Lisa Kelly

Identifying Postpartum Depression: Are 3 Questions as Good as 10?

BACKGROUND. Postpartum depression is the most common medical problem that new mothers face. Anxiety is a more prominent feature of postpartum depression than of depression that occurs at other times in life. Routine, universal screening significantly improves detection in primary health care settings. Thus, an ultrabrief scale that could be incorporated into a general health survey or interview would be useful. OBJECTIVE. We tested the hypothesis that, during the first 6 postpartum months, the 3-item anxiety subscale of the Edinburgh Postpartum Depression Scale is a better ultrabrief depression screener than 2 Edinburgh Postpartum Depression Scale questions that are almost identical to the widely used Patient Health Questionnaire. METHODS. A cohort of 199 14- to 26-year-old participants in an adolescent-oriented maternity program completed the Edinburgh Postpartum Depression Scale at well-child visits during the first 6 postpartum months. Three subscales of the Edinburgh Postpartum Depression Scale were examined as ultrabrief alternatives: the anxiety subscale (3 items; Edinburgh Postpartum Depression Scale-3), the depressive symptoms subscale (7 items; Edinburgh Postpartum Depression Scale-7), and 2 questions that resemble the Patient Health Questionnaire (Edinburgh Postpartum Depression Scale-2). The reliability, stability, and construct validity of the Edinburgh Postpartum Depression Scale and 3 subscales were compared. Criterion validity was assessed by comparison with a score of ≥10 on the full, 10-item Edinburgh Postpartum Depression Scale. RESULTS. A total of 41 mothers (20.6%) met study criteria for referral for evaluation of depression (Edinburgh Postpartum Depression Scale-10 score ≥ 10). The Edinburgh Postpartum Depression Scale-3 exhibited the best screening performance characteristics, with sensitivity at 95% and negative predictive value at 98%. It identified 16% more mothers as depressed than the Edinburgh Postpartum Depression Scale did. The performance of the Edinburgh Postpartum Depression Scale-2 was markedly inferior, with sensitivity at 48% to 80%. Moreover, the Edinburgh Postpartum Depression Scale-2 was unreliable for mothers who had not been depressed in the past. CONCLUSION. The brevity, reliability, and operating characteristics of the Edinburgh Postpartum Depression Scale-3 make it an attractive postpartum depression screening tool for primary health care settings in which the goal is to detect depression, not to assess its severity. Validation by diagnostic psychiatric interview is needed.

Reasons For First Teen Pregnancies Predict the Rate of Subsequent Teen Conceptions

Objective. To identify reasons for inconsistent contraceptive use that antedate conception and continue to predispose participants in adolescent-oriented maternity programs to unsafe sexual practices after delivery. We hypothesized that teens who attributed their failure to use contraceptives before their first conception exclusively to concerns about their side effects and/or their own lack of motivation to prevent conception would report less consistent contraceptive use and more repeat conceptions than would teens who attributed their previous failure to use contraceptives to their lack of capacity to do so. Method. We conducted a 2-year, prospective, longitudinal study of contraceptive use and repeat conceptions in a racially/ethnically diverse population of poor 13- to 18-year-olds. The 198 study participants were enrolled consecutively during their first pregnancies from an adolescent-oriented maternity program. Results. The majority (84%) of the teens attributed their failure to use contraceptives before their first pregnancy partially to a lack of capacity to do so. As hypothesized, these teen mothers were significantly more likely to use hormonal contraceptives (85% vs 62%), (particularly Norplant, 47% vs 19%) and less likely to conceive again (13% vs 41%). Most teens attributed their inconsistent contraceptive use during the postpartum study period to three factors: side effects, plans to abstain from sexual intercourse, and their lack of motivation to postpone additional childbearing. Conclusions. The reasons teen mothers give for not using contraceptives consistently before their first pregnancies predict the occurrence of subsequent conceptions during adolescence. Those who attribute their previous failure to use contraceptives consistently to side-effect concerns and their own lack of motivation to postpone childbearing are least likely to use hormonal contraceptives after delivery and most likely to conceive again. Our findings suggest that future research should focus on the development of more effective interventions for preventing repeat conceptions among adolescent mothers who had the capacity to prevent their first pregnancies.

The timing of norplant insertion and postpartum depression in teenagers.

