Prepublication Release

Maternal and Paternal Depression Symptoms During NICU Stay and Transition Home

Craig F. Garfield, MD, MAPP, Young S. Lee, PhD, Liam Warner-Shifflett, Rebecca Christie, MA, Kathryn Jackson, MA, Emily Miller, MD

DOI: 10.1542/peds.2020-042747 Journal: Pediatrics Article Type: Regular Article

Citation: Garfield CF, Lee YS, Warner-Shifflett L, Christie R, Jackson K, Miller E. Maternal and paternal depression symptoms during NICU stay and transition home. Pediatrics. 2021; doi: 10.1542/peds.2020-042747

This is a prepublication version of an article that has undergone peer review and been accepted for publication but is not the final version of record. This paper may be cited using the DOI and date of access. This paper may contain information that has errors in facts, figures, and statements, and will be corrected in the final published version. The journal is providing an early version of this article to expedite access to this information. The American Academy of Pediatrics, the editors, and authors are not responsible for inaccurate information and data described in this version.

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Maternal and Paternal Depression Symptoms During NICU Stay and Transition Home

Craig F. Garfield, MD, MAPPa,b, Young S. Lee, PhDb, Liam Warner-Shifflettb, Rebecca Christie, MAb, Kathryn Jackson, MAb, Emily Miller, MDb

Affiliations aAnn and Robert H. Lurie Children’s Hospital of Chicago, bNorthwestern University Feinberg School of Medicine Address Correspondence Craig Garfield, Professor of Pediatrics, Feinberg School of Medicine, 633 St. Clair, Suite 19- 059, Chicago, IL 60611, [[email protected]], 312-503-5465

Conflict of Interest Disclosures The authors have no conflicts of interest relevant to this article to disclose. Funding/Support All phases of this study were supported by Friends of Prentice Role of Funder/Sponsor The funders did not influence in any way the outcomes or reporting of the findings in this study. Clinical Trial Registration Registry number: NCT03505424 https://clinicaltrials.gov/ct2/show/NCT03505424

Abbreviations Neonatal Intensive Care Unit (NICU), Postpartum Depression (PPD), Edinburgh Postpartum Depression Scale (EPDS), Length of Stay (LOS), Gestational Age (GA), Receiver Operating Characteristic curves (ROCs), Area Under the Curve (AUC)

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Article Summary Measuring mothers’ and fathers’ depressive symptoms from the NICU to home, this study examines differences and similarities in scores and probability across the transition home. What’s Known on This Subject Parents with premature infants face an increased risk of poor emotional functioning, anxiety, and mood disorders which can alter parenting and child outcomes. The trajectory of maternal and paternal depressive symptoms from NICU to home is not well understood. What This Study Adds In this prospective longitudinal cohort study of 431 mothers and fathers, 33% of mothers and 17% of fathers screened positive for depressive symptoms initially. The probability of reporting depressive symptoms decreased significantly for mothers but not for fathers once home.

Contributors’ Statement: Craig F. Garfield: Dr. Garfield conceptualized and designed the study, coordinated and supervised data analysis, drafted the initial manuscript, reviewed and critically revised the manuscript and approved the final manuscript as submitted. Young S. Lee: Dr. Lee conceptualized and designed the study, carried out the initial analyses, reviewed and critically revised the manuscript, and approved the final manuscript as submitted. Liam Warner-Shifflett: Mr. Warner-Shifflett carried out the initial analyses, designed the data collection, reviewed and critically revised the manuscript, and approved the final manuscript as submitted. Katheryn Jackson: Ms. Jackson coordinated and supervised data analysis, reviewed and critically revised the manuscript, and approved the final manuscript as submitted. Rebecca Christie: Ms. Christie made substantial contributions to conception and design, coordinated and supervised data analysis, reviewed and critically revised the manuscript, and approved the final manuscript as submitted. Emily Miller: Dr. Miller made substantial contributions to conception and design, reviewed and critically revised the manuscript, and approved the final manuscript as submitted. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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ABSTRACT

Objective: To examine the trajectory and risk factors of depression symptoms among parents from NICU admission to 30-days post discharge. We hypothesized depression symptom scores would decrease from admission and then increase from discharge to 30-days.

