Recommendations for mental health professionals in the NICU.

This article describes recommended activities of social workers, psychologists and psychiatric staff within the neonatal intensive care unit (NICU). NICU mental health professionals (NMHPs) should interact with all NICU parents in providing emotional support, screening, education, psychotherapy and teleservices for families. NMHPs should also offer educational and emotional support for the NICU health-care staff. NMHPs should function at all levels of layered care delivered to NICU parents. Methods of screening for emotional distress are described, as well as evidence for the benefits of peer-to-peer support and psychotherapy delivered in the NICU. In the ideal NICU, care for the emotional and educational needs of NICU parents are outcomes equal in importance to the health and development of their babies. Whenever possible, NMHPs should be involved with parents from the antepartum period through after discharge.

Recommendations for enhancing psychosocial support of NICU parents through staff education and support.

Providing psychosocial support to parents whose infants are hospitalized in the neonatal intensive care unit (NICU) can improve parents' functioning as well as their relationships with their babies. Yet, few NICUs offer staff education that teaches optimal methods of communication with parents in distress. Limited staff education in how to best provide psychosocial support to families is one factor that may render those who work in the NICU at risk for burnout, compassion fatigue and secondary traumatic stress syndrome. Staff who develop burnout may have further reduced ability to provide effective support to parents and babies. Recommendations for providing NICU staff with education and support are discussed. The goal is to deliver care that exemplifies the belief that providing psychosocial care and support to the family is equal in importance to providing medical care and developmental support to the baby.

Affective disorders in the aftermath of miscarriage: a comprehensive review.

We review the research literature regarding affective symptomatology and disorders following miscarriage, with an emphasis on controlled studies and those that have been published since the last review article in 1996. The current review draws a sharp distinction between controlled and uncontrolled designs and clarifies the proper inferences that may be drawn from each, as only with an appropriate comparison group can it be determined whether the affective reactions following miscarriage are a specific consequence of the reproductive loss or of other life events common in women of reproductive age. In addition to providing an update of the literature on depression in the aftermath of miscarriage and associated risk factors, we also discuss reproductive loss in the context of attachment theory and grief, and present information on topics that were not covered extensively (or at all) by prior reviews, such as issues related to a pregnancy subsequent to miscarriage and the impact of miscarriage on the partners of miscarrying women. In the final section, treatment options relevant to miscarriage are presented.

Anxiety disorders following miscarriage.

BACKGROUND: Several previous studies have established that miscarriage is a risk factor for depressive symptoms and disorder. By contrast, research on miscarriage as a possible risk factor for anxiety symptoms is inconclusive, and for anxiety disorders, sparse and uninformative. The current study examines the incidence of and relative risk for 3 DSM-III anxiety disorders (obsessive-compulsive disorder [OCD], panic disorder, and phobic disorders) within the 6 months following miscarriage. Adequate diagnostic data on other anxiety disorders were not available. METHOD: Using a cohort design, we tested whether women who miscarry are at increased risk for a first or recurrent episode of an anxiety disorder in the 6 months following loss. The miscarriage cohort consisted of women attending a medical center for spontaneous abortion (N = 229); the comparison group was a population-based cohort of women drawn from the community (N = 230). RESULTS: Among miscarrying women, 3.5% experienced a recurrent episode of OCD, compared with 0.4% of community women (relative risk [RR] = 8.0; 95% confidence interval [CI] = 1.0 to 63.7). The relative risk for noncomorbid panic disorder was substantial (RR = 3.6), albeit not statistically significant (95% CI = 0.8 to 17.2). There was no strong evidence for increased risk for phobic disorders or agoraphobia, combined or considered separately, in the 6 months following loss. Relative risk for all 3 disorders combined was 1.5 (95% CI = 0.9 to 2.3). CONCLUSION: In this first miscarriage cohort study using a concurrent frequency-matched comparison group, miscarriage was a substantial risk factor for an initial or recurrent episode of OCD. Given statistical power limitations of this investigation, the current findings do not preclude a possible contribution of miscarriage to risk for other anxiety disorders.

Ourselves, our bodies, our realities: an HIV prevention intervention for women with severe mental illness.

This paper describes a 10-session behavioral intervention introducing female-initiated methods of human immunodeficiency virus (HIV) prevention to reduce vulnerability to HIV infection for women with severe mental illness. In a pilot test of the intervention, 35 women were randomly placed in the experimental intervention group or an HIV education control. Subjective norms, intentions to use, perceived efficacy, and attitudes toward the male condom, female condom, and a microbicide were assessed at baseline, postintervention, and 6-week follow-up. The participants in the treatment group reported a significantly more positive attitude toward the use of female condoms (t = -2.12, P < .05) at 6-week follow-up. Providing women with severe mental illness with choices of protective methods and the knowledge and skills to ensure proper use are among the many crucial ingredients in prevention of acquired immunodeficiency syndrome.

Minor depressive disorder in the context of miscarriage.

