Postpactum Depression in Adolescents - Research Paper Example

?Running Head: POSTPARTUM DEPRESSION IN ADOLESCENTS Postpartum Depression in Adolescents Postpartum Depression in Adolescents Introduction Postpartum Depression (PPD) is probably the most well studied and widely known of the postpartum psychiatric disorders. This heightened awareness may help erase the stigma attached to postpartum mood disorders and may encourage prompt attention to symptoms. PPD can have deleterious effects on parents, infants, older children, extended families and the community. Postpartum depression results in devastating consequences for adults. However, for adolescents, who are already in major transitional changes, postpartum depression causes insurmountable damage. Studies have reported that teen mothers are at risk since they experience higher levels of despair, lower self-esteem and suicide attempts compared to their adult counterparts (Blenning & Paladine, 2005; Logsdon, Birkimer, Simpson, & Looney, 2005; Haslam, Pakenham, & Smith, 2006). An understanding of the complexities and individual vulnerabilities of young adolescents in relation to PPD combined with early identification is a primary concern of the social workers and health practitioners to prevent PPD from becoming a more serious mental illness. Problem Overview Postpartum Depression is a potentially devastating disorder with prevalence rates ranging from 20% to 26% in adolescent mothers (Blenning & Paladine, 2005; Logsdon et al., 2005). There has been some disagreement about the peak incidence of PPD onset, with various studies indicating that onset could begin within the first 12 weeks postpartum (Blenning & Paladine, 2005; Dennis, 2004; Dennis, Janssen, & Singer, 2004). In general, onset is usually gradual, but can be rapid, and may begin any time during the first year of postpartum (Baker et al., 2005; Dennis et al., 2004). Additionally, research has shown that depressive episodes extend beyond the first postpartum year and may occur continuously and/or intermittently for extended periods. PPD is often referred to as postpartum non-psychotic depression to differentiate from PPP (postpartum psychosis), throughout this discussion PPD will maintain that definition. PPD in an adolescent mother is characterized by symptoms including debilitating depression, suicidal ideation, hopelessness, feelings of inadequacy, fatigue, lack of interest in a baby, low levels of functioning, isolation and social withdrawal, irritability, severe mood swings, difficulties in concentration, decreased libido, anhedonia (lack of interest in living and in the pleasures of life), unintended changes in eating patterns and somatic manifestations of anxiety, such as palpitations and headaches (Ammerman et al. 2007; McMahon, Barnett, Kowalenko, & Tennant, 2006; Forman et al., 2007; Mayberry, Andrews Horowitz, & Declercq, 2007; Tuohy, 2008; Dennis, 2005). Indeed, these symptoms are similar to and are often the same as those of major depression that occur at other times. Left untreated PPD can have significant and long lasting detrimental effects on the infant, the family, and the mother herself (Baker et al., 2005). Considerable evidence exists that maternal depression has adverse effects on maternal-infant attachment and long-term infant cognitive and emotional development (Baker et al., 2005). As with PP OCD, there have been reports of PPD in young fathers (Goodman, 2004). Maternal depression seems to be the strongest predictor of paternal postpartum depression (Goodman, 2004). Other factors that contribute to paternal postpartum depression are distressed marital relationship, history of depression, unemployment, poor social functioning, low socioeconomic status and stepfamily membership (Goodman, 2004). Ramchandani, Stein, Evans and O'Connor (2005) in a large longitudinal study investigated the effects of paternal depression on early childhood emotional and behavioral development. Their findings indicated that paternal depression had a specific and detrimental effect on their children's development with a particularly negative impact on boys. Although research is limited in the area of paternal postpartum depression, from what is known to date, it would be important to consider the possibility of paternal depression in the development of a comprehensive postpartum support program. Etiology and Risk Factors of Postpartum Depression A specific etiology of PPD is uncertain. Etiology appears to be multifactorial with biological, psychological, social and cultural factors acting together within the unique context of a particular woman (Bina, 2008). A personal or family history of depression, especially postpartum depression, anxiety and/or depression during pregnancy, can be fairly accurate predictors of PPD (Bina, 2008). However, while there has been no specific cause determined for the development of PPD, there do seem to be risk factors in each of these areas that may predict the onset of PPD. Biological factors in the etiology of postpartum depression Because the postpartum period is a time of rapid physiological changes, biological factors have been hypothesized to increase a woman's vulnerability to major depression during this time. The role of progesterone, estrogen, cortisol, prolactin and thyroid hormones have been studied and implicated to varying degrees in the onset of PPD (Kammerer, Taylor, & Glover, 2006; Kaslow et al., 2007). Progesterone