Authors

Sarah A. Swenson, MD, DPhil
Neonatal-Perinatal Medicine Fellow
Department of Pediatrics
University of Minnesota Medical School
swens825@umn.edu

Megan E. Paulsen, MD
Assistant Professor
Department of Pediatrics, Division of Neonatology
University of Minnesota Medical School
mgosslin@umn.edu

Corresponding Author
Sarah A. Swenson, MD, DPhil
2450 Riverside Avenue
Neonatology, AO-401
Minneapolis, MN 55454

Funding

Dr. Paulsen was supported by the National Institute of Health Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) grant HD055887.

Conflicts of Interest

The authors have no conflicts of interest to disclose.

TITLE

Elevated Depression and Anxiety Symptoms in Parents of Very Preterm Infants While Hospitalized and Post-discharge

MANUSCRIPT CITATION

Pace CC, Spittle AJ, Molesworth CM, Lee KJ, Northam EA, Cheong JL, Davis PG, Doyle LW, Treyvaud K, Anderson PJ. Evolution of Depression and Anxiety Symptoms in Parents of Very Preterm Infants During the Newborn Period. JAMA Pediatr 2016;170:863-870. PMID 27428766.

REVIEWED BY

Sarah A. Swenson, MD, DPhil
Neonatal-Perinatal Medicine Fellow
Department of Pediatrics
University of Minnesota Medical School
swens825@umn.edu

Megan E. Paulsen, MD
Assistant Professor
Department of Pediatrics, Division of Neonatology
University of Minnesota Medical School
mgosslin@umn.edu

TYPE OF INVESTIGATION

Diagnosis

QUESTION

How do the rates of anxiety and depressive symptoms in parents of very preterm infants evolve during a 6-month period after birth, and how does this compare to parents of full-term infants?

Population: Mother and fathers of very preterm (VPT) neonates admitted to the neonatal intensive care unit (NICU)

Exposure: Very preterm birth

Comparison: Mother and fathers of full term (FT) neonates not requiring admission to the NICU

Outcome: Anxiety and depression symptoms

Time period: Birth through 6-months postmenstrual age (PMA)

METHODS

Design: Prospective cohort study

Allocation: Convenience sample

Blinding: Investigators were not blinded

Follow-up period: (a) Parents of VPT infants: Every two weeks from birth to 12 weeks and at 6 months PMA (b) Parents of FT infants: once within 3 weeks of birth and at 6 months PMA.

Setting: Single large tertiary care academic hospital, Royal Women’s Hospital, Melbourne, Australia from January 2011 to March 2014.

Cohort: Parents exposed to VPT birth compared to parents exposed to FT birth. Inclusion Criteria: Parents of infants born <30 weeks’ gestational age who were admitted to the NICU or parents of infants born > 37 weeks’ gestational age with birth weight > 2499 grams not admitted to the NICU. Exclusion criteria: Parents who did not speak English, infants with congenital abnormalities likely to influence development, and/or infants who were considered unlikely to survive.

Assessment: Standardized self-report questionnaires. Symptoms of depression were assessed with the Center for Epidemiological Studies Depression Scale (CES-D). Anxiety symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS). Both assessment tools have been validated as a screening tool for depression and anxiety respectively in parents of VPT infants. A cut-off score of > 16 on the CES-D and a score of > 8 or higher on the HADS was considered to represent clinically significant depression and/or anxiety symptoms. Social determinants of health were assessed by review of the infant’s medical history, questionnaire surrounding access to NICU support services and mental health services, and the Social Risk Index.

Outcomes: (1) The trajectory of depression and anxiety symptoms in parents of VPT infants over a 12-week period following NICU admission, (2) relationship between social and infant health factors and depression and anxiety symptoms in parents of VPT infants, (3) the difference between VPT and FT parents’ symptoms of anxiety and depression following the birth of the infant and at 6-months PMA.

Analysis and Sample Size: Parents of 150 infants born VPT (52% of eligible VPT infant families) and 151 infants born FT (51% of eligible FT infant families) agreed to participate in the study.  In the VPT cohort there were 31 sets of twins and 1 set of triplets. In the FT cohort there was 1 set of twins. There were 113 mothers and 101 fathers of VPT infants included in the study analysis.  There were 112 mothers and 102 fathers of FT infants included in the study analysis.  The level and prevalence of depression and anxiety in parents of VPT infants was described using the mean and standard deviation of continuous outcomes and by proportion of parents scoring above clinical cutoff scores. Changes over time in depression and anxiety symptoms of parents of VPT infants were described using mixed-effects linear regression models fitted to the repeated measures of the continuous score on CES-D and HADS.  Effect modification by perinatal and social predictors was assessed by adding both the perinatal predictor and an interaction between predictor and chronological age to the mixed-effects models. Comparisons between parents of VPT and FT infants were made using linear and logistic regression for continuous and binary outcomes and adjusted for confounders.

