Attendance at Mental Health Appointments by Women Who Were Referred During Pregnancy or the Postpartum Period

Symptoms of Depression in the Postpartum Period: Targeting Maternal Mental Health in the Perinatal Period

This cross-sectional study aimed to examine the relationship between postpartum depression symptoms, anxiety, and stress during the postpartum period. A total of 101 women were assessed using the Depression, Anxiety and Stress Scale (DASS-21) and the Edinburgh Postnatal Depression Scale (EPDS) within 14 days after delivery. Multivariate regression analysis revealed that paid work, tobacco use, and stress symptoms were significantly associated with a higher incidence of postpartum depression symptoms. These results underscore the importance of comprehensive prenatal care and effective postpartum follow-up to address maternal mental health and prevent adverse outcomes for both mothers and children.

The feasibility and acceptability of a single-session Acceptance and Commitment Therapy (ACT) intervention to support women self-reporting fear of childbirth in a first pregnancy

OBJECTIVE

To assess the feasibility and acceptability of a single-session Acceptance and Commitment Therapy intervention to help women manage fear of childbirth during a first pregnancy.

DESIGN

A mixed-methods approach including qualitative feedback and pre/post-intervention self-report measures. Pregnant women (14-37 weeks gestation) were recruited via the UK National Health Service and attended a single-session (<3 hours) Acceptance and Commitment Therapy intervention alongside routine antenatal care. Data were analysed using content and statistical analyses.

MAIN OUTCOME MEASURES

Fear of childbirth, anxiety and wellbeing were the main outcome measures. Secondary to these, intolerance of uncertainty and valued life domains (e.g. relationships, recreation) as hypothesised mechanisms of change, were also assessed.

RESULTS

33 expressions of interest were received, 21 women signed up, 15 participated, and 11 completed follow-up measures (participation rate: 33%). Findings demonstrated clinical and statistical reductions in fear of childbirth and anxiety alongside positive feedback on the intervention. Intolerance of uncertainty and wellbeing were low at baseline and remained unchanged.

CONCLUSION

A single-session Acceptance and Commitment Therapy intervention to manage fear of childbirth is potentially feasible and acceptable. A pilot randomised controlled trial is warranted. Further research should explore efficacy and how Acceptance and Commitment Therapy may reduce perinatal distress.

A randomized controlled trial on using predictive algorithm to adapt level of psychological care for community college students: STAND triaging and adapting to level of care study protocol

BACKGROUND

There is growing interest in using personalized mental health care to treat disorders like depression and anxiety to improve treatment engagement and efficacy. This randomized controlled trial will compare a traditional symptom severity decision-making algorithm to a novel multivariate decision-making algorithm for triage to and adaptation of mental health care. The stratified levels of care include a self-guided online wellness program, coach-guided online cognitive behavioral therapy, and clinician-delivered psychotherapy with or without pharmacotherapy. The novel multivariate algorithm will be comprised of baseline (for triage and adaptation) and time-varying variables (for adaptation) in four areas: social determinants of mental health, early adversity and life stressors, predisposing, enabling, and need influences on health service use, and comprehensive mental health status. The overarching goal is to evaluate whether the multivariate algorithm improves adherence to treatment, symptoms, and functioning above and beyond the symptom-based algorithm.

METHODS/DESIGN

This trial will recruit a total of 1000 participants over the course of 5 years in the greater Los Angeles Metropolitan Area. Participants will be recruited from a highly diverse sample of community college students. For the symptom severity approach, initial triaging to level of care will be based on symptom severity, whereas for the multivariate approach, the triaging will be based on a comprehensive set of baseline measures. After the initial triaging, level of care will be adapted throughout the duration of the treatment, utilizing either symptom severity or multivariate statistical approaches. Participants will complete computerized assessments and self-report questionnaires at baseline and up to 40 weeks. The multivariate decision-making algorithm will be updated annually to improve predictive outcomes.

DISCUSSION

Results will provide a comparison on the traditional symptom severity decision-making and the novel multivariate decision-making with respect to treatment adherence, symptom improvement, and functional recovery. Moreover, the developed multivariate decision-making algorithms may be used as a template in other community college settings. Ultimately, findings will inform the practice of level of care triage and adaptation in psychological treatments, as well as the use of personalized mental health care broadly.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05591937, submitted August 2022, published October 2022.

