Engagement in perinatal depression treatment: a qualitative study of barriers across and within racial/ethnic groups

Indian immigrants' constructions of mental health and mental illness in the perinatal period: A qualitative study

AIM

The aim of this study is to explore how immigrant women and men from India construct mental health and mental illness in the perinatal period.

DESIGN

Qualitative interpretive design.

METHODS

Data were collected by conducting in-depth interviews with 19 participants. Photo elicitation, free listing and pile sorting were used during the interviews. Purposive sampling was used, and data were collected in 2018 and 2019. Data were analysed using thematic analysis.

FINDING/RESULTS

One major theme and three subthemes were identified. 'We do not talk about it' was the major theme and the subthemes: (1) 'living peacefully and feeling happy' described the views on mental health; (2) 'that's the elephant in the room still' captures how participants felt when talking about mental illness; and (3) 'why don't we talk about it' offers reasons why the Indian community does not talk about mental health and illness.

CONCLUSION

The findings of this study have highlighted the importance of understanding the impact of immigration and being culturally sensitive when assessing mental health in the perinatal period.

IMPACT

The findings of this study identify some of the reasons for non-disclosure of mental health issues by immigrants. Incorporating these findings during psychosocial assessment by health professionals in the perinatal period will help translate the cultural aspects into more effective communication.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public contribution to the study was provided by the Community Stakeholders Group; these were members of the immigrant community from India who had expertise in mental health. They contributed to the study design and the key terms and phrases for the free list used in interviews.

Latina Mothers Recommendations on a Mindfulness-Based Cognitive Behavioral Therapy Group Intervention for Perinatal Depression

Introduction: Perinatal depression affects 5-15% of childbearing women. However, literature suggests that Latina women are twice as likely to experience depression during pregnancy. Group telehealth-based interventions are a promising approach to increasing access and reducing barriers to mental health. However, little is known about the experience that Latinas have with navigating this approach. This paper aimed to explore Latina mothers' perspectives and recommendations in using telehealth to deliver a mindfulness-based cognitive behavioral therapy (MBCBT) group intervention. Methods: Fourteen pregnant or postpartum women participated in focus groups and individual interviews. Interview topics included perinatal depression, knowledge and content of interventions, and the feasibility and acceptability of the telehealth approach. Data were recorded, transcribed, and analyzed using a grounded theory approach. Results: Three broad themes emerged; (1) accessibility to telehealth, (2) relational connection through technology, and (3) technological issues affecting access (i.e., level of familiarity with portal, video quality, etc.). Enhancers promoting participation in the telehealth intervention included reduced scheduling concerns and no need for childcare. Barriers included mistrust of providers' engagement, concerns about privacy, and potential for lack of relational connection through technology. Conclusion: Specific recommendations were provided to increase participation and effectiveness of telehealth groups among Latinas.

Barriers to care and treatment experiences among individuals with postpartum psychosis

PURPOSE

Postpartum psychosis (PP) is a severe psychiatric disorder affecting 1-2 per 1,000 deliveries. Prompt access to healthcare and timely initiation of treatment are crucial to minimizing harm and improving outcomes. This analysis seeks to fill gaps in knowledge surrounding barriers to care and treatment experiences among this population.

METHODS

Participants were individuals with histories of PP who enrolled in the Massachusetts General Hospital Postpartum Psychosis Project (MGHP3). The MGHP3 Healthcare Access Survey, a cross-sectional questionnaire, assesses barriers to care, treatment-seeking behaviors, and experiences with treatment. Descriptive statistics were utilized to describe sample characteristics.

RESULTS

139 participants provided 146 episode-specific survey responses. Lack of available services was cited as the greatest barrier to care for PP. Among those who sought treatment, obstetric providers (34.5%) and emergency medical professionals (29.4%) were the most common initial points of contact. 82.2% of the respondents went to an emergency room or crisis center during their episode(s). Most (61.8%) reported being given insufficient information to manage their PP. Approximately half of participants were hospitalized (55.5%), the majority of whom had no access to their infant during hospitalization (70.4%). Of those breastfeeding or pumping at admission, 31.3% were not given access to a breast pump. 44.4% dealt with delivery-related medical issues during their hospitalization.

CONCLUSION

This report is the first of its kind to assess key public health domains among individuals with PP. Findings point to several directions for future research and clinical practice to improve treatment timeliness and quality, potentially improving long-term outcomes related to this serious illness.

Internet-based interdisciplinary therapeutic group (Grupo Interdisciplinar Online, GIO) for perinatal anxiety and depression-a randomized pilot study during COVID-19

Early interventions may promote reductions in mothers' anxiety-depression (AD) symptoms and improvements in their offspring. This longitudinal randomized research was conducted to assess the effects of interdisciplinary online therapeutic groups (GIO) in at-risk mothers and babies during the COVID-19 pandemic in a disadvantaged neighborhood in Barcelona (Spain). A total of 135 babies were born from March 2020 to June 2021 in a primary healthcare center of Barcelona (Spain). Pregnant woman and new mothers were screened for AD symptomatology through EPDS and STAI questionnaires. Seventy-two of them met high-risk criteria for AD and were included in the study. They were randomly assigned into the two groups of the study: 40 participants were assigned to GIO, the therapeutic group (TG), while 32 of them were assigned to the control group (CG) and received treatment as usual. The course of the mothers' symptomatology was assessed, as well as the baby's development at 6 months old in a blind pediatric follow-up. No differences were found in AD between both groups before the intervention. However, we obtained a significant decrease in AD symptomatology (EPDS p < .001; STAI state p = .015 and STAI trait p < .001at 6 months of life) after the intervention in the TG compared to the CG. Pediatric follow-up at 6 months demonstrated significant differences between groups in babies' development assessment (manipulation p = .003; language p < .001; sociability p < .001). The GIO helped to ensure healthy development of the baby and reduction of the mothers' depressive-anxiety symptomatology.