Patient follow-up: 66% of mothers and 72% of fathers of infants born VPT filled out the CES-D questionnaire at birth and 12 weeks following NICU admission. 63% of mothers and 77% of fathers of infants born VPT filled out the HADS questionnaire at birth and 12 weeks following NICU admission.  72% of mothers and 73% of fathers of infants born VPT filled out both CES-D and HADS questionnaires at birth and 6-months PMA. Six infants died while in the hospital. Data from these parents was included in the analysis until the time of the infant’s death. Complete data was used for two families who had a surviving twin. 81% completed the CES-D and HADS questionnaires at 6-months PMA.  5 additional mothers and 8 additional fathers of FT infants completed the CES-D and HADS questionnaires at 6-months compared to after birth.

MAIN RESULTS

Infant and Parent Characteristics

	Very Preterm	Full Term
Infant gestational age	27.7 weeks gestation	39.8 weeks gestation
Infant birth weight	1021 grams	3503 grams
Assisted reproduction	26%	11%
Multiple birth	44%	1%
Maternal age	32.7 years	32.9 years
Paternal age	34.7 years	35.9 years
Identified high social risk	43%	25%
Siblings at home	56%	39%

 Parental Differences in Support Utilization after Very Preterm Birth

	Mothers of Very Preterm Infants	Fathers of Very Preterm Infants
Accessed mental health services in last year	18%	7%
Accessed NICU support services	50%	27%

 

CONCLUSION

Parents of VPT infants exhibited rates of depression and anxiety approaching 40-50% shortly after birth, significantly higher than rates of depression and anxiety in parents of healthy FT infants. Rates of depression and anxiety declined over time in parents of VPT. Paternal depression remained increased compared to parents of healthy FT infants at 6 months.  At 12 weeks PMA, there was greater than 20% prevalence of depression and anxiety in parents of VPT infants, which remained over 10% at 6 months PMA.  Collectively, this data indicates a lasting need for recognition, referral and provision of resources, as well as appropriate mental health support and follow up for parents affected by VPT birth.

 

COMMENTARY

NICU parents have a higher prevalence of perinatal mood and anxiety disorders (PMADs) (1).  Untreated PMADs have been associated with worse health outcomes for mothers and their children (2).  While this study focuses on parental symptoms of depression and anxiety, others have shown that efforts toward PMAD prevention, diagnosis, and treatment improve health outcomes for preterm infants (2).  Here we highlight three future directions in PMAD research with potential to improve health outcomes for families who are affected by preterm birth.

 

First, broadened PMAD screening may increase diagnosis and treatment rates in NICU parents.  This study supports the American Academy of Pediatrics’ recommendations for postpartum depression screening at well infant visits (3).  A strength of this study is its inclusion of NICU fathers who are often neglected in terms of mental health initiatives and research.  Evidence outside of this study demonstrates that fathers’ involvement in preterm care enhances both parents’ engagement (4).  While both tools used in this study, the CES-D and HADS, have been reported in parents of preterm infants, a limitation of this study, as well as current gap in the literature, is the absence of a validated screening tool specific to the NICU parent population.  Current literature reports a myriad of assessment tools, yet there is no single comprehensive tool validated for NICU caregivers that screens for the most common PMAD diagnoses in this population: depression, anxiety, and post-traumatic stress disorder (2, 5).  Development of such a tool would aid screening efforts.

 

Second, Pace et al. emphasizes the disproportionate number of families with high social risk affected by preterm birth. Not surprisingly, higher social risk predicted depressive and anxiety symptoms. A limitation of this study is the exclusion of non-English speaking parents. Additionally, descriptive characteristics of the cohort, such as parental race, ethnicity, education, and socioeconomic status, are not reported. Previous work has shown that PMAD prevalence is higher in parents of lower socioeconomic status (6).  This study may therefore underestimate prevalence of PMADs, and these limitations hinder the generalizability of the study’s findings. We echo current calls to action to eliminate PMAD outcome disparities and include representative and diverse populations in research and quality improvement initiatives (7).

 

Last, Pace et al. reports an interaction between maternal depressive symptoms and presence of siblings. Currently, there is a paucity of data regarding the impact of preterm birth on siblings. Adverse childhood experiences, such as significant disruption to the home environment, is associated with chronic health and behavioral problems (8). While this was outside of the scope of this study, future research aimed to support siblings of preterm infants may improve family mental health and wellbeing.

 

In summary, inclusive NICU mental health initiatives will improve health outcomes for those affected by premature birth. Since this study in 2016, efforts towards these initiatives have gained traction (2, 9). Although there is much work to be done around PMADs and their impact on family wellbeing, we are encouraged by studies like Pace et al. that bring attention to its importance.

REFERENCES

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4. Kim THM, Delahunty-Pike A, Campbell-Yeo M. Effect of Fathers’ Presence and Involvement in Newborn Care in the NICU on Mothers’ Symptoms of Postpartum Depression. J Obstet Gynecol Neonatal Nurs. 2020;49(5):452-63.

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8. Stephenson E, DeLongis A, Steele R, Cadell S, Andrews GS, Siden H, et al. Siblings of Children With a Complex Chronic Health Condition: Maternal Posttraumatic Growth as a Predictor of Changes in Child Behavior Problems. J Pediatr Psychol. 2017;42(1):104-13.

9. Murthy S, Haeusslein L, Bent S, Fitelson E, Franck LS, Mangurian C. Feasibility of universal screening for postpartum mood and anxiety disorders among caregivers of infants hospitalized in NICUs: a systematic review. J Perinatol. 2021;41(8):1811-1824.