Women's Preferences for Treatment of Perinatal Depression and Anxiety: A Discrete Choice Experiment

Uptake rate of interventions among women who screened positive for perinatal depression: A systematic review and meta-analysis

BACKGROUND

Perinatal depression is a global public health problem that seriously affects the health of perinatal women. This study evaluated the pooled uptake rate of interventions among women who screened positive for perinatal depression to provide a basis for clinical intervention.

METHODS

We systematically searched four databases (PubMed, Embase, Cochrane Library and Web of Science) from the establishment of the database to May 1, 2023. All included studies were used to derive the pooled uptake rate. We also performed meta-regression and subgroup analysis to explore the potential sources of heterogeneity using STATA 17.0.

RESULTS

Of 15024 retrieved articles, only 41 met the inclusion criteria. The overall uptake rate was 55 % (95 % CI 43-67 %). Meta-regression and subgroup analyses both showed that the uptake rate in high-income countries 57 % (95 % CI 50-65 %) was higher than that in low and middle-income countries 37 % (95 % CI 18-56 %).

LIMITATIONS

First, only English publications were included. Therefore, articles in other languages were likely missed. Second, of the 41 studies included, there were only six randomized controlled trials, with limited quality of evidence. Third, we could not adequately explain the source of heterogeneity because there were too many mediating variables, although further subgroup and sensitivity analysis were performed.

CONCLUSIONS

About a half of women did not receive interventions after screening positive, and the uptake rate of interventions in high-income countries was higher than that in low and middle-income countries.

Treatment Preferences of Adolescents and Young Adults with Depressive Symptoms: A Discrete Choice Experiment

BACKGROUND

Depression in adolescents and young adults is common and causes considerable disease burden while hampering their development, leading to adverse consequences in later life. Although treatment is available, young people are a vulnerable group regarding uptake and completion of treatment. To improve this, insight into youth's preferences for treatment is essential.

OBJECTIVE

The aim of this study was to investigate patient preferences for depression treatment in a Dutch sample aged 16-24 years using a discrete choice experiment (DCE).

METHODS

The study was conducted in The Netherlands between October 2018 and June 2019, and included 236 adolescents and young adults with current depressive symptoms or previous treatment. The DCE included five attributes (treatment type, frequency of appointment, waiting time, effectiveness, evaluation of therapeutic alliance) with corresponding levels. Results were analysed using latent class analysis.

RESULTS

Results show a general preference for individual psychotherapy, treatment with high frequency, high effectiveness, short waiting time and a standard evaluation of the therapeutic alliance ('click' with the therapist) early in treatment. Latent class analysis revealed three different patterns of preferences regarding treatment type and willingness to engage in therapy. The first class showed a strong preference for individual therapy. The second class, including relatively older, higher educated and treatment-experienced participants, preferred high frequency treatment and was more open to different forms of therapy. The third class, including lower educated, younger and treatment-naïve adolescents showed reluctance to engage in therapy overall and in group therapy specifically.

CONCLUSION

In this DCE, three classes could be identified that share similar preferences regarding treatment effectiveness, waiting time and evaluation of the therapeutic alliance, but varied considerably in their preference for treatment type (individual, group, or combined psychotherapy) and their willingness to engage. The results from this study may inform mental health care providers and institutions and help optimize professional care for adolescents and young adults with depressive symptoms, improving engagement in this vulnerable group.

A hybrid effectiveness-implementation trial of application-based tiered care (Mom's Good Mood) in treating perinatal anxiety within a primary health care system in China

INTRODUCTION

Perinatal anxiety (PNA) is a major public health concern.

METHODS

A hybrid effectiveness-implementation trial was conducted in two antenatal clinics in Hefei, China, to assess the effectiveness and cost-effectiveness of application-based tiered care (Mom's Good Mood, MGM) in treating PNA and to understand how well it fits into routine practices. Pregnant women who scored at least 5 points on the 7-Item Generalised Anxiety Disorder Scale (GAD-7) scale were successively assigned to the control group or the intervention group, which were given the usual care and MGM on usual care, respectively. At 6 months post partum, anxiety, depression and life satisfaction were assessed. Intention-to-treat analysis and the Reach, Effectiveness, Adoption, Implementation and Maintenance framework were adopted.

RESULTS

A total of 214 women were assigned to the control group and 341 to the intervention group. The mean changes in GAD-7 scores (Least-squares means, LSM, -1.42, 95% CI -2.18 to -0.66) and the risk of anxiety (adjusted odds ratio, aOR 0.30, 95% CI 0.18 to 0.51) were decreased, and the anxiety remission rate (aOR 2.72, 95% CI 1.69 to 4.40) were improved in the intervention group. Similar findings were observed regarding the change in Edinburgh Postnatal Depression Scale scores (LS -1.92, 95% CI -2.85 to -0.99), depression remission rate (aOR 2.24, 95% CI 1.39 to 3.63) and the risk of depression (aOR 0.57, 95% CI 0.33 to 0.98). MGM only costs ¥1.88 (US$0.27) per pregnant woman to boost the postpartum anxiety remission rate by 1% and was revealed to have a high reach rate of 78.3%, an adoption rate of 51.3%-80.8%.