Examining racial/ethnic inequities in treatment participation among perinatal individuals with depression

OBJECTIVE

A cluster randomized controlled trial (RCT) of two interventions for addressing perinatal depression treatment in obstetric settings was conducted. This secondary analysis compared treatment referral and participation among Minoritized perinatal individuals compared to their non-Hispanic white counterparts.

METHODS

Among perinatal individuals with depression symptoms, we examined rates of treatment 1) referral (i.e., offered medications or referred to mental health clinician), 2) initiation (i.e., attended ≥1 mental health visit or reported prescribed antidepressant medication), and 3) sustainment (i.e., attended >1 mental health visit per study month or prescribed antidepressant medication at time of study interviews). We compared non-Hispanic white (NHW) (n = 149) vs. Minoritized perinatal individuals (Black, Asian, Hispanic/Latina, Pacific Islander, Native American, Multiracial, and white Hispanic/Latina n = 157). We calculated adjusted odds ratios (aOR) for each outcome.

RESULTS

Minoritized perinatal individuals across both interventions had significantly lower odds of treatment referral (aOR = 0.48;95% CI = 0.27-0.88) than their NHW counterparts. There were no statistically significant differences in the odds of treatment initiation (aOR = 0.64 95% CI:0.36-1.2) or sustainment (aOR = 0.54;95% CI = 0.28-1.1) by race/ethnicity.

CONCLUSIONS

Perinatal mental healthcare inequities are associated with disparities in treatment referrals. Interventions focusing on referral disparities across race and ethnicity are needed.

Stigma and its influencing factors for seeking professional psychological help among pregnant women: A cross-sectional study

BACKGROUND

Although the stigma associated with seeking professional psychological help has received significant attention, few studies have focused on the status and factors influencing this stigma among pregnant women, especially those with a Chinese cultural background. This study aimed to assess the status of stigma associated with seeking professional psychological help and its influencing factors.

METHODS

A total of 1325 pregnant women were recruited from Hunan Province, China. The Stigma for Seeking Professional Psychological Help questionnaire, Patient Health Questionnaire-9, Perceived Social Support Scale, Simplified Coping Style Questionnaire, and questionnaires on sociodemographic characteristics and pregnancy-related information were used. Descriptive, univariate, correlation, and multivariate linear regression analyses were used to investigate the status of stigma and identify its influencing factors.

FINDINGS

Pregnant Chinese women experienced a mild to moderate level of stigma associated with seeking professional psychological help, and self-stigma was more common than social stigma associated with seeking psychological help. The results of the multivariate analysis suggested that perceived social support, positive coping styles, negative coping styles, and depressive symptoms were the factors influencing self-stigma and social stigma associated with seeking professional psychological help. Advanced age and a low educational level were the only predictors associated with self-stigma, while a history of multiple pregnancies had an effect only on social stigma associated with seeking professional psychological help.

CONCLUSION

Chinese pregnant women experienced a mild to moderate level of stigma associated with seeking professional psychological help. Destigmatizing interventions focusing on self-stigma and social stigma should be designed according to maternal characteristics, social support, coping style, and depressive symptoms.

Racial and ethnic disparities in access to community-based perinatal mental health programs: results from a cross-sectional survey

BACKGROUND

Perinatal mental health is a major public health problem that disproportionately affects people from racial and ethnic minority groups. Community-based perinatal mental health programs, such as peer support groups, are essential tools for the prevention and treatment of perinatal depression. Yet, little is known about racial and ethnic disparities in accessibility and utilization of community-based perinatal mental health programs.

METHODS

We conducted a cross-sectional study using an online survey with program administrators representing perinatal mental health community-based services and support programs throughout New Jersey. Descriptive analysis and mapping software was used to analyze the data.

RESULTS

Thirty-three program administrators completed the survey. Results showed substantial racial and ethnic disparities in availability and utilization of community-based programs. In the majority of programs, Black, Hispanic, and Asian individuals made up less than 10% of total annual participants and less than 10% of facilitators. There were also geographic disparities in program accessibility and language availability across counties. Program administrators identified mental health stigma, lack of support from family, fear of disclosure of mental health challenges, social determinants, lack of language-concordant options in programs, and limited awareness of programs in the community as significant barriers to participation of racial and ethnic minorities. Strategies to address barriers included adding language options, improving program outreach, and increasing diversity of facilitators.

CONCLUSIONS

This study provides new evidence on racial and ethnic disparities in access to community-based perinatal mental health programs. Efforts to build the resources and capacities of community-based programs to identify equity gaps, increase diversity of staff, and address barriers to participation is critical to reducing racial and ethnic inequities in perinatal mental health.

