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Randomized controlled trial to prevent postpartum depression in adolescent mothers

Published:January 10, 2013DOI:https://doi.org/10.1016/j.ajog.2012.12.036

      Objective

      The purpose of this study was to estimate the effect of an interpersonally oriented intervention on the reduction of the risk of postpartum depression in primiparous adolescents.

      Study Design

      We conducted a randomized controlled trial of 106 pregnant primiparous adolescents who were ≤17 years old at their first prenatal visit. Participants were assigned randomly to the intervention program (n = 54) or the attention and dose-matched control program (n = 52). Each program included 5 sessions that were delivered during the prenatal period. A structured diagnostic interview was administered to assess for the primary outcome and depression at 6 weeks, 3 months, and 6 months after delivery.

      Results

      Participants included Hispanic (53%), non-Hispanic black (17%), and non-Hispanic white (16%) adolescents. The overall rate of depression in the intervention group (12.5%) was lower than the control group (25%) with a hazard rate ratio of 0.44 (95% confidence interval, 0.17−1.15) at 6 months after delivery.

      Conclusion

      An intervention that is delivered during the prenatal period has the potential to reduce the risk for postpartum depression in primiparous adolescent mothers.

      Key words

      Approximately 400,000 births in the United States each year are to mothers who are <20 years old
      • Martin J.A.
      • Hamilton B.E.
      • Sutton P.D.
      • et al.
      Births: final data for 2006.
      ; approximately 25-36% of these teens experience postpartum depression (PPD) after delivery.
      • Troutman B.R.
      • Cutrona C.E.
      Nonpsychotic postpartum depression among adolescent mothers.
      • Barnet B.
      • Joffe A.
      • Duggan A.K.
      • Wilson M.D.
      • Repke J.T.
      Depressive symptoms, stress, and social support in pregnant and postpartum adolescents.
      • Logsdon M.C.
      • Birkimer J.C.
      • Simpson T.
      • Looney S.
      Postpartum depression and social support in adolescents.
      These rates are significantly higher than adult postpartum women
      • Lanzi R.G.
      • Bert S.C.
      • Jacobs B.K.
      Depression among a sample of first-time adolescent and adult mothers.
      and higher than nonperinatal adolescents.
      • Troutman B.R.
      • Cutrona C.E.
      Nonpsychotic postpartum depression among adolescent mothers.
      For Editors' Commentary, see Contents
      PPD puts adolescent mothers and their children at risk during an already challenging time in their lives, and this hardship may be a major determinant of poor outcomes for these young mothers and their children. Untreated, depression is associated with school dropout, suicide, and substance use.
      • Weissman M.M.
      • Wolk S.
      • Goldstein R.B.
      • et al.
      Depressed adolescents grown up.
      • Lewinsohn P.M.
      • Rohde P.
      • Klein D.N.
      • Seeley J.R.
      Natural course of adolescent major depressive disorder: I, continuity into young adulthood.
      Among adolescent mothers, evidence suggests that depression may prevent them from engaging in health-promoting behaviors for their infants and themselves.
      • Combs-Orme T.
      Health effects of adolescent pregnancy: implications for social workers.
      • Grace S.L.
      • Evindar A.
      • Stewart D.E.
      The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature.
      Overall, children who are born to mothers with untreated depression show developmental delays, lower levels of social engagement, increased stress reactivity, and negative interactions relative to infants of nondepressed mothers.
      • Fishell A.
      Depression and anxiety in pregnancy.
      • Feldman R.
      • Granat A.
      • Pariente C.
      • Kanety H.
      • Kuint J.
      • Gilboa-Schechtman E.
      Maternal depression and anxiety across the postpartum year and infant social engagement, fear regulation, and stress reactivity.
      • Field T.
      • Pickens J.
      • Prodromidis M.
      • et al.
      Targeting adolescent mothers with depressive symptoms for early intervention.
      Although validated treatments for adolescent depression exist and include interpersonal therapy, cognitive behavioral therapy, and antidepressant medication, teen mothers with mental health problems are mostly under treated.