Perinatal depression and mental health uptake referral rate in an obstetric service

Perinatal depression is an important indicator of mothers' mental health. Studies have been carried out to identify and characterize women at risk of such affective disorder. The aim of this study is to assess mothers' adherence to our perinatal depression screening and eventual follow-up by a multidisciplinary team, including mental health and obstetrics professionals. Ultimately, a risk profile for the uptake rate of referral was described to psychological support. Pregnant women from a maternity of a tertiary center with on-site assessment and treatment (n = 2163) were included in this study. The identification of women at risk for depression was based on a two-question screening and the EPDS scale. Demographic and obstetric data were obtained from medical records. The number of screening evaluations, the uptake referral rate and the compliance to treatment were analyzed. Logistic regression was used to predict a risk profile for adherence. Among 2163 enrolled in the protocol, 10.2% screened positive for depression. Of these, 51.8% accepted referral for mental health assistance. 74.9% were compliant to Psychology appointments and 74.1% to Psychiatry appointments. Women who had a previous history of depression were more likely to accept referral for mental health support. With this study, we were able to understand the behaviour of this population towards the screening protocol we offer. Women with a previous history of depression are more likely to accept mental health assistance.

Reducing psychiatric illness in the perinatal period: A review and commentary

This brief overview highlights the global crisis of perinatal psychiatric illness (PPI). PPI is a major contributor to many adverse pregnancy, childbirth, and childhood development outcomes. It contributes to billions of dollars in spending worldwide each year and has a significant impact on the individual, their family, and their community. It is also highly preventable. Current recommendations for intervention and management of PPI are limited and vary considerably from country to country. Furthermore, there are several significant challenges asso-ciated with implementation of these recommendations. These challenges are magnified in number and consequence among women of color and/or minority populations, who experience persistent and negative health disparities during pregnancy and the postpartum period. This paper aims to provide a broad overview of the current state of recommendations and implementation challenges for PPI and layout a framework for overcoming these challenges. An equity-informed model of care that provides universal intervention for pregnant women may be one solution to address the preventable consequences of PPI on child and maternal health. Uniquely, this model emphasizes the importance of managing and eliminating known barriers to traditional health care models. Culturally and contextually specific challenges must be overcome to fully realize the impact of improved management of PPI.

Personas of pregnant and parenting women with substance use and their barriers and pathways to system engagement

BACKGROUND

Women with prenatal substance use have been identified as at-risk for the lack of engagement in perinatal services, such as medical care and home visitation programs. This issue is of particular concern in Florida (United States) where rates of fetal substance exposure have been steadily increasing.

METHODS

To identify pathways of and barriers to perinatal system and service engagement, journey mapping was used to compile various personas of perinatal women with substance use. A structured guide was developed to elicit maternal personas, system and service touchpoints, and system strengths and weaknesses from focus group participants with statewide stakeholders, including perinatal service administrators and community coalition members within three Florida communities. Workshop transcripts, debriefing, and member-checking sessions were transcribed verbatim and analyzed manually.

RESULTS

Six journey-mapping workshops and two member-checking meetings with mothers in-recovery were conducted with a total of 109 participants. Four personas were identified: women who (1) have substance use on a recreational basis, (2) have prescription drug use/misuse, (3) have chronic substance dependence, and (4) are in-recovery from substance dependence. Pathways that promote and barriers that prevent perinatal women with substance use from being identified, referred, or willing to accept and engage in medical care and social services were identified.

CONCLUSIONS

While these personas shed light on differential pathways experienced by women with OUD, they were not intended as fixed-member groups but rather fluid descriptions of circumstances in which individuals could shift over time. These personas are beneficial to understand differences in circumstances, as well as variations in pathways and barriers to service engagement. Additionally, personas may be used to identify approaches to optimize service engagement by perinatal women with substance use and to support system improvements and integrations.

Rate and Predictors of Patients with Chronic Pain Establishing Care with Pain Psychology Following Pain Physician Referral

OBJECTIVE

To determine, among patients with chronic pain who had received pain physician referral to pain psychology, the rate of establishing care and factors related to establishing care with pain psychology.

DESIGN

Retrospective study.

SETTING

Academic tertiary care center.