BACKGROUND: Although minor depressive disorder is of considerable clinical and public health importance, it has received limited research attention relative to major depressive disorder. This study examines the incidence rate and relative risk for minor depressive disorder following miscarriage. METHODS: Using a cohort design we tested whether miscarrying women are at increased risk for an episode of minor depression (diagnosed based on research criteria proposed in Appendix B of DSM-IV) in the 6 months following loss. The miscarriage cohort consisted of women attending a medical center for spontaneous abortion (n=229); the comparison group was a population-based cohort of women drawn from the community (n=230). RESULTS: Among miscarrying women, 5.2% experienced an episode of minor depression, compared with 1.0% of community women. The overall relative risk for an episode of minor depression for miscarrying women was 5.2 (95% confidence interval, 1.2-23.6). Relative risk did not vary by length of gestation at the time of loss or attitude toward the pregnancy. The majority of episodes in miscarrying women began within 1 month following loss. LIMITATIONS: Minor depression was relatively rare in both study cohorts. The resulting limits on statistical power reduced our ability to identify factors, such as sociodemographic or reproductive history variables that might moderate the effect of miscarriage on risk for minor depression. CONCLUSIONS: These results, in the context of prior work showing increased risks of major depression and depressive symptoms following miscarriage, lend some support to the conceptualization of minor depressive disorder as part of a continuum of symptom severity. Miscarrying women should be evaluated for depression at their follow-up medical visits.

Darryl, a cartoon-based measure of cardinal posttraumatic stress symptoms in school-age children.

OBJECTIVES: This report examines the reliability and validity of Darryl, a cartoon-based measure of the cardinal symptoms of posttraumatic stress disorder (PTSD). METHODS: We measured exposure to community violence through the reports of children and their parents and then administered Darryl to a sample of 110 children aged 7 to 9 residing in urban neighborhoods with high crime rates. RESULTS: Darryl's reliability is excellent overall and is acceptable for the reexperiencing, avoidance, and arousal subscales, considered separately. Child reports of exposure to community violence were significantly associated with child reports of PTSD symptoms. CONCLUSIONS: Darryl possesses acceptable psychometric properties in a sample of children with frequent exposure to community violence.

Methods for successful follow-up of elusive urban populations: an ethnographic approach with homeless men.

Public health is paying increasing attention to elusive urban populations such as the homeless, street drug users, and illegal immigrants. Yet, valid data on the health of these populations remain scarce; longitudinal research, in particular, has been hampered by poor follow-up rates. This paper reports on the follow-up methods used in two randomized clinical trials among one such population, namely, homeless men with mental illness. Each of the two trials achieved virtually complete follow-up over 18 months. The authors describe the ethnographic approach to follow-up used in these trials and elaborate its application to four components of the follow-up: training interviewers, tracking participants, administering the research office, and conducting assessments. The ethnographic follow-up method is adaptable to other studies and other settings, and may provide a replicable model for achieving high follow-up rates in urban epidemiologic studies.

Major depressive disorder in the 6 months after miscarriage.

OBJECTIVE: To test a priori hypotheses that miscarrying women are at increased risk for a first or recurrent episode of major depressive disorder in the 6 months following loss and that this increased risk is greater for childless women, women with prior reproductive loss, and women aged 35 years or older; and to evaluate whether risk varies by time of gestation or by attitude toward the pregnancy. DESIGN: Cohort study. SETTING: The miscarriage cohort consisted of women attending a medical center for a spontaneous abortion (n=229); the comparison group was a population-based cohort of women drawn from the community (n=230). PARTICIPANTS: Miscarriage was defined as the involuntary termination of a nonviable intrauterine pregnancy before 28 completed weeks of gestation. Half of all participants were between 25 and 34 years of age; 40% were white and 35% Hispanic; 55% had more than a high school education. Participants constituted 60% of miscarrying women and 72% of community women who completed the first phase of this cohort study. MAIN OUTCOME MEASURE: Major depressive disorder was measured using the Diagnostic Interview Schedule. RESULTS: Risk for an episode of major depressive disorder among miscarrying women in the 6 months following loss was compared with the 6-month risk among community women who had not been pregnant in the preceding year. Among miscarrying women, 10.9% experienced an episode of major depressive disorder, compared with 4.3% of community women. The overall relative risk (RR) for an episode of major depressive disorder for miscarrying women was 2.5 (95% confidence interval [CI], 1.2-5.1) and was substantially higher for childless women (RR, 5.0; 95% CI, 1.7-14.4) than for women with children (RR, 1.3; 95% CI, 0.5-3.5) (P<.06). Among miscarrying women, 72% of cases of major depressive disorder began within the first month after loss; only 20% of community cases started during the comparable period. Among miscarrying women with a history of major depressive disorder, 54% experienced a recurrence. However, RR did not vary significantly by history of prior reproductive loss or by maternal age, nor did risk vary by time of gestation or attitude toward the pregnancy. CONCLUSIONS: Physicians should monitor miscarrying women in the first weeks after reproductive loss, particularly women who are childless or who have a history of major depressive disorder. Where appropriate, supportive counseling or psychopharmacologic treatment should be considered.