Racial And Ethnic Inequities In Postpartum Depressive Symptoms, Diagnosis, And Care In 7 US Jurisdictions

Understanding whether racial and ethnic inequities exist along the postpartum mental health care continuum is vital because inequitable identification of depression can lead to inequitable referral to and receipt of care. We aimed to expand on existing cross-sectional and single-state data documenting potential racial and ethnic disparities in postpartum depression care. Using early (from two to six months) and late (from twelve to fourteen months) postpartum survey data from seven US jurisdictions, we documented patterns of early postpartum depressive symptoms, perinatal mood and anxiety disorder (PMAD) diagnosis, and receipt of postpartum mental health care overall and by racial and ethnic identity. Of 4,542 people who delivered live births in 2020, 11.8 percent reported early postpartum depressive symptoms. Among the sample with these symptoms, only 25.4 percent reported receiving a PMAD diagnosis, and 52.8 percent reported receiving some form of postpartum mental health care. There were no significant differences in diagnosis by race and ethnicity. Respondents identifying as Asian; Native Hawaiian or Pacific Islander; Southwest Asian, Middle Eastern, or North African; Hispanic; and non-Hispanic Black were significantly less likely than non-Hispanic White respondents to receive mental health care, demonstrating stark inequities in the management of postpartum depressive symptoms. Policies mandating and reimbursing universal postpartum depression screening, facilitating connection to care, reducing insurance coverage gaps, and enhancing clinician training in culturally responsive care may promote equitable postpartum mental health care.

Addressing the challenges of integrating care for perinatal depression in primary care in Nigeria

PURPOSE

This report provides the results of a task-shared approach for integrating care for perinatal depression (PND) within primary maternal and child healthcare (PMCH), including the factors that may facilitate or impede the process.

METHODS

This hybrid implementation-effectiveness study guided by the Replicating Effective Programmes framework was conducted in 27 PMCH clinics in Ibadan, Nigeria. The primary implementation outcome was change in the identification rates of PND by primary health care workers (PHCW) while the primary effectiveness outcome was the difference in symptom remission (EPDS score ≤ 5) 6 months postpartum. Outcome measures were compared between two cohorts of pregnant women, one recruited before and the other after training PHCW to identify and treat PND. Barriers and facilitators were explored in qualitative interviews.

RESULTS

Identification of PND improved from 1.4% before to 17.4% after training; post-training rate was significantly higher in clinics where PHCW routinely screened using the 2-item patient health questionnaire (24.8%) compared to non-screening clinics (5.6%). At 6-months postpartum, 60% of cohort one experienced remission from depression, compared to 56.5% cohort two [OR-0.9 (95%CI-0.6, 1.3) p = 0.58]. Identified facilitators for successful integration included existence of policy specifying mental health as a component of PHC, use of screening to aid identification and supportive supervision, while barriers included language and cultural attitudes towards mental health and human resource constraints. PHCW were able to make adaptations to address these barriers.

CONCLUSIONS

Successful implementation of task-shared care for perinatal depression requires addressing staff shortages and adopting strategies that can improve identification by non-specialist providers.

TRIAL REGISTRATION

This study was retrospectively registered 03 Dec 2019. https://doi.org/10.1186/ISRCTN94230307 .

Experience of postpartum depression among Chinese women: A meta-synthesis of qualitative research

Postpartum depression (PPD) is associated with various adverse health outcomes among mothers and babies. Meta-synthesis can improve our understanding of postpartum women's experiences. However, the meta-analysis of PPD among Chinese women is limited. Therefore, a meta-analysis was conducted to evaluate the prevalence of PPD among Chinese women and if and how traditional culture may exacerbate PPD. Qualitative studies on the experiences of Chinese women with PPD were searched from database establishment until May 2022 in ten databases. The meta-ethnography reporting guidelines and framework was applied to the writing and reporting of this review. The protocol for this systematic review was registered with the International Prospective Register of Systematic Reviews (CRD42022323388). 2321 studies were retrieved, and 11 studies qualified for the meta-synthesis. The final five themes extracted and re-conceptualized from these studies were as follows: the gap between expectation and reality, conflicts with family, physical and mental frustrations, critical needs for coping with changes, and measures against PPD. Chinese women with PPD frequently feel vulnerable physically, mentally, or both after childbirth and often have conflicts with their families due to the influence of traditional Chinese culture. Family relationships and social support often are factors preventing women from seeking help.

An intergenerational examination of retrospective and current depression patterns among Black families

BACKGROUND

There is limited information regarding the intergenerational transmission of mental health among three generations (i.e., grandparents, parents, and children) of Black families. Given that intergenerational and kinship ties are integral in Black families, this study explores the context that might contribute to the generational transmission of mental health among Black families.

METHODS

The present study examined the retrospective family history of mental health among fathers and mothers, current reports of their depression, and their children's internalizing and depressive symptoms among a sample of 2530 Black families from the Future of Families and Child Wellbeing Study using waves 4 to 6. All analyses were conducted using STATA 15.1.

RESULTS

Focal children's maternal and paternal grandparents' history of mental health was associated with higher odds of depression in their mothers and fathers; in addition, child-internalizing symptoms were associated with a report of depression in maternal grandparents in waves 4 and 5. Children of mothers who were depressed had higher internalizing scores in waves 4, 5, and 6.

LIMITATIONS

This descriptive study did not account for how parenting might also be protective against childhood internalizing behaviors. A retrospective account may not fully encapsulate a complete understanding of mental health patterns.

CONCLUSIONS

In treating the mental and behavioral health of Black families, it is essential to focus on multiple generations of family health, given that family history is the strongest predictor of the youth's onset of depression. The utility of these findings in understanding psychological distress and strengths among Black families is discussed.

Racial and ethnic differences in perinatal depression and anxiety

BACKGROUND

Findings on racial and ethnic differences in perinatal depression/anxiety are mixed.

METHODS

We assessed racial and ethnic differences in depression, anxiety, and comorbid depression/anxiety diagnoses in the year before, during, and the year after pregnancy (n = 116,449) and depression severity during (n = 72,475) and in the year after (n = 71,243) pregnancy among patients in a large, integrated healthcare delivery system.