SUBJECTS

Patients from the University of California, San Diego (UCSD) Center for Pain Medicine.

METHODS

This was an institutional review board-approved, retrospective study of 150 consecutive referrals of unique patients from UCSD Pain Medicine to UCSD Pain Psychology.

RESULTS

Of 150 patients referred to pain psychology, 74 (49.3%) established care with pain psychology. Of 98 patients who had previously seen mental health services, 58 established care with pain psychology (59.2%; 95% confidence interval [CI]: 49% to 69%), whereas of 52 patients who had not previously seen mental health services, 16 established care with pain psychology (30.8%; 95% CI: 18% to 43%) (odds ratio [OR] 3.26; 95% CI: 1.60 to 6.66). In the patient subset with depression and/or anxiety, of 82 patients who had previously seen mental health services, 47 established care with pain psychology (57.3%; 95% CI: 47% to 68%), whereas of 20 patients who had not previously seen mental health services, three established care with pain psychology (15%; 95% CI: -1% to 31%) (OR 7.61; 95% CI: 2.07 to 28.01). Of 96 patients referred for general pain psychology evaluations, 43 established care (45%; 95% CI: 35% to 55%), whereas of 38 patients referred for preprocedural evaluation for an implantable device, 24 established care (63%; 95% CI: 48% to 78%).

CONCLUSION

Patients are significantly more likely to establish care with pain psychology if they have previously seen a mental health professional. This was even more marked among the patient subset with a history of depression and/or anxiety who had engaged in mental health services than among those with a history of depression and/or anxiety who had not engaged in mental health services. Whether referral was for general psychological evaluation or preprocedural evaluation for an implantable device did not significantly influence whether patients established care. Targeted interventions are needed to improve the likelihood of patients engaging with pain psychology services.

Barriers and facilitators to supporting women with postnatal depression and anxiety: A qualitative study of maternal and child health nurses' experiences

AIMS AND OBJECTIVES

To explore maternal and child health nurses' experiences of supporting women with postnatal depression and anxiety and the factors which impact these.

BACKGROUND

Maternal and child health nurses play a key role in identifying women with postnatal depression and anxiety and facilitating their access to appropriate supports. Understanding how nurses carryout this work, and the conditions which impact their ability to do so, is critical to the development of service delivery frameworks that can facilitate optimal outcomes for women and their families. Despite this, little is known about this subject.

DESIGN

A qualitative descriptive study.

METHODS

Participants were maternal and child health nurses practicing for at least six months and regularly seeing new mothers in Victoria, Australia. Twelve nurses were interviewed. Thematic analysis was conducted to identify patterns across our data. Qualitative content analysis was used to identify issues which were most emphasised by nurses. Reporting complies with the COREQ checklist.

FINDINGS

Three overarching themes were identified. Theme one pertained to steps taken by nurses following the identification of depression or anxiety symptoms and the shared challenges they encountered. Theme two concerned nurses' experiences of supporting women who required acute mental health interventions and the systemic barriers they faced. Finally, theme three related to how the existing service delivery model could be improved to better support nurses in their work.

CONCLUSIONS

The complex system within which nurses operate presents barriers that can impede their ability to respond to women with postnatal mental health issues. There is a need for service delivery frameworks that better support nurses and facilitates equitable access to mental healthcare.

RELEVANCE TO CLINICAL PRACTICE

Facilitating equitable access to all perinatal mental health services and interventions must be at the heart of all future policy, funding and service delivery frameworks.

A Family-Based Collaborative Care Model for Treatment of Depressive and Anxiety Symptoms in Perinatal Women: Results from a Pilot Study (Preprint)

BACKGROUND

Untreated perinatal depression and anxiety can have detrimental consequences on family function. Logistical barriers prevent many perinatal women from accessing treatment, and these barriers are compounded for women residing in rural areas. This paper describes a Family-Based Collaborative Care Model (FBCCM) that is designed to bypass barriers to increase access to care for depressed and anxious perinatal women in rural regions of the United States. The FBCCM includes the following two components: (1) a 10-session video-delivered family therapy treatment for perinatal depression and anxiety and (2) a video-delivered infant care provider training on addressing the parenting needs of depressed and anxious mothers.