CONCLUSION

MGM is a cost-effective and accessible tool in coping with PNA.

TRIAL REGISTRATION NUMBER

ChiCTR2100053419.

Developing and evaluating an interprofessional shared decision-making care model for patients with perinatal depression in maternal care in urban China: a study protocol

BACKGROUND

The majority of patients with perinatal depression (PND) in China do not receive adequate treatment. As forming a therapeutic alliance with patients is crucial for depression treatment, shared decision-making (SDM) shows promise in promoting patients' uptake of evidence-based mental health services, but its impact on patient outcomes and implementation in real-world maternal care remain uncertain. Therefore, this study aims to develop and evaluate an interprofessional shared decision-making (IP-SDM) model for PND to enhance maternal mental health services.

METHODS

This study contains four research phases: feasibility testing (Phase 1), toolkit development (Phase 2), usability evaluation (Phase 3), and effectiveness evaluation (Phase 4). During the development stage, focus group interviews will be conducted with expectant and new mothers, as well as maternal care providers for feasibility testing. A toolkit, including a patient decision aid along with its user guide and training materials, will be developed based on the findings of Phase 1 and syntheses of up-to-date evidence and appraised by the Delphi method. Additionally, a cognitive task analysis will be used for assessing the usability of the toolkit. During the evaluation stage, a prospective randomized controlled trial embedded in a mixed methods design will be used to evaluate the effectiveness and cost-effectiveness of the IP-SDM care model. The study targets to recruit 410 expectant and new mothers who screen positive for depression. They will be randomly assigned to either an intervention group or a control group in a 1:1 ratio. Participants in the intervention group will receive decision aid, decision coaching, and clinical consultation, in addition to usual services, while the control group will receive usual services. The primary outcome is the quality of decision-making process, and the secondary outcomes include SDM, mental health service utilization and costs, depressive symptoms, and health-related quality of life. In-depth interviews will be used to explore the facilitating and hindering factors of SDM.

DISCUSSION

This study will develop an IP-SDM care model for PND that can be implemented in maternal care settings in China. This study will contribute to the understanding of how SDM impacts mental health outcomes and facilitate the integration of mental health services into maternal care.

TRIAL REGISTRATION

ChiCTR2300072559. Registered on 16 June 2023.

Treatment options and their uptake among women with symptoms of perinatal depression: exploratory study in Norway and Portugal

BACKGROUND

Perinatal depression is the most undertreated clinical condition during the perinatal period. Knowledge about women's decision-making in seeking and receiving treatment is scarce.

AIMS

To investigate and compare treatment option uptake in perinatal women with depressive symptoms in Portugal and Norway, and to identify sociodemographic and health-related factors associated with treatment uptake.

METHOD

Participants were women resident in Portugal or Norway (≥18 years) who were pregnant or had given birth in the past 12 months, who presented with active depressive symptoms (Edinburgh Postnatal Depression Scale score ≥10). In an electronic questionnaire, women reported treatment received and sociodemographic and health-related factors.

RESULTS

The sample included 416 women from Portugal and 169 from Norway, of which 79.8% and 53.9%, respectively, were not receiving any treatment. Most Portuguese women were receiving psychological treatment, either alone (45.2%) or combined with pharmacological treatment (21.4%). Most Norwegian participants were receiving only pharmacological (36.5%) or combined treatment (35.4%). Compared with the Portuguese sample, a higher proportion of Norwegian women started treatment before pregnancy (P < 0.001). In Portugal, lower depressive symptoms and self-reported psychopathology were significantly associated with higher likelihood of receiving treatment.

CONCLUSIONS

We found that, in both Norway and Portugal, a substantial number of perinatal women with depressive symptoms do not receive any treatment. Differences exist regarding the chosen treatment option and timing of treatment initiation in the two countries. Only mental health-related factors were associated with treatment uptake for perinatal depression in Portugal. Our results highlight the importance of implementing strategies aimed to improve help-seeking behaviours.

Effectiveness of cognitive behavioural therapy-based interventions for maternal perinatal depression: a systematic review and meta-analysis

BACKGROUND

Depression during the perinatal period (during pregnancy and the year after childbirth) is common and associated with a range of negative effects for mothers, infants, family members, and wider society. Although existing evidence suggests cognitive behavioral therapy (CBT) based interventions are effective for perinatal depression, less is known about the effect of CBT-based interventions on important secondary outcomes, and a number of potential clinical and methodological moderators have not been examined.

METHODS

A systematic review and meta-analysis primarily examined the effectiveness of CBT-based interventions for perinatal depression on symptoms of depression. Secondary aims examined the effectiveness of CBT-based interventions for perinatal depression on symptoms of anxiety, stress, parenting, perceived social support, and perceived parental competence; and explored clinical and methodological moderators potentially associated with effectiveness. A systematic search of electronic databases and other sources was performed up to November 2021. We included randomized controlled trials comparing CBT-based interventions for perinatal depression with control conditions allowing for the isolation of the effects of CBT.

