Identifying Depression in Neonatal Intensive Care Unit Parents: Then What?

Risk Factors for Postpartum Depression and Severe Distress among Mothers of Very Preterm Infants at NICU Discharge

OBJECTIVE

To identify psychological, medical, and socioenvironmental risk factors for maternal postpartum depression (PPD) and severe psychological distress (SPD) at intensive care nursery discharge among mothers of very preterm infants.

STUDY DESIGN

We studied 562 self-identified mothers of 641 infants born <30 weeks who were enrolled in the Neonatal Neurobehavior and Outcomes in Very Preterm Infants Study (NOVI) conducted in nine university-affiliated intensive care nurseries. Enrollment interviews collected socioenvironmental data, depression, and anxiety diagnoses prior to and during the study pregnancy. Standardized medical record reviews ascertained prenatal substance use, maternal and neonatal medical complications. The Edinburgh Postnatal Depression Scale and Brief Symptom Inventory were administered at nursery discharge to screen for PPD and SPD symptoms, respectively.

RESULTS

Unadjusted analyses indicated mothers with positive screens for depression (n = 76, 13.5%) or severe distress (n = 102, 18.1%) had more prevalent prepregnancy/prenatal depression/anxiety, and their infants were born at younger gestational ages, with more prevalent bronchopulmonary dysplasia, and discharge after 40 weeks postmenstrual age. In multivariable analyses, prior depression or anxiety was associated with positive screens for PPD (risk ratio [RR]: 1.6, 95% confidence interval [CI]: 1.1-2.2) and severe distress (RR: 1.6, 95% CI: 1.1-2.2). Mothers of male infants had more prevalent depression risk (RR: 1.7, 95% CI: 1.1-2.4), and prenatal marijuana use was associated with severe distress risk (RR: 1.9, 95% CI: 1.1-2.9). Socioenvironmental and obstetric adversities were not significant after accounting for prior depression/anxiety, marijuana use, and infant medical complications.

CONCLUSION

Among mothers of very preterm newborns, these multicenter findings extend others' previous work by identifying additional indicators of risk for PPD and SPD associated with a history of depression, anxiety, prenatal marijuana use, and severe neonatal illness. Findings could inform designs for continuous screening and targeted interventions for PPD and distress risk indicators from the preconception period onward.

KEY POINTS

· Preconceptional and prenatal screening for postpartum depression and severe distress may inform care.. · Prior depression, anxiety, and neonatal complications predicted severe distress and depression symptoms at NICU discharge.. · Readily identifiable risk factors warrant continuous NICU screening and targeted interventions to improve outcomes..

Supporting Disclosure of Unmet Mental Health Needs among Parents of Critically Ill Infants

OBJECTIVE

To characterize (1) the prevalence of mental health discussion and (2) facilitators of and barriers to parent disclosure of mental health needs to clinicians.

STUDY DESIGN

Parents of infants with neurologic conditions in neonatal and pediatric intensive care units participated in a longitudinal decision-making study from 2018 through 2020. Parents completed semi-structured interviews upon enrollment, within 1 week after a conference with providers, at discharge, and 6 months post-discharge. We used a conventional content analysis approach and NVIVO 12 to analyze data related to mental health.

RESULTS

We enrolled 61 parents (n = 40 mothers, n = 21 fathers) of 40 infants with neurologic conditions in the intensive care unit. In total, 123 interviews were conducted with 52 of these parents (n = 37 mothers, n = 15 fathers). Over two-thirds of parents (n = 35/52, 67%) discussed their mental health in a total of 61 interviews. We identified two key domains when approaching the data through the lens of mental health: (1) self-reported barriers to communicating mental health needs: parents shared uncertainty about the presence or benefit of support, a perceived lack of mental health resources and emotional support, and concerns about trust; (2) self-reported facilitators and benefits of communicating mental health needs: parents described the value of supportive team members, connecting to peer support, and speaking to a mental health professional or neutral third party.

CONCLUSIONS

Parents of critically ill infants are at high risk of unmet mental health needs. Our results highlight modifiable barriers and actionable facilitators to inform interventions to improve mental health support for parents of critically ill infants.

Screening for Postpartum Depression in a Neonatal Intensive Care Unit

BACKGROUND

Postpartum depression (PPD) is a common mental health condition that affects approximately 13% of postpartum women in the United States. However, the prevalence in the neonatal intensive care unit (NICU) has been shown to be higher. Routine screening for maternal PPD is recommended at infant primary care well-child visits up to 6 months of age. The absence of a routine PPD screening program in a level IV NICU created a large gap in screening in an at-risk population.