OBJECTIVE

This paper describes the feasibility of implementing the FBCCM with families and infant care providers. Findings are presented on the preliminary effectiveness of the video-delivered family therapy treatment in reducing maternal depressive and anxiety symptoms, and family conflict.

METHODS

This pilot study was carried out using an implementation-effectiveness hybrid trial design without a comparison group. Changes in maternal depressive symptoms, maternal anxiety symptoms, and family conflict were measured at posttreatment, 3 months, and 6 months later.

RESULTS

On average, mothers (n=24) attended 9.79 (SD 1.02) sessions. On average, their family members (n=24) attended 9.42 (SD 1.28) sessions. A total of 31 infant care providers attended the training on addressing the parenting needs of depressed and anxious mothers. Mothers reported a significant reduction in depressive symptoms (P<.001) and anxiety symptoms (P<.001) from baseline to the 6-month follow-up. Mothers reported a significant reduction in conflict (P<.001), and their family members also reported a significant reduction in conflict (P=.007) from baseline to the 6-month follow-up.

CONCLUSIONS

The findings from this study provide support for the feasibility and preliminary effectiveness of the FBCCM. The findings will be used to inform a larger study of the FBCCM.

Is Postpartum Patient Navigation Uniquely Beneficial for Women with Antenatal Depressive Symptoms?

OBJECTIVE

Women with depression benefit substantively from the comprehensive postpartum visit yet are less likely to attend such visits. Postpartum patient navigation has been associated with improved postpartum visit attendance. Thus, the objective of this study was to determine whether patient navigation was associated with differential postpartum visit attendance for low-income, largely racial/ethnic minority women with antenatal depressive symptoms.

STUDY DESIGN

This is a secondary analysis of a prospective postpartum patient navigation program for adult, low-income, largely racial/ethnic minority women receiving prenatal care at a single university clinic (n = 474). Patient navigators assumed supportive and logistical responsibilities for patients between delivery and postpartum visit completion ("navigation cohort"); women in the navigation cohort were compared with women who would have been eligible for patient navigation but received care the year before program implementation ("pre-navigation cohort"). Women were considered to have antenatal depressive symptoms if they had a Patient Health Questionnaire-9 score above 9 prior to delivery. The primary outcome was attendance at the comprehensive postpartum visit by 12 weeks. Factors associated with this outcome were assessed in a prenavigation cohort of women and were subsequently evaluated in the total cohort (prenavigation and navigation groups) using multivariable models. An interaction term between antenatal depressive symptoms and navigation status was generated to evaluate for effect modification.

RESULTS

In the prenavigation cohort, antenatal depressive symptoms were more frequent among women who did not attend the postpartum visit (25.0 vs. 10.2%, p = 0.002) and remained a risk factor for postpartum visit nonattendance on multivariable analysis (adjusted odds ratio [aOR]: 0.39, 95% confidence interval [CI]: 0.18-0.83). In the navigation cohort (n = 218), the presence of antenatal depressive symptoms was not associated with attendance (p = 0.117). In multivariable analyses of the total cohort, the interaction term between antenatal depressive symptoms and navigation was statistically significant (aOR: 11.06, 95% CI: 1.21-101.08).

CONCLUSION

Postpartum patient navigation appears particularly beneficial among women with antenatal depressive symptoms for increasing postpartum appointment attendance.

KEY POINTS

· Patient navigation has been associated with improved postpartum visit attendance.. · Among low-income women, antenatal depressive symptoms are a risk factor for postpartum visit nonattendance.. · Postpartum patient navigation appears particularly beneficial among women with antenatal depressive symptoms..

Adapting and testing a brief intervention to reduce maternal anxiety during pregnancy (ACORN): report of a feasibility randomized controlled trial

BACKGROUND

We investigated the acceptability and feasibility of a new brief intervention for maternal prenatal anxiety within maternity services in London and Exeter, UK.

METHODS

One hundred fourteen pregnant individuals attending their 12-week scan at a prenatal clinic with elevated symptoms of anxiety (GAD-7 score of ≥7) were randomly assigned to either the ACORN intervention + Treatment as usual (TAU) (n = 57) or to usual care only (n = 57). The ACORN intervention consisted of 3 2-h group sessions, led by a midwife and psychological therapist, for pregnant individuals and their partners. The intervention included psychoeducation about anxiety, strategies for problem-sovling and tolerating uncertainty during pregnancy, including communicating about these with others, and mindfulness exercises.

