Low-income Adolescent's Perceptions of Perinatal Depression and Mental Health Treatment: ²It's Not Just Because I'm Pregnant²

Approximately 44% of low-income, racial/ethnic minority pregnant adolescents meet criteria for depression, a disorder associated with high risk of negative maternal and child outcomes. Few pregnant, depressed adolescents receive mental health services and those referred for serves often do not follow-up or leave treatment early. However, despite barriers to accessing services, these adolescents can be engaged in treatment if their unique needs are addressed. This study aims to understand low-income, pregnant adolescents' perceptions of depression, mental health treatment, and barriers to accessing services in order to improve engagement and retention of in treatment for perinatal depression.

Methods: This qualitative study used a convenience sample of 20 low-income, pregnant, depressed (EPDS ≥ 10) adolescents drawn from two public health clinics. Interviews were 45-90 minutes and addressed perceptions of symptoms, treatment history, hopes for treatment, and practical, psychological, and cultural barriers to accessing services. Interviews were digitally recorded and transcribed verbatim. Data was managed using NVivo7. Analysis followed a grounded-theory approach. Two coders analyzed 25% of transcripts and developed codebooks through consensus. Intercoder reliability was conducted to ensure codebooks were appropriately applied. Emerging codes were noted, discussed, and incorporated into codebooks. Reports were produced for each coding category. Patterns and themes were derived through consensus. Expert consultants informed development of codebooks and interpretation of findings. Analysts reviewed transcripts for evidence contradictory to initial findings and triangulation of data and multiple coders were used to increase reliability and validity.

Results: Many participants distinguished depressive symptoms from pregnancy symptoms. However, they did not consistently view symptoms as depression but instead as worry, irritability, and/or difficulties with family and children. Only one adolescent disclosed a previous depression diagnosis. Few had any experience with mental health services, though most felt they needed treatment for past 'problems' or described episodes of untreated depression. Most participants reported limited knowledge of treatment and hoped for 'someone to talk to' and improvement in 'mood swings'. Practical barriers included childcare, transportation, clinic hours, and competing demands. Psychological barriers included stigma, difficulty disclosing painful issues, concerns their unique circumstances would not be understand, and insistence they were only 'lonely' or 'stressed' and did not require treatment. Cultural barriers were not identified. However, family beliefs were either strong barriers or support to treatment engagement.

Implications: Findings fill a gap by specifically examining low-income adolescent's perceptions of depression and treatment in the context of pregnancy. Findings reveal that adolescents readily perceive a need for improvement in their mood and are interested in 'someone to talk to' if services address barriers to treatment, incorporate adolescent's perspective, and openly discussing stigma. Results of screenings should be shared in a way that emphasizes adolescents' unique symptoms, knowledge, and treatment history. Family members should be included in early engagement and psychoeducation given their influence. Adolescents may be more interested in treatment than current studies lead us to believe if it is offered at a time and place that reduces the practical and psychological barriers to treatment engagement and when treatment promises relief from the most meaningful symptoms.