RESULTS

In total, 31 studies (5291 participants) were included in the systematic review and 26 studies (4658 participants) were included in the meta-analysis. The overall effect size was medium (hedges g = - 0.53 [95% CI - 0.65 to - 0.40]); with high heterogeneity. Significant effects were also found for anxiety, individual stress, and perceived social support, however few studies examined secondary outcomes. Subgroup analysis identified type of control, type of CBT, and type of health professional as significant moderators of the main effect (symptoms of depression). Some concerns of risk of bias were present in the majority of studies and one study had a high risk of bias.

CONCLUSIONS

CBT-based interventions for depression during the perinatal period appear effective, however results should be interpreted with caution given high levels of heterogeneity and low quality of included studies. There is a need to further investigate possibly important clinical moderators of effect, including the type of health professional delivering interventions. Further, results indicate a need to establish a minimum core data set to improve the consistency of secondary outcome collection across trials and to design and conduct trials with longer-term follow-up periods.

TRIAL REGISTRATION

CRD42020152254 .

Understanding depression treatment and perinatal service preferences of Kenyan pregnant adolescents: A discrete choice experiment

BACKGROUND

Understanding mental health treatment preferences of adolescents and youth is particularly important for interventions to be acceptable and successful. Person-centered care mandates empowering individuals to take charge of their own health rather than being passive recipients of services.

METHODS

We conducted a discrete choice experiment to quantitatively measure adolescent treatment preferences for different care characteristics and explore tradeoffs between these. A total of 153 pregnant adolescents were recruited from two primary healthcare facilities in the informal urban settlement of Nairobi. We selected eight attributes of depression treatment option models drawn from literature review and previous qualitative work. Bayesian d-efficient design was used to identify main effects. A total of ten choice tasks were solicited per respondent. We evaluated mean preferences using mixed logit models to adjust for within subject correlation and account for unobserved heterogeneity.

RESULTS

Respondents showed a positive preference that caregivers be provided with information sheets, as opposed to co-participation with caregivers. With regards to treatment options, the respondents showed a positive preference for 8 sessions as compared to 4 sessions. With regards to intervention delivery agents, the respondents had a positive preference for facility nurses as compared to community health volunteers. In terms of support, the respondents showed positive preference for parenting skills as compared to peer support. Our respondents expressed negative preferences of ANC service combined with older mothers as compared to adolescent friendly services and of being offered refreshments alone. A positive preference was revealed for combined refreshments and travel allowance over travel allowance or refreshments alone. A number of these suggestions were about enhancing their experience of maternity clinical care experience.

CONCLUSION

This study highlights unique needs of this population. Pregnant adolescents' value responsive maternity and depression care services offered by nurses. Participants shared preference for longer psychotherapy sessions and their preference was to have adolescent centered maternal mental health and child health services within primary care.

Patients' preferences in dental care: A discrete-choice experiment and an analysis of willingness-to-pay

INTRODUCTION

Dental diseases are a major problem worldwide. Costs are a burden on healthcare systems and patients. Missed treatments can have health and financial consequences. Compared to other health services, dental treatments are only covered in parts by statutory health insurance (SHI). Using the example of dental crowns for a cost-intensive treatment, our study aims to investigate whether (1) certain treatment attributes determine patients' treatment choice, and (2) out-of-pocket payments represent a barrier to access dental care.

METHODS

We conducted a discrete-choice-experiment by mailing questionnaires to 10,752 people in Germany. In presented scenarios the participants could choose between treatment options (A, B, or none) composed of treatment attribute levels (e.g., color of teeth) for posterior (PT) and anterior teeth (AT). Considering interaction effects, we used a D-efficient fractional factorial design. Choice analysis was performed using different models. Furthermore, we analyzed willingness-to-pay (WTP), preference of choosing no and SHI standard care treatment, and influence of socioeconomic characteristics on individual WTP.

RESULTS

Out of n = 762 returned questionnaires (response rate of r = 7.1), n = 380 were included in the analysis. Most of the participants are in age group "50 to 59 years" (n = 103, 27.1%) and female (n = 249, 65.5%). The participants' benefit allocations varied across treatment attributes. Aesthetics and durability of dental crowns play most important roles in decision-making. WTP regarding natural color teeth is higher than standard SHI out-of-pocket payment. Estimations for AT dominate. For both tooth areas, "no treatment" was a frequent choice (PT: 25.7%, AT: 37.2%). Especially for AT, treatment beyond SHI standard care was often chosen (49.8%, PT: 31.3%). Age, gender, and incentive measures (bonus booklet) influenced WTP per participant.

CONCLUSION

This study provides important insights into patient preferences for dental crown treatment in Germany. For our participants, aesthetic for AT and PT as well as out-of-pocket payments for PT play an important role in decision-making. Overall, they are willing to pay more than the current out-of-pockt payments for what they consider to be better crown treatments. Findings may be valuable for policy makers in developing measures that better match patient preferences.