      • Kataoka S.H.
      • Zhang L.
      • Wells K.B.
      Unmet need for mental health care among US children: variation by ethnicity and insurance status.
      • Power T.J.
      • Eiraldi R.B.
      • Clarke A.T.
      • Mazzuca L.B.
      • Krain A.L.
      Improving mental health service utilization for children and adolescents.
      To date, only one published report of 2 small open-trial pilot studies (n = 14 and n = 11) addressed treatment for depression in pregnant adolescents.
      • Miller L.
      • Gur M.
      • Shanok A.
      • Weissman M.
      Interpersonal psychotherapy with pregnant adolescents: two pilot studies.
      Despite the potentially high burden of depression to young women and their families, studies on the prevention of PPD in pregnant adolescents are virtually nonexistent.
      A substantial body of research demonstrates that some prevention programs for adults and adolescents with mental health conditions are capable of strengthening protective factors (eg, social support, stress-management skills), that these interventions can lessen the consequences of risk factors (eg, other psychiatric symptoms), and that the interventions may have positive economic effects.
      • Cuijpers P.
      Examining the effects of prevention programs on the incidence of new cases of mental disorders: the lack of statistical power.
      Several experts in the field of PPD have advocated for preventive interventions for PPD to commence in pregnancy.
      • Dennis C.L.
      Preventing postpartum depression: part II, a critical review of nonbiological interventions.
      • Llewellyn A.
      • Stowe Z.N.
      Psychotropic medications in lactation.
      Pregnancy provides a “window of opportunity”
      Institute of Medicine
      Fetal alcohol syndrome: diagnosis, epidemiology, prevention, and treatment.
      for prevention because pregnancy is a time when women have frequent contact with healthcare providers and is a time when pregnant women may be more open to making changes to improve their health, which would include mental health, before the birth of their baby.
      • Dennis C.L.
      Preventing postpartum depression: part II, a critical review of nonbiological interventions.
      • Cohn J.F.
      • Matias R.
      • Tronick E.Z.
      • Connell D.
      • Lyons-Ruth K.
      Face-to-face interactions of depressed mothers and their infants.
      The objective of the present study was to perform a pilot study of 100 pregnant adolescents to evaluate a novel intervention to prevent PPD in primiparous adolescent mothers. The intervention, the REACH (Relaxation, Encouragement, Appreciation, Communication, Helpfulness) program, is based on interpersonal therapy, which targets those factors that may play a significant role in the development of PPD.
      • Zlotnick C.
      • Johnson S.L.
      • Miller I.W.
      • Pearlstein T.
      • Howard M.
      Postpartum depression in women receiving public assistance: pilot study of an interpersonal-therapy-oriented group intervention.
      • Zlotnick C.
      • Miller I.W.
      • Pearlstein T.
      • Howard M.
      • Sweeney P.
      A preventive intervention for pregnant women on public assistance at risk for postpartum depression.
      Our primary hypothesis was that the REACH program would be more efficacious than the attention and dose-matched control program that is focused on prenatal education in the reduction of risk for depression up to 6 months after delivery in adolescent mothers.

      Materials and Methods

      Trial design

      A blinded randomized controlled trial was used to evaluate the REACH program as an intervention to prevent PPD. Because the focus of the REACH program is on the prevention of PPD, the intervention and control programs were conducted during the prenatal period. Depression was assessed from intake (during pregnancy) to 6 months after delivery. A preintervention survey was conducted to collect data on sociodemographic characteristics, reproductive history, and substance use. Medical charts were reviewed for pregnancy and infant outcomes.
      The study protocol was approved the Institutional Review Board of Women & Infants Hospital, Providence, Rhode Island. Local laws regarding minor participants in research were followed. All participants were consented by written consent from her guardian and assent from the minor participant. The protocol was registered at clinicaltrials.gov (NCT00436150) on Feb. 14, 2007.

