Having a newborn child in the neonatal intensive care unit (NICU) is understandably stressful. Previous studies have demonstrated that mothers in this setting are at increased risk for postpartum depression (PPD).  In addition, a recent study indicates that rates of post-traumatic disorder (PTSD) are also very high in this population.  Given the significant prevalence of PPD in this population, a recent study has explored the feasibility of screening for depression in mothers with infants in the NICU.

Participants were recruited from a NICU in Oklahoma which has about 1,200 admissions per year, with an average length of stay of 3 weeks.  The women were screened at 14 day postpartum using the Postpartum Depression Screening Scale (PDSS).  During the study period of 18 months, 385 out of 793 eligible mothers completed the screen.

In this group of women, 24% of the mothers reported a history of depression prior to delivery and 22% reported previous depression treatment.  Based on responses to the PDSS, 36% of the women had a positive screen for PPD that resulted in a mental health referral.   In addition, 30% of the women reported significant symptoms on the PDSS and were considered “at risk” for depression and indicating the possible need for a mental health referral.

It is important to note that less than half of the eligible mothers completed the screening.  The researchers were able to identify several barriers to screening in the NICU and, when possible, made adjustments to the screening protocol to enhance its effectiveness.  First, it was often difficult for the research staff to “find” mothers in the NICU as they were not always with their infants.  The research staff attempted to increase rates of screening by working in collaboration with the nursing staff and to administer the PDSS screener as part of the routine nursing activities at the 2-week PKU newborn screening. However, the research team found that, due to the size of the unit and number of support staff involved in screening, incorporating the PDSS screen into routine nursing activities proved difficult.

The authors note, “Although there was buy-in from medical and nursing staff, it was difficult obtaining hospital administration support, making it difficult to link the PDSS with routine screening procedures.”

In addition to barriers in making contact and establishing a relationship with mothers, there were other barriers related to the administration of the screening instrument itself.  Although the Spanish version of the PDSS was administered, most Spanish-speaking mothers did not fully complete the screen or indicated the same response for all of the questions.  Given the high prevalence of PPD in non-White mothers, the researchers note that future development of a NICU screening program must give greater attention to ethnic and socioeconomic diversity and to culturally sensitive methods for improving screening and identifying depression in these populations.

But perhaps the greatest barrier was related to referral for mental health services.  Referring mothers to community mental health centers simply did not work.  In this particular NICU, most families had Medicaid as their primary insurance. In the state of Oklahoma, Medicaid coverage for mothers includes pregnancy and extends to 60 days postpartum. In this study, when mothers were identified as needing mental health services, their coverage had already expired or was close to expiring.  While it was understandably difficult to refer women with no health insurance, it was also difficult to make appropriate referrals to providers who accept Medicaid or various private insurances.  

While current research has documented that screening for postpartum depression is feasible in many different settings, we run into significant and often insurmountable obstacles to providing mental health services to women in need.  Many low-income women have limited access to health insurance, and their eligibility for mental health benefits is even more limited. But even for women with health insurance, cost and access to mental health providers continue to be significant barriers for women seek services from recommended referrals.  The authors also make note of the fragmentation in care and inadequate communication that may occur in this situation, where a women identified with depression in the NICU setting is referred to outside providers.  

Screening for depression in the NICU makes great sense.  This is certainly a population at high risk for postpartum depression, and one can easily imagine that women caring for a premature infant or a child with significant medical issues, may not have the time or emotional resources to attend to their own mental health.  However, we must acknowledge that there are significant obstacles to universal screening for PPD in this setting. Developing an effective PPD screening program in the NICU involves a coordinated effort of hospital administrators, medical staff, new mothers, and mental health specialists.

Ruta Nonacs, MD PhD

Cherry AS, et al. Postpartum depression screening in the Neonatal Intensive Care Unit: program development, implementation, and lessons learned.  J Multidiscip Healthc. 2016.

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