Methods: Prospective longitudinal cohort study of premature infants (<37 weeks gestational age) in NICU. English-speaking parents, irrespective of their relationship status/type, completed the validated Edinburgh Postpartum Depression Scale (EPDS) at four time points: NICU admission, discharge, 14-days and 30-days post-discharge. EPDS score change across time and probability of a positive screen (EPDS ≥ 10) were assessed using mixed effect regression models.

Results: Of 431 parents enrolled [mothers, n=230 (53%)], 33% of mothers (n=57) and 17% of fathers (n=21) had a positive EPDS screening. Scores change was 1.9 points different between mothers and fathers [CI: (1.3,2.6); p<0.0001)] with mothers decreasing 2.9 points [CI: (2.1,3.7); p<0.0001)] and fathers decreasing 1.0 points [CI: (0.1, 2.0); p=0.04)]. Over time, mothers decreased 10.96 times [CI: (2.99,38.20); p=0.0003] while fathers decreased at a lower and non- significant rate [0.99 times (CI: (0.26,3.79), (p=0.9854)]. Admission or discharge screening improved 30-day depressive symptom prediction (AUC 0.66 baseline demographics only vs 0.84+initial (p<0.0001), and vs 0.80+discharge screening (p<0.001).

Conclusions and Relevance: Mothers and fathers experience different depressive symptom trajectories from NICU to home. Screening parents for PPD during the NICU stay is likely to result in improved identification of parents at-risk for PPD after discharge. Focused attention on fathers appears warranted.

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Introduction The neonatal intensive care unit (NICU) can be challenging for parents to navigate with their

medically vulnerable infants. Parents of NICU infants may be predisposed to poor emotional

functioning, anxiety, and mood disorders.1 “Pervasive uncertainty” was the phrase one

qualitative study used to describe parents’ feelings from NICU discharge to home.2 While

postpartum depression (PPD) is one of the most common complications of childbirth among

mothers in general,3,4 parents in the NICU may have higher risks related to their infants’ medical

vulnerability or the stress of a NICU stay.5 Mothers of premature infants PPD risk (28%-40%)6 is

nearly double that of mothers of full-term infants, with rates typically decreasing over time yet

remaining higher in the infant’s first year.7-9 Paternal PPD has received less attention10,11 despite

a prevalence of 5-13% among fathers of full term infants.9,12-14 Paternal PPD among fathers with

premature infants is less studied15 with recent literature concluding that paternal PPD among the premature population is 2%-19% higher than the rate among fathers of full-term infants in immediate postnatal period.9 Stress, self-reported and measured physiologically via salivary

cortisol, is noted to increase as fathers transition with their infants from the NICU to home and

may become a risk for increased depression16,17. While this research provides insight into the

time-dependent risk of parental PPD, few studies have examined the trajectory of depression

among large numbers of both parents through key clinical transition periods such as NICU admission, discharge, and at home.

The importance of examining parental mental health is highlighted by its connection to childhood developmental outcomes. A 2019 American Academy of Pediatrics technical report conveyed the extensive evidence that adverse childhood experiences, such as parental

Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 24, 2021 Prepublication Release depression, may have long-lasting impacts on a child’s development and general health.3 In fact, maternal PPD and psychological distress is likely to increase a child’s risk for delayed or impaired cognitive, emotional, and linguistic development as well as subsequent behavioral problems.4,18 More recent research reveals that paternal PPD detrimentally influences parenting and positive enrichment activities such as reading and telling stories.19,20 Paternal PPD has also been associated with subsequent child behavioral and emotional problems,21 with one study reporting depressed fathers are more likely to spank their 1-year-old children.20 Even while evidence supports the linkage between parental mental health, childhood development, and the emotionally taxing NICU environment, the trajectory of maternal and paternal depression symptoms from NICU admissions through the transition home is not well understood.

