Postpartum Depression

Postpartum depression (PPD) is a common complication of childbirth. It occurs in 10% to 20% of women, with studies showing increased rates of 28% to 70% in the NICU.6,14 Risk factors include a personal or family history of depression, relationship issues, low socioeconomic status, and stressful life events. Obstetric- and NICU-specific risk factors include multiple birth, very low birth weight, assisted reproductive technologies, recent stillbirth, less effective coping strategies, maternal role disruption, and lower perception of nursing support.¹⁴ Symptoms include depressed mood, decreased enjoyment, decreased sleep (difficulty even when the baby sleeps), feelings of guilt/worthlessness, appetite and energy changes, and potentially suicidal/violent thoughts. Differential diagnosis includes: baby blues (seen in the majority of women—with transient symptoms of irritability, tearfulness, and fatigue resolving within 2 weeks of delivery), postpartum psychosis, bipolar disorder, and medical illness (e.g., thyroid disease or anemia).⁶

Because of its prevalence, PPD screening and prevention measures should be integrated into NICU care. A widely used validated screening tool is the Edinburgh Postnatal Depression Scale (EPDS). A positive screen indicates that further evaluation is warranted. The EPDS is readily accessible online (e.g., through the American Academy of Pediatrics website). Mothers may be referred to psychiatry, family medicine, or obstetrics. If they are actively suicidal or homicidal, they should be evaluated emergently.

Maternal role disruption should be minimized in the NICU. Staff should encourage mothers to look beyond the machines and alarms, to touch and talk to their babies, and to participate in feeding and diapering. Melnyk and colleagues implemented a NICU educational-behavioral program, providing families with both recorded and written materials to enhance parent-infant interactions.¹³ Participating mothers reported significantly less stress, depression, and anxiety at 2 months corrected age than controls. They also evidenced stronger beliefs about their parental role and had better understanding of their infants, who had a 4-day shorter NICU length of stay.

Antidepressant medications and psychotherapy are treatments of choice. With mild symptoms psychotherapy alone may be sufficient. In risk-benefit analysis regarding medications in lactation, just as in pregnancy, the well-established risks of untreated maternal depression on development should be considered.³ Depressed mothers are more likely to be disengaged, withdrawn, or hostile, with disrupted mother-infant bonding.

Postpartum Anxiety and Post-Traumatic Stress Disorder

Anxiety is needed for self-preservation, but worries and hypervigilance can become excessive, interfering with daily life and bonding with the infant.⁹ The new parenting role can be stressful for anyone, but attempting to take on a much-anticipated role with severely ill infants—infants with tubes and who cannot be held or snuggled—can be a significant stressor. Other NICU-specific stressors include feelings of loss of control and daily uncertainties of life and death and disability. A parent’s subjective understanding of the seriousness of illness is correlated with psychological distress, rather than the objective medical seriousness.

In the postpartum period, the prevalence rate is 8%, 5%, and 3% for generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD), respectively.9,15,16 Anxiety is often comorbid with PPD. Risk factors include past traumas, prior high-risk pregnancy or postpartum course, prior fetal/infant loss, low socioeconomic status, poor social support, and preexisting mental illness.

Mothers with GAD may demonstrate excessive worry, restlessness despite appearing tired, imaginings that the situation is worse than it is, and feelings of being unable to leave the infant’s bedside because of an overwhelming fear of a bad outcome.⁹ Symptoms of PTSD include hyperarousal, numbing, avoidance of triggers, and re-experiencing of traumas. In PTSD, the mother may actually avoid the infant or the NICU if these experiences are her anxiety triggers. She may appear irritable, be easily startled, and have difficulty with bonding. Early PTSD symptoms predict less sensitive and more controlling maternal behaviors, as well as childhood sleep and eating problems. Finally, in OCD, intrusive thoughts and behaviors may occur and cause maternal distress. She may, for example, avoid holding the infant for fear that she will harm him or her because of distressing obsessive thoughts. Anxious mothers experience higher investment in infant health concerns and intrusive thoughts—correlating with more phone calls and repetitive need for reassurance. Similar to PPD, treatment for anxiety disorders includes psychotherapy and/or medication.