RESULTS

Compared to Non-Hispanic White individuals, Asian individuals had lower risk of perinatal depression and anxiety (e.g., depression during pregnancy relative risk [RR] = 0.35, 95 % confidence interval [CI]:0.33-0.38) and postpartum moderate/severe (RR = 0.63, 95 % CI:0.60-0.67) and severe (RR = 0.66, 95 CI:0.61-0.71) depression but higher risk of moderate/severe depression during pregnancy (RR = 1.18, 95 % CI:1.11-1.25). Non-Hispanic Black individuals had higher risk of perinatal depression, comorbid depression/anxiety, and moderate/severe and severe depression (e.g., depression diagnoses during pregnancy RR = 1.35, 95 % CI:1.26-1.44). Hispanic individuals had lower risk of depression during pregnancy and perinatal anxiety (e.g., depression during pregnancy RR = 0.86, 95 % CI:0.82-0.90) but higher risk of postpartum depression (RR = 1.14, 95 % CI:1.09-1.20) and moderate/severe and severe depression during and after pregnancy (e.g., severe depression during pregnancy RR = 1.59, 95 % CI:1.45-1.75).

LIMITATIONS

Information on depression severity was unavailable for some pregnancies. Findings may not generalize to individuals without insurance or outside of Northern California.

CONCLUSIONS

Non-Hispanic Black individuals of reproductive age should be targeted with prevention and intervention efforts aimed at reducing and treating depression and anxiety. Asian and Hispanic individuals of reproductive age should be targeted with campaigns to destigmatize mental health disorders and demystify treatments and systematically screened for depression/anxiety.

Maternal mental health screening and management by health workers in southwestern Uganda: a qualitative analysis of knowledge, practices, and challenges

BACKGROUND

Maternal mental health (MMH) problems, such as perinatal depression, maternal anxiety, suicide ideation and puerperal psychosis among others, have a significant impact on maternal morbidity and mortality, as well as the health and development of children. One in every four pregnant women and one in every five postpartum women in low-income countries, suffer from maternal mental health (MMH) problems. Despite this, MMH screening, diagnosis, and reporting remain scanty in Uganda. Consequently, this study aimed to investigate the knowledge, practices, and impediments that maternity care workers face when screening and managing women with maternal mental health disorders in health facilities in south-western Uganda.

METHODS

In-depth interviews were conducted with 22 health-care professionals who work in maternity care departments in primary and tertiary healthcare facilities in southwestern Uganda to investigate their medical knowledge, clinical practices, and challenges related to the screening and management of maternal mental health problems. Using qualitative content analysis, distinct categories and subcategories were found.

RESULTS

Medical staff especially midwives lacked specialized training in screening and managing women with maternal mental health problems They screened and managed MMH problems solely based on history and physical examination, and they referred nearly every mother displaying signs of mental illness because they felt ill-prepared to handle them. On the other hand, medical staff with some level of specialized training in mental health particularly staff working in mental health units, were more likely to use a mental health screening tool in addition to history and physical examination; and to treat any women exhibiting signs and symptoms of maternal mental problems without referring them. Lack of in-service training on maternal mental health, poorly coordinated referral systems, reluctance of mentally ill to visit medical facilities, scarcity of mental health specialists, and shortage of relevant medications were identified as the major challenges. Age, experience level, or gender had no effect on screening or management practices.

CONCLUSIONS

The results suggest that specialized training in mental health, and particularly maternal mental health, is essential for the effective screening and management of maternal mental health conditions in South Western Uganda.

Women's experiences of care and treatment preferences for perinatal depression: a systematic review

Understanding women's experiences of care, and treatment preferences, is vital for delivering acceptable and useful services to women with perinatal depression. This systematic review synthesises evidence on care and treatment preferences of women with perinatal depression. This qualitative evidence synthesis uses systematic review methodology. Medline, PsychINFO, CINAHL and EMBASE were searched from January 2011 to October 2021. Search terms fell into five categories: depression, the perinatal period, treatment preferences, experiences of care and qualitative research. Study quality was assessed and thematic analysis was used to synthesise findings. Thirteen papers met the inclusion criteria. Quality of included papers was of moderate to high quality. Five key themes were identified: women prioritise family needs; perinatal-specific care; when care falls short; professional empathy; and tailored care. Clinicians need to enable mothers to prioritise their own well-being. Service providers should ensure that treatment is tailored to the specifics of the perinatal period, providing specialist advice around medication, and therapy that fits with the demands of caring for a new baby.

Deep health: A qualitative, woman-centered perspective of health during pregnancy

OBJECTIVE

To explore and define a woman-centered perspective on health during pregnancy.

DESIGN

Qualitative study using abductive thematic analysis of semi-structured interview data.

SETTING & PARTICIPANTS

Twenty pregnant participants, primarily single and low-income, were recruited from an urban women's health clinic in the Midwestern United States and interviewed during mid-to-late pregnancy.

FINDINGS

Women experienced health as "deeper than physical health" to include emotional well-being, financial stability, and support. We defined the central theme of Deep Health to be an embodied sense of happiness, energy, stability, and purpose (Being) supported through positive health practices (Doing) and adequate financial and social resources (Having).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

While the Doing aspects of health are often a focal point for health promotion efforts in prenatal care, a restricted focus on lifestyle behaviors may contribute to a lack of shared understanding about health between women and their healthcare providers. Greater attention to the Being and Having aspects of health may work to bolster shared priorities for health between pregnant women and their providers.

Translating Research Evidence Into Marketplace Application: Cohort Study of Internet-Based Intervention Platforms for Perinatal Depression

BACKGROUND

Internet-based intervention platforms may improve access to mental health care for women with perinatal depression (PND). Though the majority of platforms in the market lack an evidence base, a small number of them are supported by research evidence.