A pilot randomized controlled trial of a lay telephone coaching and web-based intervention for postpartum depression and anxiety: The MPOWER study

BACKGROUND

Mental health problems are frequent in the postpartum period, but accessible treatment options are lacking. The MPOWER study investigated whether the use of trained lay coaches could increase the uptake and effectiveness of a web-based intervention (WBI) for women with postpartum depression and/or anxiety.

OBJECTIVES

First, to compare the feasibility and acceptability of a WBI for women with postpartum depression and anxiety, with and without the addition of telephone coaching calls. Second, to estimate the effectiveness of the WBI at decreasing symptoms of depression and anxiety at 6 months, with and without coaching calls.

METHODS

We conducted a pilot randomized controlled trial (RCT) that enrolled women who had recently given birth and had mild to moderate postpartum depression and/or anxiety. Study participants were provided access to the WBI. Women randomized to the intervention group also received up to 7 telephone coaching calls during the 6 months of follow up. We evaluated the feasibility of the intervention through participants' usage of the WBI, as well as the completion and fidelity of planned coach calls. We measured acceptability via two questionnaires on the usability of the WBI and participant satisfaction with the intervention. To determine the potential effectiveness of the intervention, the primary outcomes were defined as symptoms of depression and anxiety at 6 months and adjusted mean differences between groups for these outcomes were estimated using linear regression models.

RESULTS

We recruited 52 participants (25 intervention; 27 control). At 6 months, 88 % (22/25) of participants randomized to the intervention arm and 59 % (16/27) of participants randomized to the control arm remained in the study. The intervention group had an average of 11 (95 % CI: [5, 18]) more website logins than the control group. Intervention group participants completed a mean of 6.2 coaching calls with high fidelity. The estimates of the effect of the intervention on mental health outcomes at 6-months were imprecise but point estimates and confidence intervals were consistent with a moderate beneficial effect of the intervention on both symptoms of depression and anxiety (fully adjusted effects sizes: 0.51 (95 % CI: [-0.14, 1.17]) and 0.56 (95 % CI: [-0.09, 1.22]), respectively).

CONCLUSIONS

WBIs with coaching are feasible, acceptable, and potentially effective treatment options for women with mild to moderate postpartum depression and/or anxiety. The addition of coaching calls markedly increased engagement with the WBI, but a larger RCT is needed to determine the effectiveness of such an intervention.

Current Practices for Accounting for Preference Heterogeneity in Health-Related Discrete Choice Experiments: A Systematic Review

BACKGROUND

Accounting for preference heterogeneity is a growing analytical practice in health-related discrete choice experiments (DCEs). As heterogeneity may be examined from different stakeholder perspectives with different methods, identifying the breadth of these methodological approaches and understanding the differences are major steps to provide guidance on good research practices.

OBJECTIVES

Our objective was to systematically summarize current practices that account for preference heterogeneity based on the published DCEs related to healthcare.

METHODS

This systematic review is part of the project led by the Professional Society for Health Economics and Outcomes Research (ISPOR) health preference research special interest group. The systematic review conducted systematic searches on the PubMed, OVID, and Web of Science databases, as well as on two recently published reviews, to identify articles. The review included health-related DCE articles published between 1 January 2000 and 30 March 2020. All the included articles also presented evidence on preference heterogeneity analysis based on either explained or unexplained factors or both.

RESULTS

Overall, 342 of the 2202 (16%) articles met the inclusion/exclusion criteria for extraction. The trend showed that analyses of preference heterogeneity increased substantially after 2010 and that such analyses mainly examined heterogeneity due to observable or unobservable factors in individual characteristics. Heterogeneity through observable differences (i.e., explained heterogeneity) is identified among 131 (40%) of the 342 articles and included one or more interactions between an attribute variable and an observable characteristic of the respondent. To capture unobserved heterogeneity (i.e., unexplained heterogeneity), the studies largely estimated either a mixed logit (n = 205, 60%) or a latent-class logit (n = 112, 32.7%) model. Few studies (n = 38, 11%) explored scale heterogeneity or heteroskedasticity.

CONCLUSIONS

Providing preference heterogeneity evidence in health-related DCEs has been found as an increasingly used practice among researchers. In recent studies, controlling for unexplained preference heterogeneity has been seen as a common practice rather than explained ones (e.g., interactions), yet a lack of providing methodological details has been observed in many studies that might impact the quality of analysis. As heterogeneity can be assessed from different stakeholder perspectives with different methods, researchers should become more technically pronounced to increase confidence in the results and improve the ability of decision makers to act on the preference evidence.

Perinatal mental health literacy: knowledge, attitudes, and help-seeking among perinatal women and the public - a systematic review

Background

The perinatal period is a time of increased vulnerability to mental health problems, however, only a small proportion of women seek help. Poor mental health literacy (MHL) is a major barrier to seeking help for mental health problems. This study aimed to collect the existing evidence of MHL associated with perinatal mental health problems (PMHP) among perinatal women and the public. This review analysed which tools were used to assess perinatal MHL as well as the findings concerning individual components of perinatal MHL.

