Recognizing and Screening for Postpartum Depression in Mothers of NICU Infants

Adv Neonatal Care. 2003;3(1) 

In This Article

Implications for Caregivers in the NICU

Early recognition is one of the most challenging aspects of PPD. A study of 1,102 women who had recently delivered a baby found that only 49% of these women who felt seriously depressed had sought help for their depression.[34] Another study of 176 postpartum women confirmed that despite an average of 14 contacts with health care providers, nearly half of these women who were suffering from PPD had not been identified as such by their clinicians.[35] Delays in treatment are significantly related to a longer duration of PPD.[36] However, the social stigma attached to this mood disorder often prevents mothers from seeking the professional help they so desperately need.

A study exploring mothers' with PPD perceptions of nurses' caring reported that an essential component of caring was nurses having sufficient knowledge about this mood disorder to make a quick, correct working diagnosis and to make appropriate referrals.[37] Early identification and treatment for PPD can prevent months of suffering for a mother and minimize its potentially harmful effects on her infant.

Given the increased risks inherent in the NICU environment, universal screening for PPD should be a part of every family assessment. Routine assessment will normalize the process, enhance awareness, and increase the health care providers' comfort level and competency.

The PPD Screening Scale (PDSS) is a 35-item, self-report Likert scale that assesses 7 dimensions: (1) sleeping/eating disturbances, (2) anxiety/insecurity, (3) emotional lability, (4) mental confusion, (5) loss of self, (6) guilt/shame, and (7) contemplating harming self.[38,39,40] Each dimension consists of 5 items that describe how a mother may feel after delivery. Women indicate their level of disagreement or agreement with each item on a range of strongly disagree (1) to strongly agree (5) by circling the response that best describes their feelings over the past 2 weeks.

The total PDSS score ranges from 35 to 175, providing an index of the general severity of PPD symptoms. Table 2 includes information on how clinicians can interpret the PDSS total score. If the screen is negative and the mother is adjusting well, the PDPI-Revised can help a woman identify any risk factors that would place her at high risk for developing PPD at a later date.

If a mother screens positive for PPD (scores 80 or above on the PDSS), schedule a referral for psychiatric follow-up. Notify her obstetrician or nurse midwife. Identify practitioners skilled in the area of perinatal mood disorders for assessment and treatment and provide options for the mother. Referral to community supports and PPD support groups also may be helpful.

Approximately 10% to 15% of mothers experience PPD symptoms severe enough to require treatment. Depending on the severity of the PPD, either antidepressants, psychotherapy, or a combination of both may be necessary.

Guilt, shame, fear, and embarrassment may result in the covert suffering in mothers with PPD. Bedside clinicians may not be aware of these symptoms, or they may observe nonspecific behaviors, such as irritability. Be alert for signs of spiraling depression, which may manifest as guilt, anger, and anxiety. A trusting environment is imperative; mothers need to feel safe enough to open up and share any of their negative thoughts or feelings.

NICU clinicians can take an active role in putting an end to the pervasive and harmful myths about motherhood. Discuss society's unrealistic expectations openly with new mothers. Explicitly give the mother permission to speak freely about her feelings. Explore the common theme of loss that often permeates the lives of new mothers; loss of control, of self, of their relationships, and of their voice.

Be aware that the real and perceived losses of mothers whose infants are in the NICU are magnified (ie, loss of their dreams of delivering a healthy, full-term infant). Develop targeted intervention strategies based on the specific losses a mother identifies. Assisting the mother in putting her losses in perspective may facilitate the final stage of grief work, which is healing and restoration.

Teach mothers and family members about the prevalence, symptoms, and treatment of PPD. It is essential that they understand the following:

  • PPD has a biochemical basis.

  • There is nothing that a woman does wrong to bring on this mood disorder nor is she a weak person because she has it.

  • PPD is a very treatable condition, once identified.

Mothers need to be aware that PPD can occur, even after the much anticipated discharge of their NICU infant. The increased stress, separation, isolation, and disconnection from the NICU support network all contribute to the risk for PPD. Provide mothers with a list of local support groups and relevant Web resources ( Table 3 ). Emphasize the importance of early recognition and treatment.

The mental confusion associated with PPD may have an impact on learning readiness, concentration, cognitive processing, and retention, thus impairing the discharge process. When teaching mothers with PPD, strategies to minimize distractions and maximize retention are useful. Providing information in short sessions, with opportunity for later reinforcement, may be effective. Encourage the father, grandmother, or other supportive family member to participate, particularly when giving essential discharge instructions. Augment verbal communications with printed materials, pamphlets, and handouts, so that she can review important information once the infant is at home.

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