Protecting the infant-parent relationship: special emphasis on perinatal mood and anxiety disorder screening and treatment in neonatal intensive care unit parents

A systematic review of postpartum psychosis resulting in infanticide: missed opportunities in screening, diagnosis, and treatment

PURPOSE

Impacting 1 in 1000 women, untreated postpartum psychosis is associated with a 4% infanticide rate. This systematic review aims to identify factors that are associated with infanticide resulting from psychosis in the puerperal period and pinpoint areas of missed opportunity for intervention.

METHODS

A systematic literature review was conducted in accordance with PRISMA guidelines to identify and synthesize cases of maternal infanticide among perinatal females with evidence of postpartum psychosis. Four independent reviewers screened 231 articles identified in searches of three databases (PsycInfo, PubMed, and Web of Science) for studies conducted from 2013 to 2023.

RESULTS

Twelve studies were included in the final review. Findings indicate that those experiencing puerperal psychosis have increased incidence of infanticide suggesting missed opportunities for intervention and treatment. Common factors in mothers who committed infanticide as a result of delusions and/or hallucinations associated with PMADs were identified, including lack of standardized screening tools, preference for traditional and/or cultural healing practices, and access to care.

CONCLUSION

The current body of evidence supports developing and evaluating clinical interventions aimed at improving maternal mental health outcomes and infant outcomes in perinatal women experiencing puerperal psychosis.

Parental stress, depression, anxiety and participation to care in neonatal intensive care units: results of a prospective study in Italy, Brazil and Tanzania

BACKGROUND

Studies comparing the frequency of different mental health conditions across different settings and evaluating their association with parental participation in newborn care are lacking. We aimed at evaluating the frequency of parental stress, anxiety and depression, along with the level of participation in newborn care, among parents of newborns in Italy, Brazil and Tanzania.

METHODS

Parental stress, anxiety, depression and participation in care were assessed prospectively in parents of newborns in eight neonatal intensive care units (NICUs) utilising: the Parental Stressor Scale in NICU (PSS:NICU); the Edinburgh Postnatal Depression Scale (EPDS) and EPDS-Anxiety subscale (EPDS-A); the Index of Parental Participation in NICU (IPP-NICU). Univariate and multivariate analyses were conducted.

RESULTS

Study outcomes were assessed on 742 parents (Brazil=327, Italy=191, Tanzania=224). Observed scores suggested a very high frequency of stress, anxiety and depression, with an overall estimated frequency of any of the mental health condition of 65.1%, 52.9% and 58.0% in Brazil, Italy, Tanzania, respectively (p<0.001). EPDS scores indicating depression (cut-off: ≥13 for Brazil and Tanzania, ≥12 for Italy) were significantly more frequent in Tanzania (52.3%) when compared with either Brazil (35.8%) and Italy (33.3%) (p<0.001). Parental participation in care was also significantly higher in Tanzania (median IPP-NICU=24) than in the other two countries (median=21 for Brazil, 18 for Italy, p<0.001). Severe stress (PSS:NICU ≥4) was significantly more frequently reported in Brazil (22.6%), compared with Italy (4.7%) and Tanzania (0%, p<0.001). Factors independently associated with either parental stress, anxiety or depression varied by country, and a significant association with parental participation in care was lacking.

CONCLUSIONS

Study findings suggest that parental stress, anxiety and depression are extremely frequent in NICUs in all countries despite diversity in the setting, and requiring immediate action. Further studies should explore the appropriate level of parental participation in care in different settings.

Mental Health Support and Screening for Mood Disorders for Caregivers in the Neonatal Intensive Care Unit: Is the Call to Arms Being Answered?

OBJECTIVE

 Perinatal mood and anxiety disorders (PMADs) affect many neonatal intensive care unit (NICU) parents and are a significant risk factor for maternal suicide. Lack of screening and treatment interferes with infant development and bonding, compounding risks in fragile infants. We aim to describe PMAD screening in level IV NICUs across the Children's Hospitals Neonatal Consortium (CHNC) and to determine the relationship between standardized screening and mental health professionals (MHPs) presence.