While experiences from NICU admission through discharge can adversely impact the emotional health of parents, the NICU is one of the few healthcare environments where integrated care is possible.22 Awareness in the NICU could provide better preventative management for families and a springboard from which primary care physicians can further assess emotional risk factors during follow-up visits. Fundamental to this heightened understanding is knowing when to screen NICU families and what other social and clinical factors to consider when evaluating parents’ likelihood of developing depression symptoms.

Therefore, the purpose of this study is to examine the trajectory of depression symptoms among mothers and fathers at several timepoints from NICU admission to thirty days post NICU discharge using the validated Edinburgh Postpartum Depression Scale (EPDS). We hypothesized

Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 24, 2021 Prepublication Release that from birth to discharge, depression symptom scores would decrease as the infant stabilized in the NICU and subsequently increase from discharge to thirty days at home for mothers and fathers perhaps in response to the stress and additional responsibility parents take on as they assume full care for their infants once home. Further, we examined the association of key social and clinical factors with depression scores up to 30 days post-discharge to assess the role these factors have in the predictability of being at-risk for depression symptoms.

Methods

Sample

This prospective longitudinal cohort study analysis collected data from April 2019 through

February 2020 in a quasi-experimental control-intervention smartphone application trial designed to support parents of NICU infants. As no relevant sociodemographic or outcome differences as a function of the study design were found, intervention and control parents are combined in the current study. Additionally, intervention status was included as a covariate in all analyses in order to account for potential variance in outcome due to intervention; none were noted. The research protocol was approved by Northwestern University’s Institutional Review

Board and registered at Clinical Trials as https://clinicaltrials.gov/ct2/show/NCT03505424 .

Fathers and mothers of premature infants (<37 weeks gestational age) admitted to the NICU

(NICU parents) at Prentice Woman’s Hospital, Chicago, Illinois were eligible for participation in this study (separately or together, regardless of marital status) if they were legal adults, English- speaking, expected to stay a minimum of a week, and if the medical team did not identify causes

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for exclusion (e.g. eminent death, child protective services involvement). Parents were excluded

from analysis if they did not complete at least one parental depression questionnaire across the

four study time points. Parents lacking an initial or discharge depression questionnaire score and

a depression questionnaire score at 30 days post-discharge were excluded from the prediction

analyses.

Procedure

After written informed consent was obtained upon NICU admission, parent and infant

demographics were collected by chart review and parental survey. Approximately one week after

admissions, a standardized parental depression symptom questionnaire was given to parents

(Initial Assessment). The same measure was administered at three additional time points: upon

NICU discharge [DC; mean within 2 days of DC (SD=6)], two weeks after NICU discharge

(DC+14) and 30 days after discharge (DC+30). All questionnaires were requested to be completed independently by each parent.

Measures

Depression symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS).23

The EPDS is a self-report questionnaire designed to screen for depression among women during

the postnatal period. The scale has also been used reliably with fathers24 and parents of preterm

infants25 in the postpartum. While a cut-off score of ≥13 has been used to dichotomously signify

a positive screen for major depression, research has validated that a score of 10 or higher has

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better sensitivity for major or minor depression23,26 and is useful for screening. Thus, a cut-off

score of 10 was considered a positive EPDS screening result.

In addition to standard demographic variables, social (i.e. marital status, education, employment

status, and income) and clinical (i.e. infant gestational age, length of stay (LOS), and birth

weight) variables were also collected. Race was categorized as white, black, Hispanic, or other; marital status was dichotomized as “married” and “not married”; education was dichotomized as

“less than college” or “college degree and higher”; household income was dichotomized at

$100,000 annually. Gestational age (GA) was categorized into three groups: <28 weeks, 28.0-

32.6, and >32 weeks GA.

Statistical Analyses

Demographic characteristics of the sample were summarized using means (standard deviations) or medians (ranges) for continuous variables and frequencies (percentages) for categorical variables. Mean EPDS score and frequency of positive EPDS screen was summarized across all

time points for the sample as a whole and individually by gender. The percentage of patients

with continuing depression was calculated for the sample as a whole and separately by parent

gender.