      Participants (eligibility and setting)

      Participants were recruited between February 2007 and August 2008 through an urban prenatal clinic that cared for women of all ages and diverse backgrounds. Participants were eligible if they were ≤17 years old when they conceived their pregnancy and were <25 weeks gestational age at their first prenatal visit. The following exclusion criteria were determined before randomization: (1) received mental health services from a healthcare provider or (2) met criteria for a current affective disorder, substance use disorder, anxiety disorder (excluding simple phobia), or psychosis as determined by the relevant modules of the Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders, 4th edition, (DSM-IV) Childhood Diagnoses (KID-SCID).
      • Hein D.
      • Matzner F.
      • First M.
      • Spitzer R.
      • Williams J.
      • Gibbons M.
      Structured clinical interview for DSM-IV childhood disorders, KID-SCID.
      Adolescents who met the criteria for any of these disorders were excluded because the REACH program is a prevention program and is not designed to treat any of these disorders. Furthermore, the control condition is relatively inert. Hence, it would have been unethical for us to withhold treatment from an adolescent who had been diagnosed with one of these disorders.

      Intervention

      The REACH program intervention was an adaptation of an interpersonal therapy–based prevention intervention, which was found to reduce PPD in pregnant adults on public assistance.
      • Zlotnick C.
      • Johnson S.L.
      • Miller I.W.
      • Pearlstein T.
      • Howard M.
      Postpartum depression in women receiving public assistance: pilot study of an interpersonal-therapy-oriented group intervention.
      • Zlotnick C.
      • Miller I.W.
      • Pearlstein T.
      • Howard M.
      • Sweeney P.
      A preventive intervention for pregnant women on public assistance at risk for postpartum depression.
      The REACH program intervention is the product of an extensive, iterative treatment development process. To maximize acceptability of the intervention, the REACH program was tailored extensively and refined to be culturally appropriate and appealing to adolescents from diverse racial and ethnic backgrounds. Modifications were guided by input and feedback from postpartum adolescent focus groups, expert consultants (in adolescent medicine and depression and perinatal care among low-income minority adolescent female patients and an expert in interventions for minority teens), pilot participants, and pilot facilitators.
      The REACH program is a highly structured, adolescent-oriented intervention that is delivered over the course of 5 one-hour prenatal sessions with a postpartum booster session that includes multimedia (video snippets), interactive (role-playing) components, and homework with feedback. The content of the REACH program focused on the development of effective communication skills to manage relationship conflicts before and after the birth of the baby, expectations about motherhood, stress management, “baby blues” vs depression, development of a support system, development of healthy relationships, goal setting, and psychosocial resources for new mothers. The structured format and detailed facilitator manual ensured that specific defining elements of interpersonal therapy such as enhancing social support and therapeutic strategies (eg, role-playing, communication analysis) remain the central features of the intervention. The highly structured nature of the REACH intervention and the control program allowed for efficient facilitator training and monitoring for adherence and competency.
      Each participant was given the book Baby Basics: Your Month by Month Guide to a Healthy Pregnancy,
      • Rand N.
      • Greenwood A.
      Baby basics: your month by month guide to a healthy pregnancy.
      which is a comprehensive pregnancy guide that was developed by the What to Expect Foundation. The attention and dose-matched control condition involved using the Baby Basics book as a guide for the didactic control program. This program included information about maternal health throughout pregnancy and the early postpartum period, fetal development, nutrition, preparation for labor, and preparation of the home for taking a baby home. The control condition had no overlapping content with the REACH program curriculum.
      The initial plan was for the REACH program and control program sessions to be delivered as group sessions once each week for 5 consecutive weeks and an individual booster session that is delivered in the hospital after the delivery, with accommodations for make-up sessions. As the study progressed, it became clear through rescheduling and qualitative assessment that the participants preferred individual sessions. Thus, accommodations were made to deliver the sessions individually. The intervention and control sessions were administered in similar fashions to balance contact time with the facilitator. Each session lasted approximately 30-60 minutes, depending on the discussion.

