United States obstetrician-gynecologists' accuracy in the simulation of diagnosing anxiety disorders and depression during pregnancy

Perinatal Mental Health Disorders: A Review of Lessons Learned from Obstetric Care Settings

Perinatal mental health has garnered significant attention within obstetrics over the last couple of decades as the long- and short-term morbidities of untreated perinatal mental health disorders on both the mother and fetus/neonate have become increasingly apparent. There have been major strides in increasing screening for perinatal mental health disorders, clinician comfort with prescribing common psychiatric medications, and integrating mental health professionals into prenatal care via health services approaches such as the collaborative care model. Despite these advances, however, gaps still remain in the tools used for screening and diagnosis, obstetric clinician training in diagnosis and management of perinatal mood and anxiety disorders, as well as patient access to mental health care during pregnancy and especially postpartum. Herein we review the state of perinatal mental health from the perspective of the obstetric provider and identify areas of ongoing innovation.

Cultivating mental health education in obstetrics and gynecology: a call to action

Mental health disorders are common and have a significantly negative impact on the health and well-being of women. For example, perinatal mental health disorders such as anxiety and depression are widely understood to be the most common complications of pregnancy and childbirth. Untreated mental health disorders are associated with significant obstetrical and psychiatric sequelae and have a long-lasting impact on neonatal and childhood outcomes. As front-line providers for women during times of elevated risk of psychiatric morbidity, such as pregnancy and postpartum, obstetricians and gynecologists are compelled to have familiarity with such disorders. Yet, a wide gap exists between the level of education in mental health disorders that obstetrician and gynecologist providers receive and the clinical need thereof. The objectives of this commentary are to describe the urgent need for mental health education for obstetricians and gynecologists providers and to introduce our vision for a concise, evidence-based and accessible set of digital educational materials designed to convey core concepts in women's reproductive mental health.

Prenatal depression screening and antidepressant prescription: obstetrician-gynecologists' practices, opinions, and interpretation of evidence

Obstetrician-gynecologists (ob-gyns) are well-positioned to detect symptoms of perinatal depression; however, little is known about how ob-gyns respond. The purpose of this study was to evaluate ob-gyns' beliefs and practices related to prenatal depression screening and antidepressant prescription during pregnancy. A larger survey on prenatal medication was developed at the American College of Obstetricians and Gynecologists (ACOG) and distributed to a sample of 1000 Fellows. The overall response rate was 37.9% (N = 379). Two hundred eighty-eight provided care to pregnant patients and therefore, responded to questions on prenatal depression screening and antidepressant prescription. Most ob-gyns (87.8%) routinely screened patients for depression at least once during pregnancy. When symptoms of depression were reported, 52.1% "sometimes" prescribed an antidepressant medication with 22.5% doing so "usually or always". While 84.0% prescribed selective serotonin reuptake inhibitors (SSRIs) to pregnant patients, only 31.9% prescribed non-SSRIs. Ob-gyns felt comfortable prescribing SSRIs (78.1%) and counseled patients that the benefits of treating depression pharmacologically outweigh the risks (83.0%), and the use of SSRIs during pregnancy is relatively safe (87.5%). Prescribing SSRIs to pregnant patients was not significantly associated with interpretation of evidence on fetal and neonatal outcomes. Findings suggest most ob-gyns in the USA at least sometimes prescribe antidepressants in response to patient reports of depression symptoms during pregnancy. Mixed interpretations of evidence regarding the effects of SSRIs on fetal and neonatal outcomes reflect a critical need for high-quality safety data upon which to base treatment recommendations.

A systematic review on the acceptability of perinatal depression screening

BACKGROUND

Perinatal depression (PND) affects approximately 10-15% of women, worldwide. PND screening, using screening tools, has been undertaken by a broad range of healthcare professionals in different settings. Our objective was to explore the acceptability of PND screening and how acceptability was being assessed.