We used a series of mixed effects liner regression models to assess the change in EPDS score

across time. A random family effect was included in the model to account for covariance in

Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 24, 2021 Prepublication Release mother’s and father’s responses. To determine if trends in EPDS scores across time differed by parent gender and GA, we included the effect of parent gender, GA, the interactions of time*parent gender and time*GA, and the three-way interaction of time*parent gender*GA.

Final models were adjusted for additional covariates believed to be associated with the outcome

(parent age, race, marital status, education, employment status, household income, and LOS).

Additionally, intervention status was included as a covariate in all analyses to adjust for any variation in outcome caused by the intervention. Model results are reported as β estimates of the effect of each factor on the outcome of EPDS score, independent of each other factor, and model-based estimates of EPDS score at each time point were calculated for graphical display.

To assess change in probability of a positive EPDS screening across time, we repeated the above analyses using a series of mixed effect logistic regression models, including a random effect for family, the above listed interactions, and fully adjusting for covariates. Model results are reported as odds ratio of the effect of each factor on the dichotomous EPDS outcome, and estimates at each time point were calculated and transformed into odds of a positive screen to be displayed graphically. Results reported are from the fully adjusted models.

To assess the ability of depression screening while in the NICU to predict a positive screen at 30 days after discharge, we completed three simple logistic regression models: model 1 modeled the effect of baseline demographic characteristics (parent age, gender, race, marital status, education, employment status, household income and GA) on the dichotomous outcome of positive EPDS screening (i.e., EPDS ≥ 10) at 30 days after discharge; model 2 added the effect of the initial

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EPDS screening to model 1; model 3 added the effect of screening at discharge to model 1. Each

subject’s predicted outcome based on each model was compared to the subject’s actual outcome.

Receiver operating characteristic curves (ROCs) were generated, and area under the curve

(AUC) was calculated. AUC comparisons of models including prior EPDS score (models 2 and

3) were compared to those of the original model (model 1) using chi-square tests.27 These

analyses were repeated, stratifying by gender, to determine if classification differed between

mothers and fathers.

Results

Sample Characteristics

A total of 431 parents were enrolled at baseline [mothers, n=230 (53%); fathers, n=201 (47%)].

Of these parents, 75% of mothers (n=171) and 57% of fathers (n=113) completed their DC+30

days follow up EPDS screening; Table 1 shows sample demographic characteristics. Of note,

average infant gestational age was 31.5 weeks with median LOS 26 days (range 4-144 days). At

the initial EPDS assessment shortly after NICU admission, 33% of mothers (n=57) and 17% of

fathers (n=21) had a positive EPDS screening result with average scores of 8 for mothers and 6

for fathers (range 0-21).

Trajectories of Depressive Symptoms in NICU Parents

Table 2 shows the model-based estimates of effects on EPDS score, and Table 3 shows the

model-based odds ratios (that is, odds of a positive EPDS screen) for each effect. Figure 1

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shows the average EPDS score and the odds of a positive screen across all time points based on

these fully adjusted regression models. Change in score is represented by a solid line and change

in odds by a dotted line for mothers (circles) and fathers (triangles).

In the model of EPDS score across time, the interaction of time*gender and time*GA were both

significant (p<0.005 and p<0.05, respectively), indicating that the trend across time differs by

gender and gestational age (Table 2). Average change from the initial assessment to the final

assessment (30 days after discharge) was significantly different between mothers and fathers,

with mothers decreasing 2.9 points [CI: (2.1,3.7); p<0.0001)] and fathers decreasing 1.0 points

[CI: (0.1, 2.0); p=0.04)]. The three-way interaction of time*gender*GA was not significant

(p=0.19).