STUDY DESIGN

 We surveyed experts at 44 CHNC NICUs about PMADs screening practices and presence of NICU-specific MHPs. Kruskal-Wallis test was used to examine relationships.

RESULTS

 Of 44 centers, 34 (77%) responded. Fourteen centers (41%) perform screening with validated tools. Thirteen (38%) centers have NICU-dedicated psychologists. Formally screening centers tend to have higher cumulative MHPs (p = 0.089) than informally screening centers. Repeat screening practices were highly variable with no difference in the number of cumulative MHPs.

CONCLUSION

 Screening practices for PMADs vary across CHNC centers; less than half have additional MHPs beyond social workers. Creating a sustainable model to detect PMADs likely requires more MHPs in NICUs.

KEY POINTS

· PMADs affect many NICU parents.. · Systematic screening for PMADs is limited in level IV children's hospital NICUs.. · Additional MHPs may contribute to enhanced screening and support of parents.. · Hospitals should prioritize funds for NICU-specific MHPs to optimize outcomes..

Promoting mental well-being among parents in the neonatal intensive care unit: a perspective on the role of Physician Associates

Emotional disorders in parents of infants admitted to the neonatal intensive care unit (NICU) carry the potential for serious ramifications in neonatal and childhood outcomes. Despite this, current NICU mental health supports are less than optimum; postpartum mental health screening is limited, often missed in parents of inpatient infants, and may not be applicable to all family structures. Current evidence demonstrates improved outcomes in neonates and family members with early identification and multidisciplinary approaches to managing mental health problems. Physician Associates/Assistants (PAs) are a skilled group of advanced practice providers who are often a point of first contact for parents in the NICU, helping maintain continuity of care. In this perspective, we underscore leveraging the skills of PAs to promote the emotional wellbeing of parents in the NICU by way of practice and policy involvement. We also included a generic set of recommendations to equip PAs in this role.

A preliminary study of the effectiveness of video visitation on depression and stress in mothers with preterm infants during the pandemic

BACKGROUND AND PURPOSE

Parents of preterm infants experience anxiety and stress in the neonatal intensive care unit (NICU). Visitation restrictions due to COVID-19 have increased maternal pressure and limited bonding opportunities. Little research exists in Taiwan on using video conferencing as a solution. This study investigates depression and stress levels in mothers of preterm infants and evaluates the effectiveness of video visitation during NICU restrictions.

METHODS

This study adopts a cross-sectional design and a qualitative survey. Mothers of premature infants were recruited and they participated in the study. Interventions for video visits were scheduled on the third day of admission to the NICU (T1) and during the second week of the study (T2). After each video visit, participants completed an online survey. The study's online survey used structured questionnaires including demographics, the Edinburgh Postnatal Depression Scale (EPDS) and the Parental Stress Scale (PSS): Infant Hospitalization (IH).

RESULTS

A total of 51 mothers of preterm infants participated in the study. During the T1 and T2 periods, single mothers with lower educational levels and those aged below 30 experienced depression and high levels of stress. Lower birth weight and gestational age were associated with maternal depression. Video visitation intervention led to a significant decrease in depression scores (EPDS, T1: 11.3 ± 5.5 vs. T2: 10.1 ± 5.2, p = 0.039). Positive correlations were observed between EPDS and PSS: IH scores (p < 0 .005).

CONCLUSION

Video visitation intervention can reduce maternal depression in mothers with preterm infants. Since it is practical, video visitation may be applied even after the pandemic.

A Narrative Review of NICU Implementation of Evidence-Based Early Relational Health Interventions

BACKGROUND

Early relational health (ERH) interventions in the neonatal intensive care unit (NICU) buffer infants from toxic stress effects. Implementation science (IS) can guide successful uptake of evidence-based practice (EBP) ERH interventions. It is unknown if implementors of ERH interventions currently use the resources of IS to improve implementation.

PURPOSE

A narrative review of recent literature on implementation of ERH EBPs was completed to understand (a) which ERH interventions are currently being implemented in NICUs globally, (b) whether clinical implementors of ERH interventions have adopted the resources of IS, (c) existence of implementation gaps, and (d) implementation outcomes of ERH interventions in contemporary literature.