      Outcome assessment

      PPD was classified as an episode of major depressive disorder that occurred within the first 6 months after delivery. Although the DSM-IV defines PPD as major depressive disorder with an onset within 4 weeks after delivery, research has shown that at least one-third of women report the onset of PPD at 2-6 months
      • O'Hara M.W.
      • Stuart S.
      • Gorman L.L.
      • Wenzel A.
      Efficacy of interpersonal psychotherapy for postpartum depression.
      ; among teens, 32% have scores that indicate depression at 4 months after delivery.
      • Barnet B.
      • Joffe A.
      • Duggan A.K.
      • Wilson M.D.
      • Repke J.T.
      Depressive symptoms, stress, and social support in pregnant and postpartum adolescents.
      Moreover, most investigators classify a depression that occurs within the first 6 months after delivery as PPD.
      • Miller L.J.
      Postpartum depression.
      • O'Hara M.W.
      • Gorman L.L.
      Can postpartum depression be predicted?.
      The onset of a depressive episode during pregnancy, even if the episode extends to the postpartum period, was not included as a case of PPD, because the onset was not strictly after delivery. To account for variability in gestational age at birth among the participants, we used delivery as a clear and consistent marker for measuring the onset of the condition (PPD).
      The KID-SCID was used to assess for a major depressive disorder. Antepartum assessments were performed before randomization and after intervention; postpartum assessments were performed within 48 hours of delivery and at the 6-week, 3-month, and 6-month follow-up visits. All assessments were administered by trained research assistants who were blinded to study group assignment from the initial contact through follow-up evaluation.

      Sample size calculation

      The purpose of the REACH program pilot study was to develop a PPD prevention intervention that was tailored to the specific needs of a racially and ethnically diverse group of pregnant adolescents and to pilot test the intervention compared with the control program under clinical trial conditions to determine an effective size for a larger clinical trial. The study target was designed to evaluate 100 randomly assigned participants and to assess feasibility of study recruitment and retention procedures for pregnant adolescents.

      Randomization method

      The randomization scheme was developed before the study was begun. Stratified block randomization was used to keep the groups balanced in terms of history of depression. The block lengths varied to keep the randomizations scheme blinded. The groups were labeled A and B. Opaque envelopes were labeled by number and stratum. The study coordinator held the key to the randomization scheme. After a participant was screened fully for eligibility, the study group was unveiled and reported to the interventionist so that appointments could be scheduled to begin the intervention or control group program. The group allocation was not revealed to the research team members who performed the initial and follow-up assessments.

      Statistical methods

      Descriptive statistics were used to compare the distribution of baseline characteristics between the intervention and control groups. The Fisher exact test was used to compare categoric variables, and the Wilcoxon rank-sum test was used for the comparison of continuous variables. All participants with at least 1 postpartum assessment were included in the primary analysis and were classified according to their randomly assigned study group (intention-to-treat). PPD incidence in each group was calculated as a positive major depressive disorder diagnosis by the KID-SCID at ≥1 postpartum visits. The hazard rate ratio (HR) and 95% confidence interval (CI) for PPD in the REACH program vs the control group were estimated by Cox proportional hazards regression. Tied events that resulted from the discreteness of the time scale were handled by the exact method. History of depression, which was the stratification factor for randomization, was included as a covariate in all models. Baseline variables that were distributed differently between study arms were also included as covariates where appropriate. The proportional hazards assumption was assessed by a global Wald test of product interaction terms between covariates and follow-up time point.
      The primary analysis was repeated among participants who attended all follow-up visits. To formally perform an intention-to-treat analysis, assumptions were made about missing outcome data because of discontinued participation or missed visits. In the first scenario, a diagnosis of PPD was imput for all missing assessment visits. In the second scenario, it was assumed that no PPD was diagnosed at missing visits. Data analysis was performed with SAS software (version 9.1; SAS Institute, Cary, NC). Two-tailed probability values of < .05 were considered statistically significant.