Methods

Four electronic databases (PubMed, PsycINFO, Web of Science, and CINAHL) were analysed from their inception until September 1, 2020. Not only quantitative studies reporting on components of MHL (knowledge, attitudes, and help-seeking), but also studies reporting overall levels of MHL relating to PMHP were taken into account. Two independent reviewers were involved in the screening and extraction process and data were analysed descriptively.

Results

Thirty-eight of the 13,676 retrieved articles satisfied the inclusion criteria. The majority of selected studies examined MHL related to PMHP in perinatal women (N = 28). The most frequently examined component of MHL in the selected data set was help-seeking. A lack of uniformity in assessing MHL components was found. The most common focus of these studies was postpartum depression. It was found that the ability to recognize PMHP and to identify relevant symptoms was lacking among both perinatal women and the public. Perinatal women had low intentions of seeking help for PMHP and preferred seeking help from informal sources while reporting a variety of structural and personal barriers to seeking help. Stigmatizing attitudes associated with PMHP were found among the public.

Conclusions

There is a need for educational campaigns and interventions to improve perinatal MHL in perinatal women and the public as a whole.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04865-y.

Postpartum Help-Seeking: The Role of Stigma and Mental Health Literacy

BACKGROUND

Postpartum depression is the most common complication associated with child-bearing. The current study investigated attitudes toward professional psychological help-seeking and the effects of stigma and mental health literacy on postpartum women recruited from social media (N = 326).

METHOD

Hierarchical linear regression was used to analyze the data and the interaction effect of stigma and mental health literacy.

RESULTS

Stigma was negatively associated with attitudes toward professional psychological help-seeking, while mental health literacy was positively associated with attitudes toward professional psychological help-seeking. The interaction effect was not statistically significant. The results yield implications for screening practices and reducing stigma for mental health care in the postpartum period.

Patient Preferences for Anxiety and Depression Screening in Cancer Care: A Discrete Choice Experiment

OBJECTIVES

Screening for anxiety and depression in cancer care is recommended, as identification is the first step in managing anxiety and depression. Nevertheless, patient preferences for anxiety and depression screening in cancer care are unknown. The objective of this study was to investigate and identify the aspects of an anxiety and depression screening program cancer patients value most, to inform decision-makers about ways to improve patient uptake and ultimately, the provision of patient-centered care.

METHODS

A discrete choice experiment was designed and implemented within an Australian cancer population sample. Participants were presented with a series of hypothetical screening programs labeled as "screening program 1" and "screening program 2" and were asked to choose their preferred one. The discrete choice experiment was administered using an online survey platform. A mixed logit and a latent class analysis was conducted.

RESULTS

Participants (n = 294) preferred screening to be conducted by a cancer nurse, face-to-face, and at regular intervals (monthly or every 3 months). Participants also preferred follow-up care to be delivered by mental health professionals embedded within the cancer care team. Factors that influenced preferences were the low cost and short waiting times for access to care.

CONCLUSIONS

Cancer patients prefer cancer services with integrated mental healthcare services. To maximize patient uptake, anxiety and depression screening programs should be routinely offered, delivered by oncology healthcare staff in a face-to-face format, and, postscreening, to be care for by mental health professionals embedded within the cancer service.

The Impact of Reproductive Issues on Preferences of Women with Relapsing Multiple Sclerosis for Disease-Modifying Treatments

BACKGROUND

Relapsing-remitting multiple sclerosis (RRMS) is an incurable disease characterised by relapses (periods of function loss) followed by full or partial recovery, and potential permanent disability over time. Many disease-modifying treatments (DMTs) exist that help reduce relapses and slow disease progression. Most are contraindicated during conception/pregnancy and some require a discontinuation period before trying to conceive. Although around three-quarters of people with RRMS are women, there is limited knowledge about how reproductive issues impact DMT preference.

OBJECTIVE

The aim of this study was to measure the preferences for DMTs of women with RRMS who are considering pregnancy.

DESIGN

An online discrete choice experiment (DCE).

METHODS

Participants chose between two hypothetical DMTs characterised by a set of attributes, then indicated if they preferred their choice to no treatment. Attributes were identified from interviews and focus groups with people with RRMS and MS professionals, as well as literature reviews, and included the probability of problems with pregnancy, discontinuation of DMTs, and breastfeeding safety. In each DCE task, participants were asked to imagine making decisions in three scenarios: now; when trying to conceive; and when pregnant.

ANALYSIS

Two mixed logit models were estimated, one to assess the statistical significance between scenarios and one in maximum acceptable risk space to allow comparison of the magnitudes of parameters between scenarios.

SAMPLE

Women with RRMS who were considering having a child in the future, recruited from a UK MS patient register.

RESULTS

Sixty respondents completed the survey. Participants preferred no treatment in 12.6% of choices in the 'now' scenario, rising significantly to 37.6% in the 'trying to conceive' scenario and 60.3% in the 'pregnant' scenario (Kruskal-Wallis p < 0.001). This pattern corresponds with results from models that included a no-treatment alternative-specific constant (ASC) capturing differences between taking and not taking a DMT not specified by the attributes. The ASC was lower in the trying to conceive scenario than in the now scenario, and lower still in the pregnant scenario, indicating an intrinsic preference for no treatment. Participants also placed relatively less preference on reducing relapses and avoiding disease progression in the trying to conceive and pregnant scenarios compared with a lower risk of problems with pregnancy. In the trying to conceive scenario, participants' preference for treatments with shorter washout periods increased.

