatic criteria that may be part of the normal postpartum physiological process and may be confused with depressive symptoms. Alternative screening tests for postpartum depression have reported lower false positive rates [35]. In summary, owing to improved methodology and a large ethnically diverse sample, our data confirm that the prevalence of depressive symptoms among adolescent mothers, as with older mothers, is elevated after the delivery of a child and, for a subset, persists well into the postpartum period. In fact, more than one out of 10 adolescent mothers appears to have a chronic condition that places both mother and child at risk. The purpose of this article was to provide a solid foundation of the scope of this problem and to examine race/ethnic differences. Future studies are needed to identify predictors of depressive symptoms, in general, and to examine the role of social support. Clinically, our findings have important implications. Our data support the importance of screening for postpartum symptoms among adolescent mothers and to continue screening for several years after delivery. It is important for providers to remember that although symptoms may diminish across time, as these infants age, mothers continue to be at risk for future symptom development.
Acknowledgment This project was sponsored by grants DA09636 and DA08404 (Dr. Wiemann) from the National Institute on Drug Abuse, Rockville, MD, and by The Hogg Foundation for Mental Health, Austin, Tex (Dr. Wiemann). The findings presented herein do not reflect the views of these granting organizations. We are indebted to the many adolescent participants who shared their experiences with us and to the interviewers who spent hundreds of hours collecting this information. Dr. Wiemann’s time was partially supported by a grant from the Health Resources and Services Administration (T71MC00011).
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