      Results

      Participant recruitment

      Between February 2007 and August 2008, 177 patients were screened for study eligibility during their first prenatal visit (Figure). Of these patients, 140 were consented and scheduled for an initial visit. Current depression was diagnosed at the first visit in 10 enrollees; 4 participants had spontaneous abortions. Twenty additional patients were excluded from the study because of ineligibility, withdrawal from the study before the intervention was initiated, or failure to attend the initial visit.
      Figure thumbnail gr1
      FIGUREParticipant selection and follow-up evaluation
      REACH, the Relaxation, Encouragement, Appreciation, Communication, Helpfulness program.
      Phipps. Preventing PPD in adolescents. Am J Obstet Gynecol 2013.
      A total of 106 participants were assigned randomly to the REACH program (n = 54) or the control program (n = 52). All participants who remained in the study through delivery completed the 5 sessions in their assigned programs; however, 3 patients who were assigned to the REACH program discontinued participation during the intervention. After delivery, 100 participants (94%) attended at least 1 postpartum follow-up visit and were assessed for PPD.

      Baseline data

      The median age for participants was 16 years, and most participants were from Hispanic backgrounds (Table 1). Overall, a history of depression was identified in 16% of participants. There were no significant differences between the REACH program and control group participants in terms of age, gestational age, race/ethnicity, history of depression, pregnancy history, and current educational level. A few participants (n = 12) were 18 years old or >25 weeks' gestation at the time of randomization because of the time that elapsed between eligibility screening and the randomization visit.
      TABLE 1Baseline characteristics by study arm
      VariableREACH programControl programP value
      Total randomized patients, n5452
      Age at randomization, y
      Data are given as median (range);
      16 (13-18)16 (14-18).4
      Wilcoxon rank-sum test;
      Gestational age, wk
      Data are given as median (range);
      19.7 (12.6-28.9)21.3 (9.1-30.9).2
      Wilcoxon rank-sum test;
      Race/ethnicity, n (%).6
      Fisher exact test.
       Hispanic29 (53.7)27 (51.9)
       Black, non-Hispanic9 (16.7)9 (17.3)
       White, non-Hispanic7 (13.0)10 (19.2)
       Asian2 (3.7)0
       American Indian/Alaskan Native01 (1.9)
       Multiracial5 (9.3)2 (3.9)
       No answer2 (3.7)3 (5.8)
      History of depression, n (%)9 (16.7)8 (15.4)1.0
      Fisher exact test.
      Previous pregnancy, n (%)4 (7.4)4 (7.7)1.0
      Fisher exact test.
      Currently in school, n (%).5
      Fisher exact test.
       Yes44 (81.5)38 (73.1)
       No, completed 12 grade2 (3.7)2 (3.9)
       No8 (14.8)12 (23.1)
      REACH, Relaxation, Encouragement, Appreciation, Communication, Helpfulness.
      Phipps. Preventing PPD in adolescents. Am J Obstet Gynecol 2013.
      a Data are given as median (range);
      b Wilcoxon rank-sum test;
      c Fisher exact test.