CONCLUSION

Women with RRMS considering having a child prefer DMTs with more favourable reproduction-related attributes, even when not trying to conceive. Reproductive issues also influenced preferences for DMT attributes not directly related to pregnancy, with preferences dependent on the life circumstances in which choices were made. The design of the DCE highlights the benefits of considering the scenario in which participants make choices, as they may change over time.

The feasibility of acupuncture as an adjunct intervention for antenatal depression: a pragmatic randomised controlled trial

BACKGROUND

Antenatal depression is common and associated with adverse consequences for mothers, babies, and future generations. Limitations with conventional approaches has resulted in additional therapies being considered. This study examined the feasibility and effectiveness of acupuncture for improving mental health.

METHODS

Fifty-seven pregnant women with depressive symptomologies were randomised to acupuncture (n=19) plus treatment as usual (TAU), progressive muscle relaxation (PMR, n=19) plus TAU or TAU (n=19). Treatments were conducted from 24 to 31 weeks gestation. Clinical assessments were performed throughout the intervention, as well as at a six-week postnatal follow-up. The primary outcome measure was depression. Secondary outcome measurements were stress, anxiety, psychological distress, quality of life and adjustment to mothering. Intention to treat (ITT), Linear Mixed Model (LMM) repeated measures and per protocol (PP) analyses were conducted.

RESULTS

At end-of-intervention there were significantly lower depression scores in the acupuncture group versus TAU and PMR respectively [ITT p<0.001, mean difference (MD) -5.84 (95% CI -9.10 to -2.58); MD -3.42 (95% CI -6.64 to -0.20)]. LMM repeated measures analysis (including postnatal follow-up) also demonstrated significantly lowered acupuncture group scores for stress (p=0.006) and psychological distress (p<0.001) when compared to PMR and TAU. Between group differences were not significant at six-weeks postnatal. No adverse events were reported.

LIMITATIONS

Main limitations are small sample size and the use of self-reported outcome measures.

CONCLUSION

Prenatal acupuncture reduced depression, stress and distress, whilst also being well-tolerated and free from adverse events. Further research is warranted.

The effectiveness of massage for reducing pregnant women's anxiety and depression; systematic review and meta-analysis

OBJECTIVE

To critically appraise and synthesize the best available evidence on the effectiveness of massage to reduce antenatal women's anxiety and/ or depression.

DESIGN

Systematic review with meta-analysis PARTICIPANTS, INTERVENTIONS: Pregnant women over the age of 18 years who receive massage interventions.

MEASUREMENTS AND FINDINGS

Eight studies were included in the review; seven were randomized controlled trials. Data were collected via pregnant women's self-reported ratings of anxiety or depression using validated tools. Meta-analysis of four studies revealed a moderate effect of massage therapy on women's depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale (CES-D) (MD = -5.95, 95%CI = -8.11 to -3.80, I² = 0%) compared with usual care. A moderate effect of massage interventions on women's anxiety were also found based on five studies using various measures (SMD = -0.59, 95%CI = -1.06 to -0.12, I² = 75%) when compared with usual care. However, none of the trials had a low risk of bias.

KEY CONCLUSIONS

Non-pharmacologic treatments for mental health symptoms are an important option for women to use during pregnancy. As shown in meta-analysed data, massage therapy might be more effective in reducing pregnant women's anxiety and depression than usual care, although the current results may be prone to bias. Further high-quality research is required to fully evaluate the impact of massage therapy on pregnant women's mental health symptoms in the immediate and also longer term.

IMPLICATIONS FOR PRACTICE

Massage therapy may be an acceptable and feasible approach for pregnant women to employ to reduce their anxiety and depressive symptoms. More research evidence examining the safety and effectiveness of massage is required before practice recommendations can be made.

Decision-making about antidepressant medication use in pregnancy: a comparison between women making the decision in the preconception period versus in pregnancy

BACKGROUND

Decisions about antidepressant use in pregnancy are complex. Little is known about how pregnancy-planning and already pregnant women making these decisions differ.

METHODS

In 95 Canadian women having difficulty deciding whether to take antidepressants in pregnancy, we compared sociodemographic factors, clinical characteristics, and treatment intent between women planning pregnancy (preconception women) and currently-pregnant women.

RESULTS

About 90% of preconception women (n = 55) were married or cohabitating and university-educated, and over 60% had an annual income of > 80,000 CAD/year; this was not different from currently-pregnant women (n = 40). Almost all women had previously used antidepressants, but preconception women were more likely to report current use (85.5% vs. 45.0%). They were more likely to have high decisional conflict (83.6% vs. 60.0%) and less likely to be under the care of a psychiatrist (29.1% vs. 52.5%). Preconception women were more likely than pregnant women to report the intent to use antidepressants (60% vs. 32.5%, odds ratio 3.11, 95% confidence interval 1.33-7.32); this was partially explained by between-group differences in current antidepressant use.