OBJECTIVE

This study aims to assess the current status of internet-based PND intervention platforms supported by published evidence, understand the reasons behind the disappearance of any of these previously accessible platforms, examine adjustments made by those active platforms between research trials and market implementation, and evaluate their current quality.

METHODS

A cohort of internet-based PND intervention platforms was first identified by systematic searches in multiple academic databases from database inception until March 26, 2021. We searched on the World Wide Web and the iOS and Android app stores to assess which of these were available in the marketplace between April and May 2021. The basic characteristics of all platforms were collected. For inaccessible platforms, inquiries were made via email to the authors of publications to determine the reasons for their unavailability. We compared the intervention-related information of accessible platforms in the marketplace with that reported in original publications and conducted quality assessments using the App Evaluation Model of the American Psychiatric Association. Fisher exact tests were used to compare the functional characteristics in publications of available and unavailable platforms and to investigate potential associations between functional adjustments or quality indices and platform survival time.

RESULTS

Out of 35 platforms supported by research evidence, only 19 (54%) were still accessible in the marketplace. The main reason for platforms disappearing was the termination of research projects. No statistically significant differences were found in functional characteristics between available and unavailable platforms. A total of 18 (95%) platforms adapted their core functions from what was reported in related publications. The adjustments included changes to intervention methods (11/19, 58%), target population (10/19, 53%), human resources for intervention support (9/19, 47%), mood assessment and monitoring (8/19, 42%), communication modality (4/19, 21%), and platform type (2/19, 11%). Quality issues across platforms included low frequency of update, lack of crisis management mechanism, poor user interactivity, and weak evidence base or absence of citation of supporting evidence. Platforms that survived longer than 10 years had a higher tendency to use external resources from third parties compared to those that survived less than 10 years (P=.04). No significant differences were found for functional adjustments or other quality indices.

CONCLUSIONS

Internet-based platforms supported by evidence were not effectively translated into real-world practice. It is unclear if adjustments to accessible platforms made during actual operation may undermine the proven validity of the original research. Future research to explore the reasons behind the success of the implementation of evidence-based platforms in the marketplace is warranted.

Racial-Ethnic Differences in Treatment Initiation for New Diagnoses of Perinatal Depression

OBJECTIVE

The adverse consequences of untreated perinatal depression highlight the need to identify populations to target in order to increase treatment rates. The authors sought to evaluate treatment initiation for a new diagnosis of depression during pregnancy or postpartum and to describe racial-ethnic differences in initiation and type (psychotherapy, antidepressants) of treatment in a large health care system with universal perinatal depression screening.

METHODS

This retrospective cohort study included women who delivered a live birth in the Kaiser Permanente Northern California system between October 2012 and May 2017. Black, Latina, Asian, and White women ages ≥15 years were eligible. New depression diagnoses were defined by using ICD-9 and ICD-10 codes from electronic health records. Treatment initiation was defined as receiving at least one antidepressant medication dispensation or psychotherapy visit up to 90 days after the diagnosis. Modified Poisson regression was used to estimate the risk for initiating treatment and the type of treatment initiated.

RESULTS

In total, 13,637 women with a new depression diagnosis (prenatal: N=7,041, 51.6%; postpartum: N=6,596, 48.4%) were identified. Of the pregnant women, 31.4% initiated treatment, and of the postpartum women, 73.1% initiated treatment. Latina and Asian women were less likely than White women to initiate treatment postpartum. During pregnancy and postpartum, non-White women were more likely to initiate psychotherapy. White women were more likely to initiate antidepressant medication during pregnancy and postpartum or a combination of antidepressant medication and psychotherapy during the postpartum period.

CONCLUSIONS

Research is warranted to identify patient-, provider-, and system-level barriers that contribute to racial-ethnic disparities in perinatal mental health care.

Experiences of Postpartum Depression in Women of Color

PURPOSE

To examine the experiences of postpartum depression among U.S.-born women of color via an integrative review.

STUDY DESIGN AND METHOD

Databases searched were PubMed, CINAHL, Scopus, and PsycInfo. Sample inclusion criteria included qualitative research published in English that explored U.S.-born women of color's experiences of postpartum depression. There was no time limitation on when studies were published. Krippendorff's thematic content analysis method was used.

RESULTS

In this integrative review, eight qualitative studies investigating Black and Hispanic women's postpartum depression experiences and eight blog postings were synthesized. Five themes were identified that described postpartum depression experiences of Black and Hispanic women: (1) Struggling with an Array of Distressing Symptoms , (2) Cultural Stigma as a Powerful Roadblock, (3) Complicating Barriers to Seeking Much-Needed Professional Help, (4) Support as a Lifeline or "Just Pulling Yourself up by Your Bootstraps," and (5) Preferences for Help with Postpartum Depression .

CLINICAL IMPLICATIONS

Cultural stigma of mental illness plus lack of knowledge of postpartum depression were strong barriers to women of color seeking timely professional mental health care. Nurses can share information about perinatal mental illness with women in cultural communities to help decrease stigma and increase mental health literacy. All health care providers and policy makers need to focus attention on the impact that women of color's economic and social stressors have on their postpartum depression.

Early detection of depression using a conversational AI bot: A non-clinical trial

BACKGROUND

Artificial intelligence (AI) has gained momentum in behavioural health interventions in recent years. However, a limited number of studies use or apply such methodologies in the early detection of depression. A large population needing psychological-intervention is left unidentified due to barriers such as cost, location, stigma and a global shortage of health workers. Therefore, it is essential to develop a mass screening integrative approach that can identify people with depression at its early stage to avoid a potential crisis.

