Depression Among Pregnant Adolescents: An Integrated Treatment Approach
Case Report
History
Ann (a pseudonym) was a 15-year-old black girl when she was referred for treatment of depression by her school counselor and her foster parents. She was treated with weekly psychotherapy and fluoxetine, and while in treatment (6 months later) she became pregnant. Ann was abandoned by her mother during infancy and was then moved around among various relatives until age 12. Information regarding Ann’s early development or family psychiatric history was unavailable. When she was 12, Ann was placed in a nurturing foster home, where she has remained until now. Ann has never met her biological father and has had no further contact with her biological mother. Her current foster parents have been involved in foster parenting for 20 years and, in addition to Ann, have housed five other foster daughters ranging from age 10 to 17 years.
Initial Assessment
When Ann was seen for the first time, she immediately started talking about herself with cheerful but superficial chatter. Her intelligence, good sense of humor, and charm were apparent. In contrast to this outward demeanor, Ann admitted to frequently feeling sad and having extended periods of insomnia, fatigue, decreased concentration, and variable appetite. She denied having any neurocognitive depressive symptoms. She also denied having experienced any traumas, including her history of abandonment by multiple caregivers, stating that it was “no big deal.” She did recall being told by her relatives when she misbehaved that “not even your mother wanted you.”Ann described her foster home as secure and fair. Ann appeared to have some superficial friendships but did not appear to have any intimate, lasting friendships. She enjoyed playing sports and thought of herself as a “jock.” Ann denied having antisocial behaviors, promiscuity, substance abuse, or other dangerous behaviors. Her foster mother described Ann’s biggest problems as having chronically low self-esteem and an extreme fear of intimacy, thus always needing to test limits to see whether she could elicit abandonment. Ann had extremely poor insight regarding either of these latter issues.
Course of Treatment
After the initial interview, Ann was diagnosed with a depressive disorder that did not fully meet the criteria for major depression. It was decided to set a course of 30 weekly psychotherapy sessions to address her symptoms, with both a cognitive/behavioral component, to address maladaptive coping strategies and help her link her feelings to her behavior, and an insight-oriented component, to help her connect her past experiences to her present emotional and social difficulties. Ann appeared both eager to work on her problems and reassured by the time-limited nature of the treatment contract.Over the first few months of therapy, Ann behaved well at home and school. In this early phase of treatment the therapy focused on her difficulty in trusting new relationships, especially in light of her many abandonments, and her continual need to test limits by missing sessions or showing up late. In this regard, Ann was able to identify several roles that defiance played in her life: a way of being in control, a way of getting her parents to show they cared, and a way of testing the limits of rejection. At times, however, she tended to blame her behavior on external circumstances and resisted any suggestion that her problems could have an internal source.Ann remained superficially cheerful during the sessions but admitted to worsening depressive symptoms, including intermittent suicidal ideation. Given her inadequate response to a 3-month course of psychotherapy, fluoxetine was prescribed as adjunctive treatment after careful discussion of the options with Ann and her foster parents. Over the next few months, her behavior slowly stabilized, and on return to school in the fall, she began to excel academically. At this time, she denied having any depressive symptoms.During this period, Ann acquired a boyfriend, with whom she had her first sexual relations. Several sessions were spent discussing her sexual awakening and speculating about an unconscious wish to become pregnant. Ann adamantly denied wanting to become pregnant but became extremely fidgety and irritable when the subject was broached. She agreed to use appropriate birth control methods and regularly visit a gynecologist. After missing two sessions, Ann revealed that she had cheated on a recent pregnancy test and that she had missed her last menstrual period. Ann was convinced that she was 2 months pregnant because she had gained weight, felt fatigued, and craved Spam. She agreed to take a witnessed pregnancy test, the result of which was positive. Ann claimed to be ambivalent about her pregnancy. She stated that she had considered an abortion but that her boyfriend was adamantly against it. Her fantasy was that they would run away together to raise the baby and live happily ever after. Of note, her boyfriend was a musician, as was her biological father; this was the only fact that she knew about her biological father. There was little evidence that her boyfriend, also age 15, was willing to serve in any paternal or relationship capacity.A meeting with Ann, her foster parents, and her county case worker was arranged to discuss Ann’s disposition. Her foster parents were extremely angry about her promiscuous behavior and did not want her back in their home. After a long discussion, during which their love for Ann was evident, they decided to take her back on a trial basis. Their concerns about Ann’s ability to manage her impulses without medication were discussed; however, given her good behavior and commitment to attend weekly and, if needed, twice-weekly psychotherapy sessions, it was decided to continue her treatment without medication.In therapy, we spent the next couple of months exploring Ann’s feelings about her pregnancy. She exhibited