CONCLUSIONS

Preconception women were more likely than pregnant women to intend to use antidepressants in pregnancy, in part because more of them were already using this treatment. Strategies to enhance support for decision-making about antidepressant medication use in pregnancy may need to be tailored differently for pregnancy-planning and already pregnant women.

Patient preferences for a guided self-help programme to prevent relapse in anxiety or depression: A discrete choice experiment

BACKGROUND

Anxiety and depressive disorders are increasingly being viewed as chronic conditions with fluctuating symptom levels. Relapse prevention programmes are needed to increase self-management and prevent relapse. Fine-tuning relapse prevention programmes to the needs of patients may increase uptake and effectiveness.

MATERIALS AND METHODS

A discrete choice experiment (DCE) was conducted amongst patients with a partially or fully remitted anxiety or depressive disorder. Patients were presented 20 choice tasks with two hypothetical treatment scenarios for relapse prevention, plus a "no treatment" option. Each treatment scenario was based on seven attributes of a hypothetical but realistic relapse prevention programme. Attributes considered professional contact frequency, treatment type, delivery mode, programme flexibility, a personal relapse prevention plan, time investment and effectiveness. Choice models were estimated to analyse the data.

RESULTS

A total of 109 patients with a partially or fully remitted anxiety or depressive disorder completed the DCE. Attributes with the strongest impact on choice were high effectiveness, regular contact with a professional, low time investment and the inclusion of a personal prevention plan. A high heterogeneity in preferences was observed, related to both clinical and demographic characteristics: for example, a higher number of previous treatment episodes was related to a preference for a higher frequency of contact with a professional, while younger age was related to a stronger preference for high effectiveness.

CONCLUSIONS

This study using a DCE provides insights into preferences for a relapse prevention programme for anxiety and depressive disorders that can be used to guide the development of such a programme.

Help Seeking in the Perinatal Period: A Review of Barriers and Facilitators

Perinatal depression affects approximately 10 to 20 percent of women during pregnancy or the first 12 months postpartum. Increased attention has been given to the prevalence of and screening for perinatal depression, yet little research addresses help seeking for this issue. The overall barriers and facilitators of help seeking among these women have yet to be addressed in a systematic way. A systematic literature review was conducted to identify studies that focused on help seeking among women with perinatal depression. Nineteen articles met the inclusion criteria discussed below and were included in this review. Barriers to help seeking for women with perinatal depression include social (e.g. stigma), structural (e.g. provider unavailable) and instrumental factors (e.g. cost). Facilitators of help seeking for women with perinatal depression were limited in scope. Recommendations for policy and the role of social workers are discussed.

Stubbing out hypothetical bias: improving tobacco market predictions by combining stated and revealed preference data

In health, stated preference data from discrete choice experiments (DCEs) are commonly used to estimate discrete choice models that are then used for forecasting behavioral change, often with the goal of informing policy decisions. Data from DCEs are potentially subject to hypothetical bias. In turn, forecasts may be biased, yielding substandard evidence for policymakers. Bias can enter both through the elasticities as well as through the model constants. Simple correction approaches exist (using revealed preference data) but are seemingly not widely used in health economics. We use DCE data from an experiment on smokers in the US. Real-world data are used to calibrate the scale of utility (in two ways) and the alternative-specific constants (ASCs); several innovations for calibration are proposed. We find that embedding revealed preference data in the model makes a substantial difference to the forecasts; and that how models are calibrated also makes a substantial difference.

A discrete-choice experiment to assess treatment modality preferences of patients with depression

AIMS

There is an increasing interest in understanding patients' preferences in the area of healthcare decision-making to better match treatment with patients' preferences and improve treatment uptake and adherence. The aim of this study was to elicit the preferences of patients with a depressive disorder regarding treatment modalities.

MATERIALS AND METHODS

In a discrete-choice experiment, patients chose repetitively between two hypothetical depression treatments that varied in four treatment attributes: waiting time until the start of treatment, treatment intensity, level of digitalization, and group size. A Bayesian-efficient design was used to develop 12 choice sets, and patients' preferences and preference variation was estimated using a random parameters logit model.

RESULTS

A total of 165 patients with depression completed the survey. Patients preferred short (over long) waiting times, face-to-face (over digital) treatment, individual (over group) treatment, and one session per week over two sessions per week or one session per 2 weeks. Patients disfavoured digital treatment and treatment in a large group. Waiting time and treatment intensity were substantially less important attributes to patients than face-to-face (vs digital) and group size. Significant variation in preferences was observed for each attribute, and sub-group analyses revealed that these differences were in part related to education.

LIMITATIONS

The convenience sample over-represented the female and younger population, limiting generalizability. Limited information on background characteristics limited the possibilities to explore preference heterogeneity.

CONCLUSION

This study demonstrated how different treatment components for depression affect patients' preferences for those treatments. There is significant variation in treatment preferences, even after accounting for education. Incorporating individual patients' preferences into treatment decisions could potentially lead to improved adherence of treatments for depressive disorders.

