Journal of Perinatology (2014), 1–7 © 2014 Nature America, Inc. All rights reserved 0743-8346/14 www.nature.com/jp
ORIGINAL ARTICLE
Psychiatric support for mothers in the Neonatal Intensive Care Unit KA Penny1, SH Friedman2 and GM Halstead3 OBJECTIVE: This study describes mental health treatment and follow-up for mothers of infants in a Neonatal Intensive Care Unit (NICU). STUDY DESIGN: Data were collected retrospectively about 204 mothers referred to a Level 3 NICU Psychiatric Consult Liaison Team over 2 years. This included medical, demographic and treatment information about both mother and infant. RESULT: Most mothers (69%) were referred within a week of birth, and 100 (49%) of the referred mothers received a psychiatric diagnosis. Psychiatric follow-up was recommended for 13% on leaving the NICU and additional follow-up referrals were made for another 16%. Mothers with more than one initial reason for referral, a past psychiatric history, receiving therapeutic services, receiving a psychiatric diagnosis and receiving pharmacotherapy were all significantly more likely to have follow-up recommended on discharge. CONCLUSION: Approximately one-sixth of mothers in the NICU were referred, a large proportion received a psychiatric diagnosis, and over a quarter required follow-up after discharge, indicating the importance of the service. Journal of Perinatology advance online publication, 11 December 2014; doi:10.1038/jp.2014.221
INTRODUCTION Parenting a critically ill infant in the Neonatal Intensive Care Unit (NICU) can be an extremely stressful experience. Daily uncertainties of life and death are intensely emotionally taxing. Hence, the time spent by parents in the NICU is a time of increased psychological risk. Compared with parents of healthy infants, NICU parents are more likely to experience clinically relevant anxiety.1 Psychological distress in NICU mothers has the potential to be long-lasting and debilitating. Singer et al.2 reported that even at 2 years after child birth, mothers of children who had been high-risk very low birth weight (VLBW) infants had more psychological distress than mothers whose children were low-risk VLBW infants, or those whose children were born at term. Maternal mental health problems have serious long-term consequences for both the mother and the infant, including impaired bonding, early cessation of breastfeeding, and slower cognitive development in the child.3–5 Fortunately both psychotherapy and pharmacotherapy are effective treatments.6,7 Therefore, early identification and appropriate treatment can have a lasting positive impact on the future of the affected family. Psychiatric diagnoses commonly seen in NICU mothers include postpartum depression (PPD), anxiety disorders, and complicated grief reactions. Postpartum psychosis, personality disorders, and cases of substance abuse are also diagnosed.8 For a woman, the postpartum period is the time of greatest psychiatric risk.9 Risk factors predisposing a woman to PPD include a history of depression, neuroticism, stressful life events, financial problems, relationship issues, pregnancy and delivery complications, and multiple births.5,10,11 Additional NICU-specific risk factors for PPD include increased maternal stress, and decreased perceived support from nursing staff.12 A large meta-analysis found a prevalence of non-psychotic PPD of 13%.10 However, in the NICU this prevalence increases significantly.12 Mood disturbances may be exacerbated
by worries about taking the infant home after discharge, or may require treatment beyond that which is able to be provided in the NICU. Anxiety is diagnosed as disordered when it interferes with daily life, and may prevent normal bonding.8 NICU-specific stressors such as the infant’s tenuous clinical situation and changes in the maternal role may induce anxiety.8 Generalized anxiety disorder has been found in 8% of new mothers, and may be even more common in the NICU environment.13 Posttraumatic stress disorder (PTSD), also an anxiety disorder, is also more common in this environment and involves symptoms of hyper-arousal, nightmares, and re-experiencing of traumas. Parents with PTSD may avoid the NICU to prevent triggering these symptoms.8 Current scholarship about systems within the NICU to detect maternal mental health disturbances and to provide treatment is limited. Mounts et al.12,14 described the importance of screening for maternal depression in the NICU. Additionally, Friedman et al.15–17 have previously reported on a program in the Cleveland Rainbow Babies NICU. These programs are rare, but could have a vital role in early detection and treatment. This study aims to quantitatively describe the population of mothers treated in an innovative maternal mental health program in a level 3 NICU over 2 years. It seeks to further characterize the maternal mental health issues in this stressful environment. Another aim is to describe the level of necessary mental health follow-up for families after their infant has been discharged. METHODS Program description The Starship Children’s Hospital (Auckland, New Zealand) NICU admitted 1930 infants over the 2-year period. The NICU cares for more than half (61%) of the critically ill level 3 infants in the Auckland region and over a
1 School of Medicine, University of Auckland, Auckland, New Zealand; 2Psychological Medicine, School of Medicine, University of Auckland, Auckland, New Zealand and 3Starship Hospital, Auckland District Health Board, Auckland, New Zealand. Correspondence: Dr SH Friedman, Psychological Medicine, School of Medicine, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand. E-mail: [email protected] Received 20 April 2014; revised 14 October 2014; accepted 24 October 2014
Psychiatric support for mothers in NICU KA Penny et al
2 1930 admissions over 2 years
302 Referred Families
Written record unable to be located for 74
Data available for 228
24 not seen by a member of the CLT
204 Assessed by a member of the CLT
32 Referred for non-psychiatric follow-up 146 did not require additional referral
26 Referred for Psychiatric Follow-up
Figure 1.
Population of families referred into the Consult Liaison Team (CLT) service.
third (38%) of level 2 infants. Although the Psychiatric Consult Liaison Team (CLT) staff work out of a team based in the pediatric hospital, for the 7 years that the program has been running, funding has come from the NICU budget for this service. The CLT provides psychological and emotional support to family of hospitalized infants in level 2 or 3. Parents are referred by physicians, nurses, social workers and lactation specialists. Families of critically ill level 3 infants are routinely referred for psychosocial assessment either by the ward social worker or by the CLT staff. In addition, some families from levels 3 and 2 are referred to this ongoing CLT service because of high identified need for psychological or psychiatric support. Interventions were psychiatric assessment and referral on to further services or initiation of treatment for parents unable to access usual mental health services. Psychological support was offered around stress and losses involved in preterm delivery, NICU situation, prematurity-related and congenital infant diagnoses, establishing parenting role and parent–infant relationship in NICU, and assistance in managing parent–staff relationship issues. Therapeutic work included elements of problem-solving, relaxation, mindfulness, work with couples and families where relevant, Cognitive Behavioral Therapy, InterPersonal Therapy, pharmacotherapy, education and supervision of staff and input into the parent support group. The team consists of one psychiatrist, several psychotherapists and other members, such as pediatric trainees, social workers, psychologists and nurse specialists. Families in the NICU have little time to sit down for a structured consultation, and interviews completed by members of the CLT are generally unstructured and tend to take place at the infant’s bedside, the postnatal ward or NICU interview rooms. A structured clinical interview is often not appropriate in this acutely distressed setting.
Study design Data about mothers, infants and mental health treatment were collected retrospectively from medical records of families referred to the CLT during the 2-year period between January 2012 and December 2013. Journal of Perinatology (2014), 1 – 7
Demographic and medical information recorded about the mother included: past psychiatric history, substance abuse history, known past perinatal losses or infertility issues, current medical problems, living situation and relationship status. Information collected about the infants included: birth weight category (with VLBW defined as o1500 g, and low birth weight as o2500 g), sex, race, reason for NICU admission, gestational age at birth (with premature defined as o37 weeks, full term as 37–42 weeks and past dates as 442 weeks), multiplicity, malformations, birth weight and demise. In the case of twins, data were collected about an index twin. Information was recorded about the referral and subsequent interaction with the CLT, including: reason for referral, type of mental health professional involved, services provided, final diagnoses, and time between childbirth and referral to the CLT. To answer the study question about mothers requiring further follow-up after leaving the NICU, it was also noted which families were indicated as needing follow-up, and the service to which they were referred. These referrals were categorized into four groups. These included: (1) those referred to subspecialty psychiatric care including Maternal Mental Health and Infant Mental Health; (2) those referred to general psychiatric outpatient care; (3) those referrals meant to heighten the awareness of health professionals who would interact with the family in the near future such as homecare and general practitioners; and (4) those referrals to other specialty services such as those provided by non-governmental organizations (such as for grief counselling). Referrals to Child, Youth and Family Services (Child Protection Services) were also noted. Ethical approval for this study was obtained from the Auckland District Health Board (DHB) Research Review Committee. Once collected, data were analyzed using SPSS Version 20 (IBM SPSS Statistics for Windows, Version 20.0, Armonk, NY, USA). The chi-square test analyzed differences between categorical variables, and the t-test was used for continuous variables. The Fisher’s exact test was utilized when indicated. © 2014 Nature America, Inc.
Psychiatric support for mothers in NICU KA Penny et al
3 Table 1. Characteristics of infants whose mothers were seen by the NICU psychiatric CLT
Table 2.