OBJECTIVES

This study aims to understand the feasibility and efficacy of using AI-enabled chatbots in the early detection of depression.

METHODS

We use Dialogflow as a conversation interface to build a Depression Analysisn (DEPRA) chatbot. A structured and authoritative early detection depression interview guide, which contains 27 questions combining the structured interview guide for the Hamilton Depression Scale (SIGH-D) and the inventory of depressive symptomatology (IDS-C), underpins the design of the conversation flow. To attain better accuracy and a wide variety of responses, we train Dialogflow with the utterances collected from a focus group of 10 people. The occupation of the focus group members included academics and HDR candidates who are conscious, vigilant and have a clear understanding of the questions. In addition, DEPRA is integrated with a social media platform to provide practical access to all the participants. For the non-clinical trial, we recruited 50 participants aged between 18 and 80 from across Australia. To evaluate the practicability and performance of DEPRA, we also asked participants to submit a user satisfaction survey at the end of the conversation.

RESULTS

A sample of 50 participants, with an average age of 34.7 years, completed this non-clinical trial. More than half of the participants (54%) are male and the major ethnicities are Asian (63%), Middle Eastern (25%), and others 12%. The first group comprises professional academic staff and HDR candidates, the second and third groups comprise relatives, friends, and volunteers who were recruited via social media promotions. DEPRA uses two scientific scoring systems, QIDS-SR and IDS-SR to verify the results of early depression detection. As the results indicate, both scoring systems return a similar outcome with slight variations for different depression levels. According to IDS-SR, 30% of participants were healthy, 14% mild, 22% moderate, 14% severe, and 20% very severe. QIDS-SR suggests 32% were healthy, 18% mild, 10% moderate, 18% severe, and 22% very severe. Furthermore, the overall satisfaction rate of using DEPRA was 79% indicating that the participants had a high rate of user satisfaction and engagement.

CONCLUSION

DEPRA shows promises as a feasible option for developing a mass screening integrated approach for early detection of depression. Although the chatbot is not intended to replace the functionality of mental health professionals, it does show promise as a means of assisting with automation and concealed communication with verified scoring systems.

Racial disparities in treatment engagement and outcomes in digital cognitive behavioral therapy for insomnia among pregnant women

OBJECTIVES

In the United States, Black women are disproportionately afflicted with prenatal insomnia. Although cognitive-behavioral therapy for insomnia (CBTI) may represent a strategy to reduce disparities in insomnia, racial minorities attend fewer healthcare appointments and have poorer outcomes from prenatal care and mental health treatment relative to white patients. The present study examined differences in treatment engagement and patient-reported outcomes in non-Hispanic Black and white pregnant women receiving digital CBTI.

METHODS

Secondary analysis of 39 pregnant women with clinical insomnia who received digital CBTI. Treatment engagement was operationalized as the number of sessions completed (≥4 considered an adequate dose). Treatment outcomes were assessed using the Insomnia Severity Index (ISI; insomnia) and Pittsburgh Sleep Quality Index (PSQI; global sleep disturbance).

RESULTS

Black women were 4 times more likely than white women to discontinue CBTI before receiving an adequate dose (8.3% vs. 33.3%). Regarding treatment outcomes, white women reported a mean reduction of 5.75 points on the ISI and a reduction of 3.33 points on the PSQI (Cohen's dz = 1.10-1.19). By comparison, Black women reported reductions of 2.13 points on the ISI and 1.53 points on the PSQI, which were statistically non-significant. Differences in treatment engagement did not account for the disparities in patient-reported outcomes.

CONCLUSIONS

During pregnancy, Black women completed fewer CBTI sessions and experienced poorer treatment outcomes in response to digital CBTI relative to white women. Enhancements to insomnia therapy and its digital delivery may improve adherence and outcomes in Black pregnant women.

Holistic community-based group parenting programs for mothers with maternal mental health issues help address a growing public health need for a diversity of vulnerable mothers, children and families: Findings from an action research study

Background

Maternal mental illness is a major growing global concern which can affect parenting with serious negative implications for offspring. Group-based parenting programs for mothers which both enhance the parent-child relationship and address mental health symptoms in a supportive social setting may optimise better outcomes for mothers and children. The Acorn program in South Australia draws on attachment theory to integrate dance play, reflective diary keeping and therapeutic letters in a holistic program for a diversity of vulnerable mothers and children aged 1-36 months. The program seeks to nurture and enhance parental wellbeing and the quality of the parent-child relationship for mothers experiencing identified mental health illnesses that impinge upon their parenting. This study presents the evaluation of the program and its effectiveness.

Methods

Action research approach for continuous monitoring and program improvement engaging Acorn program staff in evaluation data collection and interpretation of pre and post self-completion measures and standardized observations. Additional data was collected through a telephone interview of attending mothers 6-8 months after program completion to address sustainable impacts on parenting and wellbeing.

Results

The program engaged 353 diverse vulnerable mothers with their children. Many had profound overlapping mental health issues including borderline personality disorder (BPD) and depression. The quality of the parent-child interaction, parental confidence, competence and enjoyment were enhanced; mothers' wellbeing, ability to cope and lasting social supports were augmented. This occurred for a number of "most vulnerable" subgroups including single mothers, mothers with BPD, mothers from non-English speaking households and those with lower levels of education or household income. Mothers reported sustained improvements in their wellbeing, parenting, social and family lives, and feeling closer to their child as a result of participating in the program.