PURPOSE

To develop and implement a screening program in the NICU to increase the identification of maternal PPD symptoms and to develop both a referral algorithm for NICU staff to follow and a referral resource packet to be given to mothers with positive PPD screenings.

METHODS

Mothers with infants in the NICU were screened for PPD using the Edinburgh Postnatal Depression Scale (EPDS). Bedside nurses administered the screening tool and used a referral algorithm to determine appropriate follow-up. EPDS scores of 10 or more were considered positive and indicated a need for referral.

RESULTS

The overall EPDS screening compliance was 66% with a positive rate of 26%. Nurses followed the referral algorithm appropriately 100% of the time. It was confirmed that 93% of the mothers with positive EPDS screenings sought help from a mental health provider.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Routine maternal PPD screening should be implemented in all NICU settings. Postpartum mental health issues should not be the sole responsibility of obstetricians, mental health providers, or maternal primary care providers.

Maternal and Paternal Depression Symptoms During NICU Stay and Transition Home

OBJECTIVE

To examine the trajectory and risk factors of depression symptoms among parents from NICU admission to 30 days postdischarge. We hypothesized depression symptom scores would decrease from admission and then increase from discharge to 30 days.

METHODS

Prospective longitudinal cohort study of premature infants in NICU. Parents completed the validated Edinburgh Postnatal Depression Scale (EPDS) at 4 time points: NICU admission, discharge, and 14 days and 30 days postdischarge. EPDS score change across time and probability of a positive screen (EPDS ≥10) were by assessed using mixed effect regression models.

RESULTS

Of 431 parents enrolled (mothers, n = 230 [53%]), 33% of mothers (n = 57) and 17% of fathers (n = 21) had a positive EPDS screening. Score change was 1.9 points different between mothers and fathers (confidence interval [CI]: 1.3-2.6; P < .0001), with mothers decreasing 2.9 points (CI: 2.1-3.7; P < .0001) and fathers decreasing 1.0 points (CI: 0.1-2.0; P = .04). Over time, mothers decreased 10.96 times (CI: 2.99-38.20; P = .0003); fathers decreased at a nonsignificant rate. Admission or discharge screening improved 30-day depressive symptom prediction (AUC 0.66 baseline demographics only versus 0.84+initial [P < .0001], and versus 0.80+discharge screening [P < .001]).

CONCLUSIONS

Mothers and fathers experience different depressive symptom trajectories from NICU to home. Screening parents for postpartum depression during the NICU stay is likely to result in improved identification of parents at risk for postpartum depression after discharge. Focused attention on fathers appears warranted.

Historical Perspectives: Unsilencing Suffering: Promoting Maternal Mental Health in Neonatal Intensive Care Units

Mothers of infants in the NICU suffer higher rates of psychological distress, anxiety, and depression compared with the general population. Often, their mental health concerns remain underidentified and undertreated, which can have deleterious effects on the offspring, both in short-term outcomes while in the NICU as well as long-term neurodevelopmental and behavioral outcomes. In this review, we present an overview of existing empirical evidence about how maternal mental health affects the health of infants, special considerations regarding the mental health needs of NICU mothers, and the findings about existing and developing interventions to address mental health concerns in this vulnerable population.

Adding perinatal anxiety screening to depression screening: is it worth it?

BACKGROUND

Screening for peripartum depression is widely recommended and should now be the standard of care. However, little research exists on peripartum anxiety screening.

OBJECTIVE

The purpose of this study was to assess whether adding perinatal anxiety screening would increase the identification of women who would benefit from mental health support.

STUDY DESIGN

The existing practice at our clinic was depression screening via the Patient Health Questionnaire-2 at all prenatal visits; screenings were prospectively tracked for 3 months in women presenting for visit at 24-28 weeks gestation (Patient Health Questionnaire-2-only group). We then added Generalized Anxiety Disorder 2-item validated anxiety scale assessment to prenatal visits at 24-28 weeks gestation (Patient Health Questionnaire-2+Generalized Anxiety Disorder 2-item group). Our primary study outcome was the rate of positive depression and anxiety screens during pregnancy; secondary outcomes included referral rates to mental health services and obstetric and medical outcomes.