METHODS

A systematic literature review of studies that explored the acceptability of PND screening was carried out throughout MEDLINE, PsycINFO, PubMed, CINAHL, Embase, Maternity and Infant Care and Joanna Briggs Institute databases.

RESULTS

Twenty-eight out of twenty-nine publications reported PND screening to be acceptable to most participants. A wide range of terms, questions and statements was used to infer, assess or report on acceptability. There was no uniform, psychometrically tested tool used to measure acceptability across the studies.

LIMITATIONS

Broad inclusion criteria and methodological differences limited comparisons, but are overcome by the comprehensiveness of the data and the lack of uniformity across studies.

CONCLUSIONS

Even though PND screening appears acceptable, it is difficult to draw conclusions about PND screening acceptability as studies used different methods to infer, assess or report on acceptability. The lack of a uniform, psychometrically tested tool to measure acceptability is not unique to PND. Nonetheless, the majority of perinatal women and healthcare professionals reported positive attitudes towards PND screening using different tools in different settings, indicating that it may be the responsibility of all healthcare professionals who come into contact with perinatal women.

CALM Pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety

Many women experience anxiety during pregnancy with potential negative effects on maternal, birth, and child outcomes. Because of potential risks of fetal exposure to psychotropic medications, efficacious non-pharmacologic approaches are urgently needed. However, no published studies of psychotherapeutic treatments for anxiety in pregnancy exist. Mindfulness-based cognitive therapy (MBCT) may substantially reduce anxiety and co-morbid symptoms in people with anxiety disorders. Coping with Anxiety through Living Mindfully (CALM) Pregnancy is an adaptation of MBCT designed to address anxiety in pregnant women. This study examined the feasibility, acceptability, and clinical outcomes of the CALM Pregnancy intervention in pregnant women anxiety. Twenty-four pregnant women with generalized anxiety disorder (GAD) or prominent symptoms of generalized anxiety participated in an open treatment trial of the CALM Pregnancy group intervention. Psychiatric diagnoses were determined by structured clinical interview, and self-report measures of anxiety, worry, depression, self-compassion, and mindfulness were completed at baseline and post-intervention. Qualitative feedback was elicited via questionnaire. Twenty-three participants completed the intervention with high attendance and good compliance with home practice. Completers showed statistically and clinically significant improvements in anxiety, worry, and depression, and significant increases in self-compassion and mindfulness. Of the 17 participants who met GAD criteria at baseline, only one continued to meet criteria post-intervention. Participants regarded their experience in the intervention to be overwhelmingly positive. MBCT in the form of the CALM Pregnancy intervention holds potential to provide effective, non-pharmacological treatment for pregnant women with anxiety. These promising findings warrant further testing of the intervention with a randomized controlled trial.

Early risk factors for psychopathology in offspring of parents with bipolar disorder: the role of obstetric complications and maternal comorbid anxiety

OBJECTIVE

Offspring of parents with bipolar disorder (BD) are at increased risk for developing a range of psychiatric disorders. Although genetic factors clearly confer risk to offspring, environmental factors also play a role in increasing vulnerability. Such environmental factors may occur at the initial stages of development in the form of obstetric complications (OCs). The current investigation examined the relationship between OCs and the development of psychopathology in offspring at risk for BD and the influence of parental psychopathology in this relationship.

METHODS

This cross-sectional study included 206 offspring of 119 parents with BD. Probit regression analyses examined associations between: (1) OC history and offspring psychopathology; and (2) maternal lifetime comorbid anxiety diagnoses and OCs in pregnancy/delivery with their offspring. Path analyses then tested whether OCs mediate the relationship between maternal comorbid anxiety disorders and offspring lifetime psychopathology.

RESULTS

Results indicated a specific association between OCs, particularly delivery complications, and increased risk for offspring anxiety disorders. Data also showed a significant relationship between maternal anxiety disorder comorbidity and OCs. Finally, path analyses suggested that delivery complications act as a mediator in the relationship between comorbid maternal anxiety disorder and offspring anxiety disorder.