RESULTS

Engagement rates with ACORN met or exceeded those in primary care services in England. In the intervention arm, 77% (n = 44) of participants attended at least one session, 51% (n = 29) were adherent, defined as attending two or more sessions. Feedback was positive, and participants in the ACORN treatment group demonstrated evidence of a larger drop in their levels of anxiety than the participants in the TAU-only group (Cohen's d = 0.42).

CONCLUSION

The ACORN intervention was acceptable to pregnant individuals and their partners and resulted in reductions in anxiety. With further evaluation in a larger-scale trial with child outcomes, there is significant potential for large scale public health benefit.

The birth trauma psychological therapy service: An audit of outcomes

OBJECTIVE

To evaluate routinely collected service data from a 'Birth Trauma' psychology clinic integrated into maternity services, in order to review effectiveness for women with symptoms of Post-Traumatic Stress Disorder (PTSD) following childbirth.

BACKGROUND

Prevalence of PTSD after child-birth has been estimated to be around 3% for women meeting full diagnostic criteria and up to 9% for sub-threshold symptoms. This can occur even in response to deliveries considered to be medically straightforward. NICE guidelines (2018) recommend psychological therapy as a first line treatment for symptoms of PTSD.

METHODS

The sample included 114 women referred post-natally for psychological assessment and intervention following a traumatic birth experience. Measures were routinely administered as part of initial assessment (T1) and at completion of intervention (T2). Data from these measures were collated and analyzed using a series of paired sample t tests. Following assessment 101 women were taken on for psychological intervention and of these, 74 completed both T1 and T2 measures.

RESULTS

There were highly significant reductions across all measures of PTSD, anxiety and negative mood symptoms. The treatment effect sizes were very large. Mean total score on a measure of PTSD symptomatology was no longer clinically significant following interventions.

CONCLUSION

This evaluation suggests an integrated Birth Trauma psychology clinic using a small number of contact sessions is a highly efficient and effective model of care for women experiencing symptoms of PTSD following childbirth.

Pushing beyond the silos: the obstetrician's role in perinatal depression care

Perinatal depression is one of the most common medical complications during and after pregnancy, occurring in up to 20% of new mothers in the USA. It can have both short- and long-term effects on the mother, child, and family. Multiple etiologies have been proposed for perinatal depression, and there are many reported genetic, epigenetic, environmental, socioeconomic, and psychosocial risk factors. Perinatal depression can be treatable but remains underdiagnosed and undertreated for a variety of reasons, including inconsistent clinical definitions, inconsistent screening, social stigma, and logistic/financial barriers to evidence-based treatments. The diagnosis and treatment of perinatal depression can be complicated by the frequent need for coordination among multiple care providers before and after childbirth. Among the care providers who may encounter perinatal depression, obstetricians are uniquely positioned to provide anticipatory guidance at regular prenatal visits and to identify symptoms and coordinate care, as they follow patients at multiple encounters throughout pregnancy and into the postpartum period. While obstetricians are already among the most common healthcare professionals who diagnose and treat perinatal depression, an opportunity for obstetricians to enhance early detection and treatment of perinatal depression exists. Professional societies and patient advocacy organizations support implementation of universal screening during the perinatal period, and validated clinical tools can detect nearly 50% more patients than more informal methods. This review outlines our current knowledge of perinatal depression and highlights the vital role of obstetricians in screening and treatment.

Program Evaluation of an Integrated Behavioral Health Clinic in an Outpatient Women's Health Clinic: Challenges and Considerations

Many women receive their regular check-ups and preventive care through a women's health clinic, including their behavioral health needs. Most of these clinics have not yet developed the capacity to adequately manage behavioral health concerns. We describe our clinical experience integrating behavioral health services into a women's health clinic. In one year, 108 women (54% White, M_age= 35) were referred for behavioral health treatment 47% were identified using a screening questionnaire, 51% were referred by their women's health provider and 2% were self-referred. The most common presenting concerns were anxiety (52%) and depressive symptoms (48%). Sixty-one (56%) patients completed an intake assessment, of whom 33 (54%) engaged in follow-up treatment (M = 3.7 treatment sessions, SD = 3.0). Behavioral health screening and treatment appears to be feasible and effective within a women's health setting. Further research is needed to overcome barriers to referrals and treatment engagement in this population.