Conclusions

Given the high prevalence of maternal mental health issues and substantial potential negative consequences for mothers and offspring, the Acorn parenting program offers an effective means of addressing this pressing public health issue potentially helping large numbers of vulnerable mothers and their children. This has additional gravitas in the shadow of COVID-19 due to expanded numbers of those experiencing greater parental stress, isolation and mental illness.

The Association between NICU Admission and Mental Health Diagnoses among Commercially Insured Postpartum Women in the US, 2010-2018

Maternal mental health (MH) conditions represent a leading cause of preventable maternal death in the US. Neonatal Intensive Care Unit (NICU) hospitalization influences MH symptoms among postpartum women, but a paucity of research uses national samples to explore this relationship. Using national administrative data, we examined the rates of MH diagnoses of anxiety and/or depression among those with and without an infant admitted to a NICU between 2010 and 2018. Using generalized estimating equation models, we explored the relationship between NICU admission and MH diagnoses of anxiety and/or depression, secondarily examining the association of NICU length of stay and race/ethnicity with MH diagnoses of anxiety and/or depression post NICU admission. Women whose infants became hospitalized in the NICU for <2 weeks had 19% higher odds of maternal MH diagnoses (aOR: 1.19, 95% CI: 1.14%−1.24%) and those whose infants became hospitalized for >2 weeks had 37% higher odds of maternal MH diagnoses (aOR: 1.37 95% CI: 1.128%−1.47%) compared to those whose infants did not have a NICU hospitalization. In adjusted analyses, compared to white women, all other race/ethnicities had significantly lower odds of receiving a maternal MH condition diagnosis [Black (aOR = 0.76, 0.73−0.08), Hispanic (aOR = 0.69, 0.67−0.72), and Asian (aOR: 0.32, 0.30−0.34)], despite higher rates of NICU hospitalization. These findings suggest a need to target the NICU to improve maternal MH screening, services, and support while acknowledging the influence of social determinants, including race and ethnicity, on health outcomes.

Gestational diabetes mellitus, prenatal maternal depression, and risk for postpartum depression: an Environmental influences on Child Health Outcomes (ECHO) Study

BACKGROUND

Prior research has demonstrated bidirectional associations between gestational diabetes mellitus (GDM) and perinatal maternal depression. However, the association between GDM, prenatal depression, and postpartum depression (PPD) has not been examined in a prospective cohort longitudinally.

METHODS

Participants in the current analysis included 5,822 women from the National Institutes of Health's Environmental influences on Child Health Outcomes (ECHO) Research Program: N = 4,606 with Neither GDM nor Prenatal Maternal Depression (Reference Category); N = 416 with GDM only; N = 689 with Prenatal Maternal Depression only; and N = 111 with Comorbid GDM and Prenatal Maternal Depression. The PROMIS-D scale was used to measure prenatal and postnatal maternal depressive symptoms. Primary analyses consisted of linear regression models to estimate the independent and joint effects of GDM and prenatal maternal depression on maternal postpartum depressive symptoms.

RESULTS

A higher proportion of women with GDM were classified as having prenatal depression (N = 111; 21%) compared to the proportion of women without GDM who were classified as having prenatal depression (N = 689; 13%), however this finding was not significant after adjustment for covariates. Women with Comorbid GDM and Prenatal Maternal Depression had significantly increased postpartum depressive symptoms measured by PROMIS-D T-scores compared to women with Neither GDM nor Prenatal Maternal Depression (mean difference 7.02, 95% CI 5.00, 9.05). Comorbid GDM and Prenatal Maternal Depression was associated with an increased likelihood of PPD (OR 7.38, 95% CI 4.05, 12.94). However, women with GDM only did not have increased postpartum PROMIS-D T-scores or increased rates of PPD.

CONCLUSIONS

Our findings underscore the importance of universal depression screening during pregnancy and in the first postpartum year. Due to the joint association of GDM and prenatal maternal depression on risk of PPD, future studies should examine potential mechanisms underlying this relation.

Telehealth Strategies for the Delivery of Maternal Health Care : A Rapid Review

BACKGROUND

Telehealth strategies to supplement or replace in-person maternity care may affect maternal health outcomes.

PURPOSE

To conduct a rapid review of the effectiveness and harms of telehealth strategies for maternal health care given the recent expansion of telehealth arising from the COVID-19 pandemic, and to produce an evidence map.

DATA SOURCES

Systematic searches of MEDLINE, the Cochrane Library, CINAHL, Embase, and Scopus for English-language studies (January 2015 to April 2022).

STUDY SELECTION

Randomized controlled trials (RCTs) and observational studies of maternal care telehealth strategies versus usual care.

DATA EXTRACTION

Dual data extraction and risk-of-bias assessment of studies, with disagreements resolved through consensus.

DATA SYNTHESIS

28 RCTs and 14 observational studies (n = 44 894) were included. Maternal telehealth interventions supplemented in-person care for most studies of mental health and diabetes during pregnancy, primarily resulting in similar, and sometimes better, clinical and patient-reported outcomes versus usual care. Supplementing in-person mental health care with phone- or web-based platforms or mobile applications resulted in similar or better mental health outcomes versus in-person care. A reduced-visit prenatal care schedule using telehealth to replace in-person general maternity care for low-risk pregnancies resulted in similar clinical outcomes and higher patient satisfaction versus usual care. Overall, telehealth strategies were heterogeneous and resulted in similar obstetric and patient satisfaction outcomes. Few studies addressed disparities, health equity, or harms.

LIMITATIONS

Interventions varied, and evidence was inadequate for some clinical outcomes.

CONCLUSION

Replacing or supplementing in-person maternal care with telehealth generally results in similar, and sometimes better, clinical outcomes and patient satisfaction compared with in-person care. The effect on access to care, health equity, and harms is unclear.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42021276347).

