A mother-baby psychiatric day hospital: History, rationale, and why perinatal mental health is important for obstetric medicine

Models of care: Opportunities and challenges

Perinatal mental health models can broadly be described by scope and structure. Within these two broad domains lies an array of diverse methodologies that have attempted to increase access and coordination of care. These efforts have uncovered many opportunities that, if addressed, may improve our current parent and infant outcomes within our healthcare system and community. Furthermore, there are several opportunities that, if addressed, will result in more equitable, inclusive care. These include being attentive to the unique needs of vulnerable populations, emphasizing community efforts, and closing the current gaps in legislation.

A 5 years' experience of a parent-baby day unit: impact on baby's development

Introduction

Psychiatric Mother-Baby Units are well established in France, United Kingdom, and Australia, mostly in full-time hospitalization. Inpatient units are considered as best practice for improving outcomes for mothers and babies when the mother is experiencing severe mental illness and many studies have showed the effectiveness of care for the mother or the mother-infant relationship. Only a limited number of studies have focused on the day care setting or on the development of the baby. Our parent-baby day unit is the first day care unit in child psychiatry in Belgium. It offers specialized evaluation and therapeutic interventions focused on the baby and involves parents with mild or moderate psychiatric symptoms. The advantages of day care unit is to reduce the rupture with social and family living.

Aims

The objective of this study is to evaluate the effectiveness of parent-baby day unit in prevention of babies' developmental problems. First, we present the clinical characteristics of the population treated in the day-unit in comparison to the features presented in the literature review about mother-baby units, which usually receive full-time treatment. Then, we will identify the factors that might contribute to a positive evolution of the baby's development.

Materials and methods

In this study, we retrospectively analyze data of patients admitted between 2015 and 2020 in the day unit. Upon admission, the 3 pillars of perinatal care - babies, parents, and dyadic relationships - have systematically been investigated. All the families have received a standard perinatal medico-psycho-social anamnesis, including data on the pregnancy period. In this unit, all the babies are assessed at entry and at discharge using the diagnostic 0 to 5 scale, a clinical withdrawal risk, and a developmental assessment (Bayley). Parental psychopathology is assessed with the DSM5 diagnostic scale and the Edinburgh scale for depression. Parent-child interactions are categorized according to Axis II of the 0 to 5 scale. We have evaluated the improvement of children symptomatology, the child development and the mother-child relation between the entrance (T1) and the discharge (T2) and we have compared two groups of clinical situations: a group of patients with a successful evolution (considering baby's development and the alliance with the parents) and a group of unsuccessful evolution during hospitalization.

Statistical analysis

We use descriptive statistics to characterize our population. To compare the different groups of our cohort, we use the T-test and non-parametric tests for continue variables. For discrete variables, we used the Chi² test of Pearson.

Discussion

The clinical population of the day unit is comparable to the mother-baby units in terms of psychosocial fragility but the psychopathological profile of the parents entering the day unit shows more anxiety disorder and less post-partum psychosis. The babies' development quotient is in the average range at T1 and is maintained at T2. In the day unit, the number of symptoms as well as the relational withdrawal of the babies is reduced between T1 and T2. The quality of parent-child relationship is improved between T1 and T2. The children of the group of pejorative evolution had a lower developmental quotient at the T1 and an overrepresentation of traumatic life events.

Conclusion

These results indicate that parent-baby day unit lead to positive outcomes in clinical situations with anxio-depressive parents, relational withdrawal of the babies, functional problems of the babies but not when a significant impact on the development of the baby already exists. The results of this study can guide therapeutic approaches for the benefit of care in parent-baby day units, and improve the development of the child and of the dyadic relationships.

Implementation of a Hospital-based Brexanolone Program

Postpartum depression (PPD) is a serious complication of childbearing affecting ∼1 in 7 mothers. Left unrecognized and untreated, it is associated with negative outcomes for mothers and their infants. Building upon research suggesting that, for some women, hormonal fluctuations after childbirth contribute to the onset of depression, clinical trials have found promise in a novel treatment approach, brexanolone infusion. In 2019, the Food and Drug Administration (FDA) approved brexanolone as the first medication with an indication specifically for PPD. Delivering brexanolone treatment to patients in need requires overcoming some logistical and clinical challenges that are unique to this approach. This brief report describes the process by which a university-affiliated obstetric-gynecologic hospital in the northeast United States successfully implemented a program to administer this novel treatment to women with PPD.