RESULTS

A total of 100 women with visits at 24-28 weeks gestation were eligible to be screened during the Patient Health Questionnaire-2-only period; 125 women were eligible for screening during the Patient Health Questionnaire-2+Generalized Anxiety Disorder 2-item period. In the Patient Health Questionnaire-2-only group, 51 women were screened, with 2 positive depression screens. In the Patient Health Questionnaire-2+Generalized Anxiety Disorder 2-item group, 40 women were screened, with 5 positive screens for depression and 4 for anxiety. Three women who were anxiety-positive had been negative via depression screening. Mental health referral was not different between the 2 groups (odds ratio, 1.75; 95% confidence interval, 0.76-4.97), but a significant increase in referral was noted for Patient Health Questionnaire-2+Generalized Anxiety Disorder 2-item subgroups with a history of mental health diagnosis (odds ratio, 14.9; 95% confidence interval, 5.6-39.7) or substance abuse (odds ratio, 26.7; 95% confidence interval, 4.6-155.0).

CONCLUSION

Screening for perinatal anxiety may increase referral rates to mental health professionals who can then diagnose and treat women who experience mood and anxiety disorders. Anxiety screening may be particularly useful in populations with a history of mental health diagnoses or substance abuse. Further research is necessary to understand how perinatal anxiety screening should be best implemented.

A multilayered approach is needed in the NICU to support parents after the preterm birth of their infant

The premature birth of a child and admission to the neonatal intensive care unit (NICU) is a distressing experience for parents, and has been associated with symptoms of depression, anxiety and post-traumatic stress. Supporting parents in the NICU after preterm birth is critical not only for their own mental health, but also due to potential implications for their relationship with their infant and subsequent child development. This review draws from current published clinical guidelines developed to support parents in the NICU, guidelines on family centered care in intensive care units, and reviews on the effectiveness of interventions for infants and children born preterm. A multilayered approach to supporting parents of infants born preterm in the NICU is recommended, with evidence specifically for including layers of individual psychological and psychosocial support, peer-to-peer support, and family centered care. Consideration of fathers in the NICU, and areas for future research are also discussed.

Viewpoints from families for improving transition from NICU-to-home for infants with medical complexity at a safety net hospital: a qualitative study

Background

We have limited information on families’ experiences during transition and after discharge from the neonatal intensive care unit.

Methods

Open-ended semi-structured interviews were conducted with English or Spanish- speaking families enrolled in Medicaid in an urban high-risk infant follow up clinic at a safety-net center, which serves preterm and high-risk term infants. We generated salient themes using inductive-deductive thematic analysis.

Results

Twenty-one participants completed the study. The infant’s median (IQR) birth weight was 1750 (1305, 2641) grams; 71% were Hispanic and 10% were Black non-Hispanic; 62% reported living in a neighborhood with 3-4th quartile economic hardship. All were classified as having chronic disease per the Pediatric Medical Complexity Algorithm and 67% had medical complexity. A conceptual model was constructed and the analysis revealed major themes describing families’ challenges and ideas to support transition centered on the parent-child role and parent self-efficacy. The challenges were: (1) comparison to normal babies, (2) caregiver mental health, (3) need for information. Ideas to support transition included, (1) support systems, (2) interventions using mobile health technology (3) improved communication to the primary care provider and (4) information regarding financial assistance programs. Specific subthemes differed in frequency counts between infants with and without medical complexity.

Conclusions

Families often compare their preterm or high-risk infant to their peers and mothers feel great anxiety and stress. However, families often found hope and resilience in peer support and cited that in addition to information needs, interventions using mobile health technology and transition and financial systems could better support families after discharge.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1604-6) contains supplementary material, which is available to authorized users.

Prevalence and Associated Factors to Depression and Anxiety in Women with Premature Babies Hospitalized in a Neonatal Intensive-Care Unit in a Mexican Population

PURPOSE

The aims of this study were to investigate the frequency of depression and anxiety in mothers of children hospitalized in a neonatal intensive care unit, and to determine the characteristics associated with depression and anxiety in a sample of Mexican mothers.

METHOD

We studied 188 mothers who had premature babies in a neonatal intensive-care. Sociodemographic and clinical characteristics were collected through a face to face interview performed by professional staff. We assessed depression using the Beck Depression Inventory (BDI) and clinical anxiety using the Hamilton Anxiety Rating Scale (HAM-A).

RESULTS

Clinical anxiety was reported in more than one-third of women (34.0%, n = 64) followed by depression (19.7%, n = 37), while twenty-six women reported both significant depression and anxiety (13.8%). Women with both clinical symptoms were younger, they were more frequently students and were living within extended families. Women who presented only symptoms of depression reported lower educational level (elementary school 29.7%, n = 11).

CONCLUSION

Our results show a high incidence of anxiety, depression, and both emotional disorders in Mexican mothers of premature babies hospitalized in a neonatal intensive care unit. Demographic features such as occupation or age may impact the occurrence and severity of joint symptoms of depression and anxiety which should be monitored by the health team and referred to a mental health service.