The Impact of COVID-19 on Postpartum Depression and the Responsibility of the Healthcare System

Peripartum depression is a common complication of pregnancy with the potential for dangerous consequences to maternal and infant health if left untreated. The disorder was previously classified as a global public health issue due to the high prevalence of the disorder and the mismatch between available treatment options and successful completion of those options. The coronavirus disease 2019 (COVID-19) pandemic increased the incidence of mental health disorders globally, with an even greater effect on peripartum mothers. A preliminary study on fetal implications suggests the resulting increased maternal stress and depressive mood symptoms correlates to worsened fetal brain development. The pandemic highlighted existing barriers to the treatment of peripartum mood disorders. The drastic increase in the use of telemedicine as a modality of treatment in response to the public health crisis has the potential to address some of these barriers. Future global disasters are inevitable with peripartum mothers highly susceptible to worsened mental health outcomes. We are thus highlighting the responsibility of clinicians, professional organizations, and policymakers to support, identify, and facilitate the treatment of postpartum depression for this vulnerable population to prevent short-term and long-term repercussions.

A Review of Treatments and Clinical Guidelines for Perinatal Depression

Perinatal depression occurs in approximately 1 in 7 women and is considered the most common complication of pregnancy and childbearing. Management of perinatal depression may include a combination of nonpharmacological and pharmacological therapies depending on the severity of symptoms, the stage of gestation, and maternal preference. Healthcare providers are recommended to review current guidelines and provide information to women during pregnancy and postpartum regarding the risks and benefits of nonpharmacological and pharmacological treatment options for perinatal depression. In addition, healthcare providers should consider common barriers to treatment including inadequate screening and social stigma. This article reviews common treatments of perinatal depression as well as the clinical guidelines provided by the American Association of Obstetricians and Gynecologists (ACOG), the American Psychiatric Association (APA), and the US Preventive Services Task Force (USPSTF). Discussion of nonpharmacological therapies includes cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Pharmacological treatments are reviewed by drug class and include selective serotonin reuptake inhibitors (SSRIs), serotonin/norepinephrine reuptake inhibitors (SNRIs), norepinephrine/dopamine reuptake inhibitors (NDRIs), and tricyclic antidepressants (TCAs). Adjunctive treatments of severe depression, including second-generation antipsychotics (SGAs), are also discussed.

Elevated Perinatal Depression during the COVID-19 Pandemic: A National Study among Jewish and Arab Women in Israel

This study assessed prevalence of perinatal depression symptoms (PNDS) during the COVID-19 pandemic among Arab and Jewish women in Israel and identified COVID-19-related risk factors for PNDS, while comparing Arab and Jewish women. Sample included 730 perinatal women (604 Jewish and 126 Arab) aged 19-45 years, who filled out an online self-report questionnaire. The questionnaire assessed several areas: perinatal experiences and exposure to COVID-19, social support, and financial and emotional impact. PNDS was measured by the Edinburgh Postnatal Depression Scale (EPDS). Prevalence of PNDS (EPDS ≥ 10) in the entire study population was 40.0%. Prevalence among Arab women was significantly higher compared to Jewish women (58% vs. 36%, PV < 0.001). Higher PNDS were significantly associated with anxiety symptoms (GAD ≥ 10) (PV < 0.001), stress related to COVID-19 (PV < 0.001), adverse change in delivery of healthcare services (PV = 0.025), and unemployment (PV = 0.002). PNDS has elevated more than twofold during COVID-19 in Israel. Such high rates of PNDS may potentially negatively impact women, and fetal and child health development. This situation requires special attention from public health services and policy makers to provide support and mitigation strategies for pregnant and postpartum women in times of health crises.

Pathways To Equitable And Antiracist Maternal Mental Health Care: Insights From Black Women Stakeholders

Structural racism causes significant inequities in the diagnosis of perinatal and maternal mental health disorders and access to perinatal and maternal mental health treatment. Black birthing populations are particularly burdened by disjointed systems of care for mental health. To identify strategies to address racism and inequities in maternal and infant mental health care, we interviewed ten Black women who support Black birthing people, including mental health practitioners, researchers, and activists, in February 2021. The five key pathways to address racism and inequities that we identified from the stakeholder interviews are educating and training practitioners; investing in the Black women mental health workforce; investing in Black women-led community-based organizations; valuing, honoring, and investing in community and traditional healing practices; and promoting integrated care and shared decision making. These pathways highlight critical resources needed to improve the quality of maternal mental health care for Black birthing populations.

Scaling Up Patient-Centered Psychological Treatments for Perinatal Depression in the Wake of a Global Pandemic

There is a call to action to reduce the public health burden of perinatal depression worldwide. The COVID-19 pandemic has further highlighted significant gaps in perinatal mental health care, especially among women who identify as Black, Indigenous, People of Color (BIPOC). While psychotherapeutic (cognitive, behavioral and interpersonal) interventions are endorsed for perinatal mood disorders, barriers to access and uptake contribute to inequitable access to treatment at the population level. To effectively address these barriers and increase the scalability of psychotherapy among perinatal women, we suggest four pragmatic questions to be answered from a patient-centered lens; namely, "who," "what," "how," and "when." Promising avenues include task-sharing among mental health non-specialists, an emphasis on culturally sensitive care, web-based delivery of psychotherapy with some caveats, and a lifespan approach to perinatal mental health. Innovative research efforts are seeking to validate these approaches in diverse contexts across North America and the UK, lending optimism toward scalable and long-term solutions for equitable perinatal mental health care.