Developing a Model to Address Mental Health, Substance Use, and Intimate Partner Violence Among Home Visiting Clients

Perinatal women enrolled in home visiting (HV) programs exhibit high rates of depression, substance use, and intimate partner violence (IPV). While HV programs have increasingly screened for these psychosocial risks, initiation and uptake of community-based services to address these risks remain challenging. This project used a community-engaged research approach to engage key HV stakeholders in developing the screening, referral, and individualized prevention and treatment (SCRIPT) model. We highlight how a group of key HV stakeholders-the SCRIPT Advisory Panel-collaborated with academic researchers to develop the SCRIPT model by reviewing literature on HV programs' response to psychosocial risk factors and qualitative data obtained from mental health, substance use, and IPV service providers to whom HV programs referred clients. SCRIPT focuses on (a) screening for psychosocial risks, (b) developing partnerships with outside agencies to address these risk factors, and (c) establishing concrete and systematic processes for client referral and monitoring with outside agencies. SCRIPT provides a structured model for HV programs to systematically identify clients for key psychosocial risks and structure their referral and monitoring process when working with social service agencies. Future work should examine the impact of SCRIPT on mental health, substance use, and IPV service access and use by a vulnerable population.

Experiences of Women with Postpartum Depression Participating in a Support Group Led by Mental Health Providers

PURPOSE

The purpose of this study was to explore experiences of women currently with or at high risk for developing postpartum depression (PPD) who were participating in a postpartum support group facilitated by mental health providers.

STUDY DESIGN AND METHODS

Using a qualitative design, women ≥18 years of age, who had given birth within the past 2 years, and who were currently attending, or had attended the PPD support group within the past year were invited to participate. The women provided demographic data and participated in a semistructured face-to-face interview. Data were analyzed using qualitative content analysis.

RESULTS

Seven women between 27 and 38 years of age participated. Most were married and college educated. At time of the interviews, participants were between 5 months and 2 years postpartum and all reported taking antidepressant medications for their symptoms. Qualitative content analysis revealed three overall themes: attendance, impact, and medication adherence, with associated subthemes.

CLINICAL IMPLICATIONS

Women attending a PPD support group facilitated by mental health providers felt supported, were more likely to disclose their symptoms to other women in the same situation, and were able to share their feelings without fear of judgment. Having concerns about antidepressant medication addressed at each meeting promoted medication adherence. Nurses working with childbearing women should be aware of community support services available for women at risk for developing PPD.

Intimate partner violence during pregnancy in relation to non-psychotic mental health disorders in Rwanda: a cross-sectional population-based study

OBJECTIVES

To investigate the prevalence of non-psychotic mental health disorders (MHDs) and the association between exposure to all forms of intimate partner violence (IPV) during pregnancy and MHDs.

DESIGN

Cross-sectional population-based study conducted in the Northern Province of Rwanda and Kigali city.

PARTICIPANTS AND SETTINGS

Totally, 921 women who gave birth ≤13 months before being interviewed were included. Simple random sampling was done to select villages, households and participants. Community health workers helped to identify eligible participants and clinical psychologists, nurses or midwives conducted face-to-face interviews. The collected data were analysed using descriptive statistics and bivariable and multivariable logistic regression modelling RESULTS: The prevalence rates of generalised anxiety disorder, suicide ideation and post-traumatic stress disorder (PTSD) were 19.7%, 10.8% and 8.0%, respectively. Exposure to the four forms of IPV during pregnancy was highly associated with the likelihood of meeting diagnostic criteria for each of the non-psychotic MHDs investigated. Physical, psychological and sexual violence, showed the strongest association with PTSD, with adjusted ORs (aORs) of 4.5, 6.2 and 6.3, respectively. Controlling behaviour had the strongest association with major depressive episode in earlier periods with an aOR of 9.2.

CONCLUSION

IPV and MHDs should be integrated into guidelines for perinatal care. Moreover, community-based services aimed at increasing awareness and early identification of violence and MHDs should be instituted in all villages and health centres in Rwanda. Finally, healthcare providers need to be educated and trained in a consistent manner to manage the most challenging cases quickly, discreetly and efficiently.