Postpartum depression on the neonatal intensive care unit: current perspectives

Figures & data

Table 2 Prevalence of PPD in the NICU

References	Study design	Sample	Screening instruments	Results
Carter et al (2007)^Citation23	Prospective longitudinal study of random sample	N=636; 447 parents (mother and father with NICU infant), 189 parents (mother and father of full term non-NICU infant)	EPDS	No significant difference on mean EPDS (scores between control group and NICU group)
Blucker et al (2013)^Citation81	Factor analysis	N=385 mothers of NICU infants	PDSS	36% Positive PPD screenings 30% At-risk for PPD
Davis et al (2003)^Citation28	Population study	N=62 mothers of preterm infants	EPDS	40% Significant PPD symptoms
De Magistris et al (2010)^Citation53	Comparative	N=2I3; 1l3 mothers of NICU infants, 100 mothers of healthy infants	EPDS	23% Mothers of NICU infants had positive PPD screenings 8% Mothers of healthy infants had positive PPD screenings
Doering et al (1999)^Citation26	Comparative design	N=165 mother-father pairs of high-risk NICU neonates	Psychosocial Adjustment to Illness Scale (family version)	Mothers: poorer psychosocial adjustment Mothers and fathers both have heightened distress and poor psychosocial adjustment in NICU
Gillaspy et al (2010)^Citation69	Correlational	N=111 mothers of NICU infants	PDSS	52.3% Positive PPD screenings 29.7% Significant PPD symptoms
Lefkowtiz et al (2010)^Citation7		N=127; 86 mothers of NICU infants, 41 fathers of NICU infants	PDSS	39% Positive PPD screenings 16.9% Subsyndromal PPD 16% Positive PTSD and PPD screenings
Mew et al (2003)^Citation52	Correlational	N=39 mothers of preterm infants	CES-D; PSS: NICU	50% At-risk for PPD at baseline 20% At-risk for PPD at 6 months corrected age
Meyer et al (1995)^Citation90	Correlational	N=142 mothers of NICU infants	PSS; Symptom Checklist 90-R	28% Mothers of NICU infants had clinically significant levels of psychological distress 10% Mothers in normative comparison population had clinically significant levels of psychological distress
Rogers et al (2012)^Citation32	Prospective cohort study	N=73 mothers of preterm infants	EPDS; PSS:NICU	20% Clinically significant levels of PPD 43% Moderate to severe anxiety
Ukpong et al (2003)^Citation41	Cross-sectional prospective study	N=60; 33 mothers of preterm infants, 27 mothers of full term infants	GHQ-30; BDI	27.3% Mothers of preterm infants had significant emotional distress 3.7% Mothers of full term infants had significant emotional distress
Yurdakul et al (2009)^Citation40	Case-control study	N=169; 81 mothers of NICU infants, 81 mothers of healthy term infants	PAI; EPDS	29.5% NICU mothers had high depression scores 13.6% Control mothers had high depression scores

Note: Study design was not determined independently, but it was stated by researchers of each study.

Abbreviations: PPD, postpartum depression; EPDS, Edinburgh Postpartum Depression Scale; PDSS, Postpartum Depression Screening Scale; NICU, neonatal intensive care unit; PTSD, posttraumatic stress disorder; PSS, Parental Stressor Scale; GHQ, General Health Questionnaire; BDI, Beck Depression Inventory; PAI, Postpartum Assessment Instrument; CES-D, Center for Epidemiological Studies Depression Scale.

Table 1 PPD screening instruments

Title	# of items, length/type	Availability	Administration	Used in NICU
ANRQ	9 multiple choice items	Public	Self-report	Not applicable
BDl^Citation45,Citation81	21 items, 4-point Likert scale	Purchase	Self-report	Yes
BPDS	10 items, open-ended and yes/no questions	Purchase	Self-report	No
CES-D^Citation48,Citation59	20 items	Public	Self-report	No
EPDS^Citation29,Citation42,Citation51,Citation52,Citation68,Citation84,Citation88,Citation91	10 items	Public	Self-report	Yes
GHQ^Citation47	12, 28, 30, 60 item versions	Purchase	Self-report	No
HRSD	17 or 21 item versions	Public	Health care professional	Yes
IDS	35 items	Public	Self-report	No
LQ	24 items	Public	Self-report	No
PDSS^Citation25,Citation43,Citation73,Citation74	35 items	Purchase	Self-report	Yes*
PHQ	2 or 9 item versions	Public	Self-report	Not applicable
Q1DS	16 items	Public	Self-report	Yes
SCL-90-R^Citation82	90 items	Public	Self-report	Yes
Zung SDS	20 items	Public	Self-report	No

Notes:

* Psychometric properties of instrument were studied in NICU setting. Not all instruments listed were used in the studies described in this review.