Characteristics of mothers referred to the CLT N (%)
Maternal characteristics Infant characteristics
N (%)
Reason for admission Prematurity Malformations Other
136 (67) 35 (17) 32 (16)
Malformations known Multiplicity Birth weight categorya VLBW ( o1500 g) LBW (o 2500 g) Normal birth weight
58 (28) 23 (11) 82 (40) 34 (17) 60 (29)
Gestational ageb Premature Term Past dates
145 (70) 52 (25) 2 (1)
Gender Male Female
111 (54) 92 (45)
Ethnicity European Maori (native New Zealander) Asian Pacific Islander African
115 34 33 18 3
(56) (17) (16) (9) (2)
Abbreviations: CLT, Consult Liaison Team; LBW, low birth weight; NICU, Neonatal Intensive Care Unit; VLBW, very low birth weight. aTwenty-eight (14%) did not have numerical birth weight recorded, though the majority of these were known to be premature. bGestational age was unknown for 7 (3%).
RESULTS Interaction with the CLT Over the 2 years, 302 families were referred into the mental health CLT service, encompassing approximately one-sixth of all NICU admissions (see Figure 1). Over two-thirds of referrals (68%) were evaluated by a member of the CLT. Most (109; 53%) were treated by a psychotherapist member of the team, while a large minority (80; 39%) were treated by a psychiatrist and 15 (7%) by another member of the CLT. Mothers were considered unlikely to have been seen in the case of a written record being unavailable. Significant differences were not found between those seen and not seen, regarding available variables including length of stay, birth weight, gender and residential area. Characteristics of infants of mothers seen by the CLT As shown in Table 1, infants of mothers seen by the CLT had diverse reasons for their NICU admission. The majority were admitted for prematurity or malformations, but a minority were admitted for other reasons, including respiratory distress syndrome, hypoxic insult, brain hemorrhage, seizures, twin–twin transfusion, nephrotic syndrome, endocrine problems, meningitis, metabolic syndrome and sepsis. Infant demise was known to have occurred in 15 (7%) cases; two mothers had one twin who died. Median gestational age was 30 weeks, and 82 (40%) of infants were VLBW. In 2013, 15% of Starship NICU admissions were VLBW, so this indicates that mothers of VLBW infants were more likely to be referred. Infant racial profile was similar to the overall New Zealand population profile in 2013.18 © 2014 Nature America, Inc.
Relationship status Married/de facto partnered Single Unknown
166 (81) 8 (4) 30 (15)
Living near hospital Lived within metropolitan region of hospital (within 1 h drive) Live outside region (Considerable distance from hospital)
175 (86) 29 (14)
Previous neonatal loss Known history of infertility Medical problems
20 (10) 8 (4) 30 (15)
Past psychiatric historya Major depression Postpartum depression Generalized anxiety disorder Past suicide attempt Bipolar disorder Posttraumatic stress disorder Schizophrenia Borderline personality disorder
47 27 11 10 4 3 1 1 1
Substance abuse history
(23) (13) (5) (5) (2) (1) (0.5) (0.5) (0.5)
9 (4) a
Abbreviation: CLT, Consult Liaison Team. Several mothers had more than one past psychiatric diagnosis.
Characteristics of mothers seen by the CLT Characteristics of mothers referred are shown in Table 2. The majority (141; 69%) of the mothers were referred into the CLT service in the first week after birth. The median time to referral was 4 days (range 0–92 days, mean 8 ± 12 days). A large majority (194; 95%) of referrals were for ‘coping with illness.’ A smaller proportion, 19 (9%), were referred for ‘clarification of psychiatric diagnosis’ and 13 (6%) were for ‘bereavement.’ Other, less frequent reasons for referral included ‘psychosocial review,’ (9, 4%) ‘behavioural management,’ (2, 1%) ‘separation anxiety in a sibling,’ (1, 0.5%) ‘couples conflict,’ (1, 0.5%) and ‘previous loss of a baby,’ (1,0.5%). Seventeen percent were referred for more than one reason. Mental health diagnosis and need for follow-up care Half of all the mothers who were seen were given a mental health diagnosis, as described in Table 3. The most common diagnosis was appropriate Grief Reaction (including grief regarding loss of a normal pregnancy, and grief regarding the baby’s condition, without the presence of an acute stress reaction), followed by Acute Stress Reaction. Altogether, over a quarter (58; 28%) of mothers who were seen by the CLT were referred on to other services, including 26 (13%) referred to outpatient psychiatric services and 32 (16%) referred to other services. In total, this would include approximately 3% of all families in the NICU. Of these, there were 15 referrals to subspecialty care including Maternal Mental Health and Infant Mental Health, and 11 to general psychiatric care including referrals to community mental health centers and private professionals. Another 23 were referrals meant to heighten the awareness of other health professionals, and 9 were to other specialty services including palliative care team, teen parent services, grief counselling and Triplets Plus. Additionally, four families (6%) were known to have been referred to Child, Youth and Family Services (Child Protection Services). Journal of Perinatology (2014), 1 – 7
Psychiatric support for mothers in NICU KA Penny et al
4 Table 3.
Relationship between psychiatric diagnoses and recommendation for follow-up treatment
Psychiatric diagnosis Appropriate grief reaction Acute stress reaction Major depression** Adjustment disorder PTSD** Complicated grief reaction Anxiety disorder Personality disorder** Postpartum psychosis
Prevalence of specific diagnosis among those seen in NICU, N (%) 45 39 12 12 7 6 6 3 2
(22) (19) (6) (6) (3) (3) (3) (2) (1)
Those with this diagnosis requiring follow-up, N (% requiring follow-up) 18 12 11 6 7 3 4 3 2
(40) (31) (92) (50) (100) (50) (67) (100) (100)
Those with this diagnosis not requiring follow-up, N (%) 27 27 1 6 0 3 2 0 0
(60) (69) (8) (50) (0) (50) (33) (0) (0)
Abbreviations: NICU, Neonatal Intensive Care Unit; PTSD, posttraumatic stress disorder. Po0.01 (Fisher’s exact test) comparing those who did vs did not require follow-up. **Po 0.001 (Fisher’s exact test). Thirty-two (16%) of women had more than one diagnosis and nine women had no given diagnosis but were referred for further treatment.
Table 4.
Factors correlated with recommendation by the CLT that the mother should receive follow-up care Total with characteristic, N (% of 204)
Those requiring follow-up, N (%)
Those not requiring follow-up, N(%)
More than one referral reason*
34 (17)
18 (53)
16 (47)
Role of the CLT Therapeutic work* Consultation/liaison with staff Assessment only
114 (56) 26 (13) 63 (31)
42 (38) 6 (23) 10 (16)
72 (63) 20 (77) 53 (84)
Pharmacotherapy prescribed** Psychiatric diagnosis given** Past psychiatric history known**
9 (4) 100 (49) 47 (23)
9 (100) 48 (48) 24 (51)
0 (0) 52 (52) 23 (49)
Variable
Abbreviation: CLT, Consult Liaison Team. *Po0.01 comparing those who did vs did not require follow-up. **Po 0.001 (Chi-square, Fisher’s exact test).
The CLT psychiatrist provided therapeutic work in 56% of cases. The CLT psychiatrist prescribed medication for nine mothers, all of whom were referred for further mental health treatment. Seven were prescribed an selective serotonin reuptake inhibitor antidepressant agent (Citalopram, Fluoxetine, Paroxetine), two a benzodiazepine, one an anti-psychotic agent (olanzapine) and one a sleepaide (zopiclone). Regarding diagnosis, as shown in Table 3, mothers with major depression, PTSD, personality disorders and postpartum psychosis were significantly more likely to be referred for follow-up care. Other factors significantly correlated with mothers' requirement for follow-up are found in Table 4. Of the mothers who required follow-up psychiatric care, 10 had no past psychiatric history; an additional 24 mothers without a psychiatric history were referred for additional services. Mothers referred on for further care post-discharge were significantly more likely to have more than one reason for initial referral into the CLT service (P ⩽ 0.01) Those receiving therapeutic work from the CLT were also significantly more likely to be referred (P ⩽ 0.01) than others. All mothers who received pharmacotherapy (P ⩽ 0.001) were referred, and those who received a psychiatric diagnosis (P ⩽ 0.001) and who had a past psychiatric history (P ⩽ 0.01) were significantly more likely to be referred. DISCUSSION During a 2-year period, approximately one-sixth of NICU mothers were referred to an inpatient mental health team, and approximately one-ninth of NICU mothers were evaluated. This is indicative of a substantial need within this population for supportive psychiatric services. Over half (56%) of the 204 evaluated required therapeutic work, and nearly half (49%) of the mothers Journal of Perinatology (2014), 1 – 7
were given a psychiatric diagnosis. Just over a quarter (28%) were referred on to other services after leaving the NICU, including 13% having referrals to outpatient psychiatric care. Further treatment was more likely to be recommended for mothers having more than one reason for the initial referral, women receiving therapeutic work, those receiving a psychiatric diagnosis, those who were prescribed pharmacotherapy and those with a past psychiatric history. Those with diagnoses of major depression, PTSD, personality disorder and postpartum psychosis were more likely to be referred for follow-up mental health care. NICU mothers are more likely to have clinically significant psychiatric concerns than those with healthy infants.15,19 However, as women in the NICU may feel selfish seeking help for their own problems when their infant is critically ill; many of these diagnoses could have been missed if it were not for the original referral from the NICU. This in turn could have long-term consequences for the entire family. In this sample of mothers seen by the CLT, there was a diagnosis of depression in 6% of cases, a low figure compared with the recent literature. Davis et al.19 found that 40% of women screened 1 month after their infant’s admission to the NICU scored over 12 on the EPDS (Edinburgh Postnatal Depression Scale), indicative of depressive symptoms on a well-validated and commonly used screening test. Ballard et al.15 recently reported that 41% of mothers in the NICU have an EPDS score ⩾ 10. A possible explanation for this discrepancy lies in the timing of the assessment. Most women were referred to the CLT in the first week after birth, too soon to make a DSM diagnosis of depression, which requires at least 2 weeks of symptoms.20 If postnatal mood disturbances go untreated, then they can have a measurable and permanent impact on the child’s development.4 Children are particularly susceptible to interpersonal stress and the effect of © 2014 Nature America, Inc.