DATA SOURCES

Scopus, PubMed, and CINHAL were searched for original research regarding implementation of dyadic ERH interventions using key words related to IS and ERH.

STUDY SELECTION

For inclusion, ERH EBPs had to have been implemented exclusively in NICU settings, contained data addressing an IS domain, printed in English within the last 5 years. Twenty-four studies met inclusion criteria.

DATA EXTRACTION

Studies were distilled for intervention, IS domains addressed, location, aims, design, sample, and outcomes.

RESULTS

Eleven ERH interventions were described in the literature. Few studies utilized the resources of IS, indicating variable degrees of success in implementation. Discussions of implementation cost were notably missing.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Implementors of ERH interventions appear to be largely unfamiliar with IS resources. More work is needed to reach clinicians with the tools and resources of IS to improve implementation outcomes.

Parental stress, depression, anxiety and participation in care in neonatal intensive care unit: a cross-sectional study in Italy comparing mothers versus fathers

BACKGROUND

This study aimed at documenting the levels of stress, depression, anxiety and participation in care among mothers versus fathers of newborns hospitalised in a third-level neonatal intensive care unit (NICU) in Northern Italy.

METHODS

Parental stress, depression and anxiety were assessed by the Parental Stressor Scale in NICU (PSS:NICU), the Edinburgh Postnatal Depression Scale (EPDS) and the State-Trait Anxiety Inventory (STAI). Participation in care was evaluated with the Index of Parental Participation. Differences between mothers and fathers were assessed with the Mood's median test and z-test, respectively for continuous and discrete variables. Multivariate analyses controlling for potential confounders were performed to confirm gender differences.

RESULTS

191 parents (112 mothers and 79 fathers) were enrolled. Mothers reported significantly higher median scores for stress (2.9 vs 2.2, p<0.001) and trait anxiety (37 vs 32, p=0.004) and higher depression rates (EPDS ≥12: 43.8% vs 19.0%, p<0.001). 'High stress' (PSS:NICU ≥3) was reported by 45.5% of mothers compared with 24.1% of fathers (p=0.004). The frequency of the three conditions simultaneously was significantly higher among mothers (20.0% vs 3.8%, p=0.016), with the vast majority of mothers (76.0%) suffering from at least one condition compared with less than half of fathers (45.3%, p<0.001). Participation in care was more frequent in mothers (median score: 19 vs 15, p<0.001), with the exception of activities related to advocacy (median 5 vs 4, p=0.053). In a multivariate analysis, gender differences in mental health outcomes did not change.

CONCLUSIONS

Routine screening of mental distress among parents of infants in NICU is warranted, and gender differences need to be acknowledged in order to deliver tailored support and to promote collaboration with the family of vulnerable newborns. Knowledge and skills on how to prevent and cope with mental distress of parents should be part of the core curriculum of staff working in NICU.

Predictive factors and treatment of postpartum mania: a representative case

Postpartum mania and psychosis puts both the person giving birth and their child at significant risk, so predicting its onset and determining effective treatment is crucial. Here, a representative case is presented of a patient started on an antidepressant during her pregnancy who suffered a postpartum manic episode with psychosis. The case describes many of the risk factors and treatment issues faced by clinicians when caring for patients with these symptoms in the postpartum period. Subsequent discussion provides guidance for clinicians to help predict postpartum mania and reviews factors that may increase the risk of its onset. The evidence for psychiatric treatment is also reviewed to both prevent and treat postpartum mania and psychosis.

Addressing caregiver mental health in the neonatal ICU

PURPOSE OF REVIEW

The neonatal ICU (NICU) setting is a unique opportunity to not only detect major changes in caregiver mental health through universal perinatal mood and anxiety disorder (PMAD) screening but also intervene with specialized support. We review evidence for addressing caregiver mental health in the NICU, explore current guidelines and models for integrated behavioural health programmes, and describe challenges specific to NICUs, particularly in standalone paediatric hospitals.