withdrawal has been posited as a causal factor in postpartum mood disorders. However, evidence for this hypothesis has been mixed and inconclusive (Bloch et al., 2005; Kammerer et al., 2006). Biologically active forms of estrogen, estradiol and estriol increase about 100-fold and 1,000-fold respectively during pregnancy (Riecher-Rossler & Steiner, 2005). These levels decrease rapidly and markedly after delivery. The placenta is the center of synthesis for these hormones during pregnancy. Animal studies have shown that estradiol enhances serotonin function (Kammerer et al. 2006; Kaslow et al., 2007). Because serotonin is implicated in mood regulation it is possible that the sudden drop in the level of estradiol after delivery may be associated with PPD. However, research results have been negative or inconclusive regarding an association between estradiol levels and the development of depressive symptoms (Bloch et al., 2005; Kammerer et al. 2006). The fluctuation of ovarian hormones, rather than actual levels, during reproductive cycles has been thought to contribute to affective disorders in vulnerable women (Schneider & Popik, 2007; Kaslow et al., 2007). Depression has been associated with use of oral contraceptives, the leuteal phase of the menstrual cycle, the postpartum period and, possibly, menopause. Reproductive hormones may possibly exert influences on affective states by directly or indirectly influencing neurotransmitter, neuroendocrine or circadian systems (Schneider & Popik, 2007; Kaslow et al., 2007). During pregnancy and the late follicular or preovulatory phase of the menstrual cycle, levels of reproductive hormones increase and mood is generally high. In the leuteal or premenstrual phase and in the postpartum period reproductive hormone levels decline and depression is most likely to happen (Schneider & Popik, 2007; Kaslow et al., 2007). Overall, there has been no conclusive evidence of a single biological factor that contributes to the etiology of PPD. However, biological factors may be an important vulnerability in that some women do experience depressive symptomology within this context of dramatic physiological change. Psychological factors in the etiology of postpartum depression Depression during pregnancy has been a robust predictor of PPD (Akman, Uguz, & Kaya, 2007). A personal history of PPD and/or depression, as well as other psychiatric disorders (notably bipolar disorder), has been found to be associated with the onset of PPD (Ross, Sellers, Evans, & Romach, 2004). When the index episode of PPD was not preceded by a previous nonpuerperal depression, the risk for subsequent nonpuerperal depression was significantly lower than with those women with a history of depressive episodes unrelated to childbirth (Hanna, Jarman, & Savage, 2004). Maternal self-esteem has been noted to be a significant factor in the prediction of PPD (Haslam et al., 2006). Poor self-esteem, with the concurrent doubts about competence and low levels of perceived self-worth, decreases the buffering effect that high levels of self-esteem have on stressful life events (Haslam et al., 2006). Mothers with high self-esteem have less vulnerability to stress, as well as the ability to withstand the vicissitudes of everyday life that could jeopardize their feelings of self-worth and contribute to the development of PPD. Prenatal anxiety was indicated as a significant risk factor for PPD (Blenning & Paladine, 2005). Blenning and Paladine (2005) noted that women with high levels of neuroticism or psychological vulnerability appear to be at high risk for PPD. Women who have exaggerated expectations for themselves, those who seek to control events in their lives and those who may have unrealistic expectations about their infants appear to be at greater risk for postpartum depression. Social factors in the etiology of postpartum depression There are a myriad of social factors that have been attributed to the onset of PPD in adolescent mothers. These include: childcare stress, stressful life events during pregnancy, lack of social support, poor intimate relationship adjustment, being unmarried or divorced, low socioeonomic status and unwanted or unplanned pregnancy (Ammerman et al., 2007; McMahon et al., 2006; Forman et al., 2007; Segerstrom & Miller, 2004). It is important to be aware that many of these factors are interrelated and, in combination, can elevate risk. Childcare stress is related to the health status of the infant, difficulties with feeding and sleeping routines and infant temperament (Segerstrom & Miller, 2004). Infants born prematurely, those with medical issues who need hospitalization or numerous medical visits, and infants with birth defects can be significant sources of stress. An infant who is perceived as fussy, irritable, difficult to console and unpredictable can add to the level of childcare stress. Life stress during pregnancy and the postpartum period can contribute to the development of PPD (Boyce & Hickey, 2005). These events may be positive or negative and can include events such as marriage, remarriage, divorce, occupational changes or unemployment, loss of friends or family members and events such as automobile accidents, financial crises, relocation, burglaries, natural disasters and illness requiring hospitalization. Social support consists of receiving both instrumental and emotional support (Boyce & Hickey, 2005). Instrumental support