Psychiatric support for mothers in NICU KA Penny et al
maternal depression during their formative years.21,22 These effects may linger even after the depressive episode has subsided.23 Maternal depression has been associated with neglect and early cessation of breastfeeding or no breastfeeding.3 Interpersonal psychotherapy increases the speed at which women recover from PPD, which along with other treatment methods is likely to improve quality of life and thus family functioning.7 Psychotherapeutic work occurred with depressed mothers in the current NICU sample, and 92% were referred on to other services. Similarly, clinically significant anxiety impacts the mother-child bond and child development, as well as the mother’s wellbeing. Mothers with anxiety disorders display less warmth than controls, and are less likely to promote psychological autonomy in their children.24 Therefore, it is important that anxiety symptoms are identified and treated early, ideally while the mother is still in the NICU. Ballard et al.15 found state anxiety symptoms in 38% of NICU mothers. In the current sample, 3% of mothers were diagnosed with an anxiety disorder, though it is likely that many mothers experienced state anxiety symptoms that did not meet diagnostic criteria for an anxiety disorder. As well, adjustment disorders, characterized by the onset of psychological symptoms relating to a particular stressor (symptoms of which may include depression or anxiety20) were diagnosed in 6%. In this sample, 19% of the mothers were diagnosed with acute stress reactions, and 3% were diagnosed with PTSD. Acute stress reactions are episodes similar to PTSD, but having persisted less than 4 weeks.20 Shaw et al.25 found an acute stress reaction prevalence of 28% in NICU parents. Considering PTSD can only be diagnosed after 4 weeks of experiencing symptoms,20 despite likely high frequencies of traumatic experiences during birth and the postpartum period, our low rate is to be expected at the early stage of referral. It is anticipated that the rate of PTSD would increase over time as some cases of acute stress reaction progress. A recent study (N = 29) found that at 18 months postpartum, 28% of women who experienced preterm birth had PTSD.26 PTSD is more likely to be diagnosed in mothers of preterm than healthy infants.27 Acute stress reactions and PTSD symptoms can cause serious problems in the NICU and they may even prevent a mother from visiting her baby if this triggers her anxiety.8 The most serious type of postpartum mood disturbance is postpartum psychosis. Though rare (1–3 in 1000 new mothers), due to the risk of suicide, infanticide and neglect, it is treated as a medical emergency and usually warrants admission to the psychiatric hospital.28 Because onset is usually in the first postpartum weeks, it may be diagnosed within the NICU environment. Our sample included two cases of postpartum psychosis, which is within the expected range considering our number of NICU admissions. Most commonly diagnosed in this population were grief reactions, both appropriate and complicated. Grief is not always precipitated by neonatal death. Parents may grieve the loss of their preconceived idea of a perfect baby, or in cases of probable long-term disability, they may grieve the loss of their infant’s expected normal, healthy future. In this sample, 22% of mothers were diagnosed with an appropriate grief reaction and 3% with a complicated grief reaction. Parental ‘anticipatory grief,’ or distress, is not correlated with the actual severity of the infant’s illness.29 Perception is far more important. Experiences perceived by the mother as stressful include seeing the baby surrounded by medical equipment, medical complications and setbacks, having to share the parental role with nursing staff, and a lack of professionalism displayed by health professionals.30 Previous perinatal adverse experiences also affect the mother’s reaction to her infant’s illness.30 Factors predisposing women to a pathological grief response include a lack of social support, a history of mental health issues and a neurotic personality.31 Similarly to the other described disorders, one would expect that excessive grieving may cause difficulties in the mother’s interactions with her infant. Hence, the role of the CLT is important in these cases © 2014 Nature America, Inc.
5 as there is good evidence that providing therapy to parents of chronically ill children improves parental mental health.32 Many mothers with appropriate grief were not in need of treatment after discharge. Three mothers in the current sample were diagnosed with a personality disorder. Problematic personality traits may be exacerbated in the stressful NICU environment and can make interactions with staff and other parents on the unit more difficult.8 In these cases, a CLT can be particularly helpful in liaising with staff about appropriate limit-setting with parents, who may otherwise rapidly upset the NICU environment. Previous research has shown the value of providing support to NICU parents.33,34 Melnyk et al.35 found that administering the Creating Opportunities for Parent Empowerment program reduced the average NICU length of stay by 3.8 days. Though this program was different from the CLT program in that it was administered to all parents and was focused on parenting education using activities and audio CDs, it similarly highlights the value of interventions targeting parent distress in the NICU. Considering the astronomical cost of treating a critically ill infant in the NICU, programs like the CLT may have significant economic (as well as psychosocial) benefits. Interviews with parents of babies who have received NICU care indicate that parent support groups are also a helpful tool.36 The base rates in NICU of multiples or infants conceived by assisted reproductive technology are not reported so it is not clear whether mothers of these infants were more likely to be seen. However, a recent systematic review found that mothers of multiples may be at a higher risk of developing depression.11 In the current sample, 11% of mothers seen by the CLT had multiples. There is debate around whether mothers of infants conceived with assisted reproductive technologies are more likely to develop postnatal depression, though recent evidence indicates that there may not be an association.11,37 In this sample, 4% had a documented history of infertility. Women who conceive their infant less than 1 year after a previous stillbirth have higher rates of depressive symptoms than those who are less recently bereaved or those who have never experienced a stillbirth.38 In the current referred sample, 10% of mothers had a known previous neonatal loss. This study has implications for NICU maternal mental health care at other hospitals internationally, regarding how programs might recognize, evaluate and treat significant maternal mental health issues. The stressors on parents of critically ill infants are similar across NICUs. The Cleveland Rainbow Babies study found that the majority of mothers were referred due to signs of depression (43%), anxiety (44%) and difficulty coping with their infant’s illness (60%).17 Similar to the present study, the majority were referred because of difficulties coping with their infant’s illness. In the Rainbow study, 6% of all NICU mothers were referred to the perinatal psychiatrist; depression was diagnosed in 40% of women, anxiety disorders in 31% and PTSD in 5%.17 The higher rates of depression and anxiety in the Rainbow study are likely because Rainbow Babies NICU mothers were only referred if there were specific psychiatric concerns whereas women in Starship NICU were more frequently referred (one-sixth of the NICU mothers were referred).17 The Rainbow study found that 33% of the mothers seen by the psychiatrist while in the NICU were referred for subsequent psychiatric services.17 This, together with the present study, suggests that worldwide, there exists a need for mental health follow-up for some mothers after they leave the NICU. The large number of families requiring community services per year could justify the development of specific resources detailing how community health professionals can support NICU families. However, US studies demonstrate that many pediatricians feel ill-equipped to deal with maternal mental health issues.39,40 In one study just over a quarter of mothers with depressive symptoms were correctly Journal of Perinatology (2014), 1 – 7
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6
identified as such by pediatricians.41 It is suggested that this situation is reflected in primary care professionals caring for the infant after hospital discharge worldwide, which is problematic considering that they are often also expected to provide care to depressed, anxious or grieving mothers. Methodological issues This study is limited in that it is a retrospective review from a single center and was not designed to assess outcomes (other than the need for further follow-up care) in mothers receiving the CLT service. Because written notes from various mental health professionals were assessed, some information was recorded for the majority of families but not all. Because the mother’s records were able to be accessed but not the infant’s records (due to the mother being the CLT patient), occasionally specific data (such as infant birth weight) were missing. A total of 74 of the 302 referrals during the time period of consideration were unable to be found, which may have introduced bias. Though it was presumed that these mothers were not seen, it is impossible to be certain, since CLT notes are not computerized to protect confidentiality. Additionally, this study considered maternal mental health in the NICU; however, there were several cases where the father or another family member also received some form of assistance along with the mother. It would be helpful to also quantitatively describe the population of fathers, grandparents and siblings in future studies. CONCLUSIONS Previous studies have shown that mothers in the NICU are at a substantially increased psychological risk compared with mothers of healthy infants. That over one-sixth of all NICU mothers were referred to the CLT, and nearly half of the mothers seen received a psychiatric diagnosis suggests that this is a population that desperately needs supportive psychiatric services. It can be inferred that a proportion of these cases would have gone un-noticed and untreated had this service not been provided, with potentially serious longer-term consequences for child development and family wellbeing. Having CLT support while in the NICU allowed over one-quarter of the mothers who were seen access to further follow-up services that they otherwise may not have received. This indicates that there may be value in universal screening to recognize the need for psychiatric support in parents without previously identified psychiatric issues. Future studies may support the value of the service provided by the CLT in improving the wellbeing of the population of families discharged from the NICU. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS We wish to thank the Kate Edger Trust for funding, the members of the Starship Consult Liaison Team, and staff of the Starship Neonatal Intensive Care Unit.