      Outcomes

      None of the participants were diagnosed with depression at the study assessment visit immediately after delivery. A total of 19 participants (19%) were diagnosed with PPD at a subsequent study visit through 6 postpartum months. The incidence of PPD was 12.5% (95% CI, 3.1−21.9%) for the REACH program compared with 25.0% (95% CI, 13.2−36.8%) for the control program (Table 2), which results in an absolute difference of −12.5% (95% CI, −27.5 to 2.5%) at 6 months after delivery. After adjustment for history of depression by Cox proportional hazards regression, the incidence of PPD was 56% lower for the REACH program compared with the control program (HR, 0.44; P = .1). Further adjustment for baseline patient age and gestational age did not change the estimates (HR, 0.44; 95% CI, 0.17−1.17). PPD incidence in each group was similar when the analysis was limited to 91 participants with complete follow-up assessments (risk difference, −10.0%; 95% CI, −25.6 to 5.7%; adjusted HR, 0.50; P = .2).
      TABLE 2The REACH program and incidence of postpartum depression
      Diagnosed by Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders, 4th edition, Childhood Diagnoses;
      by 6 months after delivery
      VariablePostpartum depression, n/N (%)Hazard rate ratio (95% CI)
      For the REACH program vs control;
      REACH programControl programUnadjustedAdjusted
      Proportional hazards model included stratification factor, history of depression;
      Any postpartum follow-up evaluation (n = 100)6/48 (12.5%)13/52 (25.0%)0.46 (0.18–1.22)0.44 (0.17–1.15)
      Complete postpartum follow-up evaluation (n = 91)6/47 (12.8%)10/44 (22.7%)0.54 (0.20–1.48)0.50 (0.18–1.37)
      Sensitivity analysis
      Assumed missing postpartum assessments were all postpartum depression or no postpartum depression diagnoses.
       Missing outcome: postpartum depression (n = 106)13/54 (24.1%)18/52 (34.6%)0.68 (0.33–1.39)0.67 (0.33–1.36)
       Missing outcome: no postpartum depression (n = 106)6/54 (11.1%)13/52 (25.0%)0.41 (0.16–1.09)0.40 (0.15–1.04)
      CI, confidence interval; REACH, Relaxation, Encouragement, Appreciation, Communication, Helpfulness.
      Phipps. Preventing PPD in adolescents. Am J Obstet Gynecol 2013.
      a Diagnosed by Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders, 4th edition, Childhood Diagnoses;
      b For the REACH program vs control;
      c Proportional hazards model included stratification factor, history of depression;
      d Assumed missing postpartum assessments were all postpartum depression or no postpartum depression diagnoses.
      Three participants discontinued participation before delivery; 3 participants discontinued participation after delivery, and 8 participants missed ≥1 postpartum visits. A sensitivity analysis was performed to evaluate the impact of missing data on the results; the analysis was repeated with the assumption of PPD diagnoses for all missing assessments and then the assumption of no diagnosis of PPD for the missing assessments. A 33% reduction in PPD risk for the REACH program, compared with the control program, persisted when a PPD diagnosis was imput for participants with missing data.
      No harmful effects were noted from participants in this trial.

      Comment

      To our knowledge, this is the first clinical trial of prevention for PPD in adolescent mothers. This pilot study of primiparous adolescent mothers found initial efficacy for a prenatal intervention to prevent PPD compared with an attention and dose-matched control condition. In part, this was a pilot study to test the feasibility of the program, and the results show an overwhelmingly positive trend in support of the interpersonal therapy–based intervention program. In addition to the positive outcome, the present study demonstrated strong feasibility in that there were high rates of recruitment, intervention participation, and retention and notable rates for a vulnerable group of adolescents.
      The rate of PPD in the control group (25%) is consistent with national rates of PPD in adolescent mothers, which suggests that we had a representative sample for our study. Because our sample of study participants were ethnically diverse, the results are likely generalizable to the community of pregnant adolescents. The structured nature of the program with a thorough training manual and guide for both the REACH program intervention and the control program suggests that the REACH program can be implemented in other clinical settings. Of note, a recent study published by Howell et al,
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing depressive symptoms among black and Latina mothers: a randomized trial.
      who implemented a structured behavioral-based educational intervention that included a focus on bolstering social support in black and Latina adult mothers during their postpartum hospitalization, demonstrated a reduction in positive screening for depression at 3 weeks and 3 months after delivery.
      The limitations of the current study include the nature of a pilot study with a small sample size that was underpowered to detect a statistically significant difference between the study groups. The study was designed to deliver the intervention and control programs as group sessions; however, during the course of the study, it became clear that the participants preferred individual sessions; therefore, the sessions were modified and delivered as individual sessions. Because we did not have complete follow-up data on all of the study participants, we performed a sensitivity analysis. A protective effect for the REACH intervention was observed under each scenario, which suggests that substantial bias because of missing data is unlikely.
      Findings from our study suggest that the REACH program, which is tailored specifically for pregnant adolescents, has promise as an intervention to prevent PPD. Moreover, the REACH program appears to be an accessible and feasible intervention for pregnant adolescents. With further evaluation, the REACH program has the potential to decrease disease burden for adolescent mothers and their offspring and to be a cost-effective alternative to the treatment of PPD.

      Acknowledgments

      We thank Nicole Girard and Larissa Chiulli, who previously worked for the Department of Obstetrics & Gynecology Division of Research at Women & Infants Hospital (N.G. 2006-2008; L.C. 2006-2007), for their contribution to the implementation of this study.

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