September 20, 2019/Pediatrics/Research

Depression Screening Alone May Miss Stress-Related Mental Health Issues in Mothers of Babies in NICU

Identifying mothers at risk of postpartum mental health issues


Screening NICU mothers for depression alone may mean that many who develop other mental health issues, such as anxiety or stress, in this traumatic situation may be missed, according to a new study published in The Journal of Maternal-Fetal & Neonatal Medicine.


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Left untreated, these mental health issues can have a life-long effect on both mother and baby. Research suggests that maternal mental health issues may mean that mom is less sensitive to the needs of her infant, and can also contribute to infant feeding and sleeping issues. As a whole, maternal depression, anxiety and stress may negatively impact neurodevelopmental outcomes.

“The care we provide in the NICU plays only a small part in a baby’s developmental trajectory,” states Anirudha Das, MD, a neonatologist with Cleveland Clinic Children’s and first author on the study. “Babies are in our care for perhaps two or three months, but for the most part, babies stay with their mother. If mom has untreated mental health issues, whatever interventions we provide at the outset of baby’s life will have limited impact.”

Identifying those at risk

Dr. Das and his colleagues noticed that, despite their efforts to screen NICU moms for depression, providers found that communication remained difficult with some mothers. Mental health issues seemed to be present; however, when screening tools only look for depression, severe anxiety and stress may be missed.

“New mothers are already at risk for developing depression or other mental health issues, and mothers whose newborns are in the NICU are even more vulnerable,” Dr. Das explains. “We started this study to look at mental health status of mothers, basically looking at depression, anxiety and stress. Other than depression, what else might be effecting the care of the child? What might impact our ability to communicate with the mother? What we can do to care for her? There has been a lot of research in this area, but we wanted to look at what was going on in our unit.”


Postpartum depression, anxiety and stress significantly related to depression history

In the study, the Depression Anxiety and Stress Scale (DASS-21) was administered to 96 postpartum women with neonates in the NICU for 7-29 days. A total of 48% of participants screened positive for depression (22.9%), anxiety (38.5%) or stress (33.3%). Of the mothers, 37.5% had an established history of depression — as noted in their health record before their pregnancy — while 62.5% had no previous depression. Mothers with previous depression were nearly twice as likely to develop any depression, anxiety or stress (63% vs 33%; p < 0.02), and three times as likely to develop severe or very severe anxiety (28% vs 7%; p < 0.01). The findings suggest that if providers screen only for postpartum depression, overlooking postpartum anxiety and stress, 11.4% of all mothers and 23.9% of mothers with established histories of mental health issues would be missed.

According to Dr. Das, “a certain amount of stress and anxiety is expected among women as they transition into motherhood with babies who will require extra support. However, we are really screening for severe or very severe stress and anxiety – to such an extent that a mother hates coming to the NICU. The NICU isn’t an easy environment. We want to do all that we can to ensure that these mothers develop positive bonds with their babies.”

“Implementing the DASS-21 was a great move,” Dr. Das continues. “We found a high percentage of depression, anxiety and stress. We chose the screening tool because it is a quick way to figure out if mothers are distressed. Since we rolled out the DASS-21 in all the Neonatal Intensive Care Units of Cleveland Clinic Children’s last year, we have referred many mothers for outpatient therapy. If a scores come back as moderate to severe, our social workers will try to get a mother seen as quickly as possible.”

Timely interventions and peer-to-peer mentoring

Cleveland Clinic Children’s has implemented several programs to address the stress and anxiety new mothers may experience in the NICU. Social workers administer the DASS-21 to all mothers whose infants have been in NICU for two weeks or more at Cleveland Clinic Children’s main campus, Cleveland Clinic Hillcrest Hospital and Fairview Hospital. Parents with DASS-21 scores that are moderate, severe or very severe are offered psychological support like referral to outpatient psychology and/or psychiatry. At the main campus, a psychologist, Emily Mudd, MD, is available to visit mothers in the NICU — a service that Dr. Das hopes to expand to the regional hospitals, perhaps augmented by telemedicine options, in the near future.


Beyond traditional mental health interventions, Cleveland Clinic Children’s caregivers do their best to alleviate stressors, such as finding parking or a quiet place for pumping breast milk. Such pain points have been identified in partnership with former patient families who participate in a parent advisory committee lead by our social workers. These parents give feedback into their experience in the unit, making suggestions about ways to improve care and discharge procedures.

Peer-to-peer mentoring is another important intervention at Cleveland Clinic Children’s. According to Dr. Das, roughly 10 mothers whose children have been discharged from the NICU volunteered to share their stories current NICU moms. “Current NICU mothers are given the opportunity to read these stories, and, if they would like to connect with any of these mothers with previous NICU experience, we make those connections,” Dr. Das says.

Dr. Das and his colleagues feel that the best time to address potential depression, anxiety or stress is while the infants remain in the NICU. “These babies need a lot of specialized care in their first months and years of life. We want moms to be in the best physical and mental condition possible to support the babies. A significant part of a good outcome for baby is mom’s stability, which we try to achieve in the NICU itself. It’s our best opportunity to connect with the mother, understand what’s going on with her life and help her out to prepare her for what is to come.”

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