REFERENCES 1 Carter JD, Mulder RT, Bartram AF, Darlow BA. Infants in a neonatal intensive care unit: parental response. Arch Dis Child Fetal Neonatal Ed 2005; 90: F109–F113. 2 Singer LT, Salvator A, Guo S, Collin M, Lillen L, Baley J. Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant. JAMA 1999; 281(9): 799–805. 3 Ip S, Chung M, Raman G, Chew P, Magula N, Devine D et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Agency for Healthcare Research and Quality: Rockville, MD, 2007, p 130.
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4 Ali NS, Mahmud S, Khan A, Ali BS. Impact of postpartum anxiety and depression on child’s mental development from two peri-urban communities of Karachi, Pakistan: a quasi-experimental study. BMC Psychiatry 2013; 13: 274. 5 Friedman SH, Resnick PJ. Postpartum depression: an update. Womens Health (Lond Eng) 2009; 5(3): 7–295. 6 Elkin I, Shea MT, Watkins JT, Imber SD, Sotsky SM, Collins JF et al. National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Arch Gen Psychiatry 1989; 46(11): 971–982. 7 O’Hara M, Stuart S, Gorman LL, Wenzel A. Effect of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry 2000; 57(11): 1039–1045. 8 Friedman SH, Yang SN, Parsons S, Amin J. Maternal mental health in the Neonatal Intensive Care Unit. NeoReviews 2011; 12(2): e1–e9. 9 Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 1993; 65: 445–453. 10 O’Hara MW, Swain AM. Rates and risk of postpartum depression-a meta-analysis. Int Rev Psychiatry 1996; 8(1): 37–54. 11 Ross LE, McQueen K, Vigod S, Dennis CL. Risk for postpartum depression associated with assisted reproductive technologies and multiple births: a systematic review. Hum Reprod Update 2011; 17(1): 96–106. 12 Mounts KO. Screening for maternal depression in the neonatal ICU. Clin Perinatol 2009; 36(1): 137–152. 13 Wenzel A, Haugen EN, Jackson LC, Brendle JR. Anxiety symptoms and disorders at eight weeks postpartum. J Anxiety Disord 2005; 19(3): 295–311. 14 Hynan MT, Mounts KO, Vanderbilt DL. Screening parents of high-risk infants for emotional distress: rationale and recommendations. J Perinatol 2013; 33: 748–753. 15 Ballard AR, Friedman SH, Shand JP, Martin R, Hack M. Postpartum Depression and Anxiety among Mothers of Infants in the Neonatal Intensive Care Unit. Presented at American Psychiatric Association Annual Meeting: San Francisco, 2013. 16 Friedman SH, Kessler RA, Martin R. Psychiatric help for caregivers of infants in Neonatal Intensive Care. Psychiatr Serv 2009; 60(4): 554. 17 Friedman SH, Kessler A, Yang SN, Parsons S, Friedman H, Martin RJ. Delivering perinatal psychiatric services in the neonatal intensive care unit. Acta Paediatr 2013; 102: e392–e397. 18 Statistics New Zealand [Internet]. New Zealand: 2013 Census Quickstats about national highlights. Cultural Diversity; 3 December 2013 [cited 24 February 2014]; [about 2 screens]. Available from http://www.stats.govt.nz/Census/2013-census/ profile-and-summary-reports/quickstats-about-national-highlights/cultural-diver sity.aspx. 19 Davis L, Edwards H, Mohay H, Wollin J. The impact of very premature birth on the psychological health of mothers. Early Hum Dev 2003; 73(1-2): 61–70. 20 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Revised 4th edn. Author: Washington, DC, 2000. 21 Barker ED. The duration and timing of maternal depression as a moderator of the relationship between dependent interpersonal stress, contextual risk and early child dysregulation. Psychol Med 2013; 43(8): 1587–1596. 22 Webster-Stratton C, Hammond M. Maternal depression and its relationship to life stress, perceptions of child behaviour problems, parenting behaviours, and child conduct problems. J Abnorm Child Psychol 1988; 16(3): 299–315. 23 Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behaviour: A meta-analytic review. Clin Psychol Rev 2000; 20(5): 561–592. 24 Challacombe F, Salkovskis P. A preliminary investigation of the impact of maternal obsessive-compulsive disorder and panic disorder on parenting and children. J Anxiety Disord 2009; 23(7): 848–857. 25 Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acute stress reactions among parents of infants in the Neonatal Intensive Care Nursery. Psychosomatics 2006; 47(3): 206–212. 26 Misund AR, Nerdrum P, Braten S, Pripp AH, Diseth TH. Long-term risk of mental health problems in women experiencing preterm birth: a longitudinal study of 29 mothers. Ann Gen Psychiatry 2013; 12: 33. 27 Ghrobani M, Dolatian M, Shams J, Alavi-Majd H, Tavakolian S. Factors associated with posttraumatic stress disorder and its coping styles in parents of preterm and full-term infants. Global J Health Sci 2014; 6(3): 65–73. 28 Friedman SH, Resnick PJ, Rosenthal MB. Postpartum psychosis. Curr Psychiatry 2009; 8(2): 40–46. 29 Benfield DG, Leib SA, Reuter J. Grief response of parents after referral of the critically ill newborn to a regional center. NEJM 1976; 294: 975–978. 30 Holditch-Davis D, Miles MS. Mothers’ stories about their experiences in the Neonatal Intensive Care Unit. Neonatal Netw 2000; 19(3): 13–21. 31 Hughes P, Riches S. Psychological aspects of perinatal loss. Curr Opin Obstet Gynecol 2003; 15: 107–111. 32 Eccleston C, Palermo TM, Fisher E, Law E. Psychological interventions for parents of children and adolescents with chronic illness. Cochrane Database Syst Rev 2012; 8: 1–131.
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7 33 Brett J, Staniszewska S, Newburn M, Jones N, Taylor L. A systematic mapping review of effective interventions for communicating with, supporting and providing information to parents of preterm infants. BMJ Open 2011; 1: e000023. 34 Jotzo M, Poets CF. Helping parents cope with the trauma of premature birth: an evaluation of a trauma-preventive psychological intervention. Pediatrics 2005; 115(4): 915. 35 Melnyk BM, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA et al. Reducing premature infants’ length of stay and improving parents’ mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit Program: a randomized, controlled trial. Pediatrics 2006; 118(5): e1414–e1427. 36 Turner M, Winefield H, Chur-Hansen A. The emotional experiences and supports for parents with babies in a neonatal nursery. Adv Neonatal Care 2013; 13(6): 438–446.
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37 Bloch M, Rotenberg N, Koren D, Klein E. Risk factors for early postpartum depressive symptoms. Gen Hosp Psychiatry 2006; 28(1): 3–8. 38 Hughes PM, Turton P, Evans CDH. Stillbirth as a risk factor for depression and anxiety in the subsequent pregnancy: cohort study. BMJ 1999; 318(7200): 1721–1724. 39 Earls MF. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics 2010; 126: 1032–1039. 40 Olson AL, Kemper KJ, Kelleher KJ, Hammond CS, Zuckerman BS, Dietrich AJ. Primary Care Pediatricians’ roles and perceived responsibilities in the identification and management of maternal depression. Pediatrics 2002; 110(6): 1169–1176. 41 Heneghan AM, Silver EJ, Bauman LJ, Stein REK. Do pediatricians recognize mothers with depressive symptoms? Pediatrics 2000; 106(6): 1367–1373.