denial that having a baby would change her life. She saw the baby as an extension of herself, a person who would love her unconditionally. As her pregnancy progressed from the first to the second trimester, Ann showed little evidence of bonding with the baby. She referred to her pregnancy as “it” and often made no reference at all to her pregnancy during the sessions.Ann missed the next several sessions. Her foster mother was contacted, and she described Ann as irritable, more withdrawn, easily fatigued, and apathetic about the pregnancy; her apathy included failure to seek appropriate prenatal care. Given that her previous depressive symptoms had improved with antidepressants, fluoxetine treatment was reinitiated. It was felt that the risks associated with not treating her depressive episode aggressively were greater than the risks associated with using fluoxetine during the end of the second trimester. Several psychoeducational sessions with the foster parents were held. They held the misconception that if Ann was grown up enough to become pregnant, she could be responsible for all aspects of her life in an adult fashion.Ann started to attend therapy sessions regularly, reported feeling happier, and was getting along better with her foster family at home. This was confirmed by her foster mother. These reports contrasted with how Ann appeared during her sessions. Her mood fluctuated between superficial cheerfulness and labile anger, the latter being linked to comments such as “You are always ruining my good mood by making me talk about my pregnancy” and descriptions of the sessions as “stupid and worthless.” Over the next few sessions, Ann began to speak more spontaneously about her pregnancy. She reported anger at her foster mother for trying to push Ann into adoption and telling her that she was “unsuited to be a mother.” Ann next reported a dream where “my foster mother is holding a baby boy and then gives the boy to me. I am able to care for the baby.” Her own ambivalence about being able to care for the baby was questioned during one session, and Ann answered “maybe.”Ann became more excited about her pregnancy as she began to feel the movements of the fetus. She fantasized about having a boy and naming him Victor because “all of the important men in my boyfriend’s family are named that.” She also proudly reported that she wanted to keep the baby because she felt that with her foster family’s support she could handle its care. Ann reported that she felt calmer and was not experiencing any side effects from the fluoxetine. She then quickly added, “I decided to stop the medication a month ago for the baby’s sake.” She also denied having any depressive or anxious symptoms. She was congratulated about her honesty and thoughtful consideration of her baby’s welfare. She expressed being “shocked that you aren’t angry at me or rejecting me.” This discussion was used as a transition to discussions about her fear of being a “bad mother” like her biological mother and how her parenting would differ from that of her own mother. Ann answered, “My mom abandoned me, I am going to take care of my baby, even if I get held back in school.” She continued without fluoxetine through the remainder of the pregnancy.Ann began to talk about all the things she was doing to prepare for the baby. She expressed how difficult it was to balance these activities with her schoolwork and spending time with her boyfriend. She also began to make statements such as “I’m trying to plan the baby’s life into my life,” as she grappled with the realities of becoming a mother. Ann also began to speak more tenderly about her interactions with her baby: “I also read him baby books and play light music on my stomach.” A recent ultrasound examination had identified the baby’s sex as male. Ann expressed her happiness about this and related how her boyfriend was bragging to all his friends about being “man enough to make a boy.” She added that her boyfriend had been very supportive and offered to stay home to take care of the baby so she could finish school. Ann had told him that she wanted to stay home herself “at least for the first 6 weeks” so the baby would bond with her and not call anyone else “Mom.”Ann began the next session with a list of somatic complaints that she was experiencing, such as stomach cramps, back aches, heartburn, and a feeling of heaviness. She also expressed worry about how painful labor might be, stating “I feel sorry for myself for having to go through it.” She then switched the topic to how much calmer she was feeling. She seemed more peaceful and more mature. Ann worried that her boyfriend would be jealous of the baby because she would need to spend more time with the baby than with him. She continued, “I love him but am afraid of his leaving. I think I love too much, you’re not supposed to fall too much in love.” This was the first time that Ann was able to express these feelings directly.Ann’s baby was born 2 weeks later, a beautiful healthy baby boy. She brought the baby to one of her sessions about 1 month later. She held the baby in a very tender way and watched him fondly during the session. She was given positive feedback about her interactions with him, and she said with a beaming smile, “He’s perfect.” She also spoke about how much she had grown up during the pregnancy.Over the month following her baby’s birth, Ann had felt more irritable, tearful, and tired. She requested that fluoxetine treatment be started again because “it helped to calm me before” and because “it helped my foster mom be a good mother.” Given the incipient return of her depressive symptoms and her risk of developing a full-blown postpartum depression, fluoxetine treatment was reinitiated. Ann’s symptoms remitted and continued to remain in remission for the next year with continued medication, weekly therapy, and good support from Ann’s foster family and boyfriend.
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