A discrete-choice experiment to assess treatment modality preferences of patients with anxiety disorder

AIMS

The aim of this study was to elicit the preference of patients with an anxiety disorder regarding treatment modalities. Understanding patients' preferences could help optimize treatment uptake and adherence to therapeutic interventions.

MATERIALS AND METHODS

A discrete-choice experiment was used to elicit patients' preferences with regard to four treatment characteristics: waiting time until first treatment, intensity of treatment, face-to-face vs digital treatment, and group size. In 12 choice sets, participants were asked to choose between two treatment alternatives. A random parameters logit model was used to analyse the data.

RESULTS

A total of 126 participants, aged 18 years and older, currently or in the previous year in treatment for an anxiety disorder, completed the survey. Respondents preferred short (over long) waiting times, face-to-face (over digital) treatment, individual (over group) treatment and a treatment intensity of one session per week rather than two sessions per week or one session every two weeks. Waiting time and treatment intensity were substantially less important to patients than level of digitalization and group size. Heterogeneity in preference was significant for each attribute, and sub-group analyses revealed this was partly related to education level and age.

LIMITATIONS

The convenience sample over-represented the female and younger population, limiting generalizability. Limited information on background characteristics limited the possibilities to explore preference heterogeneity.

CONCLUSIONS

This study demonstrated how different treatment components for anxiety disorders affect patients' preferences for those treatments. There is significant variation in treatment preferences, even after accounting for age and education. Incorporating patients' preferences into treatment decisions could potentially lead to improved adherence of treatments for anxiety disorders.

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

A framework to address key issues of neonatal service configuration in England: the NeoNet multimethods study

Background

There is an inherent tension in neonatal services between the efficiency and specialised care that comes with centralisation and the provision of local services with associated ease of access and community benefits. This study builds on previous work in South West England to address these issues at a national scale.

Objectives

(1) To develop an analytical framework to address key issues of neonatal service configuration in England, (2) to investigate visualisation tools to facilitate the communication of findings to stakeholder groups and (3) to assess parental preferences in relation to service configuration alternatives.

Main outcome measures

The ability to meet nurse staffing guidelines, volumes of units, costs, mortality, number and distance of transfers, travel distances and travel times for parents.

Design

Descriptive statistics, location analysis, mathematical modelling, discrete event simulation and economic analysis were used. Qualitative methods were used to interview policy-makers and parents. A parent advisory group supported the study.

Setting

NHS neonatal services across England.

Data

Neonatal care data were sourced from the National Neonatal Research Database. Information on neonatal units was drawn from the National Neonatal Audit Programme. Geographic and demographic data were sourced from the Office for National Statistics. Travel time data were retrieved via a geographic information system. Birth data were sourced from Hospital Episode Statistics. Parental cost data were collected via a survey.

Results

Location analysis shows that to achieve 100% of births in units with ≥ 6000 births per year, the number of birth centres would need to be reduced from 161 to approximately 72, with more parents travelling > 30 minutes. The maximum number of neonatal intensive care units (NICUs) needed to achieve 100% of very low-birthweight infants attending high-volume units is 36 with existing NICUs, or 48 if NICUs are located wherever there is currently a neonatal unit of any level. Simulation modelling further demonstrated the workforce implications of different configurations. Mortality modelling shows that the birth of very preterm infants in high-volume hospitals reduces mortality (a conservative estimate of a 1.2-percentage-point lower risk) relative to these births in other hospitals. It is currently not possible to estimate the impact of mortality for infants transferred into NICUs. Cost modelling shows that the mean length of stay following a birth in a high-volume hospital is 9 days longer and the mean cost is £5715 more than for a birth in another neonatal unit. In addition, the incremental cost per neonatal life saved is £460,887, which is comparable to other similar life-saving interventions. The analysis of parent costs identified unpaid leave entitlement, food, travel, accommodation, baby care and parking as key factors. The qualitative study suggested that central concerns were the health of the baby and mother, communication by medical teams and support for families.

Limitations

The following factors could not be modelled because of a paucity of data – morbidity outcomes, the impact of transfers and the maternity/neonatal service interface.

Conclusions

An evidence-based framework was developed to inform the configuration of neonatal services and model system performance from the perspectives of both service providers and parents.

Future work

To extend the modelling to encompass the interface between maternity and neonatal services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Shared decision making in mental health: the importance for current clinical practice

OBJECTIVES

We reviewed the literature on shared decision making (regarding treatments in psychiatry), with a view to informing our understanding of the decision making process and the barriers that exist in clinical practice.

METHODS

Narrative review of published English-language articles.

RESULTS

After culling, 18 relevant articles were included. Themes identified included models of psychiatric care, benefits for patients, and barriers. There is a paucity of published studies specifically related to antipsychotic medications.

CONCLUSIONS

Shared decision making is a central part of the recovery paradigm and is of increasing importance in mental health service delivery. The field needs to better understand the basis on which decisions are reached regarding psychiatric treatments. Discrete choice experiments might be useful to inform the development of tools to assist shared decision making in psychiatry.