Abbreviations: PPD, postpartum depression; NICU, neonatal intensive care unit; ANRQ, Antenatal Risk Questionnaire; BDI, Beck Depression Inventory; BPDS, Bromley Postnatal Depression Scale; CES-D, Center for Epidemiological Studies Depression Scale; EPDS, Edinburgh Postpartum Depression Scale; GHQ, General Health Questionnaire; HRSD, Hamilton Rating Scale for Depression; IDS, Inventory of Depressive Symptomatology; LQ, Leverton Questionnaire; PDSS, Postpartum Depression Screening Scale; PHQ, Patient Health Questionnaire; QIDS, Quick Inventory of Depressive Symptoms; SCL-90-R, Symptom Checklist-90-R; Zung SDS, Zung Self-Rating Depression Scale.

Table 3 Interventions

Program/intervention	References	Setting	Study design and sample	Primary outcome	Cost effectiveness/reduction	Length of stay (LOS)	Effect size*
COPE Program; educational-behavioral, theory-based intervention	Melnyk et al^Citation86	2 NICUs in northeast United States	Randomized, controlled trial of 260 families with infants in the NICU, 147 in intervention group, 113 in control group	COPE group: Significantly stronger parental beliefs, more positive interactions with infants, less maternal stress, less overall parental stress for mothers, less maternal anxiety and depressive symptoms after hospitalization	Reduced LOS: $5,000/infant (4 days × $1,250/day)	Total NICU infant LOS 3.8 days reduction for COPE group versus control group, total hospital LOS 3.9 days shorter in COPE group versus control group	Time 1 =0.11, Time 2 =0.04, Time 4 =0.09, Time 6 =0.07
Journal writing exercise	Barry and Singer^Citation87	2 Level 3 NICUs in southwestern United States	Experimental group-comparison of 38 mothers of infants previously hospitalized in NICU, 19 in treatment group, 19 in control group	Treatment group significantly decreased psychological distress symptom levels over time, initial clinical level symptoms of 37% decreased to 16%	Cost effective alternative to mothers unable to receive/utilize formal services	N/A	0.805
Nurse-led intervention	Morey and Gregory^Citation89	High-risk antenatal floor of large academic hospital in northeastern United States	Single-group interventional comparison using repeated measures design of 32 pregnant women on high-risk antenatal unit	Significantly decreased maternal stressors related to sights and sounds of NICU, as well as infant behavior and appearance; all components of intervention rated as beneficial by participants	Intervention led by trained nurses, does not require additional staff, hence its feasibility	N/A	N/A
PSE	Silverstein et al^Citation88	2 urban level 3 NICUs in academic teaching hospitals	Randomized, controlled pilot trial on 50 low-income mothers of preterm infants; 26 received PSE; 25 in control group	Mothers in PSE were less likely to experience episode of moderate–severe depression; PSE mothers experienced average of 0.52 depressive episodes; whereas, control group experienced average of 1.19 episodes. PSE mothers tended to have less stress and better overall functioning than control mothers	PSE can be led by bachelor-level trained educators; does not need to be delivered by mental health professionals, hence its feasibility	N/A	N/A
Meyer et al	Meyer et al^Citation90	Special Care Nursery and Women and Infants’ Hospital of Rhode Island	Randomized, repeated measures intervention outcome study of 34 families of preterm infants weighing <1,500 g; 18 in intervention group; 14 in control group	Significantly alleviated depressive symptoms. At discharge, only 11% of intervention mothers had depressive symptoms compared with 44% of control mothers. Interventions mothers had distinctly lower levels of stress at discharge than at baseline; whereas, control mothers found no relief in level of stress from baseline to discharge	Intervention led by trained nurses, does not require additional staff, hence its feasibility	N/A	N/A

Notes:

* Effect size provided refers specifically to study’s depressive symptoms outcome. Please refer to the authors’ work for further details.

Abbreviation: LOS, length of stay; COPE, Creating Opportunities for Parent Empowerment; NICU, neonatal intensive care unit; PSE, problem-solving education intervention; N/A, not available or included in study.

CarterJDMulderRTFramptonCMDarlowBAInfants admitted to a neonatal intensive care unit: parental psychological status at 9 monthsActa Paediatr20079691286128917718781

 PubMed Web of Science ®Google Scholar

BluckerRTGillaspyJAJrJacksonDPostpartum Depression in the NICU: An examination of the factor structure of the Postpartum Depression Screening ScaleAdvances in Neonatal Care2013

 Web of Science ®Google Scholar

DavisLEdwardsHMohayHWollinJThe impact of very premature birth on the psychological health of mothersEarly Hum Dev2003731–2617012932894

 PubMed Web of Science ®Google Scholar

De MagistrisAConiEPudduMZonzaMFanosVScreening of postpartum depression: comparison between mothers in the neonatal intensive care unit and in the neonatal sectionJ Matern Fetal Neonatal Med201023Suppl 310110320807154

 PubMed Web of Science ®Google Scholar

DoeringLVDracupKMoserDComparison of psychosocial adjustment of mothers and fathers of high-risk infants in the neonatal intensive care unitJ Perinatol199919213213710642975

 PubMedGoogle Scholar

McCaffreeMACherryAGillaspySHetheringtonCThe contribution of postpartum psychosocial variables to infant length of stay in the neonatal intensive care unitPoster presented at: American Academy of Pediatrics, National Conference and Education Meeting-Perinatal SectionOctober 2–5, 2010San Francisco, CA