Figure 1 also shows the odds of a positive EPDS screen across time. At the initial assessment soon after NICU admission, mothers were 3.23 [CI: (0.65,16.03); p=0.15] times more likely to have a positive screen than fathers, although this result was not statistically significant. The odds of reporting depressive symptoms at the initial assessment was 10.96 times higher [CI:

(2.99,38.20); p=0.0003] at the initial assessment compared to 30 days post discharge for mothers; however, fathers’ odds did not change significantly during this time period (0.99 times

[CI: (0.26,3.79), (p=0.9854)]). The trend across time is statistically significantly different

between mothers and fathers (p=0.0077) and this effect was not moderated by gestational age

(p=0.5548) (Table 3).

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Ability to Predict Depression Symptoms After Discharge

Figure 2 shows the three ROC curves obtained from each of the models predicting positive

depressive symptom screening at DC+30 for the full sample. The AUC for the demographics-

only model (model 1) was 0.66 [CI: 0.57,0.74] (0.71 [CI: 0.58,0.82] for mothers, 0.61 [CI:

0.47,0.76] for fathers), suggesting demographic characteristics alone are poor predictors.

However, with the addition of EPDS score at either the Initial Assessment (model 2) or DC

(model 3), the AUC increases to 0.84 [CI: (0.77,0.91), (p<.0001)] (0.84 [CI: (0.74,0.94), (p =

0.0047)] for mothers; 0.82 [CI: (0.71,0.94), (p=0.0035)] for fathers) and 0.80 [CI: (0.73,0.88),

(p=0.0003)] (0.80 [CI: (0.70,0.91), (p=0.0132)] for mothers; 0.82 [CI: (0.71, 0.93), (p=0.0165)]

for fathers), respectively. Together, these results indicate that screening at NICU admission or

discharge can increase the likelihood of identifying positive depression symptom screening at 30

days post-discharge. Although the rate of depression differs across mothers and fathers, the ability to predict depression at 30-days post discharge is still increased by screening during the

NICU stay regardless of gender.

Discussion

In one of the largest clinical studies to date examining PPD among mothers and fathers of

premature infants over the course of their NICU stay, transition home and first 30 days at home,

we found unanticipated differences by gender. In regards to our hypotheses, mothers indeed

experience both a decrease in average depression symptom scores and probability of screening

positive for depression. However, our hypothesis in regard to fathers was not supported. Rather,

in this sample, while fathers did have a small and significant decrease in EPDS scores from

Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 24, 2021 Prepublication Release initial assessment to one month after discharge, the probability of a positive depression screen remained the same across time. In other words, while mothers showed improvement over time in their EPDS scores, fathers essentially stayed the same.

In our analyses of potential social and demographic predictors of depression screening, few variables were associated with a positive depression screening at any one point. While this may be due to sample homogeneity, our evidence supports the notion that screening for depression during the NICU stay has an improved predictive value based on ROC curve dynamics at 30- days post-discharge.

The increased depression symptom scores reported by mothers early in the NICU admissions period is similar to other research measuring mothers of preterm infants’ depression symptoms shortly after birth6,9 and consistent with higher reports of maternal depression screening symptoms compared to fathers.9 Of note, a metanalysis of 23 longitudinal studies reported a decrease in the severity of depression symptoms among all mothers - not just mothers of medically vulnerable infants – over time.28 While the trajectory of depression screening symptoms among mothers in our study reveals lower reported average depression symptoms as time proceeds, other research shows that the pattern of maternal PPD is not homogenous.28,29

Our study includes a large sample of NICU fathers during two key life course transitions: the transition into fathering a new child and the transition from NICU to home with that child. Prior research has found that the transition to fatherhood can be associated with as much as a 68%

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increase in depression screening symptoms (prematurity unspecified).30 Despite this, fathers in

this study reported lower average depression symptom scores at 30 days post-discharge

compared to the early NICU period, consistent with other research.9 However, similar to one study with a 2-month follow-up,31 the probability of a positive score remained comparable across

the study period, and when compared to mothers, fathers showed less improvement over time.

Other research examining rates of stress disorders among parents of NICU infants found that

fathers meet the diagnostic criteria of the examined disorders at rates higher than mothers 4

months after their infants’ births17 – further highlighting the importance of closely examining

post-NICU psychological pathologies among fathers.