RECENT FINDINGS

Parents of infants admitted to the NICU are at an increased risk for developing PMADs at rates well above the general postpartum community. Select NICUs within the United States and internationally have recognized the importance of having an embedded psychologist to address caregiver PMADs. However, organizational structures within paediatric healthcare systems are not equipped to manage the logistical, ethical, legal and practical needs of comprehensive caregiver mental health programmes.

SUMMARY

To properly address caregiver mental health in NICU settings, clinical and administrative teams must work together to ensure seamless service provision. Systems that facilitate the development of unique parent medical records at the onset of paediatric care are likely to significantly reduce potential liability risks and solve several challenges related to caregiver-focused mental health support in the NICU.

VIDEO ABSTRACT

http://links.lww.com/MOP/A70.

Preliminary Validation of the Psychosocial Assessment Tool in the Neonatal Intensive Care Unit

OBJECTIVE

Research suggests families whose infants are admitted to the Neonatal Intensive Care Unit (NICU) experience elevated distress and may have pre-existing risk factors for maladjustment. This study sought to validate the newly developed Psychosocial Assessment Tool (PAT-NICU/Cardiac Intensive Care Unit [CICU]), a comprehensive screening measure for family psychosocial risk in the NICU.

METHODS

The sample included 171 mothers, who completed the PAT-NICU/CICU and other related measures within 2 weeks of their infant's NICU admission at a level 4 unit within a large pediatric hospital. PAT-NICU/CICU scores were compared to a companion risk survey completed by NICU social workers. Test-retest reliability was assessed through repeated measures at 2-month follow-up.

RESULTS

Analyses suggest the PAT-NICU/CICU is effective in classifying psychosocial risk. This is supported by statistically significant correlations between the PAT-NICU/CICU and validated measures, in addition to elevated scores on concurrent measures by risk classification. Internal consistency, test-retest reliability, and acceptability for the PAT-NICU/CICU were satisfactory.

CONCLUSIONS

This preliminary study demonstrates the validity, reliability, and acceptability of the PAT-NICU/CICU as a psychosocial screening tool to aid identification of families who may benefit from supportive services during NICU admission. This new measure is a more comprehensive tool that assesses a wide variety of risk factors and stress responses. However, future studies of this measure are needed with more diverse samples. Prompt screening of NICU parents may facilitate earlier linkage with appropriate levels of resources or intervention. This research is crucial in improving risk assessment and psychosocial care for families in the NICU.

An Updated Narrative Mini-Review on the Microbiota Changes in Antenatal and Post-Partum Depression

Background: Antenatal depression (AND) and post-partum depression (PPD) are long-term debilitating psychiatric disorders that significantly influence the composition of the gut flora of mothers and infants that starts from the intrauterine life. Not only does bacterial ratio shift impact the immune system, but it also increases the risk of potentially life-threatening disorders. Material and Methods: Therefore, we conducted a narrative mini-review aiming to gather all evidence published between 2018–2022 regarding microflora changes in all three stages of pregnancy. Results: We initially identified 47 potentially eligible studies, from which only 7 strictly report translocations; 3 were conducted on rodent models and 4 on human patients. The remaining studies were divided based on their topic, precisely focused on how probiotics, breastfeeding, diet, antidepressants, exogenous stressors, and plant-derived compounds modulate in a bidirectional way upon behavior and microbiota. Almost imperatively, dysbacteriosis cause cognitive impairments, reflected by abnormal temperament and personality traits that last up until 2 years old. Thankfully, a distinct technique that involves fecal matter transfer between individuals has been perfected over the years and was successfully translated into clinical practice. It proved to be a reliable approach in diminishing functional non- and gastrointestinal deficiencies, but a clear link between depressive women’s gastrointestinal/vaginal microbiota and clinical outcomes following reproductive procedures is yet to be established. Another gut-dysbiosis-driving factor is antibiotics, known for their potential to trigger inflammation. Fortunately, the studies conducted on mice that lack microbiota offer, without a shadow of a doubt, insight. Conclusions: It can be concluded that the microbiota is a powerful organ, and its optimum functionality is crucial, likely being the missing puzzle piece in the etiopathogenesis of psychiatric disorders.