BACKGROUND This study tested the hypothesis that teenagers who have Norplant inserted during the puerperium report more depressive symptoms during the first postpartum year than their peers who do not receive Norplant. METHODS We studied the prevalence of depressive symptoms in a group of 212 mothers aged 19 years less, in relation to the timing of Norplant insertion. The participants were divided into 3 groups: 100 (47%) had Norplant inserted during the puerperium (early Norplant users); 72 (34%) had Norplant inserted during the next 10 months (late Norplant users); and 40 (19%) used other contraceptives (40% oral contraceptives; 17% condoms; 43% nothing). Depressive symptoms were measured with the Center for Epidemiologic Studies - Depression Scale. Postpartum depression was defined as a scale score >/=16, 6-12 months after Norplant insertion or delivery. Variables examined as potential confounders were identified a priori from a review of the literature and controlled for in analysis of variance. RESULTS At delivery, members of the 3 contraceptive groups did not differ significantly with regard to age, race, parity, educational, marital, or socioeconomic status. Late Norplant users were, however, more apt to have new boyfriends (p =. 03), to rate the support they received from the babys father as poor (p =.004), and experience depression prior to Norplant insertion (p =.02). Contrary to the study hypothesis, late rather than early Norplant insertion was associated with postpartum depression. Multivariate analyses identified 3 independent predictors of the severity of depressive symptoms at follow-up (depression prior to Norplant insertion, a new boyfriend at delivery, and late Norplant insertion); R(2) = 41.3%. CONCLUSIONS Contrary to the study hypothesis, puerperal Norplant insertion did not exacerbate postpartum depression. Delaying Norplant insertion may increase the risk of depression during the first postpartum year, particularly in teenagers with other psychosocial risk factors.

Should gynecologic maturity change the management of cervical cytologic atypia during adolescence

STUDY OBJECTIVE To test the hypothesis that atypical cytology (ASCUS) portends ominous histologic diagnoses during adolescence. METHODS The prevalence of squamous intraepithelial lesions (SILs) was determined in a racially diverse group of thirty-six 14- to 21-year-olds who were undergoing colposcopic evaluation of ASCUS cytology. The prevalence of 10 widely accepted risk factors for SIL was also qualified. RESULTS SILs were detected in biopsies obtained from 20 (56%) of the 36 study subjects. There were 15 (39%) low-grade SILs and 5 (17%) high-grade SILs. No single risk factor or combination of risk factors distinguished subjects with SIL histology from those with more benign diagnoses. CONCLUSION The hypothesis was supported. More than half (56%) of the adolescents we studied with ASCUS cytology had SIL histology. The findings suggest that immediate colposcopic evaluation may be prudent for adolescents with ASCUS cytology that cannot be attributed to concurrent lower genital tract infections.

THE EFFECT OF MONETARY INCENTIVES AND PEER SUPPORT GROUPS ON REPEAT ADOLESCENT PREGNANCIES : A RANDOMIZED TRIAL OF THE DOLLAR-A-DAY PROGRAM

OBJECTIVES To test the hypotheses that (1) a monetary incentive promotes peer-support group participation; and (2) peer-support group participation decreases repeat adolescent pregnancies. DESIGN Two-year, prospective, randomized controlled trial. SETTING Denver, Colo. PARTICIPANTS A total of 286 primiparous girls younger than 18 years, whose infants were younger than 5 months. INTERVENTION Participants were randomized to 4 interventions: monetary incentive and peer-support group, peer-support group only, monetary incentive only, or no intervention. MAIN OUTCOME MEASURES Consistency of participation in planned intervention and repeat pregnancy. RESULTS Participation in interventions was generally low. Hypothesis 1 was supported: 58% of those offered a monetary incentive participated in the peer-support groups, compared with 9% of those who were not offered the incentive. Hypothesis 2 was rejected: the peer-support group experience failed to prevent repeat pregnancies. The incidence of second pregnancies at 6 months (9%, 22/248), at 12 months (20%, 49/248), at 18 months (29%, 72/248), and at 24 months (39%, 97/248) following delivery did not vary significantly in relation to intervention strategy. Background sociodemographic characteristics significantly affected the timing of subsequent conceptions but not intervention participation. CONCLUSION A monetary incentive draws adolescent mothers to sites where they can discuss the costs and benefits of contraception and conception with knowledgeable adults and supportive peers. These discussions do not prevent repeat pregnancies. Further studies are needed to determine if an intervention that produces substantive changes in the daily living environment will eliminate the sexual practices that are responsible for the high rate of repeat pregnancy in this population.