CONCLUSIONS

Our findings lend support to the importance of identifying and reducing anxiety in pregnant woman with BD. The identification of OCs as early vulnerability factors for psychopathology in offspring at familial risk may also lead to earlier detection and intervention in these offspring.

Sex differences among obstetrician-gynecologists: a review of survey studies

Whether practice differences exist between the sexes is a question of clinical and educational significance. The obstetrician-gynecologist (ob-gyn) workforce has been shifting to majority women. An examination of sex differences in ob-gyn practice contributes to the discussion about how the changing workforce may impact women's healthcare. We sought to review survey studies to assess whether there are specific topics in which differences in attitudes, opinions, and practice patterns between male and female ob-gyns are apparent. We conducted a systematic review to identify all survey studies of ob-gyns from the years 2002-2012. A total of 93 studies were reviewed to identify statements of sex differences and categorized by conceptual theme. Sex differences were identified in a number of areas. In general, women report more supportive attitudes toward abortion. A number of differences were identified with regard to workforce issues, such as women earning 23% less than their male counterparts as reported in 1 study and working an average of 4.1 fewer hours per week than men in another study. Men typically provide higher selfratings than women in a number of areas. Other noted findings include men tending toward more pharmaceutical therapies and women making more referrals for medical conditions. Although a number of areas of difference were identified, the impact of such differences is yet to be determined. Additional research may help to clarify the reasons for such differences and their potential impact on patients.

TARGET AUDIENCE

Obstetricians and gynecologists, family physicians Learning Objectives: After completing this CME activity, physicians should be better able to determine how the relevance of studying sex differences among physicians, specifically ob-gyns, can help improve patient care, assess whether there are topical areas in which male and female ob-gyns have reported different beliefs, practices, attitudes, and opinions, and examine how the limitations of survey studies and systematic reviews can affect the findings of these studies and reviews.

Community mental health provider reluctance to provide pharmacotherapy may be a barrier to addressing perinatal depression: a preliminary study

This is the first study evaluating obstetrics and gynecology (OB/Gyn) provider and staff perceptions of barriers to accessing pharmacotherapy for perinatal depression outside the obstetric setting. Four, 90 min focus groups were conducted with OB/Gyn physicians, advance practice nurses, and support and nursing staff (n = 28). Data were analyzed with a grounded theory approach. Participants perceived that community mental health providers and pharmacists often do not want to participate in pharmacotherapy for perinatal women. Participants believed the solution is training for community mental health providers in the risks and benefits of pharmacotherapy for perinatal depression and improved communication between OB/Gyn's and community mental health providers. Community mental health provider and pharmacist reluctance to provide pharmacotherapy hinders OB/Gyn's perceived ability to address perinatal depression. Community mental health provider and pharmacist training are needed to mitigate precipitous discontinuation of treatment and to improve access to pharmacotherapy for perinatal women.

Obstetrician-gynecologists' knowledge, attitudes and practices regarding major depressive disorder

BACKGROUND

Obstetrician-gynecologists (ob-gyns) provide depression screening and treatment, but these practices could be improved. This study investigated the use of depression screening tools and treatment of adolescents with depressive symptoms.

METHODS

Surveys were sent to 220 members of the American College of Obstetricians and Gynecologists (ACOG) who had responded to a survey on depression in the past two years. Response rate was 66% (n = 145). Questions included those related to standardized depression screening, antidepressant prescribing behavior, use of the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) and knowledge of adolescent depression.

RESULTS

A total of 40% use standardized screening tools for depression with 46% using the Beck Depression Inventory-II and only 5% using the Patient Health Questionnaire-2 (PHQ-2). The majority (89%) of ob-gyns do not employ the DSM-IV to confirm a diagnosis of major depressive disorder. Of the ob-gyns indicating treating depression with antidepressants, 97% prescribe selective serotonin reuptake inhibitors. Only 19 respondents do not prescribe antidepressants, and instead refer depressed patients to mental health specialists. Most (79%) ob-gyns identified sexual problems as the primary side effect deterring prescribing of antidepressant medication. Ob-gyns were fairly accurate at estimating the prevalence of adolescent depression.