consists of things such as babysitting, transportation and help with household chores. Emotional support entails partner, friends and/or family with whom the mother can share and express personal feelings. Structural aspects of her social network consist of size of network, including husband/partner, friends and family, proximity of its members, frequency of contacts, and number and quality of confidants a woman feels she has (Haslam et al., 2006; Highet & Drummond, 2004). When a new mother perceives that she is not receiving an adequate amount of instrumental or emotional support, her risk for PPD increases. Adjustment to the new roles of parenthood is often an area of discord among couples and extended family (Boyce & Hickey, 2005). Differences in styles of communication, displays of affection, and values may become highlighted as the family adjusts to the new member. Mutual activities that were once enjoyed may not be possible to the previous degree or at all. The mother may have less sexual desire as she recovers from the birth process that may lead to further disruption of the intimate relationship. If marital problems existed before birth, they may become exacerbated in the postpartum period. For some women, the relationship with their own mother may become an area of stress, especially if that relationship has been marked with discord or loss (Boyce & Hickey, 2005). Unmarried or divorced women are vulnerable to postpartum stress and depressive symptoms (Boyce & Hickey, 2005; Haslam et al., 2006; Highet & Drummond, 2004) for reasons that would appear to be obvious, including lack of an intimate partner, financial concerns, complete responsibility for the infant's care, social sanctions concerning single parents, dependency on parents or government agencies for support, and limited support systems. Low socioeconomic level, lower attained education level, and an unwanted or unplanned pregnancy may contribute to PPD (Boyce & Hickey, 2005; Flynn, 2005). Although these have not been found to be significant alone, in combination with other factors they may increase the probability of developing PPD. Cultural factors in the etiology of postpartum depression It has been speculated that postpartum depression is culture-bound and specific to industrialized countries (Gomez-Beloz, Williams, Sanchez, & Lam, 2009). In cross-cultural studies the prevalence of PPD is considerably lower in countries where there are socially sanctioned rituals and acknowledgement of the special status of new mothers (Gomez-Beloz et al., 2009). The American cultural assumption that birth and parenting will come naturally, with minimal discomfort, and ease of adjustment, denies the existence and actual experience of negative and ambivalent emotions regarding childbirth (Lamanna & Riedmann, 2005). The positive and dangerous mythology surrounding motherhood has set expectations that are impossible for mothers to attain. Cultural factors also influence the manner in which symptoms are expressed and whether they will be socially acceptable. This may be of particular relevance in determining whether a young mother will seek treatment, how she may perceive herself, and how others may respond to her distress. Conclusion Literature review has identified that Postpartum Depression has a prevalence of about 20%-26% of young adolescent mothers who give birth (Blenning & Paladine 2005). A similar prevalence has been observed in new fathers, with maternal depression being the most reliable predictor of paternal depression during the puerperium (Goodman, 2004). PPD has a complex etiology consisting of biological, psychological, social and cultural factors. There are several risk factors involved in the onset of PPD including prenatal depression, low self-esteem, childcare stress, prenatal anxiety, life stress, lack of social support, a poor marital relationship, history of depression, perceived difficult infant temperament, postpartum blues, being unmarried, low socioeconomic status and unplanned or unwanted pregnancy. However, the presence of these conditions alone is not conclusive to predicting the onset of PPD. Other individual components, such as biological sensitivity, paternal depression, socialization and cultural beliefs, in various combinations with these named risk factors seem to have etiological influence for PPD onset. Postpartum Depression and other mood disorders with postpartum onset may be construed as stress reactions to various events or conditions in a woman's life within the context of profound physiological and social changes. Circumstances that are a normal aspect of a woman's life and environment may become risk factors in the perinatal period. It is important to remain cognizant of the individual issues that are truly relevant to each particular person. It is important to remember that the specific cause of PPD is almost impossible to define; it is rather a set of biological, psychological, social and cultural variables that are unique to each woman. Although the depressive symptoms that manifest in postpartum women are the same as those in non-puerperal times, special consideration of the unique physiological and social stressors during this vulnerable time is essential. Because this illness affects not only the mother but her infant, other children, her partner, extended family, social circle and ultimately the wider community, it would seem imperative to include significant others, as