Depression in Teenage Pregnancy
In the UK, the National Institute of Clinical Excellence (NICE) produced Guideline CR192 to focus on the clinical management of antenatal and postnatal mental health.
The focus of this document is the wide range of mental illnesses such as depression, psychosis, anxiety, eating disorders, drug and alcohol use disorders.
2.9 in 100 girls in the UK between the ages of 15 and 19 years give birth which is high compared to other countries 0,9 per 100 in France, 1.1 per 100 in Germany and 0.4 per 100 in Japan. In the UK there are 48000 babies born each year to teenage mothers.
A pregnant teenage girl may present to the midwife or GP for an initial meeting or booking visit. At this visit they should be asked questions about whether or not they are depressed or worried. They should be asked whether they have experienced loss of enjoyment or excessive tiredness in the last month. They should also be asked whether or not they can control their worries. Then, screening questionnaires such as GAD 2, GAD 7, PHQ 9, or the Edinburgh Postnatal Depression Scale can be used.
If a midwife or GP is concerned about the presence of depression or anxiety. then this girl can be referred to the local Child and Adolescent Mental Health Service. If the teenage girl is in a supportive family environment with a supportive partner then natural anxieties should be alleviated. However if her context is unsafe, associated with domestic violence, or a lifestyle associated with problematic, illicit drug and alcohol misuse then the situation will be more complicated. If there are clear child protection issues then social services would have to be involved to protect the teenage girl and her unborn baby.
Maternal deaths in the first 42 days after delivery in 2010 in UK were 12 per 100000 live births, where 6.72 deaths per 100000 live births were attributed to suicide and heart disease. Both depression and cardiac disease can be exacerbated by pregnancy. Infanticide is rare but the effect of a depressed mother on the attachment relationship can be profound and is a far more common adverse consequence of post natal depression. If a mother does not bond with her baby then her baby may well develop an anxious temperament and an insecure attachment. Also, a depressed mother not receiving treatment may be more likely to be a neglectful parent.
Therefore, for pregnant teenagers and teen mums with mental illness, there needs to be good coordinated support from the GP, midwife, health visitor, family nurse, mental health services and Social Services where necessary.
The NICE guidelines update mentioned earlier indicate the importance of prompt assessments and referrals to CAMHS or a Perinatal Mental Health Service within two weeks and the commencement of psychological therapy within four weeks.
In pregnancy, psychological therapy would be preferred to medication. However there may be teenagers who are already taking antidepressant medication or medication for ADHD. There is not enough safety data regarding the use of methylphenidate in pregnancy. Sodium valproate should not be prescribed to young women at all as the risk of congenital malformations 7-10% and there is a greater risk of neurodevelopmental problems in children with an IQ reduction of 9 points.
In pregnancy a detailed history of any alcohol or drug misuse and previous history of depression or anxiety should be taken. There may be a history of depression or bipolar affective disorder in the parents which may have a bearing on the teenage girl's presentation.
After birth if the mother is found to have any psychotic features she should be referred to CAMHS or to a specialist perinatal mental health service for assessment within four hours. These specialist services can offer admission to specialist hospital for mother and baby especially if the mother has made a suicide attempt and have not formed a bond with her baby.
Postnatal depression and depression in pregnancy affect 7-10% of women and 20% of women who have a history of bipolar affective disorder will have a serious relapse after delivery. Check out www.nhs/conditions/postnataldepression
Therefore in supporting teenage mothers with depression our health service needs to be able to offer good surveillance for symptoms and prompt referral to service within hours (severe presentation) to two weeks. Good care will involve good communication and prompt liaison inthe girl's best interests between the GP, midwife, community nurses, mental health services, obstetrics and social services.