Postpartum Depression: Mothers at High Risk in the NICU

An Expert Interview With Christine Kowaleski, MSN NNP-BC FNP MHP-BC

Elizabeth McGann, DNSc, RN

October 19, 2011

October 19, 2011 — Editor's note: The March of Dimes has named postpartum depression (PPD) the number 1 complication of childbirth. It can have a devastating impact on the entire family, and has the potential to affect child development negatively. A podium presentation — Postpartum Depression Screening in the NICU: Rescuing the Children — was featured at the National Association of Neonatal Nurses (NANN) 27th Annual Educational Conference, held September 14 to 17 in Orlando, Florida.

To find out more about PPD in mothers of babies in the neonatal intensive care unit (NICU), Medscape Medical News interviewed presenter Christine Kowaleski, MSN NNP-BC FNP MHP-BC. Ms. Kowaleski has dual board certification as a neonatal nurse practitioner and a psychiatric nurse practitioner. She has extensive experience in labor and delivery, newborn nursery, and neonatal intensive care. Ms. Kowaleski is a neonatal nurse practitioner in the NICU at Crouse Hospital in Syracuse, New York, and a nurse practitioner in a local psychiatric practice. She is also a facilitator for a PPD support group in the community.

Medscape: What are the signs and symptoms of PPD?

Ms. Kowaleski: The signs and symptoms of PPD include lack of concentration or ability to focus, discomfort around the baby or lack of feeling toward the baby, failure to make eye contact with the baby, difficulty identifying the infant's cues, failure of infant to meet developmental milestones, and excessive worry or anxiety. Mothers express that caring for the baby is too much to handle. They can also be irritable or short tempered. These mothers also report that they are in a web of sadness, guilt, and helplessness, and do not know how to get out. There can also be physiological symptoms, such as weight gain or loss, insomnia, and fatigue.

Medscape: What are the risk factors for PPD for new mothers?

Ms. Kowaleski: PPD affects about 15% of new mothers. Mothers who have experienced previous PPD are at a 50% to 80% risk of a recurrence. Factors that increase risk are depression or anxiety during pregnancy, abrupt weaning of breastfeeding, history of premenstrual syndrome or premenstrual dysphoric disorder, thyroid dysfunction, unexpected events at delivery, maternity blues, poor social support, life stress, unwanted or unplanned pregnancy, and a poor relationship with a partner.

Medscape: How do risk factors for mothers with a newborn in the NICU differ?

Ms. Kowaleski: The incidence of PPD in mothers of babies in the NICU is much higher, and is estimated at 28% to 70%. Factors that affect the development of PPD in mothers of NICU babies include grief, loss, and lack of control.

A mother of an infant in the NICU may not have had a normal pregnancy or a normal delivery, and she is not able to experience the normal bonding period that occurs immediately after birth. Instead of being held and breastfed, the infant is in an incubator or warmer, connected to monitors, IVs, and other equipment. In many cases, the baby is transported to a regional center.

The baby may be on minimal handling precautions due to intolerance of stimulation. Life-saving medical treatments take precedence over interaction. Preterm babies may be in the NICU for weeks or months. Some parents are afraid to bond with a child who may not live. Most NICUs have restricted visiting, so the new parent's support system does not really understand what the parents are experiencing. Parents are left alone with their fears and anxiety.

This is overwhelming to a mother with PPD. Depression makes critical situations seem even more overwhelming. These women express that it is all-consuming, and they have nothing left to give anyone, not even their own the baby.

Posttraumatic stress can be a consequence of being a NICU parent. Mothers feel guilt that they have done something wrong and have failed. This sense of guilt is compounded when mothers feel they cannot protect their babies. They may hope for a miracle and be devastated when one does not occur.

Medscape: Which risk factors can be modified?

Ms. Kowaleski: Thyroid dysfunction can be easily treated. Many obstetricians and midwives take the proactive approach of screening for anxiety and depression during pregnancy. Psychotropic medications, such as some selective serotonin reuptake inhibitors (SSRIs), can be safely used during pregnancy; however, they are often discontinued during the last month of pregnancy to avoid the SSRI withdrawal syndrome seen in some infants. After delivery, agents can be selected that are compatible with breastfeeding. Providing healthcare practitioners with knowledge about anxiety and depression screening during pregnancy is a key factor in preventing the complication of PPD.

Medscape: What are the best assessment approaches?

Ms. Kowaleski: With 1 of 8 women affected by PPD, the best approach to prevention and treatment is universal prenatal and postpartum screening. Currently, this is not standard practice. Postpartum screening should be done at 4 weeks postpartum to avoid confusing screening results with the maternity blues that usually subside by 3 weeks postpartum. Universal screening, similarly done for hypertension and diabetes, normalizes the process and reduces the sense of stigma associated with mental illness. Several screening tools for PPD are available. The Edinburgh Postpartum Depression Scale is commonly used, and is easy to administer and score. It is available in multiple languages, and its reliability and validity are comparable to other more expensive and time-consuming instruments.

Medscape: What are the long-term effects of PPD on the baby and the family?

Ms. Kowaleski: Research has shown a 4-fold greater risk for psychiatric disorders in 11-year-old children whose mothers had PPD, and babies of depressed mothers scored poorest on all outcome measures after 9 months. Outcomes measured included social engagement, ability to self-regulate, fussiness, and crying. Doing a developmental evaluation on an infant without screening the mother for PPD can affect the accuracy of the results. A mother's view of her child remains surprisingly constant over time. If she finds her newborn difficult, she expects a difficult child and/or teenager. Lack of attachment causes long-term effects on the infant.

Medscape: What major challenges do providers and families face when dealing with women with PPD?

Ms. Kowaleski: Challenges for the family include stigma, difficulty in diagnosis and treatment, and financial challenges from third-party payment systems. For providers, accountability and liability are considerations. A positive screening requires a referral to treatment mechanism. Historically, diagnosis and referral has fallen under the purview of the midwife or obstetrician at the 6-week postpartum visit. Often, a mother comes in without her baby, limiting the observation of mother–baby interaction. Liability fears around postpartum psychosis remain. Postpartum psychosis can be a rare but devastating complication, although it does respond to treatment. Postpartum psychosis occurs in 1% to 2% of cases, and can be treated with medication.

Medscape: What resources are available for women and healthcare providers who treat mothers with PPD?

Ms. Kowaleski: There are many excellent online resources for PPD. A few examples are Reprotox, the National Alliance on Mental Illness, and Postpartum Support International.

Medscape: What were the 2 most significant aspects of your presentation?

Ms. Kowaleski: Two key points are the critical need for universal screening for all mothers for PPD, and educating providers and families that PPD has a biochemical basis — that it is not caused by the mother's actions and that it is treatable.

Ms. Kowaleski has disclosed no relevant financial relationships.

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