Father's Perspectives on Family Relationships and Mental Health Treatment Participation in the Context of Maternal Postpartum Depression

Objective: To understand the perspectives of fathers whose partners experienced postpartum depression, particularly (1) views on how fathers and family relationships were impacted by maternal PPD, and (2) attitudes regarding inclusion of fathers within the treatment process. Methods: We conducted qualitative interviews with 8 postpartum couples using a semi-structured protocol, and administered questionnaires assessing demographics, depression, and family functioning. We abstracted data from hospital records regarding the mother's depressive episode. We summarized quantitative data using descriptive statistics, and analyzed interview transcripts using qualitative analysis techniques, focusing specifically on fathers' input on postpartum relationships and treatment involvement. Results: Over one-third of fathers had elevated symptoms of depression, and family functioning scores suggested that most couples were experiencing dysfunction in their relationships. Qualitative analysis identified three major categories of themes, and subthemes in each category. Major themes included: (1) fathers' experiences during the postpartum period, including not understanding postpartum mental health conditions and desiring more information, experiencing a range of emotions, and difficulty of balancing work with family; (2) fathers' views on postpartum relationships, such as communication problems, empathy for partner, and relationship issues with other family members; (3) fathers' attitudes toward postpartum treatment, including openness to be involved, perceived benefits, and barriers and facilitators to the inclusion of partners in treatment. Conclusion: Though barriers exist, many fathers are motivated to be included in the treatment process. In addition to supporting maternal wellbeing, fathers view treatment as a means to improve issues in the couple or family system, such as communication difficulties.

Management of perinatal depression with non-drug interventions

Perinatal depression is a common disorder that has been associated with serious risks to mother and child. Recently, screening for depression in pregnant and postpartum women has increased, as has the development of new psychotherapy and non-drug treatment modalities. Matching patients to treatments can be challenging, and although research into personalized treatment of major depression in the general population has increased, no published guidelines focus on personalized treatment approaches to perinatal depression. In particular, guidelines on non-drug treatments are lacking. This review summarizes the evidence on personalized non-drug treatment of perinatal depression, how to incorporate patients' preferences, novel treatments under investigation, and the potential role of biomarkers in matching patients to treatment. The review provides recommendations for future research in personalized care of perinatal depression.

Introducing Mother Baby Connections: a model of intensive perinatal mental health outpatient programming

Perinatal mental health problems, experienced by 15-20% of women, are a significant public health issue associated with adverse effects among childbearing women; yet only 20-25% receive adequate treatment. There has been a recent proliferation of intensive perinatal day treatment programs in the United States. To meet this need in the greater Philadelphia area, we introduce Mother Baby Connections (MBC), an innovative interdisciplinary, attachment-focused, intensive, outpatient perinatal mental health program recently launched at Drexel University. The purpose of this paper is to (1) present an overview of MBC, its theoretical framework for services, and its evidence-based components, highlighting the unique factors that differentiate this program from traditional outpatient treatment, and (2) present clinical outcome data utilizing scores from reliable and valid scales, including enrollment to discharge outcomes from 20 months of MBC operation. In sum, outcomes for 20 predominantly minority women with complete measures showed significant improvements in maternal depression symptom severity, maternal functioning, birth trauma symptoms, perceived stress, parenting stress, and emotional regulation. Effect sizes were medium to large (i.e., 0.42-2.00). We conclude that MBC is a viable model for tailored intensive outpatient treatment to foster maternal mental health and functioning during the perinatal period.

Clinical correlates of perinatal bipolar disorder in an interdisciplinary obstetrical hospital setting

BACKGROUND

Pregnancy and the postpartum period can be destabilizing for women with bipolar disorder (BD), and treatment decisions particularly complex. Yet, to date, relatively little research has focused on perinatal BD.

METHOD

Following IRB approval, trained raters reviewed clinical records of 334 women who had sought treatment at a specialized partial hospitalization program serving perinatal women, including demographic, clinical, and treatment history information as noted in each patient׳s chart by treating providers.

RESULTS

Slightly over 10% of the perinatal sample was diagnosed with Bipolar I, Bipolar II, or Bipolar NOS Disorder. In addition, 26% of the sample, regardless of diagnostic status, reported recent, abnormally elevated mood persisting 4 or more days. Compared to women with other Axis I disorders, women with a BD diagnosis were more likely to report a substance abuse history, prior suicide attempts, and more extensive psychiatric histories, including greater use of pharmacotherapy. Pregnant women with BD were more likely to take psychotropic medications prenatally, and postpartum women with BD reported higher rates of birth complications and difficulty breastfeeding.

LIMITATIONS

This research is limited by use of retrospective data, and utilization of self-report and clinician diagnosis, rather than structured interviews.

CONCLUSION

Even in the context of a partial hospital sample with high levels of symptoms and impairment, the clinical features of perinatal women with BD stand out as markedly more severe in comparison to those of women seeking care for other perinatal psychiatric conditions. Risk for suicide, substance abuse, and difficulties in the mother-child relationship are concerns.