Journal of Perinatology (2014), 1 – 7
ORIGINAL ARTICLE
Psychiatric support for mothers in the Neonatal Intensive Care Unit KA Penny1, SH Friedman2 and GM Halstead3 OBJECTIVE: This study describes mental health treatment and follow-up for mothers of infants in a Neonatal Intensive Care Unit (NICU). STUDY DESIGN: Data were collected retrospectively about 204 mothers referred to a Level 3 NICU Psychiatric Consult Liaison Team over 2 years. This included medical, demographic and treatment information about both mother and infant. RESULT: Most mothers (69%) were referred within a week of birth, and 100 (49%) of the referred mothers received a psychiatric diagnosis. Psychiatric follow-up was recommended for 13% on leaving the NICU and additional follow-up referrals were made for another 16%. Mothers with more than one initial reason for referral, a past psychiatric history, receiving therapeutic services, receiving a psychiatric diagnosis and receiving pharmacotherapy were all significantly more likely to have follow-up recommended on discharge. CONCLUSION: Approximately one-sixth of mothers in the NICU were referred, a large proportion received a psychiatric diagnosis, and over a quarter required follow-up after discharge, indicating the importance of the service. Journal of Perinatology advance online publication, 11 December 2014; doi:10.1038/jp.2014.221
INTRODUCTION Parenting a critically ill infant in the Neonatal Intensive Care Unit (NICU) can be an extremely stressful experience. Daily uncertainties of life and death are intensely emotionally taxing. Hence, the time spent by parents in the NICU is a time of increased psychological risk. Compared with parents of healthy infants, NICU parents are more likely to experience clinically relevant anxiety.1 Psychological distress in NICU mothers has the potential to be long-lasting and debilitating. Singer et al.2 reported that even at 2 years after child birth, mothers of children who had been high-risk very low birth weight (VLBW) infants had more psychological distress than mothers whose children were low-risk VLBW infants, or those whose children were born at term. Maternal mental health problems have serious long-term consequences for both the mother and the infant, including impaired bonding, early cessation of breastfeeding, and slower cognitive development in the child.3–5 Fortunately both psychotherapy and pharmacotherapy are effective treatments.6,7 Therefore, early identification and appropriate treatment can have a lasting positive impact on the future of the affected family. Psychiatric diagnoses commonly seen in NICU mothers include postpartum depression (PPD), anxiety disorders, and complicated grief reactions. Postpartum psychosis, personality disorders, and cases of substance abuse are also diagnosed.8 For a woman, the postpartum period is the time of greatest psychiatric risk.9 Risk factors predisposing a woman to PPD include a history of depression, neuroticism, stressful life events, financial problems, relationship issues, pregnancy and delivery complications, and multiple births.5,10,11 Additional NICU-specific risk factors for PPD include increased maternal stress, and decreased perceived support from nursing staff.12 A large meta-analysis found a prevalence of non-psychotic PPD of 13%.10 However, in the NICU this prevalence increases significantly.12 Mood disturbances may be exacerbated
by worries about taking the infant home after discharge, or may require treatment beyond that which is able to be provided in the NICU. Anxiety is diagnosed as disordered when it interferes with daily life, and may prevent normal bonding.8 NICU-specific stressors such as the infant’s tenuous clinical situation and changes in the maternal role may induce anxiety.8 Generalized anxiety disorder has been found in 8% of new mothers, and may be even more common in the NICU environment.13 Posttraumatic stress disorder (PTSD), also an anxiety disorder, is also more common in this environment and involves symptoms of hyper-arousal, nightmares, and re-experiencing of traumas. Parents with PTSD may avoid the NICU to prevent triggering these symptoms.8 Current scholarship about systems within the NICU to detect maternal mental health disturbances and to provide treatment is limited. Mounts et al.12,14 described the importance of screening for maternal depression in the NICU. Additionally, Friedman et al.15–17 have previously reported on a program in the Cleveland Rainbow Babies NICU. These programs are rare, but could have a vital role in early detection and treatment. This study aims to quantitatively describe the population of mothers treated in an innovative maternal mental health program in a level 3 NICU over 2 years. It seeks to further characterize the maternal mental health issues in this stressful environment. Another aim is to describe the level of necessary mental health follow-up for families after their infant has been discharged. METHODS Program description The Starship Children’s Hospital (Auckland, New Zealand) NICU admitted 1930 infants over the 2-year period. The NICU cares for more than half (61%) of the critically ill level 3 infants in the Auckland region and over a
1 School of Medicine, University of Auckland, Auckland, New Zealand; 2Psychological Medicine, School of Medicine, University of Auckland, Auckland, New Zealand and 3Starship Hospital, Auckland District Health Board, Auckland, New Zealand. Correspondence: Dr SH Friedman, Psychological Medicine, School of Medicine, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand. E-mail: [email protected] Received 20 April 2014; revised 14 October 2014; accepted 24 October 2014
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2 1930 admissions over 2 years
302 Referred Families
Written record unable to be located for 74
Data available for 228
24 not seen by a member of the CLT
204 Assessed by a member of the CLT
32 Referred for non-psychiatric follow-up 146 did not require additional referral
26 Referred for Psychiatric Follow-up
Figure 1.
Population of families referred into the Consult Liaison Team (CLT) service.
third (38%) of level 2 infants. Although the Psychiatric Consult Liaison Team (CLT) staff work out of a team based in the pediatric hospital, for the 7 years that the program has been running, funding has come from the NICU budget for this service. The CLT provides psychological and emotional support to family of hospitalized infants in level 2 or 3. Parents are referred by physicians, nurses, social workers and lactation specialists. Families of critically ill level 3 infants are routinely referred for psychosocial assessment either by the ward social worker or by the CLT staff. In addition, some families from levels 3 and 2 are referred to this ongoing CLT service because of high identified need for psychological or psychiatric support. Interventions were psychiatric assessment and referral on to further services or initiation of treatment for parents unable to access usual mental health services. Psychological support was offered around stress and losses involved in preterm delivery, NICU situation, prematurity-related and congenital infant diagnoses, establishing parenting role and parent–infant relationship in NICU, and assistance in managing parent–staff relationship issues. Therapeutic work included elements of problem-solving, relaxation, mindfulness, work with couples and families where relevant, Cognitive Behavioral Therapy, InterPersonal Therapy, pharmacotherapy, education and supervision of staff and input into the parent support group. The team consists of one psychiatrist, several psychotherapists and other members, such as pediatric trainees, social workers, psychologists and nurse specialists. Families in the NICU have little time to sit down for a structured consultation, and interviews completed by members of the CLT are generally unstructured and tend to take place at the infant’s bedside, the postnatal ward or NICU interview rooms. A structured clinical interview is often not appropriate in this acutely distressed setting.
Study design Data about mothers, infants and mental health treatment were collected retrospectively from medical records of families referred to the CLT during the 2-year period between January 2012 and December 2013. Journal of Perinatology (2014), 1 – 7
Demographic and medical information recorded about the mother included: past psychiatric history, substance abuse history, known past perinatal losses or infertility issues, current medical problems, living situation and relationship status. Information collected about the infants included: birth weight category (with VLBW defined as o1500 g, and low birth weight as o2500 g), sex, race, reason for NICU admission, gestational age at birth (with premature defined as o37 weeks, full term as 37–42 weeks and past dates as 442 weeks), multiplicity, malformations, birth weight and demise. In the case of twins, data were collected about an index twin. Information was recorded about the referral and subsequent interaction with the CLT, including: reason for referral, type of mental health professional involved, services provided, final diagnoses, and time between childbirth and referral to the CLT. To answer the study question about mothers requiring further follow-up after leaving the NICU, it was also noted which families were indicated as needing follow-up, and the service to which they were referred. These referrals were categorized into four groups. These included: (1) those referred to subspecialty psychiatric care including Maternal Mental Health and Infant Mental Health; (2) those referred to general psychiatric outpatient care; (3) those referrals meant to heighten the awareness of health professionals who would interact with the family in the near future such as homecare and general practitioners; and (4) those referrals to other specialty services such as those provided by non-governmental organizations (such as for grief counselling). Referrals to Child, Youth and Family Services (Child Protection Services) were also noted. Ethical approval for this study was obtained from the Auckland District Health Board (DHB) Research Review Committee. Once collected, data were analyzed using SPSS Version 20 (IBM SPSS Statistics for Windows, Version 20.0, Armonk, NY, USA). The chi-square test analyzed differences between categorical variables, and the t-test was used for continuous variables. The Fisher’s exact test was utilized when indicated. © 2014 Nature America, Inc.
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3 Table 1. Characteristics of infants whose mothers were seen by the NICU psychiatric CLT
Table 2.
