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Frontline Report   |    
Psychiatric Help for Caregivers of Infants in Neonatal Intensive Care
Susan Hatters Friedman, M.D.; R. Ann Kessler, L.I.S.W.; Richard Martin, M.D.
Psychiatric Services 2009; doi: 10.1176/appi.ps.60.4.554
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The authors are affiliated with the Departments of Psychiatry and Pediatrics, Case Western Reserve University School of Medicine, 11100 Euclid Ave., Cleveland, OH 44106 (e-mail: susanhfmd@hotmail.com).

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Having an ill infant who requires care in a neonatal intensive care unit (NICU) is a significant stressor for parents. Ideals about healthy babies are shattered, and parents may be uprooted from work and family in order to spend time with their critically ill infants. The NICU environment itself is fast-paced and frequented by unexpected turns of events. Parents may experience depression, anxiety, and hostility, and taken together with problematic parent-infant interactions, these reactions may affect the infant's length of stay in the NICU. Parents often do not proactively seek help for their own problems because of barriers such as insurance, stigma, and the desire to spend their available time with their infants. Parents' needs may "fall through the cracks" in the usual system, simply because of fragmentation of care provided by obstetrics, pediatrics, and psychiatry. The NICU itself presents an opportune location for psychoeducation, diagnosis, and treatment of maternal and paternal mental health issues. NICU staff can also benefit from psychiatric support. Staff bond with the infants in their care, and when conditions gravely worsen, staff too need to grieve.

Rainbow Babies and Children's Hospital in Cleveland has 82 level 3 NICU beds, including a 44-bed neonatal transitional care unit. Rainbow's NICU admits approximately 1,200 infants annually, of which approximately 150 have birth weights below 1.5 kg. In 2005 the NICU Mental Health Program was formed with grant support from the Haber-Meyer Memorial Fund of the Cleveland Foundation. The program is a model of both consultation and liaison psychiatry. The perinatal psychiatrist provides evaluation and psychotherapy for parental distress related to neonates' medical problems and NICU hospitalization, parental education groups, and staff education and support. The psychiatrist is present in the NICU from one-half to one day per week.

Over a one-year period, 80 parents (primarily mothers) were referred by NICU social workers for psychiatric evaluation and psychotherapy. Parents were referred for adjustment or coping difficulties, depression, or anxiety exacerbated by the dual stressors of parenting an ill infant and chronic hospitalization. Themes of guilt, loss, fear, anger, social isolation, and sleep deprivation are prominent in this population, and supportive therapy with an interpersonal psychotherapy bent is the most often used modality. This time of sudden life crisis is opportune for interpersonal therapy, in that the crisis is often accompanied by grief, role transition, and role dispute. Because of the lack of certainty about the length of the infant's hospitalization and parental availability, strict use of structured therapy is limited. Mothers were seen up to a dozen times during their infants' stays.

The psychiatrist does not utilize pharmacotherapy in the NICU setting, because short-term psychotherapy is the most realistic intervention for referred parents, many of whom do not require medication. If psychopharmacology is needed, the psychiatrist consults with the obstetrician or makes an outside referral. As discharge approaches, referrals are made to psychiatric services in the community if needed.

Some referred parents were not seen, including those who did not visit the hospital during working hours (sometimes because of ambivalence, disinterest, or concern about stigma). Parents with chronic severe mental illness (mainly schizophrenia or bipolar disorder) or active substance dependence were referred to other appropriate services for more comprehensive treatment.

Staff support and in-services training were also given. Grief, the chronic stress of working in an intensive unit setting with very ill babies, and productive ways of dealing with difficult interactions with parents were often discussed. Staff in-services training covers topics at the intersection of neonatology and psychiatry, including maternal depression and anxiety, postpartum psychosis, parenting in the context of severe mental illness, factitious disorder by proxy, risks of child abuse and infanticide, and effective parent communications.

In summary, the NICU presents a stressful environment for both parents and staff. Maternal depression or coping difficulties can lead to fewer visits to the infant, with consequent lack of parental readiness for discharge and decreased understanding of discharge instructions because of difficulties with concentration in this high-stress environment. Potential exists for improved maternal-infant mental health and bonding. Treatment of maternal mental illness may decrease burden on mothers, infants, and staff. Staff can function more effectively with decreased stress. Both parents and staff have reported that the presence of a psychiatrist is beneficial. However, if grant support is not available, financial support for such a service is a critical issue in the United States. Liaison work is often not reimbursable, although it is greatly needed. Potential for decreased length of stay, improved parenting, and decreased staff stress should encourage programs to meet the challenge of obtaining requisite funding for this at-risk population.

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