Identifying NICU parents at-risk for PPD remains a challenge in pediatrics despite

recommendations from national organizations for screening of mothers and fathers32,33. With the

growing understanding of the importance of parental mental health on family and infant

wellbeing, universal screening of parents along with training of NICU bedside staff to help

communicate and potentially identify parents who are struggling is needed. Resources made

available to those parents at any point during the NICU or home timeframe can take the form of

trained social work or mental health professionals embedded in the NICU to begin making

referrals more available for outpatient support once the infant is discharged.

An important aspect of understanding the development of PPD among NICU mothers and fathers

is understanding what clinical and social factors are predictive of later depression. Notably,

previous research has found that elevated depression symptoms in fathers was associated with

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adverse social and relationship factors.34 Further, an array of different biological and behavioral

expressions of depression have been reported between men and women.35,36 Despite these gender

differences, the demographic characteristics we included were not associated with a positive depression screening result at 30 days post-discharge; screening at admission or discharge was associated, emphasizing the need for screening.

A number of limitations are present in this study. This study utilized depression screening questionnaires without diagnostic interviews. However, EPDS has reasonable sensitivity and clinical applicability for identifying postpartum depression. Furthermore, we are unable to predict how unpartnered parents may be impacted. While LOS or GA were used as model proxies for the severity of infant’s clinical condition, the direct effect of infant condition on outcomes may be unaccounted for. Models were also not adjusted for known depression risk factors among parents like past mental health diagnosis, substance abuse, or other trauma as this data was not collected. Finally, this study period lasted until 30-days post-discharge; symptoms may vary after this time period.

Insight into when and which parents of NICU infants experience depression symptoms and what predictive factors of positive depression screening results allows clinicians and families to better anticipate parental mental health needs after NICU discharge. Clinicians must understand how different populations are at risk for PPD37 to ensure optimal child outcomes. Screening parents

for PPD while their infant is in the NICU may be a key first step toward assisting both parents

and, in the case of fathers in particular, becoming aware of potential post-discharge needs.

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Acknowledgments

The authors acknowledge Friends of Prentice for a generous grant to conduct this research. The

funders did not influence in any way the outcomes or reporting of the findings in this study.

References

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14. Areias MEG, Kumar R, Barros H, Figueiredo E. Comparative Incidence of Depression in Women and Men, During Pregnancy and after Childbirth: Validation of the Edinburgh Postnatal Depression Scale in Portuguese Mothers. British Journal of Psychiatry. 1996;169(1):30-35. 15. Paulson JF, Bazemore SD. Prenatal and Postpartum Depression in Fathers and Its Association With Maternal Depression: A Meta-analysis. JAMA. 2010;303(19):1961- 1969. 16. Garfield CF, Simon CD, Rutsohn J, Lee YS. Stress From the Neonatal Intensive Care Unit to Home: Paternal and Maternal Cortisol Rhythms in Parents of Premature Infants. J Perinat Neonatal Nurs. 2018;32(3):257-265. 17. Shaw RJ, Bernard RS, DeBlois T, Ikuta LM, Ginzburg K, Koopman C. The Relationship Between Acute Stress Disorder and Posttraumatic Stress Disorder in the Neonatal Intensive Care Unit. Psychosomatics (Washington, DC). 2009;50(2):131-137. 18. Gray RF, Indurkhya A, McCormick MC. Prevalence, Stability, and Predictors of Clinically Significant Behavior Problems in Low Birth Weight Children at 3, 5, and 8 Years of Age. Pediatrics. 2004;114(3):736. 19. Paulson JF, Dauber S, Leiferman JA. Individual and Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting Behavior. Pediatrics. 2006;118(2):659. 20. Davis RN, Davis MM, Freed GL, Clark SJ. Fathers' Depression Related to Positive and Negative Parenting Behaviors With 1-Year-Old Children. Pediatrics. 2011;127(4):612. 21. Gutierrez-Galve L, Stein A, Hanington L, et al. Association of Maternal and Paternal Depression in the Postnatal Period With Offspring Depression at Age 18 Years. JAMA Psychiatry. 2019;76(3):290-296. 22. Bogen DL, Fisher SD, Wisner KL. Identifying Depression in Neonatal Intensive Care Unit Parents: Then What? The Journal of Pediatrics. 2016;179:13-15. 23. Cox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry. 1987;150(6):782-786. 24. Matthey S, Barnett B, Kavanagh DJ, Howie P. Validation of the Edinburgh Postnatal Depression Scale for men, and comparison of item endorsement with their partners. Journal of Affective Disorders. 2001;64(2):175-184. 25. Hawes K, McGowan E, O'Donnell M, Tucker R, Vohr B. Social Emotional Factors Increase Risk of Postpartum Depression in Mothers of Preterm Infants. The Journal of Pediatrics. 2016;179:61-67. 26. Murray L, Carothers AD. The Validation of the Edinburgh Post-natal Depression Scale on a Community Sample. British Journal of Psychiatry. 1990;157(2):288-290. 27. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the Areas under Two or More Correlated Receiver Operating Characteristic Curves: A Nonparametric Approach. Biometrics. 1988;44(3):837-845. 28. Vliegen N, Casalin S, Luyten P. The Course of Postpartum Depression: A Review of Longitudinal Studies. Harvard Review of Psychiatry. 2014;22(1). 29. McCall-Hosenfeld JS, Phiri K, Schaefer E, Zhu J, Kjerulff K. Trajectories of Depressive Symptoms Throughout the Peri- and Postpartum Period: Results from the First Baby Study. Journal of Women's Health. 2016;25(11):1112-1121.