CONCLUSION

Ob-gyns are not utilizing the recommended validated resources such as the DSM-IV or PHQ-2 for diagnosis of depression or prior to prescribing antidepressants.

Strategies for improving perinatal depression treatment in North American outpatient obstetric settings

OBJECTIVE

To identify core barriers and facilitators to addressing perinatal depression and review clinical, programmatic, and system level interventions that may optimize perinatal depression treatment.

METHOD

Eighty-four MEDLINE/PubMed searches were conducted using the terms perinatal depression, postpartum depression, antenatal depression, and prenatal depression in association with 21 other terms. Of 7768 papers yielded in the search, we identified 49 papers on barriers and facilitators, and 17 papers on interventions in obstetric settings aimed to engage women and/or providers in treatment.

RESULTS

Barriers include stigma, lack of obstetric provider training, lack of resources and limited access to mental health treatment. Facilitators include validating and empowering women during interactions with health care providers, obstetric provider and staff training, standardized screening and referral processes, and improved mental health resources.

CONCLUSION

Specific clinical, program, and system level changes are recommended to help change the culture of obstetric care settings to optimize depression treatment.

Determinants of ante-partum depression: a multicenter study

INTRODUCTION

Ante-partum depression (APD) is usually defined as a non-psychotic depressive episode of mild to moderate severity, beginning in or extending into pregnancy. APD has received less attention than postpartum depression. This is a cross-sectional study carried out in the Obstetrics and Gynaecology (OG) departments of four different general hospitals in Italy.

METHODS

Women attending consecutively the OG departments for their first ultrasound examination were asked to fill in the Edinburgh Postnatal Depression Scale (EPDS) in its Italian validated version. We used the total scores of the EPDS as a continuous variable for univariate and linear regression analyses; in accordance with the literature, the item analysis of EPDS was carried out by classifying the sample as women with "no depression" (scores 0-9), "possible depression" (scores 10-12), "probable depression" (scores 13+) and "probable APD" (scores 15+).

RESULTS

The number of women recruited was 1,608. The EPDS assessment classified 10.9 % of the women as possibly depressed, 8.3 % as probably depressed and 4.7 % probably affected from an APD. EPDS score distribution was associated with nationality (higher scores for foreigners), cohabitation (higher scores for women living with friends or in a community), occupation (higher scores for housewives), past episodes of depression and use of herbal drugs. Non-depressed women had significantly lower values on all ten items as compared with depressed women, however, the pattern of item distribution on the EPDS scale remained similar across depression severity groups. In all four groups item 4 (anxious depression) attained the highest scores, while item 10 (suicidality) attained the lowest scores.

OB CARES--The Obstetric Clinics and Resources Study: providers' perceptions of addressing perinatal depression--a qualitative study

OBJECTIVE

We conducted a qualitative study to understand how prenatal care providers perceive influences on their delivery of perinatal depression care. Given that depression screening protocols were in place at the clinics where we sampled providers, we hypothesized that clinic- and system-level factors such as resources, training opportunities and coordination would be dominant in influencing provider decisions.

METHODS

We conducted semistructured interviews with 20 prenatal care providers from six obstetric clinics. We performed a thematic analysis, including within-case and cross-case comparisons, and built a conceptual model of provider decision making from the data.

RESULTS

Although depression screening protocols were in place at our study clinics, we found that decisions to address perinatal depression were largely made at the level of the individual provider and were undefined on a clinic level, resulting in highly variable practice patterns. In addition, while providers acknowledged externally derived influences, such as logistical resources and coordination of care, they spoke of internally derived influences, including familiarity with consultants, personal engagement styles and perceptions of role identity, as more directly relevant to their decision making.

CONCLUSION

Our results highlight the pivotal role of internal factors in decisions to deliver perinatal depression care. Future interventions in obstetric settings should target the intrinsic motivations of providers.