 Google Scholar

LefkowitzDSBaxtCEvansJRPrevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the Neonatal Intensive Care Unit (NICU)J Clin Psychol Med Settings201017323023720632076

 PubMed Web of Science ®Google Scholar

MewAMHolditch-DavisDBelyeaMMilesMSFishelACorrelates of depressive symptoms in mothers of preterm infantsNeonatal Netw2003225516014598980

 PubMedGoogle Scholar

MeyerECCollCTLesterBMBoukydisCFMcDonoughSMOhWFamily-based intervention improves maternal psychological well-being and feeding interaction of preterm infantsPediatrics19949322412468121735

 PubMed Web of Science ®Google Scholar

RogersCEKidokoroHWallendorfMInderTEIdentifying mothers of very preterm infants at-risk for postpartum depression and anxiety before dischargeJ Perinatol201333317117622678144

 PubMed Web of Science ®Google Scholar

UkpongDIFatoyeFOOseniSBAdewuyaAOPost partum emotional distress in mothers of preterm infants: a controlled studyEast Afr Med J200380628929212953736

 PubMedGoogle Scholar

YurdakulZAkmanIKuşçuMKMaternal psychological problems associated with neonatal intensive care admissionInt J Pediatr2009200959135920041013

 PubMedGoogle Scholar

PaykelESCooperZRamanaRHayhurstHLife events, social support and marital relationships in the outcome of severe depressionPsychol Med19962611211338643751

 PubMed Web of Science ®Google Scholar

JohnstoneSJBoycePMHickeyARMorris-YateesADHarrisMGObstetric risk factors for postnatal depression in urban and rural community samplesAust N Z J Psychiatry2001351697411270460

 PubMed Web of Science ®Google Scholar

LiuCHTronickERates and predictors of postpartum depression by race and ethnicity: results from the 2004 to 2007 New York City PRAMS survey (Pregnancy Risk Assessment Monitoring System)Matern Child Health J20131791599161023095945

 PubMed Web of Science ®Google Scholar

PearlsteinTHowardMSalisburyAZlotnickCPostpartum depressionAm J Obstet Gynecol2009200435736419318144

 PubMed Web of Science ®Google Scholar

BernazzaniOSaucierJFDavidHBorgeatFPsychosocial predictors of depressive symptomatology level in postpartum womenJ Affect Disord199746139499387085

 PubMed Web of Science ®Google Scholar

Nielsen FormanDVidebechPHedegaardMDalby SalvigJSecherNJPostpartum depression: identification of women at riskBJOG2000107101210121711028570

 PubMed Web of Science ®Google Scholar

ZelkowitzPBardinCPapageorgiouAAnxiety affects the relationship between parents and their very low birth weight infantsInfant Ment Health J2007282296313

 Web of Science ®Google Scholar

HorowitzJAGoodmanJHIdentifying and treating postpartum depressionJ Obstet Gynecol Neonatal Nurs2005342264273

 Web of Science ®Google Scholar

SilversteinMFeinbergECabralHProblem-solving education to prevent depression among low-income mothers of preterm infants: a randomized controlled pilot trialArch Womens Ment Health201114431732421667323

 PubMed Web of Science ®Google Scholar

GennaroSBrootenDRoncoliMKumarSPStress and health outcomes among mothers of low-birth-weight infantsWest J Nurs Res1993151971138421923

 PubMedGoogle Scholar

BeckCTPredictors of postpartum depression: an updateNurs Res200150527528511570712

 PubMed Web of Science ®Google Scholar

MountsKOScreening for maternal depression in the neonatal ICUClin Perinatol200936113715219161871

 PubMed Web of Science ®Google Scholar

O’HaraMWSchlechteJALewisDAVarnerMWControlled prospective study of postpartum mood disorders: psychological, environmental, and hormonal variablesJ Abnorm Psychol1991100163732005273

 PubMed Web of Science ®Google Scholar

GemmillAWLeighBEricksenJMilgromJA survey of the clinical acceptability of screening for postnatal depression in depressed and non-depressed womenBMC Public Health2006621116914061

 PubMed Web of Science ®Google Scholar

The UK NSC policy on Postnatal depression screening in pregnancy [webpage on the Internet]LondonUK National Screening Committee, Public Health England2013 Available from: http://www.screening.nhs.uk/postnataldepressionAccessed March 2, 2013

 Google Scholar

HanusaBHScholleSHHaskettRFSpadaroKWisnerKLScreening for depression in the postpartum period: a comparison of three instrumentsJ Womens Health (Larchmt)200817458559618345995

 PubMed Web of Science ®Google Scholar

MelnykBMFeinsteinNFAlpert-GillisLReducing 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 trialPediatrics20061185e1414e142717043133

 PubMed Web of Science ®Google Scholar

BarryLMSingerGHSReducing Maternal Psychological Distress After the NICU Experience Through Journal WritingJ Early Interv2001244287297

 Web of Science ®Google Scholar

MoreyJGregoryKNurse-led education mitigates maternal stress and enhances knowledge in NICUMCN Am J Matern Child Nurs201237318219122549422

 PubMed Web of Science ®Google Scholar