Characteristics of mothers referred to the CLT N (%)
Maternal characteristics Infant characteristics
N (%)
Reason for admission Prematurity Malformations Other
136 (67) 35 (17) 32 (16)
Malformations known Multiplicity Birth weight categorya VLBW ( o1500 g) LBW (o 2500 g) Normal birth weight
58 (28) 23 (11) 82 (40) 34 (17) 60 (29)
Gestational ageb Premature Term Past dates
145 (70) 52 (25) 2 (1)
Gender Male Female
111 (54) 92 (45)
Ethnicity European Maori (native New Zealander) Asian Pacific Islander African
115 34 33 18 3
(56) (17) (16) (9) (2)
Abbreviations: CLT, Consult Liaison Team; LBW, low birth weight; NICU, Neonatal Intensive Care Unit; VLBW, very low birth weight. aTwenty-eight (14%) did not have numerical birth weight recorded, though the majority of these were known to be premature. bGestational age was unknown for 7 (3%).
RESULTS Interaction with the CLT Over the 2 years, 302 families were referred into the mental health CLT service, encompassing approximately one-sixth of all NICU admissions (see Figure 1). Over two-thirds of referrals (68%) were evaluated by a member of the CLT. Most (109; 53%) were treated by a psychotherapist member of the team, while a large minority (80; 39%) were treated by a psychiatrist and 15 (7%) by another member of the CLT. Mothers were considered unlikely to have been seen in the case of a written record being unavailable. Significant differences were not found between those seen and not seen, regarding available variables including length of stay, birth weight, gender and residential area. Characteristics of infants of mothers seen by the CLT As shown in Table 1, infants of mothers seen by the CLT had diverse reasons for their NICU admission. The majority were admitted for prematurity or malformations, but a minority were admitted for other reasons, including respiratory distress syndrome, hypoxic insult, brain hemorrhage, seizures, twin–twin transfusion, nephrotic syndrome, endocrine problems, meningitis, metabolic syndrome and sepsis. Infant demise was known to have occurred in 15 (7%) cases; two mothers had one twin who died. Median gestational age was 30 weeks, and 82 (40%) of infants were VLBW. In 2013, 15% of Starship NICU admissions were VLBW, so this indicates that mothers of VLBW infants were more likely to be referred. Infant racial profile was similar to the overall New Zealand population profile in 2013.18 © 2014 Nature America, Inc.
Relationship status Married/de facto partnered Single Unknown
166 (81) 8 (4) 30 (15)
Living near hospital Lived within metropolitan region of hospital (within 1 h drive) Live outside region (Considerable distance from hospital)
175 (86) 29 (14)
Previous neonatal loss Known history of infertility Medical problems
20 (10) 8 (4) 30 (15)
Past psychiatric historya Major depression Postpartum depression Generalized anxiety disorder Past suicide attempt Bipolar disorder Posttraumatic stress disorder Schizophrenia Borderline personality disorder
47 27 11 10 4 3 1 1 1
Substance abuse history
(23) (13) (5) (5) (2) (1) (0.5) (0.5) (0.5)
9 (4) a
Abbreviation: CLT, Consult Liaison Team. Several mothers had more than one past psychiatric diagnosis.
Characteristics of mothers seen by the CLT Characteristics of mothers referred are shown in Table 2. The majority (141; 69%) of the mothers were referred into the CLT service in the first week after birth. The median time to referral was 4 days (range 0–92 days, mean 8 ± 12 days). A large majority (194; 95%) of referrals were for ‘coping with illness.’ A smaller proportion, 19 (9%), were referred for ‘clarification of psychiatric diagnosis’ and 13 (6%) were for ‘bereavement.’ Other, less frequent reasons for referral included ‘psychosocial review,’ (9, 4%) ‘behavioural management,’ (2, 1%) ‘separation anxiety in a sibling,’ (1, 0.5%) ‘couples conflict,’ (1, 0.5%) and ‘previous loss of a baby,’ (1,0.5%). Seventeen percent were referred for more than one reason. Mental health diagnosis and need for follow-up care Half of all the mothers who were seen were given a mental health diagnosis, as described in Table 3. The most common diagnosis was appropriate Grief Reaction (including grief regarding loss of a normal pregnancy, and grief regarding the baby’s condition, without the presence of an acute stress reaction), followed by Acute Stress Reaction. Altogether, over a quarter (58; 28%) of mothers who were seen by the CLT were referred on to other services, including 26 (13%) referred to outpatient psychiatric services and 32 (16%) referred to other services. In total, this would include approximately 3% of all families in the NICU. Of these, there were 15 referrals to subspecialty care including Maternal Mental Health and Infant Mental Health, and 11 to general psychiatric care including referrals to community mental health centers and private professionals. Another 23 were referrals meant to heighten the awareness of other health professionals, and 9 were to other specialty services including palliative care team, teen parent services, grief counselling and Triplets Plus. Additionally, four families (6%) were known to have been referred to Child, Youth and Family Services (Child Protection Services). Journal of Perinatology (2014), 1 – 7
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4 Table 3.
Relationship between psychiatric diagnoses and recommendation for follow-up treatment
Psychiatric diagnosis Appropriate grief reaction Acute stress reaction Major depression** Adjustment disorder PTSD** Complicated grief reaction Anxiety disorder Personality disorder** Postpartum psychosis
Prevalence of specific diagnosis among those seen in NICU, N (%) 45 39 12 12 7 6 6 3 2
(22) (19) (6) (6) (3) (3) (3) (2) (1)
Those with this diagnosis requiring follow-up, N (% requiring follow-up) 18 12 11 6 7 3 4 3 2
(40) (31) (92) (50) (100) (50) (67) (100) (100)
Those with this diagnosis not requiring follow-up, N (%) 27 27 1 6 0 3 2 0 0
(60) (69) (8) (50) (0) (50) (33) (0) (0)
Abbreviations: NICU, Neonatal Intensive Care Unit; PTSD, posttraumatic stress disorder. Po0.01 (Fisher’s exact test) comparing those who did vs did not require follow-up. **Po 0.001 (Fisher’s exact test). Thirty-two (16%) of women had more than one diagnosis and nine women had no given diagnosis but were referred for further treatment.
Table 4.
Factors correlated with recommendation by the CLT that the mother should receive follow-up care Total with characteristic, N (% of 204)
Those requiring follow-up, N (%)
Those not requiring follow-up, N(%)
More than one referral reason*
34 (17)
18 (53)
16 (47)
Role of the CLT Therapeutic work* Consultation/liaison with staff Assessment only
114 (56) 26 (13) 63 (31)
42 (38) 6 (23) 10 (16)
72 (63) 20 (77) 53 (84)
Pharmacotherapy prescribed** Psychiatric diagnosis given** Past psychiatric history known**
9 (4) 100 (49) 47 (23)
9 (100) 48 (48) 24 (51)
0 (0) 52 (52) 23 (49)
Variable
Abbreviation: CLT, Consult Liaison Team. *Po0.01 comparing those who did vs did not require follow-up. **Po 0.001 (Chi-square, Fisher’s exact test).
The CLT psychiatrist provided therapeutic work in 56% of cases. The CLT psychiatrist prescribed medication for nine mothers, all of whom were referred for further mental health treatment. Seven were prescribed an selective serotonin reuptake inhibitor antidepressant agent (Citalopram, Fluoxetine, Paroxetine), two a benzodiazepine, one an anti-psychotic agent (olanzapine) and one a sleepaide (zopiclone). Regarding diagnosis, as shown in Table 3, mothers with major depression, PTSD, personality disorders and postpartum psychosis were significantly more likely to be referred for follow-up care. Other factors significantly correlated with mothers' requirement for follow-up are found in Table 4. Of the mothers who required follow-up psychiatric care, 10 had no past psychiatric history; an additional 24 mothers without a psychiatric history were referred for additional services. Mothers referred on for further care post-discharge were significantly more likely to have more than one reason for initial referral into the CLT service (P ⩽ 0.01) Those receiving therapeutic work from the CLT were also significantly more likely to be referred (P ⩽ 0.01) than others. All mothers who received pharmacotherapy (P ⩽ 0.001) were referred, and those who received a psychiatric diagnosis (P ⩽ 0.001) and who had a past psychiatric history (P ⩽ 0.01) were significantly more likely to be referred. DISCUSSION During a 2-year period, approximately one-sixth of NICU mothers were referred to an inpatient mental health team, and approximately one-ninth of NICU mothers were evaluated. This is indicative of a substantial need within this population for supportive psychiatric services. Over half (56%) of the 204 evaluated required therapeutic work, and nearly half (49%) of the mothers Journal of Perinatology (2014), 1 – 7
were given a psychiatric diagnosis. Just over a quarter (28%) were referred on to other services after leaving the NICU, including 13% having referrals to outpatient psychiatric care. Further treatment was more likely to be recommended for mothers having more than one reason for the initial referral, women receiving therapeutic work, those receiving a psychiatric diagnosis, those who were prescribed pharmacotherapy and those with a past psychiatric history. Those with diagnoses of major depression, PTSD, personality disorder and postpartum psychosis were more likely to be referred for follow-up mental health care. NICU mothers are more likely to have clinically significant psychiatric concerns than those with healthy infants.15,19 However, as women in the NICU may feel selfish seeking help for their own problems when their infant is critically ill; many of these diagnoses could have been missed if it were not for the original referral from the NICU. This in turn could have long-term consequences for the entire family. In this sample of mothers seen by the CLT, there was a diagnosis of depression in 6% of cases, a low figure compared with the recent literature. Davis et al.19 found that 40% of women screened 1 month after their infant’s admission to the NICU scored over 12 on the EPDS (Edinburgh Postnatal Depression Scale), indicative of depressive symptoms on a well-validated and commonly used screening test. Ballard et al.15 recently reported that 41% of mothers in the NICU have an EPDS score ⩾ 10. A possible explanation for this discrepancy lies in the timing of the assessment. Most women were referred to the CLT in the first week after birth, too soon to make a DSM diagnosis of depression, which requires at least 2 weeks of symptoms.20 If postnatal mood disturbances go untreated, then they can have a measurable and permanent impact on the child’s development.4 Children are particularly susceptible to interpersonal stress and the effect of © 2014 Nature America, Inc.