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30. Garfield CF, Duncan G, Rutsohn J, et al. A Longitudinal Study of Paternal Mental Health During Transition to Fatherhood as Young Adults. Pediatrics. 2014;133(5):836. 31. Cyr-Alves H, Macken L, Hyrkas K. Stress and Symptoms of Depression in Fathers of Infants Admitted to the NICU. Journal of obstetric, gynecologic, and neonatal nursing. 2018;47(2):146-157. 32. Earls MF, Yogman MW, Mattson G, Rafferty J. Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics. 2019;143(1):e20183259. 33. Yogman M, Garfield CF. Fathers’ Roles in the Care and Development of Their Children: The Role of Pediatricians. Pediatrics. 2016;138(1):e20161128. 34. Underwood L, Waldie KE, Peterson E, et al. Paternal Depression Symptoms During Pregnancy and After Childbirth Among Participants in the Growing Up in New Zealand Study. JAMA Psychiatry. 2017;74(4):360-369. 35. Labaka A, Goñi-Balentziaga O, Lebeña A, Pérez-Tejada J. Biological Sex Differences in Depression: A Systematic Review. Biological Research For Nursing. 2018;20(4):383- 392. 36. Cavanagh A, Wilson CJ, Kavanagh DJ, Caputi P. Differences in the Expression of Symptoms in Men Versus Women with Depression: A Systematic Review and Meta- analysis. Harvard review of psychiatry. 2017;25(1):29-38. 37. Verkerk GJM, Pop VJM, Van Son MJM, Van Heck GL. Prediction of depression in the postpartum period: a longitudinal follow-up study in high-risk and low-risk women. Journal of Affective Disorders. 2003;77(2):159-166.

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Table 1: Demographic Characteristics of Families and Infants

Overall Female Male Characteristic (n = 431) * (n = 230) * (n = 201) *

Family

Married, No. (%) 348 (82) 179 (79) 169 (86) College degree, No. (%) 319 (75) 172 (76) 147 (74) Household income of $100,000 or more, No. (%) 305 (73) 152 (68) 153 (78) Parent Age, mean (SD), y 34.0 (5.6) 33.0 (5.1) 35.1 (5.9)

Employment, No. (%)

Full-time 337 (80) 154 (68) 183 (94) Not Full-Time 82 (20) 71 (32) 11 (6)

Race, No. (%)

White 251 (59) 123 (54) 128 (64) Black 72 (17) 40 (18) 32 (16) Hispanic 54 (13) 37 (16) 17 (9) Other 49 (12) 27 (12) 22 (11)

Overall Infant (n = 336) * Gestational age, mean (SD), w 31.5 (4.5)

Gestational age category, No. (%)

<28 weeks 41 (10)

28-32.6 weeks 154 (36)

>32 weeks 236 (55)

Birth weight, mean (SD), g 1872 (788)

Length of stay, median (range), d 26 (4 to 144)

*Totals may not equal 100% due to missing data or rounding.