much as possible, in treatment planning and implementation of interventions. References Akman, C., Uguz, F., & Kaya, N. (2007). Postpartum-onset major depression is associated with personality disorders. Comprehensive Psychiatry, 48, 343-347. Ammerman, R. T., Bodley, A. L., Putnam, F. W., Lopez, W. L., Holleb, L. J., Stevens, J., & Van Ginkel, J. B. (2007). In-home cognitive behavior therapy for a depressed mother in a home visitation program. Clinical Case Studies, 6(2), 161-180. Baker, L., Cross, S., Greaver, L., Wei, G., Lewis, R., & Healthy Start CORPS (2005). Prevalence of postpartum depression in a Native American population. Maternal and Child Health Journal, 9(1), 21-25. Bina, R. (2008). The impact of cultural factors upon postpartum depression: A literature review. Health care for women international, 29(6), 568-592. Blenning, C. E., & Paladine, H. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496. Bloch M., Rubinow D.R., Schmidt P.J., Lotsikas A., Chrousos G.P., & Cizza G. (2005) Cortisol response to ovine corticotropin-releasing hormone in a model of pregnancy and parturition in euthymic women with and without a history of postpartum depression. J Clin Endocrinol Metab 90: 695–699. Boyce, P., & Hickey, A. (2005). Psychological risk factors to major depression after childbirth. Social Psychiatry & Epidemiology, 40, 605-612. Dennis, C. L. (2005). Psychosocial and psychological interventions for prevention of postnatal depression: Systematic review. BMJ (British Medical Journal), 331., Dennis, C. L. (2004). Preventing postpartum depression part II: A critical review of nonbiological interventions. Canadian Journal of Psychiatry, 49, 526-538. Dennis, C. L., Janssen, P. A., & Singer, J. (2004). Identifying women at risk for postpartum depression in the immediate postpartum period. Acta Psychiatrica Scandinavica, 110, 338-346. Flynn, H. A. (2005). Epidemiology and phenomenology of postpartum mood disorders. Psychiatric Annals, 35(7), 544-554. Forman, D. R., O'Hara, M. W., Stuart, S., Gorman, L. L., Larsen, K. E., & Coy, K. C. (2007). Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. Development and Psychopathology, 19(1), 585-602. Gomez-Beloz, A., Williams, M., Sanchez, S., & Lam, N. (2009). Intimate partner violence and risk for depression among postpartum women in Lima, Peru. Violence and Victims, 24(3), 380-98.  Goodman, J. H. (2004). Parental postpartum depression, its relationship to maternal postpartum depression and implications for family health. Journal of Advanced Nursing, 45(1), 46-35. Hanna, B., Jarman, H., & Savage, S. (2004). The clinical application of three screening tools for recognizing post-partum depression. International Journal of Nursing Practice, 10, 72-79. Haslam, D. M., Pakenham, K. I., & Smith, A. (2006). Social support and postpartum depressive symptomatology: The mediating role of maternal self-efficacy. Infant Mental Health Journal, 27, 276-291. Highet, N., & Drummond, P. (2004). A comparative evaluation of community treatments for post-partum depression: Implications for treatment and management practices. Australian and New Zealand Journal of Psychiatry, 38, 212-218. Kammerer, M., Taylor, A., & Glover, V. (2006). Original contribution: The HPA axis and perinatal depression. A hypothesis. Arch Womens Ment Health 9: 187–196. Kaslow, N. J., Bollini, A. M., Druss, B., Goldfrank, L. R., La Greca, A. M., Wang, S. S. H., Glueckauf, R. L., Kelleher, K. J., Varela, R. E., Weinreb, L, & Zeltzer, L. (2007). Health care for the whole person: Research update. Professional Psychology: Research and Practice, 38(3), 278-289. Lamanna, M. A., & Riedmann, A. (2005). Marriages & families: Making choices in a diverse society. Wadsworth Publishing. Logsdon, C. M., Birkimer, J. C. Simpson, T., & Looney, S. (2005). Postpartum depression and social support in adolescent, Journal of Obstetric Gynaecologic, and Neonatal Nursing, 24, 308-312. Mayberry, L. J., Andrews Horowitz, J., & Declercq, E. (2007). Depression symptom prevalence and demographic risk factors among US women during the first 2 years of postpartum. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 36(6), 542-549. McMahon, C. A., Barnett, B., Kowalenko, N. M., & Tennant, C. C. (2006). Maternal attachment state of mind moderates the impact of postnatal depression on infant attachment. Journal of Child Psychology and Psychiatry, 47(7), 660-669. Ramchandani, P., Stein, A., Evans, J. O., & O'Connor T. (2005). Paternal depression in the postnatal period and child development. A Prospective population study. The Lancet 365, 2201-2205. Riecher-Rossler, A., & Steiner, M. (2005). Perinatal stress, mood and anxiety disorders: From bench to bedside (Bibliotheca Psychiatrica). S Karger Publication. Ross, L. E., Sellers, E. M., Evans, S. E. G., & Romach, M. K. (2004). Mood changes during pregnancy and the postpartum period: Development of a biopsychosocial model. Acta Psychiatrica Scandinavica, 109, 457-466. Schneider, T., & Popik, P. (2007). Increased depressive-like traits in an animal model of premenstrual irritability. Hormones and Behavior. 51(1), 142–148. Segerstrom, S. C., & Miller, G. E. (2004). Psychological stress and the human immune system: A meta-analytic study of 30 years of inquiry. Psychological Bulletin, 130(4), 601-630. Tuohy, A. (2008). Experience of pregnancy and delivery as predictors of postpartum depression. Psychology, Health & Medicine, 13(1), 43-47. Read More