Psychiatric support for mothers in NICU KA Penny et al
maternal depression during their formative years.21,22 These effects may linger even after the depressive episode has subsided.23 Maternal depression has been associated with neglect and early cessation of breastfeeding or no breastfeeding.3 Interpersonal psychotherapy increases the speed at which women recover from PPD, which along with other treatment methods is likely to improve quality of life and thus family functioning.7 Psychotherapeutic work occurred with depressed mothers in the current NICU sample, and 92% were referred on to other services. Similarly, clinically significant anxiety impacts the mother-child bond and child development, as well as the mother’s wellbeing. Mothers with anxiety disorders display less warmth than controls, and are less likely to promote psychological autonomy in their children.24 Therefore, it is important that anxiety symptoms are identified and treated early, ideally while the mother is still in the NICU. Ballard et al.15 found state anxiety symptoms in 38% of NICU mothers. In the current sample, 3% of mothers were diagnosed with an anxiety disorder, though it is likely that many mothers experienced state anxiety symptoms that did not meet diagnostic criteria for an anxiety disorder. As well, adjustment disorders, characterized by the onset of psychological symptoms relating to a particular stressor (symptoms of which may include depression or anxiety20) were diagnosed in 6%. In this sample, 19% of the mothers were diagnosed with acute stress reactions, and 3% were diagnosed with PTSD. Acute stress reactions are episodes similar to PTSD, but having persisted less than 4 weeks.20 Shaw et al.25 found an acute stress reaction prevalence of 28% in NICU parents. Considering PTSD can only be diagnosed after 4 weeks of experiencing symptoms,20 despite likely high frequencies of traumatic experiences during birth and the postpartum period, our low rate is to be expected at the early stage of referral. It is anticipated that the rate of PTSD would increase over time as some cases of acute stress reaction progress. A recent study (N = 29) found that at 18 months postpartum, 28% of women who experienced preterm birth had PTSD.26 PTSD is more likely to be diagnosed in mothers of preterm than healthy infants.27 Acute stress reactions and PTSD symptoms can cause serious problems in the NICU and they may even prevent a mother from visiting her baby if this triggers her anxiety.8 The most serious type of postpartum mood disturbance is postpartum psychosis. Though rare (1–3 in 1000 new mothers), due to the risk of suicide, infanticide and neglect, it is treated as a medical emergency and usually warrants admission to the psychiatric hospital.28 Because onset is usually in the first postpartum weeks, it may be diagnosed within the NICU environment. Our sample included two cases of postpartum psychosis, which is within the expected range considering our number of NICU admissions. Most commonly diagnosed in this population were grief reactions, both appropriate and complicated. Grief is not always precipitated by neonatal death. Parents may grieve the loss of their preconceived idea of a perfect baby, or in cases of probable long-term disability, they may grieve the loss of their infant’s expected normal, healthy future. In this sample, 22% of mothers were diagnosed with an appropriate grief reaction and 3% with a complicated grief reaction. Parental ‘anticipatory grief,’ or distress, is not correlated with the actual severity of the infant’s illness.29 Perception is far more important. Experiences perceived by the mother as stressful include seeing the baby surrounded by medical equipment, medical complications and setbacks, having to share the parental role with nursing staff, and a lack of professionalism displayed by health professionals.30 Previous perinatal adverse experiences also affect the mother’s reaction to her infant’s illness.30 Factors predisposing women to a pathological grief response include a lack of social support, a history of mental health issues and a neurotic personality.31 Similarly to the other described disorders, one would expect that excessive grieving may cause difficulties in the mother’s interactions with her infant. Hence, the role of the CLT is important in these cases © 2014 Nature America, Inc.
5 as there is good evidence that providing therapy to parents of chronically ill children improves parental mental health.32 Many mothers with appropriate grief were not in need of treatment after discharge. Three mothers in the current sample were diagnosed with a personality disorder. Problematic personality traits may be exacerbated in the stressful NICU environment and can make interactions with staff and other parents on the unit more difficult.8 In these cases, a CLT can be particularly helpful in liaising with staff about appropriate limit-setting with parents, who may otherwise rapidly upset the NICU environment. Previous research has shown the value of providing support to NICU parents.33,34 Melnyk et al.35 found that administering the Creating Opportunities for Parent Empowerment program reduced the average NICU length of stay by 3.8 days. Though this program was different from the CLT program in that it was administered to all parents and was focused on parenting education using activities and audio CDs, it similarly highlights the value of interventions targeting parent distress in the NICU. Considering the astronomical cost of treating a critically ill infant in the NICU, programs like the CLT may have significant economic (as well as psychosocial) benefits. Interviews with parents of babies who have received NICU care indicate that parent support groups are also a helpful tool.36 The base rates in NICU of multiples or infants conceived by assisted reproductive technology are not reported so it is not clear whether mothers of these infants were more likely to be seen. However, a recent systematic review found that mothers of multiples may be at a higher risk of developing depression.11 In the current sample, 11% of mothers seen by the CLT had multiples. There is debate around whether mothers of infants conceived with assisted reproductive technologies are more likely to develop postnatal depression, though recent evidence indicates that there may not be an association.11,37 In this sample, 4% had a documented history of infertility. Women who conceive their infant less than 1 year after a previous stillbirth have higher rates of depressive symptoms than those who are less recently bereaved or those who have never experienced a stillbirth.38 In the current referred sample, 10% of mothers had a known previous neonatal loss. This study has implications for NICU maternal mental health care at other hospitals internationally, regarding how programs might recognize, evaluate and treat significant maternal mental health issues. The stressors on parents of critically ill infants are similar across NICUs. The Cleveland Rainbow Babies study found that the majority of mothers were referred due to signs of depression (43%), anxiety (44%) and difficulty coping with their infant’s illness (60%).17 Similar to the present study, the majority were referred because of difficulties coping with their infant’s illness. In the Rainbow study, 6% of all NICU mothers were referred to the perinatal psychiatrist; depression was diagnosed in 40% of women, anxiety disorders in 31% and PTSD in 5%.17 The higher rates of depression and anxiety in the Rainbow study are likely because Rainbow Babies NICU mothers were only referred if there were specific psychiatric concerns whereas women in Starship NICU were more frequently referred (one-sixth of the NICU mothers were referred).17 The Rainbow study found that 33% of the mothers seen by the psychiatrist while in the NICU were referred for subsequent psychiatric services.17 This, together with the present study, suggests that worldwide, there exists a need for mental health follow-up for some mothers after they leave the NICU. The large number of families requiring community services per year could justify the development of specific resources detailing how community health professionals can support NICU families. However, US studies demonstrate that many pediatricians feel ill-equipped to deal with maternal mental health issues.39,40 In one study just over a quarter of mothers with depressive symptoms were correctly Journal of Perinatology (2014), 1 – 7
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6
identified as such by pediatricians.41 It is suggested that this situation is reflected in primary care professionals caring for the infant after hospital discharge worldwide, which is problematic considering that they are often also expected to provide care to depressed, anxious or grieving mothers. Methodological issues This study is limited in that it is a retrospective review from a single center and was not designed to assess outcomes (other than the need for further follow-up care) in mothers receiving the CLT service. Because written notes from various mental health professionals were assessed, some information was recorded for the majority of families but not all. Because the mother’s records were able to be accessed but not the infant’s records (due to the mother being the CLT patient), occasionally specific data (such as infant birth weight) were missing. A total of 74 of the 302 referrals during the time period of consideration were unable to be found, which may have introduced bias. Though it was presumed that these mothers were not seen, it is impossible to be certain, since CLT notes are not computerized to protect confidentiality. Additionally, this study considered maternal mental health in the NICU; however, there were several cases where the father or another family member also received some form of assistance along with the mother. It would be helpful to also quantitatively describe the population of fathers, grandparents and siblings in future studies. CONCLUSIONS Previous studies have shown that mothers in the NICU are at a substantially increased psychological risk compared with mothers of healthy infants. That over one-sixth of all NICU mothers were referred to the CLT, and nearly half of the mothers seen received a psychiatric diagnosis suggests that this is a population that desperately needs supportive psychiatric services. It can be inferred that a proportion of these cases would have gone un-noticed and untreated had this service not been provided, with potentially serious longer-term consequences for child development and family wellbeing. Having CLT support while in the NICU allowed over one-quarter of the mothers who were seen access to further follow-up services that they otherwise may not have received. This indicates that there may be value in universal screening to recognize the need for psychiatric support in parents without previously identified psychiatric issues. Future studies may support the value of the service provided by the CLT in improving the wellbeing of the population of families discharged from the NICU. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS We wish to thank the Kate Edger Trust for funding, the members of the Starship Consult Liaison Team, and staff of the Starship Neonatal Intensive Care Unit.