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Table 2: Linear Regression Results for Edinburgh Postpartum Depression Scale (EPDS) Score Model

EPDS Outcome Model

Effect

Effect (β) 95% CI

Time -0.59*** (-0.89,-0.30)

Male Gender -2.22*** (-3.31,-1.12)

Gestational Age (reference = 32+ weeks)

<28 weeks 1.69 (-1.74,5.11)

28.0-32.6 weeks 1.18 (-0.20,2.56)

Time*Gender Interaction 0.49** (0.15,0.83)

Time*Gestational Age Interaction

<28 weeks -0.78* (-1.42,-0.13)

28.0-32.6 weeks -0.51** (-0.85,-0.17)

Time*Gender*Gestational Age Interaction

<28 weeks 0.25 (-0.62,1.12)

28.0-32.6 weeks 0.43 (-0.03,0.89)

Intervention Group -1.19* (-2.33,-0.04)

Time*Group Interaction 0.02 (-0.27,0.32)

Race (reference = White)

Black -1.18 (-2.59,0.24)

Hispanic -0.33 (-1.81,1.14)

Other 0.91 (-0.41,2.23)

Married -0.49 (-1.81,0.84)

Greater than HS Education 1.51* (0.20,2.81)

Full-time Employed 1.13 (-0.02,2.28)

Household Income > $100,000 -0.54 (-1.84,0.76)

Length of Stay 0.01 (-0.02,0.05) * p < 0.05 ** p < 0.005 *** p < 0.0001

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Table 3: Logistic Regression Results for Edinburgh Postpartum Depression Scale (EPDS) Dichotomous Outcome Model

Dichotomous Outcome Model (OR)

Odds Ratio 95% CI

Effect (OR)

Time 0.67* (0.44,1.01)

Male Gender 0.09** (0.02,0.36)

Gestational Age (reference = 32+ weeks)

<28 weeks 13.20 (0.35,494.72)

28.0-32.6 weeks 7.61* (1.52,37.83)

Time*Gender Interaction 1.99* (1.2,3.3)

Time*Gestational Age Interaction

<28 weeks 0.41 (0.16,1.05)

28.0-32.6 weeks 0.54* (0.32,0.9)

Time*Gender*Gestational Age Interaction

<28 weeks 1.58 (0.55,4.6)

28.0-32.6 weeks 1.28 (0.72,2.29)

Intervention Group 0.23* (0.06,0.91)

Time*Group Interaction 1.13 (0.73,1.73)

Race (reference = White)

Black 0.44 (0.09,2.06)

Hispanic 0.52 (0.11,2.49)

Other 1.54 (0.4,5.85)

Married 0.46 (0.1,2.09)

Greater than HS Education 3.32 (0.81,13.63)

Full-time Employed 3.32 (1.03,10.75)

Household Income > $100,000 0.73 (0.19,2.83)

Length of Stay 1.01 (0.98,1.04) * p < 0.05 ** p < 0.005 *** p < 0.0001

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Figure 1: Total Score and Probability of a Positive Edinburgh Postpartum Depression Scale (EPDS) Score

Over Time

10 0.6

9

0.5 8

7 0.4 10 6 Female Male 5 0.3 EPDS Score 4 Score Probability 0.2 Proability of EPDS ≥ 3

2 0.1

1

0 0 Initial Assessment DC DC+14 DC+30

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Figure 2. Receiver Operating Characteristic Curves for Models Predicting Depressive Symptoms 30 days after NICU Discharge

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