Having a baby who needs to stay in the neonatal intensive care unit (NICU) can be an incredibly difficult experience for mothers. They may feel guilty that their baby was premature, and they are often, understandably, anxious about their baby's health.
Ann Anderson Berry, MD, medical director of the NICU at Nebraska Medicine, wanted to identify such women and offer them better care. "Often we deal with a lot of social, mental, and emotional problems for the entire family in order to best meet the needs of our actual patient, the premature or ill newborn," says Berry.
In July 2015, Berry and her colleagues started screening all NICU mothers for postpartum depression (PPD). In her program, doctors and neonatal nurses ask each new mother a series of 11 questions starting one week after her baby is first admitted to the NICU, and then again every month during her baby's stay in the NICU.
Questions cover topics such as whether a woman has been worried or anxious for no good reason or has felt so unhappy that it's difficult to sleep. Women who answer affirmatively are considered at high risk for PPD. Medical groups recommend that all women get screened for PPD, using a similar set of questions, during well-baby visits and at ob-gyn checkups.
"[However] the women whose infants are in the NICU are really falling through the cracks of these general guidelines," says Berry. Because their infants are in the NICU, they often miss the well-baby visits at one, two, and four months.
In addition, Berry and her colleagues "found a good number of those women were skipping their [own] appointments because they did not feel their health was as important as the health of their infants, and it was difficult emotionally and physically for them to leave the NICU."
So far, the staff at Nebraska Medicine has screened all of the approximately 500 women whose babies have been cared for in the NICU. Berry and colleagues are still analyzing the data, but they found that about 28 percent of the first 300 women they screened were likely to have PPD. (Women who screen positive are generally referred to a mental health specialist for a definite diagnosis.)
The rate of 28 percent is about two times the general rate of PPD among women, which is about 15 to 20 percent. "[This] is not surprising considering all the stresses that go along with having an infant that requires [care in] the NICU," Berry says.
The Nebraska NICU screening program is not the only one that has seen a high prevalence of PPD. Studies report PPD rates among NICU moms ranging from 28 to 70 percent. Whether a woman's risk is at the high or low end of this range may depend on other factors that increase PPD risk, such as lacking financial resources or social support, says Nancy Byatt, DO, medical director of the Massachusetts Child Psychiatry Access Project for Moms.
Berry says that the mothers in her NICU are representative of the general U.S. population in terms of income, education level, and race. She suspects the PPD rate among these women would have been around 15 percent if their babies were not in the NICU.
Leena P. Mittal, MD, director of the reproductive psychiatry consultation service at Brigham and Women's Hospital in Boston, estimates the PPD rate is also about 28 percent among mothers in their NICU. She and her colleagues are piloting a program to screen women for PPD. Currently social workers at the hospital meet with families whose babies are in the NICU, and cases of PPD are hopefully recognized during these sessions, Mittal says.
NICUs in the United States vary a lot in terms of whether they offer social worker support for families, and it is probably rare for them to have special PPD screening programs, Mittal says.
Since 2013, Randall Children's Hospital at Legacy Emanuel Medical Center in Portland, Oregon, has succeeded in doing PPD screenings for about 90 percent of the mothers whose babies are in the NICU (typically through lactation consultants), says Patricia Scheans, a neonatal nurse practitioner at the hospital. Between 18 and 20 percent were considered at risk for PPD. The rate could be lower than found in the Nebraska NICU and other studies because the babies at Randall Children's have relatively short NICU stays, explains Scheans.
Connecting women with care
The Nebraska NICU screening program also connects mothers found to be at risk for PPD with support groups and psychiatrists at the University of Nebraska Medical Center. Trained NICU staff members are available to take women to the ER if they could be a danger to themselves.
"Screening alone does not translate to improved outcomes or even more care, so if you screen you absolutely have to have a system in place [to help women get care]," Byatt says. "It sounds like this group [in Nebraska] was very responsible about this," she adds.
It has been difficult to determine whether the program has helped lower PPD rates in this population of women, especially because the researchers do not follow the women once their babies leave the NICU, Berry says. But the program has had a clearly positive impact on some families.
Deseray Stevenson experienced PPD after her daughter Daliyla was born 10 weeks early. Daliyla spent almost three months in the Nebraska NICU, and during that time Deseray did not visit often, Berry recalls. The screening program determined that she was at risk of PPD and helped her get treatment. "She started to participate and get engaged and her baby responded to that and did so well," Berry says.