REFERENCES 1 Carter JD, Mulder RT, Bartram AF, Darlow BA. Infants in a neonatal intensive care unit: parental response. Arch Dis Child Fetal Neonatal Ed 2005; 90: F109–F113. 2 Singer LT, Salvator A, Guo S, Collin M, Lillen L, Baley J. Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant. JAMA 1999; 281(9): 799–805. 3 Ip S, Chung M, Raman G, Chew P, Magula N, Devine D et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Agency for Healthcare Research and Quality: Rockville, MD, 2007, p 130.
Journal of Perinatology (2014), 1 – 7
4 Ali NS, Mahmud S, Khan A, Ali BS. Impact of postpartum anxiety and depression on child’s mental development from two peri-urban communities of Karachi, Pakistan: a quasi-experimental study. BMC Psychiatry 2013; 13: 274. 5 Friedman SH, Resnick PJ. Postpartum depression: an update. Womens Health (Lond Eng) 2009; 5(3): 7–295. 6 Elkin I, Shea MT, Watkins JT, Imber SD, Sotsky SM, Collins JF et al. National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Arch Gen Psychiatry 1989; 46(11): 971–982. 7 O’Hara M, Stuart S, Gorman LL, Wenzel A. Effect of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry 2000; 57(11): 1039–1045. 8 Friedman SH, Yang SN, Parsons S, Amin J. Maternal mental health in the Neonatal Intensive Care Unit. NeoReviews 2011; 12(2): e1–e9. 9 Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 1993; 65: 445–453. 10 O’Hara MW, Swain AM. Rates and risk of postpartum depression-a meta-analysis. Int Rev Psychiatry 1996; 8(1): 37–54. 11 Ross LE, McQueen K, Vigod S, Dennis CL. Risk for postpartum depression associated with assisted reproductive technologies and multiple births: a systematic review. Hum Reprod Update 2011; 17(1): 96–106. 12 Mounts KO. Screening for maternal depression in the neonatal ICU. Clin Perinatol 2009; 36(1): 137–152. 13 Wenzel A, Haugen EN, Jackson LC, Brendle JR. Anxiety symptoms and disorders at eight weeks postpartum. J Anxiety Disord 2005; 19(3): 295–311. 14 Hynan MT, Mounts KO, Vanderbilt DL. Screening parents of high-risk infants for emotional distress: rationale and recommendations. J Perinatol 2013; 33: 748–753. 15 Ballard AR, Friedman SH, Shand JP, Martin R, Hack M. Postpartum Depression and Anxiety among Mothers of Infants in the Neonatal Intensive Care Unit. Presented at American Psychiatric Association Annual Meeting: San Francisco, 2013. 16 Friedman SH, Kessler RA, Martin R. Psychiatric help for caregivers of infants in Neonatal Intensive Care. Psychiatr Serv 2009; 60(4): 554. 17 Friedman SH, Kessler A, Yang SN, Parsons S, Friedman H, Martin RJ. Delivering perinatal psychiatric services in the neonatal intensive care unit. Acta Paediatr 2013; 102: e392–e397. 18 Statistics New Zealand [Internet]. New Zealand: 2013 Census Quickstats about national highlights. Cultural Diversity; 3 December 2013 [cited 24 February 2014]; [about 2 screens]. Available from http://www.stats.govt.nz/Census/2013-census/ profile-and-summary-reports/quickstats-about-national-highlights/cultural-diver sity.aspx. 19 Davis L, Edwards H, Mohay H, Wollin J. The impact of very premature birth on the psychological health of mothers. Early Hum Dev 2003; 73(1-2): 61–70. 20 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Revised 4th edn. Author: Washington, DC, 2000. 21 Barker ED. The duration and timing of maternal depression as a moderator of the relationship between dependent interpersonal stress, contextual risk and early child dysregulation. Psychol Med 2013; 43(8): 1587–1596. 22 Webster-Stratton C, Hammond M. Maternal depression and its relationship to life stress, perceptions of child behaviour problems, parenting behaviours, and child conduct problems. J Abnorm Child Psychol 1988; 16(3): 299–315. 23 Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behaviour: A meta-analytic review. Clin Psychol Rev 2000; 20(5): 561–592. 24 Challacombe F, Salkovskis P. A preliminary investigation of the impact of maternal obsessive-compulsive disorder and panic disorder on parenting and children. J Anxiety Disord 2009; 23(7): 848–857. 25 Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acute stress reactions among parents of infants in the Neonatal Intensive Care Nursery. Psychosomatics 2006; 47(3): 206–212. 26 Misund AR, Nerdrum P, Braten S, Pripp AH, Diseth TH. Long-term risk of mental health problems in women experiencing preterm birth: a longitudinal study of 29 mothers. Ann Gen Psychiatry 2013; 12: 33. 27 Ghrobani M, Dolatian M, Shams J, Alavi-Majd H, Tavakolian S. Factors associated with posttraumatic stress disorder and its coping styles in parents of preterm and full-term infants. Global J Health Sci 2014; 6(3): 65–73. 28 Friedman SH, Resnick PJ, Rosenthal MB. Postpartum psychosis. Curr Psychiatry 2009; 8(2): 40–46. 29 Benfield DG, Leib SA, Reuter J. Grief response of parents after referral of the critically ill newborn to a regional center. NEJM 1976; 294: 975–978. 30 Holditch-Davis D, Miles MS. Mothers’ stories about their experiences in the Neonatal Intensive Care Unit. Neonatal Netw 2000; 19(3): 13–21. 31 Hughes P, Riches S. Psychological aspects of perinatal loss. Curr Opin Obstet Gynecol 2003; 15: 107–111. 32 Eccleston C, Palermo TM, Fisher E, Law E. Psychological interventions for parents of children and adolescents with chronic illness. Cochrane Database Syst Rev 2012; 8: 1–131.
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Psychiatric support for mothers in NICU KA Penny et al
7 33 Brett J, Staniszewska S, Newburn M, Jones N, Taylor L. A systematic mapping review of effective interventions for communicating with, supporting and providing information to parents of preterm infants. BMJ Open 2011; 1: e000023. 34 Jotzo M, Poets CF. Helping parents cope with the trauma of premature birth: an evaluation of a trauma-preventive psychological intervention. Pediatrics 2005; 115(4): 915. 35 Melnyk BM, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA et al. Reducing premature infants’ length of stay and improving parents’ mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit Program: a randomized, controlled trial. Pediatrics 2006; 118(5): e1414–e1427. 36 Turner M, Winefield H, Chur-Hansen A. The emotional experiences and supports for parents with babies in a neonatal nursery. Adv Neonatal Care 2013; 13(6): 438–446.
© 2014 Nature America, Inc.
37 Bloch M, Rotenberg N, Koren D, Klein E. Risk factors for early postpartum depressive symptoms. Gen Hosp Psychiatry 2006; 28(1): 3–8. 38 Hughes PM, Turton P, Evans CDH. Stillbirth as a risk factor for depression and anxiety in the subsequent pregnancy: cohort study. BMJ 1999; 318(7200): 1721–1724. 39 Earls MF. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics 2010; 126: 1032–1039. 40 Olson AL, Kemper KJ, Kelleher KJ, Hammond CS, Zuckerman BS, Dietrich AJ. Primary Care Pediatricians’ roles and perceived responsibilities in the identification and management of maternal depression. Pediatrics 2002; 110(6): 1169–1176. 41 Heneghan AM, Silver EJ, Bauman LJ, Stein REK. Do pediatricians recognize mothers with depressive symptoms? Pediatrics 2000; 106(6): 1367–1373.